A Cochrane review examined whether pulmonary rehabilitation programmes improved the health of people who had experienced an exacerbation of COPD
Keywords COPD, Exacerbation, Pulmonary rehabilitation
- This article has been double-blind peer reviewed
What is the effect of pulmonary rehabilitation for patients with a recent exacerbation of chronic obstructive pulmonary disease (COPD) on subsequent hospital admission, mortality, health related quality of life and exercise capacity?
COPD is a life threatening condition with a degree of irreversible long-term lung airway obstruction. It represents a major health burden on patients and healthcare systems worldwide. Patients are most likely to require hospital care or die following an acute exacerbation, and such emergency and hospital care represents 70% of the healthcare costs associated with the condition.
Pulmonary rehabilitation aims to prevent acute exacerbations through a programme that may include: physical activity, psychological, medication and smoking cessation interventions. While there is existing evidence on the benefits of pulmonary rehabilitation for clinically stable COPD patients, there is a lack of evidence about its effectiveness in reducing the likelihood of subsequent re-admissions for patients whose condition is unstable immediately after an acute episode.
While Puhan et al (2009) do not discuss who may be involved in delivering pulmonary rehabilitation programmes for patients following an acute exacerbation, NICE (2010) recommends that multidisciplinary teams should be involved in rehabilitation programmes for stable COPD patients. As well as being involved their delivery nurses can also encourage COPD patients to attend pulmonary rehabilitation programmes.
This Cochrane systematic review with meta-analysis synthesised six randomised controlled trials (RCTs).
In total 241 patients (average age range 62-70 years) took part in these studies. The research intervention was ‘pulmonary rehabilitation’ which included at least some physical exercise. Outcomes for intervention group patients who received rehabilitation were compared with those for control group patients who received usual (not defined) community care without rehabilitation.
Rehabilitation was initiated from admission to up to three weeks after the start of treatment; and programmes lasted from 10 days to six months. Patients commenced rehabilitation as inpatients (three studies), following hospital discharge (two studies) or after hospital-at-home management (one study). The average (median) percentage of patients who completed rehabilitation was 76.9% and duration of study follow up ranged from 11 days to 208 weeks.
Overall, reviewers judged that the quality of reviewed studies was ‘moderate’, as there were some potential sources of bias. No study was ‘treatment group assignment blinded’; i.e. all participants were aware which study group they had been allocated to and this may have influenced responses to some outcome measures. In five studies the reviewers were uncertain if there was adequate sequence generation (how truly random assignment procedures were) or allocation concealment (if participants’ study group allocation was unknown until they agreed to take part).
Summary of key evidence
Based on three RCTs, the review identified a statistically significant reduction in odds of hospital re-admission for the intervention (rehabilitation) group (pooled odds ratio 0.13; 95% confidence intervals [CI]: 0.04-0.35) at an average (weighted mean) of 34 weeks
The odds of mortality following the intervention were significantly reduced for the rehabilitation group (0.29; 95% CI: 0.10-0.84) as measured at an average (weighted mean) of 107 weeks (based on three study results).
Four studies measured ‘health related quality of life’ by either using the Chronic Respiratory Disease Questionnaire (CRDQ) or the St George’s Respiratory Questionnaire (SGRQ). These questionnaire results exceeded recognised minimum standards of improvement for the rehabilitation group. Statistical, pooled estimates also favoured the intervention (between 1.15; 95% CI: 0.94 to 1.36; and 1.88, 95% CI: 1.67 to 2.09 on the CRDQ and between -9.9; 95% CI: -18.05 to-1.73 and -17.1; 95% CI:-23.55 to -10.68 for the SGRQ). The ‘symptoms’ domain of the SGRQ, however, did not appear to improve for the intervention group.
Exercise capacity was measured using six-minute walk tests (four studies) and shuttle walk tests (two studies). Such activity was more improved in the intervention group than the control group (by 60-215m). This improvement was more than the smallest recommended clinical difference of 35m.
No adverse events were recorded in the two studies that reported recording them.
Best practice recommendation
- Pulmonary rehabilitation may be offered after an acute exacerbation of COPD since it appears to benefit patients through reducing subsequent hospital admissions and mortality, and by improving health-related quality of life and exercise capacity.
The full report, including references can be accessed by clicking here.
AUTHOR Janice Christie, PhD, MA, BSc, RN, RSCPHN, is teaching fellow, School of Nursing and Midwifery, Queen’s University Belfast, and a member of the Cochrane Nursing Care Field
National Institute for Health and Clinical Excellence (2004) Management of chronic obstructive pulmonarydisease in adults in primary and secondary care. London: NICE. nice.org.uk/CG101
Puhan M et al Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, 2009 Issue 1. Art. No.: CD005305. DOI: 10.1002/14651858.CD005305.pub2.