Home respiratory rehabilitation: a purposes literature review focusing on the clinical pathway management


Submission Date: 2020-10-30
Review Date: 2020-11-13
Pubblication Date: 2020-12-04


Pulmonary Rehabilitation, here also defined as Respiratory Rehabilitation (RR), is an integral and essential part of the procedures and services provided within the Essential Levels of Assistance (LEA) of the national health service, aimed at managing and maintaining the health of people with chronic respiratory diseases who remain symptomatic, or who continue to have reduced function despite standard medical treatment. Clinical Care pathways are used to systematically plan and follow up a patient focused care program.  RR is defined by the American Thoracic Society (ATR) and the European Respiratory Society (ERS) as an evidence-based, multidisciplinary and comprehensive intervention for patients with chronic respiratory disease with decreased activities of daily living due to the disease . (Nici, L. et al. 2006) RR refers to a range of services that are administered to patients with respiratory diseases, and their families, generally to try to improve the quality of life. (Spruit, MA. Et al. 2014) It can be administered in different settings, depending on the patient’s needs, including the home setting. (Crisafulli, et al. 2017) The definition of home care service or “Home Care Services” was introduced many years ago in the PubMed database. (MeSH Database, 1967).Home Care Services (Kinsman, L. 2010; MeSH Database, 1996) are community Clinical Care pathways that provide multiple coordinated patient approaches in patients’ homes. In Italy, home care services are also provided in the context of  NHS home services and in the Campania Region, such as Integrated Home Care (ADI), regulated by Regional Decree 41/2011 as a 3rd level multidisciplinary service (DGRC 41/2011) for the management of the quality of assistance and standard health care, or by territorial rehabilitation services pursuant to art. 26 Law 833/78 at accredited centers, specifically for home RR, as stated the guidelines for rehabilitation activities in the Campania Region (ANISAP Campania, 2018). For standard healthcare,  it has been shown that in clinical practice the implementation of PCA reduces variability and improves outcomes  (Panella, M. 2002; Rotter, 2010; Kinsman, K. 2012). In any form and through different provision rules, PCAs aim to promote and ensure organized and efficient care pathways addressing through the most recent evidence. (Deneckere, S. et al. 2012; 2013). In this waythe care path optimizes outcomes in contexts such as acute care and home care, even if, unfrtunately  there are still no unambiguous definitions of PCA  (De Bleser, L. Et al. 2006) PCAs, therefore, can be considered as coordinating and integrated tools to promote continuity of treatment even if till representing an open challenge  needing  implementation. So, talking about Home RR model and with a focus on PCA, this narrative purpose review aims to summarize the Randomizzed Controlled Trial (RCT) and Systematic Reviews (RS) publications on the matter.

Materials and methods

Study methodology followed was  described by Arksey, H. & O’Malle et al, in  2005 The aim was therefore to summarize the state of the art of this particular topic  in relation to a specific research aspect considering and discussing the literature published between 2009 and 2019 regarding home-based RR and PCA without evaluating the quality of the studies. However, where appropriate, the studies considered were evaluated for their statistical and clinical significance. It takes place in a five-step process typical of narrative studies. (Arksey, H. & O’Malley, L. 2005; Anderson C, et al. 2018).

Step 1: Identification of the research question

I) What type of treatment pathway does home RR use in people with respiratory diseases?

II) Can PCA be identified in home RR? .

Step 2: Identification and selection of studies

A bibliographic search was conducted for articles published between (1 January 2009 and 31 December 2019) using only the PubMed electronic database in the MeSH and Clinical Queries Databases in the period February – May 2020. The MeSH Database searched for: “Home Care Services”, “Home Care Services, Hospital-Based”, “Critical / clinical pathways” combined with the Boolean AND indicator and the keywords “Respiratory Rehabilitation”,Pulmonary Rehabilitation in order to identify search strings. A similar procedure was reproduced in Clinical Queries by inserting the OR indicator in addition to the Boolean AND indicator.

