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      The Impact of COPD Exacerbations in the Year Following Pulmonary Rehabilitation: Secondary Analysis of a Randomised Controlled Trial

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          Pulmonary rehabilitation is an effective treatment for people with chronic obstructive pulmonary disease (COPD), but its benefits are poorly maintained. The aim of this study was to evaluate the impact of COPD exacerbations in the year following pulmonary rehabilitation on outcomes at 12 months.


          This was a secondary analysis from a trial of home versus hospital-based rehabilitation in COPD, with 12 months of follow-up. Moderate and severe exacerbations were identified using administrative data (prescriptions) and hospital records (admissions) respectively. The impact of exacerbations at 12 months following pulmonary rehabilitation was evaluated for quality of life (Chronic Respiratory Questionnaire, CRQ), dyspnea (modified Medical Research Council, mMRC), exercise capacity (6-minute walk distance, 6MWD) and objectively measured physical activity (moderate-to-vigorous physical activity, MVPA).


          A total of 166 participants were included, with mean age (SD) 69 (9) years and forced expiratory volume in one second (FEV 1) 49 (19)% predicted. Moderate exacerbations occurred in 68% and severe exacerbations in 34% of participants. Experiencing a severe exacerbation was an independent predictor of worse 12-month outcomes for CRQ (total, fatigue and emotional function domains), mMRC, 6MWD and MVPA (all p<0.05). Participants who completed pulmonary rehabilitation were less likely to have a severe exacerbation (29% vs 48%, p=0.02). Severe exacerbations were more likely in those with worse baseline CRQ total (odds ratio 0.97, 95% CI 0.95 to 0.99) and FEV 1%predicted (0.98, 95% CI 0.96 to 0.99).


          Severe exacerbations occur frequently following pulmonary rehabilitation and predict worse 12-month outcomes. Strategies to maintain the benefits of pulmonary rehabilitation should address exacerbation prevention and management.

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          Most cited references 31

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          Pulmonary rehabilitation for chronic obstructive pulmonary disease.

          Widespread application of pulmonary rehabilitation (also known as respiratory rehabilitation) in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function (health-related quality of life, functional and maximal exercise capacity) attributable to the programmes. This review updates the review reported in 2006.
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            Development of a self-reported Chronic Respiratory Questionnaire (CRQ-SR).

            The Chronic Respiratory Questionnaire (CRQ) is an established measure of health status for chronic obstructive pulmonary disease (COPD). It has been found to be reproducible and sensitive to change, but as an interviewer led questionnaire is very time consuming to administer. A study was undertaken to develop a self-reported version of the CRQ (CRQ-SR) and to compare the results of this questionnaire with the conventional interviewer led CRQ (CRQ-IL). Fifty two patients with moderate to severe COPD participated in the study. Subjects completed the CRQ-SR 1 week after completing the CRQ-IL, and a further CRQ-SR was administered 1 week later. For patients in group A (n=27) the dyspnoea provoking activities that they had previously selected were transcribed onto the second CRQ-SR, while patients in group B (n=25) were not informed of their previous dyspnoea provoking activities when they completed the second CRQ-SR. To assess the short term reproducibility and reliability of the CRQ-SR it was then administered twice at an interval of 7-10 days to a further group of 21 patients. The CRQ-IL was not administered. Longer term reproducibility was examined in 39 stable patients who completed the CRQ-SR at initial assessment and then again 7 weeks later. Mean scores per dimension, mean differences, and limits of agreement are given for each dimension in the comparison of the two questionnaires. There were no statistically significant differences between the CRQ-IL and CRQ-SR in the mastery and fatigue dimensions (p>0.05). A statistically significant difference between the two scores was found in the dyspnoea dimension (p=0.006) and the emotional function dimension (p=0.04), but these differences were well within the minimum clinically important threshold. No statistically significant difference in the mean dyspnoea score was seen between groups A and B. The CRQ-SR was found to be reproducible both in the short term and after the longer period of 7 weeks, with no statistically or clinically significant differences in any dimension. Test-retest reliability was found to be high in each dimension, both in the short and longer term. The CRQ-SR is a reproducible, reliable, and stable measure of health status. It compares well with the CRQ-IL but cannot be used interchangeably. The main advantage of the CRQ-SR over the CRQ-IL is that is quick to administer, reducing assessment time and hence cost.
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              Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary.

              This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 report focuses primarily on the revised and novel parts of the document. The most significant changes include: (1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (2) for each of the groups A to D, escalation strategies for pharmacologic treatments are proposed; (3) the concept of deescalation of therapy is introduced in the treatment assessment scheme; (4) nonpharmacologic therapies are comprehensively presented; and (5) the importance of comorbid conditions in managing chronic obstructive pulmonary disease is reviewed.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of Chronic Obstructive Pulmonary Disease
                31 December 2020
                : 15
                : 3423-3431
                [1 ]La Trobe University , Melbourne, Australia
                [2 ]Monash University , Melbourne, Australia
                [3 ]Institute for Breathing and Sleep , Melbourne, Australia
                [4 ]Department of Respiratory and Sleep Medicine, Austin Health , Melbourne, Australia
                [5 ]Department of Medicine, The University of Melbourne , Melbourne, Australia
                [6 ]Department of Physiotherapy, Alfred Health , Melbourne, Australia
                [7 ]The Nossal Institute of Global Health, The University of Melbourne , Melbourne, Australia
                [8 ]Department of Physiotherapy, Austin Health , Melbourne, Australia
                [9 ]Department of Pulmonary Hypertension, Alfred Health , Melbourne, Australia
                [10 ]Physiotherapy Department, Monash University , Melbourne, Australia
                [11 ]Department of Public Health, La Trobe University , Melbourne, Australia
                Author notes
                Correspondence: Anne E Holland Monash University , Central Clinical School, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, VIC3004, AustraliaTel +61 3 99030214 Email
                © 2020 Wageck et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (

                Page count
                Figures: 0, Tables: 12, References: 32, Pages: 9
                Funded by: B Wageck is the recipient of a full fee research scholarship (LTUFFRs);
                Funded by: postgraduate research scholarships (LTUPRS) from La Trobe University, Melbourne, Australia;
                B Wageck is the recipient of a full fee research scholarship (LTUFFRs) and postgraduate research scholarships (LTUPRS) from La Trobe University, Melbourne, Australia.
                Clinical Trial Report

                Respiratory medicine

                predictors, copd, exacerbations, pulmonary rehabilitation, long term maintenance


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