Expert Review of Respiratory Medicine

ISSN: 1747-6348 (Print) 1747-6356 (Online) Journal homepage: http://www.tandfonline.com/loi/ierx20

Pulmonary rehabilitation and acute exacerbations

of COPD
Samantha SC Kon, Jane L Canavan & William DC Man
To cite this article: Samantha SC Kon, Jane L Canavan & William DC Man (2012) Pulmonary
rehabilitation and acute exacerbations of COPD, Expert Review of Respiratory Medicine, 6:5,
523-531, DOI: 10.1586/ers.12.47
To link to this article: http://dx.doi.org/10.1586/ers.12.47

Published online: 09 Jan 2014.

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Pulmonary rehabilitation and

acute exacerbations of COPD
Expert Rev. Respir. Med. 6(5), 523531 (2012)

Samantha SC Kon*1,
Jane L Canavan1 and
William DC Man1,2
Respiratory Biomedical Research Unit,
Royal Brompton and Harefield NHS
Foundation Trust and Imperial College,
Hill End Road, Harefield, UB9 6JH,
London, UK
2
Harefield Pulmonary Rehabilitation
Unit, Harefield Hospital, Harefield, UK
*Author for correspondence:
Tel.: +44 189 582 8851
Fax: +44 189 582 8851
s.kon@rbht.nhs.uk

Expert Review of Respiratory Medicine 2012.6:523-531.

Acute exacerbations are major events in the natural history of chronic obstructive pulmonary
disease (COPD) and are associated with increased morbidity and mortality. Although pulmonary
rehabilitation increases exercise capacity, reduces dyspnea and improves health-related quality
of life, the effects on risk of future exacerbations (and by extension, healthcare utilization)
are less well documented. Furthermore, there has been a growing evidence base to support
provision of pulmonary rehabilitation in the acute phase of COPD, for example, shortly after
hospitalization for an acute exacerbation. This article reviews the role of pulmonary rehabilitation
in the prevention and treatment of acute exacerbations of COPD.
Keywords: acute exacerbation COPD exercise health status hospitalization physical activity
pulmonary rehabilitation skeletal muscle

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Medscape, LLC designates this Journal-based CME activity for a maximum of 1 AMA PRA
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All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures;
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Release date: 7 November 2012; Expiration date: 7 November 2013

Learning objectives
Upon completion of this activity, participants will be able to:
Assess the epidemiology and prognosis of acute exacerbations of COPD
Analyze the overall effects of PR on COPD
Distinguish how PR affects the rate of hospital readmission after an acute exacerbation of COPD
Evaluate the results of research into the efficacy and safety of PR after an acute exacerbation
ofCOPD

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10.1586/ERS.12.47

2012 Expert Reviews Ltd

ISSN 1747-6348

523

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Kon, Canavan & Man

Financial & competing interests disclosure

Expert Review of Respiratory Medicine 2012.6:523-531.

Editor
Elisa Manzotti
Publisher, Future Science Group, London, UK
Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.
CME Author
Charles P. Vega, MD
Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine
Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.
Authors and Credentials
Samantha SC Kon, BSc, MRCP
Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
Disclosure: Samantha SC Kon, BSc, MRCP, is supported by the Medical Research Council (UK). This work was supported by the NIHR Respiratory
Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College.
Jane L Canavan, PhD
Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK

Disclosure: Jane L Canavan, PhD, is supported by the Medical Research Council (UK). This work was supported by the NIHR Respiratory Biomedical
Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College.
William DC Man, MRCP, PhD
Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, United Kingdom;
Harefield Pulmonary Rehabilitation Unit, Harefield Hospital, Harefield, UK

Disclosure: William DC Man, MRCP, PhD, is supported by a National Institute for Health Research Clinician Scientist Award and a Medical
Research Council New Investigator Award. This work was supported by the NIHR Respiratory Biomedical Research Unit, Royal Brompton and
Harefield NHS Foundation Trust and Imperial College.

