Primary care of the patient with chronic obstructive pulmonary disease-part 3: pulmonary rehabilitation and comprehensive care for the patient with chronic obstructive pulmonary disease.
This article reviews the rationale for and the benefits from a pulmonary rehabilitation approach to the treatment of chronic obstructive pulmonary disease (COPD). Key clinical trials, meta-analyses, and national guidelines or statements on pulmonary rehabilitation were identified. After formal presentations to a panel of pulmonary specialists and primary care physicians, key messages to assist in the implementation of guideline-based care in the primary care setting were developed and integrated into this article, the third in a 4-part mini-symposium. The main points of the roundtable consensus were as follows: (1) Comprehensive pulmonary rehabilitation includes patient education, exercise training, psychosocial support, and nutritional intervention; the evaluation for oxygen supplementation is also conveniently done in this setting. (2) These important components of care are often best delivered in an integrated fashion in a hospital-based pulmonary rehabilitation program; when pulmonary rehabilitation is a not feasible option, clinicians can provide elements of this care to individual patients. (3) Pulmonary rehabilitation has erroneously been considered a "last-ditch" intervention for patients with advanced respiratory disease; however, referral should be considered for any patient with chronic respiratory disease who remains symptomatic or has decreased functional status despite otherwise optimal medical therapy. (4) Pulmonary rehabilitation increases exercise capacity, reduces breathlessness, improves health-related quality of life, and decreases health care utilization; this improvement may be of greater magnitude than that achieved with pharmacologic therapy. (5) Pulmonary rehabilitation has no direct effect on usual pulmonary function tests. It works, in part, through reducing nonpulmonary comorbidity. We conclude that patients with COPD-who are commonly managed in primary care settings-may benefit from multiple components of pulmonary rehabilitation.