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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Since the SEPAR guidelines on Pulmonary Rehabilitation &#40;PR&#41; were published in 2000&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the magnitude of the changes that have occurred in this discipline has been so great that we are compelled to update them in line with other scientific societies&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> In the years since then&#44; we have gained greater insight into the pathophysiology of respiratory diseases&#44; the methods of applying PR are better known&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> we understand the importance of early initiation of the therapy &#40;recommending it even after an exacerbation&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> we have learned which components of a PR program are essential<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;6</span></a> and we have achieved active patient implication through good education and the implementation of self-care and self-management programs&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Thus&#44; PR is now the therapy of choice in comprehensive long-term care models&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The key components of PR programs are currently exercise&#44; education and chest physiotherapy&#44; while occupational therapy&#44; psychosocial support and nutritional intervention should also be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> However&#44; despite the available evidence&#44; use of PR is not widespread in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and its implementation is far from ideal&#44; showing wide geographical variation and above all&#44; a considerable degree of under-use&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In these SEPAR Guidelines&#44; after establishing the general concepts of PR&#44; we will discuss exercise training&#44; patient education&#44; chest physiotherapy&#44; psychological and nutritional support&#44; the specific features of PR in patients with COPD&#44; and finally the role of PR in chronic respiratory diseases other than COPD&#46; In relation to patients with neuromuscular diseases&#44; international guidelines<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> mention the importance of considering this group as candidates for PR programs especially adapted to their needs&#46; An increasing number of such patients are treated in respiratory medicine units&#47;departments&#44; not only using mechanical ventilation techniques&#44; but also from a more comprehensive perspective&#44; with particular focus on respiratory complications&#44; mainly retention of secretions&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> To that end&#44; we have devoted an on-line supplement specifically to these diseases&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The GRADE system has been adopted to establish the level of evidence and the strength of the recommendations given in the guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">General Concepts</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Definition</span><p id="par0025" class="elsevierStylePara elsevierViewall">Recent advances in the field of PR have redefined the scope of this therapy&#46; The American Thoracic Society &#40;ATS&#41; and the European Respiratory Society &#40;ERS&#41; have defined Pulmonary Rehabilitation as&#58; <span class="elsevierStyleItalic">a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include&#44; but are not limited to&#44; exercise training&#44; education and behavior change&#44; designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Composition of the Pulmonary Rehabilitation Team</span><p id="par0030" class="elsevierStylePara elsevierViewall">A PR team should be composed of at least one respiratory physician&#44; one physiotherapist&#44; one nurse trained in respiratory diseases and&#44; if possible&#44; one rehabilitation specialist&#46; Ideally&#44; the team should also include&#44; or at least be in close contact with&#44; a social worker&#44; an occupational therapist and a psychologist&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The recent ATS&#47;ERS statement<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> considers that&#44; given the multidisciplinary nature of PR&#44; the most important factor is that the team is made up of motivated professionals with expertise in chronic respiratory diseases&#46; The composition of the team may vary from country to country&#44; and will mainly depend on the facilities available in each center&#44; although no particular staffing structure has been found to be better than others&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Selection Criteria</span><p id="par0040" class="elsevierStylePara elsevierViewall">In order to obtain the expected benefits of PR&#44; patients must be carefully selected&#59; those considered to be candidates for inclusion in PR programs are patients with COPD and limiting dyspnea greater than or equal to grade 2 on the modified Medical Research Council &#40;mMRC&#41; scale &#40;1A&#41;&#46; Also considered as candidates are hypersecretory patients with cystic fibrosis or bronchiectasia &#40;1B&#41;&#44; patients with neuromuscular disease and ineffective cough &#40;1C&#41;&#44; patients requiring chest surgery &#40;1C&#41; and those with other chronic restrictive lung diseases such as diffuse interstitial lung disease or pulmonary hypertension &#40;1B&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;12&#44;13</span></a> International guidelines<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> indicate that PR should be accessible to all patients with chronic respiratory disease&#44; irrespective of their age or severity of disease&#44; and that it is essential to tailor the program to each individual patient&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients not suitable for inclusion in a PR program are those with psychiatric or behavioral disorders that impair collaboration&#44; patients with acute or unstable cardiovascular disease that limits their ability to exercise&#44; and patients with locomotor diseases that are incompatible with exercise training&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Candidate Evaluation</span><p id="par0050" class="elsevierStylePara elsevierViewall">The pulmonologist should make an initial clinical&#44; radiological and functional assessment of patients who are candidates for PR&#46; If a muscle training program is to be proposed&#44; an electrocardiogram&#44; 6-minute walk test<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and maximal graded exercise test &#40;either with a shuttle walking test<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> or incremental ergometer test&#41; should be requested&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> It should be remembered that patients who desaturate &#40;SpO<span class="elsevierStyleInf">2</span>&#8804;90&#37;&#41; in the walk test may benefit from the use of oxygen during training<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> &#40;1C&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The PR team establishes the treatment plan and follow-up&#46; If necessary&#44; the patient should be sent for assessment by a speech therapist&#44; nutritionist&#44; cardiologist&#44; rheumatologist or other appropriate specialist&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Programs and Components</span><p id="par0060" class="elsevierStylePara elsevierViewall">PR programs should basically include muscle training &#40;1A&#41;&#44; education &#40;1B&#41; and chest physiotherapy &#40;1B&#41;&#44; while occupational therapy &#40;2D&#41;&#44; psychosocial support &#40;2C&#41; and nutritional intervention &#40;2C&#41; should also be considered&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Programs should last at least 8 weeks or 20 sessions&#44; with 2&#8211;5 sessions a week<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> &#40;1A&#41;&#44; although shorter programs may also be scheduled&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Program Location</span><p id="par0070" class="elsevierStylePara elsevierViewall">PR programs should be supervised &#40;1A&#41;&#46; They are generally carried out in a hospital setting&#44; although similar benefits can be obtained when performed in the home&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;21&#8211;26</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Measuring the Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">Assessment of PR results in patients with COPD is standardized&#44; and involves quantifying the changes in aspects of the disease can be modified by PR&#44; namely perception of dyspnea&#44; health related quality of life &#40;HRQoL&#41; and exercise capacity&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Various scales can be used to evaluate dyspnea in activities of daily living&#44; such as the modified MRC scale &#40;mMRC&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#44; Mahler baseline&#47;transitional dyspnea index&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> oxygen cost diagram<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> or the dyspnea area from the original chronic respiratory questionnaire &#40;CRQ&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> The most widely used is the mMRC scale&#44; due to its simplicity and reproducibility&#46; In the evaluation of dyspnea on exertion&#44; the most commonly used is the BORG scale&#44; applied in this case before and after an exercise stress test &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Different questionnaires can be used to evaluate HRQoL&#46; The CRQ&#44; either interviewer-<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> or self-administered&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> measures changes in dyspnea and quality of life&#44; with 0&#46;5 points being considered the minimal clinically important difference&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The Saint George Respiratory Questionnaire &#40;SGRQ&#41; also measures the effect of PR on the quality of life&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> with a score of 4 considered as the minimal clinically important