Rehab - Pulmonary Rehabilitation Pulmonary Presented by Dr...

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Unformatted text preview: Pulmonary Rehabilitation Pulmonary Presented by: Dr. Vamsi Krishna Rehabilitation Rehabilitation Disease Treatment Impairment Rehabilitation Disability Rehabilitation Handicap Pulmonary Rehabilitation Pulmonary Art of medical practice wherein individually tailored multidisciplinary program is formulated, which through accurate diagnosis, therapy, emotional support and education stabilizes or reverses both physio and psychopathology of pulmonary disease in attempts to return psychopathology the patient to highest possible functional capacity allowed by pulmonary handicap and overall life situation pulmonary American College of Chest Physicians, 1974 American Thoracic Society 1981 ATS – ERS definition (2005) ATS Evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and optimize reduce health care costs through stabilizing or reversing reduce systemic manifestations of the disease systemic History History Charles Denison 1895 After recovery from PTB Walking each day Made him feel better Increased exercise tolerance Reduced respiratory and pulse rate Albert Haas 1932 Carrying heavy books Noticed weight gain Noticed Feeling of well being History History 1965: Eighth ( Thomas L. Petty) Aspen emphysema conference COPD is not a hopeless and inexorably progressive disease and is amenable to emerging therapies 1969: Haas and Cordon first showed benefits of pulmonary rehabilitation over conventional therapy in a cohort study 1974: ACCP definition of pulmonary rehabilitation 1979: Detailed monograph on pulmonary rehabilitation by ACCP in JAMA JAMA Aims of Pulmonary Rehabilitation Aims • Increase exercise tolerance and reduce dyspnea • Increase muscle strength and endurance (peripheral and respiratory) • Improve health related quality of life • Increase independence in daily functioning • Increase knowledge of lung condition and promote self management • Promote long term commitment to exercise Essentials of Pulmonary Rehabilitation Essentials – Exercise training – Education – Nutritional therapy – Psychosocial / Behavioural intervention – Outcome assessment – Promotion of long-term adherence Pathophysiology Pathophysiology Inflammation Cachexia Malnutrition Corticosteroids Atrophy of muscles Reduction in type 1 & 2b type fibers Decreased glycogen stores Inactivity Anxiety Depression Decreased Exercise tolerance Gas exchange limitation Cardiac dysfunction Decreased capillarisation oxidative metabolic capacity Altered metabolism at rest Oxidative stress Respiratory muscle weakness Ventilatory limitation Skeletal muscle dysfunction Exercise training Exercise Benefits of Exercise training Benefits Pathophysiological abnormality Benefits of exercise training Decreased lean body mass Increases fat free mass Decreased TY1 fibers Normalizes proportion Decreased cross sectional area of muscle Increases fibers Decreased capillary contacts to muscle fibers Increases Decreased capacity of oxidative enzymes Increases Increased inflammation No effect Increased apoptotic markers No effect Reduced glutathione levels Increases Lower intracellular pH, increased lactate levels and rapid fall in pH on exercise Normalization of decline in pH Exercise training Exercise Benefits of exercise training ( mainly endurance training) : Improves exercise tolerance Improve motivation for exercise Reduce mood disturbance Decreases dyspnea Strength training improves bulk and strength of muscles but does not add to overall exercise tolerance or health status Exercise training Exercise Components of exercise training: Types of exercise: •Lower extremity exercises •Arm exercises •Ventilatory muscle training •Endurance or aerobic •Strength or resistance Lower extremity exercise Lower Walking Treadmill Treadmill Stationary bicycle Stationary Stair climbing Stair Benefits in COPD Benefits