PULMONARY HYPERTENSION AND EXERCISE-CARDIO-PULMONARY REHABILITATION - PowerPoint Presentation

Slide1

PULMONARY HYPERTENSION AND EXERCISE-CARDIO-PULMONARY REHABILITATION

Rajan Joshi MD,FCCP, FAASM

Assistant Professor, Pulmonary Critical care, Sleep Medicine at UKHC

Medical Director, Pulmonary Rehabilitation, UKHC, Lexington. KY

TLC & Sleep Center-PR, Richmond, KY

Slide2

EXERCISE & PULMONARY HYPERTENSION

YES they can.

Progress has been made in Treatment of PAH. Well defined treatment options available now.

Early Identification and Treatment of PH is suggested since advanced disease is less responsive to therapy and Lung Transplantation may be needed

14 FDA approved drugs are available for PH

Interventional and Surgical therapies available for CTEPH

If untreated high Mortality with in 2.8 years

Better QOL is now possible

Role of Cardio-Pulmonary Rehabilitation in PH

Slide3

INTRODUCTION TO PULMONARY HYPERTENSION

Definition and Classification of PH

Epidemiology of PH

Pathophysiology of PH

Prognosis in PH

Diagnosis: Assessing patient with PH

Treatment of PH

Slide4

HEMODYNAMICS & O2 SATURATIONS IN NORMAL HEART

Slide5

DEFINITION OF PH

Screening test: Echocardiogram: Mean PAP > 25 mm HG at rest

Confirmation test: Right Heart Catheterization (RHC)

PH vs PAH

Only sub-population of patients with PH have PAH

Hemodynamically: Pre-capillary PH with mean PA pressure >25mmHG

End expiratory PCWP (PAOP) < 15 mm HG

Pulmonary Vascular Resistance (PVR) >3 wood units

Slide6

S & S OF PULMONARY HYPERTENSION

Slide7

CAUSES OF PULMONARY HYPERTENSION

Slide8

CLASSIFICATION OF PH

Slide9

WHO PH CLINICAL CLASSIFICATION

Slide10

ECHOCARDIOGRAM IN PH

Slide11

ECHOCARDIOGRAM FOR DIAGNOSIS PH

Slide12

ECHOCARDIOGRAM IN PH

Qualitative & Quantitative information

Dilation of RV/RA, Septal deformity, Pulmonic regurgitation

Tricuspid jet velocity: Estimates PASP

Correlates reasonably well with RHC PA pressures

Variability in techniques and fluid status leads to false results

Poor Tricuspid regurgitation signal

PASP in ALD difficult to measure

Slide13

PATHOPHYSIOLOGY OF PAH

Slide14

CAUSES AND TREATMENT OPTIONS PH

Slide15

DIAGNOSIS OF PH

Symptoms: Most common symptom is Dyspnea, Fatigue, Dizziness, Chest pains, Near syncope, Syncope

Focused family Hx: Sudden cardiac death, congenital heart disease, OSA, PF, COPD

Social Hx: Drug use or abuse

Screening tests: BNP, Liver functions, Thyroid functions, HIV, Hemolytic disorders, Thrombo-embolic disorders

ECG: RAD, Rt. Heart strain, RVH

PFTs, 6-MWT Oximetry, ABGs, PSG

CXR, HRCT Lungs, V/Q Lung scan

CPET

Echocardiogram

Right Heart Catheterization (RHC)

Slide16

DIAGNOSIS OF PH

Slide17

RIGHT HEART CATHETERIZATION (RHC)

Slide18

CPET IN PH DIAGNOSIS

Very helpful and relatively simple-performed by Specialist

Sensitive, specific and comprehensive measure of Exercise capacity (6-MWT)

Gold standard for assessment of Exercise capacity and maximal cardio-pulmonary response

Findings in PAH: Reduced peak VO2, low VO2AT, Plateau effect of O2-Pulse with exercise

This correlates well with Prognosis

CPET is not suitable for more severe PAH

Slide19

TREATMENT OF PULMONARY HYPERTENSION

Traditional treatments: O2, Diuretics, Digoxin, Anti-coagulants, Treat underlying disorders: OSA, IPF, COPD, Hypoventilation disorders, HF

General measures: Vaccinations, avoid pregnancy

Supportive therapy: Psycho-social support, family education

Expert referral

Supervised exercise training (1A), Avoid strenuous exercises (1A) and heavy load lifting, avoid Valsalva maneuvers

Interventional & surgical treatment for CTEPH: Endovascular catheter based thrombectomy, surgical thrombo-embolectomy, Atrial septoplasty, Lung and Heart-Lung transplantation

