OverviewPulmonary rehabilitation is an integral part of the clinical management and health maintenance of those patients with chronic respiratory disease who remain symptomatic or continue to have decreased function despite standard medical treatment. [1] Show
Consequences of respiratory diseaseSee the list below:
Mechanisms for these morbiditiesSee the list below:
Definition of pulmonary rehabilitationPulmonary rehabilitation has been defined in the following terms: A multidimensional continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual's maximum level of independence and functioning in the community. The American Thoracic Society and the European Respiratory Society adopted the following definition of pulmonary rehabilitation: Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. [2] Principal goals of pulmonary rehabilitationSee the list below:
For patient education resources, see the Public Health Center, as well as Resistance Training. Benefits of Pulmonary RehabilitationThe benefits of pulmonary rehabilitation are seen even in irreversible pulmonary disorders, because much of the disability and handicap results not from the respiratory disorder per se but from secondary morbidities that often are treatable if recognized. Although the degree of airway obstruction or hyperinflation of chronic obstructive pulmonary disease (COPD) does not change appreciably with pulmonary rehabilitation, reversal of muscle deconditioning and better pacing enables patients to walk farther and with less dyspnea. Pulmonary rehabilitation programs include prevention, early recognition and treatment of morbidities, and inpatient, outpatient, and extended care of patients with chronic respiratory illness. The anticipated patient outcomes of a comprehensive pulmonary rehabilitation program include increased independence and improved QOL, as well as fewer hospitalizations or shorter hospitalization time. Disease, impairment, disability, and handicapAccording to the international classification of impairments, disabilities, and handicaps developed by the World Health Organization, a patient's specific outcomes are described as follows:
For patients with pulmonary impairment, disability can be due to muscle dysfunction, primary skeletal or cardiopulmonary pathology, poor endurance, or some combination of impairments. The patient can be handicapped further by inadequate finances, inadequate family support or education, and various public policies. BenefitsA successful rehabilitation program identifies and differentiates the disease process (ie, impairments, disabilities, handicaps) so that remedial strategies can be determined. The functional consequences of these impairments are addressed so that the person with chronic respiratory impairment is returned to the fullest possible physical, mental, social, and economic independence. The effectiveness of a comprehensive pulmonary rehabilitation program has been established by controlled clinical trials. Several impairments, such as weakness, dysfunction of peripheral and respiratory muscles, anxiety and depression, and abnormalities of nutrition, have responded to treatment. [3] Improvements in overall and exertional dyspnea, as well as health-related QOL, have been documented. Significant increases in maximal exercise capacity, as measured during exercise testing, have been observed. In the only randomized study that has been conducted, survival benefit was not demonstrated, possibly because of the inability to detect the difference. Controlled trials have shown a decrease in health care resource use after rehabilitation, indicated by reduction in the number of hospitalizations and emergency department or physician office visits. Although not conclusively proven, the effect of pulmonary rehabilitation on outcomes in patients without COPD may be substantial. Retrospective study has shown no significant difference in improvement in exercise tolerance or QOL following pulmonary rehabilitation in COPD versus non-COPD patients. Therefore, pulmonary rehabilitation is effective for patients with disability due to any chronic respiratory disease, not just COPD. Respiratory rehabilitation may improve prognosis in patients who develop COPD exacerbation. [4] Evidence from 6 trials suggests that respiratory rehabilitation is effective in COPD patients after acute exacerbation. Related Medscape Reference topics:Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease and Emphysema Patient Selection and AssessmentPulmonary rehabilitation is indicated for patients with chronic respiratory impairment who, despite optimal medical management, are dyspneic, have reduced exercise tolerance, or experience a restriction in activities. Indication for pulmonary rehabilitation is based not on the severity of physiologic impairment of the lungs but on the persistence of symptoms, disability, and