Riabilitazione Cardiorespiratoria nella BPCO

Riabilitazione Cardiorespiratoria nella BPCO

Ernesto Crisafulli - Enrico CliniErnesto Crisafulli - Enrico Clini

Corso di Formazione per Medici NYCOMED

Modena, 6-7/8-9 Settembre 2011

RATIONALE

Lung function deteriorationAirflow obstructionHyperinflationGas exchange abnormalities

COPDCOPD

Progressive muscle weaknessReduced bone mineral density

Co-morbidity CardiacType II diabetesMood disturbanceEndocrinological

Hematological

Ventilatory limitation(resting and/or during exercise)

Symptoms

“Pulmonary rehabilitation is an 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 reduce health care costs through stabilizing or reversing systemic manifestations of the disease. “

ATS-ERS Statement - AJRCCM 2006

DEFINITIONDEFINITION

SCOPES

Pulmonary rehabilitation programme Pulmonary rehabilitation programme (concept)(concept)

Outcomes

Functional performanceHealth statusDyspnoea

Cost reductionProgramme audit

Stages

SelectionAssessmentRehabilitationRe-assessmentMaintenance

Disabled patient

Individual needs

Multi disciplinary team

Family

Content

Exercise trainingDisease educationPsychological &Social support

Lifestyle change

“Pulmonary rehabilitation is a service that complies with the definition of rehabilitation and achieves its therapeutic aims through a permanent alteration of lifestyle”

W.H.O.

WHICH COMPONENTS ?

RECOMMENDED ACTIVITIESRECOMMENDED ACTIVITIES

• Muscles training• Body composition abnormalities

and interventions• Education and self management• Psychosocial issues

• Smoke quitting• Chest physiotherapy• Other interventions to increase training

ability

ATS-ERS Statement 2005

EXERCISE TRAININGEXERCISE TRAINING

THE WAY TO EXERCISE COPD

• LOWER LIMB EXERCISE (cyclo, treadmill, walking)

• UPPER LIMB EXERCISE (arm-ergometer)

RESPIRATORY MUSCLES

Protocols:Endurance trainingStrength training

Assessment:IntensityDurationFrequency

Training a COPDTraining a COPDPrinciplePrinciple

One major principle for successful training is theOne major principle for successful training is the

so that muscular adaptations will only appear if so that muscular adaptations will only appear if the muscle the muscle is sufficiently stressedis sufficiently stressed

Training a COPDTraining a COPD

Example on how to gradually increase both intensity and duration of sessions

30 20

10 0

1 2 3 4 5 6 7 8 9 10 11 12

100 80

60 40

20

0

Training weeks

Inte

nsi

ty

(% W

max

)D

ura

tio

n

(min

)

Training a COPDTraining a COPDOther strategiesOther strategies

EXERCISE WITH OXYGEN SUPPLEMENT Snider, G.L. Chest 2002, 122: 1830-6

EXERCISE WITH VENTILATORY SUPPORTAmbrosino, N. Eur Respir J 2004, 24: 313-22

ADOPT A INTERVAL TRAINING MODALITYVogiatzis, GL. Eur Respir J 2002, 20: 12-9 PASSIVE MUSCLE STIMULATIONAmbrosino N. Eur Respir J 2004, 24: 313-22

In order to enhance intensity in the most disabled individuals other strategies could be followed:

Training a COPDTraining a COPDModalitiesModalities

• ENDURANCE (ET)

The aim is to carry on exercise as longer as possible.It involves a large muscle mass at the highest intensity for a long period of time.

Training a COPDTraining a COPDModalitiesModalities

• STRENGTH (ST)

The aim is to prevent or counterbalance the muscle atrophy.It involves a small muscle mass at high intensity for a short period of time.

Training a COPDTraining a COPDEndurance or strength ?Endurance or strength ?

Puhan MA, et al. Thorax 2005; 60: 367-375.

Some studies show that endurance and strength training in COPD may similarly benefit COPD patients.

In a recent metanalysis it has been shown that the overall effect of these modalities on both the individual’s exercise performance and the specific quality of life is similar ....

