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Pulmonary rehabilitation

 

Learning objectives

  1. Explain the role of pulmonary rehabilitation in patients with COPD, including post-exacerbation
  2. Assess the suitability of a patient for referral for pulmonary rehabilitation
  3. Explore how to conduct a risk assessment for patients entering a pulmonary rehabilitation programme, including current smokers and those with multiple comorbidities
  4. Describe the structure of an optimum pulmonary rehabilitation programme, including, but not restricted to, programme duration, the nature of the training, goal setting and supervision
  5. Communicate the benefits of pulmonary rehabilitation to patients and the importance of attending the programme

Introduction

Pulmonary rehabilitation (PR) has established itself as a key management strategy in people with chronic respiratory diseases, such as COPD. PR is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education and behaviour change.

It is designed to improve the physical and psychological condition of people with chronic respiratory disease, promote the long-term adherence to health-enhancing behaviours, and optimise each patient’s physical and social functioning.

PR has prominently been studied in COPD, where impairments include airflow obstruction, increased work of breathing, skeletal muscle dysfunction and deconditioning. Although the respiratory symptoms often predominate in COPD, the condition can also have significant systemic effects and psychological wellbeing can also be markedly affected, in some cases leading to abrupt decline. The clinical course of COPD is often punctuated by acute exacerbations of COPD, which are periods associated with worsening symptoms and health-related quality of life that may persist for several months. Exercise capacity and physical activity levels are impaired during and after an exacerbation, contributing to skeletal muscle dysfunction, particularly of the lower limbs.

The UK approach to PR is supported by guidelines and quality standards developed by the British Thoracic Society (BTS).1,2 PR is a complex intervention with numerous outcomes measures that may be used to assess its benefits. Some of these are listed below. The conventional outcome measures include those reflecting a change in exercise capacity, quality of life, symptoms and levels of anxiety and depression.1

 

Consultation

Zena is 50 years old and was diagnosed with COPD five years ago. She had two acute exacerbations last year, and although she enjoys going for a gentle walk with her dog every morning, she experiences breathlessness when walking in a hurry (modified MRC [mMRC] score: 1). According to the 2017 GOLD classification, this places her in category C.3

 

Figure 1: Comparison of MRC and modified MRC (mMRC) dyspnoea scores. Both are used in clinical practice, but the GOLD COPD guidelines use the mMRC.3

On a regular visit to the GP, Zena mentioned that her breathlessness had been worse recently, and she had asked her husband to walk their dog as she was concerned her morning walk was making her more short of breath. She felt that her breathlessness was also affecting her ability to continue in her job as a teaching assistant as she was becoming out of breath when walking around the classroom. Clinical assessment had found no other conditions that would cause breathlessness, such as new-onset anaemia or heart failure, so the GP believed this was due to a worsening of her COPD.

According to the GOLD guidelines, PR should be considered as a treatment option for all patients with GOLD classification B, C or D.3 The British Thoracic Society recommend PR for patients with MRC scores of 3–5, or those with an MRC score of 2 who are ‘functionally limited’ by breathlessness.

Patients who are being referred for PR often have limited exercise capacity and are likely to have reduced their daily activity level or compensate for their increased breathlessness and fatigue. Therefore, they may not initially understand how an ‘exercise programme’ can help them and may be sceptical or worried. Providing sufficient information about the features and benefits of PR is essential to engaging patients in their treatment. This should include identifying any specific concerns the patient may have, as addressing these may improve uptake and completion.

The point of referral should be used as an opportunity to explore the patient’s understanding of PR, address concerns and educate patients about the benefits of the programme. To accomplish this, healthcare professionals making referrals must have at least a basic level of knowledge about what the programme entails, and should ideally be familiar with the structure and format of their local service so they can give detailed information about this. PR should be presented as a fundamental part of effective treatment for COPD, rather than as an ‘optional extra’.

Exacerbation

The GP told Zena that he’d like to refer her to a PR programme.

Zena attended 2 PR sessions per week for six weeks, and at her follow-up visit reported that she did generally feel stronger in herself and better able to manage her breathlessness and that she was pleased to be making some progress. Her COPD Assessment Test (CAT) score had decreased and the 6-minute walk test she undertook at the end of the PR programme had shown a significant improvement in her exercise capacity compared with when she started the programme. Unfortunately, she experienced another acute exacerbation six months later, and was hospitalised for a few days.

