X3.6 Pulmonary rehabilitation
Consider pulmonary rehabilitation at any time, including during the recovery phase following an exacerbation [evidence level I, strong recommendation]
Exacerbations of COPD are characterised by worsening dyspnoea and fatigue, decreased exercise tolerance and a reduction in health-related quality of life (HRQoL) (Seemungal 2000, Spencer 2003). Individuals are typically less active following hospitalisation for an exacerbation of COPD and this low level of activity may persist for several weeks (Pitta 2006). Quadriceps muscle strength is often reduced during an exacerbation and may be a contributor to inactivity (Spruit 2003).
Pulmonary rehabilitation should be offered to people with COPD following hospitalisation for an exacerbation of COPD. A systematic review of 17 studies (Puhan 2016) reported the effects of pulmonary rehabilitation in 1,477 participants who were in the recovery phase of a recent hospitalisation for an exacerbation of COPD. Pulmonary rehabilitation was commenced between two days and two weeks after the exacerbation, and was provided in inpatient, outpatient, and home settings, with a program duration between four days and six months. Pulmonary rehabilitation significantly improved HRQoL and exercise capacity in the short-term (median of five months for HRQoL and a median of three months for exercise capacity). Pulmonary rehabilitation also reduced hospital readmissions (pooled odds ratio 0.44, 95% CI 0.21 to 0.91, n=810 participants). The follow-up period for collection of hospitalisation data ranged from three to 18 months, with a median duration of nine months. There was no significant effect on mortality (pooled odds ratio 0.68, 95% CI 0.28 to 1.67). In another systematic review (Ryrso 2018), early supervised pulmonary rehabilitation (initiated within four weeks after a COPD exacerbation) reduced mortality (four studies, RR=0.58, 95% CI 0.35 to 0.98) after the end of treatment. There was no effect of early supervised pulmonary rehabilitation on mortality over the longer-term, most likely due to the small sample (three trials, 127 participants) [evidence level I].
In the Australian and New Zealand health care context, inpatient pulmonary rehabilitation is not easily accessible, whereas access to outpatient pulmonary rehabilitation is more feasible. Accordingly, the authors of the Australian and New Zealand Pulmonary Rehabilitation Guidelines (Alison 2017) performed a meta-analysis of five outpatient pulmonary rehabilitation studies (program duration 6-12 weeks), commenced within two weeks of hospital discharge. Consistent with the Puhan review (Puhan 2016) and confirmed by the Ryrso review (Ryrso 2018), large benefits for HRQoL and exercise capacity were found. Importantly, no adverse events were reported. Overall, the Australian and New Zealand Pulmonary Rehabilitation Guidelines recommend that outpatient pulmonary rehabilitation is provided after an exacerbation of COPD, commencing within two weeks of hospital discharge (weak strength of recommendation, moderate quality of evidence) (Alison 2017). The Ryrso review (Ryrso 2018) reported a decrease in the number of COPD-related hospital admissions in the three to 12 months following early supervised pulmonary rehabilitation programs initiated after discharge (RR=0.41, 95% CI 0.11 to 1.47), and no difference in the drop-out rate between early supervised pulmonary rehabilitation and usual care. Given the personal and health-system benefits of pulmonary rehabilitation commenced shortly after an exacerbation, it is important to have appropriate screening and referral processes to increase participation in early pulmonary rehabilitation.
Information about pulmonary rehabilitation including a list of programs known to Lung Foundation Australia can be accessed at https://lungfoundation.com.au/patients-carers/get-support/lung-disease-and-exercise/pulmonary-rehabilitation/.< Prev Next >