Effectiveness of Pulmonary Rehabilitation in Patients with COPD

Background: Pulmonary rehabilitation (PR) is beneficial for patients with COPD, with improvement in exercise capacity and health-related quality of life. Despite these overall benefits, the responses to PR vary significantly among different individuals. It is not clear if PR is beneficial for patients with COPD and normal exercise capacity. Although it is believed that longer pulmonary rehabilitation programs can provide better results, most of the evidence comes from shortterm programs. Objective: The objective of this analysis was to determine the effectiveness of respiratory services provided in the hospital or community by respiratory therapists (RTs) in reducing health care utilization and improving patient outcomes. The aim was to evaluate the outcomes of a comprehensive pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease. Methodology: All 65 Pakistani patients who met the inclusion criteria with ages between 40 to 65 years, including both male and female, with mild to severe COPD were enrolled in the study on the basis of convenient sampling. Informed consent was taken from each patient starting about the study and their rights to withdraw from study. A demographics detail (name, age, sex) was noted along with the necessary medical history. A questionnaire was made to see the effects of pulmonary rehabilitation in patients with COPD. All necessary tests were performed to evaluate the patient betterment completely. Results: The mean FEV1 in the subjects was 1.29 ± 0.47 L/min, 64.8 ± 23.0% of predicted. Clinically there is a little effect on CXR pattern, FEV1 and FEV1/FVC after pulmonary rehabilitation. But overall quality of life improved after pulmonary rehabilitation. Mainly improvement occurs in peak expiratory flow rate, BORG dyspnea scale, 6 mint walk test distance (meters) and Oxygen saturation after rehabilitation. Conclusion: These results showed that patients with COPD had benefited from a comprehensive PR program in an out-patient setting regardless of disease severity. Exercise training can result in significant improvement in healthrelated quality of life, exercise capacity, respiratory muscle strength, and exertional dyspnea in subjects with COPD and normal exercise capacity.


Introduction
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not completely reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious gaseous particles mainly caused by cigarette smoking. Although COPD affects the lungs and produces significant systemic consequences.
(1) The most common symptoms of COPD are excessive sputum, SOB and a productive cough. (2) The pursed lip breathing, barrel chest, paradoxical movement of chest (Hoovers sign) are also common.
(3) Globally tobacco smoking is primary and most important risk factor for COPD. (2) In nonsmokers, passive smoke is responsible for about 20% of COPD cases. (3) The prevalence of COPD was modeled in 12 South-east Asian countries and estimated to be 6.3%, with highest prevalence in China (6.5%) and in Vietnam (6.7%). COPD has been estimated from 3.2% in France to 5.4% in the Netherlands. COPD is a major health problem across the world with its prevalence inversely proportionate to socioeconomic status. (4) Poorly ventilated cooking fires, often fueled by coal or biomass fuels such as wood and animal dung, lead to indoor air pollution and are one of the most common causes of COPD in developing countries. (5) Currently, the only inherited risk factor is alpha 1antitrypsin deficiency (AAT). (6) COPD is the 4th leading cause of death in the world, and there are further increases in the prevalence, morbidity and mortality of the disease. (7) 14 Volume 4 (Issue 1)

Pulmonary Rehabilitation in COPD
Diagnosis of COPD primarily rely on a reduction of FEV1 and FVC ratio decrease <70% post bronchodilators therapy. (8) Assessment of COPD is based on the patient's age, level of symptoms, exacerbation history, the severity of the spirometry report abnormality, and the related co-morbidities. Spirometry is now required to make a confident diagnosis of COPD. (2) Management included smoking cessation, influenza and pneumococcal vaccines, workplace health strategies, pulmonary rehabilitation, bronchodilators, corticosteroids, long term oxygen, surgery and stem cell therapy. (9) Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Focused onto the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce patient symptoms, optimize functional status, increase participation, and reduce health care utilization through stabilizing or reversing systemic manifestations of the disease. The aim of pulmonary rehabilitation is to break this vicious cycle and help the COPD patients to take part in daily activities. (10) Pulmonary rehabilitation has been well established and increasingly recommended in COPD and other chronic diseases management plans. Main elements included a multidisciplinary team, focus on the individual patient, and attention to emotional, psychological, social and physical aspects of health care. Appropriate candidates are symptomatic patients with chronic lung disease who are aware of their disability and still motivated to actively participate in their own health care activity and program. Pulmonary rehabilitation program has also been recommended and useful for patients with other types of chronic lung diseases. (11) Pulmonary rehabilitation may be beneficial for all patients in whom respiratory symptoms are associated with decreased/diminished functional capacity or reduced health related quality of life (HRQL). (12) It has been known to improve exercise capacity, dyspnea and health related quality of life in COPD following COPD. (13) Pulmonary rehabilitation induces important changes on depression and anxiety independent of changes in dyspnea and health-related quality-of-life. (14) Morbidity measures traditionally include physician visits, emergency department visits, and hospitalizations time duration. Although COPD databases for these outcome parameters are less readily available and usually less authentic than mortality databases, the limited data available indicate that morbidity due to COPD increases with age and is greater in men than in women. (15) Improved air quality can prevent COPD or slow down the worsening of existing disease. Annual influenza vaccinations in COPD reduce exacerbations, hospitalizations and death. (16) Keeping away people from starting smoking is a key aspect of preventing COPD as well as use of medications such as nicotine replacement therapy, bupropion (17). The rationale of this research was to see the effectiveness of pulmonary rehabilitation in stable COPD patients. The research was aimed to reduce disability and handicap in people with chronic lung disease and to improve their quality of life.

