Optimizing Pulmonary Rehabilitation in COPD

Optimizing Pulmonary
Rehabilitation in COPD:
Practical Issues
Canadian Thoracic Society Clinical Practice Guideline
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Functioning, Disability, and Health in COPD
Impairment
[Function]
Disability
[Activity]
Handicap
[Participation]
FEV1, FVC
IC, EELV, FRC, RV
ABGs
Dyspnea
Exercise Capacity
Exacerbations (AECOPD)
Quality of Life
Health Care Utilization
Adapted from Can Respir J, 2004; 11(Suppl B): 7B-59B;
International Classification of Functioning, Disability and Health . WHO.
Geneva. 2001.
COPD
Exacerbations
Expiratory Flow Limitation
Air Trapping
Hyperinflation
Breathlessness
Reduced Exercise
Endurance
Deconditioning
Inactivity
Poor Health-Related Quality of Life
Adapted from Fero TJ, Schwartz DB. Clinical Pulmonary Medicine.
Vol 12, July 2005
Risk of Death - Exercise Capacity
Risk of death in subjects
with risk factors and
exercise capacity of <5
MET or 5-8 MET,
compared with subjects
with capacity >8 MET
(MET = VO2 3.5 ml/kg/min)
Myers J et al, NEJM 2002; 346:793-801
Physical Activity in COPD
Trooster T, et al. Respir Med 2010; 104:1005-1011.
Physical Activity in COPD
Active
Sedentary
Inactive
163 COPD (GOLD stages 1-4) and 29 Chronic Bronchitis (former GOLD 0) subjects
Watz H, et al. Eur Respir J 2009; 33:262-72.
What is Pulmonary Rehabilitation ?
Joint ACCP/AACVPR Statement on Pulmonary Rehabilitation.
CHEST 2007.
Components of a Pulmonary
Rehabilitation Program
Pulmonary Rehabilitation
• Activity limitation and shortness of breath are the cardinal
symptoms of COPD
• All COPD patients should be encouraged to exercise
regularly
• Pulmonary Rehabilitation is indicated for patients disabled
by respiratory symptoms despite optimal medical
treatment
• Potential benefits to patients with COPD include:
– Reduces shortness of breath, improves exercise capacity and
health-related quality of life
– Decreases hospitalizations and healthcare utilization
– Reduces anxiety and depression
– Benefits extend beyond the period of training
– Improves survival
Ries AL, et al. Chest 2007; 131:4-42; O’Donnell DE, et al. Can Resp J 2007, 14:5B-32B;
Marciniuk DD, et al. Can Resp J 2010; 17:159-168; Hailey D, et al. CADTH, 2010; 126:1-155.
A Comprehensive
Approach to COPD
Management
Surgery
Surgery
Oxygen
Inhaled corticosteroids/LABA
corticosteroids
Pulmonary rehabilitation
Long-acting
Long
bronchodilator(s)
Rapid
PRN short-acting
bronchodilators
Smoking cessation/exercise/self-management/education
cessation/exercise/self
Lung function
impairment
MRC Dyspnea
Mild
Very Severe
II
V
Early Diagnosis
(Spirometry) +
Prevention
O’Donnell DE, et al. Can Resp J 2008; 15:1A-8A.
Prevent/Rx AECOPD
Follow-up
End of Life
Care
Combined Pulmonary
Rehabilitation and LABD
Casaburi R, et al. Chest 2005; 127:809-817
Practical Considerations
• Patient selection
– Disease severity considerations
– Screening and safety
• Program design and delivery
– Initiation and maintenance phases
• Team members
– Need a minimum of two health care professionals
• Program evaluation and outcomes
– Symptoms/ exercise capacity / quality of life /health resource use
Citation: Marciniuk D et al. (2010). Optimizing pulmonary rehabilitation in chronic
obstructive pulmonary disease – practical issues: A Canadian Thoracic Society
Clinical Practice Guideline. Canadian Respiratory Journal, 17(4), 159-168.
Optimizing Pulmonary Rehabilitation
• Expert working group panel, utilizing a systematic review
process to derive evidence-informed recommendations
• Panel developed 6 PICO questions of clinical interest
• Patient-related outcomes of interest included:
Reduced dyspnea, improved exercise capacity, improved activity,
decreased exacerbations, decreased health care utilization, improved
quality of life/health status, reduced healthcare costs
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Optimizing Pulmonary Rehabilitation
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 1: Are non-hospital based pulmonary
rehabilitation programs as effective as hospitalbased pulmonary rehabilitation programs in
patients with COPD?
