Practice Guidelines

ACCP and AACVPR Release Evidence-Based Guidelines on Pulmonary Rehabilitation



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Am Fam Physician. 2008 Jan 15;77(2):242-244.

Guideline source: American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation

Literature search described? Yes

Evidence rating system used? Yes

Published source: Chest, May 2007 supplement

Available at: http://www.chestjournal.org/cgi/content/abstract/131/5_suppl/4S

Pulmonary rehabilitation is often used for patients with chronic lung disease to restore the highest possible level of independent function by helping patients become more physically active. The American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) released pulmonary rehabilitation guidelines that update the recommendations published in 1997 and examine new areas of research.

The recommendations were based on a systematic review of the literature from 1996 to 2004 that included randomized controlled trials (RCTs), meta-analyses, systematic reviews, and observational studies. Studies involved exercise training and at least one other component, with outcomes including dyspnea, exercise tolerance, quality of life and activities of daily living, and health care use.

Strength of Evidence Ratings

All recommendations were rated using the ACCP guideline grading system. Grade 1 indicates strong recommendations with certainty that the benefits do or do not outweigh risk; grade 2 indicates weaker recommendations with less certainty or more equally balanced benefits and risks.

The quality of the evidence is graded A, B, or C. High-quality evidence (A) comes from well-designed RCTs with consistent and directly applicable results, or overwhelming evidence from observational studies. Moderate-quality evidence (B) comes from RCTs with limitations such as methodologic flaws or inconsistent results, or from studies other than RCTs that yield strong results. Low-quality evidence (C) comes from other types of observational studies.

The committee also included several statements without grades when there was insufficient evidence to make a specific recommendation.

Recommendations

The ACCP and AACVPR found new evidence that pulmonary rehabilitation is beneficial for patients with chronic obstructive pulmonary disease (COPD) and other chronic lung diseases. Evidence supports (to varying degrees) the use of lower- and upper-extremity exercise training, supplemental oxygen therapy for patients with severe exercise-induced hypoxemia, longer duration of rehabilitation, maintenance strategies after rehabilitation, education, and strength training. The routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation is not supported.

BENEFITS OF PULMONARY REHABILITATION

  • Pulmonary rehabilitation improves dyspnea in patients with COPD. (1A recommendation)

  • Pulmonary rehabilitation improves health-related quality of life in patients with COPD. (1A recommendation)

  • Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases other than COPD. (1B recommendation)

  • Pulmonary rehabilitation reduces the number of days spent in the hospital and other measures of health care use in patients with COPD. (2B recommendation)

  • Comprehensive pulmonary rehabilitation programs provide psychosocial benefits in patients with COPD. (2B recommendation)

  • Pulmonary rehabilitation is cost-effective in patients with COPD. (2C recommendation)

  • There is insufficient evidence to determine whether pulmonary rehabilitation improves survival in patients with COPD. (No recommendation)

DURATION AND MAINTENANCE

  • Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. (1A recommendation) Some benefits, such as health-related quality of life, remain above control levels at 12 to 18 months. (1C recommendation)

  • Longer pulmonary rehabilitation programs (i.e., 12 weeks) produce greater sustained benefits than do shorter programs. (2C recommendation)

  • Maintenance strategies after pulmonary rehabilitation have a modest effect on long-term outcomes. (2C recommendation)

EXERCISE TRAINING

  • A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with COPD. (1A recommendation)

  • Both low- and high-intensity exercise training produce clinical benefits for patients with COPD. (1A recommendation)

  • Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs. (1A recommendation)

  • Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass. (1A recommendation)

  • Evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. (1B recommendation)

  • Higher-intensity exercise training of the lower extremities produces greater physiologic benefits than lower-intensity training in patients with COPD. (1B recommendation)

  • Supplemental oxygen should be used during rehabilitative exercise training in patients with severe exercise-induced hypoxemia. (1C recommendation)

  • As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. (2B recommendation)

  • Administration of supplemental oxygen during high-intensity exercise programs in patients without exercise-induced hypoxemia may improve gains in exercise endurance. (2C recommendation)

OTHER INTERVENTIONS

  • Education should be an integral component of pulmonary rehabilitation; it should include information on collaborative self-management and prevention and treatment of exacerbations. (1B recommendation)

  • There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. (2C recommendation)

  • Evidence does not support the routine use of anabolic agents in pulmonary rehabilitation for patients with COPD. (2C recommenedation)

  • Current practice and expert opinion support the inclusion of psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for patients with COPD. (No recommendation)

  • Current practice and expert opinion suggest that pulmonary rehabilitation for patients with chronic respiratory diseases other than COPD should be modified to include treatment strategies specific to individual diseases and patients in addition to treatment strategies common to patients with and without COPD. (No recommendation)

  • There is insufficient evidence to support the routine use of nutritional supplementation in pulmonary rehabilitation of patients with COPD. (No recommendation)


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