Early Pulmonary Rehabilitation Following Acute COPD Exacerbation
Early Pulmonary Rehabilitation Following Acute COPD Exacerbation
The principal aim of the study is to evaluate whether attendance at an exercise training and
 education programme (known as pulmonary rehabilitation) shortly following hospital discharge
 can lead to a reduction in exacerbations and improvement in exercise capacity and quality of
 life in patients with chronic obstructive pulmonary disease.
Background:

 Chronic obstructive pulmonary disease (COPD), also sometimes known as chronic asthma,
 bronchitis or emphysema, is an important health problem. Many people with COPD are admitted
 into hospital with a worsening of their symptoms, known as an exacerbation. Hospitalisations
 for acute exacerbations of chronic obstructive pulmonary disease (COPD) are a massive burden
 to the NHS. Over the past decade, these hospitalizations have increased by 50%, and annual
 hospital costs for COPD in the UK amount to more than £587 million. After being discharged,
 some people fail to cope very well due to a variety of reasons. A prolonged stay in hospital
 may lead to muscle weakness, particularly of the leg muscles [1], a loss of confidence in
 performing everyday activities, and increased anxiety [2]. A high proportion of these
 patients are re-admitted to hospital following discharge. The aim of the study is to assess
 whether attendance at an exercise training and education programme shortly following
 discharge can firstly, improve exercise capacity and quality of life, and secondly, reduce
 the use of health resources and costs to the NHS.

 It is known that an exercise training and education programme known as Pulmonary
 Rehabilitation is beneficial to stable patients with COPD by reducing breathlessness,
 increasing exercise capacity and improving quality of life. We have recently performed a
 pilot study that has shown that early Pulmonary Rehabilitation has considerable short-term
 benefits in patients with COPD who have been recently discharged following a hospital
 admission for worsening of their symptoms [3]. We hypothesise that these benefits are
 long-lasting, and may reduce use of healthcare resources and costs to the NHS.

 References:

 1. Spruit, M.A., et al., Muscle force during an acute exacerbation in hospitalised patients
 with COPD and its relationship with CXCL8 and IGF-I. Thorax, 2003. 58(9): p. 752-6.

 2. Seemungal, T.A., et al., Effect of exacerbation on quality of life in patients with
 chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 1998. 157(5 Pt 1): p.
 1418-22.

 3. Man, W.D., et al., Community pulmonary rehabilitation after hospitalisation for acute
 exacerbations of chronic obstructive pulmonary disease: randomised controlled study.
 BMJ, 2004. 329(7476): p. 1209.

 Description of Study:

 Based on the results of our pilot study [1], we hypothesise that early pulmonary
 rehabilitation (EPR) leads to long term improvements in exercise capacity, quality of life,
 use & resulting costs of healthcare resources, peripheral muscle strength and daily activity
 levels. The null hypothesis is that EPR does not lead to a significant difference in outcome
 when compared to usual care (UC).

 EXPERIMENTAL DESIGN AND METHODS: This is a prospective randomised controlled clinical trial
 of EPR vs. usual care.By using a control group, statistically significant differences in
 outcome can be attributed to EPR. No treatment considered to be part of routine care is being
 withheld from the UC group.

 Patients: Patients studied will be those with an acute exacerbation of COPD deemed
 sufficiently unwell by the duty medical registrar to warrant hospital admission. Exclusion
 criteria will include significant co-morbidity that could limit exercise training, and
 attendance at a pulmonary rehabilitation programme in the preceding year. In-patient
 treatment will include standard therapy (nebulised bronchodilators, oxygen, non-invasive
 ventilation (if required), antibiotics and a 1-2 week course of oral prednisolone 30-40mg
 daily). On hospital discharge, patients will be allocated either to the early pulmonary
 rehabilitation (EPR) group (within 7 days of hospital discharge) or usual care (UC) i.e.
 routine outpatient and primary-care follow-up.

 PROTOCOL: In the 48 hours before planned hospital discharge, the following measurements will
 be made in all patients:

 1. Pulmonary function tests, including ear-lobe blood gases, spirometry, lung volumes, and
 transfer factor.

 2. Anthropometric data, including height, weight, body mass index, lean body mass (as
 measured by bio-electrical impedance)

 3. Field exercise capacity as measured by the incremental shuttle walk, a standard
 externally paced, incremental, maximal,corridor-walking test [2].

 4. Disease-specific and generic health status, as measured by the Chronic Respiratory
 Diseases Questionnaire (CRDQ) [3],St George's Respiratory Questionnaire (SGRQ) [4].
 Interviews will take place in the lung function department at King's College Hospital.

 5. Cardiopulmonary exercise testing in a subset of voulnteers, with measurements of VO2,
 and VCO2 and lactic acid.

 6. Non-volitional and volitional quadriceps strength: twitch quadriceps tension following
 supramaximal stimulation of femoral nerve and maximum isometric voluntary contraction.
 This is a painless supramaximal method of assessing quadriceps strength and fatigue [5]
 [6].

