Pulmonary rehabilitation is the use of supervised exercise, education, support, and behavioral intervention to improve how people with chronic lung disease function in daily life and to enhance their quality of life.
Pulmonary rehabilitation is a program designed for people who have chronic lung disease. Its primary goal is to enable people to achieve and maintain their maximum level of independence and functioning. Although most pulmonary rehabilitation programs focus on people who have chronic obstructive pulmonary disease (COPD), pulmonary rehabilitation may also benefit people with other types of lung disease, including
Bronchiectasis (irreversible widening of the airways)
Neuromuscular disorders
Pulmonary rehabilitation programs may improve quality of life by
Reducing shortness of breath
Increasing exercise tolerance
Promoting a sense of well-being
Decreasing the number of hospitalizations
However, there is no clear evidence these programs significantly lengthen survival.
Pulmonary rehabilitation both before and after surgery may be beneficial for people with cancer undergoing lung resection, people with chronic obstructive pulmonary disease undergoing lung volume reduction surgery, and people with severe lung disease undergoing lung transplantation.
Pulmonary rehabilitation programs are usually conducted in an outpatient setting (in other words, the person has regular appointments in an office or clinic) or in the person’s home. However, telemedicine and web-based programs are being used more often.
Pulmonary rehabilitation programs may be used before a person's lung disease becomes severe. Even people with less severe disease may benefit from therapy to reduce shortness of breath and increase the ability to exercise. Sometimes pulmonary rehabilitation is combined with cardiac rehabilitation.
The most successful rehabilitation programs are those in which services are provided by a respiratory or physical therapist, a nurse, a doctor, a psychologist or social worker, and a dietitian working as the pulmonary rehabilitation team to coordinate complex medical services. Most people are enrolled in these programs for 8 to 12 weeks. However, the techniques learned during the program have to be continued at home after the formal rehabilitation program ends or the gains made will be lost.
Supportive respiratory therapy, which includes oxygen therapy and chest physical therapy, can be used in conjunction with pulmonary rehabilitation. Supportive therapy can also be used for people not enrolled in these programs but who have chronic lung disorders (such as cystic fibrosis or bronchiectasis) or acute lung conditions (such as pneumonia).
Enrollment and Goal Setting for Pulmonary Rehabilitation
Before pulmonary rehabilitation begins, a health care provider makes an initial assessment of the person's baseline functional status and pulmonary rehabilitation needs. This assessment is conducted in a hospital or pulmonary rehabilitation center. The first step for the team members is to determine the person's short-term and long-term goals. For example, an older adult may desire to walk a grandchild to the school bus each day. If the person can walk only 300 feet (about 90 meters) because of shortness of breath but must walk 1,000 feet (300 meters) to the bus stop, the initial short-term goal may be to increase the walking distance, starting by small increments. Team members must be encouraging while also setting realistic goals. Periodic reevaluation (weekly) is important to ensure that these goals are being met.
It is also important for team members to identify factors that may limit the program’s effectiveness for a particular person. These factors may include problems with financial resources, transportation to the rehabilitation center, cognition (particularly with respect to proper use of devices that deliver inhaled medications), and family dynamics. An example of a problem with cognition would be when a person who has lung problems also has dementia. Such a person may need a specific approach to enhance comprehension. An example of a problem with family dynamics would be when a person who is enrolled in a program is dependent on a caregiver who is not able to help the person with rehabilitation at home. It is important for team members to recognize such problems and plan ways to help the person.
Long-term goals are also established, and team members teach people to recognize changes in their lung condition, so that they will contact their doctor promptly. Treatment may need to be modified in response to changes in symptoms.
Components of Pulmonary Rehabilitation
A pulmonary rehabilitation program has several components, including
Exercise training
Inspiratory muscle training
Psychosocial counseling
Nutritional evaluation and counseling
Education, including on proper use of prescribed drugs
Exercise training
Exercise training is the most important component of pulmonary rehabilitation. It reduces the effects of inactivity and deconditioning, resulting in less shortness of breath and an increased ability to exercise. However, physical limitations may restrict the types of exercise training that can be used.
Aerobic exercise and strength training are both important components of exercise training in people with lung disorders.
Exercise of the legs is the cornerstone of training. Because walking is necessary for most activities of daily living, many rehabilitation programs use walking (sometimes on a treadmill) as the preferred mode of training. Some people may prefer exercising on a stationary bicycle. Choosing an exercise that is comfortable and satisfying for the person enhances willingness to participate long-term.
Exercise training of the arms is also beneficial for people with chronic lung diseases who have shortness of breath or other symptoms during their normal activities of daily living, such as washing their hair or shaving. Such training is needed because chronic lung disease can cause muscle loss, and some of the shoulder muscles are used in breathing as well as in moving the arms. Activities involving arm work can quickly overexert these muscles.
Inspiratory muscle training
Inspiratory muscle training (IMT) is often a component of pulmonary rehabilitation. With IMT, the person uses breathing exercises and devices to strengthen the muscles involved in breathing. IMT is usually used together with traditional aerobic exercise.
Psychosocial counseling
Depression and anxiety are common reactions to the life changes a person with lung disease experiences. In addition, shortness of breath itself may cause anxiety and depression, interfere with sexual activity, and cause difficulty managing stress and relaxing. Through counseling, group therapy, and, when needed, medication treatment, people may be able to better cope with these psychosocial problems. Sometimes family members participate in counseling to help them cope with the stress involved in caring for a person with lung disease.
Nutritional evaluation and counseling
People who have lung disease often need nutritional evaluation and counseling. For example, those with the most severe chronic obstructive pulmonary disease often experience weight loss. Pulmonary rehabilitation programs help people avoid weight loss and maintain muscle mass. People must be taught to eat in such a way that they maintain adequate caloric intake while avoiding becoming too full, which can interfere with breathing. Alternatively, some people gain weight because of a reduced activity level. In this case, breathing places a greater demand on an already taxed respiratory system. Weight reduction benefits such people.
Medication use and education
People with severe lung disease usually take several medications. Often these medications must be taken according to precise instructions and a complex schedule. Through a rehabilitation program, people can learn about the appropriate timing and doses of all medications they need to take. Education often includes information about the nature of the lung disease and the role of medication therapy, including expected benefits, potential side effects, and the proper technique for use of inhaled medications. Programs closely monitor how well people follow instructions and teach them and their families about the importance of appropriate use.
People are also taught about the need for smoking cessation, breathing strategies (such as pursed-lip breathing, in which exhalations are begun against closed lips to decrease breathing rate and shortness of breath), and the principles of conserving physical energy.
