When is the optimal time to implement pulmonary rehabilitation for people with Chronic Obstructive Pulmonary Disease (COPD)?

INTERVENTION: Participants will be randomly allocated into three groups with participants commencing pulmonary rehabilitation at these various time frames (during hospital admission, 4 weeks post hospital discharge and 8 weeks post hospital discharge). This rehabilitation program consists of a total of 16 hours of exercise training and 8 hours of education. The exercise training component includes endurance (walking and cycling program) and upper and lower limbs muscle strength training. Participants are required to exercise at 80% of maximal intensity during the rehabilitation program and will complete training for one hour (approximately 30 minutes of walking/cycling and 30 minutes of strength training (two upper and lower limb exercises using free weights), twice a week. This exercise intensity will correlate to a participant exercising at a level of perceived dyspnea between 3 and 5 on the Borg scale (from 0 for no breathlessness to 10 for the most severe breathlessness) and a Borg exertion score of less than 13 for perceived level of exertion (from 6 for no exertion at all to 20 for maximal exertion) during the exercise training. The exercise training will be delivered by a qualified physiotherapist via small group sessions at the outpatient physiotherapy department at either sites. As for the education component, participants will attend an hour of group education each week with topics delivered by a multi‐disciplinary team. Individual health professional in the multi‐disciplinary team will be responsible for delivering a topic relevant to the management of COPD each week. The list of topics include exercise principles for people with COPD, relaxation techniques, use of bronchodilators, continence management, managing dyspnea and anxiety. These sessions will take place on the same day after the completion of an exercise training so as to reduce the number of visits a participant is required to make during the rehabilitation program. The only variation to the intervention will occur in the group which commences pulmonary rehabilitation at time of hospital admission. Due to the acuity of their exacerbation of COPD, participants in this group will complete 4 1/2 hour exercise sessions which includes both 15 minutes strength (both upper and lower limb) and 15 minutes endurance training (10 minutes of walking and 5 minutes of cycling) once a week until they are discharged from hospital. Pulmonary rehabilitation will be implemented within 4 days of admission. Upon discharge, they will continue their rehabilitation as per normal protocol. A register of attendance will be use to capture the attendance at each session. In a occasion that a participant has failed to turn up for his rehabilitation session, a follow up phone call will be made by a member of the research team to offer the participant an opportunity to make up for their missed session. Each participant will be offered three opportunities to make up for their missed session. CONDITION: Chronic obstructive pulmonary disease PRIMARY OUTCOME: Completion rates of pulmonary rehabilitation. This outcome will be assessed by number of participants who had completed at least 80% of total possible exercise sessions through review of rehabilitation attendance registers. Proportion of participants who had attended their first scheduled session. This outcome will be assessed by review of attendance registers in this trial. SECONDARY OUTCOME: Mortality rates Number of respiratory‐related hospital admissions assessed by the number of hospital admissions reported by participants and data linkage to hospital records. Physical function, assessed by 6 minute walk test distances Quadriceps muscle strength as assessed by hand held dynamometer. INCLUSION CRITERIA: Patients will be eligible for recruitment if they are: i) admitted into hospital with a primary diagnosis of an acute or infective exacerbation of COPD; ii) aged 40 years and above; iii) able to ambulate independently with or without a gait aid or oxygen; iv) deemed medically stable by the treating team to commence participation of pulmonary rehabilitation during hospital admission; v) have no significant comorbidities that will affect the patient’s ability to participate in rehabilitation and vi) are willing to participate in an 8‐week pulmonary rehabilitation program.