Pulmonary Rehabilitation in COPD Concept and Benefits. Hassan Chami, MD MSc Assistant Professor American University of Beirut

Transcription

1 Pulmonary Rehabilitation in COPD Concept and Benefits Hassan Chami, MD MSc Assistant Professor American University of Beirut

2 Outline Dyspnea & Exercise limitation in COPD Mechanism Management Pulmonary Rehabilitation Structure Goals Benefits Patient Selection Components Initial assessment Exercise component Educational component

3 COPD SYMPTOMS Cough Breathlessness Exercise Limitation Frequent Hospitalization Poor Quality of Life

4 Dyspnea and Exercise Limitation Cardiopulmonary dysfunction Ventilatory limitation Gas exchange limitation Non respiratory factors Deconditioning Skeletal muscle dysfunction

5 COPD Cardiopulmonary Limitation Dyspnea Deconditioning Reduced Exercise Endurance Inactivity

6 Skeletal Muscle Dysfunction Systemic Inflammation Reduced Mass & Strength Corticosteroids Deconditioning Anabolic Hormone Deficiency Oxidative Stress Hypoxia Malnutrition

7 COPD Management Smoking Cessation Pharmacologic Bronchodilators Inhaled steroids Non pharmacologic Oxygen Pulmonary Rehab GOLD Report 2011

8 an evidence-based, multidisciplinary, & comprehensive intervention for patients with chronic respiratory disease who are symptomatic ATS/ERS statement AJRCCM 2006;173:1390

9 Goals of Pulmonary Rehabilitation Reduce symptoms Optimize functional status Improve quality of life Increase participation in everyday activities Reduce health care cost ATS/ERS statement AJRCCM 2006;173:1390

10 Rehab Addresses X Muscle wasting Weight loss Altered mood Relative social isolation

11 Benefits (Evidence level A) Improves exercise capacity Reduces perceived intensity of breathlessness Improves health related quality of life Reduces anxiety and depression associated with COPD Reduces the number of hospitalization and days in the hospital GOLD Report 2011

12 Benefits (Evidence level B) Improves survival Improves recovery after hospitalization Enhances the effect of bronchodilators The benefits extend well beyond the period of training GOLD Report 2011 Puhan, Cochrane database 2011

13 Patient Selection All COPD patients appear to benefit Improved exercise tolerance Decrease dyspnea Benefit documented in patients with Dyspnea mmrc> 1 After exacerbation

14 Model of Symptoms/Risk Evaluation Risk Spirometry Class C A D B Risk Exacerbation History mmrc 0-1 CAT<10 Symptoms mmrc >1 CAT>10 GOLD Report 2011

15 Non Pharmacalogic Management of COPD Patient Group Essential Recommended Depending on Local Guidelines A Smoking cessation Physical Activity Pneumococcal + Flu vaccination B,C &D Smoking Cessation Pulmonary Rehabilitation Physical Activity Pneumococcal + Flu vaccination GOLD Report 2011

16 Other Indications Decreased functional status Decrease occupational performance Difficulty performing activities of daily living Psychological problems related to COPD Nutritional depletion Increased use of medical resources

17 Exclusion Unstable cardiac disease Unstable angina Critical Aortic stenosis Bed/Chair bound Unlikely to benefit Active smoking is NOT a contraindication

18 Initial Assessment Identifies unique problems of the patient Gait disturbances Nutritional depletion Depression Tailoring interventions Use additional resources to meet the needs

19 Medical history Physical exam Diagnostic test Assessment Symptoms Musculoskeletal Exercise ADL Nutrition Education Psychological Components

20 Physical Exam Vitals BMI O2 Saturation Chest exam Cardiac exam Musculoskeletal exam

21 Diagnostic tests Spirometry CXR ECG CBC 6 min walk test or CPET

22 Musculoskeletal and Exercise Physical limitations (ROM, strength etc..) Orthopedic limitations Transferring abilities Gait and balance Oxygenation during exercise

23 Goal Formulation Measurable Patient specific Realistic Examples: Breath easier Be more active Be able to play with grand children Walk farther Able to take a shower Able to clean house Return to work

24 Exercise Training Cornerstone of rehab program Increase maximal exercise capacity Peak oxygen consumption Peak workload Endurance time Helps the patient cope with the sensation of breathlessness Lacasse Cochrane 2006

25 Exercise Sessions Number: 20 sessions Frequency: 3 times per week (or home) Length of the program: 6 12 weeks Session Duration: 20 to 45 minutes Intensity: % of VO2 max High preferred Low still beneficial ATS/ERS statement AJRCCM 2006;173:1390 ACCP/ACCVPR EBM guidelines Chest 2007;131:4S

26 Modes of exercise Upper extremities Lower extremities Endurance Strength training ATS/ERS statement AJRCCM 2006;173:1390 ACCP/ACCVPR EBM guidelines Chest 2007;131:4S

27 Respiratory Muscle Training Resistance breathing exercises Increase muscle strength an endurance Effect on exercise tolerance and QOL is unknown Not recommended as an essential component of pulmonary rehabilitation ATS/ERS statement AJRCCM 2006;173:1390 ACCP/ACCVPR EBM guidelines Chest 2007;131:4S

28 Oxygen Important to monitor oxygen during exercise Cannot predict exercise levels using resting levels Oxygen saturation maintained >89% Supplemental oxygen improve exercise tolerance ATS/ERS statement AJRCCM 2006;173:1390

29 Bronchodilators Home therapy optimized Nebulizer available on premises Administered prior to and during exercise as needed

30 Education: Collaborative Self Management Essential component of pulmonary rehab Coupled to exercise training Interactive group sessions with instructions Skill oriented Action plan

31 Educational Content Pulmonary anatomy and physiology Pathology of lung disease Benefits of exercise Irritant avoidance and smoking cessation End of life planning

32 Skills Breathing strategies Secretion clearance techniques Medication and Inhalers technique Energy conservation and work simplification Relaxation and stress management techniques Early recognition & treatment of exacerbation

33 Breathing Strategies Anxiety and breathing Management of Breathlessness Pursed lip breathing Active exhalation Body position

34 Exacerbation Prevention & Early Rx Early therapy speeds recovery and decrease health care utilization Exacerbation recognition Action plan Initiate medication regimen Alerting health care provider

35

36 Focusing therapy solely on reversing airway obstruction is suboptimal care and will produce suboptimal outcome

37 Questions?