The Principles of Pulmonary Rehabilitation

POSITION PAPER The Principles of Pulmonary Rehabilitation Pulmonary rehabilitation (PR) aims to restore patients to an independent, productive and satisfying life. This can often be done without measurable improvement in pulmonary function. The strategies used to treat patients chronically ill with pulmonary disease underwent a major change spurred by the work of Alvan Barach in the 1950's (1). Before this time, rest and avoidance of stress were prescribed for those with serious pulmonary conditions. Pulmonary rehabilitation now emphasizes exercise, education, physiotherapy, self-care and psychosocial support (2-5). PATIENT SELECTION The typical candidate for pulmonary rehabilitation is the patient with moderate to severe chronic obstructive pulmonary disease or asthma who is in a stable condition, but whose debility interferes with the quality of life. Such patients generally participate in programs of varying length, typically four to six weeks in duration. More severe disease leading to dyspnea at rest or hypercapnia is not necessarily a contraindication to rehabilitation (6). A new frontier in the design of rehabilitation programs is the accommodation of patients with conditions other than chronic obstructive pulmonary disease. Patients with interstitial lung disease, chest wall deformity, cystic fibrosis, asthma, stable lung cancer or superimposed cardiac disease may be appropriate rehabilitation candidates, but only in programs which recognize their specific requirements. Pulmonary rehabilitation has also been recognized as an adjunct to lung transplantation and may be helpful in the patient with chronic lung disease prior to elective surgery. Importantly, pulmonary rehabilitation has been recognized as an essential adjunct in the preparation for and selection of patients for lung volume reduction surgery (7). NIH-sponsored National Emphysema Therapy Trial (NETT) mandated a rigorous program of pulmonary rehabilitation as part of the standard of care for chronic obstructive pulmonary disease (COPD) patients selected for lung volume reduction surgery (LVRS). The NETT also demonstrated the value of PR for patients with COPD who were not candidates for surgical intervention. PATIENT EVALUATION A patient referred to a rehabilitation program is usually under the primary care of his or her own general practitioner, internist or pulmonary physician. Close consultation should take place between the referring physicians and program personnel to accomplish a comprehensive evaluation, without redundancy. The patient's medical history should be reviewed and a recent physical examination should be on file. The patient s medications and dosages should be known. Consideration of cardiovascular problems and musculoskeletal impairment is essential in structuring an individual's rehabilitation program. Required laboratory data generally includes resting arterial blood gases, an electrocardiogram, a chest radiograph, exercise oximetry and pulmonary function tests (including spirometry, lung volumes and diffusing capacity). Formal exercise testing, including ventilatory, gas exchange and electrocardiographic monitoring may be helpful to evaluate exercise tolerance and to rule out cardiovascular limitation to exercise (8). The results of exercise testing may also be useful in 1

establishing expectations for the exercise program. Arterial blood sampling during exercise can be used to detect exercise induced hypoxemia or CO 2 retention. Pulse oximetry is a non-invasive alternative that allows assessment of O 2 desaturation during exercise, but it is not always reliable (9, 10). Psychosocial assessment is also an important prelude to an effective program of pulmonary rehabilitation (11, 12). The patient's adjustment to the disease process, family support, living arrangements, and activities of daily living can be assessed through interviews or with formal testing instruments. COMPONENTS OF THE REHABILITATION PROGRAM Evidence-based analysis indicates that, of the components commonly included in pulmonary rehabilitation, excellent evidence exists for the benefits of exercise programs (13). Evidence for effectiveness of other components is less conclusive, though expert opinion favors their inclusion. Education. Community-based education when given alone, outside of a comprehensive rehabilitation program, may increase the patient's knowledge but does not necessarily produce substantial improvement in health status (14). However, in conjunction with other elements of the program, lectures and discussion groups are important in giving patients knowledge and ability to cope better with lung disease. Respiratory Physiotherapy. Patients with lung disease, particularly those with chronic bronchitis, often have difficulty in clearing secretions. Bronchial (postural) drainage and controlled coughing may be useful in selected patients. Training in breathing techniques is of help to many patients, though the benefit may be mainly in reduction of dyspnea rather than in measurable changes in physiologic variables. Pursed lip breathing, often adopted spontaneously, may decrease airways collapse, alter the breathing pattern, relieve dyspnea, and even result in better oxygenation (15-17). Diaphragmatic breathing exercises, in which the patient attempts to coordinate abdominal expansion with inspiration and to slow expiration through pursed lips, results in a slowed respiratory rate and increased tidal volume. Some investigators have found that this technique decreases dyspnea, while others have not (18) Psychosocial Support. Depression, anxiety, anger and fear of sexual activities are all common symptoms in patients with chronic lung disease. An enthusiastic, supportive well-trained staff that communicates effectively with patients can have substantial impact on the patient's adaptive response to disease. The patient's psychologic status is a substantial determinant of his/her reporting of respiratory symptoms (19). Relaxation training is an adjunct to psychosocial approaches and can help to reduce anxiety and dyspnea. Exercise. Although exercise prescription varies from program to program, an extensive literature supports inclusion of exercise in any program of pulmonary rehabilitation (2, 13). Exercise tolerance is usually improved and patients are often able to perform a given task for a longer time and/or tolerate a higher rate of work. These benefits occur without any improvement in lung function. Although it is possible that for some patients these benefits result from desensitization to the symptom of dyspnea (20), recent studies have demonstrated that it is possible for many patients obstructive lung disease to obtain a true physiologic training effect (accompanied by changes in 2