Increased work capability as assessed by incremental treadmill protocol, 6 min walking distance and 12 min walking distance (1,2,3,9,10) (1,2,3,9,10) No increase in peak work rate or VO2 max (1-5) (1 40 – 102% increase in endurance of maximal work rate (6-8) (6 Decreased VO2 at a given exercise level (1) (1) Significant improvement in subjective assessment using Borg dyspnea scale (9,10) (9,10) No changes in hemodynamics during exercise (1) (1) 1.Chester EH. Chest 1977; 72:695-70 3.Cockroft AE. Thorax 1981; 36:200-03 5.Lake FR. Chest 1990; 97:1077-82 7.Reardon J. Chest 1994; 105:1046-52 9.Strijbos JH. Chest 1996; 109:366-72 2.Mc Gavin CR. Thorax 1977; 32:307-11 4.Buscke AJ. Phys Ther 1988; 68:469-74 6.Weiner P. Chest 1992; 102:1351-56 8.Goldstein RS. Lancet 1994;344:1394-97 10.Berry MJ. AJRCCM 1996; 153:1812-16 Intensity of exercise & benefits Intensity Achievements of exercise training are proportional to intensity of exercise Exercising at maximal tolerated intensity led to greater VO2 max. and reduction in blood lactate levels at isomax. exercise. Giminez M. Arch Phys Med Rehabil. 2000;81:102-109 Most of the patients with FEV1 38 %( +/- 13) could 38 achieve exercise intensity of >60% W max (mean max (mean intensity was 60.4% Wmax). But only 5/42 could reach 80% W max. % increase in Wmax was not influenced by FEV 1 (same in FEV1< 40 and FEV1>40%) Maltias F.Am J Respir Crit Care Med.1997;155:555-561 Arm exercise training Arm Arm cycle ergometer Unsupported arm lifting Lifting weights Potential benefits Potential Has the potential to improve arm exercise performance by decreasing ventilatory demand during arm work, and by improving arm endurance. Arm training improves the ventilatory contribution of Arm those muscles by increasing shoulder girdle muscle strength. Banzett RB. Am Rev Respir Dis 1988; 138:106-09 COPD: What does evidence say? COPD: Increases exercise capacity of the arms. Belman MJ. Am Rev Respir Dis 1981;123:256-61 Belman Decreases metabolic and ventilatory demand for similar arm work (measured by Vo2) Couser JI Jr. Chest 1993;103:37–41 Couser Epstein SK. J Cardiopulm Rehabil 1997;17:171–177 Martinez FZ. Chest 1993;103:1397-1402 No significant effect on outcomes, such as functional status and performance when arm training used alone. Lake FR Chest 1990; 97:1077-82 Ries AL. Chest 1988; 93:688-92 Bernard S. Am J Respir Crit Care Med1999;159(3):896-901 Strength exercise Strength When strength exercise was added to standard exercise protocol led to greater increase in muscle strength and muscle mass But NO additional benefit in: NO Exercise capacity as assessed by 6MWD HRQOL Physiological parameters of heart rate or blood lactate levels Bernard M. Am J Respir Ctir Care Med.1999;139:896-901 Ventilatory muscle training Ventilatory Resistive IMT: Patient breaths through hand held device with which resistance to flow can be increased gradually Difficult to standardize the load Patients may hypoventilate. Leads to increased Pulm. Atr. Pressure and fall in oxygen tension Threshold IMT: Threshold Patient breaths through a device equipped with a valve which opens at a given pressure. Easily quantitated and standardized Ventilatory muscle training Ventilatory Isocapnic hyperventilation: Patient hyperventilates into a rebreathing bag so as to maintain pH. Cumbersome and requires CO2 tension monitoring. Cumbersome Predominantly a research tool and not for routine clinical use Meta-analysis of 17 RCTs, demonstrated overall lack of positive treatment effect. But adequate training loads (an intensity of at least 30% of PImax) had showed improvements in respiratory muscle strength and endurance. Smith K. Am Rev Respir Dis.1992;145:533-539 VMT: Conflicting evidence VMT: No additional increase in exercise tolerance by VMT when added to limb exercises although inspiratory muscle strength and endurance had increased Larson JL. Am J Respir Crit Care Med.1999;160: 500-507 Increase