Step 3: Select studies for detailed analyzes

The inclusion criteria adopted were RCT and RS publications including meta-analyzes focused on home-based RR produced from (2009 to 2019). All articles complying with the inclusion criteria were evaluated for their relevance, subsequently typed by the principal revisor (C.C.) and submitted to the summary view of the remaining reviewers  (A.R. &L.D.L.). The exclusion criteria were any non-RCT publications, RS. Any cross-references of the selected articles have been screened to verify their possible relevance, all double citations have been removed. For any discussion regarding the inclusion or exclusion of certain articles the opinion of the principal author reviewer (CC) was decisive.

Step 4: Data extraction

In accordance with the recommendations made by Arskey H & O’Malley L, the “descriptive-analytical” data extraction tool was developed by the author (CC), presented to the authors (AR, LDR), further revised in the method by the author (CC) and shared among the authors. The proposal of the “descriptive-analytical” data extraction tool was proposed to contextualize and rationally classify the content of the studies.

Step 5: Summary of the results of the selected studies

The qualitative analysis of the content. (Morgan, DL. 1993) was used to synthesize the data of the selected studies. No attempt in terms of statistics, analysis, effect sizes, anything else that could simulate studies

type as systematic reviews / meta-analyzes was created to represent the data obtained from the studies. This narrative review was limited to a concise description of the main data obtained from the different studies considered.

Tab. 1


A total of 1354 citations with potentially relevant titles were found in the PubMed database, of which 1336 duplicate and irrelevant citations were excluded. Relevant citations included for analyzes were (16) including RCT 13 (81,%), RS 3 (19,%) inclusive of 2 meta-analyzes. The data of the study flowchart with the modalities of the narrative studies process are reported respectively in (Figure 1. 2.). The data of the research strings with the synthesis of the studies described are reported respectively in (Table 2. 3.). Finally, the studies were grouped into 2 main categories (A. Home-Based RR; B. PCA).

Fig. 1 – Flow chart : studies included.
* randomized controlled trial ,**systematic reviews , ***meta-analysis
Fig. 2 – 5 step process of narrative studies
* respiratory rehabilitation, ** clinical assistance path
Tab. 2 – Strings Database MeSH – Clinical Queries and free research
Tab. 3 -Summary of described studies


This narrative review of purposes aimed to summarize the RCT and RS studies, published from 2009 to 2019, with reference to the home RR model with a focus on PCA. The specific clinical aspects that emerged from the home RR reference model were investigated and documented in this study.

A. Home-Based RR

A total of (12) RCTs and (1) RS studied Home Care RR . The most  followed  reference model that emerged from home RR interventions was that clinical paths were often dedicated above all to COPD and differenciated in order to different  clinical severity:  Stable COPD, severe COPD, very severe COPD, COPD with hypercapnic respiratory failure. (de Sousa Pinto, JM. et al. 2014; Duiverman, LM. et al. 2011; Chen, Y. et al. 2018; du Moulin, M. et al. 2009; Neves, LF. et al. 2016). Pathways dedicated to patients with chronic respiratory failure in O2 therapy and protocols based on self-administration with supervision of experienced personnel were also detected (Fernández, AM. Et al. 2009). (Horton, EJ. Et al.  2018; Holland. AE. Et al. 2017) both cost-benefits adapted to real life needs  (Pradella, CO. Et al. 2015; Widyastuti, K. et al. 2018) above all in clinical conditions such as cystic fibrosis in children and adolescents. (Del Corral, T. et al. 2018).  Finally several RR paths foresee other approaches such as a neuromuscular electrical stimulation program (NMES) . (Bonnevie, T. et al. 2018; Valenza, MC. Et al. 2018).  The best home RR  clinical  improvements werealmost all observed in  cardiorespiratory performance outcomes detected misuring by instruments such as Self-Paced 6 Min Walking (6 MWT), Chronic Respiratory Disease Questionnaire (CRQ), St George’s Repiratory Questionnaire (SGQR), and quality of life perceived Health Related Quality of Life (HRQol) scores.


