Integrating patients with chronic respiratory disease and heart failure into a combined breathlessness rehabilitation programme: a service redesign and pilot evaluation

Abstract

IntroductionThe successful integration of patients with chronic heart failure (CHF) into a traditional pulmonary rehabilitation (PR) programme has previously been reported. Our aim was to reconfigure both our cardiac rehabilitation (CR) and PR services to enable us to deliver a symptom-based programme—breathlessness rehabilitation (BR), for patients with a primary symptom of breathlessness irrespective of the index diagnosis, or comorbid disease.MethodsAfter a service redesign process, patients attended a two times per week, group-based, tailored exercise and education programme for 6 weeks, delivered by CR and PR staff. The classes included both aerobic and resistance exercises and an overarching generic education programme alongside disease-specific components. Home programmes were reviewed at each session to facilitate progress and influence changes in exercise behaviour beyond the supervised programme. Generic clinical outcome measures were performed pre and post BR.Staff focus groups were conducted to identify barriers and facilitators and explore staff perceptions.Results272 patients (n=193 chronic respiratory disease (CRD) and n=79 CHF) were assessed and enrolled into BR (153 men, mean (SD) age 68.8 (12.7) years, body mass index 28.8 (7.3), Medical Research Council 3 (IQR 2–4), New York Heart Association 2 (IQR 2–3)). 164 patients completed the programme. Statistically significant improvements were seen in both exercise capacity (incremental shuttle walking test: mean change 47.4 m; endurance shuttle walking test: mean change 310.7 s) and quadriceps strength (quadriceps maximal voluntary contraction: mean change 3.7 kg) (p≤0.0001) alongside a statistically significant reduction in dyspnoea (chronic respiratory questionnaire/chronic heart questionnaire - self reported - dyspnoea: mean change 0.4) and anxiety and depression scores (Hospital Anxiety and Depression Scale (HADS) - anxiety: −1.6; HADS - depression: −1.3) (p≤0.0001).Qualitative staff focus groups identified three subthemes: collaboration and integration, service quality and future challenges.DiscussionOverall the service redesign indicates the feasibility for staff and individuals with CRD and CHF to integrate into a breathlessness programme. Early data suggests clinical effectiveness. Given the significance of comorbid disease it is an approach that warrants further consideration.

British Thoracic Society Clinical Statement on pulmonary rehabilitation

“…106 Integrating individuals with CHF and those with chronic respiratory disease into breathlessness rehabilitation programmes is feasible with minor adaptations (table 2). 107 These improve exercise capacity in CHF, with a magnitude similar to that observed in COPD. 108 Only 18% of PR services in the UK currently accept patients with CHF.…”

Diagnostic delays for breathlessness in primary care: a qualitative study to investigate current care and inform future pathways

“…Research is ongoing to broaden these programmes for adults with exertional breathlessness regardless of underlying disease. 44 Recognising and describing deconditioning as a positive diagnosis with a targeted therapy, such as exercise training, may aid communication between clinician and patient.…”