• Recommendation #1: There are no differences in major
patient-related outcomes of PR between non-hospital
(community/home sites) or hospital-based sites. It is strongly
recommended that all patients should have access to PR
programs regardless of program site. (Grade of
Recommendation: 1A)
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 1: Site of Rehabilitation
Exercise
2 months
252 patients
Group
education
program
Maintenance
10 months
Home rehabilitation
Outpatient rehabilitation
Randomization
Maltais et al. Can Respir J. 2005;12:193-198.
Question 1: Site of
Rehabilitation
Maltais, et al. Ann Intern Med.
2008; 149:869-78.
Question 2: Does adding resistance training
(RT) to an aerobic training (AT) protocol
improve outcomes in individuals with COPD?
• Recommendation #2: AT + RT is more effective than AT
alone in improving endurance and functional ability. While
AT is the foundation of PR, it is recommended that both AT
and RT be prescribed to COPD patients. (Grade of
Recommendation: 2B)
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 2: AT + RT
Characteristics of Patients
Study
Gp
n
M:F
1:8
4:6
Age,
yrs
70±6
71±3
FEV1 ,
% pred
33±19
42±10
BMI,
kg/m2
26± 4
29± 6
Phillips
2006
AT
A+RT
9
10
Panton
2004
AT
A+RT
8
9
2:6
6:3
63±8
61±7
40±32
42±16
30± 7
33± 10
Mador
2004
AT
A+RT
13
11
-
68±7
74±6
40±14
44±13
28± 1
28± 7
Ortega
2002
AT
A+RT
16
14
14:2
13:1
66±6
60±9
41±11
33±12
Bernard
1999
AT
A+RT
15
21
11:4
17:4
67±9
64±7
39±12
45±15
25±4
27±5
Question 2: AT + RT
Characteristics of Interventions
Study Gp
Resistance component/Sham Exercise
Phillips AT
Free weight dumbbell exercises: for arms and trunk
2006
Add: goal of achieving 16-18 reps for each exercise.
2x/wk for 8 weeks. Load increased with 18 reps
completed “without distress”.
A+R Targeted legs, arms and trunk: 10 reps per exercise,
T
beginning with “light load” (50% 1 Rep Max for Chest
and Leg Press). 2x/wk for 8 wks (3 of 16 sessions
used for strength testing). Intensity progressed 510%.
Panton AT
AT: 30min light free-weight or dowel chair aerobics
A+R Total 45-60min; trageted legs, arms, trunk: work up
2004
T
to 12 reps x 3 sets, 2x/wk (total 4x/wk) for 12 wks.
Intensity progressed.
Aerobic
UE or LE erg or TM or
Recumb Step @ “RPE <
13, RPB ≤3, SaO2 ≥90%”,
20-40 min, 2x/wk for 8
wks. Intensity increase
toward goal of 20-40 min
constant aerobic exercise.
UE or LE erg or Airdyne
Cycle or TM or indoor
track walking: @ 50-70%
cardiac reserve, 30 min,
2x/wk for 12 weeks
Question 2: AT + RT
Characteristics of Interventions
Study Gp
Mador AT
2004
A+R
T
Resistance component/Sham Exercise
Calesthenics with small weights. Not clear whether
total time for exercises was matched to A+RT
Arm, leg and trunk exercise:10 reps x 1 set @ 60% 1
Rep Max for each exercise, 3x/wk for 8 weeks.
Intensity progressed
Aerobic
LE erg or TM @ 50%
Wpeak, 20min+, 3x/wk for
8 wks. Intensity was
progressed if able to
perform 20 min exercise
without “intolerable
dyspnea”.
Ortega AT
AT: performed twice the time of aerobic exercise
LE erg @ 70% Wpeak,
2002
compared to A+RT
3x/wk for 12 wks.
A+R Targeted arms, legs, and trunk.: 6-8 reps x 2 sets @ AT: 40 min per session
T
70-85% of 1 Rep Max. Intensity progressed
A+RT: 20 min per session
45 min sham exercise of breathing exercises and
LE erg @ 80% Wpeak, 30
Bernar AT
relaxation
min, 3x/week for 12 wks.
d
A+R 45 min total; targeted legs, arms and trunk: 8-10
1999
T
reps x 2 sets @ 60% of 1 Rep Max for each
exercise, 3x/wk for 12 weeks. Intensity progressed
Question 2: AT + RT
Training Protocols
• Of the 5 articles that compared AT versus A+RT,
– none applied similar training protocols (Table 1).
– For aerobic training, all studies used lower extremity
training for 20-40 minutes per session, 3x per week, for 8
weeks.
– For resistance training, all studies had participants perform
strengthening exercises for the upper and lower
extremities using variable resistance machines.
