Pulmonary rehabilitation in patients with an acute exacerbation of chronic obstructive pulmonary disease

Abstract

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are one of the most common causes of emergency hospital admission and place great burden upon healthcare systems. Furthermore, AECOPD represent an important life event for patients, and are associated with significant reductions in physical activity, skeletal muscle function, exercise tolerance and health-related quality of life. Pulmonary rehabilitation, an intervention comprising supervised exercise-training and education, may counteract these negative consequences and target modifiable risk factors for hospital readmission. A recent Cochrane systematic review included 20 randomized controlled trials comparing pulmonary rehabilitation after exacerbation of COPD versus conventional care. Overall, the evidence supports moderate to large effects on health-related quality of life and exercise capacity. However, there is substantial heterogeneity across studies, and more recent studies have been more equivocal, including around hospital readmissions, particularly when rehabilitation is started in the inpatient setting. In this narrative review, we examine the rationale for pulmonary rehabilitation following AECOPD with a particular focus on skeletal muscle function, review the current evidence for pulmonary rehabilitation in the AECOPD setting, and identify areas that require future research, including the structure and nature of the intervention, improving uptake and adherence, and the role of alternative rehabilitation strategies for patients with AECOPD.

Keywords: Acute exacerbation; chronic obstructive pulmonary disease; exercise; rehabilitation; skeletal muscle dysfunction.

Figure 1

Schematic of the impact of acute exacerbations of COPD upon the cycle of breathlessness (adapted from Burtin et al., 2011).

Figure 2

Referral, uptake and adherence data to post-exacerbation pulmonary rehabilitation following an admission to hospital over 12-month in a north-west London hospital, UK (adapted from Jones et al., 2013).

Figure 3

Reasons for poor referral, uptake and completion rates to post-exacerbation pulmonary rehabilitation.