Management of stable COPD: Pulmonary Rehabilitation

1. Management of stable COPD: Pulmonary Rehabilitation Kira Neal Respiratory Specialist Physiotherapist Action East Cardio-respiratory Rehabilitation Team

2. 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 individualised treatment of the patient pulmonary rehabilitation is designed to reduce symptoms, optimise functional status, increase participation, and reduce health care costs through stabilising or reversing systemic manifestations of the disease’ ATS/ERS statement on pulmonary rehabilitation (2006) American journal of respiratory and critical care medicine, 173:1390-1413

3. WHAT IS PR? • A Multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise physical and social performance and autonomy. • BTS statement 2001

4. NICE GUIDELINES 2010 • Should be offered to all appropriate patients with COPD including those who have had a recent admission for an acute exacerbation. • Should be offered to all patients considering themselves functionally disabled by COPD • Should be available within a reasonable time of referral, held at times that suit patients in buildings that are easy for patients to get to and have good access for people with respiratory disability.

5. Why Pulmonary Rehabilitation Muscle weakness Fatigue, anxiety, isolation

6. Evidence for PR Evidence (level la) • · Improvements in exercise tolerance • · Reduction in the sensation of dyspnoea • · Improvement in health related quality of life (HRQoL). Evidence (level lb) • · Improvement in peripheral muscle strength and mass • · Reductions in number of days spent in hospital Evidence (level lla) or (level llb) • · Improvement in the ability to perform routine activities of daily living • · Reductions in exacerbations • · Reduction in anxiety and depression • · Improvements in exercise tolerance maintained between 6 – 12 months

7. AIMS • Improve independence in daily functioning • Improve knowledge of lung condition and promote self-management • Increase muscle strength and endurance (peripheral and respiratory) • Increase exercise tolerance and reduce dyspnoea • Reduce length of hospital stay • Improve health related quality of life • Promote long term commitment to exercise. Garrod 2003 (Chartered society of Physiotherapy briefing)

8. BENEFITS • Reduction in number of days spent in hospital one year following pulmonary rehabilitation (Griffiths 2001) • Reduction in the number of exacerbations in patients who performed daily exercise when compared to those who did not exercise (Guell 2000) • Reduced exacerbations post pulmonary rehabilitation (Foglio 1999) • These studies all demonstrate a decrease in length of stay in hospital for admissions post pulmonary rehabilitation programmes

9. Changes to body in COPD • Ventilatory limitation • Gas exchange limitation • Cardiac dysfunction • Skeletal muscle dysfunction • Respiratory muscle dysfunction

10. Ventilatory limitation • Increased dead space ventilation • Impaired gas exchange • Increased ventilatory demands due to peripheral muscle dysfunction • Pathophysiology e.g. emphysema Delayed emptying dynamic hyperinflation increased WOB increased respiratory muscle load increased perception of respiratory discomfort

11. Gas exchange limitation • Hypoxia • Increases pulmonary ventilation

12. Cardiac dysfunction • Increase in RV afterload due to increased PVR • Hypoxic vasoconstriction • Erythrocytosis

13. Skeletal muscle dysfunction • Change in muscle fibre type • Reduced capacity of oxidative enzymes • Reduced number of capillaries • Inflammatory state • Nutrition/ body mass

14. Skeletal muscle changes • Average reduction in quadriceps strength is decreased by 20-30% in moderate to severe COPD • Reduction in the proportion of type I muscle fibres and an increase in the proportion of type II fibres compared to age matched normal subjects • Reduction in capillary to fibre ratio and peak oxygen consumption.

15. Skeletal muscle cont… • Reduction in oxidative enzyme capacity and increased blood lactate levels at lower work rates compared to normal subjects • Due to intrinsic factors which result in early activation of anaerobic glycolysis • Prolonged periods of under nutrition which results in a reduction in strength and endurance

16. In conclusion • Musculoskeletal changes suggest that patients with COPD present with muscle weakness, and fatigue (with exercise) more quickly than their normal counterparts.

17. Skeletal Muscle in COPD Type II 57% Jobin J, et al. J Cardiopulmonary Rehab 1998. Bernard et al. AJRCCM 1998.

18. Dyspnoea and leg fatigue 31% Leg fatigue 43% Dyspnoea 26% Limiting symptoms in COPD patients at peak exercise Killian KJ, et al. 1992.

