pulmonary rehabilitation for chronic lung disease

pulmonary rehabilitation for chronic lung disease 高雄長庚醫院呼吸治療科 E-Mail:chin1118@yahoo.com.tw TEL:07-7317123-2227 劉瑞芳

pulmonary rehabilitation for chronic lung disease 認識肺部復原運動? 誰需要肺部復原運動? 如何評估肺部復原運動? 如何執行肺部復原運動? 執行肺部復原運動成效?

pulmonary rehabilitation for chronic lung disease 人 45,000 42,559 圖 3.99 年及 100 年主要死因死亡人數 30,000 100 年 99 年 41,046 16,513 15,000 10,823 15,675 10,134 0 惡性腫瘤心臟疾病 ( 高血壓性疾病除外 ) 腦血管疾病 9,081 9,047 6,726 5,984 5,153 糖尿病 8,211 8,909 肺炎事故傷害 4,631 4,368 3,507 6,669 5,197 4,912 4,174 4,105 3,889 慢性下呼吸道疾病慢性肝病及肝硬化高血壓性疾病腎炎腎病症候群及腎病變蓄意自我傷害 ( 自殺 ) source: 行政院衛生署,100 年國人主要死因統計 2012 年 5 月 2 日. 取自 http://www.doh.gov.tw

pulmonary rehabilitation for chronic lung disease 肺疾病是導致十大死因的第七名惡性腫瘤占 27.3% 心臟疾病占 11.1% 腦血管疾病佔 7.5% 肺炎佔 6.1% 糖尿病佔 5.6% 意外事故佔 5% 慢性下呼吸道疾病 3.8% 導致殘障的主因呼吸道疾病花費 907 億呼吸系統疾病佔總費用 12.8% 是僅次於消化系統疾病死亡率逐年增加每十萬人囗增加到 15.49 人增加率為 2.17 倍每年增加百分率 10.36% 男性 > 女性發病率逐年增加 Source: 行政院衛生署 http://www.doh.gov.tw/cht2006/index_populace.aspx Chest 2007;131;4S-42S

pulmonary rehabilitation for chronic lung disease source:am. J. Respir. Crit. Care Med. April 1, 2001 vol. 163 no. 5 1256-1276

pulmonary rehabilitation for chronic lung disease 肺疾病是導致死因的第四名次於心臟病癌症, 中風之後導致殘障的主因每年 COPD 花費 500 億是僅次於冠心病社會保障殘疾福利氣喘估計有 9.5 兆死亡率逐年增加 1992 年 :91400 人 ;1992 年 :101870 人 ;2000 年 :119054 人男性 : 女性 <55 歲 : 男性 = 女性 >70 歲 : 男性 > 女性 (2 倍 ) >85 歲 : 男性死亡率提升至 3.5 倍 2000 年男性 < 女性發病率增加 34% 的人曾諮詢過醫生 ; 36% 否認有呼吸道症狀 ;30% 否認用力呼吸困難 2400 萬成年人肺功能受損只有 10 萬案例有醫生診斷報告 1400 萬案例慢性支氣管炎 200 萬案例 emphysema Source: 美國疾病管制局 http://www.cdc.gov/; Chest 2007;131;4S-42S

pulmonary rehabilitation for chronic lung disease source:respiratory Medicine (2005) 99, S19 S27

pulmonary rehabilitation for chronic lung disease Source: Murray & Nadel's textbook of respiratory medicine. 5th ed.

Definition of pulmonary rehabilitation American Thoracic Society (ATS; 1999) The European Respiratory Society (ERS; 1997) Multidisciplinary Individual Attention to physical and social function A Broad Therapeutic Concept Source:Am J Respir Crit Care Med Vol 173. pp 1390 1413, 2006

Essential Components of Pulmonary Rehabilitation Education Exercise training Assessment Patients Psychosocial and behavioral support PR team Follow-up Source: RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8

Who is on the pulmonary rehabilitation team Doctors Respiratory Therapists Exercise Physiologists Nurses Dietitians Physical Therapists Occupational Therapists Social service Providers Program Director: the coordinator of the program Source: RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8

誰需要肺部復原運動?

