Pulmonary rehabilitation in severe COPD - PowerPoint PPT Presentation

Pulmonary rehabilitation in severe COPD daniel.langer@faber.kuleuven.be

Content • Rehabilitation (how) does it work ? • How to train the ventilatory limited patient ?

Chronic Obstructive Pulmonary Disease NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Definition:  Chronic obstructive pulmonary disease is characterized by airflow limitation that is not fully reversible.  It is a preventable and treatable disease with some significant extrapulmonary manifestations.  Skeletal muscle dysfunction  Weight loss  Cardiovascular disease  Depression and Fatigue  Osteoporosis

Interaction between pulmonary and extrapulmonary factors 180 160 Muscle Dysfunction 140 Early lactic acidosis VE (L/min) 120 Dynamic Hyperinflation Breathing frequency 100 80 60 40 20 0 0 1 2 3 4 VO2 (L/min)

Targets of Exercise Training • Improving aerobic function of ambulation muscles • Reducing ventilatory requirement and respiratory rate during exercise • Prolonging expiration time • Reducing dynamic hyperinflation and dyspnea Casaburi et al. N Engl J Med 2009 Casaburi R and ZuWallack R. N Engl J Med 2009;360:1329-1335

Content Rehabilitation Program • Exercise Training – Endurance exercise to improve cardiorespiratory fitness – Resistance training to improve muscular strength and endurance (peripheral and respiratory muscles) • Supplemental interventions during exercise training – Oxygen – Heliox • Breathing exercises • Occupational therapy • Nutritional advise • Psychological support • Patient-education / self-management (inactivity)

Rehabilitation, the evidence: Exercise tolerance Exercise tolerance: Weighted mean difference and IQR 30 110 100 90  (% baseline)  (% baseline) 80 20 70 60 50 40 10 30 20 10 0 0 Wmax VO2max Walking Whole body end Adapted fromTroosters AJRCCM 2005

Rehabilitation, the evidence CRDQ 6MWD 3 75  HRQoL (MCID-units) 2  6MWD (m) 50 1 25 0 -1 0 Dys Fat Emo Mas 6MWD Lacasse Eura Medicophys 2007 (Cochrane)

Rehabilitation, the evidence: Health care resources Rehabilitation Controls Patients admitted n 41 40 NS Hospital admissions Resp 1.9 1.4 1.4 1.3 * All 2.2 1.5 1.7 1.1 * Days spent in hosp Resp * 18.1 19.3 9.4 10.2 All 21.0 20.7 10.4 9.7 * Days per admission 9 ± 7.6 6 ± 3.4 0.1 Griffiths Lancet 2000

Rehabilitation: the evidence Evidence from systematic review of meta-analysis of randomised controlled trials (level la) • Improvements in exercise tolerance • Clinically relevant improvement in health related quality of life (HRQoL). Evidence from at least one RCT(level lb) • Reductions in number of days spent in hospital • Pulmonary rehabilitation is cost effective

Exercise training, the core of rehabilitation How do we train patients with severe airflow obstruction, dynamic hyperinflation and complaints of dyspnea on exertion?

Knowing exercise limitations to guide training How to train the ventilatory limited patient ? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs – Increase the delivery – Reduce the demand

Improve lung function 150 Time PA outside rehab 700 Exercise enndurance * * 600 (% increase) 100 (min) * 500 400 50 300 200 0 TIO REHAB TIO+REHAB w4 w9 w13 w17 w21 w25 Casaburi et al Chest 2005 Kesten J COPD 2008

Improve maximal voluntary ventilation HeliOx Endurance time VE Air HeliOx 18 70 1.54  0.73 1.89  0.73 FEV1 16 60 3.76  1.13 3.86  1.18 FVC 14 50 12 90 40 10 Ventilation (L.min -1 ) 8 30 HE 60 6 20 4 10 2 30 0 0 0 0 10 20 Time (min) Eves AJRCCM 2006

Training at higher intensity Air (n=19) He/O 2 (n=19) ± ± FEV 1 47 19 46 14 Endurance time ± ± 129 20 122 17 120 TLC 24 ± ± 66 22 64 14 D LCO * 20 WR (%max) VO2peak 55 11 59 13 100 * 16 * 80 12 60 8 4 40 0 Air HH 0 2 4 6 8 10 12 14 16 18 20 22 Session (n) Eves Chest 2009

Lung Transplantation

1yPost-LTX Healthy n=22 n=30  /  Gender 12 / 10 18 / 12 Age yrs 59 5 58 6 kg/m 2 BMI 23 ± 4 25 ± 4 FEV 1 %pred 79 ± 18* 116 ± 18 -40% 100 ± 36* 164 ± 41 Q-Force Nm -20% MEP cm H 2 O 159 ± 44* 193 ± 47 -20% MIP cm H 2 O -76 ± 48 -97 ± 53 -15% Handgrip kgF 36 ± 16 42 ± 10 -30% 6MWD m 483 ± 66* 690 ± 83 -60% 74 ± 22* 182 ± 57 Wmax %pred Langer et al. Journal of Heart and Lung Transplantation 2009

