Breathing exercises for chronic obstructive pulmonary disease

Development and Validation of an Evidence-Based Home Pursed Lip Breathing Protocol for Improving Health Outcomes in Patients With Chronic Obstructive Pulmonary Disease

AIM

To develop and validate an evidence-based home pursed lip breathing (PLB) intervention protocol for improving related health outcomes (e.g., dyspnea and exercise capability) in patients with chronic obstructive pulmonary disease (COPD) and to present a detailed intervention development process.

METHODS

This home PLB intervention protocol employed phase one of the Medical Research Council (MRC) Framework for Developing and Evaluating Complex Interventions to guide the development process of the PLB intervention. We searched for research evidence on 5 July 2023 from several databases, including PubMed, Embase (via Ovid), Cochrane Library, Google Scholar and China Biology Medicine Disk (CBM). Using the content validity index, a panel of experts assessed the appropriateness of the PLB protocol.

RESULTS

We developed the preliminary home PLB intervention protocol on the basis of several underlying rationales, which encompass the extension of expiration time, enhancement of respiratory muscle strength, augmentation of tidal volume and integration of the most reliable research evidence obtained from four systematic reviews, five RCTs, five clinical trials, and 10 recommendations. We structured the PLB intervention with a designated time ratio of inspiration to expiration, set at 1:2. Additionally, this study recommends that the training parameters of the PLB intervention were as follows: three sessions per day, each lasting for 10 min, over 8 weeks. Individualised PLB training intensity adjusted the inhalation component according to each participant's tolerance level while emphasising the exhalation phase to ensure the complete expulsion of air from the lungs. The home PLB intervention protocol established strong content validity through consensus, which was reached among all panel experts. The item-level and scale-level content validity indices (CVIs) reached a maximum score of 1.0, indicating a high level of agreement and credibility in the protocol's content as evaluated by the expert panel.

CONCLUSION

An optimal evidence-based home PLB protocol has been adapted and developed to manage health-related outcomes of patients with COPD. The protocol is transparent and fully supported by relevant mechanisms, concrete evidence, recommendations and experts' consensus.

IMPLICATIONS FOR PRACTICE

In this study, we consulted patients with COPD about the 'Prepared Conditions Before PLB Practice', to ensure appropriate measures to prevent patients with COPD from potential risks. In addition, patients with COPD also contributed to the PLB exercise frequency distribution.

Effect of breathing exercises on patients with interstitial lung disease: A systematic review and meta-analysis

PURPOSE

This study was designed to synthesize the efficacy and safety of breathing exercises in interstitial lung disease (ILD) patients by reviewing the literature and comparing the impact of different control group types, ILD subtypes, breathing exercise action modes or methods, and intervention durations on clinical efficacy.

METHODS

Systematic searches were conducted across 9 electronic databases, including PubMed, to retrieve English and Chinese studies reporting on ILD patients from inception to February 12, 2024. Study selection and data extraction were independently conducted by two researchers. The quality of the included studies was assessed using the Cochrane risk of bias tool. The data were analysed using RevMan 5.4 and STATA 17.0 software.

RESULTS

The search identified 25 studies. Compared to the control group, the breathing exercise group exhibited significantly improved lung function (FVC%pred: MD  =  3.46, 95%CI = 1.04 to 5.88; DLCO%pred: MD = 3.20, 95% CI = 2.91 to 3.48), dyspnoea (MRC or mMRC scale: MD = - 0.50, 95%CI = - 0.77 to - 0.22), exercise capacity (6MWD: MD = 32.65, 95% CI = 14.77 to 50.53), and HRQoL (SGRQ: MD = - 6.53, 95% CI = - 8.72 to - 4.34) in ILD patients. According to the subgroup analysis, significant improvements consistent with the overall results were observed in the control group with usual treatment. Compared with the control group, breathing exercises had varying degrees of improvement in the mixed diagnostic group, known-cause group, and fibrotic group of ILD patients; breathing exercises alone significantly improved DLCO%pred, MRC (or mMRC), and SGRQ; and the improvement in breathing exercises as part of pulmonary rehabilitation (PR) was more notable. Different durations of breathing exercise could promote the efficacy of different aspects of treatment for ILD patients.

CONCLUSIONS

Compared with usual treatment, breathing exercises can improve lung function, exercise capacity, and HRQoL in ILD patients, particularly without high requirements for intervention duration. The efficacy of breathing exercises varies for different ILD subtypes, and incorporating breathing exercises as part of PR can be more beneficial for ILD patients. No studies have shown significant risks for ILD patients engaging in breathing exercises.

Efficacy and safety of a music-therapy facilitated pulmonary telerehabilitation program in COPD patients: the COPDMELODY study protocol

Despite considerable evidence for the benefit in chronic obstructive pulmonary disease (COPD), the implementation of pulmonary rehabilitation (PR) is insufficient. However, music therapy may help address this gap due to its unique benefits. Therefore, we aimed to develop a music-therapy facilitated pulmonary telerehabilitation program based on rhythm-guided walking, singing, and objective telemonitoring. A supervised, parallel-group, single-blinded, randomized controlled clinical trial will be conducted, including 75 patients with COPD anticipated to be randomized in a 1:1:1 ratio into three groups. The intervention groups will receive a 12-week remotely monitored rehabilitation program, while the usual care group will not receive any rehabilitation interventions. Of the two intervention groups, the multi-module music therapy group will contain rhythm-guided walking and singing training, while the rhythm-guided walking group will only include music tempo-guided walking. The primary outcome is the distance of the incremental shuttle walking test. Secondary outcomes include respiratory muscle function, spirometry, lower extremity function, symptoms, quality of life, anxiety and depression levels, physical activity level, training adherence, and safety measurements. The results of this study can contribute to develop and evaluate a home-based music-facilitated rehabilitation program, which has the potential to act as a supplement and/or substitute (according to the needs) for traditional center-based PR in patients with stable COPD. Clinical trial registration: https://classic.clinicaltrials.gov/, NCT05832814.

Distinguishing science from pseudoscience in commercial respiratory interventions: an evidence-based guide for health and exercise professionals

Respiratory function has become a global health priority. Not only is chronic respiratory disease a leading cause of worldwide morbidity and mortality, but the COVID-19 pandemic has heightened attention on respiratory health and the means of enhancing it. Subsequently, and inevitably, the respiratory system has become a target of the multi-trillion-dollar health and wellness industry. Numerous commercial, respiratory-related interventions are now coupled to therapeutic and/or ergogenic claims that vary in their plausibility: from the reasonable to the absurd. Moreover, legitimate and illegitimate claims are often conflated in a wellness space that lacks regulation. The abundance of interventions, the range of potential therapeutic targets in the respiratory system, and the wealth of research that varies in quality, all confound the ability for health and exercise professionals to make informed risk-to-benefit assessments with their patients and clients. This review focuses on numerous commercial interventions that purport to improve respiratory health, including nasal dilators, nasal breathing, and systematized breathing interventions (such as pursed-lips breathing), respiratory muscle training, canned oxygen, nutritional supplements, and inhaled L-menthol. For each intervention we describe the premise, examine the plausibility, and systematically contrast commercial claims against the published literature. The overarching aim is to assist health and exercise professionals to distinguish science from pseudoscience and make pragmatic and safe risk-to-benefit decisions.

An overview of Cochrane systematic reviews for pulmonary rehabilitation interventions in people with chronic obstructive pulmonary disease: a mapping synthesis

INTRODUCTION

There is a global unmet need for rehabilitation to meet which the World Health Organization, in collaboration with Cochrane Rehabilitation, is developing the Package of Interventions for Rehabilitation with the aim of identifying rehabilitation interventions relevant to a range of key health conditions, including chronic obstructive pulmonary disease (COPD). The purpose of this paper is to describe the best available evidence on pulmonary rehabilitation interventions for people with COPD.

EVIDENCE ACQUISITION

An Overview of Cochrane Systematic Reviews (CSRs). Through the search strategy, COPD-related systematic reviews published from January 2009 to November 2021 were identified. Data were extracted on each reported outcome related to an intervention and judgements about the quality of evidence were made, using the GRADE approach.

EVIDENCE SYNTHESIS

Seventeen reviews were analyzed, for a total of 314 primary studies that included 22,206 participants. CSRs provided information on the effectiveness of rehabilitation on functioning, activity, quality of life, anxiety, depression, mortality, and health care resource utilization.

CONCLUSIONS

Our findings report that comprehensive pulmonary rehabilitation programs and water exercises improve the exercise capacity and quality of life (QoL) in people with COPD. Different exercise modalities, intensities, and settings for different muscle groups, breathing exercises, and counseling can improve exercise capacity, QoL, dyspnea, hospitalizations, and physical activity. It is uncertain whether breathing exercise, low-intensity exercise, neuromuscular electrical stimulation, and psychological intervention have an effect on exercise capacity, dyspnea, QoL, and physical activity. The protocol was registered on OSF (registration DOI: 10.17605/OSF.IO/8A26Q).

