PULMONARY
REHABILITATION
Asthma/COPD Study Day
11/12/13
Fran Butler
Respiratory Physiotherapist
1
Session Objectives
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Background of pulmonary rehabilitation
How it runs in York
Outcomes of recent York groups
Barriers to rehab
Service development projects
2
Definition of Pulmonary
Rehabilitation (PR)
• ‘Pulmonary rehabilitation can be defined as an
interdisciplinary programme of care for patients
with chronic respiratory impairment that is
individually tailored and designed to optimise
each patient’s physical and social performance
and autonomy. Programmes comprise
individualised exercise programmes and
education’. BTS (2013)
3
Guidelines
NICE (2010)
• People with COPD meeting appropriate
criteria are offered an effective, timely and
accessible multidisciplinary pulmonary
rehabilitation programme
4
NICE GUIDELINES
• Structure
• a) Evidence of local arrangements to provide
multidisciplinary pulmonary rehabilitation programmes.
• b) Evidence of local arrangements to ensure
effectiveness of multidisciplinary pulmonary rehabilitation
programmes, by collection and audit of health outcome
data.
• c) Evidence of local arrangements to ensure
multidisciplinary pulmonary rehabilitation programmes
can be accessed in a timely manner.
• d) Evidence of local arrangements to ensure
multidisciplinary pulmonary rehabilitation programmes
are geographically accessible.
Aims of Pulmonary Rehabilitation
 Increase exercise tolerance and reduce
dyspnoea
 Increase muscle strength and endurance
(peripheral and respiratory)
 Improve health related quality of life
 Increase independence in daily functioning
 Increase knowledge of lung condition and
promote self-management
 Promote long term commitment to
exercise
6
Research
The British Thoracic Society (BTS) guideline 2013 recommends that:
• A program of exercise training of the muscles of ambulation is
recommended as a mandatory component of pulmonary
rehabilitation for patients with chronic obstructive pulmonary disease
(COPD).
• Pulmonary rehabilitation improves the symptom of dyspnea and
improves Health Related Quality of Life in patients with COPD.
• Six to 12 weeks of pulmonary rehabilitation produces benefits in
several outcomes that decline gradually over 12 to 18 months.
• Both low- and high-intensity exercise training produce clinical
benefits for patient with COPD. Unsupported endurance training of
the upper extremities is beneficial in patients with COPD and should
be included in pulmonary rehabilitation programs.
• Lower-extremity exercise training at higher exercise
intensity produces greater physiologic benefits than
lower-intensity training in patients with COPD.
• The scientific evidence does not support the routine use
of inspiratory muscle training as an essential component
of pulmonary rehabilitation.
• Education should be an integral component of
pulmonary rehabilitation. Education should include
information on collaborative self-management and
prevention and treatment of exacerbations.
• Pulmonary rehabilitation is beneficial for some patients
with chronic respiratory diseases other than COPD.
Examples of Effectiveness
It has been found that following a course
of pulmonary rehab patients demonstrated
a significant reduction in health care
utilization, both in hospital admissions and
out patient attendances.
Cost Analysis
• For 1 patient to attend a rehab course
costs approximately £375.
• Average or 1.85 inpatient days saved
At a average cost of £943.87 saved per
patient
• Average of 1 clinic appointment per patient
saved at a cost of £59
• Total average saving per patient £1002.87
• So reduction in spending of £627.87 per
patient
Current provision for Pulmonary
Rehabilitation in York
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Capacity of 10 programmes a year
4 in Selby (40 places)
4 in Wigginton (48 places)
2 in Foxwood (24 places)
• Total capacity 112
11
Referral Sources
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Respiratory Consultants
Respiratory Nurses
GP’s
Practice Nurses
Physiotherapists
12
Triage appointment
• Explain concept of course to the patient
• Check mobility
• Check patient is on optimum treatment (not
smoking)
• Offer choice of location
• Start home exercise programme and give
breathing control advice
• Additional advice about Chest clearance
• Baseline SpO2 and Heart Rate
• MRC scale
Medical Research Council
dyspnoea scale
Grade Degree of breathlessness related to activities
1 Not troubled by breathlessness except on strenuous
exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground
because of breathlessness, or has to stop for breath
when walking at own pace
4 Stops for breath after walking about 100m or after a few
minutes on level ground
5 Too breathless to leave the house, or breathless when
dressing or undressing
•
Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a
working population. British Medical Journal 2:257-66.
