Pulmonary rehabilitation and severe exacerbations of COPD: solution or white elephant?

Abstract

Hospitalisations for severe exacerbations of chronic obstructive pulmonary disease are associated with significant physical and psychological consequences including an increase in symptom severity, severe reductions in physical activity, a deleterious effect on skeletal muscle, impaired exercise tolerance/ability to self-care, decline in quality of life, and increased anxiety and depression. As these consequences are potentially amenable to exercise training, there is a clear rationale for pulmonary rehabilitation in the peri/post-exacerbation setting. Although a 2011 Cochrane review was overwhelmingly positive, subsequent trials have shown less benefit and real-life observational studies have revealed poor acceptability. Qualitative studies have demonstrated that the patient experience is a determining factor while the presence of comorbidities may influence referral, adherence and response to pulmonary rehabilitation. Systematic reviews of less supervised interventions, such as self-management, have shown limited benefits in the post-exacerbation setting. The recent update of the Cochrane review of peri-exacerbation pulmonary rehabilitation showed that benefits were associated with the "comprehensive" nature of the intervention (the number of sessions received, the intensity of exercise training and education delivered, and the degree of supervision) but implementation is demanding. The challenge is to develop interventions that are deliverable and acceptable around the time of an acute exacerbation but also deliver the desired clinical impact.

FIGURE 1

An audit of the post-hospitalisation pulmonary rehabilitation pathway in a northwest London hospital. Out of 448 hospital discharges following severe exacerbation of chronic obstructive pulmonary disease, a third of patients were not eligible for pulmonary rehabilitation, principally due to the presence or consequences of co-morbidities. <15% of eligible patients (9% of all patients) completed a post-hospitalisation pulmonary rehabilitation programme. AECOPD: acute exacerbation of chronic obstructive pulmonary disease.

FIGURE 2

Comorbidities that may arise de novo or worsen at the time of exacerbation.

FIGURE 3

Diagram of included randomised controlled trials of supported self-management interventions post-hospital discharge. Reproduced and modified from [58] with permission from the publisher.

FIGURE 4

A white elephant or the elephant in the room? Pulmonary rehabilitation following severe exacerbation of chronic obstructive pulmonary disease represents a complex scenario for healthcare worker and patient.