Pulmonary rehab for patients with acute exacerbations of COPD improves exercise capacity

Key takeaways:

• Rehabilitation during hospitalization vs. usual care resulted in better exercise capacity, quality of life and lower limb strength.
• Hospitalization duration was similar in both groups.

For patients with COPD hospitalized with acute exacerbations, pulmonary rehabilitation yielded better exercise capacity and quality of life vs. usual care, according to study results published in Annals of the American Thoracic Society.

“The purpose of our review was to systematically summarize the available scientific evidence, focusing on a specific clinic population (acute exacerbations of COPD) and clinical setting (in-hospital),” Pat G. Camp, PT, PhD, associate professor in the department of physical therapy, and Débora Petry-Moecke, PT, MSc, PhD student at the University of British Columbia, told Healio. “Clinicians working in this particular context can be confident that providing pulmonary rehabilitation or any rehabilitation program that involves ambulation, mobility, strengthening, physical exercise, physical activity or physical therapy to their patients is safe and improves health outcomes. Based on our review findings, clinicians are encouraged to include pulmonary rehabilitation as part of the in-hospital, acute care treatment plan.”

In a systematic review and meta-analysis, Camp, Petry-Moecke and colleagues evaluated 27 randomized controlled trials (RCTs), including 1,317 hospitalized patients with acute exacerbations of COPD, that assessed pulmonary rehab against usual care to figure out if pulmonary rehab was a safe and effective option for these patients.

Included studies had to evaluate a pulmonary rehab program that began when the patient was in the hospital and had to happen for at least two sessions, according to researchers.

In meta-analysis, researchers figured out intervention effect estimates with a random-effect model.

Importantly, researchers noted that every study had a high risk for performance bias since those involved in each study could not be blinded. A high risk for selection and detection bias and a high risk for reporting bias were each found in two studies; however, researchers could not decide the risk in some studies due to a lack of information.

Exercise capacity

Researchers found several improvements with in-hospital pulmonary rehab, with a notable and surprising result in 6-minute-walk distance (6MWD), Camp and Petry-Moecke told Healio. When evaluating the seven studies (n = 330) with complete 6MWD data and high-quality evidence, they observed a 105.41 m (95% CI, 42.8-168.05) improvement over the minimally clinically important difference of 30 m with use of pulmonary rehab.

“The improvements in 6MWD were surprisingly good, and better, in fact, than what has been seen in several outpatient pulmonary rehabilitation program trials,” Camp and Petry-Moecke told Healio. “Our hypothesis was that this was due to two RCTs in which the participants in the training group completed a longer training program in the hospital. In addition, patients who are acutely ill often have very low 6MWDs, and rehabilitation provided in the hospital may provide the appropriate stimulus for quick and substantial gains, compared to ‘usual care’ where the patient is likely quite sedentary.”

Another improvement that occurred with pulmonary rehab was in the five-repetition sit-to-stand test with a decrease of 7.02 seconds (95% CI, –13.41 to –0.63) based on moderate quality evidence from three studies (n = 135), which is over the minimally clinically important difference of 1.7 seconds for this specific test.

Quality of life, lower limb strength

In terms of health-related quality of life, moderate quality evidence from four studies (n = 247) that assessed this factor through the 5-level EuroQoL Group-5 dimension version (EQ-ED-5L) and two studies (n = 69) that assessed it through the St. George’s Respiratory Questionnaire (SGRQ) demonstrated that rehabilitation resulted in better scores than other interventions (EQ-ED-5L: mean difference, –0.41; 95% CI, –0.61 to –0.22; SGRQ: mean difference, –10.51; 95% CI, –18.25 to –2.77).

Specifically for the EQ-ED-5L assessment, researchers found that the treatment effect for rehab was higher than the 8-point minimally clinically important difference on the VAS (mean difference, 12.86 points; 95% CI, 7.93-17.78).

Additionally, lower limb muscle strength went up by 33.35 N (95% CI, 21.24-45.56) in patients who received pulmonary rehab during their hospital stay based on moderate quality evidence from four studies (n = 183), according to researchers.

Researchers further found that hospitalization duration did not differ between the treatment and usual care groups using moderate quality evidence from 17 studies (n = 1,074), highlighting that rehabilitation does not lengthen a patient’s hospital visit.

There was one serious adverse event — arrhythmia — that was deemed to be due to rehabilitation out of 15 studies with a total of 797 patients. The event was gone in an hour once the intervention was stopped, according to researchers.

“We hope our study can be used in future guidelines for pulmonary rehabilitation,” Camp and Petry-Moecke told Healio. “We would like to see support for rehabilitation for acute exacerbations of COPD, similar to levels of care we see for other significant acute events that are treated in hospital, such as stroke and myocardial infarction.

“We reinforce that future papers examining the safety and efficacy of exercise-related interventions like pulmonary rehabilitation for acute exacerbations of COPD patients and other acute respiratory conditions should separately analyze data from inpatient vs. outpatient programs,” they added. “This is because an acute care hospital setting can be very unique in providing high monitoring levels, often very structured exercise protocols and direct supervision from a specialized professional. In addition, clinical trials that initiate the intervention in the hospital and continue after discharge should also make sure to collect outcome measures at discharge to allow the analysis of in-hospital data separately.”

For more information:

Pat G. Camp, PT, PhD, can be reached at pat.camp@hli.ubc.ca.