The Effect of Comprehensive Outpatient Pulmonary Rehabilitation on Dyspnea

doi:10.1378/chest.105.4.1046

Chest

Volume 105, Issue 4, April 1994, Pages 1046-1052

https://doi.org/10.1378/chest.105.4.1046 Get rights and content

To evaluate the effect of outpatient pulmonary rehabilitation (OPR) on dyspnea, we measured this symptom using a visual analogue scale during graded treadmill exercise testing and with baseline and transitional dyspnea indices (TDI). The latter measure overall dyspnea in three spheres: functional impairment, magnitude of task, and magnitude of effort. Twenty patients with COPD referred for OPR were randomly assigned to either a treatment group (T, n=10), with dyspnea evaluated at baseline then shortly following a 6-week OPR program, or a control group (C, n=10), with dyspnea evaluated at baseline then following a 6-week waiting period. No significant change in maximal exercise performance from baseline to repeated testing was observed in either group. Dyspnea at maximum treadmill workload (Dmax), which did not significantly change in C, decreased from 74.4 ± 18.9 percent at baseline to 50.5 ± 23.2 percent post-OPR in T (p=0.006). The Dmax related to minute ventilation (Dmax/VEmax) and oxygen consumption (Dmax/Vo₂max) also significantly decreased following OPR. The reduction in exertional dyspnea was apparent by the second minute of exercise. Additionally, TDI focal scores were significantly higher in T than C (2.3 ± 1.06 vs 0.2 ± 1.75 units, p=0.006), indicating decreased overall dyspnea following OPR. These results point to significant improvements in both exertional and clinically assessed dyspnea following OPR.

Section snippets

Patients

Patients referred to our OPR program were considered for the study. Inclusion criteria included the following: (1) a clinical diagnosis of moderately severe to severe COPD; (2) a significant exertional dyspnea despite conventional medical therapy; (3) an FEV₁ equal to or less than 1.4 L; and (4) the absence of significant, associated medical problems that might interfere with the patient's ability to undergo OPR. Because our oxygen analyzer for treadmill exercise testing was not accurate at

Patients

Age, sex, FEV₁, 12-min walking distance, and BDI focal scores of the 20 study patients are given in Table 1. As indicated, all had moderately severe to severe airways obstruction. Although baseline FEV₁ tended to be somewhat lower in C than T patients (0.79 ± 0.18 L vs 0.94 ± 0.32 L), this difference was not statistically significant. Both groups were similar with respect to exercise endurance, as measured by the 12-min walk distance, and overall dyspnea, as measured by the BDI focal score.

Baseline Exercise Testing—Pre-exercise and Maximal Workload Values

DISCUSSION

The purpose of this investigation was to evaluate the effect of OPR on dyspnea in advanced COPD. One group of patients was studied before and after OPR while a control group was studied before and after a waiting period. Exertional dyspnea during graded treadmill exercise testing was measured with a visual analogue scale, while overall impairment from dyspnea was measured with the baseline and transitional dyspnea indices. A decrease in dyspnea at maximal workload was observed only in the group

ACKNOWLEDGMENT

The writers thank Bartolome Celli, M.D., Chief, Pulmonary Section, Boston VA Medical Center, for valuable assistance during the planning of this study.

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Cited by (176)

