This site is intended for health professionals only

Treating COPD with pulmonary rehabilitation

For many years it was widely accepted that little could be done to help patients with chronic obstructive pulmonary disease (COPD). However, now there is an increasing focus on therapies to relieve patients' symptoms and to improve their quality of life.
A number of studies have demonstrated the positive effects of pulmonary rehabilitation (PR), and the evidence of benefit is now established.(1) Recent guidelines on COPD management developed by the National Institute for Health and Clinical Excellence (NICE) and the British Thoracic Society (BTS), recommend that PR should be available to patients.(2)
These programmes have traditionally been run in structured and supervised environments, typically over seven to eight weeks with two two-hour sessions per week. The core focus is exercise - patients are encouraged to set goals and gradually increase their exercise capacity - but the programme also incorporates education on various areas of the disease.
However, large numbers of patients and limited resources means that only a minority of people with COPD currently have access to the schemes. Until now, most programmes have been run in secondary care, for moderate-to-severe COPD patients. But there is an increasing shift towards primary care, which should open the door to more patients, including those with milder COPD. Even when patients cannot get onto programmes, education about exercise could still have a significantly positive impact.

The current need
Nearly 900,000 people in the UK have been diagnosed as having COPD, and half as many again are thought to be living with COPD without the disease being diagnosed.(2) The progressive respiratory disease, caused by smoking in the vast majority of cases, is characterised by fixed airflow obstruction.
COPD is a major cause of morbidity and mortality, and impacts on healthcare resources.(3) The disabling lung disease causes 30,000 deaths per year in the UK, with an estimated 24 million working days lost each year due to COPD.(4) Between 1994 and 2004, hospital admissions for acute exacerbations of COPD increased by 50%.(5)
A survey conducted by the British Lung Foundation and the British Thoracic Society (BTS) investigated the current provision of PR services.(4) The survey's findings indicate that only 10,000 patients per year have access to a local programme, that 33% of programmes only provide one physical training session each week (contrary to the minimum of two, recommended by the BTS), and only 36% provide some type of continuing care.

Benefits of exercise
COPD patients are limited in their exercise tolerance by dyspnoea on exertion (the perception of respiratory discomfort), muscle weakness and fatigue. The resultant inactivity leads to progressive deconditioning that further increases the sense of respiratory effort related to any given task (COPD patients often have difficulty performing straightforward day-to-day activities). Ultimately, patients become progressively homebound and isolated, and may develop worsening depression and anxiety.(3)
Exercise tolerance is built up during a training programme, resulting in ventilatory requirement lowered at a given level of exercise. Randomised controlled trials have demonstrated consistently that lower-limb training of several types (treadmill, cycling, free walking and stair climbing) increases exercise endurance.(3) Muscle-strengthening exercises for the arms and legs are also beneficial.
"Given the differences in disease severity, each patient should set his or her own goals," says Dr Rachel Garrod, physiotherapist at St George's Hospital, Tooting, London. The hospital runs numerous PR programmes, each for seven weeks, with two sessions per week consisting of exercise and multidisciplinary education (covering inhaler technique, dietary tips, social care advice, breathing control, and so on).
Patients, therefore, benefit not only from exercise but also from learning more about their condition and having social interaction with each other. "Patients really do love it," Dr Garrod enthuses. "Many tell you about how much the programme has changed their lives, enabling them to do simple activities and perform tasks that they didn't think they would be able to do again. Some say they wish they had done it earlier."
In a recent study on COPD patients, 83% felt improved by a PR programme and 64% answered that physical training contributed much to the programme.(6)

Reaching out to more patients
Most PR data have focused on patients with moderate-to-severe COPD, but this is not to say that milder patients could not also benefit from a programme. Indeed, a study published earlier this year is the first to demonstrate an improvement in exercise tolerance and health status in patients with only mild disability.(7)
The study of 74 stable patients with COPD included equal numbers of patients with mild disability (those who described themselves as "troubled by breathlessness on strenuous exertion" and "short of breath when hurrying") as those with more severe disease. "This data shows that it is very important to give patients advice on exercise from day one of their diagnosis," says Dr Garrod.

