Pulmonary Rehabilitation

Last Updated 11/17/2022

Author:David Steiger, MD

About Pulmonary Rehabilitation

What Is Pulmonary Rehabilitation?

Pulmonary rehabilitation (PR) is a comprehensive treatment for patients with chronic respiratory disease. After receiving an assessment, patients engage in exercise training and learn about behavior changes that can reduce their symptoms. PR can improve physical and psychological well-being, and it promotes a long-term commitment to healthy behaviors.1,2

3 important parts of PR

There are three key parts of PR. They include exercise training, making healthy choices, and getting counseling.

Exercise training

Exercise training increases the amount of exercise patients can perform over time. Patients exercise their arms and legs.

For leg exercises, patients exercise on stationary bikes or treadmills. Leg exercises help the patient walk longer distances. Arm exercises can be beneficial, as well.

Exercise training helps improve how patients’ skeletal muscles work. This may help reduce a patients’ breathing discomfort and increase a patients breathing reserves. This may be achieved  by is lowering breathing rate, which makes breathing feel easier than before.

There are three types of exercise training:

  • Endurance training is the most common. These exercises are more intense than what a patient performs on a normal day. Endurance training improves exercise capacity and health related quality of life. It involves whole body exercise such as cycling and walking.
  • Resistance and strength training is repeated weightlifting. It works individual muscle groups and helps improve the strength and endurance of muscles and may improve speed and depth of patients’ breathing. This type of training may help improve lung capacity and help the body transport oxygen more efficiently.
  • Interval training switches between more intense and less intense exercises. Patients have rest periods between exercises. Interval training is a good fit for patients who are unable to do intense training for a long time. The results of interval training are similar to what patients get from continuous training.

There are new forms of exercise training, as well. One form is Tai Chi. Patients do slow, gentle movements and poses while controlling their breathing.

Another new form is breathing retraining. Patients work to breathe slower with the goal of reducing shortness of breath.

In an outpatient setting, PR sessions take place two to three times a week. In an inpatient program, sessions are up to five times a week.

At-home, online PR programs may be 8 weeks in duration. In a telemedicine session, a physiotherapist gives real-time instruction to the home-based patient. The provider will monitor symptoms and vital signs during the session.

In PR, shortness of breath, blood pressure, heart rate, and oxygen saturation are monitored. Supplemental oxygen may be required to target an oxygen saturation of at least 88%. If there is a significant shortness of breath, chest pains, palpitations, decrease in oxygenation or blood pressure falls, exercising may not be recommended.

Healthy choices

Healthy choices are another essential part of PR.

Examples of healthy choices are:

  • Exercising.
  • Eating a healthy diet.
  • Taking prescribed medications.

Quit smoking

Seeing a counselor to quit smoking is another important aspect of a successful PR program.

During PR sessions, a physiotherapist also teaches patients how to manage their respiratory disease.

References

  1. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13-e64.
  2. Rochester CL, Vogiatzis I, Holland AE, et al. An official American Thoracic Society/European Respiratory Society Policy Statement: enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015;192(11):1373-1386.

What to Expect

PR exam

PR programs start with an exam at a PR site or the patient’s home. A physiotherapist performs a medical and physical exam and sets the program goals. Compliance with medication and inhaler technique is reviewed

The physiotherapist picks exercises based on what the patient needs. If the exam is performed at a PR site, the patient can observe the first PR session.

Where does PR take place?

Patients can do PR at a hospital-based clinic, outpatient clinic, or at a patient’s home.

A patient should not do PR if they are currently hospitalized for acute respiratory illness. They should start PR 2 weeks to 3 months after they leave the hospital.

In-person vs tele-health

In-person and telehealth PR offer similar benefits. Telehealth PR can help patients access treatment more easily. Telehealth PR is safe. It may improve patient outcomes in a similar way to in-person PR.

In telehealth PR, patients are supervised through a video call. Patients use exercise equipment designed for home use. This equipment can include dumbbells and resistance bands. Aerobic exercise and breathing maneuvers are supported and monitored. Educational sessions are provided to patients, just as they are for in-person PR.

