Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease: Highly Effective but Often Overlooked

Abstract

Patients with chronic obstructive pulmonary disease receive a range of treatments including but not limited to inhaled bronchodilators, inhaled and systemic corticosteroids, supplemental oxygen, and pulmonary rehabilitation. Pulmonary rehabilitation is a multidisciplinary intervention that seeks to combine patient education, exercise, and lifestyle changes into a comprehensive program. Programs 6 to 8 weeks in length have been shown to improve health, reduce dyspnea, increase exercise capacity, improve psychological well-being, and reduce healthcare utilization and hospitalization. Although the use of pulmonary rehabilitation is widely supported by the literature, controversy still exists regarding what should be included in the programs. The goal of this review was to summarize the evidence for pulmonary rehabilitation and identify the areas that hold promise in improving its utilization and effectiveness.

Keywords: Exercise Limitation; Exercise Prescription; Pulmonary Rehabilitation; Pulmonary Disease, Chronic Obstructive.

Figure 1.

Schematic representation of the pathophysiology of chronic obstructive pulmonary disease (COPD) showing the central role of air-trapping and hyperinflation leading to increased dyspnea, activity limitations and poor health-related quality of life. Exacerbations, which worsen airflow obstruction, physical deconditioning, which increases ventilatory requirements and hypoxemia and/or anxiety, which shorten exhalation time, all aggravate hyperinflation. Reprinted with permission from Cooper CB. Am J Med 2006;119:21-31, with permission of Elsevier [29].

Figure 2.

An algorithm for the treatment of chronic obstructive pulmonary disease based on clinical staging. Maintenance long-acting inhaled bronchodilator therapy and pulmonary rehabilitation should be introduced as soon as patients start to exhibit persistent, i.e., daily, symptoms, despite the use of short-acting inhaled bronchodilators. SAMA: short-acting muscarinic antagonists; SABA: short-acting beta agonists; LAMA: long-acting antimuscarinics; LABA: long-acting beta agonists. Reprinted from Cooper CB and Barjaktarevic I. Lancet Respir Med 2015;3:266-8, with permission of Elsevier [42].

Figure 3.

A comprehensive care model for chronic obstructive pulmonary disease that incorporates formulating an action plan, educating patients, developing collaborative self-management, and implementing pulmonary rehabilitation. These elements represent an essential continuum leading to fully integrated care. Reprinted from Wagg K. Chron Respir Dis 2012;9:5-7, with permission of SAGE Publications [48].

Figure 4.

Illustration of the potential of pulmonary rehabilitation for reversing the vicious cycle of deconditioning and declining exercise capacity. Pulmonary rehabilitation leads to the reconditioning of skeletal muscle, a reduction in lactic acidosis, decreased ventilatory requirement, and increased exercise capacity. Reprinted from Cooper CB. Med Sci Sports Exerc 2001;33(7 Suppl):S671-9, with permission of Wolters Kluwer Health, Inc [57].