Early versus Late Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease Patients with Acute Exacerbations: A Randomized Trial

Abstract

Background: Around the world, the timing of referral of chronic obstructive pulmonary disease (COPD) patients for pulmonary rehabilitation differs from immediately after exacerbation (early) to later on when patients are in a stable state (late). There are no trials comparing the different time points of referral for pulmonary rehabilitation. Objectives: Our aim was to compare the effects of early and late pulmonary rehabilitation on exacerbation rates and health-related quality of life (HRQOL) in COPD patients with exacerbations. Methods: We randomized COPD patients (Global Initiative for Chronic Obstructive Lung Disease stages II–IV) with a recent exacerbation to early (within 2 weeks) or late pulmonary rehabilitation (starting 6 months after randomization and in a stable state). The primary outcome was the exacerbation rate over 18 months, and secondary outcomes included HRQOL and mortality. We used multivariate analyses and an intention-to-treat analysis approach. Results: We randomized 36 patients to pulmonary rehabilitation. On average, patients with early rehabilitation (n = 19) had 2.61 (SD 2.96) exacerbations requiring systemic corticosteroids and/or antibiotics, compared to 2.77 (SD 3.41) in patients with late rehabilitation (adjusted incidence rate ratio 0.83, 95% confidence interval 0.43–1.63; p = 0.60). Over the 18-month period, patients with late rehabilitation experienced more dyspnea (difference on Chronic Respiratory Questionnaire dyspnea domain 0.74 and on the Medical Research Council dyspnea scale 0.37), but neither these differences nor any difference in HRQOL domains reached statistical significance. Conclusions: We did not find any statistically significant differences between early and late pulmonary rehabilitation. However, our trial indicates that early rehabilitation may lead to faster recovery of HRQOL after exacerbations compared to rehabilitation later on when patients are in a stable state.

An Official American Thoracic Society/European Respiratory Society Statement: Update on Limb Muscle Dysfunction in Chronic Obstructive Pulmonary Disease

“…Keeping in mind the deleterious effects of exacerbations on limb muscles, several interventions to prevent or counteract muscle impairment have been considered (522). These interventions, mainly based on exercise training, have been used during, immediately after, or late after the exacerbation (523). A Cochrane Collaboration metaanalysis revealed that pulmonary rehabilitation immediately after an exacerbation significantly improved exercise capacity in addition to reducing hospital admissions and mortality (524).…”

British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE

“…To date, only one study has compared ‘early’ post-exacerbation pulmonary rehabilitation with ‘late’ post-exacerbation pulmonary rehabilitation (delivered 6 months after exacerbation) with an 18-month follow-up 118. No significant differences were seen in health-related quality of life or exacerbation rates between the groups.…”

“…From 12 potential abstracts; nine compared early post-exacerbation pulmonary rehabilitation with usual care; one was a review paper and the ‘early’ intervention in one study was more than 4 weeks after exacerbation. Only one study was reviewed in full 118. This compared ‘early’ (within 2 weeks of exacerbation) with ‘late’ pulmonary rehabilitation delivered 6 months after exacerbation.…”

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

“…A delayed offer of rehabilitation may be more feasible given the immediate psychological impact of the disease. The only reported attempt of an early versus delayed rehabilitation intervention did not report a successful outcome [37] and more recently, a North American study reported similar recruitment difficulties for trial comparing pulmonary rehabilitation with a modest physical activity intervention [38].

FIGURE 1An audit of the post-hospitalisation pulmonary rehabilitation pathway in a northwest London hospital.

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