Pulmonary rehabilitation in severe COPD daniel.langer@faber.kuleuven.be
Content Rehabilitation (how) does it work? How to train the ventilatory limited patient?
Chronic Obstructive Pulmonary Disease NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Definition: Chronic obstructive pulmonary disease is characterized by airflow limitation that is not fully reversible. It is a preventable and treatable disease with some significant extrapulmonary manifestations. Skeletal muscle dysfunction Weight loss Cardiovascular disease Depression and Fatigue Osteoporosis
VE (L/min) Interaction between pulmonary and extrapulmonary factors 180 160 140 120 100 80 60 40 20 0 Muscle Dysfunction Early lactic acidosis Dynamic Hyperinflation Breathing frequency 0 1 2 3 4 VO2 (L/min)
Targets of Exercise Training Improving aerobic function of ambulation muscles Reducing ventilatory requirement and respiratory rate during exercise Prolonging expiration time Reducing dynamic hyperinflation and dyspnea Casaburi et al. N Engl J Med 2009 Casaburi R and ZuWallack R. N Engl J Med 2009;360:1329-1335
Content Rehabilitation Program Exercise Training Endurance exercise to improve cardiorespiratory fitness Resistance training to improve muscular strength and endurance (peripheral and respiratory muscles) Supplemental interventions during exercise training Oxygen Heliox Breathing exercises Occupational therapy Nutritional advise Psychological support Patient-education / self-management (inactivity)
(% baseline) (% baseline) Rehabilitation, the evidence: Exercise tolerance Exercise tolerance: Weighted mean difference and IQR 30 20 10 0 Wmax VO2max Walking Whole body end 110 100 90 80 70 60 50 40 30 20 10 0 Adapted fromtroosters AJRCCM 2005
Dys Fat Emo Mas 6MWD Rehabilitation, the evidence HRQoL (MCID-units) 3 2 1 0 CRDQ 6MWD (m) 75 50 25 6MWD -1 0 Lacasse Eura Medicophys 2007 (Cochrane)
Rehabilitation, the evidence: Health care resources Controls Rehabilitation Patients admitted n Hospital admissions Resp All Days spent in hosp Resp All Days per admission 1.9 2.2 18.1 21.0 9 41 1.4 1.5 19.3 20.7 7.6 1.4 1.7 9.4 10.4 6 40 1.3 1.1 10.2 9.7 3.4 NS 0.1 Griffiths Lancet 2000
Rehabilitation: the evidence Evidence from systematic review of meta-analysis of randomised controlled trials (level la) Improvements in exercise tolerance Clinically relevant improvement in health related quality of life (HRQoL). Evidence from at least one RCT(level lb) Reductions in number of days spent in hospital Pulmonary rehabilitation is cost effective
Exercise training, the core of rehabilitation How do we train patients with severe airflow obstruction, dynamic hyperinflation and complaints of dyspnea on exertion?
Knowing exercise limitations to guide training How to train the ventilatory limited patient? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs Increase the delivery Reduce the demand
Exercise enndurance (% increase) Time PA outside rehab (min) Improve lung function 150 700 600 100 500 50 400 300 0 200 TIO REHAB TIO+REHAB w4 w9 w13 w17 w21 w25 Casaburi et al Chest 2005 Kesten J COPD 2008
Ventilation (L.min -1 ) Improve maximal voluntary ventilation HeliOx FEV1 FVC 90 Air HeliOx 1.54 0.73 1.89 0.73 3.76 1.13 3.86 1.18 18 16 14 12 10 Endurance time 70 60 50 40 VE 60 30 HE 8 6 4 2 30 20 10 0 0 0 0 10 20 Time (min) Eves AJRCCM 2006
WR (%max) Training at higher intensity 120 100 80 FEV 1 TLC D LCO VO2peak Air (n=19) He/O 2 (n=19) 47 129 66 55 19 20 22 11 46 122 64 59 14 17 14 13 24 20 16 12 Endurance time 60 8 40 4 0 2 4 6 8 10 12 14 16 18 20 22 0 Air HH Session (n) Eves Chest 2009
Lung Transplantation
1yPost-LTX n=22 Healthy n=30 Gender / 12 / 10 18 / 12 Age yrs 59 5 58 6 BMI kg/m 2 23 4 25 4 FEV 1 %pred 79 18 116 18 Q-Force Nm 100 36-40% 164 41 MEP cm H 2 O 159 44-20% 193 47 MIP cm H 2 O -76 48-20% -97 53 Handgrip kgf 36 16-15% 42 10 6MWD Wmax m %pred 483 74 66 22-30% -60% 690 182 83 57 Langer et al. Journal of Heart and Lung Transplantation 2009
