Pulmonary rehabilitation has emerged as a recommended standard of care for patients with chronic lung disease based on a growing body of scientific evidence. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) has taken a lead role in reviewing the published literature and developing evidence-based guidelines in pulmonary rehabilitation, beginning with the first systematic review of the scientific basis of pulmonary rehabilitation in 19901 and then, in conjunction with the American College of Chest Physicians (ACCP) in 1997, the first evidence-based guidelines.2,3 Since that time, the published literature on pulmonary rehabilitation has increased substantially, providing justification for recommending pulmonary rehabilitation as part of standards of care for the management of patients with chronic obstructive pulmonary disease (COPD) and other chronic lung diseases.4-6 Therefore, ACCP and AACVPR decided to update the 1997 guidelines with a systematic, evidence-based review of the literature. The purpose of this document is to summarize the main findings of the new guidelines published in Chest.7 Both AACVPR and ACCP should be lauded for their continuing support and efforts to advance the field of pulmonary rehabilitation. Such rigorous, systematic reviews have helped considerably in establishing the scientific basis of pulmonary rehabilitation as a standard of care for patients with chronic lung diseases and in convincing third parties of the value in providing coverage for pulmonary rehabilitation. Round 3 to AACVPR and ACCP-keep up the good fight!
In the United States, COPD accounted for more than 119,000 deaths in 2000, ranking it the fourth leading cause of death and the only major disease among the top 10 that continues to increase.8-11 Mortality data tend to underestimate the impact of COPD because it is more likely to be listed as contributory rather than the underlying cause of death and is often not listed at all.12,13 Between 1980 and 2000, death rates for COPD increased 282% for women compared with 13% for men. Also in 2000, the number of women dying from COPD exceeded the number of men.8
Chronic obstructive pulmonary disease develops insidiously over decades and, because of the large reserve in lung function, there is a long preclinical period. Affected individuals have few symptoms and are undiagnosed until a relatively advanced stage of disease. In a population survey, Burrows14 reported that only 34% of persons with COPD had ever consulted a physician, 36% denied having any respiratory symptoms, and 30% denied dyspnea on exertion, which is the primary symptom of COPD. National Health and Nutrition Examination Survey III data estimate that 24 million US adults have impaired lung function, whereas only 10 million report a physician diagnosis of COPD.8 Worldwide, the burden of COPD is projected to increase substantially paralleling the rise in tobacco use, particularly in developing countries. An analysis by the World Bank and World Health Organization ranked COPD 12th in 1990 in disease burden reflected in disability-adjusted years of life lost.12
The American Thoracic Society and the European Respiratory Society 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 status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease.6
This definition focuses on 3 important features of successful rehabilitation: (1) a multidisciplinary approach; (2) an individualized program tailored to the patients needs; and (3) attention to physical, psychological, and social function.
Rehabilitation programs for patients with chronic lung disease are well established as a means of enhancing standard therapy to control and alleviate symptoms and optimize functional capacity.2,3,5,6,15 The primary goal is to restore the patient to the highest possible level of independent function, which is accomplished by helping patients learn more about their disease, treatments, and coping strategies.
Pulmonary rehabilitation is appropriate for any patient with stable chronic lung disease who is disabled by respiratory symptoms. Programs typically include components such as patient assessment, exercise training, education, nutritional intervention, and psychosocial support. These programs have been successfully applied to patients with diseases other than COPD such as interstitial diseases, cystic fibrosis, bronchiectasis, and thoracic cage abnormalities.16
SUMMARY OF EVIDENCE-BASED GUIDELINES
The Guidelines Panel was selected to represent both ACCP and AACVPR and worked tirelessly to make sense of the literature reviews and develop the recommendations. In addition to Andrew Ries, MD, MPH, Chair, the Panel included Richard Casaburi, PhD, MD; Donald Mahler, MD; Barry Make, MD; and Carolyn Rochester, MD, representing ACCP and Gerene Bauldoff, RN, PhD; Brian Carlin, MD; Charles Emery, PhD; and Richard ZuWallack, MD, representing AACVPR. Particular thanks are owed to Carla Herrerias, MPH, the ACCP Clinical Research Analyst, who did the heavy lifting in reviewing the published literature and preparing the evidence-based tables.
