PULMONARY REHABILITATION IN LUNG CANCER
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Transcript of PULMONARY REHABILITATION IN LUNG CANCER
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PULMONARY REHABILITATION IN LUNG CANCER
Dr. Tuğba GÖKTALAYCelal Bayar University
Department of PulmonologyManisa
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Conflict of interest
Support for participation in the congress and the course (last 3 years)› Deva › GSK› Bayer
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Presentation Plan
Rationale of pulmonary rehabilitation in lung cancer
Goals of pulmonary rehabilitation in lung cancer
Pre-post operative pulmonary rehabilitation in lung cancer
Pulmonary rehabilitation approaches
Cancer-related fatigue and pulmonary rehabilitation
Conclusion
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Pulmonary rehabilitation;
Exercise capacity, Functional status, Improve health-related quality of life
(HRQOL) In patients with chronic lung problems
Chronic dyspnea and fatigue
a multidisciplinary intervention.
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Cancer Rehabilitation;
Restoration of the individual to the fullest physical, social, physicological and occupational potential of which the person is capable with the limitations of the disease and therapies.
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Rationale Cancer Rehabilitation;
Cancer-related fatigue
Mobility
Self-care disability
Pain
Dyspnea
Malnutrition
Psycho-social problems
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Goals of Cancer Rehabilitation;
Improve health-related quality of life
Increase the functional capacity
Enhance the efficacy of treatment
Increase the oxygen consumption
Reduce chemotherapy-related fatigue
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To achieve targets;
Multidisciplinary health care team,Exercise training,Patient and family education, Psycho-social and behavioral interventions
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5-year survival 15.6% in lung cancer
A small amount of patients eligible for surgery curative (25%)
Cardiopulmonary comorbidities
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The coexistence of COPD-Lung cancer
Males 73%, females 53%
• Loganathan R, Stover DE, Shi W, Venkatraman E. Chest 2006; 129:1305– 1312.
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n=100
Lobectomy for Lung cancer
Patient with COPD
Similar postoperative DLCO and VO2max
• Greater decline in FEV1 (p=0.0002)• Increased
cardiopulmonary morbidity (p=0.04)• Lower postoperative FEV1
(p=0.0001)
• Pompili C, Brunelli A, Refai M et al. Eur. J Cardio-thoracic Surg 2010; 525-530
Postoperative effects of COPD patients undergoing lobectomy due to lung cancer
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Preoperative pulmonary rehabilitation, leads to a significant increase exercise capacity, dyspnea and health-related quality of life in this patients.
Shannon VR. Current Opinion in Pulmonary Medicine 2010;16:334–339
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PR for patients with advanced NSCLC
n=11
Pulmonary rehabilitation; 2 times/week, 8week Aerobic and strengthening
exercises
• Reduction in symptoms
• Temel JS, Greer JA, Goldberg S et al. J Thorac Oncol 2009 (4): 595-601
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Survival was negatively affected?
≤48 day is not the predictor of survival*
The Swedish Cancer Study Group Proposal for Lung Cancer;**Consultation and investigations to be
completed within 4 wk, treatment should start within the next 2 weeks
*Bozcuk H, Martin C. Lung Cancer 2001; 34:243– 252.
**Myrdal G, Lambe M, Hillerdal G, et al. Thorax 2004; 59:45–49.
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Prepeoperatif pulmonary rehabilitation, many patients in the window period of 4-6 weeks can be done without adversely affecting survival.
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Poor performance status and exercise capacity morbidity and mortality*
Exercise capacity is a modifiable risk factor!!**
*Oga T, Nishimura K, TsukinoM, et al. Am J Respir Crit Care Med 2003; 167:544–549.
*Baser S, Shannon VR, Eapen GA, et al. Clin Lung Cancer 2006; 5:344–349.
*Brunelli A, Salati M. Curr Opin Pulm Med 2008; 14:275–281.
**Fishman A, Martinez F, Nauheim K, et al. N Engl J Med 2003; 348: 2059–2073
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CPET the main outcome
SFT predictive value is not clear
Pre-operative interventions aimed at improving VO2 peak, post-operative results improve and increase surgical candidacy.*
6MWT, CPET to be used as an alternative. **
*Brunelli A, Belardinelli R, Refai M, et al. Chest 2009; 135:1260–1267.
