Reprinted from the May 2002 issue of RESPIRATORY CARE [Respir Care 2002;37(5):617–625]
AARC Clinical Practice Guideline
PR 1.0 PULMONARY REHABILITATION:
Pulmonary rehabilitation is a restorative and preventive process for patients with chronic respiratory disease.
PR 2.0 DESCRIPTION/DEFINITION:
Pulmonary rehabilitation (PR) has been defined as a "multi-disciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy."(1)
As lung reserve declines, dyspnea worsens and independent daily activity performance erodes. PR provides multidisciplinary training to improve the patient's ability to manage and cope with progressive dyspnea.(2)
Although PR efforts are often focused on patients with chronic obstructive pulmonary disease (chronic bronchitis and/or emphysema),(3-6) other conditions appropriate for this process include, but are not limited to, patients with asthma,(7) interstitial disease,(8) bronchiectasis,(8) cystic fibrosis,(9-11) chest wall diseases,(8) neuromuscular disorders,(12,13) ventilator dependency,(14,15) and before and after lung surgery for transplantation,(16) volume reduction,(17,18) or cancer.(19,20)
PR services include critical components of assessment, physical reconditioning, skills training, and psychological support.(2,21) Additional PR services may include vocational evaluation and counseling.(22) The PR program must be tailored to meet the needs of the individual patient, addressing age-specific and cultural variables, and should contain patient-determined goals, as well as goals established by the individual team discipline.(20,23) Both patients and families participate in this training administered by health care professionals. These pulmonary rehabilitation services are overseen by a medical director to assure appropriate performance by the program staff and to assure proper service delivery.(2)
This guideline is appropriate for pediatric, adult, and geriatric patients in whom clear indications for rehabilitation are present and who possess the necessary cognitive and physical capabilities.
Based on the individualized assessment the following areas of education and training should be considered:(2)
- 2.1 pulmonary anatomy and physiology including the pathophysiology of lung disease(24-26)
- 2.2 description and interpretation of medical tests(27-33)
- 2.3 bronchial hygiene techniques(34,35)
- 2.4 exercise conditioning and techniques that include:(36)
- 2.4.1 breathing retraining(37)
- 2.4.2 endurance, strength, and flexibility training
- 220.127.116.11 upper extremity(37-42)
- 18.104.22.168 lower extremity(37,41)
- 2.4.3 ventilatory muscle training (its role is still undetermined, since no evidence exists that it contributes to functional improvement when added to a traditional upper and lower extremity exercise training program).(1,36)
- 2.4.4 energy conservation as it applies to activities of daily living(43,44)
- 2.5 indications, actions, and side-effects of medications including non-prescription products, such as vitamins, over-the-counter medications, and herbal remedies(6)
- 2.6 functional self-management
- 2.6.1 self assessment and symptom management(45)
- 2.6.2 infection control with emphasis on avoidance, early intervention, and immunization(46-48)
- 2.6.3 environment control
- 2.6.4 indications for seeking additional medical resources
- 2.7 sleep disturbances, eg, insomnia and sleep apnea as they relate to chronic lung disease
- 2.8 sexuality and intimacy(49,50)
- 2.9 nutrition(51-54)
- 2.10 smoking cessation(55-57)
- 2.11 psychosocial intervention and support(21,58)
- 2.12 available community services, including patient/family support groups(59)
- 2.13 advance care planning(60,61)
- 2.14 travel issues(62)
- 2.15 recreation/leisure activities(63)
- 2.16 stress management
- 2.17 indications for oxygen, and methods of delivery(64)
PR 3.0 SETTINGS:
PR may take place in, but is not limited to:
- 3.1 the inpatient setting, including medical center, skilled nursing facility, or rehabilitation hospital(2)
- 3.2 the outpatient setting(2,65)
- 3.2.1 outpatient hospital-based clinic
- 3.2.2 comprehensive outpatient rehabilitation facility (CORF)
- 3.2.3 physician's office
- 3.2.4 alternate or extended care facility
- 3.2.5 patient's home(65)
PR 4.0 INDICATIONS:
The indications for PR include the presence of respiratory impairment potentially responsive to the techniques available.(1,2,36) Such impairment may be manifested as:
- 4.1 dyspnea experienced during rest or exertion
- 4.2 hypoxemia, hypercapnia
- 4.3 reduced exercise tolerance or a decline in the patient's ability to perform activities of daily living
- 4.4 an unexpected deterioration or worsening symptoms against a background of long-standing dyspnea and a reduced but stable exercise tolerance level
- 4.5 the need for surgical intervention (pre- and postoperative lung resection, transplantation, or volume reduction)
- 4.6 chronic respiratory failure and the need to initiate mechanical ventilation
- 4.7 ventilator dependence
- 4.8 increasing need for acute care intervention, including emergency room visits, hospitalizations, and unscheduled physician office visits
PR 5.0 CONTRAINDICATIONS:
The initial assessment of the patient should establish his or her willingness to participate in the rehabilitation process. The presence of certain conditions would make successful completion of the rehabilitation process unlikely.(2)
- 5.1 Potential contraindications to PR include ischemic cardiac disease, acute cor pulmonale, severe pulmonary hypertension, significant hepatic dysfunction, metastatic cancer, renal failure, severe cognitive deficit, and psychiatric disease that interferes with memory and compliance. The decision to provide or withhold PR should be based on a thorough, individualized assessment.
