Chest
Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines
Section snippets
EPIDEMIOLOGY OF COPO
In the United States, COPD accounted for 119,054 deaths in 2000, ranking as the fourth leading cause of death and the only major disease among the top 10 in which mortality continues to increase.5, 6, 7, 8 In persons 55 to 74 years of age, COPD ranks third in men and fourth in women as cause of death.9 However, mortality data underestimate the impact of COPD because it is more likely to be listed as a contributory cause of death rather than the underlying cause of death, and it is often not
SEVERITY OF COPD
For consistency throughout the document, the panel used the description of severity of COPD as recommended by the Global Initiative for Chronic Obstructive Lung Disease18 and the American Thoracic Society/European Respiratory Society Guidelines19 based on FEV1, as follows: stage I (mild), FEV1 ge; 80% predicted; stage II (moderate), FEV1 50 to 80% predicted; stage III (severe), FEV1 30 to 50% predicted; and stage IV (very severe), FEV1 < 30% predicted.
PULMONARY REHABILITATION
Rehabilitation programs for patients with chronic lung diseases are well-established as a means of enhancing standard therapy in order to control and alleviate symptoms and optimize functional capacity.2,4,14,20 The primary goal is to restore the patient to the highest possible level of independent function. This goal is accomplished by helping patients become more physically active, and to learn more about their disease, treatment options, and how to cope. Patients are encouraged to become
DEFINITION
The American Thoracic Society and the European Respiratory Society have recently adopted the following definition of pulmonary rehabilitation: Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional
METHODOLOGY AND GRADING OF THE EVIDENCE FOR PULMONARY REHABILITATION
In 1997, the ACCP and the AACVPR released an evidence-based clinical practice guideline entitled āPulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Guidelines.ā2,3 Following the approved process for the review and revision of clinical practice guidelines, in 2002 the ACCP Health and Science Committee determined that there was a need for reassessment of the current literature and an update of the original practice guideline. This new guideline is intended to update the recommendations
OUTCOMES OF COMPREHENSIVE PULMONARY REHABILITATION PROGRAMS
As currently practiced, pulmonary rehabilitation typically includes several different components, including exercise training, education, instruction in various respiratory and chest physiotherapy techniques, and psychosocial support. For this review, comprehensive pulmonary rehabilitation was defined as an intervention that includes one or more of these components beyond just exercise training, which is considered to be an essential, mandatory component.
In addition to the clinical trials
DURATION OF PULMONARY REHABILITATION
There is no consensus of opinion regarding the optimal duration of the pulmonary rehabilitation intervention. From the patient's perspective, the optimal duration should be that which produces maximal effects in the individual without becoming burdensome. Significant gains in exercise tolerance, dyspnea, and HRQOL have been observed following inpatient pulmonary rehabilitation programs as short as 10 days60 and after outpatient programs as long as 18 months.61 Shorter program duration has the
POSTREHABILITATION MAINTENANCE STRATEGIES
Although the benefits of pulmonary rehabilitation have been demonstrated up to 2 years following a short-term intervention,41 most studies suggest that the clinical benefits of pulmonary rehabilitation tend to wane gradually over time. This is underscored in 12-month follow-up data from a cohort of patients with COPD who had completed a 10-week comprehensive pulmonary rehabilitation program.68 At the end of the 10-week program, participants were given a structured home exercise program to
INTENSITY OF AEROBIC EXERCISE TRAINING
Exercise training is one of the key components of pulmonary rehabilitation. The exercise prescription for the training program is guided by the following three parameters: intensity; frequency; and duration. The characteristics of exercise programs in pulmonary rehabilitation for patients with COPD have not been extensively investigated.
As noted by the previous panel and a 2005 review,74 for most patients with COPD with limited maximum exercise tolerance, training intensities at higher
STRENGTH TRAINING IN PULMONARY REHABILITATION
Although always recognized as important, improving the function of the muscles of the arms and legs has recently become a central focus of pulmonary rehabilitation. In the course of everyday activities, these muscles are asked to perform two categories of tasks. Endurance tasks require repetitive actions over an extended period of time; walking, cycling, and swimming are examples. Strength tasks require explosive performance over short time periods; sprinting, jumping, and lifting weights are
ANABOLIC DRUGS
Since exercise-training interventions are a cornerstone in pulmonary rehabilitation and yield benefits, at least in part, by improving the function of the exercising muscles, it seems reasonable to hypothesize that pharmaceutical agents that improve muscle function in similar ways might be useful adjuncts to rehabilitative therapy. However, the list of drugs that might be suitable for clinical trials is quite limited. In particular, no agent that is capable of directly improving the aerobic
UPPER EXTREMITY TRAINING
Upper extremity exercise training specifically impacts the arms and has been shown to increase arm work capacity while decreasing for a comparable work level. Postulated mechanisms for improvement in upper extremity function from such training in patients with chronic lung diseases include desensitization to dyspnea, better muscular coordination, and metabolic adaptations to exercise.
