O6.1 Pulmonary rehabilitation

Non-pharmacological strategies (such as pulmonary rehabilitation and regular exercise) should be provided to all patients with COPD [evidence level I, strong recommendation]

Pulmonary rehabilitation programs involve patient assessment, supervised exercise training, education, behaviour change, nutritional intervention and psychosocial support (Spruit 2013). The aim of pulmonary rehabilitation is to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviours (Spruit 2013). Exercise training is considered to be the cornerstone of pulmonary rehabilitation (Spruit 2013).

The benefits of pulmonary rehabilitation include a reduction in symptoms (dyspnoea and fatigue), anxiety and depression, and improvements in health-related quality of life (HRQoL), peripheral muscle function and exercise capacity. Following pulmonary rehabilitation, participants have been shown to gain an enhanced sense of control over their condition (Alison 2017, McCarthy 2015, Bolton 2013, Ries 2007, Gordon 2019, Paneroni 2020) [evidence level I/II]. There is also evidence that pulmonary rehabilitation reduces hospitalisation for exacerbations of COPD (Moore 2016) [evidence level I]. A systematic review of 21 studies (Moore 2016) reported the effects of pulmonary rehabilitation on subsequent hospitalisation for exacerbations of COPD. The meta-analysis included 18 studies (10 RCTs, five observational before and after studies, and three cohort studies) of which five studies were carried out in Australia or New Zealand.  Data from the RCTs, and from the five observational studies that compared hospital admissions in the 12 months before and following pulmonary rehabilitation, favoured rehabilitation (RCTs: mean [95% CI] number of hospitalisations/patient-year 0.62 [0.33 to 1.16] PR group versus. 0.97 [0.67 to 1.40] control group; before and after studies mean [95% CI] number of hospitalisations/patient-year 0.47 [0.28 to 0.79] pre-PR versus. 1.24 [0.66 to 2.34] post-PR). Results of the cohort studies did not support this finding. Pooled analysis of the three cohort studies showed a higher rate of hospitalisation (mean [95% CI] number of hospitalisations/patient-year in the PR group 0.28 [0.25 to 0.32]) compared to the reference group (0.18 [0.11 to 0.32]); however, this finding was influenced predominantly by the results from one study. Pulmonary rehabilitation has also been shown to be cost-effective (Griffiths 2001) [evidence level II].

Most research has been undertaken with hospital-based programs which may use exercise machines such as treadmills, stationary cycles, arm and rowing ergometers for aerobic training, and weight machines for resistance training, but there is also evidence of benefit from pulmonary rehabilitation provided to in-patients, and in community and home settings where programs involve regular face-to-face contact to facilitate exercise participation and exercise progression (Ries 2007, Spruit 2013, McCarthy 2015, Alison 2017). Travel and transport are consistently identified as barriers to participants undertaking programs that include supervised exercise training (Keating 2011). A systematic review and meta-analysis compared exercise training programs (ETPs) delivered in patients’ homes (7 trials, n=319) or community settings (3 trials n=129) with out-patient (10 trials, n=486) ETPs in people with stable COPD (Wuytack 2018).  Trials selected for this review were ETPs of at least 4 weeks duration with or without additional components often included in pulmonary rehabilitation programs such as patient education and nutritional support. Programs were equally effective for improving quality of life and exercise capacity irrespective of the setting (Wuytack 2018) [evidence level I]. A systematic review and meta-analysis of 15 RCTs comparing home-based pulmonary rehabilitation of at least 4 weeks duration to usual care or centre-based pulmonary rehabilitation, demonstrated that home-based pulmonary rehabilitation is as effective as centre-based pulmonary rehabilitation in improving functional exercise capacity and quality of life compared to usual care (Uzzaman 2022) [evidence level I]. A systematic review and meta-analysis of 19 RCTs comparing the effect of minimal equipment programs with usual care or with exercise equipment-based programs, demonstrated that pulmonary rehabilitation programs using minimal equipment elicit clinically significant improvements in 6-minute walk distance and health-related quality of life and are comparable with exercise equipment-based programs for improving 6-minute walk distance and upper limb and lower limb strength (Cheng 2023) [evidence level I]. These systematic review findings are important because providing programs in community and home-based settings where access to gymnasiums and equipment is limited may enable greater access to pulmonary rehabilitation and overcome some of the barriers to program uptake and completion.

Pulmonary rehabilitation should be offered to patients with COPD who are limited by shortness of breath on exertion and can be relevant for people with any long-term respiratory disorder characterised by dyspnoea (Ries 2007, Spruit 2013, Alison 2017). Patients with COPD, of all mMRC grades, gain significant benefit from rehabilitation (Evans 2009, Altenburg 2012, Rugbjerg 2015). However, those with the most severe dyspnoea, i.e. those who are breathless at rest or on minimal activity (mMRC grade 3 and 4) are more likely to have difficulties attending out-patient programs for reasons that include problems with transportation (Sabit 2008). Exacerbations of COPD are also an indication for referral to pulmonary rehabilitation (Spruit 2013) and every effort should be made to encourage patients to resume their rehabilitation program as early as possible following an exacerbation (see X3.6 Pulmonary rehabilitation).

Telerehabilitation may enable people with high symptom burden or travel restrictions to access pulmonary rehabilitation. Telerehabilitation is the delivery of rehabilitation services at a distance using information and communication technology (Kairy 2009). Communication between the health professional and the patient in their home may utilise telephone (including text messaging), internet or videoconferencing technologies (Hwang 2015).

