Elsevier

Thoracic Surgery Clinics

Volume 14, Issue 3, August 2004, Pages 417-428
Thoracic Surgery Clinics

Chronic respiratory failure after lung resection: the role of pulmonary rehabilitation

https://doi.org/10.1016/S1547-4127(04)00017-9Get rights and content

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Definition and goals

Rehabilitation attempts to restore the individual to the fullest medical, mental, emotional, social, and vocational potential to which he or she is capable. Based on this basic concept, pulmonary rehabilitation has been defined as “a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy.” [1] From this definition, it follows that pulmonary rehabilitation has three

Rationale for pulmonary rehabilitation

Pulmonary rehabilitation has a minimal, if any, effect on the abnormal lung function of individuals with chronic lung disease. Despite this minimal effect, rehabilitation usually results in clinically significant improvement in multiple outcome areas of considerable importance to the patient, including reduction in exertional dyspnea and dyspnea associated with daily activities, improvement in exercise performance and in health status, and reduction in health care use.

The apparent paradox

Indications for pulmonary rehabilitation

Pulmonary rehabilitation is indicated for patients with chronic respiratory disease who have persistent symptoms or disability despite standard medical therapy. Fig. 1 depicts the course of patients with lung function limitation over time and the role of pulmonary rehabilitation. Although all patients with chronic respiratory disease are eligible for consideration for pulmonary rehabilitation, to date, COPD is the most common disease for which patients are referred, often from one or more of

Smoking cessation

Cigarette smoking is the cause of COPD in more than 90% of affected patients. There is no doubt that smoking cessation is the most important therapy that can retard the progression of airflow limitation and influence survival positively. The various pharmacologic and behavior modification techniques that are available to assist persons to stop smoking are not reviewed here. Although controversy still exists, active cigarette smokers are reasonable candidates for pulmonary rehabilitation,

Exercise training

Comprehensive exercise training, including upper and lower extremity endurance training and strength training, is an essential component of comprehensive pulmonary rehabilitation. Inclusion of exercise training follows the current knowledge that the peripheral muscles in chronic lung disease not only are wasted, but also appear to have alterations in fiber-type distribution and decreased metabolic capacity. Exercise training improves endurance, increases level of functioning, aids in

Education

Education is an integral component of virtually all comprehensive pulmonary rehabilitation programs. Besides providing the patient and the family important information on the disease process, its comorbidity, and its treatment, education encourages active participation in health care, promoting adherence and self-management skills [40]. Additionally, education helps the patient and family find ways to cope better with the illness. Important components of the educational process are encouraging

Psychosocial training and support

Psychosocial problems (eg, anxiety, depression, deficiencies with coping, and decreased self-efficacy) contribute to the burden of advanced respiratory disease [46]. Psychosocial and behavioral interventions vary widely among comprehensive pulmonary rehabilitation programs but often involve educational sessions or support groups, focusing on areas such as coping strategies or stress management techniques. Techniques of progressive muscle relaxation, stress reduction, and panic control may

Nutritional support

Nutritional depletion, including decreased weight and abnormalities in body composition, such as decreased lean body mass, is present in 20% to 35% of patients with stable COPD [49], [50]. This depletion undoubtedly contributes to the morbidity of COPD. Nutritional depletion is associated with reductions in respiratory muscle strength [51], handgrip strength, exercise tolerance [52], and health status [53]. Nutritional depletion and alteration in body composition also are significant predictors

Physical modalities of ventilatory therapy

Physical modalities of ventilatory therapy have been part of the armamentarium of pulmonary rehabilitation over the years, but conclusive evidence supporting their effectiveness in pulmonary rehabilitation is lacking. These modalities comprise two categories: controlled breathing techniques (diaphragmatic breathing exercise, pursed-lip breathing, and bending forward) and chest physical therapy (postural drainage and chest percussion and vibration position). Controlled breathing techniques are

Vaccination

The causes of exacerbations of COPD are poorly understood and probably are multifactorial. Influenza virus and Streptococcus pneumoniae may play a role, and when either of these infections occurs, patients with chronic lung disease have an increased incidence of serious complications, including death [58]. One of the national health objectives in the United States for 2000 was to increase influenza and pneumococcal vaccination levels to greater than 60% among persons at high risk for

Long-term adherence to pulmonary rehabilitation

Although the short-term effects of pulmonary rehabilitation in multiple outcome areas are firmly established, the long-term effectiveness of this therapy often is disappointing. In controlled trials of pulmonary rehabilitation, gains in exercise performance and health status obtained after 6 to 8 weeks of therapy essentially disappear by 18 to 24 months [60], [61]. It seems illogical, however, to expect that a therapy that is applied only for 6 to 8 weeks could modify the natural course of the

Program organization

The pulmonary rehabilitation program needs a coordinator to organize the different components into a functioning unit. The coordinator develops the integrated program and monitors its progress and function. The program should have resources available to teach and supervise respiratory therapy techniques (eg, oxygen, use of inhalers, nebulizers), physical therapy (breathing techniques, chest physical therapy, postural drainage), exercise conditioning (upper and lower extremity), and activities

Outcomes and pulmonary rehabilitation

Outcome analysis can be defined as the assessment of the “consequences” of an intervention. Pulmonary rehabilitation does not affect the degree of respiratory impairment as measured by tests of physiologic pulmonary function. Exercise training in rehabilitation increases the content of oxidative enzymes in the trained muscles, however, and this is accompanied by a beneficial delay in the generation of lactate (a marker of muscle performance). This delay results in improved exercise performance

Summary

Pulmonary rehabilitation gradually has become the gold standard treatment for patients with severe lung disease, especially COPD. By definition, rehabilitation services are provided to patients with symptoms, most of whom have moderate-to-advanced lung disease. Because new therapeutic strategies, such as lung volume-reduction surgery and lung transplantation, require well-conditioned patients, pulmonary rehabilitation is becoming a crucial component of the overall treating strategy of many

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