This document has been developed to assist pulmonary rehabilitation (PR) programs to continue to provide patient care during the COVID-19 pandemic. The document provides organisational models of PR and options for the delivery of home-based PR supported by telehealth (i.e. telephone or videoconferencing).
Most mainstream pulmonary rehabilitation services have traditionally delivered centre-based, face-to-face interventions. The social distancing requirements to prevent community transmission of COVID-19 has meant that these face-to-face pulmonary rehabilitation services have been temporarily suspended across NSW.
Early in 2020, the NSW Agency for Clinical Innovation’s Respiratory Network Pulmonary Rehabilitation Clinical Expert Reference Group (PuReCERG) began to develop this guidance document to support face-to-face pulmonary rehabilitation to transition to virtual models of pulmonary rehabilitation, supporting this essential aspect of managing chronic respiratory conditions to continue during the COVID-19 pandemic.
A rapid review of the available evidence, both published and grey literature around the virtual delivery of pulmonary rehabilitation, was undertaken by searching PubMed and Google on 23 March 2020 using the following search terms:
Criteria for assessing the resulting evidence included, credibility of authors, inclusion of papers in high impact journals, availability of any systematic reviews and validation of tools within the Australian Pulmonary Rehabilitation Guidelines and Pulmonary Rehabilitation Toolkit.
NSW Telehealth guidelines were also used to inform the translation of research into practice within this guide. Synthesis was undertaken collaboratively by the PuReCERG, who used their academic and clinical expertise to achieve clinical consensus for literature and tools that would be used to support the development of this guide. The tools selected for use within this guide are validated, well socialised and currently widely used in standard pulmonary rehabilitation practice across NSW.
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During the COVID-19 pandemic most PR programs in NSW are no longer providing face-to-face assessments and interventions. PR improves the quality of life for people with chronic lung disease and, importantly, helps to keep people out of hospital.1-3
Keeping people with chronic lung disease out of hospital over the period of the pandemic is vital to reduce the burden on the health system at a time when resources are stretched. In addition, any admissions to hospital would potentially increase the risk of the patients being exposed to COVID-19.
This document provides suggestions about how to manage patients who are in the following situations during the COVID-19 pandemic:
Telehealth is the delivery of healthcare at a distance using information communications technology, and in this document refers to telephone or real-time video connection. Telehealth is used to connect clinicians to patients, caregivers or any person(s) responsible for providing care to the patient, for the purposes of assessment, intervention, consultation, education and/or supervision.
Guidance on options for the safe provision of PR programs via telehealth modalities in each of the above situations is provided. The information in each section below is based on current available evidence. We acknowledge that the evidence for telehealth PR is not as strong as for centre-based PR. However, at this time it is important to support our patients with the best PR programs possible in the circumstances. We are in unchartered territory with the inability to perform face-to-face patient assessments. This will be challenging and will require patient cooperation, flexibility, and experienced clinicians with confidence to learn new telehealth skills.
This document recommends transition of current PR programs to a telehealth model, making use of existing resources available in current programs. The choices that PR programs will make to manage their current and future patients over this time will depend on the availability of local infrastructure, resources, health professional skills and time commitments.
NSW Health and the NSW Agency for Clinical Innovation are providing support for clinicians to aid the rapid transition to telehealth models of care. In addition, within each local health district, there is a telehealth manager or lead who can be contacted for help and advice.
Information on support services is available from ACI Telehealth contact list
Information on how to set up PR telerehabilitation sessions is provided in Appendix 1.
Please note: This document may not be applicable to patients requiring continuous monitoring during exercise tests or close supervision for safety during exercise training, such as those with heart failure or pulmonary arterial hypertension, unless these patients were already known to the local PR programs and have been assessed face-to-face.
Patients who had already commenced PR should be given first priority of access to the telehealth model, followed by patients on the waiting list and those newly referred to the program.
Category 2 – medium priority
Category 3 – lowest priority
The following steps may help in providing PR programs for wait-listed patients and new referrals:
The inpatient setting may provide the opportunity to commence gentle exercise and to learn about the importance of PR and physical activity. Given that face-to-face PR programs are currently suspended and staff from these programs may have availability to attend the inpatient setting (if appropriate), this may offer the opportunity for PR team members to engage patients in some form of rehabilitation prior to discharge. This may be in the form of:
The components of PR via telehealth are similar to centre-based PR, with adjustments made to account for reduced patient contact. The components are:
Details of each component are provided below.
Most components of a standard PR assessment can be conducted via telehealth (Table 2), either via telephone or videoconference. A telehealth assessment may take longer than a traditional face-to-face assessment and the patient should be advised of the time required. To improve time efficiency, a pack of preparatory resources can be sent to the patient (by mail or email) prior to the initial assessment. Resources may include questionnaires already used in your program, as well as general information about lung disease and PR. Clinicians must adapt communication styles to suit interacting with patients via telehealth and being a ‘guest’ in the patient’s home.
