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. 2022 Aug 22;8(8):CD013485.
doi: 10.1002/14651858.CD013485.pub2.

Pulmonary rehabilitation versus usual care for adults with asthma

Christian R Osadnik  1   2 , Ciara Gleeson  3 , Vanessa M McDonald  4   5   6 , Anne E Holland  7   8   9
Affiliations

Pulmonary rehabilitation versus usual care for adults with asthma

Christian R Osadnik et al. Cochrane Database Syst Rev. .

Abstract

Background: Asthma is a respiratory disease characterised by variable airflow limitation and the presence of respiratory symptoms including wheeze, chest tightness, cough and/or dyspnoea. Exercise training is beneficial for people with asthma; however, the response to conventional models of pulmonary rehabilitation is less clear.

Objectives: To evaluate, in adults with asthma, the effectiveness of pulmonary rehabilitation compared to usual care on exercise performance, asthma control, and quality of life (co-primary outcomes), incidence of severe asthma exacerbations/hospitalisations, mental health, muscle strength, physical activity levels, inflammatory biomarkers, and adverse events.

Search methods: We identified studies from the Cochrane Airways Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform, from their inception to May 2021, as well as the reference lists of all primary studies and review articles.

Selection criteria: We included randomised controlled trials in which pulmonary rehabilitation was compared to usual care in adults with asthma. Pulmonary rehabilitation must have included a minimum of four weeks (or eight sessions) aerobic training and education or self-management. Co-interventions were permitted; however, exercise training alone was not. DATA COLLECTION AND ANALYSIS: Following the use of Cochrane's Screen4Me workflow, two review authors independently screened and selected trials for inclusion, extracted study characteristics and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. We contacted study authors to retrieve missing data. We calculated between-group effects via mean differences (MD) or standardised mean differences (SMD) using a random-effects model. We evaluated the certainty of evidence using GRADE methodology.

