Pulmonary rehabilitation from past to future.ppsx

progress of pulmonary rehabilitation

1. نمحرلاهللامسب
ميحرلا

2. ppPulmonary rehabilitation from past to future
By
Prof / Samiaa Hamdy Sadek
Assiut University

3. 1.Definition of pulmonary rehabilitation (PR)
2.History of pulmonary rehabilitation
3.Changing face of pulmonary rehabilitation
4.Pathophysiologic background of PR
5.Present situation of PR worldwide
6.Barriers for PR
7.Key points
8.References
Agenda

4. Definition:
According to ATS/ERS Pulmonary rehabilitation
(PR) is defined as: a “comprehensive
multidisciplinary evidence-based intervention
relied on a thorough patient assessment followed
by patient-tailored therapies that include, but are
not limited to exercise training, education, and
behavior change, designed to improve the
physical, psychological condition, and long-term
adherence to health-enhancing behaviors of
people with chronic respiratory disease”

5. History of pulmonary rehabilitation:
Dr. Alvan Barach introduced early ambulation and
oxygen therapy in the 1940s.
Thomas L Petty (1932 -2009 ) in 1960s, a respirologist at
the University of Colorado who could be considered the
father of PR, organized a multidisciplinary pulmonary
rehabilitation program to treat individuals with COPD.

 He subsequently published on this in 1969, reporting
that PR led to marked subjective involvement in
symptoms and objective improvement in exercise
tolerance and subsequent hospitalizations.

6. History of pulmonary rehabilitation:
American College of Chest Physicians in 1974 came up
with the following definition: “Art of medical practice,
where in an individually tailored, multidisciplinary
program is formulated through accurate diagnosis,
therapy, emotional support and education to stabilize or
reverse both physiopathological and psychopathological
manifestations of pulmonary diseases.
Such a program must attempt to return the patient to the
highest possible functional capacity allowed by the
handicap and overall life situation “
 This is first definition of PR included the word, “ART”.

7. History of pulmonary rehabilitation:
A clearer understanding of the constituents of a
comprehensive PR program were clarified 1980s.
 “Proper patient selection, initial assessment to determine
needs, development of appropriate goals, development of
components of care, assessment of patient progress, and
arrangement for long-term follow-up .
In this decade “The importance of exercise training was
emphasized”.

8. History of pulmonary rehabilitation:
Several studies were done in 1990s gave the following
conclusions:
“Reductions in Exercise Lactic Acidosis and Ventilation as
a Result of Exercise Training in Patients with Obstructive
Lung Disease” Casaburi and colleagues, 1991.

 Andrew Ries and colleagues, 1995 demonstrated that a
comprehensive, 8-week outpatient PR program (compared
to education alone) led to improvements in exercise
capacity, dyspnea, muscle fatigue, and self-efficacy for
walking.

9. History of pulmonary rehabilitation:
The Official Statement of the American Thoracic Society,
and Other official statements in this decade(1990s)
included Pulmonary rehabilitation in chronic obstructive
pulmonary disease (COPD) with recommendations for its
use.
 The European Respiratory Society Rehabilitation and
Chronic Care Scientific Group (1992),reported Selection
criteria and programs for pulmonary rehabilitation in
COPD patients (1997 ).

10. History of pulmonary rehabilitation:
PR became a standard of care for COPD in 2000-2010.
 Additional statements and guidelines solidified the
rationale and organizational aspects of PR program .
Among these were the joint American Thoracic Society
/ European Respiratory Society Statement on
Pulmonary Rehabilitation (2006), Clinical Competency
Guidelines for Pulmonary Rehabilitation Professionals,
and Pulmonary Rehabilitation Joint ACCP/AACVPR
Evidence-Based Guidelines (2007)

11. History of pulmonary rehabilitation:
In 2001, of considerable importance, the very
influential Global Initiative for COPD (GOLD) document
included PR as an established treatment for COPD in a
2001 publication, and their 2003 update placed it in
their algorithm for the recommended management for
this disease.
Cost effectiveness of PR (2001,2004)
The concept of bringing PR into the home and
community settings, 2010

12. History of pulmonary rehabilitation:
The first recognition of the benefits of PR in the post
exacerbation period, 2010.
Puhan and colleagues , 2016 reported in their
systematic review that “PR - in addition to already
established improvements in exercise tolerance and
health status – also may reduce health care utilization
and even mortality risk, although the quality of
evidence was not particularly high”

13. Changing face of pulmonary rehabilitation

14. 1-"Traditional Pulmonary Rehabilitation (Face-to-
Face)"
These programs have been considered the gold standard of
care, due to the direct interaction of patients with a
multidisciplinary team.“
The Beginning (1950s to 1990s): Pulmonary rehabilitation
programs started in hospitals or medical centers, focusing
on medically supervised exercise, patient education, and
breathing exercises for patients with chronic obstructive
pulmonary disease (COPD) and other chronic lung diseases."

