Original Article

Article

Impact of Pulmonary Rehabilitation and Educational

Component in Patients with Severe Asthma
Jhonatan Betancourt-Peña1,2*, Diana Marcela Castro-Valencia2, Steven García2, María Lorena
Orozco-Leyton2, Juan Carlos Ávila-Valencia1, Vicente Benavides-Cordoba1
Faculty of Health and Rehabilitation, Institución Universitaria Escuela Nacional del Deporte, Cali, Colombia; 2Universidad del
1

Valle, Cali, Colombia

Corresponding author: Abstract

Jhonatan Betancourt-Peña,
Faculty of Health and Rehabilitation, Background: Asthma is a chronic inflammatory airways disease, which produces an increase in
Institución Universitaria Escuela the reactivity and recurrent episodes of wheezing, respiratory distress and cough. Pulmonary
Nacional del Deporte, Cali,
rehabilitation (PR) and education is a strategy that improves the quality of life and health
Colombia,
Tel: 0114480016; status of patients. Objective: To determine the impact of PR with an educational component on
E-mail: [email protected] functional aerobic capacity, symptoms, anxiety, depression and quality of life related to health
in patients with severe asthma. Methods: Prospective and non-controlled intervention study
in 11 patients, who underwent the 6-minute walking test, spirometry, the Medical Research
Council dyspnoea scale (MRC), the Hospital Anxiety and Depression Scale questionnaire
(HADS) and the St George’s Respiratory Questionnaire (SGRQ). The PR program comprised
8 weeks of muscle strength training, aerobic capacity and educational component with
individual and group sessions. Results: 11 patients completed the PR program. The average
age was 55.82 ± 19.96. The FVC had an average of 49.21 of the predicted SD ± 14.94. The distance
covered in the 6-minute walking test had a difference in means and DE of 53.36 ± 50.7, being
clinically significant. In anxiety and depression there was a mean difference of 1.18 ± 2.31 and
1.54 ± 2.62 respectively, anxiety with a p-value of 0.079 and depression with a p-value of 0.12.
They did not have a statistically significant improvement, and in the quality of life related to
health, the domain that presented the greatest improvement were activities, with a p-value of
0.000. Conclusions: In a PR program, education showed good results regarding variables such
as functional aerobic capacity, symptoms and quality of life in patients with severe asthma.
Keywords: Asthma; Exercising; Pulmonary rehabilitation; Dyspnoea; Quality of life

Introduction known and the evidence is superior to other chronic pulmonary

diseases; [6-8] however, patients with severe asthma present
Asthma is a frequent and potentially serious chronic disease intolerance to exercising due to episodes of bronchospasm, [9]
that places a considerable burden on patients, their families and muscle dysfunction and behavioural alterations, thus, the effects
society. It causes respiratory symptoms, limitation of activity of RP could improve all these clinical aspects.
and exacerbations (seizures or attacks) that sometimes require
urgent medical assistance and can be fatal. [1] For the care of patients with chronic lung disease, several
strategies have been developed, among which are smoking
According to the World Health Organization (WHO) there are cessation, exercise promotion, knowledge of the disease and
approximately 383000 cases of deaths from this disease, mostly adherence to the pharmacological treatment. [10,11] All these in
corresponding to older adults. [2] Patients with severe asthma the framework of patient education. Furthermore, within PR,
comprise between 5 and 10% of the total population with respiratory physiotherapy is included, which improves dyspnoea
asthma, and they present high rates of morbidity and high costs and fatigue, the correct use of inhalers and the acquisition of
to the health system. [3] healthy lifestyles.

The asthma treatment has several strategies, among which the Due to the previously remarked, it is necessary to know how
pharmacological has been widely studied and used, however PR treatment, in which an educational program is included, can
it is necessary to find new strategies to improve the particular impact on different physiological, clinical and quality of life
state of these patients. [4] One of these strategies is pulmonary variables; being the objective of this research: To determine the
rehabilitation (PR), which has produced improvement in aerobic
capacity, physical activity, activities of daily living, muscle This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,
strength, quality of life, and it has also reduced inflammation
tweak, and build upon the work non‑commercially, as long as the author is credited
markers. [5] and the new creations are licensed under the identical terms.

