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Integration of pulmonary rehabilitation in COPD
Comment
Integration of pulmonary rehabilitation in COPD See Correspondence page 26
Pulmonary rehabilitation should be a part of integrated care of patients with chronic obstructive pulmonary disease (COPD).1,2 Patients with COPD have progressive irreversible airflow limitation, which can induce overt breathlessness during exercise and later also in rest. Breathlessness can affect exercise tolerance and disease-specific health status in COPD. Additionally, extrapulmonary features can contribute to the daily burden of COPD. Indeed, skeletal muscle weakness and wasting are related to reduced disease-specific health status and exercise intolerance in COPD, irrespective of the degree of airflow limitation.3 Decreased levels of daily physical activity in COPD have not been linked to the degree of disease severity. Consequently, supervised physical exercise training is the basis of pulmonary rehabilitation. International guidelines recommend progressive highintensity physical exercises, such as ergometry cycling, treadmill walking, strengthening exercises for muscle groups of the upper and lower limbs, and unsupported
arm exercises at least three times a week for 6–12 weeks.1,4 Self-management and educational programmes can be beneficial and could have additional positive effects on the wellbeing of patients with COPD.4 By contrast, the effects of psychosocial interventions, hormonal supplements, and nutritional supplements remain disputable,4 although a rationale does exist to add these components to pulmonary rehabilitation of patients who have severe symptoms of anxiety or depression, hypogonadism, or cachexia.5 Recent definitions of pulmonary rehabilitation emphasise tailoring the programme to the individual, an interdisciplinary approach, and outcomes based on physiological and psychosocial measures that consider a global dimension to the patient’s health status and that of their families.1 This individual treatment seems possible only by carefully phenotyping the complex extrapulmonary features that are often reported in COPD before the start of pulmonary rehabilitation,6 including (unknown) coexisting morbidities such as chronic heart
6 Outpatient consultation with chest physician for patients with COPD who are symptomatic or have decreased daily-life activity, irrespective of degree of airflow limitation
1
Specialised centre for COPD rehabilitation Intake Assessment of: Physical functioning (cardiopulmonary exercise test, 6-min walking test, skeletal muscle function tests, pulmonary function tests) Body composition (bioelectrical impedance assessment, dual X-ray absorptiometry scan, body-mass index) Psychosocial functioning (Hospital Anxiety and Depression scale) Functional effects (Medical Research Council dyspnoea scale, Canadian occupational performance measure) Health status (St George’s respiratory questionnaire) Coexisting morbidities (metabolic syndrome, cardiovascular disease, and obstructive sleep apnoea syndrome) Evaluation of results of assessment with patient present Development of interdisciplinary treatment plan
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Outpatient pulmonary rehabilitation in general hospital
4 Inpatient or outpatient pulmonary rehabilitation at specialised rehabilitation centre
Specialised centre for COPD rehabilitation Assessment of: Physical functioning Body composition Psychosocial functioning Functional impact Health status Evaluation of results of pulmonary rehabilitation with patient present
Figure: Processes of pulmonary rehabilitation centres Patients with COPD who are symptomatic or who complain of having decreased daily life-activity at outpatient consultation with chest physician, even if receiving optimum drug treatment, need referral to specialised rehabilitation centre (1) for interdisciplinary intake and assessment (2). From that assessment, and taking into account travel distance from patient’s home to rehabilitation centre, interdisciplinary team decides whether patient will enter outpatient (3) or inpatient (4) pulmonary rehabilitation. Such programmes at different general hospitals and specialised centres are similar. After completion of programme, patients need to return to specialised rehabilitation centre for outcome assessment to evaluate response (5). Finally, patients are referred back to their chest physicians for structured aftercare as part of continuous disease management (6).
