Pulmonary rehabilitation as an alternative to inhaler

What was the aim of the evidence review?

The aim of the evidence review was to improve management of Chronic Obstructive Pulmonary Diseases (COPD) and therefore reduce admissions which will save money and be better for patients.

Who completed the evidence review?

Dr Farida Ahmad, GP Clinical Evidence Fellow (funded by the West of England Academic Health Science Network and Bristol Clinical Commissioning Group).

What did they do?

Farida read and summarised the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and collated data from NHS Rightcare and the local Joint Strategic Needs Assessment.

GOLD is an international initiative launched in 1997 in collaboration with the National Heart, Lung and Blood Institute, the World Health Organisation and various committees. Its guidelines for COPD care are shaped by these committees made up of leading experts from around the world and using the best level of evidence available.

How long did it take?

Four working days over one month to complete the review plus additional time to share findings.

What did they find?

Currently, COPD is the leading cause of morbidity and mortality worldwide and in the UK it is the only major cause of death on the increase. In Bristol, the admission rate for COPD is above the national average and the average cost per patient is £6,306.

The evidence shows that pulmonary rehabilitation is a much more effective way of managing COPD than the use of inhalers. Pulmonary rehabilitation is a programme of exercise and education and the only intervention that can actually change lung function aside from stopping smoking. It is shown to be cost effective as well as clinically effective, with improvement in quality of life for patients lasting up to three years. Pulmonary rehabilitation is preventative care and therefore reduces admissions.

Hardwick CCG in Cambridgeshire have reduced admissions from COPD by 30% in seven months by following high impact interventions endorsed by GOLD.

There is also evidence that inhalation of corticosteroid using an inhaler can increase patients’ risk of pneumonia and actually increase the risk of flare ups of COPD.

Who was the evidence shared with and why?

The evidence was shared in-house with GPs and nurses at Horfield Health Centre as well as at a Bristol Primary Care Agreement meeting which was attended by about 30 GPs and other clinical staff.

How were the findings used in local decision-making?

Maximising preventative care for COPD is part of the workstream of the Bristol, North Somerset and South Gloucestershire Sustainability and Transformation Plan (STP).

What has changed as a result?

When a patient with COPD gets admitted to hospital in Bristol, they automatically get referred for pulmonary rehabilitation as a result of the COPD discharge care bundle. This pathway has been in place for approximately two years. Currently 70% of referrals for pulmonary rehabilitation come from secondary care. The aim is to increases referrals from primary care in order to help with prevention.

A nurse has been employed by North Somerset CCG to go into individual practices and try to taper patients off of inhalation corticosteroids. The nurse assesses patients with COPD to see if they are suitable and then follows a set programme to wean them off their inhalers. The programme is quite complicated and there are some risks that the nurse needs to manage. If this proves to be successful, there is a plan to roll it out to the rest of the population across Bristol, North Somerset and, South Gloucestershire areas.

Access to pulmonary rehab is being made as easy as possible for patients; for example, transport is provided and interpreters are provided for those who can’t speak English.

Dr Farida Ahmad is now the Respiratory Lead for Horfield Health Centre and has joined a regional group of people with an interest in COPD, including community and respiratory nurses. They are looking at prevention and education (of both staff and patients) in primary care and whether there is a possibility of piloting and evaluating a mobile phone app ‘My COPD’ for patients to self-manage. This app enables patients with COPD to track and store relevant health information between clinic visits.

Successes and challenges


Most GPs and nurses were well informed with regards to inhalers but were not aware of the evidence that pulmonary rehabilitation can make such a difference. Now that they are becoming more aware, it may be possible to see a reduction in admissions and therefore cost savings and improved COPD management for patients. Discussions and planning for an evaluation are in the early stages. There is also ongoing discussion around how to build on these changes and work collaboratively across the STP area.


Patients are reluctant to go for a programme of pulmonary rehabilitation and prefer to rely on their inhalers which they feel work. GPs need to be quite persuasive as there is a high drop-out rate for pulmonary rehabilitation.

In some areas, GPs can make a referral for pulmonary rehabilitation through the computer system, however, in other areas they need to complete a form. The aim is for equal and easy access across the STP area.


  • Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines
  • National COPD audit programme, November 2014
  • GP records/QOF, British Lung Foundation
  • Joint Strategic Needs Assessment
  • NHS Rightcare
  • Flame study, published in NEJM, May 2016
  • Price D, West D, Brusselle G, et al. Management of COPD in the UK primary-care setting: an analysis of real-life prescribing patterns. Int J Chron Obst Pulm Dis 2014; 9: 889–905