X3.4 Clearance of secretions and exercise training during hospitalisaton

Jump to section

X3.4.1 Clearance of secretions

Patients who regularly expectorate sputum or those with tenacious sputum may benefit from airway clearance techniques (ACTs) during an exacerbation. However, the choice of ACTs during exacerbations requires careful consideration as these episodes result in worsening of airflow limitation and lung hyperinflation, which lead to acute increases in dyspnoea. Patients are also likely to experience significant physical fatigue during an exacerbation and this impacts on the choice of ACT. A Cochrane Systematic Review of 9 trials examined the efficacy of ACTs in patients experiencing an exacerbation of COPD (Osadnik 2012). The use of ACTs was associated with a significant short-term reduction in the need for increased ventilatory assistance (odds ratio 0.21, 95% CI 0.05-0.85, data from 4 studies involving 171 patients) NNT 12, 95% CI 10-66 [evidence level I], the duration of ventilatory assistance (mean difference of -2.05 days, 95% CI -2.60 to -1.51 compared to control, data from 2 studies of 54 patients) [evidence level I] and hospital length of stay (mean difference -0.75 days, 95% CI -1.38 to -0.11 compared to control, data from one study of 35 patients) [evidence level II]. Airway clearance techniques that utilised positive expiratory pressure (PEP) tended to be associated with a greater reduction in the need for increased ventilatory assistance and hospital length of stay compared to non-PEP based ACTs however the difference was not significant.

Apart from chest wall percussion, which has been associated with a decrease in FEV₁ and one report of vomiting during treatment involving a head-down tilt position ACTs were not associated with serious adverse effects (Hill 2010, Tang 2010, Osadnik 2012) [evidence level I]. Airway clearance techniques applied during an exacerbation do not appear to improve measures of resting lung function or produce any consistent changes in gas exchange (Osadnik 2012) [evidence level I]. However, the limitations of the studies included in the systematic reviews (i.e. considerable diversity in patients’ characteristics and application of specific techniques, small sample sizes in some of the studies, large variety of outcome measures) limited the ability to pool data for meta-analysis. A multicentre RCT that involved 90 patients hospitalised with an exacerbation of COPD investigated whether the addition of PEP therapy to usual medical care that included a standardised physical exercise training regimen improved symptom, QoL and incidence of future exacerbations (Osadnik 2014). Individuals in this study were characterised by evidence of sputum expectoration or a history of chronic sputum production with over 50% of those recruited expectorating purulent sputum, however individuals with primary bronchiectasis were excluded. The authors found no significant between group differences in symptoms or quality of life assessed over a 6-month period following hospital discharge. The incidence of exacerbations during the follow-up period was low and similar in both groups. The findings of this study (Osadnik 2014) do not support a routine role for PEP therapy even in patients with purulent sputum who are hospitalised for an exacerbation of COPD.

Given the negative impact that exacerbations have on symptoms such as dyspnoea and fatigue, it is important to decide whether performing ACT is appropriate, and if so, choosing the most appropriate technique during this time. The choice of ACT should be guided by a physiotherapist experienced in this type of clinical presentation.

X3.4.2 Exercise training during hospitalisation

A systematic review and meta-analysis investigated whether initiating exercise training early during hospital admission for an exacerbation of COPD, versus not initiating exercise training during an admission, changes outcomes measured at discharge (Lai 2024) [evidence level I]. Studies conducted between December 2021 and updated in January 2024 were included if they measured exercise capacity, physical function or adverse effects at discharge, and had at least one group that was prescribed exercise training within 48 hours of hospital admission (experimental) and at least one group that received usual care which did not include prescribed exercise training (control). Analysis from 10 included studies (423 participants; mean FEV₁ range 26% to 50% predicted) measured outcomes collected at discharge to compare the experimental and control groups. The authors concluded that exercise training prescribed within 48 hours of hospitalisation improved exercise capacity (SMD 0.58, 95% CI 0.32 to 0.83; five studies, moderate effect, low certainty evidence) and physical function (SMD -0.54, 95% CI -0.86 to -0.22; four studies, moderate effect, low certainty evidence) compared to control. Though subgroup analysis for exercise capacity indicated that the size of the effect was not influenced by the method of training (aerobic exercise versus resistance training), resistance training on its own was shown to be effective in improving exercise capacity at discharge. Overall, exercise training during hospitalisation was considered safe, with no serious adverse events reported. The results of this review provides evidence supporting initiating exercise training on hospital wards in people admitted with an exacerbation of COPD.