Design of pulmonary rehabilitation programmes during acute exacerbations of COPD: a systematic review and network meta-analysis

Ana Machado, Pedro Matos Silva, Vera Afreixo, Cátia Caneiras, Chris Burtin, Alda Marques, Ana Machado, Pedro Matos Silva, Vera Afreixo, Cátia Caneiras, Chris Burtin, Alda Marques

Abstract

This systematic review aimed to systematise the different designs used to deliver pulmonary rehabilitation during acute exacerbations of COPD (AECOPD) and explore which ones are the most effective. PubMed, Scopus, Web of Science, EBSCO and Cochrane were searched. Randomised controlled trials comparing pulmonary rehabilitation or at least one of its components with usual care or comparing different components of pulmonary rehabilitation were included. Network meta-analysis was conducted in MetaXL 5.3 using a generalised pairwise modelling framework. Pooled effects compared each treatment to usual care. 42 studies were included. Most studies were conducted in an inpatient setting (57%) and started the intervention 24-48 h after hospital admission (24%). Exercise training (71%), education and psychosocial support (57%) and breathing techniques (55%) were the most used components. Studies combining exercise with breathing techniques presented the larger effects on exercise capacity (weighted mean difference (WMD) -41.06, 95% CI -131.70-49.58) and health-related quality of life (WMD 16.07, 95% CI 10.29-21.84), and breathing techniques presented the larger effects on dyspnoea (WMD 1.90, 95% CI 0.53-3.27) and length of hospitalisation (effect size =0.15, 95% CI -0.28-0.57). A few minor adverse events were found.Pulmonary rehabilitation is a safe intervention during AECOPD. Exercise, breathing techniques, and education and psychosocial support seem to be the core components for implementing pulmonary rehabilitation during AECOPD. Studies may now focus on comparisons of optimal timings to start the intervention, total duration of the intervention, duration and frequency of sessions, and intensity for exercise prescription.

Conflict of interest statement

Conflict of interest: A. Machado has nothing to disclose. Conflict of interest: P. Matos Silva has nothing to disclose. Conflict of interest: V. Afreixo has nothing to disclose. Conflict of interest: C. Caneiras has nothing to disclose. Conflict of interest: C. Burtin has nothing to disclose. Conflict of interest: A. Marques has nothing to disclose.

Copyright ©ERS 2020.

Figures

FIGURE 1
FIGURE 1
PRISMA flowchart of the included studies. AECOPD: acute exacerbation of COPD; PR: pulmonary rehabilitation.
FIGURE 2
FIGURE 2
Effects of the different interventions on exercise capacity measured with 6-min walk test. a) Network plot of treatments with nodes representing the number of interventions being compared and edges representing the available direct comparisons (comparisons evaluated in at least one study) between pairs of interventions. b) Forest plot of network meta-analysis results (all interventions versus standard of care). c) Forest plot of comparison of short-term programmes versus long-term programmes using a combination of exercise with breathing techniques. WMD: weighted mean difference.
FIGURE 3
FIGURE 3
Effects of the different interventions on dyspnoea measured with the modified Borg scale. a) Network plot of treatments with nodes representing the number of interventions being compared and edges representing the available direct comparisons (comparisons evaluated in at least one study) between pairs of interventions. b) Forest plot of network meta-analysis results (all interventions versus standard of care). WMD: weighted mean difference.
FIGURE 4
FIGURE 4
Effects of the different interventions on health-related quality of life measured with the St George's respiratory questionnaire. a) Network plot of treatments with nodes representing the number of interventions being compared and edges representing the available direct comparisons (comparisons evaluated in at least one study) between pairs of interventions. b) Forest plot of network meta-analysis results (all interventions versus standard of care).
FIGURE 5
FIGURE 5
Effects of the different interventions on length of hospitalisation measured in number of days. a) Network plot of treatments with nodes representing the number of interventions being compared and edges representing the available direct comparisons (comparisons evaluated in at least one study) between pairs of interventions. b) Forest plot of network meta-analysis results (all interventions versus standard of care).

