Pulmonary rehabilitation

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Pulmonary rehabilitation
Specialty{{#statements:P1995}}
Other codesNone universally accepted[1]
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Pulmonary rehabilitation is an integral part of the clinical management and health maintenance of those patients with chronic respiratory disease who remain symptomatic or continue to have decreased function despite standard medical treatment. It is a broad therapeutic concept. It is defined by the American Thoracic Society and the European Respiratory Society as an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities.[2] In general pulmonary rehabilitation refers to a series of services that are administered to patients of respiratory disease and their families, typically to attempt to improve the quality of life for the patient.[3] Pulmonary rehabilitation may be carried out in a variety of settings, depending on the patient's needs, and may or may not include pharmacologic intervention.[4]

Aim

  • To reduce symptoms
  • To improve knowledge of lung condition and promote self-management
  • To increase muscle strength and endurance (peripheral and respiratory)
  • To increase the exercise tolerance
  • To reduce length of hospital stay
  • To help to function better in day to day life
  • To help in managing anxiety and depression

Benefits

  • Reduction in number of days spent in hospital one year following pulmonary rehabilitation.[5]
  • Reduction in the number of exacerbations in patients who performed daily exercise when compared to those who did not exercise.[6]
  • Reduced exacerbations post pulmonary rehabilitation.[7]

Weaknesses addressed

  • Ventilatory limitation[8]
    • Increased dead space ventilation
    • Impaired gas exchange
    • Increased ventilatory demands due to peripheral muscle dysfunction
  • Gas exchange limitation[8]
    • Compromised functional inspiratory muscle strength
    • Compromised inspiratory muscle endurance
  • Cardiac dysfunction[8]
    • Increase in right ventricular afterload due to increased peripheral vascular resistance.
  • Skeletal muscle dysfunction[9]
    • Average reduction in quadriceps strength decreased by 20-30% in moderate to severe COPD
    • Reduction in the proportion of type I muscle fibres and an increase in the proportion of type II fibres compared to age matched normal subjects
    • Reduction in capillary to fibre ratio and peak oxygen consumption
    • Reduction in oxidative enzyme capacity and increased blood lactate levels at lower work rates compared to normal subjects
    • Prolonged periods of under nutrition which results in a reduction in strength and endurance
  • Respiratory muscle dysfunction[9]

Background

Pulmonary rehabilitation is generally specific to the individual patient, with the objective of meeting the needs of the patient. It is a broad program and may benefit patients with lung diseases such as chronic obstructive pulmonary disease (COPD), sarcoidosis, idiopathic pulmonary fibrosis (IPF) and cystic fibrosis, among others. Although the process is focused on the rehabilitation of the patient him/herself, the family is also involved. The process typically does not begin until a medical exam of the patient has been performed by a licensed physician.[4]

The setting of pulmonary rehabilitation varies by patient; settings may include inpatient care, outpatient care, the office of a physician, or the patient's home.[4]

Although there are no universally accepted procedure codes for pulmonary rehabilitation, providers usually use codes for general therapeutic processes.[1]

The goal of pulmonary rehabilitation is to help improve the well-being and quality of life of the patient and their families. Accordingly, programs typically focus on several aspects of the patient's recovery and can include: - Medication management - Exercise training - Breathing retraining - Education about the patient's lung disease and how to manage it - Nutrition counseling - Emotional support

Pharmacologic intervention

Medications may be used in the process of pulmonary rehabilitation including: Anti-inflammatory agents (inhaled steroids), Bronchodilators, Long-acting bronchodilators, Beta-2 agonists, Anticholinergic agents, Oral steroids, Antibiotics, Mucolytic agents, Oxygen therapy, or Preventative therapy (i.e. Vaccination).

Exercise

Exercise is the cornerstone of pulmonary rehabilitation programs. Although, exercise training does not directly improves lung function, it causes several physiological adaptations to exercise which can improve physical condition. There are three basic types of exercises to be considered. Aerobic exercise tends to improve the body's ability to use oxygen by decreasing the heart rate and blood pressure. Strengthening or resistance exercises can help build strength in the respiratory muscles. Stretching and flexibility exercises like yoga and Pilates can enhance breathing coordination. As exercise can trigger shortness of breath, it is important to build up the level of exercise gradually under the supervision of health care professionals (e.g. physiotherapist, exercise physiologist, doctor).

Guidelines

Clinical practice guidelines have been issued by various regulatory authorities.

