BACPR Annual Conference Generic versus Specialist Rehabilitation FOR

Transcription

1 BACPR Annual Conference 2016 Generic versus Specialist Rehabilitation FOR Dr William Man

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3 1) Organ-specific rehabilitation for heart failure and COPD is an outdated concept... 2) Rehabilitation should be a symptomfocused rather than organ-focused approach...

4 Vic : 78 year old man Case study STEMI 1999, CABG 2000, PPCI graft 2007, 2015, Ischaemic cardiomyopathy: LVEF 20%, NYHA III; stops after 100 yards; half a flight of stairs Recent falls Co-morbidity: hypertension, dyslipidaemia, paroxysmal AF, gout, osteoarthritis, ex-smoker 80 pack year history Referred for supervised exercise-based rehabilitation

5 Who should Vic exercise with? Ernie: 78yr, ex-builder, COPD, ex-smoker, ex tolerance 100 yards, MRC dyspnoea 4, multi-comorbidity Tristan: 42yr, financier, Ferrari, gym x4 a week, personal trainer, STEMI during squash, NYHA I, no comorbidity

6 HF and COPD are similar! Risk factors (age, smoking) Older, comorbidities Both under-diagnosed / mis-diagnosed Similar symptoms: exertional dyspnoea, wheeze, reduced ex tolerance, fatigue, anx/dep Muscle wasting and sarcopenia Common cause of emergency hospital admissions

7 Secondary alterations in HF and COPD Physical inactivity Systemic inflammation Oxidative Stress Nutritional abnormalities Neurohumeral activation Skeletal muscle dysfunction Anxiety and depression Osteoporosis Hormonal imbalance Anaemia Exercise Limitation

8 Organ impairment correlates poorlywith symptoms in HF and COPD Gosker et al Chest 2013

9 HF and COPD commonly co-exist! Roversi et al AJRCCM 2016

10 Single organ disease is rare in older adults NACR 2015

11 HF do not get (specialist) rehab! 4% of CR population have primary diagnosis of heart failure (NACR 2015) Only 40% CR centres accept HF patients (Dalal 2012) 16% provided a separate rehab programme for HF (Dalal 2012) HF patients do not get referred for CR (Golwala et al JACC 2015) Poor uptake and high drop out rates

12 Only 10% of CHF referred for cardiac rehab

13 Case study (cont) Vic also has COPD (FEV1 28% predicted) MRC dyspnoea 4 Undergoes pulmonary rehabilitation 16 ex and educat n session NYHA III to II MRC 4 to 3 ISW 100 to 240 metres HADS (A: 12 to 6; D: 11 to 4)

14 Key Messages Specialist organ-specific rehab is an outdated concept Organ impairment correlates poorly with symptoms Multi-comorbidity HF and COPD frequently co-exist There are far more similarities than differences between HF and COPD Current CR services focused on secondary prevention Breathlessness rehab as a menu option #bacpr2016

15 BACPR Annual Conference 2016 Generic versus Specialist Rehabilitation FOR Response

16 The dose of exercise training ranged widely across studies with session duration of 15 to 120 minutes, one to seven sessions/week, intensity of 40% to 80% of maximal heart rate to 50% to 85% of maximal oxygen uptake (VO 2 max) to Borg rating of 12 to 18...

17 Generic rehabilitation for COPD and HF Recruitment COPD - recruited from referrals for Pulmonary Rehabilitation CHF - recruited from Community Heart Failure nurses Inclusion criteria clinical diagnosis with supporting investigations (LVEF<40% or FEV1/FVC < 0.7) NYHA II-IV or MRC 2-5 Exclusion criteria patients with known combined disease safety criteria predominant neurological, orthopaedic or peripheral vascular limitation to exercise Evans et al Resp Med 2010

18 Intervention: Pulmonary Rehabilitation Two hospital visits a week for 7 weeks 1 hour exercise 1 hour multi-disiplinary educaion Daily endurance training at 85% VO2 peak predicted derived from ISWT

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20 89% believed common rehab for breathlessness is attractive to commissioners 75% believed rehabilitation should be symptom-based rather than disease-based 87% believed patients with HF could be exercised using COPD training principles and vice versa.

21 Joint exercise rehabilitation programmes for patients with COPD or CHF, in the same location by the same therapists, appear effective, feasible and may have the potential to unblock capacity limitations for services commissioned separately. Such a service should embrace a symptom-based approach to care, that is, the management of breathlessness, rather than the more traditional disease-centred approach Man et al CRD 2016

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