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Kylie Hill, PhD; Roger S. Goldstein, MBChB, FCCP
Author and Funding Information

From the School of Physiotherapy and Curtin Health Innovation Research Institute (Dr Hill), Curtin University; the Lung Institute of Western Australia and Centre for Asthma, Allergy and Respiratory Research (Dr Hill), University of Western Australia; the Department of Respiratory Medicine (Dr Goldstein), West Park Healthcare Centre; and the Department of Physical Therapy and Medicine (Dr Goldstein), University of Toronto.

Correspondence to: Roger S. Goldstein, MBChB, FCCP, Department of Respiratory Medicine, West Park Healthcare Centre, 82 Buttonwood Ave, Toronto, ON, M6M 2J5, Canada; e-mail: roger.goldstein@westpark.org


Funding/Support: Dr Goldstein is supported by the University of Toronto-NSA Chair in Respiratory Rehabilitation Research.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(1):281. doi:10.1378/chest.12-2291
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To the Editor:

We thank Mr Babu for his interest in our work.1 Mr Babu highlights data to support the role of rehabilitation for people hospitalized with an acute exacerbation of COPD (AECOPD) and questions whether earlier access to physiotherapy via an “on-call” service would lead to improved outcomes at discharge. He refers to the results of a randomized controlled trial (RCT) conducted by his group in which patients who were hospitalized with an AECOPD were allocated to a group that received either (1) physiotherapy during normal working hours as well as out of hours via an on-call service (intervention) or (2) physiotherapy during normal working hours only (control).2 At the time of discharge from hospital, between-group differences in favor of the intervention group were demonstrated in measures of peak expiratory flow. Unfortunately, these differences did not translate to a decrease in the length of hospital stay. Although the intervention group had a greater 6-min walk distance at discharge, this is unlikely to be attributed to the on-call service, which focused exclusively on airway clearance techniques and strategies to ameliorate acute dyspnea rather than the implementation of additional supervised exercise training.2

Offering an on-call service would only be cost effective if the provision of additional out-of-hours physiotherapy was able to reduce health-care use. Currently, there are no robust data to suggest that airway clearance techniques or approaches that aim to ameliorate acute dyspnea confer reductions in health-care use. Although the meta-analysis of RCTs that explored the effects of exercise training initiated during or shortly following hospitalization for AECOPD demonstrated a reduction in readmissions in the group that received early rehabilitation, none of the RCTs offered out-of-hours physiotherapy services.3 This suggests that such gains are conferred without access to an on-call physiotherapy service. The one service that on-call physiotherapy is likely to be appropriate for is the early implementation of noninvasive ventilation (NIV) for those admitted with hypercapnic respiratory failure. In this population, NIV reduces hospital length of stay and improves survival.4 Earlier implementation of NIV is associated with more favorable outcomes, including a reduction in the length of stay in an ICU.5 Therefore, for those jurisdictions in which the implementation of NIV falls within the scope of physiotherapy practice, the provision an on-call physiotherapy service is justified.

Acknowledgments

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

Goldstein RS, Hill K, Brooks D, Dolmage TE. Pulmonary rehabilitation: a review of the recent literature. Chest. 2012;142(3):738-749. [CrossRef] [PubMed]
 
Babu AS, Noone MS, Haneef M, Samuel P. The effects of ‘on-call/out of hours’ physical therapy in acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Clin Rehabil. 2010;24(9):802-809. [CrossRef] [PubMed]
 
Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;10):CD005305.
 
Ram FS, Wellington S, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 2005;;(3):CD004360.
 
Schmidbauer W, Ahlers O, Spies C, Dreyer A, Mager G, Kerner T. Early prehospital use of non-invasive ventilation improves acute respiratory failure in acute exacerbation of chronic obstructive pulmonary disease. Emerg Med J. 2011;28(7):626-627. [CrossRef] [PubMed]
 

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References

Goldstein RS, Hill K, Brooks D, Dolmage TE. Pulmonary rehabilitation: a review of the recent literature. Chest. 2012;142(3):738-749. [CrossRef] [PubMed]
 
Babu AS, Noone MS, Haneef M, Samuel P. The effects of ‘on-call/out of hours’ physical therapy in acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Clin Rehabil. 2010;24(9):802-809. [CrossRef] [PubMed]
 
Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;10):CD005305.
 
Ram FS, Wellington S, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 2005;;(3):CD004360.
 
Schmidbauer W, Ahlers O, Spies C, Dreyer A, Mager G, Kerner T. Early prehospital use of non-invasive ventilation improves acute respiratory failure in acute exacerbation of chronic obstructive pulmonary disease. Emerg Med J. 2011;28(7):626-627. [CrossRef] [PubMed]
 
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