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Pulmonary Rehabilitation

by Bartolome R. Celli, MD

Pulmonary rehabilitation is the use of exercise, education, and behavioral intervention to improve functional capacity and enhance quality of life. It is indicated for any condition in which respiratory symptoms restrict activity (eg, COPD, interstitial lung disease, neuromuscular disorders causing chest wall weakness) and for respiratory retraining after prolonged ventilator dependence.

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, and, to a lesser extent, decreasing the number of hospitalizations. However, these programs do not improve survival. There are no complications from pulmonary rehabilitation beyond those expected from physical exertion and exercise.

Contraindications

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

Procedure

Pulmonary rehabilitation is best administered as part of an integrated program of exercise training, education, and psychosocial and behavioral intervention by a team of physicians, nurses, respiratory therapists, physical and occupational therapists, and psychologists or social workers.

Exercise training involves aerobic exercise and respiratory muscle and extremity strength training; lower extremity strength training may be particularly important for patients with COPD.

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, keeping oxygen saturation above 90%, 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.

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