Mind-Body Intervention for Dysfunctional Breathing in Chronic Obstructive Pulmonary Disease: Feasibility Study and Lessons Learned

Purpose: Dysfunctional breathing behaviors are prevalent in chronic obstructive pulmonary disease (COPD). Although these behaviors contribute to dyspnea, abnormal carbon dioxide (CO2) levels, and COPD exacerbations, they are modifiable. Current dyspnea treatments for COPD are suboptimal, because they do not adequately address dysfunctional breathing behaviors and anxiety together. We developed a complementary mind-body breathlessness therapy, called capnography-assisted respiratory therapy (CART), that uses real-time CO2 biofeedback at the end of exhalation (end-tidal CO2 or ETCO2), to target dysfunctional breathing habits and improve dyspnea treatment and pulmonary rehabilitation (PR) adherence in COPD. The study aim was to test the feasibility of integrating CART with a traditional, clinic-based PR program in an urban setting. Methods: We used a feasibility pre- and post-test design, with 2:1 randomization to CART+PR or control (PR-alone) groups, to test and refine CART. Multi-component CART consisted of six, 1-h weekly sessions of slow breathing and mindfulness exercises, ETCO2 biofeedback, motivational counseling, and a home program. All participants were offered twice weekly, 1-h sessions of PR over 10 weeks (up to 20 sessions). Results: Thirty-one participants with COPD were enrolled in the study. Approximately a third of participants had symptoms of psychological distress. Results showed that CART was feasible and acceptable based on 74% session completion and 91.7% homework exercise completion (n = 22). Within-group effect sizes for CART+PR were moderate to large (Cohen's d = 0.51-1.22) for reduction in resting Borg dyspnea (anticipatory anxiety) and respiratory rate, St. George's Respiratory Questionnaire (SGRQ) respiratory symptoms; and increase in Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and physical activity; all p < 0.05. Conclusions: CART is a new mind-body breathing therapy that targets eucapnic breathing, interoceptive function, and self-regulated breathing to relieve dyspnea and anxiety symptoms in COPD. Study findings supported the feasibility of CART and showed preliminary signals that CART may improve exercise tolerance, reduce dyspnea, and enhance PR completion by targeting reduced dysfunctional breathing patterns (CTR No. NCT03457103).

Feasibility and potential effects of breathing exercise for chronic pain management in breast cancer survivors: study protocol of a phase II randomised controlled trial

INTRODUCTION

Chronic pain is a common symptom significantly affecting the quality of life of breast cancer survivors. Despite the achievement of pharmacological interventions, the barriers associated with this approach such as inaccessibility, misuse and side effects drive research into effective non-pharmacological interventions to improve chronic pain management, quality of life, anxiety and depression. Breathing exercise (BE) can be a promising option, but research evidence is sparse. This pilot study aims to examine the feasibility and preliminary effect of using an evidence-based BE intervention for chronic pain management in breast cancer survivors.

METHOD AND ANALYSIS

This study will be a two-parallel-arm, open-labelled, phase II randomised controlled trial with 1:1 allocation. Seventy-two participants will be recruited from a tertiary hospital in China and randomly allocated to either a BE intervention group (n=36) or a control group (n=36). The participants in the intervention group will receive the usual care, a pain information booklet and a 4-week self-administered BE intervention; the participants in the control group will receive the usual care and the pain information booklet only. The assessment will be conducted at three time points: baseline (week 0), immediately after the intervention completion (week 5) and 4 weeks after the intervention completion (week 9). The primary outcomes will be the acceptability and feasibility assessment of the study protocol and methodological procedures. The secondary outcomes will be the effects of BE on pain, quality of life, anxiety and depression in breast cancer survivors. Descriptive statistics will be applied to present the primary outcomes and the Generalised Estimating Equation Model will be utilised to analyse the clinical outcomes.

ETHICS AND DISSEMINATION

This study has received ethical approvals from the Human Research Ethics Committee at Charles Darwin University (H21089) and the Clinical Trial Ethics Committee at the Affiliated Hospital of Southwest Medical University (KY2022107). Findings from this study will be presented at academic conferences and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT05257876.

Breathing Exercises in the Treatment of COPD: An Overview of Systematic Reviews

Background

The effectiveness of breathing exercises in the treatment of chronic obstructive pulmonary disease (COPD) has been demonstrated in several systematic reviews (SRs), but a comprehensive review is still lacking. The aim of this study was to synthesize evidence from SRs, to summarise the effects of breathing exercises interventions for COPD patients.

Methods

We conducted an overview of the SRs of breathing exercises in the treatment of COPD. We include Systematic Reviews of randomized-controlled clinical trials. In the included COPD, control of breathing exercises alone was the only variable and no restriction was placed on relevant outcome measures. The SRs were screened by computer retrieval from the Chinese National Knowledge Infrastructure (CNKI), WanFang database, Chinese Science and Technology Journal Database (CSTJ), Chinese Biological Medicine (CBM), MEDLINE (PubMed), Embase, Cochrane library, and Web of Science. The Risk of Bias in Systematic reviews (ROBIS) tool, the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement, a Measure Tool to Assess Systematic Reviews (AMSTAR) 2, and the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) were used to evaluate the risk of bias, reporting quality, methodology quality, and evidence quality.

Results

Nine SRs met the inclusion criteria and were included in the overview, 4 SRs in Chinese, and 3 SRs in English. All the SRs were published between 2015-2021. According to the ROBIS tool, 4 SRs (57.14%) were rated as low risk of bias. The PRISMA scale showed that 5 SRs had some defects, and 2 SRs were relatively complete. Reporting deficiencies exist primarily in protocol and registration (28.6%), search (42.9%), risk of bias across studies (0%), additional analyses (42.9%), and funding (28.6%). Based on the AMSTAR-2 scale, 3 SRs were low quality, and the other 4 SRs were very low. The result of evidence quality assessment showed that among the 34 outcomes involved in the 7 studies, 19 were low-level outcomes, 15 were very low-level outcomes, and there were no moderate and high-level quality outcomes. Limitations and publication bias were two major factors that reduced the quality of evidence.

Conclusion

Breathing exercises in certain can improve pulmonary function, exercise endurance, dyspnea, quality of life, and respiratory muscle strength of COPD patients. However, there is an urgent need for high-quality studies to guide clinical practice due to certain deficiencies in reporting quality and the low quality of methodology and outcomes.

JD. RespiCo: A novel, flexible, and stand-alone electronic respiratory coaching device

Conscious respiratory pattern and rate control is desired by patients with some forms of pulmonary disease that are undergoing respiratory muscle conditioning and rehabilitation, by practitioners of meditation hoping to improve mindfulness and wellbeing, by athletes striving to obtain breathing control in order to increase competitiveness, and by engineers and scientists that wish to use the data from breathing subjects to test hypotheses and develop physiological monitoring systems. Although prerecorded audio sources and computer applications are available that guide breathing exercises, they often suffer from being inflexible and allow only limited customization of the breathing cues. Here we describe a small, lightweight, battery-powered, microprocessor-based respiratory coaching device (RespiCo), which through wireless or wired connections, can be easily customized to precisely guide subjects to breathe at desired respiratory rates using specific breathing patterns through visual, auditory, or haptic cues. Digital signals can also be captured from the device to document the breathing cues provided by the device for research purposes. It is anticipated that this device will have important utility for those who wish to be guided to breathe in a precise manner or in research and development of physiologic monitoring systems.

Non-pharmacological Management in Palliative Care for Patients With Advanced COPD

Chronic obstructive pulmonary disease (COPD) is a disabling condition associated with progressive airflow limitation and lung tissue damage; its main symptoms are breathlessness, fatigue, cough, and sputum production. In the advanced stage of the disease, these symptoms may severely impact on a person's physical and psychological functioning, with some also developing chronic respiratory failure, associated with blood gas abnormalities. Non-pharmacological interventions can improve quality of life and functioning in the management of people living with advanced COPD. This article will provide an overview of common non-pharmacological methods used in the symptomatic management of severe COPD, including: breathlessness and fatigue management strategies, anxiety management, pulmonary rehabilitation (PR) and physical activity (PA), neuromuscular electrical stimulation (NMES), airway clearance techniques (ACTs), nutrition and non-invasive ventilation (NIV). The importance of a holistic and multi-disciplinary approach to people living with COPD will be discussed.

