COPD

Pulmonary rehabilitation shouldn’t have a “one-size fits all” approach

Thursday, 29 Jun 2017


The principles of precision medicine should also extend to non-pharmacological treatments of COPD such as pulmonary rehabilitation, an international respiratory expert says.

Speaking at the Respiratory Insights Forum in Melbourne, Dr Frits Franssen said that while pulmonary rehabilitation was an essential component of COPD management, patients would benefit more if programs were tailored to their individual situations.

Dr Franssen, from the Centre of Expertise for Chronic Organ Failure (CIRO) and the Maastricht University Medical Centre in the Netherlands, said programs could be better personalised to patient characteristics such as their body composition and comorbidities.

For example one study showed that almost three quarters (72%) of COPD patients have three or more co-morbidities, with more than 10% living with six or more comorbidities1.

“Traditionally we focus very much on weight gain and supplements for COPD patients but what we’ve seen in the cachectic patients is they don’t have any appetite so if you give them supplements they won’t take them.”

Obese patients on the other hand were quite happy to help themselves to snacks and supplements suggesting the need to develop specific weight interventions as part of pulmonary rehabilitation, he said.

Dr Franssen said there was a huge diversity in pulmonary rehabilitation programs including the setting, duration, structure, staffing and content[1].

Relatively few programs included occupational therapists, social workers and psychologists and other medical specialists such as cardiologists. He acknowledged it might be harder to provide these resources in programs delivered at home and in the community than in hospital.

The survey of pulmonary rehabilitation also found that interventions such as neuromuscular electrical stimulation (NMES) and inspiratory muscle training (IMT) were only included in a minority of programs.

He said the DICES trial[2] had shown high frequency NMES, low frequency NMES and strength training led to comparable improvements in exercise capacity, health status, psychological symptoms, dyspnoea and lower-limb fat-free mass in severely dyspnoeic patients.

“I’m in favour of active training first but this is also a good alternative in very weak patients as it does not require any effort from patients and the metabolic load is very low,” Dr Franssen said.

He said the use of nocturnal non-invasive ventilation during rehabilitation required additional research but there was some evidence it could improve fatigue and cognitive function[3].

Nonlinear training was also very promising having been shown to deliver greater improvements in cycle endurance and health-related quality of life compared with traditional exercise training[4].

“It might be because of better adherence, it might cause less fatigue, it might be more effective on the muscular level, but it is hard to implement in practice as you need a 1:1 ratio. You cannot do it in a group.”

“The question is: should we also be looking for new strategies?,” he asked.

Dr Franssen said advanced interventions were more applicable to the population of patients with severe COPD. Encouraging more patients into a general pulmonary rehabilitation program was the first priority.

“We know only about 10% of the patients that could benefit from pulmonary rehabilitation are referred to or complete these programs.”

He also stressed that pulmonary rehabilitation programs should also be targeted to patients’ individual goals.

“If you do a program of exercise training and you expect patients to have a higher cycling endurance capacity – well, maybe the patient doesn’t want a better cycling endurance. He wants to play with his grandchildren. So that’s maybe where we need to target interventions.”

References

[1] Spruit MA, Pitta F, et al. Differences in content and organisational aspects of pulmonary rehabilitation programmes. Eur Respir J. 2014;43(5):1326-37. https://www.ncbi.nlm.nih.gov/pubmed/24337043

[2] Sillen MJ, Franssen FM, et al. Efficacy of lower-limb muscle training modalities in severely dyspnoeic individuals with COPD and quadriceps muscle weakness: results from the DICES trial. Thorax. 2014;69(6):525-31. https://www.ncbi.nlm.nih.gov/pubmed/24399630

[3]Duiverman ML, Wempe JB, et al. Nocturnal non-invasive ventilation in addition to rehabilitation in hypercapnic patients with COPD. Thorax, 2008;93:1052–57.  http://thorax.bmj.com/content/63/12/1052

[4] Klijn P, van Keimpema A, et al. Nonlinear exercise training in advanced chronic obstructive pulmonary disease is superior to traditional exercise training. A randomized trial. Am J Respir Crit Care Med, 2013;188(2):193-200. https://www.ncbi.nlm.nih.gov/pubmed/23449691

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