Materials and Methods
Study Design: It was a Randomized clinical trial. Setting: The data was collected from Gulab Devi Hospital Lahore Duration: The study was conducted in 4 months from November 2015 to February 2016 Sample Size: We included 70 patients of COPD. Sample size was calculated based on COPD prevalence i.e., 11.8%. Samples were divided in two groups A and B. Group A comprised of patients with conventional treatment while Group B patients comprised of patients taking pulmonary rehabilitation in addition to conventional treatment. Sampling Technique: Convenient sampling Inclusion Criteria: COPD patients with mild to severe COPD, stable patients with age 40-65, FEV1 40-80%, FEV1/FVC >65%, FCV 35-70%, paO2 >55% were included in this study. Exclusion criteria: Exclusion criteria include significant orthopedic or neurologic problems that reduce mobility or cooperation with physical training. In addition, poorly controlled coexisting medical conditions, especially psychiatric or unstable cardiac disease, may limit participation, thereby making the patient an unsuitable candidate. Patients with very severe COPD and Cor-pulmonale were also excluded. Statistical Analysis: Both descriptive and inferential statistics were done in Statistical Package for Social Sciences (SPSS) version 16.00.

Results
Mean age of patients was 53.96 + 6.471 with maximum age of 66 and minimum age of 45 years. In our study 32 (45.71%) patients were male; 3 (4.29%) patients were female in group A; 33(47.14%) patients were male and 2 (2.86%) patients were female in group B as shown in Figure 1.

Pulmonary Rehabilitation in COPD
In our study, 32 (45.71%) were smoker in group A, and 33 (47.14%) were smoker in group B. 3 (4.29%) were non-smoker in group A and 2(2.86%) were non-smoker in group B as shown in Figure 2. Table 1 showing chi-square value at baseline is 2.132 and P-value 0.545. Chi-Square value after 10 days is     Chi-square value at baseline is 4.597 and P-value is 0.467, chi-square value after 10 days is 20.897 and Pvalue is 0.002, chi-square value after 20 days is 20.010 and P-value is 0.003 as showed in Table 6 Group A 6 minutes-walk after 10 days t-value is -0.636 and P-value is 0.509, and mean was 54.0571±8.45383. Group B 6 minutes-walk after 10 days t-value is -0.636 and P-value is 0.509 and mean is 55.5143±9.87085. Group A 6 minutes-walk after 20 days t-value is -2.709 and P-value 0.009 is with mean was 51.3714±63674. Group B 6 minutes-walk after 20 days t-value is -2.709 and P-value is 0.009 with mean was 57.4857±10.18468. Walking time in daily life did not improve significantly at 3 months (mean improvement, 7 ± 35%; p = 0.21), but only after 6 months (mean improvement, 20 ± 36%; p = 0.008). No significant changes occurred in other activities or in the pattern of the time spent walking in daily life. Changes in dyspnea after the program were significantly related to changes in walking time in daily life (r = 0.43; p = 0.02) (21). As compared to another research Overall, patient healthrelated quality of life (HRQoL) and Exercise capacity assessed by a 6-min walking distance test (6MWD) was similarly significantly improved. However, there was some fall-off in terms of the distance walked 12 months after pulmonary rehabilitation. The improvements in exercise capacity, dyspnoea, and HRQoL did not differ between the two groups, with the exception that the 6MWD (P < 0.01) at 3 months post-pulmonary rehabilitation were significantly higher in the old-elderly group (22) while in our study P value after PR for 6MWD is 0.009 and for dyspnea scale P value is 0.003. Education of workers about the risks, smoking cessation, checking workers for early signs of COPD, use of respirators, and dust control (23). A number of measures have been taken to reduce the incidence that workers in at-risk industries such as coal mining, construction and stonemasonry will develop COPD.

Conclusions
Pulmonary rehabilitation proposed where patients who feel a loss of control as their disease advances may find that pulmonary rehabilitation offers them the opportunity to regain control. These results showed that patients with COPD had benefited from a comprehensive PR program in an out-patient setting regardless of disease severity. Even patients with earlier