Pulmonary Rehabilitation

Podcast Transcript

Raed Dweik, MD (00:04):

Hello and welcome to the Respiratory Inspirations Podcast. I'm Raed Dweik, chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care yourself and your loved ones. I hope you enjoy today's episode.

Umur Hatipoglu, MD (00:39):

Hello, everyone. I am Umur Hatipoglu, MD. I am the enterprise medical director for respiratory therapy at the Cleveland Clinic and professor of medicine at the Cleveland Clinic Lerner College of Medicine. I'm going to host this podcast on pulmonary rehabilitation, and I am delighted to have Debasis Sahoo, MD with me. Dr. Sahoo is the director of pulmonary services and pulmonary rehabilitation at Marymount and South Pointe Hospitals, and also leads the enterprise effort for integrating pulmonary rehabilitation. Welcome, Debasis.

Debasis Sahoo, MD (01:11):

Thank you, Dr. Hatipoglu for having me here.

Umur Hatipoglu, MD (01:14):

Debasis, it's my pleasure. So you and I are both believers in pulmonary rehabilitation, and we've seen the wonders that the intervention can do for patients. But I want to just delve into this a little bit deeper with you for our patients so they understand how important this is, what it entails, and how they can ask for this intervention if they needed it.

(01:40):

So let's start with that simple question. What is pulmonary rehabilitation and what are the necessary components of a pulmonary rehabilitation program?

Debasis Sahoo, MD (01:49):

So pulmonary rehabilitation is a comprehensive intervention. Okay? After patient assessment, a patient-tailored regime not only limited to, to exercise, but also includes psychosocial assessments, behavioral changes, behavioral modifications to help improve chronic respiratory and distress.

(02:17):

Now, the complement of this, like I said, the core complement is always going to be exercise training. But it is not limited to it. Now when you talk about exercise training, we talk about endurance exercise training, which normally is walking on a treadmill or a walk or bicycling, a recumbent bicycle. You talk of interval training, where we increase high-intensity intervals to help with muscle strength, resistance training, flexibility training, breathing exercises, but also other stuff which include psychosocial assessment. Most of the patients with chronic respiratory diseases have some sort of an anxiety or depression. We assess and have psychologists and behavioral modifications that help.

(03:12):

We assess nutrition. Most of these patients can be in extremes, you know? They can be malnourished, or they can be overweight, and we educate about how to eat, what to eat. And it entails a large amount of education in terms of chronic respiratory diseases. This can be medication usage, medication adherence, oxygen, nebulization, airway clearance techniques, etc. Even to the extent, we also help talk about end of life, goals of care in these educational details.

Umur Hatipoglu, MD (03:52):

Yeah, that's great. I always feel bad because we load so much on patients in the brief clinic visits that they have with us.

Debasis Sahoo, MD (03:59):

Mm-hmm.

Umur Hatipoglu, MD (04:00):

And I have heard many patients tell me, "Hey, you know, I really learned how to use my inhaler in the pulmonary rehabilitation program, how to breath, how to use my diaphragm in the pulmonary rehabilitation program, so this is hard to overemphasize.

(04:16):

So, we know that pulmonary rehabilitation is for patients with lung disease, but is it appropriate for everyone? Can you be too ill, or can you have the wrong disease? Give us an idea about that landscape.

Debasis Sahoo, MD (04:28):

So I don't think there is any absolute contraindication in terms of respiratory illness, that you have too much of oxygen use and you cannot come and do the program. I think there are some acute diseases that you may be having, and you should not do it, like if you have acute heart failure or you recently had an MI or you have symptomatic angina or have had diseases that will restrict you. But if you can follow instructions and you can exercise, then I think everybody is entitled to pulmonary rehabilitation who have chronic respiratory diseases.

Umur Hatipoglu, MD (05:15):

Yeah. And, you know, one important thing is, I guess, the supervision, right? People worry that something will happen to them while they exercise. And you are working with these, you know, professionals around you who'll catch you if you fall, right?

Debasis Sahoo, MD (05:28):

Yes, so this is a good question. So when we do pulmonary rehabilitation, actually there are guidelines set by organizations that maintain patient-to-provider ratio. For every four patients, we actually have one provider, which could be either respiratory therapist, exercise physiologist, and LPN, which supervise their patients during the program.

