Open access peer-reviewed chapter

Current and Contemporary Developments in Pulmonary Rehabilitation

Written By

Biruk Getahun and Abebe Ayalew Bekel

Reviewed: 10 August 2022 Published: 14 November 2022

DOI: 10.5772/intechopen.107050

From the Edited Volume

A Compendium of Chronic Obstructive Pulmonary Disease

Edited by Kian Chung Ong

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Abstract

Chronic obstructive pulmonary disease (COPD) is now recognized as a global health problem. It is most usually caused by smoking cigarettes, although it can also be caused by a variety of environmental toxins, noxious gases, fumes, and dust. Pulmonary rehabilitation (PR) is an effective intervention for patients with chronic obstructive pulmonary disease and is recommended by clinical guidelines. It is an important part of the treatment of chronic obstructive pulmonary disease and other chronic respiratory disorders. Pulmonary rehabilitation is a recent approach in respiratory medicine that is defined as an “individually customized and designed, interdisciplinary program of care” for patients with persistent respiratory failure. Patient selection and assessment, psychological support, self-management education, nutritional support, and exercise training (including inspiratory muscle training (IMT) are all important components of pulmonary rehabilitation.

Keywords

  • pulmonary rehabilitation
  • respiratory medicine
  • intervention
  • chronic respiratory disorder

1. Introduction

Chronic obstructive pulmonary disease (COPD) is characterized by significant functional limitation and high mortality. COPD exacerbations are associated with disease progression and are one of the leading causes of hospitalization and death, emphasizing the necessity of interventions to prevent or mitigate exacerbations. Medication management, patient education, exacerbation action plans, and pulmonary rehabilitation are all important aspects of COPD treatment [1]. Pulmonary rehabilitation, which consists of exercise and self-management education, is considered critical in the treatment of COPD patients. However, these improvements are not maintained long term. At 12 months following pulmonary rehabilitation, measures of exercise capacity, symptoms, and health-related quality of life (HRQoL) have returned toward their pre-rehabilitation values [2]. It is possible that exacerbations in the post-pulmonary rehabilitation period contribute to the lack of sustained benefit at 12 months, but this has not been systematically evaluated. Understanding the effects of exacerbations on long-term results and who is at risk for exacerbations can help with the development of more effective maintenance strategies following pulmonary rehabilitation [1, 2].

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2. Definition of pulmonary rehabilitation

Pulmonary rehabilitation (PR), which is a cornerstone in the non-pharmacological management of COPD, is defined by the American Thoracic Society/European Respiratory Society (ATS/ERS) as a “comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease [2, 3]. PR is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic lung disorders who are symptomatic and have some disability. Through stabilizing or reversing systemic signs of the disease, pulmonary rehabilitation aims to reduce symptoms, optimize functional state, increase participation, and reduce healthcare costs. To put it another way, depending on the stage of the disease, a symptomatic COPD patient has some functional compromise that can be rectified by rehabilitation [3]. In recent years, there has been increasing interest in the role of PR in the acute setting (either during or shortly after a hospital admission for AECOPD) [2].

Health behavior change is vital for optimization and maintenance of benefits from any intervention in chronic care, and PR has taken a lead in implementing strategies to achieve this goal. This model may provide more clarity on the material and methods used to achieve various levels of support. It aids in the defining of terminology and may assist practitioners in determining a person’s requirements and the amount of care necessary [4]. Healthcare professionals interested in the field might use this tool to help construct interventions, identify appropriate outcome measures, and define the intervention in a standardized way. The most comprehensive PR program, which includes self-management, should be prioritized for the most severe patients, which is referred to as integrated care (Figure 1). The minimal “action plan” intervention may be sufficient for less complicated patients with basic demands [5]. Long-term health maintenance in the face of a progressive disease is challenging. Several studies have suggested that the only approach to maintain changes in health status is to change one’s behavior. Cognitive behavioral approaches have been offered as therapies that could help people change their habits. The text recognizes self-efficacy as a critical component of behavior change. Behavior modification may be more successful if weaknesses in self-efficacy are identified and manipulated [5].

