COMMENTARY

The Best in Pulmonary Medicine

Nicholas J. Gross, MD, PhD

Disclosures

January 19, 2011

In This Article

Outpatient Pulmonary Rehabilitation Following Acute Exacerbations of COPD

Seymour JM, Moore L, Jolley CJ, et al.
Thorax. 2010;65:423-428

Study Summary

Acute exacerbations of COPD are major events that can be life-threatening.[26] Reductions in their frequency and severity are important goals in the long-term management of the disease. Pulmonary rehabilitation (PR) has become a key modality in improving the health status of patients with COPD[27,28]; therefore, its role in promoting recovery after acute exacerbations and in reducing the risk for future exacerbations is being explored. In the present study, patients admitted to hospital with an acute exacerbation of COPD (AECOPD) were randomly assigned to receive either usual care (UC) or PR after discharge. The PR consisted of twice-weekly 2-hour sessions that combined education and exercise for 8 weeks in addition to usual care. The exercise component included strength training and aerobic activities. The 2 treatment groups, 30 patients each, were initially very similar.

The primary outcome was the incidence of a readmission to hospital for AECOPD within the 3 months following the initial AECOPD hospitalization. The UC patients experienced 10 readmissions for AECOPD in the 3-month follow-up; the PR group had 2 such readmissions, giving an odds ratio of 0.15 (95% CI, 0.03-0.72; P < .02). Outcomes that were significantly improved in the PR group compared with the UC group at the end of the 3-month follow-up were quadriceps muscle strength and walking capacity. Quality of life as measured by the St. George's Respiratory Questionnaire was improved by 8 units, a relatively large amount.

Viewpoint

Acute exacerbations of COPD occur on average about once per year in patients with stage 2 or worse disease. These exacerbations can be extremely debilitating or fatal. They can last for weeks, and patients often state that they never return to their previous health status after a severe AECOPD. These events are also the single most expensive component of COPD treatment, amounting to as much as 75% of the total annual cost. In Minnesota, the average cost of a hospitalization for COPD in 2007 was $18,975, excluding professional fees.[29]

Many pharmacologic agents have been shown to reduce the frequency of acute exacerbations, but relatively few have examined the effects of PR on these events. PR has become a recognized, if underutilized component of routine COPD management. It has been shown to reduce exercise dyspnea, increase effort tolerance, and improve patients' well-being.[28,30] It does not improve pulmonary function. Previous studies on the effect of PR on the frequency of AECOPD are few, but they suggest that serious events can be reduced. Nevertheless, PR has not been exploited to the extent it should.

The present results show an enormous reduction in the frequency of AECOPD following an 8-week course of PR -- an 85% reduction, even though the total number of sessions (16) was fewer than would be considered appropriate in the United States (24 sessions). Possible confounders are that the study was, unavoidably, because of its nature, not blinded. In addition, patients in the PR group had more frequent contact with their healthcare providers than did those in the UC group, and this could have had a beneficial effect on the frequency of AECOPDs. Nevertheless, the present results are in keeping with similar studies, all of which show that PR can greatly reduce the frequency of AECOPDs.[31,32] This includes an earlier study by the same group.[33] Because a previous history of AECOPD is the strongest predictor of subsequent events and that the risk for recurrence is greatest in the weeks and months following an AECOPD,[34] it is appropriate that PR should be recommended as soon after an AECOPD as the patient can manage.

The present study adds to evidence that PR can play an important role in the management of COPD and is not nearly widely enough employed. PR is probably the single most effective preventive measure against future AECOPDs, and because these events are so expensive, it would seem to be cost-effective as well as good medical practice to follow every acute exacerbation with a course of PR.

Abstract

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