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Pulmonary rehabilitation includes patient education, exercise training, psychosocial support and advice on nutrition. Pulmonary rehabilitation has been shown to improve exercise capacity, reduce breathlessness, improve health-related quality of life, and decrease healthcare utilisation. The majority of patients considered for pulmonary rehabilitation programmes will have chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD.
- The rehabilitation process incorporates a programme of physical training, disease education, nutritional assessment and advice, and psychological, social, and behavioural intervention.
- Rehabilitation is provided by a multiprofessional team, with involvement of the patient's family and attention to individual needs.
- Rehabilitation relieves dyspneoa and fatigue, improves emotional function and enhances patients' control over their condition. These improvements are moderately large and clinically significant. Rehabilitation forms an important component of the management of COPD.
- Although evidence is lacking for the efficacy of rehabilitation for patients with non-COPD causes of pulmonary impairment, many of these patients probably benefit.
- Pulmonary rehabilitation is effective for people with moderate-to-severe COPD. It should be offered to all people with COPD who consider themselves functionally disabled. It is not suitable for people unable to walk, who have unstable angina, or who have had a recent myocardial infarction.
- Rehabilitation should be considered at all stages of disease progression when symptoms are present and not at a predetermined level of impairment. This would usually be Medical Research Council (MRC) dyspnoea scale grade 3 (the patient walks more slowly than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace), or above.
- There is currently no justification for selection on the basis of age, impairment, disability, or smoking status. Some patients with serious comorbidity such as cardiac or locomotor disability may not derive as much benefit.
- Other issues relevant to patient selection are poor motivation and the logistical factors of geography, transport, equipment usage, and the group composition.
- Pulmonary rehabilitation is effective in all settings, including hospital inpatient, outpatient, the community and in the patient's home.
- Cost comparison suggests that hospital outpatient rehabilitation is currently the most efficient form of delivery.
The commitment required for pulmonary rehabilitation and the consequent benefits to people with COPD should be explained. The programme must meet the individual needs of the patient, and include physical training, disease education, and nutritional, psychological and behavioural intervention.
- Outpatient programmes should include a minimum of six weeks of physical exercise, disease education, and psychological and social intervention.
- Physical aerobic training, particularly of the lower extremities (brisk walking or cycling), is essential.
- Upper limb and strength-building exercise can also be included.
- Exercise prescription should be individually assessed.
- Individual training intensity should be recorded and can be increased through the programme if appropriate and tolerated.
- Training intensity should usually be 60-70% of maximal walking speed achieved on a shuttle walk test. However, benefit can be obtained from lower-intensity training where necessary, and increased benefits can be obtained from higher-intensity training (85% maximal walking speed achieved on the shuttle walk test) when this can be achieved.
- Training frequency should involve three sessions (20-30 minutes) per week, of which at least two should be supervised.
- Supplementary oxygen during training should be provided if necessary.
- Comprehensive disease education for patient and family is an important part of overall management and can be included within the rehabilitation programme.
- Individual advice on physiotherapy, nutrition, occupational therapy, smoking cessation, end of life planning, and physical relationships should also be included.
- A nominated clinician with an interest in respiratory disease should be responsible for the programme. This clinician is normally responsible for medical assessment prior to entry to the programme.
- Staffing ratios will vary according to the patient characteristics, but a staff to patient ratio of 1:8 would be reasonable for the supervision of exercise classes.
- There should be multiprofessional involvement from local resources.
- Policies should exist for the stages of rehabilitation which include referral, assessment, selection, rehabilitation, and outcome assessment.
- Regular audit of the programme is desirable.
Further reading & references
- ZuWallack R, Hedges H; Primary care of the patient with chronic obstructive pulmonary disease-part 3: Am J Med. 2008 Jul;121(7 Suppl):S25-32.
- Chronic obstructive pulmonary disease; NICE Clinical Guideline (June 2010)
- Pulmonary Rehabilitation in Adults, British Thoracic Society (Sep 2013)
- Lacasse Y, Martin S, Lasserson TJ, et al; Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. A Cochrane systematic review. Eura Medicophys. 2007 Dec;43(4):475-85.
- Hill NS; Pulmonary rehabilitation. Proc Am Thorac Soc. 2006;3(1):66-74.
- Chronic obstructive pulmonary disease; NICE CKS, November 2010 (UK access only)
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Dr Colin Tidy
Dr Colin Tidy
Prof Cathy Jackson