handicap. Although chronic obstructive pulmonary disease (COPD) remains the major disease involved in referral for rehabilitation services, patients with other conditions may be appropriate candidates for pulmonary rehabilitation, because the same principles of ameliorating secondary morbidity apply. Examples include asthma, chest wall disease, cystic fibrosis, bronchiectasis, interstitial lung disease, lung cancer, selected neuromuscular diseases, postpolio syndrome, and perioperative conditions (thoracic or abdominal surgery, lung transplantation, lung volume reduction surgery). Exclusion criteria include conditions interfering with rehabilitative processes or that could cause risk during exercise training (eg, cognitive dysfunction, severe pulmonary hypertension, unstable angina, recent myocardial infarction). AssessmentComprehensive assessment of the candidate for pulmonary rehabilitation is necessary for developing an appropriate, individualized plan of care. The clinical history, physical examination, and review of pertinent investigations (eg, pulmonary function tests) are necessary to determine the severity of respiratory impairment (see the image below). The determination of baseline exercise capacity is essential in formulating the exercise training prescription and in evaluating for hypoxemia during exercise. The assessment of exercise capacity may be performed using either incremental exercise testing or a timed, 6-minute walk test. Pulmonary function testing is very helpful in identifying the disorder as obstructive (B) or restrictive (A) and also helps to quantify the severity of the dysfunction.Other assessments that may be performed include measurements of respiratory muscle strength (eg, maximum inspiratory and expiratory pressures), measurement of peripheral muscle strength, assessment of performance of ADL, health status, cognitive function, emotional and mood state, and nutritional status, as well as body composition. Questionnaires may be used to screen for anxiety and depression. Several such instruments (eg, the Beck depression inventory [BDI], the geriatric depression scale [GDS]) are available. [3] Nutritional assessment is important, because changes in body weight, body composition, or eating habits are common in patients with advanced respiratory disease. Body composition can be evaluated using anthropometry, bioelectrical impedance analysis, or dual-energy radiographic absorptiometry (DRA), which estimates lean body mass. Related Medscape Reference topics:Asthma [Emergency Medicine] Asthma [Pediatrics: General Medicine] Asthma [Pulmonology] Asthma [Radiology] Bronchiectasis [Pediatrics: General Medicine] Bronchiectasis [Pulmonology] Bronchiectasis [Radiology] Cystic Fibrosis Setting for Pulmonary RehabilitationDespite a substantial variability in program structure, the efficacy of pulmonary rehabilitation performed in inpatient, outpatient, or home settings has been documented. [5] The structure and components of the program, rather than the setting itself, determine the effectiveness of pulmonary rehabilitation. The choice of setting often depends on the variability and distance to the program, insurance payer coverage, patient preference, and the physical, functional, and psychosocial status of the patient. Inpatient rehabilitation generally is recommended for patients affected to the greatest degree, because intensive rehabilitative services and specialized training for the patient and/or family will be available. Outpatient rehabilitation, which can be hospital or community based, has the potential to benefit most patients but nonetheless requires a certain level of functional ability. Although outcomes have not been well studied, home-based pulmonary rehabilitation is convenient for the patient and family members and may provide sustained motivation for continued exercise training. Rehabilitation teamBecause rehabilitation offers a holistic and comprehensive approach to medical care, the combined expertise of an interdisciplinary team is necessary. The rehabilitation team is led by a physician specialist skilled in evaluating the neuromuscular, musculoskeletal, cognitive, and cardiopulmonary systems. The physician should be trained in cardiopulmonary and exercise fitness, ventilator management, and treatment of functional deficits. The physician should be skilled in working with a team of professionals, because he/she is responsible for the medical treatment and rehabilitation program. The other members of the rehabilitation team include a physical therapist, occupational therapist, rehabilitation nurse, social worker, respiratory therapist, vocational counselor, and psychologist. A successful team maintains coordination, cooperation, and open communication. Each member also needs to have knowledge of the general principles of other members' approaches.