Physiological changes related to 10 weeks of singing for lung health in patients with COPD

BACKGROUND

Singing for Lung Health (SLH) was non-inferior to physical exercise training in improving 6-minute walking test distance (6MWD) and quality of life (St. George's Respiratory Questionnaire (SGRQ)) within a 10-week pulmonary rehabilitation (PR) programme for COPD in our recent randomised controlled trial (RCT) (NCT03280355). Previous studies suggest that singing improves lung function, respiratory control and dyspnoea, however this has not yet been convincingly confirmed. Therefore, this study aimed to explore the impact of SLH on physiological parameters and the associations with achieving the minimal important difference (MID) in 6MWD and/or SGRQ.

METHODS

We conducted post hoc, per-protocol analyses mainly of the SLH group of the RCT, exploring associations with 6MWD and SGRQ results by stratifying into achieving versus not-achieving 6MWD-MID (≥30 m) and SGRQ-MID (≤-4 points): changes in lung function, inspiratory muscle strength/control, dyspnoea, and heart rate response using logistic regression models. Further, we explored correlation and association in achieving both 6MWD-MID and SGRQ-MID (or in neither/nor) using Cohen's κ and Cochran-Mantel-Haenszel Test.

RESULTS

In the SLH study group (n=108), 6MWD-MID was achieved by 31/108 (29%) and in SGRQ by 53/108 (49%). Baseline factors associated with achieving MID in either outcome included short baseline 6MWD and high body mass index. Achieving 6MWD-MID was correlated with improved heart rate response (OR: 3.14; p=0.03) and achieving SGRQ-MID was correlated with improved maximal inspiratory pressure (OR: 4.35; p=0.04). Neither outcome was correlated with significant spirometric changes. Agreement in achieving both 6MWD-MID and SGRQ-MID was surprisingly insignificant.

CONCLUSIONS

This explorative post hoc study suggests that SLH is associated with physiological changes after short-term PR for COPD. Future physiological studies will help us to understand the mechanisms of singing in COPD. Our study furthermore raises concern about poor agreement between subjective and objective benefits of PR despite state-of-the-art tools.

[Welche Behandlungs-Optionen wurden von COVID-19 infizierten Yoga-Übenden als hilfreich empfunden? - Ergebnisse einer Querschnittsanalyse]

Einführung: Die meisten COVID-19 Infizierten machen die Infektion im häuslichen Umfeld durch und werden vermutliche Maßnahmen zur Symptomlinderung anwenden, die aus dem Bereich der Selbstverordnung kommen. Von Interesse ist daher, welche Maßnahmen von COVID-19 Infizierten genutzt werden. Methoden: Anonyme Querschnittsanalyse, bei der die eigenen Behandlungsoptionen in Bezug zu acht Hauptsymptomen mit Hilfe von Freitextfeldern erfasst und kategorisiert werden. Einbezogen wurden Datensätze von Yoga-Übenden als spezifische Zielgruppe, die sich in den Zeiträumen der drei dominanten Virus-Varianten infiziert hatten (n=208: 89% Frauen; Altersmittel 49 ± 11). Die Aussagen wurden deskriptiv dargestellt und die Inhalte der Freitextfelder nach inhaltsanalytischen Gesichtspunkten kategorisiert und den jeweiligen Hauptsymptomen einer COVID-19 Infektion zugeordnet. Ergebnisse: In Bezug auf die acht Symptomgruppen ergab sich ein differenziertes Bild der als hilfreich empfundenen Behandlungsoptionen. Die meisten Nennungen hatte die Kategorie Zeit/Ruhe/Schlaf, insbesondere bei Schwäche/Erschöpfung und Rumpf-/Gliederschmerzen, gefolgt von Atemübungen (Pranayama), die insbesondere bei Atemnot/Kurzatmigkeit und Husten zur Anwendung kamen. Yoga-Übungen wurden insbesondere bei Rumpf-/Gliederschmerzen sowie Schwäche/Erschöpfung genutzt. Die konventionelle Schmerzmedikation stand bei Kopfschmerzen sowie Rumpf-/Gliederschmerzen im Vordergrund. Bewegung an der frischen Luft und Spaziergänge zur Regeneration waren relevant bei Schwäche/Erschöpfung, Atemnot/Kurzatmigkeit sowie Husten. Phytotherapeutische Anwendungen waren insbesondere bei Husten bedeutsam. Ätherische Öle und Riechtraining hatten ihren Schwerpunkt bei Geruchs-/Geschmacksstörungen und Husten. Schlussfolgerungen: In Bezug auf das angewendete Spektrum der unterstützenden Therapieoptionen im Sinne des Selbstmanagements wurden einige sehr häufig und differenziert angewendet. Hier könnte man eine subjektiv empfundene "Nützlichkeit" annehmen. In der Literatur lassen sich für einige dieser Optionen auch Hinweise für eine mögliche Wirksamkeit finden, für andere nicht ohne weiteres. Diese unterstützenden Therapieoptionen könnten außerdem eine Möglichkeit sein, um einer abwartenden Hilflosigkeit proaktiv entgegenzuwirken.

The effect of lung-conduction exercise in chronic obstructive pulmonary disease: Randomized, assessor-blind, multicenter pilot trial

BACKGROUND

Pulmonary rehabilitation (PR) is a management modality that improves the quality of life of patients with chronic obstructive pulmonary disease (COPD); however, PR is not readily accessible. Therefore, we developed lung-conduction exercises (LCE) that can be performed easily without any limitations. The purpose of this randomized, assessor-blind, multicenter pilot trial was to compare the effects of LCE with PR and standard care (SC) in COPD patients.

METHODS

Twenty-five participants who met the eligibility criteria were randomly allocated to the SC group (only medication, n = 9), LCE group (medication + LCE, 5 times a week, n = 8), or PR group (medication + PR, 5 times a week, n = 8). The 6-minute walk distance (6WMD), pulmonary function test, modified Medical Research Council dyspnea scale, COPD assessment test (CAT), and St. George Respiratory Questionnaire (SGRQ) survey were carried out before starting the trial and after 4 and 8 weeks to determine motor performance, lung function, and dyspnea.

RESULTS

After 8 weeks, the pulmonary function test scores were the same. The 6MWD (PR, 28.3 ± 38.5; LCE, 14.5 ± 53.1; SC, 11.5 ± 20.5; P = .984), modified Medical Research Council dyspnea scale (PR, 0.8 ± 1.0; LCE, 0.8 ± 0.8; SC, 0.3 ± 0.5; P = .772), CAT (PR, 7.3 ± 6.2; LCE, 4.2 ± 5.2; SC, 1.0 ± 2.2; P = .232), and SGRQ scores (PR, 11.5 ± 15.4; LCE, 5.5 ± 13.1; SC, 4.8 ± 5.1; P = .358 [PR vs LCE], P = .795 [PR vs SC]) had improved in order of PR, LCE, and SC group. Although there were no statistically significant differences in the outcome measures between the groups, there were clinically significant improvements in the CAT and SGRQ scores.

CONCLUSIONS

In this trial, PR showed more improvement in symptoms and quality of life than SC alone. To seek a more precise use of LCE, further full-sized studies with a long duration and additional outcome measures such as psychological assessment tools and cost-effectiveness ratio should be conducted.

TRIAL REGISTRATION

KCT0004724.

Effect of physical training on cytokine expression in CD4+ T lymphocytes in subjects with stable COPD

Introduction:

Although evidence suggests that physical exercise reduces systemic inflammation, at the plasma level, there are still contradictions in chronic obstructive pulmonary disease (COPD). In this sense, analysis of intracellular cytokines could clear off the effect of physical exercise on the inflammatory profile of these subjects.

Aim:

The aim was to evaluate the effect of physical training on cytokine expression in CD4+ T lymphocytes from subjects with COPD.

Methods:

This is a randomized controlled trial. Subjects with stable COPD were grouped into two groups, exercise and control. In total, 23 subjects with stable COPD were evaluated, of which 15 underwent aerobic strength training [physical exercise group (PEG)] and 8 underwent breathing exercises [respiratory physiotherapy group (RPG)]. Intracellular cytokines [interleukin (IL)-8, IL-13, IL-17, IL-6, IL-2, IL-10, and tumor necrosis factor alpha (TNF-α)] from CD4+ T lymphocytes were analyzed from peripheral blood through flow cytometry, before and after 8 weeks of intervention.

Results:

The PEG and RPG groups had a mean age of 68 ± 5.96 and 72.25 ± 6.86 years and predicted forced expiratory volume in the first second (FEV₁) of 58.6 ± 15.99% and 39.75 ± 10.39%, respectively. It was possible to detect a significant reduction in IL-8 (p = 0.0125) and an increase in IL-13 (p = 0.0014) and an increase in TNF-α (p < 0.001) in both groups.

Conclusion:

Eight weeks of physical training, both peripheral and respiratory, were able to reduce concentrations of IL-8 and to increase IL-13, and TNF-α in CD4+ T lymphocytes in subjects with stable COPD. The findings reinforce the benefits of interventions in subjects with COPD, revealing data not previously investigated.

The physiology of singing and implications for 'Singing for Lung Health' as a therapy for individuals with chronic obstructive pulmonary disease

Singing is an increasingly popular activity for people with chronic obstructive pulmonary disease (COPD). Research to date suggests that ‘Singing for Lung Health’ may improve various health measures, including health-related quality-of-life. Singing and breathing are closely linked processes affecting one another. In this narrative review, we explore the physiological rationale for ‘Singing for Lung Health’ as an intervention, focusing on the abnormalities of pulmonary mechanics seen in COPD and how these might be impacted by singing. The potential beneficial physiological mechanisms outlined here require further in-depth evaluation.

Use of Singing for Lung Health as an alternative training modality within pulmonary rehabilitation for COPD: an RCT

Background

Pulmonary rehabilitation (PR) is a cornerstone in chronic obstructive pulmonary disease (COPD) management. However, PR adherence is generally low, and barriers include availability, economic issues, motivation and an inability to attend or perform physical training. Therefore, alternative, evidence-based PR activities are required. Singing may have benefits for quality of life (QoL), respiratory control and well-being in COPD, but the impact on the PR key outcome, physical exercise capacity, is uncertain.

Methods

In this randomised controlled trial (NCT03280355), we investigated the effectiveness of 10 weeks of PR, including either “Singing for Lung Health” (SLH) training or standard physical exercise training (PExT). The primary outcome was a change in exercise capacity (6-min walk distance (6MWD)) from baseline to post-PR. Secondary outcomes were changes in QoL (St George's Respiratory Questionnaire (SGRQ)), Hospital Anxiety and Depression Score (HADS), lung function, dyspnoea and adherence.

Results

We included 270 COPD patients, and 195 completed the study. Demographics across groups were comparable, and both groups improved significantly in 6MWD and SGRQ score. SLH was non-inferior to PExT in improving 6MWD (mean±sd 13.1±36.3 m versus 14.1±32.3 m, p=0.81; difference 1.0 m, 95% CI −7.3–9.3 m) with 21.8% and 25.0%, respectively (p=0.57), reaching the 6MWD minimal important difference of 30 m. We found no significant between-group differences concerning SGRQ, HADS, lung function, dyspnoea or adherence.

Conclusion

Our study suggests that SLH is non-inferior to PExT in improving 6MWD during a 10-week PR programme. Future studies addressing reproducibility, long-term effects and health economics are needed.

Singing for Lung Health was non-inferior to physical exercise training in short-term improvement of 6-min walk test distance in COPD patients attending pulmonary rehabilitation. In both groups, the effect was related to high adherence.https://bit.ly/3uoP4Q8

Developing a Web Platform to Optimize the Self-Management of People Living with a Chronic Respiratory Disease

Purpose: The purpose of this article is to describe the development of a new Web platform to optimize self-management after pulmonary rehabilitation (PR) for persons living with a chronic respiratory disease (CRD) and to present data on its usability. Method: The Web platform is informed by a theoretical framework of behaviour changes and concepts of self-management and self-efficacy. It uses breathing exercises and a logbook and is meant to be a self-management tool. Usability was tested for 8 months after PR with a group consisting of five patients with chronic obstructive pulmonary disease and one with pulmonary fibrosis. We evaluated adherence (e.g., number of exercise/weeks), quality of life, dyspnoea, and functional capacity. We measured frequency count for adherence and pre-post differences per patient for clinical outcomes. Results: Four participants' adherence was higher than 50% of completed exercises (72 exercise/weeks). Five of six participants showed maintenance of functional capacity (6-minute walk test) 8 months after PR. Four participants showed maintenance of their quality of life. Four participants showed a deterioration in dyspnoea on the Borg Scale of Perceived Exertion. Conclusions: We developed a new theory-informed Web platform to optimize self-management after PR for persons living with a CRD. The pilot Web platform appears to optimize adherence to self-management techniques and possibly stabilize people's health outcomes.

Long covid-mechanisms, risk factors, and management

Since its emergence in Wuhan, China, covid-19 has spread and had a profound effect on the lives and health of people around the globe. As of 4 July 2021, more than 183 million confirmed cases of covid-19 had been recorded worldwide, and 3.97 million deaths. Recent evidence has shown that a range of persistent symptoms can remain long after the acute SARS-CoV-2 infection, and this condition is now coined long covid by recognized research institutes. Studies have shown that long covid can affect the whole spectrum of people with covid-19, from those with very mild acute disease to the most severe forms. Like acute covid-19, long covid can involve multiple organs and can affect many systems including, but not limited to, the respiratory, cardiovascular, neurological, gastrointestinal, and musculoskeletal systems. The symptoms of long covid include fatigue, dyspnea, cardiac abnormalities, cognitive impairment, sleep disturbances, symptoms of post-traumatic stress disorder, muscle pain, concentration problems, and headache. This review summarizes studies of the long term effects of covid-19 in hospitalized and non-hospitalized patients and describes the persistent symptoms they endure. Risk factors for acute covid-19 and long covid and possible therapeutic options are also discussed.

H, Jebaraj P, S. M, Das D, Norrie J, Grant L, Pinnock H, Nair H, Sheikh A, Weller D. Development of an educational intervention to reduce the burden of adult chronic lung disease in rural India: Inputs from a qualitative study

BACKGROUND

Chronic respiratory diseases (CRDs) are major causes of mortality and morbidity worldwide with a substantial burden of the disease being borne by the low and middle income countries (LMICs). Interventions to change health behaviour which aim to improve the quality of life and reduce disease burden due to CRD require knowledge of the problem and factors influencing such behaviour. Our study sought to appreciate the lived experiences of people with CRD, their understanding of the disease and its risk factors, and usual practice of health behaviour in a rural low-literate community in southern India.

METHODS

Qualitative data were collected between September and December 2018 through eight focus group discussions (FGDs), five in-depth interviews and four key-informant interviews from patients and community members. Community engagement was undertaken prior to the study and all interviews and discussions were recorded with permission. Inductive coding was used to thematically analyse the results.

RESULTS

Major themes included understanding of chronic lung disease, health behaviours, lived experiences with the disease and social norms, attitudes and other factors influencing health behaviour.

DISCUSSION

Poor understanding of CRDs and their risk factors affect health seeking behaviour and/or health practices. Stigma associated with the disease and related health behaviours (e.g. inhaler use) creates emotional challenges and mental health problems, besides influencing health behaviour. However barriers can be circumvented by increasing community awareness; communication and connection with the community through community based health care providers can turn challenges into opportunities for better health care.

Exploring Tai Chi Exercise and Mind-Body Breathing in Patients with COPD in a Randomized Controlled Feasibility Trial

In this pilot feasibility randomized controlled trial, participants with moderate to severe COPD were randomized to a 12-week tai chi or MBB intervention. Participants were assessed at baseline, 12 weeks, and 24 weeks. Feasibility, as assessed by intervention adherence, was the primary outcome. We also estimated preliminary between-group differences in COPD symptoms and health-related quality of life, cognitive-emotional function, and functional status across three timepoints: baseline, 12, and 24 weeks. A total of 92 participants were randomized 2:1 to tai chi (n = 61) or MBB (n = 31). The overall group adherence in the first 12 weeks was 62% in tai chi and 75% in MBB. From baseline to 12 weeks, tai chi demonstrated greater improvements in depressive symptoms (Cohen's d effect size (ES) = -.53; adj mean diff = -2.31 [-5.7, 1.07]), 6-minute walk test distance (ES = .47; adj mean diff = 62.04 [2.85, 121.22]), social support (ES = .36; adj mean diff = .19 [-0.11, 0.49]) and chair stand (ES = .44; adj mean diff = .91 [-0.05, 1.86]). Only improvements in social support were maintained at 24-week follow-up. Tai chi and MBB are feasible for individuals with COPD. Preliminary effects suggest that while our mindful breathing intervention may not be sufficient to impact outcomes, tai chi may result in short-term benefits in mood, social support and functional capacity. More work is needed to better understand mindful breathing for COPD and to examine methods for maintaining improvements from tai chi over time.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1928037 .

[Rehabilitation in pneumology]

Die pneumologische Rehabilitation (PR) ist eine evidenzbasierte interdisziplinäre Behandlung für Patienten mit chronischen Erkrankungen der Atmungsorgane. Die Indikation für ihre Beantragung ist bei entsprechender Rehabilitationsfähigkeit, -bedürftigkeit und günstigen -prognose gegeben. Ziele einer PR sind die Reduktion der Symptome sowie die Steigerung der Lebensqualität und körperlichen Belastbarkeit. Die Effektivität ist für COPD-Patienten (COPD: chronisch obstruktive Lungenerkrankung) mit dem höchsten und für Nicht-COPD-Patienten mit zunehmend gutem Evidenzgrad durch randomisiert kontrollierte Studien und Metaanalysen gesichert. Die Therapieinhalte einer PR werden durch ein multidisziplinäres Behandlungsteam individuell an die Bedürfnisse der Patienten angepasst. Um den Rehabilitationserfolg nachhaltig zu gestalten, besteht die Möglichkeit, an ambulanten Nachsorgeprogrammen (z. B. Lungensport) teilzunehmen sowie digitale Technologien als unterstützende Maßnahme einzusetzen.