References

    1. The Global Initiative for Chronic Obstructive Lung Disease . Global Strategy for the Diagnosis, Management and Prevention of COPD. 2019.
    1. Wedzicha JA, Miravitlles M, Hurst JR, et al. . Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J 2017; 49: 1600791. doi:10.1183/13993003.00791-2016
    1. Rochester CL, Vogiatzis I, Holland AE, et al. . An official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med 2015; 192: 1373–1386. doi:10.1164/rccm.201510-1966ST
    1. Spruit MA, Singh SJ, Garvey C, et al. . An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188: e13–e64. doi:10.1164/rccm.201309-1634ST
    1. Puhan MA, Gimeno-Santos E, Cates CJ, et al. . Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Library 2016; 12: CD005305.
    1. Spruit MA, Singh SJ, Rochester CL, et al. . Pulmonary rehabilitation for patients with COPD during and after an exacerbation-related hospitalisation: back to the future? Eur Respir J 2018; 51: 1701312. doi:10.1183/13993003.01312-2017
    1. Seemungal TA, Donaldson GC, Bhowmik A, et al. . Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 161: 1608–1613. doi:10.1164/ajrccm.161.5.9908022
    1. Cydulka RK, McFadden Jr E, Emerman CL, et al. . Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 156: 1807–1812. doi:10.1164/ajrccm.156.6.9611008
    1. Moher D, Liberati A, Tetzlaff J, et al. . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097. doi:10.1371/journal.pmed.1000097
    1. Verhagen AP, de Vet HC, de Bie RA, et al. . The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol 1998; 51: 1235–1241. doi:10.1016/S0895-4356(98)00131-0
    1. Verhagen AP, de Bie RA, Lenssen AF, et al. . Impact of quality items on study outcome: treatments in acute lateral ankle sprains. Int J Technol Assess Health Care 2000; 16: 1136–1146. doi:10.1017/S0266462300103174
    1. Kingma JJ, de Knikker R, Wittink H, et al. . Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med 2007; 41: e3. doi:10.1136/bjsm.2006.030916
    1. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159–174. doi:10.2307/2529310
    1. Morris SB. Estimating effect sizes from pretest-posttest-control group designs. Organ Res Methods 2008; 11: 364–386. doi:10.1177/1094428106291059
    1. Cohen J. Statistical power analysis for the behavioral sciences. 2nd Edn. Hillsdale, Erlbaum Associates, 1988.
    1. Doi SA, Barendregt JJ. A generalized pairwise modelling framework for network meta-analysis. Int J Evid Based Healthc 2018; 16: 187–194. doi:10.1097/XEB.0000000000000140
    1. Smith LJW, Beretvas SN. Estimation of the standardized mean difference for repeated measures designs. J Mod Appl Stat Methods 2009; 8: 27.
    1. Benzo R, Vickers K, Novotny PJ, et al. . Health coaching and chronic obstructive pulmonary disease rehospitalization. A randomized study. Am J Respir Crit Care Med 2016; 194: 672–680. doi:10.1164/rccm.201512-2503OC
    1. Casas A, Troosters T, Garcia-Aymerich J, et al. . Integrated care prevents hospitalisations for exacerbations in COPD patients. Eur Respir J 2006; 28: 123–130. doi:10.1183/09031936.06.00063205
    1. Cross JL, Elender F, Barton G, et al. . Evaluation of the effectiveness of manual chest physiotherapy techniques on quality of life at six months post exacerbation of COPD (MATREX): a randomised controlled equivalence trial. BMC Pulm Med 2012; 12: 33. doi:10.1186/1471-2466-12-33
    1. Johnson-Warrington V, Rees K, Gelder C, et al. . Can a supported self-management program for COPD upon hospital discharge reduce readmissions? A randomized controlled trial. Int J Chron Obstruct Pulmon Dis 2016; 11: 1161–1169.
    1. Osadnik CR, McDonald CF, Miller BR, et al. . The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial. Thorax 2014; 69: 137–143. doi:10.1136/thoraxjnl-2013-203425
    1. Puhan MA, Spaar A, Frey M, et al. . Early versus late pulmonary rehabilitation in chronic obstructive pulmonary disease patients with acute exacerbations: a randomized trial. Respiration 2012; 83: 499–506. doi:10.1159/000329884
    1. Ali MS, Talwar D, Jain S. The effect of a short-term pulmonary rehabilitation on exercise capacity and quality of life in patients hospitalised with acute exacerbation of chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci 2014; 56: 13–19.
    1. Babu AS, Noone MS, Haneef M, et al. . The effects of “on-call/out of hours” physical therapy in acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Clin Rehabil 2010; 24: 802–809. doi:10.1177/0269215510367558
