Pulmonary rehabilitation for people who have been in hospital with an exacerbation of chronic obstructive pulmonary disease

Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J

Published Online:

October 5, 2011

We wished to determine the impact of pulmonary rehabilitation on hospital admissions and other patient-important outcomes such as quality of life. In order to be considered for our review, the clinical trials had to involve some sort of exercise program. However some of the programs also included emphasis on endurance and strength training or breathing exercises and education about COPD. We were interested only in studies which assessed the effects of courses of exercise therapy in people with Chronic Obstructive Pulmonary Disease (COPD), who had been in hospital following an exacerbation. We included nine studies. Pulmonary rehabilitation reduced hospital admissions and mortality compared with usual community care (no rehabilitation). Quality of life was also improved and the effect was substantially larger than the minimal important difference. Pulmonary rehabilitation appears to be a highly effective and safe intervention in COPD patients after suffering an exacerbation.

Abstract (click to read)

Background:

Pulmonary rehabilitation has become a cornerstone in the management of patients with stable Chronic Obstructive Pulmonary Disease (COPD). Systematic reviews have shown large and important clinical effects of pulmonary rehabilitation in these patients. However, in unstable COPD patients who have recently suffered an exacerbation, the effects of pulmonary rehabilitation are less established.

Objectives:

To assess the effects of pulmonary rehabilitation after COPD exacerbations on future hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life and exercise capacity).

Search strategy:

Trials were identified from searches of CENTRAL, MEDLINE, EMBASE, PEDRO and the Cochrane Airways Group Register of Trials. Searches were current as of March 2010.

Selection criteria:

Randomized controlled trials comparing pulmonary rehabilitation of any duration after exacerbation of COPD with conventional care. Pulmonary rehabilitation programmes needed to include at least physical exercise. Control groups received conventional community care without rehabilitation.

Data collection and analysis:

We calculated pooled odds ratios and weighted mean differences (MD) using random-effects models. We requested missing data from the authors of the primary studies.

Main results:

We identified nine trials involving 432 patients. Pulmonary rehabilitation significantly reduced hospital admissions (pooled odds ratio 0.22 [95% CI 0.08 to 0.58], number needed to treat (NNT) 4 [95% CI 3 to 8], over 25 weeks) and mortality (OR 0.28; 95% CI 0.10 to 0.84), NNT 6 [95% CI 5 to 30] over 107 weeks). Effects of pulmonary rehabilitation on health-related quality of life were well above the minimal important difference when measured by the Chronic Respiratory Questionnaire (MD for dyspnea, fatigue, emotional function and mastery domains between 0.81 (fatigue; 95% CI 0.16 to 1.45) and 0.97 (dyspnea; 95% CI 0.35 to 1.58)) and the St. Georges Respiratory Questionnaire total score (MD -9.88; 95% CI -14.40 to -5.37); impacts domain (MD -13.94; 95% CI -20.37 to -7.51) and for activity limitation domain (MD -9.94; 95% CI -15.98 to -3.89)). The symptoms domain of the St. Georges Respiratory Questionnaire showed no significant improvement. Pulmonary rehabilitation significantly improved exercise capacity and the improvement was above the minimally important difference (six-minute walk test (MD 77.70 meters; 95% CI 12.21 to 143.20) and shuttle walk test (MD 64.35; 95% CI 41.28 to 87.43)). No adverse events were reported in three studies.

Authors' conclusions:

Evidence from nine small studies of moderate methodological quality, suggests that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD patients who have recently suffered an exacerbation of COPD.

This record should be cited as:

Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD005305. DOI: 10.1002/14651858.CD005305.pub3

Assessed as up to date:

July 12, 2010

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Primary Review Group:

Airways Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease (COPD)?

Bottom line:

Compared to usual community care (no rehabilitation), pulmonary rehabilitation reduced hospital admissions over 34 weeks (NNT* 3) and mortality over 107 weeks (NNT 6). Quality of life measures, such as dyspnoea, fatigue and emotional function, were also improved, and the effect was well above the minimal important difference. Exercise capacity was also improved. No adverse events were reported. *NNT = number needed to treat to benefit one individual.

Caveat:

Treatment group assignment was not blinded in these studies. This may have introduced bias for subjective outcomes, such as quality of life, but is less likely to be an important source of bias for mortality and hospital admission data. Another limitation is the small number of patients included in the trials and methodological shortcomings.

Context:

Pulmonary rehabilitation has become a cornerstone in the management of patients with stable COPD. Systematic reviews have shown large and important clinical effects of pulmonary rehabilitation in these patients. In patients with unstable COPD who have suffered from an exacerbation recently, however, the effects of pulmonary rehabilitation are less established.

Cochrane Systematic Review:

Puhan M et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Reviews 2009. Issue 1. Article No. CD005305. DOI:10.1002/14651858. CD005305.pub2. This review contains 6 studies involving 219 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Lungs & airways > Chronic obstructive pulmonary disease (exacerbations) > Pulmonary rehabilitation

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Pulmonary rehabilitation for people who have been in hospital with an exacerbation of chronic obstructive pulmonary disease

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