difference&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Other questionnaires used in PR are the generic SF36 questionnaire or its short version SF12<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and&#44; more recently&#44; the Chronic Obstructive Pulmonary Disease Assessment Test &#40;CAT&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Changes in exercise capacity are determined on the basis of the distance walked in the 6-minute walk test&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> with 35<span class="elsevierStyleHsp" style=""></span>m considered the minimal clinically significant difference&#44; or 26<span class="elsevierStyleHsp" style=""></span>m if the patient has COPD with severe obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Alternatively&#44; the shuttle walk test<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> may be used&#44; where the minimum change is 47&#46;5<span class="elsevierStyleHsp" style=""></span>m&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> A better&#44; more reproducible method of assessment would be to evaluate exercise capacity in terms of tolerance time using a resistance or sub-maximal test with a cycle ergometer&#46; Normally&#44; a constant level of exercise is performed that represents 70&#37;&#8211;85&#37; of the maximum achieved in a graded exercise test&#46; The minimal clinically significant difference is considered to be 100&#8211;105<span class="elsevierStyleHsp" style=""></span>s&#46; This test also analyzes dyspnea and minute ventilation at the same exercise level&#44; as well as the inspiratory capacity as a reflection of dynamic hyperinflation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></li></ul></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Components of Pulmonary Rehabilitation Programs</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">General and Respiratory Muscle Training</span><p id="par0095" class="elsevierStylePara elsevierViewall">The skeletal muscles are the main therapeutic objective of PR&#44; and muscle training programs are the only intervention that has been shown to be capable of improving peripheral muscle dysfunction in COPD&#46; Therapeutic physical exercise involves gradually and correctly overloading muscles to induce the functional adaptations pursued&#46; In patients with chronic respiratory diseases&#44; general exercise training should be aimed at improving both aerobic capacity and peripheral muscle strength&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;34</span></a></p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Aerobic or Resistance Training</span><p id="par0100" class="elsevierStylePara elsevierViewall">This is the most widely used and most evidence-based exercise modality in PR &#40;1A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;34</span></a> Aerobic exercise is a sub-maximal exercise involving large muscle masses and is maintained for a prolonged period&#46; It improves muscle strength and cardiovascular response&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Training with a cycle ergometer or treadmill are examples of aerobic exercise most widely used in PR&#44; especially in the hospital setting and outpatient programs&#46; There are other aerobic exercise modalities&#44; such as walking outdoors&#44; swimming&#44; dancing&#44; and Nordic walking&#44; but in recent studies&#44; modalities that include walking have been shown to be best if the objective is to improve the walking capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> Some of these modes of aerobic exercise have the advantage that they may be done outside the PR hospital unit&#44; in the patient&#39;s home&#44; and as such are highly recommended for the maintenance phase of programs and for exclusively home-based protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Aerobic exercise should generally be performed at least 3 times a week for 20&#8211;30<span class="elsevierStyleHsp" style=""></span>min continuously or at intervals&#44; the latter being particularly recommended for more symptomatic patients&#46; The intensity of exercise is very important in the prescription of therapeutic exercise&#46; High levels are known to result in a greater physiological response&#44; so a working intensity ranging from 60&#37; to 80&#37; of the maximal exercise capacity &#40;evaluated previously by means of an exercise test&#41; is recommended&#46; With respect to the total duration of training&#44; a minimum of 8 weeks or 20 sessions is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;34</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Interval Training<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a></span><p id="par0105" class="elsevierStylePara elsevierViewall">This is an adaptation of standard aerobic training in which short periods &#40;lasting 1 or 2<span class="elsevierStyleHsp" style=""></span>min&#41; of high intensity exercise are alternated regularly with equally short periods of rest or lower intensity exercise&#46; Patients thus achieve high levels of exercise&#44; but with less dyspnea and fatigue&#44; and obtain benefits equivalent to those of classic aerobic training&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> As previously mentioned&#44; this adaptation is particularly recommended for more symptomatic or disabled patients who cannot maintain periods of continuous exercise&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Strength Training</span><p id="par0110" class="elsevierStylePara elsevierViewall">Following the &#8220;principle of specificity&#8221;&#44; muscle strength training can increase the strength and mass of the muscles exercised&#46; The evidence available supports the use of strength training combined with general aerobic training &#40;1A&#41;&#44; as it further increases peripheral muscle strength&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> In addition to improving muscle function&#44; strength training can help maintain or increase bone mineral density levels in patients with chronic respiratory disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> Strength training in PR is generally carried out using weight lifting exercises for the upper and lower limbs using gym equipment with heavy loads&#44; at 70&#37;&#8211;85&#37; of the maximum weight that can be moved in a single preliminary maneuver &#40;or 1RM test&#41; and few repetitions&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> A recommended prescription would be to perform 1&#8211;3 sets of 8&#8211;12 repetitions of these exercises&#44; in 2&#8211;3 sessions per week&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;34</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Strength training requires greater patient supervision and proper staff training to ensure compliance and prevent potential injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The use of dumbbells and elastic bands is recommended in the home&#44; as they are easy to use&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Other Training Modalities</span><p id="par0120" class="elsevierStylePara elsevierViewall">Other important alternative strategies for peripheral muscle training in PR programs are transcutaneous electrical stimulation and electromagnetic stimulation&#46; These are useful in patients who have difficulty in carrying out regular training&#44; since they require little patient cooperation&#46; Recommendation is weak &#40;2C&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Respiratory Muscle Training</span><p id="par0125" class="elsevierStylePara elsevierViewall">As with general muscle training&#44; the strength and resistance of respiratory muscles can be increased with certain forms of exercise such as interval training specifically targeting the breathing muscles&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;34</span></a> In patients with COPD&#44; inspiratory muscle training &#40;IMT&#41; has been shown to improve muscle strength and resistance&#44; helping improve dyspnea&#44; functional capacity and quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;34</span></a> Despite this&#44; and given the available evidence&#44; adding IMT to general training within a PR program would be recommended if there is shown to be inspiratory muscle weakness &#40;MIP&#60;60<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;35</span></a> &#40;1B&#41;&#44; so this type of training is not currently considered a fundamental part of the PR program &#40;1B&#41;&#44; although it could reasonably be indicated in other chronic respiratory diseases with respiratory muscle dysfunction&#46; However&#44; results so far are inconclusive and recommendation is weak<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;36</span></a> &#40;2C&#41;&#46; In these patients&#44; respiratory muscle training &#40;RMT&#41; should be avoided if there is hypercapnia&#44; FVC &#60;25&#37; or rapid disease progression&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">RMT should generally be done twice daily&#44; at an intensity of at least 30&#37; of the MIP&#47;MEP in sessions of around 15<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;34</span></a> This type of training uses small&#44; affordable devices that are easy to manage and allow the workload to be controlled&#46; The most widely used are the Threshold<span class="elsevierStyleSup">&#174;</span> and Inspir<span class="elsevierStyleSup">&#174;</span> respiratory muscle trainers&#46; The expiratory muscles can also be trained using abdominal exercises&#46; In order to perform RMT properly&#44; the patient should be instructed by specialized personnel&#44; and if possible should learn to control their breathing pattern &#40;expert recommendation&#41;&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Education</span><p id="par0135" class="elsevierStylePara elsevierViewall">Education is one of the main components of PR programs&#44; despite the fact that it is difficult to quantify its direct impact on the benefits of PR programs&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The basic aim is for patients and caregivers to understand and accept the disease and become involved in its management&#44; becoming increasingly self-sufficient in terms of self-care and self-management&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">The term self-care is used in educational programs in