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12. Dalen JE, Alpert JS, Hirsh J. Thrombolytic therapy for pulmonary embolism: is it effective? Is it safe? When is it indicated? Arch Intern Med. 1997;157(22):2550-2556.
13. Carlbom DJ, Davidson BL. Pulmonary embolism in the critically ill. Chest. 2007;132(1):313-324.
14. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper
W; Management Strategies and Prognosis of Pulmonary
Embolism-3 Trial Investigators. Heparin plus alteplase
compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002;347(15):
15. Meneveau N, Séronde MF, Blonde MC, et al. Management
of unsuccessful thrombolysis in acute massive pulmonary
embolism. Chest. 2006;129(4):1043-1050.
Pulmonary Rehabilitation for
Restrictive Lung Diseases
respiratory conditions share a number of
C hronic
common manifestations, such as dyspnea, cough,
fatigue, and inactivity. In addition, patients often
experience secondary peripheral muscle, cardiac,
nutritional, and psychologic impairments, which
individually or in combination with their respiratory
condition further limit exercise capacity and healthrelated quality of life (HRQL). The resulting impact
on personal and family life, as well as the associated
increase in health-care use, is well known.
Given the evidence that pulmonary rehabilitation
(PR) benefits the large population with COPD, it is a
reasonable assumption that those with other respiratory
conditions might benefit similarly. Whereas the PR
literature has focused on COPD, there is growing
interest in evaluating PR for patients with restrictive lung
diseases. Two groups reported a total of 87 patients with
either idiopathic pulmonary fibrosis1 or a variety of
interstitial lung diseases (ILD),2 randomized to usual
care or to 8 to 10 weeks of outpatient exercise training. At the end of the training periods, both groups
reported significant improvements in 6-minute walk
distance (6MWD), with the exercise group improving
by 35 to 46 m relative to the control group. Subjects
in the exercise group also demonstrated an improvement in HRQL, although not in peak exercise capacity.
These results were consistent with those from earlier
observational reports of PR in ILD.3-6 Disappointingly, Holland and colleagues found that none of the
benefits was sustained when follow-up was extended
to 6 months.2
In this issue of CHEST (see page 273), Salhi and
colleagues7 present a subset of data from REVALIS,
a prospective cohort study examining the effectiveness of outpatient PR in Belgium. They report their
observations on 31 subjects entering the study with a
diagnosis of restrictive lung disease, 11 of whom had
ILD. The program extended over 24 weeks and
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bined endurance training, strength training, education, and psychologic support.
Overall, patients experienced remarkable improvements in their symptoms and in their exercise capacity.
The 11 patients with ILD experienced an impressive
improvement in functional exercise, increasing their
6MWD by 79 m at 12 weeks, and 102 m after the full
24 weeks, compared with their baseline values. The
accompanying increase in peak workload and oxygen
uptake measured by incremental cycle ergometry signified that a physiologic training effect had also been
achieved. The Chronic Respiratory Questionnaire8
dyspnea score improved by at least 2.5 points in nearly
three-quarters of patients by the end of the program.
Although the minimal clinically significant change
in scores for 6MWD and for the Chronic Respiratory
Questionnaire have not been established for patients
with ILD, the improvements noted substantially
exceed the value established for patients with COPD.
What Lessons Can Be Drawn
From This Report?
First, the study lends more support to the case that
patients with restrictive lung disease can safely participate in PR, given that 26 of 31 subjects, including 10 of
11 with ILD, were able to complete the full 24-week
program. Those on oxygen at baseline were equally
successful at completing the program, without any
serious adverse events. These data are in line with similar
observations reported for outpatient PR in COPD.9
Second, severity of illness should not disqualify
patients with ILD from participating in PR. On
the contrary, those with worse disease may benefit
more. Although the clinical trials by Nishiyama’s1 and
Holland’s2 groups included patients with mild-tomoderate lung restriction, in whom the 6MWD at
baseline was close to 400 m, the current study subjects had more severe restriction and lower baseline
6MWDs. Moreover, they required at least two other
measures of impairment in exercise capacity, muscle
function, symptoms, or quality of life. The limited
gains seen in the previous studies may have been due
to a ceiling effect, so that selecting more severely
impaired patients enabled the current study to demonstrate greater improvements after PR.
Third, the duration of rehabilitation plays an
important role. Although the 6MWD and HRQL
scores among Holland’s training group returned to
baseline on follow-up after a 9-week exercise training
program, Salhi and colleagues7 identified greater
benefits among their subjects, who completed
6 months of training. These observations are in keeping with reported outcomes in the COPD literature
in which longer programs generated greater and
more durable benefits.10-12 It is reasonable to assume
CHEST / 137 / 2 / FEBRUARY, 2010
that longer programs enable patients to reach higher
training intensities, which are known to result in
physiologic training effects.13 Longer programs may
be especially important for PR in ILD, as many of
those likely to be enrolled will have early and profound
exercise-induced oxygen desaturation in addition
to their dyspnea and peripheral muscle weakness,
thereby obliging the exercise therapist to start training at a low exercise intensity. An extended program
might offset the low initial training loads.
