Pulmonary Rehabilitation

A multidimensional continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the person's maximum level of independence and functioning in the community.

For many patients with chronic respiratory disease, medical therapy only partially allays the symptoms and complications of their illness. A comprehensive program of pulmonary rehabilitation may lead to significant clinical improvement by reducing shortness of breath, increasing exercise tolerance, improving overall quality of life, and, to a lesser extent, decreasing the number of hospitalizations. However, these programs do not improve survival. Because chronic obstructive pulmonary disease (COPD) is the most common chronic respiratory disease among the elderly, most research in pulmonary rehabilitation has addressed COPD patients. Furthermore, although most studies have involved patients aged 50 to 70 years, patients > 70 have also been shown to benefit from pulmonary rehabilitation programs.

Dyspnea is the most common symptom of COPD and often produces a vicious circle of inactivity, anxiety, and depression. The inactivity leads to deconditioning and reduction in muscle strength and cardiac function, which exacerbate activity-provoked dyspnea. Anticipatory dyspnea is another component of the vicious circle; the patient experiences anxiety when anticipating an activity that the patient thinks will lead to shortness of breath. This anxiety leads to an increased heart and respiratory rate, which in turn increases dyspnea. Anxiety and limitations on activity commonly lead to depression. Pulmonary rehabilitation programs are designed to break the vicious circle of dyspnea by lessening each symptom in the circle.

Patient Selection

Comprehensive pulmonary rehabilitation programs are effective for patients with significant impairment despite maximal medical therapy. Problems that must be addressed include severe dyspnea, which impairs quality of life; impaired exercise capacity, which may affect daily activities; and multiple hospitalizations or emergency room visits because of pulmonary disease. Other significant impairments may be attributable to anxiety and depression or to suboptimal adherence to drug regimens (especially with oxygen therapy). Education is a key component. Pulmonary rehabilitation programs may also help coordinate complex medical services (eg, by arranging transportation, home services, medical equipment, and physician visits).

The Pulmonary Rehabilitation Team

Although some elements of pulmonary rehabilitation may be successfully carried out by a single health care professional, the wide range of services needed often requires the skills of a variety of health care professionals. For example, patients may need exercise training, education, pharmacotherapy, psychosocial counseling, and nutritional guidance, which often require the expertise of a respiratory or physical therapist, a nurse, a physician, a psychologist or social worker, and a dietitian. Communication among team members and with the patient is paramount, and one team member is usually designated as the leader to ensure effective communication and coordination of services.

Patient Evaluation and Goal Setting

The first step in pulmonary rehabilitation is to clarify the patient's reasons for enrolling in rehabilitation and the desired long-term goals so as to develop realistic, achievable short-term goals. For example, an elderly patient may desire to travel by air to visit a grandchild. If the person can walk only 300 feet (91.4 meters) because of shortness of breath but must be able to walk 1000 feet (304.8 meters) to board the airplane, the initial short-term goal may be to walk 500 feet (152.4 meters). Achieving that goal motivates the patient to try for the next goal of 1000 feet (304.8 meters). Continued encouragement by staff is essential. Periodic reevaluation is important to ensure that goals are being met. An ongoing maintenance program is also essential. Identifying factors that may limit the program's effectiveness is also important. These include problems with financial resources, transportation, cognition, and family dynamics.

Exercise Training

Exercise training is probably the most important component of pulmonary rehabilitation. It reduces the effects of inactivity and deconditioning. An intensive conditioning program can result in lower lactate levels during exercise and thus reduce the ventilatory demands associated with activity. In patients who have limited ventilatory reserve because of intrinsic pulmonary disease, lower ventilatory needs during activity lessen dyspnea and increase exercise capacity. However, physical limitations may limit the types of exercise training to be used.

Most elderly patients, particularly those with limited functional capacity due to pulmonary disease and the effects of aging, are not motivated to initiate or maintain an exercise program. The rehabilitation team provides motivation and psychologic support to patients during exercise, helps patients better understand their physical limitations and gain a sense of control over shortness of breath, and ensures patient safety during exercise.

Lower extremity exercise is the cornerstone of pulmonary rehabilitation. Because walking is necessary for most activities of daily living, many programs use walking as the preferred mode of training. Walking may be initiated on a treadmill, which provides an objective measure and control of distance and speed. Many patients continue to use a treadmill, although some prefer walking outdoors or in an enclosed shopping mall. A stationary bicycle may be preferred by some patients. Choosing exercise that is comfortable and satisfying for the patient enhances long-term adherence.

Psychosocial Counseling

Because strong emotions may worsen dyspnea, patients may not express their emotions and thus may be caught in an emotional straitjacket. Yet, anxiety and depression are common. Dyspnea, along with anxiety and depression, may interfere with sexual activity, which need not be given up. Patients may be unable to manage stress and relax. Pulmonary rehabilitation programs use counseling, group therapy, and, when needed, drugs to treat psychosocial problems.

Nutritional Evaluation and Counseling

Patients with severe COPD may experience weight loss. Weight loss may be due to pulmonary cachexia or to the patient's inability to buy food because of insufficient funds or lack of transportation. Through nutritional counseling and supplementation, pulmonary rehabilitation programs help patients avoid loss of muscle mass. Loss of muscle mass impairs the ability of the patient to fully participate in an exercise program and limits the benefits of pulmonary rehabilitation. Rehabilitation programs help pulmonary patients maintain adequate caloric intake while avoiding satiety that can interfere with respiration.

Weight gain may occur from a reduced level of activity associated with dyspnea on exertion and may further exacerbate dyspnea. In such cases, the goal becomes weight loss using a weight loss diet.

Drugs

Patients with advanced pulmonary disease usually take multiple drugs on complex schedules requiring precise dosing. Patients are educated about the appropriate timing and doses of regularly scheduled and prn drugs prescribed by the physician. The proper technique for use of inhaled drugs is emphasized. Because nonadherence is a serious complicating factor in management, programs closely monitor and educate patients and families about the importance of appropriate drug use.

The goal of education is to improve the patient's long-term adherence to the prescribed drug regimen. Education often includes information about the nature of the pulmonary condition and the role of drug therapy, including expected benefits and potential adverse effects. Other important goals include teaching patients to recognize changes in their pulmonary condition and to recognize when the medical program needs to be modified in response to changes in symptoms, so that they will contact their physician promptly. The patient's physicians should emphasize and reinforce the education and training provided by the rehabilitation staff and communicate frequently with them.