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www.thelancet.com Vol 371 January 5, 2008
Comment
failure,7 obstructive sleep apnoea syndrome,8 and the metabolic syndrome.9 At present, the effect of pulmonary rehabilitation on survival in patients with COPD remains unknown. Nevertheless, changes in daily symptom burden, emotional function, patient’s control over disease, disease-specific health status, and exercise tolerance after pulmonary rehabilitation in patients with moderate to very severe airflow limitation were significantly greater than in COPD controls receiving usual care. Indeed, mean differences in changes in breathlessness (mean effect size 1·06, 95% CI 0·85 to 1·26, points per question), fatigue (0·92, 0·71 to 1·13), emotional function (0·76, 0·52 to 1·00), and patient’s control over disease (0·97, 0·74 to 1·20), as assessed with the Chronic Respiratory Disease Questionnaire,10 exceeded the minimum clinically important difference of 0·5 points per question on a seven-point scale.11 Moreover, the mean total score on the St George’s Respiratory Questionnaire, a disease-specific healthstatus questionnaire, improved by −6·11 points (−8·98 to −3·24);10 the minimum clinically important difference is −4 points.12 The mean improvement in peak cycling load was modest (8·43 W, 3·45 to 13·41); however, the mean difference in change in 6-min walking distance after pulmonary rehabilitation (48·46 m, 31·64 to 65·28)10 was below the mean minimum clinically important difference of 54 m, but was still within its 95% CI (37 to 71).13 Pulmonary rehabilitation is also cost effective. The numbers of days in hospital because of acute COPD exacerbations in the first year after an outpatient pulmonary rehabilitation programme decreased by about 50% compared with usual care.14 Thus pulmonary rehabilitation can be regarded as a value-based intervention for patients with COPD, irrespective of the degree of airflow limitation. Unfortunately, access to pulmonary rehabilitation remains limited and is underfunded in most countries. This situation might be partly because pulmonary rehabilitation is often fragmented between providers and settings, leading to poor continuity of care in COPD, systematic inefficiencies, and reduced ability to make high-quality interdisciplinary pulmonary rehabilitation available for patients. Pulmonary rehabilitation centres need to have a process-based organisation to manage business around www.thelancet.com Vol 371 January 5, 2008
their core processes (eg, intake and assessment, rehabilitation, outcome assessment, and aftercare; figure). Indeed, such organisation, with functional expertise and product and customer orientation, will most probably lead to cost reductions and improvements in quality in pulmonary rehabilitation. Additionally, specialised rehabilitation centres can increase their capacity by sharing their knowledge with general hospitals through decentralisation, including resource allocation, which will provide an appropriate response to the increasing interest in pulmonary rehabilitation for patients with COPD. *Martijn A Spruit, Ingrid Vanderhoven-Augustin, Paul P Janssen, Emiel F M Wouters Centre for Integrated Rehabilitation of Organ failure (CIRO), 6085 NM Horn, Netherlands (MAS, IVA, PPJ, EFMW); and University Hospital Maastricht, Maastricht, Netherlands (EFMW) [email protected] MAS has received lecture fees from GlaxoSmithKline and Air Liquide. IVA and PPJ declare that they have no conflict of interest. EFMW has consulted for or received honoraria, lecture fees, or research grants from AltanaPharma, AstraZeneca, BoehringerIngelheim, GSK, Numico, and Pfizer. 1
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Nici L, Donner C, Wouters E, behalf of the ATS/ERS Pulmonary Rehabilitation Writing Committee. American Thoracic Society/European Respiratory Society Statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390–413. Wilt TJ, Niewoehner D, MacDonald R, Kane RL. Management of stable chronic obstructive pulmonary disease: a systematic review for a clinical practice guideline. Ann Intern Med 2007; 147: 639-53. Baarends EM, Schols AM, Mostert R, Wouters EF. Peak exercise response in relation to tissue depletion in patients with chronic obstructive pulmonary disease. Eur Respir J 1997; 10: 2807–13. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest 2007; 131(suppl 5): 4S–42S. Spruit MA, Wouters EF. New modalities of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Sports Med 2007; 37: 501–18. Wouters EF. Management of severe COPD. Lancet 2004; 364: 883–95. Rutten FH, Cramer MJ, Grobbee DE, et al. Unrecognized heart failure in elderly patients with stable chronic obstructive pulmonary disease. Eur Heart J 2005; 26: 1887–94. Weitzenblum E, Chaouat A. Sleep and chronic obstructive pulmonary disease. Sleep Med Rev 2004; 8: 281–94. Marquis K, Maltais F, Duguay V, et al. The metabolic syndrome in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2005; 25: 226–32. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007; 3: CD003793. Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials 1989; 10: 407–15. Jones PW. St. George’s Respiratory Questionnaire: MCID. COPD 2005; 2: 75–79. Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small differences in functional status: the Six Minute Walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997; 155: 1278–82. Griffiths TL, Phillips CJ, Davies S, Burr ML, Campbell IA. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001; 56: 779–84.