relation to teaching the skills and abilities necessary for correct therapeutic compliance&#44; bringing about a change in health behavior&#44; and giving patients the emotional support they need to control their disease and live with the greatest possible functional autonomy&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Self-management&#44; on the other hand&#44; focuses on pharmacological therapy&#44; teaching patients and their caregivers how to manage their drugs on a routine basis and when warning signs appear&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p></li></ul></p><p id="par0155" class="elsevierStylePara elsevierViewall">Education is a continuous process that begins at diagnosis&#59; it is shared responsibility involving patients&#44; their caregivers and healthcare professionals &#40;doctors&#44; nurses&#44; physiotherapists&#44; etc&#46;&#41;&#46; Educational interventions should be adapted to each individual and agreed between the patient and professionals&#44; so that together they can define treatment targets and design a strategy to achieve these goals&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">It is important for PR staff to know and understand the physiopathology and appropriate therapeutic interventions for each of the different diseases that may require PR&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Education programs included in PR are fundamentally designed for patients with COPD<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and asthma&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> although by extension they can be applied to other chronic respiratory diseases&#46; The content is common to all groups&#44; but is adapted according to the teaching resources available&#44; and in particular to the circumstances and needs of each patient&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In general&#44; such educational programs should be designed to give patients the following knowledge and skills<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;40</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Basic anatomy and physiology of the lung and respiratory system&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Characteristics of the disease and symptom management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">Healthy habits &#40;diet&#44; exercise&#44; activities&#44; vaccinations&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">Risk factors&#44; such as exposure to smoke or other environmental pollutants&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">The medical treatment required at each stage of the disease &#40;inhaled therapy&#44; antibiotics&#44; oxygen&#44; ventilation&#44; etc&#46;&#41;&#44; its benefits and side effects&#44; and the strategies needed to strengthen and maintain adherence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Warning symptoms&#44; to be able to prevent and treat exacerbations promptly&#44; giving each patient individualized written instructions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Knowledge of energy saving strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Treatment of possible comorbidities&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Knowledge of community resources and means of contacting the caregiver&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Care and counseling in end-of-life decision-making&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">Educational programs for respiratory patients have shown benefits in terms of improvement in health status and a reduction in the use of healthcare services&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7&#44;37&#44;38&#44;40</span></a> Specifically&#44; the self-management strategy could be particularly beneficial for patients with poorer health status and&#47;or high frequency of exacerbations&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> There has been wide debate on the possible impact of self-management on the overuse of drugs&#46; However&#44; this was not demonstrated in a Cochrane review&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> so this strategy may be safely recommended in patients with COPD&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In summary&#44; international guidelines<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> consider education to be an indisputable part of PR programs for COPD patients&#46; Educational programs should include information on the disease and teach self-care and self-management strategies&#44; with a high level of recommendation and moderate grade of evidence &#40;1B&#41;&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Although the level of evidence for the benefits obtained by education in diseases other than COPD&#44; such as bronchial asthma&#44; is known&#44; there is no specific recommendation within PR programs for these conditions&#44; so it is considered&#44; by extension&#44; similar to that accepted for patients with COPD &#40;1B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Chest Physiotherapy</span><p id="par0240" class="elsevierStylePara elsevierViewall">Chest physiotherapy &#40;CPT&#41; is also considered an important component of PR programs&#46; This section will focus on bronchial drainage techniques&#44; breathing retraining and relaxation techniques&#46; Exercise training&#44; oxygen therapy&#44; mechanical ventilation and intervention in educational programs are also closely associated with the physiotherapist&#44; although they will be addressed in other sections of the guidelines&#46;</p><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bronchial Drainage Techniques</span><p id="par0245" class="elsevierStylePara elsevierViewall">The main aim of bronchial drainage techniques is airway clearance in patients with hypersecretion or difficulty expectorating&#46; They can be divided into three groups&#58; traditional CPT techniques&#44; manual techniques based on flow modulation and instrumental techniques&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Traditional CPT techniques&#44; such as postural drainage and manual percussion and vibration&#44; are not recommended at present due to associated adverse effects&#44; such as oxyhemoglobin &#40;SpO<span class="elsevierStyleInf">2</span>&#41; saturation&#44; onset of episodes of bronchospasm&#44; increase in gastroesophageal reflux&#44; and risk of rib injuries &#40;1B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Manual techniques based on flow modulation &#40;1B&#41; can in turn be divided into slow expiratory techniques&#44; used to drain central and distal airway secretions &#40;Slow Expiration with Glottis Opened in Lateral Posture &#91;ELTGOL&#93;&#44; Autogenic Drainage &#91;AD&#93;&#41;&#44; and rapid expiratory techniques for proximal secretions &#40;Active Cycle of Breathing Technique &#91;ACBT&#93;&#44; Forced Expiration Technique &#91;FET&#93;&#44; cough&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Instrumental techniques are aids to manual techniques and may be classified into three types&#58; Positive Expiratory Pressure &#40;PEP&#41; systems&#44; instrumental vibrations and hyperinflation maneuvers&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0265" class="elsevierStylePara elsevierViewall">PEP systems prevent airway collapse and reduce asynchronous breathing&#59; in the case of an oscillating PEP&#44; they also modify the rheological properties of the secretions &#40;1A&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Extrathoracic instrumental vibrations help reduce secretion viscoelasticity and the functional residual capacity &#40;FRC&#41;&#44; while intrathoracic vibrations &#40;interpulmonary percussive ventilation &#91;IPV&#93;&#41; have similar effects as oscillating PEP &#40;1C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">Hyperinflation maneuvers are very useful for draining secretions in non-cooperative patients or those with significant muscle weakness &#40;assisted cough&#44; intermittent positive pressure breathing &#91;IPPB&#93;&#41; &#40;1B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></li></ul></p><p id="par0280" class="elsevierStylePara elsevierViewall">At present&#44; there is no evidence to suggest the superiority of one technique over another&#44; so the technique that best suits the patient &#40;autonomy&#44; adherence&#44; preference&#44; etc&#46;&#41; should be chosen&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">If inhaled antibiotic medication has been prescribed&#44; these should be taken in the following chronological order during the session&#58; inhalation of the bronchodilator&#44; inhalation of mucolytic and&#47;or hyperosmolar agents &#40;1B&#41;&#44; drainage of secretions and&#44; finally&#44; a dose of inhaled antibiotic&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;44</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Breathing Retraining Techniques</span><p id="par0290" class="elsevierStylePara elsevierViewall">Breathing retraining techniques are intended to retrain the breathing pattern&#44; prevent chest deformation&#44; promote energy saving and reduce the sensation of dyspnea&#46; Despite the benefits of including diaphragmatic breathing&#44; in the case of patients with hyperinflation this type of respiratory work can increase the sensation of dyspnea&#44; overload the inspiratory muscles and reduce the mechanical efficiency of breathing &#40;2C&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;45</span></a> Pursed-lips breathing facilitates recovery in patients with chronic obstructive disease and exercise-induced hyperinflation&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> although there is little evidence in this respect &#40;2C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Relaxation Techniques</span><p id="par0295" class="elsevierStylePara elsevierViewall">Relaxation techniques allow patients to control the hyperventilation and dyspnea caused by the anxiety generated by the disease itself&#46; These interventions are particularly indicated in asthma and hyperventilation syndrome &#40;1B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows an outline of the various chest physiotherapy techniques discussed in this section&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Psychosocial Support</span><p id="par0305" class="elsevierStylePara elsevierViewall">Patients