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PULMONARY REABILITATION. A. CHABBOU MD MP Journées Scientifiques: SOUSSE LE 25 FEVRIER 2006. PULMONARY REABILITATION Rationel. The limitations of the patient with COPD Deconditioning ) impact on skeletal muscle Systemic manifestations ) and cardiovscular system

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Pulmonary reabilitation

PULMONARY REABILITATION

A. CHABBOU

MD MP

Journées Scientifiques:

SOUSSE LE 25 FEVRIER 2006


Pulmonary reabilitation rationel

PULMONARY REABILITATIONRationel

The limitations of the patient with COPD

  • Deconditioning ) impact on skeletal muscle

  • Systemic manifestations ) and cardiovscular system

    muscle dysfunctionEXERCISE

    LIMITATIONS

    inability to increase oxygen delivery to the

    peripheral muscle

    Pulmonary hypertension Constraints on lung mechanics

    During exercice (dynamic hyperinflamation

    and flow limitation)

    gaz exchange inefficiency in

    the lungs

    Cardio vascularPulmonary limitations

    Limitation

    Limitations are - cardiovascular

    - pulmonary

    - and skeletel muscle


Pulmonary reabilitation skeletal muscle dysfunction

PULMONARY REABILITATIONSkeletal muscle dysfunction :

- déterminant factors

- complementary mechanisms :

1-  muscle strength  exercise traning

2-  muscle endurance

3- impaired muscle oxidative capacity

-  activity of the enzymes : citrate synthase

hydrooxy acetyl

COA deshydrogenase

4- a shift toward a glycolytic fiber type distribution (low fraction of type I fibers)*

skeletal muscle endurance

 fatigability   exercise training

Lowering of the lactate threshold

 ventilatory requirements during exercise


Pulmonary reabilitation skeletal muscle dysfunction1

PULMONARY REABILITATIONSkeletal muscle dysfunction*

Proportion of type-IIA fibres % 29.4¡12.1 34.8¡11.9

Proportion of type-IIXfibres % 27.2¡12.345.8¡18.9**

CSA of type-IIX fibres mm2 4248¡1300 2566¡1137**

P<0.001

Myopathological features in skeletal muscle of patients with chronic obstructive pulmonary disease

H.R. Gosker*, B. Kubat#, G. Schaart}, G.J. van der Vussez, E.F.M. Wouters*, A.M.W.J. Schols*


Pulmonary reabilitation complementary mecanisms

PULMONARY REABILITATIONComplementary mecanisms

1- The sedentary life style of COPD patients skeletal muscle atrophy at 2 levels :

  • The whole muscle level

  • The myocyte level

    With indirectly : the loss in fat-free mass

    2- Systemic inflammation**:

    recent studies have underlined the importance of systemic inflammation as a mechanism for

    developement of muscle weakness, especially during severe exacerbations of COPD

  • Circulating levels of IL8 : are significantly correlated with muscle weakness

  • Weight loss, especially fat-free masshas been associated with systemic inflammation

  •  levels of skeletal muscle apoptosis were observed in patients presenting with weight loss

  • Oxidative stress is another factor related to the process of muscle wasting.**

  • Patients with COPD are exposed to  levels of oxidative stress :

    • when stable

    • and during exacerbations


Pulmonary reabilitation systemic inflammation

PULMONARY REABILITATIONSystemic inflammation

Nitrite and nitrate levels in patients with chronic obstructive pulmonary disease ( ) and control subjects ( ). *: p<0.05; **: p<0.01.

Skeletal muscle inflammation and nitric oxide in patients with COPD

M. Montes de Oca1, S. H. Torres2, J. De Sanctis3, A. Mata1, N. Hernández2 and C. Tálamo1

Eur Respir J 2005; 26:390-397


Pulmonary reabilitation systemic inflammation1

PULMONARY REABILITATIONSystemic inflammation

Endothelial constitutive nitric oxide synthases (eNOS), inducible isoform nitric oxide synthases (iNOS) and

nitrotyrosine levels in patients with chronic obstructive pulmonary disease ( ) and control subjects ( ). ***: p<0.001.


