Current health systems are designed to treat and resolve acute episodes, but integral care of the patient is not an objective. These models are generally fragmented and multidisciplinary intervention is rare. They are oriented toward conventional hospital admission and follow-up in hospital outpatient units and primary care. Alternatives to conventional hospitalization, such as hospital-at-home and domiciliary care of complex patients are rarely considered, despite their proven cost-effectiveness. Clinical guidelines for diseases do not address systemic manifestations and common comorbidities that often contribute to the burden of disease. COPD patients have complex health needs, and the health system must be redesigned to meet these requirements.

Complexity is difficult to define, measure or predict. The term “patient complexity” applies to individuals who may fulfill at least one of the following criteria: (a) need for follow-up by different specialists; (b) frailty, requiring additional help due to functional decline and social deficits or temporary situations, such as hospital discharge, and (c) need for highly specialized care at home.

The progress of patients with complex needs often fluctuates, so the type of follow-up and the professionals involved may vary. Innovative services with technological support that improve efficiency and contribute to a better understanding of the underlying mechanisms of chronic diseases are required.2–4 There is no universal model for the management of chronic diseases, but conceptual frameworks exist that have demonstrated better outcomes.5 The most widely used is the Chronic Care Model (CCM) proposed by the World Health Organization (WHO) (Fig. 1). One of the main components of this model is ICS. Nevertheless, the effectiveness of CCM in COPD is limited and variable, and depends on the type of interventions and the experience of the professionals involved.6,7

Fig. 1.

Universal model of chronic disease management.

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PR is one of the essential components of ICS in COPD, and its effects are well established11–15 (Fig. 3). The concept of PR from the American Thoracic Society (ATS) and the European Respiratory Society (ERS) consensus was incorporated into the 2014 update of the GesEPOC guidelines, placing more emphasis on its central role in the integrated care of the patient with chronic disease.11,16 The ATS and the ERS have also developed guidelines aimed at improving the implementation of PR.11,12,17 The new definition describes PR as a “comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, 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”.11

Fig. 3.

The components of a complete, integrated pulmonary rehabilitation program have a direct and positive physical and psychological effect on patients, helping them to become more proactive toward their disease, acquiring healthy lifestyle behaviors, thus reducing the risk of exacerbations and mortality. Adapted from Spruit et al.27

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The latest evidence and recommendations for ordering PR are summarized below:

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  Results from different studies recommend that all COPD patients are included in a PR program as part of their treatment.12

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  Structured TE programs should begin at the time of diagnosis and continue for the rest of the patient's life. Programs will be adapted to the needs of the patient and comorbidities will be taken into account.18

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  Prescribing PR in patients with mild COPD is considered a weak recommendation, despite improvements in variables such as quality of life and exercise capacity.19

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  Physical exercise, started during or immediately after a COPD exacerbation, improves quality of life and exercise capacity; however, the wide range of PR programs on offer may explain the heterogeneous effect on outcomes such as hospital readmissions and mortality.20 Doubts persist regarding the ideal timing of PR, and until more reliable information is available, the initiation of PR during hospital admission should be avoided.20

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  Limited access to PR for COPD patients is prompting further research into community-based programs that require less infrastructure.11,21,22

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  Intervention aimed at changing behaviors can help improve participation in COPD self-management programs.23,24

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  Understanding of the effects of technology applied to physical training, TE, disease management, and PA in the PR setting is still limited.25–27

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  Psychosocial factors and the perceptions of patients themselves can contribute to the adherence and maintenance of the effects of PR in the long term.23

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  PR is safe, given the low incidence of major complications.28

The importance of prescribing PA in COPD patients is determined, among other factors, by: (a) the high morbidity and mortality associated with COPD29; (b) evidence that physical inactivity is associated with an increased risk of mortality and exacerbations30,31; (c) when compared to healthy individuals of the same age, COPD patients have a lower level of PA32; (d) the comorbidities that COPD patients may present also improve with regular PA33; (e) physical inactivity is associated with progressive intolerance of exercise and muscular involvement34; (f) low levels of PA occur even in patients with mild COPD, suggesting that early intervention is needed to reduce the risk of future comorbidities and, possibly, disease progression35,36; (g) PA in patients with COPD depends on psychological, behavioral, social, environmental, and cultural factors,27 and (h) the health professional must be convinced that the prescription of PA should form part of the treatment of every COPD patient.37

To date, no specific recommendations have been established with respect to the level of PA that COPD patients should maintain. However, general recommendations on the benefits of performing moderate PA for at least 30min a day, 5 days a week (or the equivalent of 1000kcal/week), such as those of American College of Sports Medicine,38 are generally accepted.

