by Scott Cerreta, BS, RRTDirector of Education

www.copdfoundation.org

Expectations after Pulmonary Rehabilitation

Conflict of Interest

• I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of emphasis.

Objectives

1. Discuss current literature and outcomes after pulmonary rehabilitation.

2. Identify key elements that must be maintained after pulmonary rehabilitation.

3. Learn about the COPDF Pulmonary Education Program (PEP) as a post-graduation program.

4. Understand circumstances that lead to post-graduation loss of benefits gained during rehab.

Literature Review

• Long term effectiveness (>2years) of Pulmonary Rehabilitation is disappointing

• Drop-off is multifactoral • Two most significant factors

1. Exacerbations of COPD18

2. Decrease in adherence to exercise prescription18

• AACP/AACVPR Pulm Rehab Clinical Practice Guidelines suggests that PRCs include strategies to promote long-term adherence1

Literature Review• MT group had improved ESWT• No influence on QoL or hospital admissions

Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year mainenance training on physical functioning and health status in patients with COPD. JCRPJournal; 47-52.

Maintaining Benefits after Rehabilitation1. Encourage participation in Phase III rehab– Unproven health advantages long term for:

• Continuous PR• Maintenance PR programs• Repeated courses of PR

– Cost prohibitive in current health care system2. Prevent Hospitalizations– Recognition of early signs of infection

3. Continue exercises at home or gym4. Teach Optimal Care

Optimal Care Includes:

1. Smoking cessation2. Pulmonary rehabilitation– Exercise and nutrition– Recognize early signs of infection– Breathing techniques– Coping skills– End-of-Life care

3. Annual spirometry on a good day4. Testing for Alpha-1 Antitrypsin Deficiency 5. Medication adherence

FEV1 / FVC < 70%I: MildFEV1>80% pred

II:ModerateFEV1 50-80% pred

III: SevereFEV1 30-50% pred

IV: Very SevereFEV1 < 30% pred or FEV1 <50% predicted plus respiratory failure

Active Reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed

Add regular treatment with one or more long-acting bronchodilators: ß2 agonists and anticholinergicsAdd rehabilitation

Add ICS for repeated exacerbations

Add LTOTSurgical interventions

GOLD Standards of COPD Care

http://www.goldcopd.org/

The Problem with Rehab ???

• No one remembers to order it !

• Recommended for GOLD Stage II

• Only 16% of physicians send patients to Rehab

• Rehab is your key resource to improve patient adherence and understanding of this disease

Maintaining Benefits after Rehabilitation• Optimal Care must be maintained

lifelong• Encourage participation in Phase III• Find other programs and resources

to offer your patients after graduation– Develop local programs for transitional

care– Collaborate with other organizations• Local home care companies, not DME• State Smokers’ Quit Line • COPD Foundation

New Programs for the COPD Foundation1. Healthy Interactions Conversation Map– Designed for acute care / transitional care

setting – Education to decrease hospitalization and

teach patient self-management

2. Pulmonary Education Program (PEP)– Designed for pulmonary rehabilitation centers– Prolong benefits of rehab by connecting

patients to COPD Foundation resources after graduation.

Healthy Interactions Conversation Map®

• Pulmonary education not rehab– Designed for acute care admission for COPD

patient– Hospital to Home transitional care program– Small group participation 6-10– Facilitator navigates patients through a

conversation map educational tool.• Patient makes own decisions• Patient learns from others experiences• Patient learns to self-manage and become active in

care– We are still recruiting partner sites!– Final Map tool used for Rehab

Recruitment– Future role-out to clinics, hosp, home

care, etc.

All tools developed by Healthy Interactions.  Conversation Map® is a registered trademark of Healthy Interactions, Inc.