Figure 1.

Spectrum of support for chronic obstructive pulmonary disease [5].

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3. Rationale and outcomes

Recent evidence-based reviews have confirmed the effect of PR on COPD outcomes, including improved exercise capacity, reduced dyspnea and leg discomfort, improved quality of life (QoL), enhanced self-efficacy, and improved activities of daily living. PR has positive impacts on lung health without having any discernible impact on standard lung function tests like forced expiratory volume in one second (FEV1) [3]. The fact that PR lessens the systemic symptoms of COPD and its prevalent comorbidities provides a clear explanation for this discrepancy. Peripheral muscle dysfunction as a result of physical inactivity or systemic inflammation, muscle wasting, inadequate self-management skills, anxiety, and depression are all significant systemic effects of COPD [5]. Systemic effects and comorbid conditions contribute to the disease burden and might be amenable to therapy. For example, physical conditioning of leg muscles through exercise training reduces lactate production and decreases ventilator load. COPD patients with a decreased ventilatory load can breathe more slowly during exercise, reducing dynamic hyperinflation. These effects usually reduce exertional dyspnea, even without a change in FEV1 [3, 5].

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4. Essential components of pulmonary rehabilitation A

Patient selection and assessment, psychological support, self-management education, nutritional support, and exercise training (including inspiratory muscle training (IMT) are all important components of PR (Figure 2) [5]. One of the actual PR program is a multidisciplinary home-based program. In this program, breathing retraining consists of pursed-lip breathing and diaphragmatic breathing performed in the supine or sitting positions. Exercise training includes upper- and lower-extremity exercise, respiratory muscle stretching calisthenics, level walking, and IMT. Patients with COPD participate in educational activities such as lectures on respiratory conditions, dyspnea control, medication, equipment use, diet, stress management, relaxation techniques, at-home exercise, and the idea and advantages of PR [3, 6]. Each patient receives periodic home visits from a registered nurse practitioner who informs them about the function of PR. This PR program is different from recent home-based PR programs in the point of low-intensity exercise program including such as respiratory muscle stretching calisthenics and low-intensity IMT [5, 6, 7].

Figure 2.

Basic construction of pulmonary rehabilitation [5].

4.1 Self-management education

Education in self-management is a crucial and essential component of PR. It stimulates active engagement in healthcare and supports self-efficacy. It has been demonstrated that self-management education is very helpful in enhancing health and lowering healthcare utilization. It is typically given in a one-on-one or small group environment [8]. Individual educational needs are identified during an initial assessment and reviewed throughout the PR program [5, 8]. Key parts of self-management education include discussions of advance directives and counseling on the early identification and treatment of COPD exacerbations [9].

4.2 Psychosocial support

The burden of advanced respiratory disease is exacerbated by anxiety, sadness, coping issues, and a lack of self-efficacy. Despite the lack of evidence to support psychosocial therapies as a single therapeutic modality in COPD patients, complete PR programs that include these types of interventions reap advantages [10].

Comprehensive PR leads to small- to moderate-scale improvements in anxiety and dyspnea when compared to usual therapy, according to research. PR programs differ in their use of psychosocial and behavioral interventions, but they frequently contain educational sessions or support groups that concentrate on coping mechanisms and stress management. These support groups also promote participation from patients’ loved ones and friends. Patients with severe mental illness should be referred for the proper treatment [5, 11].

4.3 Exercise training

4.3.1 Exercise training for upper and lower extremities

A crucial component of PR programs is exercise training. Exercise training has been demonstrated to be the most effective method for improving muscle strength. It is also likely to increase motivation for exercise, reduce mood disorders, reduce symptoms, and improve cardiovascular health. Endurance and resistance training should be a part of PR programs, according to recent major guidelines, which are the essential components of exercise training programs for COPD patients. Although none of the recommendations give clear, accurate, and precise recommendations for full exercise training, they all support endurance training at least three to five times per week at a rate more than 60% of one’s maximum heart rate. Although it is advised to exercise for at least 20 minutes and for a target program duration of up to 12 weeks, there is disagreement on initial workloads, increasing the exercise load, or program duration [5, 11].

