Pulmonary Rehabilitation for COPD Has Greater Effect Coupled With Triple Therapy

Smoking cannabis may increase the risk of respiratory disease such as chronic bronchitis, but quitting is likely to reduce the symptoms. It is unknown at this time whether cannabis use is linked to the development of COPD or asthma.
Smoking cannabis may increase the risk of respiratory disease such as chronic bronchitis, but quitting is likely to reduce the symptoms. It is unknown at this time whether cannabis use is linked to the development of COPD or asthma.
How does inpatient pulmonary rehabilitation affect patients with severe COPD — and does the effect differ in those who use inhaled triple therapy?

Pulmonary rehabilitation (PR) significantly benefits patients with chronic obstructive pulmonary disease (COPD). Moreover, those receiving inhaled triple therapy (TT) experienced greater benefits in exercise tolerance with pulmonary rehabilitation than those not using TT. These are among study findings published in Respiratory Medicine.

Investigators assessed the effects of inpatient PR in patients with severe COPD using inhaled TT compared with other inhaled therapies (no TT). TT includes inhaled combined therapy with the long-acting muscarinic antagonist (LAMA), long-acting beta2-agonist (LABA), and inhaled corticosteroids (ICS).

The researchers conducted a retrospective study of patients diagnosed with COPD who were admitted to a hospital network in Italy from July 2018 through December 2021. Patients received 2-3 hours per day of PR that included muscle strengthening, exercise cycling, counseling, and drug optimization, as well as monitoring for pulse oximetry, arterial blood pressure, and heart rate. The study’s primary outcome measure was exercise tolerance based on use of the 6-minute walking test (6MWT). Other measures were functional dyspnea according to the Medical Research Council (MRC) scale, and disease impact assessed with the COPD assessment test (CAT).

A total of 1139 patients with pre- and postprogram assessment of 6MWT were included in the study, of these, 357 also had pre- and postprogram evaluation of MRC and CAT data. For the analysis, patients were divided into 2 cohorts based on whether or not they used TT, with 695 participants in the TT group (mean age, 70.7±8.7 years; 66.2% male) and 444 participants in the no-TT group (mean age, 70.9±8.5 years; 67.3% male).

Pulmonary rehabilitation was associated with significant improvement in the 6MWT for both groups (from 283.1±123.7 to 337.3±116.0 meters for the TT group and from 336.2±123.4 to 378.7±123.2 meters for no-TT group; P <.001 for both).

The effect size based on postprogram increase in meters (by 54.3±69.7 vs 42.5±64.2 meters, P =.004) or percentage of baseline value (by 37.2±85.2%, vs 22.2±66.5%, respectively, P <.001) as well as by the proportion of patients who achieved the minimal clinically important difference (MCID) of 6MWT (64.2% vs 54.3%, P =.001) were significantly increased among patients who used TT.

In participants using TT (vs those not using TT), the rehabilitation program resulted in greater improvement in MRC (change in MRC: in no TT group, -0.9±0.7; in TT group, -1.1±0.6; P =.004) but did not result in improvement in CAT (change in CAT: in no TT group, -6.7±4.9; in TT group, -7.6±5.9; P =.136).

Compared with patients who used combined inhaled LAMA/LABA and LABA/ICS, those who used TT had significantly lower baseline 6MWT time without any significant difference in post-training improvement or in the proportion of participants who reached the MCID. Compared with patients who did not use inhaled drugs with ICS (LABA/LAMA, LABA, LAMA), the patients who did use inhaled drugs with ICS (including TT and other combinations with ICS) had a lower baseline 6MWT time, a greater post-training effect size, and included a significantly higher proportion of participants who achieved the MCID.

Significant independent predictors of improvement in the 6MWT included hospital provenience, TT use, and high eosinophil count, according to multiple logistic regression.

Study limitations include the retrospective design and lack of a control group that did not perform PR. Also, a majority of participants were male.

“Pulmonary rehabilitation resulted in significant benefits in individuals with COPD,” irrespective of the use of inhaled therapy, said study authors. “However, the benefits were greater in individuals using TT. Whether these results are associated with the inhaled therapy used or with the characteristics leading to the use should be further evaluated with randomized controlled trials.”

Disclosure: The study received partial unrestricted funding from Chiesi Farmaceutici SpA, Italy.


Vitacca M, Paneroni M, Spanevello A, et al. Effectiveness of pulmonary rehabilitation in individuals with chronic obstructive pulmonary disease according to inhaled therapy: the Maugeri study. Respir Med. Published online August 27, 2022. doi:10.1016/j.rmed.2022.106967