Pulmonary rehabilitation practice guidelines and chronic pulmonary diseases

Abstract

The aim of this lecture is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) in chronic pulmonary disease. About ten practice guidelines have been published over the past ten years. More than 50 meta-analysis are listed about pulmonary rehabilitation. Who can benefit from a rehabilitation program, when, where, how, and which modalities? Which outcomes can we expect? Practice guidelines are often constructed in agreement with AGREE II criteria. Key questions were constructed in accordance with the PICO format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE criteria. These recommendations were externally reviewed by a panel of blinded experts. People with mild to severe COPD should attend PR to improve exercise capacity, to reduce dyspnea, to improve quality of life and to reduce hospital admissions. PR could be offered in hospital, community centers or at home and could be provided irrespective of the availability of a structured education program. PR should be offered to people with bronchiectasis, interstitial lung disease and pulmonary hypertension in specialised centers for the latter. Guidelines were unable to make recommendations relating to PR program length beyond eight weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented thereafter. Who? When? – people with stable COPD should undergo PR (strong recommandations, moderate quality evidence); – people with moderate-to-severe COPD should undergo pulmonary rehabilitation to decrease hospitalization for exacerbations (strong recommendation, moderate-to-low quality evidence); – PR is provided after a COPD exacerbation (weak recommendation, moderate quality evidence), Where? How? – home-based pulmonary rehabilitation should include regular contact to facilitate exercise participation and progression (weak recommendation, moderate-to-low quality evidence); – community-based pulmonary rehabilitation, of equivalent frequency and intensity as hospital-based programs, should be offered to people with COPD as an alternative to usual care (weak recommendation, moderate quality evidence); – supervised maintenance programs of monthly, or less frequently, are insufficient to maintain the gains of pulmonary rehabilitation and should not be offered (weak recommendation, low quality evidence).