Effect of pulmonary rehabilitation programs including lower limb endurance training on dyspnea in stable COPD: A systematic review and meta-analysis
2020, Respiratory Investigation
Citation Excerpt :
Three studies compared land-based training with water-based training [21–23], and one study used Tai Chi as a warm-up exercise [24]. Inspiratory muscle training was used in conjunction with exercise training in three studies [25–27]. A total of 29 studies had an unclear risk in the random sequence generation (Fig. 2A).
Pulmonary rehabilitation (PR) is recommended as an effective treatment for patients with chronic obstructive pulmonary disease (COPD). Previous meta-analyses showed that PR improves exercise capacity and health-related quality of life (HRQOL). However, they did not evaluate the effect of PR on the sensation of dyspnea.
We searched six databases in May 2019 for randomized controlled trials (RCTs) that examined PR, including supervised lower limb endurance training as a minimal essential component that was continued for 4–12 weeks, in patients with stable COPD, with changes from baseline dyspnea as a primary outcome. Secondary outcomes were changes in exercise capacity, HRQOL, activity of daily life (ADL), physical activity (PA), and adverse events. We calculated the pooled weighted mean difference (MD) using a random effects model. We identified 42 studies with 2150 participants. Compared with the control, PR improved dyspnea, as shown using the British Medical Research Council (MRC) questionnaire (MD, −0.64; 95% CI, −0.99 to −0.30; p = 0.0003), transitional dyspnea index (MD, 1.95; 95% CI, 1.09 to 2.81; p = 0.0001), modified Borg score during exercise (MD, −0.62; 95% CI, −1.10 to −0.14; p = 0.01), and Chronic Respiratory Questionnaire (CRQ) dyspnea score (MD, 0.91; 95% CI, 0.39 to 1.44; p = 0.0007). PR significantly increased exercise capacity measured by the 6 min walking distance time, peak workload, and peak VO₂. It improved HRQOL measured by the St. George's Respiratory Questionnaire and CRQ, but not on PA or ADL. These results indicated that PR programs including lower limb endurance training improve dyspnea, HRQOL, and exercise capacity in patients with stable COPD.
Change in V˙O<inf>2peak</inf> in Response to Aerobic Exercise Training and the Relationship With Exercise Prescription in People With COPD: A Systematic Review and Meta-analysis
2020, Chest
Citation Excerpt :
Multiple sensitivity analyses were performed (e-Appendix 1). Details of the training programs are shown in Table 210-12,21-30, (RCTs), e-Table 6 (non-RCTs/crossover studies), and e-Table 7 (uncontrolled studies) with a summary in e-Appendix 2. In RCTs, risk of bias was generally low except for blinding of participants and personnel which was high (e-Fig 3, e-Table 11).
Despite the wide-ranging benefits of pulmonary rehabilitation, conflicting results remain regarding whether people with COPD can improve their peak oxygen uptake ( $\dot{V}$ O_2peak) with aerobic training.
The goal of this study was to investigate the effect of aerobic training and exercise prescription on $\dot{V}$ O_2peak in COPD.
A systematic review was performed by using MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases for all studies measuring $\dot{V}$ O_2peak prior to and following supervised lower-limb aerobic training in COPD. A random effects meta-analysis limited to randomized controlled trials comparing aerobic training vs usual care was conducted. Other study designs were included in a secondary meta-analysis and meta-regression to investigate the influence of program and patient factors on outcome.
A total of 112 studies were included (participants, N = 3,484): 21 controlled trials (n = 489), of which 13 were randomized (n = 288) and 91 were uncontrolled (n = 2,995) studies. Meta-analysis found a moderate positive change in $\dot{V}$ O_2peak (standardized mean difference, 0.52; 95% CI, 0.34-0.69) with the intervention. The change in $\dot{V}$ O_2peak was positively associated with target duration of exercise session (P = .01) and, when studies > 1 year duration were excluded, greater total volume of exercise training (P = .01). Similarly, the change in $\dot{V}$ O_2peak was greater for programs > 12 weeks compared with those 6 to 12 weeks when adjusted for age and sex. However, reported prescribed exercise intensity (P = .77), training modality (P > .35), and mode (P = .29) did not affect $\dot{V}$ O_2peak. Cohorts with more severe airflow obstruction exhibited smaller improvements in $\dot{V}$ O_2peak (P < .001).
Overall, people with COPD achieved moderate improvements in $\dot{V}$ O_2peak through supervised aerobic training. There is sufficient evidence to show that programs with greater total exercise volume, including duration of exercise session and program duration, are more effective. Reduced effects in severe disease suggest alternative aerobic training methods may be needed in this population.
PROSPERO; No.: CRD42018099300; URL: https://www.crd.york.ac.uk/prospero/
Is the six-minute walk test a useful tool to prescribe high-intensity exercise in patients with chronic obstructive pulmonary disease?
2016, Heart and Lung: Journal of Acute and Critical Care
Citation Excerpt :
