Pulmonary rehabilitation-1999. American Thoracic Society

Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study

BACKGROUND

Information about the influence of regular physical activity on the course of chronic obstructive pulmonary disease (COPD) is scarce. A study was undertaken to examine the association between regular physical activity and both hospital admissions for COPD and all-cause and specific mortality in COPD subjects.

METHODS

From a population-based sample recruited in Copenhagen in 1981-3 and 1991-4, 2386 individuals with COPD (according to lung function tests) were identified and followed until 2000. Self-reported regular physical activity at baseline was classified into four categories (very low, low, moderate, and high). Dates and causes of hospital admissions and mortality were obtained from Danish registers. Adjusted associations between physical activity and hospital admissions for COPD and mortality were obtained using negative binomial and Cox regression models, respectively.

RESULTS

After adjustment for relevant confounders, subjects reporting low, moderate or high physical activity had a lower risk of hospital admission for COPD during the follow up period than those who reported very low physical activity (incidence rate ratio 0.72, 95% confidence interval (CI) 0.53 to 0.97). Low, moderate and high levels of regular physical activity were associated with an adjusted lower risk of all-cause mortality (hazard ratio (HR) 0.76, 95% CI 0.65 to 0.90) and respiratory mortality (HR 0.70, 95% CI 0.48 to 1.02). No effect modification was found for sex, age group, COPD severity, or a background of ischaemic heart disease.

CONCLUSIONS

Subjects with COPD who perform some level of regular physical activity have a lower risk of both COPD admissions and mortality. The recommendation that COPD patients be encouraged to maintain or increase their levels of regular physical activity should be considered in future COPD guidelines, since it is likely to result in a relevant public health benefit.

The effects of a lifestyle physical activity counseling program with feedback of a pedometer during pulmonary rehabilitation in patients with COPD: a pilot study

OBJECTIVE

To study the effects of a lifestyle physical activity counseling program with feedback of a pedometer during pulmonary rehabilitation.

METHODS

Twenty-one chronic obstructive pulmonary disease (COPD) patients were randomized to an experimental group that followed a regular rehabilitation program plus the counseling intervention or to a control group that only followed rehabilitation. The primary outcome was daily physical activity assessed by pedometers. Secondary outcomes were physical fitness, health-related quality of life, activities of daily living, depression and self-efficacy.

RESULTS

The experimental group showed an increase of 1,430 steps/day (+69% from baseline), whereas the control group showed an increase of 455 steps/day (+19%) (p = 0.11 for group x time interaction). The secondary outcomes showed no differences.

CONCLUSION AND PRACTICE IMPLICATIONS

This study showed that the use of the pedometer, in combination with exercise counseling and the stimulation of lifestyle physical activity, is a feasible addition to pulmonary rehabilitation which may improve outcome and maintenance of rehabilitation results.

Exercise capacity and quadriceps muscle metabolism following training in subjects with COPD

The aim of the study was to determine whether 16 sessions of exercise training, completed twice weekly, alters exercise capacity, quadriceps muscle metabolism, cross-sectional area (CSA) and strength in subjects with chronic obstructive pulmonary disease (COPD). We studied (a) 10 COPD subjects (mean age+/-sem = 71+/-2 years; FEV1 = 0.99+/-0.1 L) before and after 16 sessions of exercise training, and (b) 10 healthy subjects (age = 68+/-3 years). The COPD subjects underwent an incremental peak exercise test using a cycle ergometer and a 6-min walk test: both improved following exercise training (P < 0.05). Magnetic resonance spectroscopy measurements, in quadriceps muscle, of post-exercise phosphocreatinine (PCr) recovery kinetics were used to assess mitochondrial function in vivo: in the COPD subjects pre-training this was 19+/-8% lower than in healthy subjects (P = 0.03), but a 38+/-12% increase was seen in the COPD subjects following training (P = 0.003). Magnetic resonance imaging was used to assess quadriceps CSA: after training in the COPD subjects this showed a 7+/-2% increase (P = 0.03). Quadriceps strength, measured by the best of five maximum voluntary contractions, also showed a 32+/-11% increase in the COPD subjects (P = 0.007). Sixteen sessions of exercise training, performed twice weekly, increased exercise capacity as well as quadriceps mitochondrial capacity, CSA and strength in the subjects with COPD.

The Acute Effects of a Rollator in Individuals With COPD

PURPOSE

To investigate whether the acute benefits of rollator use are consistent over time in individuals with moderate to severe chronic obstructive pulmonary disease.

METHODS

Thirty-one stable subjects with chronic obstructive pulmonary disease (13 men, 18 women), aged 68 +/- 8 years, with a forced expiratory volume in 1 second of 0.7 +/- 0.2 L (33% +/- 12% predicted) and a baseline 6-minute walk (6MW) of 261 +/- 68 m, were recruited from a respiratory clinic after completion of a pulmonary rehabilitation program. Two 6MWs were performed at baseline, 4 weeks, and 8 weeks, one walking unaided and the other walking with the assistance of a rollator. The test order was randomly chosen at baseline, and the same test order was used at each time point. The primary outcome measures were distance walked in 6 minutes (meters), perceived dyspnea using a modified Borg scale, and number of rests taken.

RESULTS

Subjects achieved higher 6MW distances during assisted compared with unassisted walking at baseline (292 +/- 67 vs 263 +/- 67 m), 4 weeks (296 +/- 62 vs 275 +/- 63m), and 8 weeks (283 +/- 65 vs 259 +/- 68 m) (P = .013), with no time effect (P = .5). In addition, use of a rollator resulted in a significant improvement in dyspnea (P = .004) at baseline, 4 weeks, and 8 weeks, with no time effect (P = .7). The use of a rollator also reduced the number of rests taken during the 6MW (P < .001), with no time effect (P = .9).

CONCLUSIONS

Rollator use resulted in improvements in performance in the 6MW, which were consistent over time among individuals with moderate to severe chronic obstructive pulmonary disease who walk less than 375 m during an unaided 6MW.

Factors in maintaining long-term improvements in health-related quality of life after pulmonary rehabilitation for COPD

The purpose of this study was to reveal predictors for the long-term effects of pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) patients, in terms of health-related quality of life (HRQoL). We investigated the long-term effects of pulmonary rehabilitation in 53 COPD patients who had completed the outpatient program and could be evaluated continuously for 1 year. We also investigated factors related to long-term maintenance of HRQoL assessed by the St George's Respiratory Questionnaire (SGRQ). In the year following the program, the only items that retained a significant improvement compared with the pre-program levels were respiratory muscle strength and 6-min walking distance. Patients whose total SGRQ score showed improvements that were maintained above the minimal clinically important difference were placed in a maintained-improvements group (n = 18, 34.0%), and the others in a non-maintained group (n = 35, 66.0%). A comparison of the groups revealed that the maintained-improvements group had significantly lower forced vital capacity (FVC), inspiratory capacity (IC), and tidal volume (TV) at rest; higher PaCO(2); greater initial impairments in HRQoL; and more frequent attendance in a maintenance program. In a multiple logistic regression model, only PaCO(2) was identified as predictor for the maintenance of improvement in HRQoL over a long term. In conclusion, higher baseline PaCO(2) is predictor of maintained, long-term improvement in HRQoL after pulmonary rehabilitation. Frequent attendance in a maintenance program is another predictor.

