Chris Garvey

Pulmonary Rehabilitation in Interstitial Lung Disease: Benefits and Predictors of Response

BACKGROUND Data examining the role of pulmonary rehabilitation (PR) in interstitial lung disease (ILD) are limited. We tested the hypothesis that PR can improve functional status and dyspnea in a large group of patients with ILD, and that certain baseline patient variables can predict this improvement. METHODS Data from patients who were referred to PR with a diagnosis of ILD were included. Baseline and post-PR variables were recorded, and changes in 6-min walk test (6MWT) distance and dyspnea were evaluated. The impact of baseline variables on change in 6MWT distance and dyspnea were analyzed. RESULTS A statistically significant difference was seen in both the change in Borg score and 6MWT distance after PR (p < 0.0001). These changes were consistent with previously established clinically significant differences. Baseline 6MWT distance was a significant predictor of change in 6MWT distance (p < 0.0001), with increasing baseline 6MWT distance predicting a smaller improvement after PR. CONCLUSIONS These results suggest that PR should be considered as a standard of care for patients with ILD.

An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation

RATIONALE Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients. OBJECTIVES The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide. METHODS Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS. MAIN RESULTS This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR. CONCLUSIONS The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.

Differences in content and organisational aspects of pulmonary rehabilitation programmes

The aim was to study the overall content and organisational aspects of pulmonary rehabilitation programmes from a global perspective in order to get an initial appraisal on the degree of heterogeneity worldwide. A 12-question survey on content and organisational aspects was completed by representatives of pulmonary rehabilitation programmes that had previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Rehabilitation and Chronic Care and/or Physiotherapists Scientific Groups, all members of the American Association of Cardiovascular and Pulmonary Rehabilitation, and all American Thoracic Society Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings. The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programmes across continents for all aspects that were surveyed, including the setting, the case mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral and types of reimbursement. The current findings stress the importance of future development of processes and performance metrics to monitor pulmonary rehabilitation programmes, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice. Differences in aspects of pulmonary rehabilitation programmes suggest caution in generalisation of research findings http://ow.ly/qOJhl

Pulmonary rehabilitation: WHAT WE KNOW AND WHAT WE NEED TO KNOW.

The multidisciplinary treatment of pulmonary rehabilitation (PR), which includes exercise training, self-management education, and psychosocial and nutritional intervention, is now a standard of care for chronic obstructive pulmonary disease (COPD) and has been incorporated into major guidelines. We must now focus efforts on improving its impact and widening its applicability. 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, involving 20 experts from North America and Europe, which was convened in Fort Lauderdale, Florida, in early 2008. It is not meant to be an exhaustive review; rather, this report summarizes the roundtable proceedings, while providing direction to best position PR into the continuum of COPD care. By consensus, it was agreed upon that although PR is effective for other chronic respiratory diseases, the discussion focus was COPD since most of the evidence base and patient referral are for this disease. These proceedings provide insight into 3 broad areas appropriate for investigation or implementation: positioning PR in an integrated care model for COPD patients; improving the effectiveness of this intervention; and expanding the recognition, application, and accessibility to PR. It is the hope that this document will provide a catalyst for clinicians, investigators, and healthcare policy makers to help realize these goals as well as serve to suggest important areas for future research and development in PR.

Pulmonary rehabilitation exercise prescription in chronic obstructive lung disease: US survey and review of guidelines and clinical practices.

Chronic obstructive pulmonary disease is a common, progressive disorder associated with disabling symptoms, skeletal muscle dysfunction, and substantial morbidity and mortality. Current national guidelines recommend pulmonary rehabilitation (PR) to improve dyspnea, functional capacity, and quality of life. Many PR exercise programs are based on guidelines from the American College of Sports Medicine. Recommendations have also been published by the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Thoracic Society. Translating exercise science into effective training and clinical care requires interpretation and the use of diverse national PR guidelines and recommendations. Pulmonary rehabilitation clinicians often vary in their education and background, with most nurses and respiratory care practitioners lacking formal training in exercise physiology. Patients often have comorbidities that may further complicate exercise provision and prescription. This article describes the results of an informal, nonscientific survey of the American Association of Cardiovascular and Pulmonary Rehabilitation members exploring current PR exercise prescription practices as a basis for discussion and reviews current national exercise recommendations for chronic obstructive pulmonary disease. Further, it describes areas of uncertainty regarding exercise prescription in PR and suggests strategies for providing effective exercise training, given the diversity of guidelines, clinician preparedness, and patient complexity.

Pulmonary Rehabilitation Exercise Prescription in Chronic Obstructive Pulmonary Disease: Review of Selected Guidelines AN OFFICIAL STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION

Chronic obstructive pulmonary disease (COPD) is associated with disabling dyspnea, skeletal muscle dysfunction, and significant morbidity and mortality. Current guidelines recommend pulmonary rehabilitation (PR) to improve dyspnea, functional capacity, and quality of life. Translating exercise science into safe and effective exercise training requires interpretation and use of multiple guidelines and recommendations. The purpose of this statement is to summarize for clinicians 3 current chronic obstructive pulmonary disease guidelines for exercise that may be used to develop exercise prescriptions in the PR setting. The 3 guidelines have been published by the American College of Sports Medicine, the American Thoracic Society/European Respiratory Society, and the American Association of Cardiovascular and Pulmonary Rehabilitation. In addition to summarizing these 3 guidelines, this statement describes clinical applications, explores areas of uncertainty, and suggests strategies for providing effective exercise training, given the diversity of guidelines and patient complexity.

