|Year : 2022 | Volume
| Issue : 1 | Page : 5-12
Pulmonary rehabilitation in chronic respiratory diseases
Senior Consultant and Chief, Department of Pulmonary Medicine, Baby Memorial Hospital, Calicut, Kerala, India
|Date of Submission||15-May-2021|
|Date of Decision||31-May-2021|
|Date of Acceptance||04-Jun-2021|
|Date of Web Publication||17-Jan-2022|
Dr. Ravindran Chetambath
Baby Memorial Hospital, Calicut, Kerala
Source of Support: None, Conflict of Interest: None
Pulmonary rehabilitation (PR) is a well-established treatment modality in patients with chronic obstructive pulmonary disease. This is intended to improve exercise tolerance and activity-related dyspnea. PR also improves health-related quality of life. There is increasing evidence for similar effects of PR in people with other chronic respiratory diseases such as interstitial lung diseases and bronchiectasis. This review discusses the evidence for PR in chronic respiratory diseases, outlines the essential components of PR in this population, and highlights special considerations for exercise training in people with different diseases. Possible future directions for PR research are explored.
Keywords: Exercise limitation, exercise training, pulmonary rehabilitation
|How to cite this article:|
Chetambath R. Pulmonary rehabilitation in chronic respiratory diseases. J Adv Lung Health 2022;2:5-12
| Introduction|| |
Chronic obstructive pulmonary disease (COPD), interstitial lung diseases (ILDs), and bronchiectasis are incapacitating groups of chronic respiratory diseases having symptoms such as dyspnea, cough, fatigue, anxiety, and depression. Individuals with these diseases have reduced health-related quality of life (HRQL) that tends to worsen with disease progression. Pulmonary rehabilitation (PR) could be an effective intervention to improve symptoms, HRQL, and functional status in people suffering from these diseases. While there is strong evidence for the benefit of PR in COPD, the evidence for PR in other two diseases is also encouraging. In this review article, current best practices of PR in chronic respiratory diseases are described.
| Rationale for Pulmonary Rehabilitation|| |
PR plays an essential role in the management of symptomatic patients with chronic respiratory diseases. Advantages of PR are well established in COPD. PR has been shown to be the most effective nonpharmacological intervention for improving health status in COPD patients and has become a standard of care for those patients. These benefits can be extrapolated to other two chronic conditions such as ILD and bronchiectasis. PR helps by breaking the vicious circle of dyspnea, decreased activity, deconditioning, and isolation [Figure 1]. Indeed, the main benefits of comprehensive PR programs include a decrease in symptoms (dyspnea and fatigue), improvements in exercise tolerance and HRQL, reduction of health-care utilization (particularly bed-days), as well as an increase in physical activity.
|Figure 1: Beneficial effects of pulmonary rehabilitation in chronic respiratory diseases|
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| Exercise Limitation|| |
Reduced exercise capacity is a cardinal feature of chronic respiratory diseases, especially emphysema and ILDs. Exercise limitation may be a more robust predictor of prognosis than resting lung function. The 6-mi walk distance (6MWD) has been shown to be an independent predictor of mortality in patients with idiopathic pulmonary fibrosis (IPF). A decline in 6MWD over 50 m between baseline and 24 weeks was associated with an almost threefold increase in mortality in ILD. Oxyhemoglobin desaturation during exercise also has prognostic significance. Patients with ILD who desaturated to ≥88% during a 6-min walk test (6MWT) had a median survival of 3.21 years, compared with 6.83 years in those who did not desaturate.
| Impairments in Gas Exchange|| |
Gas exchange limitation occurs due to pulmonary capillary destruction or alveolar membrane thickening, resulting in either ventilation–perfusion inequality or impaired diffusion capacity. Consequently, exercise-induced oxygen desaturation develops, and hypoxemia may be present even at rest. Evaluation of cardiopulmonary exercise test (CPET) parameters, particularly ventilatory equivalent for carbon dioxide (CO2) at anaerobic threshold can indicate the severity of circulatory impairment and predict the prognosis of IPF.
| Impairments in Pulmonary Circulation|| |
Circulatory limitation may occur secondary to pulmonary capillary destruction, hypoxic pulmonary vasoconstriction, or cardiac dysfunction. Pulmonary hypertension is also a common comorbidity in COPD and ILD.
