Pulmonary rehabilitation in emphysema

Pulmonary rehabilitation is an established treatment for patients with chronic lung disease. Benefits include improvement in exercise tolerance, symptoms, and quality of life, with a reduction in the use of health care resources. As an adjunct to surgical programs, such as lung volume reduction surgery, pulmonary rehabilitation plays an important role not just in preparing patients for surgery and facilitating recovery but also in selecting patients and ensuring informed choices about treatment options after optimal medical care. In the National Emphysema Treatment Trial (NETT), subjects completed 6-10 weeks of comprehensive pulmonary rehabilitation before randomization and continued rehabilitation throughout the trial, both at home and with intermittent supervision at either an NETT center or an NETT-certified satellite center. Sessions included a combination of upper and lower extremity exercise, education, and psychosocial support. Before randomization, pulmonary rehabilitation resulted in highly significant changes in exercise capacity, dyspnea, and quality of life. As expected, improvements were significantly greater in those without prior rehabilitation experience. Results for patients completing rehabilitation at satellites were similar to those at NETT centers. Prerandomization pulmonary rehabilitation had a significant effect on outcome after lung volume reduction surgery. NETT identified subgroups with differential outcome by treatment (surgical vs. nonsurgical), defined in part by postrehabilitation maximum exercise capacity. Overall, NETT demonstrated the effectiveness of pulmonary rehabilitation in improving function, symptoms, and health status in a large cohort of patients with advanced emphysema treated in a cross-section of programs in the United States.     

Pulmonary rehabilitation and respiratory therapy services in the physician office setting

Pulmonary rehabilitation services benefit patients with chronic lung disease by reducing symptoms and restoring independent function. With a multidisciplinary approach to individual patient care through education, exercise, and psychosocial interventions, health-care costs and utilization may be reduced. While pulmonary rehabilitation services have typically been provided in a facility setting, many respiratory care services can be safely provided and appropriately reimbursed in the outpatient physician office setting, with appropriate physician supervision. After reviewing the utility of pulmonary rehabilitation for patients with chronic lung disease, the supervision, documentation, coding, and reimbursement requirements for providing rehabilitative respiratory care services in the outpatient office setting are detailed.     

Maintenance after pulmonary rehabilitation in chronic lung disease: a randomized trial

Pulmonary rehabilitation is beneficial for patients with chronic lung disease. However, long-term maintenance has been difficult to achieve after short-term treatment. We evaluated a telephone-based maintenance program after pulmonary rehabilitation in 172 patients with chronic lung disease recruited from pulmonary rehabilitation graduates. Subjects were randomly assigned to a 12-month maintenance intervention with weekly telephone contacts and monthly supervised reinforcement sessions (n = 87) or standard care (n = 85) and followed for 24 months. Except for a slight imbalance between sexes, experimental and control groups were equivalent at baseline and showed similar improvements after rehabilitation. During the 12-month intervention, exercise tolerance (maximum treadmill workload and 6-minute walk distance) and overall health status ratings were better maintained in the experimental group together with a reduction in hospital days. There were no group differences for other measures of pulmonary function, dyspnea, self-efficacy, generic and disease-specific quality of life, and health care use. By 24 months, there were no significant group differences. Patients returned to levels close to but above prerehabilitation measures. We conclude that a maintenance program of weekly telephone calls and monthly supervised sessions produced only modest improvements in the maintenance of benefits after pulmonary rehabilitation.     

