American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation

Predictors of poor attendance at an outpatient pulmonary rehabilitation programme

BACKGROUND

Pulmonary rehabilitation (PR) is recommended for patients with respiratory disease who feel limited by breathlessness. Poor attendance wastes finite resources, increases waiting times and is probably associated with poorer clinical outcomes. We investigated what factors, identifiable from routine hospital data, predict poor attendance once enrolled in a pulmonary rehabilitation programme (PRP).

METHODS

Retrospective case note study of 239 patients (60% male) of mean (S.D.) age of 66.6 (8.7) years, mean FEV(1) 39.6 (14.6)% predicted, who attended a 6 (short) or 18 (long) week, 18 session, outpatient PRP. Attendance data was analysed using linear multiple regression analysis with the log transformed odds ratio of attendance as the dependant variable.

RESULTS

Overall median attendance was 16 out of 18 sessions. Being a current smoker (p<0.05), attending a long PRP (p<0.05), more previous hospital admissions (p<0.01), higher Medical Research Council (MRC) dyspnoea score (p<0.01) or enduring a long journey (p<0.001) were independent risk factors for low attendance. Lower body mass index (BMI) and distance from PR centre were of borderline importance (p<0.1) but age, gender, co-morbidity, respiratory diagnosis, FEV(1) and St. Georges Respiratory Questionnaire Score at baseline did not predict later attendance (p>0.2).

CONCLUSIONS

Attendance at PRPs is independently influenced by smoking status, the degree of breathlessness, frequency of hospital admissions, length of the programme and journey time.

The role of future longitudinal studies in ICU survivors: understanding determinants and pathophysiology of weakness and neuromuscular dysfunction

PURPOSE OF REVIEW

The goals of this review are to discuss the pathophysiology and determinants of muscle weakness and neuromuscular dysfunction after critical illness, and to offer thoughts regarding the role of future longitudinal studies in this area.

RECENT FINDINGS

While recent studies support the finding that neuromuscular dysfunction is common and important after critical illness, reversible risk factors and approaches to prevention and treatment remain unproven. Pathophysiologic studies implicate disease and treatment associated factors in the development of nerve and muscle damage during critical illness; these factors may provide targets for future studies.

SUMMARY

Additional studies with improved methodology that address epidemiology and that test interventions are needed to understand and to improve neuromuscular function after critical illness.

Effects of a program of hospital-supervised chest physical therapy on lung function tests in children with chronic respiratory disease: 1-year follow-up

To investigate whether a hospital-supervised program of chest physical therapy improves lung function in children with chronic pulmonary diseases, twenty-four children (4 with Kartagener?s syndrome, 12 with common variable immunodeficiency, and 8 with primary ciliary dyskinesia) average age 11.2 +/- 3.2 years, were randomly assigned to a one-month hospital-supervised program of chest physical therapy (13 patients) or to a control group (11 patients) that continued unsupervised chest physical therapy at home. Lung function was assessed before the program, and one and 12 months after. At the one-month assessment, thoracic gas volume was significantly lower in the supervised group than in the controls. At the one-year assessment, forced expiratory volume in one second was significantly higher in the supervised group than in controls. A supervised program of chest physical therapy significantly improved lung function in children with chronic pulmonary diseases.

Nurse-led 24-h hotline for patients with chronic obstructive pulmonary disease reduces hospital use and is safe

BACKGROUND

Despite recent advances in the management of patients with chronic obstructive pulmonary disease (COPD), interventions to reduce hospitalization have had only modest success. The aim of this study was to report the outcomes of a novel, nurse-led 24-h telephone support line (hotline) for patients with COPD.

METHODS

Observational study of patients' use of hotline between September 2002 and November 2004. All patients with COPD referred to a Respiratory Ambulatory Care programme over this period (n = 458) were given access to the hotline. The number and time of calls to the hotline, outcomes of hotline calls and safety of hotline, were assessed. The characteristics of hotline callers and non-callers were compared using an unpaired Student's t-test for normally distributed variables, a chi(2) test for categorical variables and a Mann-Whitney test for non-normally distributed variables.

