Pulmonary Rehabilitation as a Precursor or Alternative to Smoking Cessation

Though the mere title of this post is likely to spur calls of heresy, I believe this is a topic worthy of discussion. First, let's be clear - no one disagrees that quitting smoking permanently provides powerful lasting health benefits, including greater life expectancy and lower incidence of chronic cardiac and respiratory disease among other positive consequences. No one disagrees that stopping permanently is the number one way that smokers can improve their health – quite quickly and dramatically.

 

But let's be real – smoking cessation success rates are dismal. Somewhere between 4-7% of people who try to stop smoking on their own are successful in abstaining for one year or more. For those who receive cessation assistance through some combination of counseling, nicotine replacement therapy, and other treatments, success rates range from 15-33% abstinence for at least six months. Overall, Nicotine addiction is excruciatingly difficult to shake off – even the minority of smokers who are successful in stopping require 8-10 attempts before they finally break through. The Center for Disease Control reports that in a given year in the U.S. less than 5% of our 43 million current adult smokers successfully stop for 3-12 months!

 

So why then do many pulmonary rehabilitation programs routinely demand COPD patients enter into (or in some case, complete) a smoking cessation program prior to entry into their rehab programs? To me, they are shutting off access to a valuable treatment option for COPD smokers despite pulmonary rehab's strong success rates for reduced shortness of breath, improved physical conditioning and overall quality of life. I'm certain that many people either forgo the opportunity to enter a PR program because of the smoking cessation requirement or are denied entry because they won't commit to a cessation program.

 

Research has shown that exercise rehabilitation programs for smokers reduces lung function declines and reduces the risk of developing COPD. For example, see Garcia-Aymerich J, et al. Regular Physical Activity Modifies Smoking-related Lung Function Decline and Reduces Risk of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2007 Mar 1; 175(5):458-63. Free full version of study results available here: http://ajrccm.atsjournals.org/cgi/reprint/175/5/458

 

Further, researchers in an article published this month regarding prescribing exercise for smokers noted, "Studies have shown that physical exercise helps reduce the intensity of some of the main symptoms that may arise when a smoker attempts to quit, yet doctors and sport therapists are generally unaware of this benefit and do not know how to prescribe exercise appropriately." Ayan, Perez C. Prescribing Exercise in Tobacco Smoking Cessation Therapy. Arch Bronconeumol.
2009 Nov; 45(11):556-60. (full study is available for free in Spanish but the free full text in English is not available yet).

 

Numerous other articles/studies reflect similar findings – regular exercise for smokers does generate positive respiratory function compared to smokers who don't exercise. And some researchers have demonstrated that exercise can actually improve smoking cessation success rates.

 

So why not enroll smokers into pulmonary rehab-style programs prior to attempting smoking cessation (whether they have COPD already or not)? The exercise will benefit them whether they give up smoking or not and it appears the effects of regular exercise may ultimately improve smoking cessation success.

 

What's for sure is that making a sizeable dent in the swelling tide of worldwide COPD cases will require innovative and provocative approaches to treatment as much as it will new pharmacotherapy research – prescribing pulmonary rehab prior to smoking cessation may be one such provocative step worth further investigation.

Pulmonary rehabilitation – an upside down approach to patient care

One of the strange circumstances that confronts people with COPD is that the medical profession seems most likely to offer pulmonary rehabilitation as a treatment option to those who are in the worst condition instead of those who are early in the development of lung disease when it would likely have greater and more lasting impact.

The reasons for this upside down view of patient care seem to stem from the following observations:

1. There is not consensus among physicians regarding the impact of pulmonary rehabilitation for those with lesser degrees of lung disease
   
2. There is not enough health care resource capacity (medical professionals/physical locations with necessary equipment) to treat a larger, broader range of patients
   
3. Reimbursement for pulmonary rehabilitation services through Medicare (and many insurance companies) is largely provided only for patients with moderate to severe conditions.
   

From an outsider's point of view, these reasons make no sense at all.

On the first point, regarding consensus among physicians about the effectiveness of pulmonary rehabilitation for those with lesser degrees of COPD, if physicians believe that regular exercise is vital for healthy adults to maintain a vibrant lifestyle, why should they disagree that regular exercise for people with lung conditions is any less valuable? I actually don't think you'd find many physicians who would disagree that regular exercise is valuable for people with COPD. Instead, I think some might argue whether it is appropriate for medical professionals to intervene and provide a structured pulmonary rehabilitation program for those with mild COPD or pre-COPD conditions from a cost/benefit standpoint given current healthcare resource constraints. Some others might cite that there is not much research evidence that people with mild to moderate COPD benefit dramatically from pulmonary rehab. While it is true that most of the studies in the field have been conducted on patients with moderate to severe COPD, there have been a number of studies published that show beneficial results of pulmonary rehab for mild COPD patients, such as Rossi G, et al. Length and Clinical Effectiveness of Pulmonary Rehabilitation in Outpatients With Chronic Airway Obstruction. Chest 2005; 127(1): 105-109. Full text of the study is available to access for free at http://chestjournal.chestpubs.org/content/127/1/105.long

Reading between the lines here, I think the real reason why pulmonary rehab isn't offered to people earlier in the development of lung conditions is more related to the second and third reasons identified above than whether pulmonary rehab is an effective treatment option.