| Limitation of Ventilatory Function|| |
COPD is a disease with abnormal ventilatory mechanics leading to hypoventilation. There are multiple factors causing this, such as poor lung and chest wall compliance, air trapping, muscle fatigue, and CO2 retention. People with ILD may exhibit an abnormal respiratory pattern with decreased tidal volume and a rapid respiratory rate, particularly during exercise.
| Muscle Dysfunction|| |
Pathogenesis of chronic respiratory diseases involves a significant inflammatory cascade. Inflammation may potentiate peripheral muscle dysfunction. Systemic inflammation leads to cachexia which is profound in emphysema. In COPD, nutritional status and age have a close relationship with muscle mass. In addition, these patients may receive treatments such as glucocorticoids and immunosuppressive therapy, which are known to cause drug-induced myopathy.
| Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease|| |
Rehabilitation serves as an important component of the management of COPD and is beneficial in improving HRQL and exercise capacity. Practice of PR in COPD should bring demonstrable improvements in HRQL and functional and maximal exercise capacity. A meta-analysis comprising 65 randomized-controlled trials (RCTs) involving 3822 participants demonstrated statistically significant improvement for all included outcomes. In four important domains of quality of life (QoL) such as dyspnea, fatigue, emotional function, and mastery, the effect was larger than the minimal clinically important difference of 0.5 units. The PR program in all studies ranged from 8 to 12 weeks which comprises hospital-based or community-based programs. PR relieves dyspnea and fatigue, improves emotional function, and enhances the sense of control that individuals have over their condition. These improvements are moderately large and clinically significant. Future research studies should focus on identifying which components of PR are essential, duration and location of the program, and how long the beneficial effects will persist.
| Pulmonary Rehabilitation in Interstitial Lung Disease|| |
There is accumulating evidence to support short-term benefits of PR in ILD. A meta-analysis of nine RCTs which included participants with several types of ILD over a period from 5 to 12 weeks demonstrated meaningful improvements in exercise capacity following PR, with a weighted mean difference (WMD) for change in 6MWD of 44.34 m and 1.24 ml/kg/min in peak oxygen consumption (VO2). These improvements were confirmed in the subgroup with IPF (WMD 35.63 m and 1.46 ml/kg/min, respectively). Dyspnea was reduced and HRQL improved, with a similar magnitude of benefit seen in the subgroup with IPF compared with other participants. No adverse effects of PR were reported. Most studies were short term, and hence, no conclusion on survival could be drawn.
| Pulmonary Rehabilitation in Bronchiectasis|| |
Patients with bronchiectasis suffer from substantially impaired QoL, likely due to chronic respiratory symptoms (dyspnea, cough, sputum production, and wheeze), respiratory exacerbations, fatigue, exercise limitation, psychological symptoms, and constitutional manifestations of chronic infection and inflammation. PR, with patient-centered exercise training and self-management education delivered by an interdisciplinary team, has shown beneficial effects in bronchiectasis. PR works through mitigating secondary impairments such as peripheral muscle dysfunction, psychosocial dysfunction, and maladaptive behaviors. These contribute to the overall disease burden and are frequently treatable. A recent systematic review including randomized or crossover trials of PR or exercise training alone demonstrated significant, short-term improvements in exercise capacity and HRQL, but these effects were not maintained at 6 months. An observational study involving 236 patients over a period of 5 years supports the belief that patients with bronchiectasis stand to improve after completing PR, with positive outcomes comparable to those found for COPD.
| Components of Care|| |
The American Thoracic Society and European Respiratory Society (ATS/ERS) definition of PR describes a comprehensive intervention of patient-tailored therapies, which may include exercise training, education, and behavior change. Consistent with this definition, exercise training is an essential component of PR, including resistance and endurance training [Figure 2]. Nonexercise components may include education, psychological support, and nutritional therapy, along with training in behaviors that will assist in optimal disease management. This could include early recognition and treatment of acute exacerbations.
| Exercise Training|| |
Exercise training is a critical component of PR. Principles of exercise training in chronic respiratory diseases are similar to those in healthy individuals, including individualized exercise prescription and progression of training load. Endurance training is an essential component of exercise training, and most studies have also included resistance training., People with ILD may need more careful planning and modification of their exercise prescription than healthy individuals or those with COPD due to the severity of dyspnea on exertion, profound exercise-induced oxyhemoglobin saturation, and rapid disease progression in some patients.