– the volume of exercise for the AT and A+RT groups was not
always well matched in the different studies.
Question 2: AT + RT
Strength Outcomes
Knee Extensors – Knee Extension or Leg Press
Study or Subgroup
Bernard 1999
Mador 2004
Ortega 2002
Panton 2004
Phillips 2006
Total (95% CI)
AT
A+RT
Mean SD Total Mean SD Total Weight
4 14
-1 10.8
6
8
4.1 17.9
-3.2 5.4
15
13
16
8
9
61
10 20
9 16.6
5
19
22.9 22.9
9.1 18
21
11
14
9
10
Mean Difference
IV, Random, 95% CI
Mean Difference
IV, Random, 95% CI
-6.00 [-17.11, 5.11]
9.0%
8.5% -10.00 [-21.43, 1.43]
71.5% -11.00 [-14.94, -7.06]
2.9% -18.80 [-38.23, 0.63]
8.1% -12.30 [-24.00, -0.60]
65 100.0% -10.80 [-14.13, -7.47]
Heterogeneity: Tau² = 0.00; Chi² = 1.46, df = 4 (P = 0.83); I² = 0%
Test for overall effect: Z = 6.36 (P < 0.00001)
-50
-25
0
25
Favours A+RT Favours AT
50
Question 2: AT + RT
Exercise Capacity
6 Minute Walk Distance (Meters)
Study or Subgroup
Bernard 1999
Mador 2004
Ortega 2002
Panton 2004
Phillips 2006
Total (95% CI)
AT
A+RT
Mean SD Total Mean SD Total Weight
66 78
26.2 32.3
39 99
-2 226
61.9 73.1
Mean Difference
IV, Random, 95% CI
15 88 81
13 33.5 35.1
16 59 145
8 208 219
9 68 51
21 16.7% -22.00 [-74.52, 30.52]
11 62.5% -7.30 [-34.48, 19.88]
14 5.7% -20.00 [-110.12, 70.12]
9 1.0% -210.00 [-422.12, 2.12]
10 14.1% -6.10 [-63.37, 51.17]
61
65 100.0%
Heterogeneity: Tau² = 0.00; Chi² = 3.67, df = 4 (P = 0.45); I² = 0%
Test for overall effect: Z = 1.13 (P = 0.26)
Mean Difference
IV, Random, 95% CI
-12.39 [-33.87, 9.09]
-100 -50 0 50 100
Favours A+RT Favours AT
Question 2: AT + RT
Exercise Capacity
Peak Work on Maximal Cycle Ergometer Test (watts)
Study or Subgroup
Bernard 1999
Mador 2004
Ortega 2002
Total (95% CI)
AT
A+RT
Mean SD Total Mean SD Total Weight
8 18
5 37.1
11 12
15
13
16
44
7 23
8 34.9
5 17
21
11
14
Mean Difference
IV, Random, 95% CI
35.8% 1.00 [-12.41, 14.41]
7.7% -3.00 [-31.85, 25.85]
6.00 [-4.67, 16.67]
56.5%
46 100.0%
Heterogeneity: Tau² = 0.00; Chi² = 0.54, df = 2 (P = 0.76); I² = 0%
Test for overall effect: Z = 0.86 (P = 0.39)
Mean Difference
IV, Random, 95% CI
3.52 [-4.50, 11.54]
-50
-25
0
25
Favours A+RT Favours AT
50
Question 2: AT + RT
Summary of Outcomes
• Meta-analyses that compared A+RT to AT showed:
– Greater improvements in knee extensor and pectoralis
strength (p<0.00001 and p<0.0006, respectively).
– A tendency for greater improvements in functional tasks
for the lower (sit-to-stand; p=0.10) and upper
extremities (reach test or arm raise; p=0.14).
– Similar improvement in the 6MWD (p=0.26) and peak
work rate on a maximal cycle ergometer test (p=0.39).
Question 2: AT + RT
Take Home Messages
• Adding resistance training to aerobic training during
pulmonary rehabilitation in COPD:
– Induces significant improvements in strength specific to the
muscle groups trained.
– Does not compromise improvements in aerobic outcomes.
– May improve function if the muscle groups that undergo
strength training match the functional needs of the patient.
Question 3: Does continuing PR beyond the
typical program length (i.e. 6-8 weeks) improve
outcomes in COPD patients compared with a
standard duration PR program?
• Recommendation #3: It is recommended that longer duration
pulmonary rehabilitation programs, beyond 6 – 8 weeks
duration, be provided for COPD patients. (Grade of
Recommendation: 2B)
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 3: Program Duration
Berry et al. J Cardiopulmonary Rehab. 2003; 23 (1): 60-8.
