Staf Inwendige Ziekten

Pulmonale revalidatie: waarom, met welke resultaten?

Eric Derom

Dienst Longziekten

Universitair Ziekenhuis Gent

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)

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 health-enhancing 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

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

Exercise Limiting Symptoms in Healthy and

COPD (% of Total)

0%

20%

40%

60%

80%

100%

Healthy (n=320) COPD (n=97)

22 26

42 30

3644

Fatigue

Dyspnea & Fatigue

Dyspnea

Killian et al, Am Rev Respir Dis 1992; 146:935-940

Distribution of 6MWD by GOLD stage (Eclipse)

Spruit et al., Respiratory Medicine 2010; 104: 849-857

Identification of the Origin of Exercise-Limitation

KNGF-richtlijn Chronisch obstructieve longziekten 2008

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

1 1 1

Dyspnea and impaired exercise tolerance

Assessment of lungfunction, dyspnea (MRC) and PA < 30 min/day

FEV1≥ 50% pred

MRC-score <1

FEV1 ≥ 50% pred

MRC-score ≥ 1

FEV1 < 50% pred

MRC-score ≥ 1

Advice:

• Improve PA

• Regular Sports

Max. exercise test Multidisciplinary evaluation

Advice:

• Improve PA

• Intake exercise

program

Adapted sportactivities

Individual exercise program

Wmax ≥ 70% pred.

VO2max ≥ 80% pred.Wmax < 70% pred.

VO2max < 80% pred.

Multidisciplinary rehabilitation

Inpatient program Outpatient program

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

Physical Inactivity in Patients with COPD

Troosters et al, Respiratory Medicine 2010; 104: 1005-11

Minimal requirement

Physical Inactivity in Patients with COPD

Troosters et al, Respiratory Medicine 2010; 104: 1005-11

Minimal requirement

Physical activity and Hospitalization for Exacerbation of COPD

Pitta et al. Chest 2006; 129:536–544

Physical Activity and Hospitalization for Exacerbation of COPD

Pitta et al. Chest 2006; 129:536–544

Time to first admission

Time to death

J Garcia-Aymerich, Thorax 2006; 61:772–778

(2015)

(2016)

Pulmonary RehabilitationMaximal Exercise Capacity

McCarthy et al, Cochrane Database of Systematic Reviews 2015

6 min Walking Distance in COPD

McCarthy et al, Cochrane Database of Systematic Reviews 2015

Pulmonary Rehabilitation after Exacerbation

6 min Walking Distance

Puhan et al, Cochrane Database of Systematic Reviews 2016

Pulmonary RehabilitationDyspnea (CRDQ)

McCArthy et al, Cochrane Database of Systematic Reviews 2015

MCID for CRDQ = 0.5

Extensiveness* of Rehabilitation Program after Exacerbation

Dyspnea (CRDQ)

Puhan et al, Cochrane Database of Systematic Reviews 2015

* = number of completed exercise sessions, type, intensity and supervision of exercise training, and

patient education

Pulmonary RehabilitationQuality of life (SGRQ)

McCarthy et al, Cochrane Database of Systematic Reviews 2015

Trial

(Year)

N Trough FEV1

(L)

SGRQ TDI FRC /

IC (L)

ET (s)

TIO/OLO 5/5 µg vs. Placebo

Beeh

(2015)

219 0.201 vs

-0.006

-0.547 vs 0.052 /

0.351 vs 0.016

Singh 1 + 2

(2015)

1624 Δ = 0.162

Δ = 0.166

Δ = -4.89

Δ = -4.59

Δ = 2.1

Δ = 1.2

O’Donnell

(2015)

586 ---/ 0.244

---/ 0.265

Δ = 54-79

GLY/IND 110/50 µg vs. PLACEBO

Bateman

(2013)

2144 Δ = 0.200 Δ = -3.0 Δ = 1.1

Beeh

(2014)

84 Δ = -0.520 /

Δ = 0.340

Δ = 60.0

UMEC/VIL 62.5/25 µg vs. PLACEBO

Donohue

(2013)

1536 Δ = 0.167 Δ = -5.5 Δ = 1.2

Maltais

(2014)

308 ---- /

Δ ≈ 0.250

Δ = 69.4

Maltais

(2014)

349 ---- /

Δ ≈ 0.400

Δ = 21.9

ACL/FORM 400/12 µg vs. PLACEBO

D’Urzo

(2014)

1692 - 0.035 vs. +

0.094

-6.57 vs. -2.21 2.0 vs. 0.6

Singh

(2014)

1729 Δ = 0.143 -8.3 vs. -6.5 2.5 vs. 1.2

Pulmonary RehabilitationHospital Readmission

Puhan et al, Cochrane Database of Systematic Reviews 2015

Results at 1 Year of Outpatient Multidisciplinary Pulmonary Rehabilitation

0

5

10

15

20

25

opnames -respiratoir

opnames - alleoorzaken

opnameduur -respiratoir

opnameduur - alleoorzaken

Controle (N = 101) Revalidatie (N = 99)

1.91.4

2.2

1.7

18.1

9.4

21.0

10.4

Griffiths et al., Lancet 2000, 355: 362-368

Results at 1 Year of Outpatient Multidisciplinary Pulmonary Rehabilitation

0

1

2

3

4

5

6

7

8

9

consultatie-respiratoir

consultatie - alleoozaken

thuisbezoek -respiratoir

thuisbezoek - alleoorzaken

Controle (N = 101) Revalidatie (N = 99)

4.5 4.7

7.3

8.6

1.81.3

2.8

1.5

Griffiths et al., Lancet 2000, 355: 362-368

Pulmonary Rehabilitation: Maximal Exercise Testing and Rehabilitation

Predominantly cardio-circulatory limitation?

Predominantly ventilatory limitation?

Desaturation? Skeletal muscle weakness?

Constant work rate test @ 70% Wmax

Consider training with NIV

Exercise tolerance enhanced by NIV

Add IMTResistance training

(NEMS)

Consider testosterone supplements

HypogonadismGas exchange impairment leads

to ventilatory limitation

No

Whole body endurance TR

Yes

< 10 min > 10 min

Yes

Whole body interval TR

O2 supplements

Yes

Inspiratory muscle weakness

Yes

Trainingsschema’s1. 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)

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

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

Physical Activity is Increased by a 12-WeekSemiautomated 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;72:415–423

Physical Activity is Increased by a 12-WeekSemiautomated Telecoaching Programme in COPD

Demeyer H, et al. Thorax 2017;72:415–423

Δ = +1469 (971 to 1965) Δ = +10.4 (6.1 to 14.7)

Physical Activity is Increased by a 12-WeekSemiautomated Telecoaching Programme in COPD

Demeyer H, et al. Thorax 2017;72:415–423

REVALIDATIE BIJ RESPIRATOIRE PATIENTEN

CRITERIA VOOR INCLUSIE EN TERUGBETALING

Pulmonale Revalidatie K30 (bidisciplinair)

• FEV1 < 60% pred.

• Algemene monodisciplinaire revalidatie

Pulmonale Revalidatie K20-K15

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

Multidisciplinair

• longarts-revalidatie-arts

• kinesitherapeut

• ergotherapeut

• diëtist/voedingsdeskundige

• psycholoog

• sociaal assistent

Practical Modalities

CONVENTIE RESPIRATOIRE REVALIDATIE MET RIZIV

• 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

Pulmonary Rehabiltation

Organisation

Besluit1. 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