Suggested components of a PR assessment via telehealth are listed in Table 2, and also available in the Pulmonary Rehabilitation Toolkit.
Social history
Home-based PR programs have been shown to be an effective method of delivering PR.4,5 However, most home-based programs that have been evaluated have included a face-to-face assessment and re-assessment, plus a home visit or face-to-face supervised exercise training. Such face-to-face assessments and supervised training during the COVID-19 pandemic will not be possible. Therefore, adaptations to assessment, exercise prescription and progression of exercise, will be necessary.
Access to email is beneficial to enable resources to be easily sent to patients. However, this is not a necessary component as resources can be mailed or discussed over the telephone.
This should be set for each mode of exercise:
Remember some activity is better than none, so although you may not be able to prescribe a specific intensity of training for a patient from an exercise test, such as the 6 minute walk test, encouragement of exercise based on increasing duration of activity and symptoms (3-4 ‘moderate’ to ‘somewhat severe’ on the modified Borg 0-10 dyspnoea or RPE scale) is still valuable.
Patients’ responses to the Active Australia Questionnaire can also be used to guide advice regarding increasing daily physical activity levels. Some useful resources regarding ways to encourage increased physical activity are available in Commonwealth Government information resources.
Supervised home-based telerehabilitation via real-time videoconferencing technology has been shown to be effective in increasing endurance exercise capacity and self-efficacy in people with COPD.7 If patients are interested in using videoconferencing technology, then real-time videoconferencing could be used to complete the assessment and re-assessment, as well as to supervise and progress the exercise training.
Telerehabilitation can be provided to an individual or a group. Telerehabilitation videoconferencing platforms can usually accommodate 4-6 patients per group. Experienced clinical and research clinicians recommend group sizes no larger than 6 for safety and ease of monitoring and communication.6,7
Home-based telerehabilitation via real-time videoconferencing consists of individually prescribed home-based supervised exercise twice a week, with advice to complete unsupervised exercise on at least two other days (Table 3).
The program is similar to unsupervised home-based exercise with telehealth support (Table 3) but the technological device (webcam or camera) should be set up on a stable position such that the clinician can view the patient exercising in real time. For example, ground-based walking in the home should be on a track that takes the person to and from the camera set-up.
If a pulse oximeter is available at home, patients will be able to report the SpO2 and HR to the clinician, otherwise the clinician can use symptoms (from modified Borg 0-10 dyspnoea or RPE scale) to guide exercise intensity.
Please refer to the Appendix 1 for information on how to set up a real-time videoconferencing program.
Education plays an important part in helping patients acquire the knowledge and skills required to self-manage their chronic lung condition. Education should address the patient’s main issues, which will vary from patient to patient.
It is recommended that education should continue to be provided to patients during home-based PR delivered via telehealth, using existing program resources or the Lung Foundation Australia Better Living with COPD booklet. Education topics should include:
Other possible topics:
Not all of these topics will be applicable to all patients. During the initial assessment, ascertain which topics will be relevant for each patient.
Re-assessment of outcome measures is important for determining effectiveness of any intervention. Following home-based PR delivered via telehealth, the clinician should make a separate appointment time to re-assess the patient on an individual basis.
There will be two groups of patients requiring re-assessment:
For both groups of patients, re-assessment should include repeating questionnaires and objective outcomes measures, as well as reviewing goals and discussion regarding ongoing self-management and maintenance exercise options. To improve time efficiency, a pack of preparatory resources (questionnaires, educational information regarding maintenance of exercise) can be sent to the patient (by mail or email) prior to the re-assessment.
In order to promote skills in self-management there are many useful resources that can be provided to patients who are either waiting to access PR, undertaking PR via telehealth, or who do not want to engage in PR via telehealth.
Increasing numbers of people who attend PR programs own a mobile phone.8 One component of ongoing support that could be offered to patients living with chronic respiratory disease is regular text messaging of health messages and support information.
Text messaging may provide an opportunity to encourage, motivate, educate, and support self-management of people with chronic respiratory disease, in the absence of face-to-face group exercise and education sessions, while being a no-cost service. All patients who choose to register will receive the 6-month text message support free of charge.
By opting into the text messaging service, patients will receive four text messages per week plus one message per fortnight related to COVID-19 support and advice (based on Australian Government advice). Patients can respond to the text messages if they wish, and a team of external clinical support staff will monitor and respond or refer to a PR clinician, if necessary. The messaging program will be administered through a secure online platform.9
There are three ways to register for this service:
Information required for registration: name, mobile phone number, date of birth, gender, primary health condition, smoking status, postcode. After providing this information, the patient (or representative) can click on the ‘activate program’ link to activate the program.
