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A Doubting Thomas Dealing With Pulmonary Rehabilitation

Francesco de Blasio, MD, FCCP (Naples, Italy ).

Dr. de Blasio is Chief, Respiratory Medicine and Pulmonary Rehabilitation Section, Clinic Center Private Hospital, Naples.

 

Correspondence to: Francesco de Blasio, MD, FCCP, Via Tripergola 4, 80072 Arco Felice, Naples 80072, Italy; e-mail: fdeblasio@cybernet.it

When I was a young pulmonary fellow, I used to distrust concepts too difficult to define. This simple self-warning led me to underestimate the importance of pulmonary rehabilitation (PR) as a component of the treatment of patients suffering from COPD. As a matter of fact, several panels of experts of different scientific societies dedicated time and spent a considerable amount of effort in defining the process of pulmonary rehabilitation. First was the American College of Chest Physicians Committee on Pulmonary Rehabilitation in 1974, which defined pulmonary rehabilitation " ... as an art of medical practice wherein an individually tailored, multidisciplinary program ... stabilizes or reverses both the physio- and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity ... ."1 Although this early definition already underlined several fundamental aspects of today’s pulmonary rehabilitation (ie, a consideration of the patient’s individual needs, the multidisciplinarity of the rehabilitation team, the aim of returning the patient to his home setting), this was followed by others that tried to improve it (European Respiratory Society, Rehabilitation and Chronic Care Scientific Group, 19922 ; National Institute of Health workshop and summary, 19943 ) which only succeeded in highlighting the educational aspect of PR as " ... a multidimensional continuum of services directed to persons with pulmonary disease and their families ... ."

More recently, a joint panel from the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation published evidence-based guidelines on PR,4 reviewing the current state of the evidence for the scientific basis of PR as a foundation on which to make recommendations for practice. This article showed that, among the components of a comprehensive PR program, the highest grade of evidence (grade A) was achieved for lower-extremities training, with very significant improvement of exercise tolerance. Similarly, among the outcomes used to assess PR programs results, symptoms of dyspnea resulted in a highly significant improvement. Nevertheless, even with a lower grade of evidence, upper extremities and ventilatory muscle training effected significant improvements of arm muscle function and respiratory muscle strength, with reduction of breathlessness. A high grade of evidence in favor of their utility was also recorded for other outcomes, including the health-related quality of life and health care utilization. Since this cornerstone article, even though a comprehensive PR program includes several components, most of the clinical trials on PR and its effects on either the hospitalized or outpatient COPD population include more and more careful considerations, as well as statistical analysis, on exercise training and its ability to improve not only exercise capacity, but also activities of daily living and quality of life.

As a matter of fact, PR has become very popular among chest specialists. Moreover, as the burden of care shifts away from the acute care hospital, PR is often more conducted within the walls of specific rehabilitation hospitals. These are facilities in which essential components of PR, such as thorough planning, experienced and committed team members (with a dedicated and supportive medical director), educational activities, and specific psychosocial support, can be more likely achieved.

The basic questions are still under discussion, but there is more and more agreement on the following: 1. Intensity of the exercise training plays a key role— the more intense the training, the more significant the improvement of exercise capacity.5 6 7 8 2. Additional beneficial effects of oxygen on exercise training have not been clearly substantiated. The major argument against oxygen use during exercise is based upon the fact that local acute hypoxia might act as a stimulus for biochemical and anatomic adaptations in the muscle.9 10

3. Training effects are connected with the training modalities; these should be as similar as possible to activities that are aimed to be improved. Data on interval training in patients with COPD are lacking.11 12 13

4. As training effects may reverse after cessation of the rehabilitation program, exercise training should not be discontinued even after discharge. Follow-up home-based programs must be provided.14 15

5. Ventilatory muscle training using a pressure threshold device improves inspiratory muscle strength and reduces dyspnea. According to scientific evidence, it must be considered in patients with COPD who have decreased respiratory muscle strength and breathlessness.16 17

6. PR programs may be conducted in either inpatient or outpatient clinical settings.

Recent surveys conducted in Europe, Japan, and North America revealed that the inpatient clinical setting is the most common setting for PR in Europe, whereas it is rarely adopted in North America (65% and 22%, respectively); the outpatient clinical setting is preferred worldwide, with percentages of 97 to 98% in North America and 55% in Europe. Home-based rehabilitation programs seem to fail adequate improvements of exercise capacity.18 19 20 21 22

It is now clear to the older pulmonary physician, which I have become, that PR is an invaluable therapeutic tool in helping patients suffering from different grades of respiratory failure to achieve better results.

