Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
t h e Ma n a g e m e n t o f C h ro n i c
Lung Disease
a b,
Sharon D. Cornelison, RCP, RRT-NPS , Rodolfo M. Pascual, MD *
KEYWORDS
Pulmonary Rehabilitation Education Training Functioning Self-management
KEY POINTS
Patients with chronic lung disease often suffer from significant exercise and functional lim-
itation due to multi-factorial causes. The increased work of breathing imposed on patients
with chronic lung disease leads to a maladaptive reduction in activity levels.
Patients with chronic lung disease experience high rates of anxiety and depression. Poor
physical and psychosocial functioning is associated with morbidity and mortality and use
of health care resources.
PR improves physical and psychosocial functioning in patients with a variety of chronic
lung diseases.
Evidence-based standardization ensures that PR programs are staffed by trained pro-
viders, that appropriate patients are enrolled, that programs have medical supervision.
and that all facets of the patient’s disability are addressed.
Although PR is efficacious, cost effective, and safe it is an underused therapy.
INTRODUCTION
a
Department of Pulmonary and Cardiac Rehabilitation, J. Paul Sticht Center on Aging and
Rehabilitation, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston Salem,
NC 27157, USA; b Department of Internal Medicine, Section on Pulmonary Medicine, Critical
Care, Allergy and Immunologic Diseases, Wake Forest Baptist Medical Center, Medical Center
Boulevard, Winston Salem, NC 27157, USA
* Corresponding author.
E-mail address: rpascual@wakehealth.edu
DEFINITION
The 2006 American Thoracic Society and European Respiratory Society statement on
pulmonary rehabilitation defines PR as: an evidence-based, multidisciplinary, and
comprehensive intervention for patients with chronic respiratory diseases who are
symptomatic and often have decreased daily life activities. Integrated into the individ-
ualized treatment of the patient, PR is designed to reduce symptoms, optimize func-
tional status, increase participation, and reduce health care costs by stabilizing or
reversing systemic manifestations of the disease.4
Ideally, PR programs should be certified by the American Association of Cardiovas-
cular and Pulmonary Rehabilitation and should include the following components indi-
vidualized to each patient: entry assessment/goal setting, disease management
education, exercise training/physical conditioning, psychosocial intervention/support,
nutrition/pharmacologic support, and an outcomes assessment at program comple-
tion.5 Pulmonary rehabilitation programs usually meet in an outpatient setting and
vary from 6 to 12 weeks in length. Patients attend 3 days per week for 1.5 to 4 hours
per session, which includes exercise training, education components, and psychoso-
cial support.
Patients with chronic lung disease experience worsening shortness of breath initially
with exertion and then at rest as their disease progresses. Much of our knowledge
of the physiology explaining physical impairment and evidence of efficacy in the
area of physical training comes from the study of patients with COPD. Currently,
most patients referred for PR have COPD. Patients with COPD and other chronic
lung diseases have higher ventilation requirements during exercise due to more
work required for breathing, increased dead space ventilation, and gas exchange ab-
normalities. This leads to decreased activity levels, which, over time, can result in pro-
gressive, peripheral muscle weakness and worsening physical deconditioning.6,7
These derangements can be reversed at least in part by exercise training. A variety
of types of training including constant-load endurance, interval, resistance/strength,
and inspiratory muscle and transcutaneous neuromuscular electrical stimulation
have demonstrated efficacy. Details about these modes is beyond the scope of this
article but have been reviewed elsewhere.8 Patients with COPD tend to be frail and
experience high rates of falls owing in part to reductions in skeletal muscle mass
and strength.9,10 In addition, as their functional status declines, many patients begin
to suffer from anxiety, isolation, and depression. If left untreated, these symptoms
lead to significant disability and increased health care use for patients.11
EVIDENCE OF EFFICACY
Globally, PR has been shown to help decrease shortness of breath, increase func-
tional and exercise capacity, reduce handicap, and improve overall QOL.12 There is
new, emerging evidence that it also helps decrease healthcare use and associated
Pulmonary Rehabilitation 579
Table 1
Pulmonary rehabilitation for chronic respiratory diseases
Adapted from 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):e13–64; with permission.
580 Cornelison & Pascual
2. When referring patients with a diagnosis of COPD and the post bronchodilator PFT
shows a ratio less than 0.70 and an FEV1 greater than 80%, consider an alternative
qualifying diagnosis, when possible. Computed tomographic scan evidence of
emphysema, chronic bronchitis, or bronchiectasis are acceptable alternatives.
Whereas a diagnosis of dyspnea on exertion or shortness of breath is acceptable
in some instances, given the specificity of the new ICD 10 coding system, it is
strongly recommended to avoid referring under these 2 diagnoses if an acceptable
alternative can be used.