- 5.2 Substance abuse without the desire to cease use would seriously interfere with successful PR.
- 5.3 Physical limitations such as poor eyesight, impaired hearing, a speech impediment, or orthopedic impairment may require modification of the PR setting but should not interfere with participation in a PR program.
PR 6.0 HAZARDS/COMPLICATIONS:
Hazards/complications associated with PR are primarily related to the exercise program. During exercise the cardiovascular and ventilatory systems must be able to respond to increased demands. Exercise can lead to muscle or ligament injuries.
PR 7.0 LIMITATIONS OF METHOD:
- 7.1 Patient related
- 7.1.1 The patient may have a disease process that has progressed to the stage where rehabilitation is not possible.
- 7.1.2 The patient may not adhere to or complete the program because it appears to be complicated or because of a sense of hopelessness, depression, or a lack of motivation.
- 7.1.3 The patient/patient family may be reluctant to make changes in their usual program, medications, start new therapy, quit smoking, use supplemental oxygen, or exercise.(23)
- 7.1.4 There might be concerns or limitations in transportation.
- 7.1.5 Financial resources might not be available.
- 7.1.6 The patient may have to stop the program because of an acute exacerbation, or worsening of another medical condition.
- 7.2 Related to the health care system
- 7.2.1 Reimbursement by intermediaries or third-party payers is not standardized.
PR 8.0 ASSESSMENT OF NEED:
- 8.1 The patient must be under the care of a physician for the pulmonary condition for which he or she needs rehabilitation. Appropriate members of the PR team participate in the patient's assessment. The initial evaluation should include the medical history, diagnostic tests, current symptoms, physical assessment, psychological, social, or vocational needs, nutritional status, exercise tolerance, determination of educational needs, and the patient's ability to carry out activities of daily living.(2)
- 8.2 Areas to be evaluated and reviewed include:(2)
- 8.2.1 effect on quality of life
- 8.2.2 pulmonary function assessment, including arterial blood gas analysis
- 8.2.3 use of medical resources such as hospitalizations, urgent care/emergency room visits, or physician visits
- 8.2.4 exercise ability
- 8.2.5 dependence vs independence in activities of daily living
- 8.2.6 impairment in occupational performance
- 8.2.7 psychosocial problems such as anxiety or depression
- 8.2.8 oxygen saturation at rest, with activity, and possibly during sleep
- 8.2.9 co-morbidity
- 8.2.10 smoking history
- 8.2.11 motivation for rehabilitation, including commitment to spending the time necessary for active program participation
- 8.2.12 current medications
- 8.2.13 appropriate blood tests
- 8.2.14 electrocardiogram
- 8.2.15 chest radiograph
- 8.2.16 social support
- 8.2.17 potential need for assistive devices, eg, walker, wheel chair
- 8.2.18 adherence to recommended treatment modalities
- 8.2.19 physician support available to patient
- 8.2.20 availability of transportation and patient/family desire to use what may be available
- 8.2.21 financial resources
PR 9.0 ASSESSMENT OF OUTCOME:
- 9.1 Evidence exists for the effectiveness of PR with respect to exercise tolerance, utilization of health care resources, and quality of life.(1,36,66-69)
- There is some evidence that PR may improve survival in patients with COPD.(36,70-73) The effectiveness of PR can best be established by comparing the baseline condition of the patient to his or her condition as a consequence of participation in the PR program and should involve both qualitative and quantitative measures. Such measurements should include:
- 9.1.1 indicators of health related quality of life(67,74-81) including a reduction in dyspnea(5,65,67,77,82,83)
- 9.1.2 enhanced ability to perform activities of daily living including energy conservation(4,84)
- 9.1.3 increased exercise tolerance and performance(37,41,67,76,77,79,84-88)
- 9.1.4 decreased respiratory symptoms, eg, frequency of cough, sputum production, wheezing
- 9.1.5 increased knowledge about pulmonary disease and its management(89-91)
- 9.1.6 reduced need for medical services including outpatient treatment and hospital admission(70,87,92,93)
- 9.1.7 increased ventilator-free time in the ventilator-dependent patient
- 9.1.8 return to productive employment
- 9.2 Documentation and data collection can develop information regarding the cost-effectiveness of PR.(70,87,92,93)
- 9.3 The benefit of long-term follow-up, including maintenance programs, should be evaluated.
