In what setting can we organize rehabilitation

Impaired health in patients with COPD is determined by several factors (Fig. 12.2) [27]. Figure 12.2 illustrates some of the elements linking lung disease to impaired quality of life and shows that the pathways between them may be complex. The task of a rehabilitation team is to unravel these links and to structure the specific problems in an individual patient with COPD. A possible strategy is to assess the three aspects of COPD—i.e. impairment, disability, and handicap. This makes it possible to focus on the specific problems of the patient, leading to the most effective type of intervention. This determines the staffing and consequently the kind of setting for rehabilitation. A European Respiratory Society (ERS) task force has recently published selection criteria for three types of programme: in-patient; outpatient; and home rehabilitation [28].

Several criteria for in-patient rehabilitation have been formulated:

1 Need for 24-h supervised monitoring management plan, including training.

2 Behavioural intervention to correct psychosocial problems.

3 Need for specific interventions, such as nutrition.

4 Pre- and postoperative rehabilitation programmes.

5 Identification of a need for long-term oxygen or long-term home mechanical ventilation.

6 Logistic reasons for outpatient rehabilitation not being possible, such as distance.

These criteria mean that a patient who is largely disabled and who has a severe handicap needs different types of intervention. On the other hand, a patient who has undergone lung volume reduction surgery needs a very intensive physical programme, which can only take place in an in-patient setting. Specific criteria for outpatient rehabilitation include:

1 The patients are in a stable state.

2 They are capable of maintaining an independent lifestyle.

3 They have no major psychological problems.

4 They have no extrapulmonary disease.

The main goals here are to alleviate dyspnoea, increase exercise tolerance and improve the quality of life. All targets can be achieved by exercise training, although other types of intervention are available in this setting when needed. Inclusion criteria for home rehabilitation are, for example:

1 Newly diagnosed patients and those hospitalized for the first time .

2 Patients with recurrent exacerbations.

3 Patients who have previously received formal in-patient or outpatient rehabilitation.

When severe extrapulmonary disease and severe desaturation during exercise have been excluded, patients who meet the criteria for outpatient rehabilitation can also be included for home rehabilitation. Several studies have been published recently showing that rehabilitation in the home setting may improve exercise tolerance, dyspnoea and quality of life [29-32]. Some studies compared rehabilitation in the home setting with outpatient rehabilitation in different settings. Strijbos [32] et al. showed that after 12weeks of rehabilitation in the home setting, long-term benefits can be achieved for walking distance and maximal exercise capacity. In contrast, patients who carried out the same programme in an outpatient setting could not maintain the positive initial effects. Puente-Maestu et al. compared a high-intensity training programme with frequent supervision in the outpatient setting with a low-intensity training programme (self-administered) in the home setting [33]. Patients who received supervised training in the outpatient setting showed a significantly higher Vo2max in the incremental test and an increased endurance time in comparison with the self-administered group. However, no significant differences in the effect on the quality of life were observed between the two groups. This suggests that high-intensity training is necessary to increase Vo2max and endurance capacity, while a low-intensity, self-administered programme is necessary to enhance the quality of life.

In summary, the complexity of the medical, psychological and social problems faced by a patient with COPD determines the staff needed for a rehabilitation programme and thus determines the appropriate setting. When the situation is less complex and less equipment/intervention is needed, patients can be trained both in an outpatient setting and at home.

Fig. 12.3 Effects of pulmonary rehabilitation in different studies on functional exercise tolerance (6-min walking distance) in chronic obstructive pulmonary disease patients. The effect size is shown with standard deviation [34].

Study Favours control

McGavin, 1977 Cockcroft, 1981 Booker, 1984

Lake, 1990

Weiner, 1992 Goldstein, 1994 Wijkstra, 1994 Guell, 1995 Strijbos, 1996

Overall effect

Favours treatment

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