Pulmonary Rehabilitation in the Treatment

of Chronic Obstructive Pulmonary Disease

LINDA NICI, MD, Providence Veterans Affairs Medical Center, Providence, Rhode Island
SUZANNE LAREAU, RN, MS, University of Colorado Denver College of Nursing, Denver, Colorado
RICHARD ZuWALLACK, MD, St. Francis Hospital and Medical Center, Hartford, Connecticut

Pulmonary rehabilitation is a nonpharmacologic therapy that has emerged as a standard of care for patients with
chronic obstructive pulmonary disease. It is a comprehensive, multidisciplinary, patient-centered intervention that
includes patient assessment, exercise training, self-management education, and psychosocial support. In the United
States, pulmonary rehabilitation is usually given in outpatient, hospital-based programs lasting six to 12 weeks.
Positive outcomes from pulmonary rehabilitation include increased exercise tolerance, reduced dyspnea and anxiety,
increased self-efficacy, and improvement in health-related quality of life. Hospital admissions after exacerbations
of chronic obstructive pulmonary disease are also reduced with this intervention. The positive outcomes associated
with pulmonary rehabilitation are realized without demonstrable improvements in lung function. This paradox
is explained by the fact that pulmonary rehabilitation identifies and treats the systemic effects of the disease. This
intervention should be considered in patients who remain symptomatic or have decreased functional status despite
optimal medical management. Medicare now covers up to 36 sessions of pulmonary rehabilitation in patients with
moderate, severe, and very severe chronic obstructive pulmonary disease. (Am Fam Physician. 2010;82(6):655-660.
Copyright © 2010 American Academy of Family Physicians.)

C
hronic obstructive pulmonary assessment, exercise training, education,
▲

Patient information:
A handout on pulmonary disease (COPD) is characterized and psychosocial support. Although most
rehabilitation in patients
with chronic obstructive
by progressive airflow limita- pulmonary rehabilitation programs include
pulmonary disease, writ- tion that is not fully reversible, these aspects, they may vary considerably
ten by Jennifer Ah-Kee, is leading to adverse respiratory effects and in their structure. Most programs involve
provided on page 661. systemic sequelae. Damage is thought to two to three hours of education and exer-
be mediated by an inflammatory response cise, three times weekly for six to 12 weeks.
to toxic substances in the lung, especially Progress toward specific educational and
cigarette smoke.1 Optimal clinical manage- exercise goals is required. At minimum, pul-
ment of COPD generally requires pharma- monary rehabilitation programs require a
cologic and nonpharmacologic therapy. This medical director and pulmonary rehabilita-
review focuses on pulmonary rehabilitation, tion coordinator. The latter may be a nurse,
an important nonpharmacologic treatment physical therapist, or respiratory therapist.
option for patients with chronic respiratory Occupational therapists, exercise physiolo-
diseases, such as COPD. gists, pharmacists, psychologists, dietitians,
Pulmonary rehabilitation is an evidence- and social workers may also be included.
based, multidisciplinary, and comprehen- Medicare recently began covering up to
sive intervention for symptomatic patients 36 sessions of pulmonary rehabilitation
who may have decreased functional status.2 for patients with moderate, severe, or very
The goals are to reduce symptoms, optimize severe COPD, based on spirometric crite-
functional status, increase participation, ria. Although the availability of pulmonary
and reduce health care costs by stabiliz- rehabilitation has been limited in some parts
ing or reversing systemic manifestations of of the United States, this improved Medicare
chronic respiratory disease.2 funding may help improve accessibility.
In the United States, pulmonary reha- Compared with other available therapies,
bilitation is most often a hospital-based, including bronchodilators, pulmonary
outpatient program that includes patient rehabilitation generally confers the greatest
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Pulmonary Rehabilitation
SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References Comment

Pulmonary rehabilitation improves exercise capacity, A 2-7 The effectiveness in these outcomes
dyspnea, and health-related quality of life in patients generally exceeds that from other
with COPD. therapies, such as bronchodilators.
Pulmonary rehabilitation should be considered for patients C 2 Consensus statement
with COPD who remain symptomatic or have decreased
functional status despite optimal medical therapy.
Compared with standard care, pulmonary rehabilitation B 4, 8, 9 Meta-analysis suggests small to
reduces anxiety and dyspnea in patients with COPD. moderate benefit
Pulmonary rehabilitation decreases health care utilization B 46 Meta-analysis of a small number of trials
and mortality after acute exacerbations of COPD.

