Evidence for early Pulmonary Rehabilitation following hospitalisation for exacerbation of COPD

Transcription

1 Centre for Inflammation Research Evidence for early Pulmonary Rehabilitation following hospitalisation for exacerbation of COPD Pulmonary Rehabilitation Clinicians Day Roberto A. Rabinovich ELEGI/Colt laboratory Centre for Inflammation Research The University of Edinburgh2

2 Chronic Obstructive Pulmonary Disease Definition Chronic Obstructive Pulmonary Disease is a preventable and treatable state characterized by airflow limitation that is not fully reversible The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles and gases, primarily caused by cigarette smoking Although COPD affects the lungs, it also produces significant systemic consequences ATS/ERS Statement 24

3 Chronic Obstructive Pulmonary Disease Classification ATS/ERS Severity GOLD Post Bd FEV 1 /FVC FEV 1 % pred At risk > 7 Cough and sputum > 8 Mild I < 7 > 8 Moderate II < Severe III < Very severe < 7 < 3 IV < 7 < 3 o < 5 plus CRF

4 Chronic Obstructive Pulmonary Disease Phenotypes 1. Variable FEV 1 6MWD MRC BMI >21 BODE Index Score < Probability of Death Score -2 Score 3-4 Score 5-6 Score Months Celli B et al NEJM 24; 35: 15

5 Exercise Tolerance in COPD More than lung function Quadriceps Twitch Force (% of Baseline) Causes for stopping: Fatigue (6%) no fatigue fatigue baseline 1 min Mador MJ, AJRCCM 2;161:

6 Quadriceps strength ( % of resting value) Muscle Dysfunction exercise tolerance Improvement in FEV 1 12% Fatigue No-fatigue * +92% 2 Rest Time (seconds) Saey D et al 23 Am J Respir Crit Care Dis;168:425

7 Muscle Dysfunction Endurance 3 * Endurance time (minutes) Control COPD control COPD Coronell, Eur Respir J 24;24:

8 Muscle mass and strength 12 1 Control COPD Thigh Cross Sectional Area Quadriceps strength (Kg) COPD control CSA thigh (cm 2 ) Bernard S., Am J Respir Crit Care Med 1998;158: control COPD

9 Chronic Obstructive Pulmonary Disease Muscle dysfunction Functional disorders Physio-pathological Changes Strength Resistance Fatigue Bioenergetics Fiber type distribution Capillarization and O 2 delivery Muscle mass It is characterized by two different, but possibly related, phenomena: Muscle wasting Malfunction of the remaining muscle

10 Physiopathological changes fibre type % Control COPD Type I Type II Jobin J, J Cardiopulm Rehabil, 1998;18(6):

11 Physiopathological changes Bionergetics and oxidative capacity mmol/min/g CS HADH Control COPD Maltais F, AJRCCM 1996;153:

12 Physiopathological changes Bionergetics and oxidative capacity 6 control COPD [Pi]/[Pcr] 6 control COPD Time (sec) Pcr recovery time Watt s Sala E, Am J Respir Crot Care Med 1999;159:

13 Physiopathological changes capillarisation and O 2 transport Controles COPD Controles COPD Capillaries/mm 2 Capillaries/fibre Jobin J, J Cardiopulm Rehabil 1998, 18(6),

14 Muscle Dysfunction Health resources Health Resources High Low Patients (N) Admissions Hospitalisations GP appointments DDM of CTC (N) (dias) (N) (mg/d) ± ± ± ± ± ± Decramer et al ERJ, 1997, 1,

15 Muscle Dysfunction Health resources 9 8 High Low * # % pred Age FEV1 DLCO QF PImax PEmax Decramer et al ERJ, 1997, 1,

16 Pulmonary Rehabilitation Rationale for exercise training COPD : is a systemic condition affecting the peripheral muscles EXERCISE TRAINING : is an intervention directed to re-establish normal muscle function

17 Benefits of Exercise Training HRQoL Meta-analysis n=277 TR, n=242 CO 1.2 Δ CRDQ (points) MCID. DYS FAT EMO MAS Lacasse et al., Cochrane database, 22

18 Benefits of Exercise Training Exercise tolerance 6 minutes walking test Cambach Booker Ringbaeck O Donnell Wijkstra Cockroft Engström Goldstein Finnerty Troosters Bendstrup Guell MCID Troosters et al., Am J Respir Crit Care Dis 25; 172:

19 Benefits of Exercise Training Exercise tolerance 1 1 Porcentaje MWT EST Watt VO 2 Const. Crítico Eaton T et al., Chron Respir Dis 26; 3: 1-2 Troosters et al., Am J Respir Crit Care Dis 25; 172: 19

20 Benefits of Exercise Training effect on exacerbations 25 Rehab Control n n 5 2 Group Per patient LTOT Guell R et al. ERJ 23; 21:

21 Benefits of Exercise Training effect on exacerbations 3 Rehab Control n n Griffiths TL et al. Lancet 2; 355: Days of hospitalisation appointments

22 Benefits of Pulmonary Rehabilitation early rehabilitation programmes after exacerbations Risk of hospitalisation Risk of death Bahnke (14/12) Man (2/21) 18 m 3 m Murphy (13/13) 6 m Global Puhan M et al. Respir Research 25; 6: 54

