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Expectations after Pulmonary
Scott Cerreta, BS, RRT
Director of Education
Conflict of Interest
• I have no real or perceived conflict of
interest that relates to this presentation.
Any use of brand names is not in any way
meant to be an endorsement of a specific
product, but to merely illustrate a point of
1. Discuss current literature and outcomes after
pulmonary rehabilitation.
2. Identify key elements that must be maintained after
pulmonary rehabilitation.
3. Learn about the COPDF Pulmonary Education Program
(PEP) as a post-graduation program.
4. Understand circumstances that lead to post-graduation
loss of benefits gained during rehab.
Literature Review
• Long term effectiveness (>2years) of Pulmonary
Rehabilitation is disappointing
• Drop-off is multifactoral
• Two most significant factors
1. Exacerbations of COPD18
2. Decrease in adherence to exercise prescription18
AACP/AACVPR Pulm Rehab Clinical Practice
Guidelines suggests that PRCs include
strategies to promote long-term adherence1
Literature Review
MT group had improved ESWT
No influence on QoL or hospital admissions
Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year mainenance training on physical functioning and
health status in patients with COPD. JCRPJournal; 47-52.
Maintaining Benefits after Rehabilitation
1. Encourage participation in Phase III rehab
Unproven health advantages long term for:
Continuous PR
Maintenance PR programs
Repeated courses of PR
Cost prohibitive in current health care system
2. Prevent Hospitalizations
Recognition of early signs of infection
3. Continue exercises at home or gym
4. Teach Optimal Care
Optimal Care Includes:
1. Smoking cessation
2. Pulmonary rehabilitation
Exercise and nutrition
Recognize early signs of infection
Breathing techniques
Coping skills
End-of-Life care
3. Annual spirometry on a good day
4. Testing for Alpha-1 Antitrypsin Deficiency
5. Medication adherence
GOLD Standards of COPD Care
FEV1 / FVC < 70%
I: Mild
III: Severe
FEV1>80% pred
FEV1 50-80% pred
FEV1 30-50% pred
IV: Very Severe
FEV1 < 30% pred or FEV1 <50%
predicted plus respiratory failure
Active Reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting
bronchodilators: ß2 agonists and anticholinergics
Add rehabilitation
Add ICS for repeated exacerbations
Surgical interventions
The Problem with Rehab ???
• No one remembers to order it !
• Recommended for GOLD Stage II
• Only 16% of physicians send patients to Rehab
• Rehab is your key resource to improve patient
adherence and understanding of this disease
Maintaining Benefits after Rehabilitation
• Optimal Care must be maintained lifelong
• Encourage participation in Phase III
• Find other programs and resources to
offer your patients after graduation
– Develop local programs for transitional care
– Collaborate with other organizations
• Local home care companies, not DME
• State Smokers’ Quit Line
• COPD Foundation
New Programs for the COPD Foundation
1. Healthy Interactions Conversation Map
Designed for acute care / transitional care setting
Education to decrease hospitalization and teach
patient self-management
2. Pulmonary Education Program (PEP)
Designed for pulmonary rehabilitation centers
Prolong benefits of rehab by connecting patients to
COPD Foundation resources after graduation.
Healthy Interactions Conversation Map®
• Pulmonary education not rehab
Designed for acute care admission for COPD patient
Hospital to Home transitional care program
Small group participation 6-10
Facilitator navigates patients through a conversation
map educational tool.
• Patient makes own decisions
• Patient learns from others experiences
• Patient learns to self-manage and become active in care
– We are still recruiting partner sites!
– Final Map tool used for Rehab Recruitment
– Future role-out to clinics, hosp, home care, etc.
All tools developed by Healthy Interactions. Conversation Map® is a registered trademark of
Healthy Interactions, Inc.
Pulmonary Education Program (PEP)
Designed for Pulm Rehab
– Promotes long-term
benefits after rehab
Sit and Be Fit Exercise DVD
Access to COPDF Resources
Access to COPD Info Line
Follow-up Program with
Rehab Center
Enhance Patient Support
Host COPD Education Day
C.O.P.D. Information Line
1-866-316-COPD (2673)
• Provides empathy and
support to callers, as well
as access to resources (e.g.
educational materials)
• Info Line associates are
people with COPD
• New branch staffed by
associates offer support
and information for
Additional COPD Resources at
Your Lung Health
COPD Research Registry
• Aims to build the proper cohort
of patients to enroll in clinical
trials and studies
• Over 2,600 patients enrolled
• Online/paper enrollment forms
• Info available through Info Line
• Created to help increase
enrollment in COPDGene Study
• National Jewish Health is data
coordinating center
BFRG Ver2.0
• Modeled after the
Alphanet BFRG for Alpha-1
• Most comprehensive guide
on COPD health
• Over 70 individuals and
organizations contributed
1. Coping with COPD
2. End-of-Life
3. Exacerbations
4. Exercise
5. Medicine
6. Nutrition
7. Oxygen Therapy
8. Travel
9. Understanding Lung Disease
10. Understanding Tests
• Teach optimal care
• Keep patients involved with lifelong care
• Know your patients – What stage COPD
– Encourage spirometry annually
– Encourage patients learn their FEV1 and stage
• Collaborate with others to maintain long
term benefits of pulmonary rehabilitation
• End result is decreased hospitalizations
and improved patient outcomes.
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Ries AL, Make BJ, Lee SM, et al. The effects of pulmonary rehabilitation in the National Emphysema Treatment
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Cambach W, Wagenaar RC, Koelman TW, et al. The long-term effects of pulmonary rehabilitation in patients with
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Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation:
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Guell R, Casan P, Belda J, et al. Long-term effects of outpatient rehabilitation of COPD: a randomized trial. Chest
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Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary
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Wijkstra PJ, van der Mark TW, Kraan J, et al. Long-term effects of home rehabilitation on physical performance in
chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996; 153:1234–124
Engstrom CP, Persson LO, Larsson S, et al. Long-term effects of a pulmonary rehabilitation programme in
outpatients with chronic obstructive pulmonary disease: a randomized controlled study. Scand J Rehabil Med 1999;
Wijkstra PJ, TenVergert EM, van Altena R, et al. Long term benefits of rehabilitation at home on quality of life and
exercise tolerance in patients with chronic obstructive pulmonary disease. Thorax 1995; 50:824–828
Berry MJ, Rejeski WJ, Adair NE, et al. A randomized, controlled trial comparing long-term and short-term exercise
in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2003; 23:60–68
Puente-Maestu L, Sanz ML, Sanz P, et al. Long-term effects of a maintenance program after supervised or selfmonitored training programs in patients with COPD. Lung 2003; 181:67–78
Grosbois J-M, Lamblin C, Lemaire B, et al. Long-term benefits of exercise maintenance after outpatient
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Cockram J, Cecins N, Jenkins S. Maintaining exercise capacity and quality of life following pulmonary rehabilitation.
Respirology 2006; 11:98–104
Brooks D, Krip B, Mangovski-Alzamora S, Goldstein RS. The effect of postrehabilitation programmes among
individuals with chronic obstructive pulmonary disease. Eur Respir J 2002; 20: 20–29.
Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year mainenance training on physical functioning
and health status in patients with COPD. JCRPJournal; 47-52.
COPD Foundation.