by Scott Cerreta, BS, RRTDirector of Education

www.copdfoundation.org

Expectations after Pulmonary Rehabilitation

Conflict of InterestConflict of Interest

• I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of emphasis.

ObjectivesObjectives

1. Discuss current literature and outcomes after

pulmonary rehabilitation.

2. Identify key elements that must be maintained

after pulmonary rehabilitation.

3. Learn about the COPDF Pulmonary Education

Program (PEP) as a post-graduation program.

4. Understand circumstances that lead to post-

graduation loss of benefits gained during rehab.

Literature ReviewLiterature Review

• Long term effectiveness (>2years) of Pulmonary Rehabilitation is disappointing

• Drop-off is multifactoral

• Two most significant factors

1. Exacerbations of COPD18

2. Decrease in adherence to exercise prescription18

• AACP/AACVPR Pulm Rehab Clinical Practice Guidelines suggests that PRCs include strategies to promote long-term adherence1

Literature ReviewLiterature Review

• MT group had improved ESWT• No influence on QoL or hospital admissions

Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year mainenance training on physical functioning and health status in patients with COPD. JCRPJournal; 47-52.

Maintaining Benefits after RehabilitationMaintaining Benefits after Rehabilitation

1. Encourage participation in Phase III rehab

– Unproven health advantages long term for:• Continuous PR

• Maintenance PR programs

• Repeated courses of PR

– Cost prohibitive in current health care system

2. Prevent Hospitalizations

– Recognition of early signs of infection

3. Continue exercises at home or gym

4. Teach Optimal Care

Optimal Care Includes:Optimal Care Includes:

1. Smoking cessation2. Pulmonary rehabilitation– Exercise and nutrition

– Recognize early signs of infection

– Breathing techniques

– Coping skills

– End-of-Life care

3. Annual spirometry on a good day4. Testing for Alpha-1 Antitrypsin Deficiency 5. Medication adherence

FEV1 / FVC < 70%

I: MildFEV1>80% pred

II:ModerateFEV1 50-80% pred

III: SevereFEV1 30-50% pred

IV: Very SevereFEV1 < 30% pred or FEV1 <50% predicted plus respiratory failure

Active Reduction of risk factor(s); influenza vaccination

Add short-acting bronchodilator when needed

Add regular treatment with one or more long-acting bronchodilators: ß2 agonists and anticholinergics

Add rehabilitation

Add ICS for repeated exacerbations

Add LTOT

Surgical interventions

GOLD Standards of COPD CareGOLD Standards of COPD Care

http://www.goldcopd.org/

The Problem with Rehab ???The Problem with Rehab ???

• No one remembers to order it !

• Recommended for GOLD Stage II

• Only 16% of physicians send patients to Rehab

• Rehab is your key resource to improve patient adherence and understanding of this disease

Maintaining Benefits after RehabilitationMaintaining Benefits after Rehabilitation

• Optimal Care must be maintained lifelong

• Encourage participation in Phase III• Find other programs and resources

to offer your patients after graduation– Develop local programs for transitional

care– Collaborate with other organizations• Local home care companies, not DME• State Smokers’ Quit Line • COPD Foundation

New Programs for the COPD FoundationNew Programs for the COPD Foundation

1. Healthy Interactions Conversation Map

– Designed for acute care / transitional care setting

– Education to decrease hospitalization and teach patient self-management

2. Pulmonary Education Program (PEP)

– Designed for pulmonary rehabilitation centers

– Prolong benefits of rehab by connecting patients to COPD Foundation resources after graduation.

Healthy Interactions Conversation Map®

Healthy Interactions Conversation Map®

• Pulmonary education not rehab– Designed for acute care admission for COPD

patient– Hospital to Home transitional care program– Small group participation 6-10– Facilitator navigates patients through a

conversation map educational tool.• Patient makes own decisions

• Patient learns from others experiences

• Patient learns to self-manage and become active in

care– We are still recruiting partner sites!– Final Map tool used for Rehab

Recruitment– Future role-out to clinics, hosp, home

care, etc.

