La riabilitazione cardiorespiratoria Antonio Spanevello Università degli Studi dell’Insubria , Varese Dipartimento di Medicina Clinica e Sperimentale Malattie dell’Apparato Respiratorio Fondazione Salvatore Maugeri, IRCCS, Tradate Dipartimento di Medicina e Riabilitazione Cardiorespiratoria U.O.C. Pneumologia Riabiltativa 1

Pulmonary Rehabilitation Rationale Efficacy in COPD + CRF (Chronic Respiratory Failure) Efficacy in COPD + Comorbiditis Efficacy in old patients Conclusions

Progressive reduction in the level of physical activity is a hallmark of patients with chronic pulmonary disease. DISEASE INACTIVITY DECONDITIONING DISABILITY

Level of Physical Activity in COPD Watz H, et al. ERJ 2009 4 4

Percentages of time spent in each of the activities or body positions in healthy subjects and patients with chronic obstructive pulmonary disease (COPD) during the day Pitta F, et al. Am J Respir Crit Care Med 2005;171:972-977

NORMAL COPD -30% Surface 79.6 cm2 Surface 118.5 cm2 PATOLOGIA SISTEMICA CHE IN PARTICOLARE DETERMINA TUTTA UNA SERIE DI ALTERAZIONI A CARICO DELLA MUSCOLATURA SCHELETRICA Surface 79.6 cm2 Surface 118.5 cm2 Bernard S, et al. AJRCCM 1998; 158:629-634

COPD: physical inactivity and survival Waschki B, et al. Chest 2012 7 7

Tutto ciò si riflette in termini di ospedalizzazioni e sopravvivenza: una regolare attività fisica riduce le ospedalizzazioni e aumenta la sopravvivenza

Movement intensity during walking improved significantly after 3 months (p=0.046) with further improvements after 6 months (p=0.0002) Pitta F, et al. Chest 2008;134:273-280

Pulmonary rehabilitation is defined as “a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise physical and social performance and autonomy” ERJ 2004; 23: 932-946

Pulmonary Rehabilitation Treatment Symptoms Partial Success Pulmonary Rehabilitation Symptoms

Pulmonary rehabilitation results in improvements in multiple outcome aereas of considerable importance to the patient, including Dyspnea Exercise tolerance Health care utilisation Health status Survival ERJ 2004; 23: 932-946

Ries AL et al Ann Intern Med 1995;122:823-832

Ries AL et al Ann Intern Med 1995;122:823-832

Pulmonary rehabilitation results in improvements in multiple outcome aereas of considerable importance to the patient, including Dyspnea Exercise tolerance Health care utilisation Health status Survival ERJ 2004; 23: 932-946

BMJ 2004; 329:1209-1213)

Griffiths TL, et al. Lancet 2000; 29:362-368

Pulmonary rehabilitation results in improvements in multiple outcome aereas of considerable importance to the patient, including Dyspnea Exercise tolerance and ability Health care utilisation Health status Survival ERJ 2004; 23: 932-946

* * * * Treshold of clinical significance Δ SGRQ SCORES Versus baseline: * p<0.001 Improvement in SGRQ scores (patients without CRF) (mean value + SE) after PR programme

† * * Δ MRF28 SCORES * Versus baseline: * p< 0.001 † p=0.04 Improvement in Δ MRF28 scores (patients with CRF) (mean value + SE) after PR programme.

Pulmonary rehabilitation results in improvements in multiple outcome aereas of considerable importance to the patient, including Dyspnea Exercise tolerance and ability Health care utilisation Health status Survival ERJ 2004; 23: 932-946

Ries AL et al Ann Intern Med 1995;122:823-832

Pulmonary Rehabilitation Treatment Symptoms Partial Success Pulmonary Rehabilitation Symptoms

Study design Visit 1 CWR CWR CWR CWR Randomization 1 wk 4 wks 1 wk Run-in Baseline Screening Rehabilitation Follow-up Incremental Test CWR CWR CWR CWR Casaburi et al. Chest 2005;127:809-17

Demographics and initial exercise responses LAMA Placebo Total Total treated (n) 55 53 108 Male (%) 59 57 Age (yrs) 65.9 67.3 66.6 Duration of COPD (yrs) 9.7 8.9 9.3 BMI (kg/cm2) 25.0 26.8 25.9 FEV1 (L) 0.82 0.94 0.88 FEV1 (% predicted) 32.6 36.2 34.4 FEV1/FVC (%) 41.5 44.6 43.0 FVC (L) 2.01 2.14 2.08 Incremental treadmill test: Maximum speed (mph) 2.98 2.81 2.90 Casaburi et al. Chest 2005;127:809-17

