Pulmonary rehabilitation and disease management offer strategies for patients to become actively involved in their care and improve their functional outcomes.
By Brian L. Tiep, MD, FAACVPR, and Rick Carter, PhD, MBA
Patients with a chronic lung disease such as COPD suffer from an illness that is not only chronic and progressive, but also often punctuated by acute exacerbations. While COPD is not presently curable, it can be argued that all aspects of the disease, including common comorbidities, are treatable to some extent.1,2 Over the last 30 years, pulmonary rehabilitation has gained recognition as the standard of care—an intervention that virtually all patients with this disease should receive.3
The original concept was that pulmonary rehabilitation would be a comprehensive program of management and would be multidisciplinary. Initially, much of the program was based on exercise, such as walking, with the support of a plurality of disciplines, including occupational therapist, physical therapist, respiratory therapist, social worker, dietitian, psychologist, and exercise physiologist, all combined in an effort to reverse these patients’ downward spirals of disability.4 Exercise tolerance improved concomitantly with a reduction in dyspnea. Commensurate with better endurance, strength, and self-management skills, patients developed confidence that a normal and active lifestyle was again achievable.5,6 Program outcomes were almost uniformly rapid and astounding, even without a significant change in pulmonary function, thereby indicating that improvements in the other organ systems were responsible. Emerging pharmaceuticals provided further support and augmented improvement. Oxygen therapy was found to significantly and substantially improve survival and exercise capacity, and some studies showed that pulmonary rehabilitation significantly reduces hospitalizations.
These programs were expensive, and insurance carriers, including Medicare, avoided paying for rehabilitation. Hospitals initially supported programs, but they became regarded as cost centers. This was at a time when hospitals were struggling to survive. However, patients and professionals championed pulmonary rehabilitation as the scientific basis for it grew. Eventually, as a result of the growing support, Congress directed Medicare to pay for the program. Meanwhile, patients continued to experience exacerbations that often resulted in protracted and costly hospitalizations.
Pulmonary rehabilitation programs were found to reduce hospitalizations; however, such an acute level of care continues to be overwhelmingly expensive. Additionally, the positive benefits derived from pulmonary rehabilitation do not last forever and some suggested that the approach should be changed or eliminated. Most, if not all, of the benefits of these programs tend to diminish over the ensuing years. For pulmonary rehabilitation to be successful in the long run, it must be practiced continually and modified where appropriate, just like taking a daily medication and reissuing a prescription through the years. Thus, compliance and understanding with regard to medical recommendations is key, and this is certainly true for maintaining function in the face of advancing age and a chronic disease with superimposed acute exacerbations. In fact, studies have shown that following each exacerbation, immediate efforts should be instituted to return the individual to pre-exacerbation functional level and beyond, if possible.
In a parallel development, disease management programs appeared and were rather well funded.7 Many were private companies—some listed on the stock exchanges—that set up call centers with nurses who contact patients most at risk of an exacerbation hospitalization. Insurance carriers and health plans and even Medicare contracted with these companies with the goal of reducing the cost of health care through heightened managed care practices and early recognition of an impending exacerbation. Initially, the results seemed worth the money and effort. Over time, however, scientific support began to be inconsistent and some of the initial interest waned.
It has become clear to some investigators and clinicians that patients with a chronic and progressive illness (often with exacerbations of increasing frequency and severity) require a continuous program of care that incorporates rehabilitation and disease action plans along with all the required self-care tools and understanding.8
In this article, we describe pulmonary rehabilitation as well as disease management, and recommend a strategy for continuing integrative care with the goal of allowing the patient to become actively involved in their care program and improve their functional outcomes, and allowing them to intervene early when signs/symptoms of an exacerbation present.
