Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction

Cough and phlegm are important predictors of health status in smokers without COPD

STUDY OBJECTIVES

The health-related quality of life of smokers without COPD and that of ex-smokers has not been defined. If abnormal, the role of small airways disease and that of cough and phlegm have never been evaluated. Therefore, the aim of the study was to explore whether the differences in quality of life between smokers and ex-smokers could be explained by cough and phlegm, differences in pulmonary function tests, or exercise capacity.

DESIGN

Observational, prospective.

SETTING

Pulmonary and Critical Care Division, COPD Center at St. Elizabeth's Medical Center.

POPULATION

In 36 smokers, 21 ex-smokers (stopped smoking for > 20 years), 19 never-smokers with normal FVC and FEV(1) values, and 41 patients with COPD (FEV(1) 38 +/- 11% predicted [mean +/- SD]), the St. George's Respiratory Questionnaire (SGRQ), pulmonary function tests, and a 6-min walk distance (6MWD) were performed.

RESULTS

The total SGRQ scores were worse in current smokers (15 +/- 15) than in ex-smokers (6 +/- 4) or never-smokers (4 +/- 3) [p < 0.05]. As expected, the worst score was seen in COPD (50 +/- 15). After correcting for cough and phlegm, the difference in SGRQ scores between smokers and ex-smokers disappeared. In current and ex-smokers, the SGRQ score was associated with the exposure to pack-years smoking history (r = 0.45, p < 0.01, and r = 0.83, p < 0.0001, respectively) but independent of lung function or exercise parameters (6MWD).

CONCLUSIONS

In smokers without COPD, the abnormal SGRQ score is due to the noxious effect of cigarette smoke, resulting in cough and phlegm, independent of its physiologic effects.

Lack of additional effect of adjunct of assisted ventilation to pulmonary rehabilitation in mild COPD patients

Different modalities of assisted ventilation improve breathlessness and exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate the effects of the addition of assisted ventilation during exercise training on the outcome of a structured pulmonary rehabilitation programme (PRP) in COPD patients. Thirty-three male patients with stable COPD (mean (SD) forced expiratory volume in 1 s (FEV1) 44 (16) % pred), without chronic ventilatory failure, undergoing a 6-week multidisciplinary outpatient PRP including exercise training, were randomised to training during either mask proportional assist ventilation (PAV: 18 patients) or spontaneous breathing (SB: 15 patients). Assessment included exercise tolerance, dyspnoea, leg fatigue, and health-related quality of life (HRQL). Five out of 18 patients (28%) in the PAV group dropped out due to lack of compliance with the equipment. Both groups showed significant post-PRP improvements in exercise tolerance (peak work rate difference: 20 (95% Cl 2.4-37.6) and 14 (3.8% CI to 24.2) W in PAV and SB group, respectively), dyspnoea and leg fatigue, but not in HRQL, without any significant difference between groups. It is concluded that with the modality and in the patients assessed in this study assisted ventilation during training sessions included in a multidisciplinary PRP was not well tolerated by all patients and gave no additional physiological benefit in comparison with exercise training alone.

In-hospital short-term training program for patients with chronic airway obstruction

OBJECTIVE

To compare the functional benefits and relative costs of administering an intense short-term inpatient vs a longer outpatient pulmonary rehabilitation program (PRP) for patients with chronic airway obstruction (CAO).

DESIGN

Retrospective case-control study.

SETTING

Pulmonary ward and outpatient clinic of a rehabilitation center.

PATIENTS

Forty-three patients (case subjects) selected on the basis of selection criteria were compared with control subjects matched to them for age, sex, FEV(1), and diagnosis of either COPD or asthma. Case subjects performed 10 to 12 daily sessions (5 sessions a week) of inpatient PRP; control subjects performed 20 to 24 sessions (3 sessions a week) of outpatient PRP.

MEASUREMENTS

At baseline and after the PRP, an incremental exercise test was performed, including evaluation of dyspnea and leg fatigue by Borg scale (D and F, respectively) at each workload step. The cost of PRP was also evaluated.

RESULTS

Both PRPs resulted in similar significant improvements in cycloergometry peak workload (from 68 +/- 18 to 82 +/- 22 and from 75 +/- 17 to 87 +/- 27 W in case subjects and control subjects, respectively), isoload D (from 6.4 +/- 1.6 to 4.2 +/- 1.8 for case subjects and from 8.5 +/- 1.9 to 6.3 +/- 2.4 for control subjects) and isoload F (from 6.6 +/- 1.8 to 4.2 +/- 1.8 for case subjects and from 8.9 +/- 1.9 to 7.0 +/- 1.8 for control subjects). Although the single daily session was less expensive, the outpatient PRP total costs were greater because of the higher number of sessions and the cost of daily transportation.

CONCLUSIONS

In patients with CAO, a shorter inpatient PRP may result in improvement in exercise tolerance similar to a longer outpatient PRP but with lower costs. Whether a shorter outpatient PRP may get physiologic and clinical benefits, while further reducing costs, must be evaluated by future controlled, randomized, prospective studies.

