Pulmonary rehabilitation explained

Pulmonary rehabilitation
Synonyms:	Respiratory rehabilitation
Othercodes:	None universally accepted^[1]

Pulmonary rehabilitation, also known as respiratory rehabilitation, is an important part of the management and health maintenance of people 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]

Medical uses

The NICE clinical guideline on chronic obstructive pulmonary disease 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)”.^[5] It is indicated not only in patients with COPD, but also for the following conditions:

• Cystic fibrosis^[6]
• Bronchitis
• Sarcoidosis^[7]
• Idiopathic pulmonary fibrosis^[8]
• Before and after lung surgery^[9]
• Interstitial lung disease: Pulmonary rehabilitation may be safe and may help improve functional exercise capacity, a person's short-term quality of life, and improve shortness of breath (dyspnoea).
• Asthma: moderate quality evidence suggests asthmatics may have improvement in quality of life and exercise capacity.^[10]
• Before and after lung transplant^[11]
• Pulmonary hypertension: exercise-based pulmonary rehabilitation has been shown to reduce mean pulmonary artery pressure and increase exercise capacity.^[12]

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 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.^[13]
• Reduction in the number of exacerbations in patients who performed daily exercise when compared to those who did not exercise.^[14]
• Reduced exacerbations post pulmonary rehabilitation.^[15]

Weaknesses addressed

• Ventilatory limitation^[16]
  • Increased dead space ventilation
  • Impaired gas exchange
  • Increased ventilatory demands due to peripheral muscle dysfunction
• Gas exchange limitation
  • Compromised functional inspiratory muscle strength
  • Compromised inspiratory muscle endurance
• Cardiac dysfunction
  • Increase in right ventricular afterload due to increased peripheral vascular resistance.
• Skeletal muscle dysfunction^[17]
  • 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

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 primarily on the rehabilitation of the patient, the family is also involved. The process typically does not begin until a medical examination 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, and 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 preventive healthcare (i.e., vaccination).

Exercise

Exercise is the cornerstone of pulmonary rehabilitation programs. Although exercise training does not directly improve lung function, it causes several physiological adaptations to exercise that 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 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., respiratory therapist, physiotherapist, exercise physiologist). Additionally, pursed lip breathing can be used to increase oxygen level in the patient's body. Breathing games can be used to motivate patients to learn the pursed lip breathing technique.

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.^[18]
• British Thoracic Society Standards of Care (BTS) Subcommittee on Pulmonary Rehabilitation has published its guidelines in 2001.^[19]
• Canadian Thoracic Society (CTS) 2010 Guideline: Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease.^[20]
• National Institute for Health and Care Excellence (NICE) Guidelines^{[21] [22]}

Contraindications

The exclusion criteria for pulmonary rehabilitation consists of the following:

• Unstable cardiovascular disease
• Orthopaedic contraindications
• Neurological contraindication
• Unstable pulmonary disease^[23]

Outcome

The clinical improvement in outcomes due to pulmonary rehabilitation is measurable through:

• Exercise testing using exercise time
• Walk test using the 6-minute walk test
• Exertion and overall dyspnoea using the Borg scale
• Respiratory specific functional status has been shown to improve using the CAT Score^[24]

