Transcript to Exercise Prescription for the Pulmonary Patient

Chuck Kitchen, MA, FAACVPR
[email protected]
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OBSTRUCTIVE DISEASES
COPD-Chronic airway obstruction
Emphysema-Hyperinflation of the lungs,
can’t get bad air out
Chronic Bronchitis-Chronic sputum
production and coughing
Asthma-increased airway reactivity leading
to narrowing of airways
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PR only covered for Moderate, Severe, Very
Severe COPD
GOLD classification
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Chronic lower respiratory diseases ICD-10: J40-J47
Obstructive Lung Disease:
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Persistent asthma: 493
Bronchitis: 491
Bronchiectasis: 494
COPD: 496
Cystic fibrosis: 277.03
Bronchiolitis obliterans: 491.8
Emphysema: 492
AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th
ed. 2010, Champaign, IL: Human Kinetics Publishers.
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Restrictive Lung Diseases:
 Interstitial diseases: 518.89 (J84.1-9)
▪ Idiopathic interstitial fibrosis: 516.31 (J84.10-J84.111-117)
▪ Other interstitial pulmonary disease with fibrosis: J84.17
▪ Occupational or environmental lung disease: 518.89(Z57.31)
▪ Sarcoidosis: 517.8 (Lung involvement) (D86.0, 86.2)
 Chest wall diseases:
▪ Kyphoscoliosis: 737.3 (M41.8)
▪ Ankylosing spondylitis: 720.0 (M45.3-45.5)
AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th
ed. 2010, Champaign, IL: Human Kinetics Publishers.
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Restrictive Lung Diseases, Continued:
 Neuromuscular diseases:
▪ Parkinson’s: 332 (G20)
▪ Postpolio syndrome: 138 (G14)
▪ Amyotrophic lateral sclerosis: 335.2 (G12.21)
▪ Diaphragmatic dysfunction: 518.89 (J98.6)
▪ Multiple sclerosis: 340 (G35)
▪ Post-tuberculosis syndrome: 518.89 (A-15)
AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th
ed. 2010, Champaign, IL: Human Kinetics Publishers.
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Obesity-related Respiratory Disorders:
 Obesity hypoventilation syndrome: 278.03
 Obstructive sleep apnea: 327.23
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Other Lung Disorders:
 Lung cancer: 162
 Pulmonary hypertension: 416-417.8 (
 Post-lung transplant: V42.6
AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th
ed. 2010, Champaign, IL: Human Kinetics Publishers.
Pulmonary Rehabilitation must be the ONLY
service billed using G0424
 Sessions limited to a maximum of two 1-hour
sessions per day for up to 36 sessions
 Contractors may approve up to an additional 36
sessions when medically necessary.
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 Providing access of up to 72 sessions of PR, when
appropriate
 Does not specify a duration by which sessions must be
completed; allowing the maximum allowable number
of 72 over a longer period of time
42.CFR 410.47
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G0424: Pulmonary rehabilitation, including exercise
(includes monitoring), per hour, per session
 Revenue Code: 0948
 Session duration:
▪ One session = > 31 minutes
▪ Two sessions = > 91 minutes, with the first session = 60
minutes and second session = 31 minutes
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Do NOT bill any other codes for the COPD patient
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Interstitial Lung Diseases
 Environmental-asbestos, dust, coal, etc
 Drugs or chemotherapy
 Collagen diseases (scleroderma, lupus, etc)
 Pulmonary fibrosis
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Vascular Lung Diseases
 Pulmonary Hypertension
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3-5 days per week
Walking (preferred) and cycle
20-60 min
RPE 5-6 (Moderate) Or 7-8 (Vigorous) for Mild
COPD
RPE 3-5 for Moderate to Severe COPD
No upper extremity recommended
Does not use GOLD criteria
Strength Training-2-4 sets, 2-3 days/week
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0.5
1
2
3
4
Nothing at all
Very, Very Light
Very Light
Fairly Light
Moderate
Somewhat Hard
5
Hard
6
7
Very Hard
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9
10 Very, Very Hard
(Maximal)
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3-5 days per week
Walking, cycle, arm ergometry, warm-up and
cool down
