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:
- 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.
- Individual: Patients with disabling lung disease require individual assessment of needs, individual attention, and a program designed to meet realistic individual goals.
- 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
- 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
- Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD. Grade of Recommendation 1A
- Pulmonary rehabilitation improves health related quality of life (HRQOL) in patients with COPD. Grade of Recommendation 1A
- Pulmonary rehabilitation reduces the number of hospital days and other measures of health-care utilization in patients with COPD. Grade of Recommendation 2B
- Pulmonary rehabilitation is cost-effective in patients with COPD. Grade of Recommendation 2C
- There is insufficient evidence to determine if pulmonary rehabilitation improves survival in patients with COPD. No recommendation is provided.
- There are psychosocial benefits from comprehensive pulmonary rehabilitation programs in patients with COPD. Grade of Recommendation 2B
- 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
- Longer pulmonary rehabilitation programs (12 weeks) produce greater sustained benefits than shorter programs. Grade of Recommendation 2C
- Maintenance strategies following pulmonary rehabilitation have a modest effect on long-term outcomes. Grade of Recommendation 2C
- Lower-extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower-intensity training in patients with COPD. Grade of Recommendation 1B
- Both low- and high-intensity exercise training produce clinical benefits for patient with COPD. Grade of Recommendation 1A
- Addition of a strength training component to a program of pulmonary rehabilitation increases muscle strength and muscle mass. Strength of evidence: 1A
- Current scientific evidence does not support the routine use of anabolic agents in pulmonary rehabilitation for patients with COPD. Grade of Recommendation 2C
- 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
- The scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation. Grade of Recommendation 1B
- 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
- There is minimal evidence to support the benefits of psychosocial interventions as a single therapeutic modality. Grade of Recommendation 2C
- 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.
- Supplemental oxygen should be used during rehabilitative exercise training in patients with severe exercise-induced hypoxemia. Grade of Recommendation: 1C
- Administering supplemental oxygen during high-intensity exercise programs in patients without exercise-induced hypoxemia may improve gains in exercise endurance. Grade of Recommendation: 2C
- 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
- There is insufficient evidence to support the routine use of nutritional supplementation in pulmonary rehabilitation of patients with COPD. No recommendation is provided
- Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases other than COPD. Grade of Recommendation: 1B
- 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
|
Balance of Benefits to Risks and Burdens |
Strength of Evidence |
Benefits Outweigh Risks/Burdens |
Risks/Burdens Outweigh Benefits |
Evenly Balanced |
Uncertain |
High |
1A |
1A |
2A |
|
Moderate |
1B |
1B |
2B |
|
Low or very low |
1C |
1C |
2C |
2C |