Pulmonary Rehabilitation

www.jcrpjournal.com Pulmonary Rehabilitation / 141

■ The multidisciplinary treatment of pulmonary rehabilitation (PR), whichincludes exercise training, self-management education, and psychosocialand nutritional intervention, is now a standard of care for chronicobstructive pulmonary disease (COPD) and has been incorporated intomajor guidelines. We must now focus efforts on improving its impact andwidening its applicability. What is the direction of PR; where does it fit inthe comprehensive care of the COPD patient; and how can cliniciansbest apply this important intervention? This was the charge of the round-table discussion, Pulmonary Rehabilitation: Moving Forward, involving20 experts from North America and Europe, which was convened in FortLauderdale, Florida, in early 2008. It is not meant to be an exhaustivereview; rather, this report summarizes the roundtable proceedings, whileproviding direction to best position PR into the continuum of COPD care.By consensus, it was agreed upon that although PR is effective for otherchronic respiratory diseases, the discussion focus was COPD since most

Pulmonary Rehabilitation

WHAT WE KNOW AND WHAT WE NEED TO KNOW

Linda Nici, MD, Jonathan Raskin, MD, Carolyn L. Rochester, MD, Jean C. Bourbeau, MSc, MD,Brian W. Carlin, MD, Richard Casaburi, PhD, MD, Bartolome R. Celli, MD, Claudia Cote, MD, Rebecca H. Crouch, PT, MS, CCS, Luis F. Diez-Morales, MD, Claudio F. Donner, MD, Bonnie F. Fahy, MN, RN,Chris Garvey, MSN, FNP, MPA, Roger Goldstein, MBChB, Alison Lane-Reticker, MD, Suzanne C. Lareau, MS, RN,Barry Make, MD, François Maltais, MD, James McCormick, MD, Michael D.L. Morgan, MD, Andrew L. Ries, MD, MPH, Thierry Troosters, PhD, PT, and Richard ZuWallack, MD

Author Affiliations: Providence VA Medical Center, Brown University School of Medicine, Providence, Rhode Island (Dr Nici); AlbertEinstein College of Medicine, Alice Lawrence Center for Health and Rehabilitation, Beth Israel Medical Center–Petrie Division, New York(Dr Raskin); Section of Pulmonary and Critical Care, Yale University School of Medicine, and Medical Director, Pulmonary Rehabilitation,VA Connecticut Healthcare System, West Haven, Connecticut (Dr Rochester); Respiratory Division, Department of Medicine, MontrealChest Institute, MUHC, McGill University, Montreal, Quebec, Canada (Dr Bourbeau); Allegheny General Hospital, PulmonaryRehabilitation, Lifeline Specialty Centers, Drexel University School of Medicine, Pittsburgh, Pennsylvania (Dr Carlin); RehabilitativeSciences, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, UCLA School of Medicine, Torrance, California (Dr Casaburi); Caritas St. Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts (Dr Celli); University ofSouth Florida, Bay Pines, Florida (Dr Cote); Duke Center for Living, Durham, North Carolina (Ms Crouch); Section of General InternalMedicine and Ambulatory Services, St Francis Hospital & Medical Center, University of Connecticut, Hartford (Dr Diez-Morales); MondoMedico, Multidisciplinary and Rehabilitation Outpatient Clinic, Italian Interdisciplinary Association for Research in Respiratory Diseases,Borgomanero, Italy (Dr Donner); St Joseph’s Hospital and Medical Center, Phoenix, Arizona (Ms Fahy); Seton Pulmonary and CardiacRehabilitation, Daly City, and University of California, San Francisco (Ms Garvey); West Park Healthcare Center, University of Toronto,Toronto, Ontario, Canada (Dr Goldstein); University of Connecticut School of Medicine, Farmington (Dr Lane-Reticker); College of Nursing,University of Colorado, Denver (Ms Lareau); Division of Pulmonary Sciences and Critical Care Medicine, National Jewish Health, Universityof Colorado School of Medicine, Denver (Dr Make); Centre de Pneumologie, Hospital Laval, Universite Laval, Quebec, Canada (Dr Maltais); University of Kentucky Medical Center, Lexington (Dr McCormick); Department of Respiratory Medicine, Allergy, and ThoracicSurgery, Glenfield Hospital, University Hospitals of Leicester, Respiratory Medicine, University of Leicester, Leicester, UK (Dr Morgan);University of California, San Diego (Dr Ries); Respiratory Division, University Hospitals Leuven, and Department of Rehabilitation Sciences,Katholieke Universiteit Leuven, Leuven, Belgium (Dr Troosters); St Francis Hospital & Medical Center, University of Connecticut School ofMedicine, Hartford (Dr ZuWallack).

Corresponding Author: Richard ZuWallack, MD, St Francis Hospital & Medical Center, Hartford, CT 06105 ([email protected]).

K E Y W O R D S

COPD

integrated care

pulmonary rehabilitation

HCR200038_141-151 5/10/09 9:16 AM Page 141

142 / Journal of Cardiopulmonary Rehabilitation and Prevention 2009;29:141–151 www.jcrpjournal.com

of the evidence base and patient referral are for this disease. These proceedings provide insight into 3 broad areasappropriate for investigation or implementation: positioning PR in an integrated care model for COPD patients; improv-ing the effectiveness of this intervention; and expanding the recognition, application, and accessibility to PR. It is thehope that this document will provide a catalyst for clinicians, investigators, and healthcare policy makers to help real-ize these goals as well as serve to suggest important areas for future research and development in PR.

The multidisciplinary treatment of pulmonary rehabil-

itation (PR), which includes exercise training, self-

management education, and psychosocial and nutri-

tional intervention, is now a standard of care for

chronic obstructive pulmonary disease (COPD) and

has been incorporated into its major guidelines.1,2

This meteoric rise in acceptance is due to the fact that

it works, and there is now high-level evidence that it

improves exercise capacity, symptoms, and quality of

life. Emerging evidence suggests that it also reduces

healthcare utilization.2 PR is defined as

an evidence-based, multidisciplinary, and compre-

hensive intervention for patients with chronic respi-

ratory diseases who are symptomatic and often have

decreased daily life activities. Integrated into the indi-

vidualized treatment of the patient, PR is designed

to reduce symptoms, optimize functional status,

increase participation, and reduce health care costs

through stabilizing or reversing systemic manifesta-

tions of the disease.1(p1391)

Pulmonary rehabilitation has no direct effect on air-

flow limitation, such as forced expiratory volume in

1 second (FEV1), but is nonetheless highly effective

because it ameliorates the systemic effects and comor-

bidities of the disease. For example, peripheral mus-

cle dysfunction, a major contributor to the morbidity

of COPD, is improved by exercise training. The reduc-

tion in respiratory rate resulting from exercise training

and other treatments such as oxygen, pharmacothera-

py, and breathing retraining reduce dynamic hyperin-

flation, thereby unloading the respiratory system and

decreasing the sensation of dyspnea.