Main results: We included 10 studies involving 894 participants (range 24 to 412 participants (n = 2 studies involving n > 100, one contributing to meta-analysis), mean age range 27 to 54 years). We identified one ongoing study and three studies awaiting classification. One study was synthesised narratively, and another involved participants specifically with asthma-COPD overlap. Most programmes were outpatient-based, lasting from three to four weeks (inpatient) or eight to 12 weeks (outpatient). Education or self-management components included breathing retraining and relaxation, nutritional advice and psychological counselling. One programme was specifically tailored for people with severe asthma. Pulmonary rehabilitation compared to usual care may increase maximal oxygen uptake (VO2 max) after programme completion, but the evidence is very uncertain for data derived using mL/kg/min (MD between groups of 3.63 mL/kg/min, 95% confidence interval (CI) 1.48 to 5.77; 3 studies; n = 129) and uncertain for data derived from % predicted VO2 max (MD 14.88%, 95% CI 9.66 to 20.1%; 2 studies; n = 60). The evidence is very uncertain about the effects of pulmonary rehabilitation compared to usual care on incremental shuttle walk test distance (MD between groups 74.0 metres, 95% CI 26.4 to 121.4; 1 study; n = 30). Pulmonary rehabilitation may have little to no effect on VO2 max at longer-term follow up (9 to 12 months), but the evidence is very uncertain (MD -0.69 mL/kg/min, 95% CI -4.79 to 3.42; I2 = 49%; 3 studies; n = 66). Pulmonary rehabilitation likely improves functional exercise capacity as measured by 6-minute walk distance, with MD between groups after programme completion of 79.8 metres (95% CI 66.5 to 93.1; 5 studies; n = 529; moderate certainty evidence). This magnitude of mean change exceeds the minimally clinically important difference (MCID) threshold for people with chronic respiratory disease. The evidence is very uncertain about the longer-term effects one year after pulmonary rehabilitation for this outcome (MD 52.29 metres, 95% CI 0.7 to 103.88; 2 studies; n = 42). Pulmonary rehabilitation may result in a small improvement in asthma control compared to usual care as measured by Asthma Control Questionnaire (ACQ), with an MD between groups of -0.46 (95% CI -0.76 to -0.17; 2 studies; n = 93; low certainty evidence); however, data derived from the Asthma Control Test were very uncertain (MD between groups 3.34, 95% CI -2.32 to 9.01; 2 studies; n = 442). The ACQ finding approximates the MCID of 0.5 points. Pulmonary rehabilitation results in little to no difference in asthma control as measured by ACQ at nine to 12 months follow-up (MD 0.09, 95% CI -0.35 to 0.53; 2 studies; n = 48; low certainty evidence). Pulmonary rehabilitation likely results in a large improvement in quality of life as assessed by the St George's Respiratory Questionnaire (SGRQ) total score (MD -18.51, 95% CI -20.77 to -16.25; 2 studies; n = 440; moderate certainty evidence), with this magnitude of change exceeding the MCID. However, pulmonary rehabilitation may have little to no effect on Asthma Quality of Life Questionnaire (AQLQ) total scores, with the evidence being very uncertain (MD 0.87, 95% CI -0.13 to 1.86; 2 studies; n = 442). Longer-term follow-up data suggested improvements in quality of life may occur as measured by SGRQ (MD -13.4, 95% CI -15.93 to -10.88; 2 studies; n = 430) but not AQLQ (MD 0.58, 95% CI -0.23 to 1.38; 2 studies; n = 435); however, the evidence is very uncertain. One study reported no difference between groups in the proportion of participants who experienced an asthma exacerbation during the intervention period. Data from one study suggest adverse events attributable to the intervention are rare. Overall risk of bias was most commonly impacted by performance bias attributed to a lack of participant blinding to knowledge of the intervention. This is inherently challenging to overcome in rehabilitation studies. AUTHORS' CONCLUSIONS: Moderate certainty evidence shows that pulmonary rehabilitation is probably associated with clinically meaningful improvements in functional exercise capacity and quality of life upon programme completion in adults with asthma. The certainty of evidence relating to maximal exercise capacity was very low to low. Pulmonary rehabilitation appears to confer minimal effect on asthma control, although the certainty of evidence is very low to low. Unclear reporting of study methods and small sample sizes limits our certainty in the overall body of evidence, whilst heterogenous study designs and interventions likely contribute to inconsistent findings across clinical outcomes and studies. There remains considerable scope for future research.

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Conflict of interest statement

CR Osadnik was recipient of a Lung Foundation Australia/Boehringer Ingelheim COPD Research Fellowship during 2016 to 2018 (unrelated to the present work). He has received fees from Novartis for non‐promotional speaking engagements (unrelated to the present work).

C Gleeson was supported by an Evidence Synthesis Ireland fellowship.

VM McDonald has participated in educational symposia funded by GlaxoSmithKline, AstraZeneca, and Menarini, and has participated on advisory boards for GlaxoSmithKline, Novartis, AstraZeneca, and Menarini (unrelated to the present work).

AE Holland has received fees from AstraZeneca and Boehringer Ingelheim for non‐promotional speaking engagements (unrelated to the present work).

To the best of all authors' knowledge, at the time of submitting this work, none of the named entities have any financial interest in the findings of this review and do not manufacture any such intervention or competing product(s).