RESULTS

Over the period studied, 675 calls were made to the hotline by 118 patients and 56% of calls were made after hours. For 78 calls (12%), advice and interventions given by hotline staff averted potential 000 calls by patients/carers. Specific advice about interventions for acute exacerbations of COPD (AECOPD) was given in a further 117 calls (17%). Callers had more severe COPD than non-callers (worse lung function, lower exercise capacity and higher prescription of home oxygen, all P < 0.05). No adverse events related to use of the hotline were documented.

CONCLUSION

A nurse-led 24-h hotline for patients with COPD is safe, is used by patients and carers and, when used, reduces hospital presentations with AECOPD.

Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals: American Association of Cardiovascular and Pulmonary Rehabilitation Position Statement

The article provides an outline of clinical competencies recommended for personnel providing comprehensive services in pulmonary rehabilitation (PR), complementing the American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for Pulmonary Rehabilitation Programs. Individuals wishing to provide PR services should possess a common core of professional and clinical competencies regardless of their academic discipline.

Mental disorders in chronic obstructive pulmonary disease (COPD)

Recent research using questionnaire measures has demonstrated high prevalence rates of mental disorders in chronic obstructive pulmonary disease (COPD). However, clinical interviews and clinical rather than healthy control groups have rarely been employed. The aim of the present study was to assess mental disorders in patients with COPD with advanced methodology, to identify moderating factors explaining mental co-morbidities and to compare results with a clinical control group without COPD. A standardized clinical interview (F-DIPS) and a range of questionnaires were used to assess mental disorders, perceived physical symptoms and cognitions in 20 hospitalized patients with mild-to-moderate COPD (mean FEV(1)/VC (%)=61.3). Results were compared with a hospitalized clinical control group without pulmonary dysfunction (CCG; N=20). Results showed that 55% of patients with COPD received a diagnosis of a mental disorder compared to 30% of CCG patients. All principal mental diagnoses in the COPD group were anxiety disorders (especially Panic Disorder with Agoraphobia), while CCG patients received a wider range of diagnoses (anxiety, pain, alcohol abuse). There was no systematic association between anxiety levels and respiratory function in the whole COPD group, but a positive correlation between anxiety levels and perceived physical symptoms (p<0.001) as well as negative cognitions (p<0.001 and p<0.05, respectively) for COPD patients with anxiety disorder (N=11). The present results confirm the high prevalence rate of anxiety in patients with COPD and suggest further that anxiety in COPD patients may be mediated by cognitive processes. These findings are discussed in terms of their implications for treatment.

Medical therapy for chronic obstructive pulmonary disease in 2007

Medical treatment for patients with stable chronic obstructive pulmonary disease (COPD) has evolved significantly over the past 2 decades. Current World Health Organization recommendations suggest a stepwise approach to therapy depending upon disease severity. As-needed use of short-acting bronchodilators is recommended for patients with mild disease. Scheduled dosing of bronchodilators is recommended for patients with more advanced disease. Inhaled beta-agonists and anti-cholinergic agents in combination have proved to be more effective than either agent alone. Long-acting preparations are associated with better disease control and have not been associated with tachyphylaxis. Inhaled corticosteroids are useful for reducing the frequency of exacerbations in patients who experience one or more episodes per year. Oxygen therapy is clearly beneficial in patients with advanced COPD and chronic respiratory failure, and its potential benefits in less severe disease are currently being studied. Pulmonary rehabilitation benefits patients with mild-to-severe disease, although the greatest benefits have been demonstrated in those with moderate COPD. New ultra-long-acting inhaled bronchodilators, phosphodiesterase inhibitors, protease inhibitors, and retinoids intended to promote tissue regeneration are currently being evaluated in clinical trials as future therapeutic agents.

Chronic obstructive pulmonary disease in the older patient

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic diseases in the world. It is a major cause of morbidity, mortality, and health care use, particularly in older adults. In the following sections, the authors review the diagnosis and management of COPD with a focus on special issues in older adults.

Pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

Background/Aim. Chronic obstructive pulmonary disease (COPD) irreversibly damages pulmonary function leading to disorder of arterial blood gases, arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2), appearance of dyspnea, and decrease of physical condition. The aim of this study was to establish if medical treatment and respiratory rehabilitation in COPD used simultaneously lead to the greater improvement of PaO2, PaCO2 and physical condition and decreaseing dyspnea than medical treatment alone. Methods. A total of 60 patients divided into three groups according to the severity of obstruction (mild - I, severe - II, very severe - III) were tested. Each group had the two subgroups of patients - first one with those treated both with medical treatment and respiratory rehabilitation (A) and the second one with the patients treated only with medical treatment (B). The treatment took 21 days. The measurements of PaO2 and PaCO2) intensity of dyspnea at rest and exercise (10 - point Borg Category Scale), and physical capacity (Six-Minute Walk Test - 6MWT) were done on the first and on the last day of testing. Results. The results showed that all of the patients who were treated with the combination of medical treatment and respiratory rehabilitation had significantly higher increase in the values of PaO2 (I - p < 0.01; II - p < 0.05; III - p < 0.01), score of Borg's scale (I - p < 0.05, p < 0.001; II - p < 0.05, p < 0.001; III - p < 0.001, p < 0.001) and 6MWT (I - p < 0.001; II - p < 0.001; III - p < 0.001), and that statistically significant increase of the values of PaCO2 (p < 0.05) had only the patients with very severe COPD treated with the combination of drugs and respiratory rehabilitation. Conclusion. Based on the obtained results we conclude that using respiratory rehabilitation in combination with pharmacological treatment of COPD gives statistically higher improvement of values of PaO2 and PaCO2, and physical condition, and also leads to decrease of intensity of dyspnea than using just drug therapy.

Self-management strategies in chronic obstructive pulmonary disease

This article enables the reader to understand the newest scientific concepts and advances in the field of self-management in chronic obstructive pulmonary disease, recognize the importance of self-management education and what might be needed to enhance behavior modification, and translate these advances into strategies and specific interventions in clinical practice.

Is exercise important in chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease impairs the ability of patients to perform maximal physical exercise, particularly in patients with severe lung disease. However, differing perceptions of the meaning and importance of exercise to patients and caregivers is likely to impair patient-physician communication about current medical status and outcomes of therapeutic interventions. Other outcomes of importance to patients including actual performance of functional activity during daily life and health-related quality of life may also be affected by impaired exercise capacity. However, the relationships between exercise, activity, and quality of life are inconsistent. Thus, measurement of physiologic and patient-centered outcomes may provide the best approach to assessing responses to therapeutic interventions. These concepts were explored in a conference sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. and Pfizer Inc and reviewed in the articles generated from the symposium in this issue of COPD.

Chronic obstructive pulmonary disease in patients who have HIV infection

An increased prevalence of chronic obstructive pulmonary disease (COPD) among persons who have HIV infection has raised the possibility that HIV may predispose to the development or progression of COPD. This article reviews the evidence that supports an association between HIV infection and COPD-namely emphysema and chronic bronchitis-and studies that suggest an association between HIV infection and small airways abnormalities and nonspecific airway hyper-responsiveness. Risk factors for COPD and potential reasons for an increased risk for COPD in HIV-positive patients are discussed. In addition, issues in the management of COPD in HIV-positive patients are reviewed.

Education in pulmonary rehabilitation: the patient's perspective

OBJECTIVES

To ascertain from patients' perspectives what should be included in the educational component of pulmonary rehabilitation and how it should be delivered, and to compare those perspectives with the views of health professionals.

DESIGN

Qualitative research method using focus groups of patients and health professionals.

SETTING

A regional respiratory center and outpatient clinic.

PARTICIPANTS

Purposive samples of 32 patients with chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1 second, 18%-67% predicted) divided into 6 focus groups; 8 health professionals knowledgeable about COPD and pulmonary rehabilitation who attended a multidisciplinary focus group meeting.

INTERVENTIONS

Participants attended focus group meetings (2-3 h) guided by a series of questions and topics; results were posted to the participants for their verification.

MAIN OUTCOME MEASURE

The educational content of a pulmonary rehabilitation program.