Study Design RCT Exercise Training after LTX Transplantation Exercise Training Pre-LTX Post-LTX 3m/6mPost- 105 days 28 days Random Control Physical activity counseling w/ feedback SenseWear

Baseline Characteristics Post-LTX Training (n=15) Control (n=13) Male / Female 8 / 7 7 / 6 Early acute rejection (yes / no) 6 / 7 3 / 9 SLTX / SSLTX 1 / 14 3 / 10 Diagnosis COPD / ILD 12 / 3 11 / 2 Age 56 ± 4 56 ± 7 BMI (kg/m²) 20,7 ± 4,6 21,6 ± 4,2 FEV 1, (% pred) 72 ± 18 74 ± 16

Exercise Training  3 sessions per week Resistance exercise Cycling Treadmill walking Stair climbing

40 50 60 70 80 90 P r e - L P T o X 3 s m t - L P T o X 6 s m t - L P T o X s * t - L T X * 6-minute walking distance (m) Control Training 300 400 500 600 P r e Results - L P T o X 3 s m t - L P T o X 6 s m t - L P T o X s * t - L T X *

Knowing exercise limitations to guide training How to train the ventilatory limited patient ? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs – Increase the delivery – Reduce the demand

Training at higher intensity Endurance time 120 24 24 * 20 20 WR (%max) 100 * 16 16 * 80 Increased O2 delivery 12 12 Lower lactate Reduced ventilatory drive 60 8 8 4 4 40 0 0 Air HH Air O2 0 2 4 6 8 10 12 14 16 18 20 22 Session (n) Emtner AJRCCM 2003

Knowing exercise limitations to guide training How to train the ventilatory limited patient ? Improve the lung function / maximum ventilatory capacity Reduce the ventilatory needs – Increase the delivery – Reduce the demand

Reduce the demand - Enhance the stress to the muscle for a given VO2 (walking vs cycling) 3.0 30  Q tw pot (%baseline) 20 10 VO 2 L/min 2.0 0 -10 -20 1.0 -30 -40 -50 0.0 R 50% 100% End Cycle @ 80% Wpeak Walk @ 80% VO 2 peak Pepin AJRCCM 2005

Reduce the demand - Enhance the stress to the muscle for a given VO2 (walking vs cycling) - Reduce the amount of muscle mass at work (resistance training, NMES). 35 * 30 VO 2 L/min 25 20 15 10 Walking Cycling Stairs Quadr Probst ERJ 2006

50 (% initial or points) STRENGTH 40 ENDURANCE 30 20 10  0 6MWD VO2max CRDQ Spruit et al. Eur.Respir.J. 2002; 19:1072-1078

Reduce the demand - Enhance the stress to the muscle for a given VO2 (walking vs cycling) - Reduce the amount of muscle mass at work (resistance training, NMES, single leg) Single Leg Exercise Dolmage Chest 2008

Single leg exercise 35 Endurance Time (min) Healthy 30 COPD @ 80% Wpeak 25 20 15 10 5 0 two legs one leg Dolmage et al Chest 2006

Single leg training 30 min of conventional cycling training versus single leg cycling (15 min each leg) 3 times per week 7 weeks FEV1 37 and 40%pred 35 25 10 30 * 20 8 25 % initial % initial min 15 6 20 15 10 4 10 5 2 5 0 0 0 Wpeak VO2peak Tlim@80% Dolmage Chest 2008

Reduce the demand - Enhance the stress to the muscle for a given VO2 - Reduce the amount of muscle mass at work - Shorten the bouts of exercise to keep ventilation lower than needed in steady state (interval training)  Slow oxygen uptake (ventilatory) kinetics : your friend in pulmonary rehab…

Interval exercise, often more realistic 100 TwQ (%change) 1.1 75 0.9 50 VO 2 (L/min) 25 0.7 Man 2003 Mador 2001 Mador 2003 Pepin 2006 Saey 2005 IPR Saey 2005 PL 0.5 0.0 0 2 8 4 6 54 56 58 60 62 Time (min) Sabapathy Thorax 2004

Conclusions • Pulmonary rehabilitation works: ‘GRADE A’ -level of evidence • Exercise training can be fine-tuned to the exercise limitations of patients • Several options available for ventilatory limited patients

Increase Ventilatory Capacity: High intensity Peripheral Bronchodilators Muscle Heliox Training Exercise training

Reduce Ventilatory Requirements: High intensity O 2 supplementation Peripheral Small muscle mass Muscle Short intervals Training One-leg exercise Interval training Resistance training

Thank you for your attention Greetings from the Leuven Pulmonary Rehabilitation team