Chuck Kitchen, MA, FAACVPR [email protected]
Jan 31, 2016
Chuck Kitchen, MA, [email protected]
OBSTRUCTIVE DISEASESCOPD-Chronic airway obstructionEmphysema-Hyperinflation of the
lungs, can’t get bad air outChronic Bronchitis-Chronic sputum
production and coughingAsthma-increased airway reactivity
leading to narrowing of airways
PR only covered for Moderate, Severe, Very Severe COPD
GOLD classification
Chronic lower respiratory diseases ICD-10: J40-J47
Obstructive Lung Disease: Persistent asthma: 493 Bronchitis: 491 Bronchiectasis: 494 COPD: 496 Cystic fibrosis: 277.03 Bronchiolitis obliterans: 491.8 Emphysema: 492
AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th
ed. 2010, Champaign, IL: Human Kinetics Publishers.
Restrictive Lung Diseases: Interstitial diseases: 518.89 (J84.1-9)
▪ Idiopathic interstitial fibrosis: 516.31 (J84.10-J84.111-117)▪ Other interstitial pulmonary disease with fibrosis: J84.17▪ Occupational or environmental lung disease:
518.89(Z57.31)▪ Sarcoidosis: 517.8 (Lung involvement) (D86.0, 86.2)
Chest wall diseases:▪ Kyphoscoliosis: 737.3 (M41.8)▪ Ankylosing spondylitis: 720.0 (M45.3-45.5)
AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th
ed. 2010, Champaign, IL: Human Kinetics Publishers.
Restrictive Lung Diseases, Continued: Neuromuscular diseases:
▪ Parkinson’s: 332 (G20)▪ Postpolio syndrome: 138 (G14)▪ Amyotrophic lateral sclerosis: 335.2
(G12.21)▪ Diaphragmatic dysfunction: 518.89 (J98.6)▪ Multiple sclerosis: 340 (G35)▪ Post-tuberculosis syndrome: 518.89 (A-15)
AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th
ed. 2010, Champaign, IL: Human Kinetics Publishers.
Obesity-related Respiratory Disorders: Obesity hypoventilation syndrome: 278.03 Obstructive sleep apnea: 327.23
Other Lung Disorders: Lung cancer: 162 Pulmonary hypertension: 416-417.8 ( Post-lung transplant: V42.6
AACVPR, Guidelines for Pulmonary Rehabilitation Programs. 4th
ed. 2010, Champaign, IL: Human Kinetics Publishers.
Pulmonary Rehabilitation must be the ONLY service billed using G0424
Sessions limited to a maximum of two 1-hour sessions per day for up to 36 sessions
Contractors may approve up to an additional 36 sessions when medically necessary. Providing access of up to 72 sessions of PR,
when appropriate Does not specify a duration by which sessions
must be completed; allowing the maximum allowable number of 72 over a longer period of time
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42.CFR 410.47
G0424: Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session Revenue Code: 0948 Session duration:
▪ One session = > 31 minutes▪ Two sessions = > 91 minutes, with the first
session = 60 minutes and second session = 31 minutes
Do NOT bill any other codes for the COPD patient
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Interstitial Lung Diseases Environmental-asbestos, dust, coal, etc Drugs or chemotherapy Collagen diseases (scleroderma, lupus,
etc) Pulmonary fibrosis
Vascular Lung Diseases Pulmonary Hypertension
3-5 days per week Walking (preferred) and cycle 20-60 min RPE 5-6 (Moderate) Or 7-8 (Vigorous) for
Mild COPD RPE 3-5 for Moderate to Severe COPD No upper extremity recommended Does not use GOLD criteria Strength Training-2-4 sets, 2-3
days/week
0 Nothing at all
0.5 Very, Very Light
1 Very Light2 Fairly Light3 Moderate4 Somewhat
Hard
5 Hard67 Very Hard8910 Very, Very
Hard (Maximal)
3-5 days per weekWalking, cycle, arm ergometry,
warm-up and cool down20-90 minutes per session Intensity to achieve patient goalsUpper extremity exercise with lower
extremity (arm ergometer)Strength Training-Hand weights, free
weights, machine weights
3 days per weekCycling or walking> 3o minRPE 4-6 or predetermined MET levelArm ergometer, free weights, elastic
bandsStrength training-2-4 sets 6-12 reps
6 Min Walk Test-Widely used tool to determine exercise prescription
Determine initial exercise intensity
F.I.T.T PRINCIPLEFrequency Intensity Time Type
FREQUENCY3 to 5 times per week
INTENSITY4-6 Borg Dyspnea scale12-14 RPE scale
INTENSITYDYSPNEA SCALE (Modified Borg)
0 None 5 Severe0.5 Very, Very slight 61 Very slight 7 Very
Severe2 Slight 83 Moderate 9 Very, Very
Severe4 Somewhat severe 10
Maximum
67 very, very light89 very light1011 light1213 somewhat
hard
1415 hard1617 very hard1819 very, very hard20
INTENSITYINTENSITYRPE SCALERPE SCALE
TIME20 to 6o minutesCan use interval training especially
for beginners or low level patientsTotal exercise time is most important
TYPEContinuous AerobicHigh Intensity Interval Training not
found to have same benefits as with Cardiac Population (CHF, etc)
Possibly due to DyspneaLow to moderate intensity interval
training can be usedResistance Training
No data for “optimal” resistance training program
Important to help maintain muscle mass (muscle wasting)
1-3 sets8-12 repetitions2-3 days per week
Exercise capacity often limited by dyspnea, not MET level or RPE, etc
SaO2 MonitoringSupplemental O2 to maintain 88%-90%Generally, cycle or other non weight
bearing equipment has higher O2 satsConsider continuous exercise on cycle,
recumbent stepper, etc. Interval on TM
Take bronchodilators prior to exercise
Short term benefits from PRSmaller improvements and shorter
lastingTypically more dyspnea than
obstructive diseaseGenerally more reliant on
supplemental O2
Careful to maintain O2 sats above 88%-90%
Monitor BP and HRConsider telemetry monitoringExercise Intensity should be light to
moderate ONLYMonitor for lightheadedness, chest
pain, etc
AACVPR and ACCP do not recognize IMT as part of Pulmonary Rehab
Devices used to impose resistance or load
Patients increase inspiratory muscle strength
Significant decreases in dyspnea Increased walking distance However, no increase in peak power Increased quality of life measures
Exercise Prescription is an Art!!Every patient is different
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American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 4th ed. Champaign, IL; Human Kinetics, 2010.
Garvey C, Fullwood MD, Rigler J. Pulmonary Rehabilitation Exercise Prescription in Chronic Obstructive Lung Disease. JCRP 2013; 33: 314-322
Johnson-Warrington V, Harrison S, Mitchell K, et al. Exercise Capacity and Physical Activity in Patients With COPD and Healthy Subjects Classified as Medical Research Council Dyspnea Scale Grade 2. JCRP 2014; 34(2): 150-154
Ryerson CJ, Cayou C, Toop F, et al. Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: A prospective cohort study. Respir Med 2014; 108(1): 203-210
Spruit MA, Singh SJ, Garvey C, et al. An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation. Am J Respir Crit Care Med 2013; 188(8): e13-e64