Background The widespread application pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function attributable to the programs. This review updates that reported by Lacasse et al Lancet 1996; 748:1115-1119. Objectives To determine the impact of rehabilitation on health-related quality of life (QoL) and exercise capacity in patients with COPD. Search strategy The 14 randomized controlled trials (RCTs) included in the original meta-analysis were included. Additional RCTs were identified from the Cochrane Airways Group's registry of COPD RCTs using the strategy: [exp, lung diseases, obstructive] and [exp, rehabilitation or exp, exercise therapy] and [research design or longitudinal studies or evaluation study or randomized controlled trial]. Abstracts presented at American Thoracic Society 1980-2000, American College of Chest Physicians 1980-2000 and European Respiratory Society 1987-2000 were also searched. Selection criteria RCTs of rehabilitation in patients with COPD in which quality of life (QoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. Rehabilitation was defined as exercise training for at least 4 weeks with or without education and/or psychological support. Control groups received conventional community care without rehabilitation. Data collection and analysis Weighted mean differences (WMD) were calculated using a random-effects model. Missing data from the primary study reports were requested from the authors. Main results 23 RCTs met the inclusion criteria. Statistically significant improvements were found for all the outcomes. In three important domains of QoL (Chronic Respiratory Questionnaire scores for Dyspnea, Fatigue and Mastery), the effect was larger than the minimal clinically important difference of 0.5 units using this instrument. For example Dyspnoea score: WMD 0.98 units, 95% Confidence Interval (95% CI) 0.74 - 1.22 units; n=9 trials. For FEC and MEC, the effect was small and a little below the threshold of clinical significance for the 6- minute walking distance: WMD 49 m, 95% CI: 26 - 72 m; n=10 trials. Reviewer's conclusions Rehabilitation relieves dyspnea and fatigue and enhances patients' sense of control over their condition. These improvements are moderately large and clinically significant. The average improvement in exercise capacity was modest. Rehabilitation forms an important component of the management of COPD.

Pulmonary rehabilitation for chronic obstructive pulmonary disease

Background
Cough and sputum production are common in chronic obstructive pulmonary disease (COPD) and are associated with adverse clinical outcomes. Airway clearance techniques (ACTs) aim to remove sputum from the lungs, however evidence of their efficacy during acute exacerbations of COPD (AECOPD) or stable disease is unclear.

Objectives
To assess the safety and efficacy of ACTs for individuals with AECOPD and stable COPD.

Search methods
We searched the Cochrane Airways Group Specialised Register of trials from inception to October 2011, and PEDro in October 2009.

Selection criteria
We included randomised parallel trials and randomised cross-over trials which compared an ACT to no treatment, cough or sham ACT in participants with investigator-defined COPD, emphysema or chronic bronchitis.

Data collection and analysis
Two review authors independently conducted data extraction and assessed the risk of bias. We analysed data from studies of AECOPD separately from stable COPD, and classified the effects of ACTs as 'immediate' (less than 24 hours), 'short-term' (24 hours to eight weeks) or 'long-term' (greater than eight weeks). One subgroup analysis compared the effects of ACTs that use positive expiratory pressure (PEP) to those that do not.

Main results
Twenty-eight studies on 907 participants were included in the review. Study sample size was generally small (range 5 to 96 people) and overall quality was generally poor due to inadequate blinding and allocation procedures. Meta-analyses were limited by heterogeneity of outcome measurement and inadequate reporting of data.

In people experiencing AECOPD, ACT use was associated with small but significant short-term reductions in the need for increased ventilatory assistance (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.05 to 0.85; data from four studies on 171 people), the duration of ventilatory assistance (mean difference (MD) -2.05 days, 95% CI -2.60 to -1.51; mean duration for control groups seven days; data from two studies on 54 people) and hospital length of stay (MD -0.75 days, 95% CI -1.38 to -0.11; mean duration for control groups nine days; one study on 35 people). Data from a limited number of studies revealed no significant long-term benefits of ACTs on the number of exacerbations or hospitalisations, nor any short-term beneficial effect on health-related quality of life (HRQoL) as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (MD -2.30, 95% CI -11.80 to 7.20; one study on 59 people).

In people with stable COPD, data from single studies revealed no significant short-term benefit of ACTs on the number of people with exacerbations (OR 3.21, 95% CI 0.12 to 85.20; one study on 30 people), significant short-term improvements in HRQoL as measured by the SGRQ total score (MD -6.10, 95% CI -8.93 to -3.27; one study on 15 people) and a reduced long-term need for respiratory-related hospitalisation (OR 0.27, 95% CI 0.08 to 0.95; one study on 35 participants).

