Selection criteria for pulmonary rehabilitation

Inquadramento Generale della Riabilitazione
Respiratoria, Indicazioni e Modalità Operative
(setting)
Claudio F. Donner
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Multidisciplinary and Rehabilitation Outpatient Clinic, Borgomanero (NO) - Italy
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American Thoracic Society Documents
American Thoracic Society/European Respiratory Society Statement
on Pulmonary Rehabilitation
Linda Nici, Claudio Donner, Emiel Wouters, Richard ZuWallack, Nicolino Ambrosino, Jean
Bourbeau,Mauro Carone, Bartolome Celli, Marielle Engelen, Bonnie Fahy, Chris Garvey,
Roger Goldstein, Rik Gosselink,Suzanne Lareau, Neil MacIntyre, Francois Maltais, Mike
Morgan, Denis O’Donnell, Christian Prefaut, Jane Reardon, Carolyn Rochester, Annemie
Schols, Sally Singh, and Thierry Troosters, on behalf of the ATS/ERS Pulmonary
Rehabilitation Writing Committee
THIS JOINT STATEMENT OF THE AMERICAN THORACIC SOCIETY (ATS) AND THE EUROPEAN
RESPIRATORY SOCIETY (ERS) WAS ADOPTED BY THE ATS BOARD OF DIRECTORS, DECEMBER
2005, AND BY THE ERS EXECUTIVE COMMITTEE, NOVEMBER 2005
AJRCCM, 173:1390-413,2006
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Pulmonary rehabilitation program
Content
Multi disciplinary
team
Exercise training
Disease education
Psychological
Social support
Outcomes
Functional
performance
Health status
Dyspnoea
Cost reduction
Disabled patient
MRC 3-5
Individual needs
Programme audit
Process
Family
Selection
Assessment
Rehabilitation
Re-assessment
Maintenance
AJRCCM, 173:1390-413,2006
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Exercise training Strategies: Practice guidelines
• A minimum of 20 sessions should be given at least three times per week
to achieve physiologic benefits; twice weekly supervised plus one
unsupervised home session may also be acceptable.
• High intensity exercise produces greater physiologic benefit and should
be encouraged; however low intensity training is also effective for those
patients who cannot achieve this level of intensity.
• Interval training may be useful in promoting higher levels of exercise
training in the more symptomatic patients.
• Both upper and lower extremity training should be utilized.
• The combination of endurance and strength training generally has
multiple beneficial effects and is well-tolerated; strength training is
particularly indicated for patients with significant muscle atrophy.
AJRCCM, 173:1390-413,2006
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Pulmonary rehabilitation settings
Setting
Advantages
Disadvantages
Inpatient
Intensive
Residential
No safety issues
Cost
Exclusion of relatives
Hospital outpatient
Safety
Economy
Daily Travel
Community
Adjacency
Potential Volume
Availability of staff
Quality of supervision
Home
Domestic relevance
No travel
Cost
No group effect
AJRCCM, 173:1390-413,2006
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Maltais et al., Annals of Internal Medicine, 2008 ;149(12):869-78.
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Targets of Exercise Training as Part of a Pulmonary Rehabilitation Program for Patients with COPD
Casaburi R, ZuWallack R. N Engl J Med 2009;360:1329-1335
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Modificazioni indotte dalla riabilitazione
La riabilitazione porta a miglioramenti in numerose aree di
considerevole importanza per il paziente, quali
- dispnea
- capacità di svolgere esercizio fisico
- stato di salute
- utilizzo di risorse sanitarie
Questi effetti positivi si realizzano nonostante si abbia un effetto
minimo o spesso nullo sulle misure di funzione respiratoria. Ciò
riflette il fatto che nella BPCO intervengono molte condizioni
secondarie (decondizionamento cardiaco, disfunzione periferica
muscolare, riduzione della massa totale corporea e della massa magra,
ansietà, ridotta capacità di confrontarsi con la realtà quotidiane) in
grado di condizionare pesantemente il quadro clinico.
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Il trattamento riabilitativo è volto a promuovere
- uno stile di vita salutare,
- migliorare l’aderenza alla terapia ed
- incoraggiare
l’attività fisica
•
e dovrebbe essere incluso nel programma di trattamento di ogni paziente
con BPCO che manifesti dispnea o altri sintomi respiratori, ridotta
tolleranza allo sforzo, restrizione nell’attività o alterato stato di salute.
Le principali componenti di un programma di riabilitazione sono
rappresentate da
- allenamento allo sforzo
- interventi psicosociali-comportamentali
- educazione
- terapia nutrizionale
- valutazione degli indicatori di risultato
- promozione di una aderenza a lungo termine al trattamento
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Purtroppo a livello nazionale ,mentre si ha una sufficiente
(seppure disomogenea dal punto di vista territoriale)
disponibilità di strutture in grado di fornire un trattamento
riabilitativo intensivo in regime di ricovero, manca in modo
pressoché totale l’offerta di riabilitazione respiratoria in
regime ambulatoriale, che sarebbe la più necessaria e
utilizzabile da ampie fasce di pazienti, ed è assolutamente
episodica quella in regime di home care.
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Lacasse Y, et al. Swiss Med Wkly 2004;134:601-605
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Lacasse Y, et al. Swiss Med Wkly 2004;134:601-605
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Lacasse Y, et al. Swiss Med Wkly 2004;134:601-605
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• Theoretically, pulmonary rehabilitation should be considered as
applicable in all stages for COPD patients who have respiratory
symptoms.
• The overwhelming evidence currently available is clearly sufficient
for regulatory authorities to conclude that there is a sound basis for
reimbursement for pulmonary rehabilitation.
• Recent clinical guidelines for COPD suggest that the two different
therapeutic modalities, pharmacological and non-pharmacological
interventions, should both apply in the long-term management of
COPD. However, such therapy occasionally causes misunderstandings
in daily practice, and so both areas have to work closely together.
Lacasse Y, et al. Swiss Med Wkly 2004;134:601-605
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Pulmonary rehabilitation, as a set of tools and disciplines that attends to the multiple
needs of the COPD patient, is a highly effective and cost-efficient means of caring
for COPD patients.
The patient's physician is rarely a part of the program and thus unable to support a
long-term response.This dichotomy does not seriously detract from the multiple
benefits of the program; it simply lends greater insight into important challenges
in treating these patients.
Although pulmonary rehabilitation is highly beneficial, often exceeding expectation, an
ideal system would entail redesigning standard medical care to create a disease
management model that would include rehabilitative tools and disciplines in a
system of self-management and regular exercise. This is as opposed to pulmonary
rehabilitation being a loose appendage to standard care. This therapeutic
construct would best enable patients to enjoy continuing benefit over the full
course of their disease, interface with their physician, and have this care available
to the full population of COPD patients.
Thus, pulmonary rehabilitation would take its place in the mainstream of disease
management through its integrative role in the multidisciplinary continuum of
services
Brian L. Tiep Chest 1997;112;1630-1656
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