Optimizing Medical CareMedical CareThe goal of treatment is to preserve optimal lung function, thereby preventing symptoms and recurrence of exacerbations and, as a result, improving function in daily living, as well as QOL. Once the diagnosis of chronic obstructive pulmonary disease (COPD) has been established, educate the patient about the disease (see the image below). Encourage the patient to actively participate in therapy. A Venn diagram shows that chronic obstructive pulmonary disease (COPD) is actually a combination of emphysema and chronic bronchitis. Many patients with COPD also have an asthmatic component. Smoking cessation continues to be the most important therapeutic intervention (see the image below). Many patients with COPD have a history of smoking, and many currently smoke. A smoking cessation plan is an essential part of a comprehensive management strategy. The success rates of smoking cessation plans are low because of the addictive potential of nicotine, the conditioned response of individuals who smoke to smoking-associated stimuli, forceful promotional campaigns by the tobacco industry, poor education, and psychological problems faced by patients who attempt to quit smoking, including depression. Any smoking cessation program must involve multiple interventions. This Fletcher and Peto diagram demonstrates the natural history of chronic obstructive pulmonary disease (COPD) and the benefits of smoking cessation, even when lung disease is advanced.Using multivariate analysis, a study by Brown et al found that among 440 patients with COPD who attended a pulmonary rehabilitation program, cigarette smoking at enrollment was the lone independent risk factor for dropping out of the program. [6] In patients with stable disease, oral and inhaled medications are used to reduce dyspnea and improve exercise tolerance. Most of the medications employed are directed at 4 potentially reversible causes of airflow limitation in a disease state with largely fixed obstruction. The following factors may be present:
Smoking cessation and physical interventionThe transition from smoking to abstention from smoking occurs in the following 5 stages:
Smoking intervention programs include self-help, group, physician-delivered, workplace, and community programs. Setting a quit date may be helpful. Physicians and other health care providers should participate in setting the target date and should follow up with respect to maintenance. Successful cessation programs usually employ such tools as patient education, establishment of a quit date, follow-up support, relapse prevention, advice for healthy lifestyle changes, social support systems, and adjuncts to treatment (eg, pharmacologic agents). According to the US Preventive Services Task Force (USPSTF) guidelines, clinicians should ask all adults about use of tobacco products and provide cessation interventions to current users. The guideline engages a “5-A” approach to counseling that includes the following: [7]
Brief behavioral counseling (ie, under 10 min) and pharmacotherapy are each effective alone—although they are most effective when used together. The task force also advises clinicians to ask all pregnant women, regardless of age, about tobacco use. Those who currently smoke should receive pregnancy-tailored counseling supplemented with self-help materials. Smoking cessation and pharmacologic interventionSee the list below:
Oxygen systems (see the images below)
Preventative therapySee the list below:
Surgical careOver the past 50-75 years, researchers have described a variety of surgical approaches for improving symptoms and restoring function in patients who suffer from emphysema. Only giant bullectomy and, possibly, lung volume reduction surgery are useful. BullectomyRemoval of giant bullae has been a standard approach in selected patients for many years. The bullae in patients with emphysema generally range in size from 1-4 cm in diameter; however, on occasion, giant bullae can occupy more than 33% of the hemithorax. Giant bullae may compress adjacent lung tissue, thereby reducing the blood flow to and ventilation of the normal tissue. Removal of these bullae may result in the expansion of compressed lungs and improved function. Patients who are symptomatic and have an FEV1 of less than 50% predicted have a better outcome after bullectomy, which is performed through either a midline sternotomy or a lateral incision with or without video-assisted thoracoscopy. Postoperative leaks are the major potential complications. Giant bullectomy can produce subjective and objective improvement in selected patients who have bullae that compress the adjacent lung and that occupy at least 30% (but preferably, 50%) of the hemithorax, who have an FEV1 of less than 50% predicted, and who otherwise have relatively preserved lung function. Lung-volume reduction surgeryBrantigan and colleagues first reported resectioning surgery for diffuse emphysema in 33 patients. They resected the 20-30% of each lung that appeared the most diseased. Brantigan hypothesized that removal of a portion of the emphysematous lung increased the radial traction on