COPD = chronic obstructive pulmonary disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.

improvements in dyspnea, exercise capacity, and reducing dynamic hyperinflation.15 These effects reduce
health-related quality of life.3 As a result, pulmonary exertional dyspnea, even without a change in FEV1.
rehabilitation is now an integral part of virtually all
major guidelines for the treatment of COPD, including Components of Pulmonary Rehabilitation
the American Thoracic Society/European Respiratory Essential components of pulmonary rehabilitation
Society standards for diagnosis and management of include patient selection and assessment, exercise
COPD (Figure 1).1 training, psychosocial support, and self-management
education.16
Outcomes and Rationale
Multiple evidence-based reviews have evalu-
ated the effect of pulmonary rehabilitation on Management of COPD
COPD outcomes, including exercise perfor- Clinical presentation
mance, dyspnea relief, quality of life, health
care utilization, cost-effectiveness, psychoso- At risk Symptomatic Exacerbations Respiratory failure
cial benefits, and survival (Table 1).4-9
The beneficial effects of pulmonary reha- Interventions
bilitation are realized without a demonstrable
Smoking cessation
effect on traditional lung function measure-
ments, such as forced expiratory volume in
one second (FEV1). This paradox is explained Disease management

by the fact that pulmonary rehabilitation

identifies and treats the systemic effects of Pulmonary rehabilitation

COPD and its common comorbidities.2,3

Prominent systemic effects of COPD include Other options
peripheral muscle dysfunction resulting
from physical inactivity or systemic inflam- Disease progression
mation10 ; muscle wasting11; inadequate self-
FEV1 Symptoms
management skills12 ; and anxiety and depres-
sion.13 Systemic effects and comorbid condi-
tions contribute to the disease burden and
may be amenable to therapy. For example, Figure 1. Continuum of care for patients with chronic obstructive
physical conditioning of leg muscles through pulmonary disease (COPD). As symptoms and functional limitations
increase, the need for pulmonary rehabilitation increases. (FEV1 =
exercise training reduces lactate produc- forced expiratory volume in one second.)
tion and decreases ventilatory burden.14 A
Adapted with permission from Celli BR, MacNee W; ATS/ERS Task Force. Standards for the
lower ventilatory burden allows the patient to diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.
breathe more slowly during exercise, thereby Eur Respir J. 2004;23(6):943.

656 American Family Physician www.aafp.org/afp Volume 82, Number 6 ◆ September 15, 2010
 Pulmonary Rehabilitation
Table 1. Pulmonary Rehabilitation: Outcomes in Patients with COPD

Outcome Source Comments

Cost-effectiveness ACCP/AACVPR 4
Weak to very weak evidence; weak recommendation

Dyspnea relief ACCP/AACVPR4 Strong evidence; strong recommendation*

ACP5,6 Average effect on dyspnea subscale of the Chronic Respiratory Questionnaire was
clinically significant†
Cochrane review 7 Effect on dyspnea subscale of the Chronic Respiratory Questionnaire was greater
than minimum clinically important difference†; strong support
GOLD8 Evidence grade A‡

Improved exercise ACCP/AACVPR4 Strong evidence; strong recommendation*

performance ACP5,6 Clinically insignificant improvement in six-minute walk distance
Cochrane review7 Clinically insignificant improvement in six-minute walk distance
GOLD8 Evidence grade A‡

Improved health- ACCP/AACVPR4 Strong evidence; strong recommendation*

related quality ACP5,6 Pooled difference in health status scores on the St. George’s Respiratory
of life Questionnaire was less than minimum clinically significant difference§
Cochrane review7 Effect on all subscales of the Chronic Respiratory Questionnaire was greater than
minimum clinically important difference†; strong support
GOLD8 Evidence grade A‡

Psychosocial ACCP/AACVPR4 Moderate evidence; weak recommendation

benefits GOLD8 Reduced anxiety and depression; evidence grade A‡
Meta-analysis9 Small to moderate improvements in anxiety and depression compared with usual care