- 9.3.1 educational/recreational support group
- 9.3.2 independent maintenance exercise
- 9.3.3 scheduled, individualized, on-going exercise/educational input from PR team
- 10.1 Personnel
- The number of disciplines contributing to a PR program varies with the size and scope of the PR program and the availability of those disciplines within the setting. Members might include a respiratory care practitioner, registered or licensed nurse, physical therapist, pharmacist, occupational therapist, dietitian, social worker, exercise physiologist, chaplain, speech therapist, and mental health professional.(2) All personnel should be trained in basic life support techniques and, if possible, advanced cardiac life support.
- 10.1.1 Medical director: should be a licensed physician with an interest in and knowledge of PR, pulmonary function, and exercise evaluation.
- 10.1.2 Program director/coordinator: should be trained in health-related profession and have clinical experience and expertise in the care of patients with chronic lung disease. She or he should understand the philosophy and goals of PR and be knowledgeable in administration, marketing, education, patient training, and obtaining reimbursement.
- 10.1.3 Team members: each member should be well-trained in his or her specialty, demonstrate the ability to establish rapport with and convey the necessary knowledge and skills to patients, and have a good working knowledge of the skills of fellow team members. Each team member should be qualified in their area of expertise to access the patient's needs, provide appropriate intervention, and monitor patient outcomes.(94) The possession of credentials appropriate to each specialty is recommended, as well as appropriate licensing for each state. Persons responsible for pulmonary function testing, blood gas analysis, exercise testing, and those engaged in any patient educational training concerning needed therapy should demonstrate the knowledge and skills specified in the relevant AARC Clinical Practice Guidelines.(33-35,64,95-99) The information and recommendations provided to patients should be evidence-based and consistent across the program. Each team member must be aware of the content of each discipline's educational content.
- 10.2 Physical facilities
- The physical area for PR can vary greatly depending upon program structure, patient population, needs, and resources. The site should provide an appropriate environment with adequate space, few interruptions or other distractions, sufficient lighting and temperature control, and comfortable seating. It is essential to have adequate parking and handicap access.
- 10.3 Patient education materials(97)
- 10.3.1 workbooks and videotapes(90)
- 10.3.2 lung and skeletal models
- 10.3.3 anatomical posters
- 10.4 Equipment
- 10.4.1 stethoscope
- 10.4.2 manual sphygmomanometer
- 10.4.3 pulse oximeter(33)
- 10.4.4 supplemental oxygen source
- 10.4.5 access to laboratory for arterial blood gas analysis(95)
- 10.4.6 stopwatch
- 10.4.7 calibrated cycle ergometer or motorized treadmill (Measured walking distance may be used if an ergometer or treadmill is not available.)(98)
- 10.4.8 free-weights or elastic bands
- 10.4.9 patient's own equipment, eg, metered-dose inhaler and spacer, compressor nebulizer for home use(99)
- 10.4.10 emergency plan and supplies(95)
- 10.4.11 EKG monitoring during exercise, if indicated, and defibrillation and crash cart(96)
- 10.4.12 spirometer
- 10.4.13 peak flow meter
- 11.1 Patient: the following should be monitored at baseline and at appropriate intervals to assure validity of results and appropriateness of intervention:
- 11.1.1 patient's response to progressive and general reconditioning exercises in conjunction with breathing techniques
- 11.1.2 patient's oxygen requirements at rest and with exercise
- 11.1.3 knowledge and skills acquisition: demonstrations and questionnaires should be used to document evidence of change
- 11.1.4 patient's subjective comments
- 11.1.5 progress in achieving goals established at baseline
- 11.2 Patient clinical monitoring during scheduled, supervised session
- 11.2.1 patient appearance
- 11.2.2 vital signs
- 11.2.3 cardiac telemetry, if needed
- 11.2.4 perceived exertion and dyspnea (eg, use of Borg Scale)
- 11.2.5 O2 saturation via oximeter
- 11.3 PR services: each program should establish clinical indicators that objectively measure the information and instruction provided to the patient and should document the outcomes. Content, goal orientation, and applicability should be reviewed on a regular basis.