How long should outpatient pulmonary rehabilitation be? A randomised controlled trial of 4 weeks versus 7 weeks

BACKGROUND

The evidence of benefit for pulmonary rehabilitation (PR) programmes is established. However, the optimal duration of a PR programme is not known. A randomised controlled trial was undertaken in patients with chronic obstructive pulmonary disease (COPD) to assess whether a 4 week PR programme was equivalent to our conventional 7 week PR programme at equivalent time points of 7 weeks and 6 months.

METHODS

One hundred patients (56 men) with stable COPD of mean (SD) age 70 (8) years and forced expiratory volume in 1 second (FEV1) 1.13 (0.50) litres were randomised to either a 7 week (n = 50) or 4 week (n = 50) supervised PR programme. Patients were assessed at baseline, at completion of the supervised PR programme, and 6 months later. Patients randomised to the 4 week group were also assessed at the 7 week time point. Outcome measures were the Incremental Shuttle Walk Test, Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire-Self Reported, and the Breathing Problems Questionnaire.

RESULTS

Forty one patients in each group completed the PR programme. Patients made significant within group improvements after supervised rehabilitation. There were no statistically significant differences between the groups for any other measure at the 7 week or 6 month time points, except that patients in the 4 week group attained higher ESWT times (mean difference 124 seconds (95% CI 17.00 to 232.16), p = 0.024) at the 7 week time point.

CONCLUSIONS

A shortened 4 week supervised PR programme is equivalent to a 7 week supervised PR programme at the comparable time points of 7 weeks and 6 months.

Pulmonary Rehabilitation and Respiratory Therapy Services in the Physician Office Setting

Pulmonary rehabilitation services benefit patients with chronic lung disease by reducing symptoms and restoring independent function. With a multidisciplinary approach to individual patient care through education, exercise, and psychosocial interventions, health-care costs and utilization may be reduced. While pulmonary rehabilitation services have typically been provided in a facility setting, many respiratory care services can be safely provided and appropriately reimbursed in the outpatient physician office setting, with appropriate physician supervision. After reviewing the utility of pulmonary rehabilitation for patients with chronic lung disease, the supervision, documentation, coding, and reimbursement requirements for providing rehabilitative respiratory care services in the outpatient office setting are detailed.

The effects of 1 year of specific inspiratory muscle training in patients with COPD

AIM

We assessed the long-term benefits of inspiratory muscle training (IMT) on inspiratory muscle strength, exercise capacity, the perception of dyspnea, quality of life, primary care use, and hospitalizations in patients with significant COPD.

PATIENTS

Forty-two consecutive COPD patients with FEV(1) < 50% of predicted were randomized into a group that received IMT for 1 year, and a control group that received training with a very low load.

RESULTS

There was a statistically significant increase in inspiratory muscle strength (at the end of the third month of training) as assessed by maximal inspiratory pressure (from 71 +/- 4.9 to 90 +/- 5.1 cm H(2)O [+/- SEM], p < 0.005) and 6-min walk distance (at the end of the third month of training; from 256 +/- 41 to 312 +/- 54 m; p < 0.005), a decrease in the mean Borg score during breathing against resistance (at the end of the ninth month of training), improvement in the health-related quality-of-life scores (at the end of the sixth month of training) in the training group but not in the control group. At the end of the training year, these changes were maintained; in addition, a decrease in primary health-care use and hospitalization days was observed.

CONCLUSIONS

Our study shows that during IMT in patients with significant COPD, there is an increase in exercise capacity, improvement in quality of life, and decrease in dyspnea. Our study also provides evidence that long-term IMT can decrease the use of health services and hospitalization days.

Does pulmonary rehabilitation give additional benefit over tiotropium therapy in primary care management of chronic obstructive pulmonary disease? Randomized controlled clinical trial in Hong Kong Chinese

OBJECTIVE

To evaluate whether multidisciplinary pulmonary rehabilitation programme (PRP) provides additional benefit over tiotropium therapy in managing chronic obstructive pulmonary disease (COPD) in primary care.

DESIGN

A randomized controlled trial to analyse the difference in outcomes of COPD patients receiving tiotropium plus PRP vs. tiotropium treatment alone.

SETTING

Two primary care teaching clinics affiliated with a university which serves a population of 600,000.

PARTICIPANTS

Fifty primary care COPD patients.

METHODS

Fifty subjects underwent spirometry and their status of COPD was confirmed by using the Vitalograph Gold Standard. They were then assessed by the 6-min walking distance (6MWD), Peak Visual Analogue Scale (Peak VAS) and Chronic Respiratory Disease Questionnaire (CRQ). All subjects were given tiotropium to optimize their treatment. After a 6-week period, half were randomized to the intervention group (i.e. receiving PRP), whereas the rest were randomized to control group which received only medication. Spirometry, 6MWD, Peak VAS and CRQ were performed in both groups at 6 weeks, 12 weeks and 3 months.

OUTCOMES

Spirometry, 6MWD, Peak VAS and CRQ.

RESULTS

Significant improvement (P < 0.05) was seen in 6MWD, symptoms of dyspnoea measured by Peak VAS and CRQ. The improvement was sustained at 3-month follow-up. However, no additional significant improvement was seen in the intervention group when compared with control.

CONCLUSION

Tiotropium therapy has improved health outcomes in COPD patients in primary care settings. A 6 weekly PRP did not give any additional benefits in patients already given tiotropium.

Pulmonary rehabilitation for COPD

Pulmonary rehabilitation is a therapeutic process, which entails taking a holistic approach to the welfare of the patient with chronic respiratory illness--most commonly chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation is considered essential throughout the lifetime management of patients with symptomatic chronic respiratory disease. It requires the coordinated action of a multidisciplinary healthcare team in order to deliver an individualised rehabilitation programme to best effect--incorporating multiple modalities, such as advice on smoking cessation, exercise training and patient self-management education, among others. As core components of pulmonary rehabilitation, exercise training and self-management education have been shown to be beneficial in improving health-related quality of life (HRQoL) in patients with chronic respiratory disease. Physical training can help to reduce the muscle de-conditioning that occurs when the activity of patients is restricted by their breathlessness and fatigue, and is often associated with an increase in patient HRQoL. HRQoL can also be improved by the use of self-management education, which is designed to provide the patient with the skills to manage the health consequences of their disease. In doing so, patients are better able to cope with disease symptoms, potentially leading to reduced healthcare costs. A great deal of research has been conducted to try and fully define which patients will benefit most from pulmonary rehabilitation. Although progress has been made, many questions remain as to the best means of delivering rehabilitation, particularly with respect to the optimum programme of physical training and patient self-management education.

[Results of an ambulatory respiratory rehabilitation program: observations in 100 COPD patients]

INTRODUCTION

Respiratory rehabilitation is a multidisciplinary approach enabling personalized management adapted for each patient's handicap.

METHOD

Our ambulatory program includes twenty sessions per week (four half-days/week) for respiratory training at the ventilatory threshold, respiratory physical therapy, and health education. One hundred COPD patients participated in this retrospective study: mean age 62.1 +/- 9.6 years; FEV1: 1.51 +/- 0.66 (53 +/- 22% of theoretical).

RESULTS

At the ventilatory threshold, there was a significant 9% gain in oxygen uptake and a 31% gain in power. At maximal exercise, there was a 6% improvement in oxygen uptake, 21% gain in power, and 7% gain in tidal volume (p<0.05). Walking distance improved 15% (+ 61 m). Quality of life was also improved significantly, with loss of 8 points on the Saint-George's Hospital respiratory questionnaire.

