Chest
Volume 131, Issue 5, Supplement, May 2007, Pages 4S-42S
Journal home page for Chest

Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.06-2418Get rights and content

Background: Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation.

Methods: The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system.

Results: The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD.

Conclusions: There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need.

Section snippets

EPIDEMIOLOGY OF COPO

In the United States, COPD accounted for 119,054 deaths in 2000, ranking as the fourth leading cause of death and the only major disease among the top 10 in which mortality continues to increase.5, 6, 7, 8 In persons 55 to 74 years of age, COPD ranks third in men and fourth in women as cause of death.9 However, mortality data underestimate the impact of COPD because it is more likely to be listed as a contributory cause of death rather than the underlying cause of death, and it is often not

SEVERITY OF COPD

For consistency throughout the document, the panel used the description of severity of COPD as recommended by the Global Initiative for Chronic Obstructive Lung Disease18 and the American Thoracic Society/European Respiratory Society Guidelines19 based on FEV1, as follows: stage I (mild), FEV1 ge; 80% predicted; stage II (moderate), FEV1 50 to 80% predicted; stage III (severe), FEV1 30 to 50% predicted; and stage IV (very severe), FEV1 < 30% predicted.

PULMONARY REHABILITATION

Rehabilitation programs for patients with chronic lung diseases are well-established as a means of enhancing standard therapy in order to control and alleviate symptoms and optimize functional capacity.2,4,14,20 The primary goal is to restore the patient to the highest possible level of independent function. This goal is accomplished by helping patients become more physically active, and to learn more about their disease, treatment options, and how to cope. Patients are encouraged to become

DEFINITION

The American Thoracic Society and the European Respiratory Society have recently adopted the following definition of pulmonary rehabilitation: Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional

METHODOLOGY AND GRADING OF THE EVIDENCE FOR PULMONARY REHABILITATION

In 1997, the ACCP and the AACVPR released an evidence-based clinical practice guideline entitled ā€œPulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Guidelines.ā€2,3 Following the approved process for the review and revision of clinical practice guidelines, in 2002 the ACCP Health and Science Committee determined that there was a need for reassessment of the current literature and an update of the original practice guideline. This new guideline is intended to update the recommendations

OUTCOMES OF COMPREHENSIVE PULMONARY REHABILITATION PROGRAMS

As currently practiced, pulmonary rehabilitation typically includes several different components, including exercise training, education, instruction in various respiratory and chest physiotherapy techniques, and psychosocial support. For this review, comprehensive pulmonary rehabilitation was defined as an intervention that includes one or more of these components beyond just exercise training, which is considered to be an essential, mandatory component.

In addition to the clinical trials

DURATION OF PULMONARY REHABILITATION

There is no consensus of opinion regarding the optimal duration of the pulmonary rehabilitation intervention. From the patient's perspective, the optimal duration should be that which produces maximal effects in the individual without becoming burdensome. Significant gains in exercise tolerance, dyspnea, and HRQOL have been observed following inpatient pulmonary rehabilitation programs as short as 10 days60 and after outpatient programs as long as 18 months.61 Shorter program duration has the

POSTREHABILITATION MAINTENANCE STRATEGIES

Although the benefits of pulmonary rehabilitation have been demonstrated up to 2 years following a short-term intervention,41 most studies suggest that the clinical benefits of pulmonary rehabilitation tend to wane gradually over time. This is underscored in 12-month follow-up data from a cohort of patients with COPD who had completed a 10-week comprehensive pulmonary rehabilitation program.68 At the end of the 10-week program, participants were given a structured home exercise program to

INTENSITY OF AEROBIC EXERCISE TRAINING

Exercise training is one of the key components of pulmonary rehabilitation. The exercise prescription for the training program is guided by the following three parameters: intensity; frequency; and duration. The characteristics of exercise programs in pulmonary rehabilitation for patients with COPD have not been extensively investigated.

As noted by the previous panel and a 2005 review,74 for most patients with COPD with limited maximum exercise tolerance, training intensities at higher

STRENGTH TRAINING IN PULMONARY REHABILITATION

Although always recognized as important, improving the function of the muscles of the arms and legs has recently become a central focus of pulmonary rehabilitation. In the course of everyday activities, these muscles are asked to perform two categories of tasks. Endurance tasks require repetitive actions over an extended period of time; walking, cycling, and swimming are examples. Strength tasks require explosive performance over short time periods; sprinting, jumping, and lifting weights are

ANABOLIC DRUGS

Since exercise-training interventions are a cornerstone in pulmonary rehabilitation and yield benefits, at least in part, by improving the function of the exercising muscles, it seems reasonable to hypothesize that pharmaceutical agents that improve muscle function in similar ways might be useful adjuncts to rehabilitative therapy. However, the list of drugs that might be suitable for clinical trials is quite limited. In particular, no agent that is capable of directly improving the aerobic

UPPER EXTREMITY TRAINING

Upper extremity exercise training specifically impacts the arms and has been shown to increase arm work capacity while decreasing VĖ™O2 for a comparable work level. Postulated mechanisms for improvement in upper extremity function from such training in patients with chronic lung diseases include desensitization to dyspnea, better muscular coordination, and metabolic adaptations to exercise.

