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Pulmonary Rehabilitation

Pulmonary Rehabilitation. March 9, 2006 Howard M. Mintz, M.D. ATS Guidelines: PR 1999 What and Why. Reduce symptoms Increase physical and social activities Improve quality of life Decrease disability Questionable increase in survival Economic savings. Exclusion Criteria for PR.

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Pulmonary Rehabilitation

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  1. Pulmonary Rehabilitation March 9, 2006 Howard M. Mintz, M.D.

  2. ATS Guidelines: PR 1999What and Why • Reduce symptoms • Increase physical and social activities • Improve quality of life • Decrease disability • Questionable increase in survival • Economic savings

  3. Exclusion Criteria for PR • Advanced arthritis • Cognitive deficits • Recent MI • Severe pulmonary hypertension • Poor motivation • *Current smokers

  4. ATS Guidelines: PR 1999 • Secondary co morbidities are the reason that PR works • *PR really changes items other than respiratory function • See table

  5. Changes in PFT’s with PR • Innumerable studies have demonstrated that typically measured parameters of pulmonary function such as the FEV1, FVC, FEV1/FVC do not change with pulmonary rehabilitation • Are we looking at the wrong parameters? • “Arm Exercise and Hyperinflation in Patients with COPD.” Gigliotti, et.al. Chest 2005: 128:1225-1232. Instead of looking at static lung volumes, they examined the response to exercise and changes in exercise induced inspiratory capacity as a measure of hyperinflation. Inspiratory capacity diminishes with upper extremity and lower extremity exercise and PR decreases the dynamic hyperinflation.

  6. Assessment for PR • Individualized programs are best suited for success • PE, history, medication review, spirometry to assess degree of obstructive disease • Educational assessment to better understand that patients knowledge of their disease process • *Determination of baseline exercise capacity, what’s necessary, check for desaturation, consider cardiac comorbidity, respiratory muscle strength, nutritional status, cognitive functional assessment

  7. Site for PR

  8. Exercise Training in PR • High intensity training is more effective in producing training effect • Most PR programs stress endurance training instead of high intensity training, typical pattern would be 20-30 minutes two to five times weekly • Research would suggest intensity of training should be at 60% of maximal oxygen consumption. • Seldom do patients undergo a formal exercise stress test prior to PR and instead a target HR is guide • HR is poorly substitute since HR in severe lung disease is highly variable because of the medications, comorbid conditions, and underlying lung impairment. • Symptom guided exercise program is a reasonable alternative

  9. Does Pulmonary Rehabilitation Work?

  10. Exercise Training • Lower extremity exercise • Upper extremity exercise • Continuous or intermittent • Weight training • Inspiratory and expiratory muscle training • Task specific training

  11. What Does the Data Reveal?#1 • “Controlled Trial of Supervised Exercise Training in Chronic Bronchitis”, Sinclair, et. al. Br Med J 1980, Feb 23;280 (6213):519-521). 33 subjects with severe chronic bronchitis. Exercise consisted of 12 minute walk and stair climbing with once weekly supervision. Exercise group attained a 24% increase in maximum exercise capacity after 8-12 months. No improvement in the control group. No changes in respiratory muscle strength nor PFT’s.

  12. What Does the Data Reveal?#2 • “Randomized Controlled Trial of Respiratory rehabilitation,” Goldstein, Lancet 1994 Nov 19; 344(8934):1394-1397). Prospective randomized controlled trial of 89 patients (45 females and 44 males), mean age 66, stable COPD. Rehabilitation vs. conventional community care.24 week program, 8 as inpatient and 16 as outpatient with supervision. Outcome measurements were exercise tolerance and quality of life. 6 minute walk, submaximal cycle time, perception of dyspnea all improved in the rehabilitation group in comparison to conventional treatment.

  13. What Does the Data Reveal?#3 • “Quality of Life in Patients with COPD Improves After Rehabilitation at Home.” Wijkstra,et al. Eur Respiratory J 1994 Feb;7(2):269-273. Severe COPD patients with FEV1 of 1.3 +/- 0.4 liters and FEV1/FVC 37% +/-7.9%. 43 patients with 28 receiving home rehabilitation for 12 weeks, and 15 usual care. Significant improvement in dyspnea, emotional well being, and mastery of tasks. No improvement in PFT’s and the improvement in quality of life was independent of the improvement in exercise tolerance.

