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The Effects of Pulmonary Rehabilitation in the National Emphysema Treatment Trial^*

Andrew L. Ries, MD, MPH; Barry J. Make, MD; Shing M. Lee, ScM; Mark J. Krasna, MD; Matthew Bartels, MD; Rebecca Crouch, PT; Alfred P. Fishman, MD; for the National Emphysema Treatment Trial Research Group

^* From the University of California, San Diego (Dr. Ries), San Diego, CA; National Jewish Medical and Research Center (Dr. Make), Denver, CO; The Johns Hopkins University (Ms. Lee), Baltimore, MD; University of Maryland (Dr. Krasna), Balrimore, MD; Columbia University (Dr. Bartels), New York, NY; Duke University (Ms. Crouch), Durham, NC; and the University of Pennsylvania (Dr. Fishman), Philadelphia, PA. A complete list of participants and centers in the NETT is located in the ^Appendix.

Correspondence to: Andrew L. Ries, MD, MPH, UCSD Medical Center, 200 W Arbor Dr, No. 8377, San Diego, CA 92103-8377; e-mail: aries{at}ucsd.edu

Study objectives: Pulmonary rehabilitation is an established treatment in patients with chronic lung disease but is not widely utilized. Most trials have been conducted in single centers. The National Emphysema Treatment Trial (NETT) provided an opportunity to evaluate pulmonary rehabilitation in a large cohort of patients who were treated in centers throughout the United States.

Design: Prospective observational study of cohort prior to randomization in a multicenter clinical trial.

Setting: University-based clinical centers and community-based satellite pulmonary rehabilitation programs.

Patients and intervention: A total of 1,218 patients with severe emphysema underwent pulmonary rehabilitation before and after randomization to lung volume reduction surgery (LVRS) or continued medical management. Rehabilitation was conducted at 17 NETT centers supplemented by 539 satellite centers.

Measurements and results: Lung function, exercise tolerance, dyspnea, and quality of life were evaluated at regular intervals. Significant (p < 0.001) improvements were observed consistently in exercise (cycle ergometry, 3.1 W; 6-min walk test distance, 76 feet), dyspnea (University of California, San Diego Shortness of Breath Questionnaire score, –3.2; Borg breathlessness score: breathing cycle, –0.8; 6-min walk, –0.5) and quality of life (St. George Respiratory Questionnaire score, –3.5; Quality of Well-Being Scale score, +0.035; Medical Outcomes Study 36-item short form score: physical health summary, +1.3; mental health summary, + 2.0). Patients who had not undergone prior rehabilitation improved more than those who had. In multivariate models, only prior rehabilitation status predicted changes after rehabilitation. In 20% of patients, exercise level changed sufficiently after rehabilitation to alter the NETT subgroup predictive of outcome. Overall, changes after rehabilitation did not predict differential mortality or improvement in exercise (primary outcomes) by treatment group.

Conclusions: The NETT experience demonstrates the effectiveness of pulmonary rehabilitation in patients with severe emphysema who were treated in a national cross-section of programs. Pulmonary rehabilitation plays an important role in preparing and selecting patients for surgical interventions such as LVRS.

Key Words: COPD • pulmonary exercise • pulmonary rehabilitation

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