Pulmonary rehabilitation

Doctors used to think that people with chronic obstructive pulmonary disease (COPD) had little hope of improvement beyond the modest benefits of medication and oxygen therapy. But research and experience have shown otherwise. Whether your condition is moderate or advanced, if you continue to have breathlessness and other symptoms even when you are using medication, chances are you will benefit from pulmonary rehabilitation. Your doctor may recommend it. But if not, you can inquire about it.

Pulmonary rehabilitation is a multifaceted program of exercise, education, and other therapies that can help you feel better and carry out day-to-day activities with greater ease and independence. It is conducted by a team of specialists that may include a doctor, a nurse, a physical therapist, a nutritionist, and sometimes a physiologist or respiratory therapist.

Like cardiovascular rehabilitation, pulmonary rehabilitation can take place in a hospital or patient rehabilitation center, at an outpatient center, or at home. Inpatient rehabilitation provides the most extensive services and is reserved for those with the most severe disease. Outpatient rehabilitation, which can be at a hospital or freestanding clinic, is the most widespread form of pulmonary rehabilitation, as well as the least expensive. Home-based rehabilitation is an alternative to outpatient rehabilitation for some people, but the range of services is more limited. Whether you get outpatient or home-based rehabilitation will depend on the options in your area and your insurance coverage.

Pulmonary rehabilitation is not a cure; nor can it slow the progression of your lung disease. But it can help reduce your symptoms, increase your muscular strength, and improve your endurance. Research has shown that patients who participate in these programs have a better quality of life and spend less time in the hospital. Patients with lung disease often cut back on physical activity due to breathlessness, which in turn leads to deconditioning, or “out of shape” muscles. Being out of shape actually worsens the symptoms of breathlessness with activity further, leading to a dangerous cycle of inactivity and worsening symptoms.

Rehabilitation works because the symptoms and disability of COPD reflect not only the disease itself, which can’t be reversed, but also a host of secondary problems such as muscle weakness, which can be reversed to some degree. If you have been missing days at work or have been unable to perform your usual daily activities because of the disease, rehabilitation can help you manage your symptoms well enough to return to work or resume your activities on a more regular basis. If your disease is advanced, rehabilitation can help you resume some activities that may have become difficult or impossible, like getting dressed without help and getting in and out of a car.

What to expect

Pulmonary rehabilitation usually lasts about six weeks, but it can be longer or shorter depending on your needs and your insurance coverage. These factors also influence how often you have rehabilitation sessions. The optimal duration for rehabilitation is not known, but most experts feel that longer rehabilitation programs provide longer lasting benefits. If you are in the hospital and therefore in need of the most intensive rehabilitation, you may be seen as often as twice a day, seven days a week. If you are attending an outpatient clinic or receiving at-home therapy, you may have rehabilitation sessions anywhere from one to three times a week. Some insurance carriers base their coverage on the results of your pulmonary function tests rather than the severity of your symptoms.

The central components of pulmonary rehabilitation are exercise therapy, breathing retraining, patient education, and psychological support. Rehabilitation also includes regular evaluation of your progress. Exercise therapy focuses primarily on aerobic activities such as walking, cycling, or swimming to increase your endurance. You may also participate in breathing exercises, to help you avoid getting out of breath during daily activities and to reduce shortness of breath. Patient education covers many important topics, such as medication use, smoking cessation, and other strategies for managing your disease symptoms. Depending on your needs, you may also receive such services as occupational therapy, nutrition counseling, and psychological therapy. Periodically throughout your rehabilitation, the doctor, nurse, and therapists will assess your progress and possibly recommend changes in your treatment or rehabilitation regimen. Assessments focus on how well you can function — how much farther you can walk, for example — after a few weeks of rehabilitation compared with before rehabilitation.


Exercise therapy

Everyone in pulmonary rehabilitation gets aerobic exercise therapy under the supervision of a health care professional, usually a physical therapist or exercise physiologist. The purpose of aerobic exercise is to increase your endurance and strengthen your muscles to lessen your symptoms and improve your tolerance for activity.

Exercise therapy typically involves lower extremity training, such as walking on a treadmill, stair climbing, or cycling on a stationary bicycle. The particular exercises you do will depend on your tolerance for exercise and the condition of your joints, bones, and muscles. Also important are the types of exercise you enjoy, whether you have access to any exercise equipment, and whether you are able to exercise independently or need regular monitoring. If your breathlessness is so severe that you can’t walk, you may start off on a stationary bicycle or making cycling motions while seated in a chair. If you can walk but have little endurance, you may use the treadmill with the goal of increasing the time and intensity of your workout. During rehabilitation, sustained periods of intense exercise lasting 20–45 minutes are usually executed, but some patients perform periods of exercise interspersed with periods of rest , an approach known as interval training.

Many rehabilitation programs also offer strength and flexibility training. Weakness in the arms, legs, and trunk muscles is a common problem in people with COPD and one of the main factors that limits their physical activity. Strength training may be done by lifting weights, using weight machines, or pulling on elastic bands. Flexibility training consists of stretching exercises. A European study found that patients who had strength training for their arm and leg muscles were able to walk farther than patients who did not have this training.

