Pulmonary rehabilitation for people with COPD :Pulmonary rehabilitation for people with COPD Kola Akinlabi Specialist Respiratory Physiotherapist and pulmonary rehabilitation Chronic Respiratory Team, Haringey NHS Presented at West Haringey Collaborative, 19/03/09


Definition :ATS/ERS statements 2006: ‘’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 activities.’’ Definition


How we came about pulmonary rehab :PR started in most centres in UK in 2002 following BTS statement released in Thorax 2001, pointed out that ‘’ PR services in the UK is very poor’’. According to BTS /BLF PR survey 2003 ‘’PR is still not available in most areas in the UK and when available are underused’’. In Feb 2004 NICE published CG which spelt out management of COPD in adults in primary and secondary care and 1.2.10.2 of the guideline stated that PR should be offered to all patients who consider themselves functionally disabled by COPD (usually MRC 3 and above. Since then we’ve had several guidelines, systemic review and evidences as seen in AACP/AACVPR 2007 ATS/ERS 2006 Cochrane Review 2006 NICE 2004 BTS 2001 How we came about pulmonary rehab


2009 Cochrane Review :A systemic review of evidence on the effectiveness of pulmonary rehabilitation. Concluded that there were large effects of pulmonary rehabilitation in the improvement of exercise capacity, health related quality of life and substantial reduction in the number of unplanned admission and mortality. Cochrane database of systemic reviews, issue 1, 2009. intervention review- pulmonary rehabilitation following exacerbation of COPD 2009 Cochrane Review


Overview – rationale :Quads weakness and reduced CSA are correlated with severity of obstruction (FeV1) with VO2 peak And Exercise capacity (Bernand et al, 1998 Am J Respir Crit Care Med, 158: 629-34 Reduction in % of type 1 muscle fibre ( fatigue resistant) Increased in type IIX fibres ( fast twitch) Overview – rationale


Quads CSA- normal and COPD Bernand et al, 1998 Am J Respir Crit Care Med, 158: 629-34 :Quads CSA- normal and COPD Bernand et al, 1998 Am J Respir Crit Care Med, 158: 629-34


CSA strength normal and COPD :CSA strength normal and COPD


Comparison of normal and COPD muscle strength :Comparison of normal and COPD muscle strength


Quads and FEV1 relationship :Quads and FEV1 relationship


ACCP/AACVPR,1997, BTS guidelines 2001 rated Reis et al work grade A evidence to support the role exercise training in rehabilitation.Reis et al: Annals of Internal Medicine 1995,112(11): 823-31 :ACCP/AACVPR,1997, BTS guidelines 2001 rated Reis et al work grade A evidence to support the role exercise training in rehabilitation.Reis et al: Annals of Internal Medicine 1995,112(11): 823-31


Reis et al 1995 :Reis et al 1995


Component of Pulmonary rehabilitation :Exercise training Endurance/ strength /RMT/upper and lower limb weight Optimal pharmacological management Bronchodilators /steroids/O2/ immunisation/NIV Education Medical management, energy conservation, smoking cessation, self management etc Psychosocial support Antidepressants/CBT/relaxation/counselling/motivation Component of Pulmonary rehabilitation


Haringey NHS Pulmonary rehabilitation :Location: Lordship lane Health centre gymnasium Staff: Consultant respiratory Physician- Dr Ian Moosie NMH Specialist Respiratory Physiotherapist –Kola Akinlabi Respiratory Nurse Specialist- Beverley Kowlessa Respiratory Assistant- Deniz Dilaver Clinical Psychologist- Ruth Marks Occupational Therapist- Beverly Johnson Dietician- Coletta Dornely Duration: 2hours exercise and educational sessions, Twice weekly Tuesdays and Fridays, for 8 week Referral system: through adult and older people central referral system online, or our service’s pulmonary rehab referral (fax or posted to SAH) Information: we encourage referral to have full consent of patient before referring and give out patient information leaflet Haringey NHS Pulmonary rehabilitation


Referral criteria, clinical guidance and referral pathways :http://www.haringey.nhs.uk/services/specialist/care_pathways_and_guidelines/respiratory_disease/index.shtm Please see the above for Haringey NHS Clinical guidelines and referral pathways for COPD Inclusion criterial Haringey resident, or registered with Haringey GP and able to travel to the course. MRC 3,4 and 5 Diagnosed with COPD (moderate- severe) and function limited by dyspnoea. Stable and optimal medical and pharmacological management in place. Patient motivated to complete the entire 8-week programme. Referral criteria, clinical guidance and referral pathways


Exclusions: - :Unstable cardiac disease: - Unstable angina Aortic stenosis Aortic valve disease Recent myocardial infarction/ CVA (6 wks) Uncontrolled hypertension Uncontrolled cardiac arrhythmias Uncompensated LVF   2. Unable to carry out exercises/walk due to severe arthritis, dementia, alcoholism, or poor motivation. Exclusions: -


Assessment and outcomes :Screening of referral Patient is contacted for an appointment Assessment take place Outcome measures (CRDQ, HAD, ISWT, predicted VO2 peak) Patient is entered into 8 week rehab if receiving optimum medical management and does not have any of the exclusions. Assessment and outcomes


Discharge and info :Discharge letters are written to referrers and patients are given information about exercise programme with 60+, leisure centre, EPP and breath easy group. 6months and 1 yr follow up for a review and inclusion into rehab. Discharge and info


Service info :Community Respiratory team St Ann’s Hospital L1 Block Tel: 02084426144 Fax: 02084426588 Contacts: Kola Akinlabi(Team Lead) or Beverley Kowlessa Service info


Questions ? :Questions ?