Depression & anxiety in COPD patients respond well to pulmonary rehabilitation but how to proceed safely in patients with comorbid CVD?
Impact of Pulmonary Rehab on Mental Health in COPD. Depression/anxiety are higher in COPD vs the general population and are linked to decreased functioning, increased exacerbations, hospitalizations, and mortality. A new study looks at the impact of PR on anxiety and depression in COPD.
Components of Pulmonary Rehabilitation. Health behavior change, psychological health, education, smoking cessation, optimizing medical therapy, dyspnea management, aerobic, interval and/or strength training, long-term management and evaluation.
PR Impact on Depression and Anxiety.2 11 randomized controlled trials compared pulmonary rehab to usual care; 734 participants; PR defined as exercise training ≥4 weeks; most subjects had ≤8 weeks PR.
PR Benefits Clinically Meaningful.Anxiety improvement – moderate: HADS anxiety mean difference: -2.2. Depression improvement – large: HADS depression mean difference: -2.5. Program duration, age, sex, disease severity did not affect results. Moderate certainty evidence for both outcomes.
COPD, CVD, PR: What You Need to Know.3COPD linked to 2.5 times increased odds of CVD.4 CVD linked to more severe COPD, worse survival, increased hospitalizations. CV comorbidities are most common in COPD BUT also most frequently undiagnosed outside of lungs in COPD. Before PR: Conduct comprehensive CV and metabolic risk assessment.
Screen Before Initiating PR. Screen for CVD risk factors in all patients with COPD and screen carefully all patients with existing CVD and COPD.
Safety of PR in COPD with CVD. Exercise training considered safe during PR. Major CV events occur at rate of 1/50,000 to 1/120,000 patient-hours of exercise.5
Contraindications for PR in CVD Patients.
COPD-specific Considerations During PR. Exercise-induced desaturation: Prescribed oxygen may be needed during training in some normoxemic patients with heart disease. Oxygen level may need adjustment in patients already on oxygen. Dynamic lung hyperinflation: May worsen dyspnea.
Cardiac Considerations During PR. In stable CVD, ensure patient is medically optimized. For patients on diuretics, assess for risk for renal dysfunction, electrolyte imbalance -- monitor blood levels. Ensure readily available defibrillation equipment for high-risk patients and that rehab team is trained in advanced life support.
Clinical Implications of Both Studies
Effects of PR on anxiety/depression in COPD are significant and clinically relevant
Program duration did not affect results
Reassure centers where longer duration not feasible More research needed on maximizing and personalizing PR for COPD
CVD is most prevalent comorbidity in COPD
CVD should be considered when referring for PR
References
1. McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;23:CD003793. doi: 10.1002/14651858.CD003793.pub3 2. Gordon CS, Waller JW, Cook RM, et al. Effect of pulmonary rehabilitation on symptoms of anxiety and depression in COPD: a systematic review and meta-analysis. Chest. 2019; 156:80-91. doi: 10.1016/j.chest.2019.04.009. 3. Triest FJ, Singh SJ, Vanfleteren LE, et al. Cardiovascular risk, chronic obstructive pulmonary disease and pulmonary rehabilitation: Can we learn from cardiac rehabilitation? Chron Respir Dis. 2016;13:286-94. doi: 10.1177/1479972316642367. 4. Chen W, Thomas J, Sadatsafavi M, et al. Risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Lancet Respir Med. 2015;3:631-9. doi: 10.1016/S2213-2600(15)00241-6 5. Franklin BA, Bonzheim K, Gordon S, et al. Safety of medically supervised outpatient cardiac rehabilitation exercise therapy: a 16-year follow-up. Chest. 1998;114:902-6.
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Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) are common comorbidities. In fact, COPD is linked to 2.5 times increased odds of CVD. Research suggests that patients with COPD undergoing pulmonary rehabilitation (PR) may experience reductions in depression and anxiety as well as improved cardiovascular and metabolic health. But to reap these benefits safely, patients with COPD need to be carefully screened for CV comorbidities before beginning PR and monitored during the program.The slides below summarize 2 recent studies on the impact of PR on mental health in COPD and how to assess CV fitness in COPD patients.
