This is the current release of the guideline.

This guideline updates a previous version: Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. American College of Chest Physicians. American Association of Cardiovascular and Pulmonary Rehabilitation. Chest 1997 Nov 5;112(5):1363-96.

Definitions for the strength of evidence and recommendation grades (1A-2C) follow the recommendations. In addition to recommendations, the committee included several statements when it thought that there was insufficient evidence to make a specific recommendation. These statements are included along with the recommendations but are not graded.

Definition of Pulmonary Rehabilitation

The American Thoracic Society and the European Respiratory Society have recently adopted the following definition of pulmonary rehabilitation: Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health-care costs through stabilizing or reversing systemic manifestations of the disease. Comprehensive pulmonary rehabilitation programs include patient assessment, exercise training, education, and psychosocial support.

This definition focuses on three important features of successful rehabilitation:

1. Multidisciplinary: Pulmonary rehabilitation programs utilize expertise from various healthcare disciplines that is integrated into a comprehensive, cohesive program tailored to the needs of each patient.
2. Individual: Patients with disabling lung disease require individual assessment of needs, individual attention, and a program designed to meet realistic individual goals.
3. Attention to physical and social function: To be successful, pulmonary rehabilitation pays attention to psychological, emotional, and social problems as well as physical disability, and helps to optimize medical therapy to improve lung function and exercise tolerance.

The interdisciplinary team of health-care professionals in pulmonary rehabilitation may include physicians; nurses; respiratory, physical, and occupational therapists; psychologists; exercise specialists; and/or others with appropriate expertise. The specific team make-up depends on the resources and expertise available, but usually includes at least one full-time staff member.

Summary of Recommendations for Pulmonary Rehabilitation

1. A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with chronic obstructive pulmonary disease (COPD). Grade of Recommendation 1A
2. Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD. Grade of Recommendation 1A
3. Pulmonary rehabilitation improves health related quality of life (HRQOL) in patients with COPD. Grade of Recommendation 1A
4. Pulmonary rehabilitation reduces the number of hospital days and other measures of health-care utilization in patients with COPD. Grade of Recommendation 2B
5. Pulmonary rehabilitation is cost-effective in patients with COPD. Grade of Recommendation 2C
6. There is insufficient evidence to determine if pulmonary rehabilitation improves survival in patients with COPD. No recommendation is provided.
7. There are psychosocial benefits from comprehensive pulmonary rehabilitation programs in patients with COPD. Grade of Recommendation 2B
8. Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months. Grade of Recommendation 1A Some benefits, such as HRQOL, remain above control at 12 to 18 months. Grade of Recommendation 1C
9. Longer pulmonary rehabilitation programs (12 weeks) produce greater sustained benefits than shorter programs. Grade of Recommendation 2C
10. Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes. Grade of Recommendation 2C
11. Lower-extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower-intensity training in patients with COPD. Grade of Recommendation 1B
12. Both low- and high-intensity exercise training produce clinical benefits for patient with COPD. Grade of Recommendation 1A
13. Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass. Strength of evidence: 1A
14. Current scientific evidence does not support the routine use of anabolic agents in pulmonary rehabilitation for patients with COPD. Grade of Recommendation 2C
15. Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs. Grade of Recommendation 1A
16. The scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. Grade of Recommendation 1B
17. Education should be an integral component of pulmonary rehabilitation. Education should include information on collaborative self-management and prevention and treatment of exacerbations. Grade of Recommendation 1B
18. There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. Grade of Recommendation 2C
19. Although no recommendation is provided since scientific evidence is lacking, current practice and expert opinion support the inclusion of psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for patients with COPD.
20. Supplemental oxygen should be used during rehabilitative exercise training in patients with severe exercise-induced hypoxemia. Grade of Recommendation: 1C
21. Administering supplemental oxygen during high-intensity exercise programs in patients without exercise-induced hypoxemia may improve gains in exercise endurance. Grade of Recommendation: 2C
22. As an adjunct to exercise training in selected patients with severe COPD, noninvasive ventilation produces modest additional improvements in exercise performance. Grade of Recommendation: 2B
23. There is insufficient evidence to support the routine use of nutritional supplementation in pulmonary rehabilitation of patients with COPD. No recommendation is provided
24. Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases other than COPD. Grade of Recommendation: 1B
25. Although no recommendation is provided since scientific evidence is lacking, 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 both COPD and non-COPD patients.

Definitions:

Strength of Evidence

High (A) Well designed randomized controlled trials (RCTs) yielding consistent and directly applicable results. In some circumstances, high-quality evidence can be the result of overwhelming evidence from observational studies.

Moderate (B) Evidence based on RCTs with limitations that may include methodological flaws or inconsistent results. Studies other than RCTs that may yield strong results are also included in the moderate-quality category.

Low (C) Evidence from other types of observational studies (the weakest type of evidence).

Grades of Recommendations and Estimates of Net Benefit

1A Strong recommendation
1B Strong recommendation
1C Strong recommendation
2A Weak recommendation
2B Weak recommendation
2C Weak recommendation

Relationship of Strength of the Supporting Evidence to the Balance of Benefits to Risks and Burdens

None provided

The type of supporting evidence is identified and graded for each recommendation (refer to "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

1997 (revised 2007 May)

American Association of Cardiovascular and Pulmonary Rehabilitation - Medical Specialty Society
American College of Chest Physicians - Medical Specialty Society

Not stated

ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel

Panel Members: Andrew L. Ries, MD, MPH, FCCP (Chair); Gerene S. Bauldoff, RN, PhD, FCCP; Brian W. Carlin, MD, FCCP; Richard Casaburi, PhD, MD, FCCP; Charles F. Emery, PhD; Donald A. Mahler, MD, FCCP; Barry Make, MD, FCCP; Carolyn L. Rochester, MD; Richard ZuWallack, MD, FCCP; Carla Herrerias, MPH

At several stages during the guideline development period, panel members were asked to disclose any conflict of interest. These occurred at the time the panel was nominated, at the first face-to-face meeting, the final conference call, and prior to publication. Written forms were completed and are on file at the American College of Chest Physicians (ACCP).

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

This is the current release of the guideline.

This guideline updates a previous version: Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. American College of Chest Physicians. American Association of Cardiovascular and Pulmonary Rehabilitation. Chest 1997 Nov 5;112(5):1363-96.

None available

This summary was completed by ECRI on November 19, 1999. The information was verified by the guideline developer as of December 15, 1999. This NGC summary was updated by ECRI Institute on July 10, 2007. The updated information was verified by the guideline developer on July 16, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.