Pulmonary reabilitation systemic inflammation2

PULMONARY REABILITATIONSystemic inflammation

Tumour necrosis factor (TNF)- levels in patients with chronic obstructive pulmonary disease ( ) and control subjects ( ). #: p<0.0001.


Pulmonary reabilitation

Variables

Nitrites µmol·mg–1 protein

11.4±2.0

13.6±3.1

NS

Low weight COPD

Nitrates µmol·mg–1 protein

19.5±2.2

24.5±2.9

NS

Total µmol·mg–1 protein

30.9±3,5

34.3±2.8

NS

Nitrotyrosine ng·mg–1 protein

24.5±6.9

25.2±0.1

NS

iNOS ng·mg–1 protein

27.1±7.6

36.6±9.4

NS

eNOS ng·mg–1 protein

32.2±6.2

31.9±3.1

NS

nNOS ng·mg–1 protein

85.3±18.4

101.7±23.1

NS

TNF-   pg·mg–1 protein

201±93

267±207

NS

CD163 ng·mg–1 protein

6.4±0.7

6.8±2.7

NS

CD154 ng·mg–1 protein

14.3±5.9

17.6±8.5

NS

Table. — Skeletal muscle levels of inflammatory markers in low and normal weight chronic obstructive pulmonary disease(COPD)

Normal weight COPD

P-value


Pulmonary reabilitation systemic inflammation3

PULMONARY REABILITATIONSystemic inflammation

Transversal section of the vastus lateralis part of quadriceps muscle. Immunohistochemical reaction with anti-CD68, clone MB11.

a) Control subject, male aged 68 yrs. The black dots are muscle fibres and endothelial cell nuclei.

b) Chronic obstructive pulmonary disease patient, male aged 68 yrs. The black stain represents macrophages infiltrate. Scale bar = 50 µm.


Pulmonary reabilitation

Oblique section of vastus lateralis part of quadriceps muscle in a 70-yr old female chronic obstructive pulmonary disease (COPD) patient. b) Longitudinal section of vastus lateralis part of quadriceps muscle in a 69-yr-old female COPD patient. Arrows show prolongations of macrophage surrounding capillary. M: macrophage; NM: nucleus of macrophage; F: muscle fibres; NF: nucleus of muscle fibre; C: capillary; NE: nucleus of capillary endothelial cell; P: pericyte. Scale bars = 1 µm.


Skeletal muscle dusfunction

Skeletal muscle dusfunction*


Pulmonary reabilitation1

PULMONARY REABILITATION

Exercice intolerance : Multifactorial

Impairment of lung mechanics Altered gaz exchange

Impairment of respiratory muscles

Cardiac dysfuntion

Deconditioning

Poor nutritional status

Psychological problems


Pulmonary reabilitation2

PULMONARY REABILITATION

Disease  Deficiency  Incapacity  Handicap

COPD Aw obstruction  dyspnea  prostration

COPD Bronchodilatation Tolerance Move

PULMONARY REHABILITATION


Pulmonary reabilitation goals

PULMONARY REABILITATIONGoals

- General :Improve physical and psychological or emotional functioning of patients in interaction with theire environment

- Specific :

- Reduce symptoms

- Improve activity and daily function QOL

- Restore the highest level of independant function (in every day activities)

