The opportunities of pulmonary rehabilitation
A blog by Dr. Frits M.E. Franssen
23 April, 2018
Devaluation of the term pulmonary rehabilitation
Although defined by international consensus as a comprehensive, patient-tailored intervention, the term pulmonary rehabilitation (PR) is commonly used as a synonym for an exercise training programme in various settings1. Without denying the challenges in access, resources and funding of PR in different healthcare settings and regions of the world2, I want to express my concerns regarding the devaluation of the term pulmonary rehabilitation and emphasize the urgency for the development of international process and performance standards for PR. I think it needs to become transparent what distinguishes home-based exercise programmes from more comprehensive programmes provided in hospitals apart from the setting and which patients are the best candidates for each of these. In the meantime, instead of stressing the limitations of interventions consisting of exercise training only, the best strategy probably is to increase awareness and knowledge regarding the outcomes and possibilities of comprehensive and personalised PR programmes among healthcare professionals, patients, policy makers and payers. Additionally, in my opinion, the introductions of novel pharmacotherapies and other medical interventions for patients with severe chronic respiratory diseases offer unique opportunities for integration with PR that warrant scientific and clinical exploration.
An obese lady with moderate COPD referred for pulmonary rehabilitation
Recently, a 60 year old obese lady was referred to our tertiary care pulmonary rehabilitation (PR) programme3 by her pulmonologist. Until a couple of years ago, she had no respiratory symptoms. Now she was diagnosed with GOLD stage 2 after 15 pack-years of smoking and with a reduced health status and functional limitations. In addition, she suffered from very frequent exacerbations despite the use of high-dose triple inhalation therapy and a macrolide as maintenance therapy and frequent rescue medication use. Diabetes and dislipidemia were her previously identified comorbidities. Her personal goals for PR were to lose weight, increase functional capacity, learn to self-manage and maybe stabilize her disease and finally improve her mood status.
During the pre-rehabilitation assessment, we confirmed the presence of moderate airflow limitation and also noticed a limited restrictive lung function impairment in relation to morbid obesity with normal diffusion capacity and blood gases. Routine blood testing revealed eosinophilia of 12%. Furthermore, tests confirmed moderate functional impairment and reduced health status. Thus, a comprehensive PR programme was initiated according to local standards3.
Triggered by the pronounced peripheral blood eosinophilia in combination with frequent exacerbations, additional tests were done. These showed lack of spirometric reversibility, multiple inhalation allergies and very high levels for exhaled nitric oxide, total immunoglobulin E and absolute numbers of eosinophils. We concluded that the lady had uncontrolled late-onset allergic asthma rather than COPD. Subsequently, we focussed on potential causes for uncontrolled disease in the PR programme including optimizing inhaler technique and medication adherence and removal of exposure to sensitizing agents. While the lady participated in her daily programme consisting of exercise training, weight counselling, education and self-management support, occupational and psychological therapy, we discussed the potential initiation and timing of add-on pharmacological treatment (anti-IgE/anti-IL5) for her asthma with the referring pulmonologist. In the fourth week of her PR an exacerbation incurred, necessitating a new course of oral corticosteroids and a temporary decrease in intensity of the PR programme. Following recovery from her exacerbation, the first dose of anti-IgE was administered. After completion of the standardized PR programme of 40 intervention days, tests showed a 6 kilograms reduction in body weight, 42 meters increase in six-minute walk distance and modest improvement in health status. Although the lady and the PR team were very satisfied with her achievements, I worried about how obvious it would have been to offer a COPD focussed programme to this lady just a couple of years ago when awareness for detailed phenotyping of obstructive lung diseases was low. Also, I wondered whether the benefits of her programme would have been more pronounced when add-on pharmacological asthma treatment had been initiated before the start of PR and whether we have sufficiently adapted our PR programme for non-COPD respiratory diseases.
Relevance of patient assessment
Assessment of the integrated health status of a patient referred for PR is essential. While patients and referring physicians frequently question the need for extensive standardized assessment of the pulmonary and extra-pulmonary characteristics of those referred to our centre, these diagnostics are critical for many reasons. First of all, they are used to confirm (stability of) the primary diagnosis. In the present case of the lady referred with COPD, establishing a different diagnosis had therapeutic consequences with potential initiation of therapies with blocking antibodies, mainly to reduce her exacerbation frequency. As new and targeted interventions become available for patients with obstructive lung disease, diagnostics need to become aligned. In addition, pulmonary treatable traits that may be addressed during PR are assessed, including exercise-induced desaturation, dynamic hyperinflation and exacerbation patterns. Extra-pulmonary features of chronic respiratory disease, including abnormal body composition, skeletal muscle dysfunction, balance disturbances and dyspnoea-related anxiety are relevant targets for specific interventions during PR. Also, previously undiagnosed comorbidities including heart disease, osteoporosis, arthritis and anaemia may not only interfere with the safety and efficacy of pulmonary rehabilitation, but may also require additional pharmacologic management4. As the spectrum of interventions during pulmonary rehabilitation broadens, including the implementation neuromuscular electrical stimulation, whole body vibration training, water-based training, targeted nutrition and anabolic agents and physical activity counselling, the importance of detailed baseline assessment increases even further. Finally, baseline and outcome assessments are important in order to evaluate the outcomes of the programme at the individual and group levels and we need to consider inclusion of non-traditional outcomes such as care dependency5 and problematic activities of daily living3.
