Pulmonary Rehabilitation
I The following definition of pulmonary rehabilitation was drafted and adopted in 1999 by the American Thoracic Society:
II Pulmonary Rehabilitation Program
A Community assessment and planning before a program is started are crucial.
1. Assess the demographic profile of patients in the target community.
2. Evaluate medical (physician) interest and awareness.
B Assessment of program resources
1. Determine available versus needed space and equipment.
2. Identify clinical personnel desired versus personnel available.
C Alternatives in program structure
1. Inpatient pulmonary rehabilitation, which may include hospital, skilled nursing facility, or rehabilitation hospital
a. Individual or group education and breathing retraining are scheduled for the patient in a general acute care unit 5 to 7 days/week.
b. Individual low-level bedside or ambulatory exercise is instituted.
c. Patients may be prepared for follow-up evaluation in an outpatient rehabilitation setting.
d. Few are structured as comprehensive multidisciplinary 1- to 2-week inpatient programs because of reimbursement limitations, time constraints, and patient acuity.
e. Most commonly created to serve rehabilitation needs of patients with greatest acuity and complex long-term needs.
2. Outpatient pulmonary rehabilitation, conducted in outpatient hospital-based clinic, comprehensive outpatient rehabilitation facility (CORF), or extended care facility
a. These are the most common formats used for pulmonary rehabilitation.
b. Usually these programs involve two or five visits per week, but program lengths vary from 4 to 12 weeks, with 6 to 8 weeks the norm.
c. Individual or small group (two to five patients) exercise and educational sessions are instituted.
3. Outpatient office-based pulmonary rehabilitation
a. These programs may include some components of outpatient programs, such as education, breathing retraining, and exercise testing and prescription.
b. A pulmonary physician, pulmonary nurse specialist, and/or respiratory care practitioner usually implements the program.
4. Home-based pulmonary rehabilitation
a. These programs may include education, breathing retraining, and a simple exercise routine.
b. They may be included in the home care services of visiting nursing agencies or occasionally by the respiratory equipment providers.
c. They are generally less comprehensive in scope than hospital- or clinic-based programs, with visits often fewer than once per week.
d. They may be the only alternative for the homebound patient or when nearby hospitals do not have a pulmonary rehabilitation program.
e. Such programs may serve as a final rehabilitative transition from other more comprehensive and intensive program formats.
D Advantages and disadvantages of various pulmonary rehabilitation settings
1. Inpatient rehabilitation advantages
a. Reserved for the most acute patients with the greatest functional deficits, monitoring by professional staff is available 24 hr/day.
b. Allows staff to teach and observe family/patient interaction during therapies.
c. Best for patients requiring assistive devices, suctioning, tracheostomy care, or long-term ventilation.
2. Inpatient rehabilitation disadvantages
a. Most labor intensive and costly format
b. Transportation/availability of family members may be problematic.
3. Outpatient rehabilitation advantages
a. Most efficient use of professional staff
b. Typically greatest scope of professional staff is available.
c. Largest exposure (availability and accessibility) to target patient population
4. Outpatient rehabilitation disadvantages
a. Requires a certain base level of functional ability to access program
b. Transportation and availability of patient and/or family members may be issues.
c. External variables such as weather and pollution alerts may present barriers.
5. Home-based pulmonary rehabilitation advantages
a. Most convenient for patient and family
b. Transportation and availability of patient/family generally are nonissues.
c. Adaptation of exercises to a familiar environment may lead to greater compliance and offer identification by staff of home limits/barriers.
6. Home-based pulmonary rehabilitation disadvantages
a. Limited availability of sophisticated monitoring, testing, and exercise equipment
b. Most labor intensive, being one on one, and requires professional staff travel
c. The smallest scope of professional staff generally is available.
d. Usually the most questionably reimbursed rehabilitation format
E Multidisciplinary team approach
1. Clinicians from a variety of health care disciplines are necessary participants in a pulmonary rehabilitation program.
