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Fast Facts: Referral/Resource Pages for Pulmonary Rehabilitation
What is pulmonary rehab?
Identifying appropriate patients
Components of pulmonary rehabilitation
How do we measure if helping?
What determines a quality program?
Where are these programs?
How do we measure if helping: Expected outcomes
Payment for programs/cost of programs
Evidence of efficacy?
What is pulmonary rehab?
Definition and scope:
The American Thoracic Society and European Respiratory Society have adopted the following definition of Pulmonary Rehabilitation in a position paper in 2006: "Pulmonary Rehabilitation is 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 individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease. (1)
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Identifying appropriate patients
Although degree of impairment noted in pulmonary function testing is often used as a primary selection criteria for establishing patient eligibility for pulmonary rehabilitation, symptoms, especially dyspnea, correlate better with functional ability than FEV1 or other measures of pulmonary function. In addition to the presence of disease, an important selection criteria should be a reduction in functional status or health-related quality of life. Symptoms, disability, and handicap dictate the need for pulmonary rehabilitation, not the degree of physiologic impairment.
In general, symptoms and functional status limitations from pulmonary disease become clinically apparent with one or more of the following:"
Criteria for appropriate referrals:
- FEV less than or equal to 65% of predicted value
- FVC less than or equal to 65% of predicted value
- Diffusing capacity for carbon monoxide adjusted for hemoglobin less than or equal to 65% of predicted
- Resting hypoxemia (SpO2 less than or equal to 90%)
- Exercise testing demonstrating hypoxemia (SpO2 less than or equal to 90%) or ventilatory limit (VE/MVV more than or equal to 0.8) or a rising Vd/Vt
Examples of conditions appropriate for pulmonary rehabilitation
Obstructive Diseases
- COPD (including alpha-1 antitrypsin deficiency)
- Persistent asthma
- Bronchiectasis
- Cystic fibrosis
- Bronchiolitis obliterans
Restrictive Diseases
- Interstitial lung diseases
- Pulmonary fibrosis
- Occupational or environmental lung disease
- Sarcoidosis, scleroderma, lymphangiomyomatosis
- Chest wall diseases
- Kyphoscoliosis
- Ankylosing spondylitis
- Neuromuscular diseases
with pulmonary impairment
- Parkinson’s disease
- Post-polio syndrome
- Amyotrophic lateral sclerosis
- Diaphragmatic dysfunction
- Multiple sclerosis
- Post-tuberculosis syndrom
Other conditions
- Lung cancer
- Pre and post thoracic and abdominal surgery with pulmonary impairment
- Pre and post lung transplantation
- Pre and post lung volume reduction surgery
- Ventilator dependency
- Pediatric patients with respiratory disease
- Obesity related respiratory disease
- Autoimmune disorders with pulmonary involvement
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Components of pulmonary rehabilitation
Pulmonary rehabilitation is a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy. The core components of pulmonary rehabilitation include:
Patient Assessment of current functional status
Exercise training and other therapeutic exercise (aerobic, strength and flexibility training)
Education and skills training (such as breathing retraining)
Secretion clearance techniques Prevention and management of exacerbations and pulmonary infections
Control of irritants and allergens
Oxygen systems, proper use, safety and portability
Nutritional assessment and intervention if necessary
Psychosocial assessment, support, panic control, and professional intervention if necessary
Smoking cessation if currently smoking
Medication use, management and education
Implementation of a home treatment program follow-up
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How do we measure if helping?
Demonstrated Outcomes of Pulmonary Rehabilitation
Reduced respiratory symptoms (dyspnea, fatigue)
Increased exercise performance
Increased knowledge about pulmonary disease and self-efficacy in its management
Enhanced ability to perform activities of daily living
Improved health-related quality of life
Improved psychosocial symptoms (reversal of anxiety and depressive symptoms)
Reduced exacerbations and use of medical resources
Return to work or leisure activities
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What determines a quality program?
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) instituted program certification in 1998 to recognize programs that were meeting the published Guidelines for Pulmonary and Cardiac Rehabilitation. These documents reflect the standard of care for programs and are regularly updated. Programs can document their adherence to these nationally developed guidelines by undergoing the review process to become certified, and then recertifying every three years.