    1. Borges RC, Carvalho CR. Impact of resistance training in chronic obstructive pulmonary disease patients during periods of acute exacerbation. Arch Phys Med Rehabil 2014; 95: 1638–1645. doi:10.1016/j.apmr.2014.05.007
    1. Chaplin EJL, Houchen L, Greening NJ, et al. . Neuromuscular stimulation of quadriceps in patients hospitalised during an exacerbation of COPD: a comparison of low (35 Hz) and high (50 Hz) frequencies. Physiother Res Int 2013; 18: 148–156. doi:10.1002/pri.1541
    1. Deepak T, Mohapatra P, Janmeja A, et al. . Outcome of pulmonary rehabilitation in patients after acute exacerbation of chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci 2014; 56: 7–12.
    1. Eaton T, Young P, Fergusson W, et al. . Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study. Respirology 2009; 14: 230–238. doi:10.1111/j.1440-1843.2008.01418.x
    1. Greulich T, Nell C, Koepke J, et al. . Benefits of whole body vibration training in patients hospitalised for COPD exacerbations-a randomized clinical trial. BMC Pulm Med 2014; 14: 60. doi:10.1186/1471-2466-14-60
    1. He M, Yu S, Wang L, et al. . Efficiency and safety of pulmonary rehabilitation in acute exacerbation of chronic obstructive pulmonary disease. Med Sci Monit 2015; 21: 806–812. doi:10.12659/MSM.892769
    1. Kirsten D, Taube C, Lehnigk B, et al. . Exercise training improves recovery in patients with COPD after an acute exacerbation. Respir Med 1998; 92: 1191–1198. doi:10.1016/S0954-6111(98)90420-6
    1. Ko FW, Dai DL, Ngai J, et al. . Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD. Respirology 2011; 16: 617–624. doi:10.1111/j.1440-1843.2010.01921.x
    1. Liao L-Y, Chen K-M, Chung W-S, et al. . Efficacy of a respiratory rehabilitation exercise training package in hospitalized elderly patients with acute exacerbation of COPD: a randomized control trial. Int J Chron Obstruct Pulmon Dis 2015; 10: 1703–1709.
    1. Man WD, Polkey MI, Donaldson N, et al. . Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ Open 2004; 329: 1209.
    1. Murphy N, Bell C, Costello RW. Extending a home from hospital care programme for COPD exacerbations to include pulmonary rehabilitation. Respir Med 2005; 99: 1297–1302. doi:10.1016/j.rmed.2005.02.033
    1. Nava S. Rehabilitation of patients admitted to a respiratory intensive care unit. Arch Phys Med Rehabil 1998; 79: 849–854. doi:10.1016/S0003-9993(98)90369-0
    1. Seymour JM, Moore L, Jolley CJ, et al. . Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax 2010; 65: 423–428. doi:10.1136/thx.2009.124164
    1. Song HY, Yong SJ, Hur HK. Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea. Rehabil Nurs 2014; 39: 147–156. doi:10.1002/rnj.92
    1. Tang CY, Blackstock FC, Clarence M, et al. . Early rehabilitation exercise program for inpatients during an acute exacerbation of chronic obstructive pulmonary disease: a randomized controlled trial. J Cardiopulm Rehabil Prev 2012; 32: 163–169. doi:10.1097/HCR.0b013e318252f0b2
    1. Torres-Sánchez I, Valenza MC, Cabrera-Martos I, et al. . Effects of an exercise intervention in frail older patients with chronic obstructive pulmonary disease hospitalized due to an exacerbation: a randomized controlled trial. COPD 2017; 14: 37–42. doi:10.1080/15412555.2016.1209476
    1. Torres-Sánchez I, Valenza MC, Sáez-Roca G, et al. . Results of a multimodal program during hospitalization in obese COPD exacerbated patients. COPD 2016; 13: 19–25. doi:10.3109/15412555.2015.1043428
    1. Troosters T, Probst VS, Crul T, et al. . Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 181: 1072–1077. doi:10.1164/rccm.200908-1203OC
    1. Kjærgaard JL, Juhl CB, Lange P, et al. . Early pulmonary rehabilitation after acute exacerbation of COPD: a randomised controlled trial. ERJ Open Res 2020; 6: 00173-2019. doi:10.1183/23120541.00173-2019
    1. Lopez-Lopez L, Torres-Sanchez I, Rodriguez-Torres J, et al. . Randomized feasibility study of twice a day functional electrostimulation in patients with severe chronic obstructive pulmonary disease hospitalized for acute exacerbation. Physiother Theory Pract 2019: in press [10.1080/09593985.2019.1694611].
    1. Lopez-Lopez L, Valenza MC, Rodriguez-Torres J, et al. . Results on health-related quality of life and functionality of a patient-centered self-management program in hospitalized COPD: a randomized control trial. Disabil Rehabil 2019: in press [10.1080/09638288.2019.1609099]. doi:10.1080/09638288.2019.1609099
    1. Garcia-Aymerich J, Hernandez C, Alonso A, et al. . Effects of an integrated care intervention on risk factors of COPD readmission. Respir Med 2007; 101: 1462–1469. doi:10.1016/j.rmed.2007.01.012
