Pulmonary Pulmonary Rehabilitation in Lung Rehabilitation in Lung

CancerCancer Pınar Ergün MD.Pınar Ergün MD.

Atatürk Chest Disease and Chest Surgery Center

Pulmonary Rehabilitation and Home Care Unit

Outline;Outline; Definition and the rational of pulmonary

rehabilitation Pre-post operative Pulmonary

Rehabilitation in Lung Cancer Cancer related fatigue and pulmonary

rehabilitation Pulmonary rehabilitation and

chemotheraphy Conclusion

Pulmonary Rehabilitation;Pulmonary 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.

Turk Phys Med Rehab 2007;53:74-7

Pulmonary rehabilitation is a multidisciplinary and individualised Pulmonary rehabilitation is a multidisciplinary and individualised theraphytheraphy

OUTCOMES

Functional performanceHRQOLDyspneaCost-effectivity

PATIENT

Multi Disciplinary TEAM

Family

STAGES

Patient selectionAssessment

Rehabilitation Maintenance

Follow-up

COMPONENTSExercise training

EducationNutritional assessment / theraphy

Psychological assessment /theraphy

Pulmonary Rehabilitation for Pulmonary Rehabilitation for which diseases?which diseases?

Obstructive pulmonary diseases

COPDPersistan AsthmaBronchiectasisCystic Fibrosis

Resrictive pulmonary diseases

Intertstitial lung diseaseThoracic wall pathologiesNeuromuscular diseasesBOOP

OtherLung CancerLung CancerProstate CaBreast CaHematological malignanciesPPHPre-post OperativePre-Post Lung

TransplantationVentilatory dependent

patientObesity related pulmonary

disease

Chest 2007; 131:4-42

JCPR&P 2007; 27: 61-4

Pulmonary Rehabilitation; evidence based out-Pulmonary Rehabilitation; evidence based out-comescomes Increases in functional

capacity Decreases in dyspnea Increases in HRQOL ( Grade A)

Reduces the number of

hospital days ( Grade B)

Chest 2007; 131:4-42

Pulmonary rehabilitation should be taken into consideration as a treatment strategy in the management of Lung cancer patients regardless of the diagnosis and the disease stages.

Rationals of Rationals of pulmonary rehabilitationpulmonary rehabilitation

??

Rationals Rationals (I);(I);

Malignancy Treatment strategies, Decreased level of activity during treatment

Exercise capacity is the best independent predictor of postoperative complications.

Exercise capacity is a modifiable risk factor !!!

Physical performance Physical performance ↓↓

Cancer 2001; 92(Suppl 4): 988-997

AACVPR 2004;86-8

Rationals Rationals (II);(II); Pulmonary rehabilitation is an effective treatment

strategy in; Symptom control

DyspneaPain

Nutritional abnormality Self management Psychologic distress

TREATMENT GOAL

Increases in HRQOLIncreases in HRQOL

•Median survival in lung cancer; 1 year after diagnosis

• 5 year survival: 15 %

•HRQOL is an independent predictor of survival in Chemotherapy !!!

Chest 2007; 132(3):1–19Chest 2007; 132:234-42J Clin Oncol 2005; 23: 6865-72

Rationals Rationals (III);(III);

Rationals Rationals (IV);(IV);Cancer related fatigue syndrome;Cancer related fatigue syndrome; Impairment of physical performance Sleep disturbance Depression Cognitive dysfunction Social isolation

Multidisciplinary Multidisciplinary approachapproach

NCCN Practice Guidelines in Oncology- 2008

Chest 2006; 129: 1305-12

Rationals (V);Rationals (V); COPD and LUNG CANCER

•Males %73•Females %53

Pre-Post OperativePre-Post Operative Pulmonary rehabilitation in Pulmonary rehabilitation in Lung cancerLung cancer

Preoperative Pulmoner Preoperative Pulmoner RehabilitationRehabilitation

Potential benefitsPotential benefits Risk modification Improvements in the lung resection

outcomes and recovery

•Risk modification 20 %•Changing from high to low risk category 13.5 %

Chest 2005;128:3799-809

European Journal of Cardio-thorac Surgery, 2008

Pulmonary Rehabilitation;Inpatient Duration (1.5h,day/ 4 w)Patient education;Smoking cessationCoughingBreathing techniquesPeripheral muscle training (Endurance)