the exercising muscles which increase aerobic capacity) (21-23). It is uncertain if "typical" programs of pulmonary rehabilitation contain exercise programs of sufficient intensity or duration to engender a physiologic training effect. In fact, the optimal exercise prescription for pulmonary patients is an area poorly understood and in need of further study. Training targets based on those used for healthy subjects or cardiac patients are likely to be inappropriate (24). Training patients at work rates that elicit ventilation levels nearing their limits may be more effective. Provision of O 2 to prevent severe hypoxemia or cardiac arrhythmias is certainly appropriate. One study in its benefit for other patients undergoing pulmonary rehabilitation has shown increased benefits in exercise training. More studies are under way. Upper extremity exercise may be an important ingredient to rehabilitative exercise programs (25). Patients with lung disease may have difficulty with the upper extremity activities of daily living because arm exercise and respiration utilize overlapping muscle groups (26). Specific exercises to train the muscles of respiration have been proposed as a reasonable procedure to improve the level of ventilation the patient can sustain. However, the weight of evidence does not support their routine inclusion in a program of rehabilitation, though selected subjects may benefit (13, 27). Continuing Care Programs. After program care may be an important adjunct to reinforce the lessons learned during the formal program of rehabilitation and to continue access to the supportive environment. At their best, such programs provide a wide range of activities, including continued exercise and psychosocial support, which encourage participants towards endeavors that improve their quality of life. SUMMARY A number of limited but excellent studies have demonstrated important benefits of pulmonary rehabilitation. The sensation of dyspnea in the course of everyday tasks is reduced (28), though the mechanism of this improvement is unclear. Well-validated measures of quality of life have consistently indicated improvements (29). Several reports have demonstrated that pulmonary rehabilitation decreases hospitalization rates and the overall use of medical resources (13, 30). A recent randomized trial demonstrated a (nonsignificant) trend for pulmonary rehabilitation to increase five year survival (31-33). A much larger randomized trial would be required to examine this issue definitively. In recent years we have seen extensive multidisciplinary application of scientific principles to the therapy of patients with lung disease. With the development of methods to optimize exercise training, reduce dyspnea, and improve lifestyle, a program of rehabilitation has become the standard of care for many patients with debilitating chronic pulmonary disease. REFERENCES 1. Barach AL, Bickerman HA, Beck G: Advances in the treatment of non-tuberculous pulmonary disease. Bull New York Acad Med. 1952; 28:353-384. 2. Casaburi R and Petty TL: Principles and Practice of Pulmonary Rehabilitation. Philadelphia: Saunders, 1993. 3. Hodgkin J, Connors GT and Bell CW: Pulmonary Rehabilitation. Guidelines to Success. Second Edition. Philadelphia: Lippincott, 1993. 4. Fishman AP: Pulmonary rehabilitation research: Am J Respir Crit Care Med 1994; 149:825-833. 3

