Pulmonary rehabilitation delivered in low resource settings for people with chronic respiratory disease: a 3-arm assessor-blind implementation trial

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Many people with chronic respiratory diseases (CRDs) such as chronic obstructive pulmonary disease, asthma, post-TB damage have disabling symptoms, especially breathlessness, which affect their day-to-day activities. Breathlessness is uncomfortable and frightening, so people tend to avoid activities that make breathlessness worse. Then, because they are not doing any exercise, muscles weaken and they become 'unfit', which makes activities even harder. This affects quality of life, and depression is common.HOW CAN PULMONARY REHABILITATION (PR) HELP?PR provides a supervised programme of exercise to reverse this vicious circle. PR combines endurance and muscle strengthening exercises, with education about the causes and treatment of CRDs, and coping with breathlessness. At the end of a course of PR, people with CRDs are less breathless and can do more, improving their quality of life.WHY DO WE NEED THIS TRIAL?Almost all PR trials were done in high-income countries, with well-equipped gyms and usually for people with one disease. In low- and middle-income countries (LMICs), PR Centres often have less equipment and limited access to tests that allow accurate diagnosis of different types of CRD. Another problem is distance; travelling to a Centre 16 times in 8 weeks may be difficult in rural LMICs, so home-based PR may be useful.Our questions are:* Does PR delivered in a low resource setting improve exercise capacity and quality of life in people with CRD?* Is PR delivered at home as effective as centre-based PR?* Do benefits of PR last 6 months?* How much does PR cost?* What do patients, PR therapists and professionals think of the services? PULMONARY REHABILITATION (PuRe) TRIAL We will recruit 465 adults with CRD from four centres (Bangladesh, India x2, Malaysia) and allocate them by chance to one of three groups:* Centre-PR: a programme of exercise and education twice a week for 8 weeks at a PR Centre * Home-PR: a programme of exercise and education twice a week for 8 weeks in their own homes, supervised remotely by video-call/telephone* Usual Care: usual clinical care. At the end of the trial, this group will be offered their choice of Centre-PR or Home-PROUTCOMES AND EXPECTED BENEFITSAt the end of the PR programme we will assess exercise capacity, quality of life, breathlessness, anxiety and depression, and again 6-months later to measure whether benefits are maintained. We will measure use of healthcare resources to assess the cost implications for the health service.IF SUCCESSFUL, HOW CAN THIS BE ROLLED OUT IN LMICS?We will interview participants to find out what they think of the PR. We will ask the therapists about the practicalities of delivering PR in their Centre and at home and how they overcame any problems. We will interview referring clinicians, health service managers and policymakers to understand how a service might be implemented and sustained in the four different settings.STAKEHOLDER AND COMMUNITY ENGAGEMENTTwo people with CRD are members of the project team (Ms Banu, Bangladesh; Mr Ku, Malaysia), and we will collaborate with community groups in each of the centres throughout the trial. Proactive stakeholder engagement will ensure our findings influence professionals and policymakers.WHO IS DOING THIS RESEARCH?Our team includes people with CRD, clinicians, therapists, researchers, statisticians, health economists and health psychologists from the University of Edinburgh and the four Centres. Together we have extensive experience in respiratory care, PR and conducting trials. Sharing that expertise with colleagues will help build research capacity in all the Centres. SHARING OUR FINDINGSWe are part of the NIHR Global Health Research Unit RESPIRE and will use their social media and networks to tell people about the PuRe trial and work with policymakers to promote change. We will present at conferences and write papers for scientific journals.