Setting hospital inpatient, hospital outpatient, the community, and the home. Cost comparison suggests that hospital out patient rehabilitation is currently the most efficient form of delivery. Source: Thorax 2001;56:827 834

Indication-1 Obstructive lung disease COPD Bronchiectasis Chronic bronchitis Emphysema Asthma Cystic fibrosis Restrictive lung disease Other Interstitial Pulmonary Fibrosis Interstitial disease Rheumatoid lung disease Pneumoconiosis Rheumatoid spondylitis Sarcoidosis Kyphosis obesity-related Restrictive chest wall Dis Pulmvascular disease. Pneumonectomy Lung transplantation Environmental Lung Disease Work-related lung DIsease Source: CHEST / 131 / 5 / MAY, 2007 SUPPLEMENT

Indication-2 Severe dyspnea and/or fatigue Decreased exercise ability Interference with performing activities of daily living Impaired health status Decreased occupational performance Nutritional depletion Increased medical resource utilization Source: CHEST / 131 / 5 / MAY, 2007 SUPPLEMENT

Contraindications Mental Disorders Acute Heart Failure/MI Cor pulmonale Cancer Metastasis Abnormal Liver Function Drug Abuse Source: Murray & Nadel's textbook of respiratory medicine. 5th ed.

Goals of Pulmonary Rehabilitation improve patients quality of life physical, psychological and social quality of life education lower and upper extremity exercise conditioning breathing retraining psychosocial support smoking cessation oxygen therapy bronchodilators respiratory muscle training and resting antibiotics nutritional support Source: Chest. 2007;131(5 Suppl):4S. Am J Respir Crit Care Med 2005; 172:19

Evidence-based support Evidence-based support enhanced patients sense of control over their condition improved exercise capacity increase exercise performance increased functional outcomes reduce dyspnea grown tremendously improved emotional function Improve health-related quality of life (HRQL) Reducing health care costs reduced length of hospital stay and number of hospitalizations reduction in primary care consultations survival benefit Source:1.Am J Respir Crit Care Med Vol 173. pp 1390 1413, 2006 2.Cochrane Database Syst Rev 2006;(4):CD003793

Evidence-based support

Evidence-based support Although evidence suggests that.. no direct effect on airflow limitation no direct effect on diffusing capacity no change in FEV1 important changes in self-efficacy in functional capacity confidence in coping with the disease reduction in health care costs survival benefit? Source:1.Am J Respir Crit Care Med Vol 173. pp 1390 1413, 2006 2. J Cardiopulm Rehabil 2004;24:52 62 3. RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8

Components of Comprehensive Pulmonary Rehabilitation Patient assessment Education Smoking Cessation Breathing retraining Airway Clearance Techniques Exercise training Psychosocial and behavioral support Nutritional support Oxygen supplementation Other- Noninvasive ventilation Outcome assessment Source:1. Chest 2007 May;131(5 Suppl):4S-42S 2.RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8

如何評估肺部復原?

Patient assessment Medical history Physical exam Symptoms assessment Dyspnea assessment Cognitive and psychosocial evaluation Pulmonary function assessment Musculoskeletal system assessment Exercise capacity assessment Nutrition assessment Activity of daily living level Source: Murray & Nadel's textbook of respiratory medicine. 5th ed.

如何執行肺部復原運動?

Education/Collaborative Self- Management Strategies patient-centered interventions (PCIs) disease education management of breathlessness management of an exacerbation medication psychosocial support welfare and benefits systems Source: Arch Phys Med Rehabil 2007;88(12):1704-1709

Education/Collaborative Self- Management Strategies What are the most important topics for patient education? Source: N Engl J Med 360:1329 1335, 2009

Educational impact of pulmonary rehabilitation: Lung Information Needs Questionnaire Rupert C.M. Jones a,*, Xu Wang a, Sam Harding a, Julia Bott b,michael Hyland Source: Respiratory Medicine (2008) 102, 1439e1445

Smoking Cessation important therapy Cause of mortality-copd/lung cancer/cvd Nearly six million deaths worldwide Over 400,000 deaths in the USA Undiagnosed in 50%-70% of persons with airflow obstruction Cigarette smoking is the cause of COPD:90% Usually >20 pack-years(including school-age children) They want to quit:70% They tried to quit in the past year :40% Intentionally did not smoke for at least one day The long-term success rate : 3% -7% Source: 1.BMJ. 2004;328(7455):1519; 2.Cochrane Database Syst Rev. 2004

Liter Smoking Cessation Indications: Symptoms or >10 pack year smoker 0 1 Normal COPD FEV 1 4.150 5.200 80 % 2.350 FVC 3.900 FEV 1 / FVC 60 % 2 FEV 1 3 4 FEV 1 COPD FVC 5 Normal FVC 1 2 3 4 5 6 Seconds

FEV 1 (% of value at age 25 y) Age-Related Decline in FEV 1 Is 100 Accelerated in Smokers Never smoked or not susceptible to smoke Stopped at 45 y Stopped at 65 y Smoked regularly and susceptible to its effects 75 50 25 0 Disability Death 25 50 75 Age (y) FEV 1, forced expiratory volume in 1 second. Adapted with permission from Fletcher C, Peto R. BMJ. 1977;1:1645-1648.

pulmonary rehabilitation for chronic lung disease Source: Murray & Nadel's textbook of respiratory medicine. 5th ed.

