1 - Front Cover [Seite 1]
2 - Pulmonary Rehabilitation:Role and Advances [Seite 2]
3 - copyright [Seite copyright]
- 3 [Seite 3]
4 - Contributors [Seite 4]
5 - Contents [Seite 8]
6 - Clinics In Chest Medicine [Seite Clinics In Chest Medicine]
- 12 [Seite 12]
7 - Preface [Seite 14]
8 - Pulmonary Rehabilitation [Seite 16]
8.1 - Key points [Seite 16]
8.2 - Definition and concept [Seite 16]
8.3 - History [Seite 17]
8.3.1 - Early Years [Seite 17]
8.3.2 - Randomized Controlled Trials Demonstrating Global Benefit from Pulmonary Rehabilitation [Seite 18]
8.3.3 - Acceptance as a Gold Standard of Care [Seite 18]
8.3.4 - The Rise of Self-Management as an Integral Component of Pulmonary Rehabilitation [Seite 18]
8.3.5 - Funding as a Specific Entity in the United States by the Centers for Medicare and Medicaid Services [Seite 18]
8.3.6 - Broadening the Scope of Pulmonary Rehabilitation [Seite 18]
8.4 - Summary [Seite 18]
8.5 - References [Seite 19]
9 - The Systemic Nature of Chronic Lung Disease [Seite 20]
9.1 - Key points [Seite 20]
9.2 - Introduction [Seite 20]
9.3 - Systemic manifestations of COPD [Seite 21]
9.3.1 - Skeletal Muscle Impairment [Seite 21]
9.3.2 - Mood Disturbance [Seite 21]
9.3.3 - Hormonal Imbalance [Seite 22]
9.3.4 - Osteoporosis [Seite 22]
9.3.5 - Anemia [Seite 22]
9.4 - Mechanisms and causes of the systemic manifestations of COPD [Seite 22]
9.4.1 - Physical Inactivity [Seite 22]
9.4.2 - Systemic Inflammation [Seite 22]
9.4.3 - Hypoxia [Seite 23]
9.4.4 - Corticosteroids [Seite 23]
9.5 - Role of pulmonary rehabilitation for the secondary manifestations [Seite 23]
9.6 - Comorbidities in COPD and pulmonary rehabilitation [Seite 24]
9.6.1 - Multiple Comorbidities [Seite 24]
9.6.2 - Cardiac Disease [Seite 24]
9.6.3 - Obesity [Seite 25]
9.6.4 - Metabolic Syndrome [Seite 25]
9.7 - Very severe disease and rehabilitation [Seite 25]
9.8 - Summary [Seite 26]
9.9 - References [Seite 26]
10 - Evidence-Based Outcomes from Pulmonary Rehabilitation in the Chronic Obstructive Pulmonary Disease Patient [Seite 32]
10.1 - Key points [Seite 32]
10.2 - Introduction [Seite 32]
10.3 - Methods [Seite 33]
10.4 - Results [Seite 33]
10.4.1 - Health-Related Quality of Life [Seite 33]
10.4.2 - Symptoms [Seite 36]
10.4.3 - Activity and Exercise Capacity [Seite 37]
10.4.4 - Exacerbations [Seite 37]
10.5 - Summary [Seite 37]
10.6 - References [Seite 37]
11 - Pulmonary Rehabilitation [Seite 40]
11.1 - Key points [Seite 40]
11.2 - Introduction [Seite 40]
11.2.1 - Who Should Be Referred? [Seite 41]
11.2.2 - Where Should Rehabilitation Take Place? [Seite 43]
11.2.2.1 - Outpatient programs in specialized centers [Seite 44]
11.2.2.2 - Inpatient rehabilitation [Seite 44]
11.2.2.3 - Rehabilitation in primary care [Seite 45]
11.2.2.4 - Community centers [Seite 45]
11.2.2.5 - Telehealth [Seite 45]
11.2.3 - Duration of Rehabilitation [Seite 45]
11.3 - Summary [Seite 46]
11.4 - Acknowledgments [Seite 46]
11.5 - References [Seite 46]
12 - Exercise Training in Pulmonary Rehabilitation [Seite 50]
12.1 - Key points [Seite 50]
12.2 - Endurance exercise training [Seite 50]
12.3 - Interval exercise training [Seite 51]
12.4 - Ground walking exercise training [Seite 52]
12.5 - Nordic walking exercise training [Seite 52]
12.6 - Resistance training [Seite 52]
12.7 - Water-based (or aquatic) exercise training [Seite 53]
12.8 - Tai chi [Seite 53]
12.9 - NLPE [Seite 54]
12.10 - Summary [Seite 54]
