Pulmonary Rehabilitation

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Pulmonary Rehabilitation

• Deborah Box - CNS Community Respiratory
• South Canterbury DHB
• Jill Young - CNS Cardio/Resp Outreach
• Canterbury DHB

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What is Pulmonary Rehabilitation?

• 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 reversing systemic
  manifestations of the disease.
• American Thoracic Society/ European
  Respiratory Society Statement on Pulmonary
  Rehabilitation 2005 American Journal Critical
  Care Medicine Vol 173, pp 1390 1413. 2006

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Who is Pulmonary Rehabilitation for?

• In general, people who have underlying chronic
  lung disease and are limited by dyspnoea.
• Partners or caregivers should also be
  encouraged to attend.

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• The Primary Aims of Pulmonary Rehabilitation are
• To reduce disability and handicap of people with
  chronic lung diseases.
• To restore people to the highest possible level
  of independent functioning.

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• The Goals of Pulmonary
• Rehabilitation are to
• Increase exercise tolerance in order to reduce
  impairment.
• Improve adherence to recommended treatments.
• Reduce frequency and severity of symptoms.
• Improve mood and motivation.
• Reduce dependency.
• Enhance participation in therapy decisions by
  building self-management capacity.
• Increase participation in everyday activities.
• Improve quality of life.
• Reduce health care burden for patients, families
  and communities.
• Improve survival.

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• A number of Pulmonary Rehabilitation Guidelines
  have been published
• National Institute for Clinical Excellence (NICE)
  2004
• Global Initiative for Chronic Obstructive Lung
  Disease 2005. 
• American Thoracic Society/European Respiratory
  Society Statement on Pulmonary Rehabilitation
  (2005)
• Joint American College of Chest
  Physicians/American Association of Cardiovascular
  and Pulmonary Rehabilitation Evidence-Based
  Clinical Practice guidelines (CHEST 2007)
• BTS Statement on Pulmonary Rehabilitation (THORAX
  2001)
• Pulmonary Rehabilitation toolkit (2006)

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Eligibility Criteria

• Include patients who
• Have stable chronic obstructive pulmonary disease
  or other respiratory conditions without acute
  illness.
• Are willing to participate (even if they are
  current smokers).
• Exclude patients who
• Have severe cognitive impairment.
• Have severe psychotic disturbance.
• Have a relevant infectious disease.
• Exclude patients from the exercise component if
  they have
• Musculoskeletal or neurological disorders that
  prevent gentle exercise.
• Unstable cardiovascular disease (e.g. unstable
  angina, aortic valve disease, unstable pulmonary
  hypertension).
• Known metastatic cancer.

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Assessment Tools

• Six Minute Walk Test (SMWT)
• Shuttle Walk Test (SWT)
• Medical Research Council (MRC) Dyspnoea scale
• 0 breathless only on strenuous activity to
• 4 too breathless to leave the house or breathless
  when dressing
• Hospital Anxiety and Depression Scale (HADS)
• Chronic Respiratory Questionnaire (CRQ)
• St Georges Quality of Life Questionnaire
• BODE
• Predictor of mortality at 5 years in COPD based
  on scores from
• B Body Mass Index
• O Obstruction (FEV1)
• D Dyspnoea (MRC scale)
• E Exercise tolerance (6MWT/SWT)

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Intervention Strategies

• Exercise physiotherapist led
• improve motivation
• reduce mood disturbance
• decrease symptoms
• improve cardiovascular function
• Should exercise at least 3 times a week so
  need to be doing some at home
• Aiming for high intensity upper and lower
  body exercise, endurance and strength training
• Education multidisciplinary
• Relaxation
• Support and sharing of experiences

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Education Topics

• Benefits of exercise breathing control.
• Goal Setting
• What is COPD?
• Medication Inhaler/spacer devices
• Energy Conservation Coping Strategies
• COPD Self Management Plan
• Stress Reduction, Relaxation Anxiety Management
• Nutrition
• Smoking Cessation
• Sleep Services
• Loving relationships sexuality
• Continence etc etc
  etc.

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Multi Disciplinary Team

• CNS
• Physiotherapist Community Physiotherapist
• Clinical Psychologist (CHCH)
• Consultant Physician
• Occupational Therapist
• Pharmacist
• Dietitian
• Social Worker
• Speech Language Therapist
• Continence Nurse
• Green Prescription Coordinator
• Respiratory Relief - support group

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Course Format

• 6 - 12 week programme of exercise education.
  Participants attend twice a week for 2 hours then
  exercise at home another day.
• Pre and post assessments
• Patients given booklet of resources
• Timaru
• Meet twice weekly on Tuesday and Friday at 1.30pm
  
• 7 week course
• Christchurch
• Meet twice a week on Wed Fri two courses 10am
  12 1pm 3pm
• 8 week course

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Pulmonary Rehabilitation in the South Island

• Nelson
• Greymouth
  Christchurch
• Timaru
• 
  Dunedin
• Invercargill and Gore

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What can you do?

• Referrals to pulmonary rehabilitation
  programs can come from
• Hospital inpatient or outpatient departments.
• Respiratory specialists
• Clinical Nurse Specialists.
• Allied health professionals.
• General practitioners.
• General physicians.
• Community health professionals.
• A referral form should be provided to the
  coordinator of the pulmonary rehabilitation
  program.  
• The coordinator would normally be a health
  professional in charge of running the program. 

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Summary

• The structure and delivery of programs are
  diverse and dependent upon available resources,
  but the aims remain the same.
• Pulmonary Rehabilitation is an integral part of
  the clinical management of all patients with
  chronic respiratory disease

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Summary cont

• Comprehensive Pulmonary Rehabilitation has been
  shown to
• Improve QOL
• Reduce emotional morbidity
• Improve exercise performance
• Improve functionality and confidence
• Reduce both primary admissions and readmissions
  to hospital.

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Summary cont

• Despite the benefits shown, the Australian Lung
  Foundation reveals that fewer than 1 of patients
  with moderate to severe COPD are receiving
  Pulmonary Rehabilitation per annum (approx 1 in
  200).
• Chronic Airflow Limitation Consultation Group.
  Case Statement COPD. Australian Lung Foundation.
  (2000)

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A former participant was so impressed about her
experience in Pulmonary Rehabilitation that she
wrote the following poem.

• I was breathing very badly
• So I gave the doctor a call,
• The hospital then sent me
• To the horticultural hall.
• Lovely young therapists
• Made sure I didnt fall,
• And every week a
  specialist
  
  Gave lectures to us all.
• 
  Then I learnt to lift my leg
• 
  And bend and kiss the wall,
• 
  And other exercises like
• 
  Bouncing a great big ball.
• 
  Many happy memories
• 
  Im sure I will recall,
• 
  So thank you
  for inviting me
• 
  To the
  horticultural hall.

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