PURPOSE: Evidence for optimal timing of pulmonary rehabilitation initiation, especially during stable chronic obstructive pulmonary disease (COPD) or following its acute exacerbation (AE), is conflicting. REVIEW METHODS: PubMed, EMBASE, and Cochrane CENTRAL were systematically searched before August 2022. The identified interventions were classified as single-component programs (endurance, resistance, and respiratory muscle training) and multi-component programs (combinations of these interventions). The revised risk-of-bias tool 2.0 was used to assess the risk of bias of the included studies. Network meta-analyses were performed separately for stable COPD and AECOPD using a random-effects model to calculate mean differences (MD). A total of 52 trials with 2,828 patients were included. For patients with stable COPD, multi-component programs combining endurance, resistance, and respiratory muscle training significantly improved the six-minute walk test (6MWT) distance (MD 72.09: 95% CI 48.16 to 96.02 meters) compared to usual care. In AECOPD, post-discharge initiation of rehabilitation with a combination of endurance and resistant training significantly reduced the readmission rate (OR 0.44: 95% CI 0.21 to 0.91); conversely, pre-discharge initiation with endurance training alone achieved the most significant improvements in both the readmission rate (OR 0.09: 95% CI 0.01 to 0.56) and 6MWT distance (MD 167.69: 95% CI 81.23 to 254.15 meters). SUMMARY: The integration of endurance, resistance, and respiratory muscle training improved exercise capacity in patients with stable COPD. Prioritizing endurance training prior to discharge demonstrated the most favorable outcomes in both readmission rates and exercise capacity for patients with AECOPD, although further validation is needed.
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