Department of Cardiorespiratory Physiotherapy and Skeletal Muscle, Federal University of Juiz de Fora, Juiz de Fora, Brazil.
Graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil.
Cochrane Database Syst Rev. 2021 Aug 17;8(8):CD013569. doi: 10.1002/14651858.CD013569.pub2.
Pulmonary rehabilitation benefits patients with chronic obstructive pulmonary disease (COPD), but gains are not maintained over time. Maintenance pulmonary rehabilitation has been defined as ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation programme. It is not yet known whether a maintenance programme can preserve the benefits of pulmonary rehabilitation over time. Studies of maintenance programmes following pulmonary rehabilitation are heterogeneous, especially regarding supervision frequency. Furthermore, new maintenance models (remote and home-based) are emerging.
To determine whether supervised pulmonary rehabilitation maintenance programmes improve health-related quality of life (HRQoL), exercise performance, and health care utilisation in COPD patients compared with usual care. Secondly, to examine in subgroup analyses the impact of supervision frequency and model (remote or in-person) during the supervised maintenance programme.
We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PEDro, and two additional trial registries platforms up to 31 March 2020, without restriction by language or type of publication. We screened the reference lists of all primary studies for additional references. We also hand-searched conference abstracts and grey literature through the Cochrane Airways Trials Register and CENTRAL.
We included only randomised trials comparing pulmonary rehabilitation maintenance for COPD with attention control or usual care. The primary outcomes were HRQoL, exercise capacity and hospitalisation; the secondary outcomes were exacerbation rate, mortality, direct costs of care, and adverse events.
Two review authors independently screened titles and abstracts, extracted data, and assessed the risk of bias. Results data that were similar enough to be pooled were meta-analysed using a random-effects model, and those that could not be pooled were reported in narrative form. Subgroup analyses were undertaken for frequency of supervision (programmes offered monthly or less frequently, versus more frequently) and those using remote supervision (e.g. telerehabilitation versus face-to-face supervision). We used the GRADE approach to assess the certainty of evidence.
We included 21 studies (39 reports) with 1799 COPD patients. Participants ranged in age from 52 years to 88 years. Disease severity ranged from 24% to 88% of the predicted forced expiratory volume in one second. Programme duration ranged from four weeks to 36 months. In-person supervision was provided in 12 studies, and remote supervision was provided in six studies (telephone or web platform). Four studies provided a combination of in-person and remote supervision. Most studies had a high risk of performance bias due to lack of blinding of participants, and high risk of detection, attrition, and reporting bias. Low- to moderate-certainty evidence showed that supervised maintenance programmes may improve health-related quality of life at six to 12 months following pulmonary rehabilitation compared to usual care (Chronic Respiratory Questionnaire total score mean difference (MD) 0.54 points, 95% confidence interval (CI) 0.04 to 1.03, 258 participants, four studies), with a mean difference that exceeded the minimal important difference of 0.5 points for this outcome. It is possible that supervised maintenance could improve six-minute walk distance, but this is uncertain (MD 26 metres (m), 95% CI -1.04 to 52.84, 639 participants, 10 studies). There was little to no difference between the maintenance programme and the usual care group in exacerbations or all-cause hospitalizations, or the chance of death (odds ratio (OR) for mortality 0.73, 95% CI 0.36 to 1.51, 755 participants, six studies). Insufficient data were available to understand the impact of the frequency of supervision, or of remote versus in-person supervision. No adverse events were reported.
AUTHORS' CONCLUSIONS: This review suggests that supervised maintenance programmes for COPD patients after pulmonary rehabilitation are not associated with increased adverse events, may improve health-related quality of life, and could possibly improve exercise capacity at six to 12 months. Effects on exacerbations, hospitalisation and mortality are similar to those of usual care. However, the strength of evidence was limited because most included studies had a high risk of bias and small sample size. The optimal supervision frequency and models for supervised maintenance programmes are still unclear.
肺康复对慢性阻塞性肺疾病（COPD）患者有益，但随着时间的推移，获益并不持久。维持性肺康复的定义是在初始肺康复计划的基础上，以较低的频率进行持续的监督运动。目前尚不清楚维持性方案是否能随着时间的推移保持肺康复的益处。肺康复后维持方案的研究结果存在异质性，尤其是在监督频率方面。此外，新的维持模式（远程和家庭为基础）正在出现。
确定与常规护理相比，监督性肺康复维持方案是否能改善 COPD 患者的健康相关生活质量（HRQoL）、运动能力和医疗保健利用。其次，在亚组分析中，检查监督维持方案中监督频率和模式（远程或面对面）的影响。
我们检索了 Cochrane Airways 试验注册库、CENTRAL、MEDLINE、Embase、PEDro 和另外两个试验注册平台，截至 2020 年 3 月 31 日，没有语言或出版类型的限制。我们对所有初级研究的参考文献进行了筛选，以寻找其他参考文献。我们还通过 Cochrane Airways 试验注册库和 CENTRAL 手工检索了会议摘要和灰色文献。
我们只纳入了比较 COPD 肺康复维持与注意对照或常规护理的随机试验。主要结局是 HRQoL、运动能力和住院率；次要结局是恶化率、死亡率、护理直接成本和不良事件。
两名综述作者独立筛选标题和摘要、提取数据，并评估偏倚风险。结果数据足够相似，可以进行汇总分析的，采用随机效应模型进行meta 分析，不能汇总的数据则以叙述性方式报告。进行了亚组分析，包括监督频率（每月或更频繁的方案与不太频繁的方案）和使用远程监督（例如远程康复与面对面监督）。我们使用 GRADE 方法评估证据的确定性。
我们纳入了 21 项研究（39 份报告），共 1799 例 COPD 患者。参与者年龄从 52 岁到 88 岁不等。疾病严重程度从预计用力呼气量的 24%到 88%不等。方案持续时间从四周到 36 个月不等。12 项研究提供了面对面监督，6 项研究提供了远程监督（电话或网络平台）。四项研究提供了面对面和远程监督的组合。由于参与者缺乏盲法，大多数研究存在高度的偏倚风险，并且在检测、失访和报告偏倚方面也存在高度风险。低到中等确定性证据表明，与常规护理相比，监督性维持方案可能在肺康复后 6 至 12 个月时改善健康相关生活质量（慢性呼吸问卷总分平均差异 0.54 分，95%置信区间 0.04 至 1.03，258 名参与者，4 项研究），该结果的平均差异超过该结局的 0.5 分的最小重要差异。监督性维持方案可能会改善 6 分钟步行距离，但这是不确定的（MD 26 米，95%置信区间 -1.04 至 52.84，639 名参与者，10 项研究）。维持方案与常规护理组在恶化或全因住院率或死亡率方面没有差异（死亡率的优势比 0.73，95%置信区间 0.36 至 1.51，755 名参与者，6 项研究）。没有足够的数据来了解监督频率或远程与面对面监督的影响。没有报告不良事件。
本综述表明，肺康复后 COPD 患者的监督性维持方案不会增加不良事件的发生，可能会改善健康相关生活质量，并可能在 6 至 12 个月时改善运动能力。恶化、住院和死亡率的影响与常规护理相似。然而，由于大多数纳入的研究存在高度偏倚风险和样本量小，证据强度有限。监督性维持方案的最佳监督频率和模式仍不清楚。
