June 13, 2007 — The joint American College of Chest Physicians (ACCP) and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) evidence-based clinical practice guidelines for pulmonary rehabilitation, published in a May supplement issue of Chest, offer new evidence of that rehabilitation is beneficial for patients with chronic obstructive pulmonary disease (COPD) and those with other chronic lung conditions.
The new recommendations, which are updated from 1997, highlight longer-term rehabilitation, maintenance strategies, and strength training, as well as supplemental oxygen use during rest and exercise for those with severe hypoxemia.
"Pulmonary rehabilitation has emerged as a recommended standard of care for patients with chronic lung disease based on a growing body of scientific evidence," write Andrew L. Ries, MD, MPH, FCCP, from the University of California, San Diego, School of Medicine, and colleagues. "A previous set of evidence-based guidelines was published in 1997 as a joint effort of the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). Since then, the published literature in pulmonary rehabilitation has increased substantially, and other organizations have published important statements about pulmonary rehabilitation (eg, the American Thoracic Society and the European Respiratory Society)."
Based on a systematic review of published literature from 1996 to 2004, the ACCP Clinical Research Analyst prepared evidence tables, which were reviewed by the guideline panel. The updated recommendations also evaluate new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated based on the ACCP guideline grading system.
The new evidence supports the earlier guidelines that recommend lower and upper extremity exercise training and that document improvements with pulmonary rehabilitation in dyspnea and health-related quality-of-life outcomes. Although additional evidence demonstrates improvements in healthcare utilization and psychosocial outcomes, there is little new evidence regarding survival.
Some new evidence highlights the benefits of longer-term rehabilitation, maintenance strategies following rehabilitation, and incorporating education and strength training into pulmonary rehabilitation.
Based on evidence available to date, the routine use in pulmonary rehabilitation of inspiratory muscle training, anabolic drugs, or nutritional supplementation cannot be recommended. However, available evidence supports the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. For selected patients with advanced COPD, noninvasive ventilation may be helpful. The guidelines also report that pulmonary rehabilitation appears to help patients with chronic lung diseases other than COPD.
"There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases," the authors write. "Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need."
Specific recommendations in the updated guidelines are as follows:
For patients with COPD, a program of exercise training of the muscles of ambulation should be a mandatory component of pulmonary rehabilitation (grade of recommendation, 1A).
In patients with COPD, pulmonary rehabilitation improves the symptom of dyspnea (1A).
In patients with COPD, pulmonary rehabilitation improves health-related quality of life (1A).
In patients with COPD, pulmonary rehabilitation reduces the number of hospital days and other measures of healthcare utilization (2B).
In patients with COPD, pulmonary rehabilitation is cost-effective (2C).
Evidence is insufficient to determine if pulmonary rehabilitation improves survival in patients with COPD.
Comprehensive pulmonary rehabilitation programs provide psychosocial benefits to patients with COPD (2B).
Although 6 to 12 weeks of pulmonary rehabilitation are associated with benefits in several outcomes, these decline gradually during 12 to 18 months (1A). However, some benefits, including health-related quality of life, are maintained above control levels at 12 to 18 months (1C).
Longer pulmonary rehabilitation programs (12 weeks) are associated with greater sustained benefits than are shorter programs (2C).
Maintenance strategies after pulmonary rehabilitation are associated with a modest improvement in long-term outcomes (2C).
Compared with lower extremity exercise training at lower intensity, higher exercise intensity is associated with greater physiologic improvement in patients with COPD (1B).
For patients with COPD, both low- and high-intensity exercise training produce clinical benefits (1A).
Adding a strength training component to a program of pulmonary rehabilitation increases both muscle strength and muscle mass (1A).
Routine use of anabolic agents in pulmonary rehabilitation for patients with COPD is not supported by current scientific evidence (2C).
In patients with COPD, unsupported endurance training of the upper extremities is beneficial and should be included in pulmonary rehabilitation programs (1A).
Routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation is not supported by currently available scientific evidence (1B).
Education on collaborative self-management and prevention and treatment of exacerbations should be an integral component of pulmonary rehabilitation (1B).
Evidence to support the benefits of psychosocial interventions as a single therapeutic modality is minimal (2C).
Current practice and expert opinion support including psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for patients with COPD. However, scientific evidence is lacking, and therefore no recommendation is provided.
In patients with severe exercise-induced hypoxemia, supplemental oxygen should be used during rehabilitative exercise training (1C).
In patients without exercise-induced hypoxemia, administering supplemental oxygen during high-intensity exercise programs may improve gains in exercise endurance (2C).
In selected patients with severe COPD, noninvasive ventilation as an adjunct to exercise training produces modest additional improvements in exercise performance (2B).
Evidence is insufficient to support the routine use of nutritional supplementation in pulmonary rehabilitation of patients with COPD.
For some patients with chronic respiratory tract diseases other than COPD, pulmonary rehabilitation is beneficial (1B).
Current practice and expert opinion suggest that pulmonary rehabilitation for patients with chronic respiratory tract diseases other than COPD should be modified to include treatment strategies specific to individual diseases and patients, as well as treatment strategies common to both COPD and non-COPD patients. However, scientific evidence to support this recommendation is lacking.
The American Thoracic Society, The European Respiratory Society, the US COPD Coalition, and the AACVPR (by way of collaborating) have endorsed these clinical practice guidelines. The authors have disclosed no relevant financial relationships.
Chest. 2007;131:4S-42S.
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