호흡재활치료 울산의대서울아산병원 호흡기내과 이상도

호흡재활치료 울산의대서울아산병원 호흡기내과 이상도

Systemic (Extrapulmonary) effects in COPD Skeletal muscle dysfunction Osteoporosis Weight loss Sexual dysfunction Cardiovascular diseases (Gross et al., Curr Opin Pulm Med 2001;7:84)

(FEV 1 ) BMI (Am J Respir Crit Care Med 1998;157:1791-1797)

(Am J Respir Crit Care Med 1998;157:1791-1797)

Pulmonary Rehabilitation Multiprofessional individually tailored programme of rehabilitation including prescribed endurance exercise training should: Improve functional exercise capacity [Ia] Improve health status [Ia] Reduce dyspnea [Ia] Have some health economic advantages [Ib] (Thorax, 2001; 56:827)

Effect of respiratory rehabilitation on functional exercise capacity. (Am J Respir Crit Care Med, 1999; 159:1666)

Effect of exercise training on dyspnea compared with bronchodilators & oxygen. (Am J Respir Crit Care Med, 1999; 159:1666)

Survival curves for patients in the rehabilitation and education groups during 6 yr of follow-up. At 6 yr of follow-up, 38 of 57 patients survived in the rehabilitation group (67%) and 35 of 62 in the education group (56%). (p = 0.3). (Am J Respir Crit Care Med, 1999; 159:1666)

Pulmonary Rehabilitation (Am J Resp Crit Care Med, 2003;167(7):A38)

Thorax, 2001; 56:827 BTS Statement Pulmonary rehabilitation Level Levels of evidence and grading of recommendations Type of evidence Ia Ib IIa IIb III IV Meta-analysis of randomised controlled trials At least one randomised controlled trial At least one well designed controlled study without randomisation At least one other type of well designed quasi-experimental study From well designed non-experimental descriptive studies Expert committee reports of opinions and/or clinical experiences of respected authorities Grade A (levels Ia,Ib) B (levels IIa, IIb, III) C (level IV) Type of evidence Requires at least one randomised controlled trial Well conducted clinical studies but no randomised controlled trial Expert committee reports or opinion. Indicates absence of directly applicable studies of good quality

Pulmonary Rehabilitation A multi-disciplinary program of care for patients with chronic respiratory impairment that is individually tailored & designed. The goals of rehabilitation are to reduce the symptoms, disability, and handicap and to improve functional independence.

International Classification (WHO, 1980) Impairment: loss or abnormality of psychologic, physiologic, or anatomic structure or function Disability: inability to perform an activity in the manner within the normal expected range Handicap: disadvantage resulting from an impairment or disability within the context of the patient s ability to perform in society or fill expected roles

Pulmonary Rehabilitation The rehabilitation process incorporates a programme of physical training, disease education, nutritional, psychological, social, and behavioural intervention. It is assumed that optimum medical management has been achieved or continues alongside the rehabilitation process

Pulmonary Rehabilitation Selection Although most patients will have COPD, the benefits of rehabilitation may apply to all patients with dyspnea from respiratory disease. [B] The introduction of rehabilitation becomes appropriate when patients become aware of their disability. Rehabilitation should be considered at all stages of disease progression when symptoms are present and not at a predetermined level of impairment. This would usually be MRC dyspnea grade 3 or above. [C]

COMMON INDICATIONS FOR REFERRAL FOR PULMONARY REHABILITATION Respiratory disease resulting in: Anxiety engaging in activities Breathlessness with activities Limitations with: Social activities Leisure activities Indoor and/or outdoor chores Basic or instrumental activities of daily living Loss of independence

NON-COPD INDICATIONS FOR PULMONARY REHABILITATION Asthma (193, 194) Chest wall disease (20, 195) Cystic fibrosis (196, 197) Interstitial lung disease, including post-ards pulmonary fibrosis (30, 152) Lung cancer (198, 199) Selected neuromuscular diseases (152, 200, 201) Perioperative states (e.g., thoracic, abdominal surgery) Postpolio syndrome (202, 203, 204) Prelung and postlung transplantation (205, 206) Prelung and postlung volume reduction surgery (207, 208)

Pulmonary Rehabilitation: Selection There is currently no justification for selection on the basis of age, impairment, disability, or smoking status. Some patients with serious co-morbidity such as cardiac or locomotor disability may not benefit as much.[b] The only issues material to selection are poor motivation and the logistical factors of geography, transport, equipment usage, and the group composition.[c]

Pulmonary Rehabilitation Setting Pulmonary rehabilitation is effective in all settings including hospital inpatient, hospital outpatient, the community, and the home. [A] Cost comparison suggests that hospital outpatient rehabilitation is currently the most efficient form of delivery.[c]

