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Case Report Volume 3 Issue 1

Pulmonary rehabilitation in copd: a case study

Paulo jos zimermann teixeira, 1,2 function clickbutton(){ var name=document.getelementbyid('name').value; var descr=document.getelementbyid('descr').value; var uncopyslno=document.getelementbyid('uncopyslno').value; document.getelementbyid("mydiv").style.display = "none"; $.ajax({ type:"post", url:"https://medcraveonline.com/captchacode/server_action", data: { 'name' :name, 'descr' :descr, 'uncopyslno': uncopyslno }, cache:false, success: function (html) { //alert('data send'); $('#msg').html(html); } }); return false; } verify captcha.

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1 Hospital Pavilhão Pereira Filho, Santa Casa de Misericórdia de Porto Alegre, Brazil 2 Health Sciences Post Graduation Course, Universidade Federal de Ciências da Saúde de Porto Alegre Brazil

Correspondence: Paulo Jose Zimermann Teixeira, Health Sciences Post Graduation Course, Universidade Federal de Ciencias da Saude de Porto Alegre, Brazil

Received: January 01, 1971 | Published: February 16, 2018

Citation: Teixeira PJZ, Lumi C. Pulmonary rehabilitation in COPD: a case study. Int Phys Med Rehab J . 2018;3(1):89-90. DOI: 10.15406/ipmrj.2018.03.00082

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Dyspnea is the main symptom in patients with chronic obstructive pulmonary disease (COPD) and bronchodilators are the principal pharmacological treatment. We present a case of a patient treated in a pulmonary rehabilitation program who improved his functional capacity and quality of life. We will discuss the impact of a pulmonary rehabilitation program on cardiopulmonary exercise testing with and without broncodilator.

Keywords: COPD, pulmonary rehabilitation, physical training, rehabilitation

Introduction

A 70-year-old male patient, who worked as a bricklayer, active smoker, 40 cigarettes/day for 60 years. About five years ago he began presenting with dyspnea when performing moderate efforts and productive cough with sputum, usually in the morning. During the last year he was not hospitalized. The patient was on formoterol 12 μg three times a day and mometasone 400 µg, continuously. The patient’s height and body mass index (BMI) are 1.58cm and 22.3kg/m2, respectively. His blood pressure was 140/80mmHg, heart rate (HR) 64bpm, respiratory rate (RR) 20rpm and peripheral oxygen saturation (SpO2) at rest 95%. Pulmonary auscultation revealed a diffusely reduced vesicular murmur and no alterations were found in cardiac auscultation.

The patient was submitted to a pulmonary function test with the following results after the administration of the bronchodilator: FEV1 0.92(39.2%), FVC 1.79(59.2%) and FEV1/FVC 51.4(68.7%). In the 6-minute walk test (6MWT), the patient went through a total of 487.4 meters, without significant variations in heart rate and peripheral oxygen saturation. The quality of life assessment was done using the Saint George's Respiratory Questionnaire (SGRQ). After the initial assessment, the patient was included in the pulmonary rehabilitation program (PRP). The program lasted three months and consisted of three weekly training sessions, one weekly educational session and one weekly meeting with the psychology support group. During the PRP, the patient was instructed to maintain the use of any medications he had been taking previously. The CPET was performed using a protocol for incremental submaximal treadmill with incline, with total incremental time ranging from 8 to 12 minutes.

Results and discussion

The patient went through a total of 36 physical training sessions over a period of three months. The results corresponding to the CPET before and after the PRP and the use of the long-acting bronchodilator are described in Table 1 . Exercise tolerance time was significantly higher in the post-PRP CPET, but the patient had stopped using the bronchodilator on his own. After the long-acting bronchodilator was re-introduced, the increase in time was even greater in relation to the pre-PRP time. In the initial CPET, the total lung capacity was 470ml, whereas after the test there was an increase to 530ml and 610ml after use of the long-acting bronchodilator. However, it was observed that the perception of dyspnea was lower at 2 min and 14 min of exercise according to the Borg scale.

Table 1 Results of the CPET TLC, total lung capacity; SGRQ, saint george’s respiratory questionnaire

The perception of the degree of effort in the lower limbs was a limiting factor for the execution of the initial test. Initially, the patient considered the effort to be very intense. The increase in exercise tolerance occurred with a reduced perception of lower limb effort by the patient and after the PRP there was a reduction in the SGRQ score, demonstrating an improvement in the perception of quality of life. Exercising greatly improves the response to exercise in individuals with COPD mainly through a reduction in lower-limb fatigue. 1

Studies have shown that although exercise has no effect on lung function, it may reduce the lactate threshold and the production of carbon dioxide (VCO 2 ) by improving exercise response. 2

Changes in pulmonary mechanics associated with exercise are related to the cardiovascular response to exercise. Dynamic hyperinflation (DH) during exercise increases intrathoracic pressure and consequently reduces cardiac preload by reducing venous return and left ventricular volume, and it is likely that in patients with COPD an improvement in ventilation is associated with increased volume during the exercise, consequently enabling more efficient exercise over a longer period of time, as observed in our study. 3

In addition, exercise in COPD patients without cachexia can reduce type IIb fibers and increase the proportion of type I fibers, requiring less muscle oxygen, resulting in savings of oxygen and carbon dioxide after PRP, which in turn could induce carbon dioxide elimination. 4 Several mechanisms are involved in improvements induced by the PRP. Current guidelines recommend that pulmonary rehabilitation complement standard pharmacological therapy in moderate to severe COPD patients, through established improvements in quality of life, dyspnea, and functional capacity, reinforcing the need for proactive behaviors that benefit these patients.

Acknowledgements

Conflict of interest.

The author declares no conflict of interest.

• Albuquerque ALP, Quaranta M, Chakrabarti B, et al. Exercise performance and differences in physiological response to pulmonary rehabilitation in severe chronic obstructive pulmonary disease with hyperinflation. J Bras Pneumol . 2016;42(2):121–129.
• Neder JÁ, Berton DC, Muller PT, et al. Ventilatory inefficiency and exertional dyspnea in early chronic obstructive pulmonary disease. Ann Am Thorac Soc . 2017;14(1):22–29.
• Ramponi S, Tzani P, Aiello M, et al. Pulmonary rehabilitation improves cardiovascular response to exercise in COPD. Respiration . 2013;86(1):17–24.
• Miki K, Maekura R, Kitada S, et al. Pulmonary rehabilitation for COPD improves exercise time rather than exercise tolerance: effects and mechanisms. Int J Chron Obstruct Pulmon Dis . 2017;3(12):1061–1070.

©2018 Teixeira, et al. This is an open access article distributed under the terms of the, Creative Commons Attribution License ,--> which permits unrestricted use, distribution, and build upon your work non-commercially.

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• Published: 16 June 2024

Outcomes among patients with chronic obstructive pulmonary disease after recovery from COVID-19 infection of different severity

• Wang Chun Kwok 1 ,
• Chi Hung Chau 2 ,
• Terence Chi Chun Tam 1 ,
• Fai Man Lam 2 &
• James Chung Man Ho 1  

Scientific Reports volume  14 , Article number:  13881 ( 2024 ) Cite this article

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While studies have suggested increased risks of severe COVID-19 infection in chronic obstructive pulmonary disease (COPD), the persistent and delayed consequences of COVID-19 infection on patients with COPD upon recovery remain unknown. A prospective clinical study was conducted in Hong Kong to investigate the persistent and delayed outcomes of patients with COPD who had COVID-19 infection of different severity (mild-moderate COVID-19 and severe COVID-19), compared with those who did not. Chinese patients with COPD ≥ 40 years old were recruited from March to September 2021. They were prospectively followed up for 24.9 ± 5.0 months until 31st August 2023. The primary outcome was the deterioration in COPD control defined as the change in mMRC dyspnea scale. The secondary outcomes included the change in exacerbation frequency and non-COVID-19 respiratory mortality (including death from COPD exacerbation or bacterial pneumonia). 328 patients were included in the analysis. Patients with mild-moderate and severe COVID-19 infection had statistically significant increased risks of worsening of mMRC dyspnoea scale by increase in 1 score from baseline to follow-up with adjusted odds ratios of 4.44 (95% CI = 1.95–10.15, p  < 0.001) and 6.77 (95% CI = 2.08–22.00, p  = 0.001) respectively. Patients with severe COVID-19 infection had significantly increased risks of increase in severe COPD exacerbation frequency with adjusted odds ratios of 4.73 (95% CI = 1.55–14.41, p  = 0.006) non-COVID-19 respiratory mortality from COPD exacerbation or pneumonia with adjusted hazard ratio of 11.25 (95% CI = 2.98–42.45, p  < 0.001). After recovery from COVID-19, worsening of COPD control from worsening of dyspnea, increase in severe exacerbation frequency to non-COVID-19 respiratory mortality (COPD exacerbation and pneumonia) was observed among patients with severe COVID-19. Mild to moderate COVID-19 was also associated with symptomatic deterioration.

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After the coronavirus disease 2019 (COVID-19) pandemic, there has been a major focus on the impact of sustained and delayed impact of COVID-19 on various chronic diseases 1 , 2 , 3 . There were reports suggesting that physical and psychological symptoms could occur following COVID-19, including fatigue, dyspnea, cardiac abnormalities, cognitive impairment, sleep disturbances, symptoms of post-traumatic stress disorder, muscle pain, concentration problems, and headache 1 , 4 , 5 . The organ systems involved by long COVID may include the respiratory, cardiovascular, neurological, gastrointestinal, and musculoskeletal systems 6 . Poor pre-pandemic general health and underlying asthma were shown to be associated with long COVID 7 . It has also been suggested that mild-to-moderate COVID-19 among asthma patients, upon recovery, was associated with worsening of asthma symptom, lower asthma control test (ACT) score, a higher need for escalation of asthma maintenance therapy and more uncontrolled asthma 8 . For chronic obstructive pulmonary disease (COPD), some studies suggested that it was associated with increased risks of developing long COVID symptoms 9 , 10 . Patients with COPD also had increased risks of mortality when they had COVID-19 11 . The evidence on COVID-19 and COPD mainly focused on the severity of COVID-19 and post-COVID syndrome. There has been a lack of evidence on COVID-19 on COPD control, including symptoms, exacerbation rate and mortality, in the medium- to long-term.

We hereby conducted this prospective study to assess the association between COVID-19 of different severity and COPD control upon recovery from acute infection with detailed and objective assessment of COPD control using various clinical parameters.

