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 (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. The 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 health-related quality of life and exercise capacity in the short-term (median of five months for health-related quality of life 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 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), large benefits for health-related quality of life and exercise capacity were found. In contrast, no statistically significant reduction in hospital readmissions was found (odds ratio 0.30, 95% CI 0.07–1.29, n=187 participants), most likely due to the small sample. 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) (Puhan 2016).

A list of pulmonary rehabilitation programs known to Lung Foundation Australia can be accessed at https://lungfoundation.com.au/patient-support/living-with-a-lung-condition/pulmonary-rehabilitation-2/pulmonary-rehabilitation-programs-2/.  The individual contact details can be obtained by calling the Lung Foundation’s Information and Support Centre (free-call 1800 654 301).