Chronic obstructive pulmonary disease (COPD) is a major health

problem, and by 2020, COPD is predicted to be the third leading
cause of death and fifth leading cause of chronic disability worldwide
[1] . Acute exacerbations of COPD (AECOPDs) represent a major
event in the natural history of the disease and are common with
a frequency of 0.82.5 AECOPD per patient per year [2] . Severe
AECOPDs, particularly those that require hospitalization, herald a
significant worsening of prognosis; in a national UK audit of hospital COPD admissions, 34% of patients were readmitted and 14%
died within 3 months [3,4] . Furthermore, AECOPDs represent a
high economic burden to health services and society, comprising a
significant proportion of total COPD costs [5] .
Pulmonary rehabilitation (PR) is a multidisciplinary package
of care, which consists principally of exercise training and education sessions with a focus on self management. PR is designed to
maximize each patients physical and social performance, reduce
symptoms and restore autonomy. Despite the initial skepticism
that COPD patients (with their pulmonary impairment) could
achieve exercise levels necessary to produce a true physiological
training effect, PR has emerged as the cornerstone of management in international COPD guidelines and is the most effective
nonpharmacological intervention in improving exercise capacity
and health status. A number of randomized controlled trials and
meta-analyses provide a solid evidence basis to support the beneficial effects of PR on exercise capacity, health status and dyspnea
in COPD [6,7] . However, the health economic consequences of
PR and its effects on acute exacerbation rate are less well documented. More recently, there has been much interest in providing
524

PR following an AECOPD to treat relevant consequences such as

skeletal muscle dysfunction [8] and to reduce risk of future hospital
readmissions [9] . This review discusses the role of PR in both the
prevention and treatment of AECOPDs.
Consequences of AECOPDs

AECOPDs represent significant life events for patients and are

associated with increased mortality, as well as substantial decline
in functional status and health-related quality of life (HRQoL).
For healthcare systems, COPD exacerbations represent one of the
most common reasons for all emergency hospital admission and
comprise a substantial proportion of healthcare costs associated
with COPD [5] .
AECOPDs & mortality

Studies have shown that the inpatient mortality rate associated

with an AECOPD ranges from 2.5 to 11%, depending on the
population and health system studied [10,11] . In the UK National
COPD audit, inpatient mortality was 7% with a 3-month
mortality of 15% [4] . Only approximately half of the patients
admitted for an AECOPD remain alive within 2 years [10] .
AECOPDs & disease progression

A reduction in forced expiratory volume in 1 s (FEV1) is the hallmark of COPD, and increased rate of decline in FEV1 is widely
used as a marker of disease progression. Donaldson etal. studied
109patients over a 4-year period. The median exacerbation rate was
2.92 per year. Frequent exacerbators (defined as >2.92 exacerbations
Expert Rev. Respir. Med. 6(5), (2012)

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Pulmonary rehabilitation & acute exacerbations of COPD

per year) had a significantly faster decline in FEV1 than in the

infrequent exacerbators (40.1 vs 32.1ml/year) [12] . Similarly, Makris
and colleagues demonstrated that the annual decline in FEV1 was
significantly greater in frequent exacerbators compared with infrequent exacerbators, particularly in current smokers [13] . In a subset
analysis (n = 9435) of the Copenhagen Heart Study, patients with
chronic mucus hypersecretion had a significantly increased decline
in FEV1 and risk of COPD hospitalization [14] . Impairments in
lung function related to acute exacerbations may persist for several
months [15,16] .

Expert Review of Respiratory Medicine 2012.6:523-531.

AECOPDs & HRQoL

Exacerbations are associated with an acute deterioration in HRQoL

[17] , but there is also indirect evidence to suggest that HRQoL in
the stable state is adversely influenced by frequent AECOPDs.
In a cohort of 70 COPD patients followed for 1 year, frequent
exacerbators (three to eight per year) had significantly worse total
and component St Georges Respiratory Questionnaire (SGRQ)
scores compared with infrequent exacerbators (zero to two per
year) [18] . Similarly, in a 2-year follow-up study of 336COPD
patients, frequent exacerbators had a two-point per year greater
(worse) SGRQ score compared with those with less than three
AECOPDs in the follow-up period.
AECOPDs, functional performance & physical activity

