Chest
ReviewsDisease Management of COPD With Pulmonary Rehabilitation
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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Cited by (73)
Collaborative self-management and behavioral change
2014, Clinics in Chest MedicineCitation Excerpt :Specific disease-related self-efficacy goals for healthy living are discussed in subsequent sections. Lower levels of physical activity in COPD are linked to a vicious circle of exertional dyspnea causing avoidance of activity, resulting in deconditioning, thereby exacerbating exertional dyspnea and ultimately leading to a loss of self-confidence about the ability to perform activities of daily living.40 Although COPD CSM differs somewhat from pulmonary rehabilitation in emphasis and approach, guiding patient behavior to increase regular physical activity is a core component of both.25,41
A better response in exercise capacity after pulmonary rehabilitation in more severe COPD patients
2012, Respiratory MedicineCitation Excerpt :Exercise capacity may be affected by many factors such as ventilatory limitation, dynamic hyperinflation and diminished oxygen uptake in the lung.5 In addition, impaired exercise capacity could be caused by factors outside the lung, such as early lactate production,2,6–8 muscle dysfunction1 and cardiovascular deconditioning (e.g. higher heart rate and lower stroke volume during exercise),9,10 which may at least be partially induced by sedentary lifestyle due to dyspnea.11 Pulmonary rehabilitation (PR) has beneficial effects on exercise-induced dyspnea, exercise capacity and daily physical activity level in COPD.12–16
COPD and heart failure
2011, Italian Journal of MedicineRecognition of depression in medical patients with heart failure
2007, PsychosomaticsIntegrated disease management interventions for patients with chronic obstructive pulmonary disease
2021, Cochrane Database of Systematic Reviews
revision accepted May 8.