12.11 - References [Seite 54]
13 - Strategies to Enhance the Benefits of Exercise Training in the Respiratory Patient [Seite 60]
13.1 - Key points [Seite 60]
13.2 - Introduction [Seite 60]
13.3 - Supplemental oxygen [Seite 61]
13.4 - Rollators (wheeled walkers) [Seite 63]
13.5 - Water-based exercise [Seite 63]
13.6 - Inspiratory muscle training [Seite 64]
13.7 - Non-invasive ventilation [Seite 64]
13.8 - Heliox/Helium-hyperoxia [Seite 65]
13.9 - Neuromuscular electrical stimulation [Seite 67]
13.10 - Partitioning exercising muscle mass [Seite 67]
13.11 - Summary [Seite 70]
13.12 - References [Seite 70]
14 - Collaborative Self-Management and Behavioral Change [Seite 74]
14.1 - Key points [Seite 74]
14.2 - Introduction [Seite 74]
14.3 - Challenges to providing high-quality COPD care [Seite 75]
14.4 - COPD CSM for the "good days" [Seite 76]
14.4.1 - Knowledge and Understanding [Seite 76]
14.4.2 - Self-Efficacy Behaviors for Healthy Living [Seite 77]
14.4.2.1 - Physical activity [Seite 77]
14.4.2.2 - Health status, psychological well-being, and dyspnea [Seite 78]
14.4.2.3 - Preventive behaviors [Seite 78]
14.4.3 - Change in Provider Behavior [Seite 78]
14.5 - COPD CSM for the "bad days" [Seite 78]
14.5.1 - Action Plans for AECOPD [Seite 78]
14.5.2 - Effect of CSM on Hospitalizations for AECOPD [Seite 79]
14.5.2.1 - COPD CSM RCTs that decreased hospitalizations [Seite 79]
14.5.2.2 - COPD CSM RCTs that did not decrease hospitalizations [Seite 80]
14.5.2.3 - Why some RCTs may have been successful while others were not [Seite 80]
14.5.2.4 - Mortality and safety concerns in COPD CSM [Seite 81]
14.6 - Integration of COPD CSM and pulmonary rehabilitation [Seite 81]
14.7 - Translational studies of COPD CSM [Seite 82]
14.7.1 - Costs [Seite 82]
14.8 - Integration of COPD CSM into clinical practice [Seite 83]
14.8.1 - Medical Home Model [Seite 83]
14.8.2 - Qualification and Training of COPD CSM Managers [Seite 83]
14.8.3 - Frequency and Intensity of Contacts [Seite 83]
14.8.4 - Patient Selection for COPD CSM [Seite 83]
14.9 - The continuum of disease: advance care planning and palliative care [Seite 84]
14.10 - Summary [Seite 84]
14.11 - Acknowledgments [Seite 84]
14.12 - References [Seite 84]
15 - Approaches to Outcome Assessment in Pulmonary Rehabilitation [Seite 90]
15.1 - Key points [Seite 90]
15.2 - Introduction [Seite 90]
15.3 - Patient outcome assessments for pulmonary rehabilitation [Seite 91]
15.3.1 - Exercise Capacity [Seite 91]
15.3.2 - Strength [Seite 93]
15.3.3 - Health-Related Quality of Life [Seite 93]
15.3.4 - Functional Performance [Seite 94]
15.3.5 - Physical Activity [Seite 94]
15.3.6 - Anxiety and Depression [Seite 95]
15.3.7 - Symptoms [Seite 95]
15.3.8 - Knowledge and Self-Efficacy [Seite 95]
15.3.9 - Nutritional Status [Seite 95]
15.3.10 - Other Outcome Assessments [Seite 96]
15.4 - Summary [Seite 96]
15.5 - References [Seite 96]
16 - Promoting Regular Physical Activity in Pulmonary Rehabilitation [Seite 100]
16.1 - Key points [Seite 100]
16.2 - Introduction [Seite 100]
16.3 - Components of pulmonary rehabilitation addressing physical activity [Seite 101]
16.3.1 - Exercise Training [Seite 101]
16.3.2 - Behavioral Intervention [Seite 102]
16.4 - How physical activity is measured as an outcome of pulmonary rehabilitation [Seite 102]
16.5 - Effects of pulmonary rehabilitation on physical activity [Seite 102]
16.6 - Challenges of pulmonary rehabilitation in promoting physical activity [Seite 103]
