PULMONARY HYPERTENSION AND EXERCISECARDIOPULMONARY REHABILITATION Rajan Joshi MD

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

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

INTRODUCTION TO PULMONARY HYPERTENSION Definition and Classification of PH Epidemiology of PH Pathophysiology Prognosis of PH in PH Diagnosis: Treatment Assessing patient with PH of PH

HEMODYNAMICS & O 2 SATURATIONS IN NORMAL HEART

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 >25 mm. HG End expiratory PCWP (PAOP) < 15 mm HG Pulmonary Vascular Resistance (PVR) >3 wood units

S & S OF PULMONARY HYPERTENSION

CAUSES OF PULMONARY HYPERTENSION

CLASSIFICATION OF PH

WHO PH CLINICAL CLASSIFICATION

ECHOCARDIOGRAM IN PH

ECHOCARDIOGRAM FOR DIAGNOSIS PH

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

PATHOPHYSIOLOGY OF PAH

CAUSES AND TREATMENT OPTIONS PH

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)

DIAGNOSIS OF PH

RIGHT HEART CATHETERIZATION (RHC)

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 VO 2, low VO 2 AT, Plateau effect of O 2 -Pulse with exercise This correlates well with Prognosis CPET is not suitable for more severe PAH

TREATMENT OF PULMONARY HYPERTENSION Traditional treatments: O 2, 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 (1 A), Avoid strenuous exercises (1 A) 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

DETERMINANTS OF DISEASE SEVERITY

FDA APPROVED TREATMENT OF PAH

WHO FUNCTIONAL CLASSIFICATION

DIAGNOSIS OF PH

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)

SUMMARY OF PAH

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 6 MWD by 60 m, peak VO 2 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(96 m vs -15 m) Following cross over: sedentary group also improved mean 6 -MWD by 74 m Exercise training improved WHO Fc class and VO 2 max. Exercise training did not improve Hemodynamic abnormalities like PASP

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 O 2 liberally Type of Programs: Cardiac vs Pulmonary rehabilitation

EXERCISE & PAH Symptoms of disease make exercise more difficult Deconditioning Improvements come from improving muscle strength, coordination of breathing with muscle activity, improved breathing techniques Efficient use of respiratory muscles with improved O 2 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

EXERCISE & PAH Exercise and respiratory training improve Exercise capacity and HRQOL 15 patients each in training and control groups VO 2 AT and VO 2 max improved in training group Dyspnea and VE improved with exercise in PAH patients Ref: Circulation 2006: 114(1482 -89)

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 O 2 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

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)

POINTS TO CONSIDER: EXERCISES TRAINING IN PH Continuous Heart rate, cardiac rhythm, O 2 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 O 2 sat. >88% and use O 2 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

TREATMENT OPTIONS

EXERCISE YOUR RIGHT TO BREATHE BETTER BREATHING BETTER LIVING LIVE THE LIFE YOU ALWAYS IMAGINED IMPROVING LIFE ONE BREATHE AT A TIME DO NOT GIVE UP, YOU ARE CLOSER THAN YOU THINK

CARDIO-PULMONARY REHABILITATION UKHC

UKHC, LEXINGTON. KY