Pulmonary Rehabilitation* Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

Andrew L. Ries, MD, MPH, FCCP (Chair); Gerene S. Bauldoff, RN, PhD, FCCP; Brian W. Carlin, MD, FCCP; Richard Casaburi, PhD, MD, FCCP; Charles F. Emery, PhD; Donald A. Mahler, MD, FCCP; Barry Make, MD, FCCP; Carolyn L. Rochester, MD; Richard ZuWallack, MD, FCCP; Carla Herrerias, MPH

Disclosures

CHEST. 2007;131(5):4S-42S. 

In This Article

Pulmonary Rehabilitation for Patients With Disorders Other Than COPD

Although they have not been studied as well to date, patients with respiratory disorders other than COPD can also benefit substantially from pulmonary rehabilitation. Indeed, the scientific rationale for providing pulmonary rehabilitation to patients with non-COPD diagnoses is the same as that for patients with COPD. General principles of rehabilitation treatment emphasize the adaptation of multidisciplinary treatment strategies to the needs of individual patients. Pulmonary rehabilitation programs provide an ideal setting to address both common and individual concerns for patients with a variety of different chronic lung diseases.

As in COPD, persons with other forms of chronic respiratory disease commonly experience deconditioning and exercise intolerance, disabling symptoms of dyspnea and fatigue, impaired health status and quality of life, systemic inflammation, nutritional impairments, and/or muscle dysfunction (related to deconditioning, loss of fat-free mass, and/or corticosteroid use) that collectively impair functional status along with abnormalities of pulmonary function. These comorbidities that are associated with chronic respiratory disease can potentially be addressed and corrected with rehabilitation strategies including exercise training and other interventions such as nutritional support, despite the presence of irreversible abnormalities of lung function. Moreover, pulmonary rehabilitation programs provide the opportunity to educate and train patients in adapting to complex treatment interventions such as immunosuppressive medications, oxygen therapy, noninvasive ventilation, tracheostomy, lung volume reduction surgery, or lung transplantation. Optimal outcomes from these depend on patient understanding and compliance with therapeutic recommendations, but there is minimal time typically available in the routine clinical care setting for patient education, training, and coaching for the complex behavioral changes included in treatment recommendations. Pulmonary rehabilitation can assist patients in adjusting complex interventions such as the technical requirements for oxygen supplementation or noninvasive ventilation. Patients undergoing lung transplantation or lung volume reduction surgery are frequently required to participate in preoperative and postoperative pulmonary rehabilitation, in part, to provide needed education and support.

Modification of the relative emphasis on the core program components and overall program content of pulmonary rehabilitation may be required to maintain patient safety and to meet individual patient needs and goals.[182] The goals of pulmonary rehabilitation for patients with chronic lung diseases other than COPD may differ from the standard goals for patients with COPD. Education of the rehabilitation program staff regarding the pathophysiology, symptoms, mechanisms of exercise limitation, natural course, and signs of disease destabilization as well as the therapeutic interventions specific for each of the various respiratory disorders is essential, as is close communication with referring physicians and the program medical director. Pulmonary rehabilitation staff must be familiar with the recommended methods of assessing patient exercise capacity, must be able to develop and safely implement the exercise program, and to identify situations in which specialized equipment or room setup may be required. Additional specific expertise may be needed in developing appropriate rehabilitation programs for non-COPD patients with disease-specific input from physical, occupational, and respiratory therapists, nurses, health psychologists, dieticians, respiratory physicians, and, when necessary, physiatrists or neurologists. Disease-appropriate and age-appropriate tools for the assessment of exercise capacity, health status, and quality of life should be utilized, and efforts must be made to integrate topics relating to non-COPD diagnoses in situations in which the patient group is composed predominantly of COPD patients. Individual patient education sessions and additional written and/or video materials may be needed.

Although most of the studies conducted and published to date investigating the outcomes of pulmonary rehabilitation for disorders other than COPD are uncontrolled trials or case series, RCTs are beginning to emerge.[183,184] The strength of existing evidence supporting the use of pulmonary rehabilitation varies across the different diseases. Thus far, existing data suggest that, as in COPD, exercise training and rehabilitation improve exercise tolerance and/or health status/quality of life for persons with asthma,[183,185,186] bronchiectasis,[187]cystic fibrosis,[184,188,189] interstitial lung disease and restrictive chest wall disease,[21,190,191] pulmonary hypertension,[192] obesity-related respiratory disease,[193,194] and lung cancer,[195,196] and selected patients with respiratory impairment from neuromuscular diseases.[197,198,199,200] For some patients with neuromuscular disease, pulmonary rehabilitation may not include traditional exercise training, but may instead focus on acclimatization to NPPV, optimization of functional status, and maintenance of the ability to live independently through the use of adaptive/assistive equipment (eg, walkers or sock reachers). Caution must be taken to avoid excess muscle fatigue, especially among persons with degenerative neuromuscular disorders. Further research is needed to identify optimal training regimens, program structures, and outcome measurement tools that are useful in pulmonary rehabilitation for patients with respiratory disorders other than COPD.

24. Pulmonary rehabilitation is beneficial for patients with some chronic respiratory diseases other than COPD. Grade of recommendation, 1B

25. Although no recommendation is provided since scientific evidence is lacking, the 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.

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