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Expert Consensus and Operational Guidelines on Exercise

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Expert Consensus and Operational Guidelines on Exercise 3346 Guideline Expert consensus and operational guidelines on exercise rehabilitation of chronic obstructive pulmonary disease with integrating traditional Chinese medicine and Western medicine Xuan Chen1,2#, Di Gong2#, Huai Huang2#, Kexin Wang2#, Wei Zhang1, Shanqun Li2; on behalf of the China COPD Respiratory Rehabilitation Writing Expert Group with integrating Traditional Chinese and Western medicine, the Respiratory Disease Rehabilitation Professional Committee of China Medical Education Association 1Department of Respiratory and Critical Care Medicine, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; 2Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China #These authors contributed equally to this work. Correspondence to: Dr. Shanqun Li. 180 Fenglin Road, Xuhui District, Shanghai 200032, China. Email: [email protected]; Dr. Wei Zhang. 185 Pu’an Road, Huangpu District, Shanghai 200120, China. Email: [email protected]. Submitted Mar 12, 2021. Accepted for publication May 21, 2021. doi: 10.21037/jtd-21-431 View this article at: https://dx.doi.org/10.21037/jtd-21-431 Introduction atrophy. These factors can result in declining motor ability, which is the critical predictor of mortality in COPD Chronic obstructive pulmonary disease (COPD) has patients (4). become a widespread global chronic respiratory disease. COPD can influence patients’ health and quality of In view of the large patient population, high mortality life. Delaying disease progression, alleviating symptoms, and disability rate, and heavy medical burden, COPD has improving psychological status, and enhancing quality of become a major challenge for public health worldwide. life are the main goals of medical interventions for COPD According to epidemiological studies and demographic data, patients. Pulmonary rehabilitation, as an indispensable part the prevalence of COPD in China is 13.7% and the number of effective treatments, is a multidisciplinary management of COPD patients has reached more than 100 million. program targeted at COPD patients to control disease Therefore, it is of considerable significance to make more progression, improve quality of life, and reduce the efforts to prevent and treat COPD (1). hospitalization rate (5). Exercise treatment, as the core of COPD is a chronic respiratory disease with dyspnea as rehabilitation programs, has a higher degree of evidence its main clinical manifestation, especially during physical in pulmonary rehabilitation that can improve dyspnea activity. COPD is often associated with cardiovascular, symptoms, increase motor abilities, and be helpful for motor, metabolic and other systemic diseases, and may improving psychological disorders and enhancing quality of lead to pathological changes in many other systems (2). life (3,6,7). Muscle dysfunction is the most common extrapulmonary To better guide exercise rehabilitation treatment for change that may influence the skeleton and respiratory COPD patients, and to provide a systematic and operational muscles. Muscle dysfunction can lead to amyotrophy, plan for community doctors, pulmonary doctors and muscle weakness, and other symptoms, which influence other health care providers on rehabilitation treatment, the skeletal muscle most significantly and result in poor evaluation, treatment and follow-up, an expert group on exercise tolerance in patients (3). The pathological changes respiratory rehabilitation and a professional committee on in skeletal muscle and dyspnea reduce the participation of respiratory rehabilitation of the China Medical Education activities in COPD patients and cause secondary muscle Association formed a common understanding by searching © Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(6):3323-3346 | https://dx.doi.org/10.21037/jtd-21-431 3324 Chen et al. The guidelines on exercise rehabilitation of COPD domestic and foreign studies, consulting with experts, and functional assessment are important prerequisites to carry discussion. This consensus is based on existing research to out rehabilitation programs, and then individual exercise develop a declarative document, focusing on the feasibility prescription, training, and guidance are recommended. of our current clinical reality. In clinical practice, we still Therapeutic effects must be continuously followed up and need to consider each patient’s specific situation to design observed (12) (Figure 1). individualized exercise rehabilitation programs. In view of the considerable heterogeneity in the basic We present the following article in accordance with the condition and mobility of COPD patients, it is necessary RIGHT reporting