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, 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].  This finding is important because providing programs in community and home-based settings may 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 (Alison 2017, Spruit 2013, Ries 2007). 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 section 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). A 12-month program of home-based telerehabilitation included both an exercise program at home (three times weekly) following a two-month hospital-based pulmonary rehabilitation program as well as self-management education, regular review by a team of health professionals via phone or Skype weekly, self-monitoring of lung function and access to a helpline. This program was compared with a hospital-based pulmonary rehabilitation program twice weekly and to usual care. The control group had no initial pulmonary rehabilitation and both groups received sustained intensive pulmonary rehabilitation. Both home-based telerehabilitation and centre-based pulmonary rehabilitation reduced exacerbations and hospitalisations compared with usual care (mean+SD for exacerbations 1.7+1.7 versus. 1.8+1.4 versus. 3.5+1.8 respectively, p<0.001; hospitalisations 0.3+0.7 versus. 0.3+0.6 versus. 1.2+1.7 respectively, p<0.001). The home-based telerehabilitation group also had a lower rate of ED attendances in the 12 months of follow-up than the hospital-based group and usual care group (0.5+0.9 versus. 1.8+1.5 versus 3.5+1.8 respectively, p<0.001). The home-based program was intensive and the results impressive, however a cost analysis was not included in the study (Vasilopoulou 2017). In an Australian study comparing an initial 8 week, twice weekly supervised home-based pulmonary 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]. According to a systematic review and meta-analysis by Bonnevie et al of 15 eligible trials, only small improvements of doubtful clinical significance were attained by at home-based exercise therapy delivered using advanced telehealth technology. Exercise capacity measured by the six-minute walk test improved with a mean benefit of 15 minutes, (95% CI 5-24) (MCID is considered to be 25 minutes). Similar limited level of benefit was seen in functional dyspnoea and quality of life compared with no exercise therapy.  What benefits were demonstrated were generally similar to in/outpatient exercise therapy, and similar to or slightly better than home-based exercise therapy without advanced telehealth technology (Bonnevie 2021). Whilst telerehabilitation may not be equivalent to centre-based pulmonary rehabilitation for all outcomes, it is safe and achieves clinically meaningful benefits, and when centre-based pulmonary rehabilitation is not available, telerehabilitation may provide an alternative program model.

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).

A list of pulmonary rehabilitation programs known to Lung Foundation Australia can be accessed at https://lungfoundation.com.au/patients-carers/support-services/lung-disease-and-exercise/pulmonary-rehabilitation. 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.