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Pulmonary Rehabilitation : pratical aspects
Beirut
April 2008 Dr karen Hardy
Pulmonary rehabilitration: pratical aspects
Définition Indications/exclusions Clinical and functional assessment Pulmonary rehabilitation : practical aspect results Clinical case
Pulmonary rehabilitation
Définition : pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activites. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functianal statues, increase participation, reduce health costs…Rehabilitation include patient assessment, exercise training, education and psychosocial support.
American Thoracic Society and the European Respiratory Society.Am J Respir Crit Care Med 2006
Pulmonary rehabilitation
Indication : WHO ? Essentially COPD patients (44 millions all
over the world) other : cystic fibrosis , bronchectiasis,
Asthma, preparation for surgical treatments, interstitial diseases…
Pulmonary rehabilitation
Indications : When ? Patient with dyspnea, exercice intolerance,
reduced of the health related quality of life (Critères SPLF 2005)
Stable patient or acute exacerbation period (Man BMJ 2004 )
Smoker or not smoker (Lacasse J Cardiopulm rehab 2002;22:148-53)
Before or after surgery Patient motivated +++
Pulmonary rehabilitation
Indication : Where ? In hospital Out patient Home care setting Physical therapist practice
Pulmonary rehabilitation
Exclusions Unstable cardiac disease. Orthopedic or neurologic problems reducing
mobility. Psychiatric unstable disease
(ATS/ERS statement on pulmonary rehabilitation AJRCCM 2006;173 : 1390)
Pulmonary rehabilitation
Evaluation (recommandations SPLF2005; Troosters AJRCCM 2005)
Blood measures and functionnal exercice capacity 6-minute walk test, or shuttle test, or endurance Shuttle Walk test Cardiopulmonary exercise testing Body mass index Inspiratory and expiratory pression measurement Evaluation of muscle strenght Health-related quality of life Breath questionnaire score (Borg)
B
Pulmonary rehabilitation
Short term results Increase exercise capacity Increase Quality of life
Reduce health care cost : (Griffith 2001, Chest 2007; 131)
Pulmonary rehabilitation
Long term results Insuffisance evidence to determine if PR
improves survival in COPD (chest 2007; 131)
Ways to maintain the benefits?
Clinical case
Medical history Surgical : shinebon fracture (2003) respiratory : COPD with emphysem
Way of life Smoker : 10 à 20 cigarettes per day, Fagerström 7/10, HAD :A =5/21 et D=2/21, 25 py, Alcool : weaning since 13 years Work : : works in « France Télécom », with a computer.
Clinical case Story of the disease Since an exacerbation of COPD 6 month ago, the patient discribes more dyspnea and a decreased exercise capacity with a deacreased quality of life
Clinical examination Saturation 94% , RR 18/min, blood pressure and temperature : normals Thoracic distension , decrease of the breath sound Body height: 170cm, weight 55kg Physical examination : normal
Treatment Bronchodilatators
Clinical case
Biology : hb15.8g/dl, hématocrite 47.7%, protidémie 66g/l, Biologic criteria of denutrition., CRP normal. Blood gases : pH = 7.43, PO2=72, PCO2=45, bicar 30, sat 95%. ECG = normal
With this informations, does this
patient need rehabilition?
Clinical case
INDICATION Dicrease quality of life, increase dyspnea Motivated patient Smoker :(Lacasse J Cardiopulm rehab 2002;22:148-53)
Personnal expérience at Aincourt : 62 COPD patients in rehabilitation, 50% smokers the beginning. 64.5% stops, 100% reduces. The increase of exercise was the same in the 2 groups but the quality of life was higher in the smoker group)
Which examinations would you
do for this patient?
Functionnal exercice capacity
6-minute walk test
Cardiopulmonary exercise testing
Where do you do the rehabilitation?
What do you propose to the patient ?
Help for smoking cessation Individual program of exercice training Physical exercise teacher Education Personnal nutritionnal intervention :
nutritional supplementation Psychosocial support
How to do?
PRESCRIPTION
Training intensity at 60% of the peak exercise = 125/MIN, Cardiac rate max=145/MIN,
Minimal SATURATION =90% 30 MINUTES MINIMUM, >20 Sessions (3 per week)
Lower extremity exercise training Endurance training Long exercice training At the Cardiac rate of the borg score of 4 to 6 for
dyspnea Or > 60% maximal work rate SPLF 2005 Clark Eur Respir J 1996;9:2590 High level intensity : 80% of the VO2max Casaburi Am J Respir Crit Care Med 1997;155;1541 Interval training or SWEET: Alternance 1 minute high intensity and 4 minutes at low
intensity Gimenez Eur J Applic phys 1982
Strenght training during = 45 minutes X3 per week
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