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Article Summaries

Dyspnea and quality of life in patients with pulmonary fibrosis after six weeks of respiratory rehabilitation.
Jastrzebski D, Gumola A, Gawlik R, Kozielski J. J Physiol Pharmacol. 2006;57(Suppl 4):139-148.

Effectiveness of pulmonary rehabilitation in restrictive lung disease.
Naji NA, Connor MC, Donnelly SC, McDonnell TJ. J Physiol Pharmacol. 2006;26(4):237-243.

Introduction:

There is a growing appreciation for the role of pulmonary rehabilitation (PR) in the management of chronic obstructive pulmonary disease, but its use in interstitial lung disease (ILD) is controversial.1 Recent data suggest that while two-thirds of the pulmonologists in the US routinely refer patients with IPF for PR, many pulmonologists do not prescribe PR in patients with ILD because of lack of data proving efficacy and difficulties with insurance coverage.2 Two recent publications provide preliminary evidence that PR is effective in improving functional status, dyspnea, and quality of life in ILD.

Findings:

  • Study 1: Dyspnea and quality of life in patients with pulmonary fibrosis after six weeks of respiratory rehabilitation.3
    • 38 patients with ILD enrolled in a 6-week individualized PR program.
    • Endpoints were:
      • Dyspnea (measured by the baseline dyspnea index, medical research council scale, oxygen cost diagram, and Borg score)
      • Quality of life (measured by the short form-36 and Saint George's Respiratory Questionnaire [SGRQ]).
    • 31 patients completed the 6-week study.
    • Mean age 49 years; diagnoses included idiopathic pulmonary fibrosis (13), non-specific interstitial pneumonia (8), connective tissue disease (5), chronic hypersensitivity pneumonitis (4), and silicosis (1).
    • Results showed significant improvement in dyspnea (Borg score) and quality of life (SGRQ) at 6 weeks.
  • Study 2: Effectiveness of pulmonary rehabilitation in restrictive lung disease.4
    • 46 patients with restrictive lung disease (35 with ILD, 11 with skeletal restriction) enrolled in an 8-week PR program.
    • Endpoints included dyspnea (measured by the chronic respiratory disease questionnaire (dyspnea component of CRDQ), quality of life (measured by the CRDQ and SGRQ), and functional status (measured by treadmill and shuttle walk testing).
    • Of the patients with ILD, 22 completed the 8-week study.
    • Mean age 66 years; diagnoses included idiopathic pulmonary fibrosis (28), connective tissue disease (4), sarcoid, radiation, and lymphangioleiomyomatosis (1 each).
    • Overall results showed significant improvement in dyspnea, quality of life, and functional capacity (treadmill) at 8 weeks. After 1 year, only the improvement in treadmill distance remained.

Expert Opinion:

The data from Jastrzebski and Naji suggest that PR improves dyspnea, quality of life, and functional status in patients with ILD. However, there are several important limitations to these studies that question their validity.

  • Both studies used small, uncontrolled cohorts. It is unknown whether these patients are truly representative of the larger ILD population, or whether patients without PR (ie, controls) might also experience the changes demonstrated.
  • Both studies failed to study PR on an intention-to-treat basis. It is unknown whether the inclusion of data from all patients enrolled (ie, those who finished and those who dropped out) would have led to a different result.
  • The metrics used to measure dyspnea and functional status are not robust; there are more valid and reliable tools available.
  • The statistical approaches in both studies are limited, failing to use paired analyses in the case of Jastrzebski,3 and failing to analyze the ILD group separately in the case of Naji.4

    Despite these limitations, these studies support the use of PR in patients with ILD, and it is the opinion of most experts in the field that PR should become standard of care. In a group of diseases that are often without effective therapy, PR is a relatively low-cost, low-risk intervention, and patients should be encouraged to participate in PR as part of their management plan. Larger, more rigorous studies of PR are needed to more definitively prove its benefit.

References

  1. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12):1390-1413.
  2. Collard HR, Loyd JE, King TE Jr. Lancaster LH. Current diagnosis and management of idiopathic pulmonary fibrosis:
    a survey of academic physicians. Respir Med. 2007;101(9):2011-2016.
  3. Jastrzebski D, Gumola A, Gawlik R, Kozielski J. Dyspnea and quality of life in patients with pulmonary fibrosis after six weeks of respiratory rehabilitation. J Physiol Pharmacol. 2006;57(Suppl 4):139-148.
  4. Naji NA, Connor MC, Donnelly SC, McDonnell TJ. Effectiveness of pulmonary rehabilitation in restrictive lung disease.
    J Cardiopulm Rehabil. 2006;26(4):237-243.

Article Links

Jastrzebski D, Gumola A, Gawlik R, Kozielski J. Dyspnea and quality of life in patients with pulmonary fibrosis after six weeks of respiratory rehabilitation. J Physiol Pharmacol. 2006;57(Suppl 4):139-148.
Click here for a direct link to the article abstract.

Naji NA, Connor MC, Donnelly SC, McDonnell TJ. Effectiveness of pulmonary rehabilitation in restrictive lung disease. J Cardiopulm Rehabil. 2006;26(4):237-243.
Click here for a direct link to the article abstract.