Pulmonary Rehabilitation: A treatment for patients with chronic respiratory disease

The incidence of chronic respiratory disease is increasing and practice nurses have a vital role to play when reviewing these patients, many of whom will have chronic breathlessness. Prompt and appropriate referral for pulmonary rehabilitation can lead to dramatic improvements in their quality of life

Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Lung Disease (ILD) are chronic and progressive respiratory conditions. One of the most distressing features of both is unremitting breathlessness. As breathlessness progresses the individual becomes less active. Inactivity causes muscles to become deconditioned, which in turn results in more breathlessness on even less exertion. If this downward spiral of breathlessness and inactivity is not addressed patients can, very quickly, become housebound and experience the social isolation that often accompanies these conditions.

Pulmonary Rehabilitation (PR) is a multidisciplinary, non-pharmacological treatment for patients with chronic respiratory disease that aims to increase exercise capacity and psychological well-being.¹

EFFECTIVENESS

The evidence for the effectiveness of PR as a treatment for patients with COPD is unequivocal.²

It can lead to:

• Statistically significant and clinically meaningful improvements in health-related quality of life
• Improved functional exercise capacity
• Increased maximum walking distance
• Reduced breathlessness.
• The evidence for increased exercise capacity is slightly less robust for patients with ILD, but the evidence strongly suggests that PR has a positive impact on the psychological status of these patients.

Pulmonary rehabilitation is also cost effective in COPD. It leads to a reduction in hospital admissions and readmissions, with a number needed to treat (NNT) of only 4 to prevent an admission.³ The London Respiratory Team (LRT) has calculated the cost per Quality Adjusted Life Year (QALY) for common interventions in the treatment of COPD, which places PR as one of the most cost-effective interventions, second only to flu immunisation and smoking cessation support plus pharmacotherapy.⁴ The LRT therefore recommends referral for PR ahead of initiating ‘triple therapy’ (short acting beta agonist, long acting muscarinic antagonist and combination inhaled corticosteroid and long acting beta agonist).

PR is usually performed in outpatient settings, and for patients who have been admitted, there is good evidence for referring them to a programme as soon as possible after discharge, ideally within one month.^1,5

REFERRAL

It has become the ‘norm’ for patients with COPD to see the practice nurse for their annual check, so the nurse is in an ideal position to identify individuals who would benefit from PR and to refer them into a programme. Patients with ILD are more usually under the care of a respiratory consultant.

The NICE Guideline for COPD states that all patients with a Medical Research Council Dyspnoea Score (MRCDS) of ≥3 would benefit from PR and should be referred.⁶ However, patients with an MRCDS of 2 who report functional breathlessness, i.e. breathlessness that interferes with their ability to carry out normal daily activity or work, should also be considered.¹ PR can also benefit patients with other respiratory conditions, such as ILD and bronchiectasis, although improvement in exercise capacity in patients with ILD is likely to be less than in those with COPD, due to the nature of the condition.

Although all patients with a respiratory condition with an MRCDS of ≥3 should be considered for referral, the uptake of PR can be affected by the way the concept is ‘sold’ to them. Patients who become breathless on minimal exertion may become anxious at the suggestion that they attend an ‘exercise session’ and be reluctant to attend. It is therefore important that the health professionals who see these individuals have an insight into what PR actually entails and, ideally, attend a session to witness how patients on a programme cope and manage their breathlessness on exercise.

CONTRAINDICATIONS

Following referral it is usual for a further detailed assessment of the patient to be performed. This is often carried out by specialist respiratory nurses or physiotherapists and will include a detailed clinical history to ensure that there are no contraindications for enrolment onto a programme.

There are relatively few contraindications for PR but people with any of the following conditions may require further assessment:

• Myocardial infarction within the previous 6 weeks – these patients would usually be enrolled onto a cardiac rehabilitation programme
• Abdominal aortic aneurysm –a vascular opinion should be sought prior to enrolment
• Recent cataract surgery – usually recommended not to attend PR for six weeks post operatively or as advised by the ophthalmic surgeon
• Recent abdominal surgery – as above
• Recent thoracic surgery e.g. lung volume reduction surgery - patients are often encouraged to attend a PR programme approximately four weeks post operatively, but this should always be on the advice of the cardiothoracic surgeon.

A patient who is considered to be at a higher level of risk of experiencing a 'medical event' might be better placed in a programme based at a hospital, where there is more immediate access to medical care, rather than referred to a programme in a community setting.

PROGRAMME STRUCTURE

PR programmes are usually led by physiotherapists but should be multidisciplinary and include other health professionals such as nurses, occupational therapists, dieticians and any other professional who can contribute to the education component of the programme.

Programmes should be between six and twelve weeks’ duration and patients are expected to attend twice weekly ‘supervised’ sessions as well as continuing to do the exercises at home.⁷ It requires commitment from the patient and it should be emphasised that they need to regard PR as just as much of a treatment for their condition as their inhaled medication.

Each session is usually 1.5 –2 hours long and consists of individually prescribed exercise aimed at increasing muscle strength, thereby increasing exercise tolerance as well as reducing the perception of breathlessness. This is followed by a group educational session covering a variety of topics including:

• Normal anatomy and physiology of the lungs
• Different lung conditions
• How to stay healthy and well
• Active cycle of breathing (ACBT) techniques
• Recognition and management of an exacerbation
• Relaxation and anxiety management
• Inhaler technique and explanation of action of inhaled medication
• Smoking cessation (this may not be appropriate if all members of the group are ex- smokers).

This list is not exclusive and other topics, such as nutrition, or benefits may be included when appropriate.