A severe AECOPD is associated with a substantial decline in

6-min walk distance (72 m), which showed little recovery even
6 months post-AECOPD [16] . Similarly, in intervention studies following the AECOPD, maximal incremental shuttle walk
distance in the control groups showed little improvement after
3 months [19] . This is not surprising given the significant impact
that AECOPDs have on daily physical activity levels. Hospitalized
COPD patients do less than 10-min walking per day, even 7days
into an admission [20] , and at 1 month after hospital discharge,
daily physical activity levels remain substantially lower (44%)
than in levels observed in stable patients of similar disease severity. Even less severe exacerbations are associated with a substantial
reduction in time spent outdoors [21] . There is now also increasing
evidence to suggest that daily physical activity may influence the
risk of hospital admission. Patients who remain inactive following
an AECOPD are more likely to be readmitted to hospital with
a subsequent exacerbation [22] . Furthermore, in a large cohort of
severe COPD patients, self-reported daily physical activity was
independently associated with hospitalizations for AECOPD,
after controlling for all other physiologic and d
emographic
variables [23] .
AECOPDs & skeletal muscle dysfunction

Skeletal muscle dysfunction is well recognized in stable COPD

and associated with increased morbidity and mortality [24,25] .
Multiple factors at the time of an AECOPD may contribute to
worsening muscle dysfunction, including physical inactivity/muscle disuse [20] , systemic inflammation [8] , systemic corticosteroids
and dietary intake. During hospitalization, studies have shown an
approximately 1% decline in quadriceps strength per day, which
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may be slow to recover following hospital discharge [8,9,20] . In a

posthospitalization intervention study, Seymour and colleagues
showed a continued decline in quadriceps strength from discharge
to 3 months in the control group [9] .
Does PR reduce AECOPDs?

Many randomized controlled trials (and meta-analyses) have

demonstrated clinically and statistically significant improvements in exercise capacity, HRQoL and dyspnea in stable COPD
patients following PR [6,7,26] . Although AECOPDs, particularly
those requiring hospitalization, comprise a significant proportion
of healthcare costs in COPD [5] , previous randomized controlled
PR studies have generally not focused on exacerbation rate as a
primary outcome. Consequently, in comparison with data on
exercise capacity or HRQoL, there are less data on the effects
of PR on exacerbation rate, particularly in the stable COPD
population. However, as AECOPDs are principally responsible
for patients seeking healthcare, data on hospital admissions and
healthcare resource usage are reasonable surrogates for rates of
AECOPD. Furthermore, since there has been increasing recent
interest in providing PR during the acute phase of the disease (i.e.,
during or shortly after hospitalization), hospital readmission and
exacerbation frequency have become more prominent clinical
end points [9] . As previously discussed, frequent AECOPDs are
associated with a more rapid decline in FEV1 [12] . If PR indeed
reduces exacerbation frequency, there is the intriguing prospect
that PR could influence disease progression.
PR in stable COPD

Several studies have compared hospital admissions or healthcare

utilization in 12 months before and after PR. Raskin and colleagues examined healthcare utilization in the year before and
after outpatient hospital-based PR in 128 COPD patients referred
to 11 centers [27] . In the year following PR, there were 0.25 fewer
total hospitalizations and 2.18 fewer hospital days per patient and
271 fewer hospital days for the group [27] . Similarly, an Australian
study of 187 COPD patients completing PR observed a 46%
reduction in the number of patients admitted to hospital with
AECOPD and a 62% reduction in total bed days in the year
following PR [28] . In a smaller study, Hui and Hewitt demonstrated a significant reduction in hospitalization and length of
stay in the 12 months following completion of PR (pre-PR 7.4 vs
post-PR 3.3bed days; p<0.005) [29] . The California Pulmonary
Rehabilitation Collaborative group studied 522 patients completing PR in nine centers. There was a high utilization of healthcare
services over the 3months before PR in terms of mean hospital
stay (2.4days), urgent care visits (0.4), physician visits (4.4) and
telephone calls (2.7), which all significantly declined over an
18-month period post-PR [30] . Stewart and colleagues showed that
an inpatient, rather than outpatient, PR program led to 67% of the
cohort spending less time in hospital during the 12months after
program completion compared with the 12months before admission [31] . In a UK study, inpatient hospital stay (bed days) dropped
significantly by a mean of 2.35days per patient in the 12months
following PR compared with the preceding 12months, although
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there was no significant change in routine or emergency primary

