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Clinical Benefits of Pulmonary Rehabilitation in COPD

Clinical Benefits of Pulmonary Rehabilitation in COPD. Darcy D. Marciniuk, MD FRCPC FCCP Division of Respirology , Critical Care and Sleep Medicine. Conflict of Interest Disclosure. Consultancy Fees / Advisory Boards

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Clinical Benefits of Pulmonary Rehabilitation in COPD

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  1. Clinical Benefits of Pulmonary Rehabilitationin COPD Darcy D. Marciniuk, MD FRCPC FCCP Division of Respirology, Critical Care and Sleep Medicine

  2. Conflict of Interest Disclosure Consultancy Fees / Advisory Boards AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Health Canada, Health Quality Council, Novartis, Nycomed, Pfizer, Public Health Agency of Canada, Saskatchewan Medical Association, Saskatoon Health Region Research Funding AstraZeneca, Boehringer Ingelheim, Canadian Agency for Drugs and Technology in Health, Canadian Institute of Health Research, GlaxoSmithKline, Lung Association of Saskatchewan, Novartis, Nycomed, Pfizer, Saskatchewan Health Research Foundation, Saskatchewan Ministry of Health, Schering-Plough Speaker’s Bureau AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Pfizer Fiduciary Positions Canadian COPD Alliance, American College of Chest Physicians, Chest Foundation, Saskatchewan Lung Association Employee University of Saskatchewan

  3. Pulmonary Rehabilitation in COPD Objectives • understand the role of Pulmonary Rehabilitation (PR) in the comprehensive management of COPD • appreciate the patient-centered clinical benefitsof effective PR in COPD • recognize and minimize barriers to patients participating and fully realizing the clinical benefits of PR in COPD

  4. A Comprehensive Approach to COPD Management Surgery Surgery Oxygen Oxygen Inhaled corticosteroids/LABA Inhaled corticosteroids Pulmonary rehabilitation Pulmonary rehabilitation Long-acting bronchodilator(s) Long PRN Rapid PRN short-acting bronchodilators Smoking cessation/exercise/self-management/education Smoking cessation/exercise/self Lung function Very Severe Mild impairment V II V MRC Dyspnea Early Diagnosis End of Life Care Prevent/Rx AECOPD (Spirometry) + Follow-up Prevention O’Donnell DE, et al. Can Resp J 2008; 15:1A-8A.

  5. Active reduction of risk factor(s); influenza vaccination Addshort-acting bronchodilator (when needed) I: Mild II: Moderate III: Severe IV: Very Severe Addregular treatment with one or more long-acting bronchodilators (when needed); Addrehabilitation Addinhaled glucocorticosteroids if repeated exacerbations Addlong term oxygenif chronic respiratory failure. Considersurgical treatments

  6. Comprehensive Approach to Management of Refractory Dyspnea in Advanced COPD Initiate & Optimize Opioid Therapies: Short- and Long-Acting Agents Initiate & Optimize Non-Pharmacologic Therapies: Exercise, Pursed-Lip Breathing, Walking Aids, Chest Wall Vibration, NMES Initiate & Optimize Pharmacologic Therapies: SABD, LAAC, ICS/LABA, PDE4 Inhibitors, Theophylline, O2 in Hypoxemic Patients Magnitude of Dyspnea V Regular Follow-up And Reassessment End of Life Care Exclude Contributing Causes Marciniuk DD, et al. Can Resp J 2011; 18:69-78.

  7. Pulmonary Rehabilitation in COPD What is Pulmonary Rehabilitation ? • … depends on who you ask ! • common theme: • multidisciplinary program designed to optimize physiological, psychological, and social outcomes for COPD patients and their care-givers • practical definition depends on the program design and intent • ‘Group Exercise’ ↔ ‘Comprehensive Care’

  8. PR improves dyspnea and activity limitation in COPD patients (1) COPD patients benefit from PR regardless of patient age, disease severity, and sex (2) PR is beneficial across all levels of COPD severity, and should be considered earlier in the course of COPD (3) allow for a greater emphasis on promoting health rather than regaining function Pulmonary Rehabilitation in COPD Who Benefits From PR? 1 Ries AL, et al. Chest 2007; 131:4S-42S. 2 Hailey D, et al. CADTHHTA Report, April 2010. 3 Nici L, et al. J Cardiopulm Rehab Prev 2009; 29:141-151.

  9. Pulmonary Rehabilitation Candidates strongly recommended patients with moderate, severe and very severe COPD participate in PR (Recommendation Grade 1C) currently, there is insufficient data to make a recommendation regarding mild COPD patients strongly recommended that both women and men be referred for Pulmonary Rehabilitation (Recommendation Grade 1C) Marciniuk DD, et al. Can Resp J 2010; 17:159-168

  10. Pulmonary Rehabilitation Candidates strongly recommended COPD patients undergo PR within 1 month following AECOPD due to evidence supporting improved dyspnea, exercise tolerance and HRQL compared with usual care (Recommendation Grade 1B) PR within 1 month following AECOPD also recommended due to evidence supporting reduced hospital admissions and mortality compared with usual care (Recommendation Grade 2C) Marciniuk DD, et al. Can Resp J 2010; 17:159-168

  11. Physical Activity in COPD Pulmonary Rehabilitation in COPD COPD Admission Mortality Copenhagen City Heart Study, n=2386 COPD subjects confirmed by lung function [833 GOLD I, 1095 GOLD II, 354 GOLD III, 94 GOLD IV] No effect modification was found for sex, age, COPD severity, or IHD Garcia-Aymerich J, et al. Thorax 2009; 61:772-778.

