pulmonary rehabilitation in lung cancer
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PULMONARY REHABILITATION IN LUNG CANCER
Dr. Tuğba GÖKTALAYCelal Bayar University
Department of PulmonologyManisa
Conflict of interest
Support for participation in the congress and the course (last 3 years)› Deva › GSK› Bayer
Presentation Plan
Rationale of pulmonary rehabilitation in lung cancer
Goals of pulmonary rehabilitation in lung cancer
Pre-post operative pulmonary rehabilitation in lung cancer
Pulmonary rehabilitation approaches
Cancer-related fatigue and pulmonary rehabilitation
Conclusion
Pulmonary rehabilitation;
Exercise capacity, Functional status, Improve health-related quality of life
(HRQOL) In patients with chronic lung problems
Chronic dyspnea and fatigue
a multidisciplinary intervention.
Cancer Rehabilitation;
Restoration of the individual to the fullest physical, social, physicological and occupational potential of which the person is capable with the limitations of the disease and therapies.
Rationale Cancer Rehabilitation;
Cancer-related fatigue
Mobility
Self-care disability
Pain
Dyspnea
Malnutrition
Psycho-social problems
Goals of Cancer Rehabilitation;
Improve health-related quality of life
Increase the functional capacity
Enhance the efficacy of treatment
Increase the oxygen consumption
Reduce chemotherapy-related fatigue
To achieve targets;
Multidisciplinary health care team,Exercise training,Patient and family education, Psycho-social and behavioral interventions
5-year survival 15.6% in lung cancer
A small amount of patients eligible for surgery curative (25%)
Cardiopulmonary comorbidities
The coexistence of COPD-Lung cancer
Males 73%, females 53%
• Loganathan R, Stover DE, Shi W, Venkatraman E. Chest 2006; 129:1305– 1312.
n=100
Lobectomy for Lung cancer
Patient with COPD
Similar postoperative DLCO and VO2max
• Greater decline in FEV1 (p=0.0002)• Increased
cardiopulmonary morbidity (p=0.04)• Lower postoperative FEV1
(p=0.0001)
• Pompili C, Brunelli A, Refai M et al. Eur. J Cardio-thoracic Surg 2010; 525-530
Postoperative effects of COPD patients undergoing lobectomy due to lung cancer
Preoperative pulmonary rehabilitation, leads to a significant increase exercise capacity, dyspnea and health-related quality of life in this patients.
Shannon VR. Current Opinion in Pulmonary Medicine 2010;16:334–339
PR for patients with advanced NSCLC
n=11
Pulmonary rehabilitation; 2 times/week, 8week Aerobic and strengthening
exercises
• Reduction in symptoms
• Temel JS, Greer JA, Goldberg S et al. J Thorac Oncol 2009 (4): 595-601
Survival was negatively affected?
≤48 day is not the predictor of survival*
The Swedish Cancer Study Group Proposal for Lung Cancer;**Consultation and investigations to be
completed within 4 wk, treatment should start within the next 2 weeks
*Bozcuk H, Martin C. Lung Cancer 2001; 34:243– 252.
**Myrdal G, Lambe M, Hillerdal G, et al. Thorax 2004; 59:45–49.
Prepeoperatif pulmonary rehabilitation, many patients in the window period of 4-6 weeks can be done without adversely affecting survival.
Poor performance status and exercise capacity morbidity and mortality*
Exercise capacity is a modifiable risk factor!!**
*Oga T, Nishimura K, TsukinoM, et al. Am J Respir Crit Care Med 2003; 167:544–549.
*Baser S, Shannon VR, Eapen GA, et al. Clin Lung Cancer 2006; 5:344–349.
*Brunelli A, Salati M. Curr Opin Pulm Med 2008; 14:275–281.
**Fishman A, Martinez F, Nauheim K, et al. N Engl J Med 2003; 348: 2059–2073
CPET the main outcome
SFT predictive value is not clear
Pre-operative interventions aimed at improving VO2 peak, post-operative results improve and increase surgical candidacy.*
6MWT, CPET to be used as an alternative. **
*Brunelli A, Belardinelli R, Refai M, et al. Chest 2009; 135:1260–1267.
