Key learning points
- There is overwhelming evidence to support the delivery of pulmonary rehabilitation (PR) to reduce the disability associated with COPD
- PR is a combination of supervised exercise and educational sessions which promotes self-management during and beyond the course of rehabilitation
- PR is recommended for individuals with COPD who have reduced functional capacity
- After graduation from a PR programme, participants should be encouraged to integrate the lifestyle changes into their everyday life
Disabling breathlessness compromises individuals with chronic lung disease, including those with COPD. Not surprisingly, those with the disease often have a restricted lifestyle due to this. Patients start avoiding activities that render them breathless, and can ultimately become socially isolated, anxious and depressed because of their disease. Management of the disease initially focuses on supporting smoking cessation and pharmaceutical management to help reduce the symptom burden.
Pulmonary rehabilitation (PR) is defined by the British Thoracic Society (BTS) as ‘an interdisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patient’s physical and social performance and autonomy. Programmes comprise individualised exercise programmes and education’.1
PR is an evidence-based intervention that is consistently recommended by all national and international guidelines.1,2 The intervention comprises a combination of supervised exercise and educational sessions that promote self-management during and beyond the course of rehabilitation. PR is recommended for all those patients with COPD who have reported reduced functional capacity as a consequence of their shortness of breath. The benefits of rehabilitation include an improved exercise capacity, reduced breathlessness, improved quality of life and a reduction in anxiety and depression. Reducing the burden of the disease has not only an impact for the individual but also the family and the health care system.
The Medical Research Council (MRC) scale is the suggested screening tool for rehabilitation and once patients recognise that they are ‘short of breath when hurrying on a level or when walking up a slight hill’ a referral to the programme should be considered (MRC grade 2).1 The Improving and Integrating Respiratory Services in the NHS (IMPRESS) guidelines for the management of COPD confirmed that PR is a highly cost-effective intervention for COPD.3 There is also evidence of clinical effectiveness for other chronic lung diseases (for example, interstitial lung disease and bronchiectasis).1
The majority of patients that attend a rehabilitation programme have stable disease, however there is clear evidence of the value post hospitalisation of an acute exacerbation.1 The benefits are mirrored in the more acute patients and moreover there is evidence to show that readmission rates are significantly lowered.4
The process of rehabilitation is one of an initial assessment, a programme of rehabilitation followed by a discharge assessment and ongoing maintenance. The process extends over a period of around eight weeks.
During the initial assessment for rehabilitation there is a comprehensive assessment of the individual, alongside the obvious demographics. The National COPD Audit Programme has identified a minimum data set that allows national evaluation and benchmarking of PR programmes across the country.5 Exercise capacity is an important measure to understand the baseline functional capacity, the limitation to exercise (considering possible co-morbid conditions), as well as guiding the exercise.5,6 Improvement in health-related quality of life is an important outcome for rehabilitation programmes. Additional measures might include assessment of disease specific knowledge and levels of anxiety and depression.
The exercise component is, to date, the most widely researched. It is critical that the exercise programme is individually prescribed and progressed to achieve the desired outcomes. The exercise training should comprise lower limb aerobic training and lower limb strengthening exercises.1
After graduation from a PR programme, the participant should be encouraged to integrate the lifestyle changes into their everyday life. This is, of course, a challenge, and there have been a number of studies attempting to identify the ideal maintenance strategy. This remains unanswered to date. However, the priority is to ensure that all appropriate patients have the opportunity to engage with a local, quality-assured PR programme. Referral to rehabilitation is less than optimal and driving up referral has to be a priority for those engaged in care of patients with COPD.7
Professor Sally Singh is Head of Cardiac and Pulmonary Rehabilitation, University Hospitals of Leicester.
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