title: Early versus late pulmonary rehabilitation in chronic obstructive pulmonary disease patients with acute exacerbations: a randomized trial.
abstract: BACKGROUND
  Around the world, the timing of referral of chronic obstructive pulmonary disease (COPD) patients for pulmonary rehabilitation differs from immediately after exacerbation (early) to later on when patients are in a stable state (late). There are no trials comparing the different time points of referral for pulmonary rehabilitation.
  
  
  OBJECTIVE
  Our aim was to compare the effects of early and late pulmonary rehabilitation on exacerbation rates and health-related quality of life (HRQOL) in COPD patients with exacerbations.
  
  
  METHODS
  We randomized COPD patients (Global Initiative for Chronic Obstructive Lung Disease stages II-IV) with a recent exacerbation to early (within 2 weeks) or late pulmonary rehabilitation (starting 6 months after randomization and in a stable state). The primary outcome was the exacerbation rate over 18 months, and secondary outcomes included HRQOL and mortality. We used multivariate analyses and an intention-to-treat analysis approach.
  
  
  RESULTS
  We randomized 36 patients to pulmonary rehabilitation. On average, patients with early rehabilitation (n = 19) had 2.61 (SD 2.96) exacerbations requiring systemic corticosteroids and/or antibiotics, compared to 2.77 (SD 3.41) in patients with late rehabilitation (adjusted incidence rate ratio 0.83, 95% confidence interval 0.43-1.63; p = 0.60). Over the 18-month period, patients with late rehabilitation experienced more dyspnea (difference on Chronic Respiratory Questionnaire dyspnea domain 0.74 and on the Medical Research Council dyspnea scale 0.37), but neither these differences nor any difference in HRQOL domains reached statistical significance.
  
  
  CONCLUSIONS
  We did not find any statistically significant differences between early and late pulmonary rehabilitation. However, our trial indicates that early rehabilitation may lead to faster recovery of HRQOL after exacerbations compared to rehabilitation later on when patients are in a stable state.
authors.affiliation: Horten Center for Patient-Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland. mpuhan@jhsph.edu
authors.forename: Milo A
authors.initials: MA
authors.lastname: Puhan
authors.forename: Anne
authors.initials: A
authors.lastname: Spaar
authors.forename: Martin
authors.initials: M
authors.lastname: Frey
authors.forename: Alexander
authors.initials: A
authors.lastname: Turk
authors.forename: Otto
authors.initials: O
authors.lastname: Brändli
authors.forename: Daniel
authors.initials: D
authors.lastname: Ritscher
authors.forename: Eva
authors.initials: E
authors.lastname: Achermann
authors.forename: Rainer
authors.initials: R
authors.lastname: Kaelin
authors.forename: Werner
authors.initials: W
authors.lastname: Karrer
mesh_terms: D000368:Aged; D018450:Disease Progression; D005260:Female; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D057146:Multivesicular Bodies; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy / Q000503:physiopathology / Q000534:rehabilitation*; D011788:Quality of Life; D012017:Referral and Consultation; D013997:Time Factors; D016896:Treatment Outcome