The larger increase in ET intensity in favor of the GNAweek1 is in accordance with findings in previous literature,40,41 demonstrating larger improvements in patients with worse exercise tolerance at the beginning of ET programs. In addition, at the last week of the ET program, there was no increase in dyspnea and sensation of fatigue, despite the higher intensities achieved by the patients (Table 5), reflecting an increase in exercise efficiency.42 There was a high drop-out rate in this study, and the reasons are described in the Results section.
It is not yet completely known whether the 6MWT can be used to prescribe high-intensity exercise for patients with COPD.
To evaluate the ability of the six-minute walk test (6MWT) to prescribe high-intensity exercise for patients with chronic obstructive pulmonary disease (COPD).
Lung function, maximal inspiratory strength, symptoms and exercise capacity were evaluated in patients with COPD (n = 27) before and after a 12-week high-intensity exercise program. Criteria for high-intensity training were: 1) ≥75% of the 6MWT average speed; 2) American Thoracic Society/European Respiratory Society (ATS/ERS) criteria (≥60% of the maximal incremental shuttle walk test speed).
The 6MWT showed good positive and negative predictive values (0.69 and 0.71, respectively), and accuracy (0.70), good reliability (ICC 0.70 [95%CI 0.45–0.85]) and moderate agreement (k 0.41 [95%CI 0.13–0.67]) with the ATS/ERS criteria.
The 6MWT has good predictive ability and accuracy in relation to high-intensity exercise for patients with COPD.
Distractive auditory stimuli in the form of music in individuals with COPD: A systematic review
2015, Chest
Music has been used as a distractive auditory stimulus (DAS) in patients with COPD, but its effects are unclear. This systematic review aimed to establish the effect of DAS on exercise capacity, symptoms, and health-related quality of life (HRQOL) under three conditions: (1) during exercise training, (2) during exercise testing, and (3) for symptom management at rest.
Randomized controlled or crossover trials as well as cohort studies of DAS during exercise training, during formal exercise testing, and for symptom management among individuals with COPD were identified from a search of seven databases. Two reviewers independently assessed study quality. Weighted mean differences (WMDs) with 95% CIs were calculated using a random-effects model.
Thirteen studies (12 of which were randomized controlled or crossover trials) in 415 participants were included. DAS increased exercise capacity when applied over at least 2 months of exercise training (WMD, 98 m; 95% CI, 47-150 m). HRQOL improved only after a training duration of 3 months. Less dyspnea was noted with DAS during exercise training, but this was not consistently observed in short-term exercise testing or as a symptom management strategy at rest.
DAS appears to reduce symptoms of dyspnea and fatigue when used during exercise training, with benefits observed in exercise capacity and HRQOL. When applied during exercise testing, the effects on exercise capacity and symptoms and as a strategy for symptom management at rest are inconsistent.
Pulmonary Rehabilitation
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
Pulmonary rehabilitation for patients with chronic airways obstruction
2015, Journal of Allergy and Clinical Immunology: In Practice
Pulmonary rehabilitation is a patient-centered and interdisciplinary intervention with major components of exercise training and self-management education. Although having no direct effect on lung function, this intervention often results in substantial improvements in respiratory symptoms, functional status, and health status. It probably also reduces subsequent health care utilization, especially when provided after a hospitalization for an exacerbation of airways disease. The beneficial effects of pulmonary rehabilitation reflect its ability to reduce the impact of systemic consequences of chronic respiratory disease and to improve patients' self-efficacy through promoting collaborative self-management. Pulmonary rehabilitation is indicated for patients with respiratory diseases (regardless of specific diagnosis) who have persistent symptoms or functional or health status limitation despite otherwise optimal medical therapy. Those patients with severe asthma (particularly those with airways remodeling) or asthma-chronic obstructive pulmonary disease overlap who have daily symptoms and substantial functional/health status limitation despite controller and bronchodilator therapy would be appropriate candidates for pulmonary rehabilitation.

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: Manuscript received March 26, 1993; revision accepted August 31

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Chest

The Effect of Comprehensive Outpatient Pulmonary Rehabilitation on Dyspnea

Section snippets

Patients

Patients

Baseline Exercise Testing—Pre-exercise and Maximal Workload Values

DISCUSSION

ACKNOWLEDGMENT

Chest

Chest

Chest

Chest

Clin Chest Med

Chest

Chest

Randomised controlled trial of rehabilitation in chronic respiratory disability?

Thorax

Multidiscipline treatment of chronic pulmonary insufficiency: I. Psychologic aspects of rehabilitation?

Psychosom Med

Psychophysical basis of perceived exertion?

Med Sci Sports Exerc

Clinical exercise testing