Pulmonary rehabilitation for healthcare providers

Pulmonary rehabilitation is defined as “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 individualised treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimise functional status, increase participation, and reduce health care costs through stabilising or reversing systemic manifestations of the disease”.

Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation(external link) Am J Respir Crit Care Med 2006; 173:1390–1413.

The following information on pulmonary rehabilitation is taken from NZ COPD guidelines 2021.(external link)

Pulmonary rehabilitation should be offered to all patients with COPD. Although there may be barriers to attending pulmonary rehabilitation classes, there are a variety of ways to deliver pulmonary rehabilitation to patients in different settings depending on local respiratory services and patient preferences. 

Pulmonary rehabilitation for people with COPD(external link) BPAC, NZ, 2017

• Pulmonary rehabilitation is an umbrella term for a structured programme which offers supervised exercise and education to patients with COPD, usually over a period of eight weeks
• Pulmonary rehabilitation is known to relieve dyspnoea and fatigue, improve mental health and quality of life, and increase the sense of control that patients with COPD have over their health while reducing their risk of hospitalisation
• All symptomatic patients with COPD will benefit from pulmonary rehabilitation, particularly:
  • At diagnosis
  • After discharge from hospital following an exacerbation
  • When symptoms are progressively deteriorating
• Health professionals may need to use creative strategies to adapt the basic components of pulmonary rehabilitation for patients unable to attend formal programmes.

Pulmonary rehabilitation for people with COPD(external link) BPAC, NZ, 2017
Pulmonary rehabilitation toolkit (external link) Australian Lung Foundation
Pulmonary rehabilitation(external link) NIH – National Heart, Lung, and Blood Institute, US
Pulmonary rehabilitation(external link) Australian Lung Foundation
Whanau Ora community provider(external link)
Hancox RJ, Jones S, Baggott C, et al.on behalf of Asthma and Respiratory Foundation New Zealand COPD Guidelines 2021 – quick reference guide(external link)

A Cochrane review of 65 randomised controlled trials confirms the benefit of pulmonary rehabilitation. They found that pulmonary rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances the sense of control that individuals have over their condition. These improvements are moderately large and clinically significant. 

McCarthy B, Casey D, Devane D, Murphy K, Murphy E Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease.(external link) Cochrane Database of Systematic Reviews, 2015.

Pulmonary rehabilitation has been found to be effective for other chronic lung disease such as interstitial lung disease. 

Dowman L, Hill CJ, May A, Holland A. Pulmonary rehabilitation for interstitial lung disease(external link) Cochrane Database of Systematic reviews 2021

A further Cochrane review looked at whether pulmonary rehabilitation was safe after a hospital admission with a COPD exacerbation and concluded that pulmonary rehabilitation reduced hospital admissions and mortality compared with usual community care (no rehabilitation). Quality of life was also improved. Pulmonary rehabilitation appears to be a highly effective and safe intervention in COPD patients after suffering an exacerbation. 

Puhan MA, Gimeno-Santos E, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease(external link) Cochrane Database of Systematic Reviews, 2016.

• Making sure your patients attend a pulmonary rehabilitation programme is one of the most useful treatments you can offer your patients with COPD.
• Pulmonary rehabilitation is a proven self-management programme that is effective in improving the quality of life and reducing hospital admissions of people with COPD. However, a New Zealand study found that only 1% of COPD patients who could benefit from pulmonary rehabilitation have access to it each year. Levack WMM, Weatherall M, et al. Uptake of pulmonary rehabilitation in New Zealand by people with chronic obstructive pulmonary disease in 2009(external link). NZMJ. 2012 Dec 20; 125(1348):23-33.
• A recent survey demonstrated  an 8-fold difference in pulmonary rehabilitation services within Aotearoa New Zealand. Meyer R, Dawkins P, Fingleton J, Shand B, Yap E. A survey of adult respiratory and sleep services in Aotearoa New Zealand – inequities in the provision of adult respiratory and sleep services N Z Med J. 2022 Dec 2;135(1566):49-68. 
• A 2016 study found that only 2% of uptake of eligible patients and cultural difference in attendance. McNaughton AA, Weatherall M, Williams G, Delacey D, George C, Beasley R. An audit of pulmonary rehabilitation program(external link) Clinical Audit, 2016
• Culturally safe rehabilitation programmes may increase uptake. Levack WMM, Jones B, Grainger R, Boland P, Brown M, Ingham TR. Whakawhanaungatanga – the importance of culturally meaningful connections to improve uptake of pulmonary rehabilitation by Māori with COPD – a qualitative study(external link) Int J Chron Obstruct Pulmon Dis. 2016 Mar 9;11:489–501
• Making programmes more acceptable to patients by including, eg, singing may in increase participation. Naughton A, Aldington S, Williams G, et al. Sing your lungs out – a qualitative study of a community singing group for people with chronic obstructive pulmonary disease (COPD)(external link) BMJ Open 2016;6:e012521

• Most COPD patients are missing out on pulmonary rehab benefits(external link) Everyday Health, US, 2018

Pulmonary rehabilitation