Learn from the past and create the future: the 2013 ATS/ERS statement on pulmonary rehabilitation

Pulmonary rehabilitation is an established intervention for the management of chronic obstructive pulmonary disease (COPD); indeed, the delivery of rehabilitation has become routine care for individuals with moderate to severe disease [1]. To guide the delivery of pulmonary rehabilitation, practitioners have looked to the European Respiratory Society (ERS) and the American Thoracic Society (ATS) to offer support in terms of describing the evidence for the intervention and to guide best practice [2]. The new ATS/ERS statement on pulmonary rehabilitation aims to harness international scientific expertise and clinical experience to achieve this challenge [3]. Why a new statement? The 2006 statement provided an excellent reference point for pulmonary rehabilitation [2], but over the past few years there have been several significant developments in the field to warrant a reconsideration of the current position. There is also an obligation to the endorsing societies to ensure that these documents are current and reflect best practice. In June 2010, the process of developing a new statement began. There have been significant developments in our understanding of COPD and the systemic manifestations of the disease, the importance of the intervention in other chronic respiratory disease and the timing of the intervention. The document is complemented by the evidence-based guidelines from the American College of Chest Physicians and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) [4], which formally graded the quality of the scientific evidence, and the AACVPR guidelines for pulmonary rehabilitation programs, which give practical recommendations [5]. By the very nature of a statement, recommendations cannot be made in the 2013 ATS/ERS statement on pulmonary rehabilitation, as these are the preserve of guidelines. The current ATS/ERS task force was represented by a broad range of professions that are reflected in the interdisciplinary …

Interstitial Lung Disease and Pulmonary Rehabilitation

Interstitial lung disease (ILD) is a heterogeneous group of lung disorders associated with exertional dyspnea, hypoxemia, which is often worse with activity, and deconditioning. The majority of evidence supporting the effectiveness of pulmonary rehabilitation (PR) comes from studies of persons with obstructive disorders such as chronic obstructive pulmonary disease. However, growing evidence supports the use of PR as an effective and safe intervention for persons with ILD. Despite the lack of clinical guidelines for PR in ILD, several recent studies have shown effectiveness of PR in improvement of dyspnea and function in patients with ILD. This article reviews the current evidence for PR in ILD and suggests an approach to management.

Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals POSITION STATEMENT OF THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognizes that interdisciplinary health care professionals providing pulmonary rehabilitation services need to have certain core competencies. This statement updates the previous clinical competency guidelines for pulmonary rehabilitation professionals, and it complements the AACVPRs Guidelines for Pulmonary Rehabilitation Programs. These competencies provide a common core of 13 professional and clinical competencies inclusive of multiple academic and clinical disciplines. The core competencies include patient assessment and management; dyspnea assessment and management; oxygen assessment, management, and titration; collaborative self-management; adherence; medication and therapeutics; non-chronic obstructive pulmonary diseases; exercise testing; exercise training; psychosocial management; tobacco cessation; emergency responses for patient and program personnel; and universal standard precautions.

Patient Perceptions of the Adequacy of Supplemental Oxygen Therapy. Results of the American Thoracic Society Nursing Assembly Oxygen Working Group Survey

Rationale: Pulmonary clinicians and patients anecdotally report barriers to home supplemental oxygen services including inadequate supply, unacceptable portable options, and equipment malfunction. Limited evidence exists to describe or quantify these problems. Objectives: To describe the frequency and type of problems experienced by supplemental oxygen users in the United States. Methods: The Patient Supplemental Oxygen Survey, a self‐report questionnaire, was posted on the American Thoracic Society Public Advisory Roundtable and patient and health care‐affiliated websites. Respondents were invited to complete the questionnaire, using targeted e‐mail notifications. Data were analyzed using descriptive statistics, paired t tests, and χ2 analysis. Results: In total, 1,926 responses were analyzed. Most respondents reported using oxygen 24 h/d, for 1‐5 years, and 31% used high flow with exertion. Oxygen use varied, with only 29% adjusting flow rates based on oximeter readings. The majority (65%) reported not having their oxygen saturation checked when equipment was delivered. Sources of instruction included the delivery person (64%), clinician (8%), and no instruction (10%). Approximately one‐third reported feeling “very” or “somewhat” unprepared to operate their equipment. Fifty‐one percent of the patients reported oxygen problems, with the most frequent being equipment malfunction, lack of physically manageable portable systems, and lack of portable systems with high flow rates. Most respondents identified multiple problems (average, 3.6 ± 2.3; range, 1‐12) in addition to limitations in activities outside the home because of inadequate portable oxygen systems (44%). Patients living in Competitive Bidding Program areas reported oxygen problems more often than those who did not (55% [389] vs. 45% [318]; P = 0.025). Differences in sample characteristics and oxygen problems were noted across diagnostic categories, with younger, dyspneic, high‐flow users, and respondents who did not receive oxygen education, relating more oxygen problems. Respondents reporting oxygen problems also experienced increased health care resource utilization. Conclusions: Supplemental oxygen users experience frequent and varied problems, particularly a lack of access to effective instruction and adequate portable systems. Initiatives by professional and patient organizations are needed to improve patient education, and to promote access to equipment and services tailored to each patients needs.