Pulmonary Rehab & Long Term Oxygen Therapy

Question 1

What is pulmonary rehab?

Answer 1

• Includes exercise training, education, behaviour change

- For patients with chronic respiratory disease

Question 2

What are the goals of pulmonary rehab?

Answer 2

• Increase exercise tolerance
• Improve adherence to recommended treatments
• Improve mood & motivation
• Decrease frequency & severity of symptoms & increase survival
• Reduce dependency & build self management capacity
• Increase participation in everyday activities & improve QOL
• Reduce health care burden for patients, families & communities

Question 3

What is the eligibility criteria for pulmonary rehab?

Answer 3

• COPD or other respiratory conditions
• Recovering from an acute exacerbation
• Willing to participate (even if current smoker)

Question 4

What patients should be excluded from PR?

Answer 4

• Severe cognitive impairment
• Severe psychotic disturbance
• Relevant infectious disease

Question 5

What patients should be excluded from the exercise component of PR?

Answer 5

• Musculoskeletal or neurological disorders that prevent exercise
• Unstable CV disease (unstable angina, aortic valve disease etc)

Question 6

What is the main component of the PR exercise program?

Answer 6

Lower limb endurance (walking, cycling)

Question 7

Aside from lower limb endurance, what can also be included in a PR exercise program?

Answer 7

• Upper limb endurance
• Lower limb strength
• Upper limb strength
• Flexibility, stretching, balance

Question 8

What are the core topics for the PR education sessions?

Answer 8

• Role & correct use of medications
• Breathing techniques/managing SOB
• PA/exercise
• Nutrition
• Info on diseases (e.g. what the lungs do)
• Coping with COPD
• Management of depression, anxiety and panic attacks
• Smoking cessation

Question 9

How can COPD patients recognise signs that they are deteriorating?

Answer 9

CHAT:

• Coughing more than usual
• Harder to breathe than usual
• Any change in sputum colour &/or volume
• Tired more than usual (less active)

Question 10

How is the PR program evaluated?

Answer 10

• Re-measure exercise capacity & QOL
• Patient feedback
• Doctor feedback

Question 11

What are the benefits of PR?

Answer 11

Improves:

• Exercise tolerance
• Sensation of dyspnoea
• ADLs
• Health-related QOL, anxiety, depression
• Muscle strength, endurance & mass

Decreases:

• Hospital admissions
• Days in hospital
• Mortality

Question 12

What are the evidence based recommendations for PR for COPD patients?

Answer 12

• Should be an integral part of treatment for all mod-severe COPD patients
• Should be considered for patients with other lung conditions
• PR should include psychosocial support &/or support groups

Question 13

What does the evidence show when comparing PR to standard medical care?

Answer 13

Both exercise training & educational training for COPD patients is more effective than standard medical care

Question 14

What did Blackstock et al 2013 find regarding PR?

Answer 14

When comparing exercise vs exercise + education

• No significant difference for 6MWT or CRQ at end program, 6/12 & 12/12 post program
• Exercise alone is effective if education is not available

Question 15

What did Wootton et al 2014 find regarding PR?

Answer 15

• Supervised walking training 3x per week for 8/52 compared to no exercise training
• Supervised walking alone increased exercise endurance & improved QOL

Question 16

What did Albores et al 2013 find regarding PR?

Answer 16

• 12 week home exercise program using Wii fit

- Significant improvements in exercise performance, arm lift, sit to stand reps, health status scores

Question 17

What did Moy et al 2016 find regarding PA & sitting time?

Answer 17

For patients with acute exacerbation COPD

• 1-149 mins MVPA/week = 28% lower risk of dying
• > 150mins MVPA/week = 47% lower risk of dying

Question 18

What are the issues with long-term oxygen therapy (LTOT)?

Answer 18

• Awkward/bulky (compressor, tubing, backpack)

- Costly

Question 19

What is the criteria for LTOT?

Answer 19

• Stable chronic lung disease
• PaO2 < 55 at rest on room air
• Condition must be stable & all reversible factors remediated
• At least 1 month since smoking cessation
• Evidence of pulmonary HT &/or right heart failure & polycythaemia

Question 20

What are the evidence based guidelines for continuous oxygen therapy?

Answer 20

• As many hours as possible per day
• > 18 hours decreases mortality compared to 15 hours or less
• Flow rates set to maintain PaO2 >60 or SpO2 > 90% during waking rest
• Increase flow by 1L during sleep, exertion or air travel

Question 21

What are the benefits of intermittent oxygen therapy?

Answer 21

• Useful for patients in PR

- Decreases ventilation, delays hyperinflation & SOB, increases fitness & exercise capacity

Question 22

What are the evidence based guidelines for intermittent oxygen therapy?

Answer 22

• Increase in endurance should be shown before prescription
• Small cylinder for emergency use may be used by patients with severe asthma
• Home oxygen for terminally ill patients
• Nocturnal if PaO2 < 55 at night

Question 23

What are the CIs for LTOT?

Answer 23

• PaO2 > 60
• Ongoing smokers (fire hazard)
• Inadequate other therapy, inadequately managed
• Unmotivated to wear oxygen for long periods

Question 24

What are the adverse effects of oxygen?

Answer 24

• O2 toxicity
• Absorption atelectasis
• Impaired mucus clearance
• Depression of hypoxic drive

Question 25

What are the limits of LTOT?

Answer 25

• Patient may not be able to maintain adequate oxygenation with increased flow
• May need positive pressure
• Might be changing to palliative care (change of O2 targets)