Pulmonary rehabilitation

What is pulmonary rehabilitation?

Pulmonary rehabilitation is individually tailored, multidisciplinary care program for people with COPD which aims to optimise physical and psychological condition through exercise training, education, and nutritional, psychological, and behavioural interventions.¹

Pulmonary rehabilitation has been shown to improve exercise capacity, reduce breathlessness, improve health-related quality of life, and decrease healthcare utilisation. Pulmonary rehabilitation has established a status of evidence-based therapy for patients with symptomatic COPD in the stable phase and after acute exacerbations.²

The majority of patients considered for pulmonary rehabilitation programmes will have chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD.³

• Rehabilitation is provided by a multiprofessional team, with involvement of the patient's family and attention to individual needs.⁴

• Rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances patients' control over their condition. These improvements are moderately large and clinically significant. Rehabilitation forms an important component of the management of COPD.⁵

Selection

Chronic obstructive pulmonary disease (COPD)¹

• Refer for pulmonary rehabilitation if functionally disabled by chronic obstructive pulmonary disease (COPD) (usually Medical Research Council (MRC) dyspnoea scale grade 3 or above), or have had a recent hospitalisation for an acute exacerbation.

• Refer directly for pulmonary rehabilitation if possible, depending on local referral pathways.

• Advise that commitment to pulmonary rehabilitation can improve quality of life, increase exercise capacity and reduce breathlessness.

• Do not refer the person for pulmonary rehabilitation if they are unable to walk, or have unstable angina, or have had a recent myocardial infarction.

There is currently no justification for selection on the basis of age, impairment, disability, or smoking status. Some patients with serious comorbidity such as cardiac or locomotor disability may not derive as much benefit.

Other issues relevant to patient selection are poor motivation and the logistical factors of geography, transport, equipment usage, and the group composition.

Other respiratory disorders

Although evidence is lacking for the efficacy of rehabilitation for patients with non-COPD causes of pulmonary impairment, pulmonary rehabilitation programmes provide opportunities to improve the integrated care of people with chronic respiratory disorders other than COPD.⁶

The principles of pulmonary rehabilitation for patients with interstitial lung diseases are the same as for patients with COPD. Major differences between interstitial lung disease and COPD patients include poorer exercise tolerance and faster development of respiratory failure in patients with interstitial lung diseases.⁷

Setting

• Pulmonary rehabilitation is effective in all settings, including hospital inpatient, outpatient, the community and in the patient's home.

• Cost comparison suggests that hospital outpatient rehabilitation is currently the most efficient form of delivery.⁴

Programme content

The commitment required for pulmonary rehabilitation and the consequent benefits to people with COPD should be explained. The programme must meet the individual needs of the patient, and include physical training, disease education, and nutritional, psychological and behavioural intervention.³

• Physical aerobic training, particularly of the lower extremities (brisk walking or cycling), is essential.

• Upper limb and strength-building exercise can also be included.

• Exercise prescription should be individually assessed.

• Individual training intensity should be recorded and can be increased through the programme if appropriate and tolerated.

• Training intensity should usually be 60-70% of maximal walking speed achieved on a shuttle walk test.⁴ However, benefit can be obtained from lower-intensity training where necessary, and increased benefits can be obtained from higher-intensity training (85% maximal walking speed achieved on the shuttle walk test) when this can be achieved.

• Training frequency should involve three sessions (20-30 minutes) per week, of which at least two should be supervised.

• Supplementary oxygen during training should be provided if necessary.

• Comprehensive disease education for patient and family is an important part of overall management and can be included within the rehabilitation programme.⁴

• Individual advice on physiotherapy, nutrition, occupational therapy, smoking cessation, end of life planning, and physical relationships should also be included.

Process⁴

• A nominated clinician with an interest in respiratory disease should be responsible for the programme. This clinician is normally responsible for medical assessment prior to entry to the programme.

• Staffing ratios will vary according to the patient characteristics, but a staff to patient ratio of 1:8 would be reasonable for the supervision of exercise classes.

• There should be multiprofessional involvement from local resources.

• Policies should exist for the stages of rehabilitation which include referral, assessment, selection, rehabilitation, and outcome assessment.

• Regular audit of the programme is desirable.