Efficacy of Repeating Pulmonary Rehabilitation in People with COPD: A Systematic Review

Abstract

Background

Pulmonary rehabilitation is an effective intervention for people with chronic obstructive pulmonary disease (COPD). People with COPD undertake repeat programs, but synthesis of evidence regarding such practice has not been undertaken. The aim of this systematic review was to establish the effects of repeating pulmonary rehabilitation subsequent to an initial program in people with COPD.

Methods

Studies where participants with COPD undertook >1 pulmonary rehabilitation program were included, incorporating RCT (randomized controlled trial) and non-randomized studies. Electronic database searches were undertaken. Two authors independently undertook study identification, data extraction and risk of bias assessment. The primary outcome was health-related quality of life (HRQoL); secondary outcomes were exercise capacity, hospitalizations and exacerbations, adherence, mortality and adverse events. Narrative synthesis was undertaken for clinically heterogeneous trials. Data from RCTs and non-randomized studies were not combined for analysis.

Results

Ten included studies (2 RCTs) involved 907 participants with COPD (n=653 had undertaken >1 program). The majority of studies were at high risk of bias. One RCT (n=33) reported no difference in HRQol after a repeat program vs usual care following exacerbation (Chronic Respiratory Disease Questionnaire dyspnea domain score MD 0.4, 95% CI −0.5 to 3). In stable patients, clinically important and statistically significant improvements in HRQoL and exercise capacity were reported after repeat programs, but of a smaller magnitude than initial programs. There was evidence for reductions in exacerbations and hospitalizations, and shorter hospital length of stay for patients who repeated a program twice in 12 months compared to those who repeated once. No data for mortality or adverse events were available.

Conclusion

This systematic review provides limited evidence for benefits of repeating pulmonary rehabilitation in people with COPD, including improved HRQoL and exercise capacity, and reduced hospitalizations. However, most studies have high risk of bias, which reduces the certainty of these conclusions.

Study Registration

PROSPERO (CRD42020215093).

Keywords:

• COPD
• repeat pulmonary rehabilitation
• systematic review

Abbreviations

CI, confidence intervals; COI, conflict of interest; COPD, chronic obstructive pulmonary disease; CRQ, Chronic Respiratory Disease Questionnaire; 6MWD, distance walked on the 6-minute walk test; 6MWT, 6-minute walk test; FER, forced expiratory ratio; FEV₁, forced expiratory volume in one second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HRQoL, health-related quality of life; IQR, interquartile range; ISWD, distance walked on incremental shuttle walk test; ISWT, incremental shuttle walk test; MD, mean difference; MCID, minimal clinically important difference; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROSPERO, Prospective Register of Systematic Reviews; RCTs, randomized controlled trials; SD, standard deviation; SGRQ, St George’s Respiratory Questionnaire.

Acknowledgments

The abstract of this paper was presented at the American Thoracic Society International Conference as a poster presentation with interim findings. The poster’s abstract was published in ‘Poster Abstracts’ in American Journal of Respiratory and Critical Care Medicine: https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2021.203.1_MeetingAbstracts.A4142

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; Have drafted or written, or substantially revised or critically reviewed the article; Have agreed on the journal to which the article will be submitted; Reviewed and agreed on all versions of the article before submission, during revision, the final version accepted for publication, and any significant changes introduced at the proofing stage; Agree to take responsibility and be accountable for the contents of the article.

Disclosure

The authors report no conflicts of interests in this work.

Additional information

Funding

This work was supported by Institute for Breathing and Sleep Research Grant 2020. The funding body had no role in study design, study conduct or manuscript preparation.