Chest
Volume 112, Issue 6, December 1997, Pages 1630-1656
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Reviews
Disease Management of COPD With Pulmonary Rehabilitation

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Pulmonary rehabilitation is a set of tools and disciplines that attends to the multiple needs of the COPD patient. It extends beyond standard care by addressing the disabling features of chronic and progressive lung disease. It centers on self-management, exercise, functional training, psychosocial skills, and contributes to the optimization of medical management. Exercise enables other components by building strength, endurance, confidence, and reducing dyspnea. Patients who have undergone rehabilitation often enjoy a reduced need for health-care utilization. On the downside, rehabilitation is a one-time intervention, the benefits of which dissolve over time. The patient's physician is rarely a participant in the program; thus, the physician is at a disadvantage in being able to support a long-term response. Rehabilitation is available to a small percentage of a large patient population who could benefit. Optimal disease management would entail redesigning standard medical care to integrate rehabilitative elements into a system of patient self-management and regular exercise. It should emphasize physician involvement in self-management, which is essential in developing and maintaining an effective exacerbation protocol. Pulmonary rehabilitation should take its place in the mainstream of disease management through its integrative and reconciliative role in the multidisciplinary continuum of services, as defined by the National Institutes of Health, Pulmonary Rehabilitation Research, Workshop of 1994.

Section snippets

COPD

COPD is a montage of chronic bronchitis, emphysema, and associated partially reversible asthmatic components that limit bronchial airflow. As these conditions are grouped together, the clinician, having identified one of these abnormalities, is obligated to address the probability that the others are also present. The proportional inclusion of each of these components may well determine the clinical presentation, the specific impact of the disease, and consequently the best intervention. The

Medical Management of COPD

Comprehensive medical management starts with prevention, but over time adds bronchodilators, anti-inflammatories, oxygen, adequate nutrition, exercise, control of anxiety and depression, and exacerbation management7, 8 (Table 1). Primary prevention, preventing the occurrence of the disease, is the first step in any disease management. COPD is basically a self-inflicted disease. The first important intervention is to halt the self-destruction through smoking cessation. Secondary prevention,

Goals of Pulmonary Rehabilitation

Pulmonary rehabilitation is ideally a comprehensive management strategy that addresses all components of the chronic and progressive lung disease. It neither is curative nor will it completely halt pathophysiologic deterioration; however, it should relieve much of the disability—the complex interaction between pathophysiology and individual adaptation. In a functional definition, pulmonary rehabilitation applies the art, skill, physiology, and multiple clinical disciplines to prevent or reverse

Admission Criteria

Evaluating candidates for pulmonary rehabilitation need not be a complicated process. The two basic questions are as follows: (1) Does the patient have a diagnosis that qualifies for pulmonary rehabilitation? (2) Is the program likely to help the patient? The diagnosis should arrive with the patient referral, along with the pulmonary function tests. The team must then determine whether the program will meet the patient's goals effectively and safely. Essential information will include the

Methods of Pulmonary Rehabilitation

Pulmonary rehabilitation programs seek to meet the goals of the patient, along with those directed by the therapeutic team (Table 2). Considering the wide variation of therapy and training within the fabric of pulmonary rehabilitation programs, some general areas of commonality prevail. Initially, the clinician must optimize medical management by assuring bronchial hygiene. Bronchodilators and anti-inflammatory medications open airways, reduce swelling, and dislodge blocking secretions.

Smoking Cessation

Patients entering a pulmonary rehabilitation program generally have quit smoking prior to their referral. Those who continue to smoke have two options: (1) complete smoking cessation prior to entering, or (2) undergoing a parallel smoking cessation program while proceeding with pulmonary rehabilitation. The rehabilitation team may have one of several roles: (1) to help the patient initiate and proceed with smoking cessation; (2) to support continued cessation for patients who had a previous

Organization and Presentation

The organization of the pulmonary rehabilitation program is designed to embody important components of training within a framework that will effectively bring about a lasting behavioral change.39 Some of the COPD population can be described as aging and debilitated. Their educational backgrounds vary, and some may not be at their cognitive zenith. These factors should be considered in the program design. Consequently, programs ought to be simple, uncluttered, and without extraneous information

Outcome Studies in General

Designing an outcome study requires careful thought and planning. The experimental and control subjects should be drawn from the same population and randomly allocated into experimental and control groups. Studies that compare after vs before suffer from an order or maturation effect. Patients always have expectations and it is always possible that the effect that was detected could be due to another reason, or simply that it was time for that effect to take place. A suffering patient will

Surgery for COPD

Successful transplantation of single and double lungs is now almost commonplace at major medical centers. Candidates for these operations are carefully selected for their disease severity, comorbidity, along with indications and contraindications that would predict surgical success. In preparing patients for such a major operation, pulmonary rehabilitation is almost universally advocated to increase their strength, endurance, knowledge, and confidence for the long road to postoperative

Drawbacks of Pulmonary Rehabilitation

Despite the many benefits of pulmonary rehabilitation, there are some drawbacks. Given a population of 15 million COPD patients in the United States, most of whom would benefit from pulmonary rehabilitation, the present accommodation is for about 10,000 patients at any given time.158 This calculates to <0.1%. Thus, pulmonary rehabilitation is not presently a solution that could support full population access. Pulmonary rehabilitation is administered over a short period of time for a COPD

Disease Management—the Ideal System

In stepping back and viewing COPD as a disease process with a clinical picture of progressive deterioration, an ideal system of care could be built on a disease management model. Disease management is a comprehensive and coordinated system of care that deals with the disease state, rather than just the acute episode. The basic components are prevention, wellness, treatment, patient tracking, and follow-up.42 It is based on self-management to prevent the disease from progressing, daily

Conclusions

Pulmonary rehabilitation, which includes smoking cessation, self-management, exercise, and optimization of medical management, is a highly effective and cost-efficient means of caring for COPD patients. Exercise has a key role in enabling the other benefits; however, exercise alone would not be expected to bring about all of the changes seen in pulmonary rehabilitation. Education, self-management, and psychological support improve the awareness of the patient and increase his or her

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