2. The number of contributing disciplines varies with the size, scope, availability, and setting of the pulmonary rehabilitation program.
3. If some or all of these disciplines are not available, a simple team composed of the physician and respiratory care practitioner, nurse, or physical therapist can provide thorough pulmonary rehabilitation in any of the previously mentioned settings.
4. Team members should have special interest or training in meeting the needs of patients with pulmonary disease.
5. Each team member should be qualified in their area of expertise to assess the patient’s needs, provide appropriate intervention, and monitor patient outcomes.
6. Each team member must be fully versed in their role and educational content, as well as completely aware of the role and content of each of the other disciplines represented.
7. All team members should be minimally trained in basic cardiac life support and ideally trained in advanced cardiac life support.
a. Are attended by all team members at regular intervals (e.g., weekly or monthly)
b. Provide a forum for initial goal setting, plan formation, and ongoing discussion of patients’ progress and discharge goals
c. Facilitate dissemination of general program information to team members (e.g., quality assurance findings, policy and procedure changes)
F Team members and their roles
a. A licensed physician with an interest in and knowledge of pulmonary rehabilitation, pulmonary function, and exercise evaluation
b. A pulmonary physician commonly fills this role.
c. Reviews and oversees all policies and procedures of the program
d. Reviews and oversees all billing and reimbursement practices
e. Participates in the initial screening of patients
(1) Reviews the medical history, medications, and diagnostic test results
f. Performs an educational and administrative role in advanced medical care planning/advanced directives
g. Represents the program to hospital administration, medical staff colleagues, and the community
h. May initiate, review, participate in, and evaluate pulmonary rehabilitation research
2. The program coordinator should be trained in a health-related profession and have demonstrated clinical experience and expertise in the care of patients with chronic pulmonary disease.
a. A respiratory care practitioner, registered nurse, or registered physical therapist commonly fills this role.
b. May serve a combined role as program coordinator and primary patient care provider/educator with responsibilities to
(1) Develop and revise program policies and procedures
(2) Implement and oversee daily program activities
(a) Assess weight, heart and breath sounds, respiratory and other symptoms, sleep, appetite, and adherence to home medication and exercise regimen at each patient visit
(3) Maintain written and verbal communication with each patient’s referring physician
(4) Participate in the development and implementation of program marketing plan
(5) Collect and report program quality assurance data
(6) Collect and report billing and reimbursement data
(7) Review current pulmonary rehabilitation literature and update protocols and equipment as indicated
(8) Represent the program to other hospital departments and to the community
c. Provides patient education on select topics
(1) Medications, with emphasis on indications, actions, side effects, drug interactions, and prescription compliance
(2) Respiratory anatomy and pathophysiology of chronic pulmonary disease
(3) Sequelae of chronic pulmonary disease
(4) Sleep disorders common to chronic pulmonary disease
(5) Description of medical procedures and test results used in pulmonary medicine
(6) Exercise testing, techniques, and conditioning
(7) Activities of daily living (ADLs)
(8) Breathing retraining, relaxation, and stress management techniques
(9) Oxygen therapy and bronchial hygiene techniques
(10) Functional self-management (e.g., self-assessment and management of symptoms, early intervention, and seeking medical attention)
d. Commonly participates in exercise testing
e. Performs assistance as needed with ADLs
f. Assesses the need for home care equipment/supplies and personnel
a. Evaluates nutritional status of patients
(3) Review of food record or calorie count
(4) Laboratory indices (e.g., total protein, albumin, cholesterol, phosphate, magnesium, transferrin, and calcium values)
(5) Anthropometric measurements (e.g., skinfold thickness, arm muscle circumference)
b. Recommends individual dietary modifications, including calories, components, supplements, and meal scheduling as indicated
a. Screens patients and families for evidence of psychosocial problems warranting referral or further treatment
b. Assesses and discusses with patients and families the impact of pulmonary disease on self-esteem, lifestyle, and relationships