What is the direction of PR; where does it fit in the

comprehensive care of the COPD patient; and how

can clinicians best apply this important intervention?

This was the charge of the roundtable discussion,

Pulmonary Rehabilitation: Moving Forward, involv-

ing 20 experts from North America and Europe,

which was convened in Fort Lauderdale, Florida, in

early 2008. This report summarizes the roundtable

proceedings, while providing direction to best

position PR into the continuum of COPD care. It is

not meant to be an exhaustive review. In addition,

although PR is effective for other chronic respiratory

diseases, the focus is COPD since most of the

evidence base and patient referral are for this

disease.

PR AND INTEGRATED CARE OF THECOPD PATIENT

It is now clear that the acute healthcare model, where

cure is the major goal, is poorly suited for the man-

agement of a chronic disease such as COPD.3,4 COPD

is a systemic condition and patients frequently have

significant comorbidities such as cardiovascular dis-

ease, osteoporosis, depression, and anxiety. These

add complexity to the management of COPD

patients, making communication and collaboration

across disciplines imperative. Therefore, a new

chronic care model is needed. This must include a

plan to integrate services and therapies tailored to the

specific needs of the individual patient.

The optimal care of the COPD patient requires

integration across settings, across providers, and lon-

gitudinally across time.5 The patient must be a central

catalyst in this process. Pulmonary rehabilitation

involves a coordinated multidisciplinary treatment

plan that focuses on all aspects of the disease over

time and is indeed a component of integrated care.

The World Health Organization defines integrated

care as “a concept bringing together inputs, delivery,

management, and organization of services related to

diagnosis, treatment, care, rehabilitation, and health

promotion.”6(p7) Integration of services improves

access, quality, user satisfaction, and efficiency of

medical care. For COPD, this involves providing the

right therapy at the right time. Therapies may include

smoking cessation intervention, promotion of a

healthy lifestyle (including increased activity and

regular exercise), collaborative self-management

strategies, optimal pharmacotherapy, palliative therapy,

and end-of-life care. This necessitates partnering,

communication, and coordination among primary

and specialty healthcare professionals, patients, and

their families. Pulmonary rehabilitation encompasses

all of these strategies and therefore fits ideally into the

World Health Organization concept of integrated

care.

Consequences of acute exacerbation of COPD can

be devastating. These include deteriorations in lung

function, peripheral muscle function, exercise capac-

ity, activity level, and quality of life. Exacerbations

also increase healthcare utilization and mortality risk.

As such, proper management of the exacerbation

HCR200038_141-151 5/10/09 9:16 AM Page 142


• Pulmonary rehabilitation as a complete pro-

gram may not be an option for a specific

COPD patient. However, its components, such

as exercise and activity promotion and self-

management strategies, are necessary for best

practice. Administering these components is

part of the integrated care of COPD.

• Integrated care is especially important at the

time of COPD exacerbations because patients

are at considerably increased risk for further

morbidity and mortality, they require many

and varied services, and are likely to be more

receptive to certain interventions. In addition,

a proper follow-up will provide an opportuni-

ty to ensure preventive treatment and new

strategies for earlier intervention in subse-

quent exacerbations.

• Healthcare professionals play a key role in

integrated care; therefore, their education is

fundamental for an effective implementation

of this model.

• The primary care provider is an important

member of the integrated care team. Lines of

communication among primary care providers,

specialists, and hospital professionals should

be fostered to optimize care.

INCREASING THE EFFECTIVENESS OF PR

Pulmonary rehabilitation improves outcomes across

multiple areas, including symptom reduction,

increased exercise capacity, and enhanced quality of

life.2 There are also emerging data suggesting that PR

reduces healthcare utilization.2 Building on this, we

must continue to refine and broaden the approach

and process of PR to maximize its benefits. This sec-

tion will discuss potential ways of enhancing the

effectiveness of PR.

Promoting Exercise and ActivityPatients with COPD have decreased exercise capaci-

ty and substantial limitations in their daily activities.

For example, the American Lung Association has stat-

ed that 51% of all COPD patients report limits in their

ability to work, 70% in normal physical exertion, 56%

in household chores, 53% in social activities, 50% in

sleeping, and 46% in family activities.9 Direct mea-

surements of physical activity in the home support

these findings.10 Decreases in functional exercise

capacity and physical activity appear to be related to

increased healthcare utilization and mortality in

COPD.11–16

necessitates an integrated care approach. More

emphasis on the early treatment of the COPD exac-

erbation is needed. Strategies that help patients rec-

ognize their exacerbations and initiate therapy

promptly may reduce complications and decrease the

risk of hospitalization.7 This requires proper follow-

up and a higher level of collaboration among health-

care professionals in the hospital and the community

than generally exists today. Furthermore, in the set-

ting of the exacerbation, patients may be more recep-

tive to “teachable moments” and therefore be more

likely to accept smoking cessation strategies, self-

management education, and exercise rehabilitation.

Regular follow-up through primary care and commu-

nity care professionals enables reinforcement of

healthcare goals and identification of when further

contact with a pulmonary specialist is required. The

introduction of PR at this time is also an important

part of integrated care, promoting multidisciplinary

communication, regular follow-up, and a means for

seamless reintegration into activities of daily living

and community life.

A recent study of an integrated care approach after

a COPD exacerbation underscores potential benefits.8

The intervention consisted of (1) comprehensive

assessment of the patient at discharge, (2) an educa-

tional plan on self-management administered upon

discharge, (3) agreement on an individually tailored

care plan, which was shared across the system, and

(4) accessibility to a specialized case manager for

patients and their caregivers facilitated by information

technology. Collaboration between the case manager

and the primary care team was considered central to

this plan of care. Patients in this program had signif-

icantly fewer hospitalizations over 12 months of

follow-up than those receiving usual care, supporting

the concept that an integrated care approach can

achieve meaningful positive results.

Recommendations• We interpret integrated care as it applies to

COPD as a systemwide, multidisciplinary,

collaborative approach that is individualized to

the specific needs of the patient. This

approach stresses comprehensive assessment,

self-management education, agreement on an

individually tailored care plan, and communi-

cation among healthcare professionals,

patients, and families/caregivers.

• The optimal management of COPD should

involve this integrated care approach.

