Scope, background and definition of pulmonary rehabilitation

The optimal therapy of an individual with chronic respiratory disease usually requires a combination of pharmacologic and non-pharmacologic therapies. A case of a 68-year-old man with advanced chronic obstructive pulmonary disease is given to illustrate this point. He is a recent ex-smoker with severe chronic obstructive pulmonary disease by spirometric criteria, frequent exacerbations of this disease, considerable recent health care utilization, dyspnea with minimal activities, severe functional status limitation, prominent systemic effects of the disease (e.g., weight loss) and substantial comorbidities. The primary respiratory disease cannot be isolated from and treated independently of these important factors. Pulmonary rehabilitation is an important therapeutic option in situations like this, providing a mode of integrating care, complementing otherwise standard medical therapy, and producing significant gains across multiple outcome areas of importance to the patient. Pulmonary rehabilitation has been defined by the American Thoracic Society and 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. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease". Its components include comprehensive assessment, education, exercise training, and psychosocial intervention. Outcomes assessment is usually performed for quality assessment. Pulmonary rehabilitation produces the greatest improvements of any available therapy in dyspnea, exercise capacity, and health-related quality of life. These gains are realized despite the fact that pulmonary rehabilitation has no direct effect on lung function. It works primarily through reducing the impact of the systemic manifestations of the disease and frequent comorbidity. Pulmonary rehabilitation also leads to substantial reductions in subsequent health care utilization, possibly through collaborative self-management strategies emphasized in the program. Although pulmonary rehabilitation has been utilized by astute clinicians for many years, its science has been developed over the past two decades.     

Exercise limitation and pulmonary rehabilitation in chronic obstructive pulmonary disease.

Impairment of exercise tolerance is a common problem in patients with severe chronic obstructive pulmonary disease. The cause of exercise intolerance in patients with severe chronic obstructive pulmonary disease is multifactorial and includes impaired lung mechanics, fatigue of inspiratory muscles, impaired gas exchange, right ventricular dysfunction, malnutrition, occult cardiac disease, deconditioning, and psychologic problems; however, impaired lung mechanics and gas exchange abnormalities seem to be the major limiting factors. Recently, the approach to management of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease has changed because improvement in exercise tolerance has been demonstrated after pulmonary rehabilitation. Other adjunctive measures that have been shown to contribute to the observed improvement in exercise tolerance include administration of oxygen, nutritional support, cessation of smoking, and psychosocial support. The roles of ventilatory muscle endurance training, respiratory muscle rest therapy, nasally administered continuous positive airway pressure, and training of the muscles of the upper extremities are less clearly defined.     

6-Minute walk test in patients with COPD: clinical applications in pulmonary rehabilitation

Pulmonary rehabilitation is an evidence-based intervention for the management of patients with chronic obstructive pulmonary disease (COPD). In clinical practice, the 6-minute walk test (6MWT) is commonly used to assess changes in functional exercise capacity in COPD patients following pulmonary rehabilitation with the primary outcome reported being the distance walked during the test (i.e. 6MWD). The 6MWD has demonstrated validity, reliability after one familiarisation test and the capacity to detect changes following pulmonary rehabilitation. In addition to assessing the outcomes of pulmonary rehabilitation, 6MWD may be used to quantify the magnitude of a patient's disability, prescribe a walking programme, identify patients likely to benefit from a rollator and to identify the presence of exercise-induced hypoxaemia. This review describes the applications of the 6MWD in patients with COPD undergoing pulmonary rehabilitation.     