Triaging
Possible exclusion criteria:
1. Loco motor problems
2. Significant cardiac disease
3. Cognitive impairment
4. Preferably non-smokers
Non-compliance
1. Behavioural
2. Lack of social support
3. Continued smoking
4. Location and transport
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Programme Format
• Pre-course assessment
• Two sessions of exercise and one
education session per week for a total of
six weeks
• Post course assessment
16
Pulmonary Rehabilitation
Programme Components
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Exercise programme (to continue at home)
Education about the disease
Self management strategies
Breathing control techniques
Effective chest clearance techniques
Relaxation
Energy saving strategies
Benefits and social support
Dietary advice
17
Assessments for the Pulmonary
Rehabilitation Programme
1. CRDQ-Chronic Respiratory Disease
Questionnaire
2. Incremental Shuttle Walk test
3. Spirometry
4. Pulse Oximetry
18
CRDQ
• Measures the quality of life in patients with
chronic lung disease.
The questions are divided into four areas:
• Dyspnoea
• Fatigue
• Emotional function
• Mastery
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Borg Scale
Assessment of perceived breathlessness
Level of breathlessness
Score
Nothing at all…………………………………………………………..0
Very, very slight (just noticeable)…………………………………....0.5
Very slight……………………………………………………………...1
Slight……………………………………………………………………2
Moderate…………………………………………………………….…3
Somewhat severe……………………………………………………..4
Severe…………………………………………………………………..5 / 6
Very severe………………………………………………………….... 7 / 8
Very, very severe (almost maximal)………………………………… 9
Maximal…………………………………………………………………10
20
Exercises
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Timed Circuit based exercise class
Try to be functional
Alternate arms then leg based exercise
Can be progressed to remain challenging
for patients
• Able to adapt for patients with pre existing
musculoskeletal problems
• Most exercises can be replicated within
the patients home
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Non Completers
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Change in social circumstances (job)
Exacerbation / hospital admission
Transport issues
Not for them
Other health problems
Lack of motivation
RIP before course starts
Unwell family member
Maintenance of benefits
Depends on:
1.
2.
3.
4.
Patient motivation
Disease deterioration
Lifestyle/Behavioural change
Frequency of exacerbations
23
On Going support
• York HEAL Programmes
• Breathe easy support and exercise group
• Re referral back to group at later date
• Home exercise programme/DVD
24
Pulmonary rehab in past 2 years
Year
2011/2012
Offered
Rehab
110
2012/2013 109
Completed Drop out
Rehab
rate
67
40%
65
40%
25
Outcomes of programmes 20112013
Year
Greatest
Average
Improvement improvement
in Shuttle Walk in Shuttle
Walk
2011/ 240m
92m
2012
%
improved
MRC by at
least 1
73%
2012/ 210m
2013
69%
69m
26
CRDQ results 2011-2013
% improvements
Year
Dyspnoea Fatigue
Emotional Mastery
Function
20112012
52%
74%
52%
61%
2012- 62%
2013
72%
63%
69%
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Limitations to the Service - 2013
• Limited to 3 locations
• Not a rolling programme
• Limited availability to maintenance
courses
• Timing of referrals – patients having to
wait several months for a course
• Limited places due to hall space and staff
to patient ratio
Referrals to Rehab
Total referrals
April 2012April 2013
192
Total
attended
triage
clinic
168
Total DNA
clinic
Total invited
to rehab
22
• This data is for rehab referrals only
109
Audit review information April 2012April 2013
Referrals to Rehab
250
Number
200
150
100
50
0
Total referrals
April 2012-April
2013
Total attended
triage clinic
Total invited to
rehab
Rehab Completion
Rehab to Completion
120
Number
100
80
60
40
20
0
Total invited to Total attended Total completed
rehab
pre Ax for rehab
course
Outcomes for DNA’s to rehab
2012-2013
Outcomes for non-attendance at rehab
RIP
DNA Triage Clinic
HEP only
Declined
Outcomes for DNA’s to rehab
2012-2013
• Some patients do not fit the inclusion
criteria therefore are given a home
exercise programme only
• Some patients decline the programme and
are also given a home exercise
programme only
• Some patients repeatedly DNA clinic
appointments so are never triaged or
given a home exercise programme
Future Plans
• Continued audit of the service
• Starting a rolling programme in Selby – February
2014
• Capture as many COPD patients on the ward
and refer to triage clinic for Ax for suitability for
rehab
• Education to referrers to improve uptake
• PhD study into adherence in Pulmonary
Rehabilitation – literature review into adherence,
motivational/behavioural assessment tools, use
of CBT in PR.