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THE ODONOHUE MEMORIAL LECTURE The ODonohue Lecture is dedicated to - - PowerPoint PPT Presentation

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3/8/2016 THE ODONOHUE MEMORIAL LECTURE The ODonohue Lecture is dedicated to Walters leadership in communicating the importance of participation in public policy debate. ODonohue Lecturers include: Atul Grover, MD

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SLIDE 1

3/8/2016 1

THE O’DONOHUE MEMORIAL LECTURE

Walter J. O’Donohue, Jr., MD was a charter member of NAMDRC. Prior to his death in July 2002, Dr. O’Donohue served on NAMDRC’s Board of Directors, and was President from 1995-97. Throughout his career in pulmonary medicine, Dr. O’Donohue worked tirelessly to remove the bureaucratic obstacles that impeded quality patient care. His efforts shaped the goals and mission of NAMDRC, and his many contributions epitomized the professionalism, leadership, and ethics to which everyone in pulmonary medicine should aspire.

  • The O’Donohue Lecture is dedicated to Walter’s leadership in communicating the

importance of participation in public policy debate.

  • O’Donohue Lecturers include:
  • Atul Grover, MD

2004

  • The Honorable Duncan Hunter (R-CA)

2005

  • Dennis Doherty, MD, FCCP

2006

  • The Honorable Norman Y Mineta

2007

  • Neil R MacIntyre, MD, FCCP

2008

  • Dennis Doherty, MD, FCCP &
  • Kent Christopher, MD

2009

  • Richard Casaburi, PhD, MD

2010

  • Donald Mahler, MD

2011

  • Christine Garvey, FNP, MSN, MPA, FAACVPR

2012

  • Frank L. Powell, PhD

2013

  • Neil R. MacIntyre, MD

2014

  • Peter C. Gay

2015

  • Andrew L. Ries, MD, MPH

2016

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SLIDE 2

THE WALTER O’DONOHUE MEMORIAL LECTURE

PRSPECTIVES ON PULMONARY REHABILITATION

ANDREW L. RIES, MD, MPH

PROFESSOR OF MEDICINE UCSD SCHOOL OF MEDICINE SAN DIEGO, CA Andrew L. Ries, MD, MPH is a Professor in the Department of Medicine in the Division of Pulmonary and Critical Care Medicine and the Department of Family Medicine and Public Health in the Division of Preventive Medicine. He has had training in epidemiology and biostatistics and extensive experience in clinical research in chronic lung diseases including pulmonary rehabilitation, evaluation of health outcomes (e.g., dyspnea, health related quality of life), pulmonary/exercise physiology, behavioral issues in lung disease, sleep disordered breathing, and cross-cultural health. He has conducted several NIH-funded, landmark studies in pulmonary rehabilitation and led efforts to develop evidence-based guidelines that have helped establish rehabilitation as an effective treatment option for patients with disabling chronic lung diseases. He has also been involved in several multicenter NHLBI studies including NETT (LVRS in emphysema, clinical center PI); FORTE (retinoids in emphysema, clinical center co-PI; SOL (Study

  • f Latinos, co-I); and LOTT (long-term oxygen therapy trial, DSMB member).
  • Dr. Ries is also committed to and experienced in mentoring students, trainees, and junior faculty in

clinical research and fostering careers in academic medicine. As Associate Vice Chancellor for Academic Affairs, he is responsible for overseeing all faculty appointments and academic reviews for advancement in Health Sciences. In this capacity he has published two manuscripts evaluating the effects of a structured junior faculty development program on faculty retention and future success in academic medicine.

  • Dr. Ries has worked closely with Dr. Powell for many years and Dr. Malhotra since his arrival at

UCSD and fully support their efforts to strengthen UCSD in translational pulmonary research and provide guidance to trainees serious about pursuing research-based careers in academic

  • medicine. I am committed to supporting the Pulmonary/Critical Care & Physiology T32 training

grant which is critical to our current and future efforts to develop the next generation of leaders in academic medicine in our fields.

