Transcript Diapositiva 1

Corso di Formazione per Medici NYCOMED
Modena, 6-7/8-9 Settembre 2011
Riabilitazione
Cardiorespiratoria nella BPCO
Ernesto Crisafulli - Enrico Clini
RATIONALE
COPD
Lung function deterioration
 Airflow obstruction
 Hyperinflation
 Gas exchange abnormalities
Co-morbidity
 Cardiac
 Type II diabetes
 Mood disturbance
 Endocrinological
 Hematological
Progressive muscle weakness
Reduced bone mineral density
Ventilatory limitation
(resting and/or during exercise)
Symptoms
DEFINITION
“Pulmonary rehabilitation is an evidence-based,
multidisciplinary, and comprehensive intervention
for patients with chronic respiratory diseases who are
symptomatic and often have decreased daily life
activities. Integrated into the individualized treatment of
the patient, pulmonary rehabilitation is designed to
reduce symptoms, optimize functional status, increase
participation, and reduce health care costs through
stabilizing or reversing systemic manifestations of
the disease. “
ATS-ERS Statement - AJRCCM 2006
SCOPES
Pulmonary rehabilitation programme
(concept)
Stages
Multi disciplinary team
Selection
Assessment
Rehabilitation
Re-assessment
Maintenance
Lifestyle change
Outcomes
Functional performance
Health status
Dyspnoea
Disabled patient
Individual needs
Cost reduction
Programme audit
Content
Family
Exercise training
Disease education
Psychological &
Social support
“Pulmonary rehabilitation is a
service that complies with the
definition of rehabilitation and
achieves its therapeutic aims
through a permanent alteration
of lifestyle”
W.H.O.
WHICH COMPONENTS ?
RECOMMENDED ACTIVITIES
• Muscles training
• Body composition abnormalities and
interventions
• Education and self management
• Psychosocial issues
• Smoke quitting
• Chest physiotherapy
• Other interventions to increase training ability
ATS-ERS Statement 2005
EXERCISE TRAINING
THE WAY TO EXERCISE COPD
• LOWER LIMB EXERCISE
(cyclo, treadmill, walking)
• UPPER LIMB EXERCISE
(arm-ergometer)

RESPIRATORY MUSCLES
Protocols:
Endurance training
Strength training
Assessment:
Intensity
Duration
Frequency
Training a COPD
Principle
One major principle for successful training is the
so that muscular adaptations will only appear if
the muscle is sufficiently stressed
Training a COPD
100
Intensity
(% W max)
80
60
40
Example on how to
gradually increase
both intensity and
duration of sessions
20
0
Duration
(min)
30
20
10
0
Training weeks
1 2 3 4 5 6 7 8 9 10 11 12
Training a COPD
Other strategies
In order to enhance intensity in the most disabled
individuals other strategies could be followed:
EXERCISE WITH OXYGEN SUPPLEMENT
Snider, G.L. Chest 2002, 122: 1830-6
EXERCISE WITH VENTILATORY SUPPORT
Ambrosino, N. Eur Respir J 2004, 24: 313-22
ADOPT A INTERVAL TRAINING MODALITY
Vogiatzis, GL. Eur Respir J 2002, 20: 12-9
PASSIVE MUSCLE STIMULATION
Ambrosino N. Eur Respir J 2004, 24: 313-22
Training a COPD
Modalities
• ENDURANCE (ET)
The aim is to carry on
exercise as longer as
possible.
It involves a large
muscle mass at the
highest intensity for a
long period of time.
Training a COPD
Modalities
• STRENGTH (ST)
The aim is to prevent
or counterbalance the
muscle atrophy.
It involves a small
muscle mass at high
intensity for a short
period of time.
Training a COPD
Endurance or strength ?
Some studies show that endurance and
strength training in COPD may similarly benefit
COPD patients.
In a recent metanalysis it has been shown that
the overall effect of these modalities on both the
individual’s exercise performance and the
specific quality of life is similar ....
