Pulmonary Rehabilitation Following Acute Exacerbation of Chronic Obstructive Pulmonary Disease

<LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions—medications, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.¹ Each article in this new PTJ series will summarize a Cochrane review or other scientific evidence resource on a single topic and will present clinical scenarios based on real patients to illustrate how the results of the review can be used to directly inform clinical decisions. The first article in the series focuses on a patient with chronic obstructive pulmonary disease (COPD) who has had a recent exacerbation that required medical intervention. Should this patient undergo pulmonary rehabilitation?

The American Thoracic Society defines COPD as “a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.”² Prevalence of COPD in adults who are 40 years old or older is approximately 10%.³ Chronic obstructive pulmonary disease is a leading cause of death and disability,⁴ and acute exacerbation is one of the main causes of hospitalization and death.⁵ An exacerbation of COPD is defined as “an event in the natural course of the disease characterized by a change in the patient's baseline dyspnea, cough, and/or sputum, that is beyond normal day-to-day variations, is acute in onset and may warrant a change in medication in a patient with underlying COPD.”^{6(p xiv)}

Pulmonary rehabilitation has been shown to be effective in improving exercise capacity, physical function, and quality of life and in reducing dyspnea and fatigue in people with COPD.⁷ Pulmonary rehabilitation takes many forms but usually includes, at a minimum, exercise training and patient education. Other interventions may include smoking cessation strategies, ventilatory muscle training, airway clearance techniques, medication management, and psychological support. Because the studies included in a 2006 Cochrane systematic review only had participants without recent COPD exacerbations,⁷ Puhan et al⁸ conducted an additional Cochrane review of randomized clinical trials to determine the effect of pulmonary rehabilitation on patients with recent COPD exacerbations requiring inpatient or outpatient care. In the review, the pulmonary rehabilitation intervention had to include at least some form of exercise training beginning within 3 weeks of the COPD exacerbation. The primary outcome of interest was subsequent hospital admissions. Secondary outcomes also were examined, such as mortality, quality of life, and exercise capacity. The results of the review are outlined in the Table.

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