Pulmonary Rehabilitation In COPD Dr. AKM Mosharraf Hossain Internist & Pulmonologist Drmosharraf_hossain@yahoo.com Mosharraf Hossain 06/11/2010

What is Pulmonary Rehabilitation? Pulmonary rehabilitation is an essential component of the comprehensive management of COPD patients “…a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patient’s physical and social performance and autonomy.” (NICE) Pulmonary rehabilitation can change outcomes that predict survival Mosharraf Hossain 06/11/2010

Global impact of copd The estimated prevalence of COPD varies from 7 to 19% in several well-conducted studies, The total number of cases of COPD in the world approximates 280 million persons, COPD was the 6th cause of death worldwide in 1990, by 2002 the ranking had risen to 5th, by 2030, COPD would become the 4th leading cause of death worldwide (WHO), The burden of COPD in Asia is currently greater than that in Western countries. Mosharraf Hossain 06/11/2010

Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 Proportion of 1965 Rate 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes 2.5 2.0 1.5 1.0 0.5 –59% –64% –35% +163% –7% 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 Source: NHLBI/NIH/DHHS

Copd is a treatable disease Mosharraf Hossain 06/11/2010

GOLD Therapy at Each Stage of COPD Gold Guidelines: COPD Treatment by Stage All Stages Active reduction of risk factor(s): influenza vaccination Add short-acting bronchodilator (when needed) Moderate through Very Severe Add regular treatment with one or more long-acting bronchodilators (when needed): Add pulmonary rehabilitation Severe through Very Severe Add inhaled glucocorticosteroids if repeated exacerbations Add long term oxygen if chronic respiratory failure C o n s i d e r s u r g i c a l t r e a t m e n t s L u n g T r a n s p l a n t a t i o n L u n g V o l u m e R e d u c t i o n S u r g e r y ( L V R S ) Key Communication Points: B r o n c h o d i l a t o r s a r e c e n t r a l t o t h e s y m p t o m a t i c m a n a g e m e n t o f C O P D a c r o s s a l l s t a g e s .   T h e y c a n b e i n h a l e d a s a e r o s o l s p r a y s o r v i a n e b u l i z a t i o n T h e e f f i c a c y o f i n h a l e d g l u c o c o r t i c o s t e r o i d s c o n t i n u e s t o b e u n d e r s t u d y , h o w e v e r s h o r t - t e r m b e n e f i t h a s b e e n d e m o n s t r a t e d .   ALA COPD Fact Sheet, Global Initiative for Chronic Obstructive Pulmonary Disease.  Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease, 2003. GOLD Therapy at Each Stage of COPD FEV1/FVC <0.70 FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure FEV1/FVC <0.70 FEV1 ≥80% predicted FEV1/FVC <0.70 30% ≤FEV1 <50% predicted FEV1/FVC <0.70 50% ≤FEV1 <80% predicted I: Mild II: Moderate III: Severe IV: Very Severe Active reduction of risk factor(s): influenza vaccination Add short-acting bronchodilator (when needed) Add regular treatment with one or more long-acting bronchodilators Add pulmonary rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments Global Initiative for Chronic Obstructive Lung Disease (GOLD). NHLBI/WHO Workshop report. www.goldcopd.com 6

benefits Improved exercise capacity (Evidence A) Improved health-related quality of life (Evidence A) Reduced perceived intensity of breathlessness (Evidence A) Reduced hospitalisations and length of stay (Evidence A) Reduced anxiety and depression associated with COPD (Evidence A) Increased survival (Evidence B) Benefits probably extend well beyond the period of rehab, especially if exercise is maintained at home (Evidence B) Improved psychological wellbeing (Evidence C) Mosharraf Hossain 06/11/2010

Development of Disability in COPD The decline in lung function may go unnoticed initially as people avoid exertion for dyspnoea Up to 50% of FEV1 may be lost before a person develop significant symptoms Significant disability develops late in the course of the disease when reversal of airway obstruction is not possible. Dyspnoea , Limb muscle dysfunction, hypoxaemia, poor nutrition, steroid myopathy and loss of confidence may contribute to disability Mosharraf Hossain 06/11/2010

