Pulmonary Rehabilitation

Original Editor - Rachael Lowe Top Contributors - Lauren Lopez, Samuel Winter, Vidya Acharya, Ashmita Patrao, Rosie Swift, Kim Jackson, Claire Knott, Rachael Lowe, Ajin Jayan Thomas, Oyemi Sillo, Naomi O'Reilly and Karen Wilson

Introduction 

Pulmonary rehabilitation has been defined by the American Thoracic Society and European Respiratory Society in 2013

Pulmonary rehabilitation (PR) is a “comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors”

PR is tailored to the individual who has recently had an exacerbation, with the aim of optimizing their respiratory function and therefore their quality of life (QOL) and participation in their everyday lives.PR has been proven to significantly improve health related Quality of life(QOL) and exercise capacity in individuals with Chronic Respiratory Pulmonary Disorder (COPD) compared to usual care. 

What is PR 

PR programmes vary from person to person and from centre to centre, depending on available resources, but in general will include: 

• Multidisciplinary input 
• Exercise 
• Dietary advice 
• Disease education 
• Psychological intervention 
• Behavioural intervention 

Typically, a session will involve a group of people with COPD attending a class together at a gym or community hall where they partake in supervised exercise with a physiotherapist and then have an education session with a nurse or educator on topics such as bronchodilator technique, nutrition and managing COPD. 

Structure 

PR programmes can vary in length, anywhere from 6-8 weeks to a year. The British Thoracic Society’s guideline recommends 6-12 weeks with twice weekly supervised exercise sessions (with a third unsupervised session), at a minimum of 12 supervised sessions. PR can be based in hospital, in the community or in both. Research suggests that better outcomes are observed in inpatient-based PR compared to community-based PR as measured by the Chronic Respiratory Questionnaire which measures dyspnoea, fatigue, emotional function and mastery. Guidelines recommend that individuals be offered some sort of exercise program after finishing PR (see below).

Adherence 

NICE guidelines recommend emphasizing the importance of adherence to PR to individuals in order to achieve improvements in QOL and respiratory function. Specific ways to improve adherence include optimising access to PR, for example: suitable times for classes, clear access to facilities and near public transport, timely referrals to PR. 

Maintenance 

Guidelines recommend maintenance of exercise after PR to maintain gains made in respiratory function, exercise tolerance and QOL. A recent study has shown that gains made after an eight-week outpatient PR programme can be maintained at two years follow up in people with moderate to severe COPD with a maintenance programme. Individuals in this study showed better maintenance in scores for 6-minute-walk distance and body mass index, airflow obstruction, dyspnea score and exercise capacity. The maintenance programme was focused on exercise and included cycle ergometers in homes and hospital-based supervised exercise sessions every other week. Adherence to this maintenance programme was 66%. 

Contraindications 

According to the NICE guideline, the following people should not undergo PR: 

• Those who are unable to walk 
• Those who have unstable angina  
• People who have had a recent myocardial infarction 

Additionally, the British Thoracic Society's guideline recommends those with a Medical Research Council (MRC) Dyspnoea score of 3–5 who are functionally limited by breathlessness should not be referred to PR.

Considerations 

Other factors worth considering include:

• Unstable cardiac disease
• Locomotor issues
• Difficulties following instructions due to cognitive or psychiatric impairments
• The attendance of a support person to enable and encourage adherence

Intervention 

Physiotherapists play an important role in prescribing, supervising, and measuring outcomes in exercise. The study (March 2020) shows a greater use of guideline-based exercise prescription methodology with an increase in the use of FITT methodology [frequency, intensity, time (duration), and type (mode)] in the 2016 survey versus 2013. Both functional and maximal exercise have shown statistically significant improvements after PR, compared with usual care.

Pulmonary care: Positioning, exercises, bronchiodialator, etc

Functional training: Important in end-stage disease or extreme weakness or fatigue

• Adapt the environment to improve ease
• Work areas supported in convenient places to avoid bending
• Locate a table to slide heavy objects while working
• Chairs at landings of stairs, besides bathtubs
• Using adaptive equipment and assistive technology
• Using good ventilation to kitchens etc where fumes are present

Altering performance tasks

• Slow pace
• Minimize large body movements
• Plan task including breaks and rest

Incorporate methods to relieve symptoms

• Maintain an uninterrupted breathing pattern, avoiding valsalva,
• Avoid unnecessary talking during tasks
• In Obstructive lung disease, the elderly population can pace during lifting tasks, lean forward (Increases the intra abdominal pressure and pushes the diaphragm up in a more advantageous position and allows the accessory muscles of inspiration to pull the chest into inspiration)
• In Restrictive lung disease, rapid shallow breaths are easier (This prevents elastic resistance of the respiratory system)
• Relaxation of non respiratory muscles(using biofeedback) reduces anxiety related to dyspnea.

Specific Exercise Intervention

For mild lung disease

•Have symptoms with extreme effort(cough, sputum)

•Spirometry: Show the predicted Vital Capacity(VC), FEV1(Forced expiratory volume in the 1st second) is 70-80%

•ABG: normal, mild hypoxaemia

•Ex testing and training , individual ex prescribed, formal rehab not required

For moderate lung disease

•Subjects with moderate lung disease typically have shortness of breath on daily activities

•Episode of acute pneumonia after major surgery is when the pulmonary disease is identified, demonstrates good results with PR

•VC and FEV1 55-70% (indicates shortness of breath at app 3-4 METS)

•Exercise testing: start at a low Metabolic equivalent(MET) ie 1.5 MET and progress 0.5 MET each stage, monitoring ECG, BP, HR or perform a 12 minute walk test

Ex prescription:

•Intensity: HR at a point when patient is 2-3 dyspnoeic on the Borgs scale

•Frequency: 5-7 times a week

•If symptoms develop use O2

For Severe Lung disease

•Shortness of breath on most activities of daily living

•VC and FEV1 <50%

•Needs oxygen at rest

•Some show R ventricular dysfunction

•Testing: low level intermittent test or exercises set at a steady endurance test of 2-3 METs

•Training: interval training, short exercise bouts , frequent rests, once a day, when duration increases to  20 mins , 5 times a week

•Intensive monitoring

When monitoring Oxygen for every decrease in SPO2 of 3%, should be notes , with a drop in SPO2 below 88% Oxygen therapy is indicated. 

Type of exercise prescribed should include supervised aerobic exercise and a progressive muscle resistance strengthening exercises. Exercise should be individually prescribed according to initial assessment and utilise goal-setting. Participants' exertion should also be monitored for chest pain or discomfort and breathlessness. For the latter, the BORG scale can be used.For exercise prescription ideas see here. 

Resources 

NICE guideline 

British Thoracic Society guideline 

Lung Foundation Australia Pulmonary Rehabilitation Toolkit 

American Thoracic Society Patient Information