Practice Guidelines

ACCP and AACVPR Release Evidence-Based Guidelines on Pulmonary Rehabilitation

LIZ SMITH

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 rehab-ilitation 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)

CDC Reports on Lead Exposure in Women of Childbearing Age

Evidence on the adverse health effects of moderate- and low-level blood lead concentrations is mounting. Public health authorities use higher levels to define blood lead levels of concern in nonpregnant women (>= 25 µg per dL [1.20 µmol per L]) than in pregnant women (>= 5 µg per dL [0.25 µmol per L]), in whom maternal and fetal levels are nearly identical because lead crosses the placenta unencumbered. The difference in blood lead levels for nonpregnant and pregnant women has received attention because of the recognition that a proportion of nonpregnant women with blood lead levels greater than 5 µg per dL may become pregnant and potentially expose their infants to the adverse health effects from lead. The Centers for Disease Control and Prevention (CDC) summarized 2004 surveillance data on elevated blood lead levels among women of childbearing age (i.e., 16 to 44 years) in 37 states participating in the CDC's Adult Blood Lead Epidemiology and Surveillance (ABLES) program, and emphasized the need for necessary surveillance measures to prevent lead exposure in women of childbearing age.

Adverse health effects in infants born to women with moderately elevated blood lead levels (i.e., 10 to 15 µg per dL [0.50 to 0.70 µmol per L]) include preterm birth, decreased gestational maturity, lower birth weight, reduced postnatal growth, increased incidence of minor congenital anomalies, and early neurologic or neurobehavioral deficits. Some evidence documents associations between prenatal elevated blood lead levels and decreased intelligence when those children are three to seven years of age. Estimates have varied widely concerning the number and rate of women of childbearing age with elevated blood lead levels; however, conducting surveillance of elevated blood lead levels in this population is important because approximately one third to one half of U.S. pregnancies are unplanned. Primary and secondary prevention of lead exposure among women of childbearing age, which includes identifying and counseling women who might become pregnant and expose their infant to lead in utero, is needed to lessen the risk of possible neurobehavioral and cognitive defects in their children.

Rates of elevated blood lead levels detected in the ABLES program among women who worked in the manufacturing sector, especially in the industry that includes battery manufacturing, were much higher than those of the general population for all lead exposures. These increased rates suggest that the workplace remains a substantial source of lead exposure, and physicians should consider work history when determining whether to measure blood lead levels.

LIZ HORSLEY

ACOG Guidelines on Premature Rupture of Membranes

Premature rupture of membranes (PROM) occurs in about one third of preterm births and can lead to significant perinatal morbidity and mortality. It typically is associated with brief latency between membrane rupture and delivery, increased risk of perinatal infection, and in utero umbilical cord compression. Management of PROM depends on gestational age and evaluation of the relative risks of preterm birth versus intrauterine infection, placental abruption, and cord complications that could occur with expectant management.

The decision on whether to deliver is based on gestational age and fetal status (Table 1). In women with PROM at term, labor should be induced immediately, generally with oxytocin (Pitocin) infusion, to reduce the risk of chorioamnionitis. Labor should be induced immediately, regardless of gestational age, in patients with intrauterine infection, placental abruption, or evidence of fetal compromise.

Table 1. Management of Premature Rupture of Membranes
Gestational age	Management
Term (37 weeks or more)	Proceed to delivery GBS prophylaxis recommended
Near term (34 to 36 weeks)	Same as above
Preterm (32 to 33 weeks)	Expectant management unless fetal pulmonary maturity is documented GBS prophylaxis recommended Antibiotics recommended to prolong latency, if no contraindications exist Corticosteroids recommended by some experts, but no consensus exists
Preterm (24 to 31 weeks)	Expectant management GBS prophylaxis recommended Antibiotics recommended to prolong latency, if no contraindications exist Single course of corticosteroids recommended No consensus on use of tocolytics
Preterm (less than 24 weeks)*	Patient counseling Expectant management or induction of labor GBS prophylaxis not recommended Data incomplete on the use of antibiotics to prolong latency Corticosteroids not recommended
GBS = group B streptococcus. *-The combination of birth weight, gestational age, and sex provides the best estimate of chances of survival and should be considered in individual cases. Adapted with permission from American College of Obstetricians and Gynecologists. Premature rupture of membranes. ACOG practice bulletin no. 80. Obstet Gynecol. 2007;109(4):1011.

Patients with PROM before 32 weeks' gestation should be cared for expectantly until they have completed 33 weeks of gestation, provided there are no maternal or fetal contraindications. Digital cervical examination should be avoided in patients with PROM unless they are in active labor or unless imminent delivery is anticipated.

Women with PROM before potential fetal viability should be counseled about the impact of immediate delivery and the risks and potential benefits of expectant management.

To prolong pregnancy and to reduce infectious and gestational age-dependent neonatal morbidity, a 48-hour course of intravenous ampicillin and erythromycin, followed by five days of amoxicillin and erythromycin, is recommended for expectant management of preterm PROM. All women with PROM and a viable fetus, including those who are known carriers of group B streptococcus (GBS) or who deliver before their GBS status can be determined, should receive intrapartum chemoprophylaxis to prevent vertical transmission of GBS. A single course of antenatal corticosteroids should be given to women with PROM at 24 to 31 weeks' gestation to reduce the risk of perinatal mortality, respiratory distress syndrome, and other morbidities.

CARRIE ARMSTRONG

Answers to This Issue's Clinical Quiz Q1. D Q2. D Q3. B Q4. A Q5. A Q6. D Q7. D Q8. A, B, C Q9. A, B, D Q10. A, B Q11. A, C, D

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