Pulmonary rehabilitation for acute and stable COPD : a systematic review and network meta-analysis

Background Evidence for optimal timing of pulmonary rehabilitation initiation, especially during stable chronic obstructive pulmonary disease (COPD) or following its acute exacerbation (AE), is conflicting. Methods PubMed, EMBASE, and Cochrane CENTRAL were systematically searched from their inception until July 2022. The identified interventions were classified as single-component programs (endurance, resistance, and respiratory muscle training) and multi-component programs (combinations of these interventions). The revised risk-of-bias tool 2.0 was used to assess the risk of bias of the included studies. Network meta-analyses were performed separately for stable COPD and AECOPD using a random-effects model to calculate mean differences (MDs). Results The analysis included 54 trials with 2,828 patients. For patients with stable COPD, multi-component rehabilitation programs combining endurance, resistance, and respiratory muscle training achieved the most significant improvements in the six-minute walk test (6 MWT) distance (MD, 72.09 m; 95% confidence interval [CI], 48.16–96.02) as compared to usual care. For patients with AECOPD, post-discharge initiation of rehabilitation with a combination of endurance and resistant training significantly reduced the readmission rate (odds ratio, 0.44; 95% CI, 0.21–0.91); conversely, pre-discharge initiation of rehabilitation with endurance training alone achieved the most significant improvements in both the readmission rate (odds ratio, 0.09; 95% CI, 0.01–0.56) and 6 MWT distance (MD, 167.69 m; 95% CI, 81.23–254.15). Conclusion The integration of endurance, resistance, and respiratory muscle training led to notable enhancements in exercise capacity among patients with stable COPD. Additionally, prioritizing endurance training alone prior to discharge demonstrated the most favorable outcomes in both readmission rates and exercise capacity for patients with AECOPD, although further studies are warranted to validate these findings. Trial registration: PROSPERO CRD42020153375