  14. What Does the Data Reveal?#4a • “Rehabilitation for Patients with COPD: Meta Analysis of Randomized Controlled Trials.” Salman, J. Gen Internal Medicine 2003 Mar;18(3):213-221. Studies were included in patients were symptomatic, FEV1<70%, FEV1/FVC <70%, at least 4 weeks duration. Outcome measurements included exercise capacity or SOB. • 69 trials, only 20 included in final analysis • 20 of the trails showed improved walking distance compared to control group • 12 trials showed improvement in less shortness of breath • Respiratory muscle training only did not show a significant improvement in dyspnea nor walking distance

  15. What Does the Data Reveal?#4b • Trials that included at least lower extremity exercises showed improvement in dyspnea and walking distance. • Those patients with the most severe disease only improved with programs lasting six months or longer • Those patients with mild to moderate disease improved with both short rehabilitation and long rehabilitation programs • Mild upper extremity weight training has been shown to give added benefit in addition to walking with decreased minute ventilation and increased ergometer distance (16%)

  16. Skeletal Muscles and Enzyme Changes with PR #1 • “Exercise Training Fails to Increase Skeletal Muscle Enzymes in Patients with COPD.” Belman Am. Rev Resp Disease 1981 Mar;123(3):256-261. Six week training period. 7 patients did upper extremity exercises, and 7 patients did lower extremity exercise. Pre-exercise biopsies were taken and post-exercise training biopsies of the trained limbs. Enzymes citrate synthase, 3-beta hydroxyacyl coenzyme A dehyrogenase, and pyruvate kinase. The patients demonstrated a training effect, but no changes in enzymes were detected. Hypothesized that patients with COPD were unable to train at enough intensity. Distinctly different than normal subjects.

  17. Skeletal Muscles and Enzyme Changes with PR #2a • “Skeletal Muscle Adaptation to Endurance Training in Patients with COPD.” Maltais. Am. J. Resp Crit Care Med 1996 Aug;154(2pt1):442-7. Patients with severe COPD, FEV1 36% +/- 11%. 30 minutes of calibrated exercise on a ergocyle for 12 weeks. Pretraining aerobic capacity was severely reduced but increased by 14% with training. Training effect manifest by decrease in VE for the same level of workload and a decrease in lactic acid production. Muscle biopsies were obtained pre and post training of the vastus lateralis. • Two oxidative enzymes, citrate synthase (CS) and 3-hydroxyacyl-CoA dehydrogenase (HADH) were measured, pre and post.

  18. Skeletal Muscles and Enzyme Changes with PR #2b • Three glycolytic enzymes were measured: lactate dehyrogenase, hexokinase, and phosphofructokinase were measured. • The two oxidative enzyme levels increased, while the glycolytic enzymes remained the same in pre and post training muscle biopsies • The increase in the oxidative enzyme levels was associated with a decrease in lactate production at the same level of exercise. • Training even in patients with moderate to severe COPD can improve skeletal muscle oxidative capacity.

  19. Skeletal Muscles and Enzyme Changes with PR #3 • “Reductions in Exercise Lactic Acidosis and Ventilation as a Result of Exercise Training in Patients with Obstructive Lung Disease.” Casaburi. Am Rev Respir Dis 1991 Jan;143(1):9-18. • Question was does the intensity of the exercise determine the benefit. • Moderate COPD. Training at two levels of intensity, about 70 W x 45 minutes and 30 W at a proportionally longer period of time. • After training, those in high intensity were able to increase level of work without increase in lactate and less VE with 73% increase in endurance. • Low intensity group was able to increase endurance by only 9%. • The absence of development of lactic acidosis is not required by a training effect.