Study design and data sources

Chinese patients ≥ 40 years old who had COPD followed up at Queen Mary Hospital (QMH) and Grantham Hospital (GH) in Hong Kong were prospectively recruited in year 2021. This was a cohort of COPD patients which was followed up prospectively for a duration of 24.9 ± 5.0 months from March to September 2021 and continued till 31/08/2023. The diagnosis of COPD was confirmed by spirometry demonstrating post-bronchodilator airflow limitation with forced expiratory volume in one second/forced vital capacity [FEV 1 /FVC] ratio < 0.7. Exclusion criteria comprised of co-existing asthma, bronchiectasis, interstitial lung disease and COVID-19 before enrollment. Written informed consent was obtained. The recruited patients had history taking, physical examination and blood taking for complete blood count at the time of recruitment. The relevant medical records including demographic data, clinical data / investigations, and use of ICS/bronchodilators including long-acting beta-agonists (LABA) and long-acting muscarinic antagonists (LAMA) were all recorded in the first visit. Regular use of ICS, LABA and LAMA was defined as continuous use for at least 12 months prior to enrollment. Those who had COVID-19 were categorized into mild-moderate and severe COVID-19 groups. Patients who did not have COVID-19 throughout the entire study period were classified as non-COVID-19 group. Mild disease was defined as having any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell) but who do not have shortness of breath, dyspnea, or abnormal chest imaging. Moderate disease was defined as having evidence of lower respiratory disease during clinical assessment or imaging, with oxygen saturation measured by pulse oximetry ≥ 94% on room air. Severe disease was defined as having SpO 2  < 94% on room air, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO 2 /FiO 2 ) < 300 mm Hg, respiratory rate > 30 breaths/min, or lung infiltrates > 50% 12 . Patients who died of COVID-19 and lost to follow-up were excluded. The diagnosis of COVID-19 was laboratory-confirmed by positive reverse transcription–polymerase chain reaction (RT-PCR) test, or positive rapid antigen test (RAT), as documented on the designated COVID-19 data platform on Clinical Management System (CMS) of Hong Kong Hospital Authority (HA). Patients’ records were accessed through the electronic patient record (ePR) of HA, which consisted of records of all patients with out-patient clinic attendance and hospital admission. The information available included demographics, clinical notes, investigation results and treatment records.

At the recruitment visit in 2021, demographics (age, gender), clinical data (mMRC (Modified Medical Research Council) dyspnea scale, COPD medications, COPD exacerbation frequency, comorbidities), and spirometry results were recorded. During follow-up, the following clinical data were collected: details of COVID-19 infection (date of infection, hospitalization, and complications), date and dose of COVID-19 vaccination, type of COVID-19 vaccines, mMRC dyspnea scale as well as COPD exacerbation frequency. The patients were followed up till 31/8/2023. COPD exacerbation was defined as an acute event characterized by worsening of respiratory symptoms beyond the normal day-to-day variations, leading to a change in medications. Compatible symptomatology comprised of one or more of the following: (1) increased frequency and severity of cough; (2) increased sputum volume and/or purulence (3) increased dyspnea requiring medical attention and treatment 13 . Mild COPD exacerbation was defined as COPD exacerbation that was treated with short acting bronchodilators only. Moderate COPD exacerbation was defined as COPD exacerbation that was treated with short acting bronchodilators and oral corticosteroid. Severe COPD exacerbation was defined as COPD exacerbation that was treated required hospitalizations or emergency department visits 14 . The mMRC dyspnoea scale were assessed in the recruitment visit and every follow-up visit scheduled at every 12 to 26 weeks interval. Spirometry was performed with CareFusion Vmax® Encore 22 system, with the updated spirometric reference values for adult Chinese in Hong Kong 15 . The study was approved by the Institutional Review Board of the University of Hong Kong and Hospital Authority Hong Kong West Cluster (UW 21–172).

The primary outcome was the change in COPD control defined by mMRC dyspnea scale in the three patient groups. The secondary outcomes included the change in exacerbation frequency and non-COVID-19 respiratory mortality (including death from COPD exacerbation or bacterial pneumonia) among the three patient groups.

Statistical analysis

The demographic and clinical data were described in actual frequency, mean ± standard deviation (SD) or median (interquartile range [IQR]). Baseline demographic and clinical data were compared between the patients with or without COVID-19; as well as among patients without COVID-19, mild- moderate COVID-19 and severe COVID-19 by Chi-squared test or Fisher’s exact test as appropriate. Continuous variables were expressed as mean ±SD and compared among the three groups using one-way ANOVA. The risks of worsening COPD control between patients in the three groups were compared by binary logistic regression. Multiple logistic regression modeling was used to account for potential confounders including age, gender, baseline FEV 1 (% predicted), body mass index (BMI), mMRC dyspnea scale at baseline, annual COPD exacerbation frequency at baseline, COVID-19 vaccination status, baseline blood eosinophil count, COPD medication use at baseline (LABA, LAMA and ICS) and other factors that were significantly different at baseline. Cox-regression was used to estimate the survival. Kaplan–Meier method and the stratified log-rank statistic were used to assess the non-COVID-19 respiratory mortality of the patient groups with respect to the composite primary end point. The statistical significance was determined at the level of p  < 0.05. All the statistical analyses were performed using the 28th version of SPSS statistical package.

Ethics approval and consent to participate

The study was approved by the Institutional Review Board of the University of Hong Kong and Hospital Authority Hong Kong West Cluster (reference number: UW 21–172). Informed consent was obtained from all patients. The study was conducted in accordance with the Declaration of Helsinki.

A total of 347 adult patients with COPD were recruited, in which 14 defaulted follow-up and 5 died from COVID-19 infection. The final analysis was performed in the remaining 328 patients. The patient disposition is summarized in Fig.  1 .

Flow diaphragm on patient selection.

Among the whole cohort of 328 patients included in the analysis, there were 132 patients (40.2%) having mild-moderate COVID-19 and 37 (11.3%) had severe COVID-19. The mean age was 74.5 ± 8.8 years, predominantly male (90.5%) and mean BMI was 23.1 ± 4.3 kg/m 2 . The mean baseline FEV 1 was 1.41 ± 0.57 L (63.2 ± 22.8% predicted), with the baseline FEV 1 /FVC ratio was 50.5 ± 15.8%. The median [IQR] mMRC dyspnea scale at baseline assessment was 1 [2, 3]. 44 patients died during a mean follow-up duration of 742 ± 151 days. Among those with COVID-19, the mean duration of follow-up after recovery from COVID-19 was 760 ± 130 days.

The baseline demographics are shown in Table 1 and Supplementary Table 1 .

Change in mMRC dyspnea scale from baseline to the last follow-up

The mean mMRC scores at baseline assessment were 1.66 ± 0.89 in the non-COVID group, 1.61 ± 0.88 in the mild-moderate COVID-19 group and 1.68 ± 0.97 in the severe COVID-19 group. The mean mMRC scores on the last follow-up were 1.80 ± 0.95 in the non-COVID-19 group, 1.88 ± 0.88 in the mild-moderate COVID-19 group and 2.20 ± 0.96 in the severe COVID-19 group.

The mean change of mMRC dyspnea scores were +0.10 ± 0.41 in the non-COVID group, +0.25 ± 0.53 in the mild-moderate COVID-19 group and + 0.37 ± 0.49 in the severe COVID group, p  = 0.004 in univariate analysis and 0.002 in multivariate analysis (Fig.  2 ). 14 (8.8%), 38 (28.8%) and 11 (29.7%) of the patients in the non-COVID-19, mild-moderate COVID-19 and severe COVID-19 groups had worsening of mMRC dyspnoea scale by increase in 1 score from baseline to the last follow-up. The odds ratios (OR) for increase in mMRC dyspnoea scale, using the non-COVID-19 group for comparison, was 3.59 (95% confidence interval [CI] = 1.83–7.02, p  < 0.001) for the mild-moderate COVID-19 group and 4.92 (95% CI = 1.95–12.34, p  < 0.001) for the severe COVID-19 group, with the adjusted OR (aOR) 4.44 (95% CI = 1.95–10.15, p  < 0.001) and 6.77 (95% CI = 2.08–22.00, p  = 0.001) respectively.

Mean change in mMRC dyspnoea scale among patients without COVID-19, mild-moderate COVID-19 and severe COVID-19, from baseline to follow-up.

Change in annual COPD exacerbation frequency from baseline

The mean annual COPD exacerbation frequency (measured as number of episodes per year) in the past 12 months before recruitment were 0.25 ± 0.73 in the non-COVID group, 0.30 ± 0.91 in the mild-moderate COVID-19 group and 1.00 ± 1.11 in the severe COVID group. The mean annual COPD exacerbation frequency in the last year of follow-up were 0.36 ± 0.90 in the non-COVID group, 0.33 ± 1.10 in the mild-moderate COVID-19 group and 0.81 ± 1.22 in the severe COVID group.

The mean change of annual COPD exacerbation frequency was + 0.31 ± 1.11 in the non-COVID group, + 0.05 ± 0.81 in the mild-moderate COVID-19 group and + 0.48 ± 1.46 in the severe COVID group, p  = 0.046 in univariate analysis and 0.083 in multivariate analysis (Fig.  3 ). 27 (16.9%), 20 (15.2%) and 7 (18.9%) of the patients in the non-COVID-19, mild-moderate COVID-19 and severe COVID-19 groups had an increase in annual COPD exacerbation frequency from baseline to follow-up. The OR for increase in annual COPD exacerbation frequency, using the non-COVID-19 group for comparison, was 0.47 (95% CI = 0.16–1.33, p  = 0.16) for the mild-moderate COVID-19 group and 1.34 (95% CI = 0.31–5.856, p  = 0.70) for the severe COVID-19 group.

Mean change in annual COPD exacerbation frequency among patients without COVID-19, mild-moderate COVID-19 and severe COVID-19, from baseline to follow-up.

Change in annual severe COPD exacerbation frequency from baseline

The mean annual severe COPD exacerbation frequency (measured as number of episodes per year) in the past 12 months before recruitment were 0.10 ± 0.59 in the non-COVID group, 0.14 ± 0.51 in the mild-moderate COVID-19 group and 0.19 ± 0.46 in the severe COVID group. The mean annual severe COPD exacerbation frequency in the last year of follow-up were 0.25 ± 0.64 in the non-COVID group, 0.21 ± 62 in the mild-moderate COVID-19 group and 0.74 ± 0.86 in the severe COVID group.