Study Design RCT Exercise Training after LTX Transplantation Pre-LTX 105 days Post-LTX 28 days Exercise Training Control 3m/6mPost- Random Physical activity counseling w/ feedback SenseWear
Baseline Characteristics Post-LTX Training (n=15) Control (n=13) Male / Female 8 / 7 7 / 6 Early acute rejection (yes / no) 6 / 7 3 / 9 SLTX / SSLTX 1 / 14 3 / 10 Diagnosis COPD / ILD 12 / 3 11 / 2 Age 56 4 56 7 BMI (kg/m²) 20,7 4,6 21,6 4,2 FEV 1, (% pred) 72 18 74 16
Exercise Training 3 sessions per week Resistance exercise Treadmill walking Stair climbing Cycling
6-minute walking distance (m) Results 600 500 400 re-ltx Post-LTX 3mPost-LTX 6mPost-LTX 300 Training Control Pre-LTX Post-LTX 3mPost-LTX 6mPost-LTX
Knowing exercise limitations to guide training How to train the ventilatory limited patient? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs Increase the delivery Reduce the demand
WR (%max) Training at higher intensity 120 24 24 Endurance time 100 80 60 20 16 Increased O2 delivery 12 Lower lactate Reduced ventilatory 8 drive 20 16 12 8 40 4 4 0 2 4 6 8 10 12 14 16 18 20 22 0 Air HH 0 Air O2 Session (n) Emtner AJRCCM 2003
Knowing exercise limitations to guide training How to train the ventilatory limited patient? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs Increase the delivery Reduce the demand
VO 2 L/min Q tw pot (%baseline) Pepin AJRCCM 2005 Reduce the demand - Enhance the stress to the muscle for a given VO2 (walking vs cycling) 3.0 2.0 1.0 0.0 R 50% 100% End 30 20 10 0-10 -20-30 -40-50 Cycle @ 80% Wpeak Walk @ 80% VO 2 peak
VO 2 L/min Reduce the demand - Enhance the stress to the muscle for a given VO2 (walking vs cycling) - Reduce the amount of muscle mass at work (resistance training, NMES). 35 30 25 20 15 10 Walking Cycling Stairs Quadr Probst ERJ 2006
(% initial or points) 50 40 STRENGTH ENDURANCE 30 20 10 0 6MWD VO2max CRDQ Spruit et al. Eur.Respir.J. 2002; 19:1072-1078
Reduce the demand - Enhance the stress to the muscle for a given VO2 (walking vs cycling) - Reduce the amount of muscle mass at work (resistance training, NMES, single leg) Single Leg Exercise Dolmage Chest 2008
Endurance Time (min) @ 80% Wpeak Single leg exercise 35 30 25 20 15 10 5 0 Healthy COPD two legs one leg Dolmage et al Chest 2006
% initial % initial min Single leg training 30 min of conventional cycling training versus single leg cycling (15 min each leg) 3 times per week 7 weeks FEV1 37 and 40%pred 35 25 10 30 25 20 8 20 15 6 15 10 5 10 5 4 2 0 Wpeak 0 VO2peak 0 Tlim@80% Dolmage Chest 2008
Reduce the demand - Enhance the stress to the muscle for a given VO2 - Reduce the amount of muscle mass at work - Shorten the bouts of exercise to keep ventilation lower than needed in steady state (interval training) Slow oxygen uptake (ventilatory) kinetics : your friend in pulmonary rehab
VO 2 (L/min) Pepin 2006 Saey 2005 PL Saey 2005 IPR Mador 2003 Mador 2001 Man 2003 TwQ (%change) Interval exercise, often more realistic 100 1.1 75 0.9 50 0.7 25 0.5 0.0 0 2 4 6 8 54 56 58 60 62 Time (min) Sabapathy Thorax 2004
Conclusions Pulmonary rehabilitation works: GRADE A -level of evidence Exercise training can be fine-tuned to the exercise limitations of patients Several options available for ventilatory limited patients
Increase Ventilatory Capacity: Bronchodilators Heliox High intensity Peripheral Muscle Training Exercise training
Reduce Ventilatory Requirements: O 2 supplementation Small muscle mass Short intervals High intensity Peripheral Muscle Training One-leg exercise Interval training Resistance training
Thank you for your attention Greetings from the Leuven Pulmonary Rehabilitation team