Optimizing Pulmonary Rehabilitation in COPD: Practical Issues Canadian Thoracic Society Clinical Practice Guideline
2011 Canadian Thoracic Society and its licensors All rights reserved. No parts of this publication may be modified, posted on-line or used for any commercial purposes without the prior written permission of the Canadian Thoracic Society (CTS). If you use this publication as a teaching tool in non-profit professional development or educational activities, please reference CTS as the source. Please contact guidelines@lung.ca for permission to use these slides. These slides can not be altered, and must be used as presented in the CTS template.
Functioning, Disability, and Health in COPD Impairment [Function] Disability [Activity] Handicap [Participation] FEV1, FVC IC, EELV, FRC, RV ABGs Dyspnea Exercise Capacity Exacerbations (AECOPD) Quality of Life Health Care Utilization Adapted from Can Respir J, 2004; 11(Suppl B): 7B-59B; International Classification of Functioning, Disability and Health. WHO. Geneva. 2001.
COPD Exacerbations Expiratory Flow Limitation Air Trapping Hyperinflation Breathlessness Deconditioning Reduced Exercise Endurance Inactivity Poor Health-Related Quality of Life Adapted from Fero TJ, Schwartz DB. Clinical Pulmonary Medicine. Vol 12, July 2005
Myers J et al, NEJM 2002; 346:793-801 Risk of Death - Exercise Capacity Risk of death in subjects with risk factors and exercise capacity of <5 MET or 5-8 MET, compared with subjects with capacity >8 MET (MET = VO 2 3.5 ml/kg/min)
Physical Activity in COPD Trooster T, et al. Respir Med 2010; 104:1005-1011.
Physical Activity in COPD Active Sedentary Inactive 163 COPD (GOLD stages 1-4) and 29 Chronic Bronchitis (former GOLD 0) subjects Watz H, et al. Eur Respir J 2009; 33:262-72.
What is Pulmonary Rehabilitation? Joint ACCP/AACVPR Statement on Pulmonary Rehabilitation. CHEST 2007.
Components of a Pulmonary Rehabilitation Program
Pulmonary Rehabilitation Activity limitation and shortness of breath are the cardinal symptoms of COPD All COPD patients should be encouraged to exercise regularly Pulmonary Rehabilitation is indicated for patients disabled by respiratory symptoms despite optimal medical treatment Potential benefits to patients with COPD include: Reduces shortness of breath, improves exercise capacity and health-related quality of life Decreases hospitalizations and healthcare utilization Reduces anxiety and depression Benefits extend beyond the period of training Improves survival Ries AL, et al. Chest 2007; 131:4-42; O Donnell DE, et al. Can Resp J 2007, 14:5B-32B; Marciniuk DD, et al. Can Resp J 2010; 17:159-168; Hailey D, et al. CADTH, 2010; 126:1-155.
A Comprehensive Approach to COPD Management Lung function impairment MRC Dyspnea Long-acting bronchodilator(s) PRN short-acting Rapid bronchodilators Surgery Oxygen Inhaled corticosteroids/laba Pulmonary rehabilitation Smoking cessation/exercise/self-management/education Mild II Very Severe V Early Diagnosis (Spirometry) + Prevention Prevent/Rx AECOPD Follow-up End of Life Care O Donnell DE, et al. Can Resp J 2008; 15:1A-8A.
Casaburi R, et al. Chest 2005; 127:809-817 Combined Pulmonary Rehabilitation and LABD
Practical Considerations Patient selection Disease severity considerations Screening and safety Program design and delivery Initiation and maintenance phases Team members Need a minimum of two health care professionals Program evaluation and outcomes Symptoms/ exercise capacity / quality of life /health resource use
Citation: Marciniuk D et al. (2010). Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease practical issues: A Canadian Thoracic Society Clinical Practice Guideline. Canadian Respiratory Journal, 17(4), 159-168.
Optimizing Pulmonary Rehabilitation Expert working group panel, utilizing a systematic review process to derive evidence-informed recommendations Panel developed 6 PICO questions of clinical interest Patient-related outcomes of interest included: Reduced dyspnea, improved exercise capacity, improved activity, decreased exacerbations, decreased health care utilization, improved quality of life/health status, reduced healthcare costs Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Optimizing Pulmonary Rehabilitation Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 1: Are non-hospital based pulmonary rehabilitation programs as effective as hospitalbased pulmonary rehabilitation programs in patients with COPD? Recommendation #1: There are no differences in major patient-related outcomes of PR between non-hospital (community/home sites) or hospital-based sites. It is strongly recommended that all patients should have access to PR programs regardless of program site. (Grade of Recommendation: 1A) Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 1: Site of Rehabilitation 252 patients Group education program Exercise 2 months Maintenance 10 months Home rehabilitation Outpatient rehabilitation Randomization Maltais et al. Can Respir J. 2005;12:193-198.