Because Medicare and many insurance companies limit reimbursement for pulmonary rehab to moderate to very severe cases of COPD, physicians have no financial incentive to offer pulmonary rehab to those with mild COPD or pre-COPD conditions. In our current health care system, why should respiratory care professionals go out of their way to offer a service for which they can't be reimbursed? Hospital administrators who oversee the operations of pulmonary rehab programs are loathe to offer wide scale, free extended medical care (understandably) and from the stories I've heard from respiratory therapists who work in these programs very few patients are self-pay. From my conversations with pulmonary rehab practitioners and from sessions I've attended at pulmonary medicine conferences, I know pulmonary rehab professionals would love to provide services to a broader range of patients and they cite reimbursement limitations as being the prime impediment to do so.

Further, since reimbursement levels for pulmonary rehabilitation in general are not attractive amounts compared to the cost incurred to provide these rehab services (especially when compared to other therapy forms for which a hospital receives more attractive reimbursement), many hospitals simply don't offer pulmonary rehab programs. Additionally, for these same reasons, hospitals who do offer pulmonary rehab services do don't devote a significant amount of human resource, physical space and equipment to outfit a sizeable rehab facility.

The result is too few pulmonary rehab programs to serve the full range of COPD and pre-COPD patients who could benefit from this valuable treatment option. In this circumstance, it makes intuitive sense that practitioners offer the limited spaces in their programs who those who are in the worst condition (what they refer to as prioritization of care). But it creates the crazy situation that in order to get admitted to a pulmonary rehabilitation program a pre-COPD or mild COPD patient (and even a good block of moderate COPD patients) must wait until their lung function has deteriorated significantly and for the most part, irreparably.

I ask you – does this treatment approach really make sense given the alarming growth rates of COPD? It feels more like a battlefield triage scenario to determine who gets access to pulmonary rehabilitation rather than a proactive strategy to confront the inevitable crushing and costly impact of severe COPD cases to come.

  
 

  
 

  
 

  
 

  

Recent study reaffirms significant benefits of long-term commitment to pulmonary rehabilitation

Over the past three decades there have been scores of studies which demonstrate the health benefits gained by COPD patients enrolled in pulmonary rehabilitation (PR) programs. Whether reflected in improved physical conditioning, reduced symptoms, or higher levels of patient reported quality of life, the magnitude of the improvements reported in these studies are impressive considering how short in duration most of these studies evaluate patient experience (typically 6-12 weeks).

So when a group of Israeli researchers reported results of their 3-year PR study in May 2009¹ it was cause for eyes to open wide and jaws to drop – at least for me The research team of David Stav, Meir Raz and Isaac Shpirer, set out to examine whether a prolonged course of pulmonary rehabilitation would provide incremental conditioning benefits for COPD patients (you can view the full text of the study results at the following Internet Link. In my view, their results were astonishing:

153% increase in maximum sustained exertion (peak load) on a stationary ergonometer for the study group after 1 year in the PR program (rose to 160% after 3 years) compared to a 7% decline for the control group in the study (those who did not participate in PR)

110% increase in sustained time on the ergonometer at 75% of maximum peak load for the study group after 1 year compared to 0% improvement for the control group (results for both groups holding relatively constant at 3 years). 

Why is this impressive? Most of the 8-12 week PR program studies that have garnered wide attention among respiratory care professionals over the past three decades show conditioning improvements that range anywhere from 10-30%. The fact that Stav and his colleagues demonstrated much larger conditioning improvements for prolonged patient participation in a PR program reinforces in my mind the substantial benefits derived from starting and maintaining a life-long commitment to PR principles and practices.

It will be interesting to see if other researchers follow in Stav, et al’s footsteps to validate/replicate these findings in subsequent prolonged PR program duration studies, but in the meantime I think there’s enough of a readily available body of evidence in shorter duration studies to conclude that pulmonary rehabilitation is a powerful treatment option for COPD patients. 

¹Stav D, Raz M, Shpirer I. Three years of pulmonary rehabilitation: inhibit the decline in airflow obstruction, improves exercise endurance time, and body-mass index, in chronic obstructive pulmonary disease. BMC Pulmonary Medicine 2009, 9:26.