Effect of LAMA on the improvement in exercise tolerance resulting from rehabilitation * 16% 32% 42% Rehabilitation LAMA (n=55) Placebo (n=53) *P<0.05 Casaburi et al. Chest 2005;127:809-17

Pulmonary Rehabilitation Rationale Efficacy in COPD + CRF (Chronic Respiratory Failure) Efficacy in COPD + Comorbiditis Efficacy in old patients Conclusions

PULMONARY REHABILITATION Maugeri Study Mean duration: 24 ± 4 days Exercise training Educational support Pharmacological therapy optimization

CHANGE IN WALKING DISTANCE (mean ± 95% CI) CHANGE IN WT6M CHANGE IN WALKING DISTANCE (mean ± 95% CI) Metres p<0.001 p<0.001 Carone et al. Resp. Med 2007

CHANGE IN MRC SCORE Carone et al. Resp. Med 2007 Punti p< 0.001

Pulmonary Rehabilitation Rationale Efficacy in COPD + CRF (Chronic Respiratory Failure) Efficacy in COPD + Comorbiditis Efficacy in old patients Conclusions

71%

Pulmonary Rehabilitation Rationale Efficacy in COPD + CRF (Chronic Respiratory Failure) Efficacy in COPD + Comorbidities Efficacy in old patients Conclusions

TRAINING AND NUTRITIONAL SUPPLEMENTATION IN VERY ELDERLY (n=100 age 87.1 ± 0.6 years) Mean (±SE) Changes in Muscle Strength after Exercise, Nutritional Supplementation, Neither, or Both Fiatarone M. et al. NEJM 1994;330(25):1769-1775)

A comprehensive inpatient pulmonary rehabilitation program is beneficial in selected patients 80 years of age or older.

CONCLUSION Pulmonary Rehabilitation improvements Dyspnea, Exercise tolerance , Health care utilisation, Health status, Survival Treatment + Pulmonary Rehabilitation further improvement

CONCLUSION Pulmonary Rehabilitation is equally effective in COPD patients with or without CRF Pulmonary Rehabilitation results in improvements in secondary conditions (BODE index) Pulmonary Rehabilitation is a feasible and effective intervention also in frail elderly

UNITA’ SUBINTENSIVA RESPIRATORIA L'Unità Gravi Patologie Respiratorie Disabilitanti è un'Unità subintensiva finalizzata alla gestione prevalente delle emergenze in via di stabilizzazione delle malattie respiratorie; in essa trovano accoglienza, oltre ai pazienti affetti da insufficienza respiratoria acuta da cause primitive respiratorie e da malattie neuromuscolari o da insufficienza respiratoria cronica riacutizzata, anche i pazienti pre- e post-trapianto del polmone. È collocata in strutture ospedaliere dotate o funzionalmente collegate con Unità di Terapia Intensiva, Cardiologia, Pneumologia e Chirurgia Toracica. Gli interventi per i pazienti trattati nell'Unità sono focalizzati alla definitiva stabilizzazione respiratoria e internistica, al ripristino dell'autonomia nelle funzioni vitali di base, al trattamento iniziale delle principali menomazioni invalidanti e, ove possibile, allo svezzamento totale o parziale dal ventilatore. I pazienti che vi accedono sono caratterizzati da: stato di insufficienza respiratoria in via di stabilizzazione o comunque potenzialmente instabili che necessitano di monitoraggio continuo ventilazione meccanica invasiva continua e/o subcontinua come elemento indispensabile di ammissione (secondaria o meno a coma ipercapnico).

La riabilitazione cardiologica secondo l’OMS Processo multifattoriale, attivo e dinamico che ha il fine di favorire la stabilità clinica, ridurre le disabilità conseguenti alla malattia e supportare al mantenimento e alla ripresa di un ruolo attivo nella società con l’obiettivo di ridurre il rischio di successivi eventi cardiovascolari, di migliorare la qualità della vita e di incidere complessivamente in modo positivo sulla sopravvivenza La riabilitazione cardiologica è raccomandata con il più alto livello di evidenza (classe I) dalle linee guida ESC e ACC/AHA per il trattamento dei pazienti con cardiopatia.

Exercise Only vs Usual Care. Total Mortality Jollife J, et al. The Cochrane Collaboration 2009

Exercise Training Meta-analysis of Trials in Patients with CHF 9 Datasets – 801 patients Mean follow-up 705 days ET reduced mortality and hospitalization rate IRCCS, Fondazione S. Maugeri, Tradate ExTRAMATCH Collaborative, Br Med J 2004