Pulmonary rehabilitation for patients with COPD during and after an exacerbation-related hospitalisation: back to the future?
- Kevin C. Wilson1⇑,
- Jerry A. Krishnan2,
- Pawel Sliwinski3,
- Gerard J. Criner4,
- Marc Miravitlles5,
- John R. Hurst6,
- Peter M.A. Calverley7,
- Richard K. Albert8,
- David Rigau9,
- Thomy Tonia10,
- Jørgen Vestbo11,
- Alberto Papi12,
- Klaus F. Rabe13,
- Antonio Anzueto14 and
- Jadwiga A. Wedzicha15
- 1Dept of Medicine, Boston University School of Medicine, Boston, MA, USA
- 2University of Illinois Hospital and Health Sciences System, Chicago, IL, USA; co-chair, representing the American Thoracic Society
- 32nd Dept of Respiratory Medicine, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
- 4Dept of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
- 5Pneumology Dept, Hospital Universitari Vall d'Hebron, CIBER de Enferlmedades Respiratorias (CIBERES), Barcelona, Spain
- 6UCL Respiratory, University College London, London, UK
- 7Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- 8Dept of Medicine, University of Colorado, Denver, Aurora, CO, USA
- 9Iberoamerican Cochrane Center, Barcelona, Spain
- 10Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- 11Division of Infection, Immunology and Respiratory Medicine, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
- 12Respiratory Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
- 13Dept of Internal Medicine, Christian-Albrechts University, Kiel and LungenClinic Grosshansdorf, Airway Research Centre North, German Centre for Lung Research, Grosshansdorf, Germany
- 14University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX, USA
- 15Airways Disease Section, National Heart and Lung Institute, Imperial College London, UK; co-chair, representing the European Respiratory Society
- Kevin C. Wilson, Dept of Medicine, Boston University School of Medicine, 10 Whitney Ave, Westwood, Boston, 02090 MA, USA. E-mail: kwilson{at}thoracic.org
Abstract
Guideline recommendation against the initiation of pulmonary rehabilitation during hospitalisation was justified http://ow.ly/ve2L30hiqop
From the authors:
We thank M.A. Spruit and colleagues for their questions about our decisions regarding initiating pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) exacerbations. Their main objection is the recommendation against initiating pulmonary rehabilitation during the patient's hospitalisation. We agree that the recommendation was based primarily on the finding of increased mortality (6-min walking test had statistically significant improvement and hospital readmission had non-statistically significant improvement) and that the trial led by Greening et al. [1] contributed 389 out of 415 patients. We further agree that there is uncertainty about whether or not inpatient-initiated pulmonary rehabilitation is associated with increased mortality, particularly since the mortality difference emerged more than 5 months after hospital discharge in the study by Greening et al. [1] and that the per protocol analysis in this study found no difference in mortality among those who actually received pulmonary rehabilitation versus the control group.
However, we believe the guideline panel's judgment is justified. Faced with the decision about whether to recommend for or against an intervention for which the only major clinical trial found increased mortality and no reduction in the re-exacerbation rate, and only a few subsequent analyses raised doubt about the finding, we elected to minimise the potential for harm by recommending against the intervention until further evidence becomes available to revisit the decision. When combined with a recommendation in favour of pulmonary rehabilitation within 3 weeks of discharge, the net effect of the recommendations is a mere delay of days to weeks in the interest patient safety.
M.A. Spruit and colleagues cite the results of a 2016 Cochrane systematic review and meta-analysis to support their concerns [2]. However, they fail to acknowledge that the Cochrane report also found substantial evidence of heterogeneity of treatment effects on hospital readmissions and mortality, and that the “reasons for diverse effects … are not fully clear. Further studies should explore whether the extent of the rehabilitation program and the organization of such programs within specific healthcare systems (e.g. within the rehabilitation setting versus embedded in the continuum of care from hospital to home to outpatient care) determines the effects of rehabilitation after COPD exacerbations.”
We agree with these conclusions in the Cochrane report and, in the European Respiratory Society/American Thoracic Society guideline [3], we advocated for further research: patients, clinicians and other decision-makers need adequately powered, well-designed randomised clinical trials to more clearly delineate the role of pulmonary rehabilitation in the peri-exacerbation period.
Disclosures
Supplementary Material
P.M.A. Calverley ERJ-02577-2017_Calverley
G.J. Criner ERJ-02577-2017_Criner
J.R. Hurst ERJ-02577-2017_Hurst
J.A. Krishnan ERJ-02577-2017_Krishnan
A. Papi ERJ-02577-2017_Papi
K.F. Rabe ERJ-02577-2017_Rabe
J. Vestbo ERJ-02577-2017_Vestbo
J.A. Wedzicha ERJ-02577-2017_Wedzicha
K.C. Wilson ERJ-02577-2017_Wilson
Footnotes
Conflict of interest: D. Rigau and T. Tonia act as methodologists for the European Respiratory Society. All other disclosures can be found alongside this article at erj.ersjournals.com
- Received December 11, 2017.
- Accepted December 12, 2017.
- Copyright ©ERS 2018