How to Cite this Article: Betancourt-Peña J, et al. Impact of Pulmonary

Structured training is a fundamental part of PR, its benefits Rehabilitation and Educational Component in Patients with Severe
in chronic obstructive pulmonary disease (COPD) are well Asthma. Ann Med Health Sci Res. 2018; 8: 122-127
122 © 2018 Annals of Medical and Health Sciences Research
 Betancourt-Peña J, et al.: Impact of Pulmonary Rehabilitation and Educational Component in Patients with Severe Asthma

impact of PR with an educational component on the functional (eight). This questionnaire is based on the prevalence of
aerobic capacity, symptoms, anxiety, depression and quality of depression and anxiety in patients who attend a general medicine
life related to health in patients with severe asthma. hospital and who may coexist with a physical illness leading to
greater stress. The score for each of the subscales is obtained by
Methodology adding up the values of the selected sentences with values of 0
Prospective uncontrolled intervention study in a population of to 3, with a score range of between 0 to 21. It is considered to be
11 patients with asthma who entered to a PR program in a fourth normal when the subscale of anxiety or depression has a score
level hospital in Cali, Colombia, during the period between of 0-7, doubtful when it is of 8-10, and a major clinical problem
January 2015 to December 2016. At the time of PR, all patients when the score is greater than 11.
were receiving long-term treatment from a pulmonologist,
according to the behavior of informed patterns of disease Quality of life related to pre- and post- RP health was
variability, triggering factors and receptivity to medications. determined with the St. George Respiratory Questionnaire
(SGRQ), an instrument designed to measure the impact on
The inclusion criteria considered were: patients with a medical general health, daily living, and the perception of well-being
diagnosis of severe asthma confirmed by reversibility in in patients with obstructive airway disease. [14] The SGRQ
spirometry, patients between 40 and 80 years of age, performing consists of 3 dimensions: symptoms, activity and impact. In
PR for the first time and patients capable of conclude the the first dimension, aspects such as the presence of dyspnoea,
8-week intervention. The exclusion criteria were: patients cough and expectoration, and the frequency with which they
with decompensated cardiovascular and metabolic diseases, occur are measured. In the second dimension, the limitation of
exacerbations requiring hospitalization or emergency visits in activity due to dyspnoea is assessed (e.g. walking slower than
the last month, treatment with intravenous corticosteroid drugs others, having to stop to rest on a flight of stairs or not being
in the last month after PR admission, current smokers or ex- able to ride a bicycle). Finally, in the third dimension, the most
smokers who gave up smoking during the previous 2 years, and psychosocial aspects are considered, such as the problems that
smoking history greater than 15 packs per year. [12] the medication intake can cause. [14]

