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Table 1 Characteristics of the included studies

From: Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis

Reference Country Study design Setting, duration and frequency Participants Intervention Intervention after discharge Usual care Notes Outcomes Dropouts
Behnke 2000 [27] Germany RCT Setting: in- and outpatient
Duration: hospital-based 10 days, home-based 6 months
Frequency: 7/week
46 admitted patients with AECOPD (mean age: 64–68 years, FEV1: 36% predicted). Comorbidities: not specified. PR consisted of conventional therapy including 30 min of daily breath exercises with respirologists and hospital-based training. Exercise training consisted of daily 6MWT and 5 self-controlled walking sessions at 75% of the treadmill walking distance of the respective day. Supervised home-based training for 6 mo.: walking training 3/day at 125% of the best 6MWD, health check every 2 weeks (mo. 0–3) followed by phone calls from mo. 3–6. Usual care: standard inpatient care and community care with respirologists (30 min of daily breathing exercises) but without exercise training Both groups (intervention and usual care) were supervised by the physician. Mortalityb Walking testb COPD related hospital readmissionsb Dropouta 16 dropouts (8 in PR group and 8 in control group)
Daabis 2017 [31] Egypt RCT Setting: outpatient Duration: 8 weeks Frequency: 3/week 30 admitted patients with AECOPD (mean age: 58–61 years, FEV1: 53–56% of predicted). Comorbidities: not specified. PR consisted of patient assessment, exercise training (ET), patient education including self-management of the disease, nutrition and lifestyle issues. Exercise training consisted of ET with 30-min of walking at the intensity of 75% 6MWT including 30-min of low-intensity RT. Outpatient PR Medical treatment. All patients received standard treatment with optimal medical treatment. HRQoLa Walking distancea No dropouts reported
Deepak 2014 [32] India RCT Setting outpatient Duration: 12 weeks 60 admitted patients with AECOPD (mean age: 59 years, FEV1: 47–53% of predicted, 93% men). Comorbidities: not specified. PR consisted of patient assessment, exercise testing, exercise training (mixture of limb strengthening and aerobic activities, tailored to individual baseline function), education, nutrition and psycho-social rehabilitation. Outpatient PR Conventional treatment without PR. All patients received conventional management consisting of medical treatment. HRQoLa Walking distancea 4 dropouts
Eaton 2009 [28] New Zealand RCT Setting: in- and outpatient
Duration: 8 weeks Frequency: 2/week
97 admitted patients with AECOPD (mean age: 70 years, FEV1: 35–36% of predicted, 42–45% men). Comorbidities: Measured with Charlson index (PR group: 3.1; control: 3.2). PR consisted of a daily 30-min structured, supervised exercise regimen that included walking and upper and lower limb strengthening exercises. Hospital-based outpatient program consisting of 1-h sessions of supervised exercise training and educational sessions (e.g. coping with dyspnea, management of ADL, nutritional advises, airway clearance). Usual care standardized in according with the ATS/ERS COPD guidelines and standardized advises on the benefits of exercise and maintaining daily activities. All patients received usual care standardized in according with the ATS/ERS COPD guidelines. Walking distancea COPD related hospital readmissionsb Dropouta 13 dropouts (8 in PR group and 5 in control group)
Kirsten 1998 [29] Germany RCT Setting: inpatient Duration: 10 days
Frequency: 7/week
31 admitted patients with AECOPD (mean age: 62–66 years, FEV1: 34–38% of predicted, 90% men). Comorbidities: not specified. PR consisted of 6MWT each day and additional 5 walking sessions per day at ≥75% of the respective walking distance. Inpatient supervised walking sessions 5/day. Usual care with optimal medical treatment. All patients received standard medical treatment. Walking testa 2 dropouts (not reported in which group)
Ko 2011 [34] China RCT Setting: outpatient Duration: 8 weeks Frequency: 3/week 60 admitted patients with AECOPD (mean age: 73–74 years, FEV1: 41–46% of predicted, 98% men). Comorbidities: coronary artery disease, cardiac arrhythmic, heart failure, hypertension, diabetes. PR consisted of supervised exercise training including treadmill, arm cycling, arm and leg strength training at 60–70% of VO2max or HRmax and were advised to perform at least 20 min home exercises a day. Education on proper breathing techniques and how to cope with daily activities. Supervised outpatient exercise training. Usual care with instructions to perform regular exercise at home (walking and muscle stretching exercise). Both groups were seen by the nurse specialist at the baseline assessment. HRQoLb Mortalitya,b Walking testb
Dropouta,b
9 dropouts (5 in PR group and 4 in control group) at the end of treatment. 6 dropouts (2 in PR group and 4 in control group) at the longest follow-up.
