Pulmonary Rehabilitation

Pulmonary Rehabilitation

 

 

 

 

                                                                                                                                                                 Dr Kripesh Ranjan Sarmah

Consultant pulmonologist and sleep specialist

kripeshdoc@gmail.com                                                                                         

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. Pulmonary Rehabilitation is the medical art and science by which people disabled with lung disease is returned to a more active and enjoyable life style.

Three important features of successful rehabilitation are:

1.Multidisciplinary: Pulmonary rehabilitation programs utilize expertise from various health-care disciplines that is integrated into a comprehensive, cohesive program tailored to the needs of each patient.

2.Individual: Patients with disabling lung disease require individual assessment of needs, individual attention, and a program designed to meet realistic individual goals.

3.Attention to physical and social function: To be successful, pulmonary rehabilitation pays attention to psychological, emotional, and social problems as well as physical disability, and helps to optimize medical therapy to improve lung function and exercise tolerance.

The aims of pulmonary rehabilitation are-

•         To reduce disability and handicap of persons with chronic respiratory impairments.

•         To restore patients to the highest possible level of independent functioning.

Goals are integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to

–        Increase exercise tolerance in order to reduce impairment.

–        Improve compliance to recommended treatments.

–        Reduce frequency and severity of symptoms.

–        Improve mood and motivation.

–        Reduce dependency.

–        Enhance participation in therapy decisions by building self-management capacity.

–        Increase participation in everyday activities.

–        Improve quality of life.

–        Reduce health care burden for patients, families and communities.

–        Improve survival.

Multidisciplinary Rehabilitation Team provide the services

Core Team includes pulmonologists, respiratory therapists, physiotherapists, occupational therapists, nurses, care coordinators, rehabilitation assistants and nutrisonist.

 Consultation is required in PFT/ Sleep Lab, exercise Lab, dietician, pharmacist, recreation therapist, social worker, psychologist, psychiatrist, priest/ chaplain etc as needed.

The types of patients who need pulmonary rehabilitation

Patients with stable COPD (moderate – severe), Bronchiectasis, Emphysema, IPF or any chronic respiratory diseases can be included in the training programme. The patients should have -

• Persistent symptoms, limited activity, and/or are unable to adjust to illness despite of optimal medical management
• Motivated to regain energy for ADL and functional ability and good quality of life

Following types of patients were excluded from exercise component:

•         Patients who have severe cognitive impairment, severe psychotic disturbance and have a relevant infectious disease are not included in the programme.

•         Musculoskeletal or neurological disorders that prevent gentle exercise.

•         Unstable cardiovascular disease (e.g. unstable angina, aortic valve disease, unstable pulmonary hypertension).

•         Known metastatic cancer

Indications for Referral to pulmonary rehabilitation

Patients at certain stage of their disease benefit most from pulmonary rehabilitation. Therefore timely referral is necessary. The following are the criteria based on which a patient can be referred for pulmonary rehabilitation ---

•         Dyspnea at rest or on exertion

•         Decreased exercise tolerance or difficulty performing activities of daily living

•         Oxygen evaluation

•         Pre-operative rehabilitation to maximize medical status prior to lung surgery

•         Evaluation of respiratory failure and the elective initiation of mechanical ventilation

•         Unexpected deterioration / worsening of symptoms

•         COPD patients at stage 2 or 3 who are limited in their activity.

Duration of training

In case of In-patient duration of 6 –7 weeks is required but for out-patient 14-17 weeks is essential

Designing and Prescribing an Exercise Program

Designing of program depends on the capacity, limitation and goal. Patient is offered customized as well as generalized rehabilitation program. After completion of training patients’ are given advice regarding home rehabilitation program.

Follow-Up

Scheduled follow up is advised after 1-3 months of training program. Subsequent appointments are scheduled every 3 months for the first year, and then frequency is reduced to biannual/annual if stable.

Conclusion

Rehabilitation programs for patients with chronic lung diseases are well-established as a means of enhancing standard therapy in order to control and alleviate symptoms and optimize functional capacity. The primary goal is to restore the patient to the highest possible level of independent function. This goal is accomplished by helping patients become more physically active, and to learn more about their disease, treatment options, and how to cope. Patients are encouraged to become actively involved in providing their own health care, more independent in daily activities, and less dependent on health professionals and expensive medical resources. Rather than focusing solely on reversing the disease process, rehabilitation attempts to reduce symptoms and reduce disability from the disease. Pulmonary rehabilitation is appropriate for any stable patient with a chronic lung disease who is disabled by respiratory symptoms. Patients with advanced disease can benefit if they are selected appropriately and if realistic goals are set. Pulmonary rehabilitation provides a multidisciplinary care to chronic lung diseases and help to lead a comfortable life with their limitations due to underlying disease.

References

o   American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. Am J Respir Crit Care Med Vol 173. pp 1390–1413, 2006

o   American College of Chest Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Chest 1997;112:1363– 1396

o   Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest 2007; 131; 4-42

Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department

Objective: To study the association between time to antibiotic administration and survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department.

Design: Single-center cohort study.

Setting: The emergency department of an academic tertiary care center from 2005 through 2006.  

Patients: Two hundred sixty-one patients undergoing early goal-directed therapy.
Interventions: None.

Measurements and Main Results: Effects of different time cutoffs from triage to antibiotic administration, qualification for early goal-directed therapy to antibiotic administration, triage to appropriate antibiotic administration, and qualification for early goal-directed therapy to appropriate antibiotic administration on
in-hospital mortality were examined. The mean age of the 261 patients was 59 16 yrs; 41% were female. In-hospital mortality was 31%. Median time from triage to antibiotics was 119 mins (interquartile range, 76–192 mins) and from qualification to antibiotics was 42 mins (interquartile range, 0–93 mins). There was
no significant association between time from triage or time from qualification for early goal-directed therapy to antibiotics and mortality when assessed at different hourly cutoffs. When analyzed for time from triage to appropriate antibiotics, there was a significant association at the <1 hr (mortality 19.5 vs. 33.2%; odds ratio, 0.30 [95% confidence interval, 0.11– 0.83]; p = .02) time cutoff; similarly, for time from qualification for early goaldirected therapy to appropriate antibiotics, a significant association was seen at the <1 hr (mortality 25.0 vs. 38.5%; odds ratio, 0.50 [95% confidence interval, 0.27– 0.92]; p = .03) time cutoff.

Conclusions: Elapsed times from triage and qualification for early goal-directed therapy to administration of appropriate antimicrobials are primary determinants of mortality in patients with severe sepsis and septic shock treated with early goal-directed therapy.

(Crit Care Med 2010; 38:1045–1053)

cochrane review on asthma

Regular treatment with formoterol and an inhaled corticosteroid versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma: serious adverse events
cochrane review
 
Background: An increase in serious adverse events with both regular formoterol and regular salmeterol in chronic asthma has been demonstrated in comparison with placebo in previous Cochrane reviews. This increase was significant in trials that did not randomise participants to an inhaled corticosteroid, but less certain in the smaller numbers of participants in trials that included an inhaled corticosteroid in the randomised treatment regimen.

Objectives: We set out to compare the risks of mortality and non-fatal serious adverse events in trials which have randomised patients with chronic asthma to regular formoterol versus regular salmeterol, when each are used with an inhaled corticosteroid as part of the randomised treatment.

Search Strategy: Trials were identified using the Cochrane Airways Group Specialised Register of trials. Manufacturers' web sites of clinical trial registers were checked for unpublished trial data and Food and Drug Administration (FDA) submissions in relation to formoterol and salmeterol were also checked. The date of the most recent search was July 2009.

Selection Criteria: Controlled clinical trials with a parallel design, recruiting patients of any age and severity of asthma were included if they randomised patients to treatment with regular formoterol versus regular salmeterol (each with a randomised inhaled corticosteroid), and were of at least 12 weeks duration.

Data collection and analysis: Two authors independently selected trials for inclusion in the review and extracted outcome data. Unpublished data on mortality and serious adverse events were sought from the sponsors and authors.

Main results: Eight studies met the eligibility criteria of the review recruiting 6,163 adults and adolescents. There were seven studies (involving 5,935 adults and adolescents) comparing formoterol and budesonide to salmeterol and fluticasone. All but one study administered the products as a combined inhaler, and most used formoterol 50 mcg and budesonide 400 mcg twice daily versus salmeterol 50 mcg and fluticasone 250 mcg twice daily. There were two deaths overall (one on each combination) and neither were thought to be related to asthma.
There was no significant difference between treatment groups for non-fatal serious adverse events, either all-cause (Peto OR 1.14; 95% CI 0.82 to 1.59, I2 = 26%) or asthma-related (Peto OR 0.69; 95% CI 0.37 to 1.26, I2 = 33%). Over 23 weeks the rates for all-cause serious adverse events were 2.6% on formoterol and budesonide and 2.3% on salmeterol and fluticasone, and for asthma-related serious adverse events, 0.6% and 0.8% respectively.
There was one study (228 adults) comparing formoterol and beclomethasone to salmeterol and fluticasone, but there were no deaths or hospital admissions. No studies were found in children.

