It’s hard to improve on pulmonary rehabilitation for COPD when it is already so effective, the American Thoracic Society (ATS) 2018 International Conference was told.
Speaking in a Clinical Year in Review session, Dr William Man, a lung and sleep specialist at the Royal Brompton & Harefield NHS Foundation Trust in the UK, said neither the addition of pedometers or inspiratory muscle training were useful as adjuncts to pulmonary rehabilitation programs.
He said a UK study, which he coauthored, found the addition of pedometers ‘blunted’ the usual improvements in quality of life seen with pulmonary rehab.
And inspiratory muscle training, which people either loved or hated, did not improve clinical outcomes from pulmonary rehab in another randomised controlled trial.
“I think pulmonary rehabilitation is a very good intervention and that’s why we have found it very difficult to find adjuncts to make it better. But we can always do better.
We are now in the era of personalised medicine and I think because it has been relatively effective in all sorts of patients, what we haven’t been so good at is identifying particular aspects of rehab that would benefit particular phenotypes of patients.”
He said there was some data now to show that frail patients were much more likely not to complete pulmonary rehabilitation.
“So are there other things we can do for these sorts of patients? For example, we could work with other specialties such as palliative care or geriatricians, and use the knowledge that other specialties have to manage these complex patients.”
Dr Man said different models of pulmonary rehabilitation typically came up short when compared to supervised, centre-based programs but there remained a real opportunity for something new to improve uptake.
“Most of the trials that have been done in the past have either problems in the methodology or problem in the follow-up or very selected populations, but I think what we have seen in the last year or so on these home-based programs is they do produce clinically significant benefits for patients.”
A trial of an internet-based app versus a face-to-face program found clinical outcomes were similar however adherence with the online model fell to just 22% over six weeks.
In another home-based program based on a self-management manual, outcomes were non-inferior to usual care although he warned the intervention arm appeared to have selected a population who preferred to have their rehab at home.
“No trials have convincingly shown they are as good as a well run, supervised program but I do think if there are patients who don’t like the idea of a centre-based program, that there are now perfectly reasonable alternatives with a good safety profile and seem to have some sort of clinical benefit.”
“I personally think it comes in as a second line option for people who decline the gold standard.”
According to Dr Man serious accessibility issues to pulmonary rehabilitation still remained.
“Most guidelines now put it at the centre of care and it may be an issue that it is not properly reimbursed in some parts of the world. When it’s not reimbursed, it’s well down the priority list.”
“But even in the UK where it is funded, there is still a recognition problem and referral issue. Patient sensibility is quite important as well.”