PR following hospitalisation because of a COPD exacerbation has shown to be beneficial and cost-effective. A systematic review found that starting PR shortly after leaving hospital for an acute exacerbation (usually within three weeks of discharge) could significantly improve patients’ exercise capacity and quality of life.1 For this reason, the British Thoracic Society (BTS) Quality Standards for Pulmonary Rehabilitation in Adults state that patients should be offered PR at hospital discharge, and that this should commence within one month of discharge.2 If a patient initially declines PR at hospital discharge, they should be offered elective PR at a later date.2 Providing post-exacerbation pulmonary rehabilitation alongside elective pulmonary rehabilitation courses can cause practical issues; however, these can be avoided through the provision of rolling, rather than cohort-based, programmes. The COPD discharge care bundle template provided by the BTS also includes a section on pulmonary rehabilitation, noting that ‘All patients who report walking slower than others on the level or who need to stop due to dyspnoea after a mile or after less than 15 minutes walking should be assessed for and offered PR’.4 Some local areas also offer PR to inpatients, although a large-scale study examining the benefits of early PR (beginning within 48 hours of hospital admission) did find an increased mortality rate associated with this.5

Adherence and goal setting

Zena began elective PR three weeks after her discharge from hospital, as planned. However, she only attended two sessions before she stopped going, and two months later she experienced a second exacerbation. She stated that the reason she had stopped going to the PR sessions was that she didn’t think they were relevant to her – she said there was too much talking about how she could take control of her treatment, but all she was really interested in was a programme to help her build her strength back up so that she could go back to taking responsibility for the morning dog walk.

It is well recognised that some patients do not attend or complete elective pulmonary rehabilitation. This is particularly true in the period immediately following hospital discharge, when patients are often physically and psychologically vulnerable.1 Services providing post-hospital discharge PR programmes should carefully record uptake, adherence and completion rates.

Structured education is a key component of PR programmes and supports patients to make healthy lifestyle and behavioural changes and to improve self-management of their condition. The educational component must be tailored to the subject, being mindful of cultural factors and any physical or cognitive barriers, but the BTS offers a list of suggested topics for inclusion.1

One controlled trial randomised patients to receive either an individually targeted exercise programme (with exercises based on specific activities of daily living chosen by the patients) or a conventional general exercise programme. This study found no significant difference between the groups, leading the BTS to recommend ‘generic exercise training as opposed to individually targeted exercise training’ for patients with COPD.1

At first reading, this recommendation for generic exercise training seems to contradict the BTS Quality Standards, which recommend that PR programmes include ‘individually tailored and prescribed’ exercise training based on assessments of the patient’s physical performance.2 However, it is important to note that although the guidelines concluded individualising the selection of exercises does not seem to provide any advantage over a generic exercise programme, they also state that the intensity of those exercises must be individualised.1

Any assessment of a patient’s suitability for PR should include a discussion about what exactly the programme will entail, such as, for example, the inclusion of group exercise sessions.

Conclusion

Zena re-enrolled in a PR programme one month later. After discussions with the physiotherapist, she agreed to commit to taking part in the group exercise sessions in the programme. Alongside this general exercise training, the physiotherapist also gave her some specific educational sessions on energy conservation and managing her breathlessness, to help Zena move towards her goals of being able to walk her dog again and reducing the amount of sick leave she takes from work.

Smoking

Neil is 70 years old and is visiting his GP for the first time in many years. He was diagnosed with COPD 20 years ago, but he has been poorly compliant with attending for reviews and collecting his prescriptions. When he arrives at the surgery on this occasion, he is very breathless and clearly struggled with walking from the waiting area to the consulting room. He tells the GP that he lives a mostly sedentary life, relying on the help of a cleaner and his adult children. The most strenuous activity he undertakes usually is walking to his local newsagent, which is around 80 metres from his house, to buy cigarettes.

The GP counsels Neil regarding the importance of regular reviews and using his medication as prescribed, and then observes and gives feedback on his inhaler technique, correcting errors. She also stresses the importance of quitting smoking in improving breathlessness, but Neil is adamant that having smoked 20 cigarettes per day since he was a teenager, he is not willing to stop now.

The GP asks Neil to return in two weeks to review his condition after a period of taking his medication correctly. After he leaves her office she wonders whether Neil might be a candidate for PR given his low level of current activity.

Studies have suggested that current smokers are less likely to complete a course of PR compared with non-smokers. However, in these studies the smokers who did attend and complete PR seemed to benefit to a similar degree as the non-smokers. Therefore, BTS guidance is that current smoking should not be a contraindication to PR; indeed, PR can provide a good opportunity to reinforce smoking cessation advice.

New symptoms

When Neil returns for his follow-up visit, his breathlessness has not improved and he says that he now finds himself out of breath when dressing and undressing, and struggles to walk to the newsagent. The GP explains again how quitting smoking would improve Neil’s health, changes his long-acting beta-agonist (LABA) prescription for a LABA–long-acting muscarinic antagonist (LAMA) combination inhaler (and checks his inhaler technique), and assesses him for suitability for PR.