A great number of PCAs  ‘ RS studies  (2) including (1) meta-analyzes and (1) RCTs studied were found, most of them focusing on  the hospital setting without any RR PCAs. The studies available in the hospital environment mostly evaluated the processes of  definition of dedicated PCA  recognizing their validity for policies aiming to improve the quality of care. (Lawal, AK. Et al. 2016). A number of variables were assessed, such as hospitalisation and mortality rates, recognising the ability of dedicated PCAs to significantly reduce the re-hospitalisation rate to 30 days in COPD, for example.(Vanhaecht, K. et al. 2016) Other clinical outcomes such as the duration of hospital stay and the patient’s quality of life during rehabilitation treatment were also monitored, recognising in conclusion that PCAs dedicated to COPD have the potential to reduce clinical complications and the rate of re-hospitalization as well as duration. The home rehabilitation models that emerged from this review are almost entirely superimposed on the rehabilitation path models described in the major guidelines for COPD or other chronic respiratory diseases.  (Spruit, MA. Et al. 2014) In Italy, the available models extractable from the guidelines have been extracted from the work of the world’s 2 largest scientific societies (ATS, ERS) and supplemented by documents prepared by regional or national commissions (Postiglione et AL., 2017). Additional resources available such as updates, recommendations and advice for good clinical practice have been produced by groups of experts in RR and home care, such as the Italian Association of Hospital Pulmonologists (AIPO), the Italian Association of Respiratory Rehabilitation (ARIR). All the works produced, and currently available, have been inspired by the ATS, ARS guidelines.

Limitations of the study

This review carried out a bibliographic research using only the PubMed database, not including any additional databases in the search, with the data search starting in 2009. This potentially excluded a number of relevant articles for the description and summary. Future research will have to extend the exploration into other databases such as ClinicalTrials.Gov, Cochrane Library, Pedro etc., with no time limits for research.

Conclusions and implications

This particular review was intended to represent an effort aimed at producing evidence of the usefulness of a dedicated rehabilitation path also for respiratory diseases in home care. The studies reviewed claim that the home RR model is useful in chronic respiratory diseases in order to reduce different disabling outcomes and are to be adapted and adaptable to the different national realities as well as to the Italian one through a future identification of a shared national and regional PCA that tends to guarantee the same clinical and prevention results as hospital ones favoring the continuity and correct management of treatment in the territory. Further analyses and studies are needed in order to facilitate the implementation of PCAs in the context of home RR and in BOX n.1 we summarize the home RR model aimed at favoring its use in the non-hospital territorial area. 