16.7 - Summary [Seite 103]
16.8 - References [Seite 104]
17 - Pulmonary Rehabilitation for Respiratory Disorders Other than Chronic Obstructive Pulmonary Disease [Seite 106]
17.1 - Key points [Seite 106]
17.2 - Introduction [Seite 106]
17.3 - Rationale for PR in non-COPD disorders [Seite 106]
17.4 - PR for other conditions associated with airflow obstruction [Seite 107]
17.4.1 - Asthma [Seite 107]
17.4.2 - Cystic Fibrosis (CF) [Seite 108]
17.4.3 - Non-CF Diffuse Bronchiectasis [Seite 112]
17.5 - PR for conditions associated with restrictive physiology [Seite 112]
17.5.1 - ILD/Pulmonary Fibrosis [Seite 112]
17.5.2 - Restrictive Chest Wall Disease [Seite 113]
17.6 - PR for other respiratory disorders [Seite 114]
17.6.1 - Pulmonary Hypertension (PH) [Seite 114]
17.6.2 - Lung Cancer [Seite 115]
17.6.3 - PR Before and After Lung Transplantation [Seite 117]
17.6.3.1 - Before transplant [Seite 117]
17.6.3.2 - After transplant [Seite 118]
17.7 - Practical challenges of providing PR to persons with respiratory disorders other than COPD [Seite 119]
17.8 - Summary [Seite 119]
17.9 - References [Seite 119]
18 - Pulmonary Rehabilitation at the Time of the COPD Exacerbation [Seite 128]
18.1 - Key points [Seite 128]
18.2 - Introduction [Seite 128]
18.3 - Definition, cause, and pathophysiology of acute exacerbation [Seite 128]
18.3.1 - Definition [Seite 128]
18.3.2 - Cause and Incidence [Seite 129]
18.4 - Acute exacerbations-the enemy of rehabilitation [Seite 129]
18.4.1 - Impact on Lung Function [Seite 129]
18.4.2 - Impact on Muscle Strength [Seite 129]
18.4.3 - Impact on Health-related Quality of Life [Seite 130]
18.4.4 - Impact on Physical Activity [Seite 130]
18.4.5 - Impact on Hospital Readmission [Seite 131]
18.5 - Psychological impact of acute exacerbation [Seite 131]
18.6 - Rehabilitation after acute exacerbation: the evidence, practice, and components [Seite 132]
18.6.1 - Airway Clearance Techniques for Acute Exacerbation [Seite 132]
18.6.2 - Pulmonary Rehabilitation [Seite 132]
18.7 - Program modification post-exacerbation [Seite 133]
18.8 - Summary [Seite 133]
18.9 - References [Seite 133]
19 - Anxiety, Depression, and Cognitive Impairment in Patients with Chronic Respiratory Disease [Seite 136]
19.1 - Key points [Seite 136]
19.2 - Introduction [Seite 136]
19.2.1 - Depression [Seite 137]
19.3 - Prevalence of depression [Seite 137]
19.3.1 - Depression Treatment [Seite 138]
19.4 - Does depression affect participation and the likelihood of benefitting from pulmonary rehabilitation? [Seite 138]
19.4.1 - Improvement in Depressive Symptoms as a Result of Pulmonary Rehabilitation [Seite 138]
19.4.2 - Should Screening for Depression be Performed Before Entry into a Pulmonary Rehabilitation Program? [Seite 140]
19.4.2.1 - Anxiety [Seite 140]
19.4.3 - Prevalence of Anxiety in COPD [Seite 141]
19.4.4 - What is the Relationship Between Anxiety and Pulmonary Rehabilitation? [Seite 141]
19.4.5 - Screening for Panic Disorder and Generalized Anxiety [Seite 141]
19.4.6 - Measures Used to Assess Anxiety as an Outcome in Pulmonary Rehabilitation [Seite 142]
19.4.6.1 - Cognitive function [Seite 142]
19.4.6.2 - Prevalence of cognitive decline in COPD [Seite 142]
19.4.6.3 - Working memory [Seite 143]
19.4.6.4 - Pulmonary rehabilitation as an intervention to improve depression, anxiety, and cognitive impairment [Seite 143]
