1. Clinical Benefits of Pulmonary Rehabilitation in COPD
Darcy D. Marciniuk, MD FRCPC FCCP
Division of Respirology, Critical Care
and Sleep Medicine

2. Conflict of Interest Disclosure
Consultancy Fees / Advisory Boards
AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Health Canada, Health Quality Council, Novartis, Nycomed, Pfizer, Public Health Agency of Canada, Saskatchewan Medical Association, Saskatoon Health Region
Research Funding
AstraZeneca, Boehringer Ingelheim, Canadian Agency for Drugs and Technology in Health, Canadian Institute of Health Research, GlaxoSmithKline, Lung Association of Saskatchewan, Novartis, Nycomed, Pfizer, Saskatchewan Health Research Foundation, Saskatchewan Ministry of Health, Schering-Plough
Speaker’s Bureau
AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Pfizer
Fiduciary Positions
Canadian COPD Alliance, American College of Chest Physicians, Chest Foundation, Saskatchewan Lung Association
Employee
University of Saskatchewan

3. Pulmonary Rehabilitation in COPD
Objectives
understand the role of Pulmonary Rehabilitation (PR) in the comprehensive management of COPD
appreciate the patient-centered clinical benefits of effective PR in COPD
recognize and minimize barriers to patients participating and fully realizing the clinical benefits of PR in COPD

4. A Comprehensive Approach to COPD Management
Surgery
Surgery
Oxygen
Oxygen
Inhaled corticosteroids/LABA
Inhaled corticosteroids
Pulmonary rehabilitation
Pulmonary rehabilitation
Long
Long-acting bronchodilator(s)
PRN Rapid
PRN short-acting bronchodilators
Smoking cessation/exercise/self-management/education
Smoking cessation/exercise/self
Lung function
Mild
Very Severe
impairment
MRC Dyspnea II V V
Early Diagnosis
Prevent/Rx AECOPD
End of Life
Care
(Spirometry) +
Follow-up
Prevention
O’Donnell DE, et al. Can Resp J 2008; 15:1A-8A.

5. Therapy at Each Stage of COPD
I: Mild
II: Moderate
III: Severe
IV: Very Severe
FEV1/FVC < 70%
FEV1 < 30% predicted
or FEV1 < 50% predicted plus chronic respiratory failure
FEV1/FVC < 70%
30% < FEV1 < 50% predicted
FEV1/FVC < 70%
50% < FEV1 < 80%
predicted
FEV1/FVC < 70%
FEV1 > 80% predicted
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
This provides a summary of the recommended treatment at each stage of COPD.
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Add long term oxygen if chronic respiratory failure. Consider surgical treatments 5

7. End of Life
Care
Magnitude of
Dyspnea V
Exclude
Contributing
Causes
Regular Follow-up
And Reassessment
Initiate & Optimize Pharmacologic Therapies:
SABD, LAAC, ICS/LABA, PDE4 Inhibitors, Theophylline, O2 in Hypoxemic Patients
Comprehensive Approach to Management of Refractory Dyspnea in Advanced COPD
Initiate & Optimize Non-Pharmacologic Therapies:
Exercise, Pursed-Lip Breathing, Walking Aids, Chest Wall Vibration, NMES
Initiate & Optimize Opioid Therapies:
Short- and Long-Acting Agents
Marciniuk DD, et al. Can Resp J 2011; 18:69-78.

8. What is Pulmonary Rehabilitation ?
Pulmonary Rehabilitation in COPD
What is Pulmonary Rehabilitation ?
… depends on who you ask !
common theme:
multidisciplinary program designed to optimize physiological, psychological, and social outcomes for COPD patients and their care-givers
practical definition depends on the program design and intent
‘Group Exercise’ ↔ ‘Comprehensive Care’

9. Pulmonary Rehabilitation in COPD
Who Benefits From PR?
PR improves dyspnea and activity limitation in COPD patients (1)
COPD patients benefit from PR regardless of patient age, disease severity, and sex (2)
PR is beneficial across all levels of COPD severity, and should be considered earlier in the course of COPD (3)
allow for a greater emphasis on promoting health rather than regaining function
1 Ries AL, et al. Chest 2007; 131:4S-42S. 2 Hailey D, et al. CADTH HTA Report, April 2010.
3 Nici L, et al. J Cardiopulm Rehab Prev 2009; 29:

10. Pulmonary Rehabilitation Candidates
strongly recommended patients with moderate, severe and very severe COPD participate in PR (Recommendation Grade 1C)
currently, there is insufficient data to make a recommendation regarding mild COPD patients
strongly recommended that both women and men be referred for Pulmonary Rehabilitation (Recommendation Grade 1C)
Marciniuk DD, et al. Can Resp J 2010; 17:

11. Pulmonary Rehabilitation Candidates
strongly recommended COPD patients undergo PR within 1 month following AECOPD due to evidence supporting improved dyspnea, exercise tolerance and HRQL compared with usual care (Recommendation Grade 1B)
PR within 1 month following AECOPD also recommended due to evidence supporting reduced hospital admissions and mortality compared with usual care (Recommendation Grade 2C)
Marciniuk DD, et al. Can Resp J 2010; 17:

12. Physical Activity in COPD
Pulmonary Rehabilitation in COPD
Physical Activity in COPD
COPD Admission
Mortality
Copenhagen City Heart Study, n=2386 COPD subjects confirmed by lung function
[833 GOLD I, 1095 GOLD II, 354 GOLD III, 94 GOLD IV]
No effect modification was found for sex, age, COPD severity, or IHD
Garcia-Aymerich J, et al. Thorax 2009; 61:

