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Lifestyle Management for Patients with IPF

Educational activity providing practitioners with tools to improve functional status through exercise and pulmonary rehabilitation. Includes benefits, survival insights, ARF ventilation recommendations, and emotional well-being strategies.

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Lifestyle Management for Patients with IPF

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  1. Lifestyle Management for Patients with IPF

  2. Educational Activity Learning Objective • Provide practitioners with patient lifestyle management tools which improve functional status

  3. Exercise and Pulmonary Rehabilitation • Formal pulmonary rehabilitation programs are preferred for initiation of exercise • Cardiovascular disease screening should be performed before initiation • Blood pressure and O2 saturation should be monitored; oxygen should be titrated to attenuate desaturation • Reimbursement varies • Benefits • Improved dyspnea • Improved endurance • Social interactions • Adherence reinforced

  4. Patient Tool: Pulmonary Rehabilitation • Decreasing respiratory symptoms and complications • Permitting a return to work or leisure activities • Increasing control over daily functioning • Improving physical conditioning and exercise performance • Improving emotional well-being • Reducing hospitalizations Pulmonary Rehabilitation. Available at: http://www.pilotforipf.org/resources/PtCounseling_07.pdf. Accessed September 2009.

  5. Diet • Goal is proper weight, BMI 18.5–25 • Not too low (danger of malnutrition) • Not too high (danger of metabolic syndrome) • Corticosteroid therapy introduces challenge of weight gain

  6. Survival and BMI • Retrospective study of 197 patients with IPF, 70% men • Survival associated with BMI (HR, 0.93 for each unit increase in BMI, P = 0.002) • Cannot exclude possibility of lead time bias (influence of BMI on diagnosis) • Replicates result of COPD study (Schols 1998) Survival (%) BMI < 25 25–30 30+ Time (Years) Alakhras M, et al. Chest. 2007;131:1448-1453. Schols AM, et al. Am J Respir Crit Care Med. 1998;157(6 Pt 1):1791-1797.

  7. Updated Acute Respiratory Failure in the ICU:Ventilate? • Meta-analysis included 135 ICU patients with IPF • Mechanical ventilation subsequent to Acute Respiratory Failure (ARF) • Mean duration of ventilation: 8.6 days • 3-month mortality rate: 94% • Recommendations • Do not ventilate patient with AE of IPF • Ventilation may be appropriate for other ILD or reversible conditions associated with IPF Mallick S. Respir Med. 2008;102(10):1355-1359.

  8. no no yes yes Updated Managing ARF in the ICU Patient in ICU with ARF Does patient have IPF? • Other condition? • Pneumothorax • Infection • Heart failure • PE • Recent surgery Address other condition; ventilation may be appropriate Address if reversible; ventilation may be appropriate If AE of IPF, ventilation is futile Mallick S. Respir Med. 2008;102(10):1355-1359.

  9. Updated Patient Tool: End-of-Life Issues • Advance directives • Will • Living will • Durable power of attorney Patient Tools can be found at www.PILOTforIPF.org Pulmonary Rehabilitation. http://www.pilotforipf.org/resources/PtCounseling_03.pdf. Accessed December 2009.

  10. Depression and Nonadherence • Depressed patients are 3 times morelikely to be nonadherent with medical treatment • Screen for depression During the past month: • Have you often been bothered by feeling down, depressed, or hopeless? • Have you often been bothered by having little interest or pleasure in doing things? DiMatteo MR, et al. Arch Intern Med. 2000;160:2101-2107. Ebell MH. Am Fam Physician. 2004;69:2421-2422.

  11. Patient Tool:Emotional Well-Being • Challenges of chronic illness • What can be done • Develop a support system • Join a support group • Talk to your doctor • Other resources Emotional Well-Being. Available at: http://www.pilotforipf.org/resources/PtCounseling_01.pdf. Accessed September 2009.

  12. Updated HRQOL Measures for IPF • Do HRQOL measures reflect disease progression? • Retrospective analysis of BUILD-1 data • Baseline and 6 month assessments Swigris JJ, et al. Respir Med. 2009 [Epub ahead of print].

  13. Updated HRQOL Measures for IPF: SF-36 Swigris JJ, et al. Respir Med. 2009 [Epub ahead of print].

  14. Updated HRQOL Measures for IPF: SGRQ DLCO Dyspnea Swigris JJ, et al. Respir Med. 2009 [Epub ahead of print].

  15. Updated HRQOL Measures for IPF:Correlations SF-36 SGRQ Top number in each cell is the Pearson product-moment correlation coefficient and the bottom number is the P value. PF = Physical functioning RP = Role physical BP = Bodily pain GH = General health VT = Vitality SF = Social functioning RE = Role emotional MH = Mental health PCS = Physical component summary MCS = Mental component summary Swigris JJ, et al. Respir Med. 2009 [Epub ahead of print].