Figures

1
1
Study flow diagram.
2
2
Overview of Cochrane Crowd Known Assessments and Screen4Me workflows for original search.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
5
5
Analysis 1.2 Peak oxygen uptake (VO2 peak, mL/kg/min) on incremental cardiopulmonary exercise test at end‐intervention
6
6
Analysis 1.4 Exercise performance: 6‐minute walk test distance at end‐intervention. Schultz 2018 is endpoint data. Cambach 1997 and Turk 2017 are change from baseline data.
7
7
Analysis 1.6 Asthma control (Asthma Control Questionnaire) at end‐intervention.
1.1
1.1. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 1: Exercise performance: % predicted VO2 max on incremental cardiopulmonary exercise test at end‐intervention
1.2
1.2. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 2: Exercise performance: Peak oxygen uptake (VO2 peak) on incremental cardiopulmonary exercise test at end‐intervention
1.3
1.3. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 3: Exercise performance: 6‐minute walk test distance at end‐intervention
1.4
1.4. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 4: Exercise performance: 6‐minute walk test distance at end‐intervention (Subgroup: duration of pulmonary rehabilitation)
1.5
1.5. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 5: Asthma control: Asthma Control Questionnaire score at end‐intervention
1.6
1.6. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 6: Asthma control: Asthma Control Questionnaire score at end‐intervention (Subgroup: duration of pulmonary rehabilitation)
1.7
1.7. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 7: Asthma control: Asthma Control Questionnaire score at end‐intervention (Subgroup: asthma severity)
1.8
1.8. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 8: Asthma control: Asthma Control Test score at end‐intervention
1.9
1.9. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 9: Health‐related quality of life: Asthma Quality of Life Questionnaire total score at end‐intervention
1.10
1.10. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 10: Health‐related quality of life: Asthma Quality of Life Questionnaire domain scores at end‐intervention
1.11
1.11. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 11: Health‐related quality of life: Asthma Quality of Life Questionnaire total score at end‐intervention (Subgroup: duration of pulmonary rehabilitation)
1.12
1.12. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 12: Health‐related quality of life: Asthma Quality of Life Questionnaire total score at end‐intervention (Subgroup: asthma severity)
1.13
1.13. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 13: Health‐related quality of life: St George's Respiratory Questionnaire total score at end‐intervention
1.14
1.14. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 14: Health‐related quality of life: St George's Respiratory Questionnaire domain scores at end‐intervention
1.15
1.15. Analysis
Comparison 1: Pulmonary rehabilitation vs usual care for adults with asthma (end‐intervention), Outcome 15: Health‐related quality of life: Chronic Respiratory Disease Questionnaire domain scores at end‐intervention
2.1
2.1. Analysis
Comparison 2: Pulmonary rehabilitation vs usual care for adults with asthma (follow‐up), Outcome 1: Exercise performance: Peak oxygen uptake (VO2 peak) on incremental cardiopulmonary exercise test at follow‐up
2.2
2.2. Analysis
Comparison 2: Pulmonary rehabilitation vs usual care for adults with asthma (follow‐up), Outcome 2: Exercise performance: 6‐minute walk test distance at follow‐up
2.3
2.3. Analysis
Comparison 2: Pulmonary rehabilitation vs usual care for adults with asthma (follow‐up), Outcome 3: Asthma control: Asthma Control Questionnaire score at follow‐up
2.4
2.4. Analysis
Comparison 2: Pulmonary rehabilitation vs usual care for adults with asthma (follow‐up), Outcome 4: Health‐related quality of life: Asthma Quality of Life Questionnaire total score at follow‐up
2.5
2.5. Analysis
Comparison 2: Pulmonary rehabilitation vs usual care for adults with asthma (follow‐up), Outcome 5: Health‐related quality of life: Asthma Quality of Life Questionnaire domain scores at follow‐up
2.6
2.6. Analysis
Comparison 2: Pulmonary rehabilitation vs usual care for adults with asthma (follow‐up), Outcome 6: Health‐related quality of life: St George's Respiratory Questionnaire total score at follow‐up
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Update of

  • doi: 10.1002/14651858.CD013485

References

References to studies included in this review

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References to studies excluded from this review

