"Can do" versus "do do": A Novel Concept to Better Understand Physical Functioning in Patients with Chronic Obstructive Pulmonary Disease

ERS International Congress, Madrid, 2019: highlights from the Respiratory Infections Assembly

The European Respiratory Society (ERS) International Congress organised in Madrid, Spain, in 2019 welcomed >22 000 participants from 134 countries. For each ERS assembly, an impressive number of abstracts were submitted. The topics covered by Assembly 10 (Respiratory Infections and Tuberculosis) were included this year in the top five research areas with the most submitted abstracts, with a total of 424 abstracts accepted for presentation. As it would be difficult for any delegate to stay up to date with all the scientific advances in the field, we wanted to highlight three of the Congress sessions that included presentations on respiratory infections and tuberculosis that we deemed as important and we hope the readers will consider this material of great interest.

Fatigue is highly prevalent in patients with COPD and correlates poorly with the degree of airflow limitation

Background:

The objective of this study was to compare fatigue levels between subjects with and without COPD, and to investigate the relationship between fatigue, demographics, clinical features and disease severity.

Methods:

A total of 1290 patients with COPD [age 65 ± 9 years, 61% male, forced expiratory volume in 1 s (FEV1) 56 ± 19% predicted] and 199 subjects without COPD (age 63 ± 9 years, 51% male, FEV1 112 ± 21% predicted) were assessed for fatigue (Checklist Individual Strength-Fatigue), demographics, clinical features and disease severity.

Results:

Patients with COPD had a higher mean fatigue score, and a higher proportion of severe fatigue (CIS-Fatigue score 35 ± 12 versus 21 ± 11 points, p < 0.001; 49 versus 10%, p < 0.001). Fatigue was significantly, but poorly, associated with the degree of airflow limitation [FEV1 (% predicted) Spearman correlation coefficient = −0.08, p = 0.006]. Multiple regression indicated that 30% of the variance in fatigue was explained by the predictor variables.

Conclusions:

Severe fatigue is prevalent in half of the patients with COPD, and correlates poorly with the degree of airflow limitation. Future studies are needed to better understand the physical, psychological, behavioural, and systemic factors that precipitate or perpetuate fatigue in COPD.

"Can do, don't do" are not the lazy ones: a longitudinal study on physical functioning in patients with COPD

Background and objective

Reduced physical capacity (PC) and physical activity (PA) are common in COPD patients and associated with poor outcome. However, they represent different aspects of physical functioning and interventions do not affect them in the same manner. To address this, a new PC-PA quadrant concept was recently generated to identify clinical characteristics of sub-groups of physical functioning. The objective of this study was to I) proof the new concept and to verify their differentiating clinical characteristics, II) evaluate the consistency of the concept over time, III) assess whether patients changed their quadrant affiliation over time, IV) and to test if changes in quadrant affiliations are associated with changes in clinical characteristics.

Methods

In a longitudinal, prospective, non-interventional cohort with mild to very severe COPD patients, PC and PA as well as respiratory variables, COPD-specific health status, comorbidities, survival, and exacerbations were yearly assessed.

Results

Data from 283 patients were analysed at baseline. Mean (min/max) follow-up time was 2.4 (0.5/6.8) years. The PC-PA quadrants could be characterized as follows: I) “can’t do, don’t do”: most severe and symptomatic, several comorbidities II) “can do, don’t do”: severe but less symptomatic, several comorbidities III) “can’t do, do do”: few patients, severe and symptomatic, less comorbidities IV) “can do, do do”: mildest and less symptomatic, less comorbidities, lowest exacerbation frequency. Of the 172 patients with at least one follow-up, 58% patients never changed their quadrant affiliation, while 17% declined either PC, PA or both, 11% improved their PC, PA or both, and 14% showed improvement and decline in PC, PA or both during study period. None of the clinical characteristics or their annual changes showed consistent significant and relevant differences between all individual sub-groups.

Conclusion

Our findings suggest that there are no clinical characteristics allowing to distinguish between the PC-PA quadrants and the concept seems not able to illustrate disease process. However, the already low PA but preserved PC in the “can do, don’t do” quadrant raises the question if regularly assessment of PA in clinical practice would be more sensitive to detect progressive deterioration of COPD compared to the commonly used PC.