19.5 - References [Seite 143]
20 - Palliative Care and Pulmonary Rehabilitation [Seite 148]
20.1 - Key points [Seite 148]
20.2 - Introduction [Seite 148]
20.3 - Disease trajectory and the palliative care model in advanced COPD [Seite 149]
20.4 - Palliative care needs in advanced COPD [Seite 150]
20.4.1 - Symptoms [Seite 150]
20.4.2 - Care Needs [Seite 150]
20.4.3 - Family Caregiving [Seite 151]
20.4.4 - Comorbidities [Seite 151]
20.4.5 - Need for Advance Care Planning [Seite 151]
20.5 - Barriers toward provision of palliative care [Seite 152]
20.5.1 - Barriers to Optimal Symptom Management [Seite 152]
20.5.2 - Barriers Toward Advance Care Planning [Seite 153]
20.6 - Advance care planning education during pulmonary rehabilitation [Seite 154]
20.7 - Summary [Seite 155]
20.8 - References [Seite 155]
21 - Program Organization in Pulmonary Rehabilitation [Seite 160]
21.1 - Key points [Seite 160]
21.2 - Introduction [Seite 160]
21.3 - Program duration [Seite 160]
21.4 - Rehabilitation setting [Seite 160]
21.5 - Structure and staffing [Seite 161]
21.6 - Medical director [Seite 161]
21.7 - Program certification [Seite 162]
21.8 - Program audit and quality control [Seite 162]
21.9 - Patient selection [Seite 162]
21.10 - Technology-assisted exercise training [Seite 162]
21.11 - Program enrollment [Seite 162]
21.12 - Maintenance [Seite 162]
21.13 - Program adherence [Seite 163]
21.14 - Health care utilization [Seite 163]
21.15 - Program costs and reimbursement issues [Seite 163]
21.16 - Summary [Seite 164]
21.17 - References [Seite 164]
22 - Promoting Long-Term Benefits of Pulmonary Rehabilitation [Seite 166]
22.1 - Key points [Seite 166]
22.2 - Introduction [Seite 166]
22.3 - Getting patients to participate in pulmonary rehabilitation [Seite 167]
22.4 - Maintenance programs following pulmonary rehabilitation [Seite 168]
22.5 - Prolonging the beneficial effects of pulmonary rehabilitation indirectly through reducing the frequency of exacerbations [Seite 168]
22.5.1 - Reduced Hospital Admissions Rather than Reduced Number of Exacerbations as an Outcome in Pulmonary Rehabilitation [Seite 168]
22.5.2 - Pulmonary Rehabilitation and COPD Exacerbations [Seite 169]
22.5.3 - Promotion of Physical Activity During Pulmonary Rehabilitation [Seite 169]
22.5.4 - Promoting Self-Efficacy and Collaborative Self-Management in the Respiratory Patient [Seite 170]
22.5.5 - Pulmonary Rehabilitation and the Integration of Care of the Respiratory Patient at the Time of the Respiratory Exacerbation [Seite 170]
22.6 - Using pulmonary rehabilitation or its components to optimize care following hospital discharge [Seite 170]
22.7 - Recommendations [Seite 172]
22.8 - References [Seite 172]
23 - Pulmonary Rehabilitation [Seite 176]
23.1 - Key points [Seite 176]
23.2 - Pulmonary rehabilitation: state of the science [Seite 176]
23.3 - Expanding the applicability of pulmonary rehabilitation [Seite 177]
23.3.1 - Pulmonary Rehabilitation for the Non-COPD Respiratory Patient [Seite 177]
23.3.2 - Pulmonary Rehabilitation in Earlier Stages of COPD [Seite 177]
23.3.3 - Pulmonary Rehabilitation in the Periexacerbation Period [Seite 177]
23.3.4 - Pulmonary Rehabilitation During Critical Illness [Seite 178]
23.3.5 - Pulmonary Rehabilitation in the Home and Community Settings [Seite 178]
23.3.6 - Technology-Assisted Pulmonary Rehabilitation [Seite 178]
23.4 - Further defining the effectiveness of pulmonary rehabilitation [Seite 178]