RESULTS

Deficits in patients' knowledge, understanding, and management of their disease were identified. Six key educational topics resulted: disease education, management of breathlessness, management of an exacerbation, medication, psychosocial support, and welfare and benefits systems. Patients and health professionals preferred group information sessions provided by knowledgeable people speaking layman's language, with oral presentations being supplemented by written information.

CONCLUSIONS

Gaining a greater understanding of patients' educational needs permits health professionals who design pulmonary rehabilitation programs to include these requirements in a format that is acceptable to patients. The key topics, content, and format for delivery of the educational component for pulmonary rehabilitation were identified. Future research should focus on the development of an educational package and assessment of its efficacy, which would facilitate equitable patient access to education in pulmonary rehabilitation.

[Magnetic stimulation of the quadriceps: analysis of 2 stimulators used for diagnostic and therapeutic applications]

Compromised muscle function can be evaluated in respiratory disease patients by supramaximal magnetic stimulation (isometric twitch) of the quadriceps, a technique that is reproducible and objective. We validated the technique, comparing a device used in our laboratory with another reference electromagnet. We also assessed whether the technique could potentially be used to train the muscle by repetitive stimulation. The Medtronic Magpro (MED) device with a circular coil and the Magstim 200 device (MAG) with a figure-of-eight coil (reference device) were used to stimulate the femoral nerve of 6 volunteers at different percentages of maximal output. MED stimulation was also applied on the quadriceps muscle. We measured voluntary contractions, comparing measurements from the 2 devices and on different days. The stimulation achieved with MED was lower than with MAG, showed greater day-to-day variability, and was not clearly supramaximal. MED quadriceps stimulation was 80.7% of MAG stimulation. In conclusion, supramaximal stimulation of the quadriceps cannot be guaranteed with MED and the circular coil. However, this device generates sufficient contraction when applied to the muscle to be used for repetitive stimulation.

Efficacy of pulmonary rehabilitation in chronic respiratory failure (CRF) due to chronic obstructive pulmonary disease (COPD): The Maugeri Study

While the effectiveness of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) is well established, its effectiveness in the most severe category of COPD, i.e. patients with chronic respiratory failure (CRF), is less well known.

OBJECTIVE

To verify the effects of PR in patients with CRF, and compare the level of improvement with PR in these patients to that of COPDs not affected by CRF.

METHODS

A multi-centre study was carried out on COPD patients with versus without CRF. The PR program included educational support, exercise training, and nutritional and psychological counselling. Lung function, arterial gases, walk test (6MWT), dyspnoea (MRC; BDI/TDI), and quality of life (MRF(28); SGRQ) were evaluated.

RESULTS

Thousand forty seven consecutive COPD inpatients (327 with CRF) were evaluated. In patients with CRF all parameters improved after PR (0.001). Mean changes: FEV(1), 112 ml; PaO(2), 3.0 mmHg; PaCO(2), 3.3 mmHg; 6MWT, 48 m; MRC, 0.85 units; MRF(28) total score, 11.5 units. These changes were similar to those observed in patients without CRF.

CONCLUSIONS

This study, featuring the largest cohort so far reported in the literature, shows that PR is equally effective in the more severe COPD patients, i.e. those with CRF, and supports the prescription of PR also in these patients.

Extra-pulmonary features in COPD patients entering rehabilitation after stratification for MRC dyspnea grade

Experts have stated that referral for rehabilitation of patients with chronic obstructive pulmonary disease (COPD) becomes appropriate when these patients become aware of their disability (e.g. usually grade 3 to 5 on the Medical Research Council (MRC) dyspnea scale). However, patients with MRC dyspnea grade 1/2 may also suffer from extra-pulmonary features, such as abnormal body composition, exercise intolerance and reduced disease-specific health status. In the present study, we have studied whether and to what extent chronic obstructive pulmonary disease (COPD) patients with MRC dyspnea grade 1/2 have extra-pulmonary features compared to patients with grade 3, 4 or 5? Pulmonary function, body composition, 6-min walking distance, peak exercise capacity, anxiety, depression and disease-specific health status have been assessed in 333 outpatients who had been referred for pulmonary rehabilitation. On average, patients with MRC dyspnea grade 1/2 had a better exercise tolerance and disease-specific health status compared to patients with grade 4 or 5. Nevertheless, grade 1/2 patients had a higher prevalence of muscle mass depletion. In addition, these patients did still have aberrant values in one or more of the aforementioned outcomes. On average, patients with MRC dyspnea grade 1/2 may clearly suffer from extra-pulmonary features, indicating the necessity to refer these patients for rehabilitation. Therefore, MRC dyspnea scale alone does not appear to be a suitable measure to identify most patients with COPD who have to be referred for rehabilitation.

Shuttle walking versus maximal cycle testing: clinical correlates in patients with kyphoscoliosis

A cross-sectional prospective design was used to compare the effectiveness of the shuttle walking test (SWT) and the maximal cycle ergometry test (CET) to assess the functional capacity of patients with chronic hypercapnic respiratory failure due to severe kyphoscoliosis. Twenty-four patients completed both the SWT and CET. Heart rate, blood pressure, leg fatigue, chest pain and dyspnea (Borg's scale) were measured immediately after each test. Correlation coefficients and Bland-Altman analysis were used to compare the two methods. Borg's dyspnea, leg and chest pain after exercise were not significantly different between tests. Only heart rate (SWT 130[20.7] versus CET 116[28.75]; p = 0.048) and diastolic blood pressure (SWT: 85.5[13.75] versus CET 95[17.5]; p = 0.021) were slightly but significantly different between the two protocols. There was a good positive correlation between the distance walked in SWT and maximal oxygen consumption (r = 0.675; p < 0.001). SWT and CET testing elicited similar clinical and hemodynamic responses. SWT is a feasible measure of functional capacity in this patient group.

Comprehensive pulmonary rehabilitation for anxiety and depression in adults with chronic obstructive pulmonary disease: Systematic review and meta-analysis

OBJECTIVES

To estimate the clinical effect of pulmonary rehabilitation (with or without education) on anxiety and depression in patients with chronic obstructive pulmonary disease (COPD). Secondary outcomes were generic and disease-specific health-related quality of life (HRQOL).

METHODS

Systematic review and meta-analysis of primary outcomes to calculate mean change effect sizes [standardized mean difference (SMD)] and associated 95% CIs.

RESULTS

Six randomized controlled trials (RCTs) that compared pulmonary rehabilitation with standard care (with or without education) were included in the review. Three studies (n=269) showed that comprehensive pulmonary rehabilitation was significantly more effective than standard care in reducing short-term anxiety (SMD=-0.33, 95% CI: -0.57 to -0.09, P=.008) and depression (SMD=-0.58, 95% CI: -0.93 to -0.23, P=.001). Education alone and exercise training alone were not associated with significant reductions in either anxiety or depression. When compared with standard care, comprehensive pulmonary rehabilitation was also associated with short-term significant gains in both disease-specific and generic HRQOL. Studies that included long-term follow-up data showed that gains in both psychological health status and HRQOL were not sustained at 12 months.

CONCLUSIONS

Rehabilitation programmes that include up to three sessions per week of incremental and supervised exercise, along with education and psychosocial support, significantly reduce anxiety and depression more than standard care in patients with COPD. Further research should focus on exploring effective and acceptable maintenance strategies along with evaluations of stepped care approaches for the management of psychological co-morbidity, especially among those with severe anxiety and depression.

Distractive Auditory Stimuli Reduce the Unpleasantness of Dyspnea During Exercise in Patients With COPD

BACKGROUND

Dyspnea is the primary symptom limiting exercise in patients with COPD. Recent research has demonstrated that psychological factors can substantially influence the perception of dyspnea, but little is known about the modulation of perceived intensity or unpleasantness of dyspnea by attentional distraction. Therefore, we examined the impact of distractive auditory stimuli on the perception of exercise-induced dyspnea and the affective state in patients with COPD during 6-min walking tests (6MWTs).

METHODS

Twenty patients with mild-to-severe COPD (mean FEV1, 55.9% predicted) underwent two 6MWTs. Under one exercise condition, distractive auditory stimuli were presented with headphones, while the other condition was performed without auditory distraction. Lung function (FEV1), heart rate (HR), pulse oximetric saturation (SpO2), perceived intensity of dyspnea (ie, visual analog scale for perceived intensity of dyspnea [VAS-I]), and perceived unpleasantness of dyspnea (visual analog scale for perceived unpleasantness of dyspnea [VAS-U]) were measured before and after exercise. In addition, the global level of dyspnea (Borg score), positive affectivity (PA), and negative affectivity were assessed after both conditions.

RESULTS

A similar exercise level during both conditions was confirmed by comparable results in FEV1, HR, SpO2, and distances walked. During auditory distraction, Borg scores and increases in VAS-U were smaller, while PA was higher compared to the nondistraction condition (p<0.05). VAS-I did not show differences across conditions.

CONCLUSIONS

Distractive auditory stimuli decrease the global level of exercise-induced dyspnea in patients with COPD by reducing the perceived unpleasantness of dyspnea and lead to an additional increase in PA. Auditory distraction might therefore serve as an intervention for the reduction of dyspnea during exercise in this patient group.

Effects of one-legged exercise training of patients with COPD

BACKGROUND

Most patients with severe COPD are limited by dyspnea and are obliged to exercise at low intensity. Even those undergoing training do not usually have increased peak oxygen uptake (Vo2). One-legged exercise, at half the load of two-legged exercise, places the same metabolic demands on the targeted muscles but reduces the ventilatory load, enabling patients to increase work capacity. The purpose of this study was to determine whether one-legged exercise training would improve aerobic capacity compared with two-legged training in stable patients with COPD.

METHODS

Eighteen patients with COPD (mean FEV(1), 38 +/- 17% of predicted [+/- SD]) were randomized to two groups after completing an incremental exercise test. Both trained on a stationary cycle for 30 min, 3 d/wk, for 7 weeks. Two-legged trainers (n = 9) cycled continuously for 30 min, whereas one-legged trainers (n = 9) switched legs after 15 min. Intensity was set at the highest tolerated and increased with training.

RESULTS

Both groups increased their training intensity (p < 0.001) and total work (p < 0.001). After training, the change in peak Vo2 of the one-legged group (0.189 L/min; confidence interval [CI], 0.089 to 0.290 L/min; p < 0.001) was greater than that of the two-legged group (0.006 L/min; CI, - 0.095 to 0.106 L/min; p = 0.91). This was accompanied by greater peak ventilation (4.4 L/min; CI, 1.8 to 7.1 L/min; p < 0.01) and lower submaximal heart rate (p < 0.05) and ventilation (p < 0.05) in the one-legged trained group.

CONCLUSION

Reducing the total metabolic demand by using one-legged training improved aerobic capacity compared with conventional two-legged training in patients with stable COPD.

Pulmonary rehabilitation in chronic obstructive pulmonary disease

Pulmonary rehabilitation, a multidisciplinary and structured intervention for patients with chronic pulmonary diseases, has been shown to improve exercise tolerance, reduce dyspnea and improve health-related quality of life. Pulmonary rehabilitation appears to be cost-effective, since it reduces health care utilization. Exercise training represents the cornerstone of every pulmonary rehabilitation program. To obtain clinically relevant effects, training should closely supervised, of high intensity, lasting 30-45 min for at least 3 days/week. Patients should undertake a minimum of 20 sessions, but longer programs result in larger and more long-lasting effects. Education and self-management programs have been shown to result in a substantial reduction in hospital admissions. Nutritional intervention should be considered for patients who are underweight or those with body composition abnormalities. Patients reporting fear and anxiety may benefit from psychosocial support, and the integration of occupational therapy in a pulmonary rehabilitation program can improve independence in activity. Multidisciplinary pulmonary rehabilitation is preferably implemented in an outpatient hospital- or community-based setting. Inpatient programs are suited for patients with limited transportation capabilities or severe deconditioning. The most convincing effects of home-based rehabilitation are in maintaining the improvements obtained in an outpatient setting.

Review article: addressing the sexual health of patients with COPD: the needs of the patient and implications for health care professionals

Sexual expression is an important part of our individual identity and yet, this area is rarely addressed by health professionals. This article will explore the possible reasons for this and will also demonstrate the importance of assessing sexuality in patients with chronic obstructive pulmonary disease (COPD).

