Pulmonary rehabilitation earns strong recommendation in new clinical practice guideline

Despite its effectiveness, pulmonary rehabilitation (PR) is underused and under-prescribed. The expert panel charged with developing guidance for practitioners is hopeful that the latest Clinical Practice Guideline from the American Thoracic Society will change that.

Posted online in the American Journal of Respiratory and Critical Care Medicine, the panel issued a "strong recommendation" for PR in adults with stable chronic obstructive pulmonary disease or COPD.

Over the last 10 years, the ATS has published more than 43 clinical practice guidelines on various conditions, including COPD. Typically, only a minority of expert panel recommendations are strong, which was the case for both COPD recommendations, as well as the ILD recommendation in the new guideline.

"A strong recommendation indicates that the committee is certain that the desirable consequences of a recommendation outweigh the undesirable consequences," said ATS Chief of Guidelines and Documents Kevin Wilson, MD.

In addition, strong recommendations that are based upon moderate or high-quality evidence lay the groundwork for developing health care performance measures, which are used to determine clinicians' adherence to specific recommendations (such as referrals of suitable patients to PR).

"We hope that these Clinical Practice Guidelines for PR will be a call to action to clinicians to refer suitable patients to PR and encourage their participation in treatment, as well as foster pulmonary specialists' communication with health care professionals in other disciplines (for example, primary care and cardiology) about the benefits of PR for patients," said lead guidelines editor Carolyn L. Rochester, MD, professor of medicine at the Yale University School of Medicine.

COPD is the third leading cause of death worldwide, resulting in more than 3 million deaths in 2019, according to the World Health Organization. Low- and middle-income countries account for more than 75% of COPD cases globally.

In the U.S., an estimated 30 million Americans suffer from COPD. The rates of disease are made starker by the estimate of PR treatment: only 3–4% of Medicare patients with COPD have been prescribed the treatment, according to a 2019 study in the Annals of the American Thoracic Society. The reasons PR is rarely part of the treatment plan are varied and include a lack of knowledge on the part of both clinicians and patients, reimbursement issues, as well as health care disparity.

"There is an overall grossly insufficient number of PR programs available relative to the number of patients who could benefit, and individual programs' capacity is limited," said Dr. Rochester. "Racial and socioeconomic barriers to PR referral and/or participation have been identified. In addition, insurance reimbursement of PR programs is insufficient (and is approximately half of the reimbursement rate for cardiac rehabilitation), despite a similar spectrum of services."

Using the thorough, evidence-based Grading of Recommendations, Assessment, Development and Evaluation or GRADE framework, the expert panel made the following recommendations for patients with COPD as well as interstitial lung disease and pulmonary hypertension:

COPD recommendations

Should adults with stable chronic obstructive pulmonary disease undertake pulmonary rehabilitation?

For adults with stable chronic obstructive pulmonary disease (COPD), we recommend participation in pulmonary rehabilitation (strong recommendation, moderate quality evidence).

Should adults with chronic obstructive pulmonary disease undertake pulmonary rehabilitation following hospitalization for an exacerbation?

For adults with COPD, we recommend participation in pulmonary rehabilitation following hospitalization for an exacerbation of COPD (strong recommendation, moderate quality evidence).

ILD recommendation

Should adults with interstitial lung disease undertake pulmonary rehabilitation?

For adults with interstitial lung disease, we recommend participation in pulmonary rehabilitation (strong recommendation, moderate quality evidence).

Pulmonary hypertension recommendation

Should adults with pulmonary hypertension undertake pulmonary rehabilitation?

For adults with pulmonary hypertension, we suggest participation in pulmonary rehabilitation (conditional recommendation, low quality evidence).