with COPD have a high incidence of depression and anxiety&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;46</span></a> The lack of autonomy and the degree of disability resulting from their clinical condition aggravates these symptoms&#46; These psychosocial disorders can cause cognitive changes&#44; alteration in HRQoL and in the ability to carry out activities of daily living&#44; as well as dependence on healthcare services&#46; Anxiety can also cause changes in the breathing pattern and increase dynamic hyperinflation&#44; resulting in increased dyspnea&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">The main aim of psychosocial treatment is to get the individual to come to terms with their disease&#44; gain as much independence and self-esteem as possible given their limitations&#44; and to have good support from those around them&#46; The most widely used psychosocial interventions are&#58; &#40;1&#41; relaxation techniques&#44; symptom control techniques or educational strategies aimed at changing lifestyle habits and acquiring skills in the control of dyspnea&#44; panic or other attacks&#59; &#40;2&#41; individual or group psychological support and advice&#59; &#40;3&#41; creation of patient associations and &#40;4&#41; pharmacological treatment when necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">Psychosocial aid has a disputed role in PR programs and the results are controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> Currently available data indicate that this strategy can facilitate changes in lifestyle and symptom management&#44; mainly dyspnea&#44; by improving the breathing pattern through physiotherapy and education strategies within a multidimensional PR program<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> &#40;2C&#41;&#46; Some randomized controlled studies have shown that PR reduces the symptoms of anxiety and depression&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;48</span></a> and improves the manner in which patients approach their disease&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> either without any specific therapy or including techniques such as psychotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a> This improvement is more evident when the patient has a greater degree of anxiety or depression before beginning the PR program&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">One aspect that should not be neglected&#44; due to its great emotional impact&#44; is sexuality&#46; In addition to individual or group therapy&#44; teaching strategies on lower energy expenditure that facilitate sexual activity and personalized advice on the use of drugs or oxygen therapy are useful&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;52</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">In summary&#44; to date there is some scientific evidence to suggest that psychosocial intervention is effective as treatment in patients with COPD&#44; especially if it forms part of a multidimensional PR program &#40;2C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Therefore&#44; recent BTS guidelines specify that patients with depression or anxiety may benefit from PR programs that include psychosocial support&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Nutritional Support</span><p id="par0330" class="elsevierStylePara elsevierViewall">Alterations in the body composition of patients with chronic respiratory diseases are a systemic indication of severity&#44; with most scientific evidence being available for COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Schols et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> showed that loss of fat-free mass is an independent predictor of mortality in COPD patients&#46; In these patients&#44; low body weight has also been associated with deteriorated lung function&#44; reduced diaphragmatic muscle mass and lower exercise capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Considering the importance of body composition in COPD&#44; international guidelines<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> recommend the inclusion of nutritional support in PR programs&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">The need to identify and treat changes in body composition in these patients is justified by high prevalence and association with morbidity and mortality&#44; high energy requirements during exercise training that may worsen these abnormalities&#44; and the greater potential benefit that could be derived from a structured training program combined with nutritional support&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#44;57</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">The best method for making a nutritional diagnosis of patients admitted to a PR program is the body mass index &#40;BMI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> Multidimensional indices such as the BODE take BMI into account&#44; with a poorer prognosis in patients with values &#60;21&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Determination of the fat-free mass &#40;FFM&#41; or lean body mass&#44; estimated by measuring skinfold thickness&#44; is another useful parameter that can provide more precise information on body cell mass&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Nutritional Supplements</span><p id="par0345" class="elsevierStylePara elsevierViewall">In recent years&#44; various studies have been published in which different nutritional interventions have been shown to benefit body composition&#44; exercise tolerance and HRQoL in patients with COPD included in PR programs&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55&#44;56&#44;61&#44;62</span></a> The main aim of these nutritional supplements is to enable patients to maintain their body weight and lean body mass within acceptable limits&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">High energy foods &#40;calories and proteins&#41; enriched with macro- and micro-nutrients are used&#44; in which essential amino acids &#40;EAA&#41; play an important role&#46; Their beneficial effects on body weight and FFM have been demonstrated by Baldi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> in a study that also showed the potential of EAA in the regulation of insulin-mediated signaling in protein and glucose metabolism&#46; Weekes et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> in a group of patients with COPD&#44; demonstrated that nutritional support improved weight gain and HRQoL&#46; Creutzberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> studied the effects of nutritional supplements administered for 8 weeks in malnourished COPD patients undergoing a PR program&#44; and found an increase in lean body mass&#44; muscle strength&#44; exercise performance and quality of life&#46; Another recent study has shown that the use of polyunsaturated fatty acids during an exercise training program reduces the levels of various systemic markers of inflammation&#44; such as C-reactive protein&#44; TNF-alfa and IL-8&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> These data justify the use of EAA as a valuable complement to physical exercises in PR programs aimed at stabilizing or even reversing the negative effects of lean body mass loss in these patients&#46; In patients with COPD included in PR programs&#44; creatine supplements do not improve exercise capacity&#44; muscle strength or HRQoL&#44; so their use is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Pharmacological Interventions</span><p id="par0355" class="elsevierStylePara elsevierViewall">Some clinical trials have investigated the benefits of using growth hormone and anabolic steroids such as nandrolone&#44; megestrol acetate and testosterone&#44; with mixed results&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">66&#44;67</span></a> The study by Pison et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> carried out in patients with severe COPD and respiratory failure&#44; showed the beneficial effects of testosterone within a PR program in improving body weight&#44; FFM&#44; exercise tolerance and patient survival&#46; Despite these isolated&#44; although promising results&#44; we cannot recommend the routine use of anabolic supplements within PR programs&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Obesity</span><p id="par0360" class="elsevierStylePara elsevierViewall">Meal planning with nutritional education&#44; calorie restriction&#44; promotion of weight loss and psychological support is recommended in overweight and obese patients&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> Even though a target has yet to be established in relation to the magnitude of weight loss obtained after PR&#44; comprehensive rehabilitation of obese patients may lead to weight loss and improvement in functional status and HRQoL&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">In summary&#44; a nutritional diagnosis should be established based on the body mass index &#40;BMI&#41; and the patient&#39;s nutritional risk&#44; followed by a personalized eating plan based on proper food education&#44; taking into account comorbidities and socio-economic and cultural factors&#46; Available evidence suggests the use of nutritional supplements within a multicomponent PR program&#44; with precise evaluation of results centered on changes in body composition&#44; exercise tolerance and HRQoL&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The data available does not recommend the routine use of anabolic supplements within PR programs&#46; Nutritional interventions should last at least 12 weeks or while the patient remains in the PR program &#40;2C&#41;&#46; In diseases other than COPD&#44; the guidelines suggest using common sense and including measures to combat malnutrition or excess weight&#44; extrapolating the COPD results&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a></p></span></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Role of Oxygen Therapy and Ventilation in Pulmonary Rehabilitation</span><p id="par0370" class="elsevierStylePara elsevierViewall">A distinction must be made between the immediate effects of oxygen while an exercise is being performed and its use as a component of training&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">Oxygen supplementation during exercise&#44; especially in patients with