Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis

Abstract

BackgroundPulmonary rehabilitation (PR), delivered as a supervised multidisciplinary program including exercise training, is one of the cornerstones in the chronic obstructive pulmonary disease (COPD) management. We performed a systematic review and meta-analysis to assess the effect on mortality of a supervised early PR program, initiated during or within 4 weeks after hospitalization with an acute exacerbation of COPD compared with usual post-exacerbation care or no PR program. Secondary outcomes were days in hospital, COPD related readmissions, health-related quality of life (HRQoL), exercise capacity (walking distance), activities of daily living (ADL), fall risk and drop-out rate.MethodsWe identified randomized trials through a systematic search using MEDLINE, EMBASE and Cocharne Library and other sources through October 2017. Risk of bias was assessed regarding randomization, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases using the Cochrane Risk of Bias tool.ResultsWe included 13 randomized trials (801 participants). Our meta-analyses showed a clinically relevant reduction in mortality after early PR (4 trials, 319 patients; RR = 0.58 (95% CI: [0.35 to 0.98])) and at the longest follow-up (3 trials, 127 patients; RR = 0.55 (95% CI: [0.12 to 2.57])). Early PR reduced number of days in hospital by 4.27 days (1 trial, 180 patients; 95% CI: [− 6.85 to − 1.69]) and hospital readmissions (6 trials, 319 patients; RR = 0.47 (95% CI: [0.29 to 0.75])). Moreover, early PR improved HRQoL and walking distance, and did not affect drop-out rate. Several of the trials had unclear risk of bias in regard to the randomization and blinding, for some outcome there was also a lack of power.ConclusionModerate quality of evidence showed reductions in mortality, number of days in hospital and number of readmissions after early PR in patients hospitalized with a COPD exacerbation. Long-term effects on mortality were not statistically significant, but improvements in HRQoL and exercise capacity appeared to be maintained for at least 12 months. Therefore, we recommend early supervised PR to patients with COPD-related exacerbations. PR should be initiated during hospital admission or within 4 weeks after hospital discharge.Electronic supplementary materialThe online version of this article (10.1186/s12890-018-0718-1) contains supplementary material, which is available to authorized users.

Adherence to early pulmonary rehabilitation after COPD exacerbation and risk of hospital readmission: a secondary analysis of the COPD-EXA-REHAB study

“…The results of the present analysis show that increased attendance seems to reduce the risk of hospital admission, suggesting that low adherence is a reason for the overall negative result of the RCT. This is in line with several studies on early pulmonary rehabilitation showing reduced hospital admissions when compared with no rehabilitation, summed up in a 2018 systematic review by Ryrsø et al 22 Seven patients in the COPD-EXA-REHAB study did not want to participate in the rehabilitation sessions, although they had read and signed the informed consent and underwent randomisation while admitted for their exacerbation. We did not register the reasons for their change of mind, and we were not allowed to check their medical charts after their drop-out.…”

Early pulmonary rehabilitation after acute exacerbation of COPD: a randomised controlled trial

“…The updated Cochrane review from 2016, European Respiratory Society (ERS)/American Thoracic Society (ATS) guidelines on the management of COPD exacerbations and a systematic review by RYRSØ et al [23,24] concluded that early pulmonary rehabilitation implemented 3 weeks after discharge, reduced hospital admissions. But in contrast to these reviews, which compared early pulmonary rehabilitation to no rehabilitation, the present study compares early to late onset rehabilitation.…”

Advances in rehabilitation for chronic diseases: improving health outcomes and function

“…However, recent evidence suggests that starting pulmonary rehabilitation within four weeks of an acute exacerbation and possibly even sooner while the patient is still in hospital may be more effective. A meta-analysis of trials that compared early pulmonary rehabilitation with either late or no pulmonary rehabilitation showed a substantial reduction in mortality (relative risk 0.58, 0.35 to 0.98) and hospital readmissions (0.47, 0.29 to 0.75) 91. Starting pulmonary rehabilitation during the inpatient stay may also improve engagement and retention in pulmonary rehabilitation after discharge (table 3).…”