Staf Inwendige Ziekten

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1 Staf Inwendige Ziekten Pulmonale revalidatie: waarom, met welke resultaten? Eric Derom Dienst Longziekten Universitair Ziekenhuis Gent

2 COPD Klachten: dyspnoe, hoesten, sputum, inspanningsintolerantie, deterioratie over jaren, exacerbaties, angst/depressie, cachexie Oorzaak: blootstelling aan schadelijke stoffen Pathologie: chronische luchtwegobstructie kleine luchtwegpathologie en parenchymdestructie Diagnose: niet (partieel) reversiebele obstructief gestoorde longfunctie Therapie: rookstop, vaccinaties, revalidatie bronchodilatatie (iedereen), inhalatiesteroiden (op indicatie)

3 ATS/ERS 2013 Definition of Pulmonary Rehabilitation a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies including, but not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of healthenhancing behaviors provided by a dedicated, interdisciplinary team, including physicians and other health care professionals individualized to the unique needs of the patient, based on initial and ongoing assessments, including disease severity, complexity, and comorbidities. ATS/ERS Guidelines 2013

4 BTS 2013 Definition of Pulmonary Rehabilitation Pulmonary rehabilitation can be defined as an interdisciplinary 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 Programmes comprise individualised exercise programmes and education BTS Guidelines 2013

5 Exercise Limiting Symptoms in Healthy and COPD (% of Total) 100% Fatigue 80% Dyspnea & Fatigue 60% Dyspnea 40% % % Healthy (n=320) COPD (n=97) Killian et al, Am Rev Respir Dis 1992; 146:

6 Distribution of 6MWD by GOLD stage (Eclipse) Spruit et al., Respiratory Medicine 2010; 104:

7 Identification of the Origin of Exercise-Limitation PaO2 PaCO2 D(A-a)O2 HR VE Borg D/F Cardiocirculatory limitation = < 15 mmhg > HRmax <75% MVV > 15 L/min VR F Ventilatory limitation /= < 15 mmhg < HRmax 75% MVV > 15 L/min VR D Pulmonary gas exchange = / > 15 mmhg < HRmax 75% MVV > 15 L/min VR D Peripheral limitation = = / < 15 mmhg < HRmax 75% MVV > 15 L/min VR F Psychogenic limitation = = < 15 mmhg <Hrmax 75% MVV > 15 L/min VR F KNGF-richtlijn Chronisch obstructieve longziekten 2008

8 Dyspnea and impaired exercise tolerance Assessment of lungfunction, dyspnea (MRC) and PA < 30 min/day FEV 1 50% pred MRC-score <1 FEV 1 50% pred MRC-score 1 FEV 1 < 50% pred MRC-score Advice: Improve PA Regular Sports Max. exercise test Multidisciplinary evaluation Wmax 70% pred. VO 2 max 80% pred. Wmax < 70% pred. VO 2 max < 80% pred. Advice: Improve PA Intake exercise program Multidisciplinary rehabilitation Individual exercise program Inpatient program Outpatient program Adapted sportactivities KNGF-richtlijn Chronisch obstructieve longziekten 2008

9 Oorzaken van Perifere Spierzwakte bij COPD Maltais et al, ATS/ERS Statement on Limb Muscle Dysfunction in COPD. Am J Respir Crit Care Med 2014

10 Physical Inactivity in Patients with COPD Minimal requirement Troosters et al, Respiratory Medicine 2010; 104:

11 Physical Inactivity in Patients with COPD Minimal requirement Troosters et al, Respiratory Medicine 2010; 104:

12 Physical activity and Hospitalization for Exacerbation of COPD Pitta et al. Chest 2006; 129:

13 Physical Activity and Hospitalization for Exacerbation of COPD Pitta et al. Chest 2006; 129:

14 Time to first admission Time to death J Garcia-Aymerich, Thorax 2006; 61:

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17 Pulmonary Rehabilitation Maximal Exercise Capacity McCarthy et al, Cochrane Database of Systematic Reviews 2015

18 6 min Walking Distance in COPD McCarthy et al, Cochrane Database of Systematic Reviews 2015

19 Pulmonary Rehabilitation after Exacerbation 6 min Walking Distance Puhan et al, Cochrane Database of Systematic Reviews 2016

20 Pulmonary Rehabilitation Dyspnea (CRDQ) MCID for CRDQ = 0.5 McCArthy et al, Cochrane Database of Systematic Reviews 2015

21 Extensiveness* of Rehabilitation Program after Exacerbation Dyspnea (CRDQ) * = number of completed exercise sessions, type, intensity and supervision of exercise training, and patient education Puhan et al, Cochrane Database of Systematic Reviews 2015

22 Pulmonary Rehabilitation Quality of life (SGRQ) McCarthy et al, Cochrane Database of Systematic Reviews 2015

23 Trial (Year) N Trough FEV 1 (L) SGRQ TDI FRC / IC (L) ET (s) Beeh (2015) Singh (2015) O Donnell (2015) Bateman (2013) Beeh (2014) Donohue (2013) Maltais (2014) Maltais (2014) vs Δ = Δ = TIO/OLO 5/5 µg vs. Placebo Δ = Δ = Δ = 2.1 Δ = vs / vs / / GLY/IND 110/50 µg vs. PLACEBO 2144 Δ = Δ = -3.0 Δ = Δ = / Δ = UMEC/VIL 62.5/25 µg vs. PLACEBO 1536 Δ = Δ = -5.5 Δ = / Δ / Δ ACL/FORM 400/12 µg vs. PLACEBO Δ = Δ = 60.0 Δ = 69.4 Δ = 21.9 D Urzo (2014) vs vs vs. 0.6 Singh (2014) 1729 Δ = vs vs. 1.2