23.4.1 - Self-Management Education [Seite 178]
23.4.2 - Maintaining the Benefits of Pulmonary Rehabilitation [Seite 179]
23.4.3 - Translating Gains in Exercise Capacity into Meaningful Physical Activity [Seite 179]
23.5 - Promoting accessibility to pulmonary rehabilitation [Seite 179]
23.5.1 - Increasing the Awareness of Pulmonary Rehabilitation [Seite 179]
23.5.2 - Fair Reimbursement for Pulmonary Rehabilitation [Seite 180]
23.6 - Pulmonary rehabilitation and integrated care of the respiratory patient [Seite 180]
23.7 - References [Seite 180]
24 - Index [Seite 182]
Pulmonary Rehabilitation
Definition, Concept, and History
Linda Nici, MDa∗linda_nici@brown.edu and Richard L. ZuWallack, MDb, aPulmonary Medicine/Critical Care Section, Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA; bPulmonary Medicine, Critical Care - Medical, Department of Pulmonary Medicine, Saint Francis Medical Group, Inc, 114 Woodland Street, Hartford, CT 06105, USA
∗Corresponding author.
Pulmonary rehabilitation is a complex intervention for which it is difficult to craft a succinct yet inclusive definition. Pulmonary rehabilitation should be considered for all patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic or have decreased functional status despite otherwise optimal medical management. The essential components of pulmonary rehabilitation are exercise training and self-management education, tailored to the needs of the individual patient and integrated into the course of the disease trajectory. Emerging data support a role for pulmonary rehabilitation in nontraditional contexts, such as during exacerbation in the non-COPD patient and in the home setting.
Keywords
Pulmonary rehabilitation
Chronic obstructive pulmonary disease
Exercise training
Behavioral change
Key points
• Pulmonary rehabilitation is a comprehensive intervention including exercise training, education, and behavior change, which improves the physical and emotional condition of people with chronic respiratory disease.
• Pulmonary rehabilitation can and should be delivered at multiple times in the disease trajectory of chronic respiratory disease.
• Pulmonary rehabilitation, by its essential nature, is designed to provide the right therapy for the right patient at the right time and therefore, fits perfectly into the concept of integrated care.
Definition and concept
Pulmonary rehabilitation is a complex intervention whose implementation varies widely among pulmonary rehabilitation centers worldwide, and indeed often varies considerably within a center, depending on the needs and goals of a particular respiratory patient. Furthermore, individual elements of the comprehensive pulmonary rehabilitation intervention, such as the promotion of exercise and self-management, are often applied in isolation as part of good medical care. Consequently, it is difficult to craft a succinct yet inclusive definition of pulmonary rehabilitation.
The 2013 American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation perhaps comes closest to a workable definition of pulmonary rehabilitation: pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies which include, but are not limited to, exercise training, education, and behavior change, 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.1
To better understand what pulmonary rehabilitation is, some amplification of this definition is necessary.
