Informing the PuRe Trial through systematic reviews and multi-country feasibility studies on pulmonary rehabilitation in low-resource settings

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Background Pulmonary rehabilitation (PR) has been implemented successfully to improve symptoms and health related quality of life in patients with chronic respiratory disease (CRD) but the evidence is from global north. Few studies are available from low- and middle-income countries (LMICs). Aim To synthesise current literature and learnings from multi-country feasibility studies to inform a trial of PR with clinical/cost effectiveness in LMIC settings for people with CRD. Methods Two systematic reviews (SRs) synthesised evidence for PR in LMIC settings (Habib 2020) and compared centre & home-based PR (Uzzaman 2022). Feasibility studies of PR in CRD patients at four sites (Bangladesh, Malaysia, Pune & Vellore, India) and routine clinical data were reviewed to develop a practical evidence-based intervention for testing in a definitive trial. Results Published studies on PR in LMICs were encouraging but at high risk of bias (RoB) emphasising the evidence gap; Home-PR (LMICs n=3), was effective compared to usual care, with similar outcomes to Centre-PR. Feasibility studies showed improved outcomes but accessing centre-PR was a major barrier in Bangladesh/Malaysia. Data from Pune found physician’s recommendation improved participation in PR. In Vellore community-level centres improved access to PR improving completion to 70%. Conclusion Two SRs and 4 feasibility studies in LMIC sites underpinned development of a 3-arm individually randomised, assessor-blind, 6-month hybrid-1 implementation trial evaluating two approaches to delivering PR (Centre or Home-based) compared to usual care for people with CRD. Funded by UKMRC(MR/Y004809/1);ISRCTN65701828

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