 7. Endurance walking capacity (endurance shuttle walk)

 8. Health resource usage (see later). The EuroQol (EQ-5D) instrument [7] will be used as
 the main measure of health-related quality-of-life in the economic evaluation.

 The measurements made at baseline will be repeated at 3 and 12 months. Of note, as this study
 is a prospective longitudinal study, patients will be familiarised with the exercise tests in
 the days before discharge to minimise learning effect. Verbal encouragement during exercise
 testing will be standardised to avoid researcher effects. The assessor will be blinded to the
 subject's intervention. However owing to the nature of the intervention, it will not be
 possible to blind the subjects to their intervention.

 RANDOMISATION: At discharge, patients will be allocated to either a hospital outpatient
 exercise rehabilitation programme, or usual care. Due to the numbers to be studied,
 allocation of treatments using the minimisation method will be used to ensure comparable
 groups. The following factors will be taken into account:

 1. Age (above and below 70)

 2. Gender (male/female)

 3. Hospital Discharge incremental shuttle walk distance (more or less than 100 metres).

 4. Length of Hospital Admission (more or less than 7 days)

 5. FEV1 more or less than 30% predicted

 INTERVENTION: Patients allocated to the EPR group will attend a pulmonary rehabilitation
 programme within 7 days of hospital discharge. This will consist of two sessions a week for 8
 weeks, and will be supervised by a multi-disciplinary team consisting of physiotherapists,
 occupational therapists, nurses and dieticians as well as the clinical research fellow funded
 by the proposed grant. Each session consists of 60 minutes exercise, made up of aerobic
 walking and cycling exercise plus lower and upper limb strength and endurance exercise, and 1
 hour of discussion focusing on psychosocial and lifestyle issues, with a particular emphasis
 on nutrition and domestic activity. The EPR group will be also be given an individualised
 home exercise programme, encouraging daily exercise. The UC group will receive usual
 outpatient and primary care follow-up.

 HEALTH ECONOMICS: The EuroQol (EQ-5D) instrument will be used as the main measure of
 health-related quality-of-life in the economic evaluation [9]. It has been developed by a
 collaborative group of European researchers as a preference-based index, suitable for the
 calculation of QALYs. The EQ-5D is one of two instruments currently recommended for use in
 economic evaluations [8]. Information on patients' use of health services will be collected
 by a review of hospital notes, patient recall and a home diary issued to all study
 participants. The resources included will be: hospital admissions, inpatient days, ITU days,
 outpatient consultations, A&E attendances, and primary care surgery and home visits.

 SAMPLE SIZE: Our preliminary pilot study was powered to detect a 50-metre difference in
 incremental shuttle walk at the 5% significance level with 90% power. Based on the health
 resource usage data collected from this pilot study, to detect a 50% reduction in hospital
 readmission rate at the 5% significance level with 80% power would require a minimum of 60
 patients (30 in each group). We propose to study 80 patients in this study

 References:

 1. Man, W.D., et al., Community pulmonary rehabilitation after hospitalisation for acute
 exacerbations of chronic obstructive pulmonary disease: randomised controlled study.
 BMJ, 2004. 329(7476): p. 1209.

 2. Singh, S.J., et al., Development of a shuttle walking test of disability in patients
 with chronic airways obstruction. Thorax, 1992. 47(12): p. 1019-24.

 3. Guyatt, G.H., et al., A measure of quality of life for clinical trials in chronic lung
 disease. Thorax, 1987. 42(10): p. 773-8.

 4. Jones, P.W., et al., A self-complete measure of health status for chronic airflow
 limitation. The St. George's Respiratory Questionnaire. Am Rev Respir Dis, 1992. 145(6):
 p. 1321-7.

 5. Man, W.D., et al., Non-volitional assessment of skeletal muscle strength in patients
 with chronic obstructive pulmonary disease. Thorax, 2003. 58(8): p. 665-9.

 6. Polkey, M.I., et al., Quadriceps strength and fatigue assessed by magnetic stimulation
 of the femoral nerve in man. Muscle Nerve, 1996. 19(5): p. 549-55.

 7. Brooks, R., EuroQol: the current state of play. Health Policy, 1996. 37(1): p. 53-72.

 8. Brazier, J., M. Deverill, and C. Green, A review of the use of health status measures in
 economic evaluation. J Health Serv Res Policy, 1999. 4(3): p. 174-84.
Inclusion Criteria:

 -  All patients admitted to King's College Hospital with a clinical diagnosis of acute
 exacerbation of COPD. Patients with radiological and microbiological evidence of
 pneumonia with co-existing COPD will also be included.

 Exclusion Criteria:

 -  Significant co-morbidity that could limit exercise training & testing: Patients unable
 to walk due to a comorbid neuromuscular or rheumatological condition; patients with
 severe sensory and cognitive impairment; patients with unstable angina or aortic valve
 disease in which exercise could be dangerous.

 -  Attendance at a pulmonary rehabilitation programme in the preceding year.