Dr Robert Rutherford

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Pulmonary Rehabilitation

• Dr Robert Rutherford

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(No Transcript)
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Definition of Pulmonary Rehabilitation

• A deliberate supervised therapeutic process of
  restoring a patients function through the
  process of rehabilitation

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Consequences of Chronic Respiratory Disease

• Peripheral Muscle dysfunction
• Respiratory muscle dysfunction
• Low or high BMI
• Cardiac impairment
• Skeletal disease
• Psychosocial dysfunction

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Mechanisms

• Deconditioning
• COPD TNF-a
• Malnutrition
• Hypoxemia
• Steroid myopathy
• Hyperinflation / Diaphragmatic fatigue
• Anxiety, depression, dependency and sleep
  disturbances

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Dynamic Hyperinflation
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Pulmonary Rehabilitation
COPD- Spiral of disability
? Breathlessness

• CO2
• Lactate

Inactivity
Leg fatigue weakness
Muscle deconditioning
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Pulmonary Rehabilitation
COPD
Pulmonary Rehabilitation
? Breathlessness
?CO2 ?Lactate
?activity
? Leg fatigue weakness
Muscle reconditioning
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Principle Goals of Pulmonary Rehabilitation

• Aims to reduce symptoms, decrease disability,
  increase participation in physical and social
  activities and improve overall quality of life.
• Reduce healthcare utilization and costs

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How

• Multi-disciplinary approach
• Individually tailored exercise program
• Patient and family education
• Addressing psychosocial issues
• Measuring outcomes

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Benefits of Rehab

• Improved exercise capacity
• Improved muscle strength
• Reduced dyspnoea
• Improve health-related QOL
• Reduced readmission rates and length of stay in
  COPD

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Duration of Benefit

• Exercise benefit 12-18 mths
• QoL benefit 24 mths

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Pulmonary Rehabilitation post AECOPD

• 60 patients randomised to PR x 8 weeks or usual
  care lt 1 week post discharge
• 33 in UC group vs 7 in PR group readmitted lt
  3/12 (p0.02)
• 57 in UC group vs 27 in PR group had an
  unplanned hosp visit (p0.02)
• Thorax 201065423-8

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Patient Selection

• Obstructive Diseases COPD, asthma,
  bronchiectasis
• Restrictive Diseases
• Interstitial IPF, sarcoid
• Chest Wall /Neuromuscular

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COPD

• MRC Dyspnoea Score
• 1 SOB only on strenuous exertion
• 2 SOB only when hurrying or on inclines
• 3 Walks slower on level or has to stop even
  walking at own pace
• 4 Stops 100 yards
• 5 Housebound or breathless with ADL

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Reducing Disability in COPD

• Optimization of weight
• Inhaled therapy
• Regular exercise 20 mins/day
• Pulmonary Rehabilitation

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Patient Selection

• Gains can be achieved regardless of age, gender,
  lung function or smoking status
• Severe nutritional depletion and low fat-free
  mass may be associated with a poor response to
  rehab

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Exclusion Criteria

• Significant neurological or orthopaedic disease
• Unstable cardiac disease
• Unstable psychiatric disease

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Setting for Pulmonary Rehabilitation

• Outpatient
• Inpatient
• Home
• Community Based

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Setting for Pulmonary Rehabilitation

• Choice varies depending on
• Availability
• Distance to program
• Patient preference
• Physical, functional, psychosocial status

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Exercise Training

• Does not alter underlying respiratory impairment
  unfortunately !
• Targets endurance training of 60 of VO2 max for
  20-30 minutes, repeated 2-5 times a week
• Interval training of 2-3 minutes high intensity
  (70-80 VO2 max) with equal periods of rest or
  low level exercise is tolerated well.

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Strength Training

• Few studies performed all show benefits.
• 50-85 of 1 Rep Max increases peripheral muscle
  function
• Improved quality of life
• Reduced ventilation

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Upper Extremity Training

• Endurance training of upper extremity to improve
  arm function also important
• Ergometry
• Free weights
• Therabands

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Respiratory Muscle Training

• Inspiratory muscle function compromised in COPD
• Start at low resistance and increase to achieve
  60-70 of PI MAX
• Definitely improves respiratory muscle strength
• Not clear if reduces dyspnoea or improves
  exercise capacity.

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Education

• Encourages active participation in health care
• Better understanding of disease including
  exacerbation management
• Improved compliance

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Energy Conservation

• Energy conservation and work simplification
  assist in maintaining ADLs
• Methods include
• Paced Breathing
• Advanced planning
• Prioritization of activities
• Use of assistance devices grabbers, etc.

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Medication and other therapies

• Types of medication, action, adverse effects,
  dose and proper us of inhaled medications
• Instructions in inhaler technique
• Appropriate use of oxygen
• Exacerbation packs

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Psychosocial Intervention

• Anxiety, depression, difficulties coping with
  chronic disease
• Aided by regular patient education session or
  support groups
• Instruction in progressive muscle relaxation,
  stress reduction, panic control

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Nutritional Assessment

• Diet history, BMI
• Over or Under weight.
• Classes in weight management and/or nutritional
  counseling to improve weight management

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Outcome Assessment

• Individual response
• Effectiveness of overall program

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Outcomes measured

• Smoking status
• QoL- CRQ, CAT, HADS
• Exercise capacity ISWT, 6MWT, Borg scale

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Future Directions of PR

• Impact of elective and acute PR on Health Care
  Costs and survival
• Effectiveness of individual educational
  components
• Best intensity, duration and optimum form of
  exercise training
• Best means of maintaining benefits

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Future Directions

• Refining patient allocation community, hospital
  based programs
• Effectiveness of PR in diseases other than COPD