In the Phenotype and Course of Chronic Obstructive Pulmonary Disease (PAC-COPD) cohort, subjects with severe to very severe COPD performed their daily activities over shorter and fewer periods than patients with mild to moderate stages of the disease.39 This pattern should be taken into account when PA is being recommended and prescribed in more severe patients, since these patients must perform short sessions of PA several times a day, instead of longer, uninterrupted sessions of 20–30min.

The prescription of PA is complex because it involves a combination of individual, socio-cultural and environmental factors that must be taken into account.30,31 Consequently, and in view of the lack of evidence and consensus in prescription criteria and in strategies to increase the PA in COPD patients, strategies adapted to everyday life should be proposed and agreed upon with the patient.

Table 2 describes randomized clinical trials in which a PA intervention was prescribed, and the tool used to measure PA in COPD patients. In a recent systematic review conducted by Mantoani et al.,40 the authors concluded that interventions with PR programs of longer than 12 weeks’ duration have a positive impact on increasing PA.

Other more specific alternatives, such as dietary intervention in patients with cachexia and nocturnal non-invasive ventilation, along with exercise in subjects with hypercapnia, appear to improve PA levels in these patients.40 Long-term oxygen therapy (≥8 weeks) and electrical muscle stimulation do not have a significant impact on PA levels, but could be used adjunctively with other interventions. Finally, bronchodilators may increase activity levels in the daily life of subjects with COPD.40

It is important to remember that behaviors associated with PA are complex, and as such, difficult to modify. Changing the attitude of the COPD patient toward PA requires an interdisciplinary approach that involves medical, social, and behavioral sciences, and interventions should be based on theoretical models of behavior change.27 The latest ERS guidelines on PA in COPD emphasize that social support and the use of specific techniques for behavior modification are essential for achieving better contact with patients and higher motivation for change, and as such, are core elements for making behavioral interventions more effective.27

In practice, COPD patients should be encouraged to increase their level of PA and they must be clearly informed of the therapeutic benefits of activity.37 Strategies aimed at increasing motivation for performing PA, and therefore, adherence to PA programs should include specific, measurable, achievable, realistic objectives, set down in writing, ensuring that the patient plays an active role in the control of their disease.27,37

Limited information is available on the implementation of the chronic care model in patients with chronic respiratory diseases such as COPD. Adams et al.6 found that patients with COPD who received interventions with 2 or more elements required fewer hospital admissions for acute COPD exacerbations and shorter hospital stays.

Living with a chronic illness is difficult, and even more so when self-care is complex. Achieving good treatment adherence is one of the most important challenges and a key therapeutic factor, although it is a complex process that is influenced by multiple factors associated with the patient, the professional, the health system, the disease, and the drugs themselves.42

The aim of TE is to help patients acquire the necessary resources to manage their lives as well as possible, and to be informed and to share decision-making regarding their health and their disease with their attending healthcare professionals.42,43

The WHO advises that all patients with chronic disease should have access to structured TE programs and an individualized treatment plan, and that it is essential that healthcare professionals acquire the knowledge and skills required to implement such programs, although the level of training in this field is still limited.43

To plan an individualized TE plan, patient priorities, treatment complexity, and healthcare models must be taken into account, and the patient must be evaluated according to an overall assessment comprising 5 dimensions: healthcare model, socioeconomic factors, treatment-related factors, patient-related factors, and finally, disease-related factors.43

Therapeutic adherence in COPD is low, leading to increased rates of exacerbations, hospitalizations, and death.44 TE alone has no impact on the use of healthcare resources or on the patient's functional status, but results are positive if it is accompanied by other interventions.45

A Cochrane review46 found that self-care interventions in COPD patients are associated with improved quality of life, fewer hospital admissions, and an improved perception of dyspnea. However, differing interventions, study populations and follow-up periods, and the range of outcome measures make it difficult to formulate clear recommendations with regard to the most effective form and content of self-care in COPD, and as such TE.

The latest ERS expert consensus47 concludes that a self-care program should be structured, personalized, and multicomponent, in order to motivate, involve and support patients in adopting healthy behaviors and developing skills to help them better manage their disease and comply with treatment.

Published studies do not provide conclusive data for designing the optimal TE program in COPD, although a recent meta-analysis showed that longer self-care interventions reduce hospitalizations for all causes.48

The GesEPOC working group proposes the essential components of a TE program in COPD and the elements that must be evaluated to determine the degree of patient adherence (Table 3). Support materials used for the development of educational interventions should be based on clinical guidelines and must be validated.49,50