**Cote C, Pinto-Plata V, Kasprzyk K, et al. Chest 2007; 132:1778–1785.
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Efficacy of Preoperative Pulmonary
Rahabilitation in Patients
with Lung Cancer
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Complete surgical resection is the most effective treatment method
Preoperative PR, recommended to reduce surgical morbidity.
Fishman A, Martinez F, Nauheim K, et al. N Engl J Med 2003; 348: 2059–2073
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PR before surgery for cancer; n=19
The standard and non-standard arm
Pulmoneary rehabilitation;
Short-term(4w)A) Standard arm Accordance
with guidelines
B) Patient-based Self-
sufficiency Inspiratory
muscle training
Slow breathing training
• Benzo R, Wigle D, Novotny P, et al. Lung Cancer 2011 Dec;74(3):441-5
•Shorter duration of hospital stay of at least 3 days (p=0.058), •The number of days for chest tube was less than (p = 0.04), •The need for prolonged chest tube drainage was less than (p = 0.03).•Can be applied to the patient-based PR
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The Effects of cardiorespiratory training prior to surgery
•There is a significant increase in peak VO2 and 6MWT (respectively 21%, 13%)
• Jones L. Cancer Chemother Pharmacol 2007; 110:590–598
n=13 Preoperatively and 30 days after the assessment
Pulmonary Rehabilitation;
Short-termConsecutive days from the operation1-4 week
• Peripheral muscle exercise (endurance
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The effect of preoperative pulmonary rehabilitation in NSCLC
n=12 akciğer
Pulmonary Rehabilitation;
• In hospital
• Short term(1.5 h, 5day/ 4 week süreli
• Patient education;
› Smoking cessation Effective coughing Controlled breathing
techniques
• Peripheral muscle training (Endurance)
•The average increase in peak VO2 2.8mL/kg/min•Increase in exercise performance•Positive effects of cardiopulmonary
• Bobbio A, Chetta A, Ampollini L, et al. Eur J Cardio-thoracic Surg 2008;33:95–98
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Preoperative PR in patients with limited performance
n=8
Candidates for surgery, patients with limited respiratory function and performance
Pulmonary Rehabilitation; Short term(4
week) Aerobic
exercise, Controlled
breathing techniques
Training sessions
• Cesario A, Ferri L, Galetta D, et al. Lung Cancer 2007; 57:118–119.
•Increase in 6MWT (47%)•Increase in PaO2 (7,2mmHg)•Increase in Pulmonary function (FEV1, FVC)
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Cost-effectiveness of PR before lobectomy
n=119
• Reduction of postoperative atelectasis (p= 0.003)• Reduction in length of hospital stay• Cost reduction
• Varela G, Ballesteros E, Jimenez MF et al. Eur J Cardio-thoracic Surg 2006; 216-220
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•Exercise capacity improved•Shorter duration of hospital stay•Reduces postoperative pulmonary complications•Preserved lung function after surgery in patients with COPD
Preoperative PR is useful?
• Nagarajan K, Bennerr A, Agostini P et al. Interact Cardiovascular Thorac Surg 2011; 300-302
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The benefits of preoperative pulmonary rehabilitation;
Shorten length of hospital stay, Improves postoperative complications,
reduces complications, Improves exercise capacity after surgery, Creates a positive impact on the post-
operative period of cardiopulmonary, Borderline patients eligible for surgery
makes Cost-effective
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Efficacy of Postoperative Pulmonary
Rahabilitation in Patients with Lung
Cancer
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Pulmonary rehabilitation after surgery, 6-9 weeks is continued.
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PR in patients undergoing radical treatment
n=16
12 week multidisciplinary PR program
Pulmonary Rehabilitation;
Resistance and endurance exercise
Nutritional assessment Dyspnea and fatigue
assessment (CRDQ)
• Salhi B, Demedts I, Simpelere A et al. Rehabilitation Research and Practice 2010, Article ID 481546, 7 pages, doi:10.1155/2010/481546
•Improved exercise capacity•Increased muscle strength •Improved Quality of life (dyspnea and fatigue)
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The effect of postoperative PR in NSCLC
Cesario A, Ferri L, Galetta D, et al. Lung Cancer 2007; 57:175–180
• Improvement in respiratory function• Improvement in exercise capacity
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Postoperative PR in NSCLC
n=103
Patients undergoing surgery for NSCLC
• Cesario A, Dall’Armi V, Cusumano G et al. Lung Cancer November 2009, 66(2); 268–269
• Improvement in exercise capacity• Improvement in respiratory function• Improvement in the perception of dyspnea• Improvement in SaO2• Improvement in BODE index
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Effect on exercise capacity in postoperative PR
n=10
Surgery, Surgery + RT, Surgery + RT+ KT
Pulmonary rehabilitation; 8 week Multidisciplinary
Increase the capacity of doing work
• Spruit M, Janssen PP, Willemsen SC, et al. Lung Cancer 2006; 52:257–260.