The mean change of annual COPD exacerbation frequency was + 0.13 ± 0.76 in the non-COVID group, + 0.07 ± 0.75 in the mild-moderate COVID-19 group and + 0.55 ± 1.01 in the severe COVID group, p  = 0.009 in univariate analysis and 0.025 in multivariate analysis. The OR for increase in annual severe COPD exacerbation frequency, using the non-COVID-19 group for comparison, were 0.49 (95% CI = 0.28–0.86, p  = 0.012) for the mild-moderate COVID-19 group and 4.82 (95% CI = 2.24–10.38, p  < 0.001) for the severe COVID-19 group. The aOR were 0.51 (95% CI = 0.23–1.11, p  = 0.09) for the mild-moderate COVID-19 group and 4.73 (95% CI = 1.55–14.41, p  = 0.006) for the severe COVID-19 group.

Non-COVID-19 respiratory mortality

Among the 44 patients who died in the follow-up period, the 17 non-COVID-19 respiratory mortality comprised 8 (5.0%) in the non-COVID-19 group, 0 (0%) in the mild-moderate COVID-19 and 9 (34.3%) in the severe COVID-19 group. 22, 3 and 2 patients died of other causes were censored. There was significant increased non-COVID-19 respiratory mortality for patients in the severe COVID-19 group, comparing with the non-COVID-19 group, with hazard ratio (HR) of 4.73 (95% CI = 1.82–12.27, p  < 0.001) and adjusted HR (aHR) of 11.25 (95% CI = 2.98–42.45, p  < 0.001) (Fig.  4 ).

Survival analysis for non-COVID-19 respiratory mortality among patients without COVID-19, mild-moderate COVID-19 and severe COVID-19.

Sensitivity analysis

Sensitivity analysis was conducted among patients who had at least 2 doses of COVID-19 vaccines 14 days or more before an episode of COVID-19 infection. There were 261 patients included in the sensitivity analysis.

The mean mMRC scores at baseline assessment were 1.65 ± 0.91 in the non-COVID-19 group, 1.55 ± 0.87 in the mild-moderate COVID-19 group and 1.75 ± 1.07 in the severe COVID-19 group. The mean mMRC scores on follow-up were 1.75 ± 0.97 in the non-COVID-19 group, 1.81 ± 0.92 in the mild-moderate COVID-19 group and 2.17 ± 1.03 in the severe COVID-19 group.

The mean change of mMRC dyspnea scale were + 0.09 ± 0.41 in the non-COVID-19 group, 0.23 ± 0.51 in the mild-moderate COVID-19 group and + 0.39 ± 0.50 in the severe COVID-19 group, p  = 0.005 in univariate analysis and 0.003 in multivariate analysis. 12/134 (9.0%), 27/103 (26.2%) and 9/24 (37.5%) of the patients in the non- COVID-19, mild-moderate COVID-19 and severe COVID-19 groups had worsening of mMRC dyspnoea scale by an increased score of 1 from baseline to the last follow-up. The OR for increase in mMRC dyspnoea scale, using the non-COVID-19 group for comparison, was 3.39 (95% CI = 1.62–7.12, p  < 0.001) for the mild-moderate COVID-19 group and 5.89 (95% CI = 2.11–16.47, p  < 0.001) for the severe COVID-19 group, with the aOR 4.15 (95% CI = 1.66–10.34, p  = 0.002) and 7.32 (95% CI = 2..11–25.42, p  = 0.002) respectively.

The mean annual COPD exacerbation frequency in the past 12 months before recruitment were 0.25 ± 0.77 in the non-COVID-19 group, 0.22 ± 0.63 in the mild-moderate COVID-19 group and 1.13 ± 1.19 in the severe COVID-19 group. The mean annual COPD exacerbation frequency in the last year of follow-up were 0.30 ± 1.08 in the non-COVID-19 group, 0.2 ± 0.88 in the mild-moderate COVID-19 group and 0.61 ± 1.09 in the severe COVID-19 group.

The mean change of annual COPD exacerbation frequency was + 0.30 ± 1.08 in the non-COVID-19 group, + 0.02 ± 0.88 in the mild-moderate COVID-19 group and + 0.61 ± 1.67 in the severe COVID-19 group, p  = 0.046 in univariate analysis and 0.52 in multivariate analysis.

24 (17.9%), 16 (15.5%) and 6 (25.0%) of the patients in the non-COVID-19, mild-moderate COVID-19 and severe COVID-19 groups had an increase in annual COPD exacerbation frequency from baseline to follow-up. The OR for increased annual COPD exacerbation frequency, using the non-COVID-19 group for comparison, was 0.48 (95% CI = 0.15–1.61, p  = 0.24) for the mild-moderate COVID-19 group and 1.66 (95% CI = 0.33–8.53, p  = 0.54) for the severe COVID-19 group.

The mean annual severe COPD exacerbation frequency (measured as number of episodes per year) in the past 12 months before recruitment were 0.11 ± 0.63 in the non-COVID group, 0.11 ± 0.46 in the mild-moderate COVID-19 group and 0.25 ± 0.53 in the severe COVID group. The mean annual severe COPD exacerbation frequency in the last year of follow-up were 0.25 ± 0.66 in the non-COVID group, 0.17 ± 0.55 in the mild-moderate COVID-19 group and 0.76 ± 0.88 in the severe COVID group.

The mean change of annual COPD exacerbation frequency was + 0.13 ± 0.78 in the non-COVID group, + 0.06 ± 0.65 in the mild-moderate COVID-19 group and + 0.50 ± 1.08 in the severe COVID group, p  = 0.049 in univariate analysis and 0.041 in multivariate analysis. The OR for increase in annual severe COPD exacerbation frequency, using the non-COVID-19 group for comparison, were 0.66 (95% CI = 0.34–1.27, p  = 0.21) for the mild-moderate COVID-19 group and 5.54 (95% CI = 2.21–13.88, p  < 0.001) for the severe COVID-19 group. The aOR were 0.65 (95% CI = 0.27–1.56, p  = 0.33) for the mild-moderate COVID-19 group and 5.62 (95% CI = 1.51–20.86, p  = 0.01) for the severe COVID-19 group.

Among the 21 patients who died in the follow-up period, the 7 non-COVID-19 respiratory mortality comprised 4 (3.0%) in the non-COVID-19 group, 0 (0%) in the mild-moderate COVID-19 and 3 (12.5%) in the severe COVID-19 group. There was a significant increased non-COVID-19 respiratory mortality for patients in the severe COVID-19 group, comparing with the non-COVID-19 group, with HR 3.94 (95% CI = 0.88–17.60, p  = 0.07) and aHR of 5.25 (95% CI = 0.74–37.28, p  = 0.10).

Our study suggested that there was worsening COPD control after recovery from COVID-19 regardless of severity. The mMRC dyspnea scale increased in both mild-moderate and severe COVID-19 groups. Patients in the severe COVID-19 group also had increased risks of having more severe exacerbations and non-COVID-19 respiratory mortality (COPD exacerbation and pneumonia) after recovery. The results suggest that the delayed impact of COVID-19 on other respiratory diseases such as asthma is also present in COPD.

From the results of our study, we believe there is imminent need to arrange early follow up with appropriate actions among patients who had COPD and recent COVID-19 infection, regardless of the severity of COVID-19, as the worsening of COPD was seen across patients with mild to severe COVID-19. Patients with COPD who recovered from COVID-19 of all severity would have worsening dyspnea as measured by mMRC dyspnea scale. They will need timely assessment to consider escalation of COPD pharmacotherapy to relieve their dyspnea, which was shown to be worsened after COVID-19. Pulmonary rehabilitation should also be considered in these patients 16 , 17 , 18 . While patients with mild to moderate COVID-19 would have symptomatic deterioration, those with severe COVID-19 also had increase in future risks of severe exacerbation and mortality. For patients who recovered from severe COVID-19, they would need more aggressive treatment to prevent future COPD exacerbation and pneumonia, as they are at increased risks for developing severe exacerbation and also non-COVID-19 respiratory mortality due to COPD exacerbation and pneumonia after recovery from severe COVID-19. Pharmacotherapy to prevent COPD exacerbation cannot be over-emphasized. Other preventive therapy such as vaccination to prevent pneumonia caused by other micro-organisms is another important strategy to be employed 19 .

Our groups previously suggested that patients with asthma, upon recovery from mild-to-moderate COVID-19, had worsening of asthma control 8 . This phenomenon was also observed among patients with COPD, as they also had worsening symptoms as measured by mMRC dyspnea scale. And among patients with COPD, those with severe COVID-19 also had increased risks of developing future severe exacerbation and non-COVID-19 respiratory mortality. This observation can be explained by the nature of COPD. While asthma is a largely controllable disease with inhalers, biologics and bronchial thermoplasty, COPD is characterized by irreversible airflow obstruction. Patients will have gradual deterioration of lung function 20 interposed by exacerbation 21 . Mortality from respiratory causes is almost an inevitable event. Severe COVID-19 could lead to major damages in pulmonary structure and mechanics, which may lead to subsequent fatal events such as severe COPD exacerbation and pneumonia 22 . The results from this study are alarming as the mortality from non-COVID-19 respiratory cause even exceeds that from COVID-19 itself in our cohort. This delayed fatal consequence should not be overlooked.

One important observation in this study is that there were more patients who completed COVID-19 vaccines in the non-COVID group, than the mild to moderate COVID and severe COVID-19 groups. The efficacy of COVID-19 vaccines in preventing severe COVID-19 in patients with COPD have been demonstrated in prior studies 23 , 24 . By preventing the development of severe COVID-19, these vaccines may be able to prevent the sequalae of severe COIVD-19 as observed in this study, including subsequent severe COPD exacerbation and mortality. Hence, the importance of completion of COVID-19 vaccination for patients with COPD should be encouraged, as we did for seasonal influenza and pneumococcal vaccines, which are within the Global Initiative for Chronic Obstructive Lung Disease recommendations 14 . The benefits from influenza and pneumococcal vaccines in patients with chronic respiratory diseases have been well demonstrated 25 , 26 , 27 , 28 , 29 , 30 , 31 and the similar benefits from COVID-19 vaccines should not be forgotten.

Another point to note is the possible overuse of ICS in some of the patients in this cohort. Almost half of the patients in this cohort were on ICS, and more in the severe COVID-19 group was on ICS than the mild to moderate and non-COVID-19 groups. This could be related to the higher exacerbation number in the past 12 months in the severe COVID-19 group, leading to this possible overuse of ICS in these patients, which might increase their risks of subsequent pneumonia 32 , 33 . We adjusted the use of ICS and other COPD treatments in the multi-variate analysis and showed consistent results, suggesting the effect of severity of COVID-19 to be an independent predictor of the outcomes, including non-COVID respiratory mortality. However, such phenomenon still rings a bell, and it is important to review the COPD treatment records of these patients to avoid unmercenary prescription of ICS which does carry risks.