(05:58):

If you actually have a high fall risk patient, this actually further changes from one to two ratio to ensure when the patient is actually doing physical activity in rehab, the provider stands besides the patient during the exercise to ensure there is no injury to the patient.

Umur Hatipoglu, MD (06:18):

That's fantastic. I also heard that when you're in the hospital because of a worsening of your respiratory illness, pulmonary rehabilitation started early can help. Can you give us a little bit more insight into that?

Debasis Sahoo, MD (06:32):

Yes. So when we look at the old data, most of the times patients used to wait to get a little bit better before they were referred to the pulmonary rehab. The new data actually suggests that people can undergo pulmonary rehabilitations inside the hospital before they are discharged. And that neither altered the outcome or they increased the length of stay. In fact, help hastened quicker recovery in these patients who had exacerbations for COPD and who enroll early in pulmonary rehabilitation.

Umur Hatipoglu, MD (07:13):

That's fantastic to know. You know, we order pulmonary rehabilitation, and I remember we had done a study with one of our fellows in the past. Some 13% of the patients who had pulmonary rehabilitation ordered actually ended up completing pulmonary rehabilitation. So there is so many barriers to ... You know, access barriers, and then financial barriers, transportation barriers. How do we make this more accessible for our patients? What are we doing as an institution for instance?

Debasis Sahoo, MD (07:44):

So we are trying to grow something called tele-rehabilitation. Tele-rehabilitation is a service that patients at home will undergo a structured pulmonary rehabilitations. In these structures, there will be a person who monitoring you during your exercise. There are programs that have provided arm cycle ergometers, recumbent bikes, and portable oxygen and heart rate monitors which are tele-transmitted and can be used during the home exercise rehabilitations. There is no clinical practice guiding model. There are various models now available, but this is something that the future is looking into.

(08:37):

As term of an institution, we are working a lot like in terms of finance. We know that there is a significant copay in patients who have Medicare and are asked to enroll in pulmonary rehabilitation. We have sat down with financial, and most of the times we actually waiver off the copay in patients who come for pulmonary rehabilitation to us by sending for financial support.

(09:09):

In terms of transportation, that tends to be a big issue. We have taken steps, small, in the hospital that I am the medical director at Marymount and South Pointe. We have actually worked with the transportation in a radius of three to five miles. If anybody doesn't have transportation, we do send the bus to pick them up and drop them back for pulmonary rehabilitation. This is also an institute-based approach that we have done.

Umur Hatipoglu, MD (09:39):

That is fantastic. So the other question I get is, when I approach a patient for pulmonary rehabilitation, they say, you know, they wanna do it on their own. They have machines at home or a treadmill or something like that. What do you say to them?

Debasis Sahoo, MD (09:56):

So again, (laughs)-

Umur Hatipoglu, MD (09:57):

By the way, this is not common.

Umur Hatipoglu, MD (09:59):

Right?

Debasis Sahoo, MD (09:59):

... yeah.

Umur Hatipoglu, MD (09:59):

Not everybody has a treadmill and then-

Debasis Sahoo, MD (09:59):

(laughs)

Umur Hatipoglu, MD (10:00):

... you know, bike at home. But those people who wanna do it all by themselves.

Debasis Sahoo, MD (10:06):

I believe structure is success. Okay?

Umur Hatipoglu, MD (10:10):

Mm-hmm.

Debasis Sahoo, MD (10:10):

People don't follow a certain structure do not get the benefit of the program. We know that people who do high-intensity exercise benefit more than low-intensity exercise. But that doesn't mean that, you know, if you don't for whatever reasons don't want to do it through the structured program, you can't do it. You can set up a meeting and do an intake. I normally recommend doing an intake and doing a few sessions to get an idea of how much you can do. And then you go ahead and do the remaining at home. Or else, you tend to do activity and monitor your level of activity by this newer device and my like watch that check how many steps you can take and show that you are consistently doing some sort of physical activity. And this has been studied. The more steps you take, well normally more than 5,000 - 6,000 steps has shown benefit in patients in terms of exercise and shortness of breath.

Umur Hatipoglu, MD (11:13):

Yeah, that makes sense. You first need the instruction. You wanna learn how to do it right, and then it becomes a part of your life and you also don't injure yourself. Like myself. You know, I have exercise equipment at home. I used to do it like I want to do it.

