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Pulmonary Rehabilitation

By Jessica Bon Field, MD, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh ; Andrea Levine, MD, Fellow, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center

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Pulmonary rehabilitation is the use of exercise, education, and behavioral intervention to improve functional capacity and enhance quality of life in patients with chronic respiratory disorders.

For many patients with chronic respiratory disorders, medical therapy only partially allays the symptoms and complications of the disorder. A comprehensive program of pulmonary rehabilitation may lead to significant clinical improvement by

  • Reducing shortness of breath

  • Increasing exercise tolerance

  • To a lesser extent, decreasing the number of hospitalizations

However, these programs do not improve survival.

Indications

In the past, pulmonary rehabilitation was reserved for patients with severe chronic obstructive pulmonary disease (COPD). However, an increasing body of evidence suggests a benefit to patients with interstitial lung disease (ILD), cystic fibrosis (CF), bronchiectasis, asthma, and lung cancer. Patients undergoing lung transplantation and lung volume reduction surgery also have benefited from pulmonary rehabilitation both before and after surgery.

Studies done in patients with COPD have suggested that pulmonary rehabilitation should start before COPD becomes severe (ie, as identified by degree of airflow obstruction) because there appears to be a poor correlation between disease severity and exercise performance. Furthermore, even patients with less severe disease are likely to benefit from reduced dyspnea, improved exercise tolerance, improved muscle strength, conditioning, improvement of cardiac and pulmonary physiology, reduced dynamic hyperinflation, and the psychosocial benefits that accompany pulmonary rehabilitation (1).

Contraindications

Contraindications are relative and include comorbidities (eg, untreated angina, left ventricular dysfunction) that could complicate attempts to increase a patient’s level of exercise. However, these comorbidities do not preclude application of other components of pulmonary rehabilitation.

Complications

There are no complications of pulmonary rehabilitation beyond those expected from physical exertion and exercise.

Procedure

Pulmonary rehabilitation is best administered as part of an integrated program of

  • Exercise training

  • Education

  • Psychosocial and behavioral interventions

Pulmonary rehabilitation is delivered by a team of physicians, nurses, respiratory therapists, physical and occupational therapists, and psychologists or social workers. The intervention should be individualized and targeted to the patient's needs. Pulmonary rehabilitation can be started at any stage of disease with the goal of minimizing disease burden and symptoms.

Exercise training involves aerobic exercise and respiratory muscle and upper and lower extremity strength training. There is increasing evidence to support doing both strength training and interval training of the extremities.

Inspiratory muscle training (IMT) is an important component of pulmonary rehabilitation. IMT strengthens respiratory muscles using devices that impose a resistive load that is set at a fraction of an individual's maximal inspiratory pressure. When used alone, IMT may decrease dyspnea, but it is not clear whether it can improve exercise tolerance and performance of activities of daily living. However, using IMT in addition to traditional pulmonary rehabilitation exercise does result in clinically meaningful reduction in dyspnea during activities of daily living and improvement in walk distance.

Neuromuscular electrical stimulation (NMES) uses a device that applies transcutaneous electrical impulses to selected muscles to stimulate contraction and thus strengthen them. NMES can be effective in patients with severe lung disease because it minimizes circulatory demand and does not cause the dyspnea that often limits these patients from participating in typical exercise training. Thus, neuromuscular electrical stimulation is uniquely suited for patients with significant deconditioning or for patients with an acute exacerbation of respiratory failure.

Education has many components. Counseling about the need for smoking cessation is important. Teaching breathing strategies (such as pursed-lip breathing, in which exhalations are begun against closed lips to decrease respiratory rate, thereby decreasing gas trapping) and the principles of conserving physical energy are helpful. Explaining treatment, including using drugs correctly and planning for end of life care, are needed.

Psychosocial interventions involve counseling and feedback for the depression, anxieties, and fear that hinder the patient’s full participation in activities.Behavioral modification strategies and an emphasis on self-management are a critical component of pulmonary rehabilitation. Strategies include techniques for goal-setting and problem solving, decision-making, medication adherence, and the maintenance of routine exercise and physical activity (1).

Although the most optimal maintenance strategy is unknown, continued participation in an exercise program is essential to maintain the benefits of pulmonary rehabilitation.

Reference

  • 1. Rochester CL, Vogiatzis I, Holland AE, et al: An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation. Am J Respir Crit Care Med192:1373–1386, 2015. doi: 10.1164/rccm.201510-1966ST.