Limitations

There are a few limitations in our study. Firstly, this study involved exclusively Chinese patients. This might affect the generalizability of the study findings in other ethnic groups. Yet, the etiology, pathophysiology and clinical features of COPD and COVID-19 are largely similar across different ethnic groups. The definition of severity of COPD and COVID-19 in our study is also consistent with the international consensus. Secondly, the patients were diagnosed with COVID-19 by RAT or PCR and therefore the measurement of viral load at the time of infection was not possible. The severity of disease and subsequent improvement were assessed based on clinical status. Thirdly, computed tomography was not available in the majority of the patients for assessment of post-COVID sequalae such as organizing pneumonia or fibrosis, which could also account for worsening of symptoms by mMRC. From chest-radiograph and clinical records, none of the patients within this cohort was diagnosed to have post-COVID organizing pneumonia or fibrosis, yet computed tomography shall be the gold standard to diagnose these conditions.

After recovery from COVID-19, worsening of COPD control from worsening of dyspnea, increase in severe exacerbation frequency to non-COVID-19 respiratory mortality (COPD exacerbation and pneumonia) was observed among patients with severe COVID-19. Mild to moderate COVID-19 was also associated with symptomatic deterioration.

Data availability

All data generated or analysed during this study are included in this published article. The data is available from author WC Kwok upon reasonable request.

Abbreviations

Asthma control test

Chronic obstructive pulmonary disease

Coronavirus disease 2019

Electronic patient record

Forced expiratory volume in one second

Forced vital capacity

Grantham Hospital

Hospital Authority

Inhaled corticosteroids

Long-acting β2-agonists

Long-acting muscarinic antagonists

Modified Medical Research Council

Queen Mary Hospital

Rapid antigen test

Reverse transcription–polymerase chain reaction

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Acknowledgements

We would like to acknowledge the assistance from Ms KWONG Pui Yi, Ms TSE Choy Ying Cherish and Ms WONG Yuen Wing in conducting this study.

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‘Nursing Times wants to ensure that the voices of nurses and midwives are heard’

STEVE FORD, EDITOR

• You are here: COPD

Diagnosis and management of COPD: a case study

04 May, 2020

This case study explains the symptoms, causes, pathophysiology, diagnosis and management of chronic obstructive pulmonary disease

This article uses a case study to discuss the symptoms, causes and management of chronic obstructive pulmonary disease, describing the patient’s associated pathophysiology. Diagnosis involves spirometry testing to measure the volume of air that can be exhaled; it is often performed after administering a short-acting beta-agonist. Management of chronic obstructive pulmonary disease involves lifestyle interventions – vaccinations, smoking cessation and pulmonary rehabilitation – pharmacological interventions and self-management.

Citation: Price D, Williams N (2020) Diagnosis and management of COPD: a case study. Nursing Times [online]; 116: 6, 36-38.

Authors: Debbie Price is lead practice nurse, Llandrindod Wells Medical Practice; Nikki Williams is associate professor of respiratory and sleep physiology, Swansea University.

• This article has been double-blind peer reviewed
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Introduction

The term chronic obstructive pulmonary disease (COPD) is used to describe a number of conditions, including chronic bronchitis and emphysema. Although common, preventable and treatable, COPD was projected to become the third leading cause of death globally by 2020 (Lozano et al, 2012). In the UK in 2012, approximately 30,000 people died of COPD – 5.3% of the total number of deaths. By 2016, information published by the World Health Organization indicated that Lozano et al (2012)’s projection had already come true.

People with COPD experience persistent respiratory symptoms and airflow limitation that can be due to airway or alveolar abnormalities, caused by significant exposure to noxious particles or gases, commonly from tobacco smoking. The projected level of disease burden poses a major public-health challenge and primary care nurses can be pivotal in the early identification, assessment and management of COPD (Hooper et al, 2012).

Grace Parker (the patient’s name has been changed) attends a nurse-led COPD clinic for routine reviews. A widowed, 60-year-old, retired post office clerk, her main complaint is breathlessness after moderate exertion. She scored 3 on the modified Medical Research Council (mMRC) scale (Fletcher et al, 1959), indicating she is unable to walk more than 100 yards without stopping due to breathlessness. Ms Parker also has a cough that produces yellow sputum (particularly in the mornings) and an intermittent wheeze. Her symptoms have worsened over the last six months. She feels anxious leaving the house alone because of her breathlessness and reduced exercise tolerance, and scored 26 on the COPD Assessment Test (CAT, catestonline.org), indicating a high level of impact.

Ms Parker smokes 10 cigarettes a day and has a pack-year score of 29. She has not experienced any haemoptysis (coughing up blood) or chest pain, and her weight is stable; a body mass index of 40kg/m 2 means she is classified as obese. She has had three exacerbations of COPD in the previous 12 months, each managed in the community with antibiotics, steroids and salbutamol.

Ms Parker was diagnosed with COPD five years ago. Using Epstein et al’s (2008) guidelines, a nurse took a history from her, which provided 80% of the information needed for a COPD diagnosis; it was then confirmed following spirometry testing as per National Institute for Health and Care Excellence (2018) guidance.

The nurse used the Calgary-Cambridge consultation model, as it combines the pathological description of COPD with the patient’s subjective experience of the illness (Silverman et al, 2013). Effective communication skills are essential in building a trusting therapeutic relationship, as the quality of the relationship between Ms Parker and the nurse will have a direct impact on the effectiveness of clinical outcomes (Fawcett and Rhynas, 2012).

In a national clinical audit report, Baxter et al (2016) identified inaccurate history taking and inadequately performed spirometry as important factors in the inaccurate diagnosis of COPD on general practice COPD registers; only 52.1% of patients included in the report had received quality-assured spirometry.

Pathophysiology of COPD

Knowing the pathophysiology of COPD allowed the nurse to recognise and understand the physical symptoms and provide effective care (Mitchell, 2015). Continued exposure to tobacco smoke is the likely cause of the damage to Ms Parker’s small airways, causing her cough and increased sputum production. She could also have chronic inflammation, resulting in airway smooth-muscle contraction, sluggish ciliary movement, hypertrophy and hyperplasia of mucus-secreting goblet cells, as well as release of inflammatory mediators (Mitchell, 2015).

Ms Parker may also have emphysema, which leads to damaged parenchyma (alveoli and structures involved in gas exchange) and loss of alveolar attachments (elastic connective fibres). This causes gas trapping, dynamic hyperinflation, decreased expiratory flow rates and airway collapse, particularly during expiration (Kaufman, 2013). Ms Parker also displayed pursed-lip breathing; this is a technique used to lengthen the expiratory time and improve gaseous exchange, and is a sign of dynamic hyperinflation (Douglas et al, 2013).

In a healthy lung, the destruction and repair of alveolar tissue depends on proteases and antiproteases, mainly released by neutrophils and macrophages. Inhaling cigarette smoke disrupts the usually delicately balanced activity of these enzymes, resulting in the parenchymal damage and small airways (with a lumen of <2mm in diameter) airways disease that is characteristic of emphysema. The severity of parenchymal damage or small airways disease varies, with no pattern related to disease progression (Global Initiative for Chronic Obstructive Lung Disease, 2018).

Ms Parker also had a wheeze, heard through a stethoscope as a continuous whistling sound, which arises from turbulent airflow through constricted airway smooth muscle, a process noted by Mitchell (2015). The wheeze, her 29 pack-year score, exertional breathlessness, cough, sputum production and tiredness, and the findings from her physical examination, were consistent with a diagnosis of COPD (GOLD, 2018; NICE, 2018).

Spirometry is a tool used to identify airflow obstruction but does not identify the cause. Commonly measured parameters are:

• Forced expiratory volume – the volume of air that can be exhaled – in one second (FEV1), starting from a maximal inspiration (in litres);
• Forced vital capacity (FVC) – the total volume of air that can be forcibly exhaled – at timed intervals, starting from a maximal inspiration (in litres).

Calculating the FEV1 as a percentage of the FVC gives the forced expiratory ratio (FEV1/FVC). This provides an index of airflow obstruction; the lower the ratio, the greater the degree of obstruction. In the absence of respiratory disease, FEV1 should be ≥70% of FVC. An FEV1/FVC of <70% is commonly used to denote airflow obstruction (Moore, 2012).

As they are time dependent, FEV1 and FEV1/FVC are reduced in diseases that cause airways to narrow and expiration to slow. FVC, however, is not time dependent: with enough expiratory time, a person can usually exhale to their full FVC. Lung function parameters vary depending on age, height, gender and ethnicity, so the degree of FEV1 and FVC impairment is calculated by comparing a person’s recorded values with predicted values. A recorded value of >80% of the predicted value has been considered ‘normal’ for spirometry parameters but the lower limit of normal – equal to the fifth percentile of a healthy, non-smoking population – based on more robust statistical models is increasingly being used (Cooper et al, 2017).

A reversibility test involves performing spirometry before and after administering a short-acting beta-agonist (SABA) such as salbutamol; the test is used to distinguish between reversible and fixed airflow obstruction. For symptomatic asthma, airflow obstruction due to airway smooth-muscle contraction is reversible: administering a SABA results in smooth-muscle relaxation and improved airflow (Lumb, 2016). However, COPD is associated with fixed airflow obstruction, resulting from neutrophil-driven inflammatory changes, excess mucus secretion and disrupted alveolar attachments, as opposed to airway smooth-muscle contraction.

Administering a SABA for COPD does not usually produce bronchodilation to the extent seen in someone with asthma: a person with asthma may demonstrate significant improvement in FEV1 (of >400ml) after having a SABA, but this may not change in someone with COPD (NICE, 2018). However, a negative response does not rule out therapeutic benefit from long-term SABA use (Marín et al, 2014).

NICE (2018) and GOLD (2018) guidelines advocate performing spirometry after administering a bronchodilator to diagnose COPD. Both suggest a FEV1/FVC of <70% in a person with respiratory symptoms supports a diagnosis of COPD, and both grade the severity of the condition using the predicted FEV1. Ms Parker’s spirometry results showed an FEV1/FVC of 56% and a predicted FEV1 of 57%, with no significant improvement in these values with a reversibility test.