Puhan MA, et al. Thorax 2005; 60: 367-375.
HOW TO ASSESS
THE EFFICACY ?
Wider outcome measures for
pulmonary rehabilitation
Patient centred Programme
(individual)
(quality control)
Public health
(societal)
Symptoms
Survival
Process
Activities of daily Satisfaction
living
Exercise
performance
Health status
Safety
Health
economics
Practice guideline:
Assessment of patient-centered outcomes
such as symptoms, performance in daily
activities, exercise capacity, and health
related quality of life should be an integral
component of pulmonary rehabilitation.
ATS-ERS Statement 2005
Tredmill endurance
Dyspnea
…20 or more sessions are needed for optimal acute changes
in exercise performance, but improvement in dyspnea and
quality of life may occur earlier….
WHEN TO START ?
Timing of rehabilitation
• Chronic Stable State
• Post Hospital Admission
Community pulmonary rehabilitation after hospitalisation for acute
exacerbations of COPD
Man et al. BMJ 2004
• During hospital admission ?
– During exacerbation
– Planned
WHICH RESULTS ?
Arch Phys Med Rehabil 2003;84:1154-7.
Conclusions: Including psychotherapy in a
pulmonary rehabilitation program for COPD
reduced patients’ anxiety and depression levels…
Outpatient pulmonary rehabilitation following acute
exacerbations of COPD
John M Seymour, Lauren Moore, Caroline J Jolley, Katie Ward, Jackie Creasey,
Joerg S Steier, Bernard Yung, William D-C Man, Nicholas Hart, Michael I Polkey,
John Moxham
Thorax 2010; 65: 423-428
UC
PEPR OR
(n=30)
(n=30)
3-mo Unplanned H. attendance
57%
27%
0.28
3-mo H. re-admission
33%
7%
0.15
HOW LONG IS THE
POSITIVE EFFECT ?
The duration of benefit of pulmonary
rehabilitation
short duration
1
2 yrs
Exercise / health status
Maintenance?
Repeated?
Trajectories of Endurance Activity following Pulmonary Rehabilitation in COPD
Patients
Authors: Judith E. Soicher, Ph.D.,Nancy E. Mayo, Ph.D.,Lise Gauvin, Ph.D.,
James A. Hanley, Ph.D., Jean Bourbeau, M.D.
ERJ Express. Published on July 7, 2011 as doi: 10.1183/09031936.00026011
The low activity group was characterized by more severe disease
and greater respiratory impairment.
The high/decline group had less severe disease and respiratory
impairment, but reported greater barriers to exercise (i.e. “exercise
is tiring”, “place to exercise too far”,”family-related barriers”….).
Pulmonary rehabilitation may need to
interventions aimed at minimizing barriers.
include
behavioral
WHO IS THE
RIGHT PATIENT ?
Troosters T. et al. ERS meeting 2004
Selection of patient
Facts
• Most activity-limited people will benefit
• No matter of age, gender, lung function, initial
disability and smoking status
• Greater benefits if weak peripheral muscles, low
anaerobic threshold or normal nutritional status
• Exclusions include significant orthopaedic or
neurological disease, uncontrolled psychiatric or
cardiac disease
• Adherence affected by social isolation and continued
smoking (drop out rates may be high)
Villa Pineta s.r.l.
Ospedale Privato Accreditato
Anno 2003
Anno 2004
Anno 2005
Totale pazienti (nr.)
1171
1242
1148
Età media (anni)
71±7
71±9
71±8
Pz. Età ≥ 75 (%)
38
40
43
COPD 33%
REHABILITATION
Summary
• Pulmonary rehabilitation results in a clinically significant
improvement in disease-specific and general measures of
quality of life.
• The effect size of pulmonary rehabilitation largely exceeds
what can be achieved by the best pharmacological therapy.
• These effects are long-lasting (>1 year), and not
necessarily related to improvements in exercise ability.
• The candidate profile and his/her baseline characteristics
should be consider since they may alter response.