End-Stage COPD Patients Don't Realize Benefits of Pulmonary Rehabilitation

Louise Gagnon

May 22, 2008

May 22, 2008 (Toronto, Ontario) — Patients with chronic obstructive pulmonary disease (COPD) should be referred earlier for pulmonary rehabilitation so that they can realize the benefits that the therapy offers, a team of Seattle investigators recommends.

Presenting study results here at the American Thoracic Society 2008 International Conference, Bonnie Steele, ARNP, PhD, a respiratory clinical nurse specialist at the Veterans Affairs Puget Sound Health Care System, in Seattle, Washington, noted that despite pulmonary rehabilitation (PR) being recognized as a means to enhance exercise capacity, dyspnea, and quality of life in COPD patients, the bulk of referrals for pulmonary rehabilitation occur when patients have severe or very severe health status, and are usually categorized as stage 3 or 4, according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

"Many of our referrals occur late in the disease process," Dr. Steele told attendees at an oral session. "It may be that the physician has tried a bunch of things with the patient [that don't work, and then tries] pulmonary rehabilitation. Second, folks with less disease may not want to participate in the program because of the time it takes. These patients may still be working and may not have the time."

Investigators retrospectively examined records from January 2001 to June 2006 of 106 patients with COPD with a mean age of 67 years who had a percent predicted forced expiratory volume in 1 second (FEV1) of 1% to 38%. A total of 14 subjects had end-stage disease or were defined as being in the last 2 years of life, and 92 did not have end-stage disease. The subjects were examined at the start and completion of the 8-week outpatient PR program.

Investigators recorded exercise capacity (6-minute walk), dyspnea in daily activities (using the Lareau Functional Status and Dyspnea Questionnaire), fatigue (using the Multidimensional Assessment of Fatigue Scale), quality of life (using the Seattle Obstructive Lung Disease Questionnaire and Short-Form [SF]36V), self-efficacy for walking (using the Self-Efficacy for Walking Scale), and comorbidities (using the Charlson Comorbidity Scale).

After adjustment for factors such as %FEV1, age, and comorbidities, Dr. Steele and colleagues concluded that there were significant differences on several measurements, including exercise capacity (147 ft; P = .01), self-efficacy for walking (2.2; P = .003), and SF36V physical functioning (3.88; P =. 025). They did not find any significant differences in other recorded variables. Of the 14 patients who were end-stage, 8 died from pulmonary complications, 4 died from heart attacks, and 2 died from cancer.

"We thought the differences between the end-stage and non-end-stage patients would be explained [by] the level of their %FEV1 (that is, their level of obstructive lung disease)," said Dr. Steele. "Even after controlling for variables like FEV1, there were significant differences in very important variables, such as exercise capacity, 6-minute walking, and confidence in walking ([from the] Self-Efficacy for Walking Scale). There was actually a decline in confidence in walking in end-stage patients."

Dr. Steele stressed that the data do not indicate anything about the effect on survival of participation in a PR program, but said prospective data could examine the impact of PR on survival. Still, the data underline the need to improve on delayed referral to PR.

"We are making a plea that COPD patients be recruited for pulmonary rehabilitation when they are in an earlier stage of disease, like GOLD stage 2," said Dr. Steele, noting that patients are categorized as having moderate disease in that stage. Linda Nici, MD, an associate professor of medicine at Brown University in Providence, Rhode Island, said that the study data illustrate the need to have patients participate in pulmonary rehabilitation at an earlier stage in the disease process.

"There is an urgency, even when they have mild disease, to have them benefit from preventive behavior strategies," said Dr. Nici, who moderated the session in which the research was presented.

Dr. Nici added that future research should be prospective in nature, include a greater proportion of women, and evaluate whether gender has any influence on outcome.

The Veterans Affairs Puget Sound Health Care System and the University of Washington funded the study. Neither Dr. Steele nor Dr. Nici have disclosed any relevant financial relationships.

American Thoracic Society 2008 International Conference: Abstract A556. Presented May 20, 2008.

Am J Respir Crit Care Med. 2008;177(suppl):A556.

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