Lessons to be learned from cardiopulmonary rehabilitation

Transcription

1 REHABILITATION AFTER CRITICAL ILLNESS: Lessons to be learned from cardiopulmonary rehabilitation Rik Gosselink, PT, PhD, FERS Faculty of Kinesiology and Rehabilitation Sciences University Hospitals Leuven, KU Leuven Questions? POST ICU REHABILITATION Effectiveness of Pulmonary Rehabilitation? Effectiveness of Rehabilitation in Post ICU Syndrome? Post ICU Syndrome: similarities with other chronic health conditions, such as COPD, cancer, CHF? What lessons can be learned from Pulmonary Rehabilitation for Post ICU Rehabilitation? Iwashyna TJ AJRCCM 2012: 186:302

2 Pulmonary Rehabilitation Population COPD Asthma Cystic Fibrosis Interstitial Lung Disease Chest wall disorders Primary Pulmonary Hypertension Lung transplantation Definition COPD NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD): Chronic obstructive pulmonary disease is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with abnormal inflammatory response of the lungs to noxious particles or gases. SYSTEMIC CONSEQUENCES EXTRAPULMONARY MANIFESTATIONS COMORBIDITIES OF Comorbidity (CVD, metabolic syndrome, osteoporosis..) Poor physical fitness Poor physical activity Muscle weakness Malnutrition Depression - Anxiety Poor quality of life COPD

3 Definition Pulmonary Rehabilitation Pulmonary rehabilitation is 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 longterm adherence of health-enhancing behaviors." Meta-analysis n=277 TR, n=242 CO Exercise tolerance in NON-COPD 6MWD CRDQ (points) MWD (m) 6MWD (m) TB ILD PAH Δ 6MWD (m) Δ 6MWD (m) DYS FAT EMO MAS 6MWD Lacasse et al., Cochrane database, 2002/2007 Kagaya Tohoku J exp Med 2009 (TB sequellae) # Non RCT

4 Pulmonary rehabilitation: Anxiety reduction Pulmonary rehabilitation: Depression reduction Coventry et al. J Psychosom Res 2007; 63: Coventry et al. J Psychosom Res 2007; 63: How are survivers of critical illness doing? Unroe et al. Ann Intern Med 2010: 153:167

5 % predicted RECOVERY OF PATIENTS (+/- 45yr) AFTER ARDS FEV1 6MWD SF-36 PF months Herridge et al. N.Engl.J.Med. 2003/2011 Our results suggest that the inability to exercise is primarily due to extrapulmonary disease; our impression is that impaired muscle function had an important effect on the long-term outcomes in these patients Herridge et al. N.Engl.J.Med. 348: , 2003 Borges et al. ICM 2015;41: EXTRAPULMONARY CONDITIONS ASSOCIATED WITH PICS Ø Poor physical fitness Ø Poor physical activity Ø Muscle weakness Ø Malnutrition Ø Depression Ø Anxiety Ø Poor quality of life

6 2015 HOW EFFECTIVE IS REHABILITATION IN PICS?

7 Why were these interventions not effective? Rehabilitation including exercise training makes the difference! Cause of exercise limitation: extrapulmonary origin? Intervention? Ries et al. Ann. Intern. Med. 1995; 122: 823

8 LUNGS AND AIRWAYS CHF COPD ANXIETY DEPRESSION MOTIVATION HEART AND CIRCULATION (Post) Critical illness LEGS ARMS Gosker et al. Chest 2003;123:1416 Factors related to exercise limitation in COPD Muscle weakness and survival in COPD T L,CO FEV 1 QF PImax. VO 2 max NS 6MWD NS NS Gosselink et al Am J Respir Crit Care Med 153: ; 1996 Marquis et al. Am J Respir Crit Care Med 166: 809, 2002

