1. Efficacy of standard rehabilitation in COPD outpatients with comorbidities 호흡기 내과 R1 박 지 윤 E. Crisafulli, P. Gorgone, B. Vagaggini, M. Pagani, G. Rossi, F. Costa,V. Guarriello, P. Paggiaro, A. Chetta, F. de Blasio, D. Olivieri, L.M. Fabbri and E.M. Clini European respiratory journal 22 April 2010

2. COPD is often associated with comorbidities Pulmonary rehabilitation (PR) nonpharmacological & comprehensive intervention showing marked efficacy in symptomatic COPD patients Previous retrospective wide cohort study in 2008 - half of enrolled patients have at least one chronic disease - presence of combined metabolic & heart diseases  reduced PR success rate INTRODUCTION

4. In COPD patients To confirm prevalence pattern of most frequent comorbidities To evaluate specific comorbidities or increasing number of comorbidities are associated with poorer outcome PURPOSE

5. Patients symptomatic patients with confirmed diagnosis of COPD January 2008–January 2009 at the four center Comorbidities diagnosed according to International Classification of Health Problems in Primary Care three categories : 0, 1, >2 METHOD

6. PR program standard activities - peripheral limb training, educational sessions, chest physiotherapy, psychological & nutritional counselling 3h sessions three times a week, minimum of 21 sessions required Rehabilitation outcomes 6-min walk distance(6MWD) Medical Research Council (MRC) scale : perceived breathlessness St George’s Respiratory Questionnaire (SGRQ) : perceived health-related quality of life Minimum clinically important difference (MCID) : assess PR efficacy

7. RESULT Figure1. Study flow diagram

8. Table 1. Baseline characteristics at admission No differences among comorbid categories

9. Figure 2. Frequency distribution of comorbidites

10. Table 2. Analysis of indivisuals’ outcome after PR

11. Figure 3. Factors affecting improvement after PR

12. Most of COPD patients have at least one chronic comorbidity Most frequent coexisting diseases hypertension, dyslipidemia, diabetes, coronary disease, CHF, osteoporosis According to MCID, more than 40% patient had significant change Coexistence of osteoporosis - negatively predicts 6MWD improvement DISCISSOIN

13. Functional disability degree at baseline and osteoporosis presence relate directly to outcome after PR Presence of comorbidity should not preclude access to and effectiveness of rehabilitation process in complex COPD CONCLUSION

14. Finally, PR outcomes in the present study were chosen as the strongest, easiest and best validated measures to represent the effectiveness of rehabilitation course in relation to patients with comorbidities. Overall, we cannot exclude that comorbidities would also have been associated with different outcomes (i.e. mood, workload exercise, functional status and healthcare utilisation). However, since this is a purely hypothesisgenerating study, it is likely that a different impact of comorbidities (number and/or type) on different outcomes could not be expected a priori.

15. Among all the other valuable factors that may predict response to PR in our study, baseline level of 6MWD, MRC and PaCO2 significantly affect the multivariate regression equation In all cases, the worse the baseline condition (lower 6MWD or higher MRC and Pa,CO2) the higher the proportion of patients gained the MCID outcome after PR. While a degree of improvement less than the MCID in those patients with a better baseline condition could be due to a possible ceiling effect, these findings inform us that inclusion of patients with poorer physical performance and lower gas exchange capacity (similarly to emphysema-type COPD) corresponds to a more elevated probability of improving their functional status independent on the presence of a ‘‘complex’’ comorbid phenotype [37]. Similar results have been already demonstrated in a smaller group of patients taken from a real-life setting and submitted for outpatient rehabilitation [38]. Thus, these patients should not be definitively excluded from standard PR in the usual clinical setting

17. Among all the other valuable factors that may predict response to PR in our study, baseline level of 6MWD, MRC and PaCO2 significantly affect the multivariate regression equation