title: Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.
abstract: BACKGROUND
  Pulmonary rehabilitation has become a cornerstone in the management of patients with stable Chronic Obstructive Pulmonary Disease (COPD). Systematic reviews have shown large and important clinical effects of pulmonary rehabilitation in these patients. However, in unstable COPD patients who have recently suffered an exacerbation, the effects of pulmonary rehabilitation are less established.
  
  
  OBJECTIVE
  To assess the effects of pulmonary rehabilitation after COPD exacerbations on future hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life and exercise capacity).
  
  
  METHODS
  Trials were identified from searches of CENTRAL, MEDLINE, EMBASE, PEDRO and the Cochrane Airways Group Register of Trials. Searches were current as of March 2010.
  
  
  METHODS
  Randomized controlled trials comparing pulmonary rehabilitation of any duration after exacerbation of COPD with conventional care. Pulmonary rehabilitation programmes needed to include at least physical exercise. Control groups received conventional community care without rehabilitation.
  
  
  METHODS
  We calculated pooled odds ratios and weighted mean differences (MD) using random-effects models. We requested missing data from the authors of the primary studies.
  
  
  RESULTS
  We identified nine trials involving 432 patients. Pulmonary rehabilitation significantly reduced hospital admissions (pooled odds ratio 0.22 [95% CI 0.08 to 0.58], number needed to treat (NNT) 4 [95% CI 3 to 8], over 25 weeks) and mortality (OR 0.28; 95% CI 0.10 to 0.84), NNT 6 [95% CI 5 to 30] over 107 weeks). Effects of pulmonary rehabilitation on health-related quality of life were well above the minimal important difference when measured by the Chronic Respiratory Questionnaire (MD for dyspnea, fatigue, emotional function and mastery domains between 0.81 (fatigue; 95% CI 0.16 to 1.45) and 0.97 (dyspnea; 95% CI 0.35 to 1.58)) and the St. Georges Respiratory Questionnaire total score (MD -9.88; 95% CI -14.40 to -5.37); impacts domain (MD -13.94; 95% CI -20.37 to -7.51) and for activity limitation domain (MD -9.94; 95% CI -15.98 to -3.89)). The symptoms domain of the St. Georges Respiratory Questionnaire showed no significant improvement. Pulmonary rehabilitation significantly improved exercise capacity and the improvement was above the minimally important difference (six-minute walk test (MD 77.70 meters; 95% CI 12.21 to 143.20) and shuttle walk test (MD 64.35; 95% CI 41.28 to 87.43)). No adverse events were reported in three studies.
  
  
  CONCLUSIONS
  Evidence from nine small studies of moderate methodological quality, suggests that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD patients who have recently suffered an exacerbation of COPD.
authors: Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 Wolfe Street, Mail room W5010, Baltimore, MD, USA, 21205.
authors: Milo A
authors: MA
authors: Puhan
authors: Elena
authors: E
authors: Gimeno-Santos
authors: Madlaina
authors: M
authors: Scharplatz
authors: Thierry
authors: T
authors: Troosters
authors: E Haydn
authors: EH
authors: Walters
authors: Johann
authors: J
authors: Steurer
mesh_terms: D018450:Disease Progression; D017079:Exercise Tolerance; D006304:Health Status; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D029424:Pulmonary Disease, Chronic Obstructive / Q000401:mortality / Q000534:rehabilitation*; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D055070:Resistance Training / Q000379:methods