PR - Background 1800 Exercise in chronic lung disease 1960 - - - PDF document

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PR - Background 1800 Exercise in chronic lung disease 1960 - - - PDF document

Mar 21, 2023 138 likes •311 views

ILD and Pulmonary Rehabilitation Chris Garvey FNP, MSN, MPA, MAACVPR Nurse Practitioner, UCSF Pulmonary Rehabilitation, Sleep Disorders, Division of Pulmonary Medicine PR - Background 1800 Exercise in chronic lung disease 1960 -

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ILD and Pulmonary Rehabilitation

Chris Garvey FNP, MSN, MPA, MAACVPR Nurse Practitioner, UCSF Pulmonary Rehabilitation, Sleep Disorders, Division of Pulmonary Medicine

PR - Background

  • 1800 – Exercise in chronic lung disease
  • 1960 - Science of PR effectiveness –
  • 2011 ATS IPF Statement
  • 2013 ATS ERS PR Statement

– Evidence based guidelines – Effectiveness: Key outcomes – Behavior change / physical activity – Patient = center of team

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Cost-effectiveness of PR vs Other Treatments Cost per quality-adjusted life year (QALY)

Zoumot Z, et al. Emphysema: time to say farewell to therapeutic nihilism. Thorax 2014;69:973–975.

IPF - Opportunities

Symptom Control Knowledge Gaps Dyspnea Cough Skeletal Muscle Dysfunction

Hypoxia

Mood, End of Life

  • 2

support

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Raghu G, Collard H, Egan J, Martinez F, Behr J, et al. An Official ATS/ERS/JRS/ALAT Statement: IPF: Evidence-based Guidelines for Diagnosis and Management 2011. 183;6 Pulmonary Rehab

Recommendation: Majority of IPF → PR High value: Moderate quality data – ↑ Functional status, ↑ Patient-centered

  • utcomes;

Uncertain benefit duration

Cochrane – PR in ILD

  • 9 trials; 5 met criteria

– n = 86 PR vs. 82 UC

  • 3 studies: IPF; 6 ILD; 36 - 71 years old
  • ↑ 6MWD 44 meter vs. control
  • ↑ Maximum exercise capacity
  • ↑ QOL, ↓ dyspnea,
  • Improvement: IPF and ILD
  • No safety concerns
  • Long term effects unclear

Dowman L, Hill CJ, Holland AE. Cochrane rev 2014 CD006322

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  • N = 54 ILD (22 IPF) from 3 PR programs
  • 6MWD, QOL, SOB, depression, physical activity
  • Pre, post, 6 months post PR
  • 6MW - 57.6 m post PR; (p<0.0005)
  • Low baseline 6MWD= predictor of improvement
  • Change in 6MWD predicted change in QOL

Ryerson CJ, et al., Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: A prospective cohort study, Respiratory Medicine (2013), http://dx.doi.org/10.1016/j.rmed.2013.11.016

PR improves long‐term outcomes in ILD: A prospective cohort study

C Ryerson , CCayou , FTopp , LHilling , PCamp, PWilcox , N Khalil , HCollard, CGarvey

Long-term Improvement

  • 6MWT - 50 m p = 0.005
  • Physical activity (RAPA) p = 0.003
  • QOL p = 0.04
  • Depression p = 0.05

QOL SOB DEPRESSION

Ryerson CJ, et al., Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: A prospective cohort study, Respiratory Medicine (2013), http://dx.doi.org/10.1016/j.rmed.2013.11.016

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Aerobic Exercise Prescription

Training loads exceed daily levels

  • Frequency: 3 to 5 times per week
  • Initial intensity: 60% max work rate
  • Type: Walking, cycling, dance, swim
  • Time: 20 to 60 min / session
  • Progression: Based on symptoms
  • Moderate breathlessness
  • 4 - 6 on 10 point Borg scale

Exercise

  • Resistance training

ꝉ muscle mass, force ↓ dyspnea

  • Interval training: For intolerable symptoms
  • = continuous training @ same = work load1
  • Stretching – no clear evidence
  • 1. Spruit M, et al. Am J Respir Crit Care Med 2013;188(8):e13-64.
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Make Exercise Successful

  • Convenient
  • Affordable
  • Pleasant
  • Safe
  • individualized

–Toolkit of options

  • Indoor options, apps, music
  • Manage symptoms, boredom

Exercise Stops the Downward Spiral of Dyspnea - Anxiety - Decreased Activity

Shortness of Breath Anxiety Decreased Activity Shortness

  • f Breath

Anxiety Shortness

  • f Breath

Interrupt

Shortness

  • f Breath

From S. Jacobs

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Effective Management of Dyspnea: Pulmonary Rehabilitation

Study Sample ∆ 6MW, m Dyspnea QOL

Dowman et al 2017 RCT 142 ILD 25 Improved Improved Ryerson et al 2014 54 ILD 57 Improved Improved Holland et al 2012 44 ILD 21 Improved NA Huppman et al 2013 402 ILD inpt. 46 Improved Improved Kozu et al 2011 65 31 (MRC 2) Improved NA Swigris et al 2011 21 62 Fatigue improved SF36 non sig Salhi et al 2010 11 RLD 107 Improved SGRQ non sig Ferreira et al 2009 99 56 Improved NA Holland et al 2008 RCT 57 35 Improved Improved Nishiyama et al 2008 RCT 30 42 No Change Improved Jastrzebski et al 2006 31 NA Improved Improved Naji et al 2006 26 NA Improved Improved .