Question 1: Site of Rehabilitation Maltais, et al. Ann Intern Med. 2008; 149:869-78.
Question 2: Does adding resistance training (RT) to an aerobic training (AT) protocol improve outcomes in individuals with COPD? Recommendation #2: AT + RT is more effective than AT alone in improving endurance and functional ability. While AT is the foundation of PR, it is recommended that both AT and RT be prescribed to COPD patients. (Grade of Recommendation: 2B) Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Characteristics of Patients Question 2: AT + RT Study Gp n M:F Age, yrs FEV 1, % pred BMI, kg/m 2 Phillips AT 9 1:8 70±6 33±19 26± 4 2006 A+RT 10 4:6 71±3 42±10 29± 6 Panton 2004 Mador 2004 Ortega 2002 Bernard 1999 AT 8 2:6 63±8 40±32 30± 7 A+RT 9 6:3 61±7 42±16 33± 10 AT 13-68±7 40±14 28± 1 A+RT 11-74±6 44±13 28± 7 AT 16 14:2 66±6 41±11 A+RT 14 13:1 60±9 33±12 AT 15 11:4 67±9 39±12 25±4 A+RT 21 17:4 64±7 45±15 27±5
Characteristics of Interventions Study Gp Resistance component/sham Exercise Aerobic Phillips AT 2006 Panton 2004 A+R T Question 2: AT + RT Free weight dumbbell exercises: for arms and trunk Add: goal of achieving 16-18 reps for each exercise. 2x/wk for 8 weeks. Load increased with 18 reps completed without distress. Targeted legs, arms and trunk: 10 reps per exercise, beginning with light load (50% 1 Rep Max for Chest and Leg Press). 2x/wk for 8 wks (3 of 16 sessions used for strength testing). Intensity progressed 5-10%. UE or LE erg or TM or Recumb Step @ RPE < 13, RPB 3, SaO2 90%, 20-40 min, 2x/wk for 8 wks. Intensity increase toward goal of 20-40 min constant aerobic exercise. AT AT: 30min light free-weight or dowel chair aerobics UE or LE erg or Airdyne A+R T Total 45-60min; trageted legs, arms, trunk: work up to 12 reps x 3 sets, 2x/wk (total 4x/wk) for 12 wks. Intensity progressed. Cycle or TM or indoor track walking: @ 50-70% cardiac reserve, 30 min, 2x/wk for 12 weeks
Characteristics of Interventions Study Gp Resistance component/sham Exercise Aerobic Mador 2004 AT Calesthenics with small weights. Not clear whether total time for exercises was matched to A+RT A+R T Ortega 2002 Bernar d 1999 AT A+R T AT A+R T Question 2: AT + RT Arm, leg and trunk exercise:10 reps x 1 set @ 60% 1 Rep Max for each exercise, 3x/wk for 8 weeks. Intensity progressed AT: performed twice the time of aerobic exercise compared to A+RT Targeted arms, legs, and trunk.: 6-8 reps x 2 sets @ 70-85% of 1 Rep Max. Intensity progressed 45 min sham exercise of breathing exercises and relaxation 45 min total; targeted legs, arms and trunk: 8-10 reps x 2 sets @ 60% of 1 Rep Max for each exercise, 3x/wk for 12 weeks. Intensity progressed LE erg or TM @ 50% Wpeak, 20min+, 3x/wk for 8 wks. Intensity was progressed if able to perform 20 min exercise without intolerable dyspnea. LE erg @ 70% Wpeak, 3x/wk for 12 wks. AT: 40 min per session A+RT: 20 min per session LE erg @ 80% Wpeak, 30 min, 3x/week for 12 wks.
Question 2: AT + RT Training Protocols Of the 5 articles that compared AT versus A+RT, none applied similar training protocols (Table 1). For aerobic training, all studies used lower extremity training for 20-40 minutes per session, 3x per week, for 8 weeks. For resistance training, all studies had participants perform strengthening exercises for the upper and lower extremities using variable resistance machines. the volume of exercise for the AT and A+RT groups was not always well matched in the different studies.