Lung Cancer 2007;57:118-19

•Sypmtom limited endurance and NMESSypmtom limited endurance and NMES

•Lobectomy + mediastinal systematic lymph node dissectionLobectomy + mediastinal systematic lymph node dissection

•0 mortality, %25 morbidity0 mortality, %25 morbidity

Jpn J Thorac Cardipvasc Surg 2005• Pulmonary rehabilitation program for high risk thoracic

surgical patients. Chest Surg Clin N Am 1997; 7:

697-706

• Factors associated with perioperative complications after pneumonectomy for primary carcinoma of the lung patients

Interactive Cardiovascular and Thoracic Surgery, 2006

Pulmonary Rehabilitation Decreases the Complication Rates

Jpn J Thorac Cardipvasc Surg 2005

Cost effective !

Cancer,2007

► Cardiopulmonary function lost due to resection was avoided

►Chance for implementing Adjuant Chemotheraphy increases!

► Improvement in the recovery period

Preoperative Pulmonary Rehabilitation The risk of delay in curative resection

??

Lung Cancer, 2001

Admition…. Duration to treatment ► mean: 48 day

Is not the predictor of survival !!!

Postoperative Pulmonary Postoperative Pulmonary RehabilitationRehabilitationPotential benefits Potential benefits Symptom control Improvements in

functional capacity Improvements in

HRQOL

Lung Cancer ,2007

IMPROVEMENTS in respiratory functions and exercise capacity

Treatment strategies;

Surgery, Surgery+ RT,

Surgery + RT+CT

•∆ 6MWT distance = 145m

•∆ Peak work rate = 26 W

Lung Cancer,2006

(P=0.0020)

(P=0.0078)

Pre-postoperatif Pulmonary RehabilitationSpecial considerations for pre- post operative

patientsSmoking cessation !Assessments of patients; ►Functional limitations ►Exercise capacity

Airway clearance and pulmonary expansion techniques

► Assisted coughing► Insentive spirometry► NIMV

Energy conservation strategies

Transfer-mobilityPrevention of venous thromboembolismPain controlStress and anxiety managementNutritional evaluation / support

Cancer-Related Fatigue Cancer-Related Fatigue Chemotheraphy Chemotheraphy

Pulmonary rehabilitationPulmonary rehabilitation

PR for Cancer-Related Fatigue PR for Cancer-Related Fatigue PR During Chemotheraphy PR During Chemotheraphy

Potential benefits; Symptom control Improvement of performance status Improvements in HRQOL Promotion of a self management for

symptom control and increase in hope

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

Fatigue should be recognised, evaluated and treated promptly for all age groups, at all stages of disease, prior to, during and following

Implementation of guidelines for fatigue management is best accomplish by interdisciplinary teams who are able to tailor interventions to the needs of the patient

NCCN Practice Guidlines in Oncology- 2008

Rehabilitation should begin with the cancer diagnosis

Fatigue in ambulatory patients with advanced lung cancer: prevalance, correlated factors and screening

Lung Cancer and FATIGUE

Conlusion:In advanced lung cancer patients, cancer related fatigue limited at least one HRQOL

Impact of dyspnea, pain and fatigue on daily life activities in ambulatory patients with advanced lung cancer.

J Pain Symptom Manage 2002;23 417-23

Conclusion:The most stressing symptom is fatigue

J Pain Symptom Manage 2001; 22: 554-64

Interventions in 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 Cautions:

Bone metastasis Immunosuppression / neutropenia Thrombocytopenia Anemia Fever Limitations due to metastasis or co-morbidities

NCCN Practice Guidlines in Oncology- 2008

NCCN Practice Guidelines in Oncology-2008 Exercise is an effective treatment

strategy in cancer related fatigue

Level of fatigue %40-50 ↓ Impairments in emotional status ↓ HRQOL

Category 1

Conlusions: Aerobic exercise can reduce fatigue and improve physical distress in cancer patients undergoing chemotheraphy

Blood, 1997

P< 0.05

Conclusion: Conclusion: Pulmonary Rehabilitation must be Pulmonary Rehabilitation must be taken into consideration of lung cancer management taken into consideration of lung cancer management for;for; Management of risk modification Improvement of lung resection outcomes and

recovery Symptom control Improvement of Cancer related Fatigue Improvement in HRQOL Promoting of self management

THANKSTHANKS