I. Pulmonary Rehabilitation

Exercising daily is the key.Walking either outside or on a treadmill,bicycling, swimming,and exercising the upper extremities with barbells,rowing machines,or high reaches are important systemic exercises.

Pulmonary rehabilitation is a method of systemized, multidisciplinary care that offers significant benefits to many patients with advanced COPD. The roots of pulmonary rehabilitation can be traced to the late 1800’s, when tuberculosis was common, scarring the lungs and causing respiratory insufficiency in patients who survived the disease.

The components of pulmonary rehabilitation are:

1. Patient and family education.
2. Smoking cessation.
3. Systemic exercise.
4. Breathing training and exercises.
5. Oxygen therapy in selected patients.
6. Patient support groups.

Pharmacologic agents are also used to treat bronchospasm, improve airflow obstruction, clear mucus, treat infection, and deal with heart failure. But pulmonary rehabilitation consists of much more than ordinary pharmacological management.

Patient and Family Education

Education is the key to rehabilitation in patients with any chronic disorder. COPD patients and their families must understand the basic anatomy and physiology of the lungs and the circulatory system, as well as the concepts of tissue oxygenation, nutrition, exercise physiology, and global health as an alternative to illness. Although patients are stricken with disease, the illness associated with that disease can be minimized through education.

Detailed instructions are provided most efficiently in small group sessions, usually formed at the beginning of a formalized pulmonary rehabilitation program. The interaction of four to six people with similar symptoms and coping problems can provide for a meaningful exchange of information. The preferred method for using a metered-dose inhaler and the roles of other medications in COPD management (See Section G) are taught. Pamphlets and short monographs should also be used to reinforce material presented in these group sessions (See references).

Smoking Cessation

Smoking cessation is critical to the success of pulmonary rehabilitation. Without it, the typical benefits of pulmonary rehabilitation, such as improved symptoms and exercise tolerance, cannot be expected. The relentless progression of airflow obstruction can be dramatically slowed by smoking cessation, even in older individuals who have smoked for 30 to 40 years. It's never too late to stop smoking! (See Section J).

The results of the Lung Health Study re-confirm that smoking cessation has a dramatic effect in slowing the rate of decline of FEV1, the key indicator of the course and prognosis of COPD. Thus, aggressive attempts at smoking cessation must be made in patients with any degree of airflow obstruction lest progressive disabling disease follows.

Systemic Exercise

Exercise is central to the rehabilitation of respiratory cripples. Even with severe airflow obstruction, i.e., an fev1 of less than 1 liter, individuals can learn to walk greater distances without much–or any–distress if they become physically reconditioned. Exercising daily is the key. Walking either outside or on a treadmill, bicycling, swimming, and exercising the upper extremities with barbells, rowing machines, or high reaches are important systemic exercises. Walking out of doors is the most beneficial and pleasant, and is certainly more useful than any form of contrived exercise. But, of course, any exercise is better than none.

Breathing Training and Breathing Exercises

Special breathing techniques, including pursed-lip breathing (Figure 7), also help mitigate dyspnea. Extensive studies have shown that the use of pursed-lip breathing results in a slower, deeper ventilatory pattern that improves oxygenation, probably by improving ventilation-perfusion matching within the lungs. Breathing against a flow or threshold resistor or doing maximum voluntary ventilation maneuvers several times a day has also been shown to strengthen the respiratory muscles. But the increased ventilation required by exercise, especially walking, does the same thing in a more physiological fashion.

Step 1: Inhale through the nose with the mouth closed.

Step 2: The patient should shape the mouth as though whistling and breathe out slowly, resisting against the force of the air leaving the lungs.

Oxygen Therapy

Oxygen therapy is now recognized as a method of care that improves both the length and quality of life in selected patients with advanced COPD. Portable oxygen is available via liquid systems, which are the most popular and practical. Small compressed gas cylinders used with a pulse inspiratory flow device are an alternative. Stationary systems include concentrators and high pressure cylinders (See Table 8).

Portable oxygen can improve exercise capacity and reduce right ventricular strain. Oxygen support during exercise can be integrated into the rehabilitation program for certain patients. Oxygen is generally used when symptomatic patients have a chronic stable PO2 of 55 mm Hg or less (saturation of 88% or less), but by no means do all patients with this degree of hypoxemia require oxygen. (Otherwise everyone living in Leadville, Colorado, at an elevation of 10 , 000 feet, would require oxygen!)

