Pulmonary Rehabilitation

1. Pulmonary Rehabilitation Presented by Wyatt E. Rousseau, MD May 14, 2009

2. Background COPD is 4th leading cause of death 13% of total hospitalizations Second to CAD for payment of Social Security disability benefits Exercise intolerance – dyspnea/fatigue

3. Pathophysiology Severity of lung disease Extrapulmonary manifestations thought to be due to deconditioning* Skeletal muscle dysfunction: decreased aerobic enzyme activity, low fraction of aerobic fibers, decreased capillarity, inflammatory cells, and increased apoptosis. All lead to early onset of lactic acidosis, decreasing aerobic activity. *Wagner, PD. Skeletal muscles in chronic obstructive pulmonary disease: deconditioning or myopathy? Respirology 2006; 11:681-686.

4. Pulmonary Rehabilitation Evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily activities. It is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs by stabilizing or reversing systemic manifestations of the disease. Nici, L et.al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390.

5. Pulmonary Rehabilitation Candidates Any patient with impairment because of lung disease and who is motivated should be a candidate for pulmonary rehabilitation.

6. Pulmonary RehabilitationCommon Indications for Referral to Pulmonary Rehabilitation Anxiety engaging in activities Breathlessness with activities Limitations – Social, Leisure, Chores, ADL’s Loss of Independence Especially those whose dyspnea is out of proportion to lung function or those with primarily leg fatigue limiting exercise

7. Pulmonary Rehabilitation Common conditions leading to referral to pulmonary rehabilitation COPD Bronchiectasis Chronic Asthma Post surgery ILD Neuromuscular Disease Cystic Fibrosis Exacerbations

8. Pulmonary Rehabilitation Contraindications PSYCHIATRIC Dementia Organic Brain Syndrome MEDICAL Unstable cardiac Substance abuse Cancer (relative) Liver Failure Neurologic or Orthopedic condition preventing ambulation

9. Pulmonary RehabilitationEffect on Exercise Capacityfrom Lacasse,Y et.al. Lancet 1996; 348:1115

10. Pulmonary Rehabilitation • Education • Exercise

11. Pulmonary RehabilitationEducation Diagnosis Smoking Cessation Pharmacology Respiratory Therapy Physical Therapy Occupational Therapy Therapeutic Recreation Nutrition Psychosocial

12. Pulmonary RehabilitationExercise Physical Therapy Occupational Therapy Respiratory Therapy

13. Pulmonary Rehabilitation-EducationDiagnosis • Physician • Pulmonary Function Tests • Spirometry • ABG’s • Diffusing Capacity • Inhalation Challenge • Exercise Testing • Cardiac Tests

14. Pulmonary Rehabilitation-EducationSmoking Cessation Counseling (Ask, Advise, Assess, Assist, Arrange F/U) Nicotine Replacement Anxiolytic/Antidepressant Varenicline Support (Quit date, past quit experience, challenges, other smokers)

15. Pulmonary Rehabilitation-EducationPharmacology OXYGEN BRONCHODILATORS Beta-agonists, LA and SA Anticholinergics, LA and SA Theophylline, other PDEI’s ANTI-INFLAMMATORY Corticosteroids Leukotriene Antagonists

16. Pulmonary Rehabilitation-Education & ExerciseRespiratory Therapy Breathing Techniques Pursed lip Diaphragmatic Medication Delivery Systems Peak Flow Measurement Self Management

17. Pulmonary Rehabilitation-Education & ExercisePhysical Therapy MAXIMIZE FUNCTIONALINDEPENDENCE Exercise Energy conservation Oxygen Adaptive devices

18. Exercise - Heliox Eves ND, Sandmeyer LC, Wong EY, et. Al. Helium-Hyperoxia: A Novel Intervention to Improve the Benefits of Pulmonary Rehabilitation for Patients with COPD. Chest. 2009:135:609-618. Breathing helium-hyperoxia (60% He-40% O2) during pulmonary rehabilitation increases the intensity and duration of exercise training that can be performed and results in greater constant-load exercise time for patients with COPD.

19. Exercise - Heliox Chiappa GR, Queriroga F, Meda, E. Heliox Improves Oxygen Delivery and Utilization During Dynamic Exercise in Patients with COPD. Am J Respir Crit Care Med 2009; Heliox (79% He-21%O2) increases lower limb O2 delivery and utilization during dynamic exercise in patients with moderate-to-severe COPD. These effects contribute to enhance exercise tolerance in this patient population.

20. Pulmonary Rehabilitation-Education & Exercise Occupational Therapy MAXIMIZE FUNCTIONAL INDEPENCENCE Exercise Energy conservation Self care Adaptive devices

21. Pulmonary Rehabilitation-EducationNutrition WEIGHT MANAGEMENT DIETS Supplements Restrictions VITAMINS/ADDITIVES

22. Pulmonary Rehabilitation-EducationPsychosocial Issues INSURANCE/REIMBURSEMENT QUALITY OF LIFE CONCERNS SOCIAL SITUATION CHAPLAIN CONSULTATION ETHICS ISSUES

23. Pulmonary RehabilitationINPATIENT ADVANTAGES 24 hour nursing care Sicker patients No transportation problems Family participation Best for ventilator, tracheostomy patients DISADVANTAGES Cost and insurance difficulties Not suitable for less severe patients Family transportation problems

24. Pulmonary RehabilitationOUTPATIENT ADVANTAGES Widely available Less costly Least intrusive to family Efficient use of staff DISADVANTAGES Potential transportation problems Cannot observe home activities

25. Pulmonary RehabilitationHOME - BASED ADVANTAGES Convenience to patient Transportation no issue Exercise in familiar environment may lead to better adherence long term DISADVANTAGES Cost/insurance issues Lack of group support Lack of full spectrum of multidisciplinary personnel

26. Pulmonary RehabilitationAdverse Effects Musculoskeletal injury Exercise-induced bronchospasm Cardiovascular event (increased risk among COPD patients)

27. Pulmonary RehabilitationExercise EffectData from Am J Respir Crit Care Med 1999; 159;321

28. Effect of Therapy- Does Not improve lung mechanics or gas exchange, but optimizes other body systems* Muscle biochemistry-higher work rates with less lactic acidosis leading to decreased carotid-body stimulation Reduced dynamic hyperinflation through reduced ventilatory demand Desensitization to dyspnea: antidepressant effect, social interaction, self management, and adaptive behaviors *Casaburi, R and ZuWallack. Pulmonary Rehabilitation for Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2009; 360:1329-1335.

29. Pulmonary RehabilitationBenefits in COPD Improves exercise capacity - Evidence A Improves perceived breathlessness - Evidence A Improves quality of life – Evidence A Reduces hospitalizations and LOS – Evidence A Reduces anxiety and depression – Evidence A UBE improves arm function – Evidence B Benefits extend beyond training period – Evidence B Improves survival – Evidence B