Enhanced exercise-induced plasma cytokine response and oxidative stress in COPD patients depend on blood oxygenation

In healthy subjects, hypoxemia and exercise represent independent stressors promoting the exercise-induced cytokine response and oxidative stress. We hypothesized that hypoxemia in patients with chronic obstructive pulmonary disease (COPD) may affect the cytokine production and/or the changes in oxidant-antioxidant status in response to maximal exercise. Exercise-induced changes in PaO2 allowed to transiently increase or decrease baseline hypoxemia and to point out its specific action on muscle metabolism. COPD patients with severe to moderate hypoxemia (56 < PaO2 < 72 mmHg) performed an incremental cycling exercise until volitional exhaustion. Two cytokines [interleukin (IL)-6 and tumour necrosis factor (TNF)-alpha] and three blood indices of oxidative stress [plasma thiobarbituric acid reactive substances (TBARS) and two antioxidants, reduced erythrocyte glutathione (GSH), and reduced plasma ascorbic acid, RAA] were measured at rest, then during and after exercise. The changes in the cytokine levels and oxidant-antioxidant status were analysed in relation with the baseline PaO2 and its exercise-induced variations. Data were compared with those obtained in an age- and body mass index-matched group of healthy subjects. Compared with healthy subjects, COPD patients presented a marked accentuation of exercise-induced increase in IL-6 level and earlier changes in their oxidant-antioxidant status. Resting levels of IL-6 and TNF-alpha and exercise-induced peak variations of TBARS, IL-6 and TNF-alpha were negatively correlated with the baseline PaO2. In COPD patients, the peak increases in IL-6 and TBARS were attenuated when exercise hyperventilation reduced the baseline hypoxemia. Our study indicates that the PaO2 level affects both the exercise-induced oxidative stress and cytokine response in hypoxemic COPD patients.     

Pathophysiology and cardiorespiratory consequences of interstitial lung disease--review and clinical implications: a special communication

The purpose of this special communication is to review the pathophysiology of interstitial lung disease (ILD) and its cardiorespiratory consequences at rest and during exercise. Patients with ILD tend to have a resting and disproportionate exercise tachycardia; resting or exercise-induced arterial desaturation; a rapid shallow breathing pattern; and in more severe cases an increase in pulmonary arterial pressure with an associated increase in right ventricular work. Although the acute exercise responses of patients with ILD have been documented, studies on their responses to exercise training are lacking. We, therefore, discuss some of the physiologic consequences of ILD and the clinical measures available to assess these patients at rest and during exercise. We present the implications of these changes for functional ability and propose that modified endurance training is important to the patient with ILD. Potential directions for clinical research in exercise training of patients with ILD are presented.     

Pulmonary rehabilitation: summary of an evidence-based guideline

Pulmonary rehabilitation has emerged as a standard of care for patients with chronic lung disease, based on a growing body of scientific evidence. Over recent decades, several organizations have championed pulmonary rehabilitation and developed comprehensive statements, practice guidelines, and evidence-based guidelines. Documenting the scientific evidence underlying clinical practice has been important in overcoming skepticism and convincing health professionals, health-care institutions, third-party payers, and regulatory agencies to support pulmonary rehabilitation programs. The literature on pulmonary rehabilitation has increased substantially and provided justification for including pulmonary rehabilitation in practice guidelines for chronic obstructive pulmonary disease and other chronic lung diseases. Therefore, the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation decided to update their 1997 guidelines with a systematic, evidence-based review of the literature since the previous review. The panel updated prior topics and recommendations and reviewed new topics. Recommendations were given for outcomes of comprehensive pulmonary rehabilitation programs, including lower-extremity exercise training, dyspnea, health-related quality of life, health-care utilization, survival, psychosocial outcomes, and long-term benefits. Additional topics include the duration of pulmonary rehabilitation, post-rehabilitation maintenance strategies, intensity of aerobic exercise training, strength training, anabolic drugs, upper-extremity training, inspiratory-muscle training, education, psychological and behavioral components, oxygen supplementation, noninvasive ventilation, nutrition supplementation, rehabilitation for patients with disorders other than chronic obstructive pulmonary disease, and future pulmonary rehabilitation research. These guidelines provide an excellent summary of the recent literature and further strengthen the scientific basis of pulmonary rehabilitation.     

Efficacy of pulmonary rehabilitation and clinical practice

Pulmonary rehabilitation(PR) is comprehensive care for patients with chronic pulmonary disorder, especially chronic obstructive pulmonary disease. PR is done by team approach and individualized according to the patient's goal. The important components of PR are assessment, patient education, exercise, psychosocial support and follow-up. Patient education includes understanding of pathophysiology of patient's own lung disease, breathing retraining, bronchial hygiene, smoking cessation, medications, nutrition and prevention of acute exacerbation. The role of exercise training is most important and its efficacy has been strongly supported. Exercise training program should include both lower and upper extremity training, and in selected patients ventilatory muscle training is recommended. PR improves exercise tolerance, dyspnea, health-related QOL. Follow-up care is needed for long-term benefits.     

