The Effects of Pulmonary Rehabilitation in the National Emphysema Treatment Trial

1. The Effects of Pulmonary Rehabilitation in the National Emphysema Treatment Trial ARTICLE 1 Study Objectives: Pulmonary rehabilitation (PR) is an established treatment in patients with chronic lung disease but is not widely utilized. Most trials have been conducted in single centers. The National Emphysema Treatment Trial (NETT) provided an opportunity to evaluate pulmonary rehabilitation is a large cohort of patients who were treated in centers through the United States. Design: Prospective observational study prior to randomization in a multicenter clinical trial. Setting: University based clinical centers and community-based satellite pulmonary rehabilitation programs. Patients and Interventions: Total of 1,218 patients with severe emphysema underwent pulmonary rehabilitation before and after randomization to lung volume reduction surgery (LVRS) or continued medical management. Rehabilitation was conducted at 17 NETT centers supplemented by 539 satellite centers. Measurements and Results: Lung function, exercise tolerance, dyspnea, and quality of life were evaluated at regular intervals. Significant improvements (p<0.001) were observed in exercise (cycle ergometry; 6- min walk distance), dyspnea (UCSD Shortness of Breath Questionnaire; Borg Breathlessness Score; 6-min walk) and quality of life (St. George Respiratory Questionnarie Score, Quality of Well Being Scale, Medical Outcomes Study 36- item short form score). Patients who had not undergone prior rehab improved more than those who had. In multivariate models, only prior rehab status predicted changes after rehab to alter the NETT subgroup predictive of outcome. Overall changes after rehab did not predict differential mortality or improvement in exercise by treatment group. Conclusion: NETT experience demonstrates the effectiveness of pulmonary rehab in patients with severe emphysema who were treated in a national cross section of programs. Pulmonary rehab plays an important role in preparing and selecting patients for surgical interventions such as LVRS. ABSTRACT Andrew L. Ries, MD, MPH; Barry J. Make, MD; Shing M. Lee, ScM; Mark J. Krasna, MD; Matthew Bartels, MD; Rebecca Crouch, PT; and Alfred Fishman, MD; for the National Emphysema Treatment Trial Research Group. Chest; Dec 2005; 128: 3788-3809. . BACKGROUND The NETT was divided into 3 phases: Prerandomization Phase: 16-20 supervised sessions of PR in 6-10 weeks. Sessions included: • Exercise Training: walking or bicycling (5x/wk), supported or unsupported upper extremity exercise (3x/wk), flexibility (5x/wk), and strength training with latex resistance bands and tubing, free weights, or circuit training (3x/wk) • Psychosocial Assessment: Evaluation completed by a mental health professional Beck Depression Inventory, Self-Examination Questionnaire of state and trait anxiety, and Trail Making Test to assess divided attention and psychomotor functioning. Postrandomization Phase: 8-9 weeks of supervised rehabilitation at either a NETT center or satellite center. LVRS patients began pulmonary rehabilitation when cleared by MD. Non-LVRS patients started PR immediately. Long-term Maintenance Phase: NETT centers continued contact with patients through individual appointments with regular telephone calls to assess compliance to the rehabilitation program. MATERIALS AND METHODS RESULTS Wehrmeister, Fernando C.; Knorst, Marli; Jardim, Jose R; et al. Pulmonary Rehabilitation for patients with COPD. J Bras Pneumol. 2011; 37: 544-555. http://www.ncbi.nlm.nih.gov/pubmed/21881745. October 13, 2011 Purpose: To review literature regarding pulmonary rehabilitation in COPD patients. The outcome measures analyzed were exercise, quality of life, symptoms, exacerbations, mortality, and pulmonary function. Methods: 5 databases were used to generate articles for this study. The Global Initiative for Chronic Obstructive Lung Disease was utilized classify articles based on their quality of evidence. Results: Exercise capacity improved in all patients who underwent underwent a PR program compared to those who only used pharmacological treatments. The 6 min walk test was used to measure the outcome of exercise tolerance. Quality of life was also shown to improve in those receiving treatment. St. George’s Respiratory Scale and SF-36 were used to measure this outcome. Symptoms in COPD patients were reduced after pulmonary rehabilitation, including dyspnea. Conclusion: The review presents important results regarding the effectiveness of pulmonary rehabilitation programs in patients with COPD. It was found