Training and informational components of PR should be delivered in a systematic manner to assure that all patient care issues are addressed. There should be repetition sufficient to ensure retention of information and skills. Giving the patient too much information at one time may cause confusion. Easy-to-read patient education materials should be used to complement and reinforce verbal instructions.(97) Program schedules vary according to staff, facilities, resources, budget, and patient needs.(100) PR services are commonly provided over a period of 12 hours per week for 6 or more weeks, governed by the patient's individual needs.(101) Patients are encouraged, when possible, to participate in an ongoing maintenance exercise program to sustain the training effect.
13.0 INFECTION CONTROL:
- 13.1 The staff, supervisors, and physicians associated with the PR program should be conversant with "Guideline for Isolation Precautions in Hospitals"(102) and develop and implement policies and procedures for the program that comply with its recommendations for Standard Precautions and Transmission-Based Precautions.
- 13.2 The program manager and its medical director should maintain communication and cooperation with the mother institution's infection control service and the personnel health service to help assure consistency and thoroughness in complying with the institution's policies related to immunizations, post-exposure prophylaxis, and job- and community-related illnesses and exposures.(103)
- 13.3 The importance of immunization for influenza(48) and pneumococcal pneumonia,(47) and avoidance of exposure during periods of high incidence of respiratory infections in the community should be stressed to patients. Staff members should receive the influenza vaccination.(104)
- 13.4 Patients and staff members with signs and symptoms of respiratory infection should avoid contact with patients.
- 13.5 Adequate handwashing(105) and proper ventilation with prescribed air exchanges should be assured.(106)
- 13.6 Equipment shared by patients must be cleaned and maintained appropriately. Specific procedures are provided in the 2001 update of static lung volume measurement (Section 13.3.4-13.3.7)(107) Proper cleaning methods for the patient's personal therapeutic equipment should be regularly reinforced.(59,97)
14.0 AGE-SPECIFIC ISSUES:
Instructions should be provided and techniques described in a manner that take into consideration the learning ability and communications skills of the patient being served.
- 14.1 Infant and Neonatal: This Guideline does not apply.
- 14.2 Pediatric: This Guideline is appropriate for children with indications who can be motivated and who can follow directions.
- 14.3 Geriatric: This Guideline is appropriate for members of the geriatric population with indications who are motivated and who can follow directions.
Pulmonary Rehabilitation Guideline Committee (The principal author is listed first):
John E Hodgkin MD FAARC, Co-Chair, Deer Park CA
Lana Hilling CRT, Co-Chair, Concord CA
Phillip D Hoberty EdD RRT, Columbus OH
Rebecca J Hoberty RRT, Hilliard OH
Christine Kelly MPA RRT, Oakland CA
Trina M Limberg RRT FAARC, San Diego CA
Kevin Ryan RRT, Deer Park CA
Paul A Selecky MD FAARC, Newport Beach CA
Dennis C Sobush MA PT, Milwaukee WI
Peter A Southorn MD, Rochester MN
- Pulmonary rehabilitation-1999. Official statement of the American Thoracic Society. Am J Respir Crit Care Med 1999; 159(5 Pt 1):1666-1682.
- American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for pulmonary rehabilitation programs, 2nd ed. Champaign, IL: Human Kinetics; 1998.
