Pulmonary RehabilitationPulmonary Rehabilitation

Professor Paul W. Jones

6-Minute Walk (m)

Usual Care Rehabilitation

Meta-analysis of improvement in 6-minute Meta-analysis of improvement in 6-minute walk following rehabilitationwalk following rehabilitation

6-Minute Walk (m)

Usual Care Rehabilitation

Meta-analysis of improvement in 6-minute Meta-analysis of improvement in 6-minute walk following rehabilitationwalk following rehabilitation

Minimum ClinicallyMinimum ClinicallyDetectable DifferenceDetectable Difference

0 1.0 1.5

Dyspnea

Fatigue

EmotionalFunction

Mastery

CRQ units (Treatment-Control)

Minimum Clinically Important Difference

Meta-Analysis of Health Status Changes FollowingMeta-Analysis of Health Status Changes Following Pulmonary RehabilitationPulmonary Rehabilitation

Mean95% CI

0.5

Lacasse et al. Lancet. 1996; 348: 1115-9

Reasons for stopping exercise Reasons for stopping exercise (COPD patients)(COPD patients)

Dyspnea 26%

Leg fatigue 43%

Both 31%

Killian et al Am Rev Respir Dis 1992; 146: 935-940

Rehabilitation reduces fatigability Rehabilitation reduces fatigability of muscles of muscles

Pre rehab

Post rehab

MoreMore

fatigable

Mador et al Am J Respir Crit Care Med 2001; 163: 930

Who should have pulmonary Who should have pulmonary rehabilitation ?rehabilitation ?

0

20

40

60

80

100

10 20 30 40 50 60 70 80 90

r = - 0.23

p < 0.0001

Upper limit

of normal

Health status and FEVHealth status and FEV11

SGRQ score

Poor Health

Good Health

FEV1 (% predicted)

Jones. Thorax 2001; 56: 880

0

20

40

60

80

100

10 20 30 40 50 60 70 80 90

Health status and FEVHealth status and FEV11

SGRQ score

Poor Health

Good Health

FEV1 (% predicted)

Patients with FEVPatients with FEV1 1 > 50% but moderate-> 50% but moderate-severe health impairment (SGRQ > 30%)severe health impairment (SGRQ > 30%)

95 %Slow down if walk fast

89 %Breathless on hills

86 %Breathless on stairs

% of patients

Basic components of Basic components of pulmonary rehabilitationpulmonary rehabilitation

• 30 min aerobic exercise

• Three times a week

• 6-8 weeks duration

Cooper. Medicine & Science in Sports and Exercise. 2001: S671

Supervised Supervised vsvs unsupervised unsupervised rehabilitationrehabilitation

• Supervised training– 4 times a week– Treadmill training

• Unsupervised training– 3-4 km in 1 hour– 4 times a week– Wore pedometers– Weekly visits

Puente-Maetsu et al ERJ. 2000; 15: 517

Supervised Supervised vsvs unsupervised rehabilitation unsupervised rehabilitation - effect on peak V- effect on peak VO2O2

1180

1200

1220

1240

1260

1280

1300

1320

1340

1360

1380

Supervised Unsupervised

PeakVO2

(mls/min)

Pre-rehabPost rehab

Puente-Maetsu et al ERJ. 2000; 15: 517

p<0.05 NS

Supervised Supervised vsvs unsupervised rehabilitation unsupervised rehabilitation - effect on quality of life- effect on quality of life

0

20

40

60

80

100

120

Supervised Unsupervised

CRQ total score

Pre-rehabPost rehab

Puente-Maetsu et al ERJ. 2000; 15: 517

NSNS

Supervised Supervised vsvs unsupervised rehabilitation unsupervised rehabilitation - effect on endurance- effect on endurance

0

2

4

6

8

10

12

14

16

18

20

Supervised Unsupervised

Endurance time (mins)

Pre-rehab

Post rehab

Puente-Maetsu et al ERJ. 2000; 15: 517

p<0.01 p<0.01

Use of supplemental oxygen during Use of supplemental oxygen during rehabilitation in non-hypoxaemic patientsrehabilitation in non-hypoxaemic patients

• Air training (air from cylinder)

• Training using 30% supplemental O2

Emtner. Am J Respir Crit Care Med. 2003; 168: 1034

Effect of supplemental oxygen during Effect of supplemental oxygen during rehabilitation on peak workrehabilitation on peak work

0

10

20

30

40

50

60

70

80

O2-trained Air-trained

PeakWork(watts)

Pre-rehabPost rehab

Emtner et al Am J Respir Crit Care Med. 2003; 168: 1034

p<0.05 p<0.05

Effect of supplemental oxygen during Effect of supplemental oxygen during rehabilitation on endurance timerehabilitation on endurance time

0

5

10

15

20

25

O2-trained Air-trained

Endurancetime

(mins)

Pre-rehabPost rehab

Emtner et al Am J Respir Crit Care Med. 2003; 168: 1034

p<0.05 p<0.05

Effect of supplemental oxygen during Effect of supplemental oxygen during rehabilitation on endurance timerehabilitation on endurance time

0

2

4

6

8

10

12

14

16

O2-trained Air-trained

Change in endurance

time(mins)

Emtner et al Am J Respir Crit Care Med. 2003; 168: 1034

p<0.05

Duration of benefitDuration of benefit

-10-9-8-7-6-5-4-3-2-10

6 weeks

Change in SGRQscore

Threshold of Clinical

Significance

1 year

95% CI

Change in health status following pulmonary Change in health status following pulmonary rehabilitation compared to control rehabilitation compared to control

Griffiths et al Lancet 2000; 355: 362-8

BetterHealth

• Control – usual care

• Maintenance– Weekly telephone– Monthly supervised reinforcement

(Ries et al Am J Respir Crit Care Med. 2003: 167: 880–8)(Ries et al Am J Respir Crit Care Med. 2003: 167: 880–8)

Maintenance programmeMaintenance programme

Maintenance programme in COPDMaintenance programme in COPD

Ries et al Am J Respir Crit Care Med. 2003: 167: 880–8

Exacerbations and Exacerbations and rehabilitationrehabilitation

Changes in muscle strength with an Changes in muscle strength with an acute exacerbationacute exacerbation

Spruit et al Thorax 2003;58:752

Early post-discharge rehabilitationEarly post-discharge rehabilitation

• Control - usual care

• Rehabilitation– Outpatient– Supervised– Started with 10 days of discharge

Man et al BMJ. 2004;329:1209

Early rehabilitation following hospital Early rehabilitation following hospital admission for acute exacerbation of COPDadmission for acute exacerbation of COPD

0

50

100

150

200

250

Rehabilitation Usual care

Shuttle distance(metres)

Dischargemonths 3

Man et al BMJ. 2004;329:1209

p<0.0002

Early rehabilitation following hospital Early rehabilitation following hospital admission for acute exacerbation of COPDadmission for acute exacerbation of COPD

0

10

20

30

40

50

60

70

80

Rehabilitation Usual care

SGRQ(units)

Dischargemonths 3

Man et al BMJ. 2004;329:1209

p<0.002Clinicallysignificantchange

Pulmonary rehabilitation in COPDPulmonary rehabilitation in COPD

Regular (3 times per week) for 6 weeks

Supervised better then unsupervised

Better physical improvement if trained breathing 30%

oxygen

Effect wears off despite maintenance programme

Exacerbations may lead to loss of effect

Can rehabilitate soon after and exacerbation