Download Pulmonary Rehabilitation

Pulmonary Rehabilitation
Susan Scherer, PT, PhD
Regis University
DPT 732
Spring 2009
Pulmonary Rehabilitation
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The American Thoracic Society /European Respiratory Society (2006)
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"Pulmonary Rehabilitation is an evidence-based,
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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.
Pulmonary Rehabilitation
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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
Criteria for Referral to Pulm Rehab
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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
Selection of Patients: Indications
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COPD
Restrictive lung disease
Neuromuscular disease resulting in decreased
ventilation
Pre and post transplant
Respiratory disease resulting in:
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Anxiety with daily activities
Breathlessness with activities
Limitation in social, leisure, work or ADLs
Loss of independence
Exclusion of Patients
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Conditions that would interfere with
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Patient participation (cognition)
Risk during exercise training
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Pulmonary hypertension
Unstable angina
Core Components of Pulm Rehab
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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
Demonstrated Outcomes
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Reduced respiratory symptoms (dyspnea, fatigue)
Increased exercise performance
Increased knowledge about pulmonary disease and selfefficacy 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
Qualified Programs
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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
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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
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Exercise Training
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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
Benefits of Pulmonary Rehabilitation
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Impairments-generally not reversed with
medication or pulmonary rehab
Disability-pulmonary rehab improves function
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Increase in exercise performed
Decrease in dyspnea for given level of exercise
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American Thoracic Society Guidelines
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Am J Respir Crit Care Med Vol 159: pp 1666-1682, 1999.
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Benefits of Pulmonary Rehabilitation :
Maximal Exercise Capacity
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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
Benefits of Pulmonary Rehabilitation :
Steady State Exercise Endurance
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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
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Clinically significant difference 54 m
RCT- + 113 m at 6 weeks
Improved daily function and community
walking ability
Benefits of Pulmonary Rehabilitation :
Dyspnea Reduction
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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)
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Clinically significant difference: 2.3 units
Decreased VAS during max exercise
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75—50%
Benefits of Pulmonary Rehabilitation :
Health –related Quality of Life
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Improved Chronic Respiratory Disease
Questionnaire
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Health status
Dyspnea
Emotional function
Benefits of Pulmonary Rehabilitation :
Mortality & Morbidity
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% alive in 6 years, not statistically significant
Decreased hospital days (2 for pulm rehab vs
6 for controls)
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Study completed before managed care
Recommendations for Rehabilitation
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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
Initial Assessment
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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
Exercise Training Parameters
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Frequency: 2-5 times/week
Intensity: Aim for general training parameters
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> 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
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Few minutes at maximal performed at intervals
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Interval training (high and low)
Type: Specificity of training – walking vs. cycle
Aerobic Exercise Training
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Intensity :
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HR response is variable
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60% of maximal and above
anaerobic threshold
As high as 75-85% of peak VO2
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
Extremity Endurance Exercise training
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Upper extremity
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Arm ergometer
Dowel or weights
unsupported UE above
shoulder level
Trains accessory and UE
muscles for endurance
Lower extremity
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Higher intensity work
(60-80% of max
workload) increases
endurance time more
than lower intensity
Strength Training
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Peripheral muscle weakness contributes to
decreased physical performance
Training
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50-85% of 1RM
Exercise capacity did not change
Improved peripheral muscle function
Improved QOL
Respiratory muscle training
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Minimal load is 30% of PI max
Pulmonary Rehabilitation -Education
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Breathing Retraining
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Individual assessment recommended
Coordinating breathing with activity
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Energy conservation
Proper use of medications
Oxygen use
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Individual or classes
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Psychosocial and Behavioral Intervention
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Anxiety
Depression
Decreased self-efficacy
Stress management
Muscle relaxation
Group therapy
Support groups
Typical Outcomes
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Exercise ability
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General health status
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Chronic Respiratory Disease Questionnaire CRDQ
Respiratory specific functional status
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SF-36
Respiratory specific health status
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Incremental or submaximal exercise test
Walking test (6 minute)
Pulmonary Functional Status Scale PFSS
Exertional dyspnea
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VAS, Borg, TDI
Typical Outcomes
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Exercise ability
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General health status
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Chronic Respiratory Disease Questionnaire CRDQ
Respiratory specific functional status
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SF-36
Respiratory specific health status
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Incremental or submaximal exercise test
Walking test (6 minute)
Pulmonary Functional Status Scale PFSS
Exertional dyspnea
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VAS, Borg, TDI
Implications for practice
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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