Pınar ERGÜN, Dicle KAYMAZ, Neşe DEMİR, Nurcan EGESEL, Cennet Filiz TAŞDEMİR, Fatma ŞENGÜL, İpek CANDEMİR

Pulmoner hipertansiyonlu KOAH'lı olgularda pulmoner rehabilitasyon etkinliği

Giriş: Kronik Obstrüktif Akciğer Hastalığı (KOAH), en sık sekonder pulmoner hipertansiyon (PH) nedenleri arasındadır. Günümüzde pulmoner rehabilitasyon (PR), KOAH tanılı olguların standart tedavisinde yer alması önerilen yöntemlerdendir. Bu çalışmada, PH olan KOAH tanılı olgularda multidispliner pulmoner rehabilitasyon etkinliğinin değerlendirilmesi hedeflenmiştir. Hastalar ve Metod: 2008-2013 yılları arasında merkezimize başvuran 88 stabil KOAH tanılı olgu çalışmaya alındı. 2009 ERS/ESC Rehberine göre ekokardiyografik olarak olasılık dışı Grup 1, mümkün ve olası PH olan olgular Grup 2 olmak üzere iki gruba ayrıldılar. Olguların KOAH dışında pulmoner hipertansiyon nedeni bulunmuyordu. Tüm olgulara kişiye özel multidispliner, ortalama sekiz hafta süren pulmoner rehabilitasyon (PR) programı uygulandı. PR programı öncesi ve sonrası dispne algıları MRC dispne skalası, sağlıkla ilişkili yaşam kaliteleri S. George yaşam kalitesi anketi (SGRQ), egzersiz kapasiteleri ise Artan Hızda Mekik Yürüme Testi (AHMYT) ve Endurans Mekik Yürüme Testi (EMYT) ile ve vücut kompozisyonları biyoelektriksel impedans yöntemi ile değerlendirildi. Bulgular: Tüm olgularda, PR sonrası vücut kompozisyonları [Vücut Kitle İndeksi (VKİ) p= 0.013], yaşam kaliteleri (SGRQ semp., aktivite, total p< 0.001), dispne algıları (MRC p< 0.001) ve egzersiz kapasitelerinde (AHMYT, EMYT, VO2 peak p< 0.001) istatiksel anlamlı kazanımlar izlendi. İki grubun kazanımları karşılaştırıldığında Grup 2nin EMYT kazanımın istatiksel olarak anlamlı fazla izlendi (p= 0.002). Sonuç: Pulmoner rehabilitasyon; PH olan KOAH tanılı olgularda da etkin ve güvenli bir yaklaşımdır. PHli KOAHlı olgular direkt gözetimli egzersiz eğitimi ve kronik hastalık yönetimi için pulmoner rehabilitasyon programlarına yönlendirilmeli ve kişiye özel PR programları yapılandırılmalıdır.

Pulmonary rehabilitation efficiency in COPD patients with pulmonary hypertension

Introduction: COPD is among the most common causes for secondary pulmonary hypertension (PH). Pulmonary rehabilitation (PR) is recommmended in the standard treatment of COPD. In this study, efficiency Patients and Methods: 88 patients stable COPD patients who applied to our center between 2008-2013 were enrolled. Un-likely PH patients were grouped as Group 1 while possible and likely PH cases were accepted as Group 2. There were no other cause for PH. All the patients received patient-specific, multidisciplinary 8-week PR. Dyspnea perception was assessed via MRC dyspnea scale, health-related quality of life with S. George life quality questionnaire, exercise capacity via incremental shuttle walking test and endurance shuttle walking test and body composition via bioelectrical impedance test before and after PR program. Results: In all the patients there were significant improvements in body composition (BMİ p= 0.013), quality of life (SGRQ semp., activity, total p< 0.001), dyspnea perception (MRC p< 0.001) and exercise capacity (ISWTT, ESWT, VO2 peak p< 0.001) after PR program. Improvements in Group 2 were observed to be significantly greater. Conclusion: PR is an effective and safe option in COPD patients with PH. These patients should be directed to PH programs for supervised exercise training and chronic disease management and patient-specific PR programs should be established.

