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.
In the past, pulmonary rehabilitation was reserved for patients with
Severe COPD Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more (chronic obstructive pulmonary disease)
However, an increasing body of evidence suggests a benefit to patients with
Patients undergoing lung transplantation Lung and Heart-Lung Transplantation Lung or heart-lung transplantation is an option for patients who have respiratory insufficiency or failure and who remain at risk of death despite optimal medical treatment. The most common... read more and lung volume reduction surgery Lung volume reduction surgery Chronic obstructive pulmonary disease (COPD) management involves treatment of chronic stable COPD and treatment of exacerbations. Treatment of chronic stable COPD aims to prevent exacerbations... read more 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 General references 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... read more ). However, most recent guidelines recommend consideration for referral to pulmonary rehabilitation for stable, moderate to severe COPD as defined by GOLD B, C, or D classifications (2 General references 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... read more ).
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.
There are no complications of pulmonary rehabilitation beyond those expected from physical exertion and exercise.
Pulmonary rehabilitation is best administered as part of an integrated program of
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 Smoking Cessation Most smokers want to quit and have tried doing so with limited success. Effective interventions include cessation counseling and drug treatment, such as varenicline, bupropion, or a nicotine... read more 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 The Dying Patient Dying patients can have needs that differ from those of other patients. So that their needs can be met, dying patients must first be identified. Before death, patients tend to follow 1 of 3... read more , 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 critical components 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 General references 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... read more ).
Although the most optimal maintenance strategy is unknown, continued participation in an exercise program is essential to maintain the benefits of pulmonary rehabilitation.
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 Med 192:1373–1386, 2015. doi: 10.1164/rccm.201510-1966ST.
2. Global Initiative for Chronic Obstructive Lung Disease: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2020 report).