in 12 MWD and bicycle exercise endurance compared to limb exercise alone was observed when Threshold IMT was added. Threshold Weiner P. Chest 1992;102:1351-1356 Increased exercise tolerance ( 6MWD) was observed in patients receiving additional Resistance IMT Van Herwardeen CLA. Chest 1991;99:128-133 ATS/ERS statement (2005) ATS/ERS A minimum of 20 sessions should be given. At least three times per week Twice weekly supervised plus one At unsupervised home session may also be acceptable. Once weekly sessions seem to be insufficient Each session to last 30 minutes Each High-intensity exercise (>60% of maximal work rate) produces greater physiologic benefit and should be encouraged; however, low-intensity training is also effective for those patients who cannot achieve this level of intensity ATS/ERS STATEMENT (2005) ATS/ERS Both upper and lower extremity training should be utilized Lower extremity exercises like treadmill and stationary bicycle Lower ergometer & Arm exercises like lifting weights and arm cycle ergometer are recommended The combination of endurance and strength training generally has multiple beneficial effects and is well tolerated; strength training would be particularly indicated for patients with significant muscle atrophy. Respiratory muscle training could be considered as adjunctive Respiratory therapy, primarily in patients with suspected or proven respiratory muscle weakness BTS STATEMENT (2001) BTS A course duration of 4–12 weeks Supervised training sessions 2–5 times per week A session duration of 20–30 minutes A target exercise intensity corresponding to at least 60% of the maximum attained power output or VO2 peak in a preliminary progressive maximal exercise test; Alternatively,60% of the maximal walking speed achieved on the shuttle walk test could be used. Strength training can be offered Respiratory muscle training is not an essential component GOLD 2006 GOLD The minimum length of an effective rehabilitation program is 6 weeks. Daily to weekly sessions Duration of 10 minutes to 45 minutes per session Intensity of 50% of VO2 max to maximum tolerated Endurance training can be accomplished through continuous or interval exercise programs. The latter involve the patient doing the same total work but divided into briefer periods of high-intensity exercise, which is useful when performance is limited by other comorbidities Additional considerations Additional Optimal bronchodilator therapy should be given prior to exercise training to enhance performance. Patients who are receiving long-term oxygen therapy should have this Patients continued during exercise training, but may need increased flow rates. Oxygen supplementation during pulmonary rehabilitation, regardless of Oxygen whether or not oxygen desaturation during exercise occurs, often allows for higher training intensity and/or reduced symptoms in the research setting. ATS/ERS STATEMENT 2005 Reasonable to recommend supplementary oxygen to those showing significant hypoxia ( Spo2 < 90%) during exercise. BTS STATEMENT 2001 Neuromuscular electrical stimulation (NMES) Neuromuscular In severely disabled COPD patients with incapacitating dyspnea, 6 week NMES of muscles involved in ambulation improved muscle strength and endurance, whole body exercise tolerance, and breathlessness during ADL. Neder JA. Thorax 2002;57:333–337 14 COPD patients with Ty 2 RF on MV through tracheostomy tube received NMES as a part of rehabilitation. Significant reduction in duration required for transfer from bed to chair ( 14.33 +/- 2.53 Vs 10.75 +/-2.41) Zanotti E. Chest 2003;124:292–296 NMES may be an adjunctive therapy for patients with severe chronic respiratory disease who are bed bound or suffering from extreme skeletal muscle weakness. ATS/ERS Guidelines 2005 ATS/ERS Non invasive mechanical ventilation Non Proportional assist ventilation while exercise training, enabled a higher training intensity, leading to a greater