13. Physical Activity in COPD
70 COPD [9 / 28 / 23 / 10] and 30 control subjects; activity monitor x 6-8 days.
Trooster T, et al. Respiratory Medicine 2010; 104:

14. Health Benefits of Physical Activity
Pulmonary Rehabilitation in COPD
Health Benefits of Physical Activity
primary and secondary prevention:
all-cause and cardiovascular-related deaths are decreased
incidence of diabetes mellitus, cancer (colon, breast), and osteoporosis are significantly reduced
how much exercise is necessary?
weekly expenditure of ~1000 kcal associated with a 20-30% reduction in all-cause mortality
less ‘volume’ of exercise is necessary solely for health benefits (~ 500 kcal/week)
not much!
Warburton DER, et al. CMAJ 2006; 174:

15. Adverse Effects of COPD
Pulmonary Rehabilitation in COPD
Adverse Effects of COPD
FEV1, FVC
IC, EELV
FRC, RV
Impairment
[Function]
Dyspnea
Exercise Endurance
Exacerbations (AECOPD)
Disability
[Activity]
Quality of Life
Health Care Utilization
Handicap
[Participation]
Adapted from Can Respir J, 2004; 11(Suppl B): 7B-59B

16. Patient-Centered Benefits
Pulmonary Rehabilitation in COPD
Patient-Centered Benefits
Pulmonary Rehabilitation:
reduces shortness of breath
benefits exceed minimally clinically important difference (MCID) ie CRQ
improves exercise capacity
~15-20% increase in maximal workload, and ~10% increase in peak VO2
~80% increase in endurance exercise time and ~50m increase in 6MWD
Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2010;
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: ; Hailey D, et al. CADTH 2010; 126:1-155.

17. Patient-Centered Benefits
Pulmonary Rehabilitation in COPD
Patient-Centered Benefits
Pulmonary Rehabilitation:
improves health related quality of life
fall in SGRQ of ~7-8 units
reduces fatigue
reduces anxiety and depression, and other documented psychosocial benefits
decreases hospitalizations, hospital days, and healthcare utilization
Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2010;
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: ; Hailey D, et al. CADTH 2010; 126:1-155.

18. More Benefits From PR … Pulmonary Rehabilitation: is cost-effective
Pulmonary Rehabilitation in COPD
More Benefits From PR …
Pulmonary Rehabilitation:
is cost-effective
incremental cost-effectiveness ratio compared with usual care is $27,924 per additional quality-adjusted life-year (QALY) gained (moderate/severe/very severe)
improves survival … (?)
29% reduction – recent Cochrane review [Puhan 2009] of PR after hospital admission
Puhan M, et al. Cochrane Database Syst Rev 2009; Ries AL, et al. Chest 2007; 131:4-42;
Marciniuk DD, et al. Can Resp J 2010; 17: ; Hailey D, et al. CADTH 2010; 126:1-155.

19. Effective “Combination” Therapy
Pulmonary Rehabilitation in COPD
Effective “Combination” Therapy
Study Drug *
Rehabilitation *
32%
42%
Endurance Time (mins)
16%
Placebo
Tiotropium
* p<0.05
Weeks on Treatment
Casaburi R, et al. Chest 2005; 127:

20. Ensuring Patient Benefits
Pulmonary Rehabilitation in COPD
Ensuring Patient Benefits
Program design, delivery and duration
CTS has recommended longer duration PR programs, beyond 6 – 8 weeks duration, be provided for COPD patients
‘Kindergarten’ vs ‘Graduation’ philosophies
lower limb aerobic exercise must always be the foundation of the program
no differences in major outcomes between community/home sites vs hospital sites
coordinated and supervised
Maltais F, et al. Ann Intern Med 2008; 149: ;
Ries AL, et al. Chest 2007; 131:4-42; Marciniuk DD, et al. Can Resp J 2010; 17:

21. Maximizing Patient Benefits
Pulmonary Rehabilitation in COPD
Maximizing Patient Benefits
explore methods to further optimize training
can we accelerate training to potentially shorten the duration of initiation phase?
can patients achieve greater physiologic gains?
start earlier in the course of the disease?
do we place a greater emphasis on promoting health rather than solely on regaining function?
how to best optimize patient outcomes with limited resources and access ie. priority setting
should coordinated group pulmonary/cardiac/ diabetes/etc rehabilitation become more common?
”trying to do too much = achieving very little”
Marciniuk DD, et al. Can Resp J 2010; 17:

23. Barriers to Implementation of PR
access and adherence highlighted as the most significant challenges
“immediate urgency for these obstacles to be address and to be 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 management
“barriers to participation in PR and burdens of therapy must be acknowledged and minimized.”
Marciniuk DD, et al. Can Resp J 2010; 17:

24. May C, et al. BMJ 2009; 339:

25. Pulmonary Rehabilitation in COPD
Summary
Pulmonary Rehabilitation plays a sentinel role in the comprehensive management of COPD
it must become ‘routine’
there are significant and meaningful patient-centered clinical benefits of effective Pulmonary Rehabilitation in COPD
we must recognize, acknowledge and eliminate barriers to patients participating and fully realizing the clinical benefits of PR in COPD

27. Marciniuk DD, et al. Can Resp J 2010; 17:159-168