PR requires a comprehensive workout program that includes upper- and lower-extremity endurance training as well as strength training. COPD is a disease of the peripheral muscles, characterized by a loss of mass, changes in fiber-type distribution, and a reduction in metabolic capacity, all of which contribute to exercise intolerance. Exercise training may be able to help with these issues. Higher degrees of exercise training are linked to a stronger physiologic training impact, dose-dependent changes in oxidative enzymes in limb muscles, and increased exercise capacity [11].

Exercise training is based on the main concepts of intensity (higher intensity produces better results), specificity (only the muscles that have been trained show an effect), and reversibility (only the muscles that have been trained show an effect) (cessation of regular exercise training results in a decrease in training effect) [6]. Although patients with COPD often have ventilatory limitations to maximal exercise, high training targets can nevertheless have a physiologic training impact. Exercise intensity of 60 to 80% of the patient’s peak work rate is often feasible [5].

Another crucial aspect of exercise training is strength training, which also offers potential advantages. Strength training can be helpful for patients who cannot withstand intense exercise regimens. Some patients might be able to train at higher intensities by maximizing bronchodilation, doing interval training (i.e. switching between high and low intensities), and taking oxygen supplements [4, 5]. The optimal training duration has not been determined; rather, it is based on how each patient is doing. A successful PR program should continue at least 8 weeks (with three to four sessions each week), following the GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria, but the longer the better [12].

Although, high-intensity exercise training is effective and ideal, the rate of implementation and continuation is low especially in home-based PR setting. Therefore, low-intensity exercise training is a realistic choice in home-based PR setting [5].

4.3.2 Inspiratory muscle training (IMT)

COPD patients have respiratory muscle weakness, which contributes to hypercapnia, dyspnea, nocturnal oxygen desaturation, and reduced walking distance. Diaphragm work is increased in COPD patients during exercise, and COPD patients use a greater proportion of the maximum inspiratory pressure (PI max) than healthy subjects [5]. This pattern of breathing is closely related to the dyspnea sensation during exercise and might potentially induce respiratory muscle fatigue [13].

Respiratory muscle training is a part of rehabilitation in selected patients with COPD. Respiratory strength has been found to correlate with improved pulmonary function, reduction of dyspnea severity, improved exercise tolerance, and enhanced functionality and quality of life [9]. By boosting type II fibers, which leads to a decrease in inspiratory time and an increase in expiratory time, inspiratory muscle training (IMT) is thought to help the diaphragm contract. Since hyperinflation is anticipated to eventually decrease, IMT is believed to have an effect on dyspnea without significantly changing inspiratory pressure [13, 14].

4.3.3 New advances in the exercise training

There have been numerous new developments in exercise training in recent years, which is a crucial part of PR. In patients with COPD and physical comorbidities, water-based exercise training has been demonstrated to be noticeably more successful than land-based exercise training and control in raising peak and endurance exercise capacity and improving health-related quality of life (HRQoL) [4, 5]. Compared to level walking, downhill walking causes higher quadriceps low-frequency fatigue in COPD patients, who also experience reduced cardiorespiratory expenses [15]. It has been proposed that downhill walking can be a beneficial component of a thorough rehabilitation program [16]. It has also been demonstrated that eccentric exercise therapy, such as downhill walking, improves bodily functions and HRQoL and increases the size of the thigh muscles. Whole-body vibration has been proven to be a useful tool for strengthening muscles and as a potential means of reducing wasting and weakening. Patients with COPD who are bedridden and unable to receive physical physiotherapy might gain anything. The use of whole-body vibration proved safe and practical, and the method results in more energy use [5, 14].