- American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;152(5 Pt 2):S77-S121.
- Celli BR. Pulmonary rehabilitation in patients with COPD. Am J Respir Crit Care Med 1995;152(3):861-864.
- Ries AL, Kaplan RM, Limberg TM, Prewitt LM. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med 1995; 122(1) : 823-832.
- Tiep BL. Disease management of COPD with pulmonary rehabilitation. Chest 1997;112(6):1630-1656.
- Cambach W, Wagenaar RC, Koelman TW, van Kiempema AR, Kemper HC. The long-term effects of pulmonary rehabilitation in patients with asthma and chronic obstructive pulmonary disease: a research synthesis. Arch Phys Med Rehabil 1999;80(1):103-111.
- Foster S, Thomas HM 3rd. Pulmonary rehabilitation in lung disease other than chronic obstructive pulmonary disease. Am Rev Respir Dis 1990;141(3):601-604.
- Buschbacher R. Outcomes and problems in pediatric pulmonary rehabilitation. Am J Phys Med Rehabil 1995;74(4):287-293.
- Orenstein DM, Franklin BA, Doershuk CF, Hellerstein HK, Germann KJ, Horowitz JG, Stern RC. Exercise conditioning and cardiopulmonary fitness in cystic fibrosis: the effects of a three-month supervised running program. Chest 1981;80(4):392-398.
- DeJong W, Grevink RG, Roorda RJ, Kapstein AP, van der Schans CR. Effect of a home exercise training program in patients with cystic fibrosis. Chest 1994;105 (2):463-468.
- Bach JR Pulmonary rehabilitation in neuromuscular disorders. Neurology 1993;14:515-529.
- Stice KA, Cunningham CA. Pulmonary rehabilitation with respiratory complications of postpolio syndrome. Rehabil Nurs 1995;20(1):37-42.
- Bach JR, Intintola P, Alba AS, Holland IE. The ventilator-assisted individual: cost analysis of institutionalization vs rehabilitation and in-home management. Chest 1992;101(1):26-30.
- Muir JF. Pulmonary rehabilitation in chronic respiratory insufficiency. 5. Home mechanical ventilation. Thorax 1993;48(12):1264-1273.
- Craven JL, Bright J, Dear CL. Psychiatric, psychosocial, and rehabilitative aspects of lung transplantation. Clin Chest Med 1990;11(2):247-257.
- Cooper JD, Trulock EP, Triantafillou A, Patterson GA, Pohl MS, Delaney PA, et al. Bilateral pneumonectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109(1):106-116; discussion 116-119.
- Colt HG, Ries AL, Brewer N, Moser K. Analysis of chronic obstructive pulmonary disease referrals for lung volume reduction surgery. J Cardiopulm Rehabil 1997;17(4):248-252.
- Bernhard J, Ganz PA. Psychosocial issues in lung cancer patients (Part I). Chest 1991;99(1):216-223.
- Ries AL. Rehabilitation for the patient with advanced lung disease: designing an appropriate program, establishing realistic goals, meeting the goals. Semin Respir Crit Care Med 1996;17:451-463.
- Emery CF, Leatherman NE, Burker ES, MacIntyre NR. Psychological outcomes of a pulmonary rehabilitation program. Chest 1991;100(3):613-617.
- Kersten L. Changes in self-concept during pulmonary rehabilitation, Parts 1 and 2. Heart Lung 1990;19(5 Pt 1):456-462 and 1990;19(5 Pt 1):463-470.
- Folden SL. Definitions of health and health goals of participants in a community-based pulmonary rehabilitation program. Public Health Nurs 1993;10(1):31-35.
- Hogg JC, Macklem PT, Thurlbeck WM. Site and nature of airways obstruction in chronic obstructive lung disease. N Engl J Med 1968;278(25):1355-1360.
- Mitchell RS, Stanford RE, Johnson JM, Silvers GW, Dart G, George MS. The morphologic features of the bronchi, bronchioles, and alveoli in chronic airway obstruction: a clinopathologic study. Am Rev Respir Dis 1976;114(1):137-145.
- Thurlbeck WM. Pathophysiology of chronic obstructive pulmonary disease. Clin Chest Med 1990;11(3):389-403.
