- Adapting. the patient to his physical handicap. by influencing.
hïs behaviour regarding the disease and by helping him to set
himself new health rules.
This entails a multidisciplinary programme. integrating education,
help in stopping smoking, psychosocial treatinent, respiratory kinesitherapy,
nutritional treatinent, and above all re-training in exercise.
Population concerned:
The people concerned are patients, often aged between fifty and eighty,
presenting dyspnea on effort which limits their daily activities, despite
maximum pharmacological treatment:
- 7% cannot wash or dress;
- 25% cannot go shopping or do odd jobs;
- 31 % cannot use any means of public transport;
- 80% are unable to go on holidays ...
In this population we mainly fmd patients sufféring from chronic
obstructive bronchopneumopathy (COBP, bronchitis caused mainly by nicotine
or secondarily of occupational origin), emphysema-primary or secondary-with
sometimes a slight participation of asthma, but also patients sufféring
from bronchiectases, kyphoscolioses, diaphragmatic paralyses-after heart
surgery, major sequelae of tuberculosis ...
Overall, they are mainly patients with a serious obstructive ventilatory
disorder: FVC included between 50 et 30% of the theoretical values,
or a restrictive disorder of at least 40%.
Education
The aim is to ùnprove knowledge of and self-management of the
disease by including the lifestyle and the observance of treatments,
with a view to the greatest possible autonomy. Education should also
help improve self-esteem, strengthen positive affects while reducing
the handicap sensation , and better manage symptoms such. as dyspnea,
and also anxiety and depression.
Respiratory kinesitherapy:
Bronchial drainage for patients with bronchial hypersecretion: controlled
cough with increased expiratory flow;
Ventilation by pursed-lip breathing, ventilation with the thorax leaning
forward, thoracoabdominal synergy;
Learning about energy saving in everyday life.
Nutritional monitoring:
In COBPs there are two situations with adverse effects on exercise
tolerance:
- Wasting caused by hypennetabolism of the ventilatory muscles, limiting
muscular performance globally, which justifies prolonged oral caloric
supplernentation corresponding to an increase of at least 30% of caloric
intakes.
- Excess weight, prejudicial to exercise tolerance, which justifies
a balanced and permanent restriction of caloric intake while keeping
muscle mass.
Re-training in exercise:
The patient can re-train in exercise by muscular reconditioning which
shifts the transition threshold of anaerobic muscle metabolism towards
more and more strenuous exercise.
The peripheral muscles rather than the respiratory muscles are worked
by re-training in exercise. The type of training involved is walking
on various types of terrain, cycling, swimming, rowing, and gymnastics
in small groups. Its efficacy is verified in programmes comprising 2
to 4 sessions (30 to 45 minutes, with an intensity limited to the threshold
at which dyspnea appears) for 4 to 6 months at specialised ambulatory
centres rather than at hospitals, and with continuation of exercise
at home in a gyrn corner. In effect the improvement is retained only
if training is continued at home at least twice a week for life.
Among the worst affected sufférers (desaturating on effort or
permanently) oxygen administration raises the possibilities of re-training
in exercise by delaying diaphragmatic fatigue and by avoiding any risk
of right cardiac insufficiency.
Results:
The following has been observed:
- An improvement in the quality of the various aspects of life: physical
mobility, dynamism, energy-fatigue, emotional reactions, sleep, social
isolation, perception of the general state of health;
- Decreasing recourse to treatinent (emergency visits, hospitalisations,
reanimations);
- A decrease in ventilatory needs and in the sensation of dyspnea
for a given effort, iraproving exercise tolerance and performance
(for example assessed by walking tests measured for 6 to 12 minutes-Mc
Gavin test);
- On the other hand the ventilatory function and blood gases remain
unchanged or at best stable for several years instead of getting worse
every year.
Cost of respiratory rebabilitation:
These programmes reduce:
- The annual number of days of hospitalisation;
- And for the 10% of patients who still have an occupational activity,
the number of days sick leave.
Limits:
Although we started such a programme as early as 1975 in our health
centre specialised in respiratory diseases, and have since participated
greatly in training our pneumologist colleagues, there are still not
enough respiratory rehabilitation centres and they are mainly a private
initiative. Their development is limited by the absence of a nomenclature
and therefore of tariffing, unlike the rehabilitation of patients with
coronary insufficiency in which we are also highly experienced. Nevertheless
the trend has now taken off-in March 2000, Lille will be the venue of
the fourth international congress on this therapy applicable to patients
with respiratory insufficiency or cardiac insufficiency.
Conclusions:
Respiratory rehabilitation is the best treatment for chronic respiratory
insufficiency as soon as patients complain of serious dyspnea on exercise.
Better than bronchodilator drugs and corticoids, better than oxygenotherapy,
it helps increase physical and therefore social and relational. activity
of everyday life, and therefore the quality of life of sufférers.
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J-C . PUJET