4.4 Nutritional support

Patients with COPD who are underweight have worse lung health, less diaphragmatic mass, less exercise tolerance, and a greater mortality rate than those who are properly fed. Nutritional supplementation could be beneficial for their comprehensive care [6] to evaluate how dietary supplementation affects anthropometric measurements, lung function, strength, endurance, functional exercise capacity, and HRQoL in COPD. If a benefit is seen, subgroup analysis should be done to determine the treatment plans and subpopulations that show the most promise [5].

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5. Physical activity in COPD

Using indirect calorimetry techniques like doubly labeled water or metabolic carts, daily physical activity can be reported as an overall metric of active energy expenditure. The duration, frequency, and intensity of physical activity are not quantified by the doubly labeled water approach, despite the fact that it is considered a criteria method [6, 17]. Metabolic cart systems that measure expired O2 and CO2 are, however, not suitable for long-term usage. Physical activity monitors can also be used to directly track physical activity [2].

In general, pedometers, accelerometers, and integrated multi-sensor systems are the three classes of activity monitors that are being utilized more frequently in populations with chronic diseases (like COPD). Pedometers are gadgets that solely measure in the vertical plane mechanically or digitally to quantify the number of steps taken [5]. This is only a small amount of exercise. One, two, or three directions of acceleration can be detected using accelerometers (uni-, bi-, or triaxial accelerometers). These tools enable measurement of movement quality, amount, and intensity [5, 15]. In an effort to improve physical activity assessments, integrated multisensory systems combine accelerometry with various sensors that record physiological reactions to exercise (such as heart rate or skin temperature). Technology has advanced to the point that a variety of activity monitors are now readily available to measure physical activity [18].

Physical activity in patients with COPD is dependent on many factors, including physiological, behavioral, social, environmental, and cultural factors. Only a weak association exists between daily physical activity and post-bronchodilator FEV1. Dynamic hyperinflation, which highly correlates with exertional dyspnea in COPD, and daily physical activity, however, have a strong inverse relationship [19]. Performance on lower-limb muscle function tests and field exercise tests correlates better with physical activity in COPD than resting lung function testing does. Lower levels of physical activity are related to daily COPD symptoms (such as dyspnea and fatigue). In patients with COPD, the relationship between impaired health status and physical activity is minimal to moderate. Interestingly, this link between a drop in physical activity and a decline in health status in COPD patients was validated in a 5-year longitudinal observational study [3, 5, 13].

Levels of physical exercise influence critical outcomes in COPD. Hospitalization due to an exacerbation is connected with lower levels of physical activity. 59 After adjusting for age, FEV1, and prior hospitalizations, a drop in physical activity over time also predicts COPD-related hospitalization in addition to baseline levels of physical activity [20]. Even after accounting for or taking into consideration pertinent confounding factors, people with COPD who engage in less physical activity have a higher chance of dying from any cause. Mortality is also predicted by a decline in physical activity over time. Physical activity has been incorporated as a factor in multidimensional predictive scores for all-cause and respiratory mortality, exacerbations, and COPD-related hospitalization in stable COPD patients, reflecting these substantial relationships [18, 21]. The importance of encouraging physical activity in the early stages of COPD, with a target of more than 2 hours per week, is highlighted by these outcome studies [5, 18].

5.1 The effects of pulmonary rehabilitation on physical activity in COPD

Exercise training and education, which work to transform behavior by encouraging self-efficacy, are the cornerstones of PR. The increases in exercise capacity shown in the rehabilitation facility would ideally translate into increases in physical activity in the home and community settings for PR to have its best long-term impact [19, 22]. To obtain a large and long-lasting increase in daily physical activity in COPD patients, both improvements in exercise capacity and adaptive behavioral modifications are required. The definition of physical activity (which is a distinct component from exercise capacity), its prevalence in COPD, its objective assessment, risk factors for physical inactivity, and potential methods to maintain or develop the physical strength components are all included in this clinical review. In stable COPD patients, PR has likely the biggest favorable impact on exercise capacity of any contemporary medication [22].