maximal exercise capacity. Hawkins P. Thorax 2002;57:853–859. Addition of nocturnal domiciliary NPPV in combination with pulmonary rehabilitation in stable COPD patients ( FEV1 0.96 L, PaO2 65.4 and PaCO2 45.6) resulted in improved exercise tolerance and quality of life. Garrod G. Am J Respir Crit Care Med 2000;162:1335–1341. Because NPPV is a very difficult and labor-intensive intervention, it should be used only in those with demonstrated benefit from this therapy. Further studies are needed to further define its role in pulmonary rehabilitation. ATS/ERS guidelines 2005 Bronchial asthma Bronchial A 10-week aerobic conditioning program led to decrease in dyspnea, ventilatory requirement and oxygen consumption for a given level of exercise. Haalstrand TS. Chest. 2000;118:1460-1469 6 week swimming training programme has a beneficial effect on aerobic capacity assessed with bicycle ergometer 4.5 watt Vs 3.8 watt p<0.001) No effect on bronchial airway reactivity measured by histamine response. Matsumoto I. Thorax 1999;54:196-201 Bronchial asthma Bronchial Aerobic exercise training for 8 weeks led to short term decrease in the daily use of inhaled and oral steroids, in moderate to severe disease. Reduction of inhaled steroid dose of fluticasone from 1125 to 575 micro grams per day ( p<0.05). Oral steroids could be withdrawn in all the 4 patients Neder JA.Thorax 1999;54:202-206 Neder Insufficient evidence to suggest that IMT provides any clinical benefit to patients with asthma (review of 5 RCTs) Ram FSF. Eur Respir J 2004; 24: Suppl. 48, 520s Cystic fibrosis Cystic Exercise training Better airway clearance Physical activity augments airway clearance in cystic fibrosis Exercise capacity Cardiovascular fitness Better HRQOL Zach MS. Lancet 1981;2:1200-1203 Anderson B. Acta Pediatrica Scand. 1987;76:70-75 Cystic fibrosis Cystic Regular aerobic exercise attenuates the decline in pulmonary function over a 3-year period compared to a control group Schneiderman-Walker, JJ Pediatr 2000;136,304-310 Review of 3 RCTs suggested addition of exercise to standard physiotherapy halted fall in FEV1 and an increase of FEV1 by 6.4% ( p<0.04) was observed Thomas J. Am J Respir Crit Care Med.1995;151:846-850 Cystic fibrosis Cystic Appropriate vigorous physical exercise enhances cardiovascular fitness, increases functional capacity, and improves quality of life. Pulmonary rehabilitation regimens previously targeted Pulmonary for adults with emphysema and chronic bronchitis will likely prove to be effective in the CF population. Aerobic activities, such as swimming, jogging, and cycling, are recommended Cystic Fibrosis Adult Care - Consensus Conference Report Cystic Chest. 2004;125:1S-39S Idiopathic Pulmonary Fibrosis Idiopathic For motivated patients a combination of exercise training, education, and psychosocial support may help, not by improvements in lung function, which are not likely to occur, but with improvement in exercise tolerance, together with decreased symptoms of breathlessness, improved quality of life ATS/ERS statement on treatment of IPF 1999 Body composition abnormalities: Body interventions Body composition abnormalities Body Increased activity related Energy expenditure Hyper metabolic state Impairment of Energy balance Loss of fat Decreased intake Imbalance in Protein synthesis and breakdown Loss of weight : BMI < 21 •10% weight loss in 6 months •5% weight loss in 1 month Loss of FFM • Anthropometry • Bioimpedence analysis • DEXA Under weight : Low BMI Under One-third of outpatients and up to two thirds of those referred for pulmonary rehabilitation are under weight Enjelen MPKJ. Eur Respir J 1994;7:1793-97 Enjelen Schols AWMJ. Am Rev Respir Dis 1993;147:1151–1156 Underweight patients with COPD have significantly greater impairment in HRQL than those with normal weight Schoup R. Eur Respir J 1997;10:1576–1580 Schoup In COPD, there is an association between underweight status and