19. Respiratory muscle dysfunction • Compromised functional inspiratory muscle strength • Compromised inspiratory muscle endurance

20. What should PR include? • Strength training • Endurance training • Education • Social and psychosocial factors

21. Exercise • The BTS statement on pulmonary rehabilitation (BTS, 2001) recommends that pulmonary rehabilitation must contain aerobic exercise, and may contain upper and lower limb strength exercises. The BTS also recommend that exercise frequency should be three times a week for 30 minutes. Intensity should be set at least 60% of maximum oxygen uptake, this can be derived from an exercise capacity test.

22. Endurance Training • COPD patients participating in endurance training had lower peak work rates and oxygen uptake than normal subjects; however these variables improved with training. • Subjects with COPD showed different physiological adaptations to endurance training than the normal subjects • COPD subjects showed an increase in peak oxygen extraction but no significant change in heart rate, ventilation or oxygen delivery. • This suggests changes from training take place at a skeletal muscle level rather than a change in ventilatory response to exercise. Sala et al., 1999

23. ATS/ERS Statement on PR 2006

24. ATS/ERS Statement on PR 2006

25. PR Education

26. So… What can exercise do? May improve Exercise tolerance Exertional dyspnoea Cardiovascular function Fatigue Ability to carry out ADL’s Mood Strength

27. What do we do in Tower Hamlets? • 8 week rolling programme • 2 hours • Twice a week • Followed by 8 week programme of maintenance • Once a week • Exercise- individual programme aimed at meeting clients personal goal • Strength • Endurance • Education • Multi professional • Coping strategies • Improve knowledge of how lung disease affects you • Cup of tea!

28. What do we do in Tower Hamlets? Pulmonary rehabilitation in 8 locations across the borough Classes in leisure centres, hospitals, GP practices, social clubs, community centres Bengali speaking rehab support workers Tai chi class Multi-disciplinary team Home programme for patients unable to attend local sites

29. PR classes Strength exercises Endurance exercises Dealing with an exacerbation Relaxation and stress management Medications and how they work Smoking cessation

30. So what do we actually do? • Patients referred by GP’s, consultants/ hospital Dr’s, practice nurses, respiratory nurse specialists, physios. • Initial assessment • Suitable for PR • medical history • cardiovascular stability • medical management optimised • exercise capacity • anxiety and depression • quality of life • Other questionnaires

31. Then… • Patient and physiotherapist discuss goals • Exercises tailored to patient to help meet goal • Exercise twice a week at PR • Exercise at least three times/ week • Home exercise booklet and diary • Reassessed at eight weeks

32. What the clients say about PR • I’m able to walk for 300-400 yards without stopping. I’ve been able to go back to my hobby of song writing as I can sing again which I hadn’t been able to do for several years. Male age 74 • Before I didn’t do anything I just sat down, now I feel I really want to do the exercises. It has given me a new lease of life. Now I have more confidence going out, I go out more often to the market and shops. Female age 70

33. The future for PR in Tower Hamlets • Changes to referral process through “prescription pads” in GP surgeries • Looking at improving compliance & uptake of PR • Re-wording of letters we use • How and where we do our initial assessments

34. Thank you! Any Questions?

35. References • ATS/ERS statement on pulmonary rehabilitation (2006). American Journal of Respiratory and Critical Care Medicine, 173,1390-1413. • Bernard et al. (1998). Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 158(2), 629-634. • BTS statement (2001). British Thoracic Society standards of care subcommittee on pulmonary rehabilitation. Thorax, 56, 827-834. • Foglio et al. (1999). Long term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction. European Respiratory Journal, 13(1), 125-32. • Griffiths et al. (2001). Cost-effectiveness of an outpatient mulit-disciplinary pulmonary rehabilitation programme. Thorax, 56(10), 779-784. • Guell et al. (2000). Long term effects of outpatient rehabilitation of COPD: A randomised trial. Chest, 117(4), 976-983.

36. References Killian, KJ et al. (1992). Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation. The American Review of Respiratory Disease, 146(4), 935-940. Jobin et al. (1998). COPD: cappilarity and fiber-type characteristics of skeletal muscle. Journal of Cardiopulmonary Rehabilitation, 18(6), 432-427. NICE CG101 Chronic obstructive pulmonary disease (update) 2010. Sala (1999). Effects of endurance training on skeletal muscle bioenergetics in COPD. American Journal of Respiratory and Critical Care Medicine, 159(6), 1726-34.