  1. ANISAP Campania. DECREE N. 41 OF 29/05/2018. Roofs 2018-2019 Rehabilitation pursuant to art. 26 Law 833/78.
  2. Available in: http://www.anisapcampania.it/index.php?option=com_content&view=article&id=962:decreto-n-41-del-29-05-2018-tetti-2018-2019-riabilitazione-ex-art -26-law-833 78 & catid = 20: regional & Itemid = 101
  3. Arksey , H & O’Malley L., (2005). Scoping studies: towards a methodological framework. Int J SocRes Methodol. 8:19–32.47.
  4. Anderson, C., Yeung, E., Tong, T., Reed, N., (Apr 2018). A narrative review on cervical interventions in adults with chronic whiplash-associated disorder. BMJ Open Sport & ExerciseMedicine ; 25;4(1):e 000299.4.
  5. Crisafulli, E., D’Abrosca, F., Delicati, O., Gaudiello, G., Pasqua, F.,  Zampogna, E., et al (2017) . AIPO, ARIR . Italian recommendations on rehabilitative pulmonology, scientific evidence and clinical-practical messages. Available in: http://www.aiponet.it/editoria/aipo-ricerche-edizioni/prodotti-editoriali/111-documenti-scientifici/1347-raccomandazioni-italiane-sulla-pneumologia-riabilitativa-evidenze-scientifiche-e-messaggi -clinico-practical.html.
  6. Bonnevie, T., Gravier, FE., Debeaumont, D., Viacroze, C., Muir, JF., Cuvelier, A., et al , (Aug 2018). Home-based Neuromuscular Electrical Stimulation as an Add-on to Pulmonary Rehabilitation Does Not Provide Further Benefits in Patients With Chronic Obstructive Pulmonary Disease: A Multicenter Randomized Trial. Arch Phys Med Rehabil. 99(8):1462-1470.
  7. Critical Pathways, MeSH Database., (1996). Disponibile in: https://www.ncbi.nlm.nih.gov/mesh/?term=critical+pathways.
  8. Chen, Yi., Niu, M., Zhang, X., Qian, H., Anwei Xie, A.,  Wang, X., (Mar 2018). Effects of home-based lower limb resistance training on muscle strength and functional status in stable Chronic obstructive pulmonary disease patients. J Clin Nurs. 27(5-6),1022-1037.
  9. Del Corral, T.,  Cebrià I Iranzo, MA.,  López-de-Uralde-Villanueva, I., Martínez-Alejos, R., Blanco, I., Jordi Vilaró, J., (2018)  Effectiveness of a Home-Based Active Video Game Programme in Young Cystic Fibrosis Patients. Respiration. 95(2):87-97.
  10. Deneckere, S., Euwema, M., Van Herck, P., Lodewijckx, C., Panella, M., Sermeus, W., et al (July 2012). Care pathways lead to better teamwork: results of a systematic review. Social Science & Medicine. 75 (2): 264–268.
  11. Deneckere, S., Euwema, Martin., Lodewijckx, C., Panella, M., Mutsvari, T., et al (January 2013). Better interprofessional teamwork, higher level of organized care, and lower risk of burnout in acute health care teams using care pathways: a cluster randomized controlled trial. Medical Care. 51 (1): 99–107.
  12. De Bleser, L., Depreitere, R., De Waele, K., Vanhaecht, K., Vlayen, J., Sermeus, W., (Oct 2006). Defining pathways. J Nurs Manag. 14(7):553-63.
  13. de Sousa Pinto, JM.,   Martín-Nogueras, AM., Calvo-Arenillas, JI.,  Ramos-González, J.,
  14. (Sept-Oct 2014) .Clinical benefits of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev. 34(5):355-9.
  15. Duiverman, LM.,  Wempe, LB., Bladder, G.,  Vonk, JM., Zijlstra, JG Kerstjens, HAM et al.,
  16. (Aug 2011) . Two-year home-based nocturnal noninvasive ventilation added to rehabilitation in chronic obstructive pulmonary disease patients: a randomized controlled trial. Respir Res. 23;12:112.
  17. du Moulin, M., Taube, Wegscheider, KK., Behnke, M., van den Bussche, H., (2009) . Home-based exercise training as maintenance after outpatient pulmonary rehabilitation. Respiration. 77(2):139-45.
  18. Fernández, AM., J Pascual, J., Ferrando, C.,  Arnal, A., Vergara , I.,  Sevila, V., (Sept -Oct 2009). Home-based pulmonary rehabilitation in very severe COPD: is it safe and useful? J Cardiopulm Rehabil Prev. 29(5):325-31.
  19. Home Care Services, MeSH Database., (1967). Disponibile in:https://www.ncbi.nlm.nih.gov/mesh/?term=Home+Care+Services.