Pulmonary Education Program (PEP)• Designed for Pulm

Rehab– Promotes long-term

benefits after rehab• Sit and Be Fit Exercise

DVD

• Access to COPDF Resources

• Access to COPD Info Line

• Follow-up Program with Rehab Center

• Enhance Patient Support Groups

• Host COPD Education Day events

C.O.P.D. Information Line1-866-316-COPD (2673)

• Provides empathy and support to callers, as well as access to resources (e.g. educational materials)

• Info Line associates are people with COPD

• New branch staffed by associates offer support and information for caregivers

www.copdfoundation.org

Additional COPD Resources atYour Lung Health

http://www.yourlunghealth.org/lung_disease/copd/resources/index.cfm

COPD Research Registry• Aims to build the proper cohort

of patients to enroll in clinical trials and studies

• Over 2,600 patients enrolled

• Online/paper enrollment forms

• Info available through Info Line

• Created to help increase enrollment in COPDGene Study

• National Jewish Health is data coordinating center

www.copdfoundation.org

BFRG Ver2.0

• Modeled after the Alphanet BFRG for Alpha-1

• Most comprehensive guide on COPD health management

• Over 70 individuals and organizations contributed

www.copdbfrg.org www.copdfoundation.org

SSRGs1. Coping with COPD

2. End-of-Life

3. Exacerbations

4. Exercise

5. Medicine

6. Nutrition

7. Oxygen Therapy

8. Travel

9. Understanding Lung Disease

10. Understanding Testswww.copdfoundation.org

Summary

• Teach optimal care• Keep patients involved with lifelong

care• Know your patients – What stage

COPD– Encourage spirometry annually– Encourage patients learn their FEV1 and

stage• Collaborate with others to maintain

long term benefits of pulmonary rehabilitation

• End result is decreased hospitalizations and improved patient outcomes.

Thank You!

References1. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR evidence based

clinical practice guidelines. Chest 2007;131;4S-42S2. Ries AL, Make BJ, Lee SM, et al. The effects of pulmonary rehabilitation in the National Emphysema

Treatment Trial. Chest 2005; 128:3799–38093.  Cambach W, Wagenaar RC, Koelman TW, et al. The long-term effects of pulmonary rehabilitation in

patients with asthma and chronic obstructive disease: a research synthesis. Arch Phys Med Rehabil 1999; 80:103–111

4. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000; 355:362–368

5. Troosters T, Gosselink R, Decramer M. Short- and longterm effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Am J Med 2000; 109:207–212 

6. Foglio K, Bianchi L, Ambrosino N. Is it really useful to repeat outpatient pulmonary rehabilitation programs in patients with chronic airway obstruction? A 2-year controlled study. Chest 2001; 119:1696–1704

7. Finnerty JP, Keeping I, Bullough I, et al. The effectiveness of outpatient pulmonary rehabilitation in chronic lung disease: a randomized controlled trial. Chest 2001; 119:1705– 1710

8. Ries AL, Kaplan RM, Myers R, et al. Maintenance after pulmonary rehabilitation in chronic lung disease: a randomized trial. Am J Respir Crit Care Med 2003; 167:880–888

9. Guell R, Casan P, Belda J, et al. Long-term effects of outpatient rehabilitation of COPD: a randomized trial. Chest 2000; 117:976–983

10. Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001; 56:779–784

References11. Wijkstra PJ, van der Mark TW, Kraan J, et al. Long-term effects of home rehabilitation on physical

performance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996; 153:1234–124

12. Engstrom CP, Persson LO, Larsson S, et al. Long-term effects of a pulmonary rehabilitation programme in outpatients with chronic obstructive pulmonary disease: a randomized controlled study. Scand J Rehabil Med 1999; 31:207–213

13. Wijkstra PJ, TenVergert EM, van Altena R, et al. Long term benefits of rehabilitation at home on quality of life and exercise tolerance in patients with chronic obstructive pulmonary disease. Thorax 1995; 50:824–828

14. Berry MJ, Rejeski WJ, Adair NE, et al. A randomized, controlled trial comparing long-term and short-term exercise in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2003; 23:60–68

15. Puente-Maestu L, Sanz ML, Sanz P, et al. Long-term effects of a maintenance program after supervised or self-monitored training programs in patients with COPD. Lung 2003; 181:67–78

16. Grosbois J-M, Lamblin C, Lemaire B, et al. Long-term benefits of exercise maintenance after outpatient rehabilitation program in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 1999; 19:216–225

17. Cockram J, Cecins N, Jenkins S. Maintaining exercise capacity and quality of life following pulmonary rehabilitation. Respirology 2006; 11:98–104

18. Brooks D, Krip B, Mangovski-Alzamora S, Goldstein RS. The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease. Eur Respir J 2002; 20: 20–29.

19. Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year mainenance training on physical functioning and health status in patients with COPD. JCRPJournal; 47-52.

20. COPD Foundation. www.copdfoundation.org