Pulmonary rehabilitation… and beyond
While the majority of patients referred for PR have COPD, it is well-known that patients with other chronic respiratory diseases also benefit. These include patients with interstitial lung diseases, pulmonary hypertension or lung cancer. Recently, several studies focussed on the effects of non-pharmacological interventions in patients with severe asthma. Since unhealthy lifestyle, low exercise capacity, poor health status, psychological and self-management problems are common in severe asthmatics, beneficial effects of PR could be anticipated. Indeed, exercise training resulted in improved aerobic capacity and health status in moderate or severe asthma6.
Interestingly, exercise training also beneficially impacted on bronchial hyper responsiveness, systemic inflammation and exacerbation frequency6, suggesting effects on the main features of the disease. Combined with a weight-loss programme, exercise training resulted in increased clinical asthma control, more pronounced weight loss and reconditioning in obese asthmatics compared to nutritional counselling only7. The outcomes of PR of the obese asthmatic lady referred to our programme were largely comparable with those published. Yet, important challenges remain for existing PR programmes when confronted with heterogeneous groups of patients with various respiratory diseases. First, components of the baseline and outcome assessment need to be specified according to the respiratory condition. For example, different questionnaires, lung function and exercise tests and biomarkers may be applicable in different respiratory conditions. Next to generic modules on the importance of healthy lifestyle, educational programmes need to be tailored to the disease conditions of the individual patients. This can be challenging, especially when patient groups are combined during PR. From a medical point of view, combining traditional components of pulmonary rehabilitation with specialized medical interventions will offer unique opportunities for research and clinical benefit. Comprehensive pulmonary rehabilitation in combination with biologicals for uncontrolled asthma, combined with endobronchial lung volume reduction for severely hyperinflated COPD or combined with high-flow nasal oxygen therapy for ILD with severe oxygen desaturation may enhance the benefits of any of these interventions. Awaiting the results of studies addressing the opportunities of these combined interventions, I want to emphasize that by definition pulmonary rehabilitation requires an out-of-the-box thinking approach, aimed at maximizing health by combining a broad spectrum of pharmacologic and nonpharmacologic interventions for the individual patient. I’m convinced that your patients will notice the difference between training only and a comprehensive approach.
About the author
Dr. Frits M.E. Franssen is chest physician, medical coordinator and clinical research theme leader in CIRO, a centre offering specialised treatments for patients with chronic lung diseases in Horn, the Netherlands. He is also a consultant of respiratory medicine at Maastricht University Medical Centre in Maastricht, the Netherlands.
His field of expertise is COPD as a respiratory and systemic disease, and pulmonary rehabilitation, and Frits is the chair of ERS group Rehabilitation and chronic care (01.02) and has contributed to several ATS/ERS taskforces.
Further, he is (co-)author of more than 150 peer-reviewed English-language articles related to systemic consequences of COPD and pulmonary rehabilitation.
In 2016, Frits was honoured with the ‘Early career achievement award’ by the Pulmonary Rehabilitation Assembly of ATS.
You can follow Frits on Twitter: @fritsfranssen
References for this article
- Franssen FM, Spruit MA. Pulmonary rehabilitation in Australia and New Zealand: From guidelines to personalized treatment. Respirology 2017;22:622-3.
- 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;192:1373-86.
- Spruit MA, Augustin IM, Vanfleteren LE, et al. Differential response to pulmonary rehabilitation in COPD: multidimensional profiling. Eur Respir J 2015;46:1625-35.
- Vanfleteren LE, Spruit MA, Wouters EF, Franssen FM. Management of chronic obstructive pulmonary disease beyond the lungs. The Lancet Respiratory medicine 2016.
- Janssen DJ, Wilke S, Smid DE, et al. Relationship between pulmonary rehabilitation and care dependency in COPD. Thorax 2016;71:1054-6.
- Franca-Pinto A, Mendes FA, de Carvalho-Pinto RM, et al. Aerobic training decreases bronchial hyperresponsiveness and systemic inflammation in patients with moderate or severe asthma: a randomised controlled trial. Thorax 2015;70:732-9.
- Freitas PD, Ferreira PG, Silva AG, et al. The Role of Exercise in a Weight-Loss Program on Clinical Control in Obese Adults with Asthma. A Randomized Controlled Trial. Am J Respir Crit Care Med 2017;195:32-42.