Procedures
Taking into account the Helsinki declaration, the study
was approved by the Institutional Ethics Committee of the All patients initially signed the informed consent before initiating
hospital where the research was conducted; all the procedures the PR and subsequently they responded, in a self-administered
were performed following international bioethics standards. way, the HADS questionnaire and the SGRQ questionnaire,
Confidentiality and all the necessary security measures for the with intervals of ten minutes between both questionnaires. The
application of assessment and intervention instruments were
estimated time in which patients answered the questionnaires
guaranteed for patients.
was 60 minutes. The application of the MRC dyspnea scale was
performed by a physiotherapist specialist in the area. Finally,
Variables
the functional capacity was evaluated with the 6MWT, taking
The variables that were evaluated were sex, age, place of into account the recommendations of the American Thoracic
residence, values obtained in spirometry as Forced Vital Capacity Society (ATS). [15] For this test, there was a 30 m long flat
(FVC), Forced Expiratory Volume in the first second (FEV1) track, with two cones at the ends to delimit the distance. At the
and the relationship between (FEV1/FVC) in percentage of the beginning of the test, the patient was encouraged to walk as
predicted, and body mass index (BMI). Moreover, dyspnoea was quickly as possible and was told of the time elapsed during the
evaluated in activities of daily living with the Medical Research test minute by minute.
Council (MRC) scale pre and post PRP, in which grade I means
dyspnoea only with very strong exercise; grade II ability to keep Pulmonary rehabilitation program
up the pace of a person of the same age in the plain without The PR program was carried out in an outpatient clinic, and
dyspnoea, but not in the flat or when climbing stairs; in grade consisted of 24 sessions of exercise and educational activities,
III, the patient is able to walk on the plain in his pace without distributed in 3 sessions per week (one hour per session)
dyspnoea, but unable to keep up the pace of people of his age; for 8 weeks. Patients were instructed to use a short-acting
in grade IV, the patient presents dyspnoea when slowly walking bronchodilator, 15 minutes before each session.
100 meters; and in grade V, there is dyspnoea at rest or with
small efforts like dressing. [13] The intervention protocol was guided by a Physiotherapist
specialized in Cardiac and PR, where patients performed
The distance travelled in the six-minute walk test (6MWT) continuous predominance exercise in endless band for 30
before and after PR was analysed. Furthermore, anxiety and minutes, starting at 60% of the estimated VO2 reached in the
depression were evaluated with the Hospital Anxiety and 6MWT. [16]
Depression Scale (HADS), pre- and post-PR. This scale consists
of a questionnaire of 14 questions, divided into two subscales The progression in exercise intensity was performed using the
of anxiety (7 questions) and depression (7 questions), with a modified Borg scale to maintain a score between 3 (moderate)
maximum score of 21 and structured Likert-type responses and 5 (severe). [17,18] Muscle strengthening was performed by

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 Betancourt-Peña J, et al.: Impact of Pulmonary Rehabilitation and Educational Component in Patients with Severe Asthma

4 sets of 12-15 repetitions starting at 50% of the maximum comorbidity, 3 out left the treatment without known justification
resistance (MR), and 4 weeks after it was increased to 60% of and 2 dropped out due to economic reasons; in the end 11
the MR for upper and lower limbs. [19] patients completed the PR program.

At the end of the PR program, each patient was given a written The socio-demographic characteristics are described in Table 1.
program of domiciliary exercises based on the activities and Most of the participants were female (73%) and predominantly
intensities performed during the last two weeks of training. married. The ages ranged between 27 and 88 years with a mean
Additionally, 30 minutes per week of individual educational of 55.82 ± 19.96. With respect to the socioeconomic stratum,
component and 60 minutes per week of group educational 46% belonged to stratum 2, a medium-low classification in
component were incorporated. Colombia, the country where the study was conducted.

Educational component Table 1: Socio-demographic and clinical features.