  20. Predictors of Improvement with PR • “Predictors of Improvement in the 12 Minute Walking Distance Following a Six Week Outpatient Pulmonary Rehabilitation Program.” Zuwallack. Chest 1991 Apr;99 (4):805-808 • 50 ambulatory outpatients exposed to six weeks of PR • 12 MD increased by 27.7% +/- 32.5% • 12 MD distance increased by 462 feet +/-427 feet. • No significant relationship between age, sex, ABG’s, oxygen requirements, and PFT’s • Patient’s with highest ventilator reserve (1- [VEmax/MVV] x 100) had the most improvement in 12 MD • The smaller the initial 12 MD and the greater the initial FEV1, the better the rehab potential • Poor initial 12 MD is not a predictor of poor PR potential • Studies showed the most improvement in those patients receiving the most intense exercise prescriptions

  21. Upper Extremity Exercise #1 • “Upper Extremity Exercise Training in COPD.” Ries. Chest 1988 Apr; 93(4):688-692 • Patients with COPD have more difficulty with upper extremity exercise • Mechanism for increase in dyspnea includes fixation of the rib cage and abdominal wall with upper extremity exercises resulting in a physiologic stiffening of the rib cage. • Most PR programs emphasize lower extremity training • 45 patients divided into three groups: gravity-resistance training (GR), modified proprioceptive neuromuscular facilitation upper extremity training (PNF), and no specific upper extremity training

  22. Upper Extremity Exercise #2 • 28 patients completed the study. GR and PNF showed improved performance of task specific exercises. • Breathlessness and perceived fatigue diminished. • No change in ventilatory muscle strength or simulated activities of ADL. • In order to help patients with COPD improve ADL skills of upper extremities, the prescription must be specific.

  23. Upper Extremity Exercise • “Supported Arm Exercises vs Unsupported Arm Exercises in the Rehabilitation of Patients with Severe Chronic Airflow Obstruction.” Martinez. Chest 1993 May; 103(5):1397-402. • Patients were divided into those with unsupported arm training (USA) and supported arm training (SAT). USA patients basically lifted light weights. SAT used a hand ergometer. • All patients were enrolled in comprehensive PR including lower extremity, inspiratory muscle training, teaching, and psychological support. • Groups were equally matched from disease severity and exercise capacity. • 12 MW, respiratory muscle function, bicycle ergometer power output similar in the two groups at the end of the training period. • USA patients had a decrease in VO2 and the metabolic costs. USA is much more akin to ADL skills and thus should be incorporated into PR

  24. Upper Extremity Exercise & Dynamic Hyperinflation #1 • “Arm Exercise and Hyperinflation in Patients with COPD.” Gigliotti, et.al. Chest 2005: 128:1225-1232. • 12 patients with moderate to severe COPD, mean FEV1 1.59 liters +/- 0.58 liters and FEV1/FVC 46% +/- 12%. • No changes in the static PFT’s nor ABG’s per and post PR • Hypothesis was that PR increased exercise tolerance and decreased dyspnea because of changes in dynamic hyperinflation. • Dynamic hyperinflation is the phenomenon in which exercise causes increases in the FRC & decreases in the IC

  25. Upper Extremity Exercise & Dynamic Hyperinflation #2 • Consequences of dynamic hyperinflation include a reduction in airway closure minimizing expiratory flow resistance (maladaptive response), increase in muscle fatigue by changing the length tension relationship • 12 patients underwent incremental (5W/min), symptom limited arm exercises with hand ergometer. • Significant education and training period that included lower extremity exercises and typical components of PR

  26. Upper Extremity Exercise & Dynamic Hyperinflation #3 • 6 week outpatient PR. • Expired gas analysis was performed along with other routine measurements • During the last 30 seconds of exercise, the patients performed two inspiratory capacity manuevers for measurement of end-expiratory lung volume. TLC does not change during exercise in patients with COPD, thus IC reliably estimates changes in EELV. • Patients rated dyspnea with Borg scale 0-10

  27. Upper Extremity Exercise & Dynamic Hyperinflation #4 • Hand ergometer training consisted of work load of 80% of maximal level to symptom limited with 80% set by pre PR testing. • Study showed significant increases in minute ventilation, oxygen consumption, CO2 production, HR, exercise dyspnea with upper extremity exercise. • Increase in work rate demonstrated with p<0.001. • IC decreased by 0.93 +/- liters with upper extremity exercise in the control period • Following PR, IC decreased by 0.59 liters +/- 0.27 liters (p<0.0001)

  28. Upper Extremity Exercise & Dynamic Hyperinflation #5 • The RR interval increased with PR, and thus there was more expiratory time, associated with less dynamic hyperinflation (p<0.03) • Dyspnea as assessed by the Borg scale diminished (p<0.02) follow PR • HR decreased following PR • Oxygen consumption and CO2 production did not change with PR • Minute ventilation decreased with PR, (p<0.01) • Arm or leg cycling in COPD results in dynamic hyperinflation and is a predictor of exercise tolerance

  29. Inspiratory Muscle Training in PR • The inspiratory muscles can be strengthened with inspiratory muscle training • The data on effectiveness of inspiratory muscle training is mixed • Inspiratory muscle training seems to decrease dyspnea • Inspiratory muscle training has not been uniformly shown to increase exercise endurance.