(P=0.0020) (P=0.0078)
•Increase in 6MWT (43%) and peak work load (34%)
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The benefits of postoperative pulmonary rehabilitation;;
Increases exercise capacity
Increases muscle strength
Provides symptom control
Improves quality of life
Shorten length of hospital stay
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Pre-Post operative Pulmonary Rehabilitation Approaches
Smoking cessation Assessments of patients;
Functional limitations Exercise capacity
Airway clearance and pulmonary expansion techniques Assisted coughing Insentive spirometry NIMV
Energy conservation strategies Transfer-mobility Prevention of venous thromboembolism Pain control Stress and anxiety management Nutritional evaluation / support
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The effect of fast-track PR after lobectomy
n=109
Avoidance of long-term preoperative benzodiazepine
Early extubation
Patient-controlled analgesia
Early ambulation
Oral nutrition
•Shortening length of hospital stay •Reduction in complication
• Das-Neves-Pereira JC, Bagan P, Coimbra-Israel AP et al. Eur J Cardio-thoracic Surg 2009; 383-392
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Cancer Related Fatigueand
Pulmonary Rehabilitation
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Fatigue
Shortness of breath
Involuntary weight
loss
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Cancer Related Fatigue (CRF)
70-100 % *
CRF during or after treatment
Decrease in activity participation and life**
*Mock V. Cancer. 2001;92(6 suppl):1699–1707 **Curt GA, Breitbart W, Cella D, et al. Oncologist.
2000;5:353–360
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CRF
Cancer- related fatigue is a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion to cancer or cancer treatment that is not proportional to recent activity and interferes with unusual functioning.
NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue
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CRF
May be isolated or accompanied by other symptoms such as pain, distress, anemia, and sleep disorders
Patient-specific systematic assessment should be performed
Guides should be approached with a multidisciplinary applied
Rehabilitation should begin with the cancer diagnosis
• NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue
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• Wagner LI, Cella D. British Journal of Cancer (2004) 91, 822 – 828
Causes of cancer-related fatigue
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Approach to cancer-related fatigue
Non-pharmacologic
Activity enhancement Maintain optimal level of activity /Exercise prescription/ Exercise training Energy conservation techniques
Education Psychosocial interventions
Assessment/support (Stress management /Relaxation ) Nutritional assessment /support Sleep assesment Cautions:
Bone metastasis Immunosuppression / neutropenia Thrombocytopenia Anemia Fever Limitations due to metastasis or co-morbidities
• NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue
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CRF CRF is associated with muscle mass and strength. *
The most common symptom, fatigue Increased fatigue, associated with low physical
activity levels. Physical activity level, regardless of age,
significant in predicting the level of fatigue.
Physical activity level, a factor that can be changed in CRF.**
• *Kilgour RD, Vigano A, Trutschnigg B et al. J Cachexia Sarcopenia Muscle (2010) 1:177–185
**Luctkar-Flude M, Groll D, Woodend K, et al. Oncol Nurs Forum. 2009 Mar; 36 (2):194-202
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•Exercise; reduces fatigue, increases walking, improves the quality of life
• Wagner LI, Cella D. British Journal of Cancer (2004) 91, 822 – 828
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The benefits of pulmonary rehabilitation in CRF;
Reduces fatigue
Provides symptom control
Increases the functional capacity
Improves the quality of life
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Pulmonary Rehabilitation;
Makes it ready for surgery patients with borderline
Shorten length of hospital stay, cost-effective
Reduce the complication rates Accelerate recovery after surgery Provides symptom control Improves cancer-related fatigue and
quality of life
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THANKS