Pulmonary rehabilitation is a comprehensive multimodal team approach for retraining patients that emphasizes exercise, reconditioning, and training self-management.4,9,10 Rehabilitation involves change—a change in lifestyle from sedentary to active and a change from disease-centered to life-centered. Loss of lung function renders patients dyspneic upon exertion. This is amplified by a logical behavioral response of avoiding exertion and retreating to a sedentary lifestyle. The result is a patient who is dyspneic not only from loss of lung function but from deconditioning, as well.
Exercise training enables patients to expend more energy while requiring a faster breath rate, thus reducing the tendency to trap air and hyperinflate their lungs.6 They can do more while breathing less. Concomitantly, patients learn self-management skills that enable them to confidently conduct their lives without the fear that they will succumb to overwhelming dyspnea.
During pulmonary rehabilitation, patients become participants in their own care as opposed to giving up control of their lives to a spouse or offspring. Patients are encouraged to develop goals and expectations from the program. The program is highly structured, yet sufficiently flexible to meet the needs of the individual patient and family.
Patients learn about their lungs, their disease, medications, nutrition, self-care, pacing and motion economy, breathing techniques to reduce dyspnea and improve oxygenation, avoidance of secondhand smoke, and methods of coping and problem solving. Patients who are current smokers are helped to quit through a variety of programs and techniques supported by medications designed to lessen the impact of addiction to nicotine.
Pulmonary rehabilitation is most often conducted in a group setting. Most of the time, a group provides the mutual support of patients experiencing similar challenges. Ideally, a full team of therapeutic professionals works with the patients. Education provides the background and reasons to pursue a rehabilitative effort, while training in techniques builds skills and habits to manage the illness. Family members, especially caregivers, are encouraged to participate.
Pulmonary rehabilitation begins with a referral. The patient is evaluated for qualifying diagnosis, disease severity, and the ability to exercise safely. Goals are identified. Therapists evaluate for their specific discipline and set goals for their patient. The program proceeds with a coordinated team effort with the patient empowered to make decisions and continually examine program goals and outcomes. Team meetings are held regularly in order to access the progress of each area of knowledge, skill, and technique. Problem solving ensues, which includes the patient, the family (caregiver), and the team. Medications are adjusted and medical issues are recognized and managed. Patients are encouraged and reinforced.
Exercise is the engine that drives the program. Expectations from exercise include the reduction of dyspnea—particularly upon exertion—and relief from the fear of dyspnea. Patients are taught to accept a certain level of dyspnea during exercise training as a means for improving exertional tolerance. Physiologically, exercise reduces dyspnea for a given level of exertion by reducing ventilatory rate, which enables the patient to empty their lungs for the next inhalation. This reduces hyperinflation, which is the ventilatory limitation to exercise.11 Exercise enables more efficient oxygen transport as it encompasses the cardiovascular system and gas exchange at the cellular level.12 Benefits of exercise tend to be specific to the area of the body that is undergoing training. Hence, it is important to train the upper and lower extremities and train for strength and endurance. Additional research suggests benefits from training and resting the respiratory muscles.
Patients with chronic lung disease, such as COPD, generally benefit from bronchodilators both atropinergic (antimuscarinic) and beta-2 agonists. Inhaled corticosteroids are the centerpiece of asthma management but also are useful for COPD patients combined with a long-acting beta-2 agonist.9 These medications are targeted to opening airways, thereby reducing hyperinflation. As such, they are adjunctive to exercise training as they extend the ability to exercise to higher work rates and limits imposed by dyspnea and limited respiratory flow and hyperinflation. Oral and IV steroids have an anti-inflammatory role during an exacerbation. Antibiotics are indicated during an exacerbation when a bacterial infection is suspected. It is important to recognize that some exacerbations are caused or complicated by viral infections. Flu vaccinations as well as pneumonia vaccinations will prevent some exacerbations. Other common medications include diuretics, digoxin, anti-inflammatory pain medication, and medications for comorbid conditions common to this patient population. An important understanding for a given patient is that they colonize very specific pathogens and in many cases these pathogens are responsible for acute exacerbations of the disease. Thus, the physician will have an understanding of the disease process and will be in a good position to prescribe based on medical history.