increased mortality, independent of the degree of airflow obstruction. Schols AWMJ .Am J Respir Crit Care Med 1998;157:1791–1797 Low lean body mass (FFM) Low Because normal-weight patients with COPD and low FFM ( FFM <16 kg/m2 for men and <15 kg/m2 for women) have more impairment in HRQL than underweight patients with normal FFM, this body composition abnormality appears to be an important independent of weight loss Mostert R. Respir Med 2000;94:859–867 Mostert Patients with COPD and reduced FFM have lower exercise tolerance as measured using either 12-minute walk distance (a) or VO2max (b,c) than those with preserved FFM. (a) Mostert R. Respir Med 2000;94:859–867 (a) (b) Baarends EM. Eur Respir J 1997;10:2807–2813 (c) Kobayashi A. Lung 2000;178:119–127 Why intervene? Why High prevalence and association with morbidity and mortality Higher caloric requirements from exercise training in pulmonary rehabilitation, which may further aggravate these abnormalities (without supplementation) Enhanced benefits, which will result from structured exercise training. Body composition abnormalities: Body interventions Increased activity related Energy expenditure Hyper metabolic state Decreased intake Protein supplements Caloric supplements Loss of fat Impairment of Energy balance Imbalance in Protein synthesis and breakdown Loss of weight : BMI < 21 •10% weight loss in 6 months •5% weight loss in 1 month Anabolic steroids Growth hormone Strength exercise Loss of FFM • Anthropometry • Bioimpedence analysis • DEXA Caloric supplementation Caloric Should be considered if : BMI less than 21 kg/m2 Involuntary weight loss of >10% during the last 6 months or more than 5% in the past month Depletion in FFM or lean body mass. May be unsuccessful if : A reduction in spontaneous food intake Suboptimal implementation of nutritional supplements in daily meal and activity pattern Portion size and macronutrient composition of nutritional supplements Presence of systemic inflammation Caloric supplementation Caloric Much of the weight gain with caloric supplementation is in the form of fat but not fat free mass. Schols AM. Am J Respir Crit Care Med 1995;152:1268–127 Meta- analysis of 9 RCTs showed nutritional support alone cannot increase exercise capacity or anthropometric measures Ferreira I M. Chest 2000 117:672–8 Nutritional supplementation combined with supervised exercise training increased body weight and FFM in underweight patients.. Creutzberg EM. Nutrition 2003;19:120–127 Nutritional supplementation Nutritional Energy dense foods Well distributed during the day No evidence of advantage of high fat diet Patients experience less dyspnea after carbohydrate rich supplement than fat rich supplement. (probably due to (probably delayed gastric emptying) Daily protein intake should be 1.5 gm/kg for positive balance Physiological intervention: Strength exercise Physiological Strength exercise 8 weeks of strength exercise lead to increase in FFM ( 52.4 +/- 7.3 to 53.4 +/7.7 kg, p<0.05) Fransen FM. Chest 2004;125:2021–2028 IGF – 1 . Addition of strength training lead to increase in strength and mid thigh circumference (measured by CT) No difference in 6MWD, HRQOL Increased muscle mass ( fat free mass ) Bernard S. Am J Respir Crit Care Med 1999;159:896–901 Pharmacological intervention : Anabolic steroids Pharmacological Anabolic steroids Nandrolone decanoate 50 mg for male 25 mg for females 2 Weekly for 4 doses Anabolic steroids increased lean body mass ( 1.4 +/-2.6 kg, p<0.05) No side effects seen IGF – 1 Anti Glucocorticoid action Erythropoietic action Increase fat free mass Anabolic therapy alone increases muscle mass but not exercise capacity (assessed with 12MWD) Schols AM. Am J Respir Crit Care Med 1995;152:1268–1274 Growth hormone Growth rhGH 0.05 mg/kg for 3 weeks in addition to 35 Kcal/kg and 1gm protein/kg per day has shown to increase fat free mass (1.37 +/0.23 Vs 0.07+/-0.11 kg) significantly. (p<0.01) Pape