Professional Documents
Culture Documents
net/publication/6336804
CITATIONS READS
912 1,112
10 authors, including:
Some of the authors of this publication are also working on these related projects:
Patient-Centered Outcomes for Pulmonary Rehabilitation: Application in Clinical Care View project
All content following this page was uploaded by Gerene S Bauldoff on 25 May 2014.
Chest 2007;131;4S-42S
DOI 10.1378/chest.06-2418
The online version of this article, along with updated information and
services can be found online on the World Wide Web at:
http://chestjournal.chestpubs.org/content/131/5_suppl/4S.full.html
Pulmonary Rehabilitation*
Joint ACCP/AACVPR Evidence-Based Clinical
Practice Guidelines
Background: Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This
document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the
1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of
Cardiovascular and Pulmonary Rehabilitation.
Methods: The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research
Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline
updates the previous recommendations and also examines new areas of research relevant to pulmonary
rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline
grading system.
Results: The new evidence strengthens the previous recommendations supporting the benefits of lower and upper
extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary
rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There
are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance
strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation
are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or
nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy
for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients
with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other
than COPD.
Conclusions: There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and
other chronic lung diseases. 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.
(CHEST 2007; 131:4S– 42S)
Key words: COPD; dyspnea; exercise training; guidelines; pulmonary rehabilitation; quality of life
Abbreviations: AACVPR ⫽ American Association of Cardiovascular and Pulmonary Rehabilitation; ACCP ⫽ American
College of Chest Physicians; ADL ⫽ activity of daily living; CRDQ ⫽ Chronic Respiratory Disease Questionnaire;
DAS ⫽ distractive auditory stimuli; DEXA ⫽ dual-energy x-ray absoptiometry; ESM ⫽ education and stress management;
HR ⫽ heart rate; HRQOL ⫽ health-related quality of life; IMT ⫽ inspiratory muscle training; MRC ⫽ Medical Research
Council; NETT ⫽ National Emphysema Treatment Trial; NPPV ⫽ noninvasive positive-pressure ventilation;
PAV ⫽ proportional assist ventilation; Pimax ⫽ maximal inspiratory pressure; RCT ⫽ randomized controlled trial;
Sao2 ⫽ arterial oxygen saturation; TCEMS ⫽ transcutaneous electrical stimulation of the peripheral muscles; V̇e ⫽ minute
ventilation; V̇o2 ⫽ oxygen uptake
spread limited resources.62 On the other hand, Successful pulmonary rehabilitation requires com-
longer program duration may produce greater gains plex behavioral changes for which the patients’ com-
and improved maintenance of benefits. This section petence and adherence may be facilitated by longer
will examine longer term pulmonary rehabilitation exposure to treatment interventions and interactions
interventions (ie, beyond 12 weeks of treatment). with staff who provide reinforcement, encourage-
Results
systems and reimbursement policies, access to pro-
grams, level of functional disability, health-care pro-
vider referral patterns, and the ability of individual
Pulmonary fx: NS
patients to make progress toward treatment goals.
Few clinical trials have focused on the impact of
(p ⬍ 0.001)
program duration on rehabilitation outcomes, but
domains
existing data suggest that gains in exercise tolerance
may be greater following longer programs (Table 5).
For example, two other randomized trials compared
3 vs 18 months of low-intensity exercise training in
pulmonary function
Outcomes
reduction in self-reported disability, and faster com-
Endurance; HRQL
pletion of stair climbing and overhead tasks. Foy and
colleagues64 showed that only male patients achieved
greater gains in CRDQ scores following the 18-
month program (compared to the 3-month pro-
gram). In a 2005 published prospective trial involv-
ing seven outpatient programs (not in Table 5),
Verrill and colleagues65 demonstrated that patients
Patients, Total No.