In the current version of the guidelines, the Panel focused on studies published since the previous review, again concentrating on patients with COPD. Because of the many advances and new areas of investigation, the Panel not only updated the areas reviewed and recommendations in the previous guideline2,3 but also reviewed additional new topics. In the current document, recommendations were developed for several outcomes of comprehensive pulmonary rehabilitation programs including lower extremity exercise training, dyspnea, health-related quality of life, healthcare utilization, survival, psychosocial outcomes, and long-term benefits. Additional topics reviewed include duration of pulmonary rehabilitation intervention, postrehabilitation maintenance strategies, intensity of aerobic exercise training, strength training, anabolic drugs, upper extremity training, inspiratory muscle training, education, psychological and behavioral components, oxygen supplementation, noninvasive ventilation, nutritional supplementation, and rehabilitation for patients with disorders other than COPD. The new document also makes recommendations for future research in pulmonary rehabilitation.
Through a thorough and systematic review of the literature based on tables prepared by the ACCP Clinical Research Analyst who reviewed published literature from 1996 to 2004, the Panel developed recommendations on rehabilitation for patients with chronic lung disease. Based on the published evidence systematically evaluated, ratings of the recommendations followed guidelines developed by ACCP and are indicated in Tables 1a and 1b.17 These ratings evaluate both the strength of the evidence (A-High, B-Moderate, and C-Low or Very Low) as well as the balance of benefits to risks and burdens (grade 1, strong recommendation-certainty that benefits do, or do not, outweigh risks and burden; grade 2, weak recommendation-evenly balanced or uncertainty regarding benefits versus risks and burden). The recommendations developed by the Panel are presented in Table 2, along with the rating for each.
For consistency throughout the guidelines, the Panel used the description of severity of COPD as recommended by the GOLD4 and the American Thoracic Society/European Respiratory Society guidelines5 based on forced expiratory volume in 1 second (FEV1) as follows:
Overall, this new guideline provides an excellent summary of the literature published over the past decade and further strengthens the justifications for including pulmonary rehabilitation as a standard of care for patients with chronic lung diseases.
Everyone who works in this field owes a debt of gratitude both to ACCP and AACVPR for leading and supporting this effort. These new guidelines clearly represent a major step forward in advancing the practice of pulmonary rehabilitation and should provide more strength to those striving to serve our deserving patients with chronic lung disease.
1. Ries AL. Position paper of the American Association of Cardiovascular and Pulmonary Rehabilitation: scientific basis of pulmonary rehabilitation. J Cardiopulm Rehabil
2. ACCP-AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary rehabilitation: Joint ACCP/AACVPR evidence based guidelines. Chest
3. ACCP-AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary rehabilitation: joint ACCP/AACVPR evidence based guidelines. J Cardiopulm Rehabil
4. Global Initiative for Chronic Obstructive Lung Disease. Workshop Report: Global Strategy for Diagnosis, Management, and Prevention of COPD-Updated 2005. 2005. Available at: http://goldcopd.org
. Accessed April 1, 2007.
5. American Thoracic Society-European Respiratory Society Task Force. Standards for the diagnosis and management of patients with COPD (Internet). Version 1.2. New York: American Thoracic Society. Available at: http://www-test.thoracic.org/copd/
. September 8, 2005.
6. American Thoracic Society, European Respiratory Society. ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med
7. ACCP-AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest
8. Mannino DM, Homa DM, Akinbami LJ, et al. Chronic obstructive pulmonary disease surveillance-United States, 1971-2000. MMWR
9. Minino AM, Smith BL. Deaths: preliminary data for 2000. Natl Vital Stat Rep
10. Mannino DM, Gagnon R, Petty TL, 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
11. Petty TL. Scope of the COPD problem in North America. Early studies of prevalence and NHANES III Data: basis for early identification and intervention. Chest
12. Pauwels RA, Buist AS, Calverley PM, 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
13. Sherrill DL, Lebowitz MD, Burrows B. Epidemiology of chronic obstructive pulmonary disease. Clin Chest Med
14. Burrows B. Epidemiologic evidence for different types of chronic airflow obstruction. Am Rev Respir Dis
15. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Pulmonary Rehabilitation Programs
. 3rd ed. Champaign, Ill: Human Kinetics; 2004.
16. Foster S, Thomas HM. Pulmonary rehabilitation in lung disease other than chronic obstructive pulmonary disease. Am Rev Respir Dis
17. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force. Chest