darcy d. marciniuk, md frcpc fccp division of respirology, critical care and sleep medicine clinical...

Darcy D. Marciniuk, Darcy D. Marciniuk, MD FRCPC FCCPMD FRCPC FCCP

Division of Respirology, Critical CareDivision of Respirology, Critical Careand Sleep Medicineand Sleep Medicine

Clinical Benefits of Clinical Benefits of Pulmonary RehabilitationPulmonary Rehabilitation

in COPDin COPD

Conflict of Interest Disclosure

Consultancy Fees / Advisory BoardsAstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Health Canada, Health Quality Council, Novartis, Nycomed, Pfizer, Public Health Agency of Canada, Saskatchewan Medical Association, Saskatoon Health Region

Research FundingAstraZeneca, Boehringer Ingelheim, Canadian Agency for Drugs and Technology in Health, Canadian Institute of Health Research, GlaxoSmithKline, Lung Association of Saskatchewan, Novartis, Nycomed, Pfizer, Saskatchewan Health Research Foundation, Saskatchewan Ministry of Health, Schering-Plough

Speaker’s BureauAstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Pfizer

Fiduciary PositionsCanadian COPD Alliance, American College of Chest Physicians, Chest Foundation, Saskatchewan Lung Association

EmployeeUniversity of Saskatchewan

Objectives

• understand the role of Pulmonary Rehabilitation (PR) in the comprehensive management of COPD

• appreciate the patient-centered clinical benefits of effective PR in COPD

• recognize and minimize barriers to patients participating and fully realizing the clinical benefits of PR in COPD

Pulmonary Rehabilitation in COPD

Surgery

(Spirometry) +Prevention

End of LifeCare

Prevent/Rx AECOPD

Oxygen

MRC Dyspnea

Lung function impairment

PRN Rapid

Smoking cessation/exercise/self

Inhaled corticosteroids

Long

Pulmonary rehabilitation

V

Surgery

Early DiagnosisFollow-up

Oxygen

PRN short-acting bronchodilators

Smoking cessation/exercise/self-management/education

Inhaled corticosteroids/LABA

Long-acting bronchodilator(s)

Pulmonary rehabilitation

Mild Very Severe

II V

A Comprehensive Approach to COPD Management

O’Donnell DE, et al. O’Donnell DE, et al. Can Resp JCan Resp J 2008; 15:1A-8A. 2008; 15:1A-8A.

IV: Very Severe III: Severe II: Moderate I: Mild

Therapy at Each Stage of COPD

FEV1/FVC < 70%

FEV1 > 80% predicted

FEV1/FVC < 70%

50% < FEV1 < 80%

predicted

FEV1/FVC < 70%

30% < FEV1 < 50% predicted

FEV1/FVC < 70%

FEV1 < 30% predicted

or FEV1 < 50% predicted plus chronic respiratory failure

Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation

Add inhaled glucocorticosteroids if repeated exacerbations

Active reduction of risk factor(s); influenza vaccinationAdd short-acting bronchodilator (when needed)

Add long term oxygen if chronic respiratory failure. Consider surgical treatments

End of LifeCare

Magnitudeof Dyspnea

V

ExcludeContributing

Causes

Regular Follow-up

And Reassessment

Initiate & Optimize Pharmacologic Therapies:Initiate & Optimize Pharmacologic Therapies:SABD, LAAC, ICS/LABA, PDE4 Inhibitors, Theophylline, O2 in Hypoxemic Patients

Comprehensive Approach to Management of Comprehensive Approach to Management of Refractory Dyspnea in Advanced COPDRefractory Dyspnea in Advanced COPD

Initiate & Optimize Non-Pharmacologic Therapies:Initiate & Optimize Non-Pharmacologic Therapies:Exercise, Pursed-Lip Breathing, Walking Aids, Chest Wall Vibration, NMES

Initiate & Optimize Opioid Therapies:Initiate & Optimize Opioid Therapies:Short- and Long-Acting Agents

Marciniuk DD, et al. Marciniuk DD, et al. Can Resp JCan Resp J 2011; 18:69-78. 2011; 18:69-78.

What is Pulmonary Rehabilitation ?

