Program Setting
Pulmonary rehabilitation can be conducted in a variety of settings, including hospital outpatient departments, community settings or at home.
Hospital-based programs
Hospital-based programs are predominantly outpatient programs provided on a hospital campus, using hospital-based staff and equipment. Hospital-based programs may be the most appropriate option for patients with very severe disease and/or complex comorbid conditions. This environment has the advantage of providing direct communication with respiratory physicians and other healthcare professionals, and access to acute medical care if required. Other indications for hospital-based programs include the requirement for high levels of supplementary oxygen and to enable direct access to the healthcare team for individuals at risk of complications in the early period following thoracic surgery. Patients who desaturate below an oxygen level of 80% during exercise training, despite the use of interval training, should be assessed in a hospital-based program to determine the benefits of supplemental oxygen.
Attendance at outpatient hospital-based programs may depend on transport availability and patient choice.
Inpatient pulmonary rehabilitation should be commenced early for patients recovering from an acute exacerbation.
Pulmonary rehabilitation (either inpatient or outpatient) following an exacerbation of COPD improves health-related quality of life and exercise capacity, and reduces hospital readmissions, and has been shown to be safe with no adverse events.23
Community-based programs
Community-based pulmonary rehabilitation programs have been shown to improve exercise capacity and health related quality of life Goftfredsen et al, 2018. The exercise training should consist of endurance and strength training with emphasis on endurance walking to mimic the hospital-based pulmonary rehabilitation program. Exercise training should be prescribed by a physiotherapist or exercise physiologist and be at a similar frequency and intensity as hospital-based programs in order to achieve clinically meaningful benefits for patients. These programs are run in community settings (e.g., leisure centres; halls, health or rehabilitation centres; senior citizens centres or private practices). These programs may be run by hospital/community health staff, by physios or accredited exercise physiologists in primary care.
Home-based programs
Home-based pulmonary rehabilitation is recommended in the Aust/NZ pulmonary rehabilitation guidelines1as an effective alternative to centre-based programs. Home-based pulmonary rehabilitation described by Holland et al is conducted in the patient’s home, with a home visit by a physiotherapist followed by weekly supportive phone calls. A variety of home-based models are available, ranging from home visits for direct supervision to weekly telephone calls.24Regardless of the model, regular contact is essential to ensure that the exercise training program is progressed throughout the program. The exercise training should consist of endurance and strength training with emphasis on endurance walking to mimic the hospital-based pulmonary rehabilitation program.
Home-based programs may be beneficial for patients who are unable to attend a centre-based program (e.g., isolation, transport difficulties, long term oxygen therapy, severe symptoms). However, potential limitations to home-based programs are that the patient do not benefits from the peer support gained from the group setting and that exercise progression is not directly supervised. There are no guidelines regarding which patients are most suitable for home-based programs and patient preference is an important consideration.
Lung Foundation has developed a resource that may complement exercise component of home program: Better Living with Exercise – Your Personal Guide. Please note, this is designed to be only used by a Physiotherapist or an Accredited Exercise Physiologist.
Virtual pulmonary rehabilitation programs (Telerehabilitation)
Virtual pulmonary rehabilitation provides a program of exercise and education via a telehealth or video-conferencing platform for people with respiratory conditions who have access to Wi-Fi and a suitable device. A recent Cochrane review that reporting on a number of different models of telerehabilitation reported that telerehabilitation programs have good completion rates with no more adverse events that centre-based pulmonary rehabilitation programs. (Cox et al al)
The model of care is still evolving. Patients would ideally be assessed face-to-face at the centre, and then join the telerehabilitation group. In some circumstances a home-visit to commence the telerehabilitation program may be required. In the presence of a pandemic when face-to-face visits are suspended, the initial assessment may be able to be modified to be performed by telehealth. At present available models of telerehabilitation may not be suitable for some vulnerable patient groups including people with significant communication barriers, cognitive impairment and those at risk of falling.
It is not possible to perform a 6MWT via telehealth. It is possible to measure oxygen saturation and heart rate, however relevant monitors need to available to participants. Other measures of exercise strength and endurance e.g., 5STS and 1min STS test, may be able to be performed however there is currently no evidence for their reliability or repeatability when measured remotely, nor can they be used to prescribe endurance training intensity. Standard pulmonary rehabilitation questionnaires can be administered remotely via telehealth.
The frequency, intensity, time and type of training should aim to reflect that of centre-based pulmonary rehabilitation programs. Although gym equipment may not be available in the home – people at home can use hand weights, body weight, marching on the spot and functional exercises (e.g., sit to stand) to achieve improved outcomes.