New Pulmonary Rehab Guidelines Update ACCP/AACVPR Recommendations

The American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation (ACCP/AACVPR) have jointly published evidence-based guidelines recommending a comprehensive pulmonary rehabilitation program for COPD patients. These guidelines update those issued by the ACCP/AACVPR in 1997.

“The new guidelines reflect the marked increase in research in the area of pulmonary rehabilitation published during the past decade,” Andrew L. Ries, MD, MPH, chair of the guidelines committee, told Pulmonary Reviews. “New areas that have been explored include duration of benefits, length of rehabilitation treatment, intensity of exercise training, strength training, use of anabolic agents, supplemental oxygen with exercise, use of noninvasive ventilation, nutritional supplementation, and chronic lung diseases other than COPD.” Whereas the 1997 guidelines had eight recommendations, the new guidelines have 25, he added. Dr. Ries is Associate Dean for Academic Affairs and Professor of Medicine and Family and Preventive Medicine at the University of California, San Diego.

BENEFITS AND LIMITATIONS

Although the optimal duration of pulmonary rehabilitation has not been determined, the guideline authors point out that six to 12 weeks of pulmonary rehabilitation produces benefits for as long as 12 to 18 months. While some outcome measures—such as exercise endurance, psychological functioning, and cognitive functioning—show gradual decline during this period among patients who do not maintain the exercise routine, health-related quality of life shows sustained improvement at 12 to 18 months. In any event, patients who participate in pulmonary rehabilitation programs for 12 weeks have better outcomes than those in six-week programs. Post rehabilitation maintenance strategies have modest effects.

The guidelines committee pointed out that exercise training is an essential component of pulmonary rehabilitation among COPD patients. Engaging in either high- or low-intensity exercise regimens yields significant benefits for COPD patients; however, high intensity particularly is more beneficial than low intensity for lower extremity exercise training. The guideline authors recommend unsupported endurance training for the upper extremities. Furthermore, the authors confirm that strength training as part of a pulmonary rehabilitation regimen increases muscle strength and mass.

The new guidelines do not support the use of anabolic agents, routine nutritional supplementation, or the routine use of inspiratory muscle training. Supplemental oxygen is recommended for patients with severe exercise-induced hypoxemia. Furthermore, administration of supplemental oxygen during high-intensity exercise in patients without exercise-induced hypoxemia may improve gains in exercise endurance. Noninvasive ventilation in patients with severe COPD modestly improved exercise performance.

The authors noted that pulmonary rehabilitation may be beneficial to some patients with chronic respiratory diseases other than COPD, with treatment strategies modified to the specific disease.

QUALITY OF LIFE AND PATIENT EDUCATION

As did the previous guidelines, the 2007 guidelines acknowledge that pulmonary rehabilitation improves dyspnea and health-related quality of life and reduces the number of hospitalizations and other measures of health care utilization. The previous guidelines tentatively offered that pulmonary rehabilitation may improve survival; however, due to a continued lack of evidence, the new guidelines therefore provide no recommendations.

Education that includes information on collaborative self-management and prevention and treatment of exacerbations should be an integral part of pulmonary rehabilitation, the guidelines state. Psychosocial interventions are not recommended as monotherapy; however, based on current practice and expert opinion, the authors support the incorporation of psychosocial interventions into the comprehensive pulmonary rehabilitation program. The joint committee determined that pulmonary rehabilitation is cost-effective.

“There is growing interest in and acceptance of pulmonary rehabilitation as a cost-effective, preventive health care treatment and as a standard of care for patients with a variety of chronic lung diseases,” Dr. Ries said. “Recommendations about pulmonary rehabilitation are now included in all published treatment guidelines for COPD. The ACCP/AACVPR guidelines for pulmonary rehabilitation are another major step forward in summarizing the current literature and advancing medical practice in this field.”           

—Adriene Marshall

Reference
Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. American College of Chest Physicians. American Association of Cardiovascular and Pulmonary Rehabilitation. Chest. 1997;112:1363-1396.
Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation executive summary: joint American College of Chest Physicians/American Association of Cardiovascular and Pulmonary Rehabilitation evidence-based clinical practice guidelines. Chest. 2007;131(5 suppl):4S-42S.

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