hypoxemia&#44; increases the exercise capacity&#44; decreases breathing requirements&#44; reduces the respiratory rate and dynamic hyperinflation&#44; and improves dyspnea and HRQoL&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> although these positive effects have not always been found&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a></p><p id="par0380" class="elsevierStylePara elsevierViewall">Supplemental oxygen therapy during exercise training should be assessed in two situations&#58; patients with resting or exercise-induced hypoxemia&#44; and patients who do not have hypoxemia&#46; Patients who receive long-term continuous oxygen therapy should use it during training&#44; generally increasing the oxygen flow prescribed at rest&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0385" class="elsevierStylePara elsevierViewall">Patients with hypoxemia&#58; For safety reasons&#44; the administration of supplementary oxygen during training for patients with resting or exercise-induced hypoxemia &#40;1C&#41; is justified&#44; and SpO<span class="elsevierStyleInf">2</span> during training should be maintained above 90&#37;&#46; However&#44; although the use of oxygen therapy greatly improves exercise performance&#44; its effect on training parameters is inconsistent&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;71&#44;72</span></a></p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0390" class="elsevierStylePara elsevierViewall">Patients without hypoxemia&#58; The administration of supplementary oxygen during high intensity training programs in patients without exercise-induced hypoxemia can improve endurance &#40;2C&#41;&#44; although at present it remains unclear whether this in turn improves clinical results&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a></p></li></ul></p><p id="par0395" class="elsevierStylePara elsevierViewall">The use of heliox or helium-hyperoxia&#44; although it increases the inspiratory capacity&#44; reduces dynamic hyperinflation and dyspnea and increases resistance time&#46; However&#44; it has not been shown to have sustained benefits&#44; and is difficult and expensive to administer&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">74&#44;75</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">Non-invasive positive pressure mechanical ventilation &#40;NIV&#41; reduces inspiratory muscle work&#44; improves oxygenation of the quadriceps&#44; reduces dyspnea and increases exercise capacity in some patients with COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> Nocturnal home NIV combined with pulmonary rehabilitation in patients with severe obstruction and hypercapnic respiratory failure can optimize the benefits of PR in terms of exercise capacity&#44;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#44;78</span></a> quality of life<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#8211;79</span></a> and gas exchange&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> probably due to the respiratory muscles having rested overnight&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">Studies have also been conducted in which NIV was use to optimize exercise training&#44; with mixed results&#46; In one clinical trial in patients with COPD and moderate-severe obstruction &#40;mean FEV<span class="elsevierStyleInf">1</span> 44&#37; of theoretical&#41; in which this strategy was applied&#44; no significant differences in dyspnea&#44; leg fatigue&#44; exercise tolerance or HRQoL were found between groups trained with spontaneous breathing or with ventilatory assistance&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> However&#44; in another clinical trial in patients with more severe obstruction &#40;mean FEV<span class="elsevierStyleInf">1</span> 27&#37; of theoretical&#41;&#44; in the group receiving ventilatory assistance training intensity was 15&#46;2&#37; higher &#91;<span class="elsevierStyleItalic">P</span>&#61;&#46;016 &#40;95&#37; CI&#44; 3&#46;2&#8211;27&#46;1&#41;&#93;&#44; peak workload was 18&#46;4&#37; higher &#91;<span class="elsevierStyleItalic">P</span>&#61;&#46;005 &#40;95&#37; CI&#44; 6&#46;4&#8211;30&#46;5&#41;&#93; lactate level was lower &#91;<span class="elsevierStyleItalic">P</span>&#61;&#46;09 &#40;95&#37; CI&#44; 3&#46;3&#8211;40&#41;&#93;&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">In short&#44; NIV as a complement to training in selected patients with COPD and severe obstruction produces modest improvements in exercise performance &#40;2B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Pulmonary Rehabilitation Results in Patients With Chronic Obstructive Pulmonary Disease</span><p id="par0415" class="elsevierStylePara elsevierViewall">PR is a fundamental part of treatment of patients with COPD and is recognized as such in most guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;82</span></a> PR programs should be compulsory for all patients with COPD who continue to be limited by symptoms despite following correct pharmacological treatment &#40;1A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0420" class="elsevierStylePara elsevierViewall">The objectives of PR in COPD are to improve symptoms and exercise capacity&#44; reduce healthcare costs&#44; and stabilize or reverse the systemic manifestations of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0425" class="elsevierStylePara elsevierViewall">Dyspnea is the most disabling symptom with the greatest impact on HRQoL in patients with COPD&#46; PR has been shown to decrease dyspnea and improve exercise capacity and HRQoL in these patients &#40;1A&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It has also been observed that after a PR program&#44; psychoemotional aspects such as anxiety and depression are improved &#40;2B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">These benefits of PR have generally been observed in patients with moderate obstruction&#44; although improvements have also been demonstrated in patients with more severe disease &#40;2C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">Moreover&#44; PR has been shown to reduce the number of days of hospitalization and use of healthcare services in patients with COPD &#40;2B&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> so it is considered to be a cost-effective intervention with evidence level 2C&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; there is insufficient evidence to determine whether PR improves survival in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It has only been possible to demonstrate that in patients who have taken part in a PR program after an exacerbation&#44; the rate of subsequent hospital admissions and mortality have been reduced &#40;1B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0440" class="elsevierStylePara elsevierViewall">The benefits of PR do not appear to be linked with the location of the programs&#46; Thus&#44; home PR programs have shown improvements in dyspnea&#44; exercise capacity and HRQoL similar to those obtained in hospital programs &#40;1A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;26&#44;84</span></a></p><p id="par0445" class="elsevierStylePara elsevierViewall">The issue of when PR programs should start is still under debate&#46; Most guidelines suggest starting in a stable phase of the disease&#44; however&#44; recent studies have shown that initiating a program immediately after an exacerbation&#44; in addition to being safe&#44; is equally beneficial in terms of improving symptoms&#44; exercise capacity and HRQoL&#44; and reducing the number of hospital admissions &#40;1B&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;85</span></a></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Long-term Benefits</span><p id="par0450" class="elsevierStylePara elsevierViewall">PR programs that include 6&#8211;12 weeks of training have been shown to improve exercise tolerance and HRQoL&#44; and to reduce dyspnea and the number of hospital admissions in patients with COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> However&#44; the benefits obtained are gradually lost over 12&#8211;18 months &#40;1A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;86</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall">Various factors can influence the long-term benefits of PR&#44; including&#58; the evolution of the disease itself&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> existence of comorbidities&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a> the intensity&#44; duration<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a> &#40;2C&#41; and location of the programs&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and particularly&#44; the use of maintenance techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">90&#8211;96</span></a></p><p id="par0460" class="elsevierStylePara elsevierViewall">So far&#44; maintenance programs have demonstrated little efficacy in sustaining the benefits obtained from an intensive PR program&#44; although admittedly few studies have been conducted in this respect &#40;2C&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0465" class="elsevierStylePara elsevierViewall">All maintenance programs must take into account strategies such as self-management&#44; defined as a program designed to support and help patients acquire the skills necessary to carry out specific medical regimes and to suggest behavioral changes that can improve disease control&#46; However&#44; few studies have evaluated self-management in COPD patients in relation to sustained activity or physical exercise &#40;2C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0470" class="elsevierStylePara elsevierViewall">There is increasing interest in designing models that sustain improvements gained in exercise capacity and HRQoL after the intensive phase of a PR program&#46; It is unclear which maintenance programs would be most effective&#46; In recent years&#44; various controlled studies have been published that have included strategies for enhancing adherence to PR treatment&#44; such as telephone monitoring&#44; exercise monitors and cell phone applications with exercise speed controlled by a preset tempo&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">90&#44;91</span></a></p><p id="par0475" class="elsevierStylePara elsevierViewall">The frequency of interventions to maintain the benefits of exercise