3. PFTs are generally not required when referring patients to PR with non-COPD res-
piratory diseases. However, providing baseline PFTs to the PR team helps quantify
the degree of lung impairment, and thus assists the team when designing an indi-
vidualized exercise and education treatment plan for the patient.
4. A referral to PR should be considered when the symptoms of chronic lung disease
become persistent and interfere with the patient’s daily life, when QOL is impaired,
when the patient’s functional status and exercise tolerance are decreasing, or the
patient’s health care resource use is increasing (ie, unscheduled hospital admis-
sions, emergency department visits, and physician office visits owing to worsening
respiratory symptoms).3
5. Patients with chronic lung disease frequently have known comorbidities or other
diseases that could potentially place them at risk for serious and sometimes life-
threatening complications during PR exercise training. These conditions should
be stabilized or corrected before patient referral. Examples of these issues include
unstable angina, critical aortic stenosis, severe and poorly controlled pulmonary
arterial hypertension, and unstable coronary artery disease.
6. Patients who continue to abuse tobacco are often excluded from entry in some PR
programs as it is believed that these patients will be less motivated to quit and un-
receptive to tobacco cessation education. There is no evidence to support this
notion. Rather, active smokers who are willing to make a good faith attempt to
quit should be referred to PR. For these patients, tobacco cessation education
and support will be a central component of their individualized treatment program.
It should be noted that lung function, particularly FEV1, in patients who continue to
abuse tobacco declines significantly faster than in those who have successfully
maintained cessation.28,29
7. For patients who have been admitted to the hospital for an acute exacerbation of
COPD, there are new, evidence-based data recommending that patients be
referred to a PR program on discharge, and these patients should begin the pro-
gram within the following 3 weeks.3,7
As stated previously, PR programs can vary in length from 4 to 12 weeks. It has been
demonstrated in prior studies that shorter courses of PR (4–7 weeks) are not as effec-
tive, and patients do not gain the same overall benefit as they would when completing
an 8- to 12-week program.33 Research has shown that it takes an average of 66 days
(range 18–254 days) to establish new, healthy habits such as exercise, mindful eating,
582 Cornelison & Pascual
Box 1
Benefits gained from outpatient pulmonary rehabilitation
Decreased dyspnea
Improvements in a 6-minute walk distance, shuttle walk test and/or CPET
Improvements in overall health-related QOL
Reduction in depression and anxiety symptoms
Reduction in health care resource utilization and associated costs
Adapted from Carlin BW. Pulmonary rehabilitation and chronic lung disease: opportunities for
the respiratory therapist. Respir Care 2009;54(8):1095; with permission.
tobacco cessation, and stress-reduction techniques.34 For patients with chronic lung
disease, adopting new, healthy habits are key components of their PR program. It
could be extrapolated that lengthier courses of PR could afford this population the
time necessary to firmly establish the lifestyle changes they need to maintain
health-related QOL and exercise-related physical strength and endurance after
completing an initial course of PR. Therefore, longer courses of PR (>8 weeks) may
be more efficacious in many patients.
The short-term benefits of PR in those with COPD are thoroughly documented in the
literature, and are found in Box 1. However, once the patient completes the initial PR
program, these gained benefits start to decline over the following 6 to 12 months, espe-
cially if they do not maintain some type of endurance and strength training.35 Studies
have shown, however, that, despite this decline, some patients may continue to expe-
rience benefits, such as improved exercise capacity and health-related QOL, for up to
2 years after completing PR if they continue with some type of exercise training.36
So, should patients continue with maintenance therapy post PR program comple-
tion to help maintain QOL and exercise-related gains in physical endurance and
strength? The evidence suggests yes, if clinicians and patients expect to maintain
the benefits gained from an initial course of PR for at least an additional 12 months.37
There are many options available for those who want to continue therapy after initial
PR completion, including on-site, medically supervised, maintenance phase pro-
grams, online, web-based programs, specialty programs such as Silver Sneakers,
and exercising at home.
SUMMARY
Pulmonary rehabilitation has been shown to improve exercise capacity and physical
functioning, to alleviate anxiety and depression, and to improve QOL for patients
with many types of chronic lung disease especially COPD. PR is cost effective and,
if well planned and executed, can provide durable benefits and reduce health care
use. Despite the wealth of evidence of efficacy and guidelines stating that PR is a
key element in the management of most chronic lung diseases it is not prescribed
for or used by many eligible patients. Further efforts are needed to improve the use,
implementation, and delivery of this valuable therapy.
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Pulmonary Rehabilitation 583
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