PDF

___

1. Minai OA, Chaouat A, Adnot S. Pulmonary hypertension in COPD: epidemiology, significance, and management: pulmonary vascular disease: the global perspective. Chest 2010;137(Suppl 6):S39-S51.
2. Chatila WM, Thomashow BM, Minai OA, Criner GJ, Make BJ. Comorbidities in chronic obstructive pulmonary disease. Proc Am Thorac Soc 2008;5:549-55.
3. Falk JA, Kadiev S, Criner GJ, Scharf SM, Minai OA, Diaz P. Cardiac disease in chronic obstructive pulmonary disease. Proc Am Thorac Soc 2008;5:543-8.
4. Chaouat A, Naeije R, Weitzenblum E. Pulmonary hypertension in COPD. Eur Respir J 2008;32:1371-85.
5. Seeger W, Adir Y, Barbera JA, Champion H, Coghlan JG, Cottin V, et al. Pulmonary hypertension in chronic lung diseases. J Am Coll Cardio 2013;62:(Suppl 25): SD109-S16.
6. Andersen KH, Iversen M, Kjaergaard J, Mortensen J, NielsenKudsk JE, Bendstrup E, et al. Prevalence, predictors and survival in pulmonary hypertensionrelated to end-stage chronic obstructive pulmonary diseases. J Heart Lung Transplant 2012;31:373-80.
7. Burrows B, Kettel KJ, Niden AH, Rabinowitz M, Diener CF. Patterns of carddiovascular dysfunction in chronic obstructive lung diseases. N Engl J Med 1972;286:912-8.
8. Oswald-Mammosser M, Weitzenblum E, Quoix E, Moser G, Chaouat A, Charpentier C, et al. Prognostic factors in COPD patients receiving long-term oxygen therapy: Importance of pulmonary artery pressure. Chest 1995;107:1193-8.
9. Wells JM, Washko GR, Han MK, Abbas N, Nath H, Mamary AJ, et al. Pulmonary arterial enlargement and acute exacerbation of COPD. N Eng J Med 2012;367:913-21.
10. Singh, SJ, Morgan L ,Hardman AE, Rowe C, Bardsley PA. Comparison of oxygen uptake during a conventional treadmill test and the shuttle walking test in chronic airflow limitation. Eur Respir J 1994;7:2016-20.
11. Ergun P, Kaymaz D, Gunay E, Erdogan Y, Yilmaz U, Demir N, et al. Comprehensive out-patient pulmonary rehabilitation: Treatment outcomes in early and late stages of COPD. Ann Thorac Med 2011;6:70-6.
12. ODonnell DE. Hyperinflation, dyspnea, and exercise intolerance in chronic obstructive pulmonary disease. Proc Am Thorac Soc 2006;3:180-4.
13. Ciftci F, Sen E, Akkoca O, Saryal S. A comparison of cardiopulmonary exercise test and 6 minute walking test in determination of exercise capacity in chronic obstructive pulmonary disease. Tuberk Toraks 2014;62:259-66.
14. Matthay RA, Berger HJ, Davies RA, Loke J, Mahler DA, Gottschalk A, et al. Right and left ventricular exercise performance in chronic obstructive pulmonary disease: radionuclide assessment. Ann Intern Med 1980;93:234-9.
15. Mahler DA, Brent BN, Loke J, Zaret BL, Matthay RA. Right ventricular performance and central circulatory hemodynamics during upright exercise in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1984;130:722-9.
16. Kessler R, Faller M, Weitzenblum E, Chaouat A, Aykut A, Ducucolone A, et al. Natural history of pulmonary hypertension in a series of 131 patients with chronic obstructive lung disease. Am J Respir Crit Care Med 2001;164:219-24.
17. Weitzenblum E , Sautegeau A , Ehrhart M , Mammosser M, Pelletier A. Long-term oxygen therapy can reverse the progression of pulmonary hypertension in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1985;131:493-8.
18. Boerrigter BG, Bogaard HJ, Trip P, Groepenhoff H, Rietema H, Holverda S, et al. Ventilatory and cardiocirculatory exercise profiles in COPD: the role of pulmonary hypertension. Chest 2012;142:1166-74.
19. Chaouat A, Minai OA. Pulmonary hypertension in patients with COPD. Eur Respir Monogr 2012;57:138-47.
20. Burrows B, Kettel LJ, Niden AH, Rabinowitz M, Diener CF. Patterns of cardiovascular dysfunction in chronic obstructive lung disease. N Engl J Med 1972;286:912-8.
21. Oswald-Mammosser M, Apprill M, Bachez P, Ehrhart M, Weitzenblum E. Pulmonary hemodynamics in chronic obstructive pulmonary disease of the emphysematous type. Respiration 1991;58:304-10.
22. Christensen CC, Ryg MS, Edvardsen A, Skjønsberg OH. Relationship between exercise desaturation and pulmonary haemodynamics in COPD patients. Eur Respir J 2004;24:580-6.
23. Sims MW, Margolis DJ, Localio AR, Panettieri RA, Kawut SM, Christie JD. Impact of pulmonary artery pressure on exercise function in severe COPD. Chest 2009;136:412-9.