Authors' conclusions: The seven identified studies in adults did not show any significant difference in safety between formoterol and budesonide in comparison with salmeterol and fluticasone. Asthma-related serious adverse events were rare, and there were no reported asthma-related deaths. There was a single small study comparing formoterol and beclomethasone to salmeterol and fluticasone in adults, but no serious adverse events occurred in this study. No studies were found in children.
Overall there is insufficient evidence to decide whether regular formoterol and budesonide or beclomethasone have equivalent or different safety profiles from salmeterol and fluticasone.

childhood respiratory illness & adult outcome

A recent study published in Chest 2010 137(1):146-155 has shown that childhood respiratory health affect adult lung function. For more detail please read the article...............

the oath of hippocrates

ATT DOSE MODIFICATION IN RENAL DISEASE

reference  Treatment of tuberculosis in chronic renal failure,
maintenance dialysis and renal transplant, KK Malhotra,Indian J Nephrol 2003;13: 69-71 and Olyaei AJ, de Mattos AM, Bennett WM. Prescribing drugs
in renal failure in The Kidney 6th edition. ed Brenner BM,
WB Saunders, Philadelphia, 2002 p. 2606-2653

my experience in Broncocon2010

i have attended broncocon2010.. it was a real happening for person like me who has just started bronchoscopy. those who are interested in bronchoscopy should attent the next conference to be held in PGI chandighar 2011...

happy new year

Wish all my friends a great happy new year
Regards
           Dr Kripesh Ranjan Sarmah and
           community respiratory critical care and sleep medicine..........
           http://www.orkut.co.in/Main#Community?cmm=92421330

quiz of month

A 60-year-old male is seen in the pulmonary clinic for evaluation of dyspnea. He underwent single-lung transplantation 3 years ago for idiopathic pulmonary fibrosis and did well until the last 5 months,
when he noted that his exercise tolerance had decreased as a result of shortness of breath. He denies fevers, chills, weight loss, or medication noncompliance. The patient does have an occasional dry cough. His current medications include immune supressant, trimethoprim-sulfamethoxazole (TMP-SMX), pantoprazole, diltiazem, and mycophenolate mofetil. He has past history of tobacco use. Physical examination show dry crackles on the side of the origin lung and decreased breath sounds on the side of the transplanted lung. Review of pulmonary function testing shows an FEV1/FVC ratio of 55% of the predicted value and an FEV1 of 0.90 L. Additionally, FEV1 has fallen by 31% progressively over the last 1-1/2 year. Which of the following can ameliorate the fall in FEV1 in this patient?
A. Augmented immunosuppression
B. Reduced immunosuppression
C. Antifungal therapy
D. Antiviral therapy
E. Administration of α1 antitrypsin
F. None of the above

Variants of DENND1B Associated with Asthma in Children

Background Asthma is a complex disease that has genetic and environmental causes. The genetic factors associated with susceptibility to asthma remain largely unknown.

Methods We carried out a genomewide association study involving children with asthma. The sample included 793 North American children of European ancestry with persistent asthma who required daily inhaled glucocorticoid therapy and 1988 matched controls (the discovery set). We also tested for genomewide association in an independent cohort of 917 persons of European ancestry who had asthma and 1546 matched controls (the replication set). Finally, we tested for an association between 20 single-nucleotide polymorphisms (SNPs) at chromosome 1q31 and asthma in 1667 North American children of African ancestry who had asthma and 2045 ancestrally matched controls.

Results In our meta-analysis of all samples from persons of European ancestry, we observed an association, with genomewide significance, between asthma and SNPs at the previously reported locus on 17q21 and an additional eight SNPs at a novel locus on 1q31. The SNP most strongly associated with asthma was rs2786098 (P=8.55x10^–9). We observed replication of the association of asthma with SNP rs2786098 in the independent series of persons of European ancestry (combined P=9.3x10^–11). The alternative allele of each of the eight SNPs on chromosome 1q31 was strongly associated with asthma in the children of African ancestry (P=1.6x10^–13 for the comparison across all samples). The 1q31 locus contains DENND1B, a gene that is expressed by natural killer cells and dendritic cells and that encodes a protein that interacts with the tumor necrosis factor receptor.

Conclusions We have identified a locus containing DENND1B on chromosome 1q31.3 that is associated with susceptibility to asthma.