- Enright PL, Hodgkin JE. Pulmonary function tests. In: Burton GG, Hodgkin JE, Ward JJ, editors. Respiratory care: a guide to clinical practice, 4th ed. Philadelphia: JB Lippincott; 1997:225-248.
- Ries AL, Farrow JT, Clausen JL. Accuracy of two ear oximeters at rest and during exercise in pulmonary patients. Am Rev Respir Dis 1985;132(3):685-689.
- Steele B. Timed walking tests of exercise capacity in chronic cardiopulmonary illness. J Cardiopulm Rehabil 1996;16(1):25-33.
- Ries AL. The role of exercise testing in pulmonary diagnosis. Clin Chest Med 1987;8(1):81-89.
- Jones NL. Clinical exercise testing, 4th ed. Philadelphia: WB Saunders; 1997.
- Wasserman K, Hansen J, Sue D, et al. Principles of exercise testing and interpretation, 3rd ed. Phladelphia: Lippincott Williams & Wilkins; 1999.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Pulse oximetry. Respir Care 1991; 36(12):1406-1409.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Postural drainage therapy. Respir care 1991; 36(12):1418-1426.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Directed cough. Respir Care 1993;38(5):495-499.
- American College of Chest Physicians/American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines Panel. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. Chest 1997;112(5):1363-1396.
- Celli BR. Physical reconditioning of patients with respiratory diseases: legs, arms, and breathing retraining. Respir Care 1994;39(5):481-495; discussion 496-500.
- Ries AL, Ellis B, Hawkins RW. Upper extremity exercise training in chronic obstructive pulmonary disease. Chest 1988;93(4):688-692.
- Martinez FJ, Vogel PD, DuPont DN, Stanopoulos I, Gray A, Beamis JF. Supported arm exercise vs unsupported arm exercise in the rehabilitation of patients with severe chronic airflow obstruction. Chest 1993;103(5): 1397-1402.
- Couser JI Jr, Martinez FJ, Celli BR. Pulmonary rehabilitation that includes arm exercise reduces metabolic and ventilatory requirements for simple arm elevation. Chest 1993;103(1):37-41.
- Lake FR, Hendersen K, Briffa T, Openshaw J, Musk AW. Upper-limb and lower-limb exercise training in patients with chronic airflow obstruction. Chest 1990; 97(5):1077-1082.
- Dugan D, Walker R, Monroe DA. The effects of a 9-week program of aerobic and upper body exercise on the maximal voluntary ventilation of chronic obstructive pulmonary disease patients. J Cardiopulm Rehabil 1995;15(2):130-133.
- Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW 3rd, Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA 1999; 281(4):327-334.
- Rashbaum I, Whyte N. Occupational therapy in pulmonary rehabilitation: energy conservation and work simplification techniques. Phys Med Rehabil Clin N Am 1996;7:325.
- Make B. Collaborative self-management strategies for patients with respiratory disease. Respir Care 1994; 39(5):566-579; discussion 579-583.
- Sturm AW, Mostert R, Rouing PJ, van Klingerin B, van Alphen L. Outbreak of multiresistant non-encapsulated Haemophilus influenzae infections in a pulmonary rehabilitation centre. Lancet 1990;335(8683):214-216.
- Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR. Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 1993:270(15):1826-1831.
- Rothbarth PH, Kempen BM, Sprenger MJ. Sense and nonsense of influenza vaccination in asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;151(5):1682-1685; discussion 1685-1686.
- Johnson B. Older adults' suggestions for health care providers regarding discussions of sex. Geriatr Nurs 1997;18(2):65-66.
- Selecky PA. Sexuality in the pulmonary patient. In: Hodgkin JE, Celli BR, Connors GL, editors. Pulmonary rehabilitation: guidelines to success, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:317-334.
- Schols AMWJ, Soeters PB, Dingemans AMC, Mostert R, Frantzen PJ, Wouters EF. Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabilitation. Am Rev Respir Dis 1993;147(5):1151-1156.
- Gray-Donald K, Gibbons L, Shapiro SH, Macklem PT, Martin JG. Nutritional status and mortality in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996;153(3):961-966.
- Schols AMWJ, Slangen J, Volovics L, Wouters EF. Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157(6 Pt 1):1791-1797.
- Wilson DO, Rogers RM, Sanders MH, Pennock BE, Reilly JJ. Nutritional intervention in malnourished patients with emphysema. Am Rev Respir Dis 1986;134(4):672-677.