Vicious cycle of Disability Mosharraf Hossain 06/11/2010

Pulmonary rehabilitation components General exercise training Breathing retraining Education Nutritional advice Psychological support Mosharraf Hossain 06/11/2010

Exercise Training Pulmonary rehabilitation general exercise training include: a) Upper limb endurance training, b) Upper limb strenthening training, c) Lower limb endurance training, d) Lower limb strenthening training, e) Flexibility and stretching exercise f) Balancing exercise Usually 4-10 weeks, daily to weekly Lower limb training improves exercise tolerance though no effect on measured lung function Upper limb training improves arm strength and reduces ventilatory demand Mosharraf Hossain 06/11/2010

Flexibility exercise Flexibility of the joints in the spine (particularly the thoracic spine) is important for people with respiratory disorders to enable thoracic mobility when breathing.   Gently rotate the trunk side to side as far as possible Mosharraf Hossain 06/11/2010

Stretching pectoral muscles Stand in the corner or in a doorway with your hands at shoulder level and your feet away from the corner or doorway Lean forward until a comfortable stretch is felt across the chest Mosharraf Hossain 06/11/2010

Stretching hamstring muscles Sit on the bed ■ Lean forward and slowly straighten your knee until you feel a stretch at the back of your thigh Mosharraf Hossain 06/11/2010

Stretching triceps Lift your arm so that your elbow is next to your ear. Place your hand between your shoulder blades. Gently push your elbow back with your other hand until you feel a stretch. Mosharraf Hossain 06/11/2010

Upper limb endurance training Hold a bar with hands at knee height. Lift bar above head, then lower. Breathe in while lifting bar up and out while lowering bar down. Mosharraf Hossain 06/11/2010

Upper limb endurance training Start with arms by your sides. Lift your arms until they are at shoulder height (breathe in while you do this). Move arms forwards to meet in the middle, keeping elbows straight (breathe out while you do this). Reverse the movement until the arms are horizontal at shoulder height (breathe in while you do this). Return arms to your side again (breathe out while you do this). Mosharraf Hossain 06/11/2010

Upper limb strength exercise Hold a weight in each hand at shoulder height. With one arm, lift the weight straight up and down. Breathe in while lifting the weight up, and breathe out while lowering the weight down. Repeat the exercise with your other arm. Fig 1: Arm exercise Mosharraf Hossain 06/11/2010

Upper limb strength exercise Start with your arms by your sides. Bend your arm at the elbow to lift your hand towards your shoulder, then lower. Repeat the exercise with your other arm. Add hand weights as necessary. This exercise can also be done in the sitting position. Fig2: Biceps Mosharraf Hossain 06/11/2010

Upper limb strength exercise Start with holding a weight in each hand on your lap. Lift both arms out to the side, but not above your shoulders (move your arms as if you were “spreading your wings”). Keep your elbows slightly bent during the exercise. Breathe in while you move your arms up, and breathe out as you lower your arms. Fig3: Arm exercise Mosharraf Hossain 06/11/2010

Lower limb endurance training Mosharraf Hossain 06/11/2010

Lower limb strength training Climbing stairs Increase the number of steps. Increase the height of the step (or walk up two steps at a time). Carry a weight on your back. Mosharraf Hossain 06/11/2010

Lower limb strength exercise Knee extension sitting Sit in a chair. Straighten your knee. Hold the knee straight for five seconds, and then relax. Repeat for other leg. Progression: Add weights to legs. Squats Lean your back against a wall. Squat down until your thighs are parallel with floor. Slide up the wall to a standing position. Start with only sliding down a short way. Progression: Increase depth of slide down. Mosharraf Hossain 06/11/2010

Breathing retrainig Retraining with breathing techniques which decrease breathing frequency, such as Yoga and pursed lip breathing, have in some studies led to increases in tidal volume and oxygen saturation, and a reduction in dyspnea. Diaphragmatic breathing strenghthens diaphragm, reduces energy of breathimg; but conflicting evaluation shows increase work of breathing and dyspnoea Mosharraf Hossain 06/11/2010

Purse lip breathing Sit down, straight but relaxed Breathe in preferably through the nose Purse lips slightly, as if whistle Breathe out slowly through pursed lips Do not force air out Mosharraf Hossain 06/11/2010

