Pulmonary rehabilitation and COPD: providing patients a good ...
Advances for rehabilitation in COPD
Transcript of Advances for rehabilitation in COPD
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Content
• Rehabilitation (how) does it work ?
• How to train the ventilatory limited patient ?
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Chronic Obstructive Pulmonary Disease
NHLBI/WHO Global Initiative for Chronic Obstructive LungDisease (GOLD) Definition:
Chronic obstructive pulmonary disease is characterized byairflow limitation that is not fully reversible.
It is a preventable and treatable disease with some significant
extrapulmonary manifestations.
Skeletal muscle dysfunction
Weight loss
Cardiovascular disease
Depression and Fatigue
Osteoporosis
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Interaction between pulmonary and extrapulmonary factors
0 1 2 3 40
20
40
60
80
100
120
140
160
180
VO2 (L/min)
VE
(L
/min
)
Muscle Dysfunction
Early lactic acidosis
Dynamic Hyperinflation
Breathing frequency
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Casaburi R and ZuWallack R. N Engl J Med 2009;360:1329-1335
Targets of Exercise Training
• Improving aerobic function of ambulation muscles
• Reducing ventilatoryrequirement and respiratory rate during exercise
• Prolonging expiration time
• Reducing dynamic hyperinflation and dyspnea
Casaburi et al. N Engl J Med 2009
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Content Rehabilitation Program
• Exercise Training
– Endurance exercise to improve cardiorespiratory fitness
– Resistance training to improve muscular strength and endurance (peripheral and respiratory muscles)
• Supplemental interventions during exercise training
– Oxygen
– Heliox
• Breathing exercises
• Occupational therapy
• Nutritional advise
• Psychological support
• Patient-education / self-management (inactivity)
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Rehabilitation, the evidence: Exercise tolerance
Wmax VO2max Walking Whole body end0
10
20
30
0
10
20
30
40
50
60
70
80
90
100
110
(% b
aseli
ne)
(% b
aselin
e)
Adapted fromTroosters AJRCCM 2005
Exercise tolerance: Weighted mean difference and IQR
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Rehabilitation, the evidence
Dy
s
Fa
t
Em
o
Ma
s
-1
0
1
2
3
H
RQ
oL
(M
CID
-un
its)
6M
WD
0
25
50
75
6
MW
D (
m)
Lacasse Eura Medicophys 2007 (Cochrane)
CRDQ 6MWD
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Patients admitted nHospital admissions
RespAll
Days spent in hospRespAll
Days per admission
1.92.2
18.121.0
9
41
±
1.41.5
19.320.77.6
1.41.7
9.410.4
6
40
±
1.31.1
10.29.73.4
Controls Rehabilitation
NS
**
**0.1
Griffiths Lancet 2000
Rehabilitation, the evidence: Health care resources
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Rehabilitation: the evidence
Evidence from systematic review of meta-analysis of randomised controlled trials (level la) • Improvements in exercise tolerance • Clinically relevant improvement in health related
quality of life (HRQoL).
Evidence from at least one RCT(level lb) • Reductions in number of days spent in hospital • Pulmonary rehabilitation is cost effective
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Exercise training, the core of rehabilitation
How do we train patients with severe airflow
obstruction, dynamic hyperinflation and
complaints of dyspnea on exertion?
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Knowing exercise limitations to guide training
How to train the ventilatory limited patient ?
Improve the lung function / maximum
ventilatory capacity
Reduce the ventilatory needs
– Increase the delivery
– Reduce the demand
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Improve lung function
Casaburi et al Chest 2005
TIO REHAB TIO+REHAB
0
50
100
150
Exerc
ise e
nn
du
ran
ce
(% i
ncre
ase)
w4 w9 w13 w17 w21 w25
200
300
400
500
600
700
Tim
e P
A o
uts
ide r
eh
ab
(min
)
*
*
*
Kesten J COPD 2008
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HeliOx
FEV1 1.540.73 1.890.73
FVC 3.761.13 3.861.18
Air HeliOx
0
10
20
30
40
50
60
70
0
2
4
6
8
10
12
14
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18
Endurance time VE
Eves AJRCCM 2006
90
60
30
00 10 20
Ven
tila
tio
n (
L.m
in-1
)
Time (min)
HE
Improve maximal voluntary ventilation
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Training at higher intensity
0 2 4 6 8 10 12 14 16 18 20 22
40
60
80
100
120
Session (n)
WR
(%
max)
0
4
8
12
16
20
24
Air HH
*
*
*
FEV1
TLC
DLCO
VO2peak
47
129
66
55
±
±
±
19
20
22
11
46
122
64
59
±
±
±
14
17
14
13
Air (n=19) He/O2(n=19)
Eves Chest 2009
Endurance time
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Lung Transplantation
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Gender
Age
BMI
FEV1
Q-Force
MEP
MIP
Handgrip
6MWD
Wmax
/
yrs
kg/m2
%pred
Nm
cm H2O
cm H2O
kgF
m
%pred
1yPost-LTXn=22
Healthyn=30
12
59
23
79
100
159
-76
36
483
74
/
±
±
±
±
±
±
±
±
10
5
4
18*
36*
44*
48
16
66*
22*
18
58
25
116
164
193
-97
42
690
182
/
±
±
±
±
±
±
±
±
12
6
4
18
41
47
53
10
83
57
Langer et al. Journal of Heart and Lung Transplantation 2009
-40%
-20%
-20%
-15%
-30%
-60%
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Physical activity counseling w/ feedback SenseWear
Study Design RCTExercise Training after LTX
Transplantation
Pre-LTX105 days
Control
Exercise Training
Post-LTX28 days
3m/6mPost-Random
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Baseline Characteristics
Post-LTX
Training (n=15) Control (n=13)
Male / Female 8 / 7 7 / 6
Early acute rejection (yes / no) 6 / 7 3 / 9
SLTX / SSLTX 1 / 14 3 / 10
Diagnosis COPD / ILD 12 / 3 11 / 2
Age 56 ± 4 56 ± 7
BMI (kg/m²) 20,7 ± 4,6 21,6 ± 4,2
FEV1, (% pred) 72 ± 18 74 ± 16
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3 sessions per week
Resistance exercise
CyclingTreadmill walking Stair climbing
Exercise Training
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Results
Pre
-LTX
Post
-LTX
3mPost
-LTX
6mPost
-LTX
40
50
60
70
80
90
**
Qu
ad
ricep
sfo
rce
%p
red
Pre
-LTX
Post
-LTX
3mPost
-LTX
6mPost
-LTX
300
400
500
600
Training
Control
**
6-m
inu
te
walk
ing
dis
tan
ce (
m)
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Knowing exercise limitations to guide training
How to train the ventilatory limited patient ?
