Pulmonary Rehabilitation

1. Pulmonary Rehabilitation Susan Scherer, PT, PhD Regis University DPT 732 Spring 2009

2. 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.

3. 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

4. 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

5. 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

6. Exclusion of Patients • Conditions that would interfere with • Patient participation (cognition) • Risk during exercise training • Pulmonary hypertension • Unstable angina

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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 • 75—50%

15. Benefits of Pulmonary Rehabilitation :Health –related Quality of Life • Improved Chronic Respiratory Disease Questionnaire • Health status • Dyspnea • Emotional function

16. 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

17. 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

18. 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

19. Exercise Training Parameters • Frequency: 2-5 times/week • Intensity: Aim for general training parameters • > 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

20. 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

21. 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

22. 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

23. Pulmonary Rehabilitation -Education • Breathing Retraining • Individual assessment recommended • Coordinating breathing with activity • Energy conservation • Proper use of medications • Oxygen use • Individual or classes

24. Psychosocial and Behavioral Intervention • Anxiety • Depression • Decreased self-efficacy • Stress management • Muscle relaxation • Group therapy • Support groups

25. 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

26. 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

27. 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