Abd El‐Kader 2016 {published data only}
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Didour 2002 {published data only}
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Freitas 2014 {published data only}
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Freitas 2014a {published data only}
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Freitas 2014b {published data only}
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Freitas 2014c {published data only}
    1. Freitas PD, Ferreira PG, Analuci S, Stelmach R, Pinto RC, Sage JM, et al. Effects of exercise training in a weight loss lifestyle intervention on clinical control, quality of life and psychosocial symptoms in obese asthmatics: a RCT. European Respiratory Journal 2014;44(Suppl 58):1710.
Freitas 2015 {published data only}
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Freitas 2015a {published data only}
    1. Freitas PD, Ferreira PG, Silva AG, Cukier A, Stelmach R, Carvalho-Pinto R, et al. Increased fitness and weight-loss are associated with improvement in daily life physical activity and clinical control in obese asthmatics: a RCT. European Respiratory Journal 2015;46(Suppl 59):OA479.
Freitas 2015b {published data only}
    1. Freitas PD, Ferreira PG, Silva AG, Cukier A, Stelmach R, Carvalho-Pinto R. Exercise training is a determinant of weight-loss and improvement on asthma control, airway inflammation and psychosocial morbidity in obese asthmatics: a RCT. European Respiratory Journal 2015;46(Suppl 59):PA734.
Freitas 2016 {published data only}
    1. Freitas PD, Silva AG, Ferreira PG, da Silva A, Salge JM, Cukier A. The role of exercise training in a weight loss program on psychosocial morbidity, sleep quality and physical activity in obese asthmatics: a RCT. European Respiratory Journal 2016;48(Suppl 60):OA3048.
Freitas 2016a {published data only}
    1. Freitas P, Ferreira PG, Silva AG, Stelmach R, Carvalho-Pinto R, Fernandes FLA, et al. Mechanisms underlying the role of exercise training as part of a weight loss program on asthma control in obese asthmatics. European Respiratory Journal 2016;48(Suppl 60):PA527.
Freitas 2016b {published data only}
    1. Freitas PD, Silva AG, Ferreira PG, da Silva A, Salge JM, Cukier A, et al. The role of exercise training in a weight loss program on psychosocial morbidity, sleep quality and physical activity in obese asthmatics: a RCT. European Respiratory Journal 2016;48(Suppl 60):OA3048.
Freitas 2017 {published data only}
    1. Freitas PD, Ferreira PG, Silva AG, Stelmach R, Carvalho-Pinto RM, Fernandes FLA, et al. The role of exercise in a weight-loss program on clinical control in obese adults with asthma: a randomized controlled trial. American Journal of Respiratory & Critical Care Medicine 2017;195(1):32-42. - PubMed
Freitas 2017a {published data only}
    1. Freitas PD, Ferreira PG, Silva AG, Stelmach R, Carvalho-Pinto RM, Fernandes FLA. The role of exercise in a weight-loss program on clinical control in obese adults with asthma: a randomized controlled trial. American Journal of Respiratory & Critical Care Medicine 2017;195(1):32-42. - PubMed
Freitas 2017b {published data only}
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Gonçalves 2008 {published data only}
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IRCT2015011420666N1 {published data only}
    1. IRCT2015011420666N1. The effect of resistance and specific training in patient with asthma. irct.ir/trial/18286 (first received 16 March 2015).
IRCT2016052328028N1 {published data only}
    1. IRCT2016052328028N1. Effect of aerobic exercise training on inflammatory markers and sex hormones in asthmatic women. irct.ir/trial/22831 (first received 5 January 2017).
Jaakkola 2017 {published data only}
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Lenz 2001 {published data only}
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Lowe 2018 {published data only}
    1. Lowe AA, Garcia DO, Stern DA, Gerald LB, Bime C. Home-based exercise intervention versus remote asthma care guidance via telephone/text message in obese asthmatics: a pilot randomized controlled trial. American Journal of Respiratory and Critical Care Medicine 2018;197(Meeting Abstracts):A2715.
Lowe 2018a {published data only}
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Ma 2010 {published data only}
    1. Ma J, Strub P, Camargo CA, Xiao L, Ayala E, Gardner CD, et al. The Breathe Easier through Weight Loss Lifestyle (BE WELL) Intervention: a randomized controlled trial. BMC Pulmonary Medicine 2010;10:16. - PMC - PubMed