| Endurance Training|| |
Endurance training helps to increase exercise endurance and improve physical activity with less breathlessness and fatigue. Initial endurance training intensity is usually set at a lower level of maximum exercise capacity (up to 70%–80%). This is decided based on a walking speed on baseline 6MWT for walking exercise or peak work rate on CPET for cycling. Participants should be encouraged to rate their breathlessness and fatigue regularly during exercise. A minimum frequency of two supervised sessions per week is suggested. The target duration of endurance exercise in each session should be 30 min. This may be broken into shorter intervals of 15 min initially depending upon the clinical condition and severity. Most participants achieve this duration of exercise within 1–2 weeks of training, with appropriate support. Once the targeted time of 30 min is achieved, graded increments in the intensity of exercise may be planned. Participants should also be encouraged to engage in a home exercise program, with the aim of completing 3–5 sessions of endurance exercise each week.
| Resistance Training|| |
Resistance training improves local muscle strength and endurance. Resistance can be generated against gravity, body weight, or through the use of fixed or free weights. American College of Sports Medicine (ACSM) recommends training 2–3 days per week, with 10–15 repetitions. This should be modified for older persons. Progression of resistance training may involve increasing the weight, number of repetitions per week, and decreasing the rest period between sets. The best practice for limb training is stair climbing or sit-to-stand. These can be easily reproduced in the home setting.
| Flexibility Training and Stretching|| |
Flexibility training aims to increase the range of motion of joints and muscles. The ACSM recommends flexibility exercise on at least 2–3 days per week, with 30–60-s stretches repeated two to four times.
| Special Considerations for Exercise Training|| |
Oxygen therapy is recommended during exercise training for patients who exhibit significant desaturation. This is especially important in ILD patients or who resume PR after an exacerbation episode. The ATS/ERS statement for PR recommends supplemental oxygen during exercise training for ILD12. Supplemental oxygen should be routinely administered to patients during exercise training in PR to ensure safety in the presence of profound desaturation. However, there is no evidence to indicate that this practice results in better PR outcomes, such as greater improvements in exercise capacity or HRQL. Retrospective studies evaluating the administration of oxygen during acute bouts of exercise in ILD have reported improvements in walking distance with oxygen therapy, suggesting there may be beneficial effects on exercise performance., Currently, usual practice would be to deliver oxygen therapy for any patient who desaturates to <85% during training, with the aim of maintaining SpO2 at >88%.
Interval training consists of periods of relative high-intensity exercise interspersed with periods of low-intensity exercise with or without rest. The aim of interval training is to allow patients to achieve the required training dose through repeated bouts rather than continuous exercise, which may reduce dyspnea and fatigue. The ATS/ERS statement for PR suggests that interval training can be performed with fewer symptoms than continuous training. A systematic review of interval training in COPD did not find any significant difference in exercise capacity and HRQL between interval training and continuous training. These studies evaluated a variety of interval training regimens, including two studies with 1-min intervals of higher intensity alternating with 2 min of low intensity; three trials with 30-s intervals; one study with high and low intervals of 20 and 40 s; and one study with 2-min intervals of high intensity and 1 min of low intensity.,
Musculoskeletal disorders are prevalent in people with ILD and may affect PR participation. For example, patients with connective tissue diseases might experience joint pain and stiffness, limiting their ability to undertake PR. Many COPD patients may suffer from proximal muscle weakness or muscle wasting. It is important that the exercise component of PR may be modified appropriately for people with musculoskeletal disorders or muscle dysfunction to avoid pain or exacerbation of chronic conditions. It is advisable to avoid weight-bearing exercises or resistance training in such patients.
Rehabilitation after exacerbation
PR has been recommended after an acute exacerbation of COPD. Delivery of PR after an episode of acute exacerbation of ILD has not been described. Recently, a large study demonstrated negative effects of exercise rehabilitation after an exacerbation of chronic respiratory disease. This study included COPD, bronchiectasis, and ILD patients (total n = 389). Patients performed 6 weeks of exercise training immediately after an exacerbation, starting in hospital and carrying over to the home setting. There were no beneficial effects on physical function or hospital readmission, and the rehabilitation group had higher mortality at 12-month follow-up. It is evident that early mobilization following an exacerbation may contribute to early hospital discharge and recovery of the ability to perform activities of daily living. At the same time, a cautious approach might be required for the commencement of PR in the early stages following an exacerbation. It is possible that the risks associated with exercise rehabilitation following an acute exacerbation could be higher in ILD patients due to greater desaturation on exercise, greater hypoxemia at rest, and associated comorbidities.