The COPE program is an online program developed by Lung Foundation Australia to enable patients to undertake the education program associated with PR. It is a simple online, interactive and informative modular program that provides information for patients on:
Patients can register and gain free access to the materials.
This booklet was developed by Lung Foundation Australia to support people with COPD so that they understand their lung disease and the steps they can take to better manage it. Families and carers may also find this information useful. This booklet can be downloaded from the Lung Foundation Australia website as a pdf document.
Exercise videos that are suitable for people not attending PR:
Exercise videos that may be suitable for people attending PR:
The Australian Federal Government have developed physical activity brochures with advice about physical activity and sedentary behaviour including:
The 5STS is reliable, valid and responsive in patients with COPD with an estimated minimum clinical important difference (MCID) of 1.7 seconds.
Use a straight-backed armless chair with a hard seat stabilised by placing it against a wall.Floor to seat height should be 48cm.
Ask patient to come forward on the chair seat until the feet are flat on the floor and to fold their upper limbs across the chest.
Instruct patient to stand up all the way and sit down once without using the upper limbs. For those unable to complete the initial manoeuvre or who require assistance, terminate the test. If successful on the initial sit to stand, ask patient to stand up all the way and sit down landing firmly, as fast as possible, five times without using the arms. Instruct patient to start test on ‘go’.
Use a stopwatch and start on the command ‘go’ and stop at the end of the completed fifth stand.
The time taken is recorded as the patient’s score.
Jones SE, Kon SSC, Canavan JL, et al. The five-repetition sit-to-stand test as a functional outcome measure in COPD. Thorax 2013;68(11):1015-20.
The 1 minute STS is reliable, valid and responsive in patients with COPD. An improvement of at least three repetitions is consistent with physical benefits after PR.
Use a straight-backed armless chair with a hard seat stabilised by placing it against a wall.Floor to seat height should be 46cm.
Ask patient to come forward on the chair seat until the feet are flat on the floor and to place hands on hips.
The purpose of the test is to assess your exercise capacity and leg muscle strength. The movement required is to get up from this chair with the legs straight and sit back continuing the repetitions as many times as possible within one minute. I will give you the countdown ‘3, 2, 1, Go’ as an indication to start and also, I will tell you when we are at the 15 remaining seconds. If required, you can have a rest and resume the test as soon as possible.
Use a stopwatch and start on the command ‘go’ and ‘stop’ at the one minute mark. Only include complete sit to stand manoeuvres.
The number of completed sit to stands during the one minute period is recorded as the test outcome.
Table 1. Symptoms to check during telehealth call
Abbreviation: CAT, COPD Assessment Test.
If patient reports any change in symptoms or reports feeling unwell, complete COVID-19 screening questions
Physical activity questionnaire: Active Australia1.
a. In the last week, how many times have you walked continuously, for at least 10 minutes, for recreation, exercise or to get to or from places? ______________ timesIn the last week, how many times have you walked continuously, for at least 10 minutes, for recreation, exercise or to get to or from places? ______________ times
b. What do you estimate was the total time that you spent walking in this way in the last week? ______________ hours _____________ minutesWhat do you estimate was the total time that you spent walking in this way in the last week? ______________ hours _____________ minutes
2.
a. In the last week, how many times did you do any vigorous physical activity which made you breathe harder or puff and pant? (e.g. jogging, cycling, aerobics, competitive tennis) _______________ times
b. What do you estimate was the total time that you spent doing this vigorous physical activity in the last week? ______________ hours ______________ minutes
3.
a. In the last week, how many times did you do any other more moderate physical activities that you have not already mentioned? (e.g. gentle swimming, social tennis, golf) _______________ times
b. What do you estimate was the total time that you spent doing these activities in the last week? ______________ hours ______________ minutes
Armstrong T, Bauman A, Davies J. Physical activity patterns of Australian Adults. Canberra: Australian Institute of Health and Welfare, 2000.
The Active Australia questionnaire has been shown to have measurement properties similar to other physical activity questionnaires (Brown 2004, Timperio 2004), and has also been shown to be responsive to change in physical activity interventions (Marshall 2004).
The NSW Agency for Clinical Innovation Respiratory Network Pulmonary Rehabilitation Clinical Expert Reference Group (Professor Jennifer Alison (University of Sydney, Sydney LHD), Dr Renae McNamara (University of Sydney, Woolcock Institute of Medical Research, South Eastern Sydney LHD), Clinical Associate Professor Lissa Spencer (Sydney LHD), Associate Professor Zoe McKeough (University of Sydney), Dr Marita Dale (University of Sydney), Dr Ling Ling Tsai (South Eastern Sydney LHD), Dr Sally Wootton (Northern Sydney LHD), Helen Kulas (Respiratory Network Manager ACI)
NSW Health COVID-19 Virtual Care Community of Practice, Professor Peter Wark
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning
Clinicians within NSW Health who are delivering pulmonary rehabilitation services to patients living with lung disease in NSW