• Pulmonary rehabilitation is one component of

the integrated care of COPD patients, yet

integrated care extends beyond PR in its

systemwide emphasis.

HCR200038_141-151 5/10/09 9:16 AM Page 143


• What roles do exercise habits, self-efficacy,

and internal/external barriers play in long-

term exercise adherence?

• What are the best strategies within the PR

intervention to effect immediate and long-

term exercise adherence and enhancement

of physical activity?

Education and Self-ManagementPulmonary rehabilitation is more than just exercise

training. Indeed, the integration of self-management

education with exercise training offers the ideal set-

ting for promoting positive health behavior change

and optimizing disease control. Simply improving

knowledge through a traditional, didactic teaching

format is insufficient to achieve these goals; rather,

education should enhance self-management through

increased self-efficacy. Self-management education

promotes learning by doing, increases knowledge,

enhances self-confidence, and promotes a “taking

charge of the disease” attitude. Specific strategies may

include smoking cessation interventions, promoting

adherence to medications and other therapies, incor-

porating increased levels of exercise and physical

activity into the home setting, and early recognition

and treatment of exacerbations. This discussion will

focus on 2 important self-management strategies, the

implementation of an action plan for the exacerbation

and ways to maintain benefits achieved with PR.

Ongoing collaboration between the patient and the

medical team is the key to effective self-management.

A hallmark of this therapeutic alliance is the devel-

opment and implementation of an individualized

action plan for the COPD exacerbation. The early

treatment of an exacerbation may reduce its severity.7

The action plan will assist the patient in recognizing

symptom changes associated with an acute exacerba-

tion and in implementing self-care strategies. The lat-

ter may include directions on when to initiate a cus-

tomized prescription of antibiotics and oral steroids

and when to contact a healthcare provider.

Implementation of an action plan in collaboration

with the healthcare provider can result in decreased

healthcare utilization and improved quality of life.24

Maintenance of improved exercise capacity over-

time relies on patient adherence to long-term exercise

participation. The optimal ways to accomplish this

remain to be determined. Lengthening the formal PR

program may sustain gains, but this is usually not a

practical option. The COPD exacerbation negatively

affects long-term exercise adherence, and repeated

short courses of PR following the exacerbation may

be of benefit. Pulmonary rehabilitation provides the

opportunity to influence adherence through effective

For the purposes of this discussion, we consider

physical activity as a broad term that encompasses all

forms of muscle movements. These include activities

of daily living such as housework, walking, or run-

ning errands. In contrast, we define exercise as a

physical activity that is a purposeful, structured move-

ment of the body, usually of higher intensity, often

designed to enhance physical fitness. Observational

data link higher levels of physical activity with better

outcomes, including a lower risk of hospitalization, a

lower rate of decline of lung function, and improved

survival.15,17,18

While PR is the best therapy for improving exer-

cise capacity in individuals with COPD, important

questions remain. Does increased exercise capacity

realized from PR translate into increased physical

activity? How do we best measure activity? How do

we optimize the PR intervention to enhance physical

activity in the home/community setting?

Although clinicians have long recognized that

COPD patients are quite sedentary, this was only

recently proven by direct activity assessments.10 Using

accelerometers on the waist and leg, investigators

demonstrated that COPD patients did considerably

less walking and standing activity than non-COPD

control subjects. Physical activities are particularly

low following an exacerbation of COPD18 and when

using long-term oxygen therapy.19

It is reasonable to assume that improved exercise

tolerance from PR will lead to increased physical

activities in COPD patients. Although 1 study failed to

demonstrate an increase in activity with outpatient

rehabilitation,20 3 have shown increased activity lev-

els after the intervention.21–23 However, increases in

physical activity may not necessarily mirror the

increase in exercise capacity.23 Pulmonary rehabilita-

tion is more than just exercise training, and its nonex-

ercise components may also increase activity, inde-

pendent of an enhancement in exercise performance.

For example, improved pacing and increased self-

efficacy for walking also promote activity. Further

investigation of the effect of PR on activity is needed.

Recommendations• Since observational data underscore the

potential benefits of higher levels of physical

activity, we support greater emphasis on activ-

ity promotion in the home and community.

• More clinical research is needed regarding

physical activity as an outcome in PR:

• What are the best ways of measuring phys-

ical activity in our patients?

• What is the link between increases in exer-

cise capacity and physical activity resulting

from PR?

HCR200038_141-151 5/10/09 9:16 AM Page 144


forcement, encouragement, and coaching from staff.

Few trials have focused on the impact of rehabilita-

tion program duration; however, existing data suggest

that gains in exercise tolerance may be greater after

longer programs.36

Recommendation• Additional research is needed to clarify the

effects of program structure and duration on

PR benefits, including traditional outcomes,

and self-efficacy leading to long-term health

behavior change. Relevant areas include

program duration, frequency and intensity of

treatment, the use of maintenance activities, or

repeating “boost” rehabilitation in the face of

progressive chronic disease and exacerbations.

Psychosocial InterventionMajor depressive disorders and general anxiety disor-

ders are common in persons with COPD.37–39 These

often go undiagnosed and untreated.40 Furthermore,

severe psychological distress negatively impacts

symptoms,41 quality of life, mood, motivation, success

in smoking cessation, physical function, activity par-

ticipation,38 healthcare utilization,42 and survival.41

Screening for psychological impairment should be

part of the initial PR assessment. Those with significant

psychiatric conditions should be referred for appropri-

ate professional care. PR itself can improve symptoms

of anxiety and depression.43–45 Aspects of PR that may

work in this regard include exercise training, progres-

sive muscle relaxation, and positive social support.

Strategies include recognition and management of

stress and related symptoms, relaxation techniques,

muscle relaxation, imagery, yoga, biofeedback, active

listening, anticipatory guidance of stressors, problem

solving, support systems, and resources.

Recommendations• We recommend routine screening for anxiety

and depression.

• Psychosocial intervention should be provided

on the basis of the needs of the individual

patient. Significant pathology should be

referred to outside specialists. We recommend

that programs incorporate more mental health

skills into their healthcare teams.

• We recommend further studies to determine

whether PR reduces the psychological symp-

tom burden in COPD.

Pharmacologic Therapy and PROptimal bronchodilation is the cornerstone of the

treatment of symptomatic COPD.46 Bronchodilators

can lead to improvements in dyspnea, quality of life,

self-management education. Self-efficacy predicts

long-term exercise adherence25 and health behavior

change, both of which have enormous potential to

modify the course of the disease.