checklist (available at https://dx.doi. to consider many related factors, such as ventilation org/10.21037/jtd-21-431). ability and the function of the cardiovascular and muscle systems to promptly adjust the plan according to the disease development. In addition, COPD is a chronic Definition wasting disease. With the progress of COPD, it affects the COPD is a normal disease that can be prevented and work ability and economic level of patients. The guides treated. It is characterized by persistent and progressive focus on the assessment process of the basic condition of airflow limitation, with an increased chronic inflammatory COPD patients, and introduce in detail various Chinese response of airways and lungs to harmful particles or gases. and Western exercise prescriptions that are beneficial to Pulmonary rehabilitation is a comprehensive individual pulmonary rehabilitation, which have been used to guide intervention program based on a comprehensive evaluation health care providers and patients to choose suitable and of the patient and disease characteristics. It includes not affordable exercise rehabilitation programs. only exercise training, but also education and behavioral changes to improve the physical and mental health of Patient assessment patients with chronic respiratory disease and promote long- term adherence to healthy behaviors (8). Limitation of activities in COPD patients is often influenced Pulmonary rehabilitation is applicable to a wide range of by many factors. Before the exercise rehabilitation people and suitable for patients with different severity and intervention, patients should be evaluated from many stages. Even elderly patients can benefit from pulmonary aspects, including medical history, physical examination, rehabilitation (9). The Global Initiative for Chronic Lung dyspnea symptoms, lung function, exercise capacity, and Disease (GOLD) also recommends pulmonary rehabilitation nutritional status to elucidate the factors and provide a for patients with severe symptoms and a high risk of acute basis for formulating an exercise prescription. Throughout exacerbation (10). Foreign guidelines recommend that this process, some complications that may lead to exercise clinicians should prescribe pulmonary rehabilitation for intolerance can be ruled out, such as cardiovascular disease, COPD patients with FEV1 <50% Pred (11). Exercise therapy thus improving exercise safety. is the cornerstone of pulmonary rehabilitation and plays an important role in pulmonary rehabilitation programs. Medical history A detailed understanding of the COPD patient’s medical The therapeutic exercise of pulmonary history is essential for selecting the correct exercise rehabilitation process rehabilitation programs. Therefore, it is necessary to pay Exercise rehabilitation is applicable to COPD patients more attention to the severity of symptoms, complications, at all stages, and early intervention is recommended. laboratory examination data, and treatments history. Although the optimal time for patients with acute COPD Moreover, further information on drug treatment history, exacerbations to start rehabilitation is unclear, the American oxygen therapy, and other relevant details is helpful to Thoracic Society (ATS) and European Respiratory Society ensure exercise safety. For example, in patients with (ERS) (ERS/ATS) guidelines recommend pulmonary diabetes, special attention should be paid to therapeutic rehabilitation within 3 weeks of hospital discharge (2). regimens, especially insulin, to prevent exercise-induced A series of procedures are included in the implementation hypoglycemia and the risk of ketosis in patients with type 1 of exercise rehabilitation programs. Clinical evaluation and diabetes. © Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(6):3323-3346 | https://dx.doi.org/10.21037/jtd-21-431 Journal of Thoracic Disease, Vol 13, No 6 June 2021 3325 Clinical assessment Exercise therapy is no Exercise therapy is available Find reasons Make suggestion and observe Evaluate the motor function Set goals Make Can’t tolerate the plan Can tolerate the plan Evaluate the results Continue or adjust the program Follow up Figure 1 The procedures of exercise rehabilitation program. Physical examination size, hepatojugular reflux syndrome, and lower limb edema should be seriously considered. A thorough and complete physical examination allows the doctor to determine if the patient is unfit for exercise rehabilitation. For COPD patients, examinations should Dyspnea assessment focus on kinematic characteristics in the lungs, including Dyspnea is an important factor affecting the motor ability the degree of emphysema, the mobility of the diaphragm, of COPD patients. Although breathing difficulty is the manner of breathing, and the distribution,
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