An interdisciplinary strategy including pulmonary medicine, rehabilitation sciences, social sciences, and behavioral sciences is required to alter physical activity behavior in COPD patients. The data in this succinct clinical review show that people with COPD are typically quite sedentary, and that this lack of physical exercise is bad for both the quality and quantity of life [23, 24]. Therefore, a major objective of PR must be to make increasing efforts to better understand the factors that influence physical activity as well as practical ways to enhance this characteristic. The ATS/ERS Official Statement on PR now lists physical activity as one of the primary outcome metrics of PR programs [25].

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6. Neuromuscular electrical stimulation (NMES)

Neuromuscular electrical stimulation (NMES) is one of the more recent forms of rehabilitation that works by depolarizing motor neurons to apply an electric current through electrodes implanted on the skin over the targeted muscles, passively stimulating the contraction of the peripheral muscles [26]. It aims to elicit favorable training effects in patients who are unable to take part in PR programs without inducing dyspnea. The stimulation frequency ranges from 8 to 120 Hz, and the stimulation pulse lasts typically between 250 and 400 s. The intensity is steadily increased throughout the entire stimulation, ranging from 10 to 100 mA, depending on the patient’s personal tolerance. NMES increased quadriceps strength and exercise capacity, according to a meta-analysis published in 2016. However, there was no statistically significant change in the degree of health-related quality of life in patients with moderate-to-severe COPD [14, 27, 28]. NMES has been linked to a reduction in muscle oxidative stress and an increase in type II fiber cross-sectional area with a decrease in type I fiber cross-sectional area in a number of investigations on COPD patients [29]. NMES could be used during times of exacerbation and during admission to the ICU for acute COPD exacerbation because it has a low influence on ventilation, heart rate, and dyspnea [14].

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7. Noninvasive mechanical ventilation (NIMV)

Exercise tolerance is increased by noninvasive mechanical ventilation (NIMV), because the acute stress on the respiratory muscles is lessened. These mechanisms explain why the impact of NIMV on PR results has been studied in various studies where NIMV was used at night or during exercise training [30]. The effect of NIMV during exercise training as part of PR was examined in a review of the Cochrane Database, and it was found that doing so increased lower limb exercise capacity and permitted exercise at higher training intensities [31, 32]. No studies looked into the impact of NIMV during exercise training on physical activity, and there was no conclusive evidence regarding quality of life. It has also been demonstrated that nocturnal NIMV following PR increased exercise tolerance and quality of life in patients with severe COPD, presumably by giving the respiratory muscles a rest at night. The ERS/ATS guidelines state that NIMV may be used as an additional therapy to unload the respiratory muscles so that certain patients with severe chronic respiratory disease who do not respond well to exercise can intensify their exercise regimen [14, 30].

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8. Conclusion

Pulmonary rehabilitation, a non-pharmacologic therapy, has become the standard of care for COPD patients. It is a comprehensive, multidisciplinary, patient-centered intervention that includes patient assessment, exercise training, self-management education, and psychosocial support. Positive outcomes from pulmonary rehabilitation include increased exercise tolerance, reduced dyspnea and anxiety, increased self-efficacy, and improvement in health-related quality of life. An interdisciplinary approach including pulmonary medicine, rehabilitation sciences, social sciences, and behavioral sciences is required to alter physical activity behavior in COPD patients. Primary care physicians, nurse practitioners, and all other allied healthcare providers require greater education and learning opportunities about the procedure and advantages of pulmonary rehabilitation. Future research will also need to address the viability and security of pulmonary rehabilitation. Increasing the number of healthcare professionals, patients’ understanding of and access to pulmonary rehabilitation, and improving the program’s quality are key processes essential to attaining these goals.

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Conflict of interest

The authors declare that they have no competing interest.

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Written By

Biruk Getahun and Abebe Ayalew Bekel

Reviewed: 10 August 2022 Published: 14 November 2022