Recommendations• On the basis of the available data, we recom-

mend that PR programs routinely develop and

implement an individualized COPD exacerba-

tion action plan for patients. This should be

done in collaboration with the primary health-

care provider(s) taking into consideration the

patient’s level of health literacy.

• The present acute care model for the delivery

of PR is generally insufficient for maintaining

long-term exercise benefits. On the basis of

the integrated care model, we recommend

development and implementation of self-man-

agement strategies in PR to promote long-term

health behavior change in this area. These

strategies will specifically target patient self-

efficacy and barriers to exercise.

Program Structure and DurationA prominent goal of PR is the maintenance of its ben-

efits. Since resources for PR are limited, a key ques-

tion in designing the optimal program is how to best

allocate available resources to achieve desirable long-

term behavior changes. How does the structure and

duration of the PR program impact long-term benefits

of PR rehabilitation?

In the real world, the length of initial PR treatment

is often based on financial constraints and dictated by

third party policies rather than an evidence base sup-

porting optimal program structure. The typical struc-

tured PR program is of relatively short duration, usu-

ally ranging from 6 to 12 weeks. Several clinical trials

of such programs that have followed patients over a

longer-term have found that benefits after the initial

intervention gradually wane but typically remain

above baseline for 12 to 18 months.26–32 Given the

severity of chronic lung disease and the complex

behaviors included in PR (eg, exercise, paced breath-

ing, medications, supplemental oxygen, and panic

control), producing even 12 to 18 months of benefit

is remarkable.

Studies that have examined maintenance or

repeated PR interventions following an initial treat-

ment program have had modest, though variable,

effects.33–35 Another approach to producing longer-

term benefits from PR is to extend the duration of the

initial supervised treatment program. Longer program

duration may produce greater gains and improved

maintenance of complex behavioral change, facilitat-

ed by longer exposure to interventions and rein-

HCR200038_141-151 5/10/09 9:16 AM Page 145


appreciable” levels of hypoxemia.59 This effect is

probably mediated through a reduction in carotid

body drive, resulting in a decrease in ventilatory

requirement for exercise and a slowing of breathing;

these changes reduce dynamic hyperinflation. There

appears to be a dose-response relationship between

supplemental oxygen dose and exercise enhance-

ment such that a fraction of inspired oxygen up to 0.5

seems to maximize benefits.59

Since exercise capacity in the laboratory is increased

with supplemental oxygen, it may allow COPD patients

to train at higher intensities during PR. Exercise training

at higher intensity should enhance its effectiveness.

Studies evaluating the use of supplemental oxygen to

enhance exercise outcome have yielded mixed results,

probably due to small numbers of subjects and differ-

ences in methodology, especially with respect to inten-

sity targets for training.58,60–63 One well-designed study

of nonhypoxemic patients with COPD who trained at

high intensity did show greater improvement in exer-

cise capacity in those receiving supplemental oxygen

versus room air.63 Even if exercise capacity is enhanced

with oxygen in this setting, the long-term benefit

after the patient leaves PR and is no longer using

supplemental oxygen remains to be determined.

Recommendations• We recommend supplemental oxygen for

COPD patients with hypoxemia during

exercise training in PR.

• Although data are limited, supplemental

oxygen for nonhypoxemic, COPD patients

may increase exercise training benefits, and

therefore may be considered as adjunctive

therapy in this setting.

Other ModalitiesEven though training at high intensity is not a manda-

tory requirement for successful PR, researchers are

currently investigating various approaches to allow

patients to attain higher exercise intensities in the

hope of better clinical outcomes. In addition to bron-

chodilators and oxygen supplementation, other

modalities such as interval training,64 helium-oxygen

mixture,65 and noninvasive ventilation66 have been

proposed as useful adjuncts to help patients achieve

higher training intensities. Further work is neverthe-

less necessary to better understand the long-term

implications of these adjuncts to exercise training on

functional status and quality of life.

Palliative CarePulmonary rehabilitation and palliative care are both

examples of integrated care. With an emphasis on

exacerbation rates, and exercise tolerance.47–51 Some of

this increase in exercise tolerance may result from a

decrease in dynamic hyperinflation. However, exercise

capacity in many is more limited by leg fatigue, which

is not responsive to bronchodilators.52 Pulmonary reha-

bilitation in conjunction with optimal bronchodilator

therapy will maximize exercise outcomes.

Exercise training results in a reduced ventilatory

requirement at a given exercise level.53 As a result,

exercise-induced dynamic hyperinflation is dimin-

ished,54 an important consideration given its negative

impact on exercise tolerance in COPD. Optimal bron-

chodilation allows the patient to exercise at higher

intensities, resulting in greater increases in exercise

capacity after rehabilitation.55 In addition, patients

probably gain confidence about their physical abili-

ties during the rehabilitation program, allowing the

physiological improvements seen in the laboratory to

translate into increased activities of daily living and

improved quality of life.

The treatment of muscle wasting is another area

where pharmacotherapy could be used in conjunc-

tion with exercise training. In a recent study, com-

bining strengthening exercises with anabolic steroids

in men with COPD and low testosterone levels was

associated with a striking gain of 3.3 kg in limb mus-

cle mass over a 12-week period.56 The effect of this

muscle growth on functional status, quality of life, or

survival, as well as the safety of this intervention will

need to be evaluated in longer-term studies. Other

substances enhancing muscle function, such as spe-

cific nutrients and antioxidants,57 are likely to be test-

ed in association with exercise training.

Recommendations• Optimal bronchodilator therapy should be

instituted prior to PR to maximize gains in

exercise performance.

• The role of anabolic or antioxidant therapy

has not been sufficiently established to recom-

mend their routine use in PR.

Oxygen Therapy and PRLong-term oxygen therapy improves survival for

hypoxemic patients with COPD. Pulmonary rehabili-

tation can facilitate the identification of hypoxemic

patients and thereby lead to initiation of this therapy.

Also, exercise-induced hypoxemia, frequently unde-

tected in routine clinical practice, can be detected and

addressed in PR. This discussion will address only the

potential role of supplemental oxygen therapy in

enhancing PR outcomes.

In the laboratory, oxygen supplementation acutely

improves exercise tolerance and reduces dyspnea in

COPD patients,58 even in those without “clinically

HCR200038_141-151 5/10/09 9:16 AM Page 146


be considered as part of the spectrum of inte-

grated care for the patient with severe disease.