• … depends on who you ask !• common theme:

– multidisciplinary program designed to optimize physiological, psychological, and social outcomes for COPD patients and their care-givers

• practical definition depends on the program design and intent– ‘Group Exercise’ ↔ ‘Comprehensive Care’


• PR improves dyspnea and activity limitation in COPD patients (1)(1)

• COPD patients benefit from PR regardless of patient age, disease severity, and sex (2)(2)

• PR is beneficial across all levels of COPD severity, and should be considered earlier in the course of COPD (3)(3)

– allow for a greater emphasis on promoting health rather than regaining function

11 Ries AL, et al. Ries AL, et al. Chest Chest 2007; 131:4S-42S. 2007; 131:4S-42S. 22 Hailey D, et al. Hailey D, et al. CADTHCADTH HTA Report, April 2010.HTA Report, April 2010.33 Nici L, et al. Nici L, et al. J Cardiopulm Rehab PrevJ Cardiopulm Rehab Prev 2009; 29:141-151. 2009; 29:141-151.

Who Benefits From PR?


Pulmonary Rehabilitation CandidatesPulmonary Rehabilitation Candidates• strongly recommended patients with

moderate, severe and very severe COPD participate in PR (Recommendation Grade 1C)– currently, there is insufficient data to make a

recommendation regarding mild COPD patients

• strongly recommended that both women and men be referred for Pulmonary Rehabilitation (Recommendation Grade 1C)

Marciniuk DD, et al. Marciniuk DD, et al. Can Resp JCan Resp J 2010; 17:159-168 2010; 17:159-168

Pulmonary Rehabilitation CandidatesPulmonary Rehabilitation Candidates• strongly recommended COPD patients undergo

PR within 1 month following AECOPD due to evidence supporting improved dyspnea, exercise tolerance and HRQL compared with usual care (Recommendation Grade 1B)

• PR within 1 month following AECOPD also recommended due to evidence supporting reduced hospital admissions and mortality compared with usual care (Recommendation Grade 2C)


Physical Activity in COPD

Garcia-Aymerich J, et al. Garcia-Aymerich J, et al. ThoraxThorax 2009; 61:772-778. 2009; 61:772-778.

Copenhagen City Heart Study, n=2386 COPD subjects confirmed by lung function[833 GOLD I, 1095 GOLD II, 354 GOLD III, 94 GOLD IV]

No effect modification was found for sex, age, COPD severity, or IHD

COPD Admission Mortality


Trooster T, et al. Respiratory Medicine 2010; 104:1005-1011

70 COPD [9 / 28 / 23 / 10] and 30 control subjects; activity monitor x 6-8 days.

Physical Activity in COPD

Health Benefits of Physical Activity

• primary and secondary prevention:– all-cause and cardiovascular-related deaths are

decreased– incidence of diabetes mellitus, cancer (colon,

breast), and osteoporosis are significantly reduced

• how much exercise is necessary?– weekly expenditure of ~1000 kcal associated

with a 20-30% reduction in all-cause mortality– less ‘volume’ of exercise is necessary solely for

health benefits (~ 500 kcal/week)– not much!

Warburton DER, et al. Warburton DER, et al. CMAJ CMAJ 2006; 174:801-8092006; 174:801-809


Adverse Effects of COPD

ImpairmentImpairment[Function][Function]

DisabilityDisability[Activity][Activity]

HandicapHandicap[Participation][Participation]

Quality of LifeHealth Care Utilization

FEV1, FVCIC, EELV FRC, RV

DyspneaExercise EnduranceExacerbations (AECOPD)

Adapted from Adapted from Can Respir J,Can Respir J, 2004; 11(Suppl B): 7B-59B 2004; 11(Suppl B): 7B-59B


Patient-Centered Benefits

Pulmonary Rehabilitation: •reduces shortness of breath

– benefits exceed minimally clinically important difference (MCID) ie. 0.9 CRQ

•improves exercise capacity– ~15-20% increase in maximal workload,

and ~10% increase in peak VO2

– ~80% increase in endurance exercise time and ~50m increase in 6MWD

Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2010;Ries AL, et al. Chest 2007; 131:4-42; O’Donnell DE, et al. Can Resp J 2007, 14:5B-32B;

Marciniuk DD, et al. Can Resp J 2010; 17:159-168; Hailey D, et al. CADTH 2010; 126:1-155.