Program content Pulmonary Rehabilitation Outpatient programmes should contain a minimum of 6 weeks of physical exercise, disease education, psychological, and social intervention.[b] Physical aerobic training, particularly of the lower extremities (brisk walking or cycling), is mandatory.[a] Upper limb and strength building exercise can be included.[b]

Pulmonary Rehabilitation: Program content Exercise prescription should be precise and individually assessed.[c] Individual training intensity should be recorded and can be increased through the program where tolerated.[c] Training intensity should usually be 60-70% of VO 2 peak. However, benefit can be obtained from lower intensity training where necessary, and increased benefits can be obtained from higher intensity training (85% VO 2 peak) when this can be achieved.[c]

Pulmonary Rehabilitation: Program content Training frequency should involve three sessions (20-30 minutes) per week of which at least two should be supervised.[c] Comprehensive disease education for patient and family is an important part of overall management that can be conducted within the rehabilitation programme.[c] Access to individual advice on physiotherapy, nutrition, occupational therapy, smoking cessation, end of life planning, and physical relationships is desirable.[c]

Suggestive content of educational sessions Anatomy, physiology, pathology and pharmacology (including oxygen therapy) Dyspnoea/symptom management, chest clearance techniques Energy conservation/pacing Nutritional advice Managing travel Benefits system Advance directives Making a change plan Anxiety management Goal setting and rewards Relaxation Identifying and changing beliefs about exercise and health related behaviours Loving relationships/sexuality Exacerbation management (including coping with setbacks and relapses) The benefits of physical exercise

Pulmonary Rehabilitation Process A nominated clinician with an interest in respiratory disease should be responsible for the program. This clinician should normally be responsible for medical assessment prior to entry to the program.[c] The programme should have a responsible officer appointed for the purpose. The coordinator may come from a profession allied to medicine or nursing.[c]

Pulmonary Rehabilitation: Process Staffing ratios will vary according to the patient characteristics, but a staff/patient ratio of 1:8 would be reasonable for the supervision of exercise classes.[c] There should be multiprofessional involvement from local resources.[c] Policies should exist for the stages of rehabilitation which include referral, assessment, selection, rehabilitation, and outcome assessment.[c]

Pulmonary Rehabilitation Outcome measures These should be embedded in the programme as part of the process.[c] The outcome measures should reflect the goals of rehabilitation by examination of relevant impairment, disability, handicap, and domestic activity.[c] Outcome measures need only be simple but centers with expertise can use advanced technology.[c]

COMMONLY USED OUTCOME MEASURES IN PULMONARY REHABILITATION Outcome Measures Impairment Disability Handicap Exercise ability Incremental exercise tests Submaximal exercise tests Walking tests General health status Sickness Impact Profile (SIP) Quality of Well Being Scale (QWB) Medical Outcomes Study, Short-From 36 (SF-36) Respiratory-specific health status St. Georg s Respiratory Questionnaire (SGRQ) Chronic Respiratory Disease Questionnaire (CRQ or CRDQ) Respiratory-specific functional status Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ) or modified version (PFSDQ-M) Pulmonary Functional Status Scale (PFSS) Exertional dyspnea Visual analog scale rating during exercise testing (VAS) Category rating (Borg) during exercise testing Overall dyspnea Medical Research Council Scale (MRC) Baseline and Transitional Dyspnea Indexes (BDI and TDI) * Symptoms independently evaluated from activities designated as follows: D = dyspnea; F = fatigue; P = pain.

ADVANTAGES AND DISADVANTAGES OF PULMONARY REHABILITATION IN DIFFERENT SETTINGS Inpatient Outpatient Advantages Closer medical monitoring makes it ideal for sickest patients with the greatest functional deficits Intensive nursing care available 24h/d Transportation to and from the program is not an issue for patient Allows participation and observation of family members in therapies Ideal setting for patients requiring assistive devices, tracheostomy care, or ventilator weaning Widely available Least costly Disadvantages Cost and potential difficulty with insurance coverage Not suitable for patients with less severe respiratory or comorbid disease Transportation potentially difficult for family members Potential transportation issues No opportunity to observe home activities Effcient use of staff resources Least intrusive to the family Home-based Convenience to the patient Cost and potential difficulty with insurance coverage Transportation not an issue for patient unless frequent trips to a health-care provider are part of the program Adaptation of exercise to a familiar environment may lead to better adherence with long-term treatment goals Lack of group support Potential lack of full spectrum of multidsciplinary health personnel Limited access to exercise equipment