Study Finds 3 Key Components That Could Make Pulmonary Rehabilitation More Effective for AECOPD

Pulmonary rehabilitation may be most effective when including exercise training, breathing techniques, and education and psychosocial components for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD), according to a recent review.

Past studies have shown pulmonary rehabilitation to improve exercise capacity, muscle strength, functional capacity, and health related quality of life (HLQOL) in patients with AECOPD. It can reduce symptoms, hospitalizations, and unscheduled healthcare visits for patients while also enhancing patients’ ability to self-manage their AECOPD and achieve self-efficacy.

However, such programs vary widely, not only in terms of which components are included, but also by where they are delivered (home, outpatient, inpatient, etc), for how long, at what intensity, and whether the patient is alone or in a group. The authors of this review wanted to determine which program designs appeared to be the most effective.

The systematic review, published in the European Respiratory Review, looked at 6029 studies and narrowed their analysis to 42 studies published before March 2020 from 19 countries.

The studies included at least 1 component of pulmonary rehabilitation, included patients within 3 weeks of AECOPD onset or until 2 weeks after hospital discharge, were written in English, French, Portuguese, or Spanish, and were randomized, controlled trials.

Results from a total of 3569 patients with a mean age of 69.1 years and a mean forced expiratory volume in 1 second of 39.4% predicted.

The list of components used in the studies included education and psychosocial support, aerobic training, strength training, breathing techniques, exercise training, electrostimulation, positive expiry pressure therapy performed with noninvasive ventilation or devices, home diaries, respiratory muscle training, nutrition, and whole body vibration.

Of the 42 included studies, only 38.1% (16) used pulmonary rehabilitation officially as an intervention. Of the studies that only used 1 or some of the intervention components, the most common ones used were exercise training (30/42), education and psychosocial support (24/42), aerobic training (23/42), strength training (23/42), and breathing techniques (23/42).

The combination of exercise and breathing techniques presented the largest weighted mean difference (WMD) (−41.06; 95% CI, −131.70-49.58). This combination intervention also presented a greater WMD than control groups.

Breathing techniques was the best performing intervention at decreasing dyspnea in patients (WMD 1.90; 95% CI, 0.53–3.27). Breathing techniques (effect sizes [ES] 0.15; 95% CI, −0.28-0.57) and breathing techniques in combination with exercise (ES 0.11; 95% CI, −0.28–0.50) were the interventions that reduced the length of hospitalization the most, but again, significant differences between the interventions were not found.

In addition, “patient’s knowledge was one of the outcome measures presenting larger ES, showing how empowering pulmonary rehabilitation can be during AECOPD,” wrote investigators.

Investigators also found that short-term programs presented better results and increased exercise capacity compared to longer-term programs.

Most of the evidence published described hospitalized patients, who often present more severe exacerbations and/or have a more severe underlying conditions than those managed in an outpatient setting. Investigators said that because more than 80% of patients with COPD are managed on an outpatient basis, future research should focus on those patients.

Investigators concluded that additional research should compare the included interventions in programs of different lengths, durations and frequencies of sessions, and intensities of exercise training to further establish what program design would be most effective.

Reference

Machado A, Silva PM, Afreixo V, Caneiras C, Burtin C, Marques A. Design of pulmonary rehabilitation programmes during acute exacerbations of COPD: a systematic review and network meta-analysis. Eur Respir Rev. November 20 2020;33(6):978-985. doi: 10.1183/16000617.0039-2020