- Enhance knowledge of the disease

- Improve self-management

Non pulmonary problems

Not addressed by medical therapy


Pulmonary reabilitation components of the rehabilitation program

PULMONARY REABILITATIONComponents of the rehabilitation program

1- Optimal medical treatment

2- Smoking cessation

3- Exercise training

4- Breathing retraining

5- Chest physiotherapy

6- Education

7- Psychological aspects and support

8- Nutritional therapy

9- Nursing care

10- Miscellaneous


Pulmonary reabilitation exercise training

PULMONARY REABILITATIONExercise Training

Limitations inability toO2

delivery to muscles

Needs

Exercise Training inefficiency of

Adapted to the gaz exchange

Individual

lung mechanics

hyper inflation

flow limitation

Training programs pulmonary

that stimulates hypertention

cardiovascular and during exercise

skeletal muscle

muscle dysfunction


Pulmonary reabilitation exercise training1

PULMONARY REABILITATIONExercise training

- Lower extremity training : lower limbs exercise

- Upper extremity training : arms exercise

- Respiratory muscles training : respiratory muscles exercise


Pulmonary reabilitation exercise training2

PULMONARY REABILITATIONExercise training

Modalities

Inpatient setting

Out patient setting

Community based setting

Home based setting

Inpatient setting

- transdisciplinary team

- favorable environnement and climate

- Patient entire disponibility

- 24 houres prolonged and tight management for weak patients


Pulmonary reabilitation exercise training3

PULMONARY REABILITATIONExercise training

1- Methods

  • Cycle ergometer

  • Walking (Treadmill)

    Better physiological benefit when exercise above a «critical level of intensity»

    2- Patients selection*

    Preliminary exercise test

    Resting respiratory function measurements (poor correlation)

    3- Type of exercise : - intensity**

    - endurance

    4- Duration : No ideal duration established

    8 weeks : common duration***

    5- Results: Physiological change : ****

     blood lactate

     ventilation

     endurance

    After high work rate training programs


Pulmonary reabilitation exercise training4

PULMONARY REABILITATIONExercise training

Duration of programs

Key Goal change the patient’s behavion from a sedentary toward a more active life style

Measurable physiological

changes : weeks

behavioral

changes months

Longer duration

Better long term effect

> 8 weeks

6 months > 3 mouths


Pulmonary reabilitation results

PULMONARY REABILITATIONResults

  • Increase in maximal exercise performance

  • Physiologic adaptations in peripheral muscles

  • Improve of cardiac function

  • Reduction in ventilation and lactate levels at identical exercise work rates


Pulmonary reabilitation exercise training5

PULMONARY REABILITATIONExercise training

Upper extremity Training

- Improve arm muscles function

- Does not improve exercise tolerance

- Does not improve QOL


Pulmonary reabilitation exercise training6

PULMONARY REABILITATIONExercise training

Outcome measures : exercise testing

  • COPD patients mean age : 60 years

  • Most COPD patients are past smokers

  • COPD patients are at risk of other tobaco-related diseases : - ischemic cardiac diseases, arteriel HT, cardiac arrhythmias

  • Stress test for coronary disease :

    • 1 death/5000

    • 1 major complication/1000

  • Exercise testing in COPD patients : 1/3 arterial blood desaturation (SaO2 < 89 %) not predicted by rest spirometry nor CO diffusing capacity

  • Need of a preliminary exercise test


Pulmonary reabilitation exercise training7

PULMONARY REABILITATIONExercise training

Outcome measures: exercise testings

Types of exercise tests

1- Submaximal exercise tests

  • cycle or treadmill

  • at a constant fraction of maximal work rate > 60 % of the peak V 02

  • at low intensity, below to the lactic acidosis threshold

  • Measures exercise endurance

  • Measurements : endurance time, heart rate, respiratory rate, blood pressure, ECG, SaO2, exhaled gazes, inspiratory capacity


Exercise training out come measures exercise testing

Exercise trainingOut come measures : exercise testing

2- Six minute walk test

  • Walks at his own pace

  • Simple, well tolerated and relevant to daily activites

  • But varies upon encouragement and coaching and should be standardized

    3- Shuttle walk test

  • Walk up and down a 10 m distance with increasing speeds dictated by a beep

  • Measures more exercise capacity than endurance

  • But self pacing is eliminated

  • Reproductible and correlates well with VO2 peak during increamental treadmill exercise ( r= 0,88)