    1. Kodric M, Garuti G, Colomban M, et al. . The effectiveness of a bronchial drainage technique (ELTGOL) in COPD exacerbations. Respirology 2009; 14: 424–428. doi:10.1111/j.1440-1843.2008.01466.x
    1. Eastwood B, Jepsen N, Coulter K, et al. . Challenges of undertaking a clinical trial using bubble-PEP in an acute exacerbation of chronic obstructive pulmonary disease: a feasibility study. NZ J Physiother 2016; 44: 8–16.
    1. Basri R, Tahir M, Naseem M. Short-term effects of chest physiotherapy in acute exacerbation of chronic obstructive pulmonary disease. J Med Sci 2017; 25: 323–327.
    1. Torres-Sánchez I, Valenza MC, Cebriá i Iranzo M, et al. . Effects of different physical therapy programs on perceived health status in acute exacerbation of chronic obstructive pulmonary disease patients: a randomized clinical trial. Disabil Rehabil 2018; 40: 2025–2031. doi:10.1080/09638288.2017.1323236
    1. Yohannes AM, Connolly MJ. Early mobilization with walking aids following hospital admission with acute exacerbation of chronic obstructive pulmonary disease. Clin Rehabil 2003; 17: 465–471. doi:10.1191/0269215503cr637oa
    1. Lopez LL, Santiago MG, Galindo MD, et al. . Efficacy of combined electrostimulation in patients with acute exacerbation of COPD: randomised clinical trial. Med Clin 2018; 151: 323–328. doi:10.1016/j.medcli.2018.03.012
    1. Bellone A, Spagnolatti L, Massobrio M, et al. . Short-term effects of expiration under positive pressure in patients with acute exacerbation of chronic obstructive pulmonary disease and mild acidosis requiring non-invasive positive pressure ventilation. Intensive Care Med 2002; 28: 581–585. doi:10.1007/s00134-002-1210-0
    1. Valenza MC, Valenza-Peña G, Torres-Sánchez I, et al. . Effectiveness of controlled breathing techniques on anxiety and depression in hospitalized patients with COPD: a randomized clinical trial. Respir Care 2014; 59: 209–215. doi:10.4187/respcare.02565
    1. Hernandez C, Casas A, Escarrabill J, et al. . Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. Eur Respir J 2003; 21: 58–67. doi:10.1183/09031936.03.00015603
    1. Lainscak M, Kadivec S, Kosnik M, et al. . Discharge coordinator intervention prevents hospitalizations in patients with COPD: a randomized controlled trial. J Am Med Dir Assoc 2013; 14: 450. doi:10.1016/j.jamda.2013.03.003
    1. Aboumatar H, Naqibuddin M, Chung S, et al. . Effect of a hospital-initiated program combining transitional care and long-term self-management support on outcomes of patients hospitalized with chronic obstructive pulmonary disease: a randomized clinical trial. JAMA 2019; 322: 1371–1380. doi:10.1001/jama.2018.17933
    1. Janaudis-Ferreira T, Carr SJ, Harrison SL, et al. . Can patients with COPD assimilate disease-specific information during an acute exacerbation? Results of a pilot randomized controlled trial. Chest 2018; 154: 588–596. doi:10.1016/j.chest.2018.05.028
    1. McCarthy B, Casey D, Devane D, et al. . Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Library 2015; 2: CD003793.
    1. Anzueto A. Impact of exacerbations on COPD. Eur Respir Rev 2010; 19: 113–118. doi:10.1183/09059180.00002610
    1. Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet 2007; 370: 786–796. doi:10.1016/S0140-6736(07)61382-8
    1. Holland AE, Spruit MA, Troosters T, et al. . An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J 2014; 44: 1428–1446.
    1. Schünemann HJ, Griffith L, Jaeschke R, et al. . Evaluation of the minimal important difference for the feeling thermometer and the St. George's Respiratory Questionnaire in patients with chronic airflow obstruction. J Clin Epidemiol 2003; 56: 1170–1176. doi:10.1016/S0895-4356(03)00115-X
    1. Oliveira A, Machado A, Marques A. Minimal important and detectable differences of respiratory measures in outpatients with AECOPD. COPD 2018; 15: 479–488. doi:10.1080/15412555.2018.1537366
    1. Puhan MA, Gimeno-Santos E, Scharplatz M, et al. . Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2011; 10: CD005305.
    1. Oliveira A, Marques A. Exploratory mixed methods study of respiratory physiotherapy for patients with lower respiratory tract infections. Physiotherapy 2016; 102: 111–118. doi:10.1016/j.physio.2015.03.3723
    1. American College of Sports Medicine . ACSM's guidelines for exercise testing and prescription. Philadelphia, Lippincott Williams & Wilkins, 2013.
    1. Bagg MK, Salanti G, McAuley JH. Comparing interventions with network meta-analysis. J Physiother 2018; 64: 128–132. doi:10.1016/j.jphys.2018.02.014

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir