Systematic review of clinical effectiveness, components, and delivery of pulmonary rehabilitation in low-resource settings

Abstract

Pulmonary rehabilitation (PR) is a guideline-recommended multifaceted intervention that improves the physical and psychological well-being of people with chronic respiratory diseases (CRDs), though most of the evidence derives from trials in high-resource settings. In low- and middle-income countries, PR services are under-provided. We aimed to review the effectiveness, components and mode of delivery of PR in low-resource settings. Following Cochrane methodology, we systematically searched (1990 to October 2018; pre-publication update March 2020) MEDLINE, EMBASE, CABI, AMED, PUBMED, and CENTRAL for controlled clinical trials of adults with CRD (including but not restricted to chronic obstructive pulmonary disease) comparing PR with usual care in low-resource settings. After duplicate selection, we extracted data on exercise tolerance, health-related quality of life (HRQoL), breathlessness, included components, and mode of delivery. We used Cochrane risk of bias (RoB) to assess study quality and synthesised data narratively. From 8912 hits, we included 13 studies: 11 were at high RoB; 2 at moderate RoB. PR improved functional exercise capacity in 10 studies, HRQoL in 12, and breathlessness in 9 studies. One of the two studies at moderate RoB showed no benefit. All programmes included exercise training; most provided education, chest physiotherapy, and breathing exercises. Low cost services, adapted to the setting, used limited equipment and typically combined outpatient/centre delivery with a home/community-based service. Multicomponent PR programmes can be delivered in low-resource settings, employing a range of modes of delivery. There is a need for a high-quality trial to confirm the positive findings of these high/moderate RoB studies.

Fig. 1. PRISMA flow diagram.

Flowchart reporting the number of articles identified, screened, excluded and included.

Fig. 2. Harvest plot illustrating the impact of pulmonary rehabilitation on functional exercise capacity, health-related quality of life, and breathlessness.

Each column represents an included study, shaded according to whether it is a RCT (solid shading) or within group comparison (hatched shading). The depth of shading represents study duration of 4-7 weeks (light shading); 8-11 weeks (moderate shading); 12 weeks or more (dark shading). The height of the bars represent the number of patients. The icon on the top of the bars represents the overall risk of bias as high risk of bias (red) or moderate risk of bias (yellow). Within the icon the mode of delivery of the PR is indicated as + (OPD-based); ^ (Home-based) or C (Community-based). The effectiveness of interventions is illustrated with respect to functional exercise capacity, health-related quality of life, and breathlessness in the three tiers of the graph. Studies are positioned according to whether overall the outcomes were positive (i.e., interventions were significantly beneficial), negative (i.e., interventions were significantly harmful), or had no effect. Table 1; Column 5 details how these decisions were reached.