Pulmonary Rehabilitation

Introduction [edit | edit source]

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”[1]

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 QOL and exercise capacity in individuals with Chronic Respiratory Pulmonary Disorder (COPD) compared to usual care[2]. Studies suggest PR is useful in patients with moderate-to-severe COPD[3]. Individuals with COPD who undergo PR are likely to have better utilisation of healthcare service for the next 12 months, although it is unclear whether these benefits last beyond this.[4]

What is PR [edit | edit source]

PR programmes vary from person to person and from centre to centre, depending on available resources, but in general will include[5]

  • 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. They then have an education session with an educator (typically a nurse or allied health professional) on a range of topics, such as: bronchodilator technique; nutrition; stress and anxiety; and managing COPD. 

Structure [edit | edit source]

PR programmes can vary in length, anywhere from 6-8 weeks to a year[2]. The British Thoracic Society’s guideline[6] 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[2]. Guidelines recommend that individuals be offered some sort of exercise program after finishing PR (see below).

Adherence [edit | edit source]

NICE guidelines recommend emphasizing the importance of adherence to PR to individuals in order to achieve improvements in QOL and respiratory function[5]. Specific ways to improve adherence include optimising access to PR, this includes: suitable times for classes, appropriate physical access to facilities, good public transport links and timely referrals to PR[5]

Maintenance [edit | edit source]

Guidelines recommend maintenance of exercise after PR[6] 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[7]. 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 [edit | edit source]

According to the NICE guideline[5], 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 

Considerations [edit | edit source]

Other factors worth considering include[6]:

  • 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 [edit | edit source]

Physiotherapists play an important role in prescribing, supervising, and measuring outcomes in exercise. Research shows there has been an increase in the use of guideline-based exercise prescription methodology (using FITT methodology - Frequency, Intensity, Time, Type)[8]. Participants engaging in both functional and maximal exercise show statistically significant improvements after PR, compared with usual care[2].

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.[9]

Specific Exercise Intervention[edit | edit source]

Exercise prescription should include supervised aerobic exercise and progressive resistance exercise[6]. Exercise should be individually prescribed according to the initial assessment and goals should be identified and agreed[6]. Participants' exertion should be regularly monitored, paying particular attention to chest pain, discomfort or breathlessness. For the latter, the BORG scale can be used. For exercise prescription ideas see here

For mild lung disease[edit | edit source]

•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

•Exercise testing and training, individual exercises prescribed, formal rehab not required

For moderate lung disease[edit | edit source]

•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 at each stage, monitoring ECG, BP, HR or perform a 12-minute walk test

Exercise prescription:

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

•Frequency: 5-7 times a week

•If symptoms develop use O2

For Severe Lung disease[edit | edit source]

•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, every decrease in SPO2 of 3%, should be noted. If the drop reached <88% SPO2 oxygen therapy is indicated.[9] 

[10]

Steps to Setting Up an Exercise Class[edit | edit source]

1) Understand your limits[edit | edit source]

Ensure you have the knowledge and skills required to teach, motivate and inspire the people that come to your classes.

2) Determine unique selling point and product[edit | edit source]

There are many types of exercises beneficial to patients with Pulmonary Pathologies, and patients are often attracted to a specific exercise. This could be aerobic exercise, such as walking, bicycling or rowing. Alternatively, others enjoy activities that involve a variety of exercises, such as cross-training or high-interval intensity training, being outdoors or developing skills, perhaps through hikes or dancing

Find a niche that will attract clients in your target location, and encourage them to stay

3) Start small and build[edit | edit source]

3I Build Participant numbers, then class size and number

Publicise through organisations in the community

Promote your group to family, friends, co-workers, and neighbours. Try posting fliers or using signs at your local YMCA, library, community centre, health club, or place of worship and market to local businesses

Join and actively engage in Facebook groups related to fitness, or even just community groups aimed at your target demographic.

Publiciseonline

Build an online presence, perhaps through blogs, websites and/or social media

  • Connect with fun, identifiable branded hashtags

Build a positive atmosphere

Good music, allow participants to choose between two favorite playlists or a new hit song

Make encouragement part of the social norm:

  • By using partner exercises (as we will discuss later),
  • Making it perfectly clear that even though everyone is there for their own reasons, they are all there to get fit and should work together hard as a team
  • Celebrate successes. When your team meets its goals, celebrate. This can be as simple as grabbing a cup of coffee after an exercise session.

3II Build intensity Level

Start at low duration, reps, sets and load

Encourage patients to listen to their body and slowly build

Resources [edit | edit source]

NICE guideline 

British Thoracic Society guideline 

Lung Foundation Australia Pulmonary Rehabilitation Toolkit 

American Thoracic Society Patient Information  


References [edit | edit source]

  1. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WD, et al.; ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/ European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013;188:e13–e64.
  2. 2.0 2.1 2.2 2.3 McCarthy  B, Casey  D, Devane  D, Murphy  K, Murphy  E, Lacasse  Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003793. DOI: 10.1002/14651858.CD003793.pub3. Accessed 28 November 2019.
  3. Lee AL, Butler SJ, Varadi RG, Goldstein RS, Brooks D. The Impact of Pulmonary Rehabilitation on Chronic Pain in People with COPD. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2020 Mar 3;17(2):165-74.
  4. Walsh JR, Pegg J, Yerkovich ST, et al. Longevity of pulmonary rehabilitation benefit for chronic obstructive pulmonary disease—health care utilisation in the subsequent 2 years. BMJ Open Respiratory Research 2019;6. Accessed 22 March 2022.
  5. 5.0 5.1 5.2 5.3 National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019. Accessed 28 November 2019.
  6. 6.0 6.1 6.2 6.3 6.4 Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. Thorax 2013;68:ii1-ii30. Accessed 28 November 2019.
  7. Güell MR, Cejudo P, Ortega F, Puy MC, Rodríguez-Trigo G, Pijoan JI, Martinez-Indart L, Gorostiza A, Bdeir K, Celli B, et alBenefits of long-term pulmonary rehabilitation maintenance program in patients with severe chronic obstructive pulmonary disease: three-year follow-up. Am J Respir Crit Care Med. 2017;195:622–629. Accessed 29 November 2019.
  8. Garvey C, Casaburi R, Spruit MA, De Brandt J. Survey of Exercise Prescription in US Pulmonary Rehabilitation Programs. Journal of Cardiopulmonary Rehabilitation and Prevention. 2020 Mar 1;40(2):116-9.
  9. 9.0 9.1 Hillegass EA, Sadowsky HS. Cardio Pulmonary Physical Therapy. 2nd ed. Philadephia: Elsevier Saunders: 1994
  10. NHS Forth ValleyPulmonary Rehabilitation for Chronic Lung Conditions Available fromhttps://www.youtube.com/watch?time_continue=2&v=j9Og5r0W6rQ&feature=emb_logo