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

7. Background 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

8. Pathophysiology 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:

9. Pulmonary Rehabilitation
Evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily activities. It is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs by stabilizing or reversing systemic manifestations of the disease.
Nici, L et.al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390.

10. Pulmonary Rehabilitation
Candidates
Any patient with impairment because of lung disease and who is motivated should be a candidate for pulmonary rehabilitation.

11. Pulmonary Rehabilitation Common Indications for Referral 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

12. Pulmonary Rehabilitation
Common conditions leading to referral to pulmonary rehabilitation
COPD
Bronchiectasis
Chronic Asthma
Post surgery
ILD
Neuromuscular Disease
Cystic Fibrosis
Exacerbations

13. Pulmonary Rehabilitation Contraindications
PSYCHIATRIC
Dementia
Organic Brain Syndrome
MEDICAL
Unstable cardiac
Substance abuse
Cancer (relative)
Liver Failure
Neurologic or Orthopedic condition preventing ambulation

14. Pulmonary Rehabilitation Effect on Exercise Capacity from Lacasse,Y et
Pulmonary Rehabilitation Effect on Exercise Capacity from Lacasse,Y et.al. Lancet 1996; 348:1115

15. Pulmonary Rehabilitation
Education
Exercise

16. Pulmonary Rehabilitation Education
Diagnosis
Smoking Cessation
Pharmacology
Respiratory Therapy
Physical Therapy
Occupational Therapy
Therapeutic Recreation
Nutrition
Psychosocial

17. Pulmonary Rehabilitation Exercise
Physical Therapy
Occupational Therapy
Respiratory Therapy

18. Pulmonary Rehabilitation-Education Diagnosis
Physician
Pulmonary Function Tests
Spirometry
ABG’s
Diffusing Capacity
Inhalation Challenge
Exercise Testing
Cardiac Tests

19. Pulmonary Rehabilitation-Education Smoking Cessation
Counseling (Ask, Advise, Assess, Assist, Arrange F/U)
Nicotine Replacement
Anxiolytic/Antidepressant
Varenicline
Support (Quit date, past quit experience, challenges, other smokers)

20. Pulmonary Rehabilitation-Education Pharmacology
OXYGEN
BRONCHODILATORS
Beta-agonists, LA and SA
Anticholinergics, LA and SA
Theophylline, other PDEI’s
ANTI-INFLAMMATORY
Corticosteroids
Leukotriene Antagonists

21. Pulmonary Rehabilitation-Education & Exercise Respiratory Therapy
Breathing Techniques
Pursed lip
Diaphragmatic
Medication Delivery Systems
Peak Flow Measurement
Self Management

22. Pulmonary Rehabilitation-Education & Exercise Physical Therapy
MAXIMIZE FUNCTIONAL INDEPENDENCE
Exercise
Energy conservation
Oxygen
Adaptive devices

23. Exercise - 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:
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.

24. Exercise - 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.

25. Pulmonary Rehabilitation-Education & Exercise Occupational Therapy
MAXIMIZE FUNCTIONAL INDEPENCENCE
Exercise
Energy conservation
Self care
Adaptive devices

26. Pulmonary Rehabilitation-Education Nutrition
WEIGHT MANAGEMENT
DIETS
Supplements
Restrictions
VITAMINS/ADDITIVES

27. Pulmonary Rehabilitation-Education Psychosocial Issues
INSURANCE/REIMBURSEMENT
QUALITY OF LIFE CONCERNS
SOCIAL SITUATION
CHAPLAIN CONSULTATION
ETHICS ISSUES

28. Pulmonary Rehabilitation INPATIENT
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

29. Pulmonary Rehabilitation OUTPATIENT
ADVANTAGES
Widely available
Less costly
Least intrusive to family
Efficient use of staff
DISADVANTAGES
Potential transportation problems
Cannot observe home activities

30. Pulmonary Rehabilitation HOME - 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

31. Pulmonary Rehabilitation Adverse Effects
Musculoskeletal injury
Exercise-induced bronchospasm
Cardiovascular event (increased risk among COPD patients)

32. Pulmonary Rehabilitation Exercise Effect Data from Am J Respir Crit Care Med 1999; 159;321

33. Effect of Therapy- Does Not improve lung mechanics or gas exchange, but optimizes other 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:

34. Pulmonary Rehabilitation Benefits 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