  12. Physical Activity in COPD 70 COPD [9 / 28 / 23 / 10] and 30 control subjects; activity monitor x 6-8 days. Trooster T, et al. Respiratory Medicine 2010; 104:1005-1011

  13. Health Benefits of Physical Activity primary and secondary prevention: all-cause and cardiovascular-related deaths are decreased incidence of diabetes mellitus, cancer (colon, breast), and osteoporosis are significantly reduced how much exercise is necessary? weekly expenditure of ~1000 kcal associated with a 20-30% reduction in all-cause mortality less ‘volume’ of exercise is necessary solely for health benefits (~ 500 kcal/week) not much! Pulmonary Rehabilitation in COPD Warburton DER, et al. CMAJ 2006; 174:801-809

  14. Pulmonary Rehabilitation in COPD Adverse Effects of COPD FEV1, FVC IC, EELV FRC, RV Impairment [Function] Dyspnea Exercise Endurance Exacerbations (AECOPD) Disability [Activity] Quality of Life Health Care Utilization Handicap [Participation] Adapted from Can Respir J, 2004; 11(Suppl B): 7B-59B

  15. Pulmonary Rehabilitation in COPD Patient-Centered Benefits Pulmonary Rehabilitation: • reduces shortness of breath • benefits exceed minimally clinically important difference (MCID) ie. 0.9 CRQ • improves exercise capacity • ~15-20% increase in maximal workload, and ~10% increase in peak VO2 • ~80% increase in endurance exercise time and ~50m increase in 6MWD Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2010; Ries AL, et al. Chest 2007; 131:4-42; O’Donnell DE, et al. Can Resp J 2007, 14:5B-32B; Marciniuk DD, et al. Can Resp J 2010; 17:159-168; Hailey D, et al. CADTH 2010; 126:1-155.

  16. Pulmonary Rehabilitation in COPD Patient-Centered Benefits Pulmonary Rehabilitation: • improves health related quality of life • fall in SGRQ of ~7-8 units • reduces fatigue • reduces anxiety and depression, and other documented psychosocial benefits • decreases hospitalizations, hospital days, and healthcare utilization Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2010; Ries AL, et al. Chest 2007; 131:4-42; O’Donnell DE, et al. Can Resp J 2007, 14:5B-32B; Marciniuk DD, et al. Can Resp J 2010; 17:159-168; Hailey D, et al. CADTH 2010; 126:1-155.

  17. Pulmonary Rehabilitation in COPD More Benefits From PR … Pulmonary Rehabilitation: • is cost-effective • incremental cost-effectiveness ratio compared with usual care is $27,924 per additional quality-adjusted life-year (QALY) gained (moderate/severe/very severe) • improves survival …(?) • 29% reduction – recent Cochrane review [Puhan 2009] of PR after hospital admission Puhan M, et al. Cochrane Database Syst Rev 2009; Ries AL, et al. Chest 2007; 131:4-42; Marciniuk DD, et al. Can Resp J 2010; 17:159-168; Hailey D, et al. CADTH 2010; 126:1-155.

  18. Tiotropium Placebo Pulmonary Rehabilitation in COPD Effective “Combination” Therapy Study Drug * * Rehabilitation 32% 42% Endurance Time (mins) 16% * p<0.05 Weeks on Treatment Casaburi R, et al. Chest 2005; 127:809-817

  19. Pulmonary Rehabilitation in COPD Ensuring Patient Benefits Program design, delivery and duration • CTS has recommended longer duration PR programs, beyond 6 – 8 weeks duration, be provided for COPD patients • ‘Kindergarten’ vs ‘Graduation’ philosophies • lower limb aerobic exercise must always be the foundation of the program • no differences in major outcomes between community/home sites vs hospital sites • coordinated and supervised Maltais F, et al. Ann Intern Med 2008; 149:869-878; Ries AL, et al. Chest 2007; 131:4-42; Marciniuk DD, et al. Can Resp J 2010; 17:159-168.

  20. Pulmonary Rehabilitation in COPD Maximizing Patient Benefits • explore methods to further optimize training • can we accelerate training to potentially shorten the duration of initiation phase? • can patients achieve greater physiologic gains? • start earlier in the course of the disease? • do we place a greater emphasis on promoting health rather than solely on regaining function? • how to best optimize patient outcomes with limited resources and access ie. priority setting • should coordinated group pulmonary/cardiac/ diabetes/etc rehabilitation become more common? • ”trying to do too much = achieving very little” Marciniuk DD, et al. Can Resp J 2010; 17:159-168.

  21. Barriers to Implementation of PR access and adherence highlighted as the most significant challenges “immediate urgency for these obstacles to be address and to be removed. It is not acceptable for health care providers, patients and health care systems to accept the current status quo – the benefits cannot be ignored” PR must be accepted as an integral component of COPD management “barriers to participation in PR and burdens of therapy must be acknowledged and minimized.” Marciniuk DD, et al. Can Resp J 2010; 17:159-168

  22. May C, et al. BMJ 2009; 339:485-487

  23. Pulmonary Rehabilitation in COPD Summary • Pulmonary Rehabilitation plays a sentinel role in the comprehensive management of COPD • it must become ‘routine’ • there are significant and meaningful patient-centered clinical benefits of effective Pulmonary Rehabilitation in COPD • we must recognize, acknowledge and eliminate barriers to patients participating and fully realizing the clinical benefits of PR in COPD

  24. Marciniuk DD, et al. Can Resp J 2010; 17:159-168

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