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SLIDE 3

OBJECTIVES:

Participants should be better able to:

  • 1. Describe the key components of a comprehensive pulmonary rehabilitation program;
  • 2. Identify at least three benefits of pulmonary rehabilitation for patients with chronic lung

diseases;

  • 3. Identify appropriate patients to refer to pulmonary rehabilitation;
  • 4. Understand the qualifications and competencies of a core pulmonary rehabilitation team

member.

S A T U R D A Y , M A R C H 5 , 2 0 1 6 9 :3 0 A M

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SLIDE 4

3/8/2016 2

Perspectives on Pulmonary Rehabilitation

Andrew Ries, MD, MPH Professor of Medicine and Family Medicine and Public Health Associate Vice Chancellor, AcademicAffairs University of California, San Diego NMDRC 2016 March 5, 2016

  • Dr. Ries serves as a consultant

for Alere Inc., but this does not create a conflict related to the following presentation.

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SLIDE 5

3/8/2016 3

Life must be lived forward, but can only be understood backwards

1813-55

  • Why am I interested in pulmonary

rehabilitation?

  • Why should you be interested in

pulmonary rehabilitation?

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SLIDE 6

3/8/2016 4

  • Why am I interested in pulmonary

rehabilitation?

  • How (on earth) did I become interested in

pulmonary rehabilitation?

Philadelphia

@ UCSanDiego

HEALTH SCIENCES

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SLIDE 7

3/8/2016 5

@ UCSanDiego

HEALTH SCIENCES 1961: 23 consecutivelosses 1964: “The Collapse” (6.5/12 games)

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SLIDE 8

3/8/2016 6

@ UCSanDiego

HEALTH SCIENCES

Kenneth M. Moser, M.D.

Founder and Director Division of Pulmonary and Critical Care Medicine University of California, San Diego 1968 - 1997

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SLIDE 9

3/8/2016 7

  • Why am I interested in pulmonary

rehabilitation?

  • How (on earth) did I become interested in

pulmonary rehabilitation?

  • Why should you be interested in

pulmonary rehabilitation?

  • Why should you be interested in pulmonary

rehabilitation?

  • Chronic lung diseases are a big problem
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SLIDE 10

3/8/2016 8

Leading Causes of Deaths U.S. 2011

Cause of Death Number

  • 1. Heart Disease

596,339

  • 2. Cancer

575,313

  • 3. Respiratory Diseases (COPD)

143,382

  • 4. Cerebrovascular disease (stroke)

128,931

  • 5. Accidents

122,777

  • 6. Alzheimers

84,691

  • 7. Diabetes

73,282

  • 8. Pneumonia and influenza

53,667

  • 9. Nephritis

45,731

  • 10. Suicide

38,285 All other causes of death 650,475

Leading Causes of Deaths U.S. 2011

Cause of Death Number

  • 1. Heart Disease

596,339

  • 2. Lung Disease

500,000+

  • a. Lung Cancer

160,000

  • b. COPD

143,000

  • c. Pneumonia/influenza

54,000

  • d. Thromboembolism

50,000+

  • e. Asthma, TB, ARDS, CF

100,000+ Occup/envir, Pulm Vasc, Inflamm/immunol, etc

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SLIDE 11

3/8/2016 9

The Mountain of COPD

1900 1940 1980 2000 Cigarette Consumption COPD Deaths @ UCSanDiego

HEALTH SCIENCES

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SLIDE 12

3/8/2016 10

Life Expectancy – United States

  • Why should you be interested in pulmonary

rehabilitation?

