1. Implementing Pulmonary Rehabilitation in Low Resource Settings
Rupert Jones
Senior Clinical Research Fellow
Plymouth School Of Medicine

2. The dream- Rehab in Africa for chronic lung disease
Rehab is effective improving :
quality of life
exercise tolerance,
health care consumption,
exacerbations
mortality
Uses local resources no expensive imports
Sustainable
Scalable
Addresses forgotten message that non-drug treatments work

3. Previous experience Started PR in 1997 in my practice in Plymouth
Helped establish PR in other sites in UK, Denmark & Norway
IPCRG central to this
Edinburgh curry house 2012

4. Environment Wanted to develop a culturally appropriate model
Came to Mulago hospital spoke to consultants, physios, nurses, researchers… even the Director.
Culturally appropriate, but they wanted something conventional

5. Mulago Hospital Pilot phase
Feasibility acceptability
Clarifying
Recruitment and retention
Assessment
Safety and outcome
Intervention
Data management
Barriers and facilitators / improvements

6. Post TB consultations at Mulago Hospital approx 20% of outpatient respiratory consultations
Symptoms
Number
(n=106)
Percent
Cough 68 64
Chest pains 42 40
Haemoptysis 24 23
Dyspnoea 18 17
Weight loss 14 13
No treatment for post TB symptoms
Many get unnecessary, expensive and ineffective rept TB Rxs
Disability & Stigma destroys peoples lives

7. Patients- Who needs it in LMICs?
Any chronic lung disease with persistent breathlessness
“COPD” relates to tobacco / biomass smoke and infections
Post TB in specific countries
Identification
Referral process

8. Entry criteria standard
MRC dyspnoea scale 2 or higher
Previous TB treatment or confirmed COPD diagnosis
No unstable cardiovascular disease, locomotor difficulties that preclude exercise training
Exclusion criteria:
Smear positive TB for those with previous TB treatment
Unwilling or unable to attend a PR programme
Unable to provide informed consent.

9. Getting started Work with experienced rehab experts
Work with respiratory leaders
Access to Patients
Access to physios
Access to research experience / data management
Suitable venue
Key attribute for the team is enthusiasm

10. Getting started - money
Get funding for a pilot project:
Health service (special pots eg winter pressures money/ development funds)
Research grants
Charities
Don ‘t wait for money for pilot,
get it started and the money will come

11. Equipment and venue Low level equipment Space for:
Venue accessible and cool
Space for:
exercise circuit
shuttle walking tests (10m) or
Access, phone
Resuscitation equipment 13

12. The team Multidisciplinary team comprising:
Medical leader
Exercise practitioner/physio
Respiratory nurse specialist
Co-ordinator
Data management
Staff : participant ratios according to risk assessment
Volunteers
Exercise
Education US
1:4
1:8 UK
1:16
Nici et al ERS/ATS statement on PR 2005

13. Exercise regime Follow evidenced based guidance: Manuals
Training videos
Support from established programmes
Tailor exercise to setting
Resistance
Endurance
Flexibility
Physio mentoring 12 15

14. Outcome measures
Use standard measures to compare with other programmes
Record before, after and follow up.
Questionnaires-
Disease specific quality of life (CCQ)
PHQ-9
EQ5D
Exercise capacity:
Incremental shuttle walk test
5 times Sit to Stand
Biometrics
Completion rates

15. Developing a toolkit Standard tools adaptable to local circumstances:
Protocols
Screening forms
Assessment forms
Invitation letters
Data collection sheets
Data handling procedures
Exercise regimes
Education materials

16. Training videos Completing case report form
Incremental shuttle walk test
Sit to stand test
Exercise regime
Individual prescribing and
Individual monitoring and increasing

17. Establishing in Crete

18. Summary- the current nightmare
The lungs of the poor are getting more poorly, making the poor poorer
Biomass TB
HIV
Tobacco
Occupational exposure
Outdoor air pollution

19. Potential Large central database Global growth Different formats
2015 Bangladesh
2016 Crete, Vietnam
2017 Kyrgystan
If funding approved
RCTs in Kampala
Zambia, Kenya, Tanzania & Malawi
Potential for many other countries- Benin, Nigeria, Bulgaria, Egypt, Ethiopia…
Different formats
Manual based and internet based rehab
Post-TB / COPD / Post discharge
Exercise consultations for those unable to attend
Large central database

20. For global expansion, we will follow great leaders!

21. The dream - Rehab in LMICs across the globe
IPCRG led with support from ERS, ELF etc
Scientifically measured, delivered with compassion
“Pulmonary Rehabilitation in Uganda - a life-giving programme for people with chronic lung disease” 
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