A Feasibility Trial of Pulmonary Rehabilitation for Patients With COPD in a Low Resource Setting

Jaffna, Sri Lanka

Mathanki Sooriyakanthan; Mark W. Orme; Kanagasabai Sivapalan; Gowry Selvaratnam; Sally J. Singh; Savithri Wimalasekera


BMC Pulm Med. 2022;22(302) 

In This Article

Abstract and Introduction


Background: Pulmonary rehabilitation is recommended for most patients with chronic obstructive pulmonary disease (COPD). Accordingly, the aim of this study was to explore the feasibility of devising a pulmonary rehabilitation program for patients with COPD in a low resource setting (Jaffna, Sri Lanka) and to observe its effects.

Methods: Non-randomized controlled feasibility trial of ambulatory patients with COPD attending the pulmonary outpatient clinic of the Jaffna Teaching Hospital, Northern Province, Sri Lanka. Age-matched patients were allocated alternatively to an intervention group or to a control group. Twice weekly, for six weeks, patients in the intervention group attended pulmonary rehabilitation sessions consisting of supervised stretching, aerobic and strengthening exercises, and patient-education. Before and at the conclusion of the study, all patients performed incremental shuttle walking test (ISWT), 6-min walk test (6MWT) and completed the Medical Research Council (MRC) dyspnea scale, COPD assessment test (CAT), chronic COPD questionnaire (CCQ), and hospital anxiety depression scale (HADS).

Results: 204 patients with COPD (94% males) were identified at screening; 136 (66.7%) were eligible for pulmonary rehabilitation and 96 patients (47%) consented to participate. Of these, 54 patients (53 males) eventually participated in the study (42 patients were discouraged to participate by family members or friends); 40 patients (20 in the rehabilitation group and 20 patients in the control group) completed the study. Baseline characteristics of the intervention group and the control group were similar. 95% of patients in the intervention group adhered to regular home training exercises (self-reported diary). At post assessment, only the intervention group experienced clinically-meaningful improvements in symptoms and exercise capacity.

Conclusion: A simple and clinically beneficial pulmonary rehabilitation program for patients with COPD can be effectively implemented in a low resource setting. However, there is a need for educating patients and the local community on the benefits of pulmonary rehabilitation to enhance uptake.


Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality worldwide, contributing to 6% of global deaths.[1] It is estimated that the burden of COPD will continue to rise due to increasing exposure to risk factors, with most of the burden in low- and middle-income countries (LMIC). The prevalence of COPD in Sri Lanka is estimated at 10.5%.[2] Unfortunately, due to lack of access to spirometry testing and the absence of community screening programs COPD is largely underdiagnosed in the country.

Dyspnea, cough and sputum production, common symptoms of COPD, reduce health-related quality of life (HRQoL) and ability to engage in employment.[1,3] COPD is also associated with co-morbidities that can lead to extra-pulmonary manifestations of the disease including weight loss, and skeletal muscle dysfunction.[4] To avoid unpleasant symptoms, patients with COPD often refrain from physical activity, which ultimately leads to further muscle deconditioning and worse dyspnea. This triggers a vicious cycle unless physical activities are maintained []. The individual and societal impact of COPD demands interventions to improve HRQoL such as pulmonary rehabilitation.[1,6,7]

In high-income countries is has been reported that pulmonary rehabilitation has both clinical and health-economic benefits.[6] In LMIC, such as Sri Lanka, resources for- and awareness of pulmonary rehabilitation are limited.[8] Not surprisingly, despite growing interest,[9,10] there have been no studies of pulmonary rehabilitation in Sri Lanka, a country in which patients with COPD are managed, at most, with pharmacotherapy alone.

The primary aim of our study was thus to test the feasibility of conducting pulmonary rehabilitation in a low resource unit in a Sri Lanka teaching hospital. The secondary aim of the study was to describe the effect of pulmonary rehabilitation on respiratory function, symptoms scores, exercise capacity, and psychological wellbeing for patients with COPD.