Noninvasive ventilation in acute respiratory failure

BACKGROUND: Noninvasive ventilation has assumed an important role in the management of respiratory failure in critical care units, but it must be used selectively depending on the patient's diagnosis and clinical characteristics. DATA: We review the strong evidence supporting the use of noninvasive ventilation for acute respiratory failure to prevent intubation in patients with chronic obstructive pulmonary disease exacerbations or acute cardiogenic pulmonary edema, and in immunocompromised patients, as well as to facilitate extubation in patients with chronic obstructive pulmonary disease who require initial intubation. Weaker evidence supports consideration of noninvasive ventilation for chronic obstructive pulmonary disease patients with postoperative or postextubation respiratory failure; patients with acute respiratory failure due to asthma exacerbations, pneumonia, acute lung injury, or acute respiratory distress syndrome; during bronchoscopy; or as a means of preoxygenation before intubation in critically ill patients with severe hypoxemia. CONCLUSION: Noninvasive ventilation has assumed an important role in managing patients with acute respiratory failure. Patients should be monitored closely for signs of noninvasive ventilation failure and promptly intubated before a crisis develops. The application of noninvasive ventilation by a trained and experienced intensive care unit team, with careful patient selection, should optimize patient outcomes.     

The 6-Minute Walk Test: Indications and Guidelines for Use in Outpatient Practices

The 6-Minute Walk Test (6MWT) is a standardized tool used to measure lung impairment. It is used in outpatient primary and pulmonary practices to objectively assess functional exercise capacity and hypoxemia in patients with chronic lung disease. Screening for functional decrease in exercise tolerance and hypoxemia aids in initiating and maintaining the use of oxygen supplementation to improve functional improvement in chronic lung patients. It has new applications for recovering COVID-19 pneumonia patients to assess for clinical compromise. Discussion includes elements and guideline recommendations for 6MWT, indications for use, appropriate patient populations appropriate, safety, coding, and current reimbursement insurance guidelines.     

The effect of a pulmonary rehabilitation programme on older patients with chronic pulmonary disease

Aim. The aim of this study was to answer the question: is there an effect on the respiratory capacity and activity tolerance of older patients with chronic obstructive pulmonary disease who participate in a pulmonary rehabilitation programme? Background. Pulmonary rehabilitation is now an integral part of chronic obstructive pulmonary disease management. Evidence supports the positive effects of breath training and exercising training on quality of life, exercise tolerance and improved physical condition of individual with chronic obstructive pulmonary disease. Limited empirical documentation exists to support the effectiveness of a nurse managed rehabilitation programme for older patients with chronic obstructive pulmonary disease. The study was done to evaluate the effects of pulmonary rehabilitation provided by nurses on the pulmonary function, gas exchange and exercise tolerance in older patients with chronic obstructive pulmonary disease. Design. A one group pre‐test–post‐test design was used to evaluate the effects of a pulmonary rehabilitation programme. Method. The sample consisted of 20 patients with chronic obstructive pulmonary disease who participated in a pulmonary rehabilitation programme including breathing exercises, upper‐limb exercises and inspiratory muscle training. Results. The findings indicated improvement in exercise performance and a decrease in dyspnea after participation in the pulmonary rehabilitation programme. Relevance to clinical practice. The clinical nurse can make a significant impact on the illness trajectory and quality of life for patients with chronic obstructive pulmonary disease. The nurse has a critical role in helping patient with chronic obstructive pulmonary disease learn to cope, adjust and adapt to life with a chronic illness. Active nurse involvement with a patient in a pulmonary rehabilitation programme can assist in the identification of factors that motivate the patient, help in establishing realistic out comes expectations and provide patient teaching opportunities. The nurse can assist the patient to develop skills of self‐awareness regarding particular symptoms, self‐monitoring and health status change identification.     

Severe hypoxemia associated with liver disease: Mayo Clinic experience and the experimental use of almitrine bismesylate

Severe hypoxemia associated with chronic liver disease is an uncommon disorder most likely due to an intrapulmonary vascular abnormality that has characteristics of both ventilation-perfusion mismatching and diffusion limitation. Anatomically, the intrapulmonary vascular abnormalities can occasionally be detected by angiography. Physiologically, the gas exchange abnormalities can be substantiated by contrast-enhanced two-dimensional echocardiography. Although orthodeoxia and platypnea have frequently been found in these patients, echocardiographic data suggest that vascular abnormalities can exist in the absence of orthodeoxia. We describe 11 patients who had severe hypoxemia and chronic liver disease and review their pulmonary angiographic, contrast echocardiographic, and arterial blood gas findings. Among five of these patients who were given almitrine bismesylate, an experimental medication thought to alter ventilation-perfusion relationships in patients with chronic obstructive pulmonary disease, one had improved oxygenation. We recommend that patients with hypoxemia associated with chronic liver disease have detailed studies to rule out reversible forms of hypoxemia and that those with severe hypoxemia undergo testing to determine the existence of intrapulmonary vascular abnormalities, especially if liver transplantation is considered.     

Stress testing in valvular heart disease: clinical benefit of echocardiographic imaging

Symptom development represents one of the most important indications for surgical intervention in patients with significant valvular heart disease. Exercise testing has an established role in the assessment of exercise capacity and symptomatic status in patients with severe valvular heart disease who claim to be asymptomatic. In these patients, clinical decision can be influenced by the results of exercise testing. In addition to the assessment of symptomatic response to exercise, stress echocardiography can provide valuable information on exercise-induced changes in valve hemodynamics, ventricular function and pulmonary artery pressure. Abnormal left ventricular response to exercise, increase in pulmonary pressure or change in the hemodynamic severity of the valvular disease adds to the prognostic value of elicited symptoms. In this article we discuss the validated indications, proven prognostic values and potential influence on clinical decisions of stress echocardiography in left valvular heart diseases.     

改良家庭肺康复训练对中度以上慢性阻塞性肺疾病患者的效果评价

目的探讨改良家庭肺康复训练对中度以上慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)患者的呼吸困难症状、肺功能、运动耐力、生活质量的影响。方法便利抽样法选择2014年9月至2015年12月在常州市第一人民医院呼吸内科出院的中度以上COPD患者125例为研究对象,根据随机数字表法,将其分为对照组和观察组,其中对照组62例,观察组63例。对照组给予常规治疗护理措施加呼吸训练,观察组给予常规治疗护理措施加改良肺康复训练计划,干预时间均为12周。观察干预前后两组患者的呼吸困难评分(modified Medical Research Council dyspnea scale,mMRC)、肺功能指标、圣乔治呼吸问卷(St·Gorge’s respiratory questionnaire,SGRQ)和6min步行试验(6minute walking test,6MWT)的变化。结果观察组患者干预后SGRQ的呼吸症状(54.93±11.90)分、活动受限(52.64±14.33)分、疾病影响(55.40±9.91)分及总分(54.66±10.68)分均显著降低,与对照组比较差异有统计学意义(P0.05)与对照组比较,观察组患者干预后6MWT(372.09±67.15)m显著提高,mMRC(秩和值1726.00)显著降低,差异均有统计学意义(均P0.05)。观察组和对照组患者干预后肺功能指标比较差异均无统计学意义(均P0.05)。结论中度以上COPD患者实施改良家庭肺康复计划,有助于改善其呼吸困难症状、提高机体活动能力、改善生活质量,可作为其缓解期康复治疗的有效手段。     

