Organization of a pulmonary rehabilitation program

In order for pulmonary rehabilitation to be successful, the organization of the program must be carefully planned. If a program seems feasible, based on an initial study, attention must be given to proper team structure, space needs, and services to be provided. A well thought out marketing plan is crucial to the success of the program, and of course obtaining maximal reimbursement is critical.     

Long-term benefits of exercise maintenance after outpatient rehabilitation program in patients with chronic obstructive pulmonary disease.

BACKGROUND: Optimal strategies to maintain short-term benefits of an initial rehabilitation program (RP) are not known. To assess the long-term effects of exercise maintenance (EM) after an initial outpatient RP, the authors conducted a prospective study. PATIENTS AND METHODS: Fifty-eight patients with moderate to moderately severe chronic obstructive pulmonary disease who completed an initial 7-week outpatient RP were included. They were allocated into four groups according to the conditions of EM they self-selected: 15 patients received a structured EM session supervised by a physiotherapist twice a week (group A); 14 patients received a structured EM session supervised by a physiotherapist once a week (group B); 15 patients continued self EM daily at home (group C); and 14 patients did not continue EM (group D). Patients were evaluated before, immediately after, and 18 months after the initial outpatient RP. Measurements included exercise testing on a cycle ergometer and a visual analog scale to evaluate chronic dyspnea. RESULTS: After RP, all patients exhibited improvements in maximal workload (P < 0.05) and in dyspnea (P < 0.05). Improvements in maximal workload were maintained at 18 months in patients in groups A, B, and C but these only reached significance in groups B and C (P < 0.05). On the other hand, maximal workload returned to baseline values in group D (P = 0.01) at 18 months. CONCLUSION: Our results indicate definite benefits of EM after an initial outpatient RP compared with no EM. Daily EM at home appears to be as efficient as structured EM sessions supervised by a physiotherapist, once or twice a week, in moderate to moderately severe chronic obstructive pulmonary disease.     

Psychological outcomes of a pulmonary rehabilitation program

This study assessed physiologic, psychological, and cognitive functioning in outpatients with COPD. Sixty-four subjects, 53 to 82 years of age, participated in the 30-day exercise rehabilitation program. The program consisted of exercise, education and psychosocial counselling. Participants were assessed prior to beginning the program and at the end of 30 days. Assessments at both times included physiologic functioning (bicycle ergometry testing, pulmonary function tests, 12-min walk), psychological well-being (anxiety, depression, psychiatric symptoms, perceived well-being) and an abbreviated neuropsychological test battery. Results indicate significant improvement in physical endurance and pulmonary function, significant reductions in symptoms of depression and anxiety, and improvement in measures of general well-being and neuropsychological functioning. The study suggests that exercise rehabilitation of older adults with COPD contributes not only to improvements in physical functioning and endurance, but also to enhanced cognitive functioning and psychological well-being.     

Regular walking and long-term maintenance of outcomes after pulmonary rehabilitation

BACKGROUND: Empirical evidence supports the role of exercise as part of pulmonary rehabilitation in improving symptoms of breathlessness (dyspnea), health-related quality of life, and exercise tolerance among patients with chronic lung disease. However, many studies show that these initial benefits tend to diminish 12 to 18 months after rehabilitation. Given the importance of exercise (ie, walking) during rehabilitation, we examined whether patient adherence to regular walking enhanced the long-term maintenance of functional benefits gained from an 8-week pulmonary rehabilitation program. METHODS: One hundred twenty-three patients with moderate to severe chronic lung disease completed an 8-week pulmonary rehabilitation program and participated in a 12-month maintenance intervention trial. Measures of weekly walking, lung function, self-efficacy for walking, dyspnea during activities of daily living, exercise capacity (6-minute walk test, 6MW), perceived breathlessness after the 6MW, and health-related quality of life were obtained at postrehabilitation, and at 6, 12, and 24 months after completing pulmonary rehabilitation. Regular walkers were defined as those active on most days or every single day of the week on the average throughout the 24-month period, whereas irregular walkers walked on some days, rarely, or not at all. RESULTS: The effects of the maintenance program on average frequency of walking were nonsignificant, with 44% of the maintenance patients and 38% of the standard care patients classified as regular walkers. There were no significant differences between walking groups on gender, healthcare utilization over the 24-month follow-up period, and postrehabilitation measures of lung function, 6MW distance, perceived breathlessness after 6MW, health-related quality of life, dyspnea, or age. Repeated measures analyses of variance using a 2 x 4 mixed model approach were applied to examine group differences and changes in outcomes over time. Overall, participants decreased in 6MW distance (P <.001), reported increases in perceived breathlessness after the 6MW (P <.05), and decreased in overall health-related quality of life (P <.001) from postrehabilitation to 24 months. Regular walkers reported significantly better health-related quality of life (P <.05) as compared to irregular walkers, averaging across time points. Irregular walkers declined significantly more than regular walkers on measures of shortness of breath during activities of daily living (P <.01) and walking self-efficacy (P <.001) from postrehabilitation to 24 months. CONCLUSIONS: Findings suggest that participation in regular exercise such as walking after completing pulmonary rehabilitation is associated with slower declines in overall health-related quality of life and walking self-efficacy as well as less progression of dyspnea during activities of daily living. Regular exercise after rehabilitation may be protective against increases in dyspnea symptoms and perceived limitations in walking which are both characteristic of progressing chronic lung disease.     