CONCLUSION

This study demonstrates the beneficial effect of respiratory rehabilitation in terms of improved tolerance to exercise and improved quality of life for COPD patients.

Minimal Clinically Important Difference for the UCSD Shortness of Breath Questionnaire

PURPOSE

A minimal clinically important difference (MCID) is important in evaluating clinical measures such as health-related quality of life (HRQOL) instruments. The purpose of this analysis is to evaluate MCID for the UCSD Shortness of Breath Questionnaire (SOBQ).

METHODS

We examined measures of disease-specific and generic HRQOL in 164 subjects with chronic lung disease before and after pulmonary rehabilitation. Subjects completed 2 disease-specific [SOBQ, Chronic Respiratory Questionnaire (CRQ)], and 2 generic HRQOL measures [RAND-36 and Quality of Well-Being Scale (QWB)]. The MCID was calculated using 3 methods: effect size, standard error of the measurement (SEM), and comparison between the SOBQ and CRQ Dyspnea scores.

RESULTS

HRQOL measures correlated moderately with measures of maximum exercise tolerance but not with lung function (FEV1, FVC). HRQOL and exercise capacity improved significantly after pulmonary rehabilitation. A change of 5 units for the SOBQ appears to be a reasonable MCID for this instrument. The calculated MCIDs for the CRQ (0.47/item) and QWB (0.031) were consistent with established change scores.

CONCLUSIONS

The MCID calculated using an SEM approach for the SOBQ, CRQ, and QWB meets clinical expectations for these instruments. HRQOL measures provide information that is complementary and distinct from physiological measures.

Functional coupling of adenine nucleotide translocase and mitochondrial creatine kinase is enhanced after exercise training in lung transplant skeletal muscle

Mechanisms responsible for limitation of exercise capacity in lung transplant recipients (LR) and benefits gained by exercise training were studied. Mitochondrial respiration parameters, energy transfer, and cell structure were assessed in vastus lateralis biopsies using the permeabilized fiber technique with histochemical and morphometric measurements. Twelve male controls (C) and 12 LR performed exercise training over 12 wk. Before exercise training, there were strong correlations between exercise capacity (maximal O2 consumption and endurance time at 70% maximal power output) and cellular events, as assessed by percentage of type I fibers and apparent Km for exogenous ADP. Anticalcineurins were not involved in LR exercise limitation, since there were no differences in maximal mitochondrial rate of respiration before exercise training and no abnormalities in respiratory chain complexes compared with C. Training resulted in a significant increase in physiological parameters both at the cellular (apparent Km for exogenous ADP and stimulating effect of creatine) and integrated (maximal O2 consumption, power output at ventilatory threshold, maximal power output, and endurance time at 70% maximal power output) levels in LR and C. After the training period, improvements in maximal O2 consumption and in maximal mitochondrial rate of respiration were noted, as well as changes in endurance time and percentage of type I fibers. Because there were no changes in diameters and fiber types, baseline alteration of apparent Km for exogenous ADP and its improvement after training might be related to changes within the intracellular energetic units. After the training period, intracellular energetic units exhibited a higher control of mitochondrial respiration by creatine linked to a more efficient functional coupling adenine nucleotide translocase-mitochondrial creatine kinase, resulting in better exercise performances in C and LR.

Effects of imposed pursed-lips breathing on respiratory mechanics and dyspnea at rest and during exercise in COPD

STUDY OBJECTIVES

To investigate the effect of volitional pursed-lips breathing (PLB) on breathing pattern, respiratory mechanics, operational lung volumes, and dyspnea in patients with COPD.

SUBJECTS

Eight COPD patients (6 male and 2 female) with a mean (+/-SD) age of 58 +/- 11 years and a mean FEV1 of 1.34 +/- 0.44 L (50 +/- 21% predicted).

METHODS

Wearing a tight-fitting transparent facemask, patients breathed for 8 min each, with and without PLB at rest and during constant-work-rate bicycle exercise (60% of maximum).

RESULTS

PLB promoted a slower and deeper breathing pattern both at rest and during exercise. Whereas patients had no dyspnea with or without PLB at rest, during exercise dyspnea was variably affected by PLB across patients. Changes in the individual dyspnea scores with PLB during exercise were significantly correlated with changes in the end-expiratory lung volume (EELV) values estimated from inspiratory capacity maneuvers (as a percentage of total lung capacity; r2 = 0.82, p = 0.002) and with changes in the mean inspiratory ratio of pleural pressure to the maximal static inspiratory pressure-generating capacity (PcapI) [r2 = 0.84; p = 0.001], measured using an esophageal balloon, where PcapI was determined over the range of inspiratory lung volumes and adjusted for flow.

CONCLUSION

PLB can have a variable effect on dyspnea when performed volitionally during exercise by patients with COPD. The effect of PLB on dyspnea is related to the combined change that it promotes in the tidal volume and EELV and their impact on the available capacity of the respiratory muscles to meet the demands placed on them in terms of pressure generation.

The effects of short-term and long-term pulmonary rehabilitation on functional capacity, perceived dyspnea, and quality of life

STUDY OBJECTIVES

The purposes of this study were as follows: (1) to determine whether physical performance, quality of life, and dyspnea with activities of daily living improved following both short-term and long-term pulmonary rehabilitation (PR) across multiple hospital outpatient programs; (2) to examine the differences in these parameters between men and women; and (3) to determine what relationships existed between the psychosocial parameters and the results of the 6-min walk (6MW) test performance across programs.

DESIGN

Non-experimental, prospective, and comparative.

SETTING

Seven outpatient hospital PR programs from urban and rural settings across North Carolina.

PARTICIPANTS

Three hundred nine women and 281 men who were 20 to 93 years of age (mean [+/- SD] age, 66.7 +/- 11.1 years) with chronic lung disease.

INTERVENTIONS

All 6MW tests and health surveys were administered prior to and immediately following 12 and 24 weeks of supervised PR participation. Scores from the 6MW tests, the Ferrans and Powers quality of life index-pulmonary version III (QLI), the Medical Outcomes Study 36-item short form (SF-36), and the University of California at San Diego shortness of breath questionnaire (SOBQ) were compared at PR entry, at 12 weeks, and at 24 weeks for differences by gender with repeated-measures analysis of variance. The study entry and follow-up SF-36 physical and mental component summary scores, the QLI health/function and overall scores, and the SOBQ scores were also compared to the 6MW test scores with Pearson correlation coefficient analysis.

RESULTS

The mean summary scores on the SF-36 and the QLI increased after 12 weeks of PR (p < 0.05), and improvements were maintained by 24 weeks of PR participation (p < 0.05). Scores on the SOBQ improved after 12 weeks (p < 0.001) among the short-term participants, but not until after 24 weeks among the long-term participants (p = 0.009). The 6MW test performance improved after 12 weeks (p < 0.001) and again from 12 to 24 weeks (p = 0.002) in the long-term participants. No relevant correlational relationships were found between 6MW scores and the summary scores of the administered surveys (r = -0.43 to 0.36).

CONCLUSIONS

Physical performance, as measured by the 6MW test, continued to improve with up to 24 weeks of PR participation. Quality-of-life measures and the perception of dyspnea improved after 12 weeks of PR participation, with improvements maintained by 24 weeks of PR participation. It is recommended that PR patients participate in supervised PR for at least 24 weeks to gain and maintain optimal health benefits.