has been variable&#44; with protocols that include supervising the exercise once a week&#44; 3 times a week or even once a month&#46; Some of these programs&#44; mainly when supervised 3 times per week&#44; could be considered to be a continuation of an intensive PR program&#44; which may not be feasible in many healthcare systems&#46; Studies that have evaluated monthly supervision have shown that benefits are generally lost&#44; and exercise capacity diminishes at 12 months&#44; indicating that this frequency of supervised training is insufficient to maintain any improvements&#46; Two studies have shown that exercises supervised once a week maintained improvements in exercise capacity and HRQoL for periods greater than 12 months&#44; although one of these studies used an initial 6-month pulmonary rehabilitation program&#44; which is much longer than those commonly available&#44;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> and the other was a randomized trial conducted in the intensive but not in the maintenance phase&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a></p><p id="par0480" class="elsevierStylePara elsevierViewall">Other designs&#44; such as repeating programs every 2 years&#44; have not been shown to be more effective&#58; a significant number of patients are lost&#44; and they are difficult to apply in clinical practice&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;94</span></a></p><p id="par0485" class="elsevierStylePara elsevierViewall">Home rehabilitation without direct patient supervision can require fewer resources and include more patients&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> The strategy to follow will depend on the setting&#44; and alternatives such as municipal facilities&#44; incentive programs or exercise plans can be used &#40;2C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Few studies have systematically evaluated the risk of adverse events with home rehabilitation&#44; and if these occur&#44; they are more related with exacerbations of the disease than with the PR intervention itself&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a></p><p id="par0490" class="elsevierStylePara elsevierViewall">Although no randomized studies have been conducted&#44; telemedicine has recently begun to be used as means of monitoring and controlling compliance in PR maintenance programs&#44; under the hypothesis that it is potentially useful for maintaining benefits in the long term&#44; and can include a large number of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;96</span></a></p><p id="par0495" class="elsevierStylePara elsevierViewall">BTS guidelines<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> recommend encouraging all patients to continue exercising after a PR program &#40;1A&#41;&#44; and good clinical practice recommends giving patients the opportunity to continue to engage in physical activity&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Pulmonary Rehabilitation in Chronic Respiratory Diseases Other Than Chronic Obstructive Pulmonary Disease and Other Diseases With Respiratory Complications</span><p id="par0500" class="elsevierStylePara elsevierViewall">Respiratory symptoms such as dyspnea&#44; as well as changes in exercise capacity or HRQoL&#44; occur in almost all chronic respiratory diseases&#46; Skeletal muscle function deteriorates in cystic fibrosis&#44; bronchial asthma&#44; obstructive sleep apnea-hypopnea syndrome &#40;OSAHS&#41; and lung cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">97&#44;98</span></a> In idiopathic pulmonary arterial hypertension&#44; exercise intolerance is one of the most common symptoms and is related with respiratory and peripheral muscle dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p><p id="par0505" class="elsevierStylePara elsevierViewall">There are no specific programs for each disease&#44; and established programs for COPD patients should be adapted to each disease group&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Bronchial Asthma</span><p id="par0510" class="elsevierStylePara elsevierViewall">Physiotherapy techniques should be included in PR programs&#44; essentially to control attacks&#44; and should include breathing retraining and relaxation techniques<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;100</span></a> &#40;1A&#41;&#46; Aerobic training &#40;cycling&#44; swimming&#44; treadmill&#41; for at least 20<span class="elsevierStyleHsp" style=""></span>min a day&#44; twice weekly for at least 4 weeks&#44; is a well tolerated therapy with no side effects that has been shown to increase oxygen consumption in patients with well controlled asthma &#40;O<span class="elsevierStyleInf">2</span> consumption&#58; 5&#46;57<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;min&#59; 95&#37;CI &#91;4&#46;36&#8211;6&#46;78&#93;&#41; &#40;1A&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a> Patients who develop exercise-induced asthma should use fast-acting &#946;-2 agonists before starting training&#44; as well as doing a preliminary gradual warm-up &#40;2B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Cystic Fibrosis and Bronchiectasis</span><p id="par0515" class="elsevierStylePara elsevierViewall">Chest physiotherapy&#44; and specifically secretion drainage techniques&#44; either manual or instrumental&#44; is essential in these diseases &#40;1A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;42&#44;102</span></a> The physiotherapy techniques should be chosen according to the patient&#39;s preference&#44; as none has been shown to be more effective&#46; Self-administered techniques are generally recommended to facilitate compliance&#46; Physiotherapy should be carried out once to three times daily&#44; after bronchodilator treatment and before inhaled antibiotics&#44; if prescribed &#40;1B&#41;&#46; Although it is unclear whether patients with non-productive cough would also benefit from physiotherapy techniques&#44; experts generally agree that they should at least undergo physiotherapy during exacerbations &#40;2C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">102</span></a> Exercise&#44; meanwhile&#44; should be moderate to intense for at least 30<span class="elsevierStyleHsp" style=""></span>min a day&#44; 3&#8211;4 times a week&#44; or failing that&#44; daily moderate physical activity should be recommended &#40;1B&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;42</span></a> One aspect mentioned in other international guidelines involves control of infections&#58; a distance of at least 1<span class="elsevierStyleHsp" style=""></span>m should be maintained between cystic fibrosis patients&#44; given the potential risk of cross-infections with resistant microorganisms&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Idiopathic Pulmonary Arterial Hypertension</span><p id="par0520" class="elsevierStylePara elsevierViewall">Recent studies have shown an improvement in exercise capacity and HRQoL after aerobic training&#44; together with upper limb training&#44; in sessions spread over 3&#8211;7 days per week&#44; for 7&#8211;15 weeks&#44; with no adverse effects having been recorded&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;103</span></a> Likewise&#44; patients with chronic thromboembolic pulmonary hypertension who do aerobic training together with low intensity strength training show an improvement in HRQoL and exercise capacity&#44; with no major adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> However&#44; although the results are promising&#44; further studies are required to establish the safety of PR &#40;2C&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Interstitial Lung Diseases</span><p id="par0525" class="elsevierStylePara elsevierViewall">These are characterized by dyspnea and hypoxemia that worsen with exercise&#46; These symptoms are due&#44; among other causes&#44; to&#58; lack of pulmonary distention&#44; impaired gas exchange&#44; altered breathing pattern &#40;superficial respiration and dynamic hypoinflation&#41; and systemic corticosteroid treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">105</span></a> As a result&#44; patients with interstitial lung diseases &#40;ILD&#41; tend to be sedentary&#44; with functional limitation and worse HRQoL&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">106</span></a> Guidelines usually recommend limiting physical exercise in patients with ILD&#46; However&#44; at present&#44; evidence suggests that PR may be an effective and safe treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">107&#44;108</span></a> Thus&#44; when training is indicated individually&#44; with an intensity established by a cardiopulmonary exercise test and taking into account possible associated comorbidities such as pulmonary arterial hypertension&#44; cardiac impairment or arrhythmias&#44; major benefits can be obtained in terms of symptoms and exercise capacity&#46; Although the most appropriate exercise protocols are not yet well established&#44; symptom-limited low intensity aerobic training is generally recommended &#40;2B&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;109</span></a></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Obstructive Sleep Apnea-Hypopnea Syndrome</span><p id="par0530" class="elsevierStylePara elsevierViewall">Randomized controlled studies with a limited number of subjects have been conducted that show that 12 weeks of moderate intensity aerobic training 4 days a week&#44; together with 2 days a week of resistance training&#44; reduces the sleep apnea-hypopnea index and objectively and subjectively improves the quality of sleep&#44;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">110</span></a> depressive symptoms and drowsiness&#44; in addition to other benefits &#40;2C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">111</span></a></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Lung Cancer</span><p id="par0535" class="elsevierStylePara elsevierViewall">Patients diagnosed with lung cancer usually undergo major changes in HRQoL&#44; mainly due to impairment of their physical condition &#40;weakness&#44; anorexia&#44; cachexia&#41;&#44; emotional changes secondary to their disease&#44; and to treatments such as chemotherapy or radiotherapy&#46; If a previous chronic disease &#40;basically COPD&#41; is also present&#44; dyspnea usually worsens the condition&#46;</p><p