Pulmonary Rehabilitation Presented by Wyatt E. Rousseau, MD May 14, 2009.

Pulmonary Pulmonary RehabilitationRehabilitation

Presented byPresented by

Wyatt E. Rousseau, MDWyatt E. Rousseau, MD

May 14, 2009May 14, 2009

BackgroundBackground

• COPD is 4th leading cause of death

• 13% of total hospitalizations

• Second to CAD for payment of Social Security disability benefits

• Exercise intolerance – dyspnea/fatigue

PathophysiologyPathophysiology

• Severity of lung disease

• Extrapulmonary manifestations thought to be due to deconditioning*– Skeletal muscle dysfunction: decreased

aerobic enzyme activity, low fraction of aerobic fibers, decreased capillarity, inflammatory cells, and increased apoptosis. All lead to early onset of lactic acidosis, decreasing aerobic activity.

*Wagner, PD. Skeletal muscles in chronic obstructive pulmonary disease: deconditioning or myopathy? Respirology 2006; 11:681-686.


Evidence-based, multidisciplinary, and Evidence-based, multidisciplinary, and comprehensive intervention for patients comprehensive intervention for patients

with chronic respiratory diseases who are with chronic respiratory diseases who are symptomatic and often have decreased symptomatic and often have decreased daily activities. It is designed to reduce daily activities. It is designed to reduce symptoms, optimize functional status, symptoms, optimize functional status,

increase participation, and reduce health increase participation, and reduce health care costs by stabilizing or reversing care costs by stabilizing or reversing

systemic manifestations of the disease.systemic manifestations of the disease.Nici, L et.al. American Thoracic Society/European Respiratory Society statement on pulmonary Nici, L et.al. American Thoracic Society/European Respiratory Society statement on pulmonary

rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390.rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390.


CandidatesCandidates

Any patient with impairment Any patient with impairment because of lung disease and who is because of lung disease and who is motivated should be a candidate for motivated should be a candidate for

pulmonary rehabilitation.pulmonary rehabilitation.

Pulmonary RehabilitationPulmonary Rehabilitation

Common Indications for Common Indications for Referral to Pulmonary RehabilitationReferral to Pulmonary Rehabilitation

• Anxiety engaging in activities• Breathlessness with activities• Limitations – Social, Leisure, Chores, ADL’s• Loss of Independence• Especially those whose dyspnea is out of

proportion to lung function or those with primarily leg fatigue limiting exercise


Common conditions leading to referral to pulmonary rehabilitation

• COPD

• Bronchiectasis

• Chronic Asthma

• Post surgery

• ILD

• Neuromuscular Disease

• Cystic Fibrosis

• Exacerbations

Pulmonary Rehabilitation Pulmonary Rehabilitation ContraindicationsContraindications

• PSYCHIATRIC– Dementia

– Organic Brain Syndrome

• MEDICAL– Unstable cardiac

– Substance abuse

– Cancer (relative)

– Liver Failure

– Neurologic or Orthopedic condition preventing ambulation

Pulmonary RehabilitationPulmonary RehabilitationEffect on Exercise CapacityEffect on Exercise Capacity

from Lacasse,Y et.al. Lancet 1996; 348:1115from Lacasse,Y et.al. Lancet 1996; 348:1115


•Education

•Exercise


EducationEducation• Diagnosis

• Smoking Cessation

• Pharmacology

• Respiratory Therapy

• Physical Therapy

• Occupational Therapy

• Therapeutic Recreation

• Nutrition

• Psychosocial


ExerciseExercise

• Physical Therapy

• Occupational Therapy

• Respiratory Therapy

Pulmonary Rehabilitation-Pulmonary Rehabilitation-EducationEducation

DiagnosisDiagnosis• Physician

• Pulmonary Function Tests–Spirometry

–ABG’s

–Diffusing Capacity

– Inhalation Challenge

–Exercise Testing

• Cardiac Tests

Pulmonary Rehabilitation-EducationPulmonary Rehabilitation-Education

Smoking CessationSmoking Cessation

• Counseling (Ask, Advise, Assess, Assist, Arrange F/U)

• Nicotine Replacement• Anxiolytic/Antidepressant• Varenicline• Support (Quit date, past quit

experience, challenges, other smokers)


PharmacologyPharmacology

• OXYGEN

• BRONCHODILATORS– Beta-agonists, LA and SA

– Anticholinergics, LA and SA

– Theophylline, other PDEI’s

• ANTI-INFLAMMATORY– Corticosteroids

– Leukotriene Antagonists

Pulmonary Rehabilitation-Education & Pulmonary Rehabilitation-Education & ExerciseExercise