Nonexercise training components of PR include education, nutritional support, and psychological support, in addition to exercise training.
Health education may help the patients to understand their condition and participate in active self-management. It has been suggested that personalized education of their condition during PR should include oxygen therapy, exacerbation supervision, energy conservation, symptom control, mood disorders, medications, surgical interventions, and end-of-life care. Holland et al., investigated the perspectives of patients and clinicians related to the ideal content of an educational component of PR for ILD. In this qualitative study, participants expressed the need for ILD-specific information and opportunity to discuss this in a group. Patients also expressed their needs for health professionals to be honest and help them prepare for future, especially regarding prognosis. Key topics for disease education in PR include disease education, symptom management, clinical tests, autonomy, oxygen use, medications, and end-of-life counseling.
Nutritional depletion and nutritional support are important issues in the management of chronic respiratory diseases. Even though cachexia and muscle wasting are due to different mechanisms in COPD, ILD, and bronchiectasis, nutritional support helps a long way when PR outcomes are evaluated. A multimodal nutritional rehabilitation program in 122 patients with chronic respiratory failure encompassing education, oral nutritional supplements, exercise, and oral testosterone found improved exercise tolerance in all participants and HRQL in females.
Depression and anxiety are always associated with chronic respiratory diseases. In one study in ILD (n = 124), the prevalence of anxiety and depression was 31% and 23%, respectively. High levels of dyspnea were an independent predictor of anxiety, and more dyspnea and comorbidities were independent predictors of depression. Although the impact of PR on mood has not been studied in RCTs, uncontrolled data suggest PR might be beneficial. Ryerson et al., reported that 6–9 weeks of PR improved depression in 52% of participants. This was maintained at the 6-month follow-up. The mechanism by which PR improves mood is not clear but may be related to improved symptoms and sense of control over the disease.
Most of the patients with chronic respiratory diseases have a high symptom burden including dyspnea, cough, and fatigue. PR may contribute to symptom control in these patients. Clinicians may have a key role to play in addressing symptom control and psychosocial support. The British PR guideline strongly recommends PR for all patients with Medical Research Council Dyspnea score of 3–5 and functional limitation. A Cochrane review of RCTs of PR confirmed reduced dyspnea after a PR program in a subgroup of patients with IPF. A statistically significant effect for reduced dyspnea was also seen in patients who desaturated on exertion.
Cough is the most distressing symptom among these patients. The efficacy of PR in reducing cough is unclear. Qualitative studies have shown that discussion of strategies to manage cough is a priority for patients undertaking PR; however, the ideal components of such an intervention are not known.
PR may be important in ameliorating fatigue in patients with chronic respiratory diseases including ILD. Exercise training improves subjective fatigue in people with ILD and sarcoidosis. A recent study affirmed improvement in objective muscle fatigability using intense aerobic-exercise training.
Length of training
The ideal duration of PR for people with chronic respiratory diseases is unclear. The British guidelines for PR recommend programs of 6–12-week duration, but no recommendations specific to ILD are made. A longer PR program may assist with the maintenance of benefits. Vainshelboim et al. randomized participants to 12 weeks of exercise training or usual care, with 11-month follow-up. Although differences between groups in 6MWD were no longer evident at 11 months following the training, significant differences were maintained for 30-s chair stand and St. George's Respiratory Questionnaire (SGRQ), suggesting sustained improvement in leg strength and HRQL following PR. At 30 months, the survival analysis showed no significant differences between the exercise training group and control group.
The RCTs of outpatient PR in ILD have had program durations ranging from 5 to 12 weeks. In general, these trials were all associated with advantageous outcomes, suggesting that a standard length of PR program might be effective for participants with ILD. Further study is required to investigate whether longer training periods can increase the duration of benefit for PR in ILD.