Effectiveness of pulmonary rehabilitation in restrictive lung disease

BACKGROUND: Pulmonary rehabilitation is effective in improving exercise endurance and quality of life in chronic obstructive pulmonary disease (COPD). However, the efficacy of pulmonary rehabilitation in restrictive lung disease has not been extensively studied. METHODS: Forty-six patients with restrictive lung disease (35 interstitial lung diseases, 11 skeletal abnormalities) were admitted to a pulmonary rehabilitation program; 26 completed the 8-week program and 15 were followed to a 1-year reassessment. Fifteen noncompliant patients were excluded and 1 patient with interstitial lung disease died at 8 weeks. Pulmonary function tests, exercise endurance, quality of life (Chronic Respiratory Disease Questionnaire, St. George's Respiratory Questionnaire, Hospital Anxiety and Depression scale and dyspnea) were measured at baseline, 8 weeks, and 1 year. RESULTS: Exercise endurance (treadmill) improved at 8 weeks (mean improvement, 10.2 +/- 7.4 minutes) and at 1 year (mean improvement, 8.7 +/- 12.2 minutes). Shuttle test improved at 8 weeks (mean improvement, 27.2 +/- 75.9 m) but not at 1 year. Patients using long-term oxygen therapy (LTOT) had a better improvement in the treadmill test (P < .01) at 8 weeks compared with those not using LTOT. Thirty-three percent of patients failed to complete the program. There was significant improvement in dyspnea and quality of life in Chronic Respiratory Disease Questionnaire, St. George's Respiratory Questionnaire, and Hospital Anxiety and Depression scale for depression at 8 weeks compared with baseline; there was a sustained significant reduction in hospital admission days noted at 1-year postrehabilitation (P < .05). CONCLUSIONS: Pulmonary rehabilitation is effective in improving exercise endurance and the quality of life and in reducing hospital admissions in this small group of patients with significant restrictive lung disease. The relatively large dropout number suggests that a standard chronic obstructive pulmonary disease program may not be ideal for patients with restrictive lung disease.     

The clinical management in extremely severe COPD

Chronic obstructive pulmonary disease (COPD) affects 6% of the general population and is the fourth-leading cause of death in the United States with severe and very severe disease accounting for 15% and 3% of physician diagnoses of COPD. Guidelines make few recommendations regarding providing the provision of care for the most severe stages of disease, namely Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV with chronic respiratory failure. The effectiveness of inhaled drug therapy in very severe patients has not been assessed yet. Health care systems in many countries include public funding of long-term oxygen therapy for eligible candidates. Currently, there is little evidence for the use of mechanical ventilatory support in the routine management of hypercapnic patients. Pulmonary rehabilitation should be considered as a significant component of therapy, even in the most severe patients. Although Lung Volume Reduction Surgery has been shown to improve mortality, exercise capacity, and quality of life in selected patients, this modality is associated with significant morbidity and an early mortality rate in the most severe patients. Despite significant progress over the past 25 years, both short- and long-term outcomes remain significantly inferior for lung transplantation relative to other "solid" organ recipients. Nutritional assessment and management is an important therapeutic option in patients with chronic respiratory diseases. Morphine may significantly reduce dyspnoea and does not significantly accelerate death. No consistent improvement in dyspnoea over placebo has been shown with anxiolytics. Supplemental oxygen during exercise reduces exertional breathlessness and improves exercise tolerance of the hypoxaemic patient. Non-invasive ventilation has been used as a palliative treatment to reduce dyspnoea. Hypoxaemic COPD patients, on long-term oxygen therapy, may show reduced health-related quality of life, cognitive function, and depression. Only a small proportion of patients with severe COPD discuss end-of-life issues with their physicians.     

Practical approach to establishing pulmonary rehabilitation for people with non‐COPD diagnoses

Pulmonary rehabilitation is a core aspect in the management of patients with chronic respiratory diseases. This paper describes a practical approach to establishing pulmonary rehabilitation for patients with non‐COPD diagnoses using examples from the interstitial lung disease (ILD), pulmonary hypertension (PH), bronchiectasis and lung cancer patient populations. Aspects of pulmonary rehabilitation, including the rationale, patient selection, setting of programmes, patient assessment and training components (both exercise and non‐exercise aspects), are discussed for these patient groups. Whilst there are many similarities in the rationale and application of pulmonary rehabilitation across these non‐COPD populations, there are also many subtle differences, which are discussed in detail in this paper. With consideration of these factors, pulmonary rehabilitation programmes can be adapted to facilitate the inclusion of respiratory patients with non‐COPD diagnoses.     