Such findings could help to encourage the development of more community-based programmes, which can usually be set up much more easily. There are data to support their success: when a three-month rehabilitation programme was run by physiotherapists at eight local practices, patients on the scheme showed significant improvements in endurance time and cardiac frequency during cycling and walking distance compared with the control group, which had drug therapy only.(8)
Theoretically there is no reason why community rehabilitation should be less effective than outpatient programmes, provided that they follow the same principles.(9) They may offer important advantages for patients and the healthcare service, as community environments are likely to be more accessible and cost-effective. They may be run in community halls, leisure centres and medical practices, for example.
"Patients need care that they can easily access," says Jude Smith, respiratory nurse consultant, East Lincolnshire Primary Care Trust. "We use the GP surgery, local halls or anywhere that is large enough to take us. Almost a third of our patients have mild COPD and these patients definitely benefit." The PCT runs a number of PR programmes. Each is eight weeks with twice-weekly attendance, and patients are also encouraged to do additional exercises at home. Patients are then reassessed after six months.
Ms Smith says that enthusiasm among patients is so strong that many return as course advocates, teaching and supporting other attendees. "Two of our localities have now set up regular meetings themselves. They meet in village halls and do exercises," she says.
Even when the "ideal" programme cannot be implemented, there is evidence to suggest that shorter programmes still offer benefits. A recent randomised controlled trial compared a four-week programme with a seven-week programme. The results showed that the shortened programme is equivalent to a seven-week programme at comparable time points of seven weeks and six months, following completion of the programme.(1)
Shorter and more community-based programmes may both contribute to an increased number of patients having the opportunity to join programmes, but meeting the needs for all patients remains a monumental challenge. The International Primary Care Respiratory Group Guidelines on COPD management advise that, if resources are minimal, benefits can still be gained from instructing patients to take regular exercise as appropriate.(10) Regular walking is an excellent start for many people.
Says Dr Garrod: "Patients can be given really simple advice, emphasising that getting out of breath is not harmful, it is a normal response to exercise, and that if they do not exercise they will do less and get worse. Some patients are frightened to exercise because of their breathlessness, so reassurance may be very important. Nurses are in an ideal position to discuss this with patients and help them to set individual and realistic goals."
Rehabilitation plans must complement drug therapy, another area in which nurses can make a significant difference. "Patients should be on optimal therapy before they think of pulmonary rehabilitation. This is important because not everyone is on optimal medication," comments Jane Scullion, respiratory nurse consultant, Department of General Practice and Primary Care, University of Aberdeen.
Bronchodilators (anticholinergics and β2-agonists) are the mainstay therapy for symptom management in COPD and when used in combination with PR they can improve exercise intolerance. The long-acting anticholinergic bronchodilator tiotropium has recently been associated with clinically significant and sustained improvements in dyspnoea, exercise endurance and health status.(11) In a randomised, placebo-controlled trial, improvements with tiotropium were maintained for at least three months following PR completion, while the control group showed a decline.(12)

Conclusion
The days of believing that smoking cessation is the only real way to help patients are now long gone. Pulmonary rehabilitation has been proven to have important benefits for patients' health status and quality of life, particularly when combined with optimal therapy. As formal programmes are not available throughout the UK, more community-based schemes are likely to emerge. Nurses can play a key role in educating patients about exercise, liaising with GPs to refer patients onto programmes where possible, and approaching primary care trusts to commission programmes.

References

  1. Sewell L, Singh SJ, Williams JEA, Collier R, Morgan MD. How long should outpatient pulmonary rehabilitation be? A randomised controlled trial of 4 weeks versus 7 weeks. Thorax 2006;61:767-71.
  2. National Institute for Health and Clinical Excellence. Chronic obstructive pulmonary disease: national clinical guideline for management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004;59 Suppl 1:1-232.
  3. Rochester CL. Exercise training in chronic obstructive pulmonary disease. J Rehabil Res Dev 2003;40 Suppl 2:59-80.
  4. British Lung Foundation and British Thoracic Society. Pulmonary rehabilitation survey. London: British Lung Foundation; 2005.
  5. Man W DC, Polkey MI, Donaldson N. Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ 2004;329:1209.
  6. Troosters T, Gosselink R, Barbier V, Droogmans R, Coosemans I, Delva D, et al. Pulmonary rehabilitation in COPD, the patient's opinion. Eur Respir J 2004; 24 Suppl 48:634.
  7. Garrod R, Marshall J, Barley E, Jones PW. Predictors of success and failure in pulmonary rehabilitation. Eur Respir J 2006;27:788-94.
  8. Cambach W, Chadwick-Straver RV, Wagenaar RC, van Keimpema AR, Kemper HC. The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Respir J 1997;10:104-13.
  9. Garrod R, Backley J. Community based pulmonary rehabilitation. Meeting demand in chronic obstructive pulmonary disease. Phys Ther Rev 2006;11:57-61.
  10. Bellamy D, Bouchard J, Henrichsen S, Johansson G,Langhammer A, Reid J, et al. International Primary Care Respiratory Group (IPCRG) guidelines: management of chronic obstructive pulmonary disease (COPD). Prim Care Respir J 2006;15: 48-57.
  11. O'Donnell DE, Flüge T, Gerken F, Hamilton A. Effects of tiotropium on lung hyperinflation, dyspnoea and exercise tolerance in COPD. Eur Respir J 2004;23:832-40.
  12. Casaburi R, Kukafka D, Cooper CB, Witek TJ, Kesten S. Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD. Chest 2005;127:809-17.

Resources

A list of UK
hospitals providing PR is available from the BLF
W:www.lunguk.org/downloads/BLF_pul_rehab_survey.pdf

"Move on Up" DVD
A new exercise DVD specifically designed for people with COPD is now available throughout the UK. The DVD was produced with experts from St George's and King's College Hospital, and aims to encourage patients to undertake exercise as part of their treatment regimen in their own homes. The DVD is available to patients free of charge from their primary healthcare providers.
Requests for copies (numbers of DVDs or videos required and details of surgery) should be sent to:
MOVE ON UP:
Exercise Programme Orders
Freepost
PO Box 70
Bracknell, Berks RG12 4GR