Rehabilitation for chronic lung disease: the challenge of implementation

As the population of the world enlarges, the burden of disease on our health services is increasing and at the same time changing in character. The spectrum of illness is becoming dominated by chronic rather than acute disease, and health services will need to adapt to the change. Chronic respiratory disease, particularly chronic obstructive pulonary disease (COPD), will form a substantial component of this burden in future as the population ages and the global smoking epidemic remains unchecked. The later stages of COPD are characterised by progressive dyspnoea, increasing disability and recurrent hospital admissions. Unfortunately, the early stages of airway obstruction are not always apparent in the absence of screening spirometry and the development of exertional dyspnoea heralds the decline towards disability. Once significant disability and handicap are present further efforts to improve airway function are often fruitless. In the absence of an early warning, many patients will only present to their general practitioner when the disease is already significantly advanced. By definition, the airflow obstruction will then be largely unresponsive to therapy though some symptomatic response can be achieved with bronchodilator drugs and inhaled corticosteroids. Disease modification in COPD can be achieved to some extent by smoking cessation and more dramatically by transplantation or lung volume reduction surgery in a select few. Pulmonary rehabilitation offers the only widely applicable mechanism to improve individual quality of life and lessen the impact of disease on the community. To date, no country is able to provide this effective therapy on a scale necessary to make a significant impact and the reasons for this deserve to be explored.