All tools developed by Healthy Interactions.  Conversation Map® is a registered trademark of Healthy Interactions, Inc.

Pulmonary Education Program (PEP)Pulmonary Education Program (PEP)

• Designed for Pulm

Rehab

– Promotes long-term

benefits after rehab

• Sit and Be Fit Exercise

DVD

• Access to COPDF

Resources

• Access to COPD Info Line

• Follow-up Program with

Rehab Center

• Enhance Patient Support

Groups

• Host COPD Education Day

events

C.O.P.D. Information Line1-866-316-COPD (2673)C.O.P.D. Information Line1-866-316-COPD (2673)

• Provides empathy and support to callers, as well as access to resources (e.g. educational materials)

• Info Line associates are people with COPD

• New branch staffed by associates offer support and information for caregivers

www.copdfoundation.org

Additional COPD Resources atYour Lung Health

http://www.yourlunghealth.org/lung_disease/copd/resources/index.cfm

COPD Research RegistryCOPD Research Registry

• Aims to build the proper cohort of patients to enroll in clinical trials and studies

• Over 2,600 patients enrolled

• Online/paper enrollment forms

• Info available through Info Line

• Created to help increase enrollment in COPDGene Study

• National Jewish Health is data coordinating center

www.copdfoundation.org

BFRG Ver2.0BFRG Ver2.0

• Modeled after the Alphanet BFRG for Alpha-1

• Most comprehensive guide on COPD health management

• Over 70 individuals and organizations contributed

www.copdbfrg.org www.copdfoundation.org

SSRGsSSRGs

1. Coping with COPD

2. End-of-Life

3. Exacerbations

4. Exercise

5. Medicine

6. Nutrition

7. Oxygen Therapy

8. Travel

9. Understanding Lung Disease

10. Understanding Testswww.copdfoundation.org

SummarySummary

• Teach optimal care• Keep patients involved with lifelong

care• Know your patients – What stage

COPD– Encourage spirometry annually– Encourage patients learn their FEV1 and

stage

• Collaborate with others to maintain long term benefits of pulmonary rehabilitation

• End result is decreased hospitalizations and improved patient outcomes.

Thank You!

ReferencesReferences

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disease: a randomized trial. Am J Respir Crit Care Med 2003; 167:880–8889. Guell R, Casan P, Belda J, et al. Long-term effects of outpatient rehabilitation of COPD: a randomized

trial. Chest 2000; 117:976–983

10. Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary

pulmonary rehabilitation programme. Thorax 2001; 56:779–784

ReferencesReferences

11. Wijkstra PJ, van der Mark TW, Kraan J, et al. Long-term effects of home rehabilitation on physical performance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996; 153:1234–124

12. Engstrom CP, Persson LO, Larsson S, et al. Long-term effects of a pulmonary rehabilitation programme in outpatients with chronic obstructive pulmonary disease: a randomized controlled study. Scand J Rehabil Med 1999; 31:207–213

13. Wijkstra PJ, TenVergert EM, van Altena R, et al. Long term benefits of rehabilitation at home on quality of life and exercise tolerance in patients with chronic obstructive pulmonary disease. Thorax 1995; 50:824–828

14. Berry MJ, Rejeski WJ, Adair NE, et al. A randomized, controlled trial comparing long-term and short-term exercise in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2003; 23:60–68

15. Puente-Maestu L, Sanz ML, Sanz P, et al. Long-term effects of a maintenance program after supervised or self-monitored training programs in patients with COPD. Lung 2003; 181:67–78

16. Grosbois J-M, Lamblin C, Lemaire B, et al. Long-term benefits of exercise maintenance after outpatient rehabilitation program in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 1999; 19:216–225

17. Cockram J, Cecins N, Jenkins S. Maintaining exercise capacity and quality of life following pulmonary rehabilitation. Respirology 2006; 11:98–104

18. Brooks D, Krip B, Mangovski-Alzamora S, Goldstein RS. The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease. Eur Respir J 2002; 20: 20–29.

19. Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year mainenance training on physical functioning and health status in patients with COPD. JCRPJournal; 47-52.

20. COPD Foundation. www.copdfoundation.org