Pulmonary rehabilitation can be equally effective in hospital and home settings

Question

Is pulmonary rehabilitation with the exercise component performed at home as effective at reducing dyspnoea as outpatient pulmonary rehabilitation?

Design

Randomised, controlled trial with concealed allocation.

Setting

Ten centres in Canada.

Participants

Adults with stable chronic obstructive pulmonary disease (COPD), aged at least 40 years, with an FEV₁ less than 70% of the predicted value, an FEV₁/FVC ratio of less than 0.70, and a Medical Research Council dyspnoea score of 2 or more. Previous pulmonary rehabilitation was an exclusion criterion. Randomisation of 252 participants allotted 126 to each group.

Interventions

Both groups received the same eight educational lectures over 4 weeks as hospital outpatients. The outpatient group then commenced combined aerobic and strength training on an outpatient basis with supervision, attending three sessions per week for 8 weeks. Each session consisted of cycle ergometry for 30 minutes at 80% of peak work capacity and progressive resistance exercises for 30 minutes. Supplemental oxygen was provided as appropriate. The other group trained at home, also for three sessions per week over the same 8 weeks. The first session was supervised, followed by weekly phone contact. Cycle ergometers were loaned to participants for the aerobic training for the 8-week period. The target intensity was 60% of peak work capacity for 40 minutes per session. The resistance exercises and oxygen supplementation were the same as for the outpatient group. Thereafter, both groups were prescribed three home exercise sessions per week for another 9 months.

Outcome measures

The primary outcome was the change in the dyspnoea domain of the Chronic Respiratory Questionnaire (CRQ) at 12 months. Secondary outcomes were other CRQ domains, the St George’s Respiratory Questionnaire (SGRQ), the 6-minute walk test, an endurance cycle test, and safety.

Results

Follow-up was 92% at 3 months and 86% at one year. The CRQ dyspnoea scores differed by 0.05 (95%CI –0.21 to 0.29) at 3 months and by 0.16 (95% CI –0.08 to 0.40) at one year. This excluded the minimum clinically important difference of 0.5, confirming that the two rehabilitation strategies had very similar effects on dyspnoea. The home-based group showed significantly better improvement on the Symptoms domain of the SGRQ at 3 months, but this difference was no longer significant at one year. On the remaining secondary outcomes, the two rehabilitation strategies had similar effects.

Conclusion

For adults with COPD, pulmonary rehabilitation with the exercise component performed at home can be as effective as outpatient pulmonary rehabilitation.