care visits from baseline. The net saving in direct hospital costs
per patient was GB1835, saving an average of GB7911313 cost
per patient per year [32] . A significant weakness of these previous
studies is the absence of a control group.
The data from randomized controlled trials have been conflicting. In a well-conducted randomized controlled study
of outpatient PR (n=200), Griffiths and colleagues did not
demonstrate a reduction in the number of patients required to be
admitted (40vs41), but the intervention group had significantly
less hospital bed days than control (10.4vs21.0) [7] . Interestingly,
this study also showed an increased number of primary care
consultations, but less home visits in the intervention group [7] ,
suggesting a more efficient use of primary care that may reflect
either increased fitness of the intervention group or a change
in behavior and attitude to their illness. Gell and colleagues
demonstrated that a year-long PR program significantly reduced
mild exacerbation frequency, compared with a control group,
from 6.9 exacerbations to 3.7 per patient over a 24-month period.
There were 39hospitalizations in the control group compared
with 18 in the PR group, but the study was inadequately powered to show a statistically significant reduction in hospitalizations [33] . In a randomized controlled trial of home PR in older
housebound COPD patients, there was no reduction in the number of hospital admissions due to exacerbation but a significant
reduction in average length of stay (5.9 vs 9.3days) [34] . Other
randomized controlled trials have shown less convincing effects
on hospitalizations. A Swedish randomized controlled study of
a 12-month outpatient exercise program showed no reduction
in hospital days despite improvement in exercise capacity [35] .
Ries and colleagues randomized 199stable COPD patients to
an 8-week comprehensive PR program or education alone and
also demonstrated significant improvements in exercise capacity
with PR but no changes in HRQoL or hospital days [36] . These
latter two studies are unusual in the PR literature for not showing
improvement in HRQoL following PR. This raises the possibility
that there may be a link between HRQoL and AECOPDs, but
not between exercise capacity and AECOPDs. The findings also
suggest that education may be the most important component of
PR in reducing healthcare costs, possibly through improved selfmanagement skills and better disease knowledge. The benefits
of self-management (often incorporating PR) on exacerbation
rate remain hotly debated, although some studies have shown
promising results [37] .
PR in acute COPD

Over the past decade, there has been increasing interest and supportive evidence for providing PR in the acute setting, either
during or shortly after hospitalization for an AECOPD. Given
that exacerbations appear to cluster temporally [38] , the immediate
posthospitalization period is a high-risk time for a new exacerbation, and a third of all patients are readmitted within 90 days
of discharge [4] . Understandably, hospital readmission is a more
prominent outcome measure in acute setting trials in comparison
with studies of stable patients.
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A recent Cochrane meta-analysis examined data from five small
randomized controlled trials (of which three only specified hospital readmission as a secondary outcome) and concluded that there
was a significant reduction in hospital admissions with PR follow
ing an AECOPD [39] , with an overall odds ratio of 0.22 (95%CI:
0.080.58) and a number needed to treat of four. However, it is
important to point out significant differences existed between
the studies in terms of intervention (inpatient followed by homebased PR [40] , inpatient followed by outpatient PR [41] , outpatient
PR only [9,19] and home-based PR only [42]), and the short duration of follow-up. Two studies from the Cochrane meta-analysis
specified healthcare utilization as the primary outcome measure.
Eaton etal. randomized patients admitted to hospital with an
exacerbation of COPD to early inpatientoutpatient PR or usual
care (UC) [41] . The study was powered to detect a reduction in
90-day readmission rate from 57 to 35%, requiring 80 patients
in each study group [19] . However, despite screening 397 patients,
only 97 patients consented to the study. Thirty nine patients in
the intervention arm completed the study but only 40% showed
good adherence to treatment (an a priori definition of at least
75% of outpatient attendances) despite the free transport being
provided door-to-door. Although there were no statistically significant between-group differences, the results showed a general trend toward reduced healthcare utilization with PR. The
intervention group had a 23% risk of hospital readmission at
90 days (16% risk in adherers only) compared with 32% for the
UC group. Similarly, there was a trend toward reduced hospital
bed days: 1.7 per patient in the PR group compared with 4.2per
patient in the UC group. Seymour and colleagues examined the
effects of early outpatient PR only following hospitalization for
an AECOPD compared with UC [9] . This study was powered to
detect a 50% reduction in the 90-day hospital readmission rate
observed in a previous study from the same group [19] . The proportion of patients experiencing at least one hospital admission
for a COPD exacerbation over 3 months was significantly lower
in the PR group than in the UC group (7 vs 33%) [9] . Although
there was no difference in the number of patients attending
emergency departments (without being admitted), the number
of subjects experiencing at least one emergency hospital attendance of any type was lower in the intervention group than in the
UC group (27 vs 57%) [9] . Furthermore, the median time to any
event was significantly shorter with UC compared with PR (29
vs 52 days) [9] . A particular point to highlight in this study is that
only 60patients were randomized despite a recruitment period of
almost 3 years across three hospitals.
One randomized controlled trial (published after the Cochrane
review) is of interest as it evaluated whether early outpatient PR
could reduce acute healthcare utilization in COPD patients over
a 12-month period compared with UC [43] . In support of the previously described studies, Ko etal. demonstrated a trend toward
reduced hospital readmissions in the PR group over the first
3months, but this effect was lost with time with no significant
difference between the two groups at 12 months [43] . A question
that arises from these data is whether providing PR when the
patient has become stable may have a longer-term effect than early
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PR. Only one study has tried to answer this question. Puhan and
colleagues randomized COPD patients with a recent exacerbation
(not all requiring hospitalization) to either early (within 2 weeks)
or late PR (6 months after randomization and in a stable state)
[44] . Over an 18-month follow-up period, there was no significant
difference in exacerbation rate (early PR had 2.61 AECOPDs
compared with 2.77 in patients with late PR) [44] . However, out
of a target sample size of 270 patients, the investigators were
only able to recruit a total of 36 patients; hence, the study was
underpowered to detect a significant change.