**Cote C, Pinto-Plata V, Kasprzyk K, et al. Chest 2007; 132:1778–1785.
Efficacy of Preoperative Pulmonary
Rahabilitation in Patients
with Lung Cancer
Complete surgical resection is the most effective treatment method
Preoperative PR, recommended to reduce surgical morbidity.
Fishman A, Martinez F, Nauheim K, et al. N Engl J Med 2003; 348: 2059–2073
PR before surgery for cancer; n=19
The standard and non-standard arm
Pulmoneary rehabilitation;
Short-term(4w)A) Standard arm Accordance
with guidelines
B) Patient-based Self-
sufficiency Inspiratory
muscle training
Slow breathing training
• Benzo R, Wigle D, Novotny P, et al. Lung Cancer 2011 Dec;74(3):441-5
•Shorter duration of hospital stay of at least 3 days (p=0.058), •The number of days for chest tube was less than (p = 0.04), •The need for prolonged chest tube drainage was less than (p = 0.03).•Can be applied to the patient-based PR
The Effects of cardiorespiratory training prior to surgery
•There is a significant increase in peak VO2 and 6MWT (respectively 21%, 13%)
• Jones L. Cancer Chemother Pharmacol 2007; 110:590–598
n=13 Preoperatively and 30 days after the assessment
Pulmonary Rehabilitation;
Short-termConsecutive days from the operation1-4 week
• Peripheral muscle exercise (endurance
The effect of preoperative pulmonary rehabilitation in NSCLC
n=12 akciğer
Pulmonary Rehabilitation;
• In hospital
• Short term(1.5 h, 5day/ 4 week süreli
• Patient education;
› Smoking cessation Effective coughing Controlled breathing
techniques
• Peripheral muscle training (Endurance)
•The average increase in peak VO2 2.8mL/kg/min•Increase in exercise performance•Positive effects of cardiopulmonary
• Bobbio A, Chetta A, Ampollini L, et al. Eur J Cardio-thoracic Surg 2008;33:95–98
Preoperative PR in patients with limited performance
n=8
Candidates for surgery, patients with limited respiratory function and performance
Pulmonary Rehabilitation; Short term(4
week) Aerobic
exercise, Controlled
breathing techniques
Training sessions
• Cesario A, Ferri L, Galetta D, et al. Lung Cancer 2007; 57:118–119.
•Increase in 6MWT (47%)•Increase in PaO2 (7,2mmHg)•Increase in Pulmonary function (FEV1, FVC)
Cost-effectiveness of PR before lobectomy
n=119
• Reduction of postoperative atelectasis (p= 0.003)• Reduction in length of hospital stay• Cost reduction
• Varela G, Ballesteros E, Jimenez MF et al. Eur J Cardio-thoracic Surg 2006; 216-220
•Exercise capacity improved•Shorter duration of hospital stay•Reduces postoperative pulmonary complications•Preserved lung function after surgery in patients with COPD
Preoperative PR is useful?
• Nagarajan K, Bennerr A, Agostini P et al. Interact Cardiovascular Thorac Surg 2011; 300-302
The benefits of preoperative pulmonary rehabilitation;
Shorten length of hospital stay, Improves postoperative complications,
reduces complications, Improves exercise capacity after surgery, Creates a positive impact on the post-
operative period of cardiopulmonary, Borderline patients eligible for surgery
makes Cost-effective
Efficacy of Postoperative Pulmonary
Rahabilitation in Patients with Lung
Cancer
Pulmonary rehabilitation after surgery, 6-9 weeks is continued.
PR in patients undergoing radical treatment
n=16
12 week multidisciplinary PR program
Pulmonary Rehabilitation;
Resistance and endurance exercise
Nutritional assessment Dyspnea and fatigue
assessment (CRDQ)
• Salhi B, Demedts I, Simpelere A et al. Rehabilitation Research and Practice 2010, Article ID 481546, 7 pages, doi:10.1155/2010/481546
•Improved exercise capacity•Increased muscle strength •Improved Quality of life (dyspnea and fatigue)
The effect of postoperative PR in NSCLC
Cesario A, Ferri L, Galetta D, et al. Lung Cancer 2007; 57:175–180
• Improvement in respiratory function• Improvement in exercise capacity
Postoperative PR in NSCLC
n=103
Patients undergoing surgery for NSCLC
• Cesario A, Dall’Armi V, Cusumano G et al. Lung Cancer November 2009, 66(2); 268–269
• Improvement in exercise capacity• Improvement in respiratory function• Improvement in the perception of dyspnea• Improvement in SaO2• Improvement in BODE index
Effect on exercise capacity in postoperative PR
n=10
Surgery, Surgery + RT, Surgery + RT+ KT
Pulmonary rehabilitation; 8 week Multidisciplinary
Increase the capacity of doing work
• Spruit M, Janssen PP, Willemsen SC, et al. Lung Cancer 2006; 52:257–260.
