ILD and Pulmonary Rehabilitation Chris Garvey FNP, MSN, MPA, MAACVPR Nurse Practitioner, UCSF Pulmonary Rehabilitation, Sleep Disorders, Division of Pulmonary Medicine PR - Background • 1800 – Exercise in chronic lung disease • 1960 - Science of PR effectiveness – • 2011 ATS IPF Statement • 2013 ATS ERS PR Statement – Evidence based guidelines – Effectiveness: Key outcomes – Behavior change / physical activity – Patient = center of team 1
Cost-effectiveness of PR vs Other Treatments Cost per quality-adjusted life year (QALY) Zoumot Z, et al. Emphysema: time to say farewell to therapeutic nihilism. Thorax 2014;69:973–975 . IPF - Opportunities Knowledge Gaps Mood, Dyspnea End of Life Symptom support Control o 2 Hypoxia Cough Skeletal Muscle Dysfunction 2
Recommendation : Majority of IPF → PR High value: Moderate quality data – ↑ Functional status, Pulmonary Rehab ↑ Patient-centered outcomes; Uncertain benefit duration Raghu G, Collard H, Egan J, Martinez F, Behr J, et al. An Official ATS/ERS/JRS/ALAT Statement: IPF: Evidence-based Guidelines for Diagnosis and Management 2011. 183;6 Cochrane – PR in ILD • 9 trials; 5 met criteria – n = 86 PR vs. 82 UC • 3 studies: IPF; 6 ILD; 36 - 71 years old • ↑ 6MWD 44 meter vs. control • ↑ Maximum exercise capacity • ↑ QOL, ↓ dyspnea, • Improvement: IPF and ILD • No safety concerns • Long term effects unclear Dowman L, Hill CJ, Holland AE. Cochrane rev 2014 CD006322 3
PR improves long‐term outcomes in ILD: A prospective cohort study C Ryerson , CCayou , FTopp , LHilling , PCamp, PWilcox , N Khalil , HCollard, CGarvey • N = 54 ILD (22 IPF) from 3 PR programs • 6MWD, QOL, SOB, depression, physical activity • Pre, post, 6 months post PR • 6MW - 57.6 m post PR; (p<0.0005) • Low baseline 6MWD= predictor of improvement • Change in 6MWD predicted change in QOL Ryerson CJ, et al., Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: A prospective cohort study, Respiratory Medicine (2013), http://dx.doi.org/10.1016/j.rmed.2013.11.016 Long-term Improvement • 6MWT - 50 m p = 0.005 • Physical activity (RAPA) p = 0.003 • QOL p = 0.04 • Depression p = 0.05 QOL SOB DEPRESSION Ryerson CJ, et al., Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: A prospective cohort study, Respiratory Medicine (2013), http://dx.doi.org/10.1016/j.rmed.2013.11.016 4
Aerobic Exercise Prescription Training loads exceed daily levels • Frequency: 3 to 5 times per week • Initial intensity: 60% max work rate • Type: Walking, cycling, dance, swim • Time: 20 to 60 min / session • Progression: Based on symptoms • Moderate breathlessness • 4 - 6 on 10 point Borg scale Exercise • Resistance training ꝉ muscle mass, force ↓ dyspnea • Interval training: For intolerable symptoms • = continuous training @ same = work load 1 • Stretching – no clear evidence 1. Spruit M, et al. Am J Respir Crit Care Med 2013;188(8):e13-64. 5
Make Exercise Successful • Convenient • Affordable • Pleasant • Safe • individualized –Toolkit of options • Indoor options, apps, music • Manage symptoms, boredom Exercise Stops the Downward Spiral of Dyspnea - Anxiety - Decreased Activity Interrupt Shortness of Breath Anxiety Anxiety Shortness of Breath Shortness Shortness of Breath of Breath Decreased Activity From S. Jacobs 6
Effective Management of Dyspnea: Pulmonary Rehabilitation Study Sample ∆ 6MW, m Dyspnea QOL Dowman et al 2017 RCT 142 ILD 25 Improved Improved Ryerson et al 2014 54 ILD 57 Improved Improved Holland et al 2012 44 ILD 21 Improved NA Huppman et al 2013 402 ILD inpt. 46 Improved Improved Kozu et al 2011 65 31 (MRC 2) Improved NA Swigris et al 2011 21 62 Fatigue improved SF36 non sig Salhi et al 2010 11 RLD 107 Improved SGRQ non sig Ferreira et al 2009 99 56 Improved NA Holland et al 2008 RCT 57 35 Improved Improved Nishiyama et al 2008 RCT 30 42 No Change Improved Jastrzebski et al 2006 31 NA Improved Improved Naji et al 2006 26 NA Improved Improved . Impact of Exercise on Dyspnea • Reverses skeletal muscle dysfunction –↑ endurance • Desensitization to dyspnea • ↓ anxiety, panic, depression • ↑ independence, travel, socialization • Improves weight From S. Jacobs 7
