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

Duration of Pulmonary Rehabilitation

There is no consensus of opinion regarding the optimal duration of the pulmonary rehabilitation intervention. From the patient’s perspective, the optimal duration should be that which produces maximal effects in the individual without becoming burdensome. Significant gains in exercise tolerance, dyspnea, and HRQOL have been observed following inpatient pulmonary rehabilitation programs as short as 10 days[60] and after outpatient programs as long as 18 months.[61] Shorter program duration has the potential to reduce the cost per patient served and to spread limited resources.[62] On the other hand, longer program duration may produce greater gains and improved maintenance of benefits. This section will examine longer term pulmonary rehabilitation interventions (ie, beyond 12 weeks of treatment).

Successful pulmonary rehabilitation requires complex behavioral changes for which the patients' competence and adherence may be facilitated by longer exposure to treatment interventions and interactions with staff who provide reinforcement, encouragement, and coaching. These changes include incorporating regular exercise into the patient's lifestyle; the use of breathing techniques, pacing and energy conservation strategies; and the use of medications and equipment, supplemental oxygen, and psychosocial adaptations. A number of external factors also influence program duration including health-care systems and reimbursement policies, access to programs, level of functional disability, health-care provider referral patterns, and the ability of individual patients to make progress toward treatment goals.

Few clinical trials have focused on the impact of program duration on rehabilitation outcomes, but existing data suggest that gains in exercise tolerance may be greater following longer programs ( Table 5 ). For example, two other randomized trials compared 3 vs 18 months of low-intensity exercise training in pulmonary rehabilitation.[63,64] Berry and colleagues[63] demonstrated that the longer intervention led to a 6% increase in the 6-min walk distance, a 12% reduction in self-reported disability, and faster completion of stair climbing and overhead tasks. Foy and colleagues[64] showed that only male patients achieved greater gains in CRDQ scores following the 18-month program (compared to the 3-month program). In a 2005 published prospective trial involving seven outpatient programs (not in Table 5 ), Verrill and colleagues[65] demonstrated that patients achieved significant gains in exercise tolerance (6-min walk distance), dyspnea (University of California, San Diego Shortness of Breath Questionnaire), and health status (Medical Outcomes Study 36-item Short Form and the quality-of-life index) after 12 weeks of pulmonary rehabilitation. Following an additional 12 weeks of rehabilitation, exercise tolerance but not health status or dyspnea outcomes improved further, suggesting that program duration may not impact all outcomes equally.

Also in support of longer term exercise training, Troosters and colleagues[33] demonstrated that a 6-month outpatient pulmonary rehabilitation program composed of moderate-to-high-intensity aerobic and strength exercise training led to significant improvements in exercise performance and quality of life. Although this study did not compare the 6-month program with a shorter one, the benefits gained following the 6-month training program persisted 18 months after the completion of rehabilitation. This contrasts with the results of other studies[35,50,66] of pulmonary rehabilitation of shorter than 6 months duration in which benefits tended to decline progressively over the year following rehabilitation. Likewise, in the study by Guell and colleagues[41] ( Table 4 ) a 12-month intervention (6 months of daily rehabilitation followed by 6 months of weekly supervision) led to gains in exercise tolerance, dyspnea, and health status that persisted over the 1 year after rehabilitation, although even these benefits tended to decline gradually over the second year of follow-up.

Green and colleagues[34] also demonstrated that patients with severe COPD achieved greater improvements in treadmill endurance, incremental shuttle walk distance, and quality of life following a 7-week outpatient pulmonary rehabilitation program compared with an identical program of only 4 weeks duration. However, patients who underwent the 4-week program were not reassessed at the 7-week time point to enable the direct comparison of outcomes.

A more recent trial (not in Table 5 ) readdressed this issue in a larger cohort of patients. Sewell and colleagues[67] randomized 100 patients with moderate-to-severe COPD (mean FEV1, 1.13 L) to receive 4 vs 7 weeks of outpatient rehabilitation. All patients were assessed at baseline, at the end of the rehabilitation intervention, and 6 months later. Patients in the 4-week training group were also evaluated at 7 weeks. Patients in both groups had significant improvements in exercise tolerance and health status. This study contrasts with the results of other published studies mentioned above in that it showed that the shorter 4-week intervention produced gains in exercise tolerance at both the 7-week and 6-month follow-up time periods that were comparable to those following the longer 7-week program. Finally, in an older trial Wijkstra and colleagues[61] showed that patients who underwent 18 months of home-based rehabilitation had greater sustained improvements in quality of life compared with patients who received twice-weekly rehabilitation over a 3-month period, but no difference was noted between groups in the magnitude of gains in the 6-min walk distance.

Overall, although some studies suggest that the duration of the pulmonary rehabilitation program impacts exercise tolerance improvement, it is less clear that other outcomes such as health status or dyspnea are similarly affected by program duration. Other studies[60,67] have demonstrated that even programs of short duration (ie, 10 days to 4 weeks) can produce significant benefits as well. Moreover, the effect of program duration on patient abilities to perform activities of daily living (ADLs) is uncertain. The clinical benefits of pulmonary rehabilitation may depend as much on program site and content as on duration.[62] Thus, given the variations in types of rehabilitation programs and differences in clinical study design, patient populations, health systems in different countries, program location, and program content, it is not possible at this time to draw firm conclusions regarding the optimal duration of pulmonary rehabilitation treatment.

9. Longer pulmonary rehabilitation programs (beyond 12 weeks) produce greater sustained benefits than shorter programs. Grade of recommendation, 2C

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