  30. Inspiratory Muscle Training in COPD #1 • “The Effects of 1 Year of Specific Inspiratory Muscle Training in Patients with COPD.” Beckerman, et.al. Chest 2005; 128:3177-3182. • Inspiratory muscle dysfunction likely result of geometric changes in diaphragm, chest wall, systemic factors, and possible changes in muscles. • Hypothesis was that one year of SIMT would improve dyspnea, exercise tolerance, quality of life, reduce hospital costs and admissions • 42 patients with mean FEV1 of 1.21 liters +/- 0.4 liters and FEV1 % predicted of 42% +/- 2.6% • Testing with spirometry, 6 MW, Borg scale for dyspnea • Health-Related Quality of Life with St. George’s Resp Questionaire

  31. Inspiratory Muscle Training in COPD #2 • Training of 2 sessions of 15 minutes six times weekly for 12 months with POWERbreathe, inspiratory muscle trainer. 1st month direct supervision at center, then home training for 11 months with weekly calls or visits. Attendance was 63% +/-7% in training group and 59% +/- in the control. • After 3 months of training, PImax increased in the trained group with smaller incremental improvement over the next 9 months. P<0.005 • After 3 months of training, 6MW in trained group with smaller incremental improvement over the next 9 months. P<0.005 • POD declined slowly and did not reach a statistically significant level of p<0.05 until 9 months of training • SGRQ improved after 6 months in trained group and was maintained over 12 months • No significant differences in hospitalizations between the trained and control group, but average days for each hospitalization was lower in trained group, p<0.05.

  32. Inspiratory muscle strength as assessed by the PImax before and after the training period in the study group and in the control group Beckerman, M. et al. Chest 2005;128:3177-3182

  33. The mean {+/-} SEM perception of dyspnea (Borg score) during breathing against load in all COPD patients before and after the training period Beckerman, M. et al. Chest 2005;128:3177-3182

  34. The mean {+/-} SEM distance walked in 6 min before and after the training period in the study group and in the control group Beckerman, M. et al. Chest 2005;128:3177-3182

  35. Changes in health-related quality-of-life scores determined by the SGRQ before and after the training period in the study group and in the control group Beckerman, M. et al. Chest 2005;128:3177-3182

  36. Hospital admissions, days spent in the hospital, and the use of primary-care consultations during the training period in the study group and in the control group Beckerman, M. et al. Chest 2005;128:3177-3182

  37. Expiratory Muscle Training in COPD #1 • “Specific Expiratory Muscle Training in COPD.” Chest 2003; 124:468-473. Weiner, et.al. • Expiratory muscles impaired in COPD • Contraction of expiratory muscles increases intrathoracic pressures, decreases lung volumes, and increase expiratory flow rates. • Expiratory muscle training has been shown to decrease dyspnea in children with neuromuscular disease and improve cough in adults with MS. • Study was designed to answer three questions: 1. Does SEMT increase exercise tolerance; 2. Does SEMT training decrease dyspnea, 3. Can one demonstrate a training SEMT increase

  38. Expiratory Muscle Training in COPD #2 • Randomized study of 26 patient with mean FEV1 of 1.32 liters +/- 0.4 liters with FEV1 of 37% of predicted +/- 2.4%. • Exercise sessions of 30 minutes six times weekly • Expiratory muscle endurance as measured by PemPeak increased by 33%, p<0.001 • 6MW increased in the treated group b 19%, p<0.05 • No significant change in perception of dyspnea with expiratory muscle training • Literature does not substantiate a significant individual benefit for this modality

  39. Breathing Retraining, Education, Other Modalities • Shallow, rapid breathing may be deleterious to ventilation and gas exchange. Pursed lipped breathing and other techniques may help. • Yoga training has been shown to improve exercise tolerance in comparison to breathing exercise, only 11 patients in both groups • Patients instructed in diaphragmatic breathing training actual had more dyspnea and increase in work of breathing (7 patients) • Educations goal is to improve compliance, no studies convincingly show improvements • Psychological support cannot be shown to have any specific benefit although depression is about 2.5 times more prevalent in patients with COPD. Group therapy has not been demonstrated to have benefit. • Energy conservation techniques, planning, prioritization, and assistive devices. • Discussion of end of life issues. • Nutrition

