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Pulmonary Rehabilitation in Lung Cancer. Pınar Ergün MD. Atatürk Chest Disease and Chest Surgery Center Pulmonary Rehabilitation and Home Care Unit. Outline;. Definition and the rational of pulmonary rehabilitation Pre-post operative Pulmonary Rehabilitation in Lung Cancer

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Pulmonary Rehabilitation in Lung Cancer


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    1. Pulmonary Rehabilitation in Lung Cancer Pınar Ergün MD. Atatürk Chest Disease and Chest Surgery Center Pulmonary Rehabilitation and Home Care Unit

    2. Outline; • Definition and the rational of pulmonary rehabilitation • Pre-post operative Pulmonary Rehabilitation in Lung Cancer • Cancer related fatigue and pulmonary rehabilitation • Pulmonary rehabilitation and chemotheraphy • Conclusion

    3. Pulmonary Rehabilitation; Restoration of the individual to the fullest physical, social, physicological and occupational potential of which the person is capablewith the limitations of the disease and therapies. Pulmonary rehabilitation is a multidisciplinary and individualised theraphy Turk Phys Med Rehab 2007;53:74-7

    4. COMPONENTS Exercise training Education Nutritional assessment / theraphy Psychological assessment /theraphy Multi Disciplinary TEAM OUTCOMES Functional performance HRQOL Dyspnea Cost-effectivity PATIENT STAGES Patient selection Assessment Rehabilitation Maintenance Follow-up Family

    5. Obstructive pulmonary diseases COPD Persistan Asthma Bronchiectasis Cystic Fibrosis Resrictive pulmonary diseases Intertstitial lung disease Thoracic wall pathologies Neuromuscular diseases BOOP Other Lung Cancer Prostate Ca Breast Ca Hematological malignancies PPH Pre-post Operative Pre-Post Lung Transplantation Ventilatory dependent patient Obesity related pulmonary disease Pulmonary Rehabilitation for which diseases? Chest 2007; 131:4-42 JCPR&P 2007; 27: 61-4

    6. Pulmonary Rehabilitation; evidence based out-comes • Increases in functional capacity • Decreases in dyspnea • Increases in HRQOL ( Grade A) • Reduces the number of hospital days ( Grade B) Chest 2007; 131:4-42

    7. Pulmonary rehabilitation should be taken into consideration as a treatment strategy in the management of Lung cancer patients regardless of the diagnosis and the disease stages. • Rationals of pulmonary rehabilitation ?

    8. Rationals (I); • Malignancy • Treatment strategies, • Decreased level of activity during treatment • Exercise capacity is the best independent predictor of postoperative complications. • Exercise capacity is a modifiable risk factor !!! Physical performance ↓ Cancer 2001; 92(Suppl 4): 988-997 AACVPR 2004;86-8

    9. Rationals (II); Pulmonary rehabilitation is an effective treatment strategy in; • Symptom control Dyspnea Pain • Nutritional abnormality • Self management • Psychologic distress

    10. Rationals (III); • Median survival in lung cancer; 1 year after diagnosis • 5 year survival: 15 % TREATMENT GOAL Increases in HRQOL • HRQOL is an independent predictor of survival in Chemotherapy !!! Chest 2007; 132(3):1–19 Chest 2007; 132:234-42 J Clin Oncol 2005; 23: 6865-72

    11. Rationals (IV); Cancer related fatigue syndrome; • Impairment of physical performance • Sleep disturbance • Depression • Cognitive dysfunction • Social isolation Multidisciplinary approach NCCN Practice Guidelines in Oncology- 2008

    12. Rationals (V); COPD and LUNG CANCER • Males %73 • Females %53 Chest 2006; 129: 1305-12

    13. Pre-Post Operative Pulmonaryrehabilitation in Lungcancer

    14. Preoperative Pulmoner Rehabilitation Potential benefits • Risk modification • Improvements in the lung resection outcomes and recovery

    15. Risk modification 20 % • Changing from high to low risk category 13.5 % Chest 2005;128:3799-809

    16. Pulmonary Rehabilitation; • Inpatient • Duration (1.5h,day/ 4 w) • Patient education; • Smoking cessation • Coughing • Breathing techniques • Peripheral muscle training (Endurance) European Journal of Cardio-thorac Surgery, 2008