Expert Review of Respiratory Medicine 2012.6:523-531.

PR in the treatment of acute exacerbations

Much of the data in the PR literature is based on stable patients

with COPD, free from exacerbation for a defined period of
time. In the infancy of PR, some critics were doubtful that stable COPD patients with ventilatory limitation could achieve
or sustain high enough exercise levels to produce a true physiological training effect. This is perhaps even more relevant in the
acute setting. Furthermore, there are obvious concerns that the
increase in physical activity associated with PR could exacerbate
the catabolic state that exists during an AECOPD [45] , aggravate
already fatiguing muscles or increase the risk of comorbidities,
such as ischemic heart disease. However, as discussed previously,
there are several consequences of AECOPDs that are amenable
to treatment with PR, such as reduced physical activity levels
and exercise capacity, impaired HRQoL and skeletal muscle
dysfunction, particularly of the locomotor muscles such as the
quadriceps [20] . A recent proof-of-principle study demonstrated
that resistance training of the lower-extremity muscles is not only
possible, but well tolerated, and led to improvements in muscle
strength and exercise tolerance that persisted at 1 month after
hospital discharge [46] .
Given the concerns about exercising patients recovering from
an acute severe illness, early reports focused on supervised rehabilitation in the inpatient setting. Foster etal. showed that it was
feasible to rehabilitate hypercapnic COPD patients and demonstrated positive changes in exercise capacity, lung function and
arterial blood gases, although there was no control group [47] .
Nava randomized COPD patients admitted to a respiratory ICU
to a hierarchical inpatient rehabilitation program of progressive
intensity, started within 35 days after admission or standard
medical care. The intervention group showed improvements
in 6-min walking distance and breathlessness [48] . Outside the
critical care setting, Kirsten and colleagues demonstrated that a
10-day inpatient rehabilitation program (consisting of endurance
walking exercises), commenced within 47 days after admission,
significantly improved 6-min walk distance, peak oxygen uptake
and breathlessness [49] . The same group extended these initial
findings first with a 6-month and then an 18-month largely unsupervised home-based training period following hospital PR [40,50] .
Interestingly, even though exercise capacity remained significantly
better than at baseline by the end of the study, the unsupervised
home training was only adequate at maintaining, rather than
improving on, the gains that occurred during initial inpatient PR
[40,50] , thus emphasizing the importance of supervised therapy.
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An alternative approach taken by investigators has been to