id="par0540" class="elsevierStylePara elsevierViewall">It is reasonable to consider that a PR program could result in an improvement in these patients&#46; Few studies have shown that respiratory physiotherapy techniques improve symptoms in this patient group with<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">112</span></a>&#59; exercise training is clearly much more effective with respect to improving not only symptoms by also exercise capacity and HRQoL&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">113&#8211;115</span></a></p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Neuromuscular Diseases</span><p id="par0545" class="elsevierStylePara elsevierViewall">The control of respiratory secretions is&#44; together with the prevention of food aspiration and maintenance of adequate alveolar ventilation&#44; fundamental for the management of respiratory problems in neuromuscular diseases &#40;NMD&#41; &#40;1C&#41; and is the basis of PR in these entities<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;116&#8211;120</span></a> &#40;see on-line section&#41;&#46;</p></span></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Pulmonary Rehabilitation and Thoracic Surgery</span><p id="par0550" class="elsevierStylePara elsevierViewall">Surgical treatment of lung cancer as well as new COPD therapies &#40;lung volume reduction surgery and lung transplant&#41; or other surgeries considered high risk in patients with chronic respiratory diseases&#44; require optimal clinical status and&#44; therefore&#44; the multidisciplinary approach of PR is a critical component of the therapeutic strategy in these situations&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a></p><p id="par0555" class="elsevierStylePara elsevierViewall">Generally&#44; in order to prevent post-operative complications in patients undergoing chest or upper abdominal surgery&#44; above all with prior respiratory disease&#44; CPT has a very important pre- and post-operative role&#46; Worth mentioning are breathing retraining techniques including incentive spirometry &#40;IS&#41; and airway clearance maneuvers when there are secretions&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">122&#44;123</span></a> Another technique to consider is continuous positive airway pressure &#40;CPAP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a> However&#44; no studies to date have shown any advantage of this treatment over CPT techniques&#46; Intermittent positive pressure breathing &#40;IPPB&#41; may also be effective in preventing post-operative lung complications&#44; but because of its higher cost and relatively high incidence of abdominal distention it is not a treatment of choice&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">124</span></a> Although CPT for patients who are candidates for thoracic surgery is strongly recommended&#44; no randomized controlled studies have so far confirmed its effectiveness&#46; Some non-randomized studies suggest that CPT may reduce the risk of atelectasia and hospitalization&#44; but it does not seem to affect the incidence of pneumonia or morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">123</span></a> Therefore&#44; the role of CPT in thoracic surgery has a low grade of evidence but a high recommendation &#40;1C&#41;&#46;</p><p id="par0560" class="elsevierStylePara elsevierViewall">Exercise training is one treatment strategy to consider in patients undergoing thoracic surgery&#46; In patients with chronic lung disease who undergo tumor resection&#44; the best approach would be to instigate a training regime in addition to CPT in the weeks prior to surgery to improve muscle strength and resistance&#44; and to restart these strategies as soon as possible post-operatively&#46;</p><p id="par0565" class="elsevierStylePara elsevierViewall">In patients who are candidates for lung volume reduction surgery or lung transplant&#44; the full PR program&#44; including exercise training&#44; should be commenced as soon as possible&#46;</p><p id="par0570" class="elsevierStylePara elsevierViewall">PR in lung volume reduction surgery candidates is safe and effective&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">125</span></a> The NETT study showed that 20&#37; of patients waiting for lung volume reduction surgery improved with PR to the point where the surgery was no longer required&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">126</span></a> Improvements affected lung function&#44; gas exchange&#44; exercise capacity and HRQoL&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">127</span></a></p><p id="par0575" class="elsevierStylePara elsevierViewall">Patients that are candidates for lung transplant have greatly impaired exercise capacity&#59; therefore&#44; PR is an essential part of the therapeutic strategy&#46; Prior to the transplant&#44; the main objective of PR is to optimize and maintain the patient&#39;s functional status while closely monitoring the underlying disease&#46; Moreover&#44; PR may be a good starting point to better refine candidate selection&#44; both through the assessments carried out &#40;walk test&#41; and monitoring program compliance&#44; which may help to detect non-compliant patients&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">128</span></a> A recent review confirmed that PR is beneficial for lung transplant candidates in terms of muscle function&#44; exercise capacity and bone mineral density&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">129</span></a> However&#44; because few studies have been made&#44; it is unclear whether improved exercise capacity prior to surgery can reduce post-operative complications and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">129</span></a> Post-transplant&#44; PR is important since exercise capacity and myopathy is greatly impaired&#59; training should be started gradually and early&#46; In these patients&#44; continuous and interval training have been shown to be equally effective&#44;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">130</span></a> both in hospital or at home&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">131</span></a></p><p id="par0580" class="elsevierStylePara elsevierViewall">At present&#44; considering the studies conducted to date&#44; it can be said that PR has a high level of evidence and recommendation for candidates for lung volume reduction surgery or transplant &#40;1A&#41;&#46;</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Other Aspects of Pulmonary Rehabilitation</span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Physical Activity</span><p id="par0585" class="elsevierStylePara elsevierViewall">Physical inactivity is common in patients with COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">132</span></a> These patients adopt a more sedentary lifestyle&#44; and it has been shown that the time that they remain active correlates poorly with the degree of airflow obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">133</span></a> Inactivity is a factor of poor prognosis and is associated with higher mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">134&#44;135</span></a> Therefore&#44; one aim of PR programs is to increase patients&#8217; physical activity&#46; Studies conducted in this respect have been unable to reliably demonstrate that improvements in exercise tolerance in patients following a PR program implies a greater degree of physical activity in their daily life&#46;<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">136&#8211;138</span></a> Transferring improvement in exercise capacity achieved in PR programs to daily life is a future challenge that must involve changing the patient&#39;s behavior and habits&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">139</span></a></p></span></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Conflict of Interest</span><p id="par0590" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "General Concepts"
          "secciones" => array:7 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Definition"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Composition of the Pulmonary Rehabilitation Team"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Selection Criteria"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Candidate Evaluation"
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            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Programs and Components"
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            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Program Location"
            ]
            6 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Measuring the Results"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0050"
          "titulo" => "Components of Pulmonary Rehabilitation Programs"
          "secciones" => array:5 [
            0 => array:3 [
              "identificador" => "sec0055"
              "titulo" => "General and Respiratory Muscle Training"
              "secciones" => array:5 [
                0 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Aerobic or Resistance Training"
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                1 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Interval Training"
                ]
                2 => array:2 [
                  "identificador" => "sec0070"
                  "titulo" => "Strength Training"
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                3 => array:2 [
                  "identificador" => "sec0075"
                  "titulo" => "Other Training Modalities"
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                4 => array:2 [
                  "identificador" => "sec0080"
                  "titulo" => "Respiratory Muscle Training"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Education"
            ]
            2 => array:3 [
              "identificador" => "sec0090"
              "titulo" => "Chest Physiotherapy"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0200"
                  "titulo" => "Bronchial Drainage Techniques"
                ]
                1 => array:2 [
                  "identificador" => "sec0095"
                  "titulo" => "Breathing Retraining Techniques"
                ]
                2 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "Relaxation Techniques"
                ]
              ]