15. 2-Home-Based Pulmonary Rehabilitation:
Emergence (in the 2000s):
This models aimed to overcome limitations such as
difficulty with transportation, cost, or physical
disability.
It depend on home visits, phone calls, and printed
educational materials.
Studies have shown that home-based rehabilitation
can be effective and more accessible, especially in
rural or underserved areas.

16. 3-"Web-Based Pulmonary Rehabilitation"
It depends on the use of internet platforms (web portals,
apps, video conferencing) to deliver PR program.
The Beginning was 2010 and beyond.
Patients can log their exercises, monitor their symptoms,
and access health education online.
Studies have shown that web-based rehabilitation achieves
outcomes comparable to traditional programs.

17. 4-" Hybrid and Personalized Approaches "
Combination of in-clinic and home-based sessions.
Tailored intensity based on comorbidities and
capacity.
Behavior change techniques integrated into delivery
Data-driven Monitoring, wearables for real-time
tracking

18. 5-" Virtual Pulmonary Rehabilitation During the
COVID-19 Pandemic:"
The pandemic forced the suspension of in-person programs.
Care providers resorted to remote consultations, video
meetings, and electronic platforms (such as Zoom or
dedicated apps).
Virtual rehabilitation included live group sessions, individual
follow-ups, remote monitoring, and online support groups.
It played a critical role in maintaining care delivery while
reducing the risk of virus transmission.

19. The terms telerehabilitation, virtual rehabilitation, and web-based rehabilitation
are related but have some nuances:
Telerehabilitation: This is a broad term that refers to delivering rehabilitation
services remotely using telecommunications technology. It can include video
calls, phone calls, mobile apps, remote monitoring devices, and more. So, it
covers any kind of rehab done at a distance through electronic communication.
Virtual Rehabilitation: Often used interchangeably with telerehabilitation but
sometimes emphasizes more immersive technologies like virtual reality (VR)
environments or simulated sessions conducted online. It usually implies
interactive, real-time sessions via digital platforms.
Web-Based Rehabilitation : Specifically refers to rehab delivered through web
platforms — websites or web applications. This is a subset of telerehabilitation
and usually involves asynchronous tools like exercise logging, educational
content, and sometimes synchronous (live) sessions via the internet.

20. Remote monitoring:
Remote monitoring means tracking and assessing a patient’s health status
from a distance, without the need for the patient to be physically present in
a healthcare facility.
In the context of pulmonary rehabilitation, remote monitoring typically
involves:
Using devices like pulse oximeters, heart rate monitors, or activity trackers
Collecting data on vital signs, oxygen levels, symptoms, or exercise
performanceTransmitting this information electronically (via apps, wearable
tech, or home devices) to healthcare providers
Allowing clinicians to review progress, adjust treatment plans, and
intervene early if problems arise

21. 5-Precision pulmonary rehabilitation:
Traditional rehab programs often use a “one-
size-fits-all” method, giving similar exercises
and education to everyone.
Precision PR uses detailed information about
a person’s health to create a program that
works best for them “tailoring rehab
programs specifically to each individual’s
unique needs”.

22. 5-Precision pulmonary rehabilitation:
What types of data is used?
Medical data: lung function tests, symptoms, and other health
conditions.
Genetic factors: some people may respond better to certain
treatments based on their DNA.
Biomarker-driven therapy selection (e.g., eosinophilic
inflammation)
Lifestyle and behavior: exercise habits, smoking status, and
motivation
Environmental factors: pollution exposure, living conditions
Psychological state: anxiety, depression, and support systems

23. 5-Precision pulmonary rehabilitation:
How precision PR is work?
Doctors and therapists use this data to design
personalized exercise plans, education, and
support.
Advanced tools like wearable devices track
progress and adjust the program in real-time.
Artificial intelligence (AI) and computer models
may help predict what treatments will work best,
enabled risk stratification and outcome prediction.

24. 5-Precision pulmonary rehabilitation:
Key aspects of Precision Rehabilitation include:
 Technology Integration: The use of advanced technologies such as
artificial intelligence (AI), machine learning (ML), wearable sensors, and
other data analytics tools to gather and analyze patient-specific data.
 Data-Driven Models: Using large, heterogeneous datasets to create
predictive models that can guide treatment strategies and make real-time
adjustments to care. This helps to identify which specific services are most
likely to benefit a patient.
 Focus on Function: A key goal is to improve function across physical,
cognitive, and psychosocial domains for all individuals.
 Personalized Interventions: The collected data is used to develop patient-
specific interventions, which is particularly relevant in cases where
standardized treatments do not work for all individuals.