Dyspnea Strategies • Exercise: Aerobic, Strengthening • Fan / cold air / open windows • Relaxation / visual imagery / meditation • Distraction: music, social interaction • Yoga (modified) • O 2 for hypoxemic • Opiates /narcotics / anti-anxiety Rx • Pursed lip breathing? From S. Jacobs Dante’s Oxygen Competitive Bidding Hell Qualify for O 2 MD face to face visit DME Heavy equipment Can’t work Can’t leave hone Can’t exercise 8
O24U? • Assessment and titration – No standardized method • Long term O 2 - continue during exercise –May require higher flow with exercise 1 • Titrate to migrate – – DME practices challenge this – Patients need tool kit, oximeter 1. Spruit M, et al. Am J Respir Crit Care Med 2013;188(8):e13-64 Severe Exercise Induced Hypoxemia Devices Used for SEIH Devices (%) Nasal cannula 62 Hi-flow NC 50 Oxymizer pendant 49 NRBM 41 Need > 6 lpm to achieve Oxymizer cannula 37 Sp0 2 > 88% with exercise NC + NRBM 25 Venturi mask 15 OxyMask 10 pts / yr % PR pts TTO 3 Mean 14 (25) 18 (22) CPAP, BPAP, misc 1 Severe Exercise-Induced Hypoxemia Garvey C, Tiep C, Carter R, Barnett M, Hart M, Casaburi R Respiratory Care 2012, 57 (7) 1154-1160 9
O 2 and Exercise: Challenges and Opportunities Continuous O 2 only Physical Activity - Strong, Complex Interface 1-8 Health beliefs Behaviors Personality Social Symptoms Cultural, External Mood factors 1. Thompson D, Circulation. 2003 2 . Garcia-Aymerich,et al. Thorax 2006 3. O’Donnell DE,et al. Respir Med 2011 4. Troosters T, et al. Eur Resp Rev 2010 5.Ng LW, et al. Chron Respir Dis 2012 6. Garcia Amyerich et al, AJRCCM 7. Sandland CJ, et al. Chest 2008 8. Casaburi R. Proc ATS 2011 10
Self Management • Self-confidence - adaptive behaviors – Regular exercise 1 – Less advise on “how to do it” • Experiment - new behaviors • Patient central to goal setting, 2 outcomes 3 • Responsible for day-to-day management 1. Janssen DJ, et al. Patient Educ Couns 2012. 2. Murray SA, et al. BMJ 2005 3. Effing T, et al. Cochrane Rev 2007 Maximize Long Term Adherence PCP Maintenance Pulmonary Rehab exercise pulmonologist program IPF specialist IPF patient Facilitators: 1-3 Apps, Monitors, Adjuncts: Remote PR Novel Exercise O 2 Nordic walking, Rollator 1. Hospes Pat Ed Counseling 2008, 2. De Blok Pat Ed Counseling 2006, 3. Moy, Respir Med 2012 11
Advance Care Planning • Communication – – End-of-life options – Advance directives – Physician Orders for Life-Sustaining Treatment (POLST) • PR - forum to discuss issues Barriers to PR – Inconvenience Limited Access – Transportation/travel • Alternatives – Parking – Remote PR • Satellite PR – Cost • Home PR – Insurance coverage – Technology – Lack of support – Illness severity – Comorbidities – Mood disorders – Lack perceived benefit – Provider influence 1,2 1. Keating A, et al. Chron Resp Dis 20112 2. Garrod R, et al. j Eur Soc 2006 12
Pulmonary Rehabilitation in US • 1,521 Cardiopulmonary Centers 1 • 237 PR Centers 1 • 66 programs in CA 2 1: aacvpr.org 2. cspr.org Alternatives to PR 1,2 • Technology - potential bridge; • Need key components of PR: –Individualized exercise Rx –Self management education –Outcome measurement –Patient support 1. Brooks D, et al Can Respir J 2007 2. Rochester C, et al Am j Respir Crit Care Med 2015 13
Barriers to Home- based PR • No evidence based guidelines –Safety, supervision, responsibilities –Outcome measurement • Lack insurance coverage • Older, < affluent, disabled - disconnected from e-health physically / psychologically 1 • Not extensively tested • Where does ILD fit? Older Adults and Technology Use by Arron Smith Pew Research Center http://www.pewinternet.org/2014/04/03/older-adults-and-technology-use Choosing a PR Program • AACVPR PR Certification, competencies • ATS - establishing quality metrics • Find a program – AACVPR.org IPF IPF – cspr.org – www.pulmonaryfibrosis.org – livingbetter.org • Support – www.pulmonaryfibrosis.org – www.rareconnect.org – www.plmjoin.com/ipf 14
Opportunities • All symptomatic chronic lung disease potentially benefit • PR duration: longer appears better 1 • Long term maintenance / physical activity / exercise • Change in physical activity requires behavior change • Access to PR – Apps / wireless options – develop evidence base • Novel 0 2 : High flow, High flow heated humidified 0 2 – Portable ventilators – Oldies but goodies: TTO, LOX – Fix the inequities 1. Pitta F, et al. Eur Respir J 2006 15
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