INCREASING REFERRAL AND ENTRYINTO PR

Although PR is effective in patients who are referred

and complete the program, conversely, candidates

for PR who do not participate have worse out-

comes.16 Unfortunately, only a small fraction of PR-

eligible COPD patients undergo PR. Its use has too

commonly been restricted to relatively stable patients

with moderate to severe disease. Emerging data indi-

cate that the indications for PR should be broadened

and that healthcare providers must champion efforts

aimed at increasing referral and entry into PR pro-

grams. Increasing awareness among healthcare

providers is the key, and the surest way of accom-

plishing this objective is through professional educa-

tion during training. In addition, healthcare providers

must educate the public ranging from patients to

advocacy groups, as well as healthcare institutions

and payers.

Expanding the Indications for PR in COPDThere is strong evidence that PR is beneficial across

all levels of COPD severity,70,71 although most

patients are not referred until they have advanced

disease. While these patients stand to benefit, referral

at an earlier stage would allow greater emphasis on

preventative strategies and maintenance of physical

function. In addition, patients with chronic respiratory

failure can also benefit from the integrated approach

to care found in PR, especially in that these patients

are medically complicated and have highly variable

individual needs and goals.

Recommendations• PR should be considered earlier in the course

of COPD. This will allow for a greater empha-

sis on promoting health rather than regaining

function.

• PR is also indicated for very severe COPD,

including chronic respiratory failure. While all

PR requires an individualized approach and

integration of services, these are especially

pertinent to these patients.

The post-exacerbation periodAn exacerbation of COPD is a serious event in the

course of the disease and can be accompanied by

acute, prolonged increases in symptoms and reduc-

tions in function, followed by increased healthcare

utilization and increased mortality risk. Instituting PR

quality of life and functional status, both approaches

are multidisciplinary and include patient and caregiver/

family education as a strategy to maximize patient

independence and improve quality of life.

Palliative care is an interdisciplinary specialty that

provides treatment aimed at relieving suffering and

improving quality of life in patients with advanced ill-

ness and their families.67 Palliative care, which is pro-

vided simultaneously with all other appropriate med-

ical treatment, focuses on 3 domains: comfort, com-

munication, and coordination across care settings. It is

important to understand that palliative care does not

refer exclusively to end-of-life care: many patients

stand to benefit at earlier stages of their disease.

Palliative care consultants can provide adjunctive help

with symptom management, such as dyspnea, in

COPD patients.

Palliative care can also help with coordination of

care at the end of life. As the patient approaches the

final stage of the disease, treatment priorities may shift

to hospice care. The availability, philosophy, and

funding for palliative care varies considerably among

healthcare systems. For the appropriate patient, a pal-

liative care consultation can assist the PR team with

the transition to another setting or another set of

goals. As the focus shifts from restoration of function

to comfort care, one integrated team transfers respon-

sibilities to another, ensuring coordination of the con-

tinuity of care across healthcare settings.68

Communication can be challenging for physicians

of patients with advanced lung disease, and both PR

and palliative care can be helpful in this area.

Pulmonary rehabilitation is an ideal setting to educate

patients on advance directives and end-of-life care.

COPD fits the illness trajectory model of organ system

failure with prolonged and progressive limitation of

function, punctuated by exacerbations and, some-

times, culminating in a final catastrophic illness.

Unfortunately, lack of advance planning by patients,

caregivers, and physicians can affect outcomes

adversely. Patients with COPD who are hospitalized

for a serious exacerbation experience more dyspnea

and as much uncontrolled pain as patients admitted

with cancer.69 It may be helpful to involve a palliative

care consultant who has the time to help the patient

and family explore treatment options even in the set-

ting of prognostic uncertainty.

Recommendations• Advance directives and end-of-life care discus-

sion should be incorporated routinely into PR.

• As COPD progresses and patient goals

change, the palliative care approach becomes

increasingly more relevant to patient care.

Therefore, we recommend that palliative care

HCR200038_141-151 5/10/09 9:16 AM Page 147


patient in the intensive care unit may improve muscle

strength and function and hasten recovery.75 For the

lung cancer patient with severe COPD, PR may

increase eligibility for potentially curable surgery.79

Recommendation• Further work is needed to better adapt PR to

other settings such as the intensive care unit

and in patients undergoing major operative

procedures such as lung resection.

Training of Healthcare ProfessionalsIn the United States, formal instruction and clinical

experience in the prevention, evaluation, and man-

agement of both inpatients and outpatients in PR are

required as a part of pulmonary fellowship training.

A close liaison with rehabilitation services is neces-

sary. However, despite these requirements, it appears

that exposure to PR is quite variable among training

programs. Pulmonary and critical care fellows should

be exposed to PR in core curricula, clinical training,

and research opportunities. Similarly, exposure to PR

may be of great value to trainees in nonphysician

specialties such as nursing, respiratory therapy, phys-

ical, and occupational therapy. This is in accord with

the multidisciplinary nature of PR.

In general, pulmonary specialists recognize the

evidence-based importance of PR as evidenced by

the prominent placement of PR in international

guidelines such GOLD guidelines and the American

Thoracic Society-European Respiratory Society

Statement on COPD. This, however, is less likely to

be the case among nonpulmonary healthcare profes-

sionals, including primary care providers, physician

trainees, and allied healthcare professionals. Efforts

must now also be directed toward educating these

professionals. The integration of COPD care into the

care plans of appropriate patients will bring the pri-

mary care providers into the team, and this should

improve PR recognition. Until this happens, however,

efforts should be made at disseminating the COPD

guidelines to primary care providers, adding PR into

continuing medical education activities, and empha-

sizing the complementary nature of nonpharmaco-

logic to pharmacologic therapies for COPD patients.

Recommendations• The application of an integrated care

approach to the treatment of COPD, recogniz-

ing the primary care provider and the patient

as part of the rehabilitation team, will have

the added benefit of promoting PR through

increased advocacy and referrals.

• Efforts should be directed toward PR educa-

tion for all healthcare professionals, especially

during or immediately after the acute exacerbation,

which at present is not routinely included, may

improve outcomes. Perhaps most importantly, the

exacerbation represents a window of opportunity to

promote health behavior change, especially in the

prevention of further exacerbations including early

recognition and utility of an action plan.

Few studies have evaluated the effectiveness of PR

in reducing exacerbation rate and severity, although

the substantial reduction in healthcare utilization

observed following PR for stable patients with COPD

probably reflects improvement in this area.26,72 One

randomized controlled trial demonstrated that outpa-

tient PR begun within 10 days of hospital discharge

was well-tolerated and resulted in better exercise

tolerance and health status, and fewer emergency vis-

its.73 In addition, patients who attended PR had 30%

fewer subsequent hospital admissions. A subsequent

meta-analysis of 6 randomized controlled trials in the

early postexacerbation period demonstrated significant

favorable effects of PR on exercise tolerance, health-

related quality of life, and hospital admissions.74 These

studies suggest that PR initiated in the postexacerba-

tion period is feasible, safe, and effective.

