Pulmonary Rehabilitation

Indications

General Comments

Clinical Indicators in Patients with Chronic Lung Disease Which Commonly Lead to Referral to Pulmonary Rehabilitation

  • Dyspnea/fatigue and chronic respiratory symptoms
  • Impaired health-related quality of life
  • Decreased functional status
  • Decreased occupational performance
  • Difficulty performing activities of daily living
  • Difficulty with the medical regimen
  • Psychosocial problems attendant on the underlying respiratory illness
  • Malnutrition (see Malnutrition, [[Malnutrition]])
  • Increased use of medical resources
    • Frequent Exacerbations/Hospitalizations
    • Frequent Emergency Room Visits
    • Frequent Provider Visits
  • Gas Exchange Abnormalities
    • Hypoxemia

Asthma (see Asthma, [[Asthma]])

  • xxxx

Bronchiectasis (see Bronchiectasis, [[Bronchiectasis]])

  • xxx

Chronic Obstructive Pulmonary Disease (COPD) (see Chronic Obstructive Pulmonary Disease, [[Chronic Obstructive Pulmonary Disease]])

General Comments

  • Most Patients Enrolled in Pulmonary Rehabilitation Have COPD
  • Exercise Capacity in Patients with Chronic Respiratory Disease (Such as COPD) is Impaired and Frequently Limited by Dyspnea
    • Factors Contributing to Exertional Dyspnea During Exercise in COPD
      • Defective Gas Exchange
      • Dynamic Hyperinflation
      • Increased Respiratory Load
      • Peripheral Muscle Dysfunction
  • Factors Contributing to Exercise Limitation in COPD
    • Ventilatory Limitation
      • In COPD, Ventilatory Requirements are Higher than Expected Due to the Presence of Increased Work of Breathing, Increased Dead Space Ventilation, Impaired Gas Exchange, Increased Ventilatory Demand Due to Deconditioning and Peripheral Muscle Dysfunction
      • Expiratory Airflow Obstruction with Dynamic Hyperinflation Limit Maximal Ventilation During Exercise: this leads to further increase in the work of breathing, increased respiratory muscle load, and increased mechanical constraint on the respiratory muscles
    • Gas Exchange Limitation
      • Hypoxia Directly Increases Pulmonary Ventilation Via Peripheral Chemoreceptors and Indirectly Via the Development of Lactic Acidosis
      • Supplemental Oxygen During Exercise Decreases Pulmonary Artery Pressure, Decreases Carotid Body Inhibition, Decreases Lactic Acidosis: this decreases the respiratory rate, with resulting decreased dynamic hyperinflation
    • Cardiac Limitation
      • Hypoxic Pulmonary Vasoconstriction, Hypoxic Pulmonary Vascular Remodeling and/or Injury, and Polycythemia-Induced Increase in Pulmonary Vascular Resistance Lead to Increased Right Ventricular Afterload
      • Air Trapping Elevates Right Atrial Pressure: elevated right atrial pressure may compromise cardiac function during exercise
    • Limitation Due to Lower Limb Muscle Dysfunction: commonly present in patients with chronic lung disease
    • Limitation Due to Respiratory Muscle Dysfunction
      • Although the Diaphragm in COPD Adapts to Chronic Overload and Has a Greater Resistance to Fatigue, Patients Often Have Static and Dynamic Hyperinflation (Putting Their Respiratory Muscles at a Mechanical Disadvantage): therefore, both functional inspiratory muscle strength and inspiratory muscle endurance are impaired in COPD (and respiratory muscle weakness is often present)
  • Exercise Training is the Best Available Means of Improving Muscle Function in COPD
    • Even Patients with Severe Lung Disease Can Often Sustain the Necessary Training Intensity and Duration for Skeletal Muscle Adaptation to Occur
    • Improvements in Skeletal Muscle Function After Exercise Training Result in Gains in Exercise Capacity Despite the Absence of Changes in Intrinsic Lung Function
    • Improved Oxidative Capacity and Efficiency of Skeletal Muscles Leads to Decreased Ventilatory Requirements for a Given Submaximal Work Rate: this may result in decreased dynamic hyperinflation (with a decrease in the degree of exertional dyspnea)
    • Exercise Training May Also Increase Motivation for Exercise Outside of the Rehabilitation Setting, Decrease Modd Disturbance, Decrease Symptom Burden, and Improve Cardiovascular Function

Clinical Efficacy-General

  • Pulmonary Rehabilitation Decreases Dyspnea, Decreases Health Care Utilization, Improves Quality of Life, and Increases Exercise Capacity in COPD
    • Patients with Lesser Degrees of Airflow Obstruction Derive Improvements from Pulmonary Rehabilitation than Patients with More Severe Airflow Obstruction
    • Pulmonary Rehabilitation Initiated Shortly After a Hospitalization for a COPD Exacerbation is Clinically Effective, Safe, and Associated with a Decreased Risk of Subsequent Hospital Admission
  • Pulmonary Rehabilitation Initiated During Acute or Critical Illness Decreases the Extent of Functional Decline and Hastens Recovery
  • Anxiety and Depression are Prevalent in Patients Referred to Pulmonary Rehabilitation, May Affect Outcomes, and Can be Ameliorated by Pulmonary Rehabilitation

