Pulmonary rehabilitation has been a core treatment for various pulmonary ailments such as cystic fibrosis, idiopathic pulmonary fibrosis (IPF), and chronic obstructive pulmonary disease (COPD) for decades.
Pulmonary rehabilitation is a simple, noninvasive way to address a decline in lung performance. It can be performed in a home-based setting, reducing the patient burden in healthcare facilities. It usually takes 3 to 48 weeks to see results.
What difference does pulmonary rehabilitation make? Studies have found that pulmonary rehabilitation improves functional fitness, as reflected in the performance of the 6-minute walk distance test. Studies also demonstrate that individuals with interstitial lung disease who participated in pulmonary rehabilitation improved their 6-minute walk distance performance by a mean difference of approximately 40 meters. In addition, patients undergoing pulmonary rehabilitation also experience improvements in peak workload and peak oxygen consumption.
Pulmonary rehabilitation can also relieve one of the more distressing symptoms associated with lung disease—dyspnea. There is enough evidence to demonstrate that pulmonary rehabilitation can significantly reduce dyspnea in patients with IPF. Along those lines, pulmonary rehabilitation positively impacts health-related quality of life; a study found that this was true across all 4 domains in 2 quality-of-life scores, the Chronic Respiratory Disease Questionnaire and the St. George’s Respiratory Questionnaire.
Read more about IPF etiology
“Five studies reported longer‐term outcomes, with improvements in exercise capacity, dyspnoea, and health‐related quality of life still evident 6 to 12 months following the intervention period,” Holland and colleagues wrote in the Cochrane Database of Systematic Reviews.
Impact on IPF
In Chest, Nolan et al explored an important question: do people with IPF on pulmonary rehabilitation improve to the same extent as a matched group of individuals with COPD? And how does noncompletion or nonresponse affect 1-year all-cause mortality?
This study by Nolan and colleagues is intended to gauge the extent to which pulmonary rehabilitation improves outcomes, particularly survival. According to their results, the evidence for the benefits of pulmonary rehabilitation is more modest in IPF than it is in COPD.
This is driven by a few factors. First, individuals with IPF deteriorate more rapidly than patients with COPD (which is best described as a chronic condition), which calls into question any associated benefits of pulmonary rehabilitation on survival. Studies on the effects of pulmonary rehabilitation in IPF are also relatively scarce. In contrast, there is a clear association between pulmonary rehabilitation and extended survival in COPD.
It is important to clarify that this study aims to assess the relative benefits of pulmonary rehabilitation in IPF. That pulmonary rehabilitation improves outcomes is not in dispute; rather, Nolan and his team were keen to identify if these improved outcomes met a certain threshold of importance in real-world settings. Pulmonary rehabilitation may improve outcomes in a number of domains, but how many patients with IPF survive 1 year after pulmonary rehabilitation discharge?
Read more about IPF treatment
For their study, they recruited 163 patients with IPF and patients with COPD as control in a 1:1 ratio. Baseline physical and functional measurements were taken in both groups of patients. The research team compared the completion rates of pulmonary rehabilitation in both groups and their responses. They also assessed survival status among patients with IPF over 1 year after completion of pulmonary rehabilitation. Statistical analysis was then performed to investigate the relationship between pulmonary rehabilitation status and all-cause mortality.
The research team discovered that patients with IPF undergoing pulmonary rehabilitation experienced improvements in exercise capacity, dyspnea, and health-related quality of life—benefits that have been validated by past studies. Importantly, these improvements were comparable with that of a propensity score-matched cohort of individuals with COPD.
“Although we found an association between pulmonary rehabilitation status and survival, uncertainty remained about the reliability of the estimate owing to wide confidence intervals,” they wrote. “Furthermore, we are unable to comment on causality, and it is plausible that this relationship could be explained by unmeasured confounding factors such as disease exacerbation, hospitalizations, or worsening of comorbidity.”
A Positive Outlook
The research team did discover that the noncompletion of or nonresponse to pulmonary rehabilitation was an independent risk factor for all-cause mortality at 1 year among patients with IPF. If anything, this reinforces the idea that pulmonary rehabilitation impacts survival in a positive way.
The results of this study alone are enough to justify the continued prescription of pulmonary rehabilitation among patients with IPF and, more broadly, patients suffering from interstitial lung diseases. In incurable conditions such as IPF and COPD, clinicians and patients should seize on any opportunity that drives improved outcomes.
It is worth noting that physicians and physiotherapists are moving from an exclusively physical form of physiotherapy to what is now termed “telerehabilitation”—conducting rehabilitation via an online connection (as opposed to an in-person consultation). This practice has blossomed as a result of the COVID-19 pandemic, during which many individuals across the globe were confined to their homes. Telerehabilitation has the potential to reach more patients with the benefits of pulmonary rehabilitation, potentially improving treatment access and changing the landscape of pulmonary care for the better.
Nolan CM, Polgar O, Schofield SJ, et al. Pulmonary rehabilitation in idiopathic pulmonary fibrosis and COPD: a propensity-matched real-world study. Chest. 2022;161(3):728-737. doi:10.1016/j.chest.2021.10.021
Dowman L, Hill CJ, May A, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev. 2021;2(2):CD006322. doi:10.1002/14651858.CD006322.pub4
Wen J, Milne S, Sin DD. Pulmonary rehabilitation in a postcoronavirus disease 2019 world: feasibility, challenges, and solutions. Curr Opin Pulm Med. 2022;28(2):152-161. doi:10.1097/MCP.0000000000000832