Question 2: AT + RT Strength Outcomes Knee Extensors Knee Extension or Leg Press Study or Subgroup Bernard 1999 Mador 2004 Ortega 2002 Panton 2004 Phillips 2006 Mean 4-1 8 4.1-3.2 AT A+RT Mean Difference Mean Difference SD 14 10.8 6 17.9 5.4 Total 15 13 16 8 9 Mean 10 9 19 22.9 9.1 SD 20 16.6 5 22.9 18 Total 21 11 14 9 10 Weight 9.0% 8.5% 71.5% 2.9% 8.1% IV, Random, 95% CI -6.00 [-17.11, 5.11] -10.00 [-21.43, 1.43] -11.00 [-14.94, -7.06] -18.80 [-38.23, 0.63] -12.30 [-24.00, -0.60] IV, Random, 95% CI Total (95% CI) 61 65 Heterogeneity: Tau² = 0.00; Chi² = 1.46, df = 4 (P = 0.83); I² = 0% Test for overall effect: Z = 6.36 (P < 0.00001) 100.0% -10.80 [-14.13, -7.47] -50-25 0 25 50 Favours A+RT Favours AT
6 Minute Walk Distance (Meters) Question 2: AT + RT Exercise Capacity Study or Subgroup Bernard 1999 Mador 2004 Ortega 2002 Panton 2004 Phillips 2006 Mean 66 26.2 39-2 61.9 AT A+RT Mean Difference Mean Difference SD 78 32.3 99 226 73.1 Total 15 13 16 8 9 Mean 88 33.5 59 208 68 SD 81 35.1 145 219 51 Total 21 11 14 9 10 Weight 16.7% 62.5% 5.7% 1.0% 14.1% IV, Random, 95% CI -22.00 [-74.52, 30.52] -7.30 [-34.48, 19.88] -20.00 [-110.12, 70.12] -210.00 [-422.12, 2.12] -6.10 [-63.37, 51.17] IV, Random, 95% CI Total (95% CI) 61 65 Heterogeneity: Tau² = 0.00; Chi² = 3.67, df = 4 (P = 0.45); I² = 0% Test for overall effect: Z = 1.13 (P = 0.26) 100.0% -12.39 [-33.87, 9.09] -100-50 0 50 100 Favours A+RT Favours AT
Question 2: AT + RT Exercise Capacity Peak Work on Maximal Cycle Ergometer Test (watts) Study or Subgroup Bernard 1999 Mador 2004 Ortega 2002 Mean 8 5 11 AT A+RT Mean Difference Mean Difference SD 18 37.1 12 Total 15 13 16 Mean 7 8 5 SD 23 34.9 17 Total 21 11 14 Weight 35.8% 7.7% 56.5% IV, Random, 95% CI 1.00 [-12.41, 14.41] -3.00 [-31.85, 25.85] 6.00 [-4.67, 16.67] IV, Random, 95% CI Total (95% CI) 44 46 Heterogeneity: Tau² = 0.00; Chi² = 0.54, df = 2 (P = 0.76); I² = 0% Test for overall effect: Z = 0.86 (P = 0.39) 100.0% 3.52 [-4.50, 11.54] -50-25 0 25 50 Favours A+RT Favours AT
Question 2: AT + RT Summary of Outcomes Meta-analyses that compared A+RT to AT showed: Greater improvements in knee extensor and pectoralis strength (p<0.00001 and p<0.0006, respectively). A tendency for greater improvements in functional tasks for the lower (sit-to-stand; p=0.10) and upper extremities (reach test or arm raise; p=0.14). Similar improvement in the 6MWD (p=0.26) and peak work rate on a maximal cycle ergometer test (p=0.39).
Question 2: AT + RT Take Home Messages Adding resistance training to aerobic training during pulmonary rehabilitation in COPD: Induces significant improvements in strength specific to the muscle groups trained. Does not compromise improvements in aerobic outcomes. May improve function if the muscle groups that undergo strength training match the functional needs of the patient.
Question 3: Does continuing PR beyond the typical program length (i.e. 6-8 weeks) improve outcomes in COPD patients compared with a standard duration PR program? Recommendation #3: It is recommended that longer duration pulmonary rehabilitation programs, beyond 6 8 weeks duration, be provided for COPD patients. (Grade of Recommendation: 2B) Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 3: Program Duration Berry et al. J Cardiopulmonary Rehab. 2003; 23 (1): 60-8.