(P=0.0020) (P=0.0078)
•Increase in 6MWT (43%) and peak work load (34%)
The benefits of postoperative pulmonary rehabilitation;;
Increases exercise capacity
Increases muscle strength
Provides symptom control
Improves quality of life
Shorten length of hospital stay
Pre-Post operative Pulmonary Rehabilitation Approaches
Smoking cessation Assessments of patients;
Functional limitations Exercise capacity
Airway clearance and pulmonary expansion techniques Assisted coughing Insentive spirometry NIMV
Energy conservation strategies Transfer-mobility Prevention of venous thromboembolism Pain control Stress and anxiety management Nutritional evaluation / support
The effect of fast-track PR after lobectomy
n=109
Avoidance of long-term preoperative benzodiazepine
Early extubation
Patient-controlled analgesia
Early ambulation
Oral nutrition
•Shortening length of hospital stay •Reduction in complication
• Das-Neves-Pereira JC, Bagan P, Coimbra-Israel AP et al. Eur J Cardio-thoracic Surg 2009; 383-392
Cancer Related Fatigueand
Pulmonary Rehabilitation
Fatigue
Shortness of breath
Involuntary weight
loss
Cancer Related Fatigue (CRF)
70-100 % *
CRF during or after treatment
Decrease in activity participation and life**
*Mock V. Cancer. 2001;92(6 suppl):1699–1707 **Curt GA, Breitbart W, Cella D, et al. Oncologist.
2000;5:353–360
CRF
Cancer- related fatigue is a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion to cancer or cancer treatment that is not proportional to recent activity and interferes with unusual functioning.
NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue
CRF
May be isolated or accompanied by other symptoms such as pain, distress, anemia, and sleep disorders
Patient-specific systematic assessment should be performed
Guides should be approached with a multidisciplinary applied
Rehabilitation should begin with the cancer diagnosis
• NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue
• Wagner LI, Cella D. British Journal of Cancer (2004) 91, 822 – 828
Causes of cancer-related fatigue
Approach to cancer-related fatigue
Non-pharmacologic
Activity enhancement Maintain optimal level of activity /Exercise prescription/ Exercise training Energy conservation techniques
Education Psychosocial interventions
Assessment/support (Stress management /Relaxation ) Nutritional assessment /support Sleep assesment Cautions:
Bone metastasis Immunosuppression / neutropenia Thrombocytopenia Anemia Fever Limitations due to metastasis or co-morbidities
• NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue
CRF CRF is associated with muscle mass and strength. *
The most common symptom, fatigue Increased fatigue, associated with low physical
activity levels. Physical activity level, regardless of age,
significant in predicting the level of fatigue.
Physical activity level, a factor that can be changed in CRF.**
• *Kilgour RD, Vigano A, Trutschnigg B et al. J Cachexia Sarcopenia Muscle (2010) 1:177–185
**Luctkar-Flude M, Groll D, Woodend K, et al. Oncol Nurs Forum. 2009 Mar; 36 (2):194-202
•Exercise; reduces fatigue, increases walking, improves the quality of life
• Wagner LI, Cella D. British Journal of Cancer (2004) 91, 822 – 828
The benefits of pulmonary rehabilitation in CRF;
Reduces fatigue
Provides symptom control
Increases the functional capacity
Improves the quality of life
Pulmonary Rehabilitation;
Makes it ready for surgery patients with borderline
Shorten length of hospital stay, cost-effective
Reduce the complication rates Accelerate recovery after surgery Provides symptom control Improves cancer-related fatigue and
quality of life
THANKS
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