The previous 1997 guidelines panel recommended that ā€œstrength and endurance training of the upper

PSYCHOLOGICAL AND BEHAVIORAL COMPONENTS OF PULMONARY REHABILITATION

Based on little published evidence, the 1997 guidelines panel concluded that ā€œEvidence to date does not support the benefits of short-term psychosocial interventions as single therapeutic modalities, but longer term interventions may be beneficialā€ and that ā€œexpert opinion supports the inclusion of education and psychosocial interventions as components of comprehensive pulmonary rehabilitation programs for patients with COPD.ā€

OXYGEN SUPPLEMENTATION AS AN ADJUNCT TO PULMONARY REHABILITATION

It was demonstrated > 25 years ago that long-term oxygen supplementation prolongs survival in patients with COPD and severe resting hypoxemia.159,160 More recently, the usefulness of oxygen therapy in improving outcomes from pulmonary rehabilitation in patients with COPD has been evaluated in several RCTs. A distinction must be made between the immediate effect of oxygen on exercise performance and its usefulness in the exercise-training component of pulmonary rehabilitation.161 This section

NONINVASIVE VENTILATION

Noninvasive positive-pressure ventilation (NPPV) includes the techniques of continuous positive airway pressure, pressure support, and proportional assist ventilation (PAV). A metaanalysis170 of nocturnal NPPV in stable hypercapneic patients with COPD, which included four eligible trials, showed that this therapy did not improve lung function, gas exchange, or sleep efficiency, but may have led to an increased walk distance. The rationale for NPPV as an adjunct to exercise training is that

Recommendation

  • 22.

    As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. Grade of recommendation, 2B

NUTRITIONAL SUPPLEMENTATION IN PULMONARY REHABILITATION

Poor nutritional status is associated with increased morbidity and mortality in patients with moderate-to-severe COPD.179 Prior studies have investigated the effects of dietary supplementation on patients with COPD, as summarized in a relatively recent metaanalysis.180 Summary data indicate that nutritional support/supplementation does not have a clinically significant effect on lung function or functional abilities. No studies have evaluated the effects of behavioral weight management (gain or

PULMONARY REHABILITATION FOR PATIENTS WITH DISORDERS OTHER THAN COPD

Although they have not been studied as well to date, patients with respiratory disorders other than COPD can also benefit substantially from pulmonary rehabilitation. Indeed, the scientific rationale for providing pulmonary rehabilitation to patients with non-COPD diagnoses is the same as that for patients with COPD. General principles of rehabilitation treatment emphasize the adaptation of multidisciplinary treatment strategies to the needs of individual patients. Pulmonary rehabilitation

SUMMARY AND RECOMMENDATIONS FOR FUTURE RESEARCH

The field of pulmonary rehabilitation has continued to develop and mature substantially since the publication of the previous evidence-based guidelines in 1997. Additional published literature has added substantially to the scientific basis of pulmonary rehabilitation interventions as well as outcomes. The new data that have been examined further strengthen the evidence that supports the benefits of lower extremity exercise training in pulmonary rehabilitation and the improvement expected in

SUMMARY OF RECOMMENDATIONS

  • 1.

    A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with COPD.

    Grade of Recommendation: 1A

  • 2.

    Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD.

    Grade of Recommendation: 1A

  • 3.

    Pulmonary rehabilitation improves health-related quality of life in patients with COPD.

    Grade of Recommendation: 1A

  • 4.

    Pulmonary rehabilitation reduces the number of hospital days and other measures of health-care

ACKNOWLEDGMENT

This clinical practice guideline has been endorsed by the American Thoracic Society, The European Respiratory Society, the US COPD Coalition and also the American Association of Cardiovascular and Pulmonary Rehabilitation (by way of collaboration on the project).

REFERENCES (210)

  • FinnertyJP et al.

    The effectiveness of outpatient pulmonary rehabilitation in chronic lung disease: a randomized controlled trial.

    Chest

    (2001)
  • GuellR et al.

    Long-term effects of outpatient rehabilitation of COPD: a randomized trial.

    Chest

    (2000)
  • GoldsteinRS et al.

    Economic analysis of respiratory rehabilitation.

    Chest

    (1997)
  • DevineEC et al.

    Meta-analysis of the effects of psychoeducational care in adults with chronic obstructive pulmonary disease.

    Patient Educ Couns

    (1996)
  • WempeJB et al.

    The influence of rehabilitation on behaviour modification in COPD.

    Patient Educ Couns

    (2004)
  • LieskerJJ et al.

    Cognitive performance in patients with COPD.

    Respir Med

    (2004)
  • VottoJ et al.

    Short-stay comprehensive inpatient pulmonary rehabilitation for advanced chronic obstructive pulmonary disease.

    Arch Phys Med Rehabil

    (1996)
  • CliniE et al.