24. Grunig E, Ehlken N, Ghofrani A, Staehler G, Meyer FJ, Juenger J, et al. Effect of exercise and repiratory training on clinical progression and survival in patients with severe chronic pulmonary hypertension. Respiraton 2011;81:394-401.
25. Miyamoto S, Nagaya N, Satoh T, Kyotani S, Sakamaki F, Fujita M, et al. Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension. Comparison with cardiopulmonary exercise testing. Am J Crit Care Med 2000;161:487-92.
26. Wensel R, Opitz CF, Anker SD, Winkler J, Höffken G, Kleber FX, et al. Assessment of survival in patients with primary pulmonary hypertension: importance of cardiopulmonary exercise testing. Circulation 2002;106:319-24.
27. Cenedese E, Speich R, Dorschner L, Ulrich S, Maggiorini M, Jenni R, et al. Measurement of quality of life in pulmonary hypertension and its significance. Eur Respir J 2006;28:808- 15.
28. Raskin J, Qua D, Marks T, Sulica R. A retrospective study on the effects of pulmonary rehabilitation in patients with pulmonary hypertension. Chron Respir Dis 2014;11:153-62.
29. Mereles D, Ehlken N, Kreuscher S, Ghofrani S, Hoeper MM, Halank M, et al. Exercise and respiratory training improve exercise capacity and quality of life in patients with severe chronic pulmonary hypertension. Circulation 2006;114:1482- 89.
30. Mainguy V, Maltais F, Saey D, Gagnon P, Martel S, Simon M, et al. Effects of a rehabilitation program on skeletal muscle function in idiopathic pulmonary arterial hypertension. J Cardiopulm Rehabil Prev 2010;30:319-23.
31. Ferreira A, Garvey C, Conners GL, Hilling L, Rigler J, Farrell S, et al. Pulmonary rehabilitation in interstitial lung disease: benefits and predictors of response. Chest 2009;135:442-7.
32. Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997;155:1278-82.
33. Chan L, Chin LM, Kennedy M, Woolstenhulme JG, Nathan SD, Weinstein AA, et al. Benefits of intensive treadmill exercise training on cardiorespiratory function and quality of life in patients with pulmonary hypertension. Chest 2013;143:333-43.
34. Mainguy V, Maltais F, Saey D, Gagnon P, Martel S, Simon M, et al. Peripheral muscle dysfunction in idiopathic pulmonary arterial hypertension. Thorax 2010;65:113-7.
35. Nickel N, Golpon H, Greer M, Knudsen L, Olsson K, Westerkamp V, et al. The prognostic impact of follow-up assessments in patients with idiopathic pulmonary arterial hypertension. Eur Respir J 2012;39:589-96.
36. Grünig E, Lichtblau M, Ehlken N, Ghofrani HA, Reichenberger F, Staehler G, et al. Safety and efficacy of eercise training in vrious of pulmonary hypertension. Eur Respiır J 2012;40:84- 92.
37. Burrows B, Kettel LJ, Niden AH, Rabinowitz M, Diener CF. Patterns of cardiovascular dysfunction in chronic obstructive lung disease. N Engl J Med 1972;286:912-18.
38. Wright JL, Lawson L, Paré PD, Hooper RO, Peretz DI, Nelems JM, et al. The structure and function of the pulmonary vasculature in mild chronic obstructive pulmonary disease. The effect of oxygen and exercise. Am Rev Respir Dis 1983;128:702-7.
39. Agusti AG, Barbera JA, Roca J, Wagner PD, Guitart R, Rodriguez-Roisín R. Hypoxic pulmonary vasoconstriction and gas exchange during exercise in chronic obstructive pulmonary disease. Chest 1990;97:268-75.
40. Fujimoto K, Matsuzawa Y, Yamaguchi S, Koizumi T, Kubo K. Benefits of oxygen on exercise performance with COPD with mild hypoxemia and pulmonary hemodynamics in patients. Chest 2002;122;457-63.
41. Woodcock AA, Gross ER, Geddes DM. Oxygen relieves breathlessness in pink puffers. Lancet 1981;1:907-9. 42. Dean NC, Brown JK, Himelman RB, Doherty JJ, Gold WM, Stulbarg SM. Oxygen may improve dyspnea and endurance in patients with chronic obstructive pulmonary disease and only mild hypoxemia. Am Rev Respir Dis 1992;146:941-5.
43. ODonnell DE, Bain DJ, Webb KA. Factors contributing to relief of exertional breathlessness during hyperoxia in chronic airflow limitation. Am J Respir Crit Care Med 1997;155:530-5.
44. Somfay A, Porszasz J, Lee SM, Cassaburi R. Dose-response effect of oxygen on hyperinflation and exercise endurance in nonhypoxaemic COPD patients. Eur Respir J 2001;18:77- 84.