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Rapid Responses: Rapid Responses published:
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Focusing on Rehabilitation
- Angela Koutsokera, Zoe Daniil, Konstantinos Gourgoulianis (14 November 2004)
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When to do it?
- M Thirumaran, Leeds,LS1 3EX ,U.K (21 November 2004)
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Pulmonary rehabilitation and hospital readmissions in chronic obstructive pulmonary disease
- Daniel K C Lee (25 November 2004)
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Education, exercise or environment?
- Trevor T Nicholson (2 December 2004)
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Angela Koutsokera, MD University Hospital of Larissa 41222 Larissa, Greece, Zoe Daniil, Konstantinos Gourgoulianis
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The article of Man et al. highlights the fact that early community pulmonary rehabilitation is safe and beneficial for patients that are admitted with a primary diagnosis of a COPD exacerbation. The investigators provide a comprehensive description of the study methods and its limitations but there are still a few points that need further clarification since they could interfere with the result analysis. For example the usual care of the control group and whether there was a standard pharmacological intervention for both groups during the follow up period are two issues that are not efficiently described. Since health care economics is always a major issue, we would like to point out that a true challenge for future research is the determination of the subgroup of patients that would benefit the most by a rehabilitation program. Perhaps this could be achieved if patient performance status is considered as a factor of randomization at the time of patient assignment to the intervention groups. Competing interests: None declared |
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M Thirumaran, Specialist Registrar Leeds General Infirmary,Great george street,, Leeds,LS1 3EX ,U.K
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Dear Editor, This is a fabulous study highlighting the need for nonpharmocological intervention in patients presenting with acute exacerbation of Chronic obstructive pulmonary disease(COPD).Pulmonary rehabilitation certainly improves symptom control and patients understanding of how to cope with the disease.This paper clearly states pulmonary rehabilitation immediately following an acute exacerbation benefits the patients and the health service.A cost benefit analysis on this would have been interesting. The author did not state the patient charecteristics in the groups to say whether they are comparable.It would have been interesting to see whether there was any improvement in lung function after rehabilitation.The patients in the rehabilitation group seem to have had better shuttle walk distance and lower scores in all the parameters in the St Georges respiratory questionnaire. The change seen at the end of three months in the intervention group is phenomenal.If the intervention group had better lung function may be it would be ideal to target this group of patients for rehabilitation.Inspite of the fact that 6 of the 18 patients in the intervention attending less than 50 % of the classes the results are excellent.This indicates may be a shorter period of rehabilitation might be sufficient following acute exacerbation. I would like to congratulate and the thank the authors for this fabulous study. Competing interests: None declared |
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Daniel K C Lee, Respiratory Physician Department of Respiratory Medicine, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, England
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Man and colleagues [1] provide impressive data pertaining to the substantial benefits of early community based pulmonary rehabilitation following hospitalisation for acute exacerbations in patients with chronic obstructive pulmonary disease (COPD). There is however, an apparent dissociation between clinical benefits and hospital readmissions, where for the latter, no significant difference was observed when comparing usual care versus early rehabilitation. The authors state that over the past decade, admissions for COPD exacerbations have soared by 50%, further burdening the National Health Service. However, the present data does not support that early pulmonary rehabilitation would serve to lessen this burden. Could the authors speculate as to why the considerable improvements observed in most of the outcome measures failed to translate into a significant reduction in hospital readmissions? Daniel K C Lee MB BCh MRCP MD, Department of Respiratory Medicine, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, Suffolk, England, United Kingdom References 1. Man WD, Polkey MI, Donaldson N, Gray BJ, Moxham J. Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ 2004;329:1209-11. Competing interests: None declared |
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Trevor T Nicholson, Staff Grade in Medicine Downe Hospital, Downpatrick, Northern Ireland
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Dear Editor, Man and colleagues (1) further highlight the effectiveness of Pulmonary Rehabilitation in the management of Chronic Obstructive Pulmonary Disease. More importantly, they show significant improvements at three months when it is initiated shortly after discharge from hospital. As with other studies, (3) they found that the duration of hospital stay in those admitted with further exacerbations tended to be shorter. They also found there were significantly fewer visits to Accident & Emergency in the rehabilitation group. Indeed one might expect this group to be better informed about the significance of their symptoms and therefore less likely to seek advice, but one wonders if the near-50% rate of patient under-reporting of symptoms of exacerbations found by Seemungal et al, (2) might be a factor in this study. However, the Authors (1) do not say if either group of patients were given an opportunity to have their pharmacological treatments optimised or altered, outside of possibly presenting to a GP or A&E. There were no significant differences in the numbers readmitted to hospital with exacerbations, a finding shared with those of Griffiths and colleagues. (3) One study that has shown a reduction in readmission rates, outside of a formal pulmonary rehabilitation programme, (4) involved high usual levels of physical activity equivalent to walking for at least 60 minutes per day. Surprisingly, high attendances at the pulmonary rehabilitation sessions do not appear to be important. Attendances have been disappointing in other trials also, (3) yet the results continue to remain positive. Griffiths et al also found that clinical and statistical improvements persisted for up to one year, but had diminished over time. This might be partly explained by intercurrent illness or exacerbations, patient motivation or other psychosocial factors. Other studies have shown a more sustainable difference and indeed continued improvement for up to 18 months, when pulmonary rehabilitation is performed in the home- environment.(5) I look forward to longer-term data by Man et al, to see how their findings might reflect these issues. Certainly the results of their study are encouraging; they support current data on Pulmonary Rehabilitation Programmes in COPD and demonstrate that it is both efficacious and safe to initiate shortly after an acute exacerbation. References (1)Man WDC, Polkey MI, Donaldson N, Gray BJ, Moxham J. Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ 2004; 329: 1209-1211 (2)Seemungal TAR, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with Chronic Obstructive Pulmonary Disease Am J Respir Crit Care Med 2000; 161: 1608-1613 (3)Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K. et al Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial Lancet 2000; 355: 362-368 (4)Garcia-Aymerich J, Farrero E, Felez MA, Izquierdo J, Marrades RM, Anto JM on behalf of EFRAM investigators. Risk factors of readmission to hospital for a COPD exacerbation: a prospective study Thorax 2003; 58:100-105 (5)Strijbos JH, Postma DS, Van Altena R, Gimeno F, Koeter GH. A comparison between and outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. A follow up of 18 months. Chest 1996; 109: 366-372 Competing interests: None declared |
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