Slide20

DETERMINANTS OF DISEASE SEVERITY

Slide21

FDA APPROVED TREATMENT OF PAH

Slide22

WHO FUNCTIONAL CLASSIFICATION

Slide23

DIAGNOSIS OF PH

Slide24

PROGNOSIS IN PAH

Troponin elevation predicts Mortality in PAH

Meta-analysis of 8 cohort studies

49% with increased cardiac troponin died vs 18.6% with normal serum cardiac troponin

(Clinical Resp. journal Jan.2019)

Slide25

SUMMARY OF PAH

Slide26

EXERCISE IN PAH

Exercise training appears to be beneficial for patients with PAH

Meta-analysis of 5 randomized trial: PAH WHO GR. 1, Exercise programs 3-15 weeks resulted in improved exercise capacity( Increase in 6MWD by 60 m, peak VO2 increase by 2.4 ml/kg/min) and improved HRQL

Randomized cross over trial: 15 weeks of exercise training improved 6-MWD compared to sedentary controls(96m vs -15m)

Following cross over: sedentary group also improved mean 6-MWD by 74 m

Exercise training improved WHO Fc class and VO2 max.

Exercise training did not improve Hemodynamic abnormalities like PASP

Slide27

EXERCISE IN PAH

Risk of exercise highest in unstable patient

Before exercise program each patient should consult their PH and Rehabilitation physician

Unsupervised training is not recommended

If difficulty getting into program CPET may help documenting limitation but also safety of exercise program and easy prescription start into exercise program

Slow start and consistent exercises (Turtle vs Rabbit)

Avoid extremes of cold and heat

Avoid straining and heavy loads lifting, Valsalva maneuvers, Avoid stooping and bending ( Near syncope and worsening SOA)

Pacing and endurance build over longer time

Use O2 liberally

Type of Programs: Cardiac vs Pulmonary rehabilitation

Slide28

EXERCISE & PAH

Symptoms of disease make exercise more difficult

Deconditioning

Improvements come from improving muscle strength, co-ordination of breathing with muscle activity, improved breathing techniques

Efficient use of respiratory muscles with improved O2 consumption

Exercise reduces risk of other chronic diseases like Metabolic syndrome, DM but also reduces exacerbation

Improve Fc status, QOL and reduces progression of disease

Slide29

EXERCISE & PAH

Exercise and respiratory training improve Exercise capacity and HRQOL

15 patients each in training and control groups

VO2 AT and VO2 max improved in training group

Dyspnea and VE improved with exercise in PAH patients

Ref: Circulation 2006:114(1482-89)

Slide30

SELECTION OF PAH PATIENTS FOR EXERCISE

TRAINING

WHO Fc class 2 or 3

Stable PAH patients (on stable medications for 3 months)

Able to use supplementary O2 in program and outside during activities too

Contraindications: Syncopal episodes or RHF patients

Avoid exercises during acute illnesses

Avoid bending over, straining and lifting heavy loads

Ref: Review Resp. Med. 2018: 12(11) 965. Lavender et al

Slide31

POINTS TO CONSIDER:PAH and EXERCISE TRAINING

Some patients may not fit Cardiac or Pulmonary Rehabilitation

Role of Respiratory muscles training in PH is unclear unless documented Respiratory muscle dysfunction (MVV,MIP, MEP,SNIP) or other Pulmonary disorders

Strength and Endurance training is important

Weight training should target single muscle groups at low weights

Low work loads at short intervals starts ( TM or Cycle ergometers are OK)

Slide32

POINTS TO CONSIDER: EXERCISES TRAINING IN PH

Continuous Heart rate, cardiac rhythm, O2 sat. monitoring

CPET with maximum HR or 6-MWT/6-MWD max. HR measurements

70% of maximal HR may be good start point

Frequent symptoms monitoring: Dyspnea and perceived effort and fatigue monitoring by BORG scale

Monitoring helps safety assessment and guides training intensity

Maintain O2 sat. >88% and use O2 liberally

Stop exercises with Diaphoresis, Palpitations, Dysrhythmias, lightheadedness, pre-syncope, Hypotension or Syncope

Supported Ventilation with NPPV during Exercise training may be helpful

Comprehensive Care Center for PH or Center of Excellence for PAH

Slide33

TREATMENT OPTIONS

Slide34

LIVE THE LIFE YOU ALWAYS IMAGINED

EXERCISE YOUR RIGHT TO BREATHE

BETTER BREATHING BETTER LIVING

IMPROVING LIFE ONE BREATHE AT A TIME

DO NOT GIVE UP,YOU ARE CLOSER THAN YOU THINK

Slide35

CARDIO-PULMONARY REHABILITATION UKHC

Slide36

UKHC, LEXINGTON. KY