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COPD – Decreased time in hospital / bad days

Evidence Summary (Updated 2022)
A large body of good quality observational data shows a reduction in hospital admissions due to COPD exacerbations with pulmonary rehabilitation / continued supervised maintenance exercise .
An observational study of 597 participants with COPD showed reduced hospitalisations over a 12 months period in the more active group.(1)
Readmission to hospital for COPD exacerbation was found to be reduced in higher activity groups. Adjusted HR (95% CI): 0.85 (0.59 to 1.24) usual physical activity 79-232 kcal/day; p=0.400; 0.49 (0.31 to 0.79) usual physical activity >232 kcal/day; p=0.003 Adjusted HR (95% CI): 0.87 (0.60 to 1.27) usual physical activity 79-232 kcal/day; p=0.469; 0.54 (0.34 to 0.86) usual physical activity >232 kcal/day; p=0.010.(2) Further observational studies also confirmed that readmission in 30 days and the year following discharge was lower in active groups.(3–5)
A 5 RCT meta-analysis showed a statistically significant reduction in the risk of experiencing ≥1 respiratory-cause hospital admission with continued supervised maintenance exercise (interventions ranging from 6-36 months) following PR (risk ratio 0.62, 95% confidence interval (CI) 0.47–0.81, P<0.001). Statistical insignificance with a marginal trend towards the intervention group was seen in exacerbations (reduced risk ratio 0.79, 95% CI 0.52–1.19, P=0.25, I2=0%), mortality, hospital admissions (all-cause), length of star and outpatients or GP visits.(6)
However, the evidence for early pulmonary rehabilitation during an exacerbation was not always shown to reduce admission length. An 8 RCT (n = 434) meta-analysis looking at early PR (within 3 days of AECOPD admission). Early PR did not reduce the duration of hospital stay (MD: 0.26; 95% CI: −0.08 to 0.61; Z = 1.49, P = 0.14).(7)
A further review looking at when to start PR following COPD exacerbations. Clinically relevant reductions in readmission up to 3–6 months after PR in both early group (within 1 week) (4 trials, n= 190, risk ratio [RR] 0.58, [95% CI 0.34–0.99]) and late group (3 trials, n= 281, RR 0.48, [95% CI 0.32–0.71]). However, pulmonary rehabilitation had no significant effect on mortality 1 year later compared with usual care (4 trials, (n= 765); RR 1.27, [95% CI 0.91–1.79]).(8)
Garcia-Aymerich(2,9) et al have conducted a number of observational studies looking at the role of physical activity and COPD outcomes. They have found the COPD admissions were reduced in active groups (Adjusted IRR (95% CI): 0.72 (0.53 to 0.97) in low/moderate/high physical activity; p=0.033)
Another SR and MA looking at early PR. They showed clinically relevant reduction in mortality after early PR (4 RCTs, (n = 319); RR = 0.58 (95% CI: [0.35 to 0.98])) and at the longest follow-up (3 RCT, (n = 127); RR = 0.55 (95% CI: [0.12 to 2.57])). Early PR reduced number of days in hospital by 4.27 days (1 RCT, (n= 180); 95% CI: [− 6.85 to − 1.69]) and hospital readmissions (6 RCTs, (n= 319); RR = 0.47 (95% CI: [0.29 to 0.75])).(10)
With regards to exacerbations and admissions, Moy et al found increases in groups that had reduced daily step counts and lower 6MWT distances. For each 1000 fewer steps per day walked at baseline, there was an increased rate of exacerbations (rate ratio 1.07; 95%CI = 1.003-1.15) and hospital admissions (rate ratio 1.24; 95%CI = 1.08-1.42).(11)

Quality of Evidence
Grade B – moderate quality.

Strength of recommendation
Grade 1 – strong recommendation.

Clinical evidence is that sustained and regular physical activity can reduce the number of exacerbations , and the need for hospital admissions .


  1. Benzo RP, Chang CCH, Farrell MH, Kaplan R, Ries A, Martinez FJ, et al. Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease. Respiration [Internet]. 2010 Jun [cited 2022 Oct 5];80(1):10–8. Available from:
  2. Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Antó JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax [Internet]. 2006 Sep 1 [cited 2022 Oct 4];61(9):772–8. Available from:
  3. Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M, Gosselink R. Physical activity and hospitalization for exacerbation of COPD. Chest [Internet]. 2006 [cited 2022 Oct 5];129(3):536–44. Available from:
  4. Chawla H, Bulathsinghala C, Tejada JP, Wakefield D, ZuWallack R. Physical activity as a predictor of thirty-day hospital readmission after a discharge for a clinical exacerbation of chronic obstructive pulmonary disease. Ann Am Thorac Soc [Internet]. 2014 Oct 1 [cited 2022 Oct 5];11(8):1203–9. Available from:
  5. Nguyen HQ, Chu L, Liu ILA, Lee JS, Suh D, Korotzer B, et al. Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease. Ann Am Thorac Soc [Internet]. 2014 [cited 2022 Oct 5];11(5):695–705. Available from:
  6. Jenkins AR, Gowler H, Curtis F, Holden NS, Bridle C, Jones AW. Efficacy of supervised maintenance exercise following pulmonary rehabilitation on health care use: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis [Internet]. 2018 Jan 10 [cited 2022 Oct 5];13:257–73. Available from:
  7. Zhang D, Zhang H, Li X, Lei S, Wang L, Guo W, et al. Pulmonary Rehabilitation Programmes Within Three Days of Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis. Int J Chron Obstruct Pulmon Dis [Internet]. 2021 [cited 2022 Oct 4];16:3525. Available from: /pmc/articles/PMC8713718/
  8. Shibuya M, Yamamoto S, Kobayashi S, Nishie K, Yamaga T, Kawachi S, et al. Pulmonary Rehabilitation for Patients After COPD Exacerbation. Respir Care [Internet]. 2022 Mar 1 [cited 2022 Oct 5];67(3):360–9. Available from:
  9. Garcia-Rio F, Rojo B, Casitas R, Lores V, Madero R, Romero D, et al. Prognostic Value of the Objective Measurement of Daily Physical Activity in Patients With COPD. Chest. 2012 Aug 1;142(2):338–46.
  10. Ryrsø CK, Godtfredsen NS, Kofod LM, Lavesen M, Mogensen L, Tobberup R, et al. Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: A systematic review and meta-analysis 11 Medical and Health Sciences 1103 Clinical Sciences 11 Medical and Health Sciences 1117 Public Health and Health Services 11 Medical and Health Sciences 1102 Cardiorespiratory Medicine and Haematology. BMC Pulm Med [Internet]. 2018 Sep 15 [cited 2022 Oct 4];18(1):1–18. Available from:
  11. Moy ML, Teylan M, Weston NA, Gagnon DR, Garshick E. Daily step count predicts acute exacerbations in a US cohort with COPD. PLoS One [Internet]. 2013 Apr 4 [cited 2022 Oct 5];8(4). Available from: