Pulmonary Rehabilitation

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Pulmonary Rehabilitation

• Susan Scherer, PT, PhD
• Regis University
• DPT 732
• Spring 2009

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Pulmonary Rehabilitation

• The American Thoracic Society /European
  Respiratory Society (2006)
• "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, and reduce health care
  costs through stabilizing or reversing systemic
  manifestations of the disease.

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Pulmonary Rehabilitation

• Symptoms correlate better with functional status
  than does FEV1 or other measures of pulmonary
  function (AACVPR)
• Symptoms, disability, and handicap dictate the
  need for pulmonary rehabilitation, not the degree
  of physiologic impairment

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Criteria for Referral to Pulm Rehab

• FEV less than or equal to 65 of predicted value
• FVC less than or equal to 65 of predicted value
• Diffusing capacity for carbon monoxide adjusted
  for hemoglobin less than or equal to 65 of
  predicted
• Resting hypoxemia (SpO2 less than or equal to
  90)
• Exercise testing demonstrating hypoxemia (SpO2
  less than or equal to 90) or ventilatory limit
  (VE/MVV more than or equal to 0.8) or a rising
  Vd/Vt

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Selection of Patients Indications

• COPD
• Restrictive lung disease
• Neuromuscular disease resulting in decreased
  ventilation
• Pre and post transplant
• Respiratory disease resulting in
• Anxiety with daily activities
• Breathlessness with activities
• Limitation in social, leisure, work or ADLs
• Loss of independence

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Exclusion of Patients

• Conditions that would interfere with
• Patient participation (cognition)
• Risk during exercise training
• Pulmonary hypertension
• Unstable angina

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Core Components of Pulm Rehab

• Patient Assessment of current functional status
• Exercise training and other therapeutic exercise
  (aerobic, strength and flexibility training)
• Education and skills training (such as breathing
  retraining)
• Secretion clearance techniques for Prevention and
  management of exacerbations and pulmonary
  infections
• Oxygen systems, proper use, safety and
  portability
• Nutritional assessment and intervention if
  necessary
• Psychosocial assessment, support, panic control,
  and professional intervention if necessary
• Smoking cessation if currently smoking
• Medication use, management and education
• Implementation of a home treatment program
  follow-up

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Demonstrated Outcomes

• Reduced respiratory symptoms (dyspnea, fatigue)
• Increased exercise performance
• Increased knowledge about pulmonary disease and
  self-efficacy in its management
• Enhanced ability to perform activities of daily
  living
• Improved health-related quality of life
• Improved psychosocial symptoms (reversal of
  anxiety and depressive symptoms)
• Reduced exacerbations and use of medical
  resources
• Return to work or leisure activities

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Qualified Programs

• American Association of Cardiovascular and
  Pulmonary Rehabilitation (AACVPR) instituted
  program certification in 1998 to recognize
  programs that were meeting the published
  Guidelines for Pulmonary and Cardiac
  Rehabilitation
• Annual staff competency skills review
• Emergency equipment and supplies
• Written policies and procedures
• Regular staff meetings
• Physician referral process
• Informed consent form
• Exercise prescription
• Preparation for possible medical emergencies
• Emergency equipment availability
• Record of untoward events
• Outcomes assessment/program evaluation
• Risk stratification
• Individualized care plan
• Educational sessions
• Feedback to physician

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Components of Pulmonary Rehabilitation

• Exercise Training
• Aerobic
• Upper extremity endurance
• Lower extremity endurance
• Strength
• Respiratory muscle
• Education
• Disease management (meds, oxygen)
• Breathing training
• Smoking cessation
• Stress management
• Psychological and Social intervention
• Support group
• Outcome Assessment

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Benefits of Pulmonary Rehabilitation

• Impairments-generally not reversed with
  medication or pulmonary rehab
• Disability-pulmonary rehab improves function
• Increase in exercise performed
• Decrease in dyspnea for given level of exercise
• American Thoracic Society Guidelines
• Am J Respir Crit Care Med Vol 159 pp 1666-1682,
  1999.

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Benefits of Pulmonary Rehabilitation Maximal
Exercise Capacity

• Positive effect size for exercise important
  because COPD progressively downhill
• Subjects FEV1 35-45 of predicted
• Maximal treadmill work (33) after 8 weeks
• Maximal cycle ergometry (11)after 12 weeks home
  rehab
• Troosters, 2000

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Benefits of Pulmonary Rehabilitation Steady
State Exercise Endurance

• Stationary cycle time (at 60 of maximal power)
  improved by 5 min over control (38)
• Treadmill time 10 min (85 over baseline)
• 6 minute walk distance
• Clinically significant difference 54 m
• RCT- 113 m at 6 weeks
• Improved daily function and community walking
  ability

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Benefits of Pulmonary Rehabilitation Dyspnea
Reduction

• Exercise training has effects on more parameters
  than dyspnea
• Benefit to dyspnea greater than medication or
  oxygen therapy
• Decreased dyspnea with daily activities
• Transitional Dyspnea Index (TDI)
• Clinically significant difference 2.3 units
• Decreased VAS during max exercise
• 7550