Variables Classification (%) n: 11
Patients received education on topics such as: knowledge Male 27% 3
Gender
of the disease, importance of not smoking, use of inhalers, Female 73% 8
recognition of warning signs, management of breathing in Married 40% 4
activities of daily living, use of home oxygen, adequate Single 10% 1
Civil status
nutrition, energy conservation techniques and domiciliary Free union 40% 4
Widower 10% 2
respiratory exercises. [20,21]
Cali 82% 9
Residence place Yumbo 9% 1
The individual educational component was performed once the
Candelaria 9% 1
patient entered the PR program. In the first session, with the help
2 45% 5
of audiovisual elements, patients were informed about issues Sociodemographic stratum 3 45% 5
related to the knowledge of the disease. Initially, we inquired 4 10% 1
about the initial knowledge the patient had and the necessary Si 27% 3
Home oxygen use
feedback was done, and later, the same process was carried out No 73% 8
once a week with the other subjects. Si 64% 7
Visits to the emergency room
No 36% 4
The group activities were carried out in sessions held once a Age Mean/(SD) 55.82 ± 19.96
week, with the collaboration of a professional in psychology,
nutrition, physiotherapy and medicine, who each week Table 2 shows the pulmonary function of the participants, which
addressed issues related to the burden of the disease, how to live was measured with flow-volume curve spirometry pre and post
and accept a chronic pulmonary disease, the support of family bronchodilator, obtaining severe obstruction in patients. The
members, leisure strategies, adequate nutrition, exercising at anthropometric measurements are shown in Table 3. The BMI
home, the knowledge of medications and home oxygen use. In had an initial mean of 23.62 ± 4.09, without significant changes
these meetings, patients could attend in the company of a family at the end of the PR (p=0.81).
member and, in a participative way; the health professionals Table 2: Spirometry data.
presented the ideas and complemented them with examples. Data Mean Mean difference
At any time, patients/relatives made contributions sharing their FEV1 49.21 14.94
experiences and questions with the group, and in the end the FVC 72.09 20.87
health professional generated a general conclusion for each FEV1/FVC 67.94 14.69
group offering recommendations of interest for each of the
The evaluation of symptoms was conducted with the MRC
members of the group.
dyspnoea scale. In this, statistically significant changes were
Statistical analysis observed (p<0.05), obtaining a difference of more than one
point in the measurement, going from a mean of 2.82 ± 1.32, to
The information was processed in Microsoft Office Excel® a final average of 1.64 and ± 1.50 [Table 3].
2010, and then, it was analyzed in the statistical package SPSS
version 24. The sociodemographic variables were presented in In terms of functional aerobic capacity, the distance travelled
frequencies and percentages, and normality tests were performed after the PR program had an average improvement of 53.36
for each of the quantitative variables with the Shapiro-Wilk test, meters, being statistically significant. The mean for METS at
presenting them as mean and ± standard deviation. To establish baseline was 2.63 with a standard deviation of 0.74, and at the
the differences between before and after the PR, t-test was end of the program there was a mean of 3.06 with a standard
done for independent samples. Considering a confidence level deviation of 0.55 with a p of 0.28 being no statistically significant
of 95%, a p-value less than 0.05 was assumed as statistically [Table 3].
significant.
Furthermore, Table 3 shows the results of HRQoL and anxiety
Results
and depression measurements. In the first, there were statistically
6 out of the 22 patients evaluated were excluded due to double significant changes in the domains of activities, impact, and

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Table 3: Changes after the pulmonary rehabilitation program.

Variables Before PR After PR Mean difference ± SD p-value
Body mass index (BMI) 23.62 ± (4.09) 23.58 (3.82) 0.03 ± 0.54 0.81
Weight 59.35 ± (13.60) 59.48 ± (13.21) 0.12 ± 0.30 0.68
MRC scale 2.82 ± (1.32) 1.64 ± (1.50) 1.18 ± 0.75 0.001
Distance covered 379.27 ± (136.21) 432.64 ± (116.79) 53.36 ± 50.7 0.006
Estimated VO2 9.23 ± (2.64) 10.71 ± (1.95) 1.48 ± 0.61 0.034
Mets 2.63 ± (0.74) 3.06 ± (0.55) 0.43 ± 0.55 0.028
HADS depression 5.18 ± (3.45) 4.00 ± (2.82) 1.18 ± 2.31 0.12
HADS anxiety 7.09 ± (3.59) 5.55 ± (3.80) 1.54 ± 2.62 0.079
SGRQ
Symptoms 52.00 ± (23.20) 42.00 ± (25.31) 10 ± 24.9 0.21
Activities 65.18 ± (19.33) 43.09 ± (24.63) 22.09 ± 13.4 0.000
Impact 40.91 ± (21.72) 28.55 ± (18.53) 12.36 ± 14.8 0.02
Total 50.82 ± (19.62) 36.18 ± (19.50) 14.63 ± 13.8 0.006

