ILD and Pulmonary Rehabilitation

Transcription

1 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 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 1

2 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: IPF - Opportunities Knowledge Gaps o 2 Mood, End of Life Hypoxia Symptom Control Skeletal Muscle Dysfunction Dyspnea Cough support 2

3 Pulmonary Rehab Recommendation: Majority of IPF PR High value: Moderate quality data Functional status, Patient-centered outcomes; Uncertain benefit duration 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 ;6 Cochrane PR in ILD 9 trials; 5 met criteria n = 86 PR vs. 82 UC 3 studies: IPF; 6 ILD; 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 CD

4 PR improves long term outcomes in ILD: A prospective cohort study C Ryerson, CCayou, FTopp, LHilling, PCamp, PWilcox, N Khalil, HCollard, CGarvey N = 54 ILD (22 IPF) from 3 PR programs 6MWD, QOL, SOB, depression, physical activity Pre, post, 6 months post PR 6MW 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), Long-term Improvement 6MWT - 50 m p = Physical activity (RAPA) p = 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), 4

5 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 same = work load 1 Stretching no clear evidence 1. Spruit M, et al. Am J Respir Crit Care Med 2013;188(8):e

6 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 Interrupt Anxiety Anxiety Shortness of Breath Shortness of Breath Shortness of Breath Decreased Activity From S. Jacobs 6

7 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 ILD 57 Improved Improved Holland et al ILD 21 Improved NA Huppman et al ILD inpt. 46 Improved Improved Kozu et al (MRC 2) Improved NA Swigris et al Fatigue improved SF36 non sig Salhi et al RLD 107 Improved SGRQ non sig Ferreira et al Improved NA Holland et al 2008 RCT Improved Improved Nishiyama et al 2008 RCT No Change Improved Jastrzebski et al NA Improved Improved Naji et al 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 7

8 Dyspnea Strategies Exercise: Aerobic, Strengthening Fan / cold air / open windows Relaxation / visual imagery / meditation Distraction: music, social interaction Yoga (modified) O 2 for hypoxemic Opiates /narcotics / anti-anxiety Rx Pursed lip breathing? From S. Jacobs Dante s Oxygen Competitive Bidding Hell Qualify for O 2 MD face to face visit DME Heavy equipment Can t work Can t leave hone Can t exercise 8

9 O24U? Assessment and titration No standardized method Long term O 2 - continue during exercise May require higher flow with exercise 1 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 Devices Used for SEIH Need > 6 lpm to achieve Sp0 2 > 88% with exercise pts / yr % PR pts Mean 14 (25) 18 (22) 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)

10 O 2 and Exercise: Challenges and Opportunities Continuous O 2 only Physical Activity - Strong, Complex Interface 1-8 Health beliefs Personality Symptoms Mood Behaviors Social Cultural, External factors 1. Thompson D, Circulation Garcia-Aymerich,et al. Thorax O Donnell DE,et al. Respir Med Troosters T, et al. Eur Resp Rev Ng LW, et al. Chron Respir Dis Garcia Amyerich et al, AJRCCM 7. Sandland CJ, et al. Chest Casaburi R. Proc ATS

11 Self Management Self-confidence - adaptive behaviors Regular exercise 1 Less advise on how to do it Experiment - new behaviors Patient central to goal setting, 2 outcomes 3 Responsible for day-to-day management 1. Janssen DJ, et al. Patient Educ Couns Murray SA, et al. BMJ Effing T, et al. Cochrane Rev 2007 Maximize Long Term Adherence PCP pulmonologist IPF specialist Pulmonary Rehab Maintenance exercise program IPF patient Facilitators: 1-3 Apps, Monitors, Remote PR Novel Exercise Nordic walking, Rollator Adjuncts: O 2 1. Hospes Pat Ed Counseling 2008, 2. De Blok Pat Ed Counseling 2006, 3. Moy, Respir Med

12 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 influence 1,2 Limited Access Alternatives Remote PR Satellite PR Home PR Technology 1. Keating A, et al. Chron Resp Dis Garrod R, et al. j Eur Soc

13 Pulmonary Rehabilitation in US 1,521 Cardiopulmonary Centers PR Centers 1 66 programs in CA 2 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 Rochester C, et al Am j Respir Crit Care Med

14 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 / psychologically 1 Not extensively tested Where does ILD fit? Older Adults and Technology Use by Arron Smith Pew Research Center Choosing a PR Program AACVPR PR Certification, competencies ATS - establishing quality metrics Find a program AACVPR.org cspr.org livingbetter.org Support IPF 14

15 Opportunities All symptomatic chronic lung disease potentially benefit PR duration: longer appears better 1 Long term maintenance / physical activity / exercise Change in physical activity requires behavior change Access to PR Apps / wireless options develop evidence base Novel 0 2 : High flow, High flow heated humidified 0 2 Portable ventilators Oldies but goodies: TTO, LOX Fix the inequities 1. Pitta F, et al. Eur Respir J