Pulmonary Rehabilitation in Chronic Lung Disease; Components and Organization

1. Pulmonary Rehabilitation in Chronic Lung Disease; Components and Organization Prof. Dr. Müzeyyen Erk Cerrahpaşa Medical Faculty Chest Disease Dept.

2. Plan • Chronic Respiratory Disease • Definition • Factors Contributing to Exercise Intolerance in CRD • Pulmonary Rehabilitation • Definition • Patient Assessment and Selection • Program Setting

3. Plan • Chronic Respiratory Disease • Definition • Factors Contributing to Exercise Intolerance in CRD • Pulmonary Rehabilitation • Definition • Patient Assessment and Selection • Program Setting

4. Chronic diseases • Definition“All impairments or deviations from normal which have one of more of the following characteristics: • they are permanent • they leave residual disability • they are caused by non-reversible pathological alterations • they require special training of the patient for rehabilitation • they may be expected to require a long period of supervision, observation or care

6. Factors limiting exercise CENTRAL PERIPHERAL • LUNG DYNAMIC HYPERINFLATION • REDUCED VENTILATORY RESERVE •  COST OF BREATHING • • MUSCLE ATROPHY, •  CAPILLAR DENSITY • • POOR NUTRITIONAL STATE • POOR BIOENERGETICS • • METABOLIC ACIDOSIS

7. 4 11 41 42 Healthyelderly(n=25) 6 27 52 12 COPDpatients(n=50) Walking Standing Sitting Lying Others 40% 0% 20% 60% 80% 100% Daily physical activity pattern in COPD Pitta et al. Am J Respir Crit Care Med. 2005;171:972-977

8. COPD Hypoxemia Airflow obstruction Exacerbations  Ventilatory requirement Tachypnea Air trapping Anxiety Deconditioning Hyperinflation Cooper CB. Am J Med 2006; 119(10A): S21-S31. Dyspnea Activity limitation Patient Centered Outcomes Poor health-related quality of life Chronic respiratory disease Pulmonary phsiological abnormality

9. InspiratoryCapacity r=0.52P<0.001 r=-0.50P<0.001 Exercise Endurance ExertionalDyspnea r=-0.61P<0.001 O’Donnell et al. Eur Respir J. 2004;23:832–840 IC, exercise endurance and dyspnea

10. Dynamic hyperinflation during exercise in COPD O’Donnell D, Chest 2000

11. Body composition Schols et al. ARRD 1993; 147: 1151-6

12. Peripheral muscle weakness in COPD Bernard S et al. AJRCCM 1998; 158: 629-34

13. Structural changes in skeletal muscle in COPD FEV1 %32 PaO2 87 (Vastus Lateralis) • Fiber type changes • Atrophy • Apoptosis Richardson RS et al. AJRCCM 2004; 169: 89-96

14. I 1.0 II 0.9 III 0.8 Proportion surviving 0.7 0.6 I: Peak VO2: >995 mL/min (n=37) II: Peak VO2: 793 -995 mL/min (n=38) III: Peak VO2: 654 - 792 mL/min (n=38) IV: Peak VO2: <654 mL/min (n=37) 0.5 IV 0.4 0.3 0 12 24 36 48 60 Months of follow-up Exercise capacity as a predictor of mortality Oga T, et al. Am J Respir Crit Care Med 2003;167:544-549

15. Interventions aimed at improving exercise capacity (i.e. quality of life) • Oxygen • Heliox • Rehabilitation • Bronchodilators • LVRS

16. Plan • Chronic Respiratory Disease • Definition • Factors Contributing to Exercise Intolerance in CRD • Pulmonary Rehabilitation • History • Definition • Patient Assessment and Selection • Program Setting

17. Pulmonary rehabilitation • 1970s:The first controlled trials on PR • 1980s: Initial skepticism • Ideal candidates:Despite optimal medical treatment,significant abnormalities in their function and their participationin everyday life, leading to impaired HRQoL • GOLD:PR should be considered inpatients with an FEV1 below 80% • Most national and international guidelines consider PR an important treatment option • NETT:Strong encouragement for the implementation of PR programs for patients with COPD.