that pulmonary rehabilitation programs can be more beneficial for exercise tolerance, quality of life, and decreasing dyspnea. Effects on pulmonary function, exacerbations, and mortality were assessed but further research needs to be done to make any conclusions. Significant improvements: Exercise Capacity: Cycle Ergometry, 3.1 W; 6-min walk test distance, 76 feet Dyspnea: UCSD Shortness of Breath Questionnaire Scale, -3.2; Borg Breathlessness Score: Breathing cycle, -0.8; 6-min walk test, -0.5 Quality of Life: St. George Respiratory Questionnaire score, -3.5; Quality of Well Being Score, +0.0035; Medical Outcomes Study 36-Item Short Form: physical health summary, +1.3; mental health summary, +2.0. No significant changes found in lung function for any group. Patients with no PR experience had significantly greater results compared to those with prior rehabilitation experience. No clinically significant predictors of differential mortality and change in maximum cycle work were found. ARTICLE 2 SUMMARY Pulmonary rehabilitation can play an important factor in maximizing function and quality of life in patients with COPD. Each of these articles found that PR programs were beneficial showing improvements in exercise capacity, quality of life, and dyspnea. Based on these results, pulmonary rehabilitation should be utilized more often as a treatment method for patients with COPD. PR aims to control and reduce symptoms, increase function capacity and decrease medical expenses to patients with emphysema. The National Emphysema Treatment Trial is designed as a multicenter trial evaluating lung reduction surgery in patients with severe emphysema. This provides an opportunity to examine effectiveness of pulmonary rehabilitation in a variety of centers. PURPOSE CLINICAL SIGNIFICANCE DISCUSSION CONCLUSION Guell, Rosa; Resqueti, Vanesa; Sangenis, Mercedes; Morante, Fatima; Martorell, Bernardi; Casan, Pere; Guyatt, Gordon H. Impact of Pulmonary Rehabilitation on Psychosocial Morbidity in Patients with Severe COPD. Chest. 2006. 129: 899-904. http://chestjournal.chestpubs.org/content/129/4/899.short. October 18, 2011 Purpose: Assess the effect of pulmonary rehabilitation on psychosocial morbidity, functional exercise capacity and health related quality of life in patients with severe COPD. Methods: 40 patients participated in a 16 week pulmonary rehabilitation program. Measurements were taken at baseline and at the end of the program then compared to the control group. Results: Significant differences found between the treatment group and control group in exercise capacity and dyspnea. The 6-min walk test assessed exercise capacity and the Chronic Respiratory Questionnaire assessed dyspnea. Conclusion: Pulmonary rehabilitation programs are beneficial in patients with COPD to improve exercise tolerance as well as feelings of dyspnea. • Clinically significant improvements found in exercise capacity, dyspnea, and quality of life. • Results may be skewed due to some patients having participated in pulmonary rehab prior to study. • Patients had severe obstructive disease, usually don’t participate in pulmonary rehab. • The outcome measures did not prove to be significant indicators of mortality and maximal exercise. • Pulmonary Rehabilitation could be beneficial for patients with COPD when paired with other treatment methods, whether pharmacological or surgical. • Pulmonary rehabilitation is a vital component to increasing physical and mental components in patients with chronic lung disease. • Physical therapists (PT’s) are equipped to design and implement exercise programs that would facilitate improving fitness levels of patients with COPD. • Pulmonary rehabilitation should be considered a valid method of treatment to improving cardiovascular fitness as well as reducing levels of dyspnea and increasing patient’s quality of life. • PT’s can educate patients on their disease and how it affects their body and function. • PT’s provide insight and guide patient towards making healthy lifestyle choices in effort to minimize the effects of COPD. • PR programs are an effective way to improve exercise capacity and quality of life. • PR does not improve lung capacity (FEV1/FVC) • Despite the fact that COPD is a progressive disease that cannot be reversed, patients should have access to different treatment methods that work to maximize their ability to improve function. • This treatment trial was not designed to evaluate pulmonary rehabilitation, but allows for a descriptive analysis of changes in health outcomes after pulmonary rehabilitation in a large cohort of patients. Ally O’Bryan, DPT Student