Ko 2017 [33] China RCT Setting: outpatient Duration: 8 weeks (1 year follow up) Frequency: 3/week 180 admitted patients with AECOPD (mean age: 75 years, FEV1: 42–47% of predicted, 94–97% men). Comorbidities: hypertension, type 2 diabetes, hyperlipidemia, ischemic heart disease, heart failure, old pulmonary tuberculosis. PR consisted of education (smoking cessation, technique of using medications, nutrition, dyspnea management, self-management, psychological distress, exercise benefits and strategies, breathing and sputum-removal techniques) and individual physical training program to perform at home or a short course of outpatient PR. Patients are offered supervised exercise training 3/week, if declining they are offered instructions for self-training, education, and telephone calls. Usual care with medical treatment. All patients received standard treatment with optimal medical therapy. HRQoLb Mortalitya
Walking testb Days in hospitala
38 dropouts (17 in PR group and 21 in control group)
Man 2004 [35] England RCT Setting: outpatient Duration: 8 weeks Frequency: 2/week 42 admitted patients with AECOPD (mean age: 70 years, FEV1: 37–42% of predicted, 40% men). Comorbidities: not specified. Supervised multidisciplinary PR, 1-h of exercise (aerobic walking and cycling, strength training for the upper and lower limb) and 1-h of education (with an emphasis on self-management of the disease, nutrition and lifestyle issues). Supervised multidisciplinary PR. Usual care with optimal medical treatment. All admitted patients received standard treatment and home diaries which included a disease specific information pack. HRQoFb Mortalityb Walking testb COPD related hospital readmissionsb Dropouta 8 dropouts (3 in PR group and 5 in control group)
Murphy 2005 [39] Ireland RCT Setting: outpatient home-based
Duration: 6 weeks Frequency: 2/week
31 admitted patients with AECOPD (mean age: 65–67 years, FEV1: 38–42% of predicted, 65% men). Comorbidities: not specified. PR consisted of 30–40-min supervised home-based exercise program, aerobic exercises including stepping up and down a stair, sitting to stand from a chair, upper limb strength exercises with low-impact elastic band at 3–5 on the Borg breathlessness score. Supervised home-based exercise program. Standard medical treatment without any form of PR exercises or lifestyle changes advice. All patients received standard medical treatment. Walking testa COPD related hospital readmissionsb
Dropouta
5 dropouts (3 in PR group and 2 in control group)
Puhan 2012 [30] Switzerland RCT Setting: in- and outpatient Duration: 12 weeks Frequency: 24 sessions (range 18–36) 36 admitted patients with AECOPD (mean age: 67 years, FEV1: 43–46% of predicted, 58% men). Comorbidities: cardiovascular, endocrine, musculoskeletal, other. Early inpatient PR within 2 weeks after exacerbation, exercise training included endurance, strength and calisthenics training in addition with education (e.g. individual action plan, mediational use, exercise at home, coping with daily activities, smoking cessation). Outpatient PR, exercise training included endurance, strength and calisthenics training in addition with education (as described under intervention). Late PR starting 6 mo. after exacerbation, exercise training included endurance, strength and calisthenics training in addition with education. Recommended number of exercise session 24 (ranged between 18 and 36). Mortalitya Dropouta 8 dropouts (4 in PR group and 4 in control group)
Revitt 2018 [37] United Kingdom RCT Setting: inpatient Duration: 6 weeks
Frequency: 2/week
28 admitted patients with AECOPD (mean age: 66 years; FEV1: 1.18 l). Comorbidities: not specified. Early PR within 4 weeks of discharge. PR consisted of individualized aerobic and resistance exercises and education on chest clearance and energy conservation. Hospital-based PR. Late PR initiated 7 weeks after discharge including exercise and education. All patients received the same PR program. Dropouta 11 dropouts (3 in control group prior to the program and 8 in PR group during the program)
Seymour 2010 [36] United Kingdom RCT Setting: outpatient (hospital-led) Duration: 8 weeks Frequency: 2/week 60 admitted patients with AECOPD (mean age: 65-67 years, FEV1: 52% of predicted, 45% men). Comorbidities: hypertension, type 2 diabetes, ischemic heart disease. PR consisted of supervised exercise training including a mixture of limb strengthening and aerobic activities tailored to individual baseline function and education session (lasting 2 h). Hospital-led supervised exercise training. Usual care with optimal medical treatment. All patients were provided with general information about COPD and offered outpatient appointments with their general practitioner or respiratory team. HRQoFb Walking testa COPD related hospital readmissionsb
Dropoutb
11 dropouts (7 in PR group and 4 in control group)
Troosters 2000 [38] Belgium RCT Setting: outpatient Duration: 6 mo (18 mo follow up)
Frequency: 2–3/week
100 patients with AECOPD referred to outpatient clinic (mean age: 60–63 years, FEV1: 41–43% of predicted, 87% men). Comorbidities: not specified. PR consisted of 90-min supervised ET and RT. ET consisting of cycling, treadmill walking, and stair climbing at 60–80% of initial Wmax during cycle ergometer/maximal walking speed. RT consisting of strength exercises for 5 muscle groups, 10 reps at 60% 1RM. Supervised outpatient exercise training. Usual medical care consisting of standard community care with respirologist. During exercise training supplemental oxygenwas given to maintain oxygen saturation above 90%. Mortalitya walking testa dropouta,b 30 dropouts (13 in PR group and 17 in control group) at the end of treatment. 21 dropouts (11 in PR group and 10 in control group) at the longest follow-up.
  1. AECOPD acute exacerbations of chronic obstructive pulmonary disease, COPD chronic obstructive pulmonary disease, CT combined training, ET endurance training, FEV1 forced expiratory volume in 1 s, HRmax maximum heart rate, HRQoL health related quality of life, RCT randomized controlled trial, 1RM one repetition maximum, RT resistance training, Reps repetitions, VO2max maximal oxygen uptake, Wmax maximal work load in Watts, 6MWD 6 min walking distance, 6MWT 6 min walking test
  2. aAfter end of treatment
  3. bAfter longest follow up
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