As part of her assessment, the GP measures Neil’s degree of airflow obstruction with a spirometer, which shows his FEV1 is 44% predicted, indicating severe COPD. She also checks his blood pressure and finds it is elevated – 164/101 mmHg. She asks Neil if he experiences any symptoms such as weight loss, coughing up blood or chest pain. He denies the first two, but admits he does sometimes experience chest pain during his walk to or from the newsagent – but the pain goes away within a few minutes of arriving home and sitting down.

Patients with chronic respiratory disease who are functionally limited due to their dyspnoea can benefit from PR. This includes patients who have COPD with an mMRC dyspnoea score of 1–3, and those with a score of 4 who are able to attend an outpatient programme.1 Patients with COPD and an mMRC score of 4 who are housebound are unlikely to gain significant improvement in walking distance, breathlessness or quality of life from a supervised PR programme, and should not routinely be offered such a programme within their home.1

However, when assessing a patient’s suitability for PR, clinicians should consider comorbidities and risk factors, and may wish to refer patients for management of these factors first to optimise the benefit the patient can receive from PR.1 This assessment should consider the programme setting and the skills of the staff involved, as well as the patient’s risk factors. Patients with chronic respiratory failure are able to benefit from PR just as much as those patients without respiratory failure, but referring clinicians should reflect on the ability of the staff to provide safe and effective PR for these patients with significant physiological impairment.1 It may not be appropriate to manage some patients with complex physical and/or psychosocial comorbidities in a ‘group-based activity’ setting.

In light of her findings, the GP decides to defer PR for the moment and instead refers Neil for further tests including an ECG and arterial blood gas sampling.

Comorbid cardiovascular disease and depression

Neil returned to his GP a few weeks later following his tests and an appointment with the local cardiology service. Looking over his notes, the GP notices he has now been diagnosed with chronic respiratory failure and stable angina secondary to coronary heart disease. She also notices Neil looks worried and doesn’t seem to be his usual forthright self; after some gentle questioning, he reveals that he is very worried about his new diagnoses. He is anxious about what the future holds and feels that there is no point in trying to improve his health or take good care of himself because ‘the damage has already been done’.

Patients with unstable cardiovascular disease (e.g. unstable angina or arrhythmias) should not enter a PR programme until their condition has been stabilised.1 However, stable cardiovascular disease is not an absolute contraindication to PR; consideration of this should form an element of the assessment of the patient’s general health before referring them for PR.1

There is little evidence on the safety of PR in people with AAAs, but the US Society for Vascular Surgery advises that moderate physical activity does not cause rupture of AAAs.5 Therefore, BTS guidance is that in people with AAAs <5.5 cm with controlled blood pressure, a standard PR programme is likely to be considered safe.1 In some patients with AAAs larger than 5.5 cm for whom surgical intervention is considered inappropriate, PR incorporating mild-to-moderate aerobic exercise can also be considered.1

Severe locomotor or neurological difficulties (e.g. severe arthritis or peripheral vascular disease) that prevent the patient taking part in exercise programmes may contraindicate PR. Anxiety or depression may reduce adherence or completion of PR programmes, but there is no evidence that patients with these conditions gain any less benefit from PR and therefore they should not be excluded.1

Conclusion

The GP decided to trial a home-based PR programme with Neil. Most of the evidence for the benefits of PR is based predominantly on supervised pulmonary rehabilitation programmes. However, the local PR service is not convenient for Neil to travel to and this might limit his adherence.

Home-based PR has been associated with similar benefits in walking distance compared with supervised hospital programmes; however, patient selection, assessment of educational needs and provision of exercise equipment all need to be considered.1 Telehealth approaches and mechanisms for offering remote support and supervision may all provide opportunities to increase the efficacy of home-based PR.

The GP and pulmonary physiotherapist both stressed to Neil the importance of taking measures to improve his health, or at least slow its decline, and that there were still things that could be done to improve his quality of life. Neil agreed to follow the PR programme and to finally quit smoking (with the help of nicotine replacement patches) and was surprised to find three months later that his breathlessness had decreased somewhat and he was better able to manage the walk to the local shop – but now to buy a copy of the newspaper there each morning, instead of his customary pack of cigarettes.

Frequency and duration

Karolina is 37 years old and recently visited her GP as she’s recently begun experiencing a ‘smokers’ cough’ and feels out of breath during her job as a children’s swimming instructor. According to her notes, she suffered from asthma as a child, but she has not attended any reviews or filled any prescriptions for her inhalers for many years. She initially denied smoking, but further questioning revealed that although she does not smoke tobacco, she has smoked marijuana approximately once a week for the past decade.

