Other rehabilitation components that were incorporated into many practice guidelines comprised dietary screening and nutritional interventions, psychological interventions, social support, smoking cessation interventions, noninvasive ventilation (NIV), and inspiratory muscle training.
Smoking cessation was recommended by 5 practice guidelines, 2 directly stated specific interventions16,43 while 2 of the other guidelines designate smoking cessation as part of the rehabilitation educational activities.44,46 The specific guideline-based interventions encompass screening and/or assessment of smoking status, nicotine replacement therapy, behavior change interventions, education, hypnosis, acupuncture, and individual or small group counseling.
Other interventions discussed in cardiac and pulmonary guidelines were inspiratory muscle training, oxygen therapy, and NIV. Inspiratory muscle training was recommended by 1 cardiac rehabilitation practice guideline45 and not advocated in a pulmonary rehabilitation practice guideline.46 Specific needs of particular groups of patients formed recommendations such as oxygen therapy for people with severe exercise-induced hypoxemia,48 and the use of NIV in patients already using domiciliary NIV for chronic respiratory failure was recommended during exercise training; however, the use of NIV in other patient groups during exercise was not recommended in pulmonary rehabilitation guideline.46
The quality of the guidelines included in this review was assessed and only 3 guidelines16,46,47 were found to meet all 23 criteria across the 6 domains of the AGREE II checklist. The criteria that were poorly reported in cardiac and pulmonary clinical guidelines were predominately in the domains of rigor, guideline development, and applicability. In this domain, criteria such as search methods, evidence selection criteria, and transparent link between recommendations and evidence were lacking. The domain for editorial independence also had limited reporting in the included guidelines. For assessing the quality of guideline recommendations, the GRADE criteria were utilized and 4 guidelines were found to meet all criteria.16,44,46,47
The results for this systematic review demonstrate concordance in design principles between cardiac and pulmonary rehabilitation clinical practice guidelines, focusing on addressing the symptom of breathlessness. The design principles aligned in terms of the programs being described as an individually tailored intervention, a program duration of between 6 and 12 wk, located in comparable settings, facilitated by comparable multidisciplinary personnel, included assessment of patients prior to and following the program, and were constructed to include exercise training and education. As the focus of rehabilitation is on improving health outcomes through education, exercise training, and empowering patient self-management to address the symptom of breathlessness evident in cardiac and pulmonary conditions, the evidence of concordance is not surprising. Furthermore, historically cardiac rehabilitation and pulmonary rehabilitation were designed and evaluated separately despite the similarities between the central concepts and fundamental principles.49,50 The evidence for the effectiveness of cardiac and pulmonary rehabilitation programs with core elements of exercise training and education resulting in behavioral change continues to grow. This may inform the potential of collaboratively designing rehabilitation programs. The opportunity for joint delivery of some aspects of the cardiac and pulmonary rehabilitation programs could possibly be exploited to ensure future benefit to patients specifically those with comorbid conditions of heart and lung disease of which the most common symptom for both conditions is breathlessness.
Despite concordance, variations in program design and emphasis exist in the educational activities and additional complementary components of the rehabilitation programs. Psychological interventions are recommended components for cardiac rehabilitation, while NIV and oxygen therapy in specific patient populations are prominent in guidelines for pulmonary rehabilitation programs. Nutritional interventions are not yet established as a recommended component of pulmonary rehabilitation but are clearly recommended for CVD to reduce risk factors. These variations are not surprising as they form contextual factors related to ensuring that rehabilitation programs are able to be individually tailored to the concerns of participants. A departure from concordance is apparent when focusing on the psychological health of cardiac and pulmonary patients. Stress management and psychological interventions have been determined to be effective at improving health outcomes for people with cardiac conditions although no evidence currently exists for patients with pulmonary diseases.51
These findings from this review suggest that there are opportunities to find synergies in designing lifestyle modification programs that assist with the rehabilitation of people with breathlessness, rather than categorizing a person to complete either pulmonary or cardiac rehabilitation. People with COPD are up to 5 times more likely to have a cardiovascular condition as well as COPD (OR = 4.98; 95% CI = 4.85 to 5.81; P < .001, n = 1 204 100).53 More specifically, they are 1.76 times (95% CI, 1.64-1.89) more likely to experience arrhythmias, 1.61 times more likely to experience angina pectoris (95% CI, 1.47-1.76), 1.61 times more likely to experience acute myocardial infarction (95% CI, 1.43-1.81), and 3.84 times (95% CI, 3.56-4.14) more likely to have congestive heart failure than the general population.54,55 Risk of hospitalization due to a cardiovascular event is elevated in people with COPD, and they are 2.07 times (95% CI, 1.82-2.36) more likely to die from cardiovascular conditions.54 There appears to be a relationship between lung function impairment and cardiovascular events, which is mediated through established CVD risk factors.55,56 Consideration may need to be given to whether running 2 separate rehabilitation programs tagged as pulmonary or cardiac is the best approach and cost-effective method for supporting individuals with chronic cardiopulmonary dysfunction.
Considering the poor completion rates currently being documented in both models of pulmonary and cardiac rehabilitations, there is a need to design sustainable programs that truly are individually tailored and meet overall needs of patients. Pulmonary rehabilitation commencement rates are approximately 50% of referrals, and of those who enter pulmonary rehabilitation 30% of patients do not complete the program.57,58 Reasons for poor uptake and completion rates are reported to be travel and transport challenges and a lack of perceived benefit of pulmonary rehabilitation.57 The issues for attendance are comparable in cardiac rehabilitation, with nonattenders being more likely to be older, have lower income and/or greater social deprivation, deny the severity of their illness, experience difficulty in accessing a program, have lower self-efficacy, and be less likely to believe that they can influence their health outcomes and/or perceive that their physician does not recommend cardiac rehabilitation.59–61
Designing a breathlessness modification program that specifically targets breathlessness symptom management within a rehabilitation framework may improve the patient's perception of benefit. When a program is tailored to address the symptom of greatest concern to the patient, as well as addressing the disease process of his or her comorbid conditions, there may be a perception of greater benefit by the patient. Such innovative changes to how health professionals view and deliver rehabilitation for people who experience breathlessness may lead to improved uptake and sustained benefits in the longer term. Future research into a centralized model of rehabilitation that focuses on symptom management and holistic care incorporating cardiac and pulmonary rehabilitation interventions rather than disease management could be justified.
This systematic review of clinical or practice guidelines may have missed publications due to the a priori protocol-defined search strategy. Furthermore, guidelines that were published after the a priori defined search period may not have been identified and therefore not included in this review. An extensive search of international society websites related to cardiac and pulmonary conditions was conducted in addition to the search of databases to source all relevant guidelines, and it is possible that guidelines may not have been identified. Overall, the evidence level for some recommendations within included guidelines was found to be low, and many guidelines have not used a GRADE approach when evaluating the literature and, therefore, may limit the application of the guideline recommendations to clinical practice.
The results for this systematic review demonstrate concordance in many design principles between cardiac and pulmonary rehabilitation clinical practice guidelines, focusing on addressing the symptom of breathlessness. These findings suggest opportunities to identify synergies across rehabilitation programs to refocus these programs on symptom management rather than prescribed features based upon disease processes. Future research could focus on deconstructing current pulmonary and cardiac rehabilitation programs and redesigning a more holistic program that is individually tailored with an additional focus on the patient's symptoms and concerns.
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