Patients with more advanced disease may require oxygen therapy. If so, they are likely to desaturate during exertion usually to a greater degree than at rest. As such, they will likely require oxygen during exercise. This is particularly true for patients undergoing pulmonary rehabilitation where exercise is so central. It is a good idea for patients to obtain an accurate pulse oximeter to monitor their oxygen saturation, and for many individuals exercising, it is recommended that they try to maintain their oxygen saturation above 90% saturation, if compatible with the severity of their disease.13
The benefits from oxygen are monumental.14,15 Oxygen protects against tissue-damaging hypoxia, improves long-term survival, facilitates the ability to exercise to a higher level, and is adjunctive to the benefits of exercise. Unfortunately, oxygen is also inconvenient, and the appearance of the cannula delivery system suggests illness to both the patient and the observer. Thus, the rehabilitation team has a critical role in enabling the patient to accept their oxygen and providing a system.16
Another important aspect with regard to oxygen therapy is titrating oxygen for nocturnal needs. In some cases, an overnight oximetry study can be used, while for others a full sleep study may be warranted. What is essential is that for a given patient, oxygen needs change and, thus, delivery settings should change to maximize benefit and lessen undesired consequences. This is often an overlooked aspect of the treatment plan and yet a critical issue for effectively managing a patient with a lung disorder.
Self-management is the core of both pulmonary rehabilitation and integrative medicine. What matters in pulmonary rehabilitation is the incorporation of self-management skills into daily life.17 Thus, pulmonary rehabilitation is a behavioral program that is restorative to a normal life.18 Incorporation of self-management skills on an ongoing basis will assist patients in coping with their disease and will place them in a better position to deal with the many challenging aspects of the disease process without panic and in a direct and definitive manner.
Patients are strongly encouraged to live an active lifestyle as enabled by their exercise program.6,19 They are taught to accept their disease and the need for an active approach to life. Pacing and motion economy, disease understanding, and adapting to a changing set of life standards, empowering one to actively participate in the daily practice of self-management, are all essential elements. Attitude and motivation help to determine the likelihood of long-term success. Patients learn optimal techniques for their metered dose inhalers and other inhalation therapy techniques for both long-acting and rapid-acting bronchodilators. Breathing techniques, including pursed lips breathing, relieve dyspnea and improve gas exchange. Some patients require airway clearance techniques.
Oxygen is an essential component of self-management for hypoxemic patients for which there is no substitute. Family members are trained to support the patient without taking over. Patients are taught how to report to their doctor and develop a partnership. A critical component is exacerbation management. Patients are taught to recognize early signs and symptoms of an exacerbation and how to utilize their rapid action plan. This is the most important aspect of the patient-doctor relationship.
Disease management has a number of implications. Commonly, it is a method of improving long-term care for patients belonging to specific health plans. As such, these are population-based with a goal of reducing the frequency of hospitalizations.17,20 In our hands, we consider disease management as a systematic approach to long-term management of this patient population. As the disease is chronic and progressive with exacerbations of increasing frequency and severity, the need is long-term with increasing attention and reinforcement of skills.21 As taught in pulmonary rehabilitation, the patient learns to recognize the signs and symptoms of an exacerbation and begins the rapid action plan as guided by their doctor. The difference is that this system is long-term and there is a structure for it to be conducted over the long-term. There are a number of disease management plans and structures, and we are only in the initial stages of being able to measure the success of these various approaches.17
Disease management focuses on the early recognition and management of a changing medical state. A unique aspect of our approach is to use daily exercise as a modality for self-evaluation. Patients are taught not only to monitor themselves during daily life but also to focus on changes in dyspnea, effort, fatigue, and other important indicators during their exercise program. Small changes occurring during exercise stress may signal that an issue is starting to present, and the more significant medical issue may be averted by adjusting medications and/or oxygen supplementation, avoiding exposure to irritant materials, and numerous other items that may give rise to an exacerbation or decrease in function. Patients are therefore encouraged to keep activity logs of their experiences and, if small changes are noted that may lead to an exacerbation, either continue to monitor closely or implement the action plan and notify the physician.
