Data from American Journal of Respiratory and Critical Care Medicine - Curated by EPG Health - Date available 15 June 2006

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15 June 2006

Since the last statements on pulmonary rehabilitation by the American Thoracic Society (ATS; 1999) and the European Respiratory Society (ERS; 1997), there have been numerous scientific advances both in our understanding of the systemic effects of chronic respiratory disease as well as the changes induced by the process of pulmonary rehabilitation. Evidence-based support for pulmonary rehabilitation in the management of patients with chronic respiratory disease has grown tremendously, and this comprehensive intervention has been clearly demonstrated to reduce dyspnea, increase exercise performance, and improve health-related quality of life (HRQL). Furthermore, an emerging literature is beginning to reveal its effectiveness in reducing health care costs.

The impressive rise in interest in pulmonary rehabilitation is likely related to both a substantial increase in the number of patients being referred as well as the establishment of its scientific basis by the use of well-designed clinical trials that use valid, reproducible, and interpretable outcome measures. Advances in our understanding of the pathophysiology of chronic respiratory conditions are extending the scope and applicability of pulmonary rehabilitation.

Individuals with chronic obstructive pulmonary disease (COPD) still comprise the largest proportion of those referred for pulmonary rehabilitation. However, it has become clear that regardless of the type of chronic respiratory disease, patients experience a substantial morbidity from secondary impairments, such as peripheral muscle, cardiac, nutritional, and psychosocial dysfunction, as well as suboptimal self-management strategies. Therefore, pulmonary rehabilitation may be of value for all patients in whom respiratory symptoms are associated with diminished functional capacity or reduced HRQL.

The timing of pulmonary rehabilitation depends on the clinical status of the individual patient and should no longer be viewed as a “last ditch” effort for patients with severe respiratory impairment. Rather, it should be an integral part of the clinical management of all patients with chronic respiratory disease, addressing their functional and/or psychologic deficits. Patient education is more than simply providing didactic information. It involves a combination of teaching, counseling, and behavior modification techniques to promote self-management skills and self-efficacy. Patient education should also integrate end-of-life decision making into the overall treatment strategy.

In light of the recent advances in our understanding of the science and process of pulmonary rehabilitation, the ATS and the ERS have adopted the following definition: “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.” Pulmonary rehabilitation programs involve patient assessment, exercise training, education, nutritional intervention, and psychosocial support. In a broader sense, pulmonary rehabilitation includes a spectrum of intervention strategies integrated into the lifelong management of patients with chronic respiratory disease and involves a dynamic, active collaboration among the patient, family, and health care providers. These strategies address both the primary and the secondary impairments associated with the respiratory disease.

This document has been developed by an international committee and has been endorsed by both the ATS and the ERS. It places pulmonary rehabilitation within the concept of integrated care. The World Health Organization has defined integrated care as “a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion”. Integration of services improves access, quality, user satisfaction, and efficiency of medical care. As such, pulmonary rehabilitation provides an opportunity to coordinate care and focus on the entire clinical course of an individual's disease.

Building on previous statements, this document presents recent scientific advances in our understanding of the multisystemic effects of chronic respiratory disease and how pulmonary rehabilitation addresses the resultant functional limitations. It was created as a comprehensive statement, using both a firm evidence-based approach and the clinical expertise of the writing committee. As such, it is complementary to two current documents on pulmonary rehabilitation: the American College of Chest Physicians and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) evidence-based guidelines, which formally grade the level of scientific evidence, and the AACVPR Guidelines for Pulmonary Rehabilitation Programs, which give practical recommendations.

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