Combining triple therapy and pulmonary rehabilitation in patients with advanced COPD: A pilot study

Background: The synergistic interactions between pharmacotherapy and pulmonary rehabilitation has been provided, but it remains to be established whether this may also apply to more severe patients. Objectives: We have examined whether tiotropium enhances the effects of exercise training in patients with advanced COPD (FEV₁ ≤ 60% predicted, hypoxemia at rest corrected with oxygen supplementation, and limitations of physical activity). Methods: We enrolled 22 patients that were randomised to tiotropium 18 μg or placebo inhalation capsules taken once daily. Both groups (11 patients in each group) underwent an in patient pulmonary rehabilitation program and were under regular treatment with salmeterol/fluticasone twice daily. Each rehabilitation session was held 5 days per week (3 h/day) for a total of 4 weeks. Results: Compared to placebo, tiotropium had larger impact on pulmonary function (FEV₁ + 0.164L, FVC +0.112L, RV -0.544L after tiotropium, FEV₁ + 0.084L, FVC -0.039L, RV -0.036L after placebo). The addition of tiotropium allowed a longer distance walked in 6 min (82.3 m vs. 67.7 m after placebo) and reduced dyspnoea (Borg score) (-0.4 vs. +0.18 after placebo) when compared with baseline (pre pulmonary rehabilitation program). The changes in SGRQ from baseline to the end of treatment were: total score -28.3U, activity -27.8U, impact -14.5U, and symptoms -33.4U in the placebo group; and total score -19.1U, activity -18.9U, impact -16.4U, and symptoms -33.8U in the tiotropium group. Conclusions: Our study clearly indicates that there is an advantage in combining pulmonary rehabilitation with an aggressive drug therapy in more severe patients.