How Breathing Exercises Influence on Respiratory Muscles and Quality of Life among Patients with COPD? A Systematic Review and Meta-Analysis

Aim

This systematic review aimed to investigate the effect of different breathing exercises on respiratory muscle function, 6-minute walk test (6MWT), and quality of life (QoL) in patients with chronic obstructive pulmonary disease (COPD).

Methods

We searched online databases including PubMed, Embase, Web of Science, Cochrane Library, and Ovid for randomized controlled trials that assessed the efficacy of breathing exercises on patients with COPD. Patient outcome parameters included changes in respiratory muscle function, 6MWT, and QoL. The Cochrane Collaboration tool was used to assess the risk of bias for each included study. Subgroup analyses concerning different interventions and outcome measurements were conducted as necessary. PROSPERO registration number is CRD42018118367.

Results

A total of 17 studies were included for final analysis. Meta-analysis based on the relevant studies showed that breathing exercises had a significant total effect on pulmonary function PImax (mean difference (MD) = 8.65, 95% confidence interval (CI) 3.13-14.16, P=0.002), as well as 6MWT (MD = 27.70, 95% CI 5.45-49.94, P=0.01) in patients with COPD.

Conclusions

This systematic review summarized the use of breathing exercises for treating patients with COPD. Breathing exercises were found to be an effective tool for treating patients with COPD by improving inspiratory muscle strength and 6MWT. However, breathing exercises showed no significant improvements on the QoL of patients with COPD.

Virtual reality for COPD rehabilitation: a technological perspective

Virtual Reality (VR) is a promising technology for implementing personalized, motivating and controlled rehabilitation scenarios. Although its clear potential benefits, VR has been poorly investigated in pulmonary rehabilitation. This review analyses the state of the art, by searching the scientific and grey literature, regarding the use of VR for the rehabilitation of patients with chronic obstructive pulmonary disease, providing a technological perspective. First, the main characteristics of the included systems are presented in terms of visualization devices, way of interaction and type of feedback they provide. Then, results of the selected studies are reported considering feasibility, safety, usability and user experience as outcomes. Finally, the main findings are discussed and future directions for research are outlined.

Comparative effectiveness of breathing exercises in patients with chronic obstructive pulmonary disease

BACKGROUND AND PURPOSE

This study aims to determine the best choice of breathing exercises (BE) for patients with chronic obstructive pulmonary disease (COPD) via a network meta-analysis.

METHODS

We searched randomized controlled trials (RCTs) of adults with COPD investigating any BEs in MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov databases. The effects of comparative treatment on the St. George Respiratory Questionnaire as the outcome were analysed and ranked according to a surface under the cumulative classification curve (SUCRA) analysis.

RESULTS

The network meta-analysis included six RCTs involving 280 patients with four intervention groups, comprising control, diaphragmatic breathing training (DBT), yoga, and singing course. Performing SUCRA, we reported that yoga is 75% likely to be the best treatment available as DBT with 66%, instead of 35% for singing and 21% for control.

CONCLUSION

DBT and yoga seem to be the best choices for breathing exercises in people with COPD.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Effects of Diaphragmatic Breathing on Health: A Narrative Review

Background: Breathing is an essential part of life. Diaphragmatic breathing (DB) is slow and deep breathing that affects the brain and the cardiovascular, respiratory, and gastrointestinal systems through the modulation of autonomic nervous functions. However, the effects of DB on human health need to be further investigated. Methods: The author conducted a PubMed search regarding the current evidence of the effect of DB on health. Results: This review consists of a total of 10 systematic reviews and 15 randomized controlled trials (RCTs). DB appears to be effective for improving the exercise capacity and respiratory function in patients with chronic obstructive pulmonary disease (COPD). Although the effect of DB on the quality of life (QoL) of patients with asthma needs to be investigated, it may also help in reducing stress; treating eating disorders, chronic functional constipation, hypertension, migraine, and anxiety; and improving the QoL of patients with cancer and gastroesophageal reflux disease (GERD) and the cardiorespiratory fitness of patients with heart failure. Conclusions: Based on this narrative review, the exact usefulness of DB in clinical practice is unclear due to the poor quality of studies. However, it may be a feasible and practical treatment method for various disorders.

Analogy between classical Yoga/Zen breathing and modern clinical respiratory therapy

Anesthesiologists and intensivists are modern-day professionals who provide appropriate respiratory care, vital for patient survival. Recently, anesthesiologists have increasingly focused their attention on the type of spontaneous breathing made by non-intubated patients with pulmonary disease cared for in an intensive care unit, and also patients with chronic pain receiving cognitive behavioral therapy. Prior to our modern understanding of respiratory physiology, Zen meditators recognized that breathing has a significant impact on a person’s mental state and general physical well-being. Examples of this knowledge regarding respiration include the beneficial effects of deep inhalation and slow exhalation on anxiety and general wellness. The classical literature has noted many suggestions for breathing and its psycho-physical effects. In the present review, we examine the effect of classical breathing methods and find an analogy between typical Yoga/Zen breathing and modern clinical respiratory therapy. Evidence is increasing about historical breathing and related meditation techniques that may be effective in modern clinical practice, especially in the field of anesthesiology, such as in improving respiratory function and reducing chronic pain. Clarification of the detailed mechanisms involved is anticipated.

Aerobic and breathing exercises improve dyspnea, exercise capacity and quality of life in idiopathic pulmonary fibrosis patients: systematic review and meta-analysis

Background

Idiopathic pulmonary fibrosis (IPF) is a progressive disease associated with significant dyspnea and limited exercise capacity. This systematic review aimed to synthesize evidence of exercise interventions during pulmonary rehabilitation that aim to improve exercise capacity, dyspnea, and health-related quality of life (HRQL) in IPF patients.

Methods

Searches were performed in MEDLINE, Embase, CENTRAL, SPORTDiscus, PubMed and PEDro from inception to January 2019 using search terms for: (I) participants: ‘IPF or interstitial lung disease’; (II) interventions: ‘aerobic training or resistance training or respiratory muscle training’; and (III) outcomes: ‘exercise capacity or dyspnea or health-related quality of life’. Two reviewers independently screened titles, abstracts and full texts to identify eligible studies. Methodological quality of studies was assessed using the Downs and Black checklist and meta-analyses were performed.

Results

Of 1,677 articles identified, 14 were included (four randomized controlled trials and 10 prospective pre-post design studies) that examined 362 patients receiving training and 95 control subjects. Exercise capacity was measured with the 6-minute walk distance, peak oxygen consumption, peak work rate, or endurance time for constant work rate cycling, which increased after exercise [aerobic exercise; aerobic and breathing exercises; aerobic and inspiratory muscle training (IMT) exercises] compared to the control groups. Dyspnea scores improved after aerobic and breathing exercises. HRQL also improved after aerobic exercise training alone or combined with breathing exercises. Aerobic training alone or combined with IMT or breathing exercises improved exercise capacity.

Conclusions

Breathing exercises appears to complement exercise training towards improved dyspnea and HRQL in patients with IPF.

Effects of Breathing Exercises in Patients With Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis

OBJECTIVE

To update evidence on the effects of breathing exercises (BEs) on ventilation, exercise capacity, dyspnea, and quality of life (QoL) in chronic obstructive pulmonary disease (COPD) patients.

METHODS

Randomized controlled trials investigating the effects of BEs in COPD patients published through May 2018, were retrieved from five electronic databases (MEDLINE, CINAHL, Cochrane, Scopus, and ScienceDirect). Risk of bias and quality of evidence were assessed, using Cochrane Collaboration's tool, and the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach, respectively.

RESULTS

Nineteen studies (n=745), were included. Quality of evidence, was low to moderate. When compared to the control groups, respiratory rate significantly (p≤0.001) improved in the pursed-lip breathing (PLB), ventilatory feedback (VF) plus exercise, diaphragmatic breathing exercise (DBE), and combined BEs. Additionally, PLB significantly improved tidal volume (p<0.001), inspiratory time (p=0.007), and total respiratory time (p<0.001). VF plus exercise significantly improved inspiratory capacity (p<0.001), and singing significantly improved the physical component of QoL, than did the control groups (p<0.001). All BEs did not significantly improve dyspnea, compared to the controls (p>0.05).

CONCLUSION

PLB, VF plus exercise, DBE, combined BEs, and singing could be used to improve ventilation and QoL. Based on low to moderate quality of evidence, use of these BEs to improve ventilation and QoL in COPD patients is conditional (Registration No. CRD42018102995).

Subterranean Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease

Pulmonary rehabilitation (PR) has been recommended as an integral part of treatment for patients with chronic obstructive pulmonary disease (COPD). Climate therapy in salt mine chambers has been found of benefit in chronic respiratory diseases. The study compares long-term effects of underground PR in the Wieliczka Salt Mine with that conducted on the surface. There were 42 COPD patients enrolled in the study, with FEV₁/FVC <0.7 predicted and post-bronchodilator reversibility <12%, randomized into pulmonary rehabilitation in the mine (Group I, n = 23) and PR on the surface (Group II, n = 19). The outcomes consisted of lung function variables, exercise performance (6-min walk test - 6MWT), dyspnea (mMRC), and compliance with the disease and quality of life (COPD Assessment Test - CAT) and BODE index, compared at baseline (P0), end (P1), and 6 months after pulmonary rehabilitation (P2). The findings were that subterranean pulmonary rehabilitation significantly reduced CAT score (p < 0.001), BODE index (p = 0.004), and dyspnea (mMRC) (p = 0.001) and increased distance in 6MWT (p < 0.001), compared with its equivalent conducted on the surface. Further, beneficial effect of subterranean treatment was sustained during the following half a year as opposed to the effect noticed on patients treated on the surface. We conclude that subterranean pulmonary rehabilitative treatment reduces symptoms and improves exercise tolerance to a greater and sustained extent, compared to a similar treatment on the surface, in patients suffering from COPD.

Pilot Study of Self-care Breath Training Exercise for Reduction of Chronic Dyspnea

PURPOSE

Dyspnea related to chronic pulmonary disorders is difficult to manage. In this single-arm study, we evaluated feasibility and potential efficacy of a self-care breath training program to reduce dyspnea that persists despite standard treatments in patients with chronic lung disease.

METHODS

Adult patients with a chronic pulmonary disorder and stable moderate dyspnea received one 30-min training on specific breathing techniques, followed by audio-guided at-home practice 15 min twice daily for 6 wk, supported with weekly telephone monitoring/coaching. The feasibility endpoints, Baseline and Transition Dyspnea Indexes, 6-min walk test, Hospital Anxiety and Depression Scale, and oxygen saturation at rest and exercise were evaluated at baseline and wk 6.

RESULTS

Of the 23 patients enrolled over 2 yr, 19 completed the study. A majority (74%; 95% CI, 49%-91%) completed at least 75% of the home practice sessions. Significant objective improvements in physical performance, defined as distance walked, were observed after 6 wk of intervention. On average, patients walked significantly further in the 6-min walk test (59 ft; 95% CI, 18-99; P = .007). In addition, 53% reported clinically significant (20%, defined a priori) subjective improvement in the Transition Dyspnea Index, although the difference was not statistically significant (0.7; 95% CI, -0.8 to 2.3; P = .3). No significant differences were seen in the Hospital Anxiety and Depression Scale or oxygen saturation.

CONCLUSIONS

A low-burden, low-cost, self-care breath training program improved distance walked by patients with chronic dyspnea after 6 wk of home practice. Promising data suggest that a randomized trial of this breath training program is warranted.

Hemodynamic characteristics of postural hyperventilation: POTS with hyperventilation versus panic versus voluntary hyperventilation

Upright hyperventilation occurs in ~25% of our patients with postural tachycardia syndrome (POTS). Poikilocapnic hyperventilation alone causes tachycardia. Here, we examined changes in respiration and hemodynamics comprising cardiac output (CO), systemic vascular resistance (SVR), and blood pressure (BP) measured during head-up tilt (HUT) in three groups: patients with POTS and hyperventilation (POTS-HV), patients with panic disorder who hyperventilate (Panic), and healthy controls performing voluntary upright hyperpnea (Voluntary-HV). Though all were comparably tachycardic during hyperventilation, POTS-HV manifested hyperpnea, decreased CO, increased SVR, and increased BP during HUT; Panic patients showed both hyperpnea and tachypnea, increased CO, and increased SVR as BP increased during HUT; and Voluntary-HV were hyperpneic by design and had increased CO, decreased SVR, and decreased BP during upright hyperventilation. Mechanisms of hyperventilation and hemodynamic changes differed among POTS-HV, Panic, and Voluntary-HV subjects. We hypothesize that the hyperventilation in POTS is caused by a mechanism involving peripheral chemoreflex sensitization by intermittent ischemic hypoxia. NEW & NOTEWORTHY Hyperventilation is common in postural tachycardia syndrome (POTS) and has distinctive cardiovascular characteristics when compared with hyperventilation in panic disorder or with voluntary hyperventilation. Hyperventilation in POTS is hyperpnea only, distinct from panic in which tachypnea also occurs. Cardiac output is decreased in POTS, whereas peripheral resistance and blood pressure (BP) are increased. This is distinct from voluntary hyperventilation where cardiac output is increased and resistance and BP are decreased and from panic where they are all increased.

Feasibility study to assess the effect of a brief mindfulness intervention for patients with chronic obstructive pulmonary disease: A randomized controlled trial

Psychological distress is common among patients with chronic obstructive pulmonary disease (COPD). This study aimed to assess whether a 10-minute mindfulness intervention reduces distress and breathlessness, improves mood and increases mindfulness among hospital inpatients following acute exacerbation of COPD.Fifty patients were recruited following an acute admission. The immediate effects of a 10-minute mindfulness-based body scan were compared with a control intervention. Participants were randomized to receive either a mindfulness-based body scan (n = 24) or a control condition (n = 26) via a 10-minute audio recording. Participants completed a self-assessment survey, including the Borg scale for breathlessness, Philadelphia Mindfulness Scale and Hospital Anxiety and Depression Scale. They then completed six brief single item measures of dyspnoea, anxiety, depression, happiness, stress and mindfulness before and after the intervention daily for three consecutive days. Acceptability was rated according to ‘usefulness’ and whether they would recommend the intervention to other patients. Results showed that there was a tendency for change in most outcomes, but no significant differences between the groups. Most participants rated the intervention as useful and would recommend it. Existing knowledge of mindfulness interventions among these patients is very limited and this study may be helpful in the development of other brief interventions.

Chronic Obstructive Pulmonary Disease: Clinical Implications for Patients With Lung Cancer

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the most common smoking-related illness. COPD often is underemphasized as a comorbidity except when considering issues surrounding surgical treatment options.

OBJECTIVES

This article aims to provide nurses with an overview of the pharmacologic and nonpharmacologic treatment implications of COPD.

METHODS

Definitions, differentials, and treatment considerations are provided, and clinical implications and resources are described.

FINDINGS

The added burden of dyspnea, fatigue, and psychological distress related to COPD may affect the overall outcome and quality of life (QOL) of patients with lung cancer. Attention to the prevention, assessment, and treatment of lung cancer and COPD and related symptomatology will help maximize patients' QOL.

Singing for adults with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Singing is a complex physical activity dependent on the use of the lungs for air supply to regulate airflow and create large lung volumes. In singing, exhalation is active and requires active diaphragm contraction and good posture. Chronic obstructive pulmonary disease (COPD) is a progressive, chronic lung disease characterised by airflow obstruction. Singing is an activity with potential to improve health outcomes in people with COPD.

OBJECTIVES

To determine the effect of singing on health-related quality of life and dyspnoea in people with COPD.

SEARCH METHODS

We identified trials from the Cochrane Airways Specialised Register, ClinicalTrials.gov, the World Health Organization trials portal and PEDro, from their inception to August 2017. We also reviewed reference lists of all primary studies and review articles for additional references.

SELECTION CRITERIA

We included randomised controlled trials in people with stable COPD, in which structured supervised singing training of at least four sessions over four weeks' total duration was performed. The singing could be performed individually or as part of a group (choir) facilitated by a singing leader. Studies were included if they compared: 1) singing versus no intervention (usual care) or another control intervention; or 2) singing plus pulmonary rehabilitation versus pulmonary rehabilitation alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and selected trials for inclusion, extracted outcome data and assessed risk of bias. We contacted authors of trials for missing data. We calculated mean differences (MDs) using a random-effects model. We were only able to analyse data for the comparison of singing versus no intervention or a control group.