  20. Horton,  JE., Mitchell, KE., Warrington, VJ., Apps, LD., Sewell, L.,  Morgan, M., et al (Jan 2018) . Comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation: a randomised non-inferiority trial. Thorax. 73(1):29-36.
  21. Holland, AE.,  Mahal, A.,   Hill, JC.,  Lee, AL.,  Burge, AT.,  Cox, NS., et al  (Jan 2017). Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial. 72(1):57-65.
  22. Lawal, AK.,  Rotter, T., Kinsman, L., Machotta, A., Ronellenfitsch, U., Scott, SD., et al  (Feb., 2016). What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. BMC Med.  23;14:35
  23. Morgan, DL., (1993). Qualitative content analysis: a guide to paths not taken. Qual Health Res .3:112-21.
  24. Nici, L., Donner, C., Wouters, E., Zuwallack, R., Ambrosino, N., Bourbeau, J., et al (2006). American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 173 (12): 1390–413.
  25. Neves, LF.,  Dos Reis, MH, Gonçalves, TR ., (Jun 2016). Home or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Cad Saude Publica.  20;32(6).
  26. Panella, M., Van Zelm, R., Sermeus, W., Vanhaecht, K., (January 2012). Care pathways for the organization of patients’ care. Bulletin: Economics, Organisation and Informatics in Healthcare. 28 (2).
  27. Panella, M., Marchisio, S., Di Stanislao, F., (December 2003). Reducing clinical variations with clinical pathways: do pathways work ? International Journal for Quality in Health Care. 15 (6): 509–521.
  28. Postiglione, A., D’Amario, S., De Luca, V., (Dicembre 2017) . Linee di indirizzo regionale. Percorso riabilitativo della persona con Broncopneumopatia Cronica Ostruttiva (BPCO) . Bollettino ufficiale della regione campania n. 93, PARTE I . Atti della regione . Disponibile in: http://burc.regione.campania.it
  29. Pradella, CO.,  Belmonte, GM., Maia, MN., Delgado, CS., Luise, AP., Nascimento, OA., et al  (Apr 2015) . Home-Based Pulmonary Rehabilitation for Subjects With COPD: A Randomized Study.  Respir Care. 60(4):526-32
  30. Rotter, R.,  Kinsman T., James, ç., Erica; Machotta, A., Gothe, Holger, G., et al (March 2010). Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. The Cochrane Database of Systematic Reviews. 17;(3):CD006632.
  31. Rotter, T., Kinsman, Leigh, J., Erica; Machotta, A., Willis, J.,  et al (March 2012). The effects of clinical pathways on professional practice, patient outcomes, length of stay, and hospital costs: Cochrane systematic review and meta-analysis.Evaluation & the Health Professions. 35 (1): 3–27.
  32. Sharma, MA., (Mar 2014). Pulmonary Rehabilitation. Eur Respir Rev. 1, 23 (131): 55-63.
  33. Spruit, MA., Pitta, F., Garvey, C.,   ZuWallack, RL,  Roberts ,CM., Collins, GE., et al (May 2014) .Differences in content and organisational aspects of pulmonary rehabilitation programmes . Eur Respir J. 43(5):1326-37.
  34. Valenza, MC.,  Torres-Sánchez, I., López, L., Cabrera-Martos, I., Ortiz-Rubio, A., Gerald Valenza-Demet, G.,  (Jun 2018) . Effects of home-based neuromuscular electrical stimulation in severe chronic obstructive pulmonary disease patients: a randomized controlled clinical trial. Eur J Phys Rehabil Med. 54(3):323-332.
  35. Vanhaecht, K., Lodewijckx, C., Sermeus, W., Decramer, M., Deneckere, S., Leigheb, F., Boto, P., et al., (Nov 2016) . Impact of a care pathway for COPD on adherence to guidelines and hospital readmission: a cluster randomized trial. Int J Chron Obstruct Pulmon Dis. 23;11:2897-2908.
  36. Kinsman, K.,  Rotter, L., James, T.,  Snow,E.,  P., Willis, J., (May 2010). What is a clinical pathway ?: development of a definition to inform the debate.  BMC Medicine 8: 31.
  37. Widyastuti, K. , Makhabah, DM.,  Rima Setijadi, A., Sutanto, YS., Suradi, N Ambrosino, N., (Jul-Aug 2018) .  Benefits and costs of home pedometer assisted physical activity in patients with COPD. A preliminary randomized controlled trial. Pulmonology. 24(4):211-218.