140
44
140
nia, San Diego Shortness of Breath Questionnaire),
and health status (Medical Outcomes Study 36-item
Short Form and the quality-of-life index) after 12
weeks of pulmonary rehabilitation. Following an
additional 12 weeks of rehabilitation, exercise toler-
United Kingdom/OP
Country/Setting
United States/OP
vs long-term PRP
Study Type
Foy et al64/2001
Study/Year
Green et al34/
Berry et al63/
2001
2003
www.chestjournal.org
Work rate: increase in strength group
6MWD: improved (p ⬍ 0.0005 both groups)
HRQL: improved (p ⬍ 0.05 both groups)
Clark et al95/2000 RCT: training vs control United Kingdom/OP 43 Muscle strength; endurance Maximum weight lifted (p ⬍ 0.001 vs control;
four of five exercises)
Endurance: increased (p ⬍ 0.001 vs control
subjects)
Spruit et al98/2002 RCT: resistance vs endurance Belgium/OP 48 PF; exercise capacity; endurance; Significant improvement in all outcomes in
HRQL exercise training group
Ortega et al97/2002 RCT: endurance vs strength vs Spain/OP 72 PF; peak exercise parameters; PF: changes NS
combined vs control capacity; muscle strength; HRQL Endurance: significant increase all groups
Strength: significant increase in all groups;
HRQL: improved fatigue and emotion
Panton et al101/ RCT: resistance vs aerobic United States/OP 18 PF; blood measures; strength; Upper and lower body strength increased in tx
2004 12MWT; ADL group
HR, Sao2, RPE, RPD: no change
12MWT: increase in tx group
ADL: improvements in tx group
Kongsgaard et al96/ RCT: resistance vs control Denmark/OP 18 Body measurements; dynamic Anthropometric parameters: no change; decrease
2004 strength; maximum leg extension in FEV1 NS in control group
power; normal/maximum gait Significant relationships among changes in
speed; stair climb; ADL strength, physical function, power; CSA,
MVC, knee extension trunk flex, power
(p ⬍ 0.05 resistance); 5 RM (kg), N-gait
(p ⬍ 0.001 resistance)
ADL: improvement (p ⬍ 0.05) in tx group
19S
average disease severity was moderately severe in the combined-training group. However, mea-
(FEV1 range, 38 to 48% predicted). The exception is sures of the increase in exercise endurance were
the study of Clark and colleagues95 in which patients comparable in the two groups (with the exception
with very mild COPD were studied (average FEV1, of the study by Panton and colleagues,101 who
77% predicted). Collectively, the total number of found a superior increase in the 12-min walk
patients studied was moderate, with the strength- distance in the combined-training group). Two
trained group in the various studies comprising 6 to studies99,101 assessed muscle mass changes; neither
26 subjects (total, 99 subjects). The training appara- detected significant changes in subjects perform-
tus, exercise repetition, and intensity progression ing endurance training alone, while both showed
varied among studies (see Storer102 for a review of increases in the groups in whom a strength-
suitable strength-training strategies). Program length training program was added (8% increase in thigh
ranged from 8 to 12 weeks; sessions were held two or
cross-section by CT scan99 and 5% increase in
three times per week, and session length (when
whole-body lean mass by DEXA scan101).
stated) ranged from 40 to 90 min. These program
These data can be interpreted to indicate that well-
characteristics are similar to those known to be
effective in healthy subjects.103 designed strength-training programs increase muscle
The recorded outcomes of these studies include strength and mass in patients with moderate-to-severe
changes in strength, endurance, muscle mass, and COPD. Strength training, when delivered as an iso-
disease-specific HRQOL. All six studies93–98 re- lated intervention may improve disease-specific quality
ported improvements in strength. A variety of of life but does not seem to produce additional gains
testing apparatuses were used, and it should be when added to a program of endurance training.
stressed that the measures of strength used in Strength training does not produce endurance benefits
these studies were effort, motivation, and practice as consistently as does specific endurance training.
dependent. In all studies but one,96 the change in It should be emphasized that, to date, all cited
exercise endurance was also assessed. Results were trials featuring combined programs have added a
mixed. The peak exercise level in an incremental strength-training component to an endurance-train-
cycle ergometer test showed a statistically signifi- ing program (ie, essentially doubling the time spent
cant increase in only one of five studies98; the training) rather than substituting part of the endur-
duration of a constant-work-rate task increased in ance-training program with an endurance compo-
three of five studies93,95,97; and the 6-min walk nent. Therefore, whether it is wise for rehabilitation
distance increased in one of the two studies in which it practitioners to include a strength-training compo-
was assessed.98 In two studies in which it was mea- nent in a session of fixed duration by reducing the
sured, muscle mass (assessed by MRI of a quadriceps time spent in endurance activities cannot be assessed
cross-section96 or dual-energy x-ray absorptiometry at this time. Importantly, no serious adverse effects
[DEXA] scan of lean leg mass94) increased significantly of strength training have been reported; these pre-
(by 4% and 3%, respectively). liminary data suggest that strength training is safe in
Four studies97,99 –101 allowed a comparison of ben- patients without obvious contraindications (eg, se-
efits to COPD patients between a combined vere osteoporosis). Little information is available on
strength-training and endurance-training program the long-term benefits of strength training in the
and an endurance-training program alone. These pulmonary rehabilitation patient. Whether strength
studies examined patients with, on average, moder- gains persist and whether adverse consequences of
ately severe to severe disease (mean FEV1 range, 33 weakness occur (eg, decreased mobility or injuries due
to 45% predicted). The number of patients included to falls) cannot be determined. Larger, longer term
in the strength-training-plus-endurance-training trials are required to resolve these issues. Finally,
group ranged from 9 to 21 (total, 55 patients). muscle biopsy studies of the cellular and biochemical
Training programs were 8 to 12 weeks in duration; adjustments following strength training have yet to be
sessions were held two or three times per week; the reported; such studies should help to determine the
duration of strength training per session was gener- extent to which strength training ameliorates the mus-
ally not stated (it was 45 min in the study by Bernard cle dysfunction seen in COPD patients.