the airways in the remaining part of the lung, thereby reducing symptoms by improving the respiratory system's expiratory airflow and mechanical function. Lung volume reduction surgery (LVRS) subsequently gained considerable momentum, after researchers documented a marked improvement in the FEV1 (+82%), the forced vital capacity (FVC; +27%), the 6-minute walk distance, and QOL indices. Currently, large, prospective clinical trials are underway in the US and Canada to evaluate the effectiveness of LVRS. The indications and patient selection criteria for LVRS have not been rigorously defined. Generally, candidates for LVRS have symptoms that are secondary to severe emphysema, as well as having marked hyperinflation (ie, elevated residual volume/total lung capacity [RV/TLC] ratio) and computed tomography (CT) scan evidence of heterogeneous emphysema. The study excluded patients who are hypercapnic or who have pulmonary hypertension or other cardiac risk factors. The surgical approach uses a midline sternotomy, with stapling of the lung margins. Surgeons generally resect 20-30% of each lung from the upper zones. The LVRS procedure has a mortality rate of 0-18%. Several complications, including pneumonia and prolonged air leaks, have been observed. [10] Lung transplantationLung transplantation continues to gain acceptance for the treatment of end-stage lung disease, particularly emphysema and idiopathic pulmonary fibrosis. Lung transplantation also is used in patients with sarcoidosis, eosinophilic granuloma, extrinsic allergic alveolitis, lymphangioleiomyomatosis, pulmonary hypertension, cystic fibrosis, and severe bronchiectasis. Single lung transplantation is preferred, because bilateral lung transplantation does not significantly alter patient survival. The initial morbidity and mortality is slightly less following a single transplant, and the lungs from 1 donor can be used to benefit 2 patients. The double lung transplant is used for patients with cystic fibrosis, because a single transplanted lung would be susceptible to the spread of infection from the native lung. Patients with severe pulmonary hypertension have received double lung transplantation in the past to minimize hemodynamic instability. Patients treated with a double lung transplant tolerate bronchiolitis obliterans syndrome better than do patients with a single transplant. For donor selection, a 10-20% difference in size between the donor and the recipient lungs is acceptable. Only blood group typing is performed. The recipient must have no history of a recent malignancy and should be taking less than 20 mg of prednisone per day. Patients aged 65 years or less are candidates for single transplant, and patients aged 55 years or less are candidates for a bilateral transplant. Patients with a multisystem disease are considered to be poor candidates for lung transplant. Patients with cystic fibrosis and pulmonary infection with pan antibiotic–resistant organisms (especially Pseudomonas cepacia) have high rates of reinfection after transplant, as well as a greater mortality rate. All patients being evaluated for lung transplant undergo CT scanning of the chest, and all noncalcified nodules need to be evaluated to exclude malignancy. Survival for patients undergoing single lung transplantation is approximately 70-90% at 1 year and 50% at 3 years. Prognosis for survival is best in patients who require transplant for obstructive pulmonary disease. The proper timing of the transplant is difficult to assess; the patients selected to receive a transplant should have a life expectancy of 2 years or less. With lung transplantation, the profound dyspnea and limited lifestyle is replaced with improved QOL at the risk of worsening survival. Related Medscape Reference topics:Lung Transplantation [Pediatrics: Surgery] Lung Transplantation [Transplantation] Transplants, Lung Components of Comprehensive Pulmonary RehabilitationComprehensive pulmonary rehabilitation programs generally have the following 4 major components:
These interventions are provided by a multidisciplinary team that often includes physicians, nurses, respiratory therapists, physical therapists, occupational therapists, psychologists, and social workers. Exercise trainingExercise training is the foundation of pulmonary rehabilitation. [11] Exercise does not alter underlying respiratory impairment, but it does ameliorate dyspnea and improve other outcome measures. [12, 13] Exercise prescription emphasizes endurance training targeted at 60% of maximal workload for about 20-30 minutes, repeated 2-5 times a week. Generally, this training is well tolerated. An interval training regimen consisting of 2-3 minutes of high-intensity training (60-80% maximal exercise capacity) alternating with equal periods of rest might be a substitute for patients who cannot tolerate sustained activity. Dyspnea ratings during maximal graded exercise testing may offer reliable predictions of exercise intensity during training. Consequently, most pulmonary programs for the improvement of aerobic capacity use dyspnea targeting to guide training intensity. [14] The training specificity refers