13
Integration of pulmonary rehabilitation in COPD See Correspondence page 26
Pulmonary rehabilitation should be a part of integrated care of patients with chronic obstructive pulmonary disease (COPD).1,2 Patients with COPD have progressive irreversible airflow limitation, which can induce overt breathlessness during exercise and later also in rest. Breathlessness can affect exercise tolerance and disease-specific health status in COPD. Additionally, extrapulmonary features can contribute to the daily burden of COPD. Indeed, skeletal muscle weakness and wasting are related to reduced disease-specific health status and exercise intolerance in COPD, irrespective of the degree of airflow limitation.3 Decreased levels of daily physical activity in COPD have not been linked to the degree of disease severity. Consequently, supervised physical exercise training is the basis of pulmonary rehabilitation. International guidelines recommend progressive highintensity physical exercises, such as ergometry cycling, treadmill walking, strengthening exercises for muscle groups of the upper and lower limbs, and unsupported
arm exercises at least three times a week for 6–12 weeks.1,4 Self-management and educational programmes can be beneficial and could have additional positive effects on the wellbeing of patients with COPD.4 By contrast, the effects of psychosocial interventions, hormonal supplements, and nutritional supplements remain disputable,4 although a rationale does exist to add these components to pulmonary rehabilitation of patients who have severe symptoms of anxiety or depression, hypogonadism, or cachexia.5 Recent definitions of pulmonary rehabilitation emphasise tailoring the programme to the individual, an interdisciplinary approach, and outcomes based on physiological and psychosocial measures that consider a global dimension to the patient’s health status and that of their families.1 This individual treatment seems possible only by carefully phenotyping the complex extrapulmonary features that are often reported in COPD before the start of pulmonary rehabilitation,6 including (unknown) coexisting morbidities such as chronic heart
6 Outpatient consultation with chest physician for patients with COPD who are symptomatic or have decreased daily-life activity, irrespective of degree of airflow limitation
1
Specialised centre for COPD rehabilitation Intake Assessment of: Physical functioning (cardiopulmonary exercise test, 6-min walking test, skeletal muscle function tests, pulmonary function tests) Body composition (bioelectrical impedance assessment, dual X-ray absorptiometry scan, body-mass index) Psychosocial functioning (Hospital Anxiety and Depression scale) Functional effects (Medical Research Council dyspnoea scale, Canadian occupational performance measure) Health status (St George’s respiratory questionnaire) Coexisting morbidities (metabolic syndrome, cardiovascular disease, and obstructive sleep apnoea syndrome) Evaluation of results of assessment with patient present Development of interdisciplinary treatment plan
2
3
5
Outpatient pulmonary rehabilitation in general hospital
4 Inpatient or outpatient pulmonary rehabilitation at specialised rehabilitation centre
Specialised centre for COPD rehabilitation Assessment of: Physical functioning Body composition Psychosocial functioning Functional impact Health status Evaluation of results of pulmonary rehabilitation with patient present
Figure: Processes of pulmonary rehabilitation centres Patients with COPD who are symptomatic or who complain of having decreased daily life-activity at outpatient consultation with chest physician, even if receiving optimum drug treatment, need referral to specialised rehabilitation centre (1) for interdisciplinary intake and assessment (2). From that assessment, and taking into account travel distance from patient’s home to rehabilitation centre, interdisciplinary team decides whether patient will enter outpatient (3) or inpatient (4) pulmonary rehabilitation. Such programmes at different general hospitals and specialised centres are similar. After completion of programme, patients need to return to specialised rehabilitation centre for outcome assessment to evaluate response (5). Finally, patients are referred back to their chest physicians for structured aftercare as part of continuous disease management (6).
