Chronic respiratory diseases: The dawn of precision rehabilitation

Pulmonary rehabilitation (PR) is undoubtedly a pivotal intervention in the management of patients with chronic respiratory diseases (CRD) with troublesome and persistent exertional symptoms and exercise intolerance. Accordingly, a special review series on PR, written by acknowledged international experts in the field, is certainly welcome and provides lucid insights into its current status while offering thoughtful commentaries on its future evolution. In the prologue, Franssen and Alison1 correctly emphasize that rehabilitation should be individualized, based on a careful assessment of ‘the current and future burden’ of the disease. The need for individualized assessment and management permeates this series and makes a great deal of sense. Troosters et al.2 remind us that exclusive focus on enhanced cardiorespiratory fitness as the traditional outcome measure of interest for PR may be a little short-sighted. They suggest that the identification of ‘treatable traits’ and the adoption of a more integrative, individualized approach that considers the most pressing needs of the participant is the ideal strategy. This line of reasoning is bolstered by Spruit and Wouters,3 who suggest that the degree of disease complexity of the individual should influence the type of intervention and the rehabilitation setting with the highest likelihood of success. Notably, they suggest an intensive, multidisciplinary, in-hospital programme for care-dependent patients in the recovery phase of acute respiratory failure. As more patients survive life-threatening episodes of acute respiratory failure than ever before, and patients with stable CRD are increasingly offered non-invasive mechanical ventilation, the need for specialized PR to support such individuals will surely escalate. However, the provision of this type of sophisticated, multi-modality PR has major economic implications and is currently limited to few specialized centres. Thus, the demonstration of long-term clinical efficacy and favourable cost–benefit analysis for such specialized PR programmes becomes important. The comprehensive reviews by Rochester4 and Amstrong and Vogiatzis5 provide clear directions on how best to select patients in order to align their needs with the most appropriate set of interventions, including personalized exercise training. It would seem that traditional PR referral criteria based mainly on individual assessments of dyspnoea, fatigue and exercise intolerance are still appropriate and have stood the test of time. The majority of patients attending PR programmes in the modern era have chronic obstructive pulmonary disease (COPD), but we increasingly see expansions to include those with other CRD. The similarities and differences in the overall impact of PR in COPD and asthma reviewed by Osadnik and Singh6 are very interesting. A careful review of the evidence for the benefits of PR for non-obstructive lung diseases (interstitial lung disease, pulmonary hypertension, bronchiectasis and lung cancer) is provided by Granger et al.7 An over-arching objective of all PR programmes is to facilitate continuous engagement in daily physical activity in patients with permanent physiological impairment. The challenge has always been to ensure that gains in functional capacity from PR translate into increased and sustained habitual physical activity. The importance of the exercise training component of PR is appropriately recognized, but clearly, a sizeable fraction of patients with advanced CRD—many with significant co-morbidities—may not reach training thresholds where physiological benefits are consistently achieved. Moreover, improvements in exercise capacity are often short lived, particularly if home-based exercise maintenance programmes are not adhered to or if acute exacerbations ‘neutralize’ hard-earned improvements in functional capacity. Spencer and McKeough8 tackle the difficult question of how best to ensure adherence to maintenance programmes and posit that longer-duration PR programmes, together with a more individualized approach that recognizes the patients' specific circumstances, are likely to be more successful. In recent years, convincing evidence has emerged that PR is associated with a reduction in the frequency and severity of exacerbations of COPD, and reducing hospitalization has now become an important goal. However, the challenges of enrolling patients early in the post-exacerbation phase are considerable, and this service is often restricted (for logistic and economic reasons) to a few specialized centres. Not all post-exacerbation patients are capable of meaningfully engaging in PR, and Ibrahim et al.9 provide an expert perspective on this topical issue. One of the major challenges for caregivers in PR is the effective management of patients referred for refractory breathlessness—one of the most distressing symptoms of CRD. Our understanding of the neurophysiological mechanisms of breathlessness has increased substantially, and our ability to measure the sensory intensity, qualitative and affective dimensions of the symptom, as well as the negative impact on daily living, has significantly improved in recent years. For chronically breathless patients, PR is arguably the most effective intervention. Therefore, when anticipating the inevitable escalating demand for PR in increasingly complex symptomatic patients, there is an urgent need for systematic research on the mechanisms and individualized management of breathlessness in patients with CRD enrolled in PR. In this context, adjunctive therapies can facilitate exercise training by delaying the rise in exertional breathlessness, facilitating higher levels of training in selected patients, as detailed by Vanfleteren and Gloeckl.10 These interventions include resistance training, neuromuscular electrical stimulation, sequential ‘one leg’ exercise training, inspiratory muscle training, non-invasive ventilation and nasal high-flow oxygen. The data supporting these new approaches are currently sparse but, nevertheless, deserve further scientific scrutiny. For patients with advanced chronic lung diseases referred to PR with incapacitating breathlessness with breakthrough panic attacks and ‘dyspnoea crisis’, PR personnel have a central role. Although often not standardized, education and behaviour modification are integral to PR and often yield major success in reducing psychological morbidity, improving self-efficacy and independence. The dearth of knowledge among new PR participants about even basic aspects of living with CRD is always concerning. The challenges in delivering patient-tailored, educational interventions that change behaviour are comprehensively reviewed by Blackstock and Evans.11 These authors point out that, while PR provides an excellent opportunity for structured educational activities, further studies are required to identify the most relevant educational outcomes and practical goals for each participant. In this context, new technologies have the potential to help convey the ‘right information at the right time’. In conclusion, the authors of this series must be commended for providing a splendid ‘state-of-the-art’ review on the current and future status of PR. The solid evidence-based foundation for PR presented here is indisputable, as is the escalating need to offer this effective interdisciplinary intervention to more and more people burdened by CRD. This series sets the stage for continued dialogue and international collaboration among caregivers and researchers to better refine selection criteria, to identify ‘treatable traits’ in order to personalize the PR intervention and, ultimately, to sustain long-term health benefits for all participants.

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