There are also practical benefits to telehealth PR. Patients can perform PR at home, and can be monitored safely without the need to travel to an outpatient clinic or hospital PR facility. Patients can participate in PR when there are few PR facilities available.

Other models for PR include web-based PR. Web-based PR uses traditional aspects of PR, including physical training and patient education.

Telehealth PR is becoming more common after many years of slow adoption. However, barriers still exist. Barriers to telehealth PR can include:

  • Need for monitoring equipment.
  • Patient discomfort with online communication.
  • Challenge of safely monitoring patients who are not at a PR facility under the supervision of health care professionals.1
  • Lack of insurance coverage for telehealth PR.

References

  1. Rawal H, Cornelison S, Flynn S, Ohar J. Will remotely based pulmonary rehabilitation water down its effectiveness? Life (Basel). 2021;11(11):1270.

What are the benefits of PR?

Studies of patients with COPD support the benefits of PR. However, patients with other causes of advanced lung disease may also benefit from PR, including patients with restrictive lung disease from musculoskeletal disease, patients with interstitial lung diseases including pulmonary fibrosis, and patients with pulmonary hypertension.

Patients with COPD who successfully perform PR have fewer symptoms of shortness of breath and are able to exercise more. They have better lung function and improved quality of life. They also have fewer hospitalizations, including fewer admissions for worsening COPD symptoms.1

PR may decrease mortality if it’s done within 90 days of a hospital discharge.2 PR can improve patients’ quality of life and reduce anxiety and depression. PR may also reduce health care costs.

It’s important to note that the benefits of PR decrease over time. It’s not clear when and how often patients should receive PR. A maintenance program in which patients self-monitor may help maintain the benefits of PR.

PR is most beneficial when it’s extended to 8-12 weeks. Further PR may not be of additional benefit.

PR promotes healthy behavior. It focuses on the following:

  1. Quitting smoking. This has the greatest impact on improving outcomes in patients with lung disease.
  2. Long-term oxygen therapy. Patients learn about different types of oxygen delivery devices, including portable oxygen.
  3. Nutrition. Eating a healthy diet, maintaining a normal weight, and addressing obesity help the patient breathe more easily.
  4. Medication. Patients learn how to use different devices, including inhalers and nebulizers.
  5. Managing your health. Patients learn how to recognize important symptom changes and use the prescribed medications. It’s also vital for the patient to exercise and stay up to date with vaccinations to decrease risks of viral and bacterial infections.
  6. Psychological support. It’s common for patients with advanced COPD to experience anxiety and depression. PR can reduce these symptoms and improve patients’ feelings of self-worth.

PR for other advanced lung conditions

In addition to benefitting patients with severe COPD, PR has also been shown to help patients with:

PR and COVID-19

Many who survive COVID-19 develop long COVID. This can cause persistent symptoms like shortness of breath and a decreased ability to exercise. Individuals who have had COVID-19 and still have symptoms can benefit from PR. PR may improve distance a patient can walk, improve lung capacity, and improve quality of life.3 Unfortunately, COVID-19 has caused a reduction in referrals to PR programs because vulnerable respiratory patients have been avoiding possible exposure to COVID-19 in hospital or outpatient clinics.

References

  1. Kong CW, Wilkinson TMA. Predicting and preventing hospital readmission for exacerbations of COPD. ERJ Open Res. 2020;6(2):00325-2019.
  2. Lindenauer PK, Stefan MS, Pekow PS, et al. Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-Year survival among Medicare beneficiaries. JAMA. 2020;323(18):1813-1823.
  3. Gloeckl R, Leitl D, Jarosch I et al. Benefits of Pul,monary Rehabilitation in COVID-19: a prospective observational cohort. ERJ Open Research 2021 7:00108-2021

Resources

American Association of Cardiovascular and Pulmonary Rehabilitation
https://www.aacvpr.org/

Resources for Patients
https://www.aacvpr.org/resources-for-patients

Resources for Professionals
https://www.aacvpr.org/resources-for-professionals