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Review
. 2012;12(6):1-75.
Epub 2012 Mar 1.

Pulmonary rehabilitation for patients with chronic pulmonary disease (COPD): an evidence-based analysis

COPD Working Group
Review

Pulmonary rehabilitation for patients with chronic pulmonary disease (COPD): an evidence-based analysis

COPD Working Group. Ont Health Technol Assess Ser. 2012.

Abstract

Objective: The objective of this evidence-based review was to determine the effectiveness and cost-effectiveness of pulmonary rehabilitation in the management of chronic obstructive pulmonary disease (COPD).

Technology: Pulmonary rehabilitation refers to a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy. Exercise training is the cornerstone of pulmonary rehabilitation programs, though they may also include components such as patient education and psychological support. Pulmonary rehabilitation is recommended as the standard of care in the treatment and rehabilitation of patients with COPD who remain symptomatic despite treatment with bronchodilators.

For the purpose of this review, the Medical Advisory Secretariat focused on pulmonary rehabilitation programs as defined by the Cochrane Collaboration—that is, any inpatient, outpatient, or home-based rehabilitation program lasting at least 4 weeks that includes exercise therapy with or without any form of education and/or psychological support delivered to patients with exercise limitations attributable to COPD.

Research Questions:

  1. What is the effectiveness and cost-effectiveness of pulmonary rehabilitation compared with usual care (UC) for patients with stable COPD?

  2. Does early pulmonary rehabilitation (within 1 month of hospital discharge) in patients who had an acute exacerbation of COPD improve outcomes compared with UC (or no rehabilitation)?

  3. Do maintenance or postrehabilitation programs for patients with COPD who have completed a pulmonary rehabilitation program improve outcomes compared with UC?

Search Strategy: For Research Questions 1and 2, a literature search was performed on August 10, 2010 for studies published from January 1, 2004 to July 31, 2010. For Research Question 3, a literature search was performed on February 3, 2011 for studies published from January 1, 2000 to February 3, 2011. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search.

Inclusion Criteria: Research questions 1 and 2:

  1. published between January 1, 2004 and July 31, 2010

  2. randomized controlled trials, systematic reviews, and meta-analyses

  3. COPD study population

  4. studies comparing pulmonary rehabilitation with UC (no pulmonary rehabilitation)

  5. duration of pulmonary rehabilitation program ≥ 6 weeks

  6. pulmonary rehabilitation program had to include at minimum exercise training

Research question 3:

  1. published between January 1, 2000 and February 3, 2011

  2. randomized controlled trials, systematic reviews, and meta-analyses

  3. COPD study population

  4. studies comparing a maintenance or postrehabilitation program with UC (standard follow-up)

  5. duration of pulmonary rehabilitation program ≥ 6 weeks

  6. initial pulmonary rehabilitation program had to include at minimum exercise training

Exclusion Criteria: Research questions 1, 2, and 3:

  1. grey literature

  2. duplicate publications

  3. non-English language publications

  4. study population ≤ 18 years of age

  5. studies conducted in a palliative population

  6. studies that did not report primary outcome of interest

Additional exclusion criteria for research question 3:

  1. studies with ≤ 2 sessions/visits per month

Outcomes of Interest: The primary outcomes of interest for the stable COPD population were exercise capacity and health-related quality of life (HRQOL). For the COPD population following an exacerbation, the primary outcomes of interest were hospital readmissions and HRQOL. The primary outcomes of interest for the COPD population undertaking maintenance programs were functional exercise capacity and HRQOL.

Quality of Evidence: The quality of each included study was assessed taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.

The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:

[Table: see text]

Research Question 1: Effect of Pulmonary Rehabilitation on Outcomes in Stable COPD: Seventeen randomized controlled trials met the inclusion criteria and were included in this review.

The following conclusions are based on moderate quality of evidence.

  1. Pulmonary rehabilitation including at least 4 weeks of exercise training leads to clinically and statistically significant improvements in HRQOL in patients with COPD.