Exercise training outcome measures exercise testing

Exercise trainingOutcome measures : exercise testing

Type of exercise tests

4- Incremental exercise tests

  • bicycle or treadmill

  • Measurements : Heart rate, respiratory rate, blood pressure, ECG, SaO2, dyspnea, leg fatigue, minute ventilation, oxygen consumption, CO2 production, anaerobic threshold and dead space

  • Equipment problems :

    • Cost of the test : 30

    • Cost of equipement/test : 10


Pulmonary reabilitation

PULMONARY REABILITATION

Level of Handicap Assessement Measures

Deficiencies

Respiration FEV1

  • A Obstruction FRC

  • P.Elasticity IC

  • Gaz exchange DLCO

    PaO2, PaCO2, SaO2

    Muscle

  • Respiratory MIP

  • Limbs and arms MEP

    Incapacity

    Dyspnea - Questionaires

    - Walk test 6 min

    Exercise - Endurance test

    - Exercise fonctional tests

    Disadvantage

    (handicap) QOL questionaires

    Life socio-professional


Pulmonary reabilitation exercise training8

PULMONARY REABILITATIONExercise Training

Specific strategies to increase training intensity

Neuromuscular electrical stimulation (NES)

Specific muscle groups of lower limbs are activated with low-intensity electrical current

2 trials of transcutaneous neuromuscular electrical stimulation of lower limbs in severe muscle weakness in stable patients  - significant - muscle strength

- exercise capacity

1 study : faster functionnal recovery in patients with respiratory failure under mechanical ventilation, bed bound for > 30 days.

Zanotti E, Felicetti G, Maini M, Fracchia C. Peripheral muscle

strength training in bed-bound patients with COPD receiving mechanical

ventilation : effect of electrical stimulaiton. Chest 2003;124 : 292-296

NES is safe and can be conducted at home

Neder JA, Sword D, Ward SA, Mackay E, Cochrane LM, Clark CJ. Home

based neuromuacular electrial stimulation as pulmonary rehabilitation in chronic obstructuve pulmonary disease. Troosters et al


Pulmonary reabilitation exercise training9

PULMONARY REABILITATIONExercise Training

Specific strategies to increase training intensity

Breathing exercises

  • Diaphragmatic breathing : Decreases breathing efficiency

  • pursed lip breathing

    Increases gaz exchange, increases tidal

    volume, reduces inspiratory time, reduces dyspnea, reduces end expiratory volumes

    Effectineness assessed by SaO2

    Bianchi R, Gigliotti F, Romagnoli I. Chest wall kinematics and breathlessness during

    pursed-lip breathing in patients with COPD. Chest 2004 ; 125 : 459465.

    Breslin EH. The pattern of respiratory muscle recruitment during pursed-lip breathing. Chest 1992 ; 101 : 75-78


Pulmonary reabilitation exercise training10

PULMONARY REABILITATIONExercise Training

Specific strategries to increase training intensity

O2 supplementation

Controversial

O2 supplementation

- Reduces the ventilatory requirement for a given work rate

  • increases maximal exercises tolerance

  • Reduces exercise – ruduced pulmonary hypertension

  • Studies did not show additional benefit

    O2 could enhance training intensity in patients with COPD

    Funther studies


Pulmonary reabilitation exercise training11

PULMONARY REABILITATIONExercise Training

Specific strategies to increase training intensity

Non invasive Mechanical Ventilation(NIMV)

  • reduces the inspiratory muscles load.