20-90 minutes per session
Intensity to achieve patient goals
Upper extremity exercise with lower
extremity (arm ergometer)
Strength Training-Hand weights, free
weights, machine weights
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3 days per week
Cycling or walking
> 3o min
RPE 4-6 or predetermined MET level
Arm ergometer, free weights, elastic bands
Strength training-2-4 sets 6-12 reps
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6 Min Walk Test-Widely used tool to
determine exercise prescription
Determine initial exercise intensity
F.I.T.T PRINCIPLE
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Frequency
Intensity
Time
Type
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FREQUENCY
3 to 5 times per week
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INTENSITY
4-6 Borg Dyspnea scale
12-14 RPE scale
INTENSITY
DYSPNEA SCALE (Modified Borg)
0
None
5 Severe
0.5 Very, Very slight
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1
Very slight
7 Very Severe
2
Slight
8
3
Moderate
9 Very, Very Severe
4
Somewhat severe
10 Maximum
INTENSITY
RPE SCALE
6
7 very, very light
8
9 very light
10
11 light
12
13 somewhat hard
14
15 hard
16
17 very hard
18
19 very, very hard
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TIME
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20 to 6o minutes
Can use interval training especially for
beginners or low level patients
Total exercise time is most important
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TYPE
Continuous Aerobic
High Intensity Interval Training not found to
have same benefits as with Cardiac
Population (CHF, etc)
Possibly due to Dyspnea
Low to moderate intensity interval training
can be used
Resistance Training
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No data for “optimal” resistance training
program
Important to help maintain muscle mass
(muscle wasting)
1-3 sets
8-12 repetitions
2-3 days per week
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Exercise capacity often limited by dyspnea,
not MET level or RPE, etc
SaO2 Monitoring
Supplemental O2 to maintain 88%-90%
Generally, cycle or other non weight bearing
equipment has higher O2 sats
Consider continuous exercise on cycle,
recumbent stepper, etc. Interval on TM
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Take bronchodilators prior to exercise
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Short term benefits from PR
Smaller improvements and shorter lasting
Typically more dyspnea than obstructive
disease
Generally more reliant on supplemental O2
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Careful to maintain O2 sats above 88%-90%
Monitor BP and HR
Consider telemetry monitoring
Exercise Intensity should be light to
moderate ONLY
Monitor for lightheadedness, chest pain, etc
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AACVPR and ACCP do not recognize IMT as
part of Pulmonary Rehab
Devices used to impose resistance or load
Patients increase inspiratory muscle strength
Significant decreases in dyspnea
Increased walking distance
However, no increase in peak power
Increased quality of life measures
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Exercise Prescription is an Art!!
Every patient is different
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American Association of Cardiovascular and
Pulmonary Rehabilitation. Guidelines for Cardiac
Rehabilitation and Secondary Prevention Programs,
4th ed. Champaign, IL; Human Kinetics, 2010.
Garvey C, Fullwood MD, Rigler J. Pulmonary
Rehabilitation Exercise Prescription in Chronic
Obstructive Lung Disease. JCRP 2013; 33: 314-322
Johnson-Warrington V, Harrison S, Mitchell K, et al.
Exercise Capacity and Physical Activity in Patients
With COPD and Healthy Subjects Classified as Medical
Research Council Dyspnea Scale Grade 2. JCRP 2014;
34(2): 150-154
Ryerson CJ, Cayou C, Toop F, et al. Pulmonary
rehabilitation improves long-term outcomes in
interstitial lung disease: A prospective cohort study.
Respir Med 2014; 108(1): 203-210
 Spruit MA, Singh SJ, Garvey C, et al. An Official
American Thoracic Society/European Respiratory
Society Statement: Key Concepts and Advances in
Pulmonary Rehabilitation. Am J Respir Crit Care Med
2013; 188(8): e13-e64
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