provide PR after, rather than during, a hospital admission for
an AECOPD. Murphy etal. evaluated the effects of supervised
home-exercise training (total of 12 training sessions) in conjunction with a hospital-at-home care program [42] . Highly significant improvements in the incremental shuttle walk were observed
in the intervention group (106 m) as well as improvements in
HRQoL (SGRQ and EuroQol-5D) [42] , but between-group statistical comparisons were not documented. Other studies have
focused on outpatient-based PR. In a UK study, Man and colleagues randomized 42 COPD patients at hospital discharge to
either usual medical care or community PR within 10 days of
hospital discharge [19] . The program consisted of two supervised
sessions per week for 8 weeks and unsupervised home-exercise
training. At 3 months, clinically and statistically significant
improvements were seen in exercise capacity, disease-specific
HRQoL (SGRQ, Chronic Respiratory Questionnaire) and
generic HRQoL (mental component score of the Short Form-36)
with outpatient PR compared with UC [19] . Furthermore, there
were a significantly reduced number of unscheduled accident and
emergency visits not requiring hospital admission. Although a
trend toward reduced hospital admissions was also observed, this
study was underpowered to demonstrate statistical significance
[19] . With this in mind, the same group of investigators performed
a randomized controlled trial of similar design and intervention
but powered sufficiently to look specifically at hospital readmissions [9] . As discussed previously, Seymour and colleagues demonstrated a reduction in 90-day hospital readmission from 33 to 7%.
However, they were also able to demonstrate large improvements
in incremental and endurance shuttle walk and HRQoL, as well
as in quadriceps muscle strength [9] .
In contrast to previous studies, other investigators have not
shown such demonstrable improvements with PR in the acute
setting. Eaton etal. compared the effects of a seamless inpatient
followed by outpatient PR program with UC. Although there
were significant clinical improvements in 6-min walk distance
and HRQoL in both groups, there were no significant differences between groups [41] . This may have been partly due to
the low adherence with the intervention. Despite the investigators providing free door-to-door transport, only 40% assigned
to early PR attended at least 75% of PR sessions [41] . Similarly,
although Ko and colleagues were able to demonstrate significant improvements in the SGRQ at 3 and 6 months post-hospital discharge in favor of early outpatient PR, these improvements did not persist until 12months [43] . Furthermore, they
were unable to demonstrate significant differences in 6-min
walk distance, peak oxygen consumption or healthcare utilization. However, it is arguable that the study population was not
medically optimized as none were on long-acting anticholinergic inhalers and only a minority were on combination inhaled
corticosteroid/long-acting bronchodilators [43] .
The studies described so far have consisted of small numbers of
patients and were of moderate methodological quality. As previously discussed, Puhan and colleagues conducted a systematic
review of clinical trials studying PR in COPD patients following
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acute exacerbations, which was recently updated [39] . Apart from

demonstrating a significant reduction in the odds of hospital
admission, the authors also examined the effects of early PR on
HRQoL, exercise capacity and mortality. Although there was no
difference seen in the symptoms domain, there were large consistent improvements in the SGRQ total score, and the domain
scores for activity limitation and impact, which exceeded the commonly accepted minimum important difference of four units.
Similarly, although there was heterogeneity between studies, the
dyspnea, emotion and fatigue domains of the Chronic Respiratory
Questionnaire all showed consistent improvements with early PR
[39] . Both 6-min walk distance and the incremental shuttle walk
increased with early PR with a weighted mean difference of 77
and 64 m, respectively. Furthermore, Puhan etal. were able to
demonstrate a significant reduction in the odds of death between
treatment and control (odds ratio: 0.28; 95% CI: 0.100.84) with
a number needed to treat of six, with no difference in adverse
events [39] . Although this should be interpreted with care given
the small number of events, this does provide evidence that PR
in the acute setting is feasible and safe.
Expert commentary

