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Pulmonary diseases are an exceedingly important cause of morbidity and mortality in the current age. Chronic Obstructive Pulmonary Disease (COPD) is amongst the most common chronic lung diseases, and is a major cause of morbidity and mortality. In addition there are several other chronic lung disorders which cause a serious handicap in the lives of patients affected by these disorders. It is in this context that the concept of pulmonary rehabilitation assumes importance. Whereas treatment aims to prevent an impairment from becoming a disability, rehabilitations aims to prevent an existing disability from becoming a handicap in the life of a patient.
There are several definitions for Pulmonary Rehabilitation but the most widely used and accepted is that given by the American Thoracic Society/European Respiratory Society recently in the year 2013. ATS/ERS defines Pulmonary rehabilitation as
"Pulmonary rehabilitation 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, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviours."
Pulmonary rehabilitation has had humble beginnings. Alvan Barach in 1952 first utilized an exercise programme to demonstrate an increase in exercise capacity in two patients with emphysema. In 1966, Thomas Petty established one of the earliest out-patient pulmonary rehabilitation programmes at the University of Colorado. The American college of chest physicians formulated a definition for Pulmonary rehabilitation in 1974 and the American thoracic society issued its first official guideline on Pulmonary rehabilitation in 1980.
Pulmonary rehabilitation is an important intervention in the management of chronic obstructive pulmonary disease (COPD) and other chronic respiratory diseases. The major objectives of rehabilitation are the following
- A reduction in symptoms
- An improved functioning in daily living
- An improved quality of life
- Prevention of recurrent exacerbations
In addition to lung dysfunction, cardiac dysfunction and skeletal muscle dysfunction contribute to exercise intolerance in patients with chronic lung diseases. Pulmonary rehabilitation improves the functioning of the other systems of the body so that the effect of lung dysfunction on exercise intolerance is minimised. Therefore, Improvements in skeletal muscle function after exercise training lead to gains in exercise capacity despite the absence of changes in lung function.
Pulmonary rehabilitation benefits patients regardless of age, sex, lung function, or smoking status. Pulmonary rehabilitation should be considered for all patients with chronic respiratory disease who are symptomatic inspite of an optimal medical management.
BENEFITS OF PULMONARY REHABILITATION:
Pulmonary Rehabilitation is advantageous in the management of chronic lung conditions in general and Chronic Obstructive Pulmonary Disease (COPD) in particular. Pulmonary rehabilitation improves the exercise tolerance, reduces the sensation of dyspnoea, and improves the health-related quality of life (HRQOL). Pulmonary rehabilitation also leads to improvement in the ability to perform activities of daily living (ADL) and reduction in the rates of exacerbations. The benefits of Pulmonary rehabilitation are presented in table no 1.
CONDITIONS IN WHICH PULMONARY REHABILITATION IS USEFUL:
Pulmonary Rehabilitation is useful in symptomatic patients with several chronic respiratory diseases. However the most important conditions for which it is frequently utilized include the following.
- Cystic Fibrosis
- Bronchial Asthma
- Pulmonary Hypertension
- Interstitial Lung Diseases
- Neuromuscular Disorders
- Prior to Lung transplantation and Lung volume reduction surgery
COMPONENTS OF PULMONARY REHABILITATION:
As is evident from the definition, Pulmonary Rehabilitation is a multidisciplinary intervention indicated in symptomatic patients suffering from chronic lung conditions. It requires a team approach with the coordinated involvement of not only a Physician but also a respiratory therapist, a physiotherapist, a social worker and adequate support from the family members of the patient. Pulmonary Rehabilitation thus requires a multipronged strategy to ensure maximisation of benefits to the patient.
Pulmonary Rehabilitation consists of the following major components.
1. Physical Rehabilitation
2. Management of body composition abnormalities and malnutrition
3. Self Management Education
4. Psychosocial and Behavioural interventions
1. Physical Rehabilitation:
Patients with chronic lung diseases are characterized by significant muscle wasting which contributes to poor exercise tolerance in these patients. Therefore a programme of exercise training is an essential component of Pulmonary rehabilitation. It is important to understand that exercise training does not alter the underlying respiratory impairment but produces an improvement in muscle dysfunction which is an important contributor to exercise intolerance.
Exercise training is mainly of two types.
a. Endurance training: Endurance training is the most commonly applied exercise training modality in pulmonary rehabilitation. The simplest form of endurance training includes activities such as cycling, walking etc.
b. Strength training: Strength training is also beneficial in patients with chronic lung diseases. This type of training is more useful in improving muscle mass and strength.
A commonly used exercise regimen consists of 20 exercise sessions at least thrice a week. Both upper limb and lower limb exercises should be encouraged. High intensity exercise produces greater benefits. Optimizing medical treatment before exercise training with bronchodilator therapy, long-term oxygen therapy, and the treatment of co- morbidities may maximize the effectiveness of the exercise training intervention.