  • Usefulness only in severily impaired patients

    Hawkins P, Johnson LC. Proportional assist ventilation as an aid to exercise training in severe chronic obstructive pulmonary disease. Thorax 2002;57:853-859

    Costes F, Agresti A, Noninvasive ventilation during exercise training improves exercise

    tolerance in patients with chronic obstructive pulmonary disease. J cardiopulm Rehabil 2003;23:307-313

  • NIMV at home associated to out patient exercise training 

    additional increase in the shuttle walk distance

  •  QOL compared to training alone

    Garrod R, Mikelsons C Paul EA. Randomized controlled trial of domiciliary noninvasive positive pressure ventilation and physical training in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 162:1335-1341


Pulmonary reabilitation exercise training12

PULMONARY REABILITATIONExercise Training

Specific strategies to increase training intensity

Ergogenic drugs

Anabolic steroïds (AS)

  • Studies included only men

  • Drugs studied areoxandrolone, nandrolone, stanozolol and testosterone

  • All studies report an increase in body weight through a gain in lean body mass

    4 studies : AS + PRH program

     Muscle strength

    • Effects of strength training

    • does not improve exercise endurance (muscle hypertrophy without capillary and aerobic enzymes increase)

    • Protection against side effects of corticosteroïds

      NI prostate hypertrophy, aProstate cancer, Hb > 16g. Dl-1, Renal disease, Congestive heart failure

      Growth hormone/Insulin like growth hormone

    • Disturbed anabolic/catabolic balance in COPD

    • Lack of evidence of benefits – high cost

    • Schols AM, Soeters PB, Mostert R, Pluymers RJ. Physiologic effects of nutritional support and anabolic steroids in patients with chronic obstructive pulmonary disease : a placebo controlled randomized trial. Am J Respir Crit Care Med 1995;152 : 1268-1274


Pulmonary reabilitation components of the rehabilitation program1

PULMONARY REABILITATIONComponents of the rehabilitation program

  • Smoking cessationthe key to the prevention and treatment of COPD

  • Give up

    • early stages interventions 

      Reduced rate of FEV1 decline

      - Function lost is however not regained

    • Advanced disease, still valuable

  • Maintenance of abstinence :

     beyond the phase of acute withdrawal

     for extended periods thereafter


Pulmonary reabilitation3

PULMONARY REABILITATION

Smoking cessation

Addiction

- Nicotine substitutes

- Psychological

- Behavioral

- Physiological

Hard to accomodate the needs of every smoker

Strategies Individual adapted programs

Rather than group programs

Pharmacological interventions

Behavioral interventions


Pulmonary reabilitation4

PULMONARY REABILITATION

Education and self-management :

 Optimally control the disease

 Achive behavioral change

 Improve coping with the disease

Up to 75 % of patients have difficulties in understanding how and when to take their

inhalation medication

Goodman DE, Israel E, Rosenberg M, Johnston R, Weiss ST, Drazen JM. The influence of age, diagnosis, and gender on proper use metered-dose inhalers. Am J Respir Crit Care Med 1994;150:1256-1261

Educational sessions

- Improve adherence to medication

- Help patients to deal with exacerbations

- Reduce hospital days

- Cost effective

- QOL

Helpful for patients with severe disease, Small groups-or individual

Gallefoss F, Bakke PS. Cost-benefit and cost-effectiveness analysis of self-management in patients with COPD : a 1-year follow-up randomized, controlled trial. Respir Med 2002;96:424-431


Pulmonary reabilitation psychosocial support

PULMONARY REABILITATIONPsychosocial support

Rationale :

- Depression in COPD 2.5 fold higher/

general population

- 20-40 % of COPD present with anxiety and depression

- Spouses of COPD suffer from depression and stress

- Smoking cessation result in mood disturbance.

Psychological interventions improve mood distrubances > exercise training only.

Can be associated to smoking cessation counselling, support and to education. Enhance the chances for sustained smoking cessation


Pulmonary reabilitation improving activities of daily living

PULMONARY REABILITATIONImproving activities of daily living

Occupational therapy

Occupational therapists interventions

aim to increase the patient functional

autonomy

Methods consist of exercise training

oriented toward daily living activities

(walking efficiency, ventilatory capacity..)