Notes and References

1. Web site: Sweeney G . Pulmonary Rehabilitation. 8 June 2011.
2. Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J, Carone M, Celli B, Engelen M, Fahy B, Garvey C, Goldstein R, Gosselink R, Lareau S, MacIntyre N, Maltais F, Morgan M, O'Donnell D, Prefault C, Reardon J, Rochester C, Schols A, Singh S, Troosters T . 6 . American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation . American Journal of Respiratory and Critical Care Medicine . 173 . 12 . 1390–1413 . June 2006 . 16760357 . 10.1164/rccm.200508-1211ST .
3. Web site: Sharma S, Arneja A, Massagli TL . Talavera F, Salcido R, Kishner S . Pulmonary Rehabilitation. eMedicine. 8 June 2011.
4. Web site: Pulmonary Rehabilitation. AARC Clinical Practice Guideline. Respiratory Care. 8 June 2011.
5. Web site: CG101 Chronic obstructive pulmonary disease (update): full guideline . https://web.archive.org/web/20120905215233/http://www.nice.org.uk/nicemedia/live/13029/49425/49425.pdf . 5 September 2012 . National Clinical Guideline Centre . Royal College of Physicians of London . 2004 .
6. Kalamara EI, Ballas ET, Pitsiou G, Petrova G . Pulmonary rehabilitation for cystic fibrosis: A narrative review of current literature . Monaldi Archives for Chest Disease = Archivio Monaldi per le Malattie del Torace . 91 . 2 . March 2021 . 33792230 . 10.4081/monaldi.2021.1501 . 232481541 . free .
7. Guber E, Wand O, Epstein Shochet G, Romem A, Shitrit D . The Short- and Long-Term Impact of Pulmonary Rehabilitation in Subjects with Sarcoidosis: A Prospective Study and Review of the Literature . Respiration; International Review of Thoracic Diseases . 100 . 5 . 423–431 . 2021-03-30 . 33784708 . 10.1159/000514917 . 232432025 .
8. Dowman L, Hill CJ, May A, Holland AE . Pulmonary rehabilitation for interstitial lung disease . The Cochrane Database of Systematic Reviews . 2021 . 2 . CD006322 . February 2021 . 34559419 . 8094410 . 10.1002/14651858.CD006322.pub4 .
9. Şahin H, Naz İ, Aksel N, Güldaval F, Gayaf M, Yazgan S, Ceylan KC . Outcomes of pulmonary rehabilitation after lung resection in patients with lung cancer . Turk Gogus Kalp Damar Cerrahisi Dergisi . 30 . 2 . 227–234 . April 2022 . 36168581 . 9473605 . 10.5606/tgkdc.dergisi.2022.21595 .
10. Osadnik CR, Gleeson C, McDonald VM, Holland AE . Pulmonary rehabilitation versus usual care for adults with asthma . The Cochrane Database of Systematic Reviews . 2022 . 8 . CD013485 . August 2022 . 35993916 . 9394585 . 10.1002/14651858.CD013485.pub2 . Cochrane Airways Group .
11. Hume E, Ward L, Wilkinson M, Manifield J, Clark S, Vogiatzis I . Exercise training for lung transplant candidates and recipients: a systematic review . European Respiratory Review . 29 . 158 . 200053 . December 2020 . 33115788 . 9488968 . 10.1183/16000617.0053-2020 .
12. Morris NR, Kermeen FD, Jones AW, Lee JY, Holland AE . Exercise-based rehabilitation programmes for pulmonary hypertension . The Cochrane Database of Systematic Reviews . 2023 . 3 . CD011285 . March 2023 . 36947725 . 10032353 . 10.1002/14651858.CD011285.pub3 . Cochrane Airways Group .
13. Griffiths TL, Phillips CJ, Davies S, Burr ML, Campbell IA . Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme . Thorax . 56 . 10 . 779–784 . October 2001 . 11562517 . 1745931 . 10.1136/thorax.56.10.779 .
14. Güell R, Casan P, Belda J, Sangenis M, Morante F, Guyatt GH, Sanchis J . Long-term effects of outpatient rehabilitation of COPD: A randomized trial . Chest . 117 . 4 . 976–983 . April 2000 . 10767227 . 10.1378/chest.117.4.976 .
15. Foglio K, Bianchi L, Bruletti G, Battista L, Pagani M, Ambrosino N . Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction . The European Respiratory Journal . 13 . 1 . 125–132 . January 1999 . 10836336 . 10.1183/09031936.99.13112599 . free .
16. Killian KJ, Leblanc P, Martin DH, Summers E, Jones NL, Campbell EJ . Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation . The American Review of Respiratory Disease . 146 . 4 . 935–940 . October 1992 . 1416421 . 10.1164/ajrccm/146.4.935 .
17. Bernard S, LeBlanc P, Whittom F, Carrier G, Jobin J, Belleau R, Maltais F . Peripheral muscle weakness in patients with chronic obstructive pulmonary disease . American Journal of Respiratory and Critical Care Medicine . 158 . 2 . 629–634 . August 1998 . 9700144 . 10.1164/ajrccm.158.2.9711023 .
18. Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF, Mahler DA, Make B, Rochester CL, Zuwallack R, Herrerias C . 6 . Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines . Chest . 131 . 5 Suppl . 4S–42S . May 2007 . 17494825 . 10.1378/chest.06-2418 . free .
19. ((British Thoracic Society Standards of Care Subcommittee on Pulmonary Rehabilitation)) . Pulmonary rehabilitation . Thorax . 56 . 11 . 827–834 . November 2001 . 11641505 . 1745955 . 10.1136/thorax.56.11.827 .
20. Marciniuk DD, Brooks D, Butcher S, Debigare R, Dechman G, Ford G, Pepin V, Reid D, Sheel AW, Stickland MK, Todd DC, Walker SL, Aaron SD, Balter M, Bourbeau J, Hernandez P, Maltais F, O'Donnell DE, Bleakney D, Carlin B, Goldstein R, Muthuri SK . 6 . Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease--practical issues: a Canadian Thoracic Society Clinical Practice Guideline . Canadian Respiratory Journal . 17 . 4 . 159–168 . 2010 . 20808973 . 2933771 . 10.1155/2010/425975 . https://web.archive.org/web/20101207060226/http://www.respiratoryguidelines.ca/2010-cts-guideline-optimizing-pulmonary-rehabilitation-in-chronic-obstructive-pulmonary-disease-prac . 7 December 2010 . free .
21. Web site: Pulmonary rehabilitation service for patients with COPD . December 2006 . The National Institute for Health and Care Excellence (NICE) . the National Health Service (NHS) . https://web.archive.org/web/20110504173353/http://www.nice.org.uk/media/63F/4D/PulmonaryRehabCommissioningGuide.pdf . 4 May 2011 .
22. Web site: Pulmonary rehabilitation . https://web.archive.org/web/20120502163351/http://www.nice.org.uk/guidance/qualitystandards/chronicobstructivepulmonarydisease/pulmonaryrehabilitation.jsp . 2 May 2012 . The National Institute for Health and Care Excellence (NICE) .
23. Web site: Bhatt S . Cardio-Pulmonary Rehab . University of Alabama Medicine . 19 November 2017 .
24. Jones PW, Harding G, Wiklund I, Berry P, Tabberer M, Yu R, Leidy NK . Tests of the responsiveness of the COPD assessment test following acute exacerbation and pulmonary rehabilitation . Chest . 142 . 1 . 134–140 . July 2012 . 22281796 . 10.1378/chest.11-0309 .