A 12-year follow-up of a methadone medical maintenance program

Methadone Medical Maintenance (MDM) is an alternative for treatment of stable methadone maintained individuals. It involves a monthly physician's visit, at which methadone take-home doses are dispensed to last until the next appointment. The safety and efficacy of this treatment modality is currently under investigation. The purpose of this study was to evaluate the long-term safety and efficacy of MDM in a methadone program in Baltimore. A sample of 21 patients was enrolled in the study and followed for 12 years. They were evaluated once a month by a primary care physician affiliated with a methadone clinic who collected urine toxicology samples and dispensed the monthly methadone dose. The results showed that only 6 (28.6%) patients dropped out during the 12 years of the study. Twelve (0.5%) of 2,290 urine samples collected were positive for drugs. No methadone overdose or diversion was observed. Participants reported significant improvement in their quality of life. The results of this study support the safety and efficacy of medical maintenance of stable methadone maintained individuals.     

Oxygen and ventilator weaning during inpatient pediatric pulmonary rehabilitation

Rates of oxygen and ventilator weaning, and factors related to successful weaning in inpatient pediatric pulmonary programs for infants and young children, have not been frequently reported in the literature. A retrospective review was conducted of 34 infants and toddlers with either a diagnostic condition of prematurity (PM) or congenital anomalies/neuromuscular disease (CA/NM) discharged from an inpatient pulmonary program. These cases represent 67 hospital admission-discharge episodes over a 6-year period. The rate of successful oxygen weaning (decrease to 0 hr per day) and ventilator weaning (decrease to <12 hr per day) and predictive factors related to successful ventilator weaning per admission-discharge episode were examined. Successful oxygen weaning was achieved during 24% and successful ventilator weaning was achieved during 30% of the admission-discharge episodes. No significant relationships were found between the selected demographic and clinical factors and oxygen weaning. Using a logistic regression model, the major variable associated with successful ventilator weaning per admission-discharge episode was diagnostic condition. Age at admission and the presence of comorbidities added slightly to the prediction model. The overall model yielded 86% accuracy for predicting a decrease in ventilator hours. However, projecting in which episodes children will not be weaned (negative predictive value = 88.9%) was more accurate than projecting in which episodes children will be weaned (positive predictive value = 73.3%). Although the program achieved a relatively low rate of successful ventilator weaning, children with a diagnostic condition of prematurity were more likely to be successfully weaned during inpatient pulmonary rehabilitation.     

A follow-up study of dropouts from a methadone maintenance program.

This is a follow-up study of 112 dropouts from one of the largest methadone maintenance programs in New York City. It was found that 47% of the sample were on methadone at other programs at the time of the follow-up interviews, 26% were drug-free, 16% were using drugs, and 11% were in institutions. However, because of certain sample biases, inferences to the total population of dropouts were made through weighted estimates. A more accurate, although approximated, percentage distribution of the outcomes is that 20% of all dropouts were on methadone at other programs, 43% were drug-free, 23% were using heroin again, and 14% were in institutions. Some of the implications of these findings are discussed.     

Long-term effectiveness of an inpatient pulmonary rehabilitation program for elderly COPD patients: comparison between young-elderly and old-elderly groups

OBJECTIVE: To evaluate the long-term effects of pulmonary rehabilitation in elderly COPD patients, we monitored patients for 1 year after they completed a 2-week inpatient pulmonary rehabilitation program. We also compared the effects of pulmonary rehabilitation on young-elderly (age 65-74 years) and old-elderly (age 75 years or over) COPD patients. METHODOLOGY: Fifty-nine elderly COPD patients (mean age 72.8 years) were studied. They underwent a comprehensive 2-week inpatient pulmonary rehabilitation program incorporating 10 exercise sessions, each of which included endurance training of the lower extremities, peripheral muscle conditioning training of the upper and lower extremities, and stretching, along with various education sessions. The effects of pulmonary rehabilitation were evaluated at 3, 6, and 12 months after completion of the program. RESULTS: Overall, patient health-related quality of life (HRQoL) as assessed by a QoL scale, and dyspnoea as assessed by an oxygen cost diagram, improved significantly over the 12-month period. Exercise capacity assessed by a 6-min walking distance test (6MWD) was similarly significantly improved. However, there was some fall-off in terms of the distance walked 12 months after pulmonary rehabilitation. The improvements in exercise capacity, dyspnoea, and HRQoL did not differ between the two groups, with the exception that the 6MWD (P < 0.01) and the QoL scale (P < 0.05) at 3 months post-pulmonary rehabilitation were significantly higher in the old-elderly group. CONCLUSIONS: Pulmonary rehabilitation is an effective treatment in terms of improving dyspnoea, exercise capacity and HRQoL in elderly COPD patients, and the benefits are almost comparable for young-elderly and old-elderly patients.     