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

New Approaches in Pulmonary Rehabilitation

Patients who have mild to severe chronic obstructive pulmonary disease may obtain improvement in dyspnea, exercise capacity, and health-related quality of life as a result of exercise training. The type and intensity of training is of key importance in determining outcomes. High-intensity aerobic training leads to physiologic gains in aerobic fitness. Nevertheless, extreme breathlessness or peripheral muscle fatigue may prevent some patients from performing high-intensity exercise; therefore, new tools are needed to improve the effectiveness of pulmonary rehabilitation.

Adherence to a home-walking prescription in patients with chronic obstructive pulmonary disease

BACKGROUND

We know little about long-term exercise behavior and adherence in patients with chronic obstructive pulmonary disease (COPD).

PURPOSE

The study's purpose was (1) to describe exercise behavior and adherence to a home-walking exercise prescription over 12 months in a sample of patients with COPD; and (2) to validate categories of exercise adherence over time in this population.

DESIGN

This was a secondary analysis of a randomized controlled trial.

SUBJECTS

A total of 103 participants with COPD who were randomly assigned to one of three versions of a dyspnea self-management program participated.

MEASURES

The components of exercise frequency, duration, and intensity were measured by exercise/dyspnea daily logs, and participants were classified into categories on the basis of their pattern of exercise adherence over the year.

RESULTS

Participants walked an average of 3 days per week initially, with a decline to 2.5 days per week over the year. On average, participants walked longer than the prescribed duration of 20 minutes per session. Dyspnea intensity at the end of the walk tended to remain stable at a mean level of 4 over the year. Classification by adherence category distinguished differences in 6-minute walk distance, endurance treadmill test time, Short Form-36 physical function, and Short Form-36 mental health, with endurance treadmill test time and physical function improvements mirroring increases in exercise adherence, and mental health highest among occasional lapse and lowest among relapser and recycle categories.

CONCLUSIONS

This investigation provides a description of long-term exercise behavior and adherence in a sample of patients with COPD. The categories suggest that physical benefits are related to consistent adherence, whereas mental health improvements are related to regular exercise with some flexibility in the schedule. Future research should test interventions to improve exercise adherence in patients with COPD and identify characteristics of patients who are most likely and least likely to adhere over time.

Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2007 update

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.

Advanced chronic obstructive pulmonary disease: innovative approaches to palliation

By the year 2020, chronic obstructive pulmonary disease (COPD) will be the third leading cause of death globally. While there have been consistent calls for increased palliative care involvement in the care of patients with advanced COPD, these calls should be based on empirical evidence that such an approach improves the symptom burden and poor quality of life associated with advanced COPD. Rather than reviewing the traditional treatments of airflow obstruction and palliative measures familiar to the palliative care community, we will focus on some novel approaches to the management of patients with advanced COPD from the perspective of clinicians involved in end of life care provision and research. By combining the clinical and research skills of pulmonologists and palliative medicine specialists we can advance the care of patients with this progressive and incurable disease.

At identical isowork rates, ageing influences cardiorespiratory adaptations in COPD out-patients

PURPOSE

To determine the extent to which younger COPD patients improve their cardiorespiratory function during exercise in comparison with older COPD patients, as a result of exercise training.

METHODS

Thirty-nine COPD patients underwent an exercise program. They were divided into two groups: a younger group (57.2+/-1.0 years, n=18 patients) and an older group (68.8+/-0.6 years, n=21 patients). Forced expiratory volume in 1s was lower than 55% of the predicted value for all patients.

RESULTS

After training, VO2 symptom-limited significantly improved by 10.3% and 8.4% for the younger and older COPD patients, respectively (P<0.05). Peak power significantly improved by 25.2% and 17.8% in the younger and older groups, respectively (P<0.05) with a greater improvement for the younger group (P<0.05). At submaximal exercise, ventilation and heart rate significantly decreased after training in the younger COPD patients (P<0.05) with no significant modification in the older COPD patients.

CONCLUSIONS

The results suggest that all patients with COPD benefit from exercise rehabilitation at maximal exercise workload, however, according to their age, submaximal cardiorespiratory adaptations were greater in younger patients.