Wheeled devices (rollators) are useful but

expensive

They could be useful in severe diseases


Pulmonary reabilitation nutritional programs

PULMONARY REABILITATIONNutritional Programs

- In COPD,

-  of body weight

- Loss of fat-free mass is related to morbidity and mortality

-  > 2 kg of body weight improve survival

-  resting energy expenditure 

Exercise traing may induce a negative protein balance

But– it is no sure that patients receiving nutritional supplements would not distrub their regular nutritional habits with a consecutive reduced calorie intake and risk of paradoxal undernourishment.

- At the opposite, obese patients should undergo weight loss through a dietary intervention without loosing fat-free mass.


Pulmonary reabilitation5

PULMONARY REABILITATION

Miscellaneous

- Erythropoietin therapy

- antioxidant therapy (Vit E, Nacetyl cysteine)

- Brondilators associated to PRH 

 improvements in QOL

- In selected subpopulations  individualized programs

- Does not concern all patients

- Physiotherapy - sputum drainage


Pulmonary reabilitation use of health care resources

PULMONARY REABILITATIONUse of health care resources

  • Benefit of PRH is due to improved knowledge of the disease and enhanced self-management rather to physiological improvements

  • Admissions are reduced by 40 % when a self management program is followed despite significant physiological effects

  • No decrease in hospital days for long term exercise training without individualized education sessions and self management strategies.

    Engström CP. Long-term effects of a pulmonary rehabilitation programme in outpatients with

    chronic obstructive pulmonary disease : a randomized controlled study. Scand J Rehabil Med

    1999;31:207-213.

  • Reduction in mild exacerbations may lead to stop disease progression

  • Exacerbation frequency linked FEV1 decline

    Donaldson GC. Relationship between exacerbation frequency and lung function

    decline in chronic obstructive pulmonary disease. Thorax 2002;57:847-852


Pulmonary reabilitation use of health care resources cost effectineness

PULMONARY REABILITATIONUse of health care resources ( cost-effectineness)

  • necessity of long – term following

    Reduction of hospitalization

  • Griffithsetal patients with COPD spent fewer days hospitalized during a 1 year follow-up period.

    Griffiths TL, Burr ML, Campbell IA. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation : a randomised controlled trial. Lancet2000 ; 355 : 362 - 368

  • Out patients PRH reduces hospital days but studies lacked statistical power

  • Hospital days are the primary cost driver of COPD care

    Croxton TL, Weinmann GG, Senior RM. Clinical research in chronic obstructive pulmonary disease : needs and opportunities. Am J Respir Crit Care Med 2003 ; 167 : 1142 - 1149


Pulmonary reabilitation6

PULMONARY REABILITATION

Maintenance strategies

Several strategies have been tried to

maintain the benefits as long as possible

after graduation from PRH programs

- Continued 3 times weekly out patient  15 months

- Once week high – intensity exercise training sessions

- Exercise advise during the follow-up

- Repeated short programs

- Telephone support

- Once monthly follow-up visits

Maintenance programs seem to be

necessary after 6 weeks out patients or 6

weeks in patients.

After longer programs (6 months), benefits

could be prolonged for > 1 year.


Pulmonary reabilitation7

PULMONARY REABILITATION

Survival

No study has convincingly shown evidence of improved survival after PRH

In 7 studies

Best estimate :Rehabilitation reduces short-term risk of dying by 31 %.

Not statistically significant ( nb of patients insufficient, patients on PRH are in a stable state)

Further studies


Conclusion

Conclusion

  • In COPD muscle deficiency and flow limitation lead to deficiency and handicap

  • PR enhances exercise capacity, improves daily life activities and ameliorate QOL

  • A successful PR is scientific, transdisciplinary, individualised and sustained for at least 8 weeks

  • PR is cost effective

  • Further studies are needed for specific added stategies


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