12
www.thelancet.com Vol 371 January 5, 2008
Comment
failure,7 obstructive sleep apnoea syndrome,8 and the metabolic syndrome.9 At present, the effect of pulmonary rehabilitation on survival in patients with COPD remains unknown. Nevertheless, changes in daily symptom burden, emotional function, patient’s control over disease, disease-specific health status, and exercise tolerance after pulmonary rehabilitation in patients with moderate to very severe airflow limitation were significantly greater than in COPD controls receiving usual care. Indeed, mean differences in changes in breathlessness (mean effect size 1·06, 95% CI 0·85 to 1·26, points per question), fatigue (0·92, 0·71 to 1·13), emotional function (0·76, 0·52 to 1·00), and patient’s control over disease (0·97, 0·74 to 1·20), as assessed with the Chronic Respiratory Disease Questionnaire,10 exceeded the minimum clinically important difference of 0·5 points per question on a seven-point scale.11 Moreover, the mean total score on the St George’s Respiratory Questionnaire, a disease-specific healthstatus questionnaire, improved by −6·11 points (−8·98 to −3·24);10 the minimum clinically important difference is −4 points.12 The mean improvement in peak cycling load was modest (8·43 W, 3·45 to 13·41); however, the mean difference in change in 6-min walking distance after pulmonary rehabilitation (48·46 m, 31·64 to 65·28)10 was below the mean minimum clinically important difference of 54 m, but was still within its 95% CI (37 to 71).13 Pulmonary rehabilitation is also cost effective. The numbers of days in hospital because of acute COPD exacerbations in the first year after an outpatient pulmonary rehabilitation programme decreased by about 50% compared with usual care.14 Thus pulmonary rehabilitation can be regarded as a value-based intervention for patients with COPD, irrespective of the degree of airflow limitation. Unfortunately, access to pulmonary rehabilitation remains limited and is underfunded in most countries. This situation might be partly because pulmonary rehabilitation is often fragmented between providers and settings, leading to poor continuity of care in COPD, systematic inefficiencies, and reduced ability to make high-quality interdisciplinary pulmonary rehabilitation available for patients. Pulmonary rehabilitation centres need to have a process-based organisation to manage business around www.thelancet.com Vol 371 January 5, 2008
their core processes (eg, intake and assessment, rehabilitation, outcome assessment, and aftercare; figure). Indeed, such organisation, with functional expertise and product and customer orientation, will most probably lead to cost reductions and improvements in quality in pulmonary rehabilitation. Additionally, specialised rehabilitation centres can increase their capacity by sharing their knowledge with general hospitals through decentralisation, including resource allocation, which will provide an appropriate response to the increasing interest in pulmonary rehabilitation for patients with COPD. *Martijn A Spruit, Ingrid Vanderhoven-Augustin, Paul P Janssen, Emiel F M Wouters Centre for Integrated Rehabilitation of Organ failure (CIRO), 6085 NM Horn, Netherlands (MAS, IVA, PPJ, EFMW); and University Hospital Maastricht, Maastricht, Netherlands (EFMW) [email protected] MAS has received lecture fees from GlaxoSmithKline and Air Liquide. IVA and PPJ declare that they have no conflict of interest. EFMW has consulted for or received honoraria, lecture fees, or research grants from AltanaPharma, AstraZeneca, BoehringerIngelheim, GSK, Numico, and Pfizer. 1
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Nici L, Donner C, Wouters E, behalf of the ATS/ERS Pulmonary Rehabilitation Writing Committee. American Thoracic Society/European Respiratory Society Statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390–413. Wilt TJ, Niewoehner D, MacDonald R, Kane RL. Management of stable chronic obstructive pulmonary disease: a systematic review for a clinical practice guideline. Ann Intern Med 2007; 147: 639-53. Baarends EM, Schols AM, Mostert R, Wouters EF. Peak exercise response in relation to tissue depletion in patients with chronic obstructive pulmonary disease. Eur Respir J 1997; 10: 2807–13. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest 2007; 131(suppl 5): 4S–42S. Spruit MA, Wouters EF. New modalities of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Sports Med 2007; 37: 501–18. Wouters EF. Management of severe COPD. Lancet 2004; 364: 883–95. Rutten FH, Cramer MJ, Grobbee DE, et al. Unrecognized heart failure in elderly patients with stable chronic obstructive pulmonary disease. Eur Heart J 2005; 26: 1887–94. Weitzenblum E, Chaouat A. Sleep and chronic obstructive pulmonary disease. Sleep Med Rev 2004; 8: 281–94. Marquis K, Maltais F, Duguay V, et al. The metabolic syndrome in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2005; 25: 226–32. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007; 3: CD003793. Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials 1989; 10: 407–15. Jones PW. St. George’s Respiratory Questionnaire: MCID. COPD 2005; 2: 75–79. Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small differences in functional status: the Six Minute Walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997; 155: 1278–82. Griffiths TL, Phillips CJ, Davies S, Burr ML, Campbell IA. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001; 56: 779–84.
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