Pulmonary Rehabilitation
in COPD
Maureen Fagan
Respiratory Specialist Nurse
“They tried to make me go to
rehab, I said no, no, no....”
Amy Winehouse
diagnosed with
emphysema
From Times Online
June 23, 2008
What is Pulmonary Rehabilitation?
“…a multidisciplinary 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.”
Spiral of Disability
Why is it pulmonary
rehabilitation important?
• COPD causes 30,000 deaths per year and leads to
extensive morbidity. It incurs massive costs in relation to
hospital admissions, incurring nearly 6 times as many
bed days of inpatient care as asthma.
• Interventions which improve quality of life and level of
functioning are important since few interventions except
smoking cessation affect disease progression.
Development of Disability in COPD
• The decline in airway function may go unnoticed initially
as people adapt their lives to avoid dyspnoea
• Up to 50% of FEV1 may be lost before a person presents
with significant symptoms
• Significant disability develops late in the course of the
disease when reversal of airway obstruction is not
possible.
• Dyspnoea , Limb muscle dysfunction, hypoxaemia , poor
nutrition, steroid myopathy and loss of confidence may
contribute to disability
Aims
• Increase exercise tolerance
• Increase muscle strength and endurance
• Reduce dyspnoea and perception of
breathlessness
• Reverse deconditioning
• Increase knowledge of lung condition and
management of the disease
• Promote self-management and coping
strategies
• Improve health-related quality of life
• Improve confidence in ability to exercise
• Increase independence in daily functioning
• Promote long-term commitment to exercise
Who is it for?
• All disease severities (but may not benefit if unable to
walk)
• …where SYMPTOMS AND DISABILITY are present
(usually MRC grade 3)
Who is it for?
• All disease severities (but may not benefit if unable to
walk)
• …where SYMPTOMS AND DISABILITY are present
(usually MRC grade 3)
• No justification for selection on basis of age, impairment,
disability, smoking status or oxygen use
• Post exacerbation
• Contra-indicated if recent MI/ unstable angina/
Course Content and Duration
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The longer the better but usually 6-12 weeks
Twice weekly minimum
Patient assessment
Baseline and outcome assessments: exercise capacity
(shuttle walk), disability/health status (questionnaire)
Exercise training upper limb and lower limb training/
respiratory muscle training / breathing exercises
Optimal pharmacological management
Educational support - can include carer
Psychological support - can include carer
Assessment of outcome
Programme evaluation
Maintenance
Programme settings & staffing
• Effective in inpatient, outpatient and community
settings and possibly at home.
• Should be held at times that suit patients in
buildings that are easy to access with
appropriate access for those with disabilities.
Patient Safety
Staff patient ratio
• Exercise 1:8
• Education 1:16
Staff trained in Basic life support
Ambulatory O2
Exercise Training:
Which muscle groups?
• Lower limb training improves exercise tolerance though
no effect on measured lung function
• Upper limb training improves arm strength and reduces
ventilatory demand
• Respiratory muscle training may influence endurance
and dyspnoea but evidence is conflicting
• DOESN’T HAVE TO BE HI TECH
Education Programme
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COPD – overview
Breathing control, pacing and relaxation
Exercise/activity
Medication, devices and O2 therapy
Managing exacerbations
Sputum clearance
OT equipment
Benefits agency
Holidays
Palliative care
Diet
Psychological components
• COPD is associated with anxiety and depressive
symptoms which may interfere with activities of daily
living (ADL’s)
• Expert opinion supports the use of educational and
psychological interventions in pulmonary rehab
programmes
• Typical goals: address depression/anxiety, teach
relaxation skills, coping strategies, discuss relevant
issues such as sexuality, family and work relationships
Patient Feedback
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Programme as a whole was excellent
Wished it was longer
Have got my life back
Im now in control
Much more confident
Achieved goals and more
Can relax better
My illness no longer runs my life
Can walk further
My life now feels worth living again
Feel better about myself
Summary - Benefits of
Pulmonary Rehabilitation
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Improved exercise capacity (Evidence A)
Improved health-related quality of life (Evidence A)
Reduces perceived intensity of breathlessness (Evidence A)
Reduced hospitalisations and length of stay (Evidence A)
Reduced anxiety and depression associated with COPD
(Evidence A)
• Increased survival (Evidence B)
• Benefits probably extend well beyond the period of
rehab, especially if exercise training is maintained at
home. (Evidence B)
• Improved psychological wellbeing (Evidence C)
References
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NICE: National clinical guidelines on management of COPD in adults in
primary and secondary care (2010)
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GOLD: Global strategy for the diagnosis, management and prevention of
chronic obstructive pulmonary disease (2009)
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Nici et al. ATS/ERS Pulmonary Rehabilitation Writing Committee American
Thoracic Society/European Respiratory Society statement on pulmonary
rehabilitation. Am J Respir Crit Care Med. 2006;173:1390-413
•
Y Lacasse, L Brosseau, S Milne, S Martin, E Wong, GH Guyatt, RS
Goldstein, White J, Pulmonary rehabilitation for chronic obstructive
pulmonary disease (Cochrane review). In: The Cochrane Library, issue 3,
2004.
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Pulmonary Rehabilitation Joint ACCP/AACVPR Evidence-Based
Guidelines. Chest/ 112 / 5 / November 1997
Resources
GPIAG Best Practice Statement
• www.gpiag.org/resources/gpiag_pul_rehab_bestpractice.200306.pdf
IMPRESS Principles Document
• www.ipmpressresp.com/portals/o/IMPRESS/PrinciplesofPR.pdf
Patient Information
• http://www.chss.org.uk/chest/index.php
Thanks for listening.
Any Questions ?