Documentation required for certification:
- Annual staff competency skills review
- Emergency equipment and supplies
- Written policies and procedures
- Regular staff meetings
- Physician referral process
- Informed consent form
- Exercise prescription
- Preparation for possible medical emergencies
- Emergency equipment availability
- Regular medical emergency inservices
- Record of untoward events
- Outcomes assessment/program evaluation
- Risk stratification
- Psychosocial assessment
- Nutritional assessment
- Educational assessment
- Individualized care plan
- Educational sessions
- Feedback to physicians
Those applying for certification or recertification are also required to complete an extensive checklist related to the daily operation of their program. The national program certification committee works with local affiliate program certification committees to review the applications and mentor programs in the process.
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Where are these programs?
- Program Directory Search click here
- Certified Program Search click here
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Payment for programs/cost of programs
Payment for services is determined by the benefits that have been established in the contract between the insurance carrier and the enrollee. Differences exist throughout the United States in how reimbursement guidelines are applied by various intermediaries and third-party payers, therefore each program is responsible for contacting the health plans, case managers or pre-certification officers to determine the extent of coverage for services. As of 2005, there is no national coverage determination for coverage for Medicare patients, therefore programs should be familiar with current reimbursement guidelines and review their local Medicare policy for coverage for pulmonary rehabilitation.
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Evidence of efficacy?
Medical/clinical evidence:
ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Guidelines. Chest 2007 [CHEST 2007; 131:supplement 5]
American Association of Cardiovascular and Pulmonary Rehabilitation: Guidelines for Pulmonary Rehabilitation Programs, third edition. Human Kinetics:2004
American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation http://www.thoracic.org/sections/publications/statements/pages/respiratory-disease-adults/atserspr0606.html
Troosters T, Casaburi R, Gosselink R, Decramer M. State of the Art Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease Am. J. Respir. Crit. Care Med. 172: 19-38.
Click here for link.
Ries AL, Kaplan RM, Limberg TM and Prewitt LM 1995. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Am Intern Med 122:823-32.\
Ries AL. Position paper of the American Association of Cardiovascular and Pulmonary Rehabilitation: Scientific basis of pulmonary rehabilitation. J Cardiopulmon Rehabil 10:418.
Reardon J, Awad E, Normandine E, et al. The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea. Chest 105:1046.
Cost Effective evidence:
ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Guidelines. Chest 2007 [CHEST 2007; 131:supplement 5]
Griffiths, TL, Phillips, CJ, Davies, S, et al Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001;56,779-784
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
Goldstein, RS, Gort, EH, Guyatt, GH, et al Economic analysis of respiratory rehabilitation. Chest 1997;112,370-379
Kaplan, RM, Ries, AL Cost-effectiveness of pulmonary rehabilitation. Fishman, AP eds. Pulmonary rehabilitation 1996,379-398 Marcel Dekker. New York, NY:
Wright RW, Larsen DF, Monie RG, et al. Benefits of a community-hospital pulmonary rehabilitation program. Respir Care 1983;28:1474-79.
Man WD, Polkey MI, Donaldson N, Gray BJ, Moxham. Community pulmonary rehabilitation after hospitalization for acute exacerbations of chronic obstructive pulmonary disease: randomized controlled study. BMJ 2004; 329:1209-1213.
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Other links: Clinical Guidelines and Reviews specific to Pulmonary Rehabilitation
Clinical Guidelines and Reviews specific to Pulmonary Rehabilitation
Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD Revised 2006. Peer-reviewed summary of GOLD recommendations for the diagnosis, management, and prevention of COPD Am J Respir Crit Care Med 2007;176:532-555.
ATS Guidelines for COPD
http://www.thoracic.org/sections/copd/index.html
Standards for the Diagnosis and Treatment of Patients with COPD: A Summary of the ATS/ERS Position Paper http://www.thoracic.org/sections/publications/statements/pages/respiratory-disease-adults/copdexecsum.html
Cochrane Review of Physical training for asthma
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001116/frame.html
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm
Idiopathic Pulmonary Fibrosis: Diagnosis and Treatment
http://www.thoracic.org/sections/publications/statements/pages/respiratory-disease-adults/idiopathic1-19.html
Cochrane review of Physical training for treatment of bronchiectasis
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002166/frame.html
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