INTRODUCTION

Dyspnea, activity intolerance and reduced quality of life are frequent manifestations in people with chronic respiratory disease (CRD)^1-4. These manifestations are not only the result of loss of lung function, but result from peripheral muscle dysfunction. If that were the case, medication alone would be effective in increasing tolerance to the activity, which is not the case ^1-2,5-6. Peripheral muscle dysfunction is characterized by the loss of strength and muscle mass, which leads to changes in the distribution of muscle fibers, which, together with alterations in gas exchanges, result in reduced exercise capacity in people with CRD.

This activity intolerance limits functional independence with a consequent negative impact on the capacity for self-care⁹, and on the increase in mortality^1,10.

Clinically, it is translated by the person's inability to carry out their daily activities, in the intensity or duration normally tolerable for healthy and sedentary people¹. This adoption of a sedentary lifestyle (in order to avoid functional dyspnea) leads to muscle deconditioning, enhancing the loss of function^1,7,10-11.

Muscle performance (strength and endurance) results from the physiological structure of the muscles, and the peripheral muscle dysfunction manifested by people with CRD results from an alteration in the distribution of muscle fibers, their size, capillary density and metabolic capacity^(2,4-5.11).

In this context, the unavoidable importance of exercise training emerges, which in a respiratory rehabilitation program (RRP) contributes to the increase in exercise tolerance, decreasing oxygen consumption in the face of the same amount of exercise and reducing the manifestations of dyspnea^1,5,8.

Exercise training in this context includes aerobic training, or endurance training and anaerobic or muscle strength training.

Aerobic training, or endurance training, uses large muscle groups with moderate to long duration and moderate to high intensity^2,4,9,12. It requires repeated physical activity over a specific period of time and aims to increase and modulate endurance capacity and increase the number of type I fibers.

On the other hand, muscle strength training (anaerobic training component) designed to increase muscle strength and mass, essential for carrying out activities of daily living, uses small muscle groups at high intensity and for a short duration, thus reducing cardiorespiratory limitations characteristics of people with chronic respiratory disease in more advanced stages of the disease.

The best physiological response is obtained by joining the two training modalities, tending to be performed at high intensity.

This is why Respiratory Rehabilitation, which obligatorily includes exercise training, is the recommended non-pharmacological treatment for people with chronic respiratory disease in an outpatient setting.

In this sense, the role of the RN should not be solely related to respiratory kinesitherapy or the educational component, but should accompany the scientific evidence and also undergo exercise training, as is furthermore enshrined in the Regulation of Specific Competencies of the Specialist Nurse Rehabilitation Nursing, which describes the competence of the Rehabilitation Nurse - to design, implement, evaluate and reformulate motor and cardio-respiratory training programs.

Given the above, it is essential to know the exercise training programs included in the respiratory rehabilitation programs (RRP) carried out by rehabilitation nurses.

A previous search carried out in MEDLINE and CINAHL did not reveal any literature review on this topic, so it was decided to carry out a Scoping Review in order to map the use of exercise training in respiratory rehabilitation programs carried out by nurses for people with disease chronic respiratory in an outpatient setting.

The option for a scoping review was linked not only to the objective of mapping scientific evidence to support the clinical decision of rehabilitation nurses, but also to identify possible areas of interest for disciplinary investigation.

METHOD

The methodology used to carry out this scoping review followed the steps proposed by the Joanna Briggs Institute®, and intended to answer the following question: "What is the impact of exercise training programs, conducted by rehabilitation nurses, on people with chronic respiratory disease?"

EXTRACTION OF RESULTS

Based on the applied search strategy, 34 potentially relevant articles were identified.

One was excluded because it was duplicated, four were excluded after title analysis and seventeen were excluded after abstract analysis.

The analysis of the full text of the remaining twelve articles led to the exclusion of two. Finally, ten articles were included in the review (figure 1).

