Revalidatie voor PH-patiënten

Anton Vonk Noordegraaf

Afd Longziekten

VUMC& AMC Amsterdam

Martijn Spruit

CIRO

Horn

VROEGER: REVALIDATIE IS SLECHT

VOOR PATIËNTEN MET PULMONALE

HYPERTENSIE WANT HET

VEROORZAAKT OVERBELASTING

VAN HET HART

2

http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwji0eCAlq_aAhULLewKHZdXDuYQjRx6BAgAEAU&url=http://www.medievalists.net/2009/01/nicolaus-copernicus-astronomer-and-physician/&psig=AOvVaw1aB_CK1v_pSoYAIFbt6bvy&ust=1523431301603194

Circulation 2008

Conclusies

• Inspanning is goed voor het hart

• Overleving van de ratten verbeterden

5

Before training After training0.0

0.5

1.0

1.5

2.0

p<0.001

Cap

illa

ries/m

yo

cyte

s

Meer vaatjes in hart na revalidatie

Multicenter Nederlandse revalidatie studie

Effecten van revalidatie bij patienten met pulmonale

hypertensie

F. S. de Man et al. Eur Respir J 2009;34:669-675

Heidelbergstudie: betere resultaten!

After 3 weeks:

T: +85 ±56 m

C: +12 ±37 m

After 15 weeks:

T: +96 ±61 m

C: -15 ±54 m

Mereles et al Circulation..

Heidelbergconcept: aandacht voor

de hele mens!

9

Wens: Een revalidatietraject (intern)

opzetten zoals in Heidelberg

toegankelijk voor alle PAH patiënten

10

Wie betaalt?

Oplossing

ERS Task Force: Exercise training and rehabilitation in patients with severe chronic pulmonary hypertension

Ekkehard Grünig, MD1* ; Christina Eichstaedt, PhD1*; Joan-Albert Barberà, MD, PhD2; Nicola Benjamin, MSc1; Isabel Blanco, MD, PhD2; Eduardo Bossone, MD3; Antonio Cittadini, MD, PhD3; Gerry Coghlan, MD4; Paul Corris, MD5; Michele D'Alto, MD, PhD6; Antonello D'Andrea, MD, PhD6; Marion Delcroix, MD, PhD7; Frances de Man, PHD8; Sean Gaine, MD,PhD9; Stefano Ghio, MD10; Simon Gibbs, MD11; Lina Gumbiene, MD, PhD12, 13; Luke S. Howard, MD14; Martin Johnson, MD15; Elena Jurevičienė, MD12, 13; David G. Kiely, MD16; Gabor Kovacs, MD17,18; Alison

MacKenzie, MD15 ; Alberto M. Marra, MD19; Noel McCaffrey, MD9; Paul McCaughey, MD15; Robert Naeije, MD, PhD20; Horst Olschewski, MD, PhD17,18; Joanna Pepke-Zaba, MD, PhD21; Abílio Reis, MD22; Mário Santos, MD22 ; Stéphanie Saxer, MD23; Robert M. Tulloh, MD24; Silvia Ulrich, MD23; Anton Vonk Noordegraaf, MD, PhD8 and Andrew J. Peacock, MD15

g

1Centre for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany; 2Hospital Clinic IDIBAPS, University of Barcelona, Barcelona and Biomedical Research Networking Center on Respiratory Diseases, Madrid, Spain; 3Department of Cardiac Surgery, University Hospital Salerno, Salerno, Italy; 4Pulmonary Hypertension Unit, Royal Free Hospital, University College London, London, United Kingdom; 5Department of Respiratory Medicine, Freeman Hospital, University of Newcastle, Newcastle upon Tyne, United Kingdom; 6Department of Cardiology, Second University of Naples - Monaldi Hospital, Naples, Italy; 7Department of Pneumology, University Hospital Leuven, Leuven, Belgium; 8Department of Pulmonology, VU University Medical Center Amsterdam, Amsterdam, Netherlands; 9Department of Respiratory Medicine, Mater Misericordiae University Hospital, Dublin, Ireland; 10Division of Cardiology, Università degli studi di Pavia, Pavia Italy; 11Faculty of Medicine, Imperial College London, National Heart and Lung Institute, London, United Kingdom;

12Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; 13Faculty of Medicine, Vilnius University, Vilnius, Lithuania; 14Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom; 15Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom; 16Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom; 17Department of Internal Medicine, Div Pulmonology, Medical University of Graz, Graz, Austria; 18Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria; 19Department of Cardiovascular Imaging, IRCCS SDN, Naples, Italy; 20Department of Cardiology, University Clinic Brussels - Erasme Hospital, Brussels, Belgium; 21Pulmonary

Vascular Disease Unit, Papworth Hospital, Cambridge, United Kingdom; 22Department of Internal Medicine, Hospital Geral de Santo António, Porto, Portugal; 23Centre for Pulmonary Hypertension, University Hospital Zurich, Zurich, Switzerland; 24Department of Congenital Heart Disease, Bristol Royal Hospital for Children, Bristol, United Kingdom; * equally contributed

Results: In studies with 784 PH patients in total, including 6 randomised controlled trials, 3 controlled trials, 10 prospective cohort studies, and 4 meta-analyses exercise training has been shown to improve exercise capacity, muscular function, quality of life and possibly right ventricular function and pulmonary haemodynamics (Table 1, Figure 2). Nevertheless, further studies are needed to confirm these data, to investigate the impact on risk profiles and to identify the most advantageous training methodology and underlying pathophysiological mechanisms.

Conclusion: As exercise training is highly effective, cost-efficient and safe, these programmes should receive more support by health care institutions, commissioners of health care and research funding institutions. There is a strong need to establish specialised rehabilitation programmes for PH patients in at least one PH/rehabilitation centre within each European country.

Background: Despite, optimised medical treatment most patients with pulmonary hypertension (PH) still suffer from reduced physical capacity, quality of life (QoL) and impaired prognosis. In an increasing number of studies, exercise training programmes have shown to improve exercise capacity, QoL and muscle function. However, only in very few countries exercise training for PH patients is currently routinely reimbursed by insurances and can be prescribed as a supportive therapy. Objectives of this ERS Task Force were to summarise current studies, to develop strategies for future research and to increase availability and awareness of exercise training for PH patients.

Methods: An evidence-based approach with the clinical expertise of the Task Force members, based on both literature search and face-to-face meetings was conducted. Eighteen centres from eleven countries contributed (Figure 1). The statement summarises the current state of knowledge regarding the clinical effects of exercise training, training modalities and setting, its implementation strategies and pathophysiologic mechanisms in patients with PH.

Fig. 1: Participating countries in this Task Force having implemented the exercise training

Centres and participating countries in alphabetical order: AT: Austria (Graz), BE: Belgium (Brussels, Leuven), CH: Switzerland (Zurich), DE: Germany (Heidelberg), ES: Spain (Barcelona), IE: Ireland (Dublin), IT: Italy (Naples, Pavia), LT: Lithuania (Vilnius), NL: the Netherlands (Amsterdam), PT: Portugal (Porto), UK: United Kingdom (Glasgow, Bristol, Cambridge, London, New Castle, Sheffield).

Type Study n Design Quality of life Functional ability Peripheral muscle function Bio-markers

SF3

6

CA

MP

HO

R

Oth

er

qu

esti

on

nai

re

6MW

D

Pea

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End

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e WH

O

Cla

ss

Trea

dm

ill

spee

d

Mu

scle

stre

ngt

h

(NT-

pro

)-

BN

P

In-patient Becker-Grünig et al. (2013) 20 p-cohort

Grünig et al. (2012a) 183 p-cohort

Grünig et al. (2011) 58 p-cohort

Grünig et al. (2012b) 21 p-cohort

Nagel et al. (2012) 35 p-cohort

Kabitz et al. (2014) 7 p-cohort

Mereles et al. (2006) 30 RCT

Ley et al. (2013) 20 RCT

Ehlken et al. (2016) 87 RCT

Ehlken et al. (2014) 58 p-cohort

Fukui et al. (2016) 41 CT

Out-patient Martinez-Quintana et al. (2010) 8 CT

Raskin et al. (2014) 23 r-cohort

Fox et al. (2011) 22 CT

Chan et al. (2013) 23 RCT

Weinstein et al. (2013) 24 RCT

Mainguy et al. (2010) 5 case series

de Man et al. (2009) 19 p-cohort

Talwar et al. (2017) 18 r-cohort

Bussotti et al. (2017) 15 case series

González-Saiz et al. (2017) 40 RCT

Home Inagaki et al. (2014) 8 p-cohort

Ihle et al. (2014) 17 p-cohort

Table 1: Outcome measures for training programmes

Statistically significant improvement No significant improvement Statistically significant deterioration