Diagnosis and treatment of pulmonary hypertension

Primary pulmonary hypertension is a rare disease of unknown etiology, whereas secondary pulmonary hypertension is a complication of many pulmonary, cardiac and extrathoracic conditions. Chronic obstructive pulmonary disease, left ventricular dysfunction and disorders associated with hypoxemia frequently result in pulmonary hypertension. Regardless of the etiology, unrelieved pulmonary hypertension can lead to right-sided heart failure. Signs and symptoms of pulmonary hypertension are often subtle and nonspecific. The diagnosis should be suspected in patients with increasing dyspnea on exertion and a known cause of pulmonary hypertension. Two-dimensional echocardiography with Doppler flow studies is the most useful imaging modality in patients with suspected pulmonary hypertension. If pulmonary hypertension is present, further evaluation may include assessment of oxygenation, pulmonary function testing, high-resolution computed tomography of the chest, ventilation-perfusion lung scanning and cardiac catheterization. Treatment with a continuous intravenous infusion of prostacyclin improves exercise capacity, quality of life, hemodynamics and long-term survival in patients with primary pulmonary hypertension. Management of secondary pulmonary hypertension includes correction of the underlying cause and reversal of hypoxemia. Lung transplantation remains an option for selected patients with pulmonary hypertension that does not respond to medical management.     

Quality of life and exercise tolerance in chronic obstructive pulmonary disease: effects of a short and intensive inpatient rehabilitation program.

The quality of life and the exercise endurance of patients with chronic obstructive pulmonary disease are impaired. The aim of our study was to determine the impact of a 3-wk intensive inpatient rehabilitation program on the quality of life of patients with chronic obstructive pulmonary disease and to examine the correlation between quality-of-life measures and physiologic measures throughout rehabilitation. Thirty-two patients with chronic obstructive pulmonary disease (20 men, 12 women) were evaluated by spirometry and maximal exercise testing for exercise endurance and by the French version of the Nottingham Health Profile for quality of life. Rehabilitation components were individualized exercise at ventilatory threshold (4 hr/day), health education, and physical therapy and relaxation for 3 wk. Our results showed an improvement in the quality of life (especially in physical mobility, energy, and social isolation) and exercise endurance (increase of 14% of maximal power and symptom-limited oxygen uptake). In contrast, no significant correlations were found between the quality of life and physiologic parameters (gas exchange, cardiovascular and lung function parameters) throughout rehabilitation. Changes in the quality of life seem to be independent of the physiologic results during the course of a short and intensive inpatient rehabilitation program. Quality of life should, therefore, be more systematically evaluated to determine the psychosocial benefits, which, although subjective, are important for encouraging patients' compliance with rehabilitation programs.     

Neuropsychiatric function in chronic lung disease: the role of pulmonary rehabilitation

Chronic lung disease is associated with increased psychological distress (especially anxiety and depression) and neuropsychological impairments (primarily in flexible problem-solving and information-sequencing), which decrease quality of life, disease management, and survival. This review summarizes current data regarding the prevalence of neuropsychiatric disorders, the assessment tools commonly used to measure and monitor neuropsychiatric symptoms, the effect of pulmonary rehabilitation on neuropsychiatric symptoms, the mechanisms by which exercise rehabilitation may influence neuropsychiatric functioning, and the clinical implications of the data.     

基于WHO-FICs心肺运动试验在肺癌患者中应用的Scoping综述

目的 基于世界卫生组织国际健康分类家族(WHO-FICs)理论,分析心肺运动试验(CPET)在肺癌患者中的应用。方法 检索2013年1月至2021年4月,PubMed、Web of Science、中国知网和万方数据库关于CPET在肺癌患者中应用的研究。采用Scoping综述方法分析CPET应用于肺癌患者时的适应证与禁忌证、运动功能障碍、肺康复干预措施、评价方法和指标以及环境因素等。结果 基于WHO-FICs框架,本文主要从5个方面对纳入文献进行分析。主要疾病为不同病理类型的非小细胞肺癌(NSCLC)(2C25),肺癌最常见的并发症是慢性阻塞性肺疾病(COPD)(CA22);肺癌患者进行CPET的障碍主要包括身体结构和功能、活动和参与障碍;基于CPET的肺康复运动训练方法被划分为治疗类、预防类和健康促进类;评价工具及指标采用摄氧量、二氧化碳排出量、氧脉搏、心率、血压、心电图、Borg量表、6分钟步行测试、健康调查简表(SF-36)等,并提供环境因素的分类和描述。结论 CPET在肺癌中的应用主要包括术前评估及预后预测、运动处方制定及运动效果评估、抗癌治疗影响评估三个方面。基于WHO-FICs理论体系,CPET应用对象主要为NSCLC,肺癌最常见的并发症是COPD;肺癌肺康复是以功能障碍和需求为导向,基于CPET评估结果进行个体化治疗类、预防类和健康促进类的肺康复运动训练,旨在提高患者整体功能,优化肺癌患者健康结局。     

The history of long-term oxygen therapy.