1. Pulmonary rehabilitation. Although combining different therapies, pulmonary rehabilitation is an entity on its own. Although each of its components could, and often should, be given as part of good medical care, these components are conveniently bundled into a package and delivered by professionals with expertise and experience in this area. Pulmonary rehabilitation is much more than the sum of its parts.2
2. Comprehensive intervention. Pulmonary rehabilitation can be delivered at multiple times in the disease trajectory of any individual patient with chronic respiratory disease. Its focus and components vary depending on the patient’s goals, functional impairments, and disabilities. This approach requires a dedicated interdisciplinary team, which may include physicians, nurses, nurse practitioners, respiratory therapists, physiotherapists, occupational therapists, psychologists, behaviorists, exercise physiologists, nutritionists, and social workers. The composition of any particular pulmonary rehabilitation program will depend on available resources.
3. Thorough patient assessment. To effectively treat the often complex and unique morbidities of the individual patient with chronic respiratory disease, these must be first identified. For instance, exercise limitation in a patient with chronic obstructive pulmonary disease (COPD) often reflects multiple factors, such as ventilatory constraints, ambulatory muscle dysfunction, cardiovascular limitation, joint disease, and psychological and cognitive problems. Their identification will allow for a targeted and thereby more effective and efficient intervention.
4. Patient-tailored therapies. The intervention must be individualized to the unique therapeutic requirements of the patient, which result from the respiratory disease itself, comorbidities, treatments, and their psychological and social consequences. These therapies should be integrated to provide a seamless intervention throughout the course of a patient’s disease.
5. Exercise training, education, and behavior change. The comprehensive pulmonary rehabilitation intervention includes multiple therapies. However, exercise training and education aimed at behavior change are its essential components. Although exercise training remains the cornerstone of pulmonary rehabilitation, in itself it is not sufficient to provide optimal and long-term benefits. It must be coupled with educational efforts aimed at promoting self-management skills and positive change in health behavior.
6. Designed to improve the physical and emotional condition of people with chronic respiratory disease. Pulmonary rehabilitation leads to substantial benefits in dyspnea, exercise capacity, health-related quality of life, and health care utilization. These benefits, which are often of greater magnitude than those from other medical therapies such as bronchodilators, are achieved without concurrent improvements in traditional measures of physiologic impairment, such as the forced expiratory volume in 1 second. This apparent paradox is explained by the fact that rehabilitation targets the often treatable systemic manifestations of chronic respiratory disease, such as peripheral muscle dysfunction, maladaptive health behaviors, and anxiety and depression. To fully delineate the beneficial effects of pulmonary rehabilitation, a comprehensive, patient-centered outcome assessment is necessary.
7. Promote the long-term adherence to health-enhancing behaviors. It would be naïve to think that an isolated, 6- to 12-week intervention such as exercise training would have a substantial long-term impact on a chronic disease, a point that underscores the need to include interventions that promote true health-behavior change so as to maintain long-term benefits. This aspect has become an important focus in the implementation of pulmonary rehabilitation.
Optimal treatment of the often complex patient with chronic respiratory disease ideally requires seamless care across settings and providers, over the course of the disease: the concept of integrated care.3 Pulmonary rehabilitation, by its essential nature, is designed to provide the right therapy for the right patient at the right time. These therapies may include providing smoking-cessation therapy when necessary, promoting regular exercise and physical activity in the home and community settings, fostering collaborative self-management strategies, optimizing pharmacotherapy and medication adherence, and, when needed, offering palliative care and hospice services. This approach requires partnering, communication, and coordination among health care providers, patients, and their families. Because pulmonary rehabilitation encompasses all of these strategies, it fits perfectly into this concept of integrated care.
History
Early Years
Components of pulmonary rehabilitation have been provided as part of good medical care for centuries. However, in the 1960s and 1970s clinicians became aware that organizing these components into a comprehensive program could lead to substantial benefits for their patients.4 Such components included breathing techniques, walking exercise, supplemental oxygen therapy, and bronchial hygiene techniques. These bundled interventions were first trialed, after which results were presented in the form of noncontrolled before-after studies or historically controlled studies.5–7 In 1974, pulmonary rehabilitation was first given an official definition by the American College of Chest Physicians, and in 1981 the American Thoracic Society published its first official statement on pulmonary rehabilitation.4
Development in 2 general outcome areas fueled the growing popularity of pulmonary rehabilitation among...