Respi-Care. An innovative home care program for the patient with chronic obstructive pulmonary disease

The purpose of the present study was to evaluate the effectiveness of a hospital-based home care program for a group of patients with severe COPD. Respi-Care was a multidisciplinary home care program administered by Norwalk Hospital in cooperation with the public health nursing departments of the city of Norwalk and the town of Wilton, Conn. The overall goal of Respi-Care was to provide more comprehensive home care services to patients previously requiring frequent hospitalizations by combining the advantages of hospital resources and community agencies through a unique cooperative effort. Preprogram and on-program data were collected on the following variables for the 48 months of Respi-Care operation: hospitalizations; hospital days; emergency room visits; home care services; and the costs of these services. Costs of operating the Respi-Care program were included in on-program data. Seventeen subjects completed 320.5 months on Respi-Care. Each subject was matched to an equal length of time prior to entering the program, for a total of 641 months analyzed. There were 88 preprogram hospitalizations for the group; hospitalizations while participating in Respi-Care dropped to 53 (p = 0.022; paired t statistics). On-program hospital days showed a significant decrease, from 1,181 preprogram days to 667 on-program days (p = 0.024). Emergency room visits decreased from 105 before the program to 64 during the program (p = 0.017). Costs of care also decreased. Costs for hospitalizations, emergency room visits, and home care fell from $908,031 to $802,999, resulting in a $105,032 savings or $328 per patient per month.(ABSTRACT TRUNCATED AT 250 WORDS)     

Asthma control and health-related quality of life one year after inpatient pulmonary rehabilitation: the ProKAR Study

Objectives: Although pulmonary rehabilitation (PR) is commonly used for asthmatics in many countries, so far there are no studies addressing the question of whether and for how long an improvement in asthma control (AC) is seen after rehabilitation. The ProKAR study (Prospektive Katamnesestudie Asthma-Rehabilitation) was performed to provide data concerning the short- and long-term impact of PR on AC. Methods: Two-hundred one adult patients with mild to severe persistent asthma were prospectively followed one year after completion of a 3-week PR program. AC, the primary outcome parameter, and health-related quality of life (HRQoL) were monitored using the Asthma Control Test (ACT) and St. George’s Respiratory Questionnaire (SGRQ) at initiation (T0) and end of the PR (T1) and 3, 6 and 12 months thereafter. Pulmonary function, physical fitness (6MWD) and asthmatic inflammation (FENO) were measured at T0 and T1. Results: The proportion of patients with well-controlled asthma (ACT score ≥20) increased from 33.2% to 67.3% after PR and was still at 51% after 12 months. Slight but statistically significant improvements in pulmonary functions and an increase in 6MWD of nearly 60?m were reported at T1. One year after discharge 55.8% of the patients still showed a clinically relevant improvement of at least 4 points in the total SGRQ score. Conclusions: The multidisciplinary inpatient PR program resulted in significant short and long-term improvement in AC and HRQoL in adult asthmatic patients.     

Objective evaluation of results of a pulmonary rehabilitation program in a community hospital

Objective evidence of improvement from participation in an outpatient pulmonary rehabilitation program in a community hospital is shown. Selection criteria included a decrease in functional capacity due to pulmonary disease, stability of underlying pulmonary disease, proper motivation, the absence of other significant diseases, and evidence of continued improvement in the course of the program. Objective evidence of improved functional ability, as measured by treadmill exercise testing and improved understanding of their disease, was demonstrated in 86 percent of patients who completed the program. An increased work load was performed at a lower heart rate and respiratory rate. Eleven of 41 patients reached anaerobic threshold at a higher work load. Most importantly, however, was improved quality of life. In follow-up of 101 patients from one to five years later, 31.7 percent remained improved, while 31.7 percent had died, and 36.5 percent were worse from progression of pulmonary or occurrence of other diseases. Outpatient pulmonary rehabilitation can be objectively shown to be an important therapeutic tool in the treatment of patients with pulmonary disease.