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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