GS. Chest 1991;99:1495-1500 Daily administration of 0.15 IU/kg rhGH during 3 wk increases lean body mass when assessed in in underweight patients with COPD. at 3 weeks (2.3 +/- 1.6 Vs 1.1 +/- 0.9 kg , p<0.01) and at 8 weeks (1.9 +/- 1.6 Vs 0.7 +/-1.1 kg, p<0.05). But does not improve muscle strength or exercise tolerance ( hand grip and maximal exercise ) and no change in well being of the patient. REE has significantly increased by 107.8% in study group (p<0.001) Burdet C. Am J Respir Crit Care Med. 1997;156: 1800-1806 Testosterone Testosterone Testosterone 100 mg weekly for ten weeks in men with low testosterone levels 320 ng/ml showed weight gain of 2.3 kg Addition of exercise to testosterone has augmented weight gain to 3.3 kg (p<0.001) Casburi R. Am J Respir Crit Care Med.2004;170:870-878 Physiological consequences and long term effects not studied. Body composition abnormalities: Body interventions Intervention Caloric supp. Weight gain FFM gain Exercise capacity + - - Caloric supplementation + exercise training ++ + + Strength exercise - + - Anabolic steroids ++ ++ - Anabolic steroids + exercise ++ +++ ? Guidelines Guidelines Increased calorie intake is best accompanied by exercise regimes that have a nonspecific anabolic action Anabolic steroids in COPD patients with weight loss increase body weight and lean body mass but have little or no effect on exercise capacity. GOLD 2006 Pulmonary rehabilitation programs should address body composition abnormalities. Intervention may be in the form of caloric, physiologic, pharmacologic or combination therapy. ATS/ERS STATAEMENT 2005 Education Education Self management education Self Should involve : Patient Family Primary care physician Other health care providers Patient education : BTS statement 2001 Patient Self management Education Self ATS & ERS Joint statement on pulmonary rehabilitation, 2005 Early treatment of exacerbations Early Detection of exacerbation: Sustained worsening of symptoms from beyond day to day variations Activating predetermined action plan: Pre-determined medication regime Informing health care providers Bronchial hygiene techniques Bronchial Postural drainage Percussion & vibration Directed cough Forced expiratory technique (huff cough) Active cycle of breathing Autogenic drainage Positive expiratory pressure Bronchial hygiene techniques Bronchial Meta analysis of 6 RCTs suggested chest percussion and vibration to be very effective in clearance of secretions in cystic fibrosis. SD 0.61, p<0.0001. Thomas J. Am J Respir Crit Care Med.1995;151:846-850 Combination of postural drainage, percussion, directed cough and forced expiration improved airway clearance, but not pulmonary function, in patients with COPD and bronchiectasis The Cochrane Database of Systematic Reviews 2007 Issue 1 PT advice to patients with sputum production is appropriate. BTS STATEMENT 2001 In selected patients bronchial hygiene techniques can be considered. ATS/ERS STATEMENT 2005 Breathing strategies Breathing Adopting specific postures : Leaning forward Slow deep breathing Purse lipped breathing Purse Bianchi R. Chest 2004;125:459–465 Diaphragmatic breathing : Increases work & increases dyspnea Gosselink RA. Am J Crit Care Med.1995;151:1136-442 Vitacca M. Eur Respir J. 1998;11:408-415 Should be considered (although individualized) ATS & ERS statement 2005 Psychological considerations Psychological Psychological considerations Psychological Chronic disease Dyspnoea Abnormalities in Blood gases Disability Fear and anxiety Irritability Depressive symptoms (45%): • Pessimism • Hopelessness • Withdrawal from social interactions Heightened physiological arousal Neuropsychological impairments Magnitude of problem Magnitude Approximate prevalence of symptoms of depression in moderate to severe COPD is about 45% Mills TL. Soc Sci Med 2001;53:569–578 Sub-threshold depression (clinically relevant depression that does not fit