  2. Pulmonary rehabilitation also leads to a clinically and statistically significant improvement in functional exercise capacity (weighted mean difference, 54.83 m; 95% confidence interval, 35.63–74.03; P < 0.001).

Research Question 2: Effect of Pulmonary Rehabilitation on Outcomes Following an Acute Exacerbation of COPD: Five randomized controlled trials met the inclusion criteria and are included in this review. The following conclusion is based on moderate quality of evidence.

  1. Pulmonary rehabilitation (within 1 month of hospital discharge) after acute exacerbation significantly reduces hospital readmissions (relative risk, 0.50; 95% confidence interval, 0.33–0.77; P = 0.001) and leads to a statistically and clinically significant improvement in HRQOL.

Research Question 3: Effect of Pulmonary Rehabilitation Maintenance Programs on COPD Outcomes: Three randomized controlled trials met the inclusion criteria and are included in this review. The conclusions are based on a low quality of evidence and must therefore be considered with caution.

  1. Maintenance programs have a nonsignificant effect on HRQOL and hospitalizations.

  2. Maintenance programs have a statistically but not clinically significant effect on exercise capacity (P = 0.01). When subgrouped by intensity and quality of study, maintenance programs have a statistically and marginally clinically significant effect on exercise capacity.

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Figures

Figure 1:
Figure 1:. Citation Flow Chart
Figure 2:
Figure 2:. Citation Flow Chart
Figure 3:
Figure 3:. Citation Flow Chart
Figure A1:
Figure A1:. Forest Plot of Pooled Quality of Life Data Measured by the Total Score of the St. George’s Respiratory Questionnaire
Figure A2:
Figure A2:. Forest Plot of Pooled Quality of Life Data Measured by the Symptom Score of the St. George’s Respiratory Questionnaire
Figure A3:
Figure A3:. Forest Plot of Pooled Quality of Life Data Measured by the Impacts Score of the St. George’s Respiratory Questionnaire
Figure A4:
Figure A4:. Forest Plot of Pooled Quality of Life Data Measured by the Activity Score of the St. George’s Respiratory Questionnaire
Figure A5:
Figure A5:. Forest Plot of Pooled Quality of Life Data Measured by the Mastery Score of the Chronic Respiratory Questionnaire
Figure A6:
Figure A6:. Forest Plot of Pooled Quality of Life Data Measured by the Emotional Function Score of the Chronic Respiratory Questionnaire
Figure A7:
Figure A7:. Forest Plot of Pooled Quality of Life Data Measured by the Dyspnea Score of the Chronic Respiratory Questionnaire
Figure A8:
Figure A8:. Forest Plot of Pooled Quality of Life Data Measured by the Fatigue Score of the Chronic Respiratory Questionnaire
Figure A9:
Figure A9:. Forest Plot of Pooled Data on Functional Exercise Capacity Measured by the Six Minute Walking Test
Figure A10:
Figure A10:. Forest Plot of Pooled Data on Hospital Readmissions Subgrouped by Type of Readmission
Figure A11:
Figure A11:. Forest Plot of Pooled Data on Health-Related Quality of Life as Measured by the CRQ, Subgrouped by Components of the CRQ
Figure A12:
Figure A12:. Forest Plot of Pooled Data on Health-Related Quality of Life as Measured by the SGRQ, Subgrouped by Components of SGRQ
Figure A13:
Figure A13:. Forest Plot of Pooled Data on Exercise Capacity as Measured by the Six Minute Walking Test
Figure A14:
Figure A14:. Forest Plot of Pooled Data on Emergency Department Visits
Figure A15:
Figure A15:. Forest Plot of Pooled Data on Mortality
Figure A16:
Figure A16:. Forest Plot of Pooled Data on Exercise Capacity as Measured by the Six Minute Walking Test
See this image and copyright information in PMC

References

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