Figure 1 PRISMA Flowchart of the Article Selection Process 

All of the studies are Portuguese, eight resulting from master's dissertations and two from scientific articles published in a journal.

From a methodological point of view, all studies are quantitative, seven being quasi-experimental, two exploratory descriptive and one systematic literature review.

There was little scientific production on this topic considering the different contexts.

Six studies have respiratory kinesitherapy intervention that is not recommended in this context.

From the analysis of the articles, the following categories of information emerged: duration/frequency of the exercise training program, type of exercise training and results obtained.

DISCUSSION

The results of this review allow us to identify that the exercise training programs designed, implemented and carried out by rehabilitation nurses contribute to the reduction of dyspnea, anxiety, increasing tolerance to effort and life activities, thus contributing to the improvement quality of life.

These results overlap with the scientific evidence clearly identified in the latest European Respiratory Society Guidelines published in 2013³ and confirmed in 2017 by Shioya et al¹³.

Recently, studies such as those by Robinson et al.⁸ and McNamara et al.¹², both in 2018, confirmed the role of exercise training in improving dyspnea.

Gordon et al., 2019¹⁴ published a meta-analysis showing the impact of exercise training on depression and anxiety. Regarding the increase in exercise tolerance and its consequences on the ability to perform activities of daily living, the evidence is vast, as shown by the studies by Bisca et al., 2014¹⁵, Spruit et al, 2015⁵ and more recently in 2019 the study by Vaes¹⁵ showing the positive impact on these variables.

Figure 2: Summary of articles included in the review 

The multisystemic character of chronic respiratory diseases (especially COPD) leads to a progressive functional decline, resulting from sarcopenia secondary to immobility, with important consequences, namely in terms of autonomy in carrying out activities of daily living and self-care^9-10,13.

In this context, Respiratory Rehabilitation emerges as the non-pharmacological treatment indicated for people with chronic respiratory disease, fundamentally focused on an approach in which exercise training is, along with education, the main component^1,4,6.

Respiratory rehabilitation programs increase activity tolerance and reduce dyspnea, aspects that translate into functional gains and the capacity for self-care^2,9,15.

In addition to these effects, respiratory rehabilitation also reduces hospitalizations and mortality¹⁶.

There is no consensus about its duration and the most recent recommendation defines it as a minimum duration of 8 weeks with 3 sessions per week^1,3,16. As most symptoms result from peripheral muscle dysfunction (which leads to increased oxygen consumption) it is clear that the objective of respiratory rehabilitation programs is to improve activity tolerance and later exercise tolerance through improving strength and peripheral muscle resistance, thus contributing to improve quality of life^1,3,5.

There is, in fact, a direct relationship between walking time and functional status¹¹, as well as between upper limb performance and performance in activities of daily living ¹⁷.

All indicators show that the usual tendency of immobility in these people is not only respiratory, but also muscular, since the muscle morphological changes found in these people are important, namely the reduction of type I fibers, the loss of strength and capacity of resistance, especially of the lower limbs^1-2,4,7.

When compared to healthy people, tolerance to exertion is lower, resulting in increased shortness of breath secondary to dynamic hyperinflation and immobility^2,4,12.

This is the reason why it is concluded that the combination of aerobic and anaerobic training is more effective^1,3,5.

The evidence related to the results of exercise training programs is quite vast. Studies show that there are health gains in practically all the indicators studied, namely dyspnea and activity intolerance, with an important impact on the promotion of self-care and quality of life.

CONCLUSION

This study allowed us to identify two central aspects: the first is that exercise training programs conducted by nurses adhere to international guidelines; the second is that the results obtained (improved perception of dyspnea; decreased anxiety; increased tolerance to exertion and activities of daily living, as well as improved quality of life) are comparable to the best available scientific evidence.

This study demonstrates the positive impact of the action of rehabilitation nurses on the health condition of people with chronic respiratory disease who participate in exercise training programs.

Given the widely described importance of the benefits of exercise training in this context, more studies should be carried out and published on this topic.