Improve the lung function / maximum
ventilatory capacity
Reduce the ventilatory needs
– Increase the delivery
– Reduce the demand
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Training at higher intensity
0 2 4 6 8 10 12 14 16 18 20 22
40
60
80
100
120
Session (n)
WR
(%
max)
0
4
8
12
16
20
24
Air O20
4
8
12
16
20
24
Air HH
*
*
*
Emtner AJRCCM 2003
Increased O2 delivery
Lower lactate
Reduced ventilatory drive
Endurance time
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Knowing exercise limitations to guide training
How to train the ventilatory limited patient ?
Improve the lung function / maximum
ventilatory capacity
Reduce the ventilatory needs
– Increase the delivery
– Reduce the demand
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- Enhance the stress to the muscle for a given VO2 (walking vs cycling)
0.0
1.0
2.0
3.0
Cycle @ 80% Wpeak
Walk @ 80% VO2peak
R 50% 100% End
0102030
-10
-20-30-40-50
Qtw
pot
(%base
line
)
Pepin AJRCCM 2005
Reduce the demandV
O2
L/m
in
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- Enhance the stress to the muscle for a given VO2 (walking vs cycling)
- Reduce the amount of muscle mass at work (resistance training, NMES).
Probst ERJ 2006
10
15
20
25
30
35
Walking Cycling Stairs Quadr
*
Reduce the demand
VO
2L
/min
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0
10
20
30
40
50
6MWD VO2max CRDQ
STRENGTH
ENDURANCE
(%
in
itia
l o
r p
oin
ts)
Spruit et al. Eur.Respir.J. 2002; 19:1072-1078
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- Enhance the stress to the
muscle for a given VO2
(walking vs cycling)
- Reduce the amount of muscle
mass at work (resistance
training, NMES, single leg)
Dolmage Chest 2008
Single Leg Exercise
Reduce the demand
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Single leg exercise
Dolmage et al Chest 2006
two legs one leg
0
5
10
15
20
25
30
35
COPD
Healthy
En
du
ran
ce T
ime (
min
)
@ 8
0%
Wp
eak
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Single leg training
Dolmage Chest 2008
*
30 min of conventional cycling training versus single leg cycling (15 min each leg)
3 times per week
7 weeks
FEV1 37 and 40%pred
0
5
10
15
20
25
30
35
Wpeak0
5
10
15
20
25
VO2peak0
2
4
6
8
10
Tlim@80%
% i
nit
ial
% i
nit
ial
min
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- Enhance the stress to the muscle for a given VO2
- Reduce the amount of muscle mass at work
- Shorten the bouts of exercise to keep ventilation lower
than needed in steady state (interval training)
Slow oxygen uptake (ventilatory) kinetics : your friend in
pulmonary rehab…
Reduce the demand
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Sabapathy Thorax 2004
Interval exercise, often more realistic
0.0
0.5
0.7
0.9
1.1
VO
2(L
/min)
Time (min)
0 2 4 6 8 54 56 58 60 62
25
50
75
100
Tw
Q (
%ch
an
ge)
Pe
pin
20
06
Sa
ey 2
00
5 P
L
Sa
ey 2
00
5 IP
R
Ma
do
r 2
00
3
Ma
do
r 2
00
1
Ma
n 2
00
3
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Conclusions
• Pulmonary rehabilitation works: ‘GRADE A’-level of evidence
• Exercise training can be fine-tuned to the exercise limitations of patients
• Several options available for ventilatorylimited patients
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IncreaseVentilatory Capacity:
BronchodilatorsHeliox
High intensityPeripheral
MuscleTraining
Exercise training
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ReduceVentilatoryRequirements:
O2 supplementationSmall muscle massShort intervals
High intensityPeripheral
MuscleTraining
One-leg exerciseInterval training
Resistance training
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Thank you for your attention
Greetings from the Leuven Pulmonary Rehabilitation team