The nonpharmacologic treatment of chronic obstructive pulmonary disease: advances in our understanding of pulmonary rehabilitation

The optimal care of patients with chronic obstructive pulmonary disease generally requires combining pharmacologic and nonpharmacologic therapies. The latter include smoking cessation, the encouragement of physical activity and exercise, influenza and pneumonia vaccinations, education on adherence to medical therapy, collaborative self-management strategies, such as a plan to manage exacerbations, and advance directives. Although each of these is a component of good medical practice, they can be given together in the form of a comprehensive outpatient pulmonary rehabilitation program. Pulmonary rehabilitation, which includes exercise training, education, psychosocial support, and nutritional intervention, has demonstrated effectiveness over multiple outcome areas, despite the fact that it has virtually no direct effect on the underlying pathophysiology of the lung. This intervention works primarily through its beneficial effects on associated morbidity, such as physical deconditioning. Pulmonary rehabilitation is indicated when respiratory symptoms or functional limitations persist despite otherwise standard medical therapy. Combining optimal bronchodilator therapy and/or supplemental oxygen therapy with exercise training will enhance the effectiveness of the latter.     

间质性肺病的呼吸康复治疗

间质性肺病(ILD)是一组异质性慢性呼吸系统疾病,主要表现为劳力性呼吸困难和健康相关生活质量评分下降。ILD运动受限的病生理机制包括限制性通气功能障碍、换气功能障碍、血流动力学异常以及骨骼肌功能障碍。近年来,越来越多的证据表明呼吸康复治疗对ILD安全、有效,能短期内显著改善患者的运动能力、呼吸困难症状和健康相关生活质量评分。该篇综述总结了ILD呼吸康复治疗的研究证据、目前的指南推荐、ILD的呼吸康复治疗个体化的特殊问题以及ILD合并肺动脉高压、ILD急性加重期呼吸康复情况。     

Symptom‐based management of the idiopathic interstitial pneumonia

The term ‘idiopathic interstitial pneumonia’ (IIP) encompasses a wide variety of diseases with different and often unexplained pathophysiology as well as diverse natural histories. Unfortunately, many of these diseases are progressive and some are poorly responsive to available therapies. Despite the varied nature of IIPs, patients experience common symptoms related to their chronic lung disease. Dyspnoea, cough, fatigue and depression contribute substantially to morbidity and are often difficult to manage. The psychological stress of having a chronic and often life‐limiting disease further complicates symptom control. Effective symptom‐management requires a multidisciplinary approach that incorporates patient education and self‐management to formulate goals of care and treatment plans. In this context, palliative care is incorporated from the time of diagnosis of an IIP and is not restricted to the end stages of the disease. Pulmonary rehabilitation plays a central role in symptom‐management and has beneficial effects across multiple domains. In patients who do not respond to disease‐specific treatments and are not candidates for lung transplant, early referral to hospice may improve quality of life for both patients and their families near the end of life.     

The effects of pulmonary rehabilitation in the national emphysema treatment trial

