Understanding Pulmonary Rehabilitation

Health Professional
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I previously wrote about Ted Koppel’s wife, Grace, who has been living with COPD for a number of years. COPD is a disease that results in permanent damage to the lungs. It’s a disease that cannot be “repaired or reversed” by medication, although this is the main reason patients seek medical attention. They want this "fixed.”

There is something, however, that can be done to improve the quality of life and preserve daily function. Pulmonary Rehabilitation (PR) is a viable therapy that has the potential to increase quality-of-life and support the ability to continue with daily activities.

Pulmonary rehabilitation is considered the most effective therapy for COPD. It's a multidisciplinary program with supervised exercise training and self-management education.

A healthy person doesn't have to think about breathing when performing typical daily tasks. He only encounters some breathing limitations when doing strenuous exercise like walking stairs or carrying heavy items. For someone living with COPD, life is quite different. Even routine activities which are called activities-of-daily-life, or ADLs, are limited by breathing difficulties.

As a result, individuals with COPD will usually decrease their level of daily activity because even the simplest tasks can make them breathless. The net result is that muscle mass and tone decreases, and general fitness levels become more and more compromised, adding yet another layer of limitation.  Shortness of breath doesn’t only result from lung limitations but also from the developing musculoskeletal compromise.

Pulmonary rehabilitation has been around for years, but given the cost of the program — which involves physical, respiratory, occupational, and speech therapists, as well as doctors and nurses participation — it has not been a standard insurance-covered therapy.

Insurance companies further maintain that there is a dearth of clear research to show demonstrable results in improvement of lung function or decreased mortality. Since most individuals with COPD are disabled, the main payer for their care is the federal government - the Center for Medicare and Medicaid Services (CMS). Currently, the system is not routinely covering costs associated with pulmonary rehabilitation and in April of 2017, coverage was actually reduced.

Currently there is no national coverage determination for a comprehensive pulmonary rehabilitation program. However, there is limited coverage for some respiratory therapy services when they are offered at an accredited outpatient rehabilitation facility. Local coverage determination is usually decided on a case-by-case basis.

There's also the problem of lack of standardization among pulmonary rehabilitation programs. There are excellent hospital-based opportunities and also private centers that offer comprehensive programs but there has been no effort to expand access or create a nationwide protocol that all centers follow. Because these programs should have specific components and interaction between the service providers, there is a strong chance that without standardization, the patient will not experience a full-bodied comprehensive experience where all service providers are communicating and tracking progress and problems.

In the past, there was coverage and approval for a one-time in-hospital program and then for a 12-week home program for individuals with COPD who were homebound.

Nowadays, the focus in management of COPD is not improvement in lung functions as measured by pulmonary function tests (PFTs) but in reducing exacerbations. It is well-recognized that having more than two exacerbations per year results in progression of the disease. With this in mind, there's been an effort to take a new look at the idea of "pulmonary rehabilitation to reduce exacerbations."

A recent analysis by the National Health Service (NHS) in the United Kingdom looked at PR and results were published in Chest. The title of the editorial which discussed the findings is very appropriately called “Pulmonary Rehabilitation: The Lead Singer of COPD Therapy But Not a One Man Band.”

The research was actually an audit of the pulmonary rehabilitation (PR) services, using data gathered from UK general practitioners and then examining the degree of the therapies effect on the subsequent health care services needed by these patients. Specifically, the research looked at the effect of PR on the acute exacerbations of COPD (which is the current metric used to determine progression of disease).

The audit found that the referral rates by the general practitioners were disappointingly low-on the order of 10 percent of the possible eligible candidates. In addition, there was no significant "benefit effect" on the rate of acute exacerbations of COPD in the patients who did participate in the PR programs. This finding raises some doubt regarding the supposed economic benefits of reduced health care costs for patients with COPD who have PR.

It's important to note that there are several flaws in this Chest discussion:

  • The diagnosis of COPD was dependent on primary care physicians who may not accurately identify COPD patients.

  • The diagnosis of the exacerbations may also have been inconsistent if the initial diagnosis was not precise, and the definition of exacerbation may also not be accurate since primary care physicians are not typically involved in the hospital care of these patients.

  • Financial incentives in the UK may be influential in the data collection. For example, recording smoking status is rewarded with increase reimbursement in the UK, while referral to PR is not.

  • More importantly, the real benefits of pulmonary rehabilitation may not be subject to clear objective measurements. Enrollment in this program is expected to result in improvement in the subjective perceptions of shortness of breath by components in the PR that include physical conditioning, the goal of which is enhanced ability to better engage in activities-of-daily living. It is expected that through self-knowledge of one's condition (education component) there will be improved ability to manage acute exacerbations. This may not be easily or readily measured.

Every COPD patient has individual characteristics and co-morbid conditions. Pulmonary rehabilitation, in my opinion, offers a structured approach that can be individualized. The physical conditioning component would be central to all of the medical problems.

Empowering each individual to self -manage breathlessness and exercise limitation can be an attainable goal, and reduction in admissions would follow as a measurable observation. I do believe that the benefits are well worth the investment. PR can certainly play "the lead singer" in comprehensive management of the COPD patient.

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