to the benefit gained only in those activities involving the specific muscle groups that are trained. Because the performance of many ADL involves the use of the arms, endurance training of the upper extremities to improve arm function is important. [15] Supported arm exercises are prescribed with ergometry or unsupported arm exercises by lifting free weights or stretching armbands. Because peripheral muscle weakness contributes to exercise limitation in patients with lung disease, strength training is a rational component of exercise training during pulmonary rehabilitation. Even low-intensity leg and arm muscle conditioning has led to reduced ventilatory equivalent for oxygen and carbon dioxide. See the images below. A regular walking schedule is an important component of pulmonary rehabilitation. Walking distance is increased progressively, and oxygen supplementation often is used in a patient who desaturates with exercise. Lower extremity exercise by stationary bicycling improves strength and endurance.The reversibility of training effects is well known. The effects of training are maintained only as long as exercise is continued. Therefore, efforts at improving long-term adherence with exercise training at home are necessary for the long-term effectiveness of pulmonary rehabilitation. A literature review by Meshe et al indicated that in patients with COPD who have undergone pulmonary rehabilitation, participation in an exercise maintenance program leads to improvements in exercise capacity, QOL, and dyspnea. Six months after pulmonary rehabilitation, persons who engaged in increased physical activity in the intervening time improved by 62 meters on the six-minute walk distance test and saw their scores increase on the St. George’s Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Disease Questionnaire (CRDQ), by 2.31 and 15.55 points, respectively. [16] Respiratory muscle trainingRespiratory muscle training using adequate loads improves the strength of the inspiratory muscles in patients with chronic obstructive pulmonary disease (COPD); however, it remains unclear whether this improvement results in a decrease in symptoms, disability, and handicap. Although improvement in inspiratory muscle strength is accompanied by decreased breathlessness and increased respiratory muscle endurance, the benefits have not been well established. [17] EducationEducation is an integral part of comprehensive pulmonary rehabilitation programs, encouraging active participation in health care, which leads to a better understanding of the physical and psychological changes that occur with chronic illness. With education, patients can become more skilled at collaborative self-management and have improved compliance. In small groups or on an individual basis, the following topics generally are covered:
Psychosocial and behavioral interventionAnxiety, depression, difficulties in coping with chronic lung disease, and the inability to cope with illness contribute to the handicap of advanced respiratory disease. Psychosocial and behavioral interventions in the form of regular patient education sessions or support groups focusing on specific problems are very helpful. Instructions in progressive muscle relaxation, stress reduction, and panic control may help to reduce dyspnea and anxiety. Because of the effects of chronic respiratory disease on the family, participation of family members or friends in pulmonary rehabilitation support groups is encouraged. Depression is often comorbid with COPD. The prevalence rate for morbid depression in patients with COPD ranges from 20-60%. The etiologies for this elevated rate include genetic predisposition, grief reaction, and the effects of COPD on the central nervous system. Once depression develops, patients are less likely to follow treatment plans; they lose function and there is a potential for them to suffer worse outcomes in exacerbations. Few data demonstrate the efficacy of antidepressants in this population, although some studies suggest selective serotonin reuptake inhibitors to be effective. Other interventions, including psychotherapy, physical rehabilitation, and improved social support, may also be effective, but additional study is needed before their effectiveness can be proven. [18] Chest physical therapy and breathing techniquesControlled breathing techniques and chest physical therapy are the 2 major components of the multidisciplinary approach to the rehabilitation of patients with COPD, bronchiectasis, and cystic fibrosis. Although only smoking cessation and long-term oxygen therapy prolong life in patients with COPD, it is likely that chest physical therapy does the same for persons with cystic fibrosis and diffuse bronchiectasis. The 3 major breathing techniques include the following [19] :
