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Meta-Analysis
. 2014 May 14;2014(5):CD007714.
doi: 10.1002/14651858.CD007714.pub2.

Non-invasive ventilation during exercise training for people with chronic obstructive pulmonary disease

Collette Menadue  1 , Amanda J Piper, Alex J van 't Hul, Keith K Wong
Affiliations
Meta-Analysis

Non-invasive ventilation during exercise training for people with chronic obstructive pulmonary disease

Collette Menadue et al. Cochrane Database Syst Rev. .

Abstract

Background: Exercise training as a component of pulmonary rehabilitation improves health-related quality of life (HRQL) and exercise capacity in people with chronic obstructive pulmonary disease (COPD). However, some individuals may have difficulty performing exercise at an adequate intensity. Non-invasive ventilation (NIV) during exercise improves exercise capacity and dyspnoea during a single exercise session. Consequently, NIV during exercise training may allow individuals to exercise at a higher intensity, which could lead to greater improvement in exercise capacity, HRQL and physical activity.

Objectives: To determine whether NIV during exercise training (as part of pulmonary rehabilitation) affects exercise capacity, HRQL and physical activity in people with COPD compared with exercise training alone or exercise training with sham NIV.

Search methods: We searched the following databases between January 1987 and November 2013 inclusive: The Cochrane Airways Group specialised register of trials, AMED, CENTRAL, CINAHL, EMBASE, LILACS, MEDLINE, PEDro, PsycINFO and PubMed.

Selection criteria: Randomised controlled trials that compared NIV during exercise training versus exercise training alone or exercise training with sham NIV in people with COPD were considered for inclusion in this review.

Data collection and analysis: Two review authors independently selected trials for inclusion in the review, extracted data and assessed risk of bias. Primary outcomes were exercise capacity, HRQL and physical activity; secondary outcomes were training intensity, physiological changes related to exercise training, dyspnoea, dropouts, adverse events and cost.

Main results: Six studies involving 126 participants who completed the study protocols were included. Most studies recruited participants with severe to very severe COPD (mean forced expiratory volume in one second (FEV1) ranged from 26% to 48% predicted). There was an increase in percentage change peak and endurance exercise capacity with NIV during training (mean difference in peak exercise capacity 17%, 95% confidence interval (CI) 7% to 27%, 60 participants, low-quality evidence; mean difference in endurance exercise capacity 59%, 95% CI 4% to 114%, 48 participants, low-quality evidence). However, there was no clear evidence of a difference between interventions for all other measures of exercise capacity. The results for HRQL assessed using the St George's Respiratory Questionnaire do not rule out an effect of NIV (total score mean 2.5 points, 95% CI -2.3 to 7.2, 48 participants, moderate-quality evidence). Physical activity was not assessed in any study. There was an increase in training intensity with NIV during training of 13% (95% CI 1% to 27%, 67 participants, moderate-quality evidence), and isoload lactate was lower with NIV (mean difference -0.97 mmol/L, 95% CI -1.58mmol/L to -0.36 mmol/L, 37 participants, moderate-quality evidence). The effect of NIV on dyspnoea or the number of dropouts between interventions was uncertain, although again results were imprecise. No adverse events and no information regarding cost were reported. Only one study blinded participants, whereas three studies used blinded assessors. Adequate allocation concealment was reported in four studies.

Authors' conclusions: The small number of included studies with small numbers of participants, as well as the high risk of bias within some of the included studies, limited our ability to draw strong evidence-based conclusions. Although NIV during lower limb exercise training may allow people with COPD to exercise at a higher training intensity and to achieve a greater physiological training effect compared with exercise training alone or exercise training with sham NIV, the effect on exercise capacity is unclear. Some evidence suggests that NIV during exercise training improves the percentage change in peak and endurance exercise capacity; however, these findings are not consistent across other measures of exercise capacity. There is no clear evidence that HRQL is better or worse with NIV during training. It is currently unknown whether the demonstrated benefits of NIV during exercise training are clinically worthwhile or cost-effective.

PubMed Disclaimer

Conflict of interest statement

Amanda Piper has received honoraria for educational presentations conducted on behalf of Respironics, Australia; ResMed, Australia; and Weinmann, Germany. She has also received a grant from the ResMed Foundation. The sleep laboratory of Collette Menadue, Amanda Piper and Keith Wong has previously received industry‐sponsored project grants from ResMed, Australia, and positive airway pressure equipment for other research projects from Philips Respironics, Australia; Air Liquide, Australia; and MayoHealthcare, Australia. Alex van't Hul is an author of one of the studies included in the present review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, outcome: 1.3 Exercise capacity: percentage change.
5
5
Forest plot of comparison: 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, outcome: 1.5 Health‐related quality of life: St George's Respiratory Questionnaire.
6
6
Forest plot of comparison: 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, outcome: 1.6 Training intensity: Final training session (% baseline peak work capacity).
7
7
Forest plot of comparison: 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, outcome: 1.7 Physiological outcomes: Isoload lactate (mmol/L).
1.1
1.1. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 1 Exercise capacity: peak cycle work rate (watts).
1.2
1.2. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 2 Exercise capacity: peak VO2 (L/min).
1.3
1.3. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 3 Exercise capacity: percentage change.
1.4
1.4. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 4 Exercise capacity: constant work rate cycle endurance time (minutes).
1.5
1.5. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 5 Health‐related quality of life: St George's Respiratory Questionnaire.
1.6
1.6. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 6 Training intensity: final training session (% baseline peak work capacity).
1.7
1.7. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 7 Physiological outcomes: isoload lactate (mmol/L).
1.8
1.8. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 8 Physiological outcomes: peak exercise lactate (mmol/L).
1.9
1.9. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 9 Physiological outcomes: isotime exercise minute ventilation (L/min).
1.10
1.10. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 10 Physiological outcomes: peak exercise minute ventilation (L/min).
1.11
1.11. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 11 Physiological outcomes: change in VO2 at anaerobic threshold (L/min).
1.12
1.12. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 12 Dyspnoea: isotime exercise dyspnoea (Borg scale).
1.13
1.13. Analysis
Comparison 1 Non‐invasive ventilation during exercise training versus exercise training alone or exercise training with sham non‐invasive ventilation, Outcome 13 Dropouts.
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Ricci 2013 {published data only}
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Soo Hoo 2003 {published data only}
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Wijkstra 2011 {published data only}
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