GOLD (2018) guidance is widely accepted and used internationally. However, it was developed by medical practitioners with a medicalised approach, so there is potential for a bias towards pharmacological management of COPD. NICE (2018) guidance may be more useful for practice nurses, as it was developed by a multidisciplinary team using evidence from systematic reviews or meta-analyses of randomised controlled trials, providing a holistic approach. NICE guidance may be outdated on publication, but regular reviews are performed and published online.

NHS England (2016) holds a national register of all health professionals certified in spirometry. It was set up to raise spirometry standards across the country.

Assessment and management

The goals of assessing and managing Ms Parker’s COPD are to:

• Review and determine the level of airflow obstruction;
• Assess the disease’s impact on her life;
• Risk assess future disease progression and exacerbations;
• Recommend pharmacological and therapeutic management.

GOLD’s (2018) ABCD assessment tool (Fig 1) grades COPD severity using spirometry results, number of exacerbations, CAT score and mMRC score, and can be used to support evidence-based pharmacological management of COPD.

When Ms Parker was diagnosed, her predicted FEV1 of 57% categorised her as GOLD grade 2, and her mMRC score, CAT score and exacerbation history placed her in group D. The mMRC scale only measures breathlessness, but the CAT also assesses the impact COPD has on her life, meaning consecutive CAT scores can be compared, providing valuable information for follow-up and management (Zhao, et al, 2014).

After assessing the level of disease burden,  Ms Parker was then provided with education for self-management and lifestyle interventions.

Lifestyle interventions

Smoking cessation.

Cessation of smoking alongside support and pharmacotherapy is the second-most cost-effective intervention for COPD, when compared with most other pharmacological interventions (BTS and PCRS UK, 2012). Smoking cessation:

• Slows the progression of COPD;
• Improves lung function;
• Improves survival rates;
• Reduces the risk of lung cancer;
• Reduces the risk of coronary heart disease risk (Qureshi et al, 2014).

Ms Parker accepted a referral to an All Wales Smoking Cessation Service adviser based at her GP surgery. The adviser used the internationally accepted ‘five As’ approach:

• Ask – record the number of cigarettes the individual smokes per day or week, and the year they started smoking;
• Advise – urge them to quit. Advice should be clear and personalised;
• Assess – determine their willingness and confidence to attempt to quit. Note the state of change;
• Assist – help them to quit. Provide behavioural support and recommend or prescribe pharmacological aids. If they are not ready to quit, promote motivation for a future attempt;
• Arrange – book a follow-up appointment within one week or, if appropriate, refer them to a specialist cessation service for intensive support. Document the intervention.

NICE (2013) guidance recommends that this be used at every opportunity. Stead et al (2016) suggested that a combination of counselling and pharmacotherapy have proven to be the most effective strategy.

Pulmonary rehabilitation

Ms Parker’s positive response to smoking cessation provided an ideal opportunity to offer her pulmonary rehabilitation (PR)  – as indicated by Johnson et al (2014), changing one behaviour significantly increases a person’s chance of changing another.

PR – a supervised programme including exercise training, health education and breathing techniques – is an evidence-based, comprehensive, multidisciplinary intervention that:

• Improves exercise tolerance;
• Reduces dyspnoea;
• Promotes weight loss (Bolton et al, 2013).

These improvements often lead to an improved quality of life (Sciriha et al, 2015).

Most relevant for Ms Parker, PR has been shown to reduce anxiety and depression, which are linked to an increased risk of exacerbations and poorer health status (Miller and Davenport, 2015). People most at risk of future exacerbations are those who already experience them (Agusti et al, 2010), as in Ms Parker’s case. Patients who have frequent exacerbations have a lower quality of life, quicker progression of disease, reduced mobility and more-rapid decline in lung function than those who do not (Donaldson et al, 2002).

“COPD is a major public-health challenge; nurses can be pivotal in early identification, assessment and management”

Pharmacological interventions

Ms Parker has been prescribed inhaled salbutamol as required; this is a SABA that mediates the increase of cyclic adenosine monophosphate in airway smooth-muscle cells, leading to muscle relaxation and bronchodilation. SABAs facilitate lung emptying by dilatating the small airways, reversing dynamic hyperinflation of the lungs (Thomas et al, 2013). Ms Parker also uses a long-acting muscarinic antagonist (LAMA) inhaler, which works by blocking the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors in airway smooth muscle; release of acetylcholine by the parasympathetic nerves in the airways results in increased airway tone with reduced diameter.

At a routine review, Ms Parker admitted to only using the SABA and LAMA inhalers, despite also being prescribed a combined inhaled corticosteroid and long-acting beta 2 -agonist (ICS/LABA) inhaler. She was unaware that ICS/LABA inhalers are preferred over SABA inhalers, as they:

• Last for 12 hours;
• Improve the symptoms of breathlessness;
• Increase exercise tolerance;
• Can reduce the frequency of exacerbations (Agusti et al, 2010).

However, moderate-quality evidence shows that ICS/LABA combinations, particularly fluticasone, cause an increased risk of pneumonia (Suissa et al, 2013; Nannini et al, 2007). Inhaler choice should, therefore, be individualised, based on symptoms, delivery technique, patient education and compliance.

It is essential to teach and assess inhaler technique at every review (NICE, 2011). Ms Parker uses both a metered-dose inhaler and a dry-powder inhaler; an in-check device is used to assess her inspiratory effort, as different inhaler types require different inhalation speeds. Braido et al (2016) estimated that 50% of patients have poor inhaler technique, which may be due to health professionals lacking the confidence and capability to teach and assess their use.

Patients may also not have the dexterity, capacity to learn or vision required to use the inhaler. Online resources are available from, for example, RightBreathe (rightbreathe.com), British Lung Foundation (blf.org.uk). Ms Parker’s adherence could be improved through once-daily inhalers, as indicated by results from a study by Lipson et al (2017). Any change in her inhaler would be monitored as per local policy.

Vaccinations

Ms Parker keeps up to date with her seasonal influenza and pneumococcus vaccinations. This is in line with the low-cost, highest-benefit strategy identified by the British Thoracic Society and Primary Care Respiratory Society UK’s (2012) study, which was conducted to inform interventions for patients with COPD and their relative quality-adjusted life years. Influenza vaccinations have been shown to decrease the risk of lower respiratory tract infections and concurrent COPD exacerbations (Walters et al, 2017; Department of Health, 2011; Poole et al, 2006).

Self-management

Ms Parker was given a self-management plan that included:

• Information on how to monitor her symptoms;
• A rescue pack of antibiotics, steroids and salbutamol;
• A traffic-light system demonstrating when, and how, to commence treatment or seek medical help.

Self-management plans and rescue packs have been shown to reduce symptoms of an exacerbation (Baxter et al, 2016), allowing patients to be cared for in the community rather than in a hospital setting and increasing patient satisfaction (Fletcher and Dahl, 2013).

Improving Ms Parker’s adherence to once-daily inhalers and supporting her to self-manage and make the necessary lifestyle changes, should improve her symptoms and result in fewer exacerbations.

The earlier a diagnosis of COPD is made, the greater the chances of reducing lung damage through interventions such as smoking cessation, lifestyle modifications and treatment, if required (Price et al, 2011).

• Chronic obstructive pulmonary disease is a progressive respiratory condition, projected to become the third leading cause of death globally
• Diagnosis involves taking a patient history and performing spirometry testing
• Spirometry identifies airflow obstruction by measuring the volume of air that can be exhaled
• Chronic obstructive pulmonary disease is managed with lifestyle and pharmacological interventions, as well as self-management

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Role of pulmonary rehabilitation in chronic obstructive pulmonary disease - a historical perspective

Introduction.

Pulmonary rehabilitation is known as an effective therapy for patients with chronic obstructive pulmonary disease (COPD). This article is a brief introduction into the history of medical and pulmonary rehabilitation, presenting the evolution of applied therapies and methods from ancient to present times. It also highlights the role of physical effort in the prevention and treatment of lung diseases, with special consideration to COPD.

For this literature review, the international databases Medline and Scopus were used to identify relevant articles, between January 1981 to December 2021; eighty articles were considered: thirty-six reviews, eight original research and six general articles which met the criteria for inclusion. A total of thirty references were excluded because they were not relevant.

Available published data suggest a rich history of rehabilitation reaching for thousands of years even though it was developed as a medical branch only in the 20th century. Pulmonary rehabilitation is currently an important component of the management of COPD patients, with a positive impact on symptoms, frequency of exacerbations, severity and mortality rates.

Conclusions

Even though this type of intervention is known to be beneficial for this type of patients more studies need to be conducted in this field.

Pulmonary rehabilitation is currently a complex and multi modal therapeutic system with clear benefits demonstrated by evidence-based research at least for some respiratory conditions. Its proven efficacy explains why various rehabilitation techniques are adopted in widely accepted standards of care - such is the case of chronic obstructive pulmonary disease (COPD).

Still, we should not forget that rehabilitation in general and respiratory techniques were being developed before the scientific method emerged and was implemented in the medical field; some elements remain in use today even if the principles on which they were based were refuted in modern times.

Along these lines we consider of potential interest to provide a short review of available data on respiratory rehabilitation from a historic point of view and focusing on obstructive respiratory disease.

The aim of this review was to conduct a brief introduction into the history of medical and pulmonary rehabilitation, presenting the evolution of applied therapies and methods from ancient to present times and also to highlight the role of physical effort into the prevention and treatment of lung diseases, with special consideration to COPD. Another purpose was to explore the beginning of pulmonary rehabilitation in Romania.

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [ 1 ]. No ethics committee approval was deemed necessary considering the bibliographic nature of this study.

Search strategy

A comprehensive literature research was conducted to present the evolution of applied therapies and methods from ancient to present times and also to highlight the role of physical effort into the prevention and treatment of lung diseases, with special consideration to COPD. For this literature review, the international databases Medline or Scopus database were searched between January 1981 to December 2021, using keywords for the relevant literature. The following search keywords : “copd history”, “pulmonary rehabilitation”, “role”, “impact”, “mortality”, “effectiveness” and “exacerbation” were used separately or in combination. The results were limited to articles written in English.

Eligibility criteria

To be eligible for the analysis, studies had to meet the following criteria: (a) to contain information about the use of pulmonary rehabilitation; (b) to contain information about important personalities in this field; (c) to assess the usefulness, the role and the impact of PR in COPD.

Data extraction

The initial screening for the identification of potentially eligible articles was performed by two independent readers (E.I.S. and I.B.) by an initial screening of the databases considering the title and abstract of all identified references. After the relevant literature was collected, each article was analyzed and read in detail to identify and extract the discussions.