  16. Updated HRQOL Measures for IPF: Minimum Important Differences Swigris JJ, et al. Respir Med. 2009 [Epub ahead of print].

  17. Sleep • Caregiver should observe • Oxygen desaturation common with ILD, independent of obstructive sleep apnea (OSA) • Frequent awakenings • Arrhythmia • MI more common during sleep • GERD: don’t eat just before sleep

  18. GERD • Acid GERD prevalent in IPF (87%) • 47% experience classic GERD symptoms • GERD and IPF severities not correlated Raghu G, et al. Eur Respir J. 2006;27:136-142.

  19. Patient Tool: GERD • What is GERD? • Diagnosis • Treatment • Lifestyle changes • Medications • Surgery

  20. Updated Is OSA Common in IPF? • 55 subjects with IPF • Sleep apnea evaluation • Epworth sleepiness scale (ESS) • Sleep apnea scale of sleep disorders (SA-SDQ) • Nocturnal polysomnography (NPSG) • Other measures • Spirometry (FEV1, FVC) • Total lung capacity • DLCO • BMI Lancaster LH, et al. Chest. 2009;136(3):772-778.

  21. Updated OSA Is Common in IPF No OSA AHI  5/h • Did not correlate with OSA • Spirometry • Lung volume • DLCO • ESS • Did correlate with OSA • SA-SDQ: r = 0.45, P = 0.01 • BMI: r = 0.30, P = 0.05 12% 20% 68% Mild AHI 5–15/h Moderate/Severe AHI > 15 events/h Lancaster LH, et al. Chest. 2009;136(3):772-778.

  22. Recreational Activities • Normalcy should be maintained as much as possible • Regular activities give rhythm to life • Low intensity activities enhance pleasure and social contact • Socializing • Cultural activities • Family events • Sexual activity • Exercise

  23. Role of Family/Caregiver • Caregiver is a critical partner • Caregiver needs information • Disease course • Special needs of patient • Ways to access other resources (eg, Web sites, local support groups, etc) • Engagement in disease management • Attend clinic with patient • Encourage exercise • Monitor symptoms and medications • Help organize medical care • Taking care of the caregiver • Emotional stress • Time management • Independent needs

  24. Patient Tool: Air Travel with Oxygen • Security • Oxygen and arrangements • Airline checklist • Oxygen supplier checklist Condensed from TSA website. Available at: http://www.tsa.dhs.gov/travelers/airtravel/specialneeds/editorial_1374.shtm#2 Accessed September 2009.

  25. Smoking • Increased risk of respiratory infection • Increased risk for IPF • IPF is risk factor for lung cancer • First line treatments • Counseling • Nicotine replacement • Gum • Inhaler • Nasal spray • Transdermal patch • Sublingual tablet • Lozenge • Medication GOLD Guidelines 2008. http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2=1&intId=2003. Accessed September 2009.

  26. Updated Emphysema Decreases Survival in IPF Survival Months Significant factors for mortality Mejía M, et al. Chest. 2009;136(1):10-15.

  27. Factors That Enhance Smoking Cessation • Individual and group counseling • Proactive phone calls • Social support • Medication • Nicotine • Bupropion • Varenicline Adapted from Jorenby DE. Circulation. 2001;104;E51-E52.

  28. Updated Patient Tool: Lung Transplantation • Lung Transplantation in IPF • Questions to ask • Are you a candidate? • The procedure • Postsurgical care and rehabilitation • Benefits and risks • Preparation for Transplant • What is a lung transplant? • How does the system work? • What can I expect after my transplant? • How can I prepare for a transplant? • Where do I begin? 2 Patient Tools on lung transplantation can be found at www.PILOTforIPF.org Lung Transplantation. http://www.pilotforipf.org/resources/PtCounseling_04.pdf http://www.pilotforipf.org/resources/PILOTPamphlet3.pdf. Accessed December 2009.

  29. Clinical Trial Participation • Offer high standard of care • Add to patient empowerment • Burdens • May require travel • Frequent visits to research center • Selected open Phase 3 trials • ARTEMIS and ARTEMIS-PH (ambrisentan) • BUILD 3 (bosentan extension) • PANTHER (prednisone, azathioprine, N-acetylcysteine (NAC)) • Chronic cough (thalidomide) • Pulmonary hypertension secondary to IPF (sildenafil) • Pulmonary hypertension secondary to IPF (bosentan, phase 4) Clinical trials.gov. Available at: http://www.clinicaltrials.gov/ct2/results?term=ipf. Accessed September 2009.

  30. Patient Tool:Clinical Trial Participation • What is a clinical trial? • Questions to ask the physician • First steps in participation • Benefits and risks Clinical trials as a treatment option for IPF. Available at: http://www.pilotforipf.org/resources/PILOTPamphlet1.pdf. Accessed September 2009.

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