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Pulmonary rehabilitation for COPD

 

Clinical bottom line

Rehabilitation relieves dyspnea and fatigue and enhances patients' sense of control over their condition. These improvements are moderately large and clinically significant.


Reference

Y Lacasse et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease (Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software.

Systematic review

The search included studies from a previous review, and additional RCTs identified from the Cochrane Airways group register of controlled trials in COPD. Abstracts of major meetings were also examined, and authors contacted for additional information.

Only randomized controlled trials comparing rehabilitation to conventional community care were considered for inclusion in the meta-analysis, and comparisons with education, for instance, were excluded. More than 90% of patients had COPD defined according to the following criteria: (1) a clinical diagnosis of COPD, and (2) one of the following: (a) best recorded FEV1/FVC ratio of individual patients <0.7; (b) best recorded FEV1 of individual patients <70% of predicted value.

The intervention was any in-patient, out-patient, or home-based rehabilitation program of at least four weeks duration that included exercise therapy with or without any form of education and/or psychological support delivered to patients with exercise limitation attributable to COPD.

Outcomes were health-related quality of life and/or maximal or functional exercise capacity. Maximal exercise capacity was defined as the peak capacity measured in the exercise laboratory using an incremental exercise test and functional exercise capacity according to the results of timed walk tests.

Results

Twenty-three RCTs were included in the meta-analysis, and all but one were parallel group trials. Trials were often small, with generally well under 200 patients in any comparison.

In three important domains of QoL (Chronic Respiratory Questionnaire scores for Dyspnoea, Fatigue and Mastery), the effect was larger than the minimal clinically important difference of 0.5 units using this instrument.

For functional and maximal exercise capacity the effect was small and a little below the threshold of clinical significance for the 6- minute walking distance.

Comment

This is an exceptionally fine review. Not just methodologically, but particularly in its claims.

It is conservative in only concluding clear benefit when the confidence interval representing the smallest treatment effect was still greater than the minimum clinically important difference. There is an important example here that few reviews follow.

Because the care of patients with COPD is largely symptomatic, the review chose quality of life as the primary outcome in respiratory rehabilitation. That seems fair and sensible.