and colleagues99). Strength-training exercises were
included for both the arms and the legs.
Recommendation
In all four studies, improvement in measures of
muscle strength was superior in the group receiv- 13. The addition of a strength-training com-
ing a strength-training component to that seen ponent to a program of pulmonary rehabilita-
among those receiving endurance training alone. tion increases muscle strength and muscle
In one study,101 measures of ADLs improved more mass. Strength of evidence, 1A
www.chestjournal.org
Dyspnea at 10 wk: significant decrease (p ⫽ 0.036 group 1 vs
group 2)
Walk distance: group 1: significant increase (p ⬍ 0.01) with
decrease in dyspnea (p ⬍ 0.05)
Borg score: significant difference between groups (p ⬍ 0.05)
Wmax: NS
Pulmonary function: group 1: significant increase (p ⬍ 0. 001)
Larson et al207/1999 RCT: single-blind; IMT vs cycle United States/home 130 Respiratory muscle strength and Intensity: equal both IMT groups
training vs IMT/cycle vs endurance, performance, Muscle Strength/Endurance: increase both IMT groups
control group dyspnea, fatigue Exercise Performance:
Peak work rate: IMT/Cycling increase (p ⬍ 0.01); O2 uptake
(p ⬍ 0.01);
Heart rate, Tidal Volume, breathlessness, leg fatigue: NS
Dyspnea/Fatigue: improved in cycling group
Sanchez Riera et al137/ RCT: double-blind; IMT vs Spain/home 20 PF; inspiratory muscle endurance, Spirometry: NS
2001 control group exercise capacity and Pimax: increased IMT (p ⬍ 0.003)
performance, dyspnea, QOL V̇o2max; Wmax: NS
Walk distance: increased IMT (p ⬍ 0.05 vs control)
Borg Score: no change
Dyspnea: change IMT (p ⬍ 0. 003)
QOL: treatment effect greater all domains
Covey et al 2001208 RCT: single-blind; IMT vs control United States/OP 27 Respiratory muscle performance Pimax: increase in IMT group
group and endurance; dyspnea; HRQL Pemax: NS (p ⬎ 0.05)
Endurance: increase IMT (p ⬍ 0. 05)
Dyspnea: decrease IMT (p ⬍ 0.05)
HRQL: improved IMT (p ⬍ 0.05)
25S
4 for abbreviations not used in the text.
phenotypes, such as stage of COPD, evidence of ponents because it could not identify a sufficient
inspiratory muscle weakness, degree of hyperinfla- number of studies that were focused solely on
tion, severity of breathlessness, level of exercise education. The panel reviewed education along with
impairment, and/or reduced health status, were con- the psychosocial and behavioral components and
sidered for inclusion or exclusion criteria in these recommended that “although scientific evidence is
studies. In a metaanalysis, Lotters and colleagues135 lacking, expert opinion supports the inclusion of
found that neither the degree of severity of COPD educational and psychosocial interventions as com-
nor hyperinflation had any effect on the efficacy of ponents of comprehensive pulmonary rehabilitation
IMT. However, subgroup analysis revealed that programs for patients with COPD” (strength of
those patients with inspiratory muscle weakness (ie, evidence, C).
Pimax, ⱕ 60 cm H2O) improved Pimax significantly Patient education is a central component of most
more with IMT combined with exercise training pulmonary rehabilitation programs. Education
compared to patients without inspiratory muscle classes are generally conducted in a lecture/discus-
weakness. sion format and may cover a wide variety of topics
The consideration of outcome measures is also regarding the management of chronic lung disease.