Chest physical therapy, along with postural drainage, enhances mucus clearance from central and peripheral lung airways. The value of this therapy in stable patients with COPD and in acute COPD exacerbation is uncertain. Nonetheless, for patients who produce more than 30 mL of sputum every 24 hours or who have difficulty with sputum expectoration, chest physical therapy combined with postural drainage and effective coughing techniques enhances sputum expectoration; the actual benefit, however, has not been determined. Chest physical therapy remains an essential component of therapy for bronchiectasis and cystic fibrosis. The frequency of treatments must be individualized based on the severity of disease and on the quantity of airway secretions that must be cleared. Standard chest physical therapy with postural drainage, cough, and the forced expiratory technique is the cornerstone of such treatment regimen. Newer modalities, such as mechanical chest percussion and mask positive airway pressure, warrant further clinical trials before they can be used routinely. Chest physiotherapy is essential for the management of atelectasis in postoperative or seriously ill patients with COPD who are hospitalized. The image below depicts a patient using a flutter device to aid in sputum expectoration. Nutritional assessmentThe onset of weight loss in a patient with chronic respiratory disease is a poor prognostic indicator. Approximately 50% of hospitalized patients with COPD are reported to suffer from protein and calorie malnutrition. Progressive weight loss occurs from inadequate dietary intake, diet-induced thermogenesis, increased resting energy expenditure, and failure of normal adaptive response to undernutrition. These mechanisms lead to energy imbalance and weight loss. Maintenance of adequate nutritional status by timely screening and appropriate management is essential. Provide patient education in weight maintenance techniques and emphasize the importance of preserving muscle mass and tissue stores. Optimal nutritional status in pulmonary rehabilitation should help to maximize the patient's state of health, respiratory muscle function, and overall sense of well-being; it also may improve disease outcome. Obesity, which is defined as a body weight that is 20% greater than the ideal body weight, may be detrimental to respiratory function. The large fat mass increases the work of the compromised respiratory system, particularly during weight-bearing activities. [21] Encourage reduction of the body fat mass in this patient population.
Nutritional interventionWith an adequate provision of calories, the usual intervention for a malnourished patient with chronic respiratory disorder results in weight gain. A calorie intake of 1.7 times the resting energy expenditure is recommended. Provision of adequate nitrogen to maintain body stores, replete tissue mass, and spare calories is required. Based on trials, it appears that protein supplementation of at least 1.7 g/kg of body weight per day is associated with nitrogen retention and physiologic improvement. Nutrition counseling to address the planning and preparation of a nutritionally adequate meal plan, the adequacy of the food supply, the use of nutritional supplements, and other details is essential to the success of any intervention program. [22] Outcome AssessmentOutcome assessment is an important component of a comprehensive pulmonary rehabilitation program, being used to determine individual patient responses and to evaluate the overall effectiveness of the program. Measurement of outcomes should be incorporated into every comprehensive pulmonary rehabilitation program. Minimal requirements include the assessment of the following measures of the patient's recovery before and after rehabilitation:
Consideration also should be given to follow-up measurements after longer periods of time, such as 6 and/or 12 months. Measures of disabilityExercise testing Progressive exercise testing on a stationary bicycle or treadmill is performed to a heart rate of 85% of predicted maximum. Dyspnea during exertion can be rated using a visual analogue scale. This test is reproducible and is sensitive to improvements from pulmonary rehabilitation. Instead of an incremental increase in work rate, endurance capacity can be measured at a constant fraction of maximal work rate. A longer exercise time indicates greater exercise endurance and leads to a reduction in ventilatory requirements. Walk tests The 6-minute and 12-minute walk tests, as well as shuttle walk tests, correlate positively to peak exercise performance on graded exercise tests. [24] The minimal increase that is clinically meaningful in 6-minute walking distance is about 54 meters. A retrospective study by Maestri et al indicated that in patients with COPD, including those with or without either respiratory failure or obstructive sleep apnea, achievement of an increase of 30 meters in the 6-minute walk test (6MWT) following completion of an inpatient pulmonary rehabilitation program is associated with age, male gender, severity of airway obstruction, and baseline value for the 6MWT. [25] Exertion and overall dyspnea Dyspnea is the most common symptom of individuals with chronic pulmonary disease and is frequently the major reason for seeking acute care. Dyspnea during exercise usually is measured with a category scale, such as the Borg scale or the visual analogue scale. [26] The effect of dyspnea on daily activities can be measured