MAIN RESULTS

Three studies (a total of 112 participants) were included. All studies randomised participants to a singing group or a control group. The comparison groups included a film workshop, handcraft work, and no intervention. The frequency of the singing intervention in the studies ranged from 1 to 2 times a week over a 6 to 24 week period. The duration of each singing session was 60 minutes.All studies included participants diagnosed with COPD with a mean age ranging from 67 to 72 years and a mean forced expiratory volume in one second (FEV₁) ranging from 37% to 64% of predicted values. The sample size of included studies was small (33 to 43 participants) and overall study quality was low to very low. Blinding of personnel and participants was not possible due to the physical nature of the intervention, and selection and reporting bias was present in two studies.For the primary outcome of health-related quality of life, there was no statistically significant improvement in the St George's Respiratory Questionnaire total score (mean difference (MD) -0.82, 95% confidence interval (CI) -4.67 to 3.02, 2 studies, n = 58, low-quality evidence). However, there was a statistically significant improvement in the SF-36 Physical Component Summary (PCS) score favouring the singing group (MD 12.64, 95% CI 5.50 to 19.77, 2 studies, n = 52, low-quality evidence). Only one study reported results for the other primary outcome of dyspnoea, in which the mean improvement in Baseline Dyspnoea Index (BDI) score favouring the singing group was not statistically significant (MD 0.40, 95% CI -0.65 to 1.45, 1 study, n = 30, very low-quality evidence).No studies examined any long-term outcomes and no adverse events or side effects were reported.

AUTHORS' CONCLUSIONS

There is low to very low-quality evidence that singing is safe for people with COPD and improves physical health (as measured by the SF-36 physical component score), but not dyspnoea or respiratory-specific quality of life. The evidence is limited due to the low number of studies and the small sample size of each study. No evidence exists examining the long-term effect of singing for people with COPD. The absence of studies examining singing performed in conjunction with pulmonary rehabilitation precludes the formulation of conclusions about the effects of singing in this context. More randomised controlled trials with larger sample sizes and long-term follow-up, and trials examining the effect of singing in addition to pulmonary rehabilitation, are required to determine the effect of singing on health-related quality of life and dyspnoea in people with COPD.

Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease

People with advanced chronic obstructive pulmonary disease (COPD) have distressing physical and psychological symptoms, often have limited understanding of their disease, and infrequently discuss end-of-life issues in routine clinical care. These are strong indicators for expert multidisciplinary palliative care, which incorporates assessment and management of symptoms and concerns, patient and caregiver education, and sensitive communication to elicit preferences for care towards the end of life. The unpredictable course of COPD and the difficulty of predicting survival are barriers to timely referral and receipt of palliative care. Early integration of palliative care with respiratory, primary care, and rehabilitation services, with referral on the basis of the complexity of symptoms and concerns, rather than prognosis, can improve patient and caregiver outcomes. Models of integrated working in COPD could include: services triggered by troublesome symptoms such as refractory breathlessness; short-term palliative care; and, in settings with limited access to palliative care, consultation only in specific circumstances or for the most complex patients.

Reducing Anxiety to Increase Exercise in Individuals With Decreased Lung Capacity

The management of chronic disease is complex. For many diseases, the treatment for the disease may mimic disease symptoms. For example, exercise training is recommended as part of the treatment of chronic obstructive pulmonary disease (COPD). Individuals may confuse the physiological experiences related to exercise with COPD symptoms. This type of association between treatment and disease can cause anxiety. For health care practitioners to successfully motivate their patients to make the necessary behavior changes for disease treatment, anxiety must also be addressed.

Sing Your Lungs Out-a community singing group for chronic obstructive pulmonary disease: a 1-year pilot study

OBJECTIVE

Singing group participation may benefit patients with chronic obstructive pulmonary disease (COPD). Previous studies are limited by small numbers of participants and short duration of generally hospital-based singing group intervention. This study examines the feasibility of long-term participation in a community singing group for patients with COPD who had completed pulmonary rehabilitation (PR).

METHODS

This was a feasibility cohort study. Patients with COPD who had completed PR and were enrolled in a weekly community exercise group were recruited to a new community-based singing group which met weekly for over 1 year. Measurements at baseline, 4 months and 1 year comprised comprehensive pulmonary function tests including lung volumes, 6 min walk test (6MWT), Clinical COPD Questionnaire (CCQ), Hospital Anxiety and Depression Scale (HADS) and hospital admission days for acute exacerbation of COPD (AECOPD) for 1 year before and after the first singing group session.

FINDINGS

There were 28 participants with chronic lung disease recruited from 140 people approached. Five withdrew in the first month. 21 participants meeting Global Initiative for Chronic Obstructive Lung Disease criteria for COPD completed 4-month and 18 completed 1-year assessments. The mean attendance was 85%. For the prespecified primary outcome measure, total HADS score, difference between baseline and 12 months was -0.9, 95% CI -3.0 to 1.2, p=0.37. Of the secondary measures, a significant reduction was observed for HADS anxiety score after 1 year of -0.9 (95% CI -1.8 to -0.1) points, p=0.038 and an increase in the 6MWT at 1 year, of 65 (95% CI 35 to 99) m compared with baseline p<0.001.

CONCLUSIONS

Our findings support the feasibility of long-term participation in a community singing group for adults with COPD who have completed PR and are enrolled in a weekly community exercise group and provide evidence of improved exercise capacity and a reduction in anxiety.

TRIAL REGISTRATION NUMBER

ACTRN12615000736549; Results.

Yoga Therapy in Children with Cystic Fibrosis Decreases Immediate Anxiety and Joint Pain

This study was designed to determine whether yoga might alleviate symptoms of pain, sleep disturbance, anxiety, and depression in children with cystic fibrosis (CF). CF is the most common genetic, life-limiting chronic disease among Caucasian populations. It primarily affects the lungs but also many other secretory organs and consequently leads to significant morbidities. Research has shown that children with CF have significantly increased depression, anxiety, and pain compared to their healthy counterparts. Subjects participated in six one-on-one sessions over a 10-week period with a certified instructor who designed each yoga practice based on a preestablished list of 30 yoga asanas. Questionnaires evaluating pain, sleep disturbance, sustained anxiety, immediate anxiety, and depression were administered. Differences between premeasures and postmeasures were evaluated using a two-sided test. Twenty subjects were assessed (12 females/8 males), median age of 11 (7-20) years. Mean immediate anxiety scores decreased (before session to after session 29 to 23.6, respectively, p < 0.001). Joint pain improved (3.25 to 3.65, p = 0.028). CFQ-R emotion subscale improved from 79.2 to 85 (p = 0.073), and the respiratory subscale improved from 66.7 to 79.2 (p = 0.076). Other results were less notable. We conclude that yoga may reduce immediate anxiety and joint pain in patients with CF.

The effect of positioning and diaphragmatic breathing exercises on respiratory muscle activity in people with chronic obstructive pulmonary disease

BACKGROUND

Body positioning and diaphragmatic breathing may alter respiratory pattern and reduce dyspnoea in people with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To determine the effect of positioning and diaphragmatic breathing on respiratory muscle activity in a convenience sample of people with COPD, using surface electromyography (sEMG).

METHODS

This prospective descriptive study recorded sEMG measurements at baseline, after upright positioning, during diaphragmatic breathing and 5 minutes thereafter. Vital signs and levels of perceived dyspnoea were recorded at baseline and at the end of the study. Data were analysed using repeated measures ANOVAs with post hoc t-tests for dependent and independent variables.

RESULTS

Eighteen participants (13 male; mean ± standard deviation age 59.0 ± 7.9 years) were enrolled. Total diaphragmatic activity did not change with repositioning (p = 0.2), but activity increased from 7.3 ± 4.2 µV at baseline to 10.0 ± 3.3 µV during diaphragmatic breathing (p = 0.006) with a subsequent reduction from baseline to 6.1 ± 3.5 µV (p = 0.007) at the final measurement. There was no change in intercostal muscle activity at different time points (p = 0.8). No adverse events occurred. Nutritional status significantly affected diaphragmatic activity (p = 0.004), with participants with normal body mass index (BMI) showing the greatest response to both positioning and diaphragmatic breathing. There were no significant changes in vital signs, except for a reduction in systolic/diastolic blood pressure from 139.6 ± 18.7/80.4 ± 13.0 to 126.0 ± 15.1/75.2 ± 14.7 (p < 0.05).

CONCLUSION

A single session of diaphragmatic breathing transiently improved diaphragmatic muscle activity, with no associated reduction in dyspnoea.

Altered breathing mechanics and ventilatory response during exercise in children born extremely preterm

Background

Extreme preterm birth confers risk of long-term impairments in lung function and exercise capacity. There are limited data on the factors contributing to exercise limitation following extreme preterm birth. This study examined respiratory mechanics and ventilatory response during exercise in a large cohort of children born extremely preterm (EP).

Methods

This cohort study included children 8–12 years of age who were born EP (≤28 weeks gestation) between 1997 and 2004 and treated in a large regionalised neonatal intensive care unit in western Canada. EP children were divided into no/mild bronchopulmonary dysplasia (BPD) (ie, supplementary oxygen or ventilation ceased before 36 weeks gestational age; n=53) and moderate/severe BPD (ie, continued supplementary oxygen or ventilation at 36 weeks gestational age; n=50). Age-matched control children (n=65) were born at full term. All children attempted lung function and cardiopulmonary exercise testing measurements.