Pulmonary rehabilitation in the post-exacerbation

period must be modified to address the acute

declines in pulmonary and physical function.

Traditional aerobic exercise training used for stable

COPD patients may not be tolerated in this setting.

Exercise strategies for patients with lower ventilatory

load, including early mobilization, resistive and inter-

val training,75,76 and transcutaneous electrical muscle

stimulation,77,78 have been shown to be beneficial.

Since lower levels of physical activity in the periex-

acerbation period are associated with a higher rate of

subsequent hospitalization,15 promotion of physical

activity should be a prominent goal.

Recommendation• The post-exacerbation period represents an

extremely important time for initiation of PR

services. Although currently underutilized, it

represents a window of opportunity to impact

the course of the disease. More randomized

controlled trials of PR in the periexacerbation

period are needed, especially those evaluating

outcomes such as exacerbation rates, healthcare

utilization, disease progression, and mortality.

Other applications and settingsPulmonary rehabilitation may also be beneficial in

other nontraditionally thought of disease states.

Among these are the COPD patient with an acute crit-

ical illness and the COPD patient with lung cancer.

Emerging data suggest that PR strategies for the COPD

HCR200038_141-151 5/10/09 9:16 AM Page 148


References1. Nici L, Donner C, Wouters E, et al. American Thoracic

Society/European Respiratory Society statement on pul-

monary rehabilitation. Am J Respir Crit Care Med. 2006;173:

1390–1413.

2. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilita-

tion: joint ACCP/AACVPR evidence-based clinical practice

guidelines. Chest. 2007;131:4–42.

3. Holman H, Lorig K. Patients as partners in managing chronic

disease. Partnership is a prerequisite for effective and efficient

health care. Br Med J. 2000;320:526–527.

4. Simpson AC, Rocker GM. Advanced chronic obstructive pul-

monary disease: rethinking models of care. QJM. 2008;101:

697–704.

5. World Health Organization. Innovative Care for Chronic

Conditions. Building Blocks for Action: Global Report

(Executive Summary). Geneva: Noncommunicable Diseases

and Mental Health, World Health Organization; 2002:5.

http://www.who.int/diabetesactiononline/about/iccc_exec_

summary_eng.pdf. Accessed December 11, 2008.

6. Grone O, Garcia-Barbero M. Integrated care. A position paper

of the WHO European office for integrated care services. Int J

Integr Care. 2001;1:1–10.

7. Wilkinson TMA, Donaldson GC, Hurst JR, et al. Early therapy

improves outcomes of exacerbations of chronic obstructive pul-

monary disease. Am J Respir Crit Care Med. 2004;169:1298–1303.

8. Casas A, Troosters T, Garcia-Aymerich J, et al. Integrated care

prevents hospitalisations for exacerbations in COPD patients.

Eur Respir J. 2006;28:123–130.

9. American Lung Association. Fact sheet: chronic obstructive

pulmonary disease. http://www.lungusa.org. Published March

2002. Accessed December 11, 2008.

10. Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M,

Gosselink R. Characteristics of physical activities in daily life in

COPD. Am J Respir Crit Care Med. 2005;171:972–977.

11. Fan VS, Curtis JR, Tu SP, McDonell MB, Fihn SD. Using quali-

ty of life to predict hospitalization and mortality in patients

with obstructive lung diseases. Chest. 2002;122:429–436.

12. Gerardi DA, Lovett L, Benoit-Connors ML, Reardon JZ,

ZuWallack RL. Variables related to increased mortality follow-

ing out-patient pulmonary rehabilitation. Eur Respir J. 1996;9:

431–435.

13. Bowen JB, Votto JJ, Thrall RS, et al. Functional status and sur-

vival following pulmonary rehabilitation. Chest. 2000;118:

697–703.

14. Ringbaek TJ, Lange P. Outdoor activity and performance status

as predictors of survival in hypoxaemic chronic obstructive

pulmonary disease (COPD). Clin Rehabil. 2005;19:331–338.

15. Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Anto JM.

Regular physical activity reduces hospital admission and mor-

tality in chronic obstructive pulmonary disease: a population

based cohort study. Thorax. 2006;61:772–778.

16. Cote CG, Celli BR. Pulmonary rehabilitation and the BODE

index in COPD. Eur Respir J. 2005;26:630–636.

17. Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Anto JM.

Regular physical activity modifies smoking-related lung func-

tion decline and reduces risk of chronic obstructive pulmonary

disease. A population-based cohort study. Am J Respir Crit

Care Med. 2007;175:458–463.

18. Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M,

Gosselink R. Physical activity and hospitalization for exacerba-

tion of COPD. Chest. 2006;129:536–544.

19. Garcia-Aymerich J, Felez MA, Escarrabill J, et al. Physical activ-

ity and its determinants in severe chronic obstructive pul-

monary disease. Med Sci Sports Exerc. 2004;36:1667–1673.

primary care providers, trainees, and non-

physician healthcare professionals.

Increasing AvailabilityStudies of PR have demonstrated that only a fraction

of those referred to the program actually agree to par-

ticipate. An even smaller fraction completes the formal

process. We need to understand the reasons why this

occurs and make efforts to change this. Until we have

this knowledge, it would be reasonable to advertise

the benefits of PR among patient advocacy groups.

We know that PR program availability is a problem,

partly because of a shortage of programs resulting

from financial constraints. If a greater number of

healthcare providers were to refer more appropriately

to PR and more patients enroll, the inaccessibility of PR

would become even more acute. This will require con-

siderable and continued support from government and

private funding agencies. More support will ultimately

lead to more programs and increased accessibility. It is

very encouraging that on January 1, 2010, PR will be

an approved medical benefit in the United States under

the Centers for Medicare & Medicaid Services.

Recommendation• Efforts by medical societies and patient groups

must persist to build upon any successes in

increasing funding.

CONCLUSION

Where we go from here? Now that the effectiveness

of PR is indisputable, we must focus efforts on

improving its impact and widening its applicability.

This report briefly summarizes the discussions of 20

experts who met to address these issues. Although PR

is indicated for patients with chronic respiratory dis-

ease, we chose to focus on COPD, since most of the

medical science pertains to this disease. This docu-

ment does not provide an exhaustive list of important

areas for future research and development in PR;

rather, it provides insight into 3 broad areas appro-

priate for investigation or implementation: position-

ing PR in an integrated care model for COPD patients;

improving the effectiveness of this intervention; and

expanding the recognition, application, and accessi-

bility of PR. We hope this document will serve as a

catalyst for clinicians, investigators, and healthcare

policy makers to help realize these goals.

