Integral Health Status-Based Cluster Analysis in Moderate–Severe COPD Patients Identifies Three Clinical Phenotypes: Relevant for Treatment As Usual and Pulmonary Rehabilitation

Abstract

PurposeThe purposes of the study are to identify clinical phenotypes that reflect the level of adaptation to the disease and to examine whether these clinical phenotypes respond differently to treatment as usual (TAU) and pulmonary rehabilitation (PR), the latter with its strong emphasis on improving adaptation.MethodsClusters were identified by a cluster analysis using data on many subdomains of the four domains of health status (HS) (physiological functioning, functional impairment, symptoms and quality of life) in 160 outpatients with chronic obstructive pulmonary disease (COPD) receiving TAU. By discriminant analysis in the TAU sample, all 459 PR patients could be assigned to one of the identified clusters. The effect of TAU and PR on HS was examined with paired t tests.ResultsThree distinct phenotypes were identified in the TAU sample. Two types were labelled adapted: phenotype 1 (moderate COPD–low impact on HS, n = 53) and phenotype 3 (severe COPD–moderate impact on HS, n = 73). One type was labelled non-adapted: phenotype 2 (moderate COPD–high impact on HS, n = 34). After 1-year TAU, the integral health status of all patients did not improve in any subdomain. In contrast, at the end of PR, significant improvements in HS were found in all three phenotypes especially the non-adapted.ConclusionsDifferent phenotypes exist in COPD that are based on behavioural aspects (i.e. the level of adaptation to the disease). Non-adapted patient responds better to treatments with a strong emphasis on improving adaptation by learning the patient better self-management skills. Knowing to which clinical phenotype a patient belongs helps to optimize patient-tailored treatment.

Fatigue in Chronic Respiratory Diseases: Theoretical Framework and Implications For Real-Life Performance and Rehabilitation

“…Some recent clinical trials demonstrated the effectiveness of multidisciplinary pulmonary rehabilitation programs to reduce perceived fatigability. For instance, both a 3- and 12-week program have proven effective in reducing fatigue, in patients with sarcoidosis (Lingner et al, 2018 ) and COPD (Peters et al, 2017 ), respectively. However, in both studies fatigue was chosen as a secondary outcome and it is not known which component of these multimodal programs actually reduced fatigue.…”

A Review of Non-Pharmacological Pulmonary Rehabilitation for Patients Receiving Palliative Care

“…60 Of note, pulmonary rehabilitation offers the most benefits to patients who score highest in anxiety and depression before starting rehabilitation, as well as patients who have not adapted (physically or psychologically) well to the disease. 23,27 Unfortunately, as noted above, these are also the same patients whom are least likely to finish rehabilita-tion even though they would derive the most benefit. Noticing a change in baseline, or the development of anxiety and depression, should warrant the involvement of palliative care and pulmonary rehabilitation in the patient's care if they are not already.…”

“…24 Often, reported symptoms of the disease are not in line with expected results from physiological test results, which may result from poorly adapted beliefs and viewpoints of the disease. 23 One study was able to put moderate COPD suffers into two categories: patients who reported low impact of disease on health status and patients who reported high impact of disease on health status despite both populations having similar physiological impairments. 23 Although, both patient populations improved with pulmonary rehabilitation, the patients that subjectively experienced a higher impact of disease on their overall health status benefited most from a pulmonary rehabilitation program.…”

Organizational aspects of pulmonary rehabilitation in chronic respiratory diseases

“…Indeed, the effects of a conventional, home‐based exercise training programme on the performance of activities of daily life and daily symptoms beyond dyspnoea (i.e. anxiety, depression and fatigue) remain unknown, while this is clearly shown following a comprehensive, hospital‐based pulmonary rehabilitation programme . The home‐based approach does also not allow to truly target the training interventions to the possibilities/limitations of each individual patient.…”