Current best practice in pulmonary rehabilitation for chronic obstructive pulmonary disease

Abstract

Definition of pulmonary rehabilitation The American Thoracic Society and the European Respiratory Society have recently adopted the following definition: pulmonary rehabilitation (PR) is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, PR is designed to reduce symptoms, optimize functional status, increase participation, and reduce healthcare costs through stabilizing or reversing systemic manifestations of the disease. Comprehensive PR programs include patient assessment, exercise training, education, and psychosocial support [Nici et al. 2006]. We will first address the pathophysiology and main consequences of chronic obstructive pulmonary disease (COPD), since it is a disease not only characterized by pulmonary inflammation and structural abnormalities leading to airflow obstructions, exercise limitation and symptoms of dispnea and fatigue, but also extended to a variety of systemic alterations. These extrapulmonary effects include systemic inflammation, nutritional abnormalities and weight loss, skeletal muscle dysfunction, and additional organ effects. The high burden of COPD is further contributed to by systemic effects, leading to a pronounced deterioration in health status and a diminished quality of life (QoL). Chronic obstructive pulmonary disease: pathophysiology and consequences Peripheral and respiratory muscles dysfunction The principal symptom limiting exercise in patients with COPD is dyspnea, due to changes in the respiratory mechanics and impaired pulmonary gas exchange (Table 1). Hamilton and colleagues [Hamilton et al. 1996] noted that lower limb fatigue in isolation was greater than the sensation of dyspnea in 43% of patients with COPD who had maximal exercise testing. Although lower limb muscles are largely responsible for limiting activities such as walking and going up inclines or

Pulmonary rehabilitation and COPD: providing patients a good environment for optimizing therapy

“…This assessment is carried out under the direction of the pulmonary physician specialized in rehabilitation. The pulmonary physician leads and coordinates the multidisciplinary team and is responsible for the medical treatment and rehabilitation program and for investigating comorbidities that could contraindicate or interact with PR (as described previously) 6,9,55. The possible assessments include past medical history (including comorbidities), physical examination, cycling cardiopulmonary exercises (incremental workload), the 6-minute walk test, the shuttle walking test, pulmonary function tests, maximal expiratory and inspiratory pressure evaluations, measurement of peripheral muscle forces, disease-specific questionnaires, and nutritional and psychological evaluations.…”

“…The total effective training time should ideally be over 30 minutes 8. Endurance exercise of the leg muscles is the main focus, with walking, stationary cycling, and treadmill exercise being commonly performed 55. In clinical practice, symptom scores can be used to adjust the training load (eg, a Borg score of 4 to 6 for dyspnea) 8,60…”

“…In such cases, an interval training regime may be preferred 55,62. Here, the continuous exercise session is substituted by a succession of shorter high-intensity exercise periods alternated with low-to moderate-intensity exercise recovery periods 62.…”

“…Chest physiotherapy represents a nonessential component of PR but proves its usefulness in patients with a marked bronchial hypersecretion 55. Relaxation exercises, flexibility and stretching exercises, breathing techniques (eg, pursed lip and diaphragmatic breathing) are often coupled with an exercise training session 35,73.…”

Role of Pulmonary Rehabilitation in Copd Patients

“…10 For severely breathless patients, an interval training regime may be preferred. 11 Here, the continuous exercise session is substituted by a succession of shorter high-intensity exercise periods alternated with low-tomoderate-intensity exercise recovery periods.…”