Question 4: Are pulmonary rehabilitation
programs as effective in pts with mild/moderate
COPD compared with pts with severe/very
severe COPD?
• Recommendation #4: It is strongly recommended that
patients with moderate, severe and very severe COPD
participate in pulmonary rehabilitation. (Grade of
Recommendation: 1C)
• Currently, there is insufficient data to make a
recommendation regarding patients with mild COPD.
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 4: Disease Severity
Patients: COPD classified according to GOLD stage:
Group 1 (stage 2a, n=48, FEV1 63±9% pred.)
Group 2 (stage 2b, n=53, FEV1 42±6% pred.)
Group 3 (stage 3, n=48, FEV1 25±7% pred.)
Garuti et al. Monaldi Arch Chest Dis. 2003; 59(1):56-61.
Question 4: Disease Severity
Patients: COPD classified according to GOLD stage:
Group 1 (stage 2a, n=48, FEV1 63±9% pred.)
Group 2 (stage 2b, n=53, FEV1 42±6% pred.)
Group 3 (stage 3, n=48, FEV1 25±7% pred.)
Garuti et al. Monaldi Arch Chest Dis. 2003; 59(1):56-61.
Question 5: Are pulmonary rehabilitation
programs as effective in female compared with
male patients with COPD?
• Recommendation #5: The benefits of Pulmonary
Rehabilitation are realized by both women and men. It is
strongly recommended that both women and men be
referred for Pulmonary Rehabilitation. (Grade of
Recommendation: 1C)
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 5: Gender
Laviolette et al. Can Respir J. 2007; 14 (2):93-98.
Question 5: Gender
Foy et al. CHEST. 2001; 119:70-6.
Question 6: Do patients who undergo PR
within 1 month of an AECOPD do better than
patients who do not undergo PR within 1 month
of an AECOPD?
• Recommendation #6: It is strongly recommended that
patients with COPD undergo PR within 1 month following
AECOPD due to evidence supporting improved dyspnea,
exercise tolerance and HRQL compared with usual care.
(Grade of Recommendation: 1B)
• PR within 1 month following AECOPD is also recommended
due to evidence supporting reduced hospital admissions and
mortality compared with usual care. (Grade of
Recommendation: 2C)
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Question 6: Timing after AECOPD
HRQoL
Exercise Capacity
Rehab
Usual
Care
Behnke et al. Monaldi Arch Chest Dis. 2003; 59:44-51.
Rehab
Usual
Care
Question 6: Timing after AECOPD
Hospital Admission
Medication Use
Usual
Care
Usual
Care
Rehab
Rehab
Behnke et al. Monaldi Arch Chest Dis. 2003; 59:44-51.
Question 6: Timing after AECOPD
Hospital Admission
Puhan et al. Cochrane Database Syst Rev. 2009; 1:CD005305.
Question 6: Timing after AECOPD
Mortality
Puhan et al. Cochrane Database Syst Rev. 2009; 1:CD005305.
Summary of
Recommendations
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Discussion Highlights
• Systematically reviewed the evidence and utilized the
experience of a representative inter-professional panel of
experts
• Numerous gaps in our understanding and practices to
optimize pulmonary rehabilitation remain:
– Maintenance programming, exercise intensity, incremental benefits of
various program components, contributions and management of comorbidities, various adjunct training techniques (altered inspired
gases, NIVS, NMES, hormones), participation barriers, adherence, and
others.
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Discussion Highlights
• Access and adherence were highlighted as significant
challenges:
– “there is an immediate urgency for these obstacles to be
addressed and …removed. It is not acceptable for health
care providers, patients and health care systems to accept
the current status quo – the benefits cannot be ignored”
• PR must be accepted as an integral component of COPD
chronic disease management:
– “barriers to participation in PR and burdens of therapy
must be acknowledged and minimized.”
Marciniuk DD, et al. Can Resp J 2010; 17:159-168
Pulmonary Rehabilitation Resources
• Online:
–
–
–
–
www.copdtoolkit.org
www.respiratoryguidelines.ca
www.chestnet.org
www.goldcopd.org
• Textbooks:
– Pulmonary Rehabilitation. (2005). Eds: Donner, Ambrosino,
Goldstein. Hodder Arnold, London.
• Publications:
– Ries AL, et al. (2007). Pulmonary Rehabilitation: Joint
ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest,
131, 4-42.
For More Information:
Canadian Thoracic Society
c/o The Lung Association – National Office
1750 Courtwood Crescent, Suite 300
Ottawa, ON K2C 2B5
Kristen Curren [email protected]
(613) 569-6411, ext. 266
www.lung.ca/cts
www.respiratoryguidelines.ca