Guideline sources The following summarized guidelines for the evaluation and management of pulmonary rehabilitation are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2013). 1 Guidelines 1. Diagnostic investigations Evaluation for comorbidities: consider initial assessment for pulmonary rehabilitation as it provides an opportunity to assess and refer for treatment of comorbidities prior to commencing. E 2. Medical management Indications, stable outpatients: refer patients with a Medical Research Council (MRC) dyspnea score of 3-5 who are functionally limited by breathlessness for outpatient pulmonary rehabilitation. A Indications, post COPD exacerbation: administer pulmonary rehabilitation to patients hospitalized for acute exacerbation of COPD at hospital discharge to commence within 1 https://web.pathway.md/diseases/recvQwutHqGX4yBP4 1/4 6/29/23, 11:36 PM Pulmonary rehabilitation Pathway month of discharge. A Goals of pulmonary rehabilitation: administer pulmonary rehabilitation to patients with COPD with a view to improving exercise capacity by a clinically important amount. A Duration of pulmonary rehabilitation programmes: advise pulmonary rehabilitation programmes of 6-12 weeks. A Bronchodilators: initiate bronchodilator therapy for patients with COPD in line with National Institute for Health and Clinical Excellence (NICE) COPD guidelines prior to referral to pulmonary rehabilitation. B Noninvasive ventilation: avoid long-term domiciliary noninvasive ventilation for the sole purpose of improving outcomes during pulmonary rehabilitation. D Supplemental oxygen: avoid the routine use of supplemental oxygen for all patients undergoing pulmonary rehabilitation. D Supplemental heliox: avoid using heliox as an adjunct to pulmonary rehabilitation unless there are comorbidities which require its administration. D 3. Nonpharmacologic interventions Smoking cessation: refer patients with COPD for pulmonary rehabilitation regardless of their smoking status. B Hormonal and nutritional supplements: at present, no specific hormonal or nutritional supplement can be prescribed as a routine adjunct to pulmonary rehabilitation. B Nature of exercise training: advise generic exercise training as opposed to individually targeted exercise training for pulmonary rehabilitation. B Frequency of exercise training: advise pulmonary rehabilitation programmes for a minimum of twice-weekly supervised sessions. B Interval and continuous aerobic training: advise interval and continuous training as it can be applied safely and effectively within the context of pulmonary rehabilitation to patients with COPD. A Inspiratory muscle training: avoid inspiratory muscle training as a routine adjunct to pulmonary rehabilitation. D Supervision of pulmonary rehabilitation: advise a supervised pulmonary rehabilitation programme for patients with COPD. A 4. Therapeutic procedures Neuromuscular electrical stimulation: consider neuromuscular electrical stimulation in selected patients with low BMI and evidence of quadriceps weakness who are unable or unwilling to participate in pulmonary rehabilitation. C 5. Specific circumstances https://web.pathway.md/diseases/recvQwutHqGX4yBP4 2/4 6/29/23, 11:36 PM Pulmonary rehabilitation Pathway Patients with asthma: avoid routinely referring patients with asthma for pulmonary rehabilitation. D Show 3 more Patients with chronic obstructive pulmonary disease: consider referring patients with COPD for pulmonary rehabilitation regardless of whether or not they have chronic respiratory failure. C Patients with cardiovascular disease: avoid precluding referral to pulmonary rehabilitation and being included in moderate-intensity aerobic exercise training in case of a coexistent AAA < 5.5 cm, provided BP is controlled. D Patients with psychiatric conditions: avoid precluding referral to pulmonary rehabilitation in case of coexistent symptoms of anxiety and/or depression in patients with COPD. D Patients with non-cystic fibrosis bronchiectasis: consider patients with non-cystic fibrosis bronchiectasis who have breathlessness affecting their activities of daily living for pulmonary rehabilitation. C Patients with interstitial lung diseases: discuss the benefits of exercise and the recommendation of incorporating exercise activities into a healthy lifestyle with all patients with ILD. Tailor such discussion to realistic achievability for that person's condition. E Patients with other chronic respiratory diseases: minimal clinically important different changes and tools used to assess exercise capacity and quality of life for pulmonary rehabilitation in COPD are not necessarily transferable to other chronic respiratory diseases. E 6. Patient education General counseling: acquire basic knowledge about what pulmonary rehabilitation programs entail and about their effectiveness. Present pulmonary rehabilitation programs as a fundamental treatment for COPD, rather than an optional add-on. E 7. Follow-up and surveillance Indications for specialist referral: consider the setting of pulmonary rehabilitation, skill mix of the team and other comorbidities in the risk assessment of patients entering a rehabilitation programme. E Repeat pulmonary rehabilitation: consider repeat pulmonary rehabilitation in patients who have completed a course of pulmonary rehabilitation over 1 year ago. Discuss likely benefits and refer interested patients. C References 1. Bolton CE, Bevan-Smith EF, Blakey JD et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax. 2013 Sep;68 Suppl 2:ii1 30. Open https://web.pathway.md/diseases/recvQwutHqGX4yBP4 3/4 6/29/23, 11:36 PM Pulmonary rehabilitation Pathway 2. Romina Wahab, Natalie H Yip, Subani Chandra et al. The implementation of an early rehabilitation program is associated with reduced length of stay: A multi-ICU study. J Intensive Care Soc. 2016 Feb;17 1 2 11. Open https://web.pathway.md/diseases/recvQwutHqGX4yBP4 4/4