important to assess the benefits of IMT. Overall, the The scientific evidence for education in the 1997
six investigations summarized in Table 8137,206 –210 guidelines was based on four randomized studies and
show consistent improvements in inspiratory muscle one observational study.138 –142 Three of these stud-
function, increases in exercise performance, and ies138 –140 demonstrated mild improvement in dys-
reductions in dyspnea. These data generally support pnea. One of these studies140 compared dyspnea
the findings of the metaanalysis by Lotters and self-management to health education as the control,
colleagues135 that IMT by itself significantly in- finding that the self-management group reported
creased inspiratory muscle strength and endurance, deceased dyspnea on baseline dyspnea index/transi-
significantly improved dyspnea related to ADLs and tional dyspnea index. In addition, both forms of
during exercise, and showed a nonsignificant trend education resulted in significant improvement in
for an increase in exercise capacity. dyspnea. Conflicting results were reported in the two
Collectively, the positive results of the six new additional studies reviewed.141,142 One study141
studies137,206 –210 (Table 8) provide further support found that education imparted no benefit on coping
for the efficacy (both physiologic and patient-cen- skills, while the second study142 reported increased
tered outcomes) of IMT. However, each study was psychological distress following an education inter-
performed at a single institution and included rela- vention.
tively small numbers of patients with COPD. Based In the current review, four new RCTs were iden-
on this information, the panel continues to recom- tified.49,55,143,144 The results of all of these studies
mend that IMT be considered in selected patients demonstrate that education alone has no indepen-
with COPD who have decreased inspiratory muscle dent benefit (Table 9).
strength and breathlessness despite receiving opti- In the study by Emery and colleagues,55 a three-
mal medical therapy. The panel believes that a group design tested comprehensive pulmonary reha-
large-scale, multicenter RCT should be performed bilitation vs education and stress management
with appropriate statistical power to more com- (ESM) vs a waiting-list group in 79 stable patients
pletely examine the role of IMT in treating patients with COPD using blinded data collectors. The find-
with COPD. Appropriate patient characteristics, ings were that the pulmonary rehabilitation group
training methodologies, and outcome measures are demonstrated significant improvements in endur-
important considerations. ance exercise, maximum V̇o2, psychological well-
being, and illness-related impairment when com-
Recommendation pared to the education group (p ⬍ 0.05). Significant
improvement was seen over time for anxiety as well
16. The scientific evidence does not support
as cognitive function in the pulmonary rehabilitation
the routine use of IMT as an essential compo-
group vs the education group (p ⬍ 0.05). However,
nent of pulmonary rehabilitation. Grade of rec-
all groups achieved significant improvement in men-
ommendation, 1B
tal efficiency over time. The authors concluded that
comprehensive pulmonary rehabilitation produced
Education
significant improvements in endurance exercise, anx-
The 1997 guidelines panel agreed that “education iety, and cognitive performance when compared to
is generally considered to be a necessary, but not either the education-alone group or to the waiting-
sufficient, part of pulmonary rehabilitation” but did list group.
not review the topic independent of the other com- The study by Stulbarg and colleagues144 also used
Rooyackers et al165/ RCT; O2 vs RA; Sao2 Yes 24 50 sessions over No differences in peak work rate, peak V̇o2,
1997 kept at ⬎ 90%; 10 wk 6MWT, or health status
blinding not stated
Garrod et al166/ RCT; double blind; O2 Yes 25 18 sessions over No difference in shuttle walk test, health
2000 vs RA 6 wk status, ADL scale; less postrehabilitation
dyspnea with O2 treatment
Wadell et al167/ RCT; O2 vs RA; Sao2 Yes 20 24 sessions over No difference in exercise performance or
2001 kept at ⬎ 90%, 8 wk health status
patient blinded to tx
group
Emtner et al168/ RCT; double-blind; O2 No 29 21 sessions over O2 group achieved higher levels of exercise
2003 vs RA group 7 wk training and greater increases in constant
work rate testing
*RA ⫽ room air. See Tables 3 and 4 for abbreviations not used in the text.
†Testing conducted with patients breathing room air.
Study/Year Design Patients, No. Duration Between-Group Differences After Exercise Training
173
Garrod et al / Nocturnal NPPV vs SB 45 16 sessions over The nocturnal NPPV group had increased shuttle
2000 8 wk walk distance and health status compared to the
control group
Bianchi et al174/ PAV vs SB 33 18 sessions over No significant differences in exercise tolerance,
2002 6 wk dyspnea, leg fatigue, or health status
Hawkins et al175/ PAV vs SB 19 18 sessions over Higher training intensity with PAV, higher peak work
2002 6 wk rate, trend for lower lactate at iso-work rate
Johnson et al176/ NPPV vs heliox vs SB 39 12 sessions over NPPV allowed for longer exercise training duration;
2002 6 wk no difference in peak workload
Costes et al177/ NPPV vs SB 14 24 sessions over The NPPV group had a greater increase in peak V̇o2;
2003 8 wk no differences in exercise endurance or lactate
measured at isotime
van’t Hul et al178/ Inspiratory pressure support 29 24 sessions over Inspiratory pressure support group had greater
2006 vs SB 8 wk improvement in shuttle walk distance and cycle
endurance time
*SB ⫽ spontaneous breathing.
