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Article by Jordan Rosenfeld

For patients with lung disease, such as COPD, trouble breathing often leads to a sedentary lifestyle, which causes physical and quality of life decline. To help improve these patients’ ability to function and live independently, experts recommend pulmonary rehabilitation (PR), an exercise and education program tailored specifically for lung disease.

PR helps patients with lung disease improve their quality of life through two key prongs, increasing their ability to exercise, which reduces shortness of breath, promotes mental and cognitive well-being and decreases hospitalizations. Second, it utilizes education about the disease state to help patients understand their disease so they can manage it more effectively. These programs are typically outpatient, and often involve a team of healthcare professionals that may include a combination of: a respiratory or physical therapist, a nurse, a doctor, a psychologist or social worker, and a dietitian.

Research shows that not only do PR programs improve the general health and quality of life for COPD patients, they reduce mortality rates, as well.

While these programs are limited in number around the U.S., the COVID-19 pandemic may increase the number of remote programs soon available out of necessity.

Strengthening muscles and lungs

Most COPD patients are unlikely to exercise or do so properly without guidance, according to Dr. Sudheer Penupolu, a pulmonary critical care medicine physician. “When a lung patient comes into a clinic, we give them inhalers and medications but we don’t concentrate on making their muscles stronger,” he said.

The medical director of the pulmonary rehabilitation program at Geisinger Medical Center in Pennsylvania, Penupolu said, “PR is about the muscles as much as the lungs. We introduce them to exercise in a supervised fashion. [Then] we help optimize their inhaler use and their lung capacity.”

As patients undertake the program, he said, the outcomes of their lung disease improve because they are more active, have better lung capacity and an improved understanding of their disease process.

PR is effective for patients at almost any stage of lung disease, said Dr. Madelyn Rosenthal, pulmonologist. She suggests that it is never too early to refer a patient to PR. Patients in earlier stages of lung disease might even benefit more than those in late stages of the disease, she said.

An assistant professor of pulmonary medicine and co-director of the department of pulmonary rehabilitation at The Ohio State University, Rosenthal said, “Whenever a physician is unsure about it, contacting a facility that has PR and asking their opinion would be beneficial to the patient,” she said.

Treating the whole patient with PR

A good PR program should be comprehensive, said Rosenthal. “It should not just be limited to exercise training, but also focus on education regarding the different disease states the patients have.”

PR should also offer some sort of mindfulness or cognitive behavioral training programs to assist with mental health concerns which are common among patients with COPD, she said. It may also offer training in topics such as nutrition in addition to teaching patients to notice and address symptoms of their disease earlier.

Many COPD patients tend to become malnourished. Part of the reasons for this may have to do with smaller abdominal cavities due to hyperinflated lungs. Or, she said, “because they are extremely fatigued and it just requires too much energy to eat.”

Some PR programs offer nutritional supplementation until patients show improved nutrition on their own, which has been shown to improve respiratory function.

Education can also help educate patients to notice when they are having any flares of their disease, so they can recognize those symptoms early on and take care earlier, Rosenthal explained.

PR typically lasts 8 to 12 weeks, and is often done in a group setting, which also encourages social interaction and may reduce feelings of isolation.

COPD can trigger anxiety, depression and other mental health concerns, Rosenthal said. “The majority of patients with some sort of end stage lung disease tend to develop a lot of anxiety or fear around leaving the house. It tends to make them fearful about living their everyday life and keeps them in the house.”

Being in a PR group together, whether in-person or remote, can alleviate some of the anxiety that patients feel. “They share stories and resources,” Penupolu said. “They are [in a program] with people that are like them. Sometimes they strike up relationships with people in the program.”

Additionally, for any patients who are still smoking, tobacco and smoking cessation education is an essential component of the program, Rosenthal said.

Remote PR

As successful as PR programs are shown to be, with nearly all those who participate experiencing some benefit, PR is not offered in every medical setting, and achieving PR can be difficult due to patient frailty, transportation issues, and other health care access problems.

Telehealth could make these programs more widely available, and “research has shown that tele-PR is as good as regular PR,” Penupolu said. COVID-19 has made getting remote PR programs off the ground more necessary, he said.

“By definition remote PR programs would need some amount of orientation and exercise supervision at least at initiation of the process,” Penupolu said. “With absolute limitation in any movement right now, starting remote PR has been a little challenging. We are trying to figure out ways around this.”

However, the need to solve these problems may accelerate the availability and adoption of remote PR programs in the long-run.

Fortunately there are new efforts to offer PR remotely, including a bill introduced into U.S. Congress, known as the BREATHE Act, which would allow respiratory therapists to bill for telemedicine related chronic care management services, under which PR would fall.

“There are some programs that are trying to push for it,” Penupolu said.

Due to the COVID-19 pandemic, these programs may become more readily available as the Centers for Medicare and Medicaid Services (CMS) have eased some restrictions around telemedicine, making it possible for physicians to be reimbursed for more telemedicine functions, he said.

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