Reduced health ACCP/AACVPR4 Moderate evidence; weak recommendation

care utilization ACP5,6 Equivocal for health care utilization outcomes
GOLD8 Evidence grade A‡

Survival ACCP/AACVPR4 Insufficient evidence; no recommendation provided

GOLD8 Evidence grade B||

AACVPR = American Association of Cardiovascular and Pulmonary Rehabilitation; ACCP = American College of Chest Physicians; ACP = American
College of Physicians; COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Obstructive Lung Disease; RCT = randomized
controlled trial.
*—Evidence from well-designed RCTs with consistent and directly applicable results; benefits outweigh the risks and burden.
†—The Chronic Respiratory Questionnaire is a health status questionnaire for COPD, with dyspnea, fatigue, emotion, and mastery subscales.
‡—Evidence from well-designed RCTs with consistent findings, with a substantial number of studies involving many participants.
§—The St. George’s Respiratory Questionnaire is a health status questionnaire for COPD and asthma, with symptom, activity, and impact subscales.
||—Limited data.
Information from references 4 through 9.

PATIENT SELECTION AND ASSESSMENT (e.g., unstable angina) or conditions that substantially
Pulmonary rehabilitation is patient centered; therefore, interfere with the rehabilitative process. In many cases,
an initial assessment and goal setting are important. The the underlying contraindication can be treated or the
initial assessment sets the stage for subsequent treat- pulmonary rehabilitation can be adapted so that the
ment. Because there are no randomized controlled stud- patient can participate.
ies of the assessment process, the strength of evidence Pulmonary rehabilitation guidelines state that based
is weak, and recommendations are based primarily on on expert opinion, the degree of airflow limitation (as
expert opinion.2,16 measured by FEV1) is not a major selection criterion for
Indications for pulmonary rehabilitation include pulmonary rehabilitation, but that symptom burden and
persistent respiratory symptoms (especially dyspnea) functional status limitation are the major indications.2
or functional status limitation despite optimal medi- However, a recent evidence-based practice guideline
cal therapy.2 Contraindications include conditions from the American College of Physicians recommends
that substantially increase risk during rehabilitation that physicians consider pulmonary rehabilitation for

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Pulmonary Rehabilitation

patients with an FEV1 less than 50 percent of that pre- oxidative enzymes in ambulatory muscles, and greater
dicted.6 It states that the evidence is not clear whether improvement in exercise performance.14,23,24
pulmonary rehabilitation is beneficial in patients Exercise training is based on general principles of
whose FEV1 is greater than 50 percent of that predicted. intensity (higher intensity produces greater results),
The recommendation was graded as weak, based on specificity (only those muscles trained show an effect),
moderate-quality evidence in the randomized clini- and reversibility (cessation of regular exercise train-
cal trials that were reviewed. The recommendation ing results in a decrease in training effect).25 Although
contradicts expert opinion that symptomatic patients patients with COPD often have ventilatory limitations
may benefit from pulmonary rehabilitation, regardless to maximal exercise, a physiologic training effect can
of their FEV1.2,16 The severity of COPD, including its be achieved if high training targets are used.26 Exercise
symptom burden, is clearly influenced by more than air- intensity of 60 to 80 percent of the patient’s peak work
flow limitation alone.17 rate is often feasible.26
Strength training is also an important component of
EXERCISE TRAINING exercise training and may yield additional benefits.27
Comprehensive exercise training, including upper- and Patients who cannot tolerate high levels of exercise train-
lower-extremity endurance training and strength train- ing can also benefit from strength training.28 Maximiz-
ing, is an essential component of pulmonary rehabili- ing bronchodilation, interval training (i.e., alternating
tation (Table 2).4 COPD can be considered a disease of high and low intensities), and oxygen supplementation
the peripheral muscles,18 with decreased mass, altera- may allow for higher intensity exercise training in some
tions in fiber-type distribution, and decreased metabolic patients.29-34 The optimal duration of training has not
capacity contributing to exercise intolerance.19-22 These been established but depends on the progress of the indi-
abnormalities may be amenable to exercise training. vidual patient. Guidelines from the Global Initiative for
Higher levels of exercise training are associated with a Chronic Obstructive Lung Disease state that six weeks
physiologic training effect, dose-dependent increases in (with three sessions per week) is the minimum duration
of an effective program,8 but longer duration
confers greater benefits.
Table 2. Guidelines for Exercise Training in Patients
with COPD SELF-MANAGEMENT EDUCATION

