Abstract
Pulmonary rehabilitation (PR) is a guideline-recommended multifaceted intervention that improves the physical and psychological well-being of people with chronic respiratory diseases (CRDs), though most of the evidence derives from trials in high-resource settings. In low- and middle-income countries, PR services are under-provided. We aimed to review the effectiveness, components and mode of delivery of PR in low-resource settings. Following Cochrane methodology, we systematically searched (1990 to October 2018; pre-publication update March 2020) MEDLINE, EMBASE, CABI, AMED, PUBMED, and CENTRAL for controlled clinical trials of adults with CRD (including but not restricted to chronic obstructive pulmonary disease) comparing PR with usual care in low-resource settings. After duplicate selection, we extracted data on exercise tolerance, health-related quality of life (HRQoL), breathlessness, included components, and mode of delivery. We used Cochrane risk of bias (RoB) to assess study quality and synthesised data narratively. From 8912 hits, we included 13 studies: 11 were at high RoB; 2 at moderate RoB. PR improved functional exercise capacity in 10 studies, HRQoL in 12, and breathlessness in 9 studies. One of the two studies at moderate RoB showed no benefit. All programmes included exercise training; most provided education, chest physiotherapy, and breathing exercises. Low cost services, adapted to the setting, used limited equipment and typically combined outpatient/centre delivery with a home/community-based service. Multicomponent PR programmes can be delivered in low-resource settings, employing a range of modes of delivery. There is a need for a high-quality trial to confirm the positive findings of these high/moderate RoB studies.
Highlights
The epidemiological transition from communicable to noncommunicable disease (NCD) imposes a ‘double burden’ on lowand middle-income countries (LMICs)[1], which continue to combat infectious diseases but are typically not yet ready to manage NCDs including chronic respiratory diseases (CRDs)[2]
Attrition 35%: similar in both groups FUNCTIONAL EXERCISE CAPACITYa Illustrated as no significant changes BREATHLESSNESSa Illustrated as no significant changes
We identified three models of Pulmonary rehabilitation (PR) service in our included studies according to the settings in which they were delivered
Summary
The epidemiological transition from communicable to noncommunicable disease (NCD) imposes a ‘double burden’ on lowand middle-income countries (LMICs)[1], which continue to combat infectious diseases but are typically not yet ready to manage NCDs including chronic respiratory diseases (CRDs)[2]. CRDs are common[3,4] and disabling[5,6,7] imposing a substantial burden in LMICs. Poor awareness and insufficient resources[8,9,10] in terms of infrastructure for diagnosis, availability of essential drugs, skilled health professionals, and overall healthcare priorities[5] limit management options[11]. The components of PR include, but are not limited to, exercise programmes, chest physiotherapy, education, and supporting self-management and lifestyle change, after optimising the recommended pharmacotherapy[13,14,15]. PR costeffectively reduces symptoms, morbidity, hospital admission (and readmission), duration of hospital stay, and emergency medical help and improves functional exercise capacity and health-related quality of life (HRQoL)[16,17,18,19,20]
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