—Acknowledgment—The roundtable conference was supported in part by

an unrestricted grant from Boehringer Ingelheim

Pharmaceuticals, Inc.

HCR200038_141-151 5/10/09 9:16 AM Page 149


40. Kunik M, Roundy F, Veazey C, et al. Surprisingly high preva-

lence of anxiety and depression in chronic breathing diseases.

Chest. 2005;127;1205–1211.

41. Ng TP, Niti M, Tan WC, et al. Depressive symptoms and COPD

effect on mortality, hospital readmission, symptom burden,

functional status and QOL. Arch Intern Med. 2007;167:60–67.

42. Fan V, Ramsey S, Giardino N. Sex, depression, and risk of hos-

pitalization and mortality in chronic obstructive pulmonary dis-

ease. Arch Intern Med. 2007;167:2345–2353.

43. Emery C, Hauck E, Schein R, et al. Psychological and cognitive

outcomes of a randomized trial of exercise among patients

with COPD. Health Psychol. 1998;17:232–240.

44. Kayahan B, Karapolat H, Atyntoprak E, et al. Psychological

outcomes of an outpatient pulmonary rehabilitation program

in patients with COPD. Respir Med. 2006;100:1050–1057.

45. Paz-Diaz H, Montes de Oca M, Lopez JM, Celli B. Pulmonary

rehabilitation improves depression, anxiety, dyspnea and

health status in patients with COPD. Am J Phys Med Rehabil.

2007;86:30–36.

46. Global Initiative for Chronic Obstructive Lung Disease

(GOLD). Strategy for the diagnosis, management and preven-

tion of COPD. http://www.goldcopd.org. Accessed December

11, 2008.

47. Mahler DA, Donohue JF, Barbee RA, et al. Efficacy of salmeterol

xinafoate in the treatment of COPD. Chest. 1999;115:957–965.

48. Casaburi R, Mahler DA, Jones PW, et al. A long-term evalua-

tion of once-daily inhaled tiotropium in chronic obstructive

pulmonary disease. Eur Respir J. 2002;19:217–224.

49. Niewoehner DE, Rice K, Cote C, et al. Prevention of exacer-

bations of chronic obstructive pulmonary disease with tiotropi-

um, a once-daily inhaled anticholinergic bronchodilator: a ran-

domized trial. Ann Intern Med. 2005;143:317–326.

50. O’Donnell DE, Fluge T, Gerken F, et al. Effects of tiotropium

on lung hyperinflation, dyspnoea and exercise tolerance in

COPD. Eur Respir J. 2004;23:832–840.

51. O’Donnell DE, Sciurba F, Celli B, et al. Effect of fluticasone

propionate/salmeterol on lung hyperinflation and exercise

endurance in COPD. Chest. 2006;130:647–656.

52. Saey D, Debigaré R, LeBlanc P, et al. Contractile leg fatigue

after cycle exercise: a factor limiting exercise in patients with

COPD. Am J Respir Crit Care Med. 2003;168:425–430.

53. Casaburi R, Patessio A, Ioli F, Zanaboni S, Donner CF,

Wasserman K. Reductions in exercise lactic acidosis and venti-

lation as a result of exercise training in patients with obstruc-

tive lung disease. Am Rev Respir Dis. 1991;143:9–18.

54. Porszasz J, Emtner M, Goto S, Somfay A, Whipp BJ, Casaburi

R. Exercise training decreases ventilatory requirements and

exercise-induced hyperinflation at submaximal intensities in

patients with COPD. Chest. 2005;128:2025–2034.

55. Casaburi R, Kukafka D, Cooper CB, Witek TJ Jr, Kesten S.

Improvement in exercise tolerance with the combination of

tiotropium and pulmonary rehabilitation in patients with

COPD. Chest. 2005;127:809–817.

56. Casaburi R, Bhasin S, Cosentino L, et al. Effects of testosterone

and resistance training in men with chronic obstructive pul-

monary disease. Am J Respir Crit Care Med. 2004;170:870–878.

57. Koechlin C, Couillard A, Simar D, et al. Does oxidative stress

alter quadriceps endurance in chronic obstructive pulmonary

disease? Am J Respir Crit Care Med. 2004;169:1022–1027.

58. O’Donnell DE, D’Arisigny C, Webb KA. Effects of hyperoxia on

ventilatory limitation during exercise in advanced chronic

obstructive pulmonary disease. Am J Respir Crit Care Med.

2001;163:892–889.

59. Somfay A, Porszasz J, Lee SM, Casaburi R. Dose-response

effect of oxygen on hyperinflation and exercise endurance in

nonhypoxaemic COPD patients. Eur Respir J. 2001;18:77–84.

20. Steele BG, Belza B, Cain KC, et al. A randomized clinical trial

of an activity and exercise adherence intervention in chronic

pulmonary disease. Arch Phys Med Rehabil. 2008;89:404–412.

21. Sewell L, Singh SJ, Williams JEA, Collier R, Morgan MDL. Can

individualized rehabilitation improve functional independence

in elderly patients with COPD? Chest. 2005;128:1194–1200.

22. Pitta F, Troosters T, Probst VS, Langer D, Decramer M,

Gosselink R. Are patients with COPD more active after pul-

monary rehabilitation? Chest. 2008;134:273–280.

23. Walker PP, Burnett A, Flavahan PW, Calverley PMA. Lower

limb activity and its determinants in COPD. Thorax. 2008;63:

683–689.

24. Bourbeau J, Julien M, Maltais F, et al. Reduction of hospital uti-

lization in patients with chronic obstructive pulmonary disease:

a disease-specific self management intervention. Arch Intern

Med. 2003;163:585–591.

25. McAuley E. Self-efficacy and the maintenance of exercise par-

ticipation in older adults. J Behav Med. 1993;16:103–111.

26. Ries AL, Kaplan RM, Limberg TM, et al. Effects of pulmonary

rehabilitation on physiologic and psychosocial outcomes in

patients with chronic obstructive pulmonary disease. Ann

Intern Med. 1995;122:823–832.

27. Strijbos JH, Postma DS, van Altena R, et al. A comparison

between an outpatient hospital-based pulmonary rehabilitation

program and a home-care pulmonary rehabilitation program in

patients with COPD: a follow-up of 18 months. Chest. 1996;

109:366–372.

28. Engstrom CP, Persson LO, Larsson S, et al. Long-term effects of

a pulmonary rehabilitation programme in outpatients with

chronic obstructive pulmonary disease: a randomized con-

trolled study. Scand J Rehabil Med. 1999;31:207–213.

29. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of

outpatient multidisciplinary pulmonary rehabilitation: a ran-

domised controlled trial. Lancet. 2000;355:362–368.

30. Guell R, Casan P, Belda J, et al. Long-term effects of outpatient

rehabilitation of COPD: a randomized trial. Chest. 2000;117:

976–983.

31. Ries AL, Kaplan RM, Myers R, et al. Maintenance after pul-

monary rehabilitation in chronic lung disease: a randomized

trial. Am J Respir Crit Care Med. 2003;167:880–888.

32. California Pulmonary Rehabilitation Collaborative Group.

Effects of pulmonary rehabilitation on dyspnea, quality of life

and health care costs in California. J Cardiopulm Rehabil.

2004;24:52–62.

33. Grosbois J-M, Lamblin C, Lemaire B, et al. Long-term benefits

of exercise maintenance after outpatient rehabilitation pro-

gram in patients with chronic obstructive pulmonary disease.

J Cardiopulm Rehabil. 1999;19:216–225.

34. Foglio K, Bianchi L, Ambrosino N. Is it really useful to repeat

outpatient pulmonary rehabilitation programs in patients with

chronic airway obstruction? A 2-year controlled study. Chest.

2001;119:1696–1704.

35. Brooks D, Krip B, Mangovski-Alzamora S, et al. The effect of

postrehabilitation programmes among individuals with

chronic obstructive pulmonary disease. Eur Respir J. 2002;20:

20–29.

36. Wijkstra PJ, TenVergert EM, van Altena R, et al. Long term ben-

efits of rehabilitation at home on quality of life and exercise

tolerance in patients with chronic obstructive pulmonary dis-

ease. Thorax. 1995;50:824–828.

37. Norwood R. Prevalence and impact of depression in COPD

patients. Curr Opin Pulm Med. 2006;12:113–117.

38. Norwood R, Balkissoon R. Current perspectives on management

of co-morbid depression in COPD. COPD. 2005;2:185–193.

39. Brenes GA. Anxiety and COPD: prevalence, impact and treat-

ment. Psychosom Med. 2003;65:963–970.

HCR200038_141-151 5/10/09 9:16 AM Page 150


70. Berry MJ, Rejeski WJ, Adair NE, Zaccaro D. Exercise rehabili-

tation and chronic obstructive pulmonary disease stage. Am J

Respir Crit Care Med. 1999;160:1248–1253.

71. Takigawa N, Tada A, Soda R, et al. Comprehensive pulmonary

rehabilitation according to severity of COPD. Respir Med.

2007;101:326–332.

72. Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an

outpatient multidisciplinary pulmonary rehabilitation pro-

gramme. Thorax. 2001;56:779–784.

73. Man WD, Polkey MI, Donaldson N, Gray BJ, Moxham J.

Community pulmonary rehabilitation after hospitalisation for

acute exacerbations of chronic obstructive pulmonary disease:

randomised controlled study. Br Med J. 2004;329:1209.

74. Puhan MA, Scharplatz M, Troosters T, Steurer J. Respiratory

rehabilitation after acute exacerbation of COPD may reduce

risk for readmission and mortality—a systematic review. Respir

Res. 2005;6:54.

75. Zanotti E, Felicetti G, Maini M, Fracchia C. Peripheral muscle

strength training in bed-bound patients with COPD receiving

mechanical ventilation: effect of electrical stimulation. Chest.

2003;124:292–296.

76. Vogiatzis I, Nanas S, Roussos C. Interval training as an alterna-

tive modality to continuous exercise in patients with COPD.

Eur Respir J. 2002;20:12–19.

77. Vivodtzev I, Pepin JL, Vottero G, et al. Improvement in quadri-

ceps strength and dyspnea in daily tasks after 1 month of elec-

trical stimulation in severely deconditioned and malnourished

COPD. Chest. 2006;129:1540–1548.

78. Neder JA, Sword D, Ward SA, Mackay E, Cochrane LM, Clark CJ.

Home-based neuromuscular electrical stimulation as a new reha-

bilitative strategy for severely disabled patients with chronic

obstructive pulmonary disease (COPD). Thorax. 2002;57:333–337.

79. Benzo RP. Pulmonary rehabilitation in lung cancer: a scientific

opportunity. J Cardiopulm Rehabil Prev. 2007;27:61–64.

60. Rooyackers JM, Dekhuijzen PN, Van Herwaarden CL, et al.

Training with supplemental oxygen in patients with COPD and

hypoxaemia at peak exercise. Eur Respir J. 1997;10:1278–1284.

61. Garrod R, Wedzicha JA. Supplemental oxygen during pul-

monary rehabilitation in patients with COPD with exercise

hypoxaemia. Thorax. 2000;55:539–543.

62. Wadell K, Henriksson-Larsen K, Lundgren R. Physical training

with and without oxygen in patients with chronic obstructive

pulmonary disease and exercise-induced hypoxaemia.

J Rehabil Med. 2001;33:200–205.

63. Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits

of supplemental oxygen in exercise training in non-hypoxemic

COPD patients. Am J Respir Crit Care Med. 2003;168:

1034–1042.

64. Troosters T, Casaburi R, Gosselink R, et al. Pulmonary rehabil-

itation in chronic obstructive pulmonary disease. Am J Respir

Crit Care Med. 2005;172:19–38.

65. Laude EA, Duffy NC, Baveystock C, et al. The effect of helium

and oxygen on exercise performance in chronic obstructive

pulmonary disease. Am J Respir Crit Care Med. 2006;173:

865–870.

66. Ambrosino N, Strand V. New strategies to improve exercise tol-

erance in chronic obstructive pulmonary disease. Eur Respir J.

2004;24:313–322.

67. Center to Advance Palliative Care. Defining palliative care.

http://www.capc.org. Accessed April 8, 2009.

68. Seamark DA, Seamark CJ, Halpin DMG. Palliative care in

chronic obstructive pulmonary disease: a review for clinicians.

J R Soc Med. 2007;100:225–233.

69. Claessens MT, Lynn J, Zhong Z, et al. Dying with lung cancer

or chronic obstructive pulmonary disease: insights from SUP-

PORT. Study to Understand Prognoses and Preferences for

Outcomes and Risks of Treatments. J Am Geriatr Soc. 2000;

48(suppl 5):S146–S153.

HCR200038_141-151 5/10/09 9:16 AM Page 151

Date post:	14-Nov-2023
Category:	Documents
Upload:	independent
View:	0 times
Download:	0 times

Pulmonary Rehabilitation

Documents