Front Cover 1
Pulmonary Rehabilitation:Role and Advances 2
copyright 
3 
Contributors 4
Contents 8
Clinics In Chest Medicine 
12 
Preface 14
Pulmonary Rehabilitation 16
Key points 16
Definition and concept 16
History 17
Early Years 17
Randomized Controlled Trials Demonstrating Global Benefit from Pulmonary Rehabilitation 18
Acceptance as a Gold Standard of Care 18
The Rise of Self-Management as an Integral Component of Pulmonary Rehabilitation 18
Funding as a Specific Entity in the United States by the Centers for Medicare and Medicaid Services 18
Broadening the Scope of Pulmonary Rehabilitation 18
Summary 18
References 19
The Systemic Nature of Chronic Lung Disease 20
Key points 20
Introduction 20
Systemic manifestations of COPD 21
Skeletal Muscle Impairment 21
Mood Disturbance 21
Hormonal Imbalance 22
Osteoporosis 22
Anemia 22
Mechanisms and causes of the systemic manifestations of COPD 22
Physical Inactivity 22
Systemic Inflammation 22
Hypoxia 23
Corticosteroids 23
Role of pulmonary rehabilitation for the secondary manifestations 23
Comorbidities in COPD and pulmonary rehabilitation 24
Multiple Comorbidities 24
Cardiac Disease 24
Obesity 25
Metabolic Syndrome 25
Very severe disease and rehabilitation 25
Summary 26
References 26
Evidence-Based Outcomes from Pulmonary Rehabilitation in the Chronic Obstructive Pulmonary Disease Patient 32
Key points 32
Introduction 32
Methods 33
Results 33
Health-Related Quality of Life 33
Symptoms 36
Activity and Exercise Capacity 37
Exacerbations 37
Summary 37
References 37
Pulmonary Rehabilitation 40
Key points 40
Introduction 40
Who Should Be Referred? 41
Where Should Rehabilitation Take Place? 43
Outpatient programs in specialized centers 44
Inpatient rehabilitation 44
Rehabilitation in primary care 45
Community centers 45
Telehealth 45
Duration of Rehabilitation 45
Summary 46
Acknowledgments 46
References 46
Exercise Training in Pulmonary Rehabilitation 50
Key points 50
Endurance exercise training 50
Interval exercise training 51
Ground walking exercise training 52
Nordic walking exercise training 52
Resistance training 52
Water-based (or aquatic) exercise training 53
Tai chi 53
NLPE 54
Summary 54
References 54
Strategies to Enhance the Benefits of Exercise Training in the Respiratory Patient 60
Key points 60
Introduction 60
Supplemental oxygen 61
Rollators (wheeled walkers) 63
Water-based exercise 63
Inspiratory muscle training 64
Non-invasive ventilation 64
Heliox/Helium-hyperoxia 65
Neuromuscular electrical stimulation 67
Partitioning exercising muscle mass 67
Summary 70
References 70
Collaborative Self-Management and Behavioral Change 74
Key points 74
Introduction 74
Challenges to providing high-quality COPD care 75
COPD CSM for the “good days” 76
Knowledge and Understanding 76
Self-Efficacy Behaviors for Healthy Living 77
Physical activity 77
Health status, psychological well-being, and dyspnea 78
Preventive behaviors 78
Change in Provider Behavior 78
COPD CSM for the “bad days” 78
Action Plans for AECOPD 78
Effect of CSM on Hospitalizations for AECOPD 79
COPD CSM RCTs that decreased hospitalizations 79
COPD CSM RCTs that did not decrease hospitalizations 80
Why some RCTs may have been successful while others were not 80
Mortality and safety concerns in COPD CSM 81
Integration of COPD CSM and pulmonary rehabilitation 81
Translational studies of COPD CSM 82
Costs 82
Integration of COPD CSM into clinical practice 83
Medical Home Model 83
Qualification and Training of COPD CSM Managers 83
Frequency and Intensity of Contacts 83
Patient Selection for COPD CSM 83
The continuum of disease: advance care planning and palliative care 84
Summary 84
Acknowledgments 84
References 84
Approaches to Outcome Assessment in Pulmonary Rehabilitation 90
Key points 90
Introduction 90
Patient outcome assessments for pulmonary rehabilitation 91
Exercise Capacity 91
Strength 93
Health-Related Quality of Life 93
Functional Performance 94
Physical Activity 94
Anxiety and Depression 95
Symptoms 95
Knowledge and Self-Efficacy 95
Nutritional Status 95
Other Outcome Assessments 96
Summary 96
References 96
Promoting Regular Physical Activity in Pulmonary Rehabilitation 100
Key points 100
Introduction 100
Components of pulmonary rehabilitation addressing physical activity 101
Exercise Training 101
Behavioral Intervention 102
How physical activity is measured as an outcome of pulmonary rehabilitation 102
Effects of pulmonary rehabilitation on physical activity 102
Challenges of pulmonary rehabilitation in promoting physical activity 103
Summary 103
References 104
Pulmonary Rehabilitation for Respiratory Disorders Other than Chronic Obstructive Pulmonary Disease 106
Key points 106
Introduction 106
Rationale for PR in non-COPD disorders 106
PR for other conditions associated with airflow obstruction 107
Asthma 107
Cystic Fibrosis (CF) 108
Non-CF Diffuse Bronchiectasis 112
PR for conditions associated with restrictive physiology 112