  • American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation has provided evidence-based guidelines in 1997 and has updated it.[10]
  • British Thoracic Society Standards of Care (BTS) Subcommittee on Pulmonary Rehabilitation has published its guidelines in 2001.[11]
  • Canadian Thoracic Society (CTS) 2010 Guideline: Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease.[12]
  • National Institute for Health and Care Excellence (NICE) Guidelines[13][14]

Indications

The NICE clinical guideline on COPD states that “pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually MRC [Medical Research Council] grade 3 and above)”.[15] It is indicated not only in patients with COPD, but also in:

Contraindications

The exclusion criteria for pulmonary rehabilitation consists of the following:

  • Unstable cardiovascular disease[15]
  • Orthopaedic contraindications
  • Neurological contraindications

Outcome

The clinical improvement in outcomes due to pulmonary rehabilitation is measureable.

  • Exercise testing using exercise time.
  • Walk test using the 6-minute walk test.
  • Exertion and overall dyspnoea using Borg scale.
  • Respiratory specific functional status has been shown to improve using the CAT Score.[16]

References

  1. 1.0 1.1 Sweeney, Greg. "Pulmonary Rehabilitation". Retrieved 8 June 2011.
  2. Nici L; Donner C; Wouters E; Zuwallack R; Ambrosino N; Bourbeau J; et al. (2006). "American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation". Am J Respir Crit Care Med. 173 (12): 1390–413. doi:10.1164/rccm.200508-1211ST. PMID 16760357. Explicit use of et al. in: |author7= (help)
  3. Sharma, Sat. "Pulmonary Rehabilitation". eMedicine. Retrieved 8 June 2011.
  4. 4.0 4.1 4.2 "Pulmonary Rehabilitation". AARC Clinical Practice Guideline. Respiratory Care (journal). Retrieved 8 June 2011.
  5. Griffiths, T L; Phillips, C J; Davies, S; Burr, M L; Campbell, I A (30 September 2001). "Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme". Thorax. 56 (10): 779–784. doi:10.1136/thorax.56.10.779. PMC 1745931. PMID 11562517.
  6. Güell, R (April 2000). "Long-term effects of outpatient rehabilitation of COPD: A randomized trial". Chest. 117 (4): 976–83. doi:10.1378/chest.117.4.976. PMID 10767227. Unknown parameter |coauthors= ignored (|author= suggested) (help)
  7. Foglio, K.; Bianchi, L.; Bruletti, G.; Battista, L.; Pagani, M.; Ambrosino, N. (Jan 1999). "Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction". The European respiratory journal. 13 (1): 125–32. doi:10.1183/09031936.99.13112599. PMID 10836336.
  8. 8.0 8.1 8.2 Killian, Kieran J. (1 October 1992). "Exercise Capacity and Ventilatory, Circulatory, and Symptom Limitation in Patients with Chronic Airflow Limitation". American Review of Respiratory Disease. 146 (4): 935–940. doi:10.1164/ajrccm/146.4.935. PMID 1416421. Unknown parameter |coauthors= ignored (|author= suggested) (help)
  9. 9.0 9.1 Bernard, Sarah; LeBlanc, Pierre; Whittom, Francois; Carrier, Guy; Jobin, Jean; Belleau, Roger; Maltais, Francois (Aug 1998). "Peripheral muscle weakness in patients with chronic obstructive pulmonary disease". Am J Respir Crit Care Med. 158 (2): 629–34. doi:10.1164/ajrccm.158.2.9711023. PMID 9700144.
  10. Ries, AL.; Bauldoff, GS.; Carlin, BW.; Casaburi, R.; Emery, CF.; Mahler, DA.; Make, B.; Rochester, CL.; Zuwallack, R. (May 2007). "Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines". Chest. 131 (5 Suppl): 4S–42S. doi:10.1378/chest.06-2418. PMID 17494825.CS1 maint: display-authors (link)
  11. British Thoracic Society Standards of Care Subcommittee on Pulmonary Rehabilitation (31 October 2001). "Pulmonary rehabilitation". Thorax. 56 (11): 827–834. doi:10.1136/thorax.56.11.827. PMC 1745955. PMID 11641505.
  12. CTS 2010 Guideline
  13. Pulmonary rehabilitation service for patients with COPD
  14. Pulmonary rehabilitation
  15. 15.0 15.1 CG101 Chronic obstructive pulmonary disease (update): full guideline
  16. Jones, Paul W.; Harding, G; Wiklund, I; Berry, P; Tabberer, M; Yu, R; Leidy, NK (1 July 2012). "Tests of the Responsiveness of the COPD Assessment Test Following Acute Exacerbation and Pulmonary Rehabilitation<alt-title alt-title-type="short">COPD Assessment Test Responsiveness</alt-title>". CHEST Journal. 142 (1): 134–40. doi:10.1378/chest.11-0309. PMID 22281796.
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