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Management of stable
COPD: Pulmonary
Rehabilitation
Kira Neal
Respiratory Specialist Physiotherapist
Action East Cardio-respiratory
Rehabilitation Team
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
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
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.
Why Pulmonary Rehabilitation
Reduced exercise
tolerance
Muscle weakness
Fatigue, anxiety,
isolation
Fear of breathlessness
Inactivity/Immobility
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
AIMS
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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)
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
Changes to body in COPD
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Ventilatory limitation
Gas exchange limitation
Cardiac dysfunction
Skeletal muscle dysfunction
Respiratory muscle dysfunction
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
Gas exchange limitation
• Hypoxia
– Increases pulmonary ventilation
Cardiac dysfunction
• Increase in RV afterload due to increased PVR
– Hypoxic vasoconstriction
– Erythrocytosis
Skeletal muscle dysfunction
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Change in muscle fibre type
Reduced capacity of oxidative enzymes
Reduced number of capillaries
Inflammatory state
Nutrition/ body mass
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.
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
In conclusion
• Musculoskeletal changes suggest that patients
with COPD present with muscle weakness, and
fatigue (with exercise) more quickly than their
normal counterparts.
Skeletal Muscle in COPD
300
Capillary Density
200
Type I Type II
43% 57%
100
0
Type I Type II
57% 43%
Normal
COPD
Normals
Jobin J, et al. J Cardiopulmonary Rehab 1998.
Bernard et al. AJRCCM 1998.
Limiting symptoms in COPD
patients at peak exercise
Dyspnoea and leg
fatigue
31%
Dyspnoea
26%
Killian KJ, et al. 1992.
Leg fatigue
43%
Respiratory muscle dysfunction
• Compromised functional inspiratory muscle
strength
• Compromised inspiratory muscle endurance
What should PR include?
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Strength training
Endurance training
Education
Social and psychosocial factors
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.
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
ATS/ERS Statement on PR 2006
ATS/ERS Statement on PR 2006
PR Education
So… What can exercise do?
May improve
• Exercise tolerance
• Exertional dyspnoea
• Cardiovascular function
• Fatigue
• Ability to carry out ADL’s
• Mood
• Strength
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
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Multi professional
Coping strategies
Improve knowledge of how lung disease affects you
Cup of tea!
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
PR classes
Strength exercises
Dealing with an
exacerbation
Relaxation and stress
management
Smoking cessation
Endurance exercises
Medications and
how they work
So what do we actually do?
• Patients referred by GP’s, consultants/ hospital Dr’s,
practice nurses, respiratory nurse specialists, physios.
• Initial assessment
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Suitable for PR
medical history
cardiovascular stability
medical management optimised
exercise capacity
anxiety and depression
quality of life
Other questionnaires
Then…
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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
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
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
Thank you!
• Any Questions?
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.
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), 172634.