18. Definition • Pulmonary rehabilitation is an evidence-based,multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. • Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to: • reduce symptoms • optimize functional status • increase participation • reduce health care costs through stabilizing or reversingsystemic manifestations of the disease. ERS-ATS statement 2006

19. Pulmonary rehabilitation • Integrated into the lifelong management of patientswith chronic respiratory disease • Involves a dynamic,active collaboration among the patient, family, and health careproviders ERS-ATS statement 2006

20. Chronic respiratory conditions that benefit from PR program • COPD • Asthma • Chest wall disease • Cystic fibrosis • Interstitial lung disease; post-ARDS pulmonary fibrosis • Lung cancer • Neuromuscular diseases such as post–polio syndrome • Exercise program may not be appropriate for advanced disease • Flexibility training • Optimization of ventilator assistance re: • Perioperative states (e.g., thoracic, abominal surgery) • Pre- and post–lung transplantation, LVRS • Pulmonary vascular disease

21. Symptomatic impairment attributable to pulmonary disability Failure of standard medical regimen to achieve adequate symptomatic relief Motivated, adherent patient Indications to pulmonary rehabilitations Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006

22. Contrindications to pulmonary rehabilitation • Lack of motivation • Nonadherence • Inadequate financial resources • Severe cognitive dysfunction or psychiatric illness • Unstable comorbidity (unstable angina, uncompensated congestive heart failure) • Severe exercise-induced hypoxemia, not correctable with O2 supplementation • Inability to exercise due to severe lung or other disease (arthritis, stroke) • Cigarette smoking* Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006

23. Setting for pulmpnary rehabilitation Pulmonary rehabilitation is administered: • inpatient • outpatient • home settings • combination of these inpatient rehabilitation: In the United States: • To be disabled to travel to and from an outpatient program • Focus of these programs is more often on optimizing medical or ventilator regimens than on the exercise components In Europe: • Ambulatory patients may be admitted to an inpatient program to undergo intensive therapy • To avoid the inconvenience of daily travel

24. Physicians Pulmonologist Physiatrist Therapists Physical Occupational Respiratory Nurse or exercise physiologist Nutritionist Social worker Psychologist MULTIDISCIPLINARY TEAM PARTICIPATING ON A PULMONARY REHABILITATION TEAM TEAM Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006

25. Keys for successful pulmonary rehabilitation ? • Patient selection • Program components

26. PATIENTSELECTION • ANY STABLE PATIENT WITH DISABLING SYMPTOMS (ACCP/AACVPR) ? • PULMONARY FUNCTION ? • AGE ? • CO-MORBIDITY ? • SMOKING ? • PSYCHOSOCIAL CONDITIONS ? • MUSCLE WEAKNESS ? MODIFICATION

27. Components of a rehabilitation programme • Patient education • Psychosocial support • Chest physiotherapy • Exercise training • Muscle training • Nutritional support Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006

28. Main components of PR programmes Donner CF, Decramer M. Pulmonary Rehabilitation ERJ Monograph, 2000: 13:132-142 (+): No evidence, (++): Few evidences, (+++): Good evidence, (*): Before transplantation

29. Topics often covered during group education sessions • What’s wrong in common lung diseases • Breathing medications • Oxygen therapy • Energy conservation techniques • Relaxation techniques • Breathing techniques • Pursed lip breathing • Diaphragmatic breathing • Nutrition • What to do in emergencies • Traveling with lung disease • End-of-life issues Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006

30. Significant benefits of pulmonary rehabilitation • Established by multiple randomized controlled trials (Level A evidence) 1. Improved functional capacity (6-min walk or Shuttle Walk Test) 2. Reduced dyspnea* 3. Improved health-specific quality of life* • Observed in some randomized controlled trials (Level B evidence) • Reduced need for hospitalization* * Only in patients with COPD with severe airway obstr. Hill N.Proc Am Thorac Soc Vol 3. pp 66–74, 2006

31. Benefits of Pulmonary Rehabilitation in COPD GOLD Exc. Summ. 2008

32. The vicious circle Chronic Pulmonary Disease Increased VE Requirements Decreased VE Requirements Physical Deconditioning Physical Reconditioning Immobility Pulmonary Rehabilitation Decreased Exercise Capacity Increased Exercise Capacity Increased Breathlessness Decreased Breathlessness Cooper. Med Sci Sports Exerc. 2001;33(7 suppl):S643-S646.