Acute exacerbations significantly impact on the lives of patients

with COPD. They have a profound effect on morbidity and
mortality and are a significant health economic burden. Decline
in FEV1 and disease progression are common consequences of
frequent exacerbations and only approximately half of patients
hospitalized remain alive at 2 years. Exacerbations are associated
with a deleterious effect on quality of life and exercise capacity.
Many patients enter a vicious cycle of reduced physical activity,

skeletal dysfunction and poor physical performance, increasing

their risk of subsequent exacerbation.
The evidence presented here suggests that PR is undoubtedly
an effective intervention for COPD patients, both in the stable
and acute setting. It is particularly attractive as it can increase
exercise capacity, reduce symptoms and improve HRQoL,
restoring autonomy in these individuals. With data to support
the notion that PR can reduce healthcare utilization, and by
extension risk of further exacerbation, it should be considered
an integral part of the multidisciplinary management of COPD
patients, both in the stable and peri-/post-exacerbation recovery
period.
Five-year view

Despite a paucity of data on the effects of PR on exacerbation

rate and hospital admissions, it is unlikely that any further randomized controlled trials of PR will be undertaken in the stable
COPD population, as it is now a widely accepted effective intervention in the clinical management of such patients. Although
there are a few studies surrounding PR in the acute COPD setting
following an exacerbation, they have consisted of small numbers
of patients and were of variable methodological quality. The next
5 years is likely to herald a wave of more robust studies in this area,
and we anticipate that these will address the duration and nature
of PR after exacerbation and whether there is added long-term
benefit of early PR compared with delayed PR when the patient
is more stable. Existing trials have also suggested that uptake of
posthospitalization PR is poor, and further research is likely to
reveal different ways of delivering peri-/post-hospitalization PR
that may be more acceptable to patients.

Key issues
Acute exacerbations are common and are associated with significant increased morbidity and mortality in patients with chronic
obstructive pulmonary disease (COPD).
Acute exacerbations of COPD are one of the most common causes of emergency hospital admission and represent a high economic
burden to health services and society.
Exacerbations of COPD have been associated with an acute deterioration in health-related quality of life (QoL), forced expiratory
volume in 1 s, physical performance and skeletal muscle dysfunction.
Randomized controlled trials and meta-analyses support the benefits of pulmonary rehabilitation in increasing exercise capacity,
reducing dyspnea and improving health-related QoL.
There is currently a paucity of data on the effects of pulmonary rehabilitation on exacerbation rate, hospital admissions and healthcare
resource usage.
There is now emerging evidence to support the provision of pulmonary rehabilitation in the acute phase of COPD.
A recent Cochrane meta-analysis concluded that there was a significant reduction in odds of hospital admissions and death with
pulmonary rehabilitation following acute exacerbations as well as demonstrating consistent improvements in QoL and exercise capacity.
Evidence suggests that pulmonary rehabilitation is an effective intervention for COPD patients both in the stable and acute setting.

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Roberts CM, Lowe D, Bucknall CE,

Ryland I, Kelly Y, Pearson MG. Clinical
audit indicators of outcome following
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You are admitting a 60-year-old man with a long history of smoking and severe chronic obstructive pulmonary
disease (COPD). What should you consider regarding the epidemiology and prognosis of acute exacerbations of
COPD (AECOPD)?

A
B
C
D

AECOPD is a rare event among patients with COPD

One third of patients admitted for AECOPD may be readmitted within 3 months
The rate of inpatient mortality associated with AECOPD remains under 1%
Patient activity after hospitalization for AECOPD does not influence the rate of subsequent exacerbations

2. You consider initiating pulmonary rehabilitation (PR) for this patient during his hospitalization. What should you
consider regarding research of PR for COPD?

A PR is not as effective as holistic therapy such as meditation in improving exercise capacity and health status
B PR has been demonstrated to reduce the risk of hospitalization among patients with stable COPD
C Randomized trials of PR are more supportive of it effects in reducing hospitalization compared with observational
studies

D Education is the least important part of PR in reducing healthcare costs

3. What can you expect regarding prescribing PR for this patient with AECOPD?

A
B
C
D

No effect on the risk of hospital readmission

An overall reduced risk of hospital readmission
A reduced risk of hospital readmission if PR is initiated early
A reduced risk of hospital readmission if PR is initiated late

4. In prescribing a PR regimen for this patient, what should you keep in mind?

A
B
C
D

Only in-hospital PR has proven to be effective

Only at-home PR has proven to be effective
PR following AECOPD is associated with a small but significant increased risk of death
PR may improve exercise tolerance, health-related quality of life, and the risk of mortality following AECOPD

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