  • Chronic lung diseases are a big problem
  • PR can help and support MDs in managing a

challenging group of patients

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SLIDE 13

3/8/2016 11

Disability

Smoker 60 70 80 50 40 30 20 Nonsmoker

Death

25 50 75

Natural History of COPD

Symptoms

@ UCSanDiego

HEALTH SCIENCES

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SLIDE 14

3/8/2016 12

The Changing Picture of COPD

COPD: Goals of Rx

  • Prevention
  • Slow progression
  • Maintain function
  • Minimize complications
  • Reduce symptoms
  • Improve function
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SLIDE 15

3/8/2016 13

Treatment of COPD

  • Stop smoking
  • Medications
  • Oxygen
  • Vaccination
  • Rehabilitation
  • Surgery: LVRS, Transplant

Pulmonary Rehabilitation

… an individually tailored, multidisciplinary program … which through accurate diagnosis, therapy, emotional support and education, stabilizes or reverses both the physio- and psychopathology of pulmonary diseases …

ACCP , 1974

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SLIDE 16

3/8/2016 14

Pulmonary Rehabilitation Goal

Restore the patient to the highest level of independent function i.e., improve disability from disease, not necessarily change disease process

Symptoms Costs

AIMS

ADLs Exercise Independence

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SLIDE 17

3/8/2016 15

Program Content

  • Initial evaluation
  • Education
  • Chest Physiotherapy
  • Psychosocial support
  • Exercise

Patient Selection

  • Chronic lung disease
  • Not just COPD (e.g., ILD, CF

, Asthma, PH, CA, LVRS, Trans, NM, Bronchiectasis)

  • Symptomatic, stable
  • After exacerbation - reduced hosp admissions/? mortality
  • After critical illness - hastens recovery, reduces decline
  • Motivated – active participant in care
  • Realistic goals
  • Earlier the better
  • Benefits for patients with less severe disease
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SLIDE 18

3/8/2016 16

  • Why should you be interested in pulmonary

rehabilitation?

  • Chronic lung diseases are a big problem
  • PR can help and support MDs in managing a

challenging group of patients

  • It’s an interesting model to study health
  • utcomes for chronic disease

Is It Worth It?

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SLIDE 19

3/8/2016 17

Which of the following improvements from pulmonary rehabilitation has NOT been well established?

  • A. Lung function
  • B. Symptoms (dyspnea)
  • C. Exercise tolerance
  • D. Hospitalizations

Which of the following improvements from pulmonary rehabilitation has NOT been well established?

  • A. Lung function
  • B. Symptoms (dyspnea)
  • C. Exercise tolerance
  • D. Hospitalizations
A. B. C. D.

81% 19% 0% 0%

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SLIDE 20

3/8/2016 18

The benefits from participation in a pulmonary rehabilitation typically last

  • A. 3-6 months
  • B. 6-12 months
  • C. 12-18 months
  • D. 18-24 months

The benefits from participation in a pulmonary rehabilitation typically last:

  • A. 3-6 months
  • B. 6-12 months
  • C. 12-18 months
  • D. 18-24 months
A. B. C. D.

33% 11% 18% 38%

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SLIDE 21

3/8/2016 19

Pulmonary Rehabilitation Education CPT 02 RT BRT Exercise Psychological Pulmonary Rehabilitation

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SLIDE 22

3/8/2016 20

  • ...

@ UCSanDiego

HEALTH SCIENCES

Symptoms Knowledge Exercise ADLs PFTs Survival Hospitalizations Quality of Life Pulmonary Rehabilitation

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SLIDE 23

3/8/2016 21

  • Why should you be interested in pulmonary

rehabilitation?

  • Chronic lung diseases are a big problem
  • PR can help and support MDs in managing a

challenging group of patients

  • It’s an interesting model to study health
  • utcomes for chronic disease
  • It works!
  • WHO/NHLBI GOLD (2001)
  • ATS (1995)
  • ERS (1995)
  • CTS (Canada) (1992)
  • Others (1994-99): Arg, Nor, Aust/NZ, Ger,

Spa, Swi, Pol, Fre, BTS, SAfr, Chile, Fin

Pulmonary Rehab in COPD Practice Guidelines

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SLIDE 24

3/8/2016 22 ACCP/AACVPR 1997 Pulmonary Rehab Guidelines

Evidence Grade: A B C

Components: Lower extremity exercise Upper extremity exercise Ventilatory muscle training (no) Psychosocial Outcomes: Dyspnea Quality of life Health care utilization Survival Psychosocial

