title: Pulmonary rehabilitation and severe exacerbations of COPD: solution or white elephant?
abstract: Hospitalisations for severe exacerbations of chronic obstructive pulmonary disease are associated with significant physical and psychological consequences including an increase in symptom severity, severe reductions in physical activity, a deleterious effect on skeletal muscle, impaired exercise tolerance/ability to self-care, decline in quality of life, and increased anxiety and depression. As these consequences are potentially amenable to exercise training, there is a clear rationale for pulmonary rehabilitation in the peri/post-exacerbation setting. Although a 2011 Cochrane review was overwhelmingly positive, subsequent trials have shown less benefit and real-life observational studies have revealed poor acceptability. Qualitative studies have demonstrated that the patient experience is a determining factor while the presence of comorbidities may influence referral, adherence and response to pulmonary rehabilitation. Systematic reviews of less supervised interventions, such as self-management, have shown limited benefits in the post-exacerbation setting. The recent update of the Cochrane review of peri-exacerbation pulmonary rehabilitation showed that benefits were associated with the "comprehensive" nature of the intervention (the number of sessions received, the intensity of exercise training and education delivered, and the degree of supervision) but implementation is demanding. The challenge is to develop interventions that are deliverable and acceptable around the time of an acute exacerbation but also deliver the desired clinical impact.
authors.affiliation: NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK.
authors.forename: William D-C
authors.initials: WD
authors.lastname: Man
authors.affiliation: Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
authors.forename: Milo A
authors.initials: MA
authors.lastname: Puhan
authors.affiliation: Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, ON, Canada.
authors.forename: Samantha L
authors.initials: SL
authors.lastname: Harrison
authors.affiliation: Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Rachel E
authors.initials: RE
authors.lastname: Jordan
authors.affiliation: Department of Respiratory Epidemiology, Occupational Medicine and Public Health, National Heart and Lung Institute, Imperial College London, London, UK.
authors.forename: Jennifer K
authors.initials: JK
authors.lastname: Quint
authors.affiliation: NIHR CLAHRC-EM, Centre for Exercise and Rehabilitation Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK; School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.
authors.forename: Sally J
authors.initials: SJ
authors.lastname: Singh