Oxygen should be prescribed when patients exhibit dyspnea upon exertion, morning headaches, or evidence of right ventricular strain (as judged by clinical criteria including the presence of electrocardiographic, roentgenographic, and clinical signs suggesting right-sided heart failure or erythrocytosis). In these instances, oxygen tensions as high as 59 mm Hg will qualify for third party reimbursement under Medicare and most insurance plans (See Table 9). Oxygen can sometimes improve exercise tolerance in patients with oxygen tensions of 60 mm Hg or above, probably by providing the additional oxygen required by exercise.

Table 9 Guidelines for Prescribing Home Oxygen Therapy

The patient has chronic,severe hypoxemia related to:

1. Chronic obstructive pulmonary disease 2.Cystic ?brosis
2. Interstitial lung disease
3. Kyphoscoliosis

Attempts at stabilization with one or more of these agents have failed:

1. Antimicrobial drugs
2. Bronchodilators
3. Corticosteroids
4. Diuretics

One of the following blood gas criteria has been met:

1. Oxygen saturation is <89%.
2. The PO2 is <56 mm Hg.
3. The PO2,which is <60 mm Hg,is associated with cor pulmonale, erythrocytosis and a hematrocit >55%,pulmonary hypertension,and/or right ventricular hypertrophy.

Patient Support Groups

Patient support groups provide an important social outlet for patients and their families. Educational meetings and social outings such as trips on trains, buses, or cruise ships help enhance the quality of life and the happiness of patients with advanced COPD. These groups usually meet on a regular basis, often monthly. At each meeting, a local or outside speaker offers a presentation on a matter of immediate and practical interest; popular discussion topics include human sexuality and coping with sexual dysfunction, diet and nutrition, medications, and medicolegal issues such as advance directives (living wills and durable powers of attorney). A meal, often followed by entertainment, completes the program.

Organization and Structure of a Pulmonary Rehabilitation

The great majority of pulmonary rehabilitation programs are provided on an outpatient basis. Referrals usually come from pulmonologists, but today more primary care physicians are referring their patients to 4 to 6 week programs. In all cases, patients remain under the immediate care of their referring physician, who continues to prescribe all medications. Most programs are staffed by 2 to 4 nurses, respiratory therapists, or physical therapists. Daily sessions of 1 to 2 hours are common. Pursed-lip breathing and breathing exercises are demonstrated, then performed by the entire group. Supervised exercise on treadmills and bicycles, with pulse rate and saturation being monitored, is common. Walks around a large room or gymnasium, when available, are also done.

A report of the patient's progress is sent to the referring physician upon completion of the program. “Graduates” are encouraged to continue to participate in the activities of the associated patient support group as long as they find these sessions valuable. In most cases, graduates continue to participate for years. Costs for pulmonary rehabilitation vary and may be $2,000 to $4,000 per patient, a gross average. Reimbursement is approved on a regional basis, usually following detailed negotiations with third party payers such as hcfa or hmos. In most cases, third party payers recognize the tangible cost benefits from pulmonary rehabilitation: fewer hospitalizations, emergency room visits, and clinic visits.

Patients with Early COPD

In the future, pulmonary rehabilitation will probably focus on patients with mild or even asymptomatic disease. It has recently been learned that men with mild COPD have a poor ability to exercise and cannot begin to achieve their maximum oxygen consumption. Poor cardiovascular conditioning results in premature exercise impairment. By contrast, women seem to do better. Further research will determine whether or not exercise training can recondition patients with early COPD. If so, pulmonary rehabilitation techniques should be applied much earlier in the course of COPD than is now the case.

A perspective on the past, present, and future of pulmonary rehabilitation is listed in the References at the end of this Section.

References

Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of fev1. jama 1994;272:1497-1505. This is the first complete report on the outcomes of the Lung Health Study, which enrolled 5,887 patients aged 35 to 60 (mean 48.5 years) with mild airflow obstruction. Smoking cessation was associated with an improved fev1 in younger participants who had the mildest degrees of airflow obstruction. Declines in airflow over five years were much slower in nonsmokers than in continuing smokers.

Petty TL. Pulmonary rehabilitation in perspective: Historical roots, present status and future projections. Thorax 1993;48:855-862. A comprehensive review of the past, present, and future of pulmonary rehabilitation.

Petty TL. Pulmonary rehabilitation: A personal historical perspective. Chapter 1 in Casaburi R, Petty TL (eds). Principles and Practice of Pulmonary Rehabilitation. Philadelphia: WB Saunders, 1993. The first chapter of a complete textbook on pulmonary rehabilitation for COPD and other disorders.

Petty TL, Tiep B, Burns M. Essentials of a Pulmonary Rehabilitation Program: A Do It Yourself Program. Part I (1991), Part II (1992), Part III (1993). These are brief pamphlets available from the Pulmonary Education and Research Foundation, PO Box 1133, Lomita CA 90717-5133. (A Spanish version is also available).