Pulmonary rehabilitation (PR) is recommended for all persons living with chronic lung disease including, chronic obstructive pulmonary disease (COPD), and should be the cornerstone in the treatment plan1. PR must consist of an initial comprehensive assessment of patient’s exercise capacity, dyspnea and nutrition to individualize the program to fit patient goals. Subsequently, an exercise program should be individually prescribed, progressed and delivered by trained health care professionals2. Furthermore, delivery of a structured education program and measurement of core outcomes is recommended3.
The evidence that favours pulmonary rehabilitation is enormous
Participation in PR relieves dyspnea, reduces fatigue, improves exercise capacity enhances health-related quality of life, increases participants control over their disease and reduces hospital admissions4,5. The body of evidence is so extensive and clinically relevant that the Cochrane review4, who is gathering all information on pulmonary rehabilitation for COPD, stated that:
“It is our opinion that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted”
What are the challenges?
However, as with all behaviour change interventions, the challenges lie in the implementation processes and scaling up of evidence-based intervention programmes that extends beyond 1-year of participation.
Professor Singh highlighted key features that will help to increase the probability of a successful pulmonary rehab program. Important features include education and motivation of staff, service guided by evidence and robust data collection of key performance indicators that can help improve quality of care. Also, PR needs to be delivered promptly. Patients often wait a long time before included in a PR program, while pharmacological treatments are immediately available, which is not optimal.
Excellent evidence – poor access
Despite the substantial evidence in favour of PR many COPD patients do not have access to PR in their care6. One limiting factor is the referral physicians’ lack of understanding of the value of PR.
“You can have the best PR program in the world, but if you do not get patients referred, the program is useless” – Professor Sally Singh
Many doctors are uncertain about the effect of PR and recent evidence show that adding a pulmonary specialist in primary care could be a way to increase adherence to treatment guidelines in primary care8.
Pulmonary rehabilitation does not have to be complicated
Effective programs do not have to be complex with large investments in training equipment. For example, Patel and colleagues found that there were similar changes in exercise capacity or quality of life when comparing an exercise program performed in a well-equipped gym with an exercise program performed with minimal equipment9. But when designing PR program, it is essential to understand the patients’ preferences to optimize adherence.
National audit program – essential for up-scaling
On a national level, Professor Singh stressed that it is highly important to collect data on key performance indicators to assess the quality and the access of PR in the care of asthma and COPD. The national Asthma and Chronic Obstructive Pulmonary Disease Audit Programme is a report that combines data on asthma, COPD and pulmonary rehabilitation from primary and secondary care to inform about the quality and availability of different core measures within respiratory care in the UK6. The report shows that only 40 % of adults with stable COPD started a PR-program within 90 days of receiving the referral or receipt. For adults admitted to hospital with a COPD exacerbation, only 20 % started a PR within 30 days after receiving referral or receipt6.
In summary, PR is an effective intervention with clear evidence and guidance for delivery. It does not have to be difficult or complex to achieve effect, but we need to consider referrers AND patients preferences when we develop interventions. Furthermore, routinely collection and analysis of data is essential to support delivery of high-quality care and to inform stakeholders PR is essential to prioritize in respiratory care.
Emil Bojsen-Møller Medical Advisor, Chiesi Nordic
References:
Global Initiative for Chronic Obstructive Lung Disease (GOLD) – Global Strategy for Prevention, Diagnosis and Management of COPD [Internet]. 2023. Available from: https://goldcopd.org/2023-gold-report-2/
Holland AE, Cox NS, Houchen-Wolloff L, Rochester CL, Garvey C, ZuWallack R, et al. Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2021 May;18(5):e12–29.
Souto-Miranda S, Saraiva I, Spruit MA, Marques A. Core outcome set for pulmonary rehabilitation of patients with COPD: results of a modified Delphi survey. Thorax. 2023 Dec 1;78(12):1240–7.
McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 24;2015(2):CD003793.
Puhan MA, Gimeno‐Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016 Dec 8;2016(12):CD005305.
Wadell K, Janaudis Ferreira T, Arne M, Lisspers K, Ställberg B, Emtner M. Hospital-based pulmonary rehabilitation in patients with COPD in Sweden–A national survey. Respiratory Medicine. 2013 Aug;107(8):1195–200.
Patel K, Pye A, Edgar RG, Beadle H, Ellis PR, Sitch A, et al. Cluster randomised controlled trial of specialist-led integrated COPD care (INTEGR COPD). Thorax. 2024 Mar;79(3):209–18.
Patel S, Palmer MD, Nolan CM, Barker RE, Walsh JA, Wynne SC, et al. Supervised pulmonary rehabilitation using minimal or specialist exercise equipment in COPD: a propensity-matched analysis. Thorax. 2021 Mar;76(3):264–71.
ID 10099-17.09.2024
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