Effect of once weekly pulmonary rehabilitation on exercise tolerance in patients with chronic lung disease

BACKGROUND

Pulmonary rehabilitation (PR) programmes improve exercise tolerance and reduce breathlessness in patients with chronic obstructive pulmonary disease.

AIM

A retrospective audit was undertaken to assess the effectiveness of the pulmonary rehabilitation programme at Belfast City Hospital (BCH).

METHODS

Data from 74 patients who completed a six-week PR programme were reviewed. Exercise tolerance was assessed by the shuttle walk test (SWT), and breathlessness by the BORG scale. Paired t-tests were used for within group analysis.

RESULTS

The mean (SD) exercise tolerance assessed by the SWT improved significantly as did duration of individual exercises. Patients were able to exercise more without increasing their breathlessness or heart rate.

CONCLUSIONS

This paper highlights the effect of PR on exercise tolerance and breathlessness in patients with chronic lung disease. The results compare favourably with published literature where more frequently supervised exercise sessions were provided.

Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme

BACKGROUND

Pulmonary rehabilitation programmes improve the health of patients disabled by lung disease but their cost effectiveness is unproved. We undertook a cost/utility analysis in conjunction with a randomised controlled clinical trial of pulmonary rehabilitation versus standard care.

METHODS

Two hundred patients, mainly with chronic obstructive pulmonary disease, were randomly assigned to either an 18 visit, 6 week rehabilitation programme or standard medical management. The difference between the mean cost of 12 months of care for patients in the rehabilitation and control groups (incremental cost) and the difference between the two groups in quality adjusted life years (QALYs) gained (incremental utility) were determined. The ratio between incremental cost and utility (incremental cost/utility ratio) was calculated.

RESULTS

Each rehabilitation programme for up to 20 patients cost pound 12,120. The mean incremental cost of adding rehabilitation to standard care was pound -152 (95% CI -881 to 577) per patient, p=NS. The incremental utility of adding rehabilitation was 0.030 (95% CI 0.002 to 0.058) QALYs per patient, p=0.03. The point estimate of the incremental cost/utility ratio was therefore negative. The bootstrapping technique was used to model the distribution of cost/utility estimates possible from the data. A high likelihood of generating QALYs at negative or relatively low cost was indicated. The probability of the cost per QALY generated being below pound 0 was 0.64.

CONCLUSIONS

This outpatient pulmonary rehabilitation programme produces cost per QALY ratios within bounds considered to be cost effective and is likely to result in financial benefits to the health service.

Effect of pulmonary rehabilitation on exhaled nitric oxide in patients with chronic obstructive pulmonary disease

BACKGROUND

In patients with mild to moderate chronic obstructive pulmonary disease (COPD) the exercise induced increase in exhaled nitric oxide (eNO) parallels that observed in normal untrained subjects. There is no information on the effects of the level of exercise tolerance on eNO in these patients. The aim of this study was to evaluate the effect of a pulmonary rehabilitation programme including exercise training on eNO in patients with COPD.

METHODS

In 14 consecutive male patients with stable COPD of mean (SD) age 64 (9) years and forced expiratory volume in one second (FEV1) 55 (14)% predicted, fractional eNO concentration (FeNO), peak work rate (Wpeak) and oxygen uptake (VO2peak) were assessed at baseline (T-1), at the end of a 1 month run in period (T0), and after an 8 week outpatient multidisciplinary pulmonary rehabilitation programme (T1) including cycloergometer training.

RESULTS

FeNO did not significantly differ at T-1 and T0 (mean (SE) 4.3 (0.6) and 4.4 (0.6) ppb, respectively), whereas it rose significantly at T1 to 6.4 (0.7) ppb (p<0.02). Compared with T0, both Wpeak and VO2 were significantly (p<0.05) increased at T1 (mean (SE) Wpeak from 89 (5.6) W to 109 (6.9) W); VO2peak from 1.27 (0.1) l/min to 1.48 (0.1) l/min). A significant correlation was found between baseline FEV1 and the change in FeNO following the rehabilitation programme (r=-0.71; p<0.05) and between changes in FeNO and Wpeak from T0 to T1(r=0.60; p<0.05).

CONCLUSIONS

Pulmonary rehabilitation in patients with mild to moderate COPD is associated with an increase in exhaled nitric oxide.

Effect of pulmonary rehabilitation on exhaled nitric oxide in patients with chronic obstructive pulmonary disease

BACKGROUND

In patients with mild to moderate chronic obstructive pulmonary disease (COPD) the exercise induced increase in exhaled nitric oxide (eNO) parallels that observed in normal untrained subjects. There is no information on the effects of the level of exercise tolerance on eNO in these patients. The aim of this study was to evaluate the effect of a pulmonary rehabilitation programme including exercise training on eNO in patients with COPD.