with the Medical Research Council dyspnea questionnaire or with the dyspnea component of the chronic respiratory disease questionnaire. The relief in dyspnea correlates with a fallen ventilatory demand during exercise, indicating a training effect. Respiratory specific functional status Functional capacity is what the patient is capable of doing, whereas functional performance is what the patient actually does on a day-to-day basis. Functional reserve is the difference between the two of these; pulmonary rehabilitation improves a patient's functional reserve. Functional status usually is measured by a questionnaire, which estimates the impact of the program on various activities. Measures of handicap and QOLA health-related QOL instrument can assess the overall benefit of improvements in the patient's symptoms, disability, and handicap. QOL has been described as a person's satisfaction or happiness with life in demands that the patient considers important. QOL may be considered a balance between what is desired in life and what is achieved (although these indicators are difficult to measure). In rehabilitation, the following instruments have been used:
The disease-specific measures demonstrate greater sensitivity to change from baseline after rehabilitation intervention. The cost-effectiveness of pulmonary rehabilitation is largely unknown; a Canadian study determined the cost-effectiveness of a community-based pulmonary rehabilitation program for chronic obstructive pulmonary disease (COPD). Over 1 year, pulmonary rehabilitation was associated with decreased health service use, reduced direct costs, and improved health status for patients with COPD. Thus, pulmonary rehabilitation is cost-effective for patients with a relatively high use of emergency and hospital-based services. [27, 28] Future Directions of Pulmonary RehabilitationDespite the progress made in understanding pulmonary rehabilitation, more information is needed to ensure appropriate treatment for the increasing number of patients with chronic respiratory disease. Pulmonary rehabilitation remains an art of medical practice, but one that is built increasingly on a foundation of scientific research. The research embraces traditional outcome measures (eg, mortality and physiologic indices of lung and exercise function), as well as psychosocial measures (eg, symptoms, health-related QOL, economic analysis of costs and benefits). New evidence strengthens previous recommendations that pulmonary rehabilitation encompassing lower and upper extremity exercise training improves dyspnea and health-related QOL outcomes. Additional evidence supports improvements in healthcare utilization and psychosocial outcomes. Insufficient data support survival benefit at this time. Some new evidence indicates that longer-term rehabilitation, maintenance strategies following rehabilitation, and incorporation of education and strength training in pulmonary rehabilitation are beneficial. Data on routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation are insufficient to recommend incorporating these in pulmonary rehabilitation. Supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise has shown to be beneficial. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD. The following are several areas where further study or research is needed as the field of pulmonary rehabilitation continues to grow:
These questions should be assessed in future investigations. As an established preventive health care strategy for patients with chronic lung disease that is effective, noninvasive, and low in cost, pulmonary rehabilitation is an ideal subject for logical scientific inquiry. Patient adherenceA study by Guo and Bruce indicated that among patients with COPD, adherence to a pulmonary rehabilitation program can be improved in the following three ways [30] :
What is involved in pulmonary rehabilitation?In pulmonary rehab, patients are monitored and taught to exercise safely by paying attention to their breathing and oxygen levels, as well as learning modifications such as using a chair for weight lifting and yoga.
What are the anticipated results of pulmonary rehabilitation?Expected outcomes of pulmonary rehabilitation are improvements in dyspnea, quality of life and exercise tolerance, and, for patients with COPD, a reduction in hospital admissions (16).
What is the role of pulmonary rehabilitation in patients with COPD?Pulmonary rehabilitation is a program for people with chronic lung diseases like COPD, emphysema and chronic bronchitis. It will allow them to be as active as possible. Pulmonary rehab is aimed to improve quality of life by: Decreasing respiratory symptoms and complications.
What are the medical interventions to be expected for chronic obstructive pulmonary disease?For most people with COPD, short-acting bronchodilator inhalers are the first treatment used. Bronchodilators are medicines that make breathing easier by relaxing and widening your airways. There are 2 types of short-acting bronchodilator inhaler: beta-2 agonist inhalers – such as salbutamol and terbutaline.
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