Pulmonary Rehabilitation
What do these patients have in common?
Factors contributing to exercise intolerance
Factors contributing to exercise intolerance
Factors contributing to exercise intolerance
Factors contributing to exercise intolerance
Factors contributing to exercise intolerance
Common indications for referral for pulmonary rehabilitation American Thoracic Society. Am J Respir Crit Care Med. 1999;159:1666-1682.
The Dyspnea Spiral Dyspnea during moderate exertion Respiratory impairment Dyspnea during mild exertion Abstinence from exercise Further abstention Dyspnea during ADL * Further deconditioning Physical deconditioning *Stay at home, depression, oxygen therapy, etc. Adapted from Dennis O Donnell, MD.
Timing of pulmonary rehabilitation
ABCD Assessment Tool 2017 Global Initiative for Chronic Obstructive Lung Disease
Pulmonary rehabilitation ATS/ERS definition
Goals of pulmonary rehabilitation American Thoracic Society. Am J Respir Crit Care Med. 1999;159:1666-1682. British Thoracic Society Standards of Care Subcommittee on Pulmonary Rehabilitation. Thorax. 2001;56:827-834. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Chest. 1997;112:1363-1396.
What is pulmonary rehabilitation? Dyspnea Functional Capacity QOL
What is Pulmonary rehabilitation?
Exercise training
Exercise training
Exercise practice guidelines
Maximizing the effects of exercise training
Behavior change and collaborative self-management
Body composition abnormalities and interventions
Body composition impact
Body composition interventions
Pulmonary rehabilitation outcome measurements
Pulmonary rehab in NETT Max medical Rx (with rehab) + LVRS NETT centers + >400 rehab satellite centers Improved exercise, symptoms, QOL after rehab Slightly greater exercise at NETT centers vs. satellites; no difference symptoms/qol
10 5 % Change 0-5 -10-15 -20 Wmax PB PMF 6MW 6PB 6PMF all p < 0.0001
% Change 8 6 4 2 0-2 -4-6 -8-10 -12 SOBQ SGRQ Total SGRQ Activ SGRQ Impact SGRQ Symp QWB all p < 0.0001
Effect of rehab location % Change 15 10 5 0-5 -10-15 -20 * ** * Wmax PB PMF 6MW 6PB 6PMF NETT Center Satellite
Effect of rehab location 0 * -2 % Change -4-6 -8-10 -12 SOBQ SGRQ Total SGRQ Activ SGRQ Impact SGRQ Symp NETT Center Satellite
Effect of prior rehab % Change 0-2 -4-6 -8-10 -12-14 -16 ** *** *** ** SOBQ SGRQ Total SGRQ Activ SGRQ Impact SGRQ Symp No Prior Rehab Prior Rehab
Effect of prior rehab % Change 15 10 5 0-5 -10-15 -20 * * *** ** * Wmax PB PMF 6MW 6PB 6PMF No Prior Rehab Prior Rehab
Lessons from NETT
Lessons from NETT Effectiveness of pulmonary rehab Multiple centers Patients with severe disease Important adjunct to surgery Preparation for surgery Recovery from surgery CMS coverage for LVRS requires pulmonary rehab pre- and post-op
Cote et al. ERJ 2005; 26.
Puhan et al. Respiratory Research 2005; 6.
Puhan et al. Respiratory Research 2005; 6.
Puhan et al. Respiratory Research 2005; 6.
Puhan et al. Respiratory Research 2005; 6.
Outpatient Pulmonary Rehabilitation: Study Objective and Design Griffiths TL et al. Lancet. 2000;355:362-368.
Outpatient Pulmonary Rehabilitation: Study Results SGRQ = St. George s Respiratory Questionnaire; CRDQ = Chronic Respiratory Disease Questionnaire. Griffiths TL et al. Lancet. 2000;355:362-368.
The effect of pulmonary rehabilitation on health status 0 6 Weeks 1 Year -2 Change from Baseline in SGRQ Score -4-6 -8-10 -12 Symptoms Activity Impact Total Improvement SGRQ = St. George s Respiratory Questionnaire. Griffiths TL et al. Lancet. 2000;355:362-368.
Pulmonary rehabilitation and days spent in hospital 25 20 21.0 Nonrespiratory Respiratory Total Days 15 10 5 0 Control 10.4 Rehabilitation P =.021. Griffiths TL et al. Lancet. 2000;355:362-368.
Cochrane meta-analysis McCarthy et al. Cochrane Database Syst Rev. 2015;2.
McCarthy et al. Cochrane Database Syst Rev. 2015;2.
McCarthy et al. Cochrane Database Syst Rev. 2015;2.
McCarthy et al. Cochrane Database Syst Rev. 2015;2.
Guell et al. AJRCCM 2017:195; 622-29.
Guell et al. AJRCCM 2017:195; 622-29.
Guell et al. AJRCCM 2017:195; 622-29.
Guell et al. AJRCCM 2017:195; 622-29.
Guell et al. AJRCCM 2017:195; 622-29.
Summary: Impact of pulmonary rehabilitation
The Dyspnea Spiral Dyspnea during moderate exertion Respiratory impairment Dyspnea during mild exertion Abstinence from exercise Further abstention Dyspnea during ADL * Further deconditioning Physical deconditioning *Stay at home, depression, oxygen therapy, etc. Adapted from Dennis O Donnell, MD.