Smoking Cessation Brief Strategies to Help the Patient Willing to Quit Smoking ASK Systematically identify all tobacco users at every visit ADVISE Strongly urge all tobacco users to quit ASSESS Determine willingness to make a quit attempt ASSIST Aid the patient in quitting ARRANGE Schedule follow-up contact. Source: Global Initiative for Chronic Obstructive Lung Disease

Smoking Cessation Smoking Cessation Strategies Behavioral counseling Pharmacologic treatments A. nicotine replacement therapy B. bupropion C.varenicline Alternative therapies Clonidine patch Combination of behavior modification and pharmacologic intervention Source: 1.NCAP. J Respir Dis. 2000;21(suppl):S5-S21 2.N Engl J Med. 1999;340:685-691 3. Am Rev Respir Dis. 1987;135:354

Breathing retraining Therapeutic objectives Alleviate dyspnea Reduce the work of breathing Reduce the incidence of postoperative pulmonary complication Physiological objectives Improve ventilation Improve oxygenation

Breathing retraining Diaphragmatic Breathing Exercises Pursed-Lip Breathing Exercises Segmental Breathing Exercises Forced Expiratory Technique (Huffing) Directed Cough Manually assisted cough Relaxation Exercise Techniques

Breathing retraining Potential outcomes Eliminate accessory muscle action Decrease respiratory rate Increase tidal ventilation Improve distribution of ventilation Decrease need for postoperative therapy

Breathing retraining Baseline dyspnea index (BDI) Visual Analogy Scale(VAS) Borg Scale index Modified british medical research council dyspnea scale Borgs ratio scale

Bronchial Hygiene Therapy CPT Positive Airway Pressure Adjuncts Continuous positive airway pressure (CPAP) Expiratory positive airway pressure (EPAP) Positive expiratory pressure (PEP) High Frequency Chest Wall Compression (HFCC) Intrapulmonary Percussive Ventilation Flutter Valve Therapy Acapella

CPT Bronchial Hygiene Therapy

Bronchial Hygiene Therapy

pulmonary rehabilitation for chronic lung disease

Fiber type changes / Atrophy/ Apoptosis Source: AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 169 2004

Exercise Training Source: N Engl J Med. 2002;346:793-801.

Effects Exercise Training improves endurance/the level of functioning improves dyspnea/activities of daily living reduces anxiety /depression/ blood pressure Combinations of the various types endurance training / strength training Lower extremity exercise/ upper-extremity training Source:1RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8

Exercise Training Exercise Prescription Mode Intensity Duration Frequency Source:1RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8

Exercise Training Source:Am Fam Physician. 2010;82(6):655-660.

Oxygen Supplementation Survival benefit of continuous long-term oxygen therapy in COPD Source: Ann Intern Med 1980; 93:391

Oxygen Supplementation Survival benefit of long-term oxygen therapy in COPD Source: Lancet 1981; 1:681.

Oxygen Supplementation Benefits improve survival improve exercise capacity improve Hypoxemia quality of life cardiovascular morbidity depression cognitive function frequency of hospitalization Source: 1.RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8 1095 2. J Bras Pneumol. 2007;33(2):161

Oxygen Supplementation Adverse Effects No evidence Types of oxygen-delivery systems Dose of oxygen Oxygen prescription Monitored Source: 1.Am J Respir Crit Care Med. 2006;174(4):373 2.RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8 1095

Indications for long-term oxygen therapy Source: 2012 UpToDate

Prescribing Oxygen Selection of a qualified oxygen equipment supplier 1. Oxygen flow at rest, during exercise, and during sleep, where appropriate 2. Oxygen delivery systems: A. Stationary unt B. Portable or ambulatory equipment C. Oxygen-conserving device, if desired D. Nasal cannula or transtracheal catheter 3. Justification for portable or ambulatory oxygen, if requested 4. Verify that the supplier has correctly restated the prescription before signing Monitor use and environment (with home oxygen supplier) Reevaluation for possible changes in the prescription Renewal of therapy as required Source: 2012 UpToDate

Home Oxygen prescription Source: 2012 UpToDate

Psychosocial and behavioral support Scientific evidence was lacking Nearly 50% of patients with moderate to severe COPD have depression. reduced distress reduced symptoms of anxiety reduced symptoms of depression improved cognitive function self-efficacy improved quality of life improved patient perceptions of positive consequences enhanced psychological well-being Source: 1.Chest 2007 May;131(5 Suppl):4S-42S 2. RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8

Nutritional support Nutritional depletion -worsening mortality and health status Poor nutrition/ decreased weight/ abnormalities/muscle wasting BMI estimates / obese /diet weight loss Nutritional supplements - BMI<21 kg/m2 or BW loss>10% caloric support/ increase fat free mass /increase muscle strength Pharmacologic supplementation Anabolic agents/anabolic steroids /Testosterone Efficiency of physical training is unknown increase muscle bulk but not exercise capacity Source: Thorax 2001;56:827 834

Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease Felix SF Ram1, Joanna Picot2, Josephine Lightowler3, Jadwiga A Wedzicha4

Main components of PR programmes Donner CF, Decramer M. Pulmonary Rehabilitation ERJ Monograph, 2000: 13:132-142 Educa- tion Psycosocial support General exercise training Selected muscle training Chest physiotherapy Occupational therapy Nutritional inter- vention COPD +++ ++ +++ ++ + ++ + Asthma ++ ++ +++ ++ CF & bronchiect. Chest wall disor. ++ ++ +++(*) ++(*) +++ + ++ + + + Neuromusc. dis + ++ + Respir sleep dis + ++ + + + Interst lung dis Pre-post surgery Tracheostom pat ++ ++ +++ ++ +++ ++ ++ ++ + + + + (+): No evidence, (++): Few evidences, (+++): Good evidence, (*): Before transplantation

Outcomes Assessment Source: RESPIRATORY CARE AUGUST 2009 VOL 54 NO 8 1093

clinical experience

肺部復原是跨學科專業團隊胸腔科醫師胸腔科護士運動專家職業顧問社工 inpatient outpatient 呼吸治療師職能治療師物理治療師心理治療師營養師

病患教育呼吸控制痰液清除藥物教導運動訓練輔具訓練戒菸教育長期氧氣社會資源其他 COPD Asthma Emphysema Bronchiectasis Cystic fibrosis dischest wall disor. Interstitial disease Pre-post surgery

The Impacts of Pulmonary Recovery therapy on Patients with Chronic Obstructive Pulmonary Disease after Thoracic Surgery Chia-Ling Chang 13, Jui-Fang Chin 13, Su-Chyn Lin 4, Mei-Lien Tu 13, Chin-Chou Wang 123 1Department of Respiratory therapy, 2Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 3Department of Respiratory Care, Chang Gung University of Science and Technology. 4Department of Nursing, Kaohsiung Veterans General Hospital Purpose: To evaluate the impacts of pulmonary recovery therapy on patients with chronic obstructive pulmonary disease (COPD) after thoracic surgery. Methods: A prospective study of 127 patients undergoing thoracic surgery from January 2010 to December 2010 was carried out and was classified into two groups. The control group was with normal pulmonary function test; The COPD group with COPD patients. Breathing exercise, limb movements exercise, incentive spirometry training, chest physical therapy (CPT) and Intermittent Positive Pressure Breathing (IPPB) training were executed after extubation post-surgery in both groups. Informations regarding pulmonary function test, muscle power, oxygen saturation, complication, and severity of dyspnea were collected and analyzed in first and seventh day after extubation. Results: There were significantly different in FVC, MEF25-75, FEV1/FVC between both groups. There were significantly different in MIP cmh2o,mep cmh2o,rr, Borg scale in both groups.

The impacts of pulmonary recovery therapy on Elderly patients With coronary artery bypass graft surgery Nai-Ying Kuo 1, Jui -Fang Chin 13, Su-Chyn Lin 4, Mei-Lien Tu 13, Chin-Chou Wang 123, Yu-Hsiu Chung 12 1Department of Respiratory therapy, 2Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 3Department of Respiratory Care, Chang Gung University of Science and Technology. 4Department of Nursing, Kaohsiung Veterans General Hospital Purpose: To evaluate the impacts of pulmonary recovery therapy between different advanced aged patients with coronary artery bypass graft (CABG) surgery. Methods: A prospective study of 78 advanced aged patients undergoing CABG from January 2010 to December 2010 was carried out and was classified into two groups. Middle advanced aged group (MA group, age =60~69 years old) was with 46 patients and high advanced aged group (HA group, age >=70 years old) with 32 patients. Smoking cessation, breathing exercise, limb movements exercise, and incentive spirometry training were executed since one week before CABG surgery in both groups. Chest physical therapy (CPT) and Intermittent Positive Pressure Breathing (IPPB) training were added after extubation post-surgery until patients were discharged in both groups. Informations regarding pulmonary function test, muscle power, oxygen saturation, complication, and severity of dyspnea were collected and analyzed in first and seventh day after extubation. Results: There were significantly different in FVC, Peak Flow, MEF25-75 between first and seventh day in MA group. There were significantly different in FVC, FEV1, Peak Flow, and MEF25-75 between first and seventh day in HA group. There were significantly different in MIPcmH2O, MEPcmH2O, SPO2, RR, Borg scale between first and seventh day in both MA and HA groups. There were significantly different in chest tube drainage time in both MA and HA groups.

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