In the UK, 1 in 5 people have a respiratory illness and it is the 3rd biggest cause of death (NHS England, 2019). Not unexpectedly therefore, tackling respiratory disease is not only a huge issue in primary care but also a national clinical priority that features in the NHS Long Term Plan (NHS England, 2019) and the Quality and Outcomes Framework (NHS England, 2023).
An estimated 26,000 hospital admissions could be avoided if every eligible person completed a PR programme (Taskforce for Lung Health, online), yet only 13% of those people eligible for PR service receive it (Royal College of Physicians, 2017) and the average completion rate in England is only 67%, with wide geographic variation. Given that picture of low uptake and variable completion rates to something that could really benefit patients, referral to and liaison with a local (PR) service is therefore an essential part of the practice nursing respiratory service.
What is pulmonary rehabilitation?
Pulmonary rehabilitation is an exercise and education programme designed for people with lung disease who experience symptoms of breathlessness (NHS England, 2020). PR is primarily an evidence-based intervention for those with chronic obstructive pulmonary disease although it may benefit those with other long term respiratory conditions (BTS, 2013). It helps people to understand their condition better and helps them to manage their dyspnoea. A PR exercise programme is tailored to the needs of the individual. It includes strength training combined with aerobic exercise. The level of exercise required ranges from a minimum level of 60% of an individual's maximum exercise capacity up to an 85% level – that is, people work hard!
The education component is wide-ranging and covers elements such as understanding how we breathe, education about their illness, relaxation techniques, nutrition and approaches to manage breathlessness (see NHS England and NHS Improvement 2020 for more information).
PR is offered by a specialist pulmonary rehabilitation service and consists of a 6-8 week programme, delivered twice a week by a team that may consist of physiotherapists, occupational therapists and nurses (NHS England, 2020). Programmes are offered at convenient times in accessible locations to make it easy for people to attend. The programme, although challenging, is generally considered enjoyable because it not only builds confidence but enables attendees to make friends with others in a similar position.
A Pulmonary Rehabilitation Services Accreditation Scheme (PRSAS) has been in place since 2018 (Royal College of Physicians, online) and, although not mandatory, this helps commissioners to quality assure services.
Of the patients who complete the programme, 90% experience an improved quality of life or exercise capacity (Royal College of Physicians, 2017). PR can also reduce symptoms and improve levels of anxiety and depression (NICE 2016).
A national priority
The Taskforce for Lung Health (https://www.blf.org.uk/taskforce), a collaboration between a large group of organisations and individuals who have come together to improve lung health, is prioritising ‘treatments that don't use drugs’ such as PR, as part of a personalised plan.
The NHS Long Term Plan (2019) enabled respiratory disease to be highlighted for the first time as a national priority, alongside cardiovascular disease. This prioritisation was translated into the GP contract to systematically offer PR to practice populations. Alongside this, a new 5-year framework set out the requirements for GP contract reform (British Medical Association and NHS England, 2019). This included a new chronic obstructive pulmonary disease (COPD) indicator (NHS England 2023) to offer pulmonary rehabilitation (PR) to patients with COPD with a Medical Research Council (MRC) dyspnoea scale ≥3 at any time in the preceding 12 months.
This means that general practice nurses (GPNs) need to assess the level of dyspnoea (table 1) in people with COPD and then discuss the idea of referral to a PR service.
Table 1. MRC Dyspnoea Scale
| Grade | Degree of breathlessness related to activities |
|---|---|
| 0 | No breathlessness, except with strenuous exercise |
| 1 | Breathless when hurrying on the level or walking up a slight hill |
| 2 | Walks slower than other people on the level or walking up a slight hill |
| 3 | Stops for breath after walking about 100 metres or after a few minutes on level ground |
| 4 | Too breathless to leave the house, or breathless when dressing or undressing |
There is some early evidence that those in recovery from COVID-19 may benefit from PR (BTS, 2020; Vinicius Santana et al, 2021; Gloeckl et al, 2021), but referral must be based on the individual needs of the person. A decision to refer must be based on local or national guidelines and revised as more evidence emerges.
In secondary care, PR forms part of a ‘care bundle’ - a small set of evidence-based interventions which form a cohesive unit of actions that must all be completed to achieve best outcomes. For COPD, the care bundle for people discharged from hospital with COPD consists of ‘TAPSS’ (British Thoracic Society, 2014):
- Technique (inhaler)
- Action plan
- Pulmonary rehabilitation
- Smoking cessation
- Specialist follow-up.
Referral criteria
GPNs should screen for suitability for referral. This may be according to local guidelines but in general, see Table 2.
Table 2. Criteria for referral to pulmonary rehabilitation (based on British Thoracic Society (BTS) Pulmonary Rehabilitation Guideline Development Group, 2013)
| Suitable | Not suitable | It depends |
| All those with long term respiratory disease, according to local criteria. QOF requires those on scoring ≥3 on the MRC dyspnoea scale | MRC dyspnoea score of 5 who are housebound should not routinely be offered supervised pulmonary rehabilitation within their home. | Significant chronic respiratory failure – a risk assessment is needed |
| Both smokers (offer brief intervention) and non-smokers | Unstable cardiac disease or locomotor difficulties that preclude exercise (eg, severe arthritis or severe peripheral vascular disease) | Abdominal aortic aneurism <5.5 cm – if blood pressure is stable |
| On portable oxygen therapy | Significant cognitive or psychiatric impairment that would lead to an inability to follow simple commands in a group setting | In case of doubt over the appropriateness of a patient for pulmonary rehabilitation, clinicians are advised to contact their local provider
|
| Co-existent stable cardiovascular disease | Idiopathic pulmonary fibrosis (IPF) – may have a potential for significant desaturation during exercise | |
| Anxiety and/or depression | ||
Making a referral
It is important for GPNs to be able to describe both the process and the benefits so they can properly discuss the option of PR with someone with long term respiratory illness. One way to do this of course is to attend a PR session and observe it first-hand. Additionally a visit to PR class can enable GPNs to make better relationships with staff to improve care integration. However, this may be impractical if time is short.