The magnitude of effect of PEP-based ACTs on the need for increased ventilatory assistance and hospital length of stay was greater than for non-PEP ACTs, however we found no statistically significant subgroup differences. There was one report of vomiting during treatment with postural drainage and head-down tilt.

Authors' conclusions
Evidence from this review indicates that airway clearance techniques are safe for individuals with COPD and confer small beneficial effects on some clinical outcomes. Consideration may be given to the use of airway clearance techniques for patients with COPD in both acute and stable disease, however current studies suggest that the benefits achieved may be small.

Airway clearance techniques for chronic obstructive pulmonary disease

Background: Airway clearance is a key component of respiratory physiotherapy management for patients with excess secretions, including patients with chronic obstructive pulmonary disease (COPD). The aim of this review is to give an overview of the available evidence for the use of different airway clearance techniques (ACT) and their effects in patients with COPD. Methods: A systematic literature search was performed on CEBAM, PUBMED, Cochrane CT, Science Direct and Biomed central data bases. After screening, a total of 26 articles were included. Results: Studies that provide solid evidence of the effectiveness of different airway clearance techniques in patients with COPD are rather scarce. The available evidence indicates that active breathing techniques, such as active cycle of breathing techniques, autogenic drainage and forced expiration, can be effective in the treatment of COPD. The evidence for passive techniques such as postural drainage and percussion is low. Supporting techniques such as intrap...

Airway Clearance in COPD: Need for a Breath of Fresh Air? A Systematic Review

Physiotherapy in cystic fibrosis: optimising techniques to improve outcomes

Background: Positive expiratory pressure (PEP) has been used to promote airway clearance in individuals with chronic obstructive pulmonary disease (COPD) for many years; however, its mechanism of action and benefits are unclear. Previous authors have suggested that PEP improves collateral ventilation via changes in lung volumes. Objectives: It was the aim of this study to determine whether PEP improves ventilation inhomogeneity more than controlled huffing and coughing in individuals with stable COPD. Methods: Twelve participants with COPD (mean forced expiratory volume in 1 s 45% predicted) and chronic sputum expectoration performed PEP therapy (10-20 cm H2O) or controlled huffing and coughing in random order on alternate study days with a 48-hour washout. Measures of acinar and conductive airway ventilation (Sacin, Scond), lung volumes, spirometry and sputum wet weight were recorded before, immediately after and 90 min following treatment. Ease of expectoration [visual analogue scale (VAS)] and oxyhaemoglobin saturation were assessed immediately following treatment. Results: There were no significant differences between the effect of either test condition at any time point for any test parameter. Mean Sacin immediately following PEP and control conditions was 0.465 and 0.438 litre-1, respectively (p = 0.45 for comparison between conditions) and mean Scond was 0.042 and 0.039 litre-1 (p = 0.55). PEP therapy did not significantly enhance total mean sputum expectoration compared to controlled huffing and coughing (7.06 vs. 6.15 g; p = 0.51) and did not improve ease of expectoration (VAS PEP 4.8 cm vs. control 4.1 cm; p = 0.53). Conclusion: Any therapeutic benefits of PEP in individuals with COPD and chronic sputum expectoration are unlikely to be mediated by improvements in ventilation or lung volumes.

/pdf/positive-expiratory-pressure-via-mask-does-not-improve-2dlbuj4tua.pdf

Positive Expiratory Pressure via Mask Does Not Improve Ventilation Inhomogeneity More than Huffing and Coughing in Individuals with Stable Chronic Obstructive Pulmonary Disease and Chronic Sputum Expectoration

The efficacy of respiratory physiotherapy by combined-PEP (RC-Cornet® in combined-PEP-position) was evaluated in a long-term study with the following set up Study design: Randomized prospective clinical trial over 2 years in 50 patients with severe COPD (12 f, 38 m, 63,1 y, FEV 1 41 %, DLCO 51 % of the normal) Patients were without infection and exsmokers at begin of the trial One group was treated only by drug therapy (theophylline, salmeterol, ipratropiumbromide, systemic steroids 5 mg prednisolone equivalent) The second group received the same drug therapy plus physical therapy with the RC-Cornet® (oscillating PEP; in combined PEP-position) 3 times daily at least for 5 minutes or whenever needed Lung function data were controlled every 3 month during first year and every 4 month in the second year The compliance was checked by theophylline and cortisol blood levels, inspection of the functionality of the RC-Cornet® and by questioning the patient about compliance with the therapy Results: TGV (% of normal) and airway resistance (measured by bodyplethysmography) decreased significantly in contrast to the "mere" drug therapy (p < 00177, p < 00179) VC (% of normal) increased significant p < 00179 in the RC-Cornet® therapy group In this group significantly less patients (13/24) needed antibiotics in comparison to the "mere" drug group (Chi-Quadrat p < 00004) Also the need for hospital care was significantly less in the RC-Cornet® group (5/12) in comparison to the drug therapy group (Chi-Quadrat < 0000765) The length of hospital stay in the two groups was not significantly different: 162 ′ 63 days in the RC-Cornet®-group and 183 ′ 47 days in the drug therapy-group Conclusion: This study proves the efficacy of respiratory physiotherapy with combined-PEP in addition to drug therapy in the management of COPD-patients