- Hurt RD, Sachs DPL, Glover ED, Offord KP, Johnston JA, Dale LC, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 1997;337(17):1195-1202.
- Silagy C, Mant DC, Fowler G, Lodge M. Meta-analysis on efficacy of nicotine replacement therapies in smoking cessation. Lancet 1994;343(8890):139-142.
- Fiore MC, for the Guideline Panel and Staff. US Public Health Service Clinical Practice Guideline: Treating tobacco use and dependence. Summary. Rockville, MD: US Dept of Health and Human Services. June 2000. Also published in Respir Care 2000;45(10):1200-1262.
- Emery CF. Adherence in cardiac and pulmonary rehabilitation. J Cardiopulm Rehabil 1995;15(6):420-423.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Discharge planning for the respiratory care patient. Respir Care 1995;40(12):1308-1312.
- Heffner JE, Fahy B, Hilling L, Barbieri C. Outcomes of advance directive education of pulmonary rehabilitation patients. Am J Respir Crit Care Med 1997;155(3):1055-1059.
- Heffner JE, Fahy B, Barbieri C. Advance direction education during pulmonary rehabilitation. Chest 1996; 109(2):373-379.
- Stoller JK. Travel for the technology-dependent individual. Respir Care 1994;39(4):347-360; discussion 360-362.
- Burns MR. Social and recreational support of the pulmonary patient. In: Hodgkin JE, Celli BR, Connors GL, editors. Pulmonary rehabilitation: guidelines to success, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:465-477.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Oxygen therapy in the home or extended care facility. Respir Care 1992;37(8):918-922.
- Strijbos JH, Postma DS, van Altena R, Gimeno F, Koeter GH. A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD: a follow-up of 18 months. Chest 1996;109(2):366-372.
- Hodgkin JE. Benefits of pulmonary rehabilitation. In: Fishman AP, editor. Pulmonary rehabilitation. New York: Marcel Dekker; 1996:33-54.
- Lacasse Y, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet 1996;348(9035):1115-1119.
- Donner CF, Muir JF. Selection criteria and programmes for pulmonary rehabilitation in COPD patients. Rehabilitation and Chronic Care Scientific Group of the European Respiratory Society. Eur Respir J 1997;10(3): 744-757.
- Pulmonary rehabilitation. Thorax 2001;56(11):827-834.
- Sneider R, O'Malley JA, Kahn M. Trends in pulmonary rehabilitation at Eisenhower Medical Center: an 11-years experience (1976-1987). J Cardiopulm Rehabil 1988;8:453-461.
- Sahn SA, Nett LM, Petty TL. Ten year follow-up of a comprehensive rehabilitation program for severe COPD. Chest 1980;77(2 Suppl):311-314.
- Anthonisen NR, Wright EC, Hodgkin JE. Prognosis in chronic obstructive pulmonary disease. Am Rev Respir Dis 1986;133(1):14-20.
- Burns MR, Sherman B, Madison R, et al. Pulmonary rehabilitation outcome. RT: J Respir Care Pract 1989;2:25-30.
- Petty T. Pulmonary rehabilitation. Am Rev Respir Dis 1980;122(5 Pt 2):159-161.
- Guyatt GH, Berman LB, Townsend M, Pugsley SO, Chambers LW. A measure of quality of life for clinical trials in chronic lung disease. Thorax 1987;42(10):773-778.
- Vale F, Reardon JZ, ZuWallack RL. The long-term benefits of outpatient pulmonary rehabilitation on exercise endurance and quality of life. Chest 1993;103(1):42-45.
- Goldstein RS, Gort EH, Stubbing D, Avendano MA, Guyatt GH. Randomized controlled trial of respiratory rehabilitation. Lancet 1994;344(8934):1394-1397.
- Wijkstra PJ, Van Altena R, Kraan J, Otten V, Postma DS, Koeter GH. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. Eur Respir J 1994;7(2):269-273.
- Troosters T, Gosselink R, Decramer M. Short- and long-term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Am J Med 2000;109(3):207-212.
- Wijkstra PJ, TenVergert EM, Van Altena R, Otten V, Postma DS, Kraan J, Koeter GH. Reliability and validity of the chronic respiratory disease questionnaire (CRQ). Thorax 1994;49(5):465-467.