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    1. Ma J, Strub P, Xiao L, Lavori PW, Camargo CA Jr, Wilson SR, et al. Behavioral weight loss and physical activity intervention in obese adults with asthma: a randomized trial. Annals of the American Thoracic Society 2015;12(1):1-11. - PMC - PubMed
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    1. Mendes F, Franca-Pinto A, Cukier A, Stelmach R, Agondi R, Martins MA, et al. Aerobic training decreases bronchial hyperresponsiveness, serum chemokines and symptoms in asthmatic patients: randomized controlled trial. European Respiratory Journal 2013;42(Suppl 57):680s.
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    1. Meyer A, Gunther S, Volmer T, Taube K, Baumann HJ. A 12-month, moderate-intensity exercise training program improves fitness and quality of life in adults with asthma: a controlled trial. BMC Pulmonary Medicine 2015;15(1):56. - PMC - PubMed
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NCT00195117 (a) {published data only}
    1. NCT00195117. A randomized trial of changing exercise and physical activity behavior in asthma patients. clinicaltrials.gov/ct2/show/NCT00195117 (first received 19 September 2005).
NCT00195117 (b) {published data only}
    1. NCT00195117. A randomised trial of changing exercise and physical activity behavior in asthma patients. clinicaltrials.gov/ct/show/NCT00195117 (first received 19 September 2005).
NCT00839137 {published data only}
    1. NCT00839137. Exercise therapy for asthma (ETA Trial). clinicaltrials.gov/ct2/show/NCT00839137 (first received 9 February 2009).
NCT00901095 {published data only}
    1. NCT00901095. Can diet- and exercise-induced weight loss improve asthma control in adults? clinicaltrials.gov/ct2/show/NCT00901095 (first received 13 May 2009).
NCT00953342 {published data only}
    1. NCT00953342. Impact of aerobic exercise on asthma morbidity. clinicaltrials.gov/ct2/show/NCT00953342 (first received 6 August 2009).
NCT00989365 {published data only}
    1. Mendes FA, Gonçalves RC, Nunes MP, Saraiva-Romanholo BM, Cukier A, Stelmach R, et al. Effects of aerobic training on psychosocial morbidity and symptoms in patients with asthma: a randomized clinical trial. Chest 2010;138(2):331-7. - PubMed
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NCT01097473 {published data only}
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NCT02012400 {published data only}
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    1. NCT02033122. Effect of aerobic training on bronchial hyperresponsiveness and systemic inflammation in patients with moderate or severe asthma: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT02033122 (first received 10 January 2014).
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    1. NCT02188940. Effects of exercise training in a weight-loss lifestyle intervention on clinical control and psychosocial morbidity in obese asthmatics: a randomized and controlled trial. clinicaltrials.gov/ct2/show/NCT02188940 (first received 14 July 2014).
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Pinto 2012 {published data only}
    1. Pinto A, Mendes F, Agondi R, Saraiva-Romanholo B, Stelmach R, Cukier A. Effect of aerobic exercise training on bronchial hyperresponsiveness, airway inflammation and health related quality of life in asthmatic patients: a pilot study. European Respiratory Journal 2012;40(Suppl 56):69s.
Pinto 2012a {published data only}
    1. Pinto A, Mendes F, Agondi R, Saraiva-Romanholo B, Stelmach R, Cukier A, et al. Effect of aerobic exercise training on bronchial hyperresponsiveness, airway inflammation and health related quality of life in asthmatic patients: a pilot study. European Respiratory Journal 2012;40(Suppl 56):69s.
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    1. Pollart SM, Elward KS, Platts-Mills TAE. Improvements in quality of life measures in a structured exercise program for persistent asthma. Journal of Allergy and Clinical Immunology 2012;129(2 Suppl 1):AB60.
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Shaw 2011 {published data only}
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References to studies awaiting assessment

Budnevsky 2018 {published data only}
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IRCT2014041617299N {published data only}
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NTR4398 {published data only}
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References to ongoing studies

NCT03630432 {published data only}
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