STUDY OBJECTIVES: Pulmonary rehabilitation is an established treatment in patients with chronic lung disease but is not widely utilized. Most trials have been conducted in single centers. The National Emphysema Treatment Trial (NETT) provided an opportunity to evaluate pulmonary rehabilitation in a large cohort of patients who were treated in centers throughout the United States. DESIGN: Prospective observational study of cohort prior to randomization in a multicenter clinical trial. SETTING: University-based clinical centers and community-based satellite pulmonary rehabilitation programs.Patients and intervention: A total of 1,218 patients with severe emphysema underwent pulmonary rehabilitation before and after randomization to lung volume reduction surgery (LVRS) or continued medical management. Rehabilitation was conducted at 17 NETT centers supplemented by 539 satellite centers. MEASUREMENTS AND RESULTS: Lung function, exercise tolerance, dyspnea, and quality of life were evaluated at regular intervals. Significant (p < 0.001) improvements were observed consistently in exercise (cycle ergometry, 3.1 W; 6-min walk test distance, 76 feet), dyspnea (University of California, San Diego Shortness of Breath Questionnaire score, -3.2; Borg breathlessness score: breathing cycle, -0.8; 6-min walk, -0.5) and quality of life (St. George Respiratory Questionnaire score, -3.5; Quality of Well-Being Scale score, +0.035; Medical Outcomes Study 36-item short form score: physical health summary, +1.3; mental health summary, + 2.0). Patients who had not undergone prior rehabilitation improved more than those who had. In multivariate models, only prior rehabilitation status predicted changes after rehabilitation. In 20% of patients, exercise level changed sufficiently after rehabilitation to alter the NETT subgroup predictive of outcome. Overall, changes after rehabilitation did not predict differential mortality or improvement in exercise (primary outcomes) by treatment group. CONCLUSIONS: The NETT experience demonstrates the effectiveness of pulmonary rehabilitation in patients with severe emphysema who were treated in a national cross-section of programs. Pulmonary rehabilitation plays an important role in preparing and selecting patients for surgical interventions such as LVRS.     

Pulmonary rehabilitation in Switzerland

Pulmonary rehabilitation is a form of therapy for patients with chronic lung disease that is evidence based, which ameliorates performance and endurance of the patient and improves quality of life significantly. Pulmonary rehabilitation also diminishes the amount of hospitalisations and the duration of stay in hospitals. It can improve capacity of work and diminishes the absenteeism. Motivated patients who have stopped or intend to stop smoking are the best candidates for a pulmonary rehabilitation programme.     

Extra-pulmonary features in COPD patients entering rehabilitation after stratification for MRC dyspnea grade

Experts have stated that referral for rehabilitation of patients with chronic obstructive pulmonary disease (COPD) becomes appropriate when these patients become aware of their disability (e.g. usually grade 3 to 5 on the Medical Research Council (MRC) dyspnea scale). However, patients with MRC dyspnea grade 1/2 may also suffer from extra-pulmonary features, such as abnormal body composition, exercise intolerance and reduced disease-specific health status. In the present study, we have studied whether and to what extent chronic obstructive pulmonary disease (COPD) patients with MRC dyspnea grade 1/2 have extra-pulmonary features compared to patients with grade 3, 4 or 5? Pulmonary function, body composition, 6-min walking distance, peak exercise capacity, anxiety, depression and disease-specific health status have been assessed in 333 outpatients who had been referred for pulmonary rehabilitation. On average, patients with MRC dyspnea grade 1/2 had a better exercise tolerance and disease-specific health status compared to patients with grade 4 or 5. Nevertheless, grade 1/2 patients had a higher prevalence of muscle mass depletion. In addition, these patients did still have aberrant values in one or more of the aforementioned outcomes. On average, patients with MRC dyspnea grade 1/2 may clearly suffer from extra-pulmonary features, indicating the necessity to refer these patients for rehabilitation. Therefore, MRC dyspnea scale alone does not appear to be a suitable measure to identify most patients with COPD who have to be referred for rehabilitation.     

Rehabilitation und Trainingstherapie als Baustein der COPD-Therapie

Pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) involves the application of complex, multidisciplinary, scientifically based therapeutic methods to improve productivity and quality of life. This leads to better social integration, and reduces disease related disabilities and limitations in activities of daily life. Exercise training is the most important part of the rehabilitation process, with respiratory and physical therapy, evaluation and adjustment of medication playing important roles. Education in smoking cessation programs, nutritional support and osteoprotection can add substantial benefits to the therapeutic process. Essential goals of the treatment program are to provide psychological and social support as well as education, motivation to give the patient the necessary tools to handle exacerbation and develop competence in self management. COPD leads to a progressive reduction in cardiopulmonary function. This article is based on exercise training as the “gold standard” for rehabilitation in these patients. Other essential therapeutic options in the rehabilitation of COPD patients are discussed in other parts of this journal.     