global in the SGRQ questionnaire, with the activity domain improvement. However, in other studies the MRC scale has not
having the greatest difference in change: (22.09 ± 13.4), followed been used as a result variable since these changes have generally
by global (14.63 ± 13.8), impact (12.36 ± 14.8) and symptoms been evidenced using the domains of quality of life. [12]
(10 ± 24.9). Regarding anxiety and depression, patients with
severe bronchial asthma who were in the RP program, both at The improvement in the symptoms (dyspnoea) of patients with
the beginning and at the end had a mean difference of 1.18 for bronchial asthma after RP can also be attributed to intrinsic
depression and 1.54 for anxiety, without obtaining statistically conditions of the disease, as mentioned by Cruz C. et al. They
significant impacts. stated that in the medium term, well-planned exercise provides
optimal adaptations, increasing the production of antioxidants
Discussion such as reactive nitrogen species (NRN), eosinophils and
The importance of this research lies in determining the neutrophils that counteract the effect of the disease on the
repercussion of the addition of an educational component respiratory system, producing benefits over the patient’s quality
to PR in patients with severe asthma, and how there may be of life. [24] Dyspnoea is also a good predictor of cardiovascular
changes in physiological and clinical variables when carrying function and therefore the benefits are not only symptomatic. [25]
out interventions of health promotion and prevention of It is necessary to establish whether the educational component
diseases. From the point of view of public health, there could be in PR, through relaxation techniques, allows this parameter to
significant reductions of costs to the health system that could be be improved.
generated if all available primary care strategies were applied,
considering the limited resources destined to that area in many In 2012, in a systematic review of clinical trials conducted
countries. in children with asthma, Crosbie concluded that PR does not
influence the results of lung function, which can be explained
Despite the fact that the population with severe asthma has from the morphological point of view since changes in the PR
the lowest proportion in this type of disease, it consumes are expressed mostly in skeletal muscle of extremities and not
more than half of the total resources allocated for treatment, in pulmonary smooth muscle. [26] This result agrees with the
[22]
which is why it is important to identify the causes that lead present investigation where, with a p-value of 0.81, there were
these patients to develop diseases of advanced stage, with high no differences before and after the educational intervention or
rates of exacerbations, hospitalizations and greater use of health exercise.
systems, a situation that justifies this investigation. In the present
study, it was found that most patients were female, married and According to Trevor et al.the distance covered in the 6MWT is a
with an average age of 56 years old. These results coincide with measure of the functional status and response to the intervention.
those found in a research developed by Trevor et al.[21] were In our study, the average improvement distance was 53 meters,
they found similar ages and greater frequency in females. This being statistically significant at the end of the PR program.
situation is possibly explained by the fact that the prevalence of
[21]
These data coincide with that of the patients evaluated by
asthma is observed in patients over 40 years old and in females, Lingner et al. in 2015, [27] who had an increase of 60 meters
indicating the need for an increasing number of patients with before and after PR. Furthermre, in a study conducted in patients
asthma and indicating the need to perform PR. with severe asthma but with home intervention, Renolleau et
al. obtained an average improvement of 33 meters (p<0.05),
Dyspnoea is a prevalent symptom in patients with asthma, demonstrating the effectiveness of training in this type of
constituting a qualitative variable that was evaluated by the patients. [28] It is important to clarify that in the study of Lingner
MRC scale, finding a significant improvement after PR. et al.they included patients with moderate asthma and thus,
Similar results were found in a case study with severe asthma the superiority of their results might come from there, whereas
in the city of Bogotá, [23] where the decrease in the score of the in the Renolleau study, there were baseline characteristics of
scale is greater than 1, which implies a clinically significant pulmonary function and tolerance to effort similar to those of our

Annals of Medical and Health Sciences Research | January 2018 | Vol 8 | Special Issue 1 | 125
 Betancourt-Peña J, et al.: Impact of Pulmonary Rehabilitation and Educational Component in Patients with Severe Asthma

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