A pragmatic randomised controlled trial of tailored pulmonary rehabilitation in participants with difficult-to-control asthma and elevated body mass index

Helen Clare Ricketts, Varun Sharma, Femke Steffensen, Anna Goodfellow, Elaine Mackay, Gordon MacDonald, Duncan S Buchan, Rekha Chaudhuri, Douglas C Cowan, Helen Clare Ricketts, Varun Sharma, Femke Steffensen, Anna Goodfellow, Elaine Mackay, Gordon MacDonald, Duncan S Buchan, Rekha Chaudhuri, Douglas C Cowan

Abstract

Background: Difficult-to-control asthma associated with elevated body mass index (BMI) is challenging with limited treatment options. The effects of pulmonary rehabilitation (PR) in this population are uncertain.

Methods: This is a randomised controlled trial of an eight-week asthma-tailored PR programme versus usual care (UC) in participants with difficult-to-control asthma and BMI ≥ 25 kg/m2. PR comprised two hours of education and supervised exercise per week, with encouragement for two individual exercise sessions. Primary outcome was difference in change in Asthma Quality of Life Questionnaire (AQLQ) in PR versus UC groups between visits. Secondary outcomes included difference in change in Asthma Control Questionnaire-6 (ACQ6), and a responder analysis comparing proportion reaching minimum clinically important difference for AQLQ and ACQ6.

Results: 95 participants were randomised 1:1 to PR or UC. Median age was 54 years, 60% were female and median BMI was 33.8 kg/m2. Mean (SD) AQLQ was 3.9 (+/-1.2) and median (IQR) ACQ6 2.8(1.8-3.6). 77 participants attended a second visit and had results analysed. Median (IQR) change in AQLQ was not significantly different: 0.3 (- 0.2 to 0.6) in PR and - 0.1 (- 0.5 to 0.4) in UC, p = 0.139. Mean change in ACQ6 was significantly different: - 0.4 (95% CI - 0.6 to - 0.2) in PR and 0 (- 0.3 to + 0.3) in UC, p = 0.015, but below minimum clinically important difference. In ACQ6 responder analysis, minimum clinically important difference was reached by 18 PR participants (54.5%) versus 10 UC (22.7%), p = 0.009. Dropout rate was 31% between visits in PR group, and time to completion was significantly prolonged in PR group at 94 (70-107) days versus 63 (56-73) in UC, p < 0.001.

Conclusions: PR improved asthma control and reduced perceived breathlessness in participants with difficult-to-control asthma and elevated BMI. However, this format appears to be suboptimal for this population with high drop-out rates and prolonged time to completion. Trial registration Clinicaltrials.gov. ID NCT03630432. Retrospectively registered, submitted May 26th 2017, posted August 14th 2018.

Keywords: Asthma; Difficult-to-control asthma; Obesity; Pulmonary rehabilitation.

Conflict of interest statement

HCR, VS, FS, AG, EM, GM, DSB and DCC have no conflicts of interest. RC has received grants from Astra-Zeneca for being an investigator on an MRC study, payments from GSK, AstraZeneca, Teva, Chiesi for lecturing, support from Teva, Chiesi, Napp Sanofi, Boehringer for attending conferences and from GSK, AstraZeneca, Teva, Chiesi, Novartis for advisory board meetings.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
A flowchart demonstrating recruitment, randomisation and follow-up
Fig. 2
Fig. 2
Graphical representation of key results. AQLQ asthma quality of life questionnaire, PR pulmonary rehabilitation group, UC usual care group, V1 visit 1, V2 visit 2, CI confidence intervals, ACQ6 6 point version asthma control questionnaire, MRC Medical Research Council Dyspnoea Scale score, 6MWD six minute walk distance
Fig. 3
Fig. 3
Bar chart showing those who met the minimum clinically important difference for each questionnaire. ACQ6 6 point version asthma control questionnaire, AQLQ asthma quality of lie questionnaire, PR pulmonary rehabilitation group, UC usual care group

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