Impact of Exercise on Dyspnea

  • Reverses skeletal muscle dysfunction

–↑ endurance

  • Desensitization to dyspnea
  • ↓ anxiety, panic, depression
  • ↑ independence, travel, socialization
  • Improves weight

From S. Jacobs

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Dyspnea Strategies

  • Exercise: Aerobic, Strengthening
  • Fan / cold air / open windows
  • Relaxation / visual imagery / meditation
  • Distraction: music, social interaction
  • Yoga (modified)
  • O2 for hypoxemic
  • Opiates /narcotics / anti-anxiety Rx
  • Pursed lip breathing?

From S. Jacobs

Qualify for O2 MD face to face visit DME Heavy equipment

Dante’s Oxygen Competitive Bidding Hell

Can’t work Can’t leave hone Can’t exercise

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O24U?

  • Assessment and titration

– No standardized method

  • Long term O2 - continue during exercise

–May require higher flow with exercise1

  • Titrate to migrate –

– DME practices challenge this – Patients need tool kit, oximeter

  • 1. Spruit M, et al. Am J Respir Crit Care Med 2013;188(8):e13-64

Severe Exercise Induced Hypoxemia

Need > 6 lpm to achieve Sp02 > 88% with exercise

pts / yr % PR pts Mean 14 (25) 18 (22) Devices Used for SEIH

Devices (%) Nasal cannula 62 Hi-flow NC 50 Oxymizer pendant 49 NRBM 41 Oxymizer cannula 37 NC + NRBM 25 Venturi mask 15 OxyMask 10 TTO 3 CPAP, BPAP, misc 1

Severe Exercise-Induced Hypoxemia Garvey C, Tiep C, Carter R, Barnett M, Hart M, Casaburi R Respiratory Care 2012, 57 (7) 1154-1160

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O2 and Exercise: Challenges and Opportunities

Continuous O2 only

Physical Activity - Strong, Complex Interface1-8

Health beliefs Personality Symptoms Mood Behaviors Social Cultural, External factors

  • 1. Thompson D, Circulation. 2003

2 . Garcia-Aymerich,et al. Thorax 2006

  • 3. O’Donnell DE,et al. Respir Med 2011
  • 4. Troosters T, et al. Eur Resp Rev 2010

5.Ng LW, et al. Chron Respir Dis 2012 6. Garcia Amyerich et al, AJRCCM

  • 7. Sandland CJ, et al. Chest 2008 8. Casaburi R. Proc ATS 2011
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Self Management

  • Self-confidence - adaptive behaviors

– Regular exercise1 – Less advise on “how to do it”

  • Experiment - new behaviors
  • Patient central to goal setting,2 outcomes3
  • Responsible for day-to-day management
  • 1. Janssen DJ, et al. Patient Educ Couns 2012.
  • 2. Murray SA, et al. BMJ 2005
  • 3. Effing T, et al. Cochrane Rev 2007

Maximize Long Term Adherence

Pulmonary Rehab

Novel Exercise Nordic walking, Rollator PCP pulmonologist IPF specialist Facilitators:1-3 Apps, Monitors, Remote PR

Maintenance exercise program

IPF patient

Adjuncts: O2

  • 1. Hospes Pat Ed Counseling 2008, 2. De Blok Pat Ed Counseling 2006, 3. Moy, Respir Med 2012
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Advance Care Planning

  • Communication –

– End-of-life options – Advance directives – Physician Orders for Life-Sustaining Treatment (POLST)

  • PR - forum to discuss issues

Barriers to PR

– Inconvenience – Transportation/travel – Parking – Cost – Insurance coverage – Lack of support – Illness severity – Comorbidities – Mood disorders – Lack perceived benefit – Provider influence1,2 Limited Access

  • Alternatives

– Remote PR

  • Satellite PR
  • Home PR

– Technology

  • 1. Keating A, et al. Chron Resp Dis 20112
  • 2. Garrod R, et al. j Eur Soc 2006
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Pulmonary Rehabilitation in US

  • 1,521 Cardiopulmonary Centers1
  • 237 PR Centers1
  • 66 programs in CA2

1: aacvpr.org

  • 2. cspr.org

Alternatives to PR 1,2

  • Technology - potential bridge;
  • Need key components of PR:

–Individualized exercise Rx –Self management education –Outcome measurement –Patient support

1. Brooks D, et al Can Respir J 2007 2. Rochester C, et al Am j Respir Crit Care Med 2015

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Barriers to Home- based PR

  • No evidence based guidelines

–Safety, supervision, responsibilities –Outcome measurement

  • Lack insurance coverage
  • Older, < affluent, disabled - disconnected

from e-health physically / psychologically1

  • Not extensively tested
  • Where does ILD fit?

Older Adults and Technology Use by Arron Smith Pew Research Center http://www.pewinternet.org/2014/04/03/older-adults-and-technology-use

Choosing a PR Program

  • AACVPR PR Certification, competencies
  • ATS - establishing quality metrics
  • Find a program

– AACVPR.org – cspr.org – www.pulmonaryfibrosis.org – livingbetter.org

  • Support

– www.pulmonaryfibrosis.org – www.rareconnect.org – www.plmjoin.com/ipf

IPF IPF

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Opportunities

  • All symptomatic chronic lung disease potentially benefit
  • PR duration: longer appears better1
  • Long term maintenance / physical activity / exercise
  • Change in physical activity requires behavior change
  • Access to PR

– Apps / wireless options – develop evidence base

  • Novel 02: High flow, High flow heated humidified 02

– Portable ventilators – Oldies but goodies: TTO, LOX – Fix the inequities

  • 1. Pitta F, et al. Eur Respir J 2006