Reconciling Goals of Pulmonary Rehabilitation and Disease Management
Pulmonary rehabilitation is acute and restorative. Programs teach patients how to care for themselves while building and enabling endurance and strength. However, when the patient leaves the program and goes back to the care of their own doctor, there is no mechanism for long-term continuation of the practice of skills or reinforcement of habits. As the disease is progressive, the challenges to successful management increase over time. Each exacerbation hospitalization renders the next acute care hospitalization more likely and more acute. Disease management is not acute and does not have a restorative component. It focuses on the long-term disease management process, allowing the patient and physician to actively manage the disease in a timely and direct manner.
Ideally, pulmonary rehabilitation and disease management are tied together in a system of long-term management that takes into account the trajectory of the disease and its impact on the patient and family. For the patient, the pulmonary rehabilitation should initiate a set of skills and habits that are reinforced for improving proficiency. Rather than the benefits waning as pathophysiology deteriorates, the patient should become better at managing their disease through long-term practice and skill reinforcement as part of their standard care plan. Thus, rehabilitation should impart a lifetime system of care with ready support from the health care team.22 A rapid action plan should be an integral part of the program in order to successfully manage exacerbations.
Brian L. Tiep, MD, FAACVPR, is medical director, Respiratory Disease Management Institute, Monrovia, Calif, and director of pulmonary rehabilitation, City of Hope, Duarte, Calif.
Rick Carter, PhD, MBA, is professor, exercise sciences, Lamar University, Beaumont, Tex.
For further information, contact [email protected]
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- Lacasse Y, Martin S, Lasserson TJ, Goldstein RS. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. A Cochrane systematic review. Eura Medicophys. 2007;43:475-85.
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- Tiep BL Carter R. COPD Disease Management. ATS Best of the Web Series. New York: American Thoracic Society; 2007. Available at: http://www.thoracic.org/clinical/best-of-the-web/pages/obstructive-disease/copd-disease-management.php Accessed May 30, 2012
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- Porszasz J, Emtner M, Gotos S, Somfay A, Whipp BJ, Casaburi R. Exercise training decreases ventilatory requirements and exercise-induced hyperinflation at submaximal intensities in patients with COPD. Chest. 2005;128:2025-34.
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- Tiep BL, Barnett M, Tiep R. Oximetry Video (Patient Training Video) 2011. Available at: www.pulrehab.org. Accessed May 30, 2012.
- Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients. Am J Respir Crit Care Med. 2003;168:1034-42.
- Somfay A, Porszasz J, Lee SM, Casaburi R. Dose-response effect of oxygen on hyperinflation and exercise endurance in nonhypoxaemic COPD patients. Eur Respir J. 2001;18:77-84.
- Tiep B, Carter R. Oxygen conserving devices and methodologies. Chron Respir Dis. 2008;5:109-14.
- Bourbeau J, Collet JP, Schwartzman K, Ducruet T, Nault D, Bradley C. Economic benefits of self-management education in COPD. Chest. 2006;130:1704-11.
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- Maltais F, Bourbeau J, wShapiro S, et al; Chronic Obstructive Pulmonary Disease Axis of Respiratory Health Network. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008;149:869-78.
- Bourbeau J, Julien M, Maltais F, et al; Chronic Obstructive Pulmonary Disease Axis of Respiratory Health Network. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med. 2003;163:585-91.
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- Chavannes NH, Grijsen M, van den Akker M, et al. Integrated disease management improves one-year quality of life in primary care COPD patients: a controlled clinical trial. Prim Care Respir J. 2009;18:171-6.