Pulmonary rehabilitation in severe COPD - - PowerPoint PPT Presentation

Pulmonary rehabilitation in severe COPD

daniel.langer@faber.kuleuven.be

Content

• Rehabilitation (how) does it work ?
• How to train the ventilatory limited patient ?

Chronic Obstructive Pulmonary Disease

NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Definition:  Chronic obstructive pulmonary disease is characterized by airflow limitation that is not fully reversible.  It is a preventable and treatable disease with some significant extrapulmonary manifestations.  Skeletal muscle dysfunction  Weight loss  Cardiovascular disease  Depression and Fatigue  Osteoporosis

Interaction between pulmonary and extrapulmonary factors

1 2 3 4 20 40 60 80 100 120 140 160 180

VO2 (L/min) VE (L/min)

Muscle Dysfunction Early lactic acidosis Dynamic Hyperinflation Breathing frequency

Casaburi R and ZuWallack R. N Engl J Med 2009;360:1329-1335

Targets of Exercise Training

• Improving aerobic function
• f ambulation muscles
• Reducing ventilatory

requirement and respiratory rate during exercise

• Prolonging expiration time
• Reducing dynamic

hyperinflation and dyspnea

Casaburi et al. N Engl J Med 2009

Content Rehabilitation Program

• Exercise Training

– Endurance exercise to improve cardiorespiratory fitness – Resistance training to improve muscular strength and endurance (peripheral and respiratory muscles)

• Supplemental interventions during exercise training

– Oxygen – Heliox

• Breathing exercises
• Occupational therapy
• Nutritional advise
• Psychological support
• Patient-education / self-management (inactivity)

Rehabilitation, the evidence: Exercise tolerance

Wmax VO2max Walking Whole body end 10 20 30 10 20 30 40 50 60 70 80 90 100 110

 (% baseline)  (% baseline)

Adapted fromTroosters AJRCCM 2005

Exercise tolerance: Weighted mean difference and IQR

Rehabilitation, the evidence

Dys Fat Emo Mas

• 1

1 2 3

 HRQoL (MCID-units)

6MWD 25 50 75

 6MWD (m)

Lacasse Eura Medicophys 2007 (Cochrane)

CRDQ 6MWD

Patients admitted n Hospital admissions Resp All Days spent in hosp Resp All Days per admission 1.9 2.2 18.1 21.0 9 41 ± 1.4 1.5 19.3 20.7 7.6 1.4 1.7 9.4 10.4 6 40 ± 1.3 1.1 10.2 9.7 3.4 Controls Rehabilitation NS * * * *

0.1 Griffiths Lancet 2000

Rehabilitation, the evidence: Health care resources

Rehabilitation: the evidence

Evidence from systematic review of meta-analysis of randomised controlled trials (level la)

• Improvements in exercise tolerance
• Clinically relevant improvement in health related

quality of life (HRQoL). Evidence from at least one RCT(level lb)

• Reductions in number of days spent in hospital
• Pulmonary rehabilitation is cost effective

Exercise training, the core of rehabilitation

How do we train patients with severe airflow

• bstruction, dynamic hyperinflation and

complaints of dyspnea on exertion?

Knowing exercise limitations to guide training How to train the ventilatory limited patient ? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs

– Increase the delivery – Reduce the demand

Improve lung function

Casaburi et al Chest 2005

TIO REHAB TIO+REHAB

50 100 150

Exercise enndurance

(% increase)

w4 w9 w13 w17 w21 w25 200 300 400 500 600 700

Time PA outside rehab (min) * * * Kesten J COPD 2008

HeliOx

FEV1 1.540.73 1.890.73 FVC 3.761.13 3.861.18 Air HeliOx

10 20 30 40 50 60 70 2 4 6 8 10 12 14 16 18

Endurance time VE

Eves AJRCCM 2006 90 60 30 10 20 Ventilation (L.min-1)

Time (min) HE

Improve maximal voluntary ventilation

Training at higher intensity

2 4 6 8 10 12 14 16 18 20 22 40 60 80 100 120

Session (n) WR (%max)

4 8 12 16 20 24

Air HH

* * * FEV1 TLC DLCO VO2peak 47 129 66 55 ± ± ± 19 20 22 11 46 122 64 59 ± ± ± 14 17 14 13 Air (n=19) He/O2(n=19)

Eves Chest 2009

Endurance time

Lung Transplantation

Gender Age BMI FEV1 Q-Force MEP MIP Handgrip 6MWD Wmax / yrs kg/m2 %pred Nm cm H2O cm H2O kgF m %pred

1yPost-LTX

n=22

Healthy

n=30 12 59 23 79 100 159

• 76

36 483 74 / ± ± ± ± ± ± ± ± 10 5 4 18* 36* 44* 48 16 66* 22* 18 58 25 116 164 193