Patient-Centered Benefits

Pulmonary Rehabilitation: •improves health related quality of life

– fall in SGRQ of ~7-8 units•reduces fatigue•reduces anxiety and depression, and other documented psychosocial benefits•decreases hospitalizations, hospital days, and healthcare utilization

Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2010;Ries AL, et al. Chest 2007; 131:4-42; O’Donnell DE, et al. Can Resp J 2007, 14:5B-32B;

Marciniuk DD, et al. Can Resp J 2010; 17:159-168; Hailey D, et al. CADTH 2010; 126:1-155.


More Benefits From PR …

Pulmonary Rehabilitation: •is cost-effective

– incremental cost-effectiveness ratio compared with usual care is $27,924 per additional quality-adjusted life-year (QALY) gained (moderate/severe/very severe)

•improves survival … (?)– 29% reduction – recent Cochrane review

[Puhan 2009] of PR after hospital admission

Puhan M, et al. Puhan M, et al. Cochrane Database Syst Rev Cochrane Database Syst Rev 2009; Ries AL, et al. 2009; Ries AL, et al. ChestChest 2007; 131:4-42; 2007; 131:4-42;Marciniuk DD, et al. Marciniuk DD, et al. Can Resp JCan Resp J 2010; 17:159-168; Hailey D, et al. 2010; 17:159-168; Hailey D, et al. CADTHCADTH 2010; 126:1-155. 2010; 126:1-155.


Effective “Combination” Therapy

Casaburi R, et al. Casaburi R, et al. ChestChest 2005; 127:809-817 2005; 127:809-817

8

12

16

20

24

0 2 4 6 8 10 12 14 16 18 20 22 24

* * Rehabilitation

Study Drug

16%

32% 42%

* p<0.05

End

ura

nce

Tim

e (

min

s)

Weeks on Treatment

Placebo

Tiotropium


Ensuring Patient BenefitsProgram design, delivery and duration

– CTS has recommended longer duration PR programs, beyond 6 – 8 weeks duration, be provided for COPD patients•‘Kindergarten’ vs ‘Graduation’

philosophies– lower limb aerobic exercise must always be

the foundation of the program– no differences in major outcomes between

community/home sites vs hospital sites•coordinated and supervised

Maltais F, et al. Maltais F, et al. Ann Intern Med Ann Intern Med 2008; 149:869-878;2008; 149:869-878;Ries AL, et al. Ries AL, et al. ChestChest 2007; 131:4-42; Marciniuk DD, et al. 2007; 131:4-42; Marciniuk DD, et al. Can Resp JCan Resp J 2010; 17:159-168. 2010; 17:159-168.


Maximizing Patient Benefits• explore methods to further optimize training

– can we accelerate training to potentially shorten the duration of initiation phase?

– can patients achieve greater physiologic gains?• start earlier in the course of the disease?

– do we place a greater emphasis on promoting health rather than solely on regaining function?

• how to best optimize patient outcomes with limited resources and access ie. priority setting– should coordinated group pulmonary/cardiac/

diabetes/etc rehabilitation become more common?

– ”trying to do too much = achieving very little”


Marciniuk DD, et al. Marciniuk DD, et al. Can Resp JCan Resp J 2010; 17:159-168. 2010; 17:159-168.

Barriers to Implementation of PRBarriers to Implementation of PR• access and adherence highlighted as the most

significant challenges – “immediate urgency for these obstacles to be address

and to be removed. It is not acceptable for health care providers, patients and health care systems to accept the current status quo – the benefits cannot be ignored”

• PR must be accepted as an integral component of COPD management– “barriers to participation in PR and burdens of therapy

must be acknowledged and minimized.”


May C, et al. BMJ 2009;

339:485-487

Summary• Pulmonary Rehabilitation plays a sentinel

role in the comprehensive management of COPD– it must become ‘routine’

• there are significant and meaningful patient-centered clinical benefits of effective Pulmonary Rehabilitation in COPD

• we must recognize, acknowledge and eliminate barriers to patients participating and fully realizing the clinical benefits of PR in COPD


darcy d. marciniuk, md frcpc fccp division of respirology, critical care and sleep medicine clinical...

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