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Benefits of Pulmonary Rehabilitation Health
related Quality of Life

• Improved Chronic Respiratory Disease
  Questionnaire
• Health status
• Dyspnea
• Emotional function

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Benefits of Pulmonary Rehabilitation Mortality
Morbidity

• alive in 6 years, not statistically significant
• Decreased hospital days (2 for pulm rehab vs 6
  for controls)
• Study completed before managed care

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Recommendations for Rehabilitation

• Exercise training muscles of ambulation is
  recommended as mandatory component for patients
  with COPD 1A
• Lower extremity exercise at higher intensity
  produces greater physiologic benefits than lower
  intensity in patients with COPD 1B
• Both high and low intensity exercise provide
  clinical benefits 1A
• Addition of a strength training component in
  creases muscle strength and mass 1A
• Unsupported endurance training of the UE is
  beneficial 1A
• Inspiratory muscle training is not supported by
  literature 1B
• Supplemental oxygen should be used in exercise
  training in patients with exercise-induced
  hypoxemia 1C
• Supplemental oxygen during high intensity
  exercise in patients without exercise induced
  hypoxemia may improve endurance 2A
• Chest 2007

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Initial Assessment

• Review disease process PFTs
• Educational assessment for knowledge gaps
• Baseline exercise capacity
• Respiratory muscle strength
• Peripheral muscle strength
• ADLs
• Health status
• Anxiety/depression/mood states
• Nutritional status (low weight associated with
  decreased exercise performance aerobic capcity

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Exercise Training Parameters

• Frequency 2-5 times/week
• Intensity Aim for general training parameters
• gt 60 max VO2
• Does ventilatory limitation allow patients to
  train at levels that will provide physiologic
  adaptations?
• Time Unrealistic to expect 20-30 minutes
  originally
• Few minutes at maximal performed at intervals
• Interval training (high and low)
• Type Specificity of training walking vs. cycle

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Aerobic Exercise Training

• Intensity
• 60 of maximal and above anaerobic threshold
• As high as 75-85 of peak VO2
• HR response is variable
• Can be used to measure cardiac adaptation to
  exercise
• Dyspnea ratings during exercise are better
  indicators of training
• Peripheral adaptations occur in exercising
  muscle
• Reduced ventilation lactate levels at identical
  work rates indicates training effect

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Extremity Endurance Exercise training

• Upper extremity
• Arm ergometer
• Dowel or weights unsupported UE above shoulder
  level
• Trains accessory and UE muscles for endurance
• Lower extremity
• Higher intensity work (60-80 of max workload)
  increases endurance time more than lower
  intensity

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Strength Training

• Peripheral muscle weakness contributes to
  decreased physical performance
• Training
• 50-85 of 1RM
• Exercise capacity did not change
• Improved peripheral muscle function
• Improved QOL
• Respiratory muscle training
• Minimal load is 30 of PI max

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Pulmonary Rehabilitation -Education

• Breathing Retraining
• Individual assessment recommended
• Coordinating breathing with activity
• Energy conservation
• Proper use of medications
• Oxygen use
• Individual or classes

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Psychosocial and Behavioral Intervention

• Anxiety
• Depression
• Decreased self-efficacy
• Stress management
• Muscle relaxation
• Group therapy
• Support groups

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Typical Outcomes

• Exercise ability
• Incremental or submaximal exercise test
• Walking test (6 minute)
• General health status
• SF-36
• Respiratory specific health status
• Chronic Respiratory Disease Questionnaire CRDQ
• Respiratory specific functional status
• Pulmonary Functional Status Scale PFSS
• Exertional dyspnea
• VAS, Borg, TDI

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Typical Outcomes

• Exercise ability
• Incremental or submaximal exercise test
• Walking test (6 minute)
• General health status
• SF-36
• Respiratory specific health status
• Chronic Respiratory Disease Questionnaire CRDQ
• Respiratory specific functional status
• Pulmonary Functional Status Scale PFSS
• Exertional dyspnea
• VAS, Borg, TDI

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Implications for practice

• The results of this meta-analysis strongly
  support respiratory rehabilitation including at
  least four weeks of exercise training as part of
  the spectrum of management for patients with
  COPD. We found clinically and statistically
  significant improvements in dyspnea, fatigue and
  mastery.
• When compared with the treatment effect of other
  important modalities of care for patients with
  COPD such as bronchodilators or oral theophylline
  (McKay 1993 Jaeschke 1994), rehabilitation
  resulted in greater improvements in important
  domains of health-related quality of life and
  functional exercise capacity.
• Clinical practice guidelines must however
  consider that respiratory rehabilitation is often
  unavailable. For instance, in Canada, a recent
  national survey indicated that less than 2 of
  the population with COPD per annum has access to
  such program (Brooks 1999).
• We hope that the results of this meta-analysis
  will encourage the implementation of new programs
  
• Lacasse Y, Brosseau L, Milne S, Martin S, Wong E,
  Guyatt GH, Goldstein RS, White J.
• Pulmonary rehabilitation for chronic obstructive
  pulmonary disease. The Cochrane Database of
  Systematic Reviews Reviews 2001