26. 1-Effect of exercise training on dyspnea:
Reduced ventilatory demand at standardised work rates during exercise
Improved oxidative capacity of the trained peripheral muscles and consequent
delayed metabolic (lactic) acidosis, means less hydrogen ion generation and CO2
output and therefore reduced chemo-stimulation of central medullary and bulbo-
pontine control centers result in reduced perceived respiratory discomfort.
Reduced breathing frequency has potentially favorable physiological consequences:
Reduced velocity of shortening of the inspiratory muscles may improve their dynamic
strength and endurance and by increasing expiratory time, dynamic lung
hyperinflation (gas trapping) is reduced at a given level of expiratory flow limitation.
Improve oxygen consumption

27. 2. Enhanced cardiovascular oxygen delivery
Endurance exercise, a key component of PR, helps to
reduce pulmonary arterial pressure and improves
endothelial function. So, may reduces cardiac afterload
and improves blood flow, and cardiac output.
Reduces systemic inflammation
Improves oxygen delivery and utilization
Regular exercise improves cardiovascular fitness

28. 3-Effect of exercise training on peripheral muscles:
A combination of factors, including systemic inflammation, poor nutrition, and
hypoxemia, contributes to significant abnormalities in peripheral muscles.
High-intensity exercise training within PR serves as an anabolic stimulus that
improves muscle oxidative capacity and reduced lactic acid production.
Exercise, particularly endurance and aerobic training, is a potent stimulus that
increases the number and function of mitochondria in peripheral muscles .
 This process is known as mitochondrial biogenesis and is a cornerstone of the
physiological adaptations that occur during pulmonary rehabilitation (PR).
A higher mitochondrial content promotes a greater reliance on fat oxidation
during submaximal exercise, which spares valuable muscle glycogen . This also
reduces lactate production, delaying the onset of fatigue and the associated
increase in ventilation.

29. 4-Improved mood and emotional function : By reducing
dyspnea and fatigue, PR helps to lessen the anxiety and
depression commonly associated with chronic respiratory
illness.
5-Increased self-efficacy: As patients regain strength and
control over their symptoms, they experience a greater
sense of mastery and confidence in their ability to
manage their condition and engage in daily life.

31. Despite its proven benefits, PR utilization remain suboptimal on a
global scale with some heterogeneity in its implementation.
international studies of 10 developed countries report a referral rate
of 35% in over 90% of studies (Milner SC, et al, 2019).
Study in France showed an 8.6% of PR uptake 90 days after an
admission for acute COPD exacerbation(Guecamburu M et al, 2023).
In United States, studies among Medicare beneficiaries with COPD
showed an uptake ranging from 1.9% to 4%(Spitzer KA, et al, 2019).
The percentage of Medicare beneficiaries with COPD receiving PR
increased from 2.6% in 2003 to 3.7% in 2012 41 while in a
subsequent study showed an increase from 2.5% in 2013 to 4.0% in
2019(Bhatt SP et al. 2024).

32. Barriers for pulmonary rehabilitation:
1-Patient and healthcare professional HCPs related factors:
Lack of knowledge of PR from both the HCPs and the patient
(HCPs therefore must not only know about PR but also be
able to inform the patients about the benefits of PR).
Active cigarette smokers and patients with co-morbidities
such as depression have been shown to have lower PR
uptake.
Lower socioeconomic status, older age and black race have
been shown to be associated with decreased PR uptake.

33. Barriers for pulmonary rehabilitation:
2-systemic factors:
Suboptimal reimbursement for PR is a major limiting
factor in the referral and expansion of PR programs.
Poor access to PR centers is certainly a major factor in
suboptimal PR uptake (Spitzer et al 2019, showed that
patients living more than 10 miles or 30 minutes away
from a PR center were half as likely to initiate PR).
lack of standardization of PR and lack of trained
providers who can provide PR.

34. Summary of Key Points:
Pulmonary rehabilitation has evolved from basic rest therapy to a
multi-disciplinary, evidence-based intervention.
Precision PR represents the future of rehabilitation, leveraging
technology and personalized data.
PR significantly improves exercise tolerance, dyspnea, quality of life,
and even survival in chronic lung diseases (e.g., COPD, ILD).
PR is Proven to positively influence pathophysiological mechanisms
like ventilation efficiency, muscle function, and systemic inflammation.
A National PR Action Plan similar to the National COPD Action Plan
should be implemented to overcome PR barriers (as said by Carolin
Rochester, 2024).

35. References:
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36. References:
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38. References:
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