A study of the long-term effectiveness of an outpatient pulmonary rehabilitation program]

Pulmonary rehabilitation is one of the most important components of comprehensive care for patients with significant disability due to chronic respiratory failure. Because pulmonary rehabilitation has not been popular in Japan, the long-term effectiveness of pulmonary rehabilitation has rarely been reported. We therefore examined the long-term effectiveness of an outpatient pulmonary rehabilitation program for patients with chronic respiratory failure. Our program was composed of a once-a-week introduction program for 2 months and a support program that was continued every 4 weeks as long as possible. Thirty stable patients with chronic respiratory failure were enrolled in the program; 21 patients (COPD: 15, lung complications of tuberculosis: 6) completed the 9-week introduction program and the ensuing 6-month support program. Good compliance with the home training regimen was maintained during the period. The introduction program significantly alleviated dyspnea (Fletcher's grade: 3.3 to 3.0, p < 0.01) and improved the data for activity (Spector's score: 5.3 to 5.8, p < 0.01) and 6-minute walking distance (319 to 384 m, p < 0.01). These benefits were sustained during the 6-month support program. We concluded that outpatient pulmonary rehabilitation can alleviate dyspnea and improve the activity and exercise tolerance of patients with chronic respiratory failure, and that the effectiveness of training can be well maintained with a minimal support program.     

Marital adjustment among patients with chronic obstructive pulmonary disease who are participating in pulmonary rehabilitation

BACKGROUND: Marital adjustment has been associated with morbidity and mortality across various chronic diseases but has been largely ignored among patients with chronic obstructive pulmonary disease (COPD). PURPOSE: This study was designed to evaluate the relationship among marital adjustment, quality of life, psychologic functioning, and functional capacity among married patients with COPD who are participating in a 5-week exercise rehabilitation program and their spouses. SAMPLE: A convenience sample of 31 patients with COPD and their partners was included. DESIGN: A prospective 1-group pretest-posttest study was conducted. RESULTS: Marital adjustment scores indicated that patients and partners were, on average, satisfied with their marriages. Patient marital adjustment was associated with patient psychologic well-being, whereas partner marital adjustment was associated with patient physical functioning. In addition, patient and partner perceptions of marital adjustment predicted change in patient functioning after exercise rehabilitation. Patients who entered the program with poor marital adjustment experienced a greater magnitude of improvement in mental health after rehabilitation than did well-adjusted patients. CONCLUSIONS: These findings suggest that marital adjustment is associated with both psychologic well-being and physical functioning among patients with COPD, and that it may predict change among patients with COPD participating in exercise rehabilitation.     

The effects of pulmonary rehabilitation in elderly patients]

Pulmonary rehabilitation is one of the most important treatment modalities for patients with chronic lung disease. To determine the effects of an outpatient pulmonary rehabilitation program for the older members (aged 77 +/- 3 years; seniors) of an elderly patient group with chronic lung disease, we prospectively compared the degrees of improvement of lung function, dyspnea, daily activities and exercise tolerance (6-minute walking distance) after a 9-week rehabilitation program in 27 seniors with chronic lung disease (COPD 18, post-tuberculosis lung disorders 8, lung fibrosis 1; %FEV1 50.9 +/- 17.1%) with that in disease- and %FEV1-matched younger members (aged 70 +/- 2 years; juniors; %FEV1 49.3 +/- 16.1%) of the elderly patient group. All patients performed supervised weekly outpatient exercise and education activities for 9 weeks and a home exercise regimen. Assessments were made before and after the program. Twenty-three of the seniors and 25 of the juniors completed the program. There was no significant difference in the withdrawal rates between these groups. Although lung function and blood gas data had not changed significantly after rehabilitation, the clinical symptoms and the 6-minute walking exercise improved significantly in both groups (Baseline Dyspnea Index focal score: +1.3 +/- 0.9 in the seniors and +0.6 +/- 0.9 in the juniors: 6-minute walking distance: +/- 52 m and +/- 62 m, respectively) and the improvement of the Baseline Dyspnea Index focal score was significantly greater in the seniors than in the juniors. We observed the patients after they had followed the program for 2,000 days and found that the continuation ratio of rehabilitation in the seniors was far inferior to that in the juniors (continuation ratios for 1.2 and 3 years in the seniors were 50.5, 18.0 and 0%, respectively, and in the juniors, 79.5, 66.2 and 61.5%). We concluded that, although the senior elderly patients could benefit from the pulmonary rehabilitation program, it is difficult to maintain this benefit for many years.     