Self-management education is an integral

Recommendation Strength of evidence component of pulmonary rehabilitation.2,4
Lower-extremity exercise training should be Strong evidence; strong It promotes self-efficacy 35-37 and encourages
a mandatory component of pulmonary recommendation active participation in health care.38,39 Self-
rehabilitation. management education has been shown to
Low- and high-intensity exercise training Strong evidence; strong be highly effective in improving health sta-
produces clinical benefits for patients with recommendation tus and reducing health care utilization.40
COPD.
It is usually provided in small group set-
Lower-extremity exercise training performed Moderate
tings and in a one-on-one format. An ini-
at a high level of intensity produces greater evidence; strong
physiologic benefits than lower-intensity recommendation tial evaluation helps determine educational
training. needs, which are then reassessed during the
Unsupported upper-extremity endurance Strong evidence; strong course of the program. Discussions about
training should be included in pulmonary recommendation advance directives are an important part of
rehabilitation exercise programs. self-management education,41,42 as is coun-
Including a strength training component in a Strong evidence; strong seling about early recognition and treatment
pulmonary rehabilitation exercise program recommendation
of COPD exacerbations.4
increases muscle strength and muscle mass.
There is no evidence to support the routine use Moderate PSYCHOSOCIAL SUPPORT
of inspiratory muscle training as an essential evidence; strong
component of pulmonary rehabilitation. recommendation Anxiety, depression, coping problems, and
decreased self-efficacy contribute to the
COPD = chronic obstructive pulmonary disease. burden of advanced respiratory disease.43-45
Information from reference 4. Although there is minimal evidence to sup-
port psychosocial interventions as a single

658 American Family Physician www.aafp.org/afp Volume 82, Number 6 ◆ September 15, 2010
 Pulmonary Rehabilitation

therapeutic modality in patients with COPD, benefits are into lifelong COPD management for all patients, even if
derived from comprehensive pulmonary rehabilitation pulmonary rehabilitation is not available. The primary
programs that include these types of interventions.4,8 care physician is in a unique position to provide and coor-
A systematic review and meta-analysis that included dinate this care across settings.48,49
three randomized trials comparing comprehensive
pulmonary rehabilitation with standard care showed The Authors
that pulmonary rehabilitation led to small to moderate
LINDA NICI, MD, is associate chief of pulmonary and critical care at the
improvements in anxiety and dyspnea.9 Psychosocial Providence (R.I.) Veterans Affairs Medical Center and a clinical professor
and behavioral interventions vary among pulmonary of medicine at Brown University Alpert School of Medicine, Providence.
rehabilitation programs, but often involve educational SUZANNE LAREAU, RN, MS, is a senior instructor at the University of
sessions or support groups that focus on coping strate- Colorado Denver College of Nursing and serves on the American Thoracic
gies and stress management. Patients’ family members Society Board of Directors.
and friends are also encouraged to participate in these RICHARD ZuWALLACK, MD, is associate chief of pulmonary and critical
support groups. Patients with substantial psychiatric care at St. Francis Hospital and Medical Center, Hartford, Conn., and a
disease should be referred for appropriate care. professor of clinical medicine at the University of Connecticut School of
Medicine, Farmington.
Pulmonary Rehabilitation After Acute COPD Address correspondence to Richard ZuWallack, MD, St. Francis Hospital
Exacerbations and Medical Center Dept. of Pulmonary and Critical Care, 114 Wood-
land St., Hartford, CT 06105 (e-mail: [email protected]).
COPD exacerbations are responsible for substantial Reprints are not available from the authors.
health care utilization and carry a high mortality risk.
Author disclosure: Nothing to disclose.
Recent studies indicate that pulmonary rehabilitation is
beneficial shortly after an acute exacerbation of COPD.
In an analysis of six trials involving 219 patients with REFERENCES
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660 American Family Physician www.aafp.org/afp Volume 82, Number 6 ◆ September 15, 2010