ILD/Pulmonary Fibrosis 112
Restrictive Chest Wall Disease 113
PR for other respiratory disorders 114
Pulmonary Hypertension (PH) 114
Lung Cancer 115
PR Before and After Lung Transplantation 117
Before transplant 117
After transplant 118
Practical challenges of providing PR to persons with respiratory disorders other than COPD 119
Summary 119
References 119
Pulmonary Rehabilitation at the Time of the COPD Exacerbation 128
Key points 128
Introduction 128
Definition, cause, and pathophysiology of acute exacerbation 128
Definition 128
Cause and Incidence 129
Acute exacerbations—the enemy of rehabilitation 129
Impact on Lung Function 129
Impact on Muscle Strength 129
Impact on Health-related Quality of Life 130
Impact on Physical Activity 130
Impact on Hospital Readmission 131
Psychological impact of acute exacerbation 131
Rehabilitation after acute exacerbation: the evidence, practice, and components 132
Airway Clearance Techniques for Acute Exacerbation 132
Pulmonary Rehabilitation 132
Program modification post-exacerbation 133
Summary 133
References 133
Anxiety, Depression, and Cognitive Impairment in Patients with Chronic Respiratory Disease 136
Key points 136
Introduction 136
Depression 137
Prevalence of depression 137
Depression Treatment 138
Does depression affect participation and the likelihood of benefitting from pulmonary rehabilitation? 138
Improvement in Depressive Symptoms as a Result of Pulmonary Rehabilitation 138
Should Screening for Depression be Performed Before Entry into a Pulmonary Rehabilitation Program? 140
Anxiety 140
Prevalence of Anxiety in COPD 141
What is the Relationship Between Anxiety and Pulmonary Rehabilitation? 141
Screening for Panic Disorder and Generalized Anxiety 141
Measures Used to Assess Anxiety as an Outcome in Pulmonary Rehabilitation 142
Cognitive function 142
Prevalence of cognitive decline in COPD 142
Working memory 143
Pulmonary rehabilitation as an intervention to improve depression, anxiety, and cognitive impairment 143
References 143
Palliative Care and Pulmonary Rehabilitation 148
Key points 148
Introduction 148
Disease trajectory and the palliative care model in advanced COPD 149
Palliative care needs in advanced COPD 150
Symptoms 150
Care Needs 150
Family Caregiving 151
Comorbidities 151
Need for Advance Care Planning 151
Barriers toward provision of palliative care 152
Barriers to Optimal Symptom Management 152
Barriers Toward Advance Care Planning 153
Advance care planning education during pulmonary rehabilitation 154
Summary 155
References 155
Program Organization in Pulmonary Rehabilitation 160
Key points 160
Introduction 160
Program duration 160
Rehabilitation setting 160
Structure and staffing 161
Medical director 161
Program certification 162
Program audit and quality control 162
Patient selection 162
Technology-assisted exercise training 162
Program enrollment 162
Maintenance 162
Program adherence 163
Health care utilization 163
Program costs and reimbursement issues 163
Summary 164
References 164
Promoting Long-Term Benefits of Pulmonary Rehabilitation 166
Key points 166
Introduction 166
Getting patients to participate in pulmonary rehabilitation 167
Maintenance programs following pulmonary rehabilitation 168
Prolonging the beneficial effects of pulmonary rehabilitation indirectly through reducing the frequency of exacerbations 168
Reduced Hospital Admissions Rather than Reduced Number of Exacerbations as an Outcome in Pulmonary Rehabilitation 168
Pulmonary Rehabilitation and COPD Exacerbations 169
Promotion of Physical Activity During Pulmonary Rehabilitation 169
Promoting Self-Efficacy and Collaborative Self-Management in the Respiratory Patient 170
Pulmonary Rehabilitation and the Integration of Care of the Respiratory Patient at the Time of the Respiratory Exacerbation 170
Using pulmonary rehabilitation or its components to optimize care following hospital discharge 170
Recommendations 172
References 172
Pulmonary Rehabilitation 176
Key points 176
Pulmonary rehabilitation: state of the science 176
Expanding the applicability of pulmonary rehabilitation 177
Pulmonary Rehabilitation for the Non-COPD Respiratory Patient 177
Pulmonary Rehabilitation in Earlier Stages of COPD 177
Pulmonary Rehabilitation in the Periexacerbation Period 177
Pulmonary Rehabilitation During Critical Illness 178
Pulmonary Rehabilitation in the Home and Community Settings 178
Technology-Assisted Pulmonary Rehabilitation 178
Further defining the effectiveness of pulmonary rehabilitation 178
Self-Management Education 178
Maintaining the Benefits of Pulmonary Rehabilitation 179
Translating Gains in Exercise Capacity into Meaningful Physical Activity 179
Promoting accessibility to pulmonary rehabilitation 179
Increasing the Awareness of Pulmonary Rehabilitation 179
Fair Reimbursement for Pulmonary Rehabilitation 180
Pulmonary rehabilitation and integrated care of the respiratory patient 180
References 180
Index 182