Modifying the Course of Chronic Obstructive Pulmonary Disease: Looking Beyond the FEV1

Abstract

COPD is defined by airflow limitation that is not fully reversible and is usually progressive. Thus, airflow obstruction (measured as FEV₁) has traditionally been used as the benchmark defining disease modification with therapy. However, COPD exacerbations and extrapulmonary effects are common and burdensome and generally become more prominent as the disease progresses. Therefore, disease progression should be broader than FEV₁ alone. Interventions that reduce the frequency or severity of exacerbations or ameliorate extrapulmonary effects should also be considered disease modifiers. A narrow focus on FEV₁ will fail to capture all the beneficial effects of therapy on disease modification. Although smoking cessation has been unequivocally demonstrated to slow the rate of FEV₁ decline, inhaled corticosteroid–long-acting bronchodilator therapy may also have modest effects according to post hoc analysis. Maintenance pharmacotherapy with inhaled long-acting anti-muscarinic or ®-adrenergic agents or combined ®-adrenergic—inhaled corticosteroid reduces symptoms, improves lung function, reduces the frequency of exacerbations, and improves exercise capacity and HRQL. Pulmonary rehabilitation reduces symptom burden, increases exercise capacity, improves HRQL, and reduces health care utilization, probably through reducing the severity of exacerbations. Smoking cessation, lung volume reduction surgery, inhaled maintenance pharmacotherapy, and pulmonary rehabilitation administered in the post-exacerbation period may reduce mortality in COPD. These improvements over multiple outcome areas and over relatively long durations suggest that disease modification is indeed possible with existing therapies for COPD. Therefore, therapeutic nihilism in COPD is no longer warranted.     

Surgery for chronic obstructive pulmonary disease: the place for lung volume reduction and transplantation

Lung volume reduction surgery and lung transplantation have been shown to improve lung function, exercise capacity, and quality of life in patients with advanced emphysema. Because the indications for both surgical procedures overlap, lung volume reduction surgery may be used as an alternative treatment or as a "bridge" to lung transplantation. In this article, we discuss patient selection, clinical outcome parameters, and the morbidity and mortality associated with each surgical procedure. We focus on the different preoperative predictors of good and poor outcomes after lung volume reduction surgery, the role of pulmonary rehabilitation, and the preferred surgical techniques for lung volume reduction surgery. An overview of the postoperative care of emphysema patients who undergo single-lung transplantation is also discussed.     

Regular exercise as a part of treatment for patients with end-stage renal disease

Physical inactivity and its negative influence on health and the quality of life is a common problem generally, especially in patients with chronic illness and also in patients with end-stage renal disease. Motivation for regular physical exercise could be a problem. A supervised outpatient program in a rehabilitation center, a home exercise rehabilitation program and an exercise rehabilitation program during the first hours of the hemodialysis treatment with a bed bicycle ergometer in the renal unit could be carried out. Low intensity aerobic activity has a favorable effect on cardiovascular risk factor, and gymnastics to increase strength, flexibility and coordination, as well as relaxation techniques are very effective exercises in a rehabilitation program. The positive influence of individual regular exercise on health, quality of life, physical exercise capacity, endurance, muscle strength, social, professional and emotional status is also very high in patients. Side effects of exercise are very rare.