Quality statement 4: Pulmonary rehabilitation for stable COPD and exercise limitation

Quality statement

People with stable chronic obstructive pulmonary disease (COPD) and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme. [2011, updated 2016]

Rationale

Pulmonary rehabilitation programmes improve a person's exercise capacity, quality of life, symptoms and levels of anxiety and depression.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme: pulmonary rehabilitation clinical audit and organisational audit.

Process

a) Proportion of people with stable COPD and exercise limitation due to breathlessness who are referred to a pulmonary rehabilitation programme.

Numerator – the number in the denominator who are referred to a pulmonary rehabilitation programme.

Denominator – the number of people with stable COPD and exercise limitation due to breathlessness.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme: pulmonary rehabilitation clinical audit.

b) Proportion of referrals of people with stable COPD and exercise limitation due to breathlessness that result in the person attending a pulmonary rehabilitation programme.

Numerator – the number in the denominator that result in the person attending a pulmonary rehabilitation programme.

Denominator – the number of referrals of people with stable COPD and exercise limitation due to breathlessness to pulmonary rehabilitation programmes.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme: pulmonary rehabilitation clinical audit.

c) Proportion of attendances of people with stable COPD and exercise limitation due to breathlessness that result in the person completing a pulmonary rehabilitation programme.

Numerator – the number in the denominator that result in the person completing a pulmonary rehabilitation programme.

Denominator – the number of attendances of people with stable COPD and exercise limitation due to breathlessness at pulmonary rehabilitation programmes.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme: pulmonary rehabilitation clinical audit.

Outcomes

a) Hospital admissions for acute exacerbation.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme.

b) Quality of life.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme.

c) Exercise capacity.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme: Pulmonary rehabilitation clinical audit.

d) GP attendances.

Data source: Local data collection. Royal College of Physicians' National COPD Audit Programme.

What the quality statement means for different audiences

Service providers (secondary care and community services) ensure that systems are in place for people with stable COPD and exercise limitation due to breathlessness to be referred to a pulmonary rehabilitation programme.

Healthcare professionals refer people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

Commissioners (clinical commissioning groups) ensure that they commission services in which people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

People with COPD that is stable and who have difficulty walking and have to walk slowly and stop often or soon become breathless, are referred to a pulmonary rehabilitation programme. This includes exercises, information about COPD, diet advice and support depending on the person's needs.

Source guidance

Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018, updated 2019) NICE guideline NG115, recommendations 1.2.81 and 1.2.82

Definitions of terms used in this quality statement

Exercise limitation

Medical Research Council dyspnoea scale of breathlessness grade 3 and above. A breathlessness of grade 3 is defined as 'walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace'.

[NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.1.3]

Pulmonary rehabilitation programme

A multidisciplinary programme of care for people with chronic respiratory impairment that is individually tailored and designed to optimise each person's physical and social performance and autonomy.

[NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.2.84 and British Thoracic Society's guideline on pulmonary rehabilitation in adults]

Pulmonary rehabilitation programmes should be held at times that suit people with COPD and in locations that are easy for people with COPD to get to, and have good access for people with disabilities. Programmes should be available within a reasonable time from referral.

[Adapted from NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.2.83]

Programmes comprise individualised exercise programmes and education, and:

  • are at least 6 weeks in duration and include a minimum of twice‑weekly supervised sessions

  • include supervised, individually tailored and prescribed, progressive exercise training including both aerobic and resistance training

  • include a defined, structured education programme.

[British Thoracic Society's guideline on pulmonary rehabilitation in adults]

Equality and diversity considerations

Pulmonary rehabilitation is not suitable for people with unstable cardiac disease, locomotor or neurological difficulties precluding exercise such as severe arthritis or peripheral vascular disease, and people in a terminal phase of an illness or with significant cognitive or psychiatric impairment.