In 2006, the American Thoracic Society (ATS) and European Respiratory Society (ERS) released a joint statement on pulmonary rehabilitation, a comprehensive, interdisciplinary intervention that had been recognized as a core component in managing patients with chronic respiratory disease. Since that time, there has been considerable growth in the science and application of pulmonary rehabilitation. In the American Journal of Respiratory and Critical Care Medicine, the ATS and ERS updated the 2006 statement, addressing newly gained knowledge surrounding the efficacy and scope of pulmonary rehabilitation.

A New Definition

A key component of the new statement is an updated definition of pulmonary rehabilitation endorsed by the ATS and ERS based on current insights. It states that “pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, including (but not limited to) exercise training, education, and behavior changes.” The definition notes that pulmonary rehabilitation is designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors.

Bundling Approaches

Whereas components of pulmonary rehabilitation can be provided as good medical care, pulmonary rehabilitation combines these interventions. The major components of pulmonary rehabilitation include exercise training and behavioral interventions.

Update-Pulm-Rehab-Callout

Dr. ZuWallack says that, when used as a bundle in pulmonary rehabilitation, these interventions are tailored to the needs and goals of the individual patient. To meet these goals, pulmonary rehabilitation is provided by an experienced and dedicated interdisciplinary team, including a combination of physicians, nurses, nurse practitioners, respiratory therapists, physical therapists, occupational therapists, psychologists, behaviorists, exercise physiologists, nutritionists, and social workers.

“Pulmonary rehabilitation programs will vary from center to center based on the types of professionals available to that center,” says Dr. ZuWallack, who was a co-author of the ATS/ERS statement update. A thorough patient assessment by the interdisciplinary team is needed prior to initiating pulmonary rehabilitation. Evaluation goes beyond respiratory issues and includes setting baselines for comorbidities, systemic effects of respiratory disease, and current treatment side effects.

Exercise training for pulmonary rehabilitation is necessary and can include the use of treadmills, stationary bikes, walking, and weight lifting, according to Dr. ZuWallack. “Achieving the greatest effects from pulmonary rehab requires more than just exercise training,” he says. “Education and behavior changes are also crucial.” He notes that patients with chronic respiratory disease tend to develop maladaptive behaviors, such as a sedentary lifestyle, continuing to smoke, and not receiving vaccinations. Patients with chronic respiratory disease also tend to depend too heavily on the care from their healthcare providers, meaning the promotion of self-efficacy is vital to a successful pulmonary rehabilitation program.

“The ultimate goal of pulmonary rehabilitation is to improve the overall condition of patients with chronic respiratory disease,” says Dr. ZuWallack. “Often, it provides the greatest improvement in shortness of breath, exercise capacity, and quality of life when compared with standard medical therapy. In addition, it can help reduce healthcare utilization when implemented appropriately. These benefits can occur even with no direct effect on lung function. A comprehensive pulmonary rehabilitation program works by addressing the systemic nature of the illness, but this takes time. Patients may go through a long waiting period before gains in exercise capacity translate into meaningful improvements at home.”

Special Populations

Modified pulmonary rehabilitation is now being recommended for acutely ill patients in the hospital and even the ICU. When provided in the immediate post-hospitalization period, it appears to reduce re-hospitalization and mortality risks, says Dr. ZuWallack.

Although traditionally offered to patients with COPD, pulmonary rehabilitation appears to also be effective in patients with other chronic respiratory diseases (Table). “The disablement process and physical deconditioning seen in patients with COPD are not unique to that disease,” Dr. ZuWallack explains. “Pulmonary rehabilitation appears to address these areas in many chronic respiratory conditions.”

Regardless of a patient’s type of chronic respiratory disease, pulmonary rehabilitation strives to promote long-term adherence to health-enhancing behaviors, says Dr. ZuWallack. “This is not a 6- or 12-week intervention,” he says. “Instead, we’re trying to provide life-long benefits through getting people to exercise regularly and staying physically active, using action plans and self-management strategies, receiving their vaccinations, and taking their medications properly.”

“Healthcare providers should encourage patients to get up and out of the house and exercise in a supportive environment with other people with similar diseases,” he says. “If we can get patients to understand the importance of doing this, they will increase their likelihood of improving their overall quality of life.”

References

Spruit M, Singh S, Garvey C, et al. An official American Thoracic Society/European Respiratory Society Statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188:e13-e64. Available at www.atsjournals.org/doi/abs/10.1164/rccm.201309-1634ST#.UmVIAPlOMmM.

Bhandari N, Jain T, Marolda C, Zuwallack R. Comprehensive pulmonary rehabilitation results in clinically meaningful improvements in anxiety and depression in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev. 2013;33:123-127.

Datta D, Zuwallack R. Measuring unsupported arm lifts as an outcome in pulmonary rehabilitation of chronic obstructive pulmonary disease patients. Chron Respir Dis. 2013; 10:159-163.

Nici L, ZuWallack R. An official American Thoracic Society workshop report: the integrated care of the COPD patient. Proc Am Thorac Soc. 2012;9:9-18.