24 Pulmonary Rehabilitation Hospital Readmission Puhan et al, Cochrane Database of Systematic Reviews 2015

25 Results at 1 Year of Outpatient Multidisciplinary Pulmonary Rehabilitation Controle (N = 101) Revalidatie (N = 99) opnames - respiratoir opnames - alle oorzaken opnameduur - respiratoir opnameduur - alle oorzaken Griffiths et al., Lancet 2000, 355:

26 Results at 1 Year of Outpatient Multidisciplinary Pulmonary Rehabilitation Controle (N = 101) Revalidatie (N = 99) consultatierespiratoir consultatie - alle oozaken thuisbezoek - respiratoir thuisbezoek - alle oorzaken Griffiths et al., Lancet 2000, 355:

27 Pulmonary Rehabilitation: Maximal Exercise Testing and Rehabilitation Predominantly cardiocirculatory limitation? Predominantly ventilatory limitation? Desaturation? Skeletal muscle weakness? Exercise tolerance enhanced by NIV No Yes Consider training with NIV Inspiratory muscle weakness Gas exchange impairment leads to ventilatory limitation Yes Hypogonadism Yes Constant work rate 70% Wmax Yes Consider testosterone supplements > 10 min < 10 min O 2 supplements Whole body endurance TR Whole body interval TR Add IMT Resistance training (NEMS)

28 Trainingsschema s 1. Duurtraining (fietsen, loopband) Bij patiënten met COPD I en II (cardiocirculatoir beperkt) 2. Intervaltraining (fietsen, loopband, trappen) Bij patiënten COPD III en IV die ventilatoir beperkt zijn en geen langdurige inspanning kunnen volhouden 3. Perifere spiertraining In het bijzonder bij spierzwakte: bovenste en onderste ledematen 4. Ademspiertraining In het bijzonder bij ademspierzwakte, dyspnoe, transplantkandidaat 5. Trainen onder zuurstof bij desaturatie, mogelijks ook nuttig bij niet desaturende patiënten Trainen onder ventilatie (Bipap) Experimenteel (bij uitgesproken dyspnoe)

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37 Andere Interventies 1. Gezondheidsvoorlichting en -opvoeding 2. Psychosociale ondersteuning Angst en depressie 3. Vocational therapy (ergotherapy) Ventilatie (energiesparende) maatregelen bij ADL Pursed lip breathing Hulpmiddelen Activiteitspreiding 4. Nutritional intervention Obesitas en malnutritie

38 Does Exercise Training change Physical Activity in COPD? A systematic Review and Meta-Analysis 0.12 or 0.14 is equivalent to an increase of approximately 4.6 or 5.4 min of walking per day, following the intervention Li Whye Cindy Ng et al., Chronic Respiratory Disease 2012; 9: 17 26

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40 Physical Activity is Increased by a 12-Week Semiautomated Telecoaching Programme in COPD Patients: 343 COPD patients (A-D) Intervention telecoaching intervention group vs. usual care group automated coaching by displaying an activity goal (number of steps) and feedback on a daily basis Outcome measurements number of steps per day over 3 months time in moderate intense physical activity (MPA) walking time movement intensity Demeyer H, et al. Thorax 2017;72:

41 Physical Activity is Increased by a 12-Week Semiautomated Telecoaching Programme in COPD Δ = (971 to 1965) Δ = (6.1 to 14.7) Demeyer H, et al. Thorax 2017;72:

42 Physical Activity is Increased by a 12-Week Semiautomated Telecoaching Programme in COPD Demeyer H, et al. Thorax 2017;72:

43 REVALIDATIE BIJ RESPIRATOIRE PATIENTEN CRITERIA VOOR INCLUSIE EN TERUGBETALING Pulmonale Revalidatie K30 (bidisciplinair) FEV 1 < 60% pred. Pulmonale Revalidatie K20-K15 Algemene monodisciplinaire revalidatie

44 CONVENTIE RESPIRATOIRE REVALIDATIE MET RIZIV CRITERIA VOOR INCLUSIE EN TERUGBETALING ESW < 50% of TL,CO < 50% en 2 van de volgende criteria ademspierkracht < 70% quadricepskracht < 70% maximale belasting (fiets) < 90 Watt 6 min. wandelafstand < 70% CRDQ-score < 100 of < 20 voor dimensie dyspnoe

45 CONVENTIE RESPIRATOIRE REVALIDATIE MET RIZIV Practical Modalities Multidisciplinair longarts-revalidatie-arts kinesitherapeut ergotherapeut diëtist/voedingsdeskundige psycholoog sociaal assistent

46 Pulmonary Rehabiltation Organisation In-hospital more expensive indicated if transportation problems or severe deconditioning Out-patient acceptable prize and good outcome At home results less impressive lack of multidisciplinary program no group effect indicated for post-rehabilitation program

47 Besluit 1. Klachten van COPD blijven vaak persisteren, ondanks rookstop en medicatie 2. Graad van inspanning wordt bij patiënten met COPD niet uitsluitend door pulmonale factoren bepaald 3. Inactiviteit van COPD patiënten komt voor vanaf stadium I en is uitgesproken na exacerbaties 4. Pulmonale revalidatie heeft een bewezen gunstig effect op het inspanningsvermogen, dyspnoe, levenskwaliteit, heropnames na exacerbaties en medische consumptie