Design of pulmonary rehabilitation programmes during acute exacerbations of COPD: a systematic review and network meta-analysis

This systematic review aimed to systematise the different designs used to deliver pulmonary rehabilitation during acute exacerbations of COPD (AECOPD) and explore which ones are the most effective. PubMed, Scopus, Web of Science, EBSCO and Cochrane were searched. Randomised controlled trials comparing pulmonary rehabilitation or at least one of its components with usual care or comparing different components of pulmonary rehabilitation were included. Network meta-analysis was conducted in MetaXL 5.3 using a generalised pairwise modelling framework. Pooled effects compared each treatment to usual care. 42 studies were included. Most studies were conducted in an inpatient setting (57%) and started the intervention 24–48 h after hospital admission (24%). Exercise training (71%), education and psychosocial support (57%) and breathing techniques (55%) were the most used components. Studies combining exercise with breathing techniques presented the larger effects on exercise capacity (weighted mean difference (WMD) −41.06, 95% CI −131.70–49.58) and health-related quality of life (WMD 14.64, 95% CI 8.73–20.54), and breathing techniques presented the larger effects on dyspnoea (WMD 1.90, 95% CI 0.53–3.27) and length of hospitalisation (effect size =0.15, 95% CI −0.28–0.57). A few minor adverse events were found. Pulmonary rehabilitation is a safe intervention during AECOPD. Exercise, breathing techniques, and education and psychosocial support seem to be the core components for implementing pulmonary rehabilitation during AECOPD. Studies may now focus on comparisons of optimal timings to start the intervention, total duration of the intervention, duration and frequency of sessions, and intensity for exercise prescription.