Initiating outpatient pulmonary rehabilitation within 3 weeks post hospital discharge for chronic obstructive pulmonary disease (COPD) exacerbations can cut hospital readmissions by nearly half, according to findings from a systematic review and meta-analysis published in Thorax.
Researchers updated previously published Cochrane reviews that have assessed the efficacy of pulmonary rehabilitation programs after hospital discharge for COPD exacerbation on clinical outcomes. Notably, the 2016 Cochrane review included evidence that “reduced confidence in the observed benefits of pulmonary rehabilitation in the context of an acute exacerbation of COPD,” noted researchers for the current review. The current review, which was used to inform an American Thoracic Society guideline on pulmonary rehabilitation, therefore focused on outpatient rehabilitation programs started within 3 weeks of patient discharge for exacerbation of COPD.
The reviewers identified 17 studies from October 2015 to August 2023, which in total included 1724 patients enrolled in pulmonary rehab programs following hospital discharge for exacerbation of COPD symptoms. Study sample sizes varied between 26 and 389 participants. Of the studies, 6 involved a rehabilitation program initiated during inpatient acute care and continued as outpatient rehabilitation post-discharge; in the remaining studies, outpatient rehabilitation began within 4 weeks post-discharge. The control group constituted 4 studies involving ‘delayed’ pulmonary rehabilitation.
Inclusion/exclusion criteria did not specify a minimum number of exercise sessions. Some of the pulmonary rehabilitation programs studied offered additional components like self-management education, dietary guidance, breathing exercises, and psychological support. For studies that included patients with mixed diagnoses, the results were included if more than 90% of participants had COPD.
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[T]hese findings support the need to develop strategies to ensure that people with COPD are
offered pulmonary rehabilitation following hospital discharge for an exacerbation.
The meta-analysis found that pulmonary rehabilitation significantly reduced hospital readmissions by nearly half for patients with COPD (OR, 0.48, 95% CI, 0.30-0.77; I2=67%). In addition, pulmonary rehabilitation programs led to other quality of life improvements, including increased exercise capacity, as evidenced by the ability to walk longer distances in both the 6-minute walk test (mean difference [MD], 57 m; 95% CI, 29-86; I2=89%) and an incremental shuttle walk test (MD, 43 m; 95% CI, 6-79; I2=81%).
Pulmonary rehabilitation was also linked to notable improvements related to respiratory health, as measured by the St. George’s Respiratory Questionnaire (MD, −8.7 points; 95% CI, −12.5 to −4.9; I2=59%) and specific aspects of the Chronic Respiratory Disease Questionnaire (CRQ; emotion: MD, 1.0 points; 95% CI, 0.4-1.6; I2=74).
Moreover, rehabilitation programs led to reductions in dyspnea, as noted by improvements in the CRQ and the modified Medical Research Council Dyspnea Scale (CRQ dyspnea scale MD, 1.0 points; 95% CI, 0.3-1.7; I2=87%; modified Medical Research Council Dyspnea Scale MD, −0.3 points; 95% CI, −0.5 to −0.1; I2=60%).
The analysis did not note that pulmonary rehabilitation had any significant effects on self-efficacy, overall COPD assessment, general quality of life, or mortality rates. No adverse events were reported by those participating in rehabilitation programs.
Limitations of this analysis include the risk for bias in all 17 studies used in the meta-analysis; 12 studies were identified as having a high risk of bias and 5 had a moderate risk of bias. The 2 main issues contributing to bias were the inability to blind participants to the exercise training, which introduced performance bias, and inadequate reporting of methods and outcomes in some studies.
The study authors concluded that “Improvements in key clinical outcomes such as hospital re-admission, exercise capacity and health-related quality of life in the absence of adverse events support the use of pulmonary rehabilitation in the postacute exacerbation phase.” As they further noted, “[T]hese findings support the need to develop strategies to ensure that people with COPD are offered pulmonary rehabilitation following hospital discharge for an exacerbation.”
Disclosures: This research was funded by the American Thoracic Society. Please see original reference for more information.