c. Provides information on community resources to meet social, vocational, financial, transportation, and counseling needs
d. Assists physician and clergy in performing an educational and administrative role in advanced medical care planning/advanced directives
5. Psychologist or psychiatrist
a. Most often serves the pulmonary rehabilitation program on a consultant basis for select patients and families
b. Administers and interprets psychological tests
c. Conducts ongoing group or individual therapy
d. Recommends or prescribes psychotropic medications (e.g., anxiolytics, antidepressants, and sedative hypnotics)
a. Evaluates the impact of chronic pulmonary disease on the patient’s ability to perform ADLs and home maintenance, social, and vocational activities
b. Provides instruction and opportunities for practice in energy conservation and work simplification techniques
c. Recreational and leisure activity assessment and education
d. Includes instruction on coordinated breathing strategies
e. Recommends vocational alternatives or modifications for continued employment in the same setting
a. Serves as program coordinator and primary patient caregiver in some institutions
b. Teaches relaxation and biofeedback techniques
c. Provides consultation, treatment, and modified exercise recommendations for pulmonary rehabilitation patients with specific neuromusculoskeletal conditions
d. May design warm-up, strengthening, and toning exercise routines
a. Provides consultation to program staff on medication selections, actions, and interactions
b. May provide group education to patients and families on medications
a. Participates in exercise testing and prescription
b. May assist in conducting or monitoring group exercise sessions
a. May receive referrals as a consultant for patients and families with identified spiritual concerns
b. Provides spiritual counseling on issues such as death, dying, and quality of life, assisting physician and social worker in performing an educational and administrative role in advanced medical care planning/advanced directives
III Evaluation of the Pulmonary Rehabilitation Candidate
A Thorough screening of each patient is essential to the optimal planning and success of the individual treatment program.
B Pulmonary rehabilitation is indicated for patients with chronic respiratory impairment who, despite optimal medical management, remain dyspneic, have reduced exercise tolerance, or a restriction in activities. It is therefore not exclusionary on a disease-specific basis.
C The ideal candidate meets the following criteria.
1. Correctly diagnosed with symptomatic chronic pulmonary disease (most commonly chronic obstructive pulmonary disease [COPD]); however, with recent expansion to also include
g. Selected neuromuscular disease
h. Thoracic/abdominal surgical perioperative state
2. Willing and motivated to participate in the program
3. Free from concurrent medical problems precluding safe, successful program participation, such as
a. Recent myocardial infarction or ischemic heart disease
d. Severe pulmonary hypertension
e. Febrile or symptomatic infectious illness
f. Significant hepatic dysfunction
h. Recent gastrointestinal (GI) bleeding
i. Severe disabling neuromusculoskeletal condition
k. Psychiatric disorder or substance abuse, with significant impairment in concentration, motivation, judgment, or mood
l. Physical limitations secondary to poor eyesight, hearing, or orthopedic impairment may require modified techniques but should not represent a barrier to participation in pulmonary rehabilitative programs.
D The program medical director and primary patient caregiver (usually the program coordinator) should participate in the initial evaluation visit.
1. The patient should undergo a physical examination (see Chapter 18).
2. A patient and family medical history interview is conducted with assessment of the following
a. Respiratory symptoms: Onset, duration, severity, and ameliorating or aggravating factors
b. Family history of respiratory problems
c. Childhood respiratory health and illness
e. General medical and surgical history
f. Effects of pulmonary disease on quality of life
g. Exercise/activity abilities
h. Dependence versus independence in ADLs
i. Impairment in occupational performance
j. Current medications and schedule
k. History of psychosocial issues, such as depression and/or anxiety
l. Patient social support network
m. Use of assistive devices, such as cane, walker, or wheelchair
3. The goals and expectations of the patient and family are determined.
4. The program’s overall goals, activities, and expected benefits (Box 31-1), as well as limitations and risks, should be explained verbally and detailed on an informed written consent or program contract form.
a. Program risks/hazards are typically precipitated by exercise and are usually either
(1) An acute cardiac or respiratory event