Early investigators of oxygen therapy reported an overall clinical improvement in persons with chronic lung disease who received oxygen. Later American and British studies showed that oxygen therapy could decrease pulmonary vascular pressures and red cell mass in some patients with pulmonary hypertension and polycythemia secondary to severe hypoxemia. The British Research Council Study showed that survival rates were significantly higher in patients receiving 15 hours of oxygen than in those receiving no oxygen. The Nocturnal Oxygen Therapy Trial showed that survival rates for persons receiving continuous oxygen therapy has also been shown to improve exercise tolerance and neuropsychiatric function. Further advances in the administration of long-term oxygen therapy and studies in the criteria for its use are needed.     

Minimally supervised home rehabilitation improves exercise capacity and health status in patients with COPD

OBJECTIVE: The purpose of this study was to investigate the effects on exercise tolerance and quality of life of an outpatient rehabilitation program implemented at home without a physiotherapist's direct supervision in patients with chronic obstructive lung disease. DESIGN: Patients with moderate chronic obstructive pulmonary disease were studied. The rehabilitation program included lower limb exercise on a stationary bicycle and upper limb exercise and stretching, together with education, and it lasted for 12 wks. Every 2 wks, a physiotherapist contacted patients by phone to evaluate their compliance with the rehabilitation program and any adverse effects. The main measures of outcome were the Health Status Index, cycle ergometer test, forced expiratory volume in 1 sec, and forced vital capacity. Patients were evaluated at the baseline and at 12 wks. RESULTS: A total of 32 patients were recruited and 28 (mean age, 70.4 yrs) completed the trial. After pulmonary rehabilitation, a significant improvement was found in seven of the nine Health Status Index quality-of-life subscales. Exercise tolerance also improved significantly, whereas no variation was observed in pulmonary function tests. There was no correlation between the improvement in quality of life and the improvement in exercise tolerance. The improvements in the Health Status Index physical function and general health subscales correlated negatively with forced expiratory volume in 1 sec (percentage of predicted value) and positively with residual volume/total lung capacity ratio. The improvement in exercise tolerance (expressed in watts or as maximum oxygen uptake), but not in quality-of-life indexes, was associated negatively with age and positively with weight, cognitive function, and forced expiratory volume in 1 sec/forced vital capacity ratio. CONCLUSIONS: We conclude that an inexpensive home rehabilitation program can improve quality of life and exercise tolerance in patients with moderate chronic obstructive pulmonary disease. Furthermore, our results indicate that exercise tolerance evaluated by cycloergometry and quality of life evaluated by the mean of the Health Status Index questionnaire are independent outcome measures of pulmonary rehabilitation.     

The effects of home-based pulmonary rehabilitation in patients with chronic lung disease

The purpose of this study was to examine the effects of a home-based pulmonary rehabilitation program on lung function, dyspnea, exercise tolerance, and quality of life in 23 Koreans with moderate to severe chronic lung disease. The outcome measures were forced expiratory volume in 1 s (FEV₁, % predicted), Borg score, 6 min walking distance (6 MWD), and chronic respiratory disease questionnaire (CRDQ). Experimental group (n=15) performed the 8-week home-based pulmonary rehabilitation program, composed of inspiratory muscle training, upper and lower extremity exercise, relaxation, and telephone visit. Patients in control group (n=8) were only given educational advice. The experimental group showed a lower level of exertional dyspnea, more exercise tolerance, and greater improvement in health-related quality of life than the control group (p<0.05). Lung function was not statistically different. This study yielded evidence for the beneficial effects of home-based pulmonary rehabilitation program.