Question 4: Are pulmonary rehabilitation programs as effective in pts with mild/moderate COPD compared with pts with severe/very severe COPD? Recommendation #4: It is strongly recommended that patients with moderate, severe and very severe COPD participate in pulmonary rehabilitation. (Grade of Recommendation: 1C) Currently, there is insufficient data to make a recommendation regarding patients with mild COPD. Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 4: Disease Severity Patients: COPD classified according to GOLD stage: Group 1 (stage 2a, n=48, FEV1 63±9% pred.) Group 2 (stage 2b, n=53, FEV1 42±6% pred.) Group 3 (stage 3, n=48, FEV1 25±7% pred.) Garuti et al. Monaldi Arch Chest Dis. 2003; 59(1):56-61.
Question 4: Disease Severity Patients: COPD classified according to GOLD stage: Group 1 (stage 2a, n=48, FEV1 63±9% pred.) Group 2 (stage 2b, n=53, FEV1 42±6% pred.) Group 3 (stage 3, n=48, FEV1 25±7% pred.) Garuti et al. Monaldi Arch Chest Dis. 2003; 59(1):56-61.
Question 5: Are pulmonary rehabilitation programs as effective in female compared with male patients with COPD? Recommendation #5: The benefits of Pulmonary Rehabilitation are realized by both women and men. It is strongly recommended that both women and men be referred for Pulmonary Rehabilitation. (Grade of Recommendation: 1C) Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Laviolette et al. Can Respir J. 2007; 14 (2):93-98. Question 5: Gender
Foy et al. CHEST. 2001; 119:70-6. Question 5: Gender
Question 6: Do patients who undergo PR within 1 month of an AECOPD do better than patients who do not undergo PR within 1 month of an AECOPD? Recommendation #6: It is strongly recommended that patients with COPD undergo PR within 1 month following AECOPD due to evidence supporting improved dyspnea, exercise tolerance and HRQL compared with usual care. (Grade of Recommendation: 1B) PR within 1 month following AECOPD is also recommended due to evidence supporting reduced hospital admissions and mortality compared with usual care. (Grade of Recommendation: 2C) Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 6: Timing after AECOPD HRQoL Exercise Capacity Rehab Rehab Usual Care Usual Care Behnke et al. Monaldi Arch Chest Dis. 2003; 59:44-51.
Question 6: Timing after AECOPD Hospital Admission Usual Care Medication Use Usual Care Rehab Rehab Behnke et al. Monaldi Arch Chest Dis. 2003; 59:44-51.
Question 6: Timing after AECOPD Hospital Admission Puhan et al. Cochrane Database Syst Rev. 2009; 1:CD005305.
Question 6: Timing after AECOPD Mortality Puhan et al. Cochrane Database Syst Rev. 2009; 1:CD005305.
Marciniuk DD, et al. Can Resp J 2010; 17:159-168 Summary of Recommendations
Discussion Highlights Systematically reviewed the evidence and utilized the experience of a representative inter-professional panel of experts Numerous gaps in our understanding and practices to optimize pulmonary rehabilitation remain: Maintenance programming, exercise intensity, incremental benefits of various program components, contributions and management of comorbidities, various adjunct training techniques (altered inspired gases, NIVS, NMES, hormones), participation barriers, adherence, and others. Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Discussion Highlights Access and adherence were highlighted as significant challenges: there is an immediate urgency for these obstacles to be addressed and removed. It is not acceptable for health care providers, patients and health care systems to accept the current status quo the benefits cannot be ignored PR must be accepted as an integral component of COPD chronic disease management: barriers to participation in PR and burdens of therapy must be acknowledged and minimized. Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Pulmonary Rehabilitation Resources Online: www.copdtoolkit.org www.respiratoryguidelines.ca www.chestnet.org www.goldcopd.org Textbooks: Pulmonary Rehabilitation. (2005). Eds: Donner, Ambrosino, Goldstein. Hodder Arnold, London. Publications: Ries AL, et al. (2007). Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest, 131, 4-42.
For More Information: Canadian Thoracic Society c/o The Lung Association National Office 1750 Courtwood Crescent, Suite 300 Ottawa, ON K2C 2B5 Kristen Curren kcurren@lung.ca (613) 569-6411, ext. 266 www.lung.ca/cts www.respiratoryguidelines.ca