Suzanne C Lareau, RN, MS, FAAN,
Senior Instructor, College of Nursing, University Colorado Denver and Chair, Pulmonary Rehabilitation Assembly of the American Thoracic Society
September 2018
TIPS FOR REFERRAL TO PULMONARY REHABILITATION
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Pulmonary rehabilitation (PR) is an evidence-based, comprehensive intervention for patients with lung disease who have decreased functional status. PR programs are individualized to improve functional status, decrease symptoms of dyspnea and fatigue, improve quality of life, and assist patients in managing their lung condition. PR has been shown to lower health care costs by reversing or stabilizing the systemic effects of chronic lung disease.
PR involves a multidisciplinary group of physicians, nurses, physical therapists, and respiratory therapists. A psychologist, nutritionist, occupational therapist, and others may also be involved.
PR is complementary to the care provided by the patients' clinician, so coordination of care is important. Patients are encouraged to be active partners in the management of their chronic lung disease. Clinicians should be familiar with the PR program to which they are referring their patients to facilitate communication and maximize benefits to the patient.
Table 1. Examples of Lung Conditions for Which Pulmonary Rehabilitation Should be Considered
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Who is a Candidate for Pulmonary Rehabilitation?
While many clinicians think only of severe COPD as a condition that benefits from PR, a patient who is symptomatic from any lung disease should be considered a candidate for PR (Table 1). In some cases, however, the availability of PR will depend on the skills of the team, third-party reimbursement, and the ability of the program to offer rehabilitation for those with severe lung disease and fragile health.
Poor candidates for PR are those in whom exercise is contraindicated, such as patients with unstable cardiac disease (Table 2). Patients with conditions that interfere with learning, such as cognitive disorders and psychiatric illness, are also poor candidates. Patients who smoke can benefit from PR, but insurers may require evidence that the patient is making an attempt at smoking cessation.
Patients referred for PR are expected to have been maximally evaluated and treated for their underlying lung disease by their primary care clinician. Those with COPD, for example, should have a post-bronchodilator spirometry to establish the presence and degree of airway obstruction. This information guides the PR staff in setting exercise goals. The PR program coordinator and medical director also assess candidates to assure that patients can exercise safely and that their underlying condition is stable at the time of entry into the program.
Table 2. Patients with Conditions Such as These are Not Candidates for Pulmonary Rehabilitation
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What happens in a Pulmonary Rehabilitation Program?
PR programs can vary from 4 to 12 weeks in length and include both formal and informal exercise, along with pulmonary education sessions. Supervised exercise typically takes place 3 to 5 times per week, with each session lasting 2 to 3 hours.
Because skeletal muscle dysfunction is prevalent in patients with COPD and other lung diseases, a combination of strength and endurance training is used to reverse deconditioning. Baseline exercise testing with a walk test such as the six-minute walk distance (6MWD) or shuttle walk test (SWT) is used to both evaluate the patient's ability to exercise as well as to serve as baseline for comparison to assess the outcome of PR.
The exercise capacity of patients with lung disease is limited by ventilatory capacity, not by heart rate, so target heart rate is not used as a guide to increase exercise as it is in cardiac patients. Rather, the exercise level is increased incrementally based on the patient's perceived intensity of exertion (Borg rating scale). The goal is to eventually reach 60 to 80% of peak work rate at baseline.
Exercise consists of upper and lower extremity strength and endurance training (Table 3). Resistance exercises build upper and lower extremity strength. Resistance is gradually increased and strength is built over the course of the program. Thirty minutes of continuous endurance exercise is a goal, though patients who are debilitated may require different goals that include shorter duration with frequent rest breaks, or interval training.
Program staff also modify duration and degree of resistance depending on a patient's exercise tolerance, oxygen desaturation, or changes in heart rate or blood pressure.
| Table 3: Upper and Lower Extremity Training Devices | ||
| Training | Upper Extremity | Lower Extremity |
| Strength |
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| Endurance |
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Education The educational program includes: anatomy and physiology of the lung, how to use inhalers, and self-care strategies (Table 4). "Teaching moments" occur often throughout the program, such as reinforcing proper inhaler technique.
Table 4: Example of Educational Topics in a Pulmonary Rehabilitation Program
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References and Resources
- American Association for Cardiovascular and Pulmonary Rehabilitation.
- American Thoracic Society: Information about Pulmonary Rehabilitation.
- Canadian Lung Association: COPD Treatment.
- Spruit MA, Pitta F, McAuley E, ZuWallack RL, Nici L. Pulmonary rehabilitation and physical activity in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2015;192: 924-933.
- Spruit MA, Singh SJ, Garvey C, et al. ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013;188:e13-e64.