BMJ. November 2004;20:329
Objective
To evaluate the effects of an early community-based pulmonary rehabilitation programme after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease (COPD).
Design
A single-centre, randomized controlled trial.
Setting, participants, intervention, and main outcome measures
An inner city, secondary and tertiary care hospital in London was the setting for the study. Participants were 42 patients admitted with an acute exacerbation of COPD. Intervention was an 8-week pulmonary rehabilitation programme for outpatients, started within 10 days of hospital discharge, or usual care. Main outcome measures were incremental shuttle walk distance, disease specific health status (St George's respiratory questionnaire [SGRQ]; chronic respiratory questionnaire, [CRQ]); and generic health status (medical outcomes short form-36 questionnaire [SF-36]) at 3 months after hospital discharge.
Results
Early pulmonary rehabilitation, compared with usual care, led to significant improvements in median incremental shuttle walk distance (60 m, 95% confidence interval 26.6 m - 93.4 m, P = .0002), mean SGRQ total score (-12.7, -5.0 to -20.3, P = -.002), all 4 domains of the CRQ (dyspnoea 5.5, 2.0-9.0, P = .003; fatigue 5.3, 1.9-8.8, P = -.004; emotion 8.7, 2.4-15.0, P = .008; and mastery 7.5, 4.2-10.7, P < .001) and the mental component score of the SF-36 (20.1, 3.3-36.8, P = .02). Improvements in the physical component score of the SF-36 did not reach significance (10.6, -0.3-21.6, P = .057).
Conclusion
Early pulmonary rehabilitation after admission to hospital for acute exacerbations of COPD is safe and leads to statistically and clinically significant improvements in exercise capacity and health status at 3 months.
Comment
Patients with COPD are typically enrolled in PR programs while in their chronic, medically stable state, if they remain symptomatic once medical therapy has been optimized. However, COPD exacerbations often lead to significant decline in the patient's functional status, and prolonged recovery periods may be needed to regain pre-exacerbation exercise tolerance and level of symptoms. This study demonstrates that early intervention with PR (within 10 days of hospital discharge) lead to significantly greater improvements in walking endurance and self-reported health status (measured by the SGRQ and CRQ) compared with usual postdischarge medical care. Strikingly, those persons who underwent early PR also had fewer hospital readmissions and hospital days (aldiough not statistically significant in this small study), and 70% fewer emergency department visits in the 3 months following hospital discharge. Larger studies are needed to confirm these findings, However, given the results of this study, early enrollment in PR following hospitalization for COPD exacerbations should be considered strongly. Early PR may lead not only to faster recovery of functional capacity and quality of life after exacerbations but may also attenuate the frequency and/or severity of exacerbations, and as such could affect healthcare costs and respiratory as well as global health of patients over time.