Clinical trial registration

www.ClinicalTrials.gov, NCT01527773.

Organizational aspects of pulmonary rehabilitation in chronic respiratory diseases

Adult patients with chronic respiratory diseases may suffer from multiple physical (pulmonary and extra-pulmonary), emotional and social features which necessitate a comprehensive, interdisciplinary rehabilitation programme. To date, pulmonary rehabilitation programmes show a lot of variation in setting, content, frequency and duration. Future projects should strive for a standard set of assessment measures to identify patients eligible for pulmonary rehabilitation, taking disease complexity into consideration, which should result in referral to an appropriate rehabilitation setting. Local circumstances may complicate this crucial endeavour.

Physical Activity Levels Are Low in Inoperable Lung Cancer: Exploratory Analyses from a Randomised Controlled Trial

Background: In inoperable lung cancer, evidence is limited regarding physical activity (PA) and associations with other outcomes. Aims: in the usual care (UC) group of an RCT to (1) explore whether baseline PA was associated with improved follow-up outcomes, (2) identify baseline variables associated with higher follow-up PA and in all RCT participants, to (3) analyse patterns of objectively measured PA, and (4) report on characteristics of those who were able to maintain or increase PA levels. Methods: exploratory analyses of an assessor-blinded RCT. Outcomes, assessed at baseline, nine weeks and six months, included PA (seven-days of accelerometry), six-minute walk distance (6MWD), muscle strength, symptoms, mood and health-related quality of life (HRQoL). Results: 92 participants were randomised, 80 completed baseline accelerometry (39 intervention group (IG), 41 UC), characteristics: mean (SD) age 63.0 (12.3) years, 56% male, 51% stage IV disease. Baseline PA: median (IQR) steps/day 2859.6 (2034.0–3849.2) IG versus 3195.2 (2161.2–4839.0) UC. Associations between baseline PA and six-month outcomes were significant for HRQoL and 6MWD. PA at six months was significantly associated with baseline age, 6MWD and quadriceps strength. Between-group change score (steps/day) mean differences (95% CI) at nine weeks (174.5 (−1504.7 to 1853.7), p = 0.84) and six months (574.0 (−1162.3 to 2310.3), p = 0.52). Conclusions: further research is required to determine patient subgroups deriving the greatest benefits from PA interventions.

Pulmonary Rehabilitation Reduces Subjective Fatigue in COPD: A Responder Analysis

To date, it remains unknown which patients report a clinically-relevant improvement in fatigue following pulmonary rehabilitation (PR). The purpose of this study was to identify and characterize these responders. Demographics, lung function, anxiety (anxiety subscale of the 90-item symptom checklist (SCL-90-A)), depression (Beck depression inventory for primary care (BDI-PC)), exercise tolerance (six-minute walking distance test (6MWD)), and health status (Nijmegen clinical screening instrument (NCSI)) were assessed before and after a 12-week PR programme. Fatigue was assessed using the checklist individual strength (CIS)-Fatigue. Patients with a decline ≥ 10 points (minimally clinically important difference, MCID) on the CIS-Fatigue were defined as responders. Chronic obstructive pulmonary disease (COPD) patients (n = 446, 61 ± 9 years, 53% male, forced expiratory volume in 1 s (FEV1) 43% ± 18% predicted, 75% severe fatigue) were included. Mean change in fatigue after PR was 10 ± 12 points (p < 0.01) and exceeded the MCID. In total, 56% were identified as fatigue responders. Baseline CIS-Fatigue (45 ± 7 vs. 38 ± 9 points, respectively, p < 0.001) and health-related quality-of-life (HRQoL; p < 0.001) were different between responders and non-responders. No differences were found in demographics, baseline anxiety, depression, lung function, 6MWD, and dyspnoea (p-values > 0.01). Responders on fatigue reported a greater improvement in anxiety, depression, 6MWD, dyspnoea (all p-values < 0.001), and most health status parameters. PR reduces fatigue in COPD. Responders on fatigue have worse fatigue and HRQoL scores at baseline, and are also likely to be responders on other outcomes of PR.