1200 1000 800 600 400 200

1970 1980 1990 2000 2010 2014

Pulmonary Rehab PubMed Citations (English)

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SLIDE 25

3/8/2016 23 ACCP/AACVPR 2007 Pulmonary Rehab Guidelines

  • Literature search 1996 – 2004
  • 928 abstracts, 202 articles, 81 in evidence tables
  • Studies graded 0 – 5
  • Selected articles added in text from 2005-06
  • Recommendation grading
  • Strength of evidence: A, B, C
  • Balance of benefits to risks/burdens:
  • 1: Certainty of imbalance
  • 2: Evenly balanced/uncertain

Chest 2007;131(5 Suppl):4S-42S www.chestjournal.org

ACCP/AACVPR 2007 Pulmonary Rehab Guidelines

  • Outcomes of Comprehensive PR
  • LE exercise, dyspnea, HRQOL, hosp/health care utilization,

cost-effectiveness, psychosocial

  • Duration of benefits
  • Length of Rx
  • Maintenance following PR
  • Intensity of exercise training
  • Upper extremity training

Chest 2007;131(5 Suppl):4S-42S www.chestjournal.org

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SLIDE 26

3/8/2016 24 ACCP/AACVPR 2007 Pulmonary Rehab Guidelines

  • Strength training
  • Anabolic agents
  • Inspiratory muscle training
  • Education, collaborative self-management
  • Psychosocial Rx
  • Supplemental O2 with exercise
  • Noninvasive ventilation
  • Nutritional supplementation
  • Chronic lung diseases other than COPD

Chest 2007;131(5 Suppl):4S-42S www.chestjournal.org

Which of the following types of exercise training is NOT recommended for routine use in the rehabilitation of patients with chronic lung disease?

  • A. Lower extremity endurance training
  • B. Lower extremity strength training
  • C. Upper extremity training
  • D. Inspiratory muscle training
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SLIDE 27

3/8/2016 25

Which of the following types of exercise training is NOT recommended for routine use in the rehabilitation of patients with chronic lung disease?

  • A. Lower extremity endurance
  • B. Lowe extremity strength training
  • C. Upper extremity training
  • D. Inspiratory muscle training
A. B. C. D.

9% 66% 16% 9%

ACCP/AACVPR 2007 Pulmonary Rehab Guidelines

1A Recommendations

  • Outcomes of Comprehensive Pulmonary Rehab
  • Lower extremity training (muscles of ambulation)
  • Dyspnea: improved
  • HR-QOL: improved
  • Long-term: benefits in several outcomes from 6-12 weeks
  • f PR decline gradually over 12-18 months
  • Exercise training intensity: high & low beneficial
  • Strength training: increased strength/muscle mass
  • Upper extremity training: beneficial

Chest 2007;131(5 Suppl):4S-42S www.chestjournal.org

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SLIDE 28

3/8/2016 26 ACCP/AACVPR 2007 Pulmonary Rehab Guidelines

1B Recommendations

  • Exercise training intensity: greater physiologic benefits

from higher intensity lower extremity training

  • Inspiratory muscle training: no routine use
  • Education: integral component of pulmonary rehab

(collaborative self-management, prevention/treatment

  • f exacerbations)
  • Non-COPD: pulmonary rehab beneficial for some

patients with chronic respiratory diseases other than COPD

Chest 2007;131(5 Suppl):4S-42S www.chestjournal.org

ATS/ERS Satement 2013: Key Concepts and Advances in Pulmonary Rehabilitation

  • Update of 2006 ATS/ERS Statement on PR
  • Updated definition of PR, including effectiveness in

acutely ill with COPD and other chronic respiratory diseases

  • Important role of PR in chronic disease

management

  • PR within context of integrated care
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SLIDE 29

3/8/2016 27 New Definition of Pulmonary Rehabilitation

… a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies which include, but are not limited to, exercise training, education and behavior change, designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.” ATS/ERS 2012

ATS/ERS 2013 Statement

  • PR implemented by a dedicated, interdisciplinary team,

including physicians and other health care professionals (e.g., PT , RT , RN, Psych, RD, OT , ExP , etc)

  • Individualized to the unique needs of the patient
  • Integrated throughout the clinical course of patient’s

disease

  • May be initiated at any stage of disease – stable, during or

after exacerbation

  • Goals to minimize symptom burden, maximize exercise

performance, promote autonomy, increase ADLs, enhance HR QOL, and effect long-term health-enhancing behavior

  • PR within the concept of integrated care
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SLIDE 30

3/8/2016 28

  • Why should you be interested in pulmonary

rehabilitation?

