Delivering pulmonary rehabilitation

Abstract

Optimum therapy for chronic lung disease is similar to that for any chronic illness that has no cure and includes not only attempts to improve lung function (usually with limited success), but also, perhaps more importantly, management strategies to help patients best cope with the unavoidable consequences of this devastating disease. In the case of chronic obstructive pulmonary disease (COPD), the systemic effects of the disease, secondary physical deconditioning, the presence of co-morbid illness and disease-induced psychosocial stressors quickly emerge as major priorities for optimum management. Not surprisingly, therefore, patient education directed at promoting disease self-management has become an integral component in the therapy of many chronic diseases (1, 2), including COPD. For example, patient self-management education has been shown to reduce the frequency of asthma attacks and improve patient disability from this disease (3). The positive impact of patient and family education for chronic lung disease has been implicitly recognized by health care professionals through its almost obligatory inclusion in formalized pulmonary rehabilitation programmes (4-7). Despite this tacit endorsement of the value of patient education, a recent systematic review of pulmonary rehabilitation in COPD, concluded that the only essential component of pulmonary rehabilitation was exercise training, and that strong evidence supporting the value of other programme components including education, was lacking (8). In anothersystematic review of patient education in COPD, but which did not include pulmonary rehabilitation programmes, the authors also concluded that there was insufficient evidence to support a stand alone role for patient education in COPD management, and that additional clinical trials were needed (9). However, the primary goal of pulmonary rehabilitation is not simply improved exercise tolerance, but rather to help the patient achieve the highest possible level of independent function, despite the challenges of living with chronic lung disease (6, 10, 11). This includes important elements of emotional and psychosocial functioning, and successful programmes help patients and their families to become better educated about the disease and its management and, most importantly, to become more self-sufficient and involved in their own care. This often involves effecting psychosocial changes and behaviour modification for these patients, such as improved adaptation to stress and improved coping strategies. In order to accomplish this holistic or whole-patient goal, pulmonary rehabilitation programmes must adopt a multidisciplinary approach consisting of several components which, in addition to exercise training and chest physiotherapy techniques, include education for the patients and their family/care-givers, as well as psychosocial support designed to address the often difficult psychological, emotional and social challenges faced by these individuals (12, 13).