Effects of exercise training on papain-induced pulmonary emphysema in Wistar rats

The purpose of the present study was to evaluate the role of exercise training on the development of papain-induced emphysema in rats. Our hypothesis was that the increase in pulmonary tissue stretching associated with exercise could increase the severity of a protease-induced emphysema. Wistar rats were randomly assigned to four groups (n = 10 for each group) that received, respectively, intratracheal infusion of papain (6 mg in 1 ml of 0.9% NaCl) or vehicle and were submitted or not to a protocol of exercise on a treadmill. Rats exercised at 13.3 m/min, 6 days/wk, for 9 wk (increasing exercise time, from 10 to 35 min). We measured respiratory system elastance and resistance, the size and weight of the heart, and pulmonary mean linear intercept (Lm). After 9 wk of exercise training, there were no differences in respiratory system resistance and elastance values among the four experimental groups. Volume of the heart was significantly greater in rats submitted to exercise training (P = 0.007) compared with sedentary rats due to increases in volumes of both right and left cardiac chambers. Lm was significantly greater in rats that received papain compared with saline-infused rats (P = 0.025). Surprisingly, this was true, even though there was no significant decrease in elastance, possibly due to connective tissue remodeling. However, Lm was significantly greater in papain + exercise rats compared with rats that received papain and were not submitted to exercise. We conclude that exercise training can increase alveolar damage induced by papain infusion.

Preoperative pulmonary evaluation of the thoracic surgical patient

Fig. 2 is an algorithm for the preoperative pulmonary evaluation of the lung resection candidate. Patients should undergo routine spirometry and diffusion capacity testing. If the FEV1 and DLCO are greater than 80% predicted, no further study is needed. When these parameters are less than 80%, some estimation of postoperative function is likely needed, taking into account the proposed resection. Patients with ppoFEV1 or ppoDLCO less than 40% are at increased risk of perioperative complications or death and should undergo formal exercise testing. A VO2max or ppoVO2max less than 10 mL/kg/min is associated with prohibitive risk for anatomic lung resection, and alternative treatment modalities should be considered.

The Effectiveness of Different Combinations of Pulmonary Rehabilitation Program Components

STUDY OBJECTIVES

To study the short-term and long-term effects of combining activity training or lectures to exercise training on quality of life, functional status, and exercise tolerance.

DESIGN

Randomized clinical trial.

SETTING

Outpatient pulmonary rehabilitation center.

PARTICIPANTS

Forty-three outpatients with COPD.

INTERVENTIONS

Patients were randomized to one of three treatment groups: exercise training alone, exercise training plus activity training, and exercise training plus a lecture series. The mean treatment period was 10 weeks.

MEASUREMENT

The Chronic Respiratory Disease Questionnaire, the modified version of the Pulmonary Functional Status and Dyspnea Questionnaire, and the COPD Self-Efficacy Scale were administered at baseline, and 6, 12, 18, and 24 weeks from the beginning of the rehabilitation program. The 6-min walk test was used to measure exercise tolerance.

RESULTS

Benefits of activity training combined with exercise included less dyspnea (p < or = 0.04) and fatigue (p < or = 0.01), and increased activity involvement (p < or = 0.02) and total functional status (p < or = 0.02) in the short term compared to comparison treatment groups for comparatively older participants. Compared to the lecture series adjunct, the activity training adjunct resulted in significantly higher gains in total quality of life (p = 0.04) maintained at 24 weeks. Significantly worse emotional function and functional status resulted from the lecture series adjunct in the oldest participants (p < or = 0.03). Treatment groups did not differ significantly on exercise tolerance or self-efficacy.

CONCLUSIONS

Evidence for additional benefits of activity-specific training combined with exercise was found. A behavioral method emphasizing structured controlled breathing and supervised physical activity was statistically significantly more effective than didactic instruction in facilitating additional gains and meeting participants' learning needs.

Quadriceps weakness is related to exercise capacity in idiopathic pulmonary fibrosis

STUDY OBJECTIVE

In COPD, it has been shown that peripheral muscle dysfunction is a factor determining exercise intolerance. We examined the hypothesis that exercise capacity of patients with idiopathic pulmonary fibrosis (IPF) is, at least in part, determined by peripheral muscle dysfunction.

METHODS

Maximum oxygen uptake (V(O2)max) was evaluated in 41 consecutive patients with IPF, along with potential determinants of exercise capacity, both in the lungs and in the peripheral muscles.

RESULTS

Patients had reduced V(O2)max (893 +/- 314 mL, 46.0% predicted) and reduced quadriceps force (QF) [65% predicted]. Significant correlates of V(O2)max reduction were vital capacity (VC) [r = 0.79], total lung capacity (r = 0.64), diffusion capacity (r = 0.64), QF (r = 0.62), maximum expiratory pressure (r = 0.48), and Pa(O2) at rest (r = 0.33). In stepwise multiple regression analysis, VC and QF were independent predictors of V(O2)max. Furthermore, in subgroup analysis, QF was a significant contributing factor for V(O2)max in patients who discontinued exercise because of dyspnea and/or leg fatigue.

CONCLUSIONS

We conclude that QF is a predictor of exercise capacity in IPF. Measures that improve muscle function might improve exercise tolerance.

The Value of Preoperative Pulmonary Rehabilitation

Although data are limited for preoperative pulmonary rehabilitation, benefit can be inferred largely from studies done on COPD and pulmonary rehabilitation because of the similarity of patient populations. Although underlying lung function is unchanged, patients who undergo preoperative pulmonary rehabilitation seem to experience an enhanced quality of life and increased functional capacity. Likewise, multidisciplinary rehabilitation programs can result in better patient compliance with medications and smoking cessation and decreased use of various health care resources. Although pulmonary rehabilitation works to benefit patients anticipating surgery, it also represents a valuable treatment alternative to patients who are poor surgical candidates. Pulmonary rehabilitation seems to be a cost-effective, benign intervention with no adverse effects and should remain an essential component of patient management before lung transplantation, LVRS, lung resection, and potentially any other elective thoracic surgical procedure.

Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease

OBJECTIVE

The purpose of this study was to investigate the impact of pulmonary rehabilitation on surgical morbidity and lung function in lung cancer patients with chronic obstructive pulmonary disease (COPD).

METHODS

Prospectively, 22 lung cancer patients with COPD who underwent lobectomy between 2000 and 2003 were enrolled for this study as a rehabilitation group (Rehab. Group). The criteria of COPD were preoperative forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) < or =70% and more than 50% of low attenuation area in a computed tomography. Preoperatively patients performed aggressive pulmonary exercise for two weeks and received chest physiotherapy postoperatively. As a historical control, 60 patients with lung cancer who fulfilled the same criteria but did not receive rehabilitation between 1995 and 1999 (control group) were entered in this study.

RESULTS

Patient backgrounds were all equivalent between the two groups. However, FEV1 and FEV1/FVC were significantly lower in the Rehab. Group (p < 0.05). Prolonged oxygen supplement and tracheostomy tended to be more frequent in the control group. The ratio of actual postoperative to predicted postoperative FEV1 was significantly better in the Rehab. Group (p = 0.047). Furthermore, postoperative hospital stay was significantly longer in the control group (p = 0.0003).

CONCLUSION

Despite lower FEV1 and FEV1/FVC in the Rehab. Group, postoperative pulmonary complications and long hospital stay could be effectively prevented and FEV1 was well preserved by rehabilitation and physiotherapy.

Validation of the Clinical COPD questionnaire in Italian language

BACKGROUND

The development and validation study of the Clinical Chronic Obstructive Disease (COPD) Questionnaire (CCQ) has recently been published in this journal. The CCQ is the first questionnaire that incorporates both clinician and patient guideline goals in the clinical control evaluation of patients with COPD in general clinical practice. The aim of this study is the validation of the CCQ questionnaire in Italian, in specific pulmonary disease clinical practice.

METHODS

Validity was tested on a population of healthy subjects and patients with COPD, using the Italian validated version of the Short Form Health Survey (SF-36) and guideline recommended routine measurement in COPD patients (FEV1, FVC, BMI and functional dyspnoea). Test-retest reliability was tested by re-administering the CCQ after 2 weeks. Responsiveness was tested by re-administering the CCQ after three weeks of hospital pulmonary rehabilitation. Distance walked and Borg breathlessness rating were measured at the end of the six-minute walking test (6 MWT), before and after rehabilitation.

RESULTS

Cross-sectional data were collected from 175 subjects (55 healthy; 40 mild-moderate, 50 severe and 25 very severe COPD). Cronbach's alpha was high (0.89). The CCQ scores in patients were significantly worse than in healthy subjects. The CCQ total score in patients with COPD was significantly worse in those with BMI < or = 21. Significant correlations were found between the CCQ total score and domains of the SF-36 (rho = -0.43 to rho = -0.72). The correlation between the CCQ and FEV1 % predicted was rho = -0.57. The correlation between the CCQ and MRC was rho = 0.63. Test-retest reliability was determined in 112 subjects over a period of two weeks (Intra Class Coefficient = 0.99). Forty-six patients with COPD showed significant improvement in CCQ scores, distance-walked and Borg breathlessness rating after 3 weeks of pulmonary rehabilitation, indicating CCQ responsiveness.

CONCLUSIONS

The CCQ is self-administered and has been specially developed to measure clinical control in patients with COPD. Data support its validity, reliability and responsiveness in Italian and in specific pulmonary disease clinical practice.

Measurement of agreement on health-related quality of life changes in response to respiratory rehabilitation by patients and physicians--a prospective study

INTRODUCTION

To provide optimal care for patients with chronic obstructive pulmonary disease physicians need to understand if their patients benefit from an intervention. The objective of this study was to assess agreement between patients and physicians on health-related quality of life (HRQL) changes in response to respiratory rehabilitation and to explore sources for disagreement.

METHODS

Sixty-one patients rated their health states on a validated preference-based instrument, the feeling thermometer (FT). In an analogous manner, the eight treating physicians rated the patients' health states on the FT. Patients and physicians were blinded to each other's ratings. We calculated intraclass correlation coefficients (ICC) to assess agreement between patients and physicians and used HRQL instruments and the 6-min walking test to assess the evaluative properties of the FT.

RESULTS

We found moderate agreement at baseline (ICC 0.40, P = 0.018) and follow-up (ICC 0.49, P = 0.008) but large disagreement about change scores (ICC 0.02, P = 0.46). Patients' FTchange scores correlated well with change scores of the Chronic Respiratory Questionnaire, SF-36 and the Borg scale for dyspnoea whereas physicians' FT change scores correlated significantly with the change score of the 6- min walking test (r = 0.33). Physicians' ratings showed an inconsistent pattern for correlations with HRQL measures.

CONCLUSIONS

There is large disagreement between patients and physicians on HRQL changes in response to respiratory rehabilitation. Investigators should assess whether the introduction of HRQL instruments into clinical practice raises the awareness of physicians towards HRQL and improves agreement with their patients.

Exercise Outcomes After Pulmonary Rehabilitation Depend on the Initial Mechanism of Exercise Limitation Among Non-Oxygen-Dependent COPD Patients

STUDY OBJECTIVES

Pulmonary rehabilitation (PR) that includes exercise training can improve exercise tolerance and quality of life for patients with COPD. However, the degree of benefit from PR is variable. We hypothesized that the exercise response to PR varies depending on the initial factors that limit exercise.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

We retrospectively analyzed the change in exercise capacity after PR in 290 nonhypoxemic patients with COPD. We classified patients into the following subgroups based on the primary limitation seen on initial exercise testing: (1) ventilatory-limited (VL); (2) cardiovascular-limited (CVL); (3) mixed ventilatory/cardiovascular-limited (VLCVL); and (4) non-cardiopulmonary-limited (NL). We compared outcomes among subgroups.

RESULTS

In the entire study population, PR led to increased timed walk distance (30.3%; p < 0.0001) and maximal oxygen consumption (VO2max) [84.8 mL/min; p < 0.0001]. Stepwise multiple regression selected age, ventilatory reserve at peak exercise, and exercise arterial oxygen pressure as individual predictors of improvement in VO2max. VO2max increased in the VL subgroup (30.4 mL/min; p = 0.008), the CVL subgroup (109.0 mL/min; p < 0.0001), the mixed VLCVL subgroup (61.3 mL/min; p < 0.0001), and NL subgroups (110.5 L/min; p < 0.0001). The improvement in VO2max was greater in the CVL subgroup than in the VL subgroup (p < 0.0001). Timed walk distance improved to a similar degree in all subgroups (26 to 36%).

CONCLUSIONS

Patients with nonventilatory exercise limitations experience the greatest increase in VO2max after PR. However, even patients with severe ventilatory limitation can improve exercise tolerance with PR.

Feasibility of Distractive Auditory Stimuli on Upper Extremity Training in Persons With Chronic Obstructive Pulmonary Disease

OBJECTIVE

To determine the feasibility of distractive auditory stimuli (DAS) used during an upper extremity training (UET) program on perceived dyspnea, functional performance, and health-related quality of life. In addition, to determine the appropriate music tempo used during the UET.

DESIGN

Experimental, randomized, 3-group design with testing at baseline and 4 weeks.

SETTING

Outpatient.

PATIENTS

Thirty patients (13 male and 17 female) with moderate to severe chronic obstructive pulmonary disease (FEV1 41.27% +/- 18% predicted).

INTERVENTION

Moderate DAS group (n = 10) and slow DAS group (n = 10) subjects were instructed to perform UET for up to 15 minutes 3 to 5 times a week using DAS (walkman, audiocassettes). The control group (n = 10) received the same instructions, but no DAS.

MEASURES AND RESULTS

Primary outcome measures were perceived dyspnea, functional performance using the 6-minute peg and ring board (6MRPB) count and health-related quality of life. In addition, all subjects recorded the time of UET performance using self-report (daily logs). A significant increase was seen in 6MRPB count (P = .002) between groups. Moderate DAS subjects increased 6MPRB count 46 +/- 21 rings and slow DAS subjects increased 46 +/- 20 rings from baseline to 4 weeks whereas control subjects increased only 5 +/- 4 rings. No significant differences were noted for the remaining variables.

CONCLUSION

Subjects who used DAS (music) while performing UET improved functional performance whereas controls failed to continue improvement. The DAS is a feasible adjunct to UET that may have the potential to augment the effectiveness of pulmonary rehabilitation training.