The previous 1997 guidelines panel recommended that āstrength and endurance training of the upper
PSYCHOLOGICAL AND BEHAVIORAL COMPONENTS OF PULMONARY REHABILITATION
Based on little published evidence, the 1997 guidelines panel concluded that āEvidence to date does not support the benefits of short-term psychosocial interventions as single therapeutic modalities, but longer term interventions may be beneficialā and that āexpert opinion supports the inclusion of education and psychosocial interventions as components of comprehensive pulmonary rehabilitation programs for patients with COPD.ā
OXYGEN SUPPLEMENTATION AS AN ADJUNCT TO PULMONARY REHABILITATION
It was demonstrated > 25 years ago that long-term oxygen supplementation prolongs survival in patients with COPD and severe resting hypoxemia.159,160 More recently, the usefulness of oxygen therapy in improving outcomes from pulmonary rehabilitation in patients with COPD has been evaluated in several RCTs. A distinction must be made between the immediate effect of oxygen on exercise performance and its usefulness in the exercise-training component of pulmonary rehabilitation.161 This section
NONINVASIVE VENTILATION
Noninvasive positive-pressure ventilation (NPPV) includes the techniques of continuous positive airway pressure, pressure support, and proportional assist ventilation (PAV). A metaanalysis170 of nocturnal NPPV in stable hypercapneic patients with COPD, which included four eligible trials, showed that this therapy did not improve lung function, gas exchange, or sleep efficiency, but may have led to an increased walk distance. The rationale for NPPV as an adjunct to exercise training is that
Recommendation
- 22.
As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. Grade of recommendation, 2B
NUTRITIONAL SUPPLEMENTATION IN PULMONARY REHABILITATION
Poor nutritional status is associated with increased morbidity and mortality in patients with moderate-to-severe COPD.179 Prior studies have investigated the effects of dietary supplementation on patients with COPD, as summarized in a relatively recent metaanalysis.180 Summary data indicate that nutritional support/supplementation does not have a clinically significant effect on lung function or functional abilities. No studies have evaluated the effects of behavioral weight management (gain or
PULMONARY REHABILITATION FOR PATIENTS WITH DISORDERS OTHER THAN COPD
Although they have not been studied as well to date, patients with respiratory disorders other than COPD can also benefit substantially from pulmonary rehabilitation. Indeed, the scientific rationale for providing pulmonary rehabilitation to patients with non-COPD diagnoses is the same as that for patients with COPD. General principles of rehabilitation treatment emphasize the adaptation of multidisciplinary treatment strategies to the needs of individual patients. Pulmonary rehabilitation
SUMMARY AND RECOMMENDATIONS FOR FUTURE RESEARCH
The field of pulmonary rehabilitation has continued to develop and mature substantially since the publication of the previous evidence-based guidelines in 1997. Additional published literature has added substantially to the scientific basis of pulmonary rehabilitation interventions as well as outcomes. The new data that have been examined further strengthen the evidence that supports the benefits of lower extremity exercise training in pulmonary rehabilitation and the improvement expected in
SUMMARY OF RECOMMENDATIONS
- 1.
A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with COPD.
Grade of Recommendation: 1A
- 2.
Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD.
Grade of Recommendation: 1A
- 3.
Pulmonary rehabilitation improves health-related quality of life in patients with COPD.
Grade of Recommendation: 1A
- 4.
Pulmonary rehabilitation reduces the number of hospital days and other measures of health-care
ACKNOWLEDGMENT
This clinical practice guideline has been endorsed by the American Thoracic Society, The European Respiratory Society, the US COPD Coalition and also the American Association of Cardiovascular and Pulmonary Rehabilitation (by way of collaboration on the project).
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