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Pulmonary rehabilitation in clinical exercise programming

This is an excerpt from Clinical Exercise Physiology 5th Edition With HKPropel Access by Jonathan K Ehrman,Paul M. Gordon,Paul S. Visich & Steven J. Keteyian.

Pulmonary rehabilitation (PR) is a comprehensive multidisciplinary program considered a core part of the overall management plan for patients with chronic lung disease who are functionally limited. Among patients with lung disease, reductions in physical function are often related to limitations in breathing reserve from either obstructive or restrictive processes; patients can lose skeletal muscle mass, causing reductions in strength, power, and endurance. This can lead to a spiraling effect of increasing sedentary living, which can further accelerate the decline in physical function (27). Similar to many individuals with other chronic diseases, patients referred to PR have higher rates of depression and anxiety and a poorer quality of life than the general population. And similar to patients in CR programs, PR patients tend to have a high level of social isolation. These issues increase the risk for hospitalization and death (9).

Program Effectiveness
Although mortality benefits have not been observed, PR programs offer a number of functional and psychological benefits. These include a reduction in the discomfort of dyspnea at a given workload and throughout daily life, improvements in functional capacity, reductions in self-reported depression and anxiety, and reductions in health care utilization and costs (4). Upon entering a PR program, patients tend to be more physically debilitated when compared to patients entering CR. Evidence about the benefits of PR are not as strong for benefits in patients with interstitial lung disease, but improvements in this patient group have been observed (7).

Program Structure and Processes
PR programs are usually in the outpatient setting and often share space with CR programs, either concurrently or during nonconflicting hours or days of the week. Programs typically run 3 d/wk, and daily sessions tend to be longer than in CR. A patient can spend 1.5 to 4 h at each PR session. The longer duration is related to additional lung-specific exercise training and self-care taught to patients in a PR program (figure 7.4).

On the first day of PR, patients may be assessed for medical history, fitness (6 min walk test or gas exchange exercise test), and goal setting. Daily, each patient performs exercise training, attends an education session, and receives psychosocial support. Exercise training can include aerobic activity (moderate continuous to higher-intensity interval); muscular strength and endurance exercises, with a focus on the respiratory muscles; and balance and flexibility exercises. A common goal is for pulse oximetry (SpO₂) values to remain greater than 88% during exercise. If oxygen saturation drops below 88%, supplemental oxygen can be administered or the delivery of oxygen increased (20). The education sessions cover a wide range of topics (e.g., nutrition, breathing techniques, energy conservation, medication review, home and ambulatory O₂ use) over the course of up to 36 visits.

Program Policies
To be eligible, patients must have moderate to very severe chronic obstructive pulmonary disease (COPD). This is defined as global obstructive lung disease (GOLD) classification II to IV (see chapter 19 for information about the GOLD classification) (10). Patients must be referred by their treating physicians. Programs are most often staffed by respiratory therapists but may also include clinical exercise physiologists, nurses, and physical therapists. Similar to CR programs, PR programs can become AACVPR certified to demonstrate a minimal level of program competency.

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