operational criteria) is seen in 25% of elderly patients with COPD Yohannes AM. Int J Geriatr Psychiatry 2003;18:412–416 Psychological considerations Psychological Screening for anxiety and depression should be part of the initial assessment. Mild or moderate levels of anxiety or depression related to the disease process may improve with pulmonary rehabilitation Withers NJ. J Cardiopulm Rehabil 1999;19:362-5 Withers Patients with significant psychiatric disease should be referred for appropriate professional care. ATS/ERS STSTEMENT Antidepressants and anxiolytics appear not to have additional general value BTS STATEMENT Patient selection Patient and Assessment Patient selection Patient Gains can be achieved from pulmonary rehabilitation regardless of age, sex, lung function, or smoking status ATS/ERS statement 2005 No justification for selection on the basis of age, impairment, disability or smoking status. BTS statement 2001 COPD patients at all stages of disease appear to benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue GOLD 2006 Initial assessment Initial Mahler DA. Chest 1998;113;263-268 Exclusion criteria Exclusion Patients with severe orthopedic or neurological disorders limiting their mobility Severe pulmonary arterial hypertension Exercise induced syncope Exercise Unstable angina or recent MI Refractory fatigue Inability to learn, psychiatric instability and disruptive behavior. Outcome assessment Outcome Control of symptoms of cough and fatigue: Real time evaluation: VAS & Borg dyspnea scale Recall of symptoms Performance evaluation: Ability to do ADL Directly observed or self reported Exercise tolerance: Exercise 6 minute walking test Cardiopulmonary exercise testing Quality of life: Chronic respiratory disease questionnaire St Georges’s respiratory questionnaire SF- 36 Assessment of respiratory and peripheral muscle strength (GOLD 2006) Pulmonary rehabilitation: At what cost ? Pulmonary Incremental health care cost of pulmonary rehabilitation was 11,597 Incremental dollars per annum per patient. NNT for improvement in dyspnea 4.1, fatigue 4.4 and 3.3 for emotion Goldstein RS. Chest 1997;112(2):370-9. Decreased no of exacerbations ( 3.7+/- 2.2 Vs 6.9+/-3.9) in 24 months. No change in hospitalization rates. Guell K. Chest 2000;117:976-83 Decrease in utilization of health care services: Decreased length of hospital stay when admitted No change in number of hospital admissions Fewer primary care home visits Grifiths TL. Lancet 2000;355:362-8. Long term efficacy pulmonary rehabilitation Long Benefits of rehabilitation ( exercise tolerance, dyspnea, HRQOL) are evident up to 1 year and may last longer. Foglio K. Eur Respir J.1999;13:125-32 One third of the patients (both COPD and bronchial asthma) retain the benefits for 2 years (NNT 3) Guell R. Chest 2000;117:976-83 Meta-analysis showed significant improvement in exercise capacity and 6 MWD 9 months post rehabilitation. Cambach W. Arch Phys Med Rehab 1999;80:103-111 Cambach Maintenance rehabilitation & Maintenance Repeat rehabilitation program Continued participation in supervised program is essential for sustenance of benefits. Swerts PMJ. Arch Phys Med Rehab 1990;71:570-573 Yearly repeat rehabilitation program had shown: Short term benefits in the form of less frequent exacerbations But no long term physiological effects on exercise tolerance, dyspnea & HRQL. Foglio K. Chest. 2001; 119:1696–1704 Current guidelines does not comment on maintenance & repeat rehabilitation Proper patient selection Patient assessment Exercise training: Leg and arm exercises Sessions For weeks Caloric supplements Strength exercise Anabolic steroids Self management education Individualization of programme Psychological aspects Depression Anxiety Structure of Pulmonary rehabilitation program Outcome assessment: Symptoms Exercise performance Quality of life GOLD 2006 Thank you Thank ...
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