23 COPD Exacerbations Impact on the muscle Quadriceps strength (Nm) * Day 3 Day No exercise training 9 Teme (Days) Pitta, F. Chest, 26 Spruit, M. A. Thorax, 23

24 Exacerbations of COPD Effect on Physical Activity Patients with COPD complain about feeling tired and not being able to cope with daily life activities early during exacerbations Hospitalisation Probablity Time Walking (min) years High Moderate Low Very Low * Risk of death Day 2 Day 7 1. * Month Stable COPD years High Moderate Low Very low Pitta, Kessler, Garcia-Aymerich F. Chest, R. Chest 26 Thorax 13: ; 61: 772

25 Physical Activity Effect of exacerbations of COPD Dyspnoea Weakness Hypoxemia Acidosis Corticosteroids Psychology Not a good time for a walk

26 Pulmonary Rehabilitation During exacerbations Control Rehab 6 6 6MWD (m) Visits to ER (%) * Hospital Home Day 1 Day 1 Month 1 Month 2 Month 3 Month 6 Behnke M et al 2 Res Med; 94: 1184 Man W et al 24 BMJ; 329: 129

27 Pulmonary Rehabilitation During exacerbations Symtoms (-1) Strength Training Dyspnoea Fatigue Weight (%1RM) Troosters T et al. Am J Respir Crit Care Med, 21 D2 D3 D4 D5 D6 D7 D8

28 Pulmonary Rehabilitation Strength training during exacerbations Quadriceps strength (% day 2) Control Training Myogenin / MyoD Training Control Troosters T et al. Am J Respir Crit Care Med, 21

29 NMES: Pulmonary Rehabilitation NMES during exacerbations Frequency 5Hz 8 s On Pulse duration 4 μs Cycle duty 8/2s On/Off 2 s Off 5 Hz 4 μs Amplitud Selected By patient Session duration 3 min Amplitud (ma) (on tolerance) Sessions: 14 Neder, J. A. Thorax, 22

30 Pulmonary Rehabilitation NMES during exacerbations NMES

31 Pulmonary Rehabilitation NMES during exacerbations 14 days of stimulation Stimulated leg Ward Screening Hospital Home Control leg Strength Strength Giavedoni S et al. ERS 21

32 Pulmonary Rehabilitation NMES during exacerbations 2 * Δ Fuerza (%) % -5.8 % -3 Stimulated leg Control leg Giavedoni S et al. ERS 21

33 Pulmonary Rehabilitation NMES during exacerbations 5 Δ Fuerza (N) R=.94 P < Σ ma Giavedoni S et al. ERS 21

34 Pulmonary Rehabilitation NMES during exacerbations ΔStrength Stimulated leg (% Basal) Favours NMES Favours Control Giavedoni S et al. ERS 21 Δ Strength Control leg (% Basal)

35 Pulmonary Rehabilitation Themore, Intensity thebest High Intensity Training Low Intensity Training Lactate VE VO2 VCO2 VE/VO2 HR Lactate VE VO2 VCO2 VE/VO2 HR % change post-training Casaburi Am Rev Respir Dis. 1981;144:122

36 6MWD (% Pred) Pulmonary Rehabilitation Duration Short programmes (6-8 weeks) are effective in improving outcomes However a key goal of pulmonary rehabilitation 6 is to change patient s behavior % Time Walking * 3 Months 6 Months 3 Months 6 Months Pitta F et al. CHEST 28; 134: 273

37 Pulmonary Rehabilitation Duration 7 weeks 4 weeks ESWT CRQt CRQd CRQf CRQe CRQm Green et al. Thorax 21; 56:143-5

38 meters Pulmonary Rehabilitation Duration * seconds MWT Steps Overhead * * Berry et al. J Cardiop Rehab 23; 23:6-8

39 Training control Pulmonary Rehabilitation Effect of 6 month (6sessions) 3 15 Δ CRDQ (points) Δ 6MWD (m) start 6 months 18 months start 6 months 18 months Longer pulmonary rehabilitation programs (beyond 12 weeks) produce greater sustained benefits than shorter programs (ACCP/AACVPR) Troosters et al. AJM 2; 19(3):27-12

40 Conclusions COPD is a complex disease affecting the lungs but incurring in several systemic effects such as muscle dysfunction Muscle dysfunction, together with lung function impairment, causes exercise intolerance Pulmonary rehabilitation, particularly exercise training, is an intervention aimed at restoring normal muscl function PR improves exercise tolerance, HRQoL and improves rate of exacerbations and hospitalisation days Early PR has the same beneficial effects that PR for stable COPD patients and may have an impact on survival

41 Conclusions Strength training and NMES may help preventing muscle dysfunction during exacerbations and incur beneficial effects for the patients High intensity programmes are preferable to low intensity programmes since achieve greater effects Longer programmes seems to achieve greater effect than shorter programmes It is generally believed that longer programes yield more endurable training effects

42 Centre for Inflammation Research Evidence for early Pulmonary Rehabilitation following hospitalisation for exacerbation of COPD Pulmonary Rehabilitation Clinicians Day Roberto A. Rabinovich ELEGI/Colt laboratory Centre for Inflammation Research The University of Edinburgh2