Pulmonary

Rehabilitation
Presented by
Wyatt E. Rousseau, MD
May 14, 2009
 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
 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; 11:681-686.
 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.
 Pulmonary
Rehabilitation
Candidates
Any patient with impairment
because of lung disease and who is
motivated should be a candidate for
pulmonary rehabilitation.
 Pulmonary Rehabilitation
Common Indications for
Referral to Pulmonary Rehabilitation
Anxiety engaging in activities
Breathlessness with activities
Limitations Social, Leisure, Chores, ADLs
Loss of Independence
Especially those whose dyspnea is out of
proportion to lung function or those with primarily
leg fatigue limiting exercise
 Pulmonary Rehabilitation
Common conditions COPD
leading to referral to Bronchiectasis
pulmonary
Chronic Asthma
rehabilitation
Post surgery
ILD
Neuromuscular Disease
Cystic Fibrosis
Exacerbations
 Pulmonary Rehabilitation
Contraindications
PSYCHIATRIC MEDICAL
Dementia Unstable cardiac
Organic Brain Substance abuse
Syndrome Cancer (relative)
Liver Failure
Neurologic or
Orthopedic condition
preventing ambulation
 Pulmonary Rehabilitation
Effect on Exercise Capacity
from Lacasse,Y et.al. Lancet 1996; 348:1115
Pulmonary Rehabilitation

Education

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

Physical Therapy
Occupational Therapy
Respiratory Therapy
 Pulmonary Rehabilitation-
Education
Diagnosis
Physician
Pulmonary Function Tests
Spirometry
ABGs
Diffusing Capacity
Inhalation Challenge
Exercise Testing
Cardiac Tests
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)
 Pulmonary Rehabilitation-Education
Pharmacology

OXYGEN
BRONCHODILATORS
Beta-agonists, LA and SA
Anticholinergics, LA and SA
Theophylline, other PDEIs
ANTI-INFLAMMATORY
Corticosteroids
Leukotriene Antagonists
Pulmonary Rehabilitation-Education &
Exercise
Respiratory Therapy

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

MAXIMIZE FUNCTIONAL INDEPENDENCE

Exercise
Energy conservation
Oxygen
Adaptive devices
 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.
2009:135:609-618.
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.
 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.
 Pulmonary Rehabilitation-Education &
Exercise
Occupational Therapy

MAXIMIZE FUNCTIONAL INDEPENCENCE

Exercise
Energy conservation
Self care
Adaptive devices
 Pulmonary Rehabilitation-Education
Nutrition

WEIGHT MANAGEMENT
DIETS
Supplements
Restrictions
VITAMINS/ADDITIVES
 Pulmonary Rehabilitation-Education
Psychosocial Issues

INSURANCE/REIMBURSEMENT
QUALITY OF LIFE CONCERNS
SOCIAL SITUATION
CHAPLAIN CONSULTATION
ETHICS ISSUES
 Pulmonary Rehabilitation
INPATIENT
ADVANTAGES DISADVANTAGES
24 hour nursing care Cost and insurance
Sicker patients difficulties
No transportation Not suitable for less
problems severe patients
Family participation Family transportation
Best for ventilator, problems
tracheostomy patients
 Pulmonary Rehabilitation
OUTPATIENT

ADVANTAGES DISADVANTAGES
Widely available Potential
Less costly transportation
Least intrusive to problems
family Cannot observe home
Efficient use of staff activities
 Pulmonary Rehabilitation
HOME - BASED
ADVANTAGES DISADVANTAGES
Convenience to Cost/insurance issues
patient Lack of group support
Transportation no Lack of full spectrum
issue of multidisciplinary
Exercise in familiar personnel
environment may lead
to better adherence
long term
 Pulmonary Rehabilitation
Adverse Effects

Musculoskeletal injury
Exercise-induced bronchospasm
Cardiovascular event (increased risk
among COPD patients)
 Pulmonary Rehabilitation
Exercise Effect
Data from Am J Respir Crit Care Med 1999; 159;321
 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; 360:1329-
1335.
 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