Diaphragmatic breathing Lie on your back in a bed with knees bent Place one hand on abdomen, other hand upper chest As you inhale through nose make your stomach move out As you exhale through pursed lips let your stomach fall in Your upper chest must remain as still as possible Practice 3-4 times, 5-10 mins daily Mosharraf Hossain 06/11/2010

yoga The "complete breath" in yoga incorporates all three areas of your lungs, which helps 1)diaphragmatic breathing, 2) oxygenation of blood, 3) prevent air trapping in the lungs, and 4) relaxes the mind and body. Mosharraf Hossain 06/11/2010

Location of training Hospital based Community based Home based Mosharraf Hossain 06/11/2010

Hospital-based programs Hospital based programs has the advantage of providing direct communication with respiratory physicians and other healthcare professionals. This may be the most appropriate option for patients with very severe disease and/or complex comorbid conditions. Sometimes provided for patients recovering from an acute exacerbation. Mosharraf Hossain 06/11/2010

Community-based programs Community-based programs are centre-based programs run in community settings (eg leisure centres; halls, health or rehabilitation centres; senior citizens centres or private practices).  These programs may be run by hospital/community health staff, or may use clinicians in community practices (eg GPs, practice nurses, private practice clinicians). Mosharraf Hossain 06/11/2010

Home training Started within 1-2 weeks after commencing the supervised training program to allow any difficulties undertaking the home program to be discussed and resolved during the supervised period. Performed on 2 or 3 days per week (i.e. in addition to the 2 or 3 days that the patient is attending the supervised training program). In total, the patient should exercise 4 or 5 days per week Walking for 30 minutes at the same pace as in the supervised program. Mosharraf Hossain 06/11/2010

Importance of Education Education to improve compliance in medication, oxygen therapy, smoking cessation, nutrition, exercise, and health preservation. Education in an interactive session is more effective than didactic teaching. Education helps patients to become active participants in their health care Mosharraf Hossain 06/11/2010

Use of Supplemental Oxygen Oxygen saturation should be regularly monitored using a pulse oximeter Patients who desaturate below an oxygen saturation of 88% during exercise training, despite the use of interval training, should be assessed to determine the benefit of supplementary oxygen.  Assessment for supplementary oxygen is done by providing oxygen via nasal prongs at a flow rate of 2-4 L/min. If the patient shows improved oxygen saturation or improved exercise tolerance or reduced dyspnoea when using oxygen, supplementary oxygen should then be given in future exercise training sessions. Specific exercises that often cause desaturation include moderate to high intensity walking, climbing stairs, doing step-ups and sit-to-stand. Patients receiving LTOT, increase the flow rate by 1-2 L/min, above the prescribed flow rate, when the patient is exercising. Mosharraf Hossain 06/11/2010

Psychological components COPD is associated with anxiety and depressive symptoms which may interfere with activities of daily living (ADL’s) and sexuality Protracted psychological counselling is not necessary About 15 to 20 rehabilitation sessions that include education, exercise breathing techniques, and relaxation techniques are more effective Occasionally, it may be necessary to administer short courses of antidepressant medications Mosharraf Hossain 06/11/2010

Nutritional counselling Both overweight and underweight can be a problem 25% of patients with moderate to severe COPD show a reduction in BMI which is an independent risk factor for mortality in COPD Reasons for difficulty eating should be explored: poor dentition, dyspnoea whilst eating Frequent small meals with low carbohydrate are usually advised. Mosharraf Hossain 06/11/2010

OUTcome Assessment Exercise capacity measurement Providing patients with an opportunity to give feedback about the program is a useful measure of quality control.  Patient feedback also allows coordinators to evaluate the components of pulmonary rehabilitation that patients find most useful. The questionnaire should also provide patients with a variety of answering options Exercise capacity measurement Mosharraf Hossain 06/11/2010

Pulmonary rehabilitation? Comprehensive COPD care Smoking cessation ? Pulmonary rehabilitation? Non-invasive ventilation? Mosharraf Hossain 06/11/2010

All the best Mosharraf Hossain 06/11/2010

Mosharraf Hossain 06/11/2010