Pulmonary rehabilitation: art or science?

In recent years growing attention has been paid to rehabilitation of patients with chronic obstructive lung disease and other respiratory cripples. Issue number 6 of the European Respiratory Review is devoted to this topic [1], and in the present issue of the Respiratory Journal, recommendations for the use of Pulmonary Rehabilitation are published [2). The latter publication is from the European Respiratory Society Rehabilitation and Chronic Care Scientific Group. Pulmonary rehabilitation aims to restore an independent, productive and gratifying life, and prevent further clinical deterioration of the disease to the maximum extent compatible with the stage of the disease. Its goal is to minimize pulmonary limitation and to achieve an optimal functional and activity level for a given pulmonary impairment. Mter smoking cessation and optimal medical therapy, patients are admitted to multidisciplinary programmes, sometimes even in specialized institutions, which are aimed at maximal restoration of their functional capacity [3, 4). Various means and techniques are used. These include: patient and family education, chest physiotherapy, exercise reconditioning, training of respiratory muscles, respiratory muscle rest and oxygen therapy. A detailed account of the clinical usefulness of these techniques is found in the European Respiratory Review [1]. The present editorial will attempt to focus on recent developments and improved insight into the techniques used for pulmonary rehabilitation which have been evaluated scientifically in the past few years. The degree of airflow obstruction, as estimated by forced expiratory volume in one second (FEV1), and exercise capacity do not correlate well in chronic obstructive pulmonary disease (COPD) patients [5]. Several factors interfere, adding complexity to the relationship. These include: pulmonary vascular disease, diffusion disorder and generalized muscle weakness. Malnutrition, detraining and treatment with corticosteroids may contribute to the latter [6-8). Steroidinduced muscle weakness in COPD patients is of great conceptual interest and, consequently, reduction of steroids to the lowest dose possible may prove to be an important step in rehabilitation. Alternatively, if FEV1 does not correlate well with exercise capacity, it also means that improving FEV1 by bronchodilators