Economic evaluation of a community-based pulmonary rehabilitation program for chronic obstructive pulmonary disease

Pulmonary rehabilitation has been demonstrated to be efficacious in chronic obstructive pulmonary disease (COPD), however, its cost-effectiveness is largely unknown. The present study determined the cost-effectiveness of a community-based pulmonary rehabilitation program for COPD patients with mild, moderate, and severe disease. We compared the direct costs (in Canadian dollars) and disease-specific quality of life (measured by the St. George's Respiratory Questionnaire, SGRQ) of patients with COPD (N = 210) who enrolled in the rehabilitation program in Edmonton, Canada one year before and after completion of the program. To determine temporal trends in health service utilization between 2000 and 2002 we used similar data from 592 COPD patients from the same region who did not participate in the rehabilitation program. We found that the health status of patients enrolled in the program improved significantly following pulmonary rehabilitation, irrespective of the severity of disease (total SGRQ score improved by 4.85%, p = 0.001). The total direct cost per 100 person-years of follow-up before the program was $122,071 (SE = 29,566); after the program it was $87,704 (SE = 26,146). The average reduction of total costs before and after the program was $34,367 per 100 person-years or approximately $344 per person per year (p = 0.02). Over one-year, pulmonary rehabilitation was associated with decreased health service utilization, reduced direct costs and improved health status of COPD patients. This suggests that pulmonary rehabilitation is cost-effective for patients with relatively high utilization of emergency and hospital-based services.

Value of supplemental interventions to enhance the effectiveness of physical exercise during respiratory rehabilitation in COPD patients. A systematic review

BACKGROUND

There is a controversy about the additional benefit of various supplemental interventions used in clinical practice to further enhance the effectiveness of respiratory rehabilitation in patients with Chronic obstructive pulmonary disease (COPD). The aim of this research was to assess randomised controlled trials (RCTs) testing the additional benefit of supplemental interventions during respiratory rehabilitation in COPD patients.

METHODS

Systematic review with literature searches in six electronic databases, extensive hand-searching and contacting of authors. Two reviewers selected independently eligible RCTs, rated the methodological quality and extracted the data, which were analyzed considering the minimal important difference of patient-important outcomes where possible.

FINDINGS

We identified 20 RCTs whereof 18 provided sufficient data for analysis. The methodological quality was low and sample sizes were too small for most trials to produce meaningful results (median total sample size = 28). Data from five trials showed that supplemental oxygen during exercise did not have clinically meaningful effects on health-related quality of life while improvements of exercise capacity may be even larger for patients exercising on room air. RCTs of adding assisted ventilation, nutritional supplements or a number of anabolically acting drugs do not provide sufficient evidence for or against the use any of these supplemental interventions.

INTERPRETATION

There is insufficient evidence for most supplemental interventions during respiratory rehabilitation to estimate their additional value, partly due to methodological shortcomings of included RCTs. Current data do not suggest benefit from supplemental oxygen during exercise, although the methodological quality of included trials limits conclusions. To appropriately assess any of the various supplemental interventions used in clinical practice, pragmatic trials on respiratory rehabilitation of COPD patients need to consider methodological aspects as well as appropriate sample sizes.

Reductions in functional balance, coordination, and mobility measures among patients with stable chronic obstructive pulmonary disease

PURPOSE

To compare measures of balance, coordination, and mobility between patients with chronic obstructive pulmonary disease (COPD) and healthy control subjects, and to determine whether differences in these measures are associated with measures of disease severity.

METHODS

The subjects were divided into three groups: 15 patients with COPD who required the use of supplemental oxygen (WO), 15 patients with COPD who did not require the use of supplemental oxygen (NO), and 21 healthy control subjects (CO). The subjects performed spirometry and several measures of balance, coordination, and mobility including the Community Balance and Mobility Scale, the timed up and go test, the fast-gait speed test, posturography, and both a finger-to-nose test and a toe-tapping coordination test. Significance was set at an alpha less than 0.05.

RESULTS

When control was used for age, significant differences were found between the WO group and the CO group for the finger-to-nose test, and for both the sway index and peak sway index for the eyes open, moving-platform test. Differences were found among all three groups for the Community Balance and Mobility Scale overall score. The scores for the WO group were significantly worse than for the NO group on the timed up and go and the fast-gait speed tests. Moderate correlation was found among all of the measures, demonstrating significant differences in forced-expiratory volume in 1 second (FEV1), peak expiratory flow, and forced-expiratory volume. When controls were used for both age and FEV1, between-group differences disappeared.

CONCLUSIONS

Patients with COPD exhibit deficiencies in functional balance, coordination, and mobility tasks associated with disease severity or differences in activity levels, but not in the requirement for supplemental oxygen.

Does Unsupported Upper Limb Exercise Training Improve Symptoms and Quality of Life for Patients With Chronic Obstructive Pulmonary Disease?

PURPOSE

Many patients with chronic obstructive pulmonary disease (COPD) report dyspnea and fatigue when performing upper limb activities. Unsupported upper limb training has been shown to improve upper limb endurance, but its effects on symptoms and quality of life have not been examined. The aim of this study was to compare the effects of upper limb and lower limb training with lower limb training alone on exercise capacity, symptoms, and quality of life with COPD.

METHODS

For this study, 38 patients with moderate to severe COPD were randomly allocated to unsupported upper limb endurance training or to a control group that completed a sham training task. All the patients underwent lower limb endurance training. The 6-minute walk test, the Incremental Unsupported Upper Limb Exercise Test, and the Chronic Respiratory Disease Questionnaire (CRQ) were completed before training and then 6 weeks afterward. Both patients and assessors were blinded to group allocation.

RESULTS

All the patients reported symptoms associated with upper limb activities on the initial CRQ. Both groups showed significant improvements in all domains of the CRQ and in the 6-minute walk test after training. Only the upper limb training group showed improvement in upper limb endurance time (57 +/- 75 vs 2 +/- 58 seconds; P = .02). There were no significant differences between the groups for 6-minute walk test or any domain of the CRQ.

CONCLUSIONS

Unsupported upper limb training for patients COPD improves upper limb exercise capacity, but has no additional effect on symptoms or quality of life, as compared with leg training alone. This type of upper limb training may not adequately address the complex interaction between respiratory mechanics and upper limb function.

Respiratory lumenal change of the pharynx and trachea in normal subjects and COPD patients: assessment by cine-MRI

The purpose of this study was to use cine-MRI during continuous respiration to measure the respiratory lumenal diameter change in the pharynx and at an upper tracheal level. Fifteen non-smokers and 23 chronic obstructive pulmonary disease (COPD) patients with smoking history (median 50 pack-years) were included. Cine-MRI with seven frames/s was performed during continuous respiration. Minimal and maximal cross-sectional lumenal diameters within the pharynx and the upper tracheal lumen area were measured. The median diameter change in the pharynx (tracheal area) was 70% (1.4 cm(2)) in volunteers and 76% (1.7 cm(2)) in smokers (P=0.98, P=0.04). Tracheal lumenal collapse was a median of 43% in volunteers and 64% in smokers (P=0.011). No clear disease-related difference of the pharynx-lumen was found. The maximal cross-sectional area of the upper trachea lumen as well as the respiratory collapse was larger in COPD patients than in normal subjects. This information is important for the modelling of ventilation and prediction of drug deposition, which are influenced by the airway diameter.

Acute Exacerbation of COPD

Nurses in acute care settings play a vital role in caring for individuals during an acute exacerbation of chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States. In addressing this health concern, the Global Initiative for Chronic Obstructive Lung Disease Report summarized the goals for COPD management and recommended treatment supported by current data and research. It is imperative that our clinical nursing practice is based upon research-supported interventions: use of appropriate medications, monitoring acid-base status, administering controlled oxygen therapy, assessing the need for mechanical ventilation, and close monitoring of comorbid illnesses. Health promotion includes patient and family education on early recognition of symptoms, smoking cessation strategies, and participation in pulmonary rehabilitation that can reduce long-term morbidity from this chronic disease.