• 97

42 690 182 / ± ± ± ± ± ± ± ± 12 6 4 18 41 47 53 10 83 57

Langer et al. Journal of Heart and Lung Transplantation 2009

• 40%
• 20%
• 20%
• 15%
• 30%
• 60%

Physical activity counseling w/ feedback SenseWear

Study Design RCT Exercise Training after LTX

Transplantation Pre-LTX 105 days

Control Exercise Training

Post-LTX 28 days

3m/6mPost- Random

Baseline Characteristics

Post-LTX Training (n=15) Control (n=13)

Male / Female 8 / 7 7 / 6 Early acute rejection (yes / no) 6 / 7 3 / 9 SLTX / SSLTX 1 / 14 3 / 10 Diagnosis COPD / ILD 12 / 3 11 / 2 Age 56 ± 4 56 ± 7 BMI (kg/m²) 20,7 ± 4,6 21,6 ± 4,2 FEV1, (% pred) 72 ± 18 74 ± 16

 3 sessions per week

Resistance exercise Cycling Treadmill walking Stair climbing

Exercise Training

Results

P r e

• L

T X P

• s

t

• L

T X 3 m P

• s

t

• L

T X 6 m P

• s

t

• L

T X 40 50 60 70 80 90

* *

P r e

• L

T X P

• s

t

• L

T X 3 m P

• s

t

• L

T X 6 m P

• s

t

• L

T X 300 400 500 600

Training Control

* *

6-minute walking distance (m)

Knowing exercise limitations to guide training How to train the ventilatory limited patient ? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs

– Increase the delivery – Reduce the demand

Training at higher intensity

2 4 6 8 10 12 14 16 18 20 22 40 60 80 100 120

Session (n) WR (%max)

4 8 12 16 20 24

Air O2

4 8 12 16 20 24

Air HH

* * *

Emtner AJRCCM 2003

Increased O2 delivery Lower lactate Reduced ventilatory drive Endurance time

Knowing exercise limitations to guide training How to train the ventilatory limited patient ? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs

– Increase the delivery – Reduce the demand

• Enhance the stress to the muscle for a given VO2 (walking vs cycling)

0.0 1.0 2.0 3.0 Cycle @ 80% Wpeak Walk @ 80% VO2peak R 50% 100% End 10 20 30

• 10
• 20
• 30
• 40
• 50

 Qtw pot (%baseline)

Pepin AJRCCM 2005

Reduce the demand

VO2 L/min

• Enhance the stress to the muscle for a given VO2 (walking vs cycling)
• Reduce the amount of muscle mass at work (resistance training, NMES).

Probst ERJ 2006 10 15 20 25 30 35 Walking Cycling Stairs Quadr

*

Reduce the demand

VO2 L/min

10 20 30 40 50 6MWD VO2max CRDQ STRENGTH ENDURANCE

 (% initial or points)

Spruit et al. Eur.Respir.J. 2002; 19:1072-1078

• Enhance the stress to the

muscle for a given VO2 (walking vs cycling)

• Reduce the amount of muscle

mass at work (resistance training, NMES, single leg)

Dolmage Chest 2008

Single Leg Exercise

Reduce the demand

Single leg exercise

Dolmage et al Chest 2006

two legs

• ne leg

5 10 15 20 25 30 35

COPD Healthy Endurance Time (min) @ 80% Wpeak

Single leg training

Dolmage Chest 2008

* 30 min of conventional cycling training versus single leg cycling (15 min each leg) 3 times per week 7 weeks FEV1 37 and 40%pred

5 10 15 20 25 30 35 Wpeak 5 10 15 20 25 VO2peak 2 4 6 8 10 Tlim@80%

% initial % initial min

• Enhance the stress to the muscle for a given VO2
• Reduce the amount of muscle mass at work
• Shorten the bouts of exercise to keep ventilation lower

than needed in steady state (interval training)  Slow oxygen uptake (ventilatory) kinetics : your friend in pulmonary rehab…

Reduce the demand

Sabapathy Thorax 2004

Interval exercise, often more realistic

0.0 0.5 0.7 0.9 1.1 VO2 (L/min) Time (min) 2 4 6 8 54 56 58 60 62

25 50 75 100 TwQ (%change)

Pepin 2006 Saey 2005 PL Saey 2005 IPR Mador 2003 Mador 2001 Man 2003

Conclusions

• Pulmonary rehabilitation works:

‘GRADE A’-level of evidence

• Exercise training can be fine-tuned to

the exercise limitations of patients

• Several options available for ventilatory

limited patients

Increase Ventilatory Capacity: Bronchodilators Heliox

High intensity

Peripheral Muscle Training

Exercise training

Reduce Ventilatory Requirements: O2 supplementation Small muscle mass Short intervals

High intensity

Peripheral Muscle Training One-leg exercise Interval training Resistance training

Thank you for your attention

Greetings from the Leuven Pulmonary Rehabilitation team