9 Wischmeyer et al Crit Care 2015 SYSTEMIC CONSEQUENCES OF Critical Illness: ICUAW! %pred Muscle strength 2yr post ICU Quadriceps Handgrip 2y Post ICU Control Hermans, Van Mechelen PhD thesis 2016 Factors related to exercise limitation in PICS ICU ACQUIRED WEAKNESS and 1 year SURVIVAL T L,CO FEV 1 QF HGF 6MWD Cumulative survival MRC in ICU >48/60 MRC in ICU 36-48/60 MRC in ICU <36/60 Hermans, Van Mechelen PhD thesis 2016 Hermans et al. AJRCCM 2014

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11 How translate this knowledge and clinical experience to the rehabilitation of patients with PICS? PATIENT SELECTION AFTER OPTIMAL MEDICAL TREATMENT : SYMPTOMATIC: DYSPNOEA - FATIGUE REDUCED PHYSICAL FITNESS AND DAILY PHYSICAL ACTIVITY MALNUTRITION REDUCED QUALITY OF LIFE ANXIETY - DEPRESSION HIGH UTILISATION OF HEALTH CARE RESOURCES

12 Exercise training is the cornerstone of any rehabilitation programme Casaburi & ZuWallack NEJM Dutch English French Portugese The ACSM recommends symptom-limited exercise testing before vigorous exercise (>60% VO 2 max) is undertaken by men > 45 yr and women > 55 yr, those with 2 or more major cardiac risk factors (smoking, inactivity ), persons with any signs or symptoms of coronary artery disease, or those with known cardiac, pulmonary, or metabolic disease. AMERICAN COLLEGE OF SPORTS MEDICINE. ACSM s Guidelines for Exercise Testing and Prescription, 7th ed, Baltimore, Lippincott Williams & Wilkins, 2006.

13 EXERCISE TRAINING: HOW? Cardiorespiratory Fitness Kind of activity: Any activity that uses large muscle groups that can be maintained continuously and is rhythmical and aerobic in nature. Activities include: walking, cycling, stair climbing, swimming and endurance game activities Training Frequency: 3-5 days per week Training Intensity: 40-60% of heart rate reserve/vo 2peak, or 5-6 on the modified Borg-scale Training Duration: minutes of continuous or intermittent (in sessions lasting 10 or more minutes) aerobic activity Muscular Strength and Endurance Kind of activity: Resistance training of the major muscle groups of upper and lower limbs Training Frequency: 2-3 days per week Training Intensity: 60-80% of the 1RM Training Duration: 8-15 repetitions, multiple set regimens (2-5 sets) may provide greater benefits Flexibility Kind of activity: Stretches for the major muscle groups that should include appropriate static and/or dynamic techniques Training Frequency: 2-3 days per week Training Duration: 4 repetitions, held for seconds AMERICAN COLLEGE OF SPORTS MEDICINE. ACSM s Guidelines for Exercise Testing and Prescription, 7th ed, Baltimore, LippincottWilliams & Wilkins, Stimulus Rest Modality Intensity Duration

14 TRAINING INTENSITY Supervised vs. Unsupervised training % change High work rate Low work rate (longer duration) Work (kj) Supervised Unsupervised -35 Lact VE VE/VO2 HR Casaburi et al. Am.Rev.Respir.Dis: 143, 9-18, 1991 week 1 week 4 week 8 Training time TRAINING TIME Puente-Maestu, et al. Eur.Respir.J., 15: , 2000 Supervised vs. Unsupervised training CONCLUSIONS VO2peak VE isowork CRDQ Endurance Puente-Maestu, Eur.Respir.J., 15: , 2000 Supervised Unsupervised Ø PICS and chronic cardiopulmonary conditions have common extra-pulmonary features associated with poor clinical outcome Ø Cardiopulmonary rehabilitation -in contrast to PICS rehabilitation- has been shown effective Ø Lessons to learn PICS rehabilitation are: Ø Assessment of exercise performance Ø Individualized exercise prescription (ACSM) and supervised exercise training Ø Multidisciplinairy approach

15 Multidiciplinary Rehabilitation GP Physician Social worker Physiotherapist Patient Nurse Occupational therapist Nutritionist Psychologist