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Pulmonary rehabilitation 

Pulmonary rehabilitation
Chapter:
Pulmonary rehabilitation
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

DOI:
10.1093/med/9780198703860.003.0060
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date: 27 January 2022

Aims and patient selection

Pulmonary rehabilitation (PR) is a well-established evidence-based multidisciplinary programme of care for patients with symptomatic chronic respiratory impairment, targeting the extrapulmonary manifestations of the disease. The programme is individually tailored and should contain high-intensity progressive aerobic training, strength training, and self-management education. PR is probably the most cost-effective intervention for COPD. It interrupts the vicious cycle of dyspnoea leading to inactivity, subsequent deconditioning, and further worsening dyspnoea on more minimal exertion.

Aims of rehabilitation

  • To reduce disability in people with chronic lung disease

  • To improve QoL and restore independence

  • To diminish the health care burden of disease.

Early studies

demonstrated there were improvements in functional status with PR despite no change in severity of airflow obstruction.

Meta-analysis

of 23 RCTs, where PR included exercise training for at least 4 weeks (although the content was varied), confirmed the benefit of rehabilitation, with statistically and clinically significant improvements in functional or maximal exercise capacity and/or QoL. Symptoms of dyspnoea and fatigue are improved, and patients gain an enhanced sense of control over their condition.

Other benefits of PR

  • Patients across the disease severity spectrum of COPD (including those with severe airflow obstruction) can benefit from PR

  • Studies show patients who completed a rehabilitation course may have fewer hospital admissions for exacerbations than those who had not had rehabilitation, and hospital stays were shorter (10 days vs 21 days)

  • Respiratory muscle training improves dyspnoea, but not exercise capacity or health-related QoL, above aerobic training

  • High-intensity lower limb aerobic training is recommended, rather than low-intensity training

  • Supplemental strength training improves muscle strength but does not provide additional benefit to exercise capacity or health-related QoL than aerobic training alone

  • Early PR is recommended after a COPD exacerbation. It is safe and improves exercise tolerance, health-related QoL and reduces hospital admissions

  • Short-term programmes achieve overall similar outcome benefits across the spectrum of patient disability. A minimum programme length of 6 weeks is recommended

  • Decline in exercise tolerance and health status tends to occur between 6 and 12 months after completion of a course. Sustained improvement with ongoing rehabilitation sessions has yet to be evaluated.

Candidates

  • Anyone with chronic lung disease causing functional impairment despite receiving optimum medical treatment

  • Well-motivated patients seem to benefit most

  • Patients with poor lower limb mobility may still benefit from upper limb exercise and the education package

  • O2 therapy is not a contraindication to rehabilitation

  • Recent exacerbation of COPD is not a contraindication

  • Stable ischaemic heart disease and heart failure are not contraindications

  • Depression should be addressed prior to participation in PR, if possible, to increase the likelihood of benefit.

Candidates in whom rehabilitation may not be indicated

  • Unstable ischaemic heart disease, severe valvular heart disease, severe cognitive impairment, or locomotor difficulties

  • Poorly motivated people, with geographical or transport problems making attendance difficult, tend to do less well. It may be, however, that different locations (community or home-based) and different interfaces (manuals or web-based) may help these challenges of hospital-based programmes.

Further information

BTS guideline on pulmonary rehabilitation in adults. Thorax 2013;68(Suppl 2).Find this resource:

Pulmonary rehabilitation: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007;131(5 Suppl):4S–42S.Find this resource:

Puhan M et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2009;1:CD005305.Find this resource:

Nici L et al. ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006;173:1390–413.Find this resource:

Troosters T et al. Pulmonary rehabilitation in COPD. Am J Respir Crit Care Med 2005;172:19–38.Find this resource:

Lacasse Y et al. Pulmonary rehabilitation for COPD (Cochrane review). Cochrane Database Syst Rev 2002;3:CD003793.Find this resource:

Salman GF et al. Rehabilitation for patients with COPD: meta-analysis of RCTs. J Gen Intern Med 2003;18(3):213–21.Find this resource:

BTS statement on pulmonary rehabilitation. Thorax 2001;56:827–34.Find this resource:

Griffiths TL et al. Results at one year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000;355:362–68.Find this resource:

Programme

Programmes are usually run on an outpatient basis but can be done in the community, home, or as an inpatient. They are run by a multiprofessional team—physician, physiotherapist, occupational therapist, dietician, nurse, pharmacist, social worker, and psychologist. A minimum programme length of 6 weeks is recommended. Programmes should be regularly audited by the department.

  • Physical training The main component of the programme is progressive high-intensity aerobic exercise, such as walking and cycling, for a minimum of 2–3 times per week, with two supervised/class sessions. The prescription is individualized, and the benefits are improved with higher-intensity training. Upper or lower limb strength exercise with weights is often included. O2 supplementation may be required if significant desaturation occurs during exercise to below 80% and if exercise tolerance improves with O2

  • Performance enhancement has been investigated. Improvements shown with: tiotropium, in addition to PR, vs PR alone, NIV, partitioned training (single leg cycling), testosterone (improves muscle strength). No improvement with: creatine, O2. Neutral or subgroups: helium hyperoxia, nutrition

  • Disease education

  • Psychological and social intervention with advice on anxiety and depression, smoking cessation, plus physiotherapy and occupational therapy input

  • Nutritional education to optimize body weight and muscle mass.

Pre-rehabilitation assessment

  • Optimize medical treatment

  • O2 saturation on exercise

  • ECG may be warranted, especially if history of cardiac disease.

Outcome assessment measures

  • Exercise performance Often with SWT or 6MWT to assess ability and progress (see Box 60.1)

  • Health status Disease-specific questionnaires:

    • Chronic Respiratory Questionnaire (CRQ)

    • St George’s Respiratory Questionnaire

    • Generic questionnaires, e.g. the Short Form-36 (SF-36)

    • Hospital Anxiety and Depression scores (HADS) are measured

  • Practical Pedometers can be used for direct feedback and to improve performance.

Future developments

  • Access to PR for all who may benefit

  • How to optimally maintain the improvements following a rehabilitation programme

  • Using technology to enhance compliance and delivery of PR

  • Expanding the potential population who may benefit from PR

  • Further understanding the mechanisms of health benefits from improving physical activity

  • Targeting exercise training earlier in the disease process.