The following are the summary recommendations from "Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines." (3) This document, produced by collaborative efforts of the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation, updated a previous evidence-based guidelines review of pulmonary rehabilitation. Their recommendations were categorized as strong (grade 1) or weak (grade 2). The strength of evidence was determined based on the quality of the data: high (grade A, from well-designed randomized clinical trials yielding consistent and directly applicable results or from overwhelming evidence from observational studies), moderate (grade B, for the most part randomized clinical trials with limitations that may include methodological flaws or inconsistent results), and low (grade C, from other types of observational studies).
- A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with COPD. Grade of recommendation: 1A
- Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD. Grade of recommendation: 1A
- Pulmonary rehabilitation improves health-related quality of life in patients with COPD. Grade of recommendation: 1A
- Pulmonary rehabilitation reduces the number of hospital days and other measures of health care utilization in patients with COPD. Grade of recommendation: 2B
- Pulmonary rehabilitation is cost-effective in patients with COPD. Grade of recommendation: 2C
- There is insufficient evidence to determine if pulmonary rehabilitation improves survival in patients with COPD. No recommendation is provided.
- There are psychosocial benefits from comprehensive pulmonary rehabilitation programs in patients with COPD. Grade of recommendation: 2B
- Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. Grade of recommendation: 1A
- Some benefits, such as health-related quality of life, remain above control at 12 to 18 months. Grade of recommendation: 1C
- Longer pulmonary rehabilitation programs (12 weeks) produce greater sustained benefits than shorter programs. Grade of recommendation: 2C
- Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes. Grade of recommendation: 2C
- Lower-extremity exercise training at higher exercise intensity produces greater physiological benefits than lower-intensity training in patients with COPD. Grade of recommendation: 1B
- Both low- and high-intensity exercise training produce clinical benefits for patients with COPD. Grade of recommendation: 1A
- Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass. Strength of evidence: 1A
- Current scientific evidence does not support the routine use of anabolic agents in pulmonary rehabilitation for patients with COPD. Grade of recommendation: 2C
- Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs. Grade of recommendation: 1A
- The scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. Grade of recommendation: 1B
- Education should be an integral component of pulmonary rehabilitation. Education should include information on collaborative self-management and prevention and treatment of exacerbations. Grade of recommendation: 1B
- There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. Grade of recommendation: 2C
- Although no recommendation is provided since scientific evidence is lacking, current practice and expert opinion support the inclusion of psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for patients with COPD.
- Supplemental oxygen should be used during rehabilitative exercise training in patients with severe exercise-induced hypoxemia. Grade of recommendation: 1C
- Administering supplemental oxygen during high-intensity exercise programs in patients without exercise-induced hypoxemia may improve gains in exercise endurance. Grade of recommendation: 2C
- As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. Grade of recommendation: 2B
- There is insufficient evidence to support the routine use of nutritional supplementation in pulmonary rehabilitation of patients with COPD. No recommendation is provided.
- Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases other than COPD. Grade of recommendation: 1B
- Although no recommendation is provided since scientific evidence is lacking, current practice and expert opinion suggest that pulmonary rehabilitation for patients with chronic respiratory diseases other than COPD should be modified to include treatment strategies specific to individual diseases and patients in addition to treatment strategies common to both COPD and non-COPD patients.
Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines, (4) reproduced with approval.
Pulmonary Rehabilitation and Integrated Care of the Respiratory Patient
Patient assessment and goal setting, exercise training, self-management education, psychosocial support, and outcome measurement are conveniently and efficiently packaged as an interdisciplinary pulmonary rehabilitation program. However, pulmonary rehabilitation principles should be integrated into the lifelong management of all people with chronic respiratory disease. The World Health Organization defines integrated care as "a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion." (5) For years, pulmonary rehabilitation has used an integrated, interdisciplinary approach to the management of chronic respiratory disease. As such, it has been a paradigm for chronic disease management. As we age as a society, the tenets of pulmonary rehabilitation should serve to provide insight and direction as a model for chronic disease management.
Integration of care is germane in light of the fact that patients with chronic respiratory disease often have multiple and important comorbidities, such as cardiovascular disease, osteoporosis, and diabetes. For example, the COPD patient has, on average, 3.7 other chronic medical conditions, compared to 1.8 for patients with other chronic illnesses. (6) Because of this complexity, single disease-specific guidelines often fall short in meeting the needs of the individual patient and may even have undesirable effects. In a recent analysis, a hypothetical 79-year-old woman with COPD, non-insulin-dependent diabetes, osteoporosis, hypertension, and osteoarthritis, following individual clinical practice guidelines, would be prescribed 12 medications, costing $406 per month. (7) This polypharmacy, besides being expensive, could foster adverse drug reactions and other problems.
The acute exacerbation of chronic respiratory disease can be devastating, with further impairments in lung function, further peripheral muscle dysfunction, further decreases in exercise capacity, decreased activity levels, worsening quality of life, increased health care utilization, and an increased mortality risk. The proper management of the exacerbation requires an integrated care approach, requiring collaboration among health care professionals in the hospital and the community. (8) Patients in this setting may be more receptive to "teachable moments," may adopt self-management strategies, and may participate in rehabilitation. The introduction of pulmonary rehabilitation at the time of an acute respiratory exacerbation is important in the integrated care approach to management, fostering interdisciplinary communication, promoting regular follow-up, and providing a means for seamless transition back to the community.
In light of this complexity, the optimal care of the patient with chronic respiratory disease mandates effective collaboration and integration of services within a complex network including the patient, the family, and all health care providers. Optimal care requires integration across settings, across providers, and across time. The motivated and educated patient is a central catalyst to this process. Pulmonary rehabilitation provides the opportunity to both address the complex needs of the individual patient and coordinate the multiple services and interventions to provide effective care.