2. Management of body composition abnormalities and malnutriition
Patients with chronic lung diseases are generally underweight. Nutritional interventions in addition to strength training play an important role in the correction of these abnormalities. Patients with a low BMI or a significant weight loss should be considered for caloric supplementation. Adequate protein intake (approximately 1- 1.5 gm/kg body weight) should be ensured. The role of anabolic steroids and growth hormone remains debatable.
3. Self Management Education:
Education is an essential component of pulmonary rehabilitation. The major objective of educating the patient is the prevention and early treatment of respiratory exacerbations. The other components of self management education include breathing strategies, bronchial hygiene techniques and end of life decision making. Educating the patient lowers health service and reduces the burden on an already overstretched health care system. The successful implementation of educational training to the home setting should be emphasized.
4. Psychosocial and Behavioural Interventions:
Chronic respiratory disease is associated with an increased risk for anxiety, depression, and other mental health disorders. This is most often related to the extreme anxiety and fear provoked by episodes of dyspnea. Screening for anxiety and depression must be a part of the initial assessment in any Pulmonary rehabilitation programme. When a patient is depressed, the involvement of a mental health specialist should be considered. Selective serotonin re-uptake inhibitors (SSRIs) are the first-line treatment in patients with co-morbid depressive or anxiety disorders.
Pulmonary rehabilitation should be considered for all patients with chronic respiratory disease who have persistent symptoms inspite of adequate medical management. Traditionally patients with dyspnea mMRC grade 2-4 have been considered as ideal candidates for Pulmonary rehabilitation. However there has been a recent trend towards extending the benefits to patients with mMRC grade 1 dyspnea with an intention to address chronic lung disease earlier.
The patients benefit the most from Pulmonary Rehabilitation Programmes are the ones who are motivated to take part in the programme and who have a strong support from family and relatives.
Conditions such as significant orthopaedic or neurologic problems, severe pulmonary artery hypertension and poorly controlled co morbid illnesses may preclude the participation of a patient in these programmes..
Initial assessment provides an opportunity to assess the exercise capacity of a patient prior to commencing the programme A baseline 6 minute walk test is usually performed. Pulmonary function tests including spirometry and diffusion capacity for carbon monoxide should also be performed. Subjective dyspnea assessment tools such as the Borg scale are also useful tools in the initial assessment of these patients.
It is prudent to screen patients for anxiety and depression prior to including them in the programme.
THE PULMONARY REHABILITATION TEAM:
Pulmonary rehabilitation involves a team approach. The composition of the team varies according to patient population, economic constraints, as well as the availability of qualified and well trained personnel. The rehabilitation team usually includes a physician specialised in cardio-respiratory care, a physical therapist, an occupational therapist, a respiratory therapist, a social worker and a mental health specialist.
THE PROCESS OF PULMONARY REHABILITATION:
Pulmonary rehabilitation begins with appopriate patient selection. Subsequently an initial patient assessment is performed which is followed by the formal pulmonary rehabilitation program. Maintenance programmes are then pursued to maintain the benefits of rehabilitation. It is summarized in Figure no. 1DURATION OF THE PROGRAMME:
Pulmonary rehabilitation programmes are conventionally 8 to 12 weeks in duration. However there does not seem to be a universal consensus regarding the duration of these programmes. Short-term benefits have been seen from even brief 2-week inpatient programs. Certain studies suggest that the benefits ofpulmonary rehabilitation decline toward baseline after 6 to 12 months, but still remain improved compared with control subjects after 1 year.
It is important to maintain benefits obtained from Pulmonary rehabilitation programmes over time and see them translated into reduced health care resource utilization, especially through hospital admission prevention, reduced length of hospital stay, and improved self-management.
Low cost maintenance programs are a feature of many established rehabilitation programs. Patient self management education goes a long way in prolonging the benefits of a Pulmonary rehabilitation programme.
The major risks of pulmonary rehabilitation programs are related to the exercise component of such programs. Musculoskeletal injury is a risk, since patients with COPD tend to be elderly and are often debilitated. This risk is reduced when rehabilitation is supervised by trained personnel.
Exercise induced bronchospasm occurs in some patients with COPD and judicious use of bronchodilators before or during exercise may be appropriate. The greatest risk is that of a cardiovascular event. Patients with COPD have a substantially increased risk of cardiovascular death as compared with healthy age - matched controls. Before a patient starts an exercise program, evaluation for ischemic heart disease by means of a stress test is advisable.
Pulmonary rehabilitation is an indispensible aspect in the management of patients with chronic lung diseases. It is a dynamic area which is witnessing lot of new developments with passing time. The most important aim of health care delivery systems should be to provide quality Pulmonary rehabilitation programmes at affordable prices as a huge proportion of patients with chronic lung diseases come from economically disadvantaged sections of the society, especially in a country like India. Concerted efforts are needed in the area of training personnel who are an important part of the implementation of these programmes. This is an area which may benefit from a public-private partnership.
TABLES AND FIGURES:
TABLE No. 1 BENEFITS OF PULMONARY REHABILITATION:
FIGURE No. 1 THE PROCESS OF PULMONARY REHABILITATION:
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