She was surprised to be diagnosed with COPD (GOLD classification B) and has now come to see the practice respiratory specialist nurse for a discussion about ongoing management. As her breathlessness is limiting her capacity to do her job, the nurse is considering referring her for PR. Not all local services would accept Karolina on a PR service as her symptoms are at the milder end of the spectrum – but luckily, in this case, the nurse knows that her local PR programme is willing to accept people with Karolina’s level of symptoms.

The body of literature supporting the benefits of PR is generally based on two supervised sessions per week, plus a third session of prescribed exercise (either a third supervised session or a formalised but unsupervised session).1 There is insufficient evidence to show whether once-weekly PR is as effective as twice-weekly. In parallel with this, the UK Department for Health’s advice recommends moderate physical activity on 5 days per week, for 30 minutes each time, and COPD patients should be encouraged to aim to achieve this in addition to their structured PR sessions.1

Practical and economic reasons may limit the duration of PR programmes, but a programme of 6–12 weeks’ duration is recommended by the BTS and has been associated with significant benefits in exercise tolerance, dyspnoea and health status.1 There are queries over the efficacy of programmes lasting less than 6 weeks, but these may be considered for some patients.1 If PR for less than 6 weeks is considered suitable for a patient, care should be taken to ensure benefit is adequately measured. For some patients, PR for 4 weeks followed by independent exercise training at a local gym may be feasible.1

There is no high-quality evidence comparing the efficacy of cohort-based PR programmes compared with rolling programmes and both are currently considered acceptable forms of service delivery depending on local considerations.

Approach

The nurse recommended Karolina to begin a community PR programme, having confirmed the service would be suitable for her and that she had no comorbidities that would prevent PR being safe or effective. She provided Karolina with information regarding the format and structure of the service.

BTS recommends progressive resistance training in combination with aerobic exercise to maximise the strength and endurance benefits for patients with COPD.1

Lower limb weakness is common in COPD and therefore training delivered in PR is generally based around lower limb endurance training – commonly walking or cycling.1 The aim is to accumulate 30–60 minutes per session, although for some individuals a single bout of 30 minutes of continuous exercise is not achievable. In these cases, multiple shorter periods of exercise should be used with the aim of reaching 30 minutes of cumulative exercise time in the session. The aim should be to gradually increase the length of the longest bout until 30 minutes of continuous activity is achieved.1

Resistance training involves the major muscle groups, in particular the quadriceps muscles, and two to four sets of 10–15 repetitions should be completed.1 The weights chosen should be individualised taking into consideration the patient’s general health and any comorbidities, and increased once all sets can be completed with the selected weight. A minimum of 48 hours between each session is advised.1

Adjusting the approach

Karolina came back to see the nurse after attending six PR sessions over 3 weeks. She stated she was starting to see a reduction in coughing frequency and she felt less out of breath while at work. However, she was growing frustrated with the programme as she felt she could be doing more to improve her health and that the PR sessions were not challenging enough.

Interval training delivers short periods of high-intensity aerobic training interspersed with rest or low-intensity periods, which allows periods of work to be conducted at a higher intensity compared with continuous training.1

A Cochrane review specifically examining this subject included 11 studies and concluded that interval training was not superior to continuous training for improving physiological outcomes, walking time or symptoms in patients with moderate-to-severe COPD.1 The BTS viewpoint is that interval and continuous training are equally effective methods of delivering exercise training, and that the decision should be made based on patient and therapist preference.1 However, in practice, interval training may require a higher therapist-to-patient ratio to ensure an adequate work rate is achieved during the high-intensity periods and that adequate rest intervals are observed.1

Conclusion

The nurse, with Karolina’s permission, spoke to the physiotherapist running the PR programme. At Karolina’s next PR session, the physiotherapist introduced her to interval training as this allowed Karolina to take part in periods of aerobic activity that were much more challenging than the level she had previously been working at. Karolina was very happy with this new approach as she now felt that she was really achieving something with her sessions, and the physiotherapist also gave her a personalised plan on how she could continue to work independently to improve her fitness after the structured PR programme finishes.

  1. Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax. 2013;68:ii1–ii30.
  2. British Thoracic Society. Quality standards for pulmonary rehabilitation in adults. British Thoracic Society Reports. 2014;6(2).
  3. Global Initiative for Chronic Obstructive Lung Disease, Global strategy for the diagnosis, management, and prevention of Chronic Obstructive Pulmonary Disease: 2017 report. 2017.
  4. British Thoracic Society. Chronic Obstructive Pulmonary Disease (COPD) Discharge Care Bundle, v9. October 2016.
  5. Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009;50(4 Suppl):S2–49.

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