1 Whilst telemonitoring of symptoms and physiological signals in community-dwelling people with COPD had promising initial results,77 a recent large Volasertib solubility dmso trial in the UK showed no impact on hospitalisation for AECOPD.78 In this trial both the telemonitoring and usual care groups had access to the same high-quality and accessible clinical care, suggesting that telemonitoring alone is not enough to improve outcomes. Randomised trials have not shown an impact of long-term oxygen therapy on exacerbation rate or hospitalisation, despite its mortality benefit.79 and 80 Smoking cessation

is a cornerstone of COPD management with a range of benefits for patients, including reduced exacerbation rate81 and reduced hospitalisation.82 Smoking cessation should therefore be encouraged and supported in all people with COPD. Like all health professionals, physiotherapists should take every opportunity to systematically identify smokers, assess smoking status, offer smoking cessation advice and refer for smoking cessation treatment. In recent years physiotherapy management for AECOPD has increasingly focussed on exercise-based rehabilitation, both in the outpatient and inpatient settings. In the light of recent evidence,54 there is an urgent need for research that helps us to understand the risks versus buy UMI-77 benefits of very early rehabilitation

for AECOPD. Whilst studies in other populations such as critical care and stroke indicates that very early rehabilitation has a greater balance of benefits than harms, this may not be applicable to AECOPD. Future research should carefully investigate the physiological effects of very early rehabilitation, including impact Idoxuridine on inflammatory status, and rigorously document the total dose of rehabilitation achieved over the course of the trial. Usual care should be defined in detail. A well-powered study conducted

across multiple settings will be required, and a safety monitoring board will be mandatory. Although physiotherapists commonly use breathing strategies to manage symptoms and enhance exercise tolerance during AECOPD, the evidence underpinning this practice is not convincing. As hospital admissions for AECOPD become shorter and the emphasis on achieving readiness for discharge becomes larger, there is a need to demonstrate that breathing techniques contribute to both patient wellbeing and improved function. Future research should examine whether breathing exercises give rise to clinically meaningful and measurable benefits for patients hospitalised with AECOPD; these include improved functional exercise tolerance, a faster return to independence and improved disease mastery. Similarly, any future trials of airway clearance techniques for AECOPD should select clinically meaningful outcomes and include only those phenotypes considered most likely to benefit (eg, those who are productive of sputum).