This systematic review aimed to systematise the different designs used to deliver pulmonary rehabilitation during acute exacerbations of COPD (AECOPD) and explore which ones are the most effective. PubMed, Scopus, Web of Science, EBSCO and Cochrane were searched. Randomised controlled trials comparing pulmonary rehabilitation or at least one of its components with usual care or comparing different components of pulmonary rehabilitation were included. Network meta-analysis was conducted in MetaXL 5.3 using a generalised pairwise modelling framework. Pooled effects compared each treatment to usual care. 42 studies were included. Most studies were conducted in an inpatient setting (57%) and started the intervention 24–48 h after hospital admission (24%). Exercise training (71%), education and psychosocial support (57%) and breathing techniques (55%) were the most used components. Studies combining exercise with breathing techniques presented the larger effects on exercise capacity (weighted mean difference (WMD) −41.06, 95% CI −131.70–49.58) and health-related quality of life (WMD 16.07, 95% CI 10.29–21.84), and breathing techniques presented the larger effects on dyspnoea (WMD 1.90, 95% CI 0.53–3.27) and length of hospitalisation (effect size =0.15, 95% CI −0.28–0.57). A few minor adverse events were found.Pulmonary rehabilitation is a safe intervention during AECOPD. Exercise, breathing techniques, and education and psychosocial support seem to be the core components for implementing pulmonary rehabilitation during AECOPD. Studies may now focus on comparisons of optimal timings to start the intervention, total duration of the intervention, duration and frequency of sessions, and intensity for exercise prescription.

BackgroundIncremental step tests (IST) can be used to assess exercise capacity in people with chronic obstructive pulmonary disease (COPD). The development of a new step test based on the characteristics of the incremental shuttle walk test (ISWT) is an important study to explore. We aimed to develop a new IST based on the ISWT in people with COPD, and assess its validity (construct validity) and reliability, according to Consensus-based Standards for the selection of health status Measurement Instruments (COSMIN) recommendations.MethodsA cross-sectional study was conducted in participants recruited from hospitals/clinics. During the recruitment, the participants who presented a 6-minute walk test (6MWT) report in the previous month were also identified and the respective data was collected. Subsequently, participants attended two sessions at their homes. IST was conducted on the first visit, along with the 1 min sit-to-stand (1MSTS) test. IST was repeated on a second visit, performed 5–7 days after the first one. Spearman’s correlations were used for construct validity, by comparing the IST with the 6MWT and the 1MSTS. Intraclass correlation coefficient (ICC2,1), SE of measurement (SEM) and minimal detectable change at 95% CI (MDC95) were used for reliability. The learning effect was explored with the Wilcoxon signed-rank test.Results50 participants (70.8±7.5 years) were enrolled. IST was significant and moderate correlated with the 6MWT (ρ=0.50, p=0.020), and with the 1MSTS (ρ=0.46, p=0.001). IST presented an ICC2,1=0.96, SEM=10.1 (16.6%) and MDC95=27.9 (45.8%) for the number of steps. There was a statistically significant difference between the two attempts of the IST (p=0.030).ConclusionDespite the significant and moderate correlations with the 6MWT and 1MSTS, the inability to full compliance with the COSMIN recommendations does not yet allow the IST to be considered valid in people with COPD. On the other hand, the IST is a reliable test based on its high ICC, but a learning effect and an ‘indeterminate’ measurement error were shown.Trial registration numberNCT04715659.

Pulmonary rehabilitation (PR) has well-established benefits for the management of stable chronic obstructive pulmonary disease (COPD). However, its role during acute exacerbations of COPD (AECOPD) has been controversial, which may be related with the variety of designs used. This study aimed to identify the most effective design to deliver PR during AECOPD.PubMed, Scopus, Web of Science, EBSCO and Cochrane were searched. Two independent reviewers assessed the quality of studies using the Delphi List. Comprehensive meta-analysis was used to calculate the individual and pooled effect sizes (ES). 35 randomized controlled trials were included. Most studies were conducted in an inpatient setting (19/35) and started the intervention 24-48h after admission (7/35). Most used components were aerobic training (21/35), breathing techniques (21/35), strength training (19/35) and education (19/35). Studies that combined breathing techniques with exercise training had larger effects (ES=1.3, 95%Confidence Interval (CI) 1.1-1.5) than exercise only (ES=0.4, 95%CI 0.1-0.7) in exercise capacity (Fig. 1).A large variety of designs has been used to delivery PR during AECOPD. The addition of breathing techniques in the management of AECOPD seems to be more effective than just exercise training in improving patients' exercise capacity. Studies assessing other outcomes and aspects of design are needed to establish recommendations for PR during AECOPD.