Pulmonary Rehabilitation
Pulmonary rehabilitation (PR) is programme of care carried out by a multidisciplinary team that is tailored to an individual patient’s needs. It combines physical exercise sessions with advice on topics such as symptoms of COPD. Patients would need to be referred for PR course by their GP. A course involves attending two sessions a week for six to eight weeks. Each session is approximately one hour and a half long, with a group of between eight and 16 people attending.
Why offer PR?
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It has been shown that PR can reduce breathlessness, increase exercise capacity and improve a patient’s quality of life by helping them feel stronger and fitter which allows them to do more. Research has also shown that PR can reduce mortality, hospital admissions and re-admissions, inpatient hospital days, and the number of home visits.
What do the guidelines recommend?
NICE guidelines recommend that all COPD patients that are functionally disabled due to their condition (MRC dyspnoea scale grade 3 or above) or that have recently been hospitalised due to an exacerbation should be referred for PR. It is important that all interventions undertaken during PR are tailored to each individual person’s need. In order for PR to be effective, it should be held in accessible buildings and at times to suit the patient.
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Do not refer for PR if the person is unable to walk, has unstable angina or recently had a myocardial infarction.
What does PR involve?
Structured exercise therapy that has graded physical activity is key to PR. Along with postural training and relaxation exercises it helps to stop physical deconditioning which is what increases disease progression. Other things involved in PR include:
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Aerobic exercise – increased exercise endurance and capacity
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Strength training – upper and lower limbs
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Relaxation techniques
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Advice on smoking cessation
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Nutritional assessment
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Education – self-management and lifestyle
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Breathing techniques – e.g. pursed lip (for more information see below)
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Inhaler technique
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Psychological support
How is PR carried out?
Before starting PR (around a week or two before) each patient undergoes an assessment of their health and current abilities including how they are coping with their condition, what they can and cannot do, and how different activities affect them (this could include a timed walking test).
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Each session is split, with half the time spent on physical exercises based on their assessment to achieve the correct activity level for each person. Patients will become breathless during this exercise part of the session; however, they are continuously monitored so that they remain safe (including blood pressure, heart rate and oxygen level). The other half of the session is then used as an opportunity for education and offering advice (based on the topics mentioned above).
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PR requires the patient to be committed by regularly attending sessions and following advice given. It is also important that they continue to use techniques learnt and exercise regularly after completing the course.
Breathing techniques
These are designed to stop COPD patients working so hard to breathe. The technique used depends on patient preference. The main technique used is known as ‘pursed-lips breathing’ which aims to slow breathing down and to keep airways open longer. This reduces the effort it takes to breathe and helps to remove stale, trapped air due to COPD. It can improve gas exchange and so increase the patient’s exercise tolerance. To carry out this technique the patient should inhale through their nose (as if smelling something) for around two seconds, then purse their lips before exhaling slowly over a few seconds (it should be around double the inhalation time). This can then be repeated.
Other techniques include:
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Paced breathing which is useful during activity as breathing is paced to the person’s steps. For example, climbing stairs, breathe in while on a step and then breathe out while climbing up to the next step.
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Relaxed slow deep breathing, which involves inhaling through the nose and exhaling through the nose and mouth while trying to remain calm and relaxed.
Patient’s experience and views
Patients find the experience worthwhile as it not only improves their physical health but educates them on COPD and the techniques that can be used to improve their quality of life. Patent’s find it helpful to be around people with the same condition as they feel their better understood.
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For more patient views see the following website: https://www.blf.org.uk/your-stories/3-reasons-to-love-pulmonary-rehab
Bibliography:
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https://www.nice.org.uk/guidance/CG101/chapter/1-Guidance#managing-stable-copd
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https://www.blf.org.uk/support-for-you/exercise/pulmonary-rehabilitation
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Clinical Pharmacy and Therapeutics by Walker and Whittlsea
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https://www.blf.org.uk/your-stories/3-reasons-to-love-pulmonary-rehab
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NHS Service Specification, Pulmonary Rehabilitation
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CPPE – Chronic Obstructive Pulmonary Disease Book 1
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http://www.copdfoundation.org/What-is-COPD/Living-with-COPD/Breathing-Techniques.aspx