METHODS

In 14 consecutive male patients with stable COPD of mean (SD) age 64 (9) years and forced expiratory volume in one second (FEV1) 55 (14)% predicted, fractional eNO concentration (Feno), peak work rate (Wpeak) and oxygen uptake (V˙o2peak) were assessed at baseline (T–1), at the end of a 1 month run in period (T0), and after an 8 week outpatient multidisciplinary pulmonary rehabilitation programme (T1) including cycloergometer training.

RESULTS

Fenodid not significantly differ at T–1 and T0 (mean (SE) 4.3 (0.6) and 4.4 (0.6) ppb, respectively), whereas it rose significantly at T1 to 6.4 (0.7) ppb (p<0.02). Compared with T0, both Wpeak andV˙o2 were significantly (p<0.05) increased at T1 (mean (SE) Wpeak from 89 (5.6) W to 109 (6.9) W);V˙o2peak from 1.27 (0.1) l/min to 1.48 (0.1) l/min). A significant correlation was found between baseline FEV1 and the change in Feno following the rehabilitation programme (r=–0.71; p<0.05) and between changes in Feno and Wpeak from T0 to T1(r=0.60; p<0.05).

CONCLUSIONS

Pulmonary rehabilitation in patients with mild to moderate COPD is associated with an increase in exhaled nitric oxide.

Is it really useful to repeat outpatient pulmonary rehabilitation programs in patients with chronic airway obstruction? A 2-year controlled study

STUDY OBJECTIVES

To answer the following questions: in patients with chronic airway obstruction (CAO), (1) can pulmonary rehabilitation lead to similar short-term gains at successive, yearly interventions, and (2) is there any real clinical or physiologic long-term benefit by yearly repetition of pulmonary rehabilitation programs (PRPs)?

DESIGN

Randomized, controlled clinical study.

SETTING

Pulmonary rehabilitation center.

PATIENTS

Sixty-one CAO patients studied 1 year after completing an initial 8-week outpatient PRP (PRP1).

INTERVENTION

Patients were randomly classified into two groups. A second PRP (PRP2) was completed by the first group (group 1) but not by the second group (group 2). One year later, a third PRP (PRP3) was performed by both groups.

MEASUREMENTS

Lung function, cycloergometry, walking test, dyspnea, and health-related quality of life (HRQL) were assessed before and after PRP2, and before and after PRP3. The numbers of hospitalizations and exacerbations over the year were also recorded.

RESULTS

Complete data sets were obtained from 36 patients (17 patients in group 1 and 19 patients in group 2). The two groups did not differ in any parameter either before PRP1, after PRP1, or at randomization. There was no significant change over time for airway obstruction in either group. After PRP2, exercise tolerance, dyspnea, and HRQL improved in group 1. Nevertheless, 1 year later, patients of group 1 did not differ from patients of group 2 in any outcome parameter, such that in comparison to before PRP1, only HRQL was still better in both groups 24 months after PRP1. Yearly hospitalizations and exacerbations per patient significantly decreased in both groups in the 2 years following PRP1, when compared to the 2 years prior. Nevertheless, at the 24-month follow-up visit, a further reduction in yearly exacerbations was observed only in group 1 but not in group 2 in comparison to what was observed at the 12-month follow-up visit. The PRP3 resulted in improvement in exercise tolerance in both groups.

CONCLUSION

In patients with CAO, an outpatient PRP can achieve benefits in HRQL and a decreased number of hospitalizations, which persist for a period of 2 years. Successive, yearly interventions lead to similar short-term gains but do not result in additive long-term physiologic benefits. Further reduction in yearly exacerbations seems to be the main benefit of an additional PRP.

Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial

BACKGROUND

Pulmonary rehabilitation seems to be an effective intervention in patients with chronic obstructive pulmonary disease. We undertook a randomised controlled trial to assess the effect of outpatient pulmonary rehabilitation on use of health care and patients' wellbeing over 1 year.

METHODS

200 patients with disabling chronic lung disease (the majority with chronic obstructive pulmonary disease) were randomly assigned a 6-week multidisciplinary rehabilitation programme (18 visits) or standard medical management. Use of health services was assessed from hospital and general-practice records. Analysis was by intention to treat.

FINDINGS

There was no difference between the rehabilitation (n=99) and control (n=101) groups in the number of patients admitted to hospital (40 vs 41) but the number of days these patients spent in hospital differed significantly (mean 10.4 [SD 9.7] vs 21.0 [20.7], p=0.022). The rehabilitation group had more primary-care consultations at the general-practitioner's premises than did the control group (8.6 [6.8] vs 7.3 [8.3], p=0.033) but fewer primary-care home visits (1.5 [2.8] vs 2.8 [4.6], p=0.037). Compared with control, the rehabilitation group also showed greater improvements in walking ability and in general and disease-specific health status.

INTERPRETATION

For patients chronically disabled by obstructive pulmonary disease, an intensive, multidisciplinary, outpatient programme of rehabilitation is an effective intervention, in the short term and the long term, that decreases use of health services.