            ]
            3 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Psychosocial Support"
            ]
            4 => array:3 [
              "identificador" => "sec0110"
              "titulo" => "Nutritional Support"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0115"
                  "titulo" => "Nutritional Supplements"
                ]
                1 => array:2 [
                  "identificador" => "sec0120"
                  "titulo" => "Pharmacological Interventions"
                ]
                2 => array:2 [
                  "identificador" => "sec0125"
                  "titulo" => "Obesity"
                ]
              ]
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0130"
          "titulo" => "Role of Oxygen Therapy and Ventilation in Pulmonary Rehabilitation"
        ]
        8 => array:2 [
          "identificador" => "sec0135"
          "titulo" => "Pulmonary Rehabilitation Results in Patients With Chronic Obstructive Pulmonary Disease"
        ]
        9 => array:2 [
          "identificador" => "sec0140"
          "titulo" => "Long-term Benefits"
        ]
        10 => array:3 [
          "identificador" => "sec0145"
          "titulo" => "Pulmonary Rehabilitation in Chronic Respiratory Diseases Other Than Chronic Obstructive Pulmonary Disease and Other Diseases With Respiratory Complications"
          "secciones" => array:7 [
            0 => array:2 [
              "identificador" => "sec0150"
              "titulo" => "Bronchial Asthma"
            ]
            1 => array:2 [
              "identificador" => "sec0155"
              "titulo" => "Cystic Fibrosis and Bronchiectasis"
            ]
            2 => array:2 [
              "identificador" => "sec0160"
              "titulo" => "Idiopathic Pulmonary Arterial Hypertension"
            ]
            3 => array:2 [
              "identificador" => "sec0165"
              "titulo" => "Interstitial Lung Diseases"
            ]
            4 => array:2 [
              "identificador" => "sec0170"
              "titulo" => "Obstructive Sleep Apnea-Hypopnea Syndrome"
            ]
            5 => array:2 [
              "identificador" => "sec0175"
              "titulo" => "Lung Cancer"
            ]
            6 => array:2 [
              "identificador" => "sec0180"
              "titulo" => "Neuromuscular Diseases"
            ]
          ]
        ]
        11 => array:2 [
          "identificador" => "sec0185"
          "titulo" => "Pulmonary Rehabilitation and Thoracic Surgery"
        ]
        12 => array:3 [
          "identificador" => "sec0190"
          "titulo" => "Other Aspects of Pulmonary Rehabilitation"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0195"
              "titulo" => "Physical Activity"
            ]
          ]
        ]
        13 => array:2 [
          "identificador" => "sec0205"
          "titulo" => "Conflict of Interest"
        ]
        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-07-23"
    "fechaAceptado" => "2014-02-17"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec335042"
          "palabras" => array:7 [
            0 => "Respiratory therapy"
            1 => "Muscle training"
            2 => "Chronic obstructive pulmonary disease"
            3 => "Diseases other than chronic obstructive pulmonary disease"
            4 => "Location and duration of the programs"
            5 => "Exacerbations"
            6 => "Maintenance"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec335041"
          "palabras" => array:7 [
            0 => "Rehabilitaci&#243;n respiratoria"
            1 => "Entrenamiento muscular"
            2 => "Enfermedad pulmonar obstructiva cr&#243;nica"
            3 => "Enfermedades distintas de la enfermedad pulmonar obstructiva cr&#243;nica"
            4 => "Ubicaci&#243;n y duraci&#243;n de los programas"
            5 => "Exacerbaciones"
            6 => "Mantenimiento"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pulmonary rehabilitation &#40;PR&#41; has been shown to improve dyspnea&#44; exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#46; PR has also shown benefits in diseases other than COPD but the level of evidence is lower&#46; The fundamental components of PR programs are muscle training&#44; education and chest physiotherapy&#46; Occupational therapy&#44; psychosocial support and nutritional intervention should also be considered&#46; Home programs have been shown to be as effective as hospital therapy&#46; The duration of rehabilitation programs should not be less than 8 weeks or 20 sessions&#46; Early initiation of PR&#44; even during exacerbations&#44; has proven safe and effective&#46; The use of oxygen or noninvasive ventilation during training is controversial and dependent on the patient&#39;s situation&#46; At present&#44; the best strategy for maintaining the benefits of PR in the long term is unknown&#46; Longer PR programs or telemedicine could play a key role in extending the results obtained&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La rehabilitaci&#243;n respiratoria &#40;RR&#41; ha demostrado mejorar la disnea&#44; la capacidad de esfuerzo y la calidad de vida relacionada con la salud en los pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;&#46; En otras enfermedades distintas de la EPOC tambi&#233;n ha mostrado beneficios&#44; aunque el grado de evidencia es menor&#46; Los componentes fundamentales de los programas de RR son el entrenamiento muscular&#44; la educaci&#243;n y la fisioterapia respiratoria&#44; siendo aconsejable tambi&#233;n contemplar la terapia ocupacional&#44; el soporte psicosocial y la intervenci&#243;n nutricional&#46; Los programas domiciliarios han demostrado igual eficacia que los hospitalarios&#46; La duraci&#243;n de los programas de RR no debe ser inferior a 8 semanas o 20 sesiones&#46; La RR iniciada precozmente&#44; incluso durante las exacerbaciones&#44; ha demostrado ser eficaz y segura&#46; La utilizaci&#243;n de ox&#237;geno o ventilaci&#243;n no invasiva durante el entrenamiento es controvertida y dependiente de la situaci&#243;n del paciente&#46; En el momento actual desconocemos cu&#225;l es la mejor estrategia para mantener los beneficios de la RR a largo plazo&#46; Una mayor duraci&#243;n de los programas o la telemedicina podr&#237;an ser claves para prolongar los resultados conseguidos&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; G&#252;ell Rous MR&#44; D&#237;az Lobato S&#44; Rodr&#237;guez Trigo G&#44; Morante V&#233;lez F&#44; San Miguel M&#44; Cejudo P&#44; et al&#46; Rehabilitaci&#243;n respiratoria&#46; Arch Bronconeumol&#46; 2014&#59;50&#58;332&#8211;344&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0600" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0215"
          ]
        ]
      ]
    ]
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; Modified MRC dyspnea scale&#46; &#40;b&#41; Borg dyspnea scale&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
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        "mostrarDisplay" => false
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Techniques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Objectives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bronchial drainage techniques</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Airway clearance</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Manual techniques for flow modulation &#40;1B&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Slow expiratory&#58; central and distal secretions</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rapid expiratory&#58; proximal secretions</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Instrumental techniques</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PEP systems<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;1 A&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prevent airway collapse</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oscillating&#58; modify rheological properties of the secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vibrations &#40;1C&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intrathoracic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Modify rheological properties of the secretions</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extrathoracic&#58; &#8595;FRC<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hyperinflation techniques&#58; drainage of secretions in non-cooperative patients or those with significant muscle weakness &#40;assisted cough&#44; IPPB<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#41; &#40;1B&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Breathing retraining techniques</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retraining of the breathing pattern&#44; prevention of chest deformities&#44; energy saving and reduction in dyspnea</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Integration of the diaphragmatic pattern&#58; except for hyperinflated patients in whom it should not be done automatically &#40;2C&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pursed-lips breathing&#58; facilitates recovery after the exercise &#40;2C&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Techniques for reducing energy expenditure during activities of daily living &#40;2C&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Relaxation techniques&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Self-control of hyperventilation and dyspnea &#40;1B&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Particularly indicated in asthma and hyperventilation syndrome</td></tr></tbody></table>
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Normativa Rehabilitaci&#243;n Respiratoria"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2000"
                        "volumen" => "36"
                        "paginaInicial" => "257"
                        "paginaFinal" => "274"
                        "link" => array:1 [ …1]
                      ]
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                      "titulo" => "An Official American Thoracic Society&#47;European Respiratory Society Statement&#58; key concepts and advances in pulmonary rehabilitation"
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                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
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