- Jones PW, Quirk FH, Baveystock CM, Littlejohns P. A self-complete measure of health status for chronic airflow limitation: the St George's respiratory questionnaire. Am Rev Respir Dis 1992;145(6):1321-1327.
- Lareau SC, Carrieri-Kohlman V, Janson-Bjerklie S, Roos PJ. Development and testing of the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ). Heart Lung 1994;23(3):242-250.
- Reardon J, Awad E, Normandin E, Vale F, Clark B, ZuWallack RL. The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea. Chest 1994; 105(4):1046-1052.
- Bendstrip KE, Ingemann Jensen J, Holm S, Bengtsson B. Out-patient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary disease. Eur Respir J 1997;10(12):2801-2806.
- White RJ, Rudkin ST, Ashley J, Stevens VA, Burrows S, Pounsford JC, et al. Outpatient pulmonary rehabilitation in severe chronic obstructive pulmonary disease. J R Coll Physicians Lond 1997;31(5):541-545.
- Casaburi R, Porszasz J, Burns MR, Carithers ER, Chang RS, Cooper CB. Physiologic benefits of exercise training in rehabilitation of patients with severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997;155(5):1541-1551.
- Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000;355(9201):362-368.
- Guell R, Casan P, Belda J, Sangenis M, Morante F, Guyatt GH, Sanchis J. Long-term effects of outpatient rehabilitation of COPD: a randomized trial. Chest 2000;117(4):976-983.
- Hopp JW, Lee JW, Hills R. Development and validation of a pulmonary rehabilitation knowledge test. J Cardiopulm Rehabil 1989;9:273-278.
- Morris K, Hodgkin JE, editors. Pulmonary rehabilitation administration and patient education manual. Gaithersburg, MD: Aspen; 1996.
- Neish CM, Hopp JW. The role of education in pulmonary rehabilitation. J Cardiopulm Rehabil 1988;8:439-441.
- Lewis D, Bell SK. Pulmonary rehabilitation, psychosocial adjustment, and use of healthcare services. Rehabil Nurs 1995;20(2):102-107.
- Parker L, Walker J. Effects of a pulmonary rehabilitation program on physiologic measures, quality of life, and resource utilization in a health maintenance organization setting. Respir Care 1998;43(3):177-182.
- Clinical competency guidelines for pulmonary rehabilitation professionals. American Association of Cardiovascular and Pulmonary Rehabilitation Position Statement. J Cardiopulm Rehabil 1995;15(3):173-178.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Sampling for arterial blood gas analysis. Respir Care 1992;37(8):913-917.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Resuscitation in acute care hospitals. Respir Care 1993;38(11):1179-1188.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Providing patient and caregiver training. Respir Care 1996; 41(7):658-663.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Exercise testing for evaluation of hypoxemia and/or desaturation. Respir Care 1992;37(8):907-912.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Selection of an aerosol delivery device. Respir care 1992;37(8):891-897.
- Bickford KS, Hodgkin JE, McInturff SL. National pulmonary rehabilitation survey: update. J Cardiopulm Rehabil 1995;15(6):406-411.
- Outpatient pulmonary rehabilitation. Local medical review policy. Policy #16.6 Blue Cross of California. (Updated 3/15/00). www.ugsmedicare.com/provider/Lmrp CA/lmrp index.htm#P
- Garner JS. Guideline for isolation precautions in hospitals. Part I. Evolution of isolation practices. Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1996 Feb;24(1):24-31.
- Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998;19(6):407-463. [Erratum in: Infect Control Hosp Epidemiol 1998;19(7):493.]
- US Center for Disease Control and Prevention. Prevention of influenza: recommendations of the Advisory Committee on Immunization Practices. MMWR 2000;49(RR-03):1-38.
- Larson EL. APIC guideline for handwashing and hand antisepsis in health care settings. AM J Infect Control 1995;23(4):259-269.
- Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 1994 Oct 28;43(RR-13):1-132 or Federal Register 1994;59(208):54242-54303.
- American Association for Respiratory Care. AARC Clinical Practice Guideline. Static lung volume, 2001 revision and update. Respir Care 2001;46(5):531-539.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the May 2002 issue of RESPIRATORY CARE [Respir Care 2002;37(5):617–625]