Umur Hatipoglu, MD (11:29):

You know, no pain, no gain principle? But then I came across a video, instructional video, and that made it a part of my life, and I'm now injury-free and I'm able to exercise. So a little, you know, personal story there.

(11:42):

So, let's take a patient, Debasis, who has not exercised before. In fact, they're afraid to exercise because they have a fall risk. They're unsteady. Are there solutions for those patients?

Debasis Sahoo, MD (11:55):

Yes. So normally if it is just a fall risk, we tend to send for evaluation by the physical therapy and see if that is solvable or not. If it is not, then there is something called this neuromuscular electrical stimulation. Neuromuscular electrical stimulation is the stimulation of the muscle. It is equivalent to exercise. So if you can stimulate the lower extremity, lower limb muscles, they tend to improve in terms of the muscle mass and strength, which is an important part of pulmonary rehabilitation, which is exercise of the lower extremity. And they have benefit in terms of the pulmonary rehabilitation.

Umur Hatipoglu, MD (12:40):

Wonderful. You know, the other thing, the benefit that we may not have spoken about and my patients tell me all the time, is when these patients go to pulmonary rehabilitation, they form these bonds with the people that they exercise with. Right? It's almost like an exercise community, a Facebook group of,

Debasis Sahoo, MD (12:58):

Hm.

Umur Hatipoglu, MD (12:58):

... some sorts. (laughs) Tell me a little bit about that. What do people tell you?

Debasis Sahoo, MD (13:04):

You know, in my few years of being the pulmonary director, I have these patients that have been still following up with their old buddies that-

Umur Hatipoglu, MD (13:04):

(laughs)

Debasis Sahoo, MD (13:18):

... they have become who had the disease. It's like when you have same respiratory disease and you talk about your problem and you share your problem, you tend to get quicker answers and easier, oh, this is the right thing and I must do it. And you get people when, in pulmonary rehab with the same problem and they have the same education and discussion of the problem, it tends to help them and motivate them to exercise. Like you have an exercise buddy now. You have-

Umur Hatipoglu, MD (13:18):

Mm-hmm.

Debasis Sahoo, MD (13:50):

... a same disease friend who has the same problem. And you will be surprised in the clinic. They will come. Sometimes they talk more about a friend who-

Umur Hatipoglu, MD (13:50):

(laughs)

Debasis Sahoo, MD (14:00):

... they do exercise with, rather than about themselves and how they have bonded and what all they do besides exercise outside the rehabilitation.

Umur Hatipoglu, MD (14:09):

Yeah, that's great. That’s the story I hear all the time. So it's a definite benefit for pulmonary rehabilitation.

(14:16):

So you touched upon this a little bit, but our audience may be interested in knowing, how do they preserve the benefits they get from the program? I mean, you get 32 to 36 sessions. That's, you know, typically reimbursed by insurance companies. And then after that is out-of-pocket expense. So are there any ways of maintaining those benefits? Can you tell us-

Debasis Sahoo, MD (14:39):

Yes.

Umur Hatipoglu, MD (14:39):

... our audience about that?

Debasis Sahoo, MD (14:40):

Yes. So once you complete the pulmonary rehabilitation, you normally have a discharge exercise prescription. This exercise prescription is based on the amount of exercise and the activity you were doing at the end of pulmonary rehabilitation. You are enforced or educated to go join local gyms that are there and continue to do the exercise that was suggested. There are maintenance programs that you can join. But again, the cost factor tends to be an issue.

(15:21):

So in such situations, I recommend that you should continue to do exercise in your local centers. Because if you don't exercise, the benefit of the pulmonary rehabilitation tends to wear off in six months to one year, and you are at the same point.

Umur Hatipoglu, MD (15:42):

Yeah. So it's really important to keep those benefits-

Debasis Sahoo, MD (15:46):

Yes.

Umur Hatipoglu, MD (15:46):

... maintain yourself after the pulmonary rehabilitation program.

(15:50):

Well, that's that's great. I really appreciate your helping our patients with this important knowledge. It was a pleasure having you, Debasis.

Debasis Sahoo, MD (15:50):

Thank you, Dr. Hatipoglu. It was my joy.

Raed Dweik, MD (16:01):

Thank you for listening to this episode of the Respiratory Inspirations Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter at @RaedDweikMD.