Evaluation of outcomes is also an essential component of PR to confirm its effects. All components of PR must work smoothly together to achieve optimal outcomes for people with chronic respiratory diseases [Figure 3].
| Outcome Assessment|| |
Assessment of exercise capacity
Assessment of exercise capacity is essential in PR to establish exercise tolerance, evaluate exercise-induced desaturation, prescribe appropriate exercise intensity for endurance training, and document outcomes of PR.
The 6-min walk test
The 6MWT is the most commonly used test of exercise capacity in PR. A systematic review of field walking tests reports the 6MWD is a valid and reliable measure of exercise capacity. The reproducibility of the 6MWD has been confirmed. No serious adverse events have been reported during the 6MWT, although significant desaturation is often observed.
Shuttle walking test
The shuttle walking test (SWT) is an incremental test of exercise capacity, with walking speeds increasing each minute in time to an external cue. De Boer et al. compared a modified SWT (allowing patients to run) with CPET in patients with sarcoidosis. Peak VO2 on CPET had a strong correlation with SWT distance (r = 0.87; P < 0.0001). The SWT could be a useful measure of peak exercise capacity, although it has not yet been widely used.
Cardiopulmonary exercise test
The CPET provides detailed information about exercise responses and exercise capacity. This test is complex and may not be available in all settings; however, it has clear advantages for accurate prescription of exercise in PR, as a percentage of measured peak exercise capacity. However, the 6MWT elicits greater desaturation than the CPET, which may be useful when planning an exercise prescription for walking.
Other measures of exercise capacity
Other tests of exercise capacity may have greater sensitivity to change following PR. A comparison of five exercise measurements (endurance time, peak work rate, peak oxygen consumption, 6MWD, and SWT) at the beginning and end of PR found that cycle endurance time was the most responsive.
Health-related quality of life, dyspnea, and mood
Measurement of HRQL is an essential component of PR. A variety of tools are available for this purpose. Many PR programs use HRQL measures originally designed for patients with COPD (e.g., the chronic respiratory disease questionnaire and the SGRQ. Data from clinical trials of PR suggest these measures are responsive to change following PR. More recently, ILD-specific measures have become available, including the IPF-specific version of SGRQ and the King's Brief ILD Questionnaire. These have not been widely used in PR to date but are worthy of further study.
Dyspnea is an important symptom, which is expected to improve following PR. The Borg Scale is often used to assess exertional breathlessness during exercise testing. The impact of dyspnea on daily function is often evaluated using the modified Medical Research Council Scale, which grades breathlessness associated with daily activities into five levels from a scale of 0–4.
Mood disturbance is common and may improve following PR. Outcome tools used to measure mood in PR studies include the Hospital Anxiety and Depression Scale, the Center for Epidemiologic Studies-Depression Score, the Geriatric Depression Scale, and the General Anxiety Disorder-7 Scale.
Despite the proven benefits of PR, there are important issues still to be addressed which include the ideal format and content for PR; methods to extend duration of benefit; and how PR can best be tailored to the complex needs of people with chronic respiratory diseases. For example, the best methods to provide comprehensive PR for people with progressive or end-stage disease have not been determined. More information is needed to define the nonexercise components of PR that contribute to optimal outcomes such as psychosocial support, education, behavioral intervention, and group therapy. Although the clinical effectiveness of PR in ILD is increasingly understood, clarification of cost-effectiveness of PR would provide impetus for policymakers to ensure this intervention is widely practiced.
PR should also focus on nonexercise components such as health education, smoking cessation, and regular counseling. Nonconventional programs such as YOGA are also practiced in some centers with substantial benefits. These programs can be easily done at domicillary settings and can be adopted by resource-limited subjects. Due to the COVID-19 pandemic, many patients develop chronic respiratory disability due to prolonged inflammation and fibrosis. These cohorts may need short-term or long-term rehabilitation programs to improve their health quality.
| Conclusion|| |
PR is an important component of comprehensive care for patients with chronic respiratory diseases, delivering clinically important improvements in exercise capacity, symptoms, and HRQL. Current studies do not suggest that PR impacts on prognosis. Exercise training is an essential component of PR and should include endurance and resistance training. Nonexercise components may include education, psychological support, symptom management, and nutritional support. Given the positive impact of PR on patient-centered outcomes, efforts should be made to ensure that PR is made widely available across all categories of chronic respiratory diseases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]