tory bilevel pressure ventilation. Compared with the Costes and colleagues177 randomized 14 patients
exercise-training-only group, those patients using with severe COPD into NPPV or spontaneous-
nocturnal NPPV as an adjunct to exercise training breathing groups. Bilevel pressure ventilation set-
had a significantly increased shuttle walk distance tings were adjusted to tolerance. All were given 24
(72 m) and greater improvement in health status. sessions of exercise training over 8 weeks. The NPPV
Two trials174,175 evaluated the adjunctive effect of group demonstrated greater improvement in peak
NPPV during supervised exercise training. Bianchi V̇o2 following exercise training compared to the
and colleagues174 randomized 33 men with moder- group trained conventionally.
ate-to-severe COPD (mean FEV1, 44% predicted) More recently, van’t Hul and colleagues178 ran-
beginning a 6-week pulmonary rehabilitation pro- domized 29 patients with COPD into the following
gram into receiving mask PAV or spontaneous two groups: (1) inspiratory pressure support (10 cm
breathing during exercise training. Five of the 18 H2O) as an adjunct to an 8-week high-intensity cycle
patients in the PAV group dropped out because of exercise-training program; and (2) sham therapy
lack of compliance with the equipment. There were (inspiratory support at 5 cm H2O) with exercise
no between-group differences in dyspnea, leg fa- training. Although both the patients and the investi-
tigue, exercise performance, or health status. In a gator assessing the outcomes were blinded to the
similar trial, but including patients with more severe treatment group, the physiotherapists supervising exer-
disease (mean FEV1, 27% predicted), Hawkins and cise training were not. Significant between-group im-
colleagues175 found that PAV during 6 weeks of provements in favor of the treatment group were seen
high-intensity cycle exercise training led to better in shuttle walk distance and cycle endurance time.
outcomes. Compared to those patients breathing In summary, several randomized trials have com-
without assistance during exercise training, the PAV pared spontaneous breathing with NPPV as an ad-
group had a 15.2% higher training intensity, higher junct to exercise in patients with COPD. Obvious
peak work rate, and a trend (p ⫽ 0.09) of lower lactate methodological issues exist with respect to blinding
levels at the isowork rate. There was no significant patients and investigators, differences in exercise
between-group difference in exercise endurance. training and outcome assessments, and the small
Johnson and colleagues176 randomized 39 patients numbers of subjects. However, it appears that this
with severe COPD (mean FEV1, 34% predicted) therapy does confer an immediate postrehabilitation
who were undergoing 6 weeks of pulmonary reha- benefit in improving exercise tolerance in selected
bilitation into the following three groups: (1) heliox patients with more advanced disease.
breathing; (2) nasal NPPV therapy; and (3) spontane-
ous breathing during exercise training. Bilevel pressure Recommendation
ventilation was administered via nasal mask, with in-
spiratory positive airway pressure at 8 to 12 cm H2O (as 22. As an adjunct to exercise training in se-
tolerated) and expiratory positive airway pressure at 2 lected patients with severe COPD, noninvasive
cm H2O. NPPV allowed for a longer exercise time ventilation produces modest additional im-
during training, but there were no between-group provements in exercise performance. Grade of
differences in the percentage change in peak workload. recommendation, 2B
6. There is insufficient evidence to determine if 16. The scientific evidence does not support
pulmonary rehabilitation improves survival the routine use of inspiratory muscle
in patients with COPD. No recommendation training as an essential component of pul-
is provided. monary rehabilitation.
Grade of Recommendation: 1B
7. There are psychosocial benefits from com-
prehensive pulmonary rehabilitation pro- 17. Education should be an integral compo-
grams in patients with COPD. nent of pulmonary rehabilitation. Educa-
Grade of Recommendation: 2B tion should include information on collab-
orative self-management and prevention
8. Six to 12 weeks of pulmonary rehabilitation and treatment of exacerbations.
produces benefits in several outcomes that Grade of Recommendation: 1B
decline gradually over 12 to 18 months.
(Grade of Recommendation: 1A) 18. There is minimal evidence to support the
Some benefits, such as health-related quality benefits of psychosocial interventions as a
of life, remain above control at 12 to 18 single therapeutic modality.
months. Grade of Recommendation: 2C