  40. Nutrition and COPD • Weight loss to level of <90% of IBW occurs in 25% to 43% with about 14% of patients having weight loss in excess of 50% of premorbid weight • Weight loss with loss of lean body mass is associated with skeletal muscle dysfunction that contributes to dyspnea, decreased mobility, and increase risk of falls. • Significant weight loss typically begins about 3.5 years prior to death • Unintentional weight loss and mortality

  41. Nutrition and COPD • At an FEV1 of <35% of predicted, those patient with >IBW have a 50% higher exercise capacity than patients with <90% of ideal body weight • Body weight is correlated with exercise capacity with p<0.0001. • Reversal of weight loss has been associated with improved outcomes such as increased survival and improvements in 12 MWD, hand grip, PEmax, and PImax. • Difficulty to restore body weight • Patients with low body weight have more gas trapping, lower DLCO, and lower exercise capacity when matched for patients with similar pulmonary functions but normal weight

  42. Nutrition, COPD, and Anabolic Steroids #1 • “Reversal of COPD-Associated Weight Loss Using the Anabolic Agent Oxandrolone.” Yeh, et. al. Chest 2002 122:421-428. • Oxandrolone oral anabolic steroid shown to be useful in patients with chronic infections, burns, severe trauma, extensive surgery, offset catabolism associated with corticosteroids. • Oxandrolone has a high anabolic activity and low androgenic activity (Testosteron 1:1 ratio & oxandrolone 3:1 to 13:1. • Safety demonstrated in over 30 years of us.

  43. Nutrition, COPD, and Anabolic Steroids #1 • Community study, 25 sites in USA, 10 mgm of oxandrolone for 4 months, males and females • History of involuntary weight loss and IBW <90% with COPD and FEV1<50% of predicted • No specific exercise program or nutritional support offered • 128 patient entered study but only 55 analyzed for 4 months • IBW 79% +/- 9.2% of predicted • Mean FEV1 34% +/- 15.83% • At 2 months, 72/82 patients had gained mean of 6.0 lbs +/-4.36 lbs • At month 4, 46/55 patients had gained 6.0 lbs +/- 5.83 lbs (p<0.0) • Males and females had equal response and body cell mass increased substantially while body fat did not

  44. Nutrition, COPD, and Anabolic Steroids #2 • No changes in spirometry • No changes in 6 MW • No changes in VAS for dyspnea • Subgroup did demonstrate an increase in 6 MW and performance status, but it is unclear why these patients were separated

  45. Meta-Analysis for Nutritional Support in COPD • “Nutritional Support for Individuals with COPD.” Ferreira, et al. Chest 2000; 117:672 • RCT reviewed and 272 abstracts with 9 felt adequate for data extraction with 272 subjects (144 study and 133 control) • At least 2 weeks of nutritional support (any caloric supplementation) • Did this impact FEV1 or 6 MW? NO!!

  46. Anabolic Steroids and PR in COPD #1 • “A Role for Anabolic Steroids in the Rehabilitation of Patients With COPD?” Creutzberg, et al. Chest 2003;124:1733-1742 • Low levels of testosterone are seen in COPD patients especially those receiving glucocorticosteroids • Glucocorticosteroids contribute to respiratory and peripheral muscle weakness seen in COPD independent of muscle wasting • Anabolic steroids might work through effects on erythropoietin • Does the anabolic steroids nandrolone 50 mgm IM q 2 weeks benefit patients undergoing 8 weeks of PR?

  47. Anabolic Steroids and PR in COPD #2 • Measured were body composition, muscle function, exercise capacity, erythropoietic values, and laboratory values • Subgroup analysis looked at patients receiving oral glucocorticoids • PR rehabilitation improved the following variables in both the patients receiving Nandrolone and those receiving placebo, but the addition of the Nandrolone did not confirm an additive benefit: Maximum inspiratory muscle strength, maximum isometric hand grip, maximum isometric leg strength, work load, maximum oxygen consumption, SGRQ scores

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