Pulmonary Rehabilitation After Exacerbation of Bronchiectasis

A Pilot Randomized Controlled Trial

James D. Chalmers; Megan L. Crichton; Gill Brady; Simon Finch; Mike Lonergan; Thomas C. Fardon

Disclosures

BMC Pulm Med. 2019;19(85) 

In This Article

Background

Exacerbations have a major impact on prognosis in patients with bronchiectasis.[1,2] Patients with frequent exacerbations experience a high risk of hospitalization, have significantly worse quality of life and an increase in mortality of 86% for patients experiencing 3 or more exacerbations per year.[2,3]

Exacerbations are inflammatory events that also increase the risk of cardiovascular complications.[4,5] Exacerbation symptoms last for a median of 16 days and up to 1 in 5 patients have not recovered symptomatically 35 days after an exacerbation.[6] Forced expiratory volume in 1 s and peak expiratory flow rate fall at exacerbation and improve at a variable rate during recovery leading to reduced physical activity and impairment of quality of life.[6,7] Physical activity and exercise capacity are key determinants of quality of life in bronchiectasis and have been most frequently evaluated using the 6 min walk test.[8,9]

Disease progression in bronchiectasis is associated with a reduction in exercise capacity. 6-min walk distance is correlated with lung function and extent of bronchiectasis on CT scan and was found by McDonnell et al. to reflect disease severity measured by the bronchiectasis severity index.[7] Patients with severe disease walked an average of 83 m less than patients with moderate disease and 198 m less than those with mild disease.[7]

Therefore maximising exercise capacity following exacerbations of bronchiectasis can be seen as preventing an important element of the disease progression associated with exacerbations.[10–12]

In COPD, it is accepted that performing pulmonary rehabilitation after exacerbations are acceptable and highly beneficial.[13] In the systematic review by Puhan et al., pulmonary rehabilitation reduced future hospital admissions (OR 0.22 95% CI 0.08–0.58, number needed to treat = 4) and reduced mortality (OR 0.28 95% CI 0.10–0.84, number needed to treat = 6) with substantial impacts on quality of life and a mean 6-min walk distance improvement of 77.7.[13,14] For this reason the use of pulmonary rehabilitation after exacerbations of COPD is accepted into clinical practice.

Pulmonary rehabilitation has shown benefits in bronchiectasis.[15] A recent systematic review by Lee et al. found 4 trials involing 164 participants which showed an improvement in incremental shuttle walk distance in trials in stable patients with improvement in health related quality of life immediately post intervention which faded by 6 months.[16] One study of 20 patients which attempted rehabilitation during hospital admission was identified but no studies were identified testing rehabilitation post-exacerbation.[17]

The Tayside Rehabilitation in Bronchiectasis Exacerbations (TRIBE) study was designed as a pilot study to determine potential benefits of rehabilitation following exacerbations of bronchiectasis.

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