In an Australian randomised controlled study comparing an initial 8-week, twice weekly, supervised home-based pulmonary video-conferenced telerehabilitation program compared to a centre-based pulmonary rehabilitation program, there were no significant differences between the groups for any outcome at either 8 weeks or 12 months follow-up, and both groups achieved meaningful improvement in dyspnoea and exercise capacity at the end of rehabilitation (Cox 2022) [evidence level II]. In a Cochrane review including 15 studies, there was no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured by 6-minute walking distance (6MWD) (mean difference (MD) 0.06m, 95% CI -10.82m to 10.94m), quality of life measured by the St George’s Respiratory Questionnaire (MD -1.26, 95% CI -3.97 to 1.45), or breathlessness measured by the Chronic Respiratory Disease Questionnaire dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40). Telerehabilitation was associated with higher completion rates compared to in-person pulmonary rehabilitation (93% vs 70%). Ongoing maintenance telerehabilitation was associated with a greater 6MWD by 78.1m (95% CI 49.6m-106.6m) (Cox 2021) [evidence level I]. Long-term telerehabilitation consisting of 2 years of unsupervised exercise at home on a treadmill and strength training, plus either supervised exercise sessions once/week for 8 weeks or supervised exercise sessions once/week for 8 weeks followed by once/month for the 2 year duration of the study, reduced the rate of hospitalisations and ED presentations compared to standard care (Zanaboni 2022) [evidence level II].

Exercise programs alone have clear benefits (McCarthy 2015) while the benefits of education or psychosocial support without exercise training are less well documented (Ries 2007, Spruit 2013, Alison 2017). There are few robust studies that have attempted to evaluate the role of disease-specific education within a pulmonary rehabilitation program in addition to exercise training. An RCT, carried out in Australia, of 267 people with COPD failed to show any additional benefit with the combination of an 8-week pulmonary rehabilitation program comprising exercise training and disease-specific education with a self-management focus, compared to exercise training alone. The outcomes assessed in this study included disease-specific and generic HRQoL, functional exercise capacity, dyspnoea, health behaviours, self-efficacy and healthcare utilisation (respiratory-related hospital admissions, physician consultations and prescriptions) (Blackstock 2014). Further, a sub-analysis undertaken within the Cochrane Review of pulmonary rehabilitation for people with COPD showed no significant differences in the magnitude of improvement in HRQoL between programs that delivered exercise training alone (31 trials) when compared to those that delivered exercise training combined with any form of education and/or psychosocial support (34 trials) (McCarthy 2015).

Some patients who experience marked oxygen desaturation on exertion may benefit from ambulatory oxygen during exercise training and activities of daily living (see section P10 Oxygen therapy).

The duration of pulmonary rehabilitation programs reported in the literature ranges from 4 weeks to 18 months. Many programs within Australia and New Zealand are of 8 weeks duration, with patients attending two supervised group sessions each week supplemented by an unsupervised home exercise program (Alison 2017) consistent with the recommendations reported in pulmonary rehabilitation statements (Spruit 2013) and international guidelines (Bolton 2013, Marciniuk 2010, Ries 2007).  It is unclear as to whether greater or more sustained benefits occur following programs of longer duration because there are no RCTs that directly compare the outcomes of 8-week programs with those of longer programs.

The improvements in functional exercise capacity and HRQoL begin to decline by 12 months following completion of a pulmonary rehabilitation program (Brooks 2002, Ries 2003).  For this reason, within Australia, patients may be offered supervised exercise training at a lower frequency (≤1 session per week) than the initial pulmonary rehabilitation program (unpublished data Lung Foundation Australia, 2015). Several studies have investigated maintenance strategies aimed at preserving the benefits in exercise capacity and HRQoL (Spruit 2013, Alison 2017); however, more research is needed before any specific strategy can be recommended. A Cochrane review of 21 studies comparing supervised maintenance pulmonary rehabilitation programs with usual care showed an improvement in health-related quality of life at 6-12 months (Chronic Respiratory Disease Questionnaire total score mean difference (MD) 0.54 points, 95% CI 0.04-1.03, n=258, 4 studies, which exceeds the minimal important difference of 0.5 points). It is uncertain whether supervised maintenance programs improve 6-minute walk distance (MD 26 meters, 95% CI -1.04 – 52.84, n=639, 10 studies) (Malaguti 2021). Unsupervised home-based exercise for 12 months has been shown to improve 1-minute sit-to-stand performance compared to usual care, had no effect on dyspnoea, but was well accepted by people with COPD (Frei 2022) [evidence level III-2]. Whilst the optimal model for supervised maintenance exercise programs is still unclear, some form of regular exercise should be encouraged following completion of a pulmonary rehabilitation program to sustain the benefits gained (Alison 2017). There is some evidence (n=2 RCT) that repeating a course of pulmonary rehabilitation within 12 months following an initial program may be beneficial (Burge 2022) [evidence level I].

A list of pulmonary rehabilitation programs known to Lung Foundation Australia can be accessed at Pulmonary Rehabilitation – Lung Foundation Australia. The individual contact details can be obtained by calling the Lung Foundation’s Information and Support Centre (free-call 1800 654 301). An online toolkit is available to assist health professionals to implement a Pulmonary Rehabilitation Program. See www.pulmonaryrehab.com.au.