HOW TO ASSESS THE EFFICACY ?

Wider outcome measures for Wider outcome measures for pulmonary rehabilitationpulmonary rehabilitation

Patient centred

(individual)

Programme

(quality control)

Public health

(societal)

Symptoms Process Survival

Activities of daily living

Satisfaction Health economics

Exercise performance

Safety

Health status

Practice guideline: Assessment of patient-centered outcomes such as symptoms, performance in daily activities, exercise capacity, and health related quality of life should be an integral component of pulmonary rehabilitation.

ATS-ERS Statement 2005

…20 or more sessions are needed for optimal acute changes in exercise performance, but improvement in dyspnea and quality of life may occur earlier….

Tredmill endurance Dyspnea

WHEN TO START ?

Timing of rehabilitationTiming of rehabilitation

• Chronic Stable State

• Post Hospital AdmissionCommunity pulmonary rehabilitation after hospitalisation for acute exacerbations of COPDMan et al. BMJ 2004

• During hospital admission ?– During exacerbation – Planned

WHICH RESULTS ?

Arch Phys Med Rehabil 2003;84:1154-7.

Conclusions: Including psychotherapy in a pulmonary rehabilitation program for COPD reduced patients’ anxiety and depression levels…

Outpatient pulmonary rehabilitation following acute exacerbations of COPDJohn M Seymour, Lauren Moore, Caroline J Jolley, Katie Ward, Jackie Creasey, Joerg S Steier, Bernard Yung, William D-C Man, Nicholas Hart, Michael I Polkey, John Moxham

Thorax 2010; 65: 423-428

3-mo Unplanned H. attendance

3-mo H. re-admission

UC(n=30)

57%

33%

PEPR(n=30)

27%

7%

OR

0.28

0.15

HOW LONG IS THEPOSITIVE EFFECT ?

The duration of benefit of pulmonary rehabilitation

1 2 yrs

short duration

Maintenance?

Repeated?

Exercise / health status

Trajectories of Endurance Activity following Pulmonary Rehabilitation in COPD PatientsAuthors: Judith E. Soicher, Ph.D.,Nancy E. Mayo, Ph.D.,Lise Gauvin, Ph.D.,James A. Hanley, Ph.D., Jean Bourbeau, M.D.ERJ Express. Published on July 7, 2011 as doi: 10.1183/09031936.00026011

The low activity group was characterized by more severe disease and greater respiratory impairment.

The high/decline group had less severe disease and respiratory impairment, but reported greater barriers to exercise (i.e. “exercise is tiring”, “place to exercise too far”,”family-related barriers”….).

Pulmonary rehabilitation may need to include behavioral interventions aimed at minimizing barriers.

WHO IS THE RIGHT PATIENT ?

Troosters T. et al. ERS meeting 2004

Selection of patientSelection of patientFactsFacts

• Most activity-limited people will benefit

• No matter of age, gender, lung function, initial disability and smoking status

• Greater benefits if weak peripheral muscles, low anaerobic threshold or normal nutritional status

• Exclusions include significant orthopaedic or neurological disease, uncontrolled psychiatric or cardiac disease

• Adherence affected by social isolation and continued smoking (drop out rates may be high)

Totale pazienti Totale pazienti (nr.)(nr.)

Età media Età media (anni)(anni)

Pz. Età Pz. Età ≥ 75 ≥ 75 (%)(%)

Anno 2003Anno 2003

11711171

7171±7±7

3838

Anno 2004Anno 2004

12421242

7171±9±9

4040

Anno 2005Anno 2005

11481148

7171±8±8

4343

COPD 33%

• Pulmonary rehabilitation results in a clinically significant improvement in disease-specific and general measures of quality of life.

• The effect size of pulmonary rehabilitation largely exceeds what can be achieved by the best pharmacological therapy.

• These effects are long-lasting (>1 year), and not necessarily related to improvements in exercise ability.

• The candidate profile and his/her baseline characteristics should be consider since they may alter response.

REHABILITATIONSummary