Literature search outcomes

The initial literature search retrieved a total of 100 potentially eligible articles. However, only 80 titles and abstracts were screened as 20 were found to be irrelevant for the chosen topic. Of the 80 articles left, 30 articles were further excluded as they did not meet our eligibility criteria (mainly not covering COPD rehabilitation or not available in English). Finally, 50 articles were included into the analysis. Figure 1 presents the flow chart showing the research literature strategy to identify the eligible studies.

Flow chart showing strategy to identify eligible studies.

Medical and pulmonary rehabilitation in ancient times

Physical medicine and rehabilitation is a medical specialty focused on prevention, diagnosis, rehabilitation and therapy for patients who face functional limitations resulting from injuries, diseases or malformations. The word “therapy” comes from the ancient Hebrew word „ refua ” which means healing [ 2 ]. Although rehabilitation as a medical branch has been developed from the beginning of the 20th century, for thousands of years the peoples of Asia have resorted to exercise in order to maintain and promote health. They built pathophysiological theories based on local philosophical or theological currents such as Qigong and Tai Chi. Although these theories have a questionable physiological value, there are data suggesting positive health effects. Basically, the first “therapy” through movement was born consciously or not, with the appearance of human beings on earth and their need for adaptation. Humans have constantly tried to find means to alleviate the physical or spiritual suffering, in their archaic faith these two states being interdependent. In addition to prayers, traditions or customs dedicated to divinity, man discovered various postures that had the effect of reducing physical pain and found specific positions for concentration and meditation which helped stabilizing and coordinating the rhythm of his breathing. From this perspective, some components of pulmonary rehabilitation have been part of medical care for centuries.

Thousands of years ago, the ancient Chinese used a series of therapeutic postures and movements collectively called martial arts (Kong Fu). This practice was used to relieve pain, correct spinal deviations or as post-surgery therapy, while having a philosophical and spiritual meaning within their culture [ 3 ]. The positive effects of martial arts practice on cardiorespiratory function and muscle strength are demonstrated today. Also, aerobic capacity as well as maximum muscle strength, speed and endurance to exercise are further improved among those who practice Kong Fu compared to other types of contact sports (such as Tai Chi, Tai Kwando) [ 4 ].

The idea of recovery and rehabilitation may be found in the holistic practices of ancient times such as Ayurveda - the name given to the corpus of medical practices developed in India over 5,000 years ago, probably one of the oldest known medical systems [ 5 ]. Its theoretical basis is considered to have influenced the Japanese, Chinese, Arab, Greek and Roman medical systems, too. Ayurveda, which means life or longevity in Sanskrit, has its roots in Vedas philosophy, which means knowledge [ 5 ]. In the original text of Vedas , in ancient India where the oldest religious scriptures of Hinduism are found, dating to about 3000 years ago, there are mentions of practical education about care and hygiene of individuals, with various descriptions of anatomy, physiology, surgery and the use of plants, combined with ethics and spiritual (moral) activity, also prevalent talk of recommended therapeutic exercises in chronic rheumatism and other diseases [ 4 , 5 ].

New neuroelectrophysiological studies on meditative breathing ( Dan Tian Breathing ) revealed its association with a relaxed state or with a state of enhanced awareness (or enhanced consciousness). Such exercises induce the brain in a relaxed state and improve the performance of individuals, preventing distraction, allowing them to remain focused on tasks, and to cope with the stressful work demands in a relaxed and flexible manner. Clinical observations and empirical evidence suggest that meditative breathing has a beneficial effect on mood disorders such as depression and anxiety, and cognitive problems related to brain disorders (epilepsy, autism spectrum disorders) [ 6 ]. Similar approaches and concepts have been developed at a geographical and temporal distance - in modern times breathing techniques have been successfully used to treat not only functional disorders but also respiratory conditions such as asthma (although mental states may act as triggers). While of minor interest today, techniques such as Buteyko breathing must be mentioned.

It is accepted that the basis of science and the study of physiology, anatomy and psychology were developed in ancient Greece, aiming to find the source of diseases and to enhance human health. The Greeks developed the study of physical exercises, like prophylactic and therapeutic gymnastics, because they believed that mental and physical health are interrelated. They also believed that the body and mind must be in harmony, and understood that sport and gymnastics are essential to this goal. Motor activity, exercises and even sports were considered very important in ancient Greece, as evidenced by the Olympic Games - hence the famous phrase “healthy mind in a healthy body” [ 2 , 3 ]. The Greek physician Herodicus (5th century BC), considered by some scholars Hippocrates’s tutor, is the first person in the history of medicine to combine, physical exercise and sport with medicine. He is also the first who developed a system of gymnastic exercises for the prevention and treatment of diseases [ 7 ].

Hippocrates ( figure 2 ) (c. 460 - c. 370 BC), the most prominent figure in the history of medicine, focused on the “natural” treatment of diseases and approached medicine as a rational discipline and not just theocratically as his predecessors. He pointed out the cause of illnesses as due to the environment and emphasized the therapeutic importance of psychological factors, nutrition, lifestyle, independence of mind, body, and spirit, and the need for harmony between individual and the social and natural environment. This credo is reflected in the Hippocratic oath. Hippocrates founded the art of observation, which involved using all the senses to consult the patient (sight, hearing, smell, touch, and judgment) [ 3 , 8 ].

Hippocrates.

Medical recovery after the emergence of Christianity

The Christian era produced a change of mentality, focused on encouragement, preventive, solidarity, sympathy and support between individuals. People with disabilities (deaf, blind, lame, lepers) were often described in the gospels, becoming the subject of miraculous healing. Once they were physically and spiritually rehabilitated, they could once again participate in social and civic life of the city [ 8 ].

In the Middle Ages, the practice of regular exercise as well as adequate rest adapted to the state of health remained generally unorganized. The philosopher and physician Moses Maimonides (1138–1204), a Sephardic Jew, born in Córdoba, Spain, emphasized the Talmudic principles of healthy habits consisting of exercise, as well as diet, as a preventive medicine. “Treatise on Asthma” are part of Maimonides’ writings, where through a logical and systematic approach, he describes how to diagnose, prevent and treat asthma. Maimonides describes different remedies for asthma depending on its severity. The practices he describes aim to cleanse the lungs, ease breathing and eliminate coughs. He states that: “the first thing to consider ... is to ensure clean air, fresh water and a healthy diet” [ 9 ]. Clean air is described in detail: “the city air is stagnant, cloudy and dense, a natural result of large buildings, of narrow streets, of the garbage of its inhabitants ... a wide open house should be chosen ... better living spaces, to be located on a higher floor ... where it can benefit of ample sunlight exposure... toilets should be located as far away as possible from living areas. The air should be kept dry at all times by sweet flavors, fumigation and drying agents. Concern for clean air is the most important rule in maintaining the health of one’s body and soul” [ 9 ].

Between 1187–1190 he wrote in Arabic a content of 1500 aphorisms describing many medical conditions, published in 1970 in English, “The Medical Aphorisms of Moses” . This book provides a detailed description of medicine as practiced in the thirteenth century in most civilized regions of the West, held at that time by the Arabs [ 2 , 10 ].

During the Renaissance, between the 15th and 16th centuries AD, the progress of the study of human anatomy and the systematic understanding of the medical role of physical activity and exercise were characteristic of this period, and medical rehabilitation became a distinct discipline. Among the most important schools that promoted an active life are those of: Méndez, Castiglione, Mercuriale, Paré, Joubert, Cagmatis, Cogan, Leonardo and Michelangelo [ 11 ].

The first book of physiotherapy ( figure 3 ) is considered to have been written by the doctor Cristóbal Méndez (1500–1553), born in Huelva, Spain. He spent much of his life, respectively 15 years, in Mexico, being investigated by the Spanish Inquisition because he was trying to decipher the zodiac inscriptions. Back in Spain, he wrote a 72-page text entitled “Libro del Exercicio Corporal” (1553) in which he defined exercise as “a voluntary movement in which breathing becomes rapid ... and frequent.” He concluded that exercise is beneficial because it creates heat, helps digestion and gets rid of excess body mass. “Exercise was invented and used to cleanse the body when it is too full of harmful things” [ 11 ].

Cover of the book of physical exercise and its benefits, by Cristobal Mendez, 1553.

An innovative work on human anatomy at the time was written by the Flemish anatomist Andreas Vesalius (1514–1564). Published in 1543, the book “De Humani Corporis Fabrica Libri Septem” placed more emphasis on illustrations than text, contained drawings of several organs, so as to allow the creation of three-dimensional diagrams by cutting organs and pasting them on cut figures [ 8 , 12 ].

During the late Renaissance, the Italian physician and philologist Girolamo Mercuriale (1530–1606), studying literature and medicine, had access to the great libraries of Bologna, Padua and Venice. In 1569 he printed his landmark text entitled “De Arte Gymnastica” (Art of Gymnastics) considered the first book on sports medicine, where he provided explanations of the principles of physical therapy used as a preventive, therapeutic intervention, aimed at people with disabilities, and old patients, as a tool for rehabilitation [ 2 , 13 ].

The seventeenth century is considered the century of the “scientific method” because during this period, the systematic approach to the study of biological phenomena became predominant in the Western world. The scientist contemporary to that period emphasized the importance of approaching empirical experiments, mathematical concepts, and explanations only through the physical laws of nature. Physiologist and mathematician, Giovanni Alfonso Borelli (1608–1679) was one of the most charismatic and brilliant scientists of his generation in Europe. He analyzed muscle contraction, heart function, blood flow, nerve transmission, lung function and many other biological problems using modern scientific methods [ 2 , 14 ].

The first description of pulmonary emphysema

COPD is probably not a new condition. In the past, doctors may have used different terms to describe what we knew today as COPD. The evolution of knowledge about COPD and its components (emphysema, chronic bronchitis and asthmatic bronchitis) covers over 200 years. Some of the earliest references to pulmonary emphysema include the description of the Genevan physician Théophile Bonet (1620–1689) about “bulky lungs” of 1679 [ 15 , 16 ].

The Italian anatomist Giovanni Battista Morgagni (1682–1771) considered the father of pathological anatomy, described the pathology of the respiratory system, the hepatized lung in pneumonia, the fibrinous bronchitis and the pulmonary tuberculosis, which remains relevant to these days. In 1769 he reported 19 cases in which the lungs were “turgid”, mainly due to air pollution [ 15 ].