/pdf/krankheitsverlauf-bei-schwerer-copd-mit-und-ohne-4soi5uz61h.pdf

Krankheitsverlauf bei schwerer COPD mit und ohne Physiotherapie mit dem RC-Cornet®

UNLABELLED The efficacy of respiratory physiotherapy by combined-PEP (RC-Cornet(R) in combined-PEP-position) was evaluated in a long-term study with the following set up STUDY DESIGN Randomized prospective clinical trial over 2 years in 50 patients with severe COPD (12 f, 38 m, 63,1 y, FEV 1 41 %, DLCO 51 % of the normal) Patients were without infection and exsmokers at begin of the trial One group was treated only by drug therapy (theophylline, salmeterol, ipratropiumbromide, systemic steroids 5 mg prednisolone equivalent) The second group received the same drug therapy plus physical therapy with the RC-Cornet(R) (oscillating PEP; in combined PEP-position) 3 times daily at least for 5 minutes or whenever needed Lung function data were controlled every 3 month during first year and every 4 month in the second year The compliance was checked by theophylline and cortisol blood levels, inspection of the functionality of the RC-Cornet(R) and by questioning the patient about compliance with the therapy RESULTS TGV (% of normal) and airway resistance (measured by bodyplethysmography) decreased significantly in contrast to the "mere" drug therapy (p < 00177, p < 00179) VC (% of normal) increased significant p < 00179 in the RC-Cornet(R) therapy group In this group significantly less patients (13/24) needed antibiotics in comparison to the "mere" drug group (Chi-Quadrat p < 00004) Also the need for hospital care was significantly less in the RC-Cornet(R) group (5/12) in comparison to the drug therapy group (Chi-Quadrat < 0000765) The length of hospital stay in the two groups was not significantly different: 162 +/- 63 days in the RC-Cornet(R)-group and 183 +/- 47 days in the drug therapy-group CONCLUSION This study proves the efficacy of respiratory physiotherapy with combined-PEP in addition to drug therapy in the management of COPD-patients

/pdf/course-of-severe-copd-with-and-without-physiotherapy-with-389ml0i5ud.pdf

[Course of Severe COPD with and without Physiotherapy with the RC-Cornet(R)].

In 35 patients with severe COPD and tracheal-bronchial instability the bronchodilatory effect of salbutamol (Salbulair(R) Autohaler) was tested prospectively, randomized and crossover on two consecutive days by bodyplethysmography. Following the salbutamol inhalation, the effect of ipratropiumbromide inhalation (by Pariboy and LC-plus-nebulizer) was evaluated in group A with an oscillating PEP-system (RC-Cornet(R), Position 1) in the expiratory outlet of the nebulizer and in group B with conventional inhalation by the Pari-system. The bronchodilatory effect was statistically significant better in group A inhaling ipratropiumbromide with the RC-Cornet(R) in the expiratory limb of the nebulizer in comparison to "normal" inhalation (decrease in airway resistance p < 0.0002, increase in vitacapacity p < 0.0051, increase in FEV1 p < 0.0161, Wilcoxon-Test for matched pairs). Using an oscillating PEP-system in the expiratory outlet of a nebulizer does not only increase the bronchodilatory effect of ipratropiumbromide but also shortens by combining inhalation and physiotherapy the time necessary for therapy in those patients.

/pdf/rc-cornet-r-improves-the-bronchodilating-effect-of-4otolo7z3q.pdf

[RC-Cornet(R) improves the bronchodilating effect of Ipratropiumbromide (Atrovent(R)) inhalation in COPD-patients].

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Krankheitsverlauf bei schwerer COPD mit und ohne Physiotherapie mit dem RC-Cornet®

[Course of Severe COPD with and without Physiotherapy with the RC-Cornet(R)].

[RC-Cornet(R) improves the bronchodilating effect of Ipratropiumbromide (Atrovent(R)) inhalation in COPD-patients].