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Pulmonary Rehabilitation

Pulmonary Rehabilitation. Professor Paul W. Jones. Meta-analysis of improvement in 6-minute walk following rehabilitation. 6-Minute Walk (m). Rehabilitation. Usual Care. Meta-analysis of improvement in 6-minute walk following rehabilitation. Minimum Clinically Detectable Difference.

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Pulmonary Rehabilitation

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  1. Pulmonary Rehabilitation Professor Paul W. Jones

  2. Meta-analysis of improvement in 6-minute walk following rehabilitation 6-Minute Walk (m) Rehabilitation Usual Care

  3. Meta-analysis of improvement in 6-minute walk following rehabilitation Minimum Clinically Detectable Difference 6-Minute Walk (m) Rehabilitation Usual Care

  4. Meta-Analysis of Health Status Changes Following Pulmonary Rehabilitation Minimum Clinically Important Difference Mean 95% CI Mastery Emotional Function Fatigue Dyspnea 0 0.5 1.0 1.5 CRQ units (Treatment-Control) Lacasse et al. Lancet. 1996; 348: 1115-9

  5. Reasons for stopping exercise (COPD patients) Dyspnea 26% Leg fatigue 43% Both 31% Killian et al Am Rev Respir Dis 1992; 146: 935-940

  6. More Post rehab More fatigable Pre rehab Rehabilitation reduces fatigability of muscles Mador et al Am J Respir Crit Care Med 2001; 163: 930

  7. Who should have pulmonary rehabilitation ?

  8. Health status and FEV1 r = - 0.23 Poor Health 100 p < 0.0001 80 60 SGRQ score 40 20 Upper limit of normal Good Health 0 10 20 30 40 50 60 70 80 90 FEV1 (% predicted) Jones. Thorax 2001; 56: 880

  9. Health status and FEV1 Poor Health 100 80 60 SGRQ score 40 20 Good Health 0 10 20 30 40 50 60 70 80 90 FEV1 (% predicted)

  10. % of patients Breathless on stairs 86 % Breathless on hills 89 % Slow down if walk fast 95 % Patients with FEV1 > 50% but moderate-severe health impairment (SGRQ > 30%)

  11. Basic components of pulmonary rehabilitation • 30 min aerobic exercise • Three times a week • 6-8 weeks duration Cooper. Medicine & Science in Sports and Exercise. 2001: S671

  12. Supervised vs unsupervised rehabilitation • Supervised training • 4 times a week • Treadmill training • Unsupervised training • 3-4 km in 1 hour • 4 times a week • Wore pedometers • Weekly visits Puente-Maetsu et al ERJ. 2000; 15: 517

  13. Supervised vs unsupervised rehabilitation - effect on peak VO2 p<0.05 NS Puente-Maetsu et al ERJ. 2000; 15: 517

  14. Supervised vs unsupervised rehabilitation - effect on quality of life NS NS Puente-Maetsu et al ERJ. 2000; 15: 517

  15. Supervised vs unsupervised rehabilitation - effect on endurance p<0.01 p<0.01 Puente-Maetsu et al ERJ. 2000; 15: 517

  16. Use of supplemental oxygen during rehabilitation in non-hypoxaemic patients Emtner. Am J Respir Crit Care Med. 2003; 168: 1034 • Air training (air from cylinder) • Training using 30% supplemental O2

  17. Effect of supplemental oxygen during rehabilitation on peak work p<0.05 p<0.05 Emtner et al Am J Respir Crit Care Med. 2003; 168: 1034

  18. Effect of supplemental oxygen during rehabilitation on endurance time p<0.05 p<0.05 Emtner et al Am J Respir Crit Care Med. 2003; 168: 1034

  19. Effect of supplemental oxygen during rehabilitation on endurance time p<0.05 Emtner et al Am J Respir Crit Care Med. 2003; 168: 1034

  20. Duration of benefit

  21. Change in health status following pulmonary rehabilitation compared to control Threshold of Clinical Significance 6 weeks 1 year 0 -1 -2 Change in SGRQ score -3 -4 -5 -6 -7 -8 -9 Better Health 95% CI -10 Griffiths et al Lancet 2000; 355: 362-8

  22. Maintenance programme (Ries et al Am J Respir Crit Care Med. 2003: 167: 880–8) • Control • usual care • Maintenance • Weekly telephone • Monthly supervised reinforcement

  23. Maintenance programme in COPD Ries et al Am J Respir Crit Care Med. 2003: 167: 880–8

  24. Exacerbations and rehabilitation

  25. Changes in muscle strength with an acute exacerbation Spruit et al Thorax 2003;58:752

  26. Early post-discharge rehabilitation Man et al BMJ. 2004;329:1209 • Control - usual care • Rehabilitation • Outpatient • Supervised • Started with 10 days of discharge

  27. Early rehabilitation following hospital admission for acute exacerbation of COPD p<0.0002 Man et al BMJ. 2004;329:1209

  28. Early rehabilitation following hospital admission for acute exacerbation of COPD p<0.002 Clinically significant change Man et al BMJ. 2004;329:1209

  29. Pulmonary rehabilitation in COPD • Regular (3 times per week) for 6 weeks • Supervised better then unsupervised • Better physical improvement if trained breathing 30% oxygen • Effect wears off despite maintenance programme • Exacerbations may lead to loss of effect • Can rehabilitate soon after and exacerbation

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