SF-36: Short form health survey 36, CAMPHOR: Cambridge Pulmonary Hypertension Outcome Review, 6MWD: 6-minute walking distance, CT: non-randomised controlled trial, p-cohort: prospective cohort study, peak VO2: peak oxygen consumption, r-cohort: retrospective cohort study, RCT: randomised controlled trial, WHO: World Health Organisation, NT-proBNP: N-terminal pro brain natriuretic peptide

Fig. 2: Main physiological effects of exercise training Exercise training in pulmonary hypertension acts on heart function, skeletal and respiratory muscles on a macroscopic as well as molecular level. Inflammation and cell proliferation are reduced. 6MWD: 6-minute walking distance, peak VO2: peak oxygen uptake, RV: right ventricular, TAPSE: Tricuspid annular plane systolic excursion

CIRO Horn

14 april 2018

Geschiedenis van Hornerheide: 1935

Geschiedenis van Hornerheide: 1935

Sanatorium Hornerheide

1921

1968

Longkliniek Hornerheide

1985

De geschiedenis van CIRO

45 bedden voor klinische behandeling (@Health) 15 bedden voor palliatieve zorg (@Care) 9 bedden Academisch slaapcentrum (@Sleep) ± 650 patiënten per jaar (@Health) ±150 medewerkers (120 FTE)

Enkele kerngetallen anno 2018

Verwijsbrief via longarts 2.5 dagen ‘beginassessment’ in Horn Besluit: revalidatie in Horn (8 weken) Zorg op maat 1.5 dagen ‘eindassessment’ in Horn Overname behandeling door eigen longarts

Verwijzing naar CIRO

Longrevalidatie is een gepersonaliseerde interventie (tenminste bestaande uit inspanningstraining, educatie en

gedragsverandering), gebaseerd op een uitgebreid beginonderzoek, gericht op de fysieke/psychologische

conditie van personen met een chronische longaandoening en op gezond gedrag op de langere termijn.

Spruit et al. AJRCCM 2013

Longrevalidatie

Voor de juiste uitkomst(en)

De juiste behandeling

For The Right Patien

Op het juiste moment

Voor de juiste patiënt(e)

Zorg op maat

Inzicht in beweeggedrag

Voedingssupplementen

Psychosociale begeleiding

Educatie

Zelfzorg / ADL training

Leefstijl coaching

Interval training

Duurtraining

Arbeidsreïntegratie

Krachttraining

Creatieve therapie

Ontspanningsoefeningen

Rookstop Beh. bijkomende aandoeningen

Meeloopdag familie ……

Programma op maat

Inzicht in beweeggedrag

Voedingssupplementen

Psychosociale begeleiding

Educatie

Zelfzorg / ADL training

Leefstijl coaching

Interval training

Duurtraining

Arbeidsreïntegratie

Krachttraining

Creatieve therapie

Ontspanningsoefeningen

Rookstop Beh. bijkomende aandoeningen

Meeloopdag familie ……

Programma op maat

Een programma op maat

Interdisciplinair team

Afra: Specialist van haar eigen leven

Roy: Specialist van zijn eigen leven

Grenzen verleggen!

Resultaten

Vermindering van kortademigheid Toename inspanningsvermogen Afname zorgafhankelijkheid Toename kwaliteit van leven Afname somberheid en depressie Verbeterde lichaamssamenstelling Gezondere leefstijl Minder ziekenhuisopnames

Resultaten

PHATIGUE studie

N=45 8 weken leefstijl interventie door Chermaine Kwant (www.feads.nl) 8 weken klinische longrevalidatie in CIRO te Horn

Durf anders te zijn

Nabije toekomst

a.vonk@vumc.nl

martijnspruit@ciro-horn.nl

Dank voor uw aandacht!