    In-hospital short-term training program for patients with chronic airway obstruction.

    Chest

    (2001)
  • FoyCG et al.

    Gender moderates the effects of exercise therapy on health-related quality of life among COPD patients.

    Chest

    (2001)
  • VerrillD et al.

    The effects of short-term and long-term pulmonary rehabilitation on functional capacity, perceived dyspnea and quality of life.

    Chest

    (2005)
  • GimenezM et al.

    Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity.

    Arch Phys Med Rehabil

    (2000)
  • EngelenMP et al.

    Skeletal muscle weakness is associated with wasting of extremity fat-free mass but not with airflow obstruction in patients with chronic obstructive pulmonary disease.

    Am J Clin Nutr

    (2000)
  • LillegardWA et al.

    Appropriate strength training.

    Med Clin North Am

    (1994)
  • KongsgaardM et al.

    Heavy resistance training increases muscle size, strength and physical function in elderly male COPD patients: a pilot study.

    Respir Med

    (2004)
  • MadorMJ et al.

    Endurance and strength training in patients with COPD.

    Chest

    (2004)
  • HigginsITT

    Epidemiology of bronchitis and emphysema.

  • American College of Chest Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation.

    Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines; ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Chest

    (1997)
  • ACCP-AACVPR Pulmonary Rehabilitation Guidelines Panel.

    Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. J Cardiopulm Rehabil

    (1997)
  • American Thoracic Society, European Respiratory Society.

    ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med

    (2006)
  • ManninoDM et al.

    Chronic obstructive pulmonary disease surveillance: United States, 1971-2000.

    MMWR Morb Mortal Wkly Rep

    (2002)
  • MininoAM et al.

    Deaths: preliminary data for 2000.

    Natl Vital Stat Rep

    (2001)
  • ManninoDM et al.

    Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994.

    Arch Intern Med

    (2000)
  • American Cancer Society.

    Cancer statistics, 1989. CA Cancer J Clin

    (1989)
  • PauwelsRA et al.

    Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary.

    Am J Respir Crit Care Med

    (2001)
  • HigginsMW et al.

    Incidence, prevalence and mortality: intra- and intercountry differences.

  • BurrowsB

    Epidemiologic evidence for different types of chronic airflow obstruction.

    Am Rev Respir Dis

    (1991)
  • American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma.

    Am Rev Respir Dis

    (1995)
  • AdamsPF et al.

    Current estimates from the National Health Interview Survey, 1996.

    Vital Health Stat

    (1999)
  • FeinleibM et al.

    Trends in COPD morbidity and mortality in the United States.

    Am Rev Respir Dis

    (1989)
  • SinDD et al.

    The impact of chronic obstructive pulmonary disease on work loss in the United States.

    Am J Respir Crit Care Med

    (2002)
  • Global Initiative for Chronic Obstructive Lung Disease. Workshop report: global strategy for diagnosis, management, and...
  • American Thoracic Society-European Respiratory Society Task Force. Standards for the diagnosis and management of...
  • American Association of Cardiovascular and Pulmonary Rehabilitation

    Guidelines for pulmonary rehabilitation programs.

    (1998)
  • FosterS et al.

    Pulmonary rehabilitation in lung disease other than chronic obstructive pulmonary disease.

    Am Rev Respir Dis

    (1990)
  • PalmerSM et al.

    Pulmonary rehabilitation in the surgical patient: lung transplantation and lung volume reduction surgery.

    Respir Care Clin N Am

    (1998)
  • BiggarDG et al.

    Pulmonary rehabilitation before and after lung transplantation.

  • RiesAL

    Pulmonary rehabilitation and lung volume reduction surgery.

  • CelliBR

    Pulmonary rehabilitation and lung volume reduction surgery in the treatment of patients with chronic obstructive pulmonary disease.

    Monaldi Arch Chest Dis

    (1998)
  • RiesAL et al.

    The team concept in pulmonary rehabilitation.

  • LacasseY

    Pulmonary rehabilitation for chronic obstructive pulmonary disease.

    Cochrane Database Syst Rev (database online).

    (2006)
  • Cited by (0)

    The evidence-based practice guidelines published by The American College of Chest Physicians (ACCP) incorporate data obtained from a comprehensive literature review of the most recent studies then available. Guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any specific condition. Furthermore, guidelines may not be complete or accurate because new studies that may have become available late in the process of guideline development may not be incorporated into any particular guideline before it is disseminated. The ACCP and its officers, regents, governors, executive committee, members, and employees (the ACCP Parties) disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, express or implied. Guideline users always are urged to seek out newer information that might impact the diagnostic and treatment recommendations contained within a guideline. The ACCP Parties further disclaim all liability for any damages whatsoever (including, without limitation, direct, indirect, incidental, punitive, or consequential damages) arising out of the use, inability to use, or the results of use of a guideline, any references used in a guideline, or the materials, information, or procedures contained in a guideline, based on any legal theory whatsoever and whether or not there was advice of the possibility of such damages.

    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text