Clinical Efficacy-Site of Pulmonary Rehabilitation

  • Meta-Analysis of Efficacy of Pulmonary Rehabilitation in Different Settings (J Clin Nurs, 2007) [MEDLINE]
    • Efficacy of Pulmonary Rehabilitation is Not Influenced by FEV1, Duration and Frequency of the Rehab, Whether Program was Lower Extremity Only Training vs Combined Upper and Lower Extremity Training, or Exercise Intensity
    • Efficacy of Pulmonary Rehabilitation is Not Influenced by Hopsital-Based vs Community-Based Program
  • Randomized Trial of Home-Based vs Outpatient-Based Pulmonary Rehabilitation in COPD (Ann Intern Med, 2008) [MEDLINE]
    • Home Pulmonary Rehabilitation is Equivalent to Outpatient-Based Pulmonary Rehabilitation: both produced similar improvements in dyspnea at 1 year
    • Most Adverse Events Were Related to COPD Exacerbations: no serious events were related to the study intervention

Clinical Efficacy-Prevention of Hospitalization for COPD Exacerbation

  • Systematic Review and Meta-Analysis of Pulmonary Rehab in the Prevention of Hospitalization for COPD Exacerbation (Chest, 2016) [MEDLINE]; n = 18 studies
    • Pulmonary Rehab Did Not Decrease the Rate of Hospitalization for COPD Exacerbation: likely due to the heterogeneous nature of patients included in observational studies and the varying standard of pulmonary rehab programs

Recommendation (American College of Chest Physicians/Canadian Thoracic Society Guidelines on the Prevention of COPD Exacerbations, 2015) (Chest, 2015) [MEDLINE]

  • In Moderate-Very Severe COPD with a Recent Exacerbation (Within 4 wks), Pulmonary Rehabilitation is Recommended to Decrease the COPD Exacerbation Rate (Grade 1C Recommendation)
  • In Moderate-Very Severe COPD with an Exacerbation >4 wks Ago, Pulmonary Rehabilitation is Not Recommended to Decrease the COPD Exacerbation Rate (Grade 2B Recommendation)

Cystic Fibrosis (CF) (see Cystic Fibrosis, [[Cystic Fibrosis]])

  • xxx

Interstitial Lung Disease (ILD) (see Interstitial Lung Disease, [[Interstitial Lung Disease]])

Clinical Efficacy

  • Study of Pulmonary Rehabilitation in Patients with Interstitial Lung Disease (Eur Respir J, 2013) [MEDLINE]
    • Pulmonary Rehab Had a Positive Impact on Functional Status and Quality of Life in Interstitial Lung Disease

Lung Cancer (see xxxx, [[xxxx]])

  • xxx

Lung Transplantation (see Lung Transplant, [[Lung Transplant]])

  • xxx

Lung Volume Reduction Surgery

  • xxx

Pulmonary Hypertension (see Pulmonary Hypertension, [[Pulmonary Hypertension]])

  • xxxx

Other Diseases


Technique

  • Pre-Rehabilitation Cardiopulmonary Exercise Testing (see Cardiopulmonary Exercise Test, [[Cardiopulmonary Exercise Test]])
    • Usually Recommended to Assess for Exercise-Associated Hypoxemia, Arrhythmias, Musculoskeletal Problems, and Myocardial Ischemia Prior to the Start of Pulmonary Rehabilitation
  • Site of Pulmonary Rehabilitation
    • Hospital-Based
    • Outpatient-Based
    • Home-Based

References

  • Meta-analysis of the effects of respiratory rehabilitation programmes on exercise capacity in accordance with programme characteristics. J Clin Nurs. 2007 Jan;16(1):3-15 [MEDLINE]
  • Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008 Dec 16;149(12):869-78 [MEDLINE]
  • Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease–practical issues: a Canadian Thoracic Society Clinical Practice Guideline. Can Respir J. 2010 Jul-Aug;17(4):159-68 [MEDLINE]
  • An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013 Oct 15;188(8):e13-64. doi: 10.1164/rccm.201309-1634ST [MEDLINE]
  • Effects of inpatient pulmonary rehabilitation in patients with interstitial lung disease. Eur Respir J 2013; 42:444–453 [MEDLINE]
  • Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest. 2015 Apr;147(4):894-942. doi: 10.1378/chest.14-1676 [MEDLINE]
  • Pulmonary Rehabilitation as a Mechanism to Reduce Hospitalizations for Acute Exacerbations of COPD: A Systematic Review and Meta-Analysis. Chest. 2016 Oct;150(4):837-859. doi: 10.1016/j.chest.2016.05.038. Epub 2016 Aug 3 [MEDLINE]