A PR programme consists of:
- Physical training
- Aerobic exercise to a minimum of 60% and up to 85% of an individual's maximum exercise capacity.
- Strength training
- Disease education
- Normal respiratory physiology and mechanics
- Understanding COPD/chronic respiratory diseases; their pathophysiology, causes and treatment
- Supportive information for self-management
- Relaxation techniques and stress management
- Medicines management and exacerbations
- Psychological impacts and minimising their effects
- The role of family and carers in managing the conditions
- How to manage breathlessness, breathing control, chest clearance, positioning, pacing and energy conservation
- Smoking and smoking cessation services if appropriate
- The benefits of regular physical activity and exercise, and how to undertake physical activity and exercise safely and effectively
- Nutritional advice and eating strategies, including nutritional supplements where appropriate
- Lifestyle issues e.g. climate change, relationship management (NHS England, 2020)
There are two main routes into PR:
- Post-exacerbation PR, which is organised by secondary care within 1 month of discharge
- Elective PR, offered in primary care
In addition, there may be local options for:
- Home based rehabilitation
- Telerehabilitation: there may be remote NHS programmes or online support programmes such as
- MyCOPD (a self-help App that con be downloaded from App stores)
- Space for COPD – an online PR programme (https://www.spaceforcopd.co.uk/)
These offer options for those who may be clinically very vulnerable to infections, are infectious or experience agoraphobia for example.
In reviewing the research evidence, the BTS PR guidelines (2013) conclude that
- PR one month post exacerbation is not associated with adverse effects
- It is effective in improving short term quality of life and exercise capacity
- Research on post exacerbation course completion rates vary: One study reported 67% of attendees completed 50% of the course
- There is no conclusive evidence around whether the setting (in-patient or outpatient) or offering transport services improves attendance.
- There is insufficient evidence to conclude that take up rates differ between post exacerbation and elective PR courses
A recent systematic review of home-based rehabilitation programmes compared to out-patient programmes concluded that results were comparable (Stafinski et al, 2022).
In some areas, where there may be long waits for PR because of the ending of face-to-face services during the COVID-19 pandemic, it may be helpful to encourage self-help by downloading PR resources from the Asthma and Lung UK website, such as an exercise handbook (https://www.blf.org.uk/support-for-you/keep-active/your-exercise-handbook).
GPNs may want to check if people have declined PR post exacerbation and may be more successful in offering it as a ‘family doctor’ recommendation. GPNs should present PR as a fundamental part of the treatment rather than an optional extra (BTS, 2013). GPNs should:
- Invite the person to explore their understanding of PR and their health beliefs
- Correct any misconceptions
- Explain the benefits (Asthma and Lung UK, online)
- improve muscle strength so the muscles become more efficient and use less oxygen, so they will feel less breathless
- help cope with feelings of dyspnoea
- improve fitness so they feel more confident to do everyday tasks
- help with stress, depression and anxiety
- help understand and manage their condition better
- Sometimes the presence and support of a friend or family member at PR class may encourage attendance.
Pulmonary rehabilitation pathway
PR services are guided by a PR pathway (NHS England and NHS Improvement, 2020). Upon receipt of referral, the person is invited to an appointment where they undergo a comprehensive clinical assessment including pulse oximetry and spirometry. This enables the development of a personalised activity programme.
Keeping active after PR
At the end of the PR programme, participants are encouraged to keep active and take some sort of exercise every day. GPNs may wish to encourage this and provide advice on how to exercise safely (Box 1). They may also signpost people to social prescribing and local exercise on prescription options, such as Tai Chi classes and walking groups to continue their rehabilitation journey.
Box 1.Exercising safely: Best practice for those with long term lung conditions
- Start slowly and gradually build up
- Warm up before and cool down after exercising
- If prescribed, carry reliever inhaler and/or glyceryl trinitrate (GTN) spray. Use them when you need to (discuss with your GPN)
- Wear loose, comfortable clothing and supportive non-slip shoes, like trainers
- Drink plenty of water
- Wait for at least an hour after eating before exercising
- If normally using oxygen, even for just some of the time or overnight, use oxygen at their regular setting when exercising
- Be active at a level that's right for the person – able to still talk when out of breath
Psychological issues
PR improves not only physical but psychological wellbeing. But since many people with significant respiratory illness may have shielded during the pandemic they may have become deconditioned and may feel more unsure about leaving the home.
It is the perception of breathlessness by the individual that matters, and how they translate this into feelings and behaviours, rather than the severity of the disease (Spathis et al., 2017). Therefore, it useful for the GPN to explore this if a person feels unsure about becoming more active. Helping them to understand their feelings can offer reassurance that being more out of breath may be because they haven't exercised for a long while rather than necessarily signalling that their illness is worse. Some may actively avoid the sensation of breathlessness because they have had a bad experience, so talking through how they breathe (maybe apical breathing) and the element of breath retraining that PR offers (such as relaxed tummy breathing) may help.
Summary
Pulmonary rehabilitation is effective and is an essential part of respiratory care. It is delivered in a standardised way over 6-8 weeks by local multidisciplinary teams. It consists of an intensive programme of aerobic exercise and strength training coupled with an education programme. The role of the GPN is to encourage attendance and support the person to continue their rehabilitation after the programme has ended.