5. American Thoracic Society: Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. Am J Respir Crit Care Med 1995; 152:S77-121. 6. Foster S, Lopez D, Thomas HM: Pulmonary rehabilitation in COPD patients with elevated PCO2. Am Rev Respir Dis 1988; 138:1519-23. 7. Moser KM, Kerr KM, Cott HG, Ries AL: Lung reduction surgery: what role in emphysema? J Respir Dis 1996; 17:351-358. 8. Wasserman K, Hansen JE, Sue DY, Whipp BJ and Casaburi R: Principles of Exercise Testing and Interpretation. 2nd edition. Philadelphia: Lea and Febiger, 1994. 9. Ries AL, Farrow JT and Clausen JL: Accuracy of two ear oximeters at rest and during exercise in pulmonary patients. Am Rev Respir Dis 1985; 132:685-689. 10. Hansen JE and Casaburi R: Validity of ear oximetry in clinical exercise testing. Chest 1987; 91:333-337. 11. McSweeney AJ, Czajkowsk SM, and Labuhn KT: Psychosocial factors in the rehabilitation of patients with chronic respiratory disease. In: Fishman AP (ed). Pulmonary Rehabilitation. New York: Marcel Dekker, 1996, pp 43-479. 12. Kaplan RM, Eakins EG and Ries AL: Psychosocial issues in the rehabilitation of patients with chronic obstructive pulmonary disease. In: Casaburi R and Petty TL (eds), Principles and Practice of Pulmonary Rehabilitation. Philadelphia: Saunders, 1993, pp 351-365. 13. Ries AL, Carlin BW, Carrieri-Kohlman V et al: Pulmonary rehabilitation. Joint ACCP/ AACVPR evidence-based guidelines. Chest 1997; 112:1363-1396. 14. Blake RL Jr, Vandiver TA, Braun S et al: A randomized controlled evaluation of a psychosocial intervention in adults with chronic lung disease. Fam Med 1990; 22:365-370. 15. Tiep BL, Burns M, Kao D et al: Pursed lips breathing training using ear oximetry. Chest 1986; 90:218-221. 16. Barach AL: Physiologic advantage of grunting, groaning and pursed lip breathing: Adaptive symptoms related to the development of continuous positive pressure breathing. Bull N.Y. Acad Med 1973; 49:666-673. 17. Mueller RE, Petty TL and Filley GF: Ventilation and arterial blood gas changes induced by pursed lips breathing. J Appl Physiol 1970; 28:784-789. 18. Faling LJ: Controlled breathing techniques and chest physical therapy in chronic obstructive pulmonary disease and allied conditions. In: Casaburi R and Petty TL (eds). Principles and Practice of Pulmonary Rehabilitation. Philadelphia: Saunders, 1993, pp 167-182. 19. Dales RE, Spitzer WO, Schechter MT et al: The influence of psychological status on respiratory symptom reporting. Am Rev Respir Dis 1989; 139:1459-1463. 20. Haas F, Salazar-Schicchi J and Axen K: Desensitization to dyspnea in chronic obstructive pulmonary disease. In: Casaburi R and Petty TL (eds). Principles and Practice of Pulmonary Rehabilitation. Philadelphia: Saunders, 1993, pp 241-251. 21. Casaburi R, Patessio A, Ioli F et al: Reductions in lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am Rev Respir Dis 1991;143:9-18. 22. Casaburi R, Porszasz J, Burns MR et al: Physiologic benefits of exercise training in rehabilitation of patients with severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 155:1541-1551. 23. Maltais F, LeBlanc P, Simard C et al: Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996; 154:442-447. 24. Punzal PA, Ries AL, Kaplan RM and Prewitt LM: Maximum intensity exercise training in patients with chronic obstructive lung disease. Chest 1991; 100:618-623. 25. Martinez FJ, Vogel PD, Dupont DN et al: Supported arm exercise vs unsupported arm 4

exercise in the rehabilitation of patients with severe chronic airflow obstruction. Chest 1993; 103:1397-1402. 26. Celli BR, Rassulo J, Make BJ: Dyssynchronous breathing during arm but not leg exercise in patients with chronic airflow obstruction. N Engl J Med 1986; 214:2485-2490. 27. Smith K, Cook D, Guyatt GH et al: Respiratory muscle training in chronic airflow limitation: a meta-analysis. Am Rev Respir Dis 1992; 145:533-539. 28. Lacasse Y, Wong E, Guyatt GH et al: Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet 1996; 348:1115-1119. 29. Goldstein RS, Gort EH, Stubbing D et al: Randomized controlled trial of respiratory rehabilitation. Lancet 1994; 344:1394-1397. 30. Ries AL: Position paper of the American Association of Cardiovascular and Pulmonary Rehabilitation: Scientific basis of pulmonary rehabilitation. J Cardiopulmonary Rehabil 1990; 10:418-441. 31. Ries AL, Kaplan RM, Limberg TM et al: Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med 1995; 122:823-832. 32. California Pulmonary Rehabilitation Collaborative Group. Effects of pulmonary rehabilitation on dyspnea, quality of life and health care costs in California. J Cardiopulmonary Rehabil 2004; 24:52-62. 33. Ries AL, Make BJ, Lee SM, Krasna MJ, Bartels M, Crouch R, Fishman AP for the NETT Research Group. The effects of pulmonary rehabilitation in the National Emphysema Treatment Trial. Chest 2005; 128:3799-3809. DEVELOPED FOR THE CTS CLINICAL PRACTICE (CP) COMMITTEE Prepared by Richard Casaburi, PhD, MD, Robert S. Y. Chang, MD, and Andrew Ries, MD MPH Approved by CTS Executive Committee and CTS 1991, reviewed 2008 CTS guidelines are developed to enhance a physician s ability to practice evidence-based medicine; these should not be considered a substitute for the experience and judgment of a health care provider. FAX: 714-730-4057 VOICE: 714-730-1944 E-MAIL: ctsinfo@alac.org WEBSITE: www.thoracic.org/ca.html ADDRESS: 202 FASHION LANE SUITE 219 TUSTIN CA 92780-3320 CONTACT YOUR AMERICAN LUNG ASSOCIATION: CALL 1-800-LUNG-USA, or download ALA public and patient items at www.lungusa.org Visit the ALA of California website for state activities & advocacy issues at www.californialung.org We welcome your comments: see CTS contact information above! 9/91; 3/2708 O:\CTSAAword\CTS position papers v5 86\Principles of Pulm Rehab08.doc 5