Inquadramento Generale della Riabilitazione Respiratoria, Indicazioni e Modalità Operative (setting)

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1 Inquadramento Generale della Riabilitazione Respiratoria, Indicazioni e Modalità Operative (setting) Claudio F. Donner Mondo Medico Multidisciplinary and Rehabilitation Outpatient Clinic, Borgomanero (NO) - Italy

4 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: ,2006

9 Pulmonary rehabilitation program Multi disciplinary team Content Exercise training Disease education Psychological Social support Disabled patient MRC 3-5 Individual needs Outcomes Functional performance Health status Dyspnoea Cost reduction Process Programme audit Family Selection Assessment Rehabilitation Re-assessment Maintenance AJRCCM, 173: ,2006

10 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: ,2006

11 Pulmonary rehabilitation settings Setting Advantages Disadvantages Inpatient Intensive Cost Residential Exclusion of relatives No safety issues Hospital outpatient Safety Daily Travel Economy Community Adjacency Availability of staff Potential Volume Quality of supervision Home Domestic relevance Cost No travel No group effect AJRCCM, 173: ,2006

12 Maltais et al., Annals of Internal Medicine, 2008 ;149(12):

13 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:

14 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.

15 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

16 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.

17 Lacasse Y, et al. Swiss Med Wkly 2004;134:

18 Lacasse Y, et al. Swiss Med Wkly 2004;134:

19 Lacasse Y, et al. Swiss Med Wkly 2004;134:

20 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:

21 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;

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