Results

Compared with control children, EP children had lower airway flows and diffusion capacity but preserved total lung capacity. Children with moderate/severe BPD had evidence of gas trapping relative to other groups. The mean difference in exercise capacity (as measured by oxygen uptake (VO₂)% predicted) in children with moderate/severe BPD was −18±5% and −14±5.0% below children with no/mild BPD and control children, respectively. Children with moderate/severe BPD demonstrated a potentiated ventilatory response and greater prevalence of expiratory flow limitation during exercise compared with other groups. Resting lung function did not correlate with exercise capacity.

Conclusions

Expiratory flow limitation and an exaggerated ventilatory response contribute to respiratory limitation to exercise in children born EP with moderate/severe BPD.

Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis

BACKGROUND

Self-management (SM) support for patients with chronic obstructive pulmonary disease (COPD) is variable in its coverage, content, method and timing of delivery. There is insufficient evidence for which SM interventions are the most effective and cost-effective.

OBJECTIVES

To undertake (1) a systematic review of the evidence for the effectiveness of SM interventions commencing within 6 weeks of hospital discharge for an exacerbation for COPD (review 1); (2) a systematic review of the qualitative evidence about patient satisfaction, acceptance and barriers to SM interventions (review 2); (3) a systematic review of the cost-effectiveness of SM support interventions within 6 weeks of hospital discharge for an exacerbation of COPD (review 3); (4) a cost-effectiveness analysis and economic model of post-exacerbation SM support compared with usual care (UC) (economic model); and (5) a wider systematic review of the evidence of the effectiveness of SM support, including interventions (such as pulmonary rehabilitation) in which there are significant components of SM, to identify which components are the most important in reducing exacerbations, hospital admissions/readmissions and improving quality of life (review 4).

METHODS

The following electronic databases were searched from inception to May 2012: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index [Institute of Scientific Information (ISI)]. Subject-specific databases were also searched: PEDro physiotherapy evidence database, PsycINFO and the Cochrane Airways Group Register of Trials. Ongoing studies were sourced through the metaRegister of Current Controlled Trials, International Standard Randomised Controlled Trial Number database, World Health Organization International Clinical Trials Registry Platform Portal and ClinicalTrials.gov. Specialist abstract and conference proceedings were sourced through ISI's Conference Proceedings Citation Index and British Library's Electronic Table of Contents (Zetoc). Hand-searching through European Respiratory Society, the American Thoracic Society and British Thoracic Society conference proceedings from 2010 to 2012 was also undertaken, and selected websites were also examined. Title, abstracts and full texts of potentially relevant studies were scanned by two independent reviewers. Primary studies were included if ≈90% of the population had COPD, the majority were of at least moderate severity and reported on any intervention that included a SM component or package. Accepted study designs and outcomes differed between the reviews. Risk of bias for randomised controlled trials (RCTs) was assessed using the Cochrane tool. Random-effects meta-analysis was used to combine studies where appropriate. A Markov model, taking a 30-year time horizon, compared a SM intervention immediately following a hospital admission for an acute exacerbation with UC. Incremental costs and quality-adjusted life-years were calculated, with sensitivity analyses.

RESULTS

From 13,355 abstracts, 10 RCTs were included for review 1, one study each for reviews 2 and 3, and 174 RCTs for review 4. Available studies were heterogeneous and many were of poor quality. Meta-analysis identified no evidence of benefit of post-discharge SM support on admissions [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.52 to 1.17], mortality (HR 1.07, 95% CI 0.74 to 1.54) and most other health outcomes. A modest improvement in health-related quality of life (HRQoL) was identified but this was possibly biased due to high loss to follow-up. The economic model was speculative due to uncertainty in impact on readmissions. Compared with UC, post-discharge SM support (delivered within 6 weeks of discharge) was more costly and resulted in better outcomes (£683 cost difference and 0.0831 QALY gain). Studies assessing the effect of individual components were few but only exercise significantly improved HRQoL (3-month St George's Respiratory Questionnaire 4.87, 95% CI 3.96 to 5.79). Multicomponent interventions produced an improved HRQoL compared with UC (mean difference 6.50, 95% CI 3.62 to 9.39, at 3 months). Results were consistent with a potential reduction in admissions. Interventions with more enhanced care from health-care professionals improved HRQoL and reduced admissions at 1-year follow-up. Interventions that included supervised or unsupervised structured exercise resulted in significant and clinically important improvements in HRQoL up to 6 months.

LIMITATIONS

This review was based on a comprehensive search strategy that should have identified most of the relevant studies. The main limitations result from the heterogeneity of studies available and widespread problems with their design and reporting.

CONCLUSIONS

There was little evidence of benefit of providing SM support to patients shortly after discharge from hospital, although effects observed were consistent with possible improvement in HRQoL and reduction in hospital admissions. It was not easy to tease out the most effective components of SM support packages, although interventions containing exercise seemed the most effective. Future work should include qualitative studies to explore barriers and facilitators to SM post exacerbation and novel approaches to affect behaviour change, tailored to the individual and their circumstances. Any new trials should be properly designed and conducted, with special attention to reducing loss to follow-up. Individual participant data meta-analysis may help to identify the most effective components of SM interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001588.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Yoga as a Therapy for Adolescents and Young Adults With Cystic Fibrosis: A Pilot Study

Rationale:

Yoga has been shown to improve outcomes in patients with asthma but has not been investigated in cystic fibrosis (CF) patients.

Methods:

This was a prospective pilot study to evaluate the safety of a standardized yoga program among CF patients aged 12 to 25 years. Participants engaged in a 50-minute yoga session twice weekly for 8 weeks conducted by a certified yoga instructor using a standardized program designed to be safe for health-compromised individuals. Yoga sessions were individual to avoid transmission of infections. Primary outcome was safety and tolerability. Secondary outcome measures included respiratory symptoms, the Cystic Fibrosis Quality of Life instrument (CFQ-R), lung function, Ease of Breathing Score (measure of exercise tolerance), and weight.

Results:

Eleven participants were enrolled, and 10 completed the study. Adherence was very good; the mean (SD) number of sessions completed was 14.2 (1.3) out of 16 sessions. Eight patients reported 25 adverse events. The most common was cough, reported in 7. Two events were possibly related to study procedures: calf pain and headache. There were no significant changes in dyspnea or pain scales. The mean (SD) CFQ-R respiratory domain score increased from screening to end of study: 67.9 (11.4) to 82.1 (9.9), P=.04. There were no significant changes in the other outcome measures.

Conclusions:

In this pilot study, a standardized 8-week yoga program was safe and well tolerated among adolescent and young adult CF patients with mild to moderate lung disease. This study may be helpful to yoga instructors who are interested in working with CF patients. Larger controlled trials are warranted to determine further benefits.

Efficacy of a minimal home-based psychoeducative intervention versus usual care for managing anxiety and dyspnoea in patients with severe chronic obstructive pulmonary disease: a randomised controlled trial protocol

INTRODUCTION

In its final stages, chronic obstructive pulmonary disease is a severely disabling condition that is characterised by dyspnoea, which causes substantial anxiety. Anxiety is associated with an impaired quality of life and increased hospital admissions. Untreated comorbid anxiety can have devastating consequences for both patients and their relatives. Non-pharmacological interventions, including cognitive-behavioural therapy, have been effective in managing anxiety and dyspnoea in patients with chronic obstructive pulmonary disease. However, the majority of existing interventions have tested the efficacy of relatively intensive comprehensive programmes and primarily targeted patients who have moderate pulmonary disease. We present the rationale and design for a trial that focused on addressing the challenges experienced by severe pulmonary disease populations. The trial investigates the efficacy of a minimal home-based psychoeducative intervention versus usual care for patients with severe chronic obstructive pulmonary disease.

METHODS AND ANALYSIS

The trial is a randomised controlled trial with a 4-week and 3-month follow-up. 66 patients with severe chronic obstructive pulmonary disease and associated anxiety will be randomised 1:1 to either an intervention or control group. The intervention consists of a single psychoeducative session in the patient's home in combination with a telephone booster session. The intervention is based on a manual, with a theoretical foundation in cognitive-behavioural therapy and psychoeducation. The primary outcome is patient-reported anxiety as assessed by the Hospital and Anxiety and Depression Scale (HADS).

ETHICS AND DISSEMINATION

This trial complies with the latest Declaration of Helsinki, and The Ethics Committee of the Capital Region of Denmark (number H-1-2013-092) was queried for ethical approval. Trial results will be disseminated in peer-reviewed publications and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT02366390.