The British physician Matthew Baillie (1761–1823) is known for his illustrations of the emphysematous lung. In 1793 he published a book entitled “The Morbid Anatomy of Some of the Most Important Parts of the Human Body.” The work consisted only of text, but in 1799 he published another work, “ A Series of Engravings Accompanied with Explanations” , which illustrates the morbid anatomy of some of the most important parts of the human body, providing 206 illustrations of different pathological types which were previously described in the 1793 book. Baillie is credited with being the first to produce an illustrated systematic textbook of morbid anatomy and probably the first to illustrate pulmonary emphysema and the composition of large vessels ( Figure 4 ) [ 15 , 16 ].

Section of lung of Samuel Johnson.

The beginning of the clinical understanding of chronic bronchitis as an associated component of COPD can be attributed to the English physician Charles Badham (1780–1845) in 1814. He used the word “cough” to describe the symptoms of chronic cough and mucus hypersecretion [ 15 ]. The component of pulmonary emphysema was described in detail by the French physician and musician René Laënnec (1781–1826) in 1821. In his paper “Treatise on Thoracic Diseases” he described the emphysematous component of lung disease and the combination of bronchitis and emphysema. Because smoking at the beginning of the XIX century was not a widespread habit among the population, Laënnec identified air pollution and hereditary as risk factors among the causes for COPD development [ 16 , 17 ]. Having the ability to sculpt various wooden objects, especially flutes for singing, he invented, initially in a different form, the stethoscope in 1816.

The main tool in diagnosing COPD, the spirometer, was invented by the English surgeon John Hutchinson (1811–1861). He invented a calibrated bell, overturned in water, to be able to capture and measure the volume of exhaled air from a completely swollen lung. He coined the term vital capacity, meaning life capacity, a concept that later became known as FEV 1 (Forced expiratory volume in 1 second). 100 years later, Robert Tiffeneau (1910–1961) would build a comprehensive diagnostic tool in the diagnosis of COPD [ 18 ].

Pulmonary rehabilitation in the contemporary period

The concept of respiratory recovery was imposed worldwide after the Second World War, first in the assistance of restrictive and postoperative syndromes and only after 1950 in the assistance of obstructive syndromes [ 19 ]. In the twentieth century, COPD clearly became a major public health problem. Initially, patients were advised to avoid dyspnea caused by physical activity, just as today patients with coronary heart disease are advised to avoid activities that cause angina pectoris. These recommendations were part of the management of the disease at that time. Contrary to these opinions, the doctor Alvan L. Barach (1895–1977) did not agree with this approach. Barach is considered a pioneer of oxygen therapy in research of respiratory diseases. He created the first “tent” ( figure 5 ) with oxygen in 1926 and also developed the first continuous method of aerosol therapy, and later became the leading developer of devices that allow people with chronic respiratory problems to exercise with small oxygen-containing devices [ 20 ].

The first practical oxygen tent by adding ice for cooling and soda-lime for carbon dioxide absorption, 1926.

Affiliated with Columbia University in New York, he is credited with the statement that COPD patients should strive to be more active. He had a long medical career, between 1920 and 1970 and a rich publishing career, totaling over 300 articles, some of them (128) indexed and still found in PubMed [ 20 ]. In a 1926 publication he described the effect of oxygen in reducing shortness of breath in pneumonia patients. In 1936 he described the use of heliox to relieve dyspnea in asthma and emphysema. In 1945 he published a description about the benefits of penicillin in treating pneumonia. In the 1950’s he worked on the development of portable oxygen systems for patients with emphysema [ 21 ]. In a 1952 paper he wrote the following: “In 2 patients with pulmonary emphysema in whom exertional dyspnea was relieved during oxygen inhalation, an exercise program was established, followed visibly by increased exercise capacity without oxygen… the progressive improvement of the ability to walk without dyspnea suggests that a physiological response similar to a sports training program may have been produced” [ 22 , 23 ].

The pulmonologist Thomas L. Petty (1932–2009) ( figure 6 ) is considered the most important doctor in the history of respiratory rehabilitation, due to the importance of his original contributions and their practical relevance. He was one of the first specialists to organize a lung rehabilitation program and showed the beneficial effects of long-term oxygen therapy in COPD pathology. He published original investigations involving new devices, including fans, monitors and equipment for oxygen and aerosol therapy [ 21 , 23 ]. Working at the University of Colorado, he established and coordinated an outpatient pulmonary recovery team in the 1960s. He conducted several studies related to drug therapy in tuberculosis and the long-term sequelae of this disease [ 21 ]. In 1969 he published “A Comprehensive Care Program for Chronic Airway Obstruction,” in which he notified on the beneficial effects of pulmonary rehabilitation programs for patients recently discharged from the intensive care unit and for those with COPD [ 24 ]. Petty and his medical team estimated that the results obtained in 94 patients out of 124 included in a rehabilitation program made them have a better tolerance to effort, a reduced number of days of hospitalization and earlier return to work [ 17 , 21 ]. As a consequence of these amazing results, rehabilitation programs based on Petty’s model began to be established worldwide, and many researchers reported new rehabilitation programs with encouraging effects at various international congresses. In 1974 the American College of Chest Physicians formulated a definition of pulmonary rehabilitation, and in 1980 the American Thoracic Society (ATS) issued an official provision recognizing the effectiveness of exercising as an “essential” component of pulmonary rehabilitation [ 17 , 21 ].

Thomas L. Petty in his office at the University of Colorado Medical Center.

In the 1980’s, there was some skepticism about lung rehabilitation, arguing that patients’ exercise tolerance is limited by lung condition, so exercise cannot improve lung function because the intensity cannot exceed the critical training threshold. In 1999, a group of muscle biologists authored an extensive scientific paper presenting evidence that the ambulatory muscles of COPD patients are weakened and argued that these patients need to improve their muscle function, especially those involving locomotion [ 23 ]. After the 2000s, understanding the effectiveness and benefits of physical training became convincing, as it was shown that improving muscle function through rehabilitation directly improves exercise tolerance. In a 2005 paper, Professor Janos Porszasz together with a team of researchers had shown “the mechanism by which recovery training reduces dyspnea - at a certain level of exercise, it reduces the respiratory rate, thus allowing more time for exhalation, which decreases the dynamics of hyperinflation and therefore would improve resistance to submaximal exertion” [ 23 , 25 ].

The twentieth century is the century in which information technology has spread rapidly, having an impact on all areas of activity and daily life. In the medical field, with the help of studies and research, this medical branch has begun to develop worldwide, in a scientific and rigorous manner. Over time, special techniques and devices used in the recovery of lung patients have been developed, and the emergence of respiratory recovery centers, clinics and services are now widespread throughout the world.

Pulmonary rehabilitation and COPD: concepts, programs and importance of rehabilitation in current pneumology practice

The first time that physical therapy was used as a way to help pulmonary patients was during the First World War, when a British nurse applied this type of exercises on soldiers that suffered traumatic respiratory complication. The nurse name was Winifred Linton and after the war she continued applying these methods to pulmonary patients and also to teach others at the Royal Brompton Hospital in London. In the United States the use of airway clearance techniques was started by the polio epidemic, during 1940’s. As mentioned before, the first definition of pulmonary rehabilitation was draw up in 1974. Since then, due to the results obtained and the improvement of lung rehabilitation techniques, the definition has undergone multiple changes and additions. In 1979, was tried to redefine the term “respiratory rehabilitation” and to set new objectives. In 1981, was established a logical hierarchy of the stages included in a respiratory recovery program. In 1986, Professor Barry J. Make of Boston University School of Medicine wrote an article entitled Pulmonary Rehabilitation: Myth or Reality? in which he revises the previous definition and emphasizes the important role of respiratory rehabilitation [ 26 ]. In 1994 the NHLBI (National Heart, Lung, and Blood Institute) published a new definition where for the first time the role of the “interdisciplinary team of specialists” is specified in order to “acquire and maintain the maximum level of independence and functionality of the patient” . In 1999, the term “pulmonary rehabilitation” (PR) supports a new definition, this time referring to “individually adapting and designing to optimize physical performance” of respiratory rehabilitation programs. In 2006, ATS adopted a new broad definition, which is still valid today. As a novelty, it is specified that pulmonary rehabilitation is “an evidence-based, multidisciplinary, and comprehensive intervention” [ 27 ]. The current definition was given in 2013, it also emphasizes the prophylactic behavior, “promote long-term adherence to health-enhancing behaviors” [ 28 ]. In this last statement, pulmonary rehabilitation was defined as a comprehensive program, which included a team of professionals who worked together for the benefit of the patient. The multidisciplinary team included: a physician, a pulmonary and a physical therapist, nurses and other staff. Although the current definition of pulmonary rehabilitation remains relevant today with a few additions. The emergence of the COVID-19 pandemic made ATS to design new “models that aim to enhance access and uptake, including telerehabilitation and home-based models” [ 29 , 30 ].

The role of rehabilitation programs for COPD patients was scientifically proven by the studies conducted in this field during the years; the results show that rehabilitation programs improve the quality of life of these patients by alleviating symptoms like dyspnea and also by reducing anxiety and depression. The exercise training conducted during rehabilitation programs has a positive impact on the walking distance, the tolerance of the patients to exercise and on the physical function of patients with mild and severe COPD. Another important role of pulmonary rehabilitation is the positive impact it has on the exacerbation of COPD, because it helps patients overcome the event and also increase the time interval between the appearance of these episodes in the evolution of the disease by applying different type of methods of rehabilitation [ 31 ]. PR seems to also have an impact on the mortality rate of COPD patients, impact shown also in a study conducted by Özmedir et al. The authors assed the number of COPD patients that were referred and underwent a PR program, in Turkey, between 2008 and 2016, and also the general annual mortality rates which were lower in the patients included in a PR program in 2008 (6.2% – 11.1% vs 52.8%) [ 32 ].

The British Thoracic Society published a Pulmonary Rehabilitation program in 2013 in the Journal of the British Thoracic Society stating that PR should be offered to all patients suffering of COPD with the aim to improve the health status and the quality of life of these patients, by decreasing the intensity of the symptoms and the need for hospitalization [ 33 ]. In 2017 The Lung Foundation Australia and the Thoracic Society of Australia and New Zealand published a Pulmonary Rehabilitation Guideline, with the same recommendations that COPD patients should be recommended to follow a PR program [ 34 ]. In the European Lung White Book published by the European Respiratory Society the subject of PR is also addressed and recommendations are made [ 35 ]. The 2020 GOLD (Global Initiative for Chronic Obstructive Lung Disease) guideline, which is a reference point for COPD treatment, also shows the importance of pulmonary rehabilitation for these types of patients, and states that rehabilitation is the most useful therapeutic strategy used to improve shortness of breath, exercise tolerance and health status [ 36 ]. The interest showed for this field over the years highlights the importance of PR for this type of patients.

