2. Background
• COPD is 4th leading cause of death
• 13% of total hospitalizations
• Second to CAD for payment of Social
Security disability benefits
• Exercise intolerance –
dyspnea/fatigue
3. Pathophysiology
• Severity of lung disease
• Extrapulmonary manifestations thought to
be due to deconditioning*
– Skeletal muscle dysfunction: decreased
aerobic enzyme activity, low fraction of
aerobic fibers, decreased capillarity,
inflammatory cells, and increased apoptosis.
All lead to early onset of lactic acidosis,
decreasing aerobic activity.
*Wagner, PD. Skeletal muscles in chronic obstructive pulmonary disease:
deconditioning or myopathy? Respirology 2006; 11:681-686.
4. Pulmonary
Rehabilitation
Evidence-based, multidisciplinary, and
comprehensive intervention for patients
with chronic respiratory diseases who are
symptomatic and often have decreased
daily activities. It is designed to reduce
symptoms, optimize functional status,
increase participation, and reduce health
care costs by stabilizing or reversing
systemic manifestations of the disease.
Nici, L et.al. American Thoracic Society/European Respiratory Society statement on pulmonary
rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390.
6. Pulmonary Rehabilitation
Common Indications for
Referral to Pulmonary Rehabilitation
• Anxiety engaging in activities
• Breathlessness with activities
• Limitations – Social, Leisure, Chores, ADL’s
• Loss of Independence
• Especially those whose dyspnea is out of
proportion to lung function or those with primarily
leg fatigue limiting exercise
7. Pulmonary Rehabilitation
Common conditions
leading to referral to
pulmonary
rehabilitation
• COPD
• Bronchiectasis
• Chronic Asthma
• Post surgery
• ILD
• Neuromuscular Disease
• Cystic Fibrosis
• Exacerbations
18. Exercise - Heliox
• Eves ND, Sandmeyer LC, Wong EY, et. Al.
Helium-Hyperoxia: A Novel Intervention to
Improve the Benefits of Pulmonary
Rehabilitation for Patients with COPD. Chest.
2009:135:609-618.
Breathing helium-hyperoxia (60% He-40% O2)
during pulmonary rehabilitation increases the
intensity and duration of exercise training that
can be performed and results in greater
constant-load exercise time for patients with
COPD.
19. Exercise - Heliox
• Chiappa GR, Queriroga F, Meda, E. Heliox
Improves Oxygen Delivery and Utilization
During Dynamic Exercise in Patients with
COPD. Am J Respir Crit Care Med 2009;
Heliox (79% He-21%O2) increases lower
limb O2 delivery and utilization during
dynamic exercise in patients with
moderate-to-severe COPD. These effects
contribute to enhance exercise tolerance
in this patient population.
23. Pulmonary Rehabilitation
INPATIENT
• ADVANTAGES
– 24 hour nursing care
– Sicker patients
– No transportation
problems
– Family participation
– Best for ventilator,
tracheostomy patients
• DISADVANTAGES
– Cost and insurance
difficulties
– Not suitable for less
severe patients
– Family transportation
problems
24. Pulmonary Rehabilitation
OUTPATIENT
• ADVANTAGES
– Widely available
– Less costly
– Least intrusive to
family
– Efficient use of staff
• DISADVANTAGES
– Potential
transportation
problems
– Cannot observe home
activities
25. Pulmonary Rehabilitation
HOME - BASED
• ADVANTAGES
– Convenience to
patient
– Transportation no
issue
– Exercise in familiar
environment may lead
to better adherence
long term
• DISADVANTAGES
– Cost/insurance issues
– Lack of group support
– Lack of full spectrum
of multidisciplinary
personnel
28. Effect of Therapy- Does Not
improve lung mechanics or gas
exchange, but optimizes other
body systems*
• Muscle biochemistry-higher work rates
with less lactic acidosis leading to
decreased carotid-body stimulation
• Reduced dynamic hyperinflation through
reduced ventilatory demand
• Desensitization to dyspnea:
antidepressant effect, social interaction,
self management, and adaptive behaviors
*Casaburi, R and ZuWallack. Pulmonary Rehabilitation for Management of
Chronic Obstructive Pulmonary Disease. N Engl J Med 2009; 360:1329-
1335.
29. Pulmonary Rehabilitation
Benefits in COPD
• Improves exercise capacity - Evidence A
• Improves perceived breathlessness - Evidence A
• Improves quality of life – Evidence A
• Reduces hospitalizations and LOS – Evidence A
• Reduces anxiety and depression – Evidence A
• UBE improves arm function – Evidence B
• Benefits extend beyond training period – Evidence B
• Improves survival – Evidence B
