1. Pulmonary Rehabilitation in COPD
Maureen Fagan
Respiratory Specialist Nurse

2. Amy Winehouse diagnosed with emphysema From Times Online June 23, 2008
“They tried to make me go to rehab, I said no, no, no....”
Amy Winehouse diagnosed with emphysema From Times Online June 23, 2008

3. What is Pulmonary Rehabilitation?
“…a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patient’s physical and social performance and autonomy.”

4. Spiral of Disability

5. Why is it pulmonary rehabilitation important?
COPD causes 30,000 deaths per year and leads to extensive morbidity. It incurs massive costs in relation to hospital admissions, incurring nearly 6 times as many bed days of inpatient care as asthma.
Interventions which improve quality of life and level of functioning are important since few interventions except smoking cessation affect disease progression.

6. Development of Disability in COPD
The decline in airway function may go unnoticed initially as people adapt their lives to avoid dyspnoea
Up to 50% of FEV1 may be lost before a person presents with significant symptoms
Significant disability develops late in the course of the disease when reversal of airway obstruction is not possible.
Dyspnoea , Limb muscle dysfunction, hypoxaemia , poor nutrition, steroid myopathy and loss of confidence may contribute to disability

7. Aims Increase exercise tolerance
Increase muscle strength and endurance
Reduce dyspnoea and perception of breathlessness
Reverse deconditioning
Increase knowledge of lung condition and management of the disease
Promote self-management and coping strategies
Improve health-related quality of life
Improve confidence in ability to exercise
Increase independence in daily functioning
Promote long-term commitment to exercise

8. Who is it for?
All disease severities (but may not benefit if unable to walk)
…where SYMPTOMS AND DISABILITY are present (usually MRC grade 3)

10. Who is it for?
All disease severities (but may not benefit if unable to walk)
…where SYMPTOMS AND DISABILITY are present (usually MRC grade 3)
No justification for selection on basis of age, impairment, disability, smoking status or oxygen use
Post exacerbation
Contra-indicated if recent MI/ unstable angina/

11. Course Content and Duration
The longer the better but usually 6-12 weeks
Twice weekly minimum
Patient assessment
Baseline and outcome assessments: exercise capacity (shuttle walk), disability/health status (questionnaire)
Exercise training upper limb and lower limb training/ respiratory muscle training / breathing exercises
Optimal pharmacological management
Educational support - can include carer
Psychological support - can include carer
Assessment of outcome
Programme evaluation
Maintenance

12. Programme settings & staffing
Effective in inpatient, outpatient and community settings and possibly at home.
Should be held at times that suit patients in buildings that are easy to access with appropriate access for those with disabilities.

13. Patient Safety Staff patient ratio Exercise 1:8 Education 1:16
Staff trained in Basic life support
Ambulatory O2

14. Exercise Training: Which muscle groups?
Lower limb training improves exercise tolerance though no effect on measured lung function
Upper limb training improves arm strength and reduces ventilatory demand
Respiratory muscle training may influence endurance and dyspnoea but evidence is conflicting
DOESN’T HAVE TO BE HI TECH

15. Education Programme COPD – overview
Breathing control, pacing and relaxation
Exercise/activity
Medication, devices and O2 therapy
Managing exacerbations
Sputum clearance
OT equipment
Benefits agency
Holidays
Palliative care
Diet

16. Psychological components
COPD is associated with anxiety and depressive symptoms which may interfere with activities of daily living (ADL’s)
Expert opinion supports the use of educational and psychological interventions in pulmonary rehab programmes
Typical goals: address depression/anxiety, teach relaxation skills, coping strategies, discuss relevant issues such as sexuality, family and work relationships

17. Patient Feedback Programme as a whole was excellent
Wished it was longer
Have got my life back
Im now in control
Much more confident
Achieved goals and more
Can relax better
My illness no longer runs my life
Can walk further
My life now feels worth living again
Feel better about myself

18. Summary - Benefits of Pulmonary Rehabilitation
Improved exercise capacity (Evidence A)
Improved health-related quality of life (Evidence A)
Reduces perceived intensity of breathlessness (Evidence A)
Reduced hospitalisations and length of stay (Evidence A)
Reduced anxiety and depression associated with COPD (Evidence A)
Increased survival (Evidence B)
Benefits probably extend well beyond the period of rehab, especially if exercise training is maintained at home. (Evidence B)
Improved psychological wellbeing (Evidence C)

19. References
NICE: National clinical guidelines on management of COPD in adults in primary and secondary care (2010)
GOLD: Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (2009)
Nici et al. ATS/ERS Pulmonary Rehabilitation Writing Committee American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation.  Am J Respir Crit Care Med. 2006;173:
Y Lacasse, L Brosseau, S Milne, S Martin, E Wong, GH Guyatt, RS Goldstein, White J, Pulmonary rehabilitation for chronic obstructive pulmonary disease (Cochrane review). In: The Cochrane Library, issue 3, 2004.
Pulmonary Rehabilitation Joint ACCP/AACVPR Evidence-Based Guidelines. Chest/ 112 / 5 / November 1997

20. Resources GPIAG Best Practice Statement
IMPRESS Principles Document
Patient Information

21. Thanks for listening.
Any Questions ?