    17. Sypmtom limited endurance and NMES • Lobectomy + mediastinal systematic lymph node dissection • 0 mortality, %25 morbidity Lung Cancer 2007;57:118-19

    18. Pulmonary Rehabilitation Decreases the Complication Rates Jpn J Thorac Cardipvasc Surg 2005 • Pulmonary rehabilitation program for high risk thoracic surgical patients. • Chest Surg Clin N Am 1997; 7: 697-706 • Factors associated with perioperative complications • after pneumonectomy for primary carcinoma of the lung patients Interactive Cardiovascular and Thoracic Surgery, 2006

    19. Cost effective ! Jpn J Thorac Cardipvasc Surg 2005

    20. Cardiopulmonary function lost due to resection was avoided ►Improvement in the recovery period ►Chance for implementing Adjuant Chemotheraphy increases! Cancer,2007

    21. Preoperative Pulmonary Rehabilitation The risk of delay in curative resection ?

    22. Admition…. Duration to treatment ► mean: 48 day Is not the predictor of survival !!! Lung Cancer, 2001

    23. Postoperative Pulmonary Rehabilitation Potential benefits • Symptom control • Improvements in functional capacity • Improvements in HRQOL

    24. IMPROVEMENTS in respiratory functions and exercise capacity Lung Cancer ,2007

    25. Treatment strategies; • Surgery, Surgery+ RT, • Surgery + RT+CT • ∆ 6MWT distance = 145m • ∆ Peak work rate = 26 W (P=0.0020) (P=0.0078) Lung Cancer,2006

    26. Pre-postoperatif Pulmonary Rehabilitation Special considerations for pre- post operative patients • Smoking cessation ! • Assessments of patients; • ►Functional limitations • ►Exercise capacity • Airway clearance and pulmonary expansion techniques • ►Assisted coughing • ►Insentive spirometry • ►NIMV • Energy conservation strategies • Transfer-mobility • Prevention of venous thromboembolism • Pain control • Stress and anxiety management • Nutritional evaluation / support

    27. Cancer-Related Fatigue Chemotheraphy Pulmonary rehabilitation

    28. PR for Cancer-Related Fatigue PR During Chemotheraphy • Potential benefits; • Symptom control • Improvement of performance status • Improvements in HRQOL • Promotion of a self management for symptom control and increase in hope

    29. Cancer- related fatigue is a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion to cancer or cancer treatment that is not proportional to recent activity and interferes with unusual functioning Fatigue should be recognised, evaluated and treated promptly for all age groups, at all stages of disease, prior to, during and following Implementation of guidelines for fatigue management is best accomplish by interdisciplinary teams who are able to tailor interventions to the needs of the patient Rehabilitation should begin with the cancer diagnosis NCCN Practice Guidlines in Oncology- 2008

    30. Fatigue in ambulatory patients with advanced lung cancer: prevalance, correlated factors and screening Lung Cancer and FATIGUE Impact of dyspnea, pain and fatigue on daily life activities in ambulatory patients with advanced lung cancer. Conlusion:In advanced lung cancer patients, cancer related fatigue limited at least one HRQOL J Pain Symptom Manage 2002;23 417-23 Conclusion:The most stressing symptom is fatigue J Pain Symptom Manage 2001; 22: 554-64

    31. Interventions in Cancer Related Fatigue; Non-pharmacologic Activity enhancement ►Maintain optimal level of activity /Exercise prescription/ Exercise training ►Energy conservation techniques Education Psychosocial interventions ►Assessment/support (Stress management /Relaxation ) Nutritional assessment /support Cautions: Bone metastasis Immunosuppression / neutropenia Thrombocytopenia Anemia Fever Limitations due to metastasis or co-morbidities NCCN Practice Guidlines in Oncology- 2008

    32. NCCN Practice Guidelines in Oncology-2008 • Exercise is an effective treatment strategy in cancer related fatigue • Level of fatigue %40-50 ↓ • Impairments in emotional status ↓ • HRQOL  Category 1

    33. P< 0.05 Conlusions: Aerobic exercise can reduce fatigue and improve physical distress in cancer patients undergoing chemotheraphy Blood, 1997

    34. Conclusion: PulmonaryRehabilitationmust be takenintoconsideration of lungcancermanagementfor; • Management of risk modification • Improvement of lung resection outcomes and recovery • Symptom control • Improvement of Cancer related Fatigue • Improvement in HRQOL • Promoting of self management

    35. THANKS