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Overview of Pulmonary Rehabilitation

by Bartolome R. Celli, MD

Pulmonary rehabilitation is a program designed for people who have chronic lung disease. Its primary goal is to enable people to achieve and maintain their maximum level of independence and functioning. Although most pulmonary rehabilitation programs focus on people who have chronic obstructive pulmonary disease, people with other types of lung disease may benefit as well. People in all age groups can benefit, including those older than 70.

Pulmonary rehabilitation programs may improve quality of life by reducing shortness of breath, increasing exercise tolerance, promoting a sense of well-being, and, to a lesser extent, decreasing the number of hospitalizations. However, these programs do not significantly improve survival.

Pulmonary rehabilitation programs are usually conducted in an outpatient setting or in the person’s home. Inpatient services often take place in special rehabilitation centers. Inpatient services are used mainly for people who are recovering from a hospitalization, often because of a severe lung problem. These people are often not stable enough to go home but no longer require care in an intensive care unit. The most successful rehabilitation programs are those in which services are provided by a respiratory or physical therapist, a nurse, a doctor, a psychologist or social worker, and a dietitian working as the pulmonary rehabilitation team to coordinate complex medical services. Most people are enrolled in these programs for 8 to 12 weeks. However, the techniques learned during the program have to be continued at home after the rehabilitation program ends or the gains made will be lost.

Supportive respiratory therapy, which includes oxygen therapy and chest physical therapy, can be used in conjunction with pulmonary rehabilitation. Supportive therapy can also be used for people not enrolled in these programs but who have chronic lung disorders (such as cystic fibrosis or bronchiectasis) or acute lung conditions (such as pneumonia).

Enrollment and goal setting

The first step for the team members is to determine the person's short-term and long-term goals. For example, an older person may desire to travel by air to visit a grandchild. If the person can walk only 300 feet (about 90 meters) because of shortness of breath but must be able to walk 1,000 feet (300 meters) to board the airplane, the initial short-term goal may be to increase the walking distance by small increments. Team members must be encouraging while also setting realistic goals. Periodic reevaluation (weekly) is important to ensure that these goals are being met.

It is also important for team members to identify factors that may limit the program’s effectiveness for a particular person. These factors may include problems with financial resources, transportation to the rehabilitation center, cognition, and family dynamics. An example of a problem with cognition would be when a person who has lung problems also has dementia. Such a person may need a specific approach to enhance comprehension. An example of a problem with family dynamics would be when a person who is enrolled in a program is dependent on a caregiver who is not able to help the person with rehabilitation at home. It is important for team members to recognize such problems and plan ways to help the person.

Long-term goals are also established, and team members teach people to recognize changes in their lung condition, so that they will contact their doctor promptly. Treatment may need to be modified in response to changes in symptoms.

Exercise training

Exercise training is the most important component of pulmonary rehabilitation. It reduces the effects of inactivity and deconditioning, resulting in less shortness of breath and an increased ability to exercise. However, physical limitations may restrict the types of exercise training that can be used. Exercise training may help some people who are dependent on ventilators to function without ventilator assistance.

Exercise of the legs is the cornerstone of training. Because walking is necessary for most activities of daily living, many rehabilitation programs use walking (sometimes on a treadmill) as the preferred mode of training. Some people may prefer exercising on a stationary bicycle. Choosing an exercise that is comfortable and satisfying for the person enhances willingness to participate long-term.

Exercise training of the arms is also beneficial for people with chronic lung diseases who have shortness of breath or other symptoms during their normal activities of daily living, such as washing their hair or shaving. Such training is needed because some of the shoulder muscles are used in breathing as well as in moving the arms, and arm work can quickly overexert these muscles.

Psychosocial counseling

Because strong emotions tend to worsen shortness of breath, some people suppress their emotions, but depression and anxiety are common reactions to the life changes a person with lung disease experiences. In addition, shortness of breath itself may cause anxiety and depression, interfere with sexual activity, and cause difficulty managing stress and relaxing. Through counseling, group therapy, and, when needed, drug treatment, people may be able to better cope with these psychosocial problems. Sometimes family members participate in counseling to help them cope with the stress involved in caring for a person with lung disease.

Nutritional evaluation and counseling

People who have lung disease often need nutritional evaluation and counseling. For example, those with the most severe chronic obstructive pulmonary disease often experience weight loss. Pulmonary rehabilitation programs help people avoid weight loss and maintain muscle mass. People must be taught to eat in such a way that they maintain adequate caloric intake while avoiding becoming too full, which can interfere with breathing. Alternatively, some people gain weight because of a reduced activity level. In this case, breathing places a greater demand on an already taxed respiratory system. Weight reduction benefits such people.

Drug use and education

People with severe lung disease usually take several drugs. Often these drugs must be taken according to precise instructions and a complex schedule. Through a rehabilitation program, people can learn about the appropriate timing and doses of all drugs they need to take. Education often includes information about the nature of the lung disease and the role of drug therapy, including expected benefits, potential side effects, and the proper technique for use of inhaled drugs. Programs closely monitor how well people follow instructions and teach them and their families about the importance of appropriate drug use.