Exercise therapy as a whole has many benefits. Scientific research has shown that patients treated with exercise therapy experience less shortness of breath and fatigue, have greater exercise capacity (can walk farther distances), are able to perform more day-to-day activities, and feel better emotionally. But the benefits appear to last only as long as you keep doing the exercises — and that means for the rest of your life.

Making the transition to exercising on your own is one of the most important aspects of your rehabilitation. Some pulmonary rehab programs run a maintenance program. For a small fee, you can attend perhaps once a week and exercise in the presence of a health professional who can assess your progress. Even if such a program is not available, it is imperative for you to continue exercising on your own — either at a local facility, such as a gym or community center, or at home. When you complete a rehabilitation program, you should be provided with a clear exercise plan so you are able to continue training outside of the formal environment. You should discuss your exercise regimen not only with the healthcare professionals in your rehabilitation program, but also with your pulmonologist and primary care physician.

Many people do not own exercise equipment at home because they lack the necessary space or money. If this is your situation, try the alternatives suggested in the table below.

Exercise alternatives

Once your pulmonary rehab program ends, you may have difficulty establishing a home exercise routine because you lack the same equipment. Here are some alternatives to common equipment found in an exercise center.
Equipment Alternative
  • Outdoor walking
  • Indoor walking at a mall or apartment building hallway (pedometer optional)
Stationary bicycle
  • Regular bicycle attached to trainer device
  • Small pedaling device (may or may not be attached to a chair)
Stair climbing machine
  • Home staircase or a staircase at the mall or other public space
  • Elastic exercise bands or tubing
  • Lifting canned foods
  • Lifting rolls of pennies in a sock tied onto a limb (1 roll = ½ pound)
Exercise stability ball
  • Can be purchased inexpensively for home use


Breathing retraining

Just as a trumpet player or singer learns to breathe in deeply and breathe out slowly to make smooth and sustained music, pulmonary disease patients learn how to modulate their breathing to get through everyday activities more easily. One of the biggest problems you may have is running out of air while you are exercising or exerting yourself. If this happens, you may pant or hold your breath, which can tire you out. Breathing retraining aims to solve this problem by teaching you strategies to improve your breathing efficiency and lessen your symptoms.

Breathing retraining is usually guided by either a respiratory therapist or a physical therapist. Most aspects focus on your ability to slow down your breathing. The training may include such techniques as yoga, paced breathing, pursed-lip breathing, and diaphragmatic breathing. With paced breathing, you inhale just before you start a physical activity — getting out of a chair, for example — and then exhale slowly as you carry it out. The therapist may tell you to break down more complex activities, such as getting in and out of a car, into a series of breaths: You take a breath when you reach the car door and exhale as you open it, then you inhale again before you sit down on the car seat, and so on. The therapist may also suggest you purse your lips as you breathe out to slow down your exhalation. Diaphragmatic breathing is a technique musicians use to fill their lungs to capacity by feeling their abdomen move out when they inhale. It teaches you to use your breathing muscles more efficiently and may make paced breathing more effective. There is controversy regarding the effectiveness of these techniques, and diaphragmatic breathing in particular may in fact require more effort for some patients. Not every method will work for every person, so it is important to work with your therapists to develop safe and effective strategies for your individual symptoms.

Many patients who use these breathing techniques have more stamina and less breathlessness and are able to participate in more activities.


Inspiratory muscle training

Damaged airways and lung tissue aren’t the only causes of difficult breathing for patients with emphysema or chronic bronchitis. Another contributing factor is fatigued respiratory muscles. The respiratory muscles become fatigued because they have to work harder when you breathe. In addition, the diaphragm, the main muscle involved in inhaling, is less effective when its position is altered — a common condition for people with COPD. Inspiratory muscle training aims to strengthen these muscles so you can pump more air in and out of your chest. It’s like weight lifting for your breathing muscles.

To do inspiratory muscle training, you will use a mouthpiece and a device that provides resistance to your breathing efforts. The device forces you to work your respiratory muscles harder while breathing, which helps strengthen those muscles. There is some evidence that for people with weak respiratory muscles, adding inspiratory muscle training to a regimen improves strength and endurance more than exercise training alone. Some people experience improvement in breathlessness with muscle training, and it is possible that this activity will improve your exercise tolerance. Just as your arms become tired after exercise, your breathing muscles may also become tired with this form of exercise. It is important to perform this type of training under the supervision of trained experts.


Taking an active role in managing your lung disease

An important part of pulmonary rehabilitation is learning how to take an active role in managing your illness. Patient education can be conducted in small groups or on an individual basis, depending on the resources of the rehabilitation program and the needs of individual patients.

One of the most important topics to master is how to use medication and oxygen therapy correctly. A nurse or a respiratory therapist can discuss the types of medications and their side effects. If you are using an inhaler, you should have received training from your doctor or a nurse in the doctor’s office. But during rehabilitation, a nurse or therapist may review the procedure to ensure that you’re doing it correctly. If you are using oxygen therapy, you will get some tips on how to use it to greatest benefit.

Other important topics include breathing strategies, how to recognize an exacerbation, and when to call for assistance, which is very important for reducing the need for hospitalizations. You should also ask about ways to avoid environmental substances that can irritate your airways, practical advice for traveling, nutrition guidance, and psychosocial and behavioral counseling.

The pulmonary rehabilitation team

Pulmonary rehabilitation is a multidisciplinary program carried out by several different health care professionals who meet as a team to assess each patient. Responsibilities of each member of the team can vary. Depending on your needs, your rehabilitation team may include some or all of the following types of professionals:

  • a physician specializing in pulmonary medicine, who assesses and monitors your medical status and recommends specific treatments
  • a pulmonary nurse specialist, who is trained in treating lung diseases
  • a respiratory therapist, who performs pulmonary function and blood gas tests, teaches you how to use inhaled medication and oxygen therapy, and performs chest physiotherapy
  • a physical therapist, who guides exercise training and breathing retraining and performs chest physiotherapy
  • an occupational therapist, who teaches strategies for performing everyday tasks, such as bathing and dressing
  • a dietitian, who provides nutrition counseling if you are having trouble eating or managing your weight because of your disease
  • a psychiatrist or psychologist, who evaluates you and treats you for anxiety, depression, or other psychological disturbances related to your lung disease.


Chest physiotherapy

This technique may help clear mucus from your airways if you are having trouble doing this on your own. A nurse or therapist taps on your chest or your back to loosen the secretions from your airways and make you cough. This is done in different positions to allow gravity to help drain the mucus. You may also use medical devices that help loosen the mucus from your airways. There are many products available, but most of them are small plastic devices that use a valve to produce vibrations in your breathing tubes. Breathing into these tools may help you cough up and clear the mucus from your chest. Although chest physiotherapy may be given as part of your rehabilitation program and can be done at home, studies have not shown a clear benefit for most people. Your therapist can help you choose the devices and techniques that work best for you and your lifestyle.


Psychosocial and behavioral intervention

The struggle to control symptoms and the need to cut back on activities contribute to depression in many people with COPD. Breathing difficulty can also lead to anxiety and fatigue which interfere with regular day-to-day activities. Therefore, psychosocial counseling is part of many pulmonary rehabilitation programs.

Psychologists or psychiatrists are usually available to meet with you individually or in a group. Group therapy usually involves emotional support and teaches stress reduction techniques such as progressive muscle relaxation. Attending group therapy can counteract the feelings of isolation that come from suffering with a disabling illness. Talking with other people who are going through the same experience can be reassuring. Alternatively, working individually with a therapist can help you sort through your own feelings and reactions to your condition and also improve relations with people who are close to you. While participation in pulmonary rehabilitation does lead to improvement in anxiety symptoms for many patients, individuals deal with the stress of illness in variable ways and the approach must be tailored for each participant.

If you and your therapist think you may be suffering from depression or anxiety, medication is available to treat these conditions. Research shows that a combination of medication and psychotherapy is often most effective.

Smoking and pulmonary rehabilitation

We know that cigarette smoking has many detrimental effects on your overall health and in particular your respiratory symptoms. Patients with lung disease are especially susceptible to complications related to smoking. If you are still smoking, you may not be able to have pulmonary rehabilitation until you quit. Although some rehabilitation programs offer smoking cessation, increasingly such programs are requiring you to go to an outside smoking cessation program, where you can get counseling or medication to help you break the habit. Many health insurers will not cover pulmonary rehabilitation unless you have stopped smoking for at least three months. That’s because studies show pulmonary rehabilitation is less effective for people who smoke or who quit during rehabilitation than it is for people who do not smoke. If you are having difficulty abstaining from smoking, most rehabilitation programs can provide educational resources, literature, helpful strategies, and medications to help you avoid this dangerous habit.


Evaluating your progress

An essential part of pulmonary rehabilitation is outcomes assessment, in which a doctor, nurse, or therapist periodically checks your symptoms and measures your physical abilities to track your improvement. An objective measure of your exercise capacity before and after a rehabilitation program is one way of evaluating your progress. This physical assessment is used to see how much longer and more intensely you can exercise over time. Three common tests include the six-minute walk test, the shuttle walk test, and a cardiopulmonary exercise test. In a six-minute walk you are asked to walk as far as possible for six minutes, while in a shuttle walk you are asked to walk back and forth between two cones as many times as possible. A cardiopulmonary exercise test uses a treadmill or a stationary bicycle in order to measure your exercise capacity.

While your exercise capacity is one key component, the symptoms you experience are also an important measure of your progress. Rehabilitation programs also use assessment tools, such as questionnaires, that ask you about your symptoms and have you rate your overall sense of well-being.

You will also get pulmonary function tests. Don’t be discouraged if your pulmonary function tests fail to improve appreciably during rehabilitation — in general, the readings don’t get much better. It is far more likely that you’ll have fewer symptoms, you’ll feel better, and you’ll be able to participate in more activities. These are the goals of pulmonary rehabilitation.



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