For many patients, the PR programme becomes a place where they gain peer support and the feeling that it is ‘safe’ to feel breathless. While breathlessness when exercising is to be expected, the healthcare professionals involved with a programme are instrumental in ensuring that each individual recognises the point at which they need to stop and regain their breathing control. The value of the peer support should not be under estimated.

PR programmes can be delivered to a ‘cohort‘, when all patients start and finish the programme at the same time, or as a ‘rolling programme’ where patients join and complete the programme on an ongoing basis. Both types of programmes have advantages and disadvantages. Dropout rates are a concern as completion rates are varied.⁸ In a ‘cohort’ programme this has the potential to significantly impact on the dynamics of the group.

OUTCOME MEASURES

It is important for health care professionals and patients alike to measure the impact that a programme has had. At enrolment onto the programme an initial walk assessment will be performed to establish a baseline measurement. This would usually be either a 6 minute walk test or an incremental shuttle walk test, both of which measure the distance walked. In addition, measurements of the degree of breathlessness experienced by the patient during the walk test, using the Borg Scale of Breathlessness (Table 1), oxygen saturation levels and the recovery time to baseline will be recorded. These tests are then repeated at the end of the programme and the results compared. A clinically significant improvement is considered to be 54 metres for the 6 minute walk test and 75.9 metres for the Incremental Shuttle Walk test.^9,10

Questionnaires that assess an individual’s emotional and psychological state are also administered at the start and end of a PR programme. The Chronic Respiratory Questionnaire (CRQ) is a tool that assesses fatigue, mastery (ability to cope) and emotional function. Other tools that assess health status include the St George’s Respiratory Questionnaire (SGRQ) and the COPD Assessment Tool (CAT).^11,12 Whichever assessment tool is used at baseline should also be used on completion of the programme. Patients with chronic respiratory conditions often experience anxiety symptoms as a result of their breathlessness and these can have a significant impact on their daily lives. Anxiety can lead to depression and attending PR sessions can give these patients a different perspective, and, alongside educational sessions covering anxiety management and relaxation, can help to alleviate symptoms.

FOLLOW UP

Once the main programme has been completed it is essential that patients maintain their exercise levels. Some areas of the country have historically provided ‘maintenance programmes’ which are effectively the exercise component of a usual PR programme without the educational component. With increasing demand on resources other areas have focused on providing regular sessions in local authority fitness centres with specially trained fitness instructors. The latter has been reported, anecdotally, to ‘normalise’ exercise for these patients and the BTS Pulmonary Rehabilitation Guidelines recommend that all patients completing a programme are offered this opportunity.¹

QUALITY AND PROVISION

Clinical Commissioning Groups (CCGs) have a specific Outcome Indicator Set that they must achieve. One of the indicators is that patients with COPD and other chronic respiratory conditions who are functionally breathless should be referred to PR. The recent All Party Parliamentary Report (APPR) for Respiratory Health report voices concerns as to how this might be achieved when there is so much variability and lack of equity of access to programmes across the UK.¹³

CONCLUSION

Pulmonary rehabilitation is a cost effective treatment for patients with unremitting breathlessness. It reduces the risk of the admissions and readmissions that not only have a financial impact for the NHS, but also have significant impact on the health status of patients.

Patients who attend a PR programme not only experience improvements in exercise capacity and health status but also gain peer support. Practice nurses play a pivotal role in informing patients about PR as well as referring them to a local programme – where this is available.

REFERENCES

1. Bolton CE, Bevan-Smith EF, Blakey JD et al., The BTS Guideline on Pulmonary Rehabilitation in Adults. Thorax 2013;68 (Supplement 2): ii1-ii30 https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/pulmonary-rehabilitation-guideline/

2. National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in primary and secondary care. 2010. http://guidance.nice.org.uk/CG101/Guidance/pdf/English

3. Garcia-Aymerich J, Lange P, Benet M, et al. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 2006;61:772–8

4. London Respiratory Team Cost Pyramid http://www.london.nhs.uk/webfiles/London%20Respiratory%20Team/Value%20Pyramid.pdf

5. Puhan MA, Gimeno-Santos E, Scharplatz M, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2011;(10):CD005305

6. NICE. Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. CG101, 2010. https://www.nice.org.uk/Guidance/CG101

7. White RJ, Rudkin ST, Harrison ST, et al. Pulmonary rehabilitation compared with brief advice given for severe chronic obstructive pulmonary disease. J Cardpulm Rehabil 2002;22:338–44

8. Man WDC, Polkey MI, Donaldson N, et al. Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ 2004;329:1209

9. Redelmeier DA, Bayoumi AM, Goldstein RS, et al. Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997;155:1278–82

10. Singh SJ, Jones PW, Evans R, et al. Minimum clinically important improvement for the incremental shuttle walking test. Thorax 2008;63:775–7

11. Lacasse Y, Goldstein R, Lasserson Toby J, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006;(4): CD0037993. doi: 10.1002/14651858.CD003793.pub2

12. Ringbaek T, Martinez G, Lange P. A comparison of the assessment of quality of life with CAT, CCQ, and SGRQ in COPD patients participating in pulmonary rehabilitation. COPD 2012;9:12–15.

13. All Party Parliamentary Group Report on inquiry into Respiratory Deaths 2014 file:///C:/Users/Office/AppData/Local/Temp/APPG_Respiratory_deaths_2014_online.pdf

14. Quality Standards for Pulmonary Rehabilitation in Adults. British Thoracic Society Reports Vol 6;No 2:2014 https://www.brit-thoracic.org.uk/document-library/clinical-information/pulmonary-rehabilitation/bts-quality-standards-for-pulmonary-rehabilitation-in-adults/