La réhabilitation respiratoire à domicile : données de la littérature, aspects pratiques et médico-économiques

INTRODUCTION

Pulmonary rehabilitation is an established part of the management of chronic obstructive airway disease. For longer-term effects, extending rehabilitation into domiciliary care settings may be necessary. There are few studies evaluating precisely this modality of management in a home setting.

STATE OF THE ART

This review analyses the current literature on home based rehabilitation. The benefits of pulmonary rehabilitation, the practical aspects of its application, and its advantages and limitations are detailed. The few data on economic aspects of home rehabilitation are also discussed.

PERSPECTIVES

Home-based pulmonary rehabilitation is effective with positive short-term effects on quality of life, breathlessness and effort tolerance. Its practical application needs to be defined.

CONCLUSION

Home-based pulmonary rehabilitation appears to be an effective intervention in patients with COPD but more studies are necessary to evaluate it fully.

Pulmonary rehabilitation programmes in the UK: a national representative survey

BACKGROUND

Respiratory disease is a common cause of disability in middle and late life. Pulmonary rehabilitation programmes improve exercise capacity and quality of life in patients with chronic lung diseases. However, currently, in the UK the availability of pulmonary rehabilitation programmes and their characteristics are unknown.

METHODS

We surveyed pulmonary rehabilitation programmes in terms of number, size, duration, content of educational and exercise programme, and staffing. We mailed a 17-item questionnaire previously used in Canadian study to 190 physiotherapy departments within acute hospitals in UK.

RESULTS

One hundred and seventy-one (90%) responses were received. Sixty-eight centres (40%) run a pulmonary rehabilitation programme (99% outpatient). Mean age of subjects was > or = 70 in only seven centres (10%), though most cited no upper age limit. Ninety-nine per cent of centres incorporated exercise training. Programmes recruited a median group size of 10 patients (range 4-17) at a given time with a median duration of eight weeks (range 5-24) weeks. Most (71%) run twice per week with a duration of 2 hours (63%). Only half offered smoking cessation support, and a minority gave advice on coping with disease, travel and sexual matters.

CONCLUSION

Around 40% of surveyed hospitals run a pulmonary rehabilitation programme and most of the programmes are similar in their format, content and staffing. Despite the high prevalence of chronic obstructive pulmonary disease (COPD)-related disability in old age most programmes chiefly included younger subjects. This may reflect lack of referral. Greater awareness and expansion of availability of programmes is indicated.

Interval exercise versus continuous exercise in patients with moderate to severe chronic obstructive pulmonary disease--study protocol for a randomised controlled trial [ISRCTN11611768]

BACKGROUND

Physical exercise has become a cornerstone of management of chronic obstructive pulmonary disease (COPD) because it leads to clinically relevant improvements of exercise capacity and health-related quality of life (HRQL). Despite the scarcity of randomised trials directly comparing exercise protocols, current guidelines recommend high intensity continuous exercise for lower extremities as the probably most effective exercise modality. However, for patients admitted to inpatient respiratory rehabilitation programmes, it is often difficult to initiate such an exercise programme because they are severely limited by dyspnoea and leg fatigue and therefore unable to perform continuous exercise at higher intensities and for periods longer than 30 minutes. Interval exercise may be an attractive alternative for these COPD patients because it allows high intensity exercise with recovery periods. The aim of this study is to assess if interval exercise compared to high intensity continuous exercise is not of inferior effectiveness in terms of HRQL and exercise capacity improvements but associated with better exercise tolerance in patients with moderate to severe COPD at the beginning of a respiratory rehabilitation.

METHODS/DESIGN

We will assign patients with moderately severe to severe COPD to either continuous exercise or interval exercise using a stratified randomisation. Patients will follow 12-15 exercise sessions during a comprehensive inpatient respiratory rehabilitation. Primary end point for effectiveness is HRQL as measured by the Chronic Respiratory Questionnaire (CRQ) two weeks after the end of rehabilitation and secondary endpoints include additional clinical outcomes such as functional exercise capacity, other HRQL measures, patients' experience of physical exercise as well as physiological measures of the effects of physical exercise such as cardiopulmonary exercise testing. Including expected drop-outs, we will need 52 patients per group to show differences corresponding to the minimal clinically important difference of the CRQ. Outcome assessors and investigators involved in data analysis will be blinded to group assignment until analyses have been carried out.

DISCUSSION

Clinicians and the scientific community need evidence on the benefits and tolerance of exercise protocols available in clinical practice. The proposed trial will provide important and needed data on interval and continuous exercise for decision making in clinical practice.

Chronic respiratory failure after lung resection: the role of pulmonary rehabilitation

Pulmonary rehabilitation gradually has become the gold standard treatment for patients with severe lung disease, especially COPD. By definition, rehabilitation services are provided to patients with symptoms, most of whom have moderate-to-advanced lung disease. Because new therapeutic strategies, such as lung volume-reduction surgery and lung transplantation, require well-conditioned patients, pulmonary rehabilitation is becoming a crucial component of the overall treating strategy of many patients who heretofore were deemed untreatable. The positive results in several randomized trials have documented the effectiveness of pulmonary rehabilitation. Currently, pulmonary rehabilitation should be made available to all patients with symptomatic respiratory disease and be an integral part of any program considering high-risk surgery.

Long-term effectiveness of an inpatient pulmonary rehabilitation program for elderly COPD patients: Comparison between young-elderly and old-elderly groups

OBJECTIVE

To evaluate the long-term effects of pulmonary rehabilitation in elderly COPD patients, we monitored patients for 1 year after they completed a 2-week inpatient pulmonary rehabilitation program. We also compared the effects of pulmonary rehabilitation on young-elderly (age 65-74 years) and old-elderly (age 75 years or over) COPD patients.

METHODOLOGY

Fifty-nine elderly COPD patients (mean age 72.8 years) were studied. They underwent a comprehensive 2-week inpatient pulmonary rehabilitation program incorporating 10 exercise sessions, each of which included endurance training of the lower extremities, peripheral muscle conditioning training of the upper and lower extremities, and stretching, along with various education sessions. The effects of pulmonary rehabilitation were evaluated at 3, 6, and 12 months after completion of the program.

RESULTS

Overall, patient health-related quality of life (HRQoL) as assessed by a QoL scale, and dyspnoea as assessed by an oxygen cost diagram, improved significantly over the 12-month period. Exercise capacity assessed by a 6-min walking distance test (6MWD) was similarly significantly improved. However, there was some fall-off in terms of the distance walked 12 months after pulmonary rehabilitation. The improvements in exercise capacity, dyspnoea, and HRQoL did not differ between the two groups, with the exception that the 6MWD (P < 0.01) and the QoL scale (P < 0.05) at 3 months post-pulmonary rehabilitation were significantly higher in the old-elderly group.

CONCLUSIONS

Pulmonary rehabilitation is an effective treatment in terms of improving dyspnoea, exercise capacity and HRQoL in elderly COPD patients, and the benefits are almost comparable for young-elderly and old-elderly patients.

IRAD2 : Insuffisant respiratoire à domicile 2 (2e étude) effets d’une réhabilitation à domicile chez l’insuffisant respiratoire chronique dénutri

STATE OF THE ART

The IRAD2 trial is evaluating a 3-month home intervention which includes education, oral supplements, exercise and androgenic steroids in undernourished patients with chronic respiratory failure. The main objective is to increase the six-minute walking distance by more than 50 m with an improvement in health-related quality-of-life. Secondary end-points include a reduction in exacerbation rates by 25%, a reduction in health-related costs and an increase in survival during the year following intervention.

