Subjective and Objective Outcomes in Patients With COPD After Pulmonary Rehabilitation - The Impact of Comorbidities

Community-Based Pulmonary Rehabilitation Programs in Individuals With COPD

BACKGROUND

Community-based pulmonary rehabilitation (PR) programs can be offered to patients with COPD, but the literature on its effects is still not well summarized. Our purpose was to investigate the health-, physical-, and respiratory-related effects of community-based PR in individuals with COPD as compared to control groups.

METHODS

The PubMed and Embase databases were searched up to May 17, 2021. We included randomized control trials that compared the effects of community-based PR as compared to control groups in individuals with COPD. The risk of bias was judged using the Cochrane Risk of Bias 2 (RoB2). Meta-analysis was performed using a random-effects model to estimate the standardized mean difference (SMD) with 95% CI of the mean changes from baseline between groups. The Grading of Recommendations Assessment, Development, and Evaluation was used to interpret certainty of results.

RESULTS

We included 10 randomized control studies comprising a total of 9,350 participants with weighted mean age of 62.3 ± 2.38 y. The community-based interventions were based on exercise programs (resistance and/or endurance). All studies were judged as high risk and/or some concerns in one or more domains the risk of bias. All meta-analyses displayed very low certainty of evidence. The community-based PR interventions were significantly superior to control interventions in improving the St. George Respiratory Questionnaire Activity subscore (-0.40 [95% CI -0.72 to -0.08]; k = 5, n = 382) and total score (-0.73 [95% CI -1.29 to -0.18]; k = 4, n = 268) and the Chronic Respiratory Disease Questionnaire dyspnea subscore (0.36 [95% CI 0.03-0.69]; k = 6, n = 550). The mean changes from baseline were not different between the groups for all other outcomes.

CONCLUSIONS

Community-based PR tended to result in superior health-related quality of life and symptoms than control interventions, but the findings were inconsistent across outcomes and with very low certainty of evidence. Further studies are warranted for stronger conclusions.

Exercise-Based Rehabilitation Delivery Models in Comorbid Chronic Pulmonary Disease and Chronic Heart Failure

Among the most prevalent multimorbidities that accompany the aging process, chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) stand out, representing the main causes of hospital admissions in the world. The prevalence of COPD coexistence in patients with CHF is higher than in control subjects, given the common risk factors associated with a complex process of chronic diseases developing in the aging process. COPD-CHF coexistence confers a marked negative impact on mechanical-ventilatory, cardiocirculatory, autonomic, gas exchange, muscular, ventilatory, and cerebral blood flow, further impairing the reduced exercise capacity and health status of either condition alone. In this context, integrated approach to the cardiopulmonary based on pharmacological optimization and non-pharmacological treatment (i.e., exercise-based cardiopulmonary and metabolic rehabilitation) can be emphatically encouraged by health professionals as they are safe and well-tolerated, reducing hospital readmissions, morbidity, and mortality. This review aims to explore aerobic exercise, the cornerstone of cardiopulmonary and metabolic rehabilitation, resistance and inspiratory muscle training and exercise-based rehabilitation delivery models in patients with COPD-CHF multimorbidities across the continuum of the disease. In addition, the review address the importance of adjuncts to enhance exercise capacity in these patients, which may be used to optimize the gains obtained in these programs.

Integrating Comorbidities and Phenotype-Based Medicine in Patient-Centered Medicine in COPD

Despite recent notable innovations in the management of chronic obstructive pulmonary disease (COPD), no major advances in patient-centered medicine have been achieved. Current guidelines base their proposals on the average results from clinical trials, leading to what could be termed ‘means-based’ medical practice. However, the therapeutic response is variable at the patient level. Additionally, the variability of the clinical presentation interacts with comorbidities to form a complex clinical scenario for clinicians to deal with. Consequently, no consensus has been reached over a practical approach for combining comorbidities and disease presentation markers in the therapeutic algorithm. In this context, from the patients’ first visit, the clinician faces four major dilemmas: (1) establishing the correct diagnosis of COPD as opposed to other airway diseases, such as bronchial asthma; (2) deciding on the initial therapeutic approach based on the clinical characteristics of each case; (3) setting up a study strategy for non-responding patients; (4) pursuing a follow-up strategy with two well-defined periods according to whether close or long-term follow-up is required. Here, we will address these major dilemmas in the search for a patient-centered approach to COPD management and suggest how to combine them all in a single easy-to-use strategy.

Ten Research Questions for Improving COPD Care in the Next Decade

With the 60th anniversary of the CIBA symposium, it is worth evaluating research questions that should be prioritized in the future. Coming research initiatives can be summarized in 10 main areas. (1) From epidemiology the impact of new forms of electronic cigarettes on prevalence and mortality of COPD will be sought. (2) The study of the disease endotypes and its relationship phenotypes will have to be unraveled in the next decade. (3) Diagnosis of COPD faces several challenges opening the possibility of a change in the definition of the disease itself. (4) Patients' classification and risk stratification will need to be clarified and reassessed. (5) The asthma-COPD overlap dilemma will have to be clarified and define whether both conditions represent one only chronic airway disease again. (6) Integrating comorbidities in COPD care will be key in a progressively ageing population to improve clinical care in a chronic care model. (7) Nonpharmacological management have areas for research including pulmonary rehabilitation and vaccines. (8) Improving physical activity should focus research because of the clear prognostic impact. (9). Pharmacological therapies present several challenges including efficacy and safety issues with current medications and the development of biological therapy. (10) The definition, identification, categorization and specific therapy of exacerbations will also be an area of research development. During the next decade, we have a window of opportunity to address these research questions that will put us on the path for precision medicine.

Exercise Training in Patients with Chronic Respiratory Diseases: Are Cardiovascular Comorbidities and Outcomes Taken into Account?-A Systematic Review

Patients with chronic obstructive pulmonary disease (COPD), asthma and interstitial lung diseases (ILD) frequently suffer from cardiovascular comorbidities (CVC). Exercise training is a cornerstone intervention for the management of these conditions, however recommendations on tailoring programmes to patients suffering from respiratory diseases and CVC are scarce. This systematic review aimed to identify the eligibility criteria used to select patients with COPD, asthma or ILD and CVC to exercise programmes; assess the impact of exercise on cardiovascular outcomes; and identify how exercise programmes were tailored to CVC. PubMed, Scopus, Web of Science and Cochrane were searched. Three reviewers extracted the data and two reviewers independently assessed the quality of studies with the Quality Assessment Tool for Quantitative Studies. MetaXL 5.3 was used to calculate the individual and pooled effect sizes (ES). Most studies (58.9%) excluded patients with both stable and unstable CVC. In total, 26/42 studies reported cardiovascular outcomes. Resting heart rate was the most reported outcome measure (n = 13) and a small statistically significant effect (ES = -0.23) of exercise training on resting heart rate of patients with COPD was found. No specific adjustments to exercise prescription were described. Few studies have included patients with CVC. There was a lack of tailoring of exercise programmes and limited effects were found. Future studies should explore the effect of tailored exercise programmes on relevant outcome measures in respiratory patients with CVC.