References

 

  1. . American Thoracic Society. (1981) Pulmonary rehabilitation. Am Rev Respir Dis 124,663-666[Medline]
  2. Donner, CF, Howard, P (1992) Pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) with recommendation for its use. Report of the European Respiratory Society: Rehabilitation and Chronic Care Scientific Group. Eur Respir J 6,266-275
  3. NIH Workshop summary: pulmonary rehabilitation research. Am J Respir Crit Care Med 1994; 149:825–833
  4. . ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel (1997) Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. Chest 112,1363-1396[Medline]
  5. Maltais, F, Leblanc, P, Jobin, J, et al (1997) Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 155,555-561[Abstract]
  6. Horowitz, MB, Littenberg, B, Mahler, DA (1996) Dyspnea ratings for prescribing exercise intensity in patients with COPD. Chest 109,1169-1175[Abstract]
  7. Kirsten, DK, Taube, C, Lehnigk, B, et al (1998) Exercise training improves recovery in patients with COPD after an acute exacerbations. Respir Med 92,1191-1198[Medline]
  8. Rooyackers, JM, Folgering, HTM (1998) Cardio-respiratory load of exercise training in patients with severe COPD. Int J Rehabil Res 21,259-271[Medline]
  9. Rooyackers, JM, Dekhuijzen, PNR, Van Herwaarden, CLA, et al (1997) Training with supplemental oxygen in patients with COPD and hypoxemia at peak exercise. Eur Respir J 10,1278-1284[Medline]
  10. Terrados, N, Jansson, E, Sylven, C, et al (1990) Is hypoxia a stimulus for synthesis of oxidative enzymes and myoglobin? J Appl Physiol 68,2369-2372[Medline]
  11. Lake, FR, Henderson, K, Briffa, T, et al (1990) Upper-limb and lower-limb exercise training in patients with chronic airflow obstruction. Chest 97,1077-1082[Abstract]
  12. Troosters, T, Gosselink, R, Rollier, H, et al (1996) Change in lower limb muscle strength contributes to altered six minute walking distance in COPD. Eur Respir J 9,144S
  13. Dekhuijzen, PNR, Folgering, HTM, Van Herwaarden, CLA (1991) Target-flow inspiratory muscle training during pulmonary rehabilitation in patients with COPD. Chest 99,128-133[Abstract]
  14. Ries, AL, Kaplan, RM, Limberg, TM, et al (1995) Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med 122,823-832[Medline]
  15. Wijkstra, PJ, Van der Mark, TW, Kraan, J, et al (1996) Long-term effects of home rehabilitation on physical performance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 153,1234-1241[Abstract]
  16. Preusser, BA, Winningham, ML, Clanton, TL (1994) High- vs low-intensity inspiratory muscle interval training in patients with COPD. Chest 106,110-117[Abstract]
  17. Nield, MA (1999) Inspiratory muscle training protocol using a pressure threshold device: effect on dyspnea in chronic obstructive pulmonary disease. Arch Phys Med Rehabil 80,100-102[Medline]
  18. Cambach, W, Chadwick-Straver, RVM, Wagenaar, RC, et al (1997) The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Respir J 10,104-113[Medline]
  19. Strijbos, JH, Postma, DS, Van Altena, R, et al (1996) A comparison between outpatient hospital-based pulmonary rehabilitation program and home-care pulmonary rehabilitation program in patients with COPD: a follow-up of 18 months. Chest 109,366-372[Abstract]
  20. De Blasio, F, Scarano, F, Miracco Berlingieri, G (1998) Effects of an outpatient comprehensive pulmonary rehabilitation program on subjects suffering from COPD [abstract]. Chest 114,322S
  21. Kida, K, Jinno, S, Nomura, K, et al (1998) Pulmonary rehabilitation program survey in North America, Europe and Tokyo. J Cardiopulm Rehabil 18,301-308[Medline]
  22. Brooks, D, Lacasse, Y, Goldstein, RS (1999) Pulmonary rehabilitation programs in Canada: national survey. Can Respir J 6,55-63[Medline]