As with many observational studies, a note of caution must be applied to the interpretation of these
results. The absence of a control group or random
treatment allocation weakens the message, as the
additional benefit of rehabilitation over usual care
could not be reported. Furthermore, the small number of subjects with ILD who enrolled in PR does
not exclude the possibility of observed differences
arising from the play of chance. In summary, our
view of PR for patients with ILD is an optimistic one.
We anticipate that the optimal duration, intensity,
and program content will be further refined during
the next few years.
Robert G. Varadi, MDCM
Roger S. Goldstein, MB ChB, FCCP
Toronto, ON, Canada
Affiliations: From the University of Toronto, Department of
Respiratory Medicine, West Park Healthcare Centre.
Financial/nonfinancial disclosure: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be
discussed in this article.
Correspondence to: Roger Goldstein, MB ChB, FCCP West
Park Healthcare Centre, 82 Buttonwood Ave., Toronto, ON,
M6M 2J5 Canada; e-mail: [email protected]
© 2010 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians (
DOI: 10.1378/chest.09-1857
1. Nishiyama O, Kondoh Y, Kimura T, et al. Effects of pulmonary rehabilitation in patients with idiopathic pulmonary
fibrosis. Respirology. 2008;13(3):394-399.
2. Holland AE, Hill CJ, Conron M, Munro P, McDonald CF.
Short term improvement in exercise capacity and symptoms
following exercise training in interstitial lung disease. Thorax.
3. Holland A, Hill C. Physical training for interstitial lung
disease. Cochrane Database Syst Rev. 2008;(4):CD006322.
4. Varadi RG, Goldstein RS, Stanbrook MB. Outcomes of pulmonary rehabilitation (PR) in idiopathic pulmonary fibrosis
(IPF) [abstract]. Am J Respir Crit Care Med. 2008;177:A792.
5. Jastrzebski D, Gumola A, Gawlik R, Kozielski J. Dyspnea
and quality of life in patients with pulmonary fibrosis after
six weeks of respiratory rehabilitation. J Physiol Pharmacol.
2006;57(suppl 4):139-148.
6. Naji NA, Connor MC, Donnelly SC, McDonnell TJ. Effectiveness of pulmonary rehabilitation in restrictive lung disease. J Cardiopulm Rehabil. 2006;26(4):237-243.
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7. Salhi B, Troosters T, Behaeqel M, Joos G, Derom E. Effects
of pulmonary rehabilitation in patients with restrictive lung
diseases. Chest. 2010;137(2):273-279.
8. Lacasse Y, Wong E, Guyatt G. A systematic overview of the
measurement properties of the chronic respiratory questionnaire. Can Respir J. 1997;4(3):131-139.
9. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of
outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;355(9201):362-368.
10. Green RH, Singh SJ, Williams J, Morgan MD. A randomised
controlled trial of four weeks versus seven weeks of pulmonary rehabilitation in chronic obstructive pulmonary disease.
Thorax. 2001;56(2):143-145.
11. Güell R, Casan P, Belda J, et al. Long-term effects of outpatient rehabilitation of COPD: a randomized trial. Chest.
12. Troosters T, Gosselink R, Decramer M. Short- and long-term
effects of outpatient rehabilitation in patients with chronic
obstructive pulmonary disease: a randomized trial. Am J Med.
13. Casaburi R, Patessio A, Ioli F, Zanaboni S, Donner CF,
Wasserman K. Reductions in exercise lactic acidosis and
ventilation as a result of exercise training in patients with
obstructive lung disease. Am Rev Respir Dis. 1991;143(1):9-18.
Life and Death Decisions in the
Middle of the Night
Teaching the Assessment of
Decision-Making Capacity
2:00 am one morning, when I was a much
attending physician, I received a call from
a resident on service in the ICU. He called about a
case with “an FYI,” because he had a few minutes
and thought I might want to be informed. He told me
of a 25-year-old man admitted that night with what
appeared to be severe community-acquired pneumonia. The patient carried the diagnosis of developmental delay, but, the resident informed me, the patient
had been previously determined to be legally competent to make his own decisions by the courts, and he
lived alone. The patient was developing acute respiratory failure, and he refused intubation and mechanical ventilation. The resident informed the patient
that he would likely die without this treatment, and
the patient told the resident that he understood. The
resident tried noninvasive ventilation, and the patient
refused it. The resident was calling to tell me that
he was planning to transition to comfort measures
only. The team had tried unsuccessfully to reach
the patient’s parents, although the social worker was
still trying.
On hearing this story from my warm bed at home,
my mind—and heart—began racing. What makes a
25-year-old, previously healthy man want to refuse
life-sustaining mechanical ventilation, and how do I