The essential components of pulmonary rehabilitation programs, are defined by ATS in an article published in 2021. During the first visit the patient assessment is conducted, and includes: assessment of the patients by a health care professional, performance of an exercise test and a field exercise test, measurement of the quality of life, quantification of dyspnea, evaluation of nutritional and professional status. After the first visit the program components are chosen taking in to account the information about the patient obtained during the first visit, the multidisciplinary team will conduct endurance and resistance training. During and after the program the quality assessment of the exercise prescribed is performed. The duration of such a pulmonary rehabilitation program is between 4 weeks to 20 months, with an average of 8 weeks, depending on the stage of the disease and the characteristics of each patient [ 30 ].

A key part of a COPD rehabilitation program is thought to be the education of the patient and this is why a special importance was given to it and every patient included in this type of programs were asked to participated in courses or were given information’s regarding the disease, the importance of treatment and the way devises should be used. In 2021 ATS stated that education remains an important part of COPD PR even though studies were not conducted in this domain and the most beneficial way to provide information to patient has to be determine. It is important to provide these types of information because in this way changes in behavior and the control of the disease can be obtain [ 30 ]. Long at el, studied the role of health coaching in improving the quality of life of this category of patients in a systematic review and meta-analysis, and showed that health coaching should be considered as a candidate intervention for improving quality of life and also shown that it has an impact on hospital admissions, reducing the numbers of readmissions [ 37 ].

Cardiopulmonary test should be conducted at the inclusion of patients in PR because it helps assess the influence of the cardiac and respiratory system on the exercise tolerance of a patient, especially because COPD patients can have underlying diseases. After the tests are performed the multidisciplinary team of the PR can establish the most helpful exercise training [ 38 ].

Most studies on the effects of physical training in COPD patients focus on whole-body endurance exercises, such as treadmill walking or using of a cycle ergometer. These exercises should be performed for a minimum of 20 minutes with an intensity of 60% or more of the maximum intensity tolerated by the patient. However, it is not possible for all COPD patients to follow these recommendations, due to the stage of the disease, associated diseases, etc. In their case, other types of exercises are used, such as Nordic walking for those individuals who have a relatively preserved tolerance to exercise or neuromuscular electrical stimulation (NMES) for those patients with a high degree of dyspnea or even mechanically ventilated patients [ 39 , 40 ]. Santos et al conducted a study comparing the effects of different intensities aerobic exercises in COPD patients (60% vs 80% maximum work rate) showing that exercises conducted with higher intensity than 60% W max did not have any additional benefits, regarding symptoms control or exercise tolerance [ 41 ].

The results of a meta-analysis conducted by Ryrsø et al, showed that the initiation as soon as possible (during or in the first 4 weeks after hospitalization) of a respiratory rehabilitation program in patients with COPD hospitalized for exacerbations of the disease, causes a decrease in mortality, number of days of hospitalization and number of readmissions [ 42 ]. A study also conducted in patients with acute exacerbation of COPD by Lioa et al concluded that pulmonary rehabilitation improves symptoms such as dyspnea and cough, and also increases exercise tolerance and decrease sputum expectoration [ 43 ].

Another important part of the respiratory rehabilitation program is represented by the supportive strategies, like psychotherapy and nutritional advice. Nutritional advice can also involve prescription of nutritional supplements or even pharmacological treatment, part attributed to the nutritionist in the multidisciplinary team. Its role has been shown especially in patients suffering from weight loss or muscle loss. The effectiveness of targeted nutrition was analyzed by Bool et al in a study conducted on 81 patients diagnosed with COPD with low muscle mass included in a PR program. The results of the study showed that Specific nutritional supplementation has a positive impact on nutritional status, inspiratory muscle strength and on the physical activity of these patients compared to placebo [ 44 ]. Psychotherapy is also a well-known supportive strategy, because COPD patients struggle with depression and anxiety. The results of a meta-analysis conducted by Farver-Vestergaard et al, support the use of psychosocial intervention in patients diagnosed with COPD as a multidisciplinary respiratory care tool because of the potential it has to improve both psychological and physical outcomes [ 45 ].

Because the underlying disease for which rehabilitation is performed is a condition with gradual evolution that involves the progressive loss of respiratory function, the repetition of the rehabilitation program may be considered depending on the needs of patients. An important aspect to consider is that at least 1 year should pass after the last PR if repetition is needed [ 34 ]. Blervaque et al. conducted a 5-year cohort study in which patients diagnosed with COPD how underwent a pragmatic multidisciplinary PR maintenance program with a duration between 1 and 5 years and the results showed that the less severe COPD patients included in this group showed significant PR benefits at 4 years for the 6-min walking distance and the Health-Related Quality of Life and at 5 years for the modified Medical Research Council. Also, in the PR group the 5-year survival probability was found to be higher [ 46 ].

As stated above rehabilitation is an important component in the management of COPD patients, but unfortunately 50% of patients diagnosed with this disease are not willing to participate in such a program and 30 to 50% give up attending after a few sessions. Debilitating symptoms and encountering difficulties in transportation to centers or hospitals are the most incriminated reasons [ 31 ]. In order to create more accessible programs for different type of patients, researchers are trying to find new ways to make patients with COPD more adherent to rehabilitations programs by using all the technologies available today. This is why telerehabilitation programs started to be implemented worldwide and studies are conducted to assess the efficacy of this type of rehabilitation.

Pulmonary rehabilitation in Romania

Our literature review returned no relevant data on Romanian history of rehabilitation medicine; using alternative sources (medical treatises, medical courses, magazines) we were able to summarize some important milestones.

In Romania, pulmonary rehabilitation is a component part of Medical Rehabilitation, a clinical medical specialty which prior to 2013 was called Recovery, Physical Medicine and Balneology . According to the medical practice guide for the specialty of Recovery, physical medicine and balneology , medical rehabilitation is defined as the independent clinical medical specialty responsible for the prevention, diagnosis, treatment, and management of rehabilitation of people with disabilities and comorbidities at all ages. This specialty is also responsible for the physical and cognitive performance of such patients, as well as increasing their quality of life. Its purpose is to improve and restore the functional capacity and to ameliorate symptoms in people with physical disabilities. Among the objectives of rehabilitation can be listed: improving the quality of life, reducing dyspnea, increasing exercise tolerance, reducing anxiety, increasing joint mobility, increasing muscle strength, psychosocial reintegration, etc [ 17 , 47 ].

Medical rehabilitation as a concept emerged in Romania in the 1920’s but dedicated medical establishments sprung into existence in the second half of the 1970’s. The demand for rehabilitation services was only partially satisfied in an erratic and inconstant way. The existence of medical resorts such as Felix, Herculane, Govora, Tuşnad, Olăneşti, Slănic Moldova had a positive impact and helped develop services and even a certain experience and tradition in the field of recuperative medicine. In the seventh decade of the XXth century local public health leaders in Iasi and Cluj advanced the idea of founding rehabilitation hospitals; in Iasi construction commenced in 1974 - three years later the first patients were admitted.

The first respiratory rehabilitation treaty was drafted by Prof. Tudor Zbenghe in 1983 to formalize such approaches. It must be mentioned that respiratory rehabilitation and physical therapies have been part of standard of care in respiratory medicine from the beginning of pneumology and thoracic surgery: simple recruiting techniques to prevent postoperative atelectasis, respiratory gymnastics to prevent fibrothorax, postural drainage and tapotage for bronchiectasis and pulmonary abscesses, nutritional supplementation and physical exercise for tuberculosis are but few examples of tools that have been used during the twentieth century for pulmonary disorder in Romanian respiratory centers. Halotherapy must be mentioned as a trademark eastern European respiratory therapy (a situation explained by the large salt deposits in the area) - known and used for at least two hundred years. This approach was first backed up by anecdotic evidence and popular beliefs, but recent high-quality data supports the use of inhaled saline by products for suppurative pulmonary disorders [ 48 ]. It should be noted that doctors in Romania have been closely concerned with this branch of medicine with all the syncopes and obstacles imposed by the times. An illustrious name is that of Prof. Dr. Iuliu Moldovan (1882–1966) from the Cluj Faculty of Medicine, he discovered and used therapeutic reticulin, with beneficial effect for the treatment of human patients with allergic disease, some moderate vascular alterations but especially to prevent different forms of anaphylactic shock [ 49 ]. Another important name of Romanian medicine is that of Prof. Dr. Octavian Fodor (1913–1976), who made some original contributions for that period, published in his treatise on internal medicine in 1972 [ 50 ].

In Romania, pulmonary rehabilitation programs are carried out according to international guidelines and standards, Iaşi and “Grigore T. Popa” University of Medicine and Pharmacy being a center of prime importance in this field. Over 1000 patients included annually in the lung recovery program, of which over 500 have COPD. In Iaşi, the cardiopulmonary recovery clinic was founded on the initiative of Prof. Dr. Ioan Lungu, starting with 2008 it split in two medical directions. Nowadays, in the Respiratory Recovery Clinic of the Clinical Recovery Hospital in Iaşi, approximately 500 patients with COPD are treated annually out of a total of 800,000 patients with COPD, the rest being patients with asthma, chronic bronchitis, pulmonary emphysema, bronchiectasis, bronchopulmonary neoplasm, sequelae of tuberculosis, idiopathic pulmonary fibrosis etc. Respiratory rehabilitation is practiced and promoted also in other university centers, such as Bucharest, Timişoara, Craiova, Cluj-Napoca, Constanţa, Oradea, Braşov, Sibiu or other county hospitals [ 17 ].

Various respiratory physical techniques have been employed since ancient times to achieve or to maintain health drawing from direct observation and traditional and religious/philosophical practices and teachings. While lacking a theoretical basis some of these practices proved to be effective and withstood the test of time being still employed today in various refined forms.

Modern scientific approaches validated some traditional respiratory rehabilitation practices and consolidated an evidence-based body of knowledge. Wide acceptance and further development of pulmonary rehabilitation was somewhat hindered by a certain lack of standardization and methodology of quantifying the health effects – a difficult task as rehabilitation is frequently intermingled with other therapeutic approaches. At the present moment there is reliable data supporting the role of pulmonary rehabilitation in COPD management and current guidelines strongly recommends its use.

There are few published data relevant to the history of Romanian pulmonary rehabilitation - this topic should be addressed by future research focusing on alternative sources such as medical archives, public annuaries and using the tools of historiography. Speleotherapy and more specific halotherapy may be mentioned as a Romanian/Eastern European particular contribution to respiratory rehabilitation armamentarium.