  • Chronic lung diseases are a big problem
  • PR can help and support MDs in managing a

challenging group of patients

  • It’s an interesting model to study health
  • utcomes for chronic disease
  • It works!
  • Skills and expertise of PR staff can be valuable

in other settings

Patient MD

Comorbidities Meds O2 CPT Exercise ADLs Nutrition Psych Social

MDs RN RT PT Psych OT SW RD ? Rehab

Physician Centered Medical Care

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SLIDE 31

3/8/2016 29

Patient Individualized Rehab Treatment Plan Meds O2 CPT Nutrition Social Psych ADLs Exercise MD Pulmonary Rehab Comprehensive Rehab Eval BRT

Holistic Pulmonary Rehabilitation Care Shopping 1900 Shopping 2000

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SLIDE 32

3/8/2016 30

"What do you meany

  • u're out of br

ea th? Ihaven'tswitched itonyet."

( , UCSanDiego

HEALTH SCIENCES

Pulmonary Rehab Team

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SLIDE 33

3/8/2016 31

The ideal model for team structure in pulmonary rehabilitation is?

  • A. Multidisciplinary
  • B. Interdisciplinary
  • C. Transdisciplinary
  • D. Huh?

The ideal model for team structure in pulmonary rehabilitation is?

  • A. Multidisciplinary
  • B. Interdisciplinary
  • C. Transdisciplinary
  • D. Huh?
A. B. C. D.

60% 8% 12% 20%

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SLIDE 34

3/8/2016 32 Models of Team Structure

Multidisciplinary Interdisciplinary T ransdisciplinary

Evaluation (Set Goals) RT (O2, CPT , BRT) RN (Meds) PT (Exer , ADLs) MH (Psych) SW (Social) Treatment RT RN PT MH SW

Patient

T eam Conference (Evaluate Progress)

Multidisciplinary Team

Medical Director Core Members (RT , RN, PT) Extended Members (MH, SW)

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SLIDE 35

3/8/2016 33

Interdisciplinary Team

Evaluation RT (O2, CPT , BRT) RN (Meds) PT (Exer , ADLs) MH (Psych) SW (Social)

Medical Director Core Members (RT , RN, PT) Extended Members (MH, SW)

T reatment RT RN PT MH SW

Patient

T eam Conference Set Goals Evaluate Progress Plan Treatment

Transdisciplinary Team

Medical Director Core Members (RT , RN, PT) Extended Members (MH, SW)

Evaluation (Team Member) O2 CPT BRT Meds Exer ADLs Psych Social Treatment (Team Member) O2 CPT BRT Meds Exer ADLs Psych Social

Patient

T eam Conference Set Goals Evaluate Progress Plan Treatment

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SLIDE 36

3/8/2016 34

Chronic Lung Disease Patients

Pulmonary Rehabilitation Program

Mild (Dx, OPC)

Mod (Exac, Hosp)

Severe (ICU, Tx)

Pulmonary Rehabilitation Team Expertise

Mild (Dx, OPC)

Mod (Exac, Hosp)

Severe (ICU, Tx)

Chronic Lung Disease Patients

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SLIDE 37

3/8/2016 35 Summary

  • Chronic lung diseases are a large and increasing

problem in the world today

  • Comprehensive pulmonary rehabilitation is a well

established, effective treatment strategy that can help manage a challenging group of patients

  • The broad skills and expertise of pulmonary

rehab staff members in evaluating and treating patients may be helpful in managing chronic lung disease patients in other settings and across the disease spectrum