MATERIAL AND METHODS

This interventional, multi-centre, prospective, two-armed parallel, controlled trial is being conducted in 200 patients. In both groups, "Control" and "Rehabilitation", 7 home visits are scheduled during the 3-month intervention for education purpose. In the "Rehabilitation" group, patients will receive 160 mg/d of oral testosterone undecanoate in men, 80 mg/d in women, oral dietary supplements (563 kcal/d) and exercises on an ergometric bicycle 3 to 5 times a week.

EXPECTED RESULTS

In the event of significant responses to intervention, this trial would validate a comprehensive and global home-care for undernourished patients with chronic respiratory failure combining therapeutic education, oral supplements, androgenic substitution and physical activity.

Aerobic exercise attenuates airway inflammatory responses in a mouse model of atopic asthma

Recent reports indicate that aerobic exercise improves the overall physical fitness and health of asthmatic patients. The specific exercise-induced improvements in the pathology of asthma and the mechanisms by which these improvements occur, however, are ill-defined; thus, the therapeutic potential of exercise in the treatment of asthma remains unappreciated. Using an OVA-driven mouse model, we examined the role of aerobic exercise in modulating inflammatory responses associated with atopic asthma. Data demonstrate that moderate intensity aerobic exercise training decreased leukocyte infiltration, cytokine production, adhesion molecule expression, and structural remodeling within the lungs of OVA-sensitized mice (n = 6-10; p < 0.05). Because the transcription factor NF-kappaB regulates the expression of a variety of genes that encode inflammatory mediators, we monitored changes in NF-kappaB activation in the lungs of exercised/sensitized mice. Results show that exercise decreased NF-kappaB nuclear translocation and IkappaBalpha phosphorylation, indicating that exercise decreased NF-kappaB activation in the lungs of sensitized mice (n = 6). Taken together, these results suggest that aerobic exercise attenuates airway inflammation in a mouse model of atopic asthma via modulation of NF-kappaB activation. Potential exists, therefore, for the amelioration of asthma-associated chronic airway inflammation through the use of aerobic exercise training as a non-drug therapeutic modality.

Severe chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) exacts a heavy toll on society, yet its prevention, diagnosis and treatment receives inadequate attention from both the medical community and from society at large. Guidelines released in 2001 from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) are aimed at redressing this inequity. In this review, we integrate information from the GOLD guidelines with recent updates on the prevention, treatment and management as related specifically to the most severe form of this disease. In order to help distinguish COPD from other disorders that may mimic or confound its treatment, we place particular emphasis on the definition, underlying pathophysiology and diagnosis of COPD. In addition, we discuss future directions in pharmacotherapy.

The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by an incompletely reversible limitation in airflow. A physiological variable--the forced expiratory volume in one second (FEV1)--is often used to grade the severity of COPD. However, patients with COPD have systemic manifestations that are not reflected by the FEV1. We hypothesized that a multidimensional grading system that assessed the respiratory and systemic expressions of COPD would better categorize and predict outcome in these patients.

METHODS

We first evaluated 207 patients and found that four factors predicted the risk of death in this cohort: the body-mass index (B), the degree of airflow obstruction (O) and dyspnea (D), and exercise capacity (E), measured by the six-minute-walk test. We used these variables to construct the BODE index, a multidimensional 10-point scale in which higher scores indicate a higher risk of death. We then prospectively validated the index in a cohort of 625 patients, with death from any cause and from respiratory causes as the outcome variables.

RESULTS

There were 25 deaths among the first 207 patients and 162 deaths (26 percent) in the validation cohort. Sixty-one percent of the deaths in the validation cohort were due to respiratory insufficiency, 14 percent to myocardial infarction, 12 percent to lung cancer, and 13 percent to other causes. Patients with higher BODE scores were at higher risk for death; the hazard ratio for death from any cause per one-point increase in the BODE score was 1.34 (95 percent confidence interval, 1.26 to 1.42; P<0.001), and the hazard ratio for death from respiratory causes was 1.62 (95 percent confidence interval, 1.48 to 1.77; P<0.001). The C statistic for the ability of the BODE index to predict the risk of death was larger than that for the FEV1 (0.74 vs. 0.65).

CONCLUSIONS

The BODE index, a simple multidimensional grading system, is better than the FEV1 at predicting the risk of death from any cause and from respiratory causes among patients with COPD.

Managing COPD: no more nihilism!

This special issue of Patient Education and Counseling is long overdue. During most of the last two decades asthma, and notably asthma self-management has been in the spotlight, while COPD has had to endure a nihilistic approach. The first sign that interest was shifting to the treatment of COPD came from a few large randomized trials on the use of inhaled corticosteroids (ICS) in COPD. Although these studies demonstrated a moderate effect of ICS in COPD, it has become clear that true improvements in the management of this chronic disease will have to come from behavioral interventions. This special issue of Patient Education and Counseling is dedicated solely to the non-pharmaceutical management of COPD. It addresses many issues related to behavioral therapy, such as smoking cessation, exercise training, nutritional aspects, and self-management programs, including action plans to self-treat exacerbations. With the availability of all the treatment and management options, described in this special issue, a nihilistic attitude toward the patient with COPD is no longer justified.

Management of stable COPD

Chronic obstructive pulmonary disease (COPD) is a systemic disease with major impact worldwide. In the treatment of COPD a holistic approach should be taken. In order to reach this, an individual treatment plan should be made which includes at least elements of smoking cessation, optimisation of pulmonary status by pharmacotherapy and exercise embedded in a new lifestyle. Furthermore, more research on nutritional and metabolic intervention strategies for COPD patients is needed. With the availability of all these treatment options, a nihilistic attitude toward the patient with COPD is no longer justified.

Respiratory muscle strength training with nonrespiratory maneuvers

The diaphragm and abdominal muscles can be recruited during nonrespiratory maneuvers. With these maneuvers, transdiaphragmatic pressures are elevated to levels that could potentially provide a strength-training stimulus. To determine whether repeated forceful nonrespiratory maneuvers strengthen the diaphragm, four healthy subjects performed sit-ups and biceps curls 3-4 days/wk for 16 wk and four subjects served as controls. The maximal transdiaphragmatic pressure was measured at baseline and after 16 wk of training. Maximum static inspiratory and expiratory mouth pressures and diaphragm thickness derived from ultrasound were measured at baseline and 8 and 16 wk. After training, there were significant increases in diaphragm thickness [2.5 ± 0.1 to 3.2 ± 0.1 mm (mean ± SD) ( P < 0.001)], maximal transdiaphragmatic pressure [198 ± 21 to 256 ± 23 cmH2O ( P < 0.02)], maximum static inspiratory pressure [134 ± 22 to 171 ± 16 cmH2O ( P < 0.002)], maximum static expiratory pressure [195 ± 20 to 267 ± 40 cmH2O ( P < 0.002)], and maximum gastric pressure [161 ± 5 to 212 ± 40 cmH2O ( P < 0.03)]. These parameters were unchanged in the control group. We conclude that nonrespiratory maneuvers can strengthen the inspiratory and expiratory muscles in healthy individuals. Because diaphragm thickness increased with training, the increase in maximal pressures is unlikely due to a learning effect.