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


CHEST. 2007;131(5):4S-42S. 

In This Article

Summary and Recommendations for Future Research

The field of pulmonary rehabilitation has continued to develop and mature substantially since the publication of the previous evidence-based guidelines in 1997. Additional published literature has added substantially to the scientific basis of pulmonary rehabilitation interventions as well as outcomes. The new data that have been examined further strengthen the evidence that supports the benefits of lower extremity exercise training in pulmonary rehabilitation and the improvement expected in symptoms of dyspnea from comprehensive pulmonary rehabilitation programs. The evidence supporting important changes in HRQOL has also been strengthened in new studies. Although there is some additional evidence, there is still a need for more systematic studies of the effect of pulmonary rehabilitation on health-care costs and utilization. The question is still open about whether pulmonary rehabilitation improves survival in patients with COPD. Trends observed in existing studies suggest that pulmonary rehabilitation may have a modest effect on survival, but a larger study powered to address survival would add important new information to the field and would have a significant impact on future health policy decisions. There is also a need for more studies about psychosocial outcomes and interventions. New evidence adds support for the inclusion of psychosocial components in comprehensive pulmonary rehabilitation programs and the important beneficial effects of such programs on psychosocial health, but more is clearly needed. Several promising studies lend continued support for upper extremity training as a means of achieving important benefits in ADLs for many patients with disabling chronic lung diseases. There remains little evidence to support the routine inclusion of specific ventilatory muscle training in pulmonary rehabilitation. There is little evidence that education alone, outside the context of comprehensive pulmonary rehabilitation treatment, is beneficial. However, there have been no systematic studies evaluating educational delivery, topic selection, and reinforcement of information. Investigation may be warranted regarding patient-specific learning styles, the duration of educational sessions, topic selection, and the use of educational reinforcement. Finally, emerging data have demonstrated that exercise training and pulmonary rehabilitation are beneficial for patients with respiratory disorders other than COPD.

An important area for future research relates to the duration of pulmonary rehabilitation treatment and strategies to help patients sustain benefits over a longer period of time. The existing literature strongly indicates that the typical 6-week to 12-week comprehensive pulmonary rehabilitation program produces benefits that are sustained for approximately 12 to 18 months. This, in itself, is remarkable in the face of progressive chronic lung diseases. However, it is likely that new treatment strategies could be developed to help patients maintain the benefits from pulmonary rehabilitation over longer periods of time. Changes in the typical program structure, the period of intervention, the more efficient use of limited resources, as well as the tailoring of the rehabilitation intervention to different clinical phenotypes of COPD (eg, with or without peripheral or respiratory muscle weakness, and depleted or nondepleted fat-free mass) may allow principles of pulmonary rehabilitation to be adapted to longer term chronic disease management, improve postprogram maintenance of benefits, and allow many more patients who are in need to benefit from pulmonary rehabilitation. The development of better postprogram strategies to help patients adhere to rehabilitative treatments and to better maintain the complex behavior changes acquired in pulmonary rehabilitation might extend the duration of benefits.

Interesting new evidence in the literature highlights several areas for fruitful future research in relation to pulmonary rehabilitation, and the treatment of patients with chronic lung diseases. Possible topics include strength training in addition to endurance exercise training (and optimal methods for such strength-training protocols), better definition of optimal exercise-training regimens, supplemental oxygen therapy for patients with less severe resting hypoxemia or hypoxemia specific to exercise or sleep, use of noninvasive ventilatory assistance as an adjunct to exercise training, nutritional supplementation, and use of rehabilitation strategies for patients with chronic lung diseases other than COPD.

One interesting new area for future research is to further define the role for the transcutaneous electrical stimulation of the peripheral muscles (TCEMS) as a rehabilitative strategy for patients with COPD and other forms of chronic respiratory disease. Studies published thus far have demonstrated that TCEMS in the muscles of ambulation can lead to significant improvements in muscle strength, exercise endurance, dyspnea,[201,202] and VO2 max[201] among stable patients with moderate-to-severe COPD, as well as in severely deconditioned patients with severe airflow obstruction and low body mass index who are recovering from acute COPD exacerbations.[203] TCEMS also may facilitate improvement in mobility among bed-bound patients with COPD and respiratory failure requiring mechanical ventilation.[204] This safe, well-tolerated technique can even be performed COPD exacerbations and may help to prevent functional decline during COPD exacerbations.[201] Further work is needed to clarify which subpopulations of patients benefit most from this technique, to define the role of TCEMS as a routine component of pulmonary rehabilitation, and to understand the mechanisms by which TCEMS confers its benefits among patients with chronic lung disease.

One novel approach to encouraging adherence is through the use of distractive auditory stimuli (DAS). A 2002 RCT[205] of the effects of DAS (ie, listening to music while exercising) on exercise adherence and exercise outcomes among patients with COPD who had completed a pulmonary rehabilitation program found no differences in amount of exercise, velocity of exercise, or physical symptoms during the study period between DAS participants and control subjects receiving standard care. However, participants in the DAS group experienced reductions in dyspnea during ADLs and a significant increase in exercise endurance (as determined by the 6-min walk distance). Thus, DAS may help to distract participants from exercise-related dyspnea and may help patients to increase exercise duration during individual bouts.

Finally, an important area of research in COPD relates to the importance of exacerbations in influencing the natural history of the disease, and in accelerating the subsequent morbidity and mortality. Preliminary evidence[48] suggests that pulmonary rehabilitation after an exacerbation could improve mortality in these high-risk patients. Additional work in this area would be very important.

In summary, this is an exciting time that is full of opportunities in the field of pulmonary rehabilitation. Pulmonary rehabilitation has now become well established as a recommended treatment that can provide important benefits to substantial numbers of disabled patients with chronic lung diseases. A review of the various components of pulmonary rehabilitation also highlights opportunities, and challenges, for future research that have the potential to improve and broaden the scope of pulmonary rehabilitation practice for the large population of patients with chronic lung diseases, most of whom do not currently have access to such programs.


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