Respiratory TherapyRespiratory Therapy

• Breathing Techniques– Pursed lip– Diaphragmatic

• Medication Delivery Systems

• Peak Flow Measurement

• Self Management

Pulmonary Rehabilitation-Education & Pulmonary Rehabilitation-Education & ExerciseExercise

Physical TherapyPhysical Therapy

• MAXIMIZE FUNCTIONAL INDEPENDENCE– Exercise

– Energy conservation

– Oxygen

– Adaptive devices

Exercise - HelioxExercise - Heliox

• Eves ND, Sandmeyer LC, Wong EY, et. Al. Helium-Hyperoxia: A Novel Intervention to Improve the Benefits of Pulmonary Rehabilitation for Patients with COPD. Chest. 2009:135:609-618.

Breathing helium-hyperoxia (60% He-40% O2) during pulmonary rehabilitation increases the intensity and duration of exercise training that can be performed and results in greater constant-load exercise time for patients with COPD.

Exercise - HelioxExercise - Heliox

• Chiappa GR, Queriroga F, Meda, E. Heliox Improves Oxygen Delivery and Utilization During Dynamic Exercise in Patients with COPD. Am J Respir Crit Care Med 2009;

Heliox (79% He-21%O2) increases lower limb O2 delivery and utilization during dynamic exercise in patients with moderate-to-severe COPD. These effects contribute to enhance exercise tolerance in this patient population.

Pulmonary Rehabilitation-Education & Pulmonary Rehabilitation-Education & Exercise Exercise

Occupational TherapyOccupational Therapy

• MAXIMIZE FUNCTIONAL INDEPENCENCE– Exercise

– Energy conservation

– Self care

– Adaptive devices


NutritionNutrition

• WEIGHT MANAGEMENT

• DIETS– Supplements– Restrictions

• VITAMINS/ADDITIVES


Psychosocial IssuesPsychosocial Issues

• INSURANCE/REIMBURSEMENT

• QUALITY OF LIFE CONCERNS

• SOCIAL SITUATION

• CHAPLAIN CONSULTATION

• ETHICS ISSUES


INPATIENTINPATIENT• ADVANTAGES

– 24 hour nursing care

– Sicker patients

– No transportation problems

– Family participation

– Best for ventilator, tracheostomy patients

• DISADVANTAGES– Cost and insurance

difficulties

– Not suitable for less severe patients

– Family transportation problems


OUTPATIENTOUTPATIENT

• ADVANTAGES– Widely available

– Less costly

– Least intrusive to family

– Efficient use of staff

• DISADVANTAGES– Potential

transportation problems

– Cannot observe home activities


HOME - BASEDHOME - BASED• ADVANTAGES

– Convenience to patient

– Transportation no issue

– Exercise in familiar environment may lead to better adherence long term

• DISADVANTAGES– Cost/insurance issues

– Lack of group support

– Lack of full spectrum of multidisciplinary personnel

Pulmonary RehabilitationPulmonary RehabilitationAdverse EffectsAdverse Effects

• Musculoskeletal injury

• Exercise-induced bronchospasm

• Cardiovascular event (increased risk among COPD patients)

Pulmonary RehabilitationPulmonary RehabilitationExercise EffectExercise Effect

Data from Am J Respir Crit Care Med 1999; 159;321Data from Am J Respir Crit Care Med 1999; 159;321

Effect of Effect of Therapy-Therapy- Does Not Does Not improve lung improve lung mechanicsmechanics or gas or gas exchange, but optimizes other exchange, but optimizes other

body systems*body systems*• Muscle biochemistry-higher work rates with

less lactic acidosis leading to decreased carotid-body stimulation

• Reduced dynamic hyperinflation through reduced ventilatory demand

• Desensitization to dyspnea: antidepressant effect, social interaction, self management, and adaptive behaviors

*Casaburi, R and ZuWallack. Pulmonary Rehabilitation for Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2009; 360:1329-1335.


Benefits in COPDBenefits in COPD• Improves exercise capacity - Evidence A• Improves perceived breathlessness - Evidence A• Improves quality of life – Evidence A• Reduces hospitalizations and LOS – Evidence A• Reduces anxiety and depression – Evidence A• UBE improves arm function – Evidence B• Benefits extend beyond training period – Evidence B• Improves survival – Evidence B

Pulmonary Rehabilitation Presented by Wyatt E. Rousseau, MD May 14, 2009.

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Transcript of Pulmonary Rehabilitation Presented by Wyatt E. Rousseau, MD May 14, 2009.