Dyspnea in COPD: New Mechanistic Insights and Management Implications

Beyond Spirometry: Linking Wasted Ventilation to Exertional Dyspnea in the Initial Stages of COPD

Exertional dyspnea, a key complaint of patients with chronic obstructive pulmonary disease (COPD), ultimately reflects an increased inspiratory neural drive to breathe. In non-hypoxemic patients with largely preserved lung mechanics - as those in the initial stages of the disease - the heightened inspiratory neural drive is strongly associated with an exaggerated ventilatory response to metabolic demand. Several lines of evidence indicate that the so-called excess ventilation (high ventilation-CO2 output relationship) primarily reflects poor gas exchange efficiency, namely increased physiological dead space. Pulmonary function tests estimating the extension of the wasted ventilation and selected cardiopulmonary exercise testing variables can, therefore, shed unique light on the genesis of patients' out-of-proportion dyspnea. After a succinct overview of the basis of gas exchange efficiency in health and inefficiency in COPD, we discuss how wasted ventilation translates into exertional dyspnea in individual patients. We then outline what is currently known about the structural basis of wasted ventilation in "minor/trivial" COPD vis-à-vis the contribution of emphysema versus a potential impairment in lung perfusion across non-emphysematous lung. After summarizing some unanswered questions on the field, we propose that functional imaging be amalgamated with pulmonary function tests beyond spirometry to improve our understanding of this deeply neglected cause of exertional dyspnea. Advances in the field will depend on our ability to develop robust platforms for deeply phenotyping (structurally and functionally), the dyspneic patients showing unordinary high wasted ventilation despite relatively preserved FEV1.

Gas exchange efficiency slopes to assess exercise tolerance in chronic obstructive pulmonary disease

BACKGROUND

In patients with chronic obstructive pulmonary disease (COPD), the clinical use of the minute ventilation-carbon dioxide production ([Formula: see text]E-[Formula: see text]CO2) slope has been reported as a measure of exercise efficiency, but the oxygen uptake efficiency slope (OUES), i.e., the slope of oxygen uptake ([Formula: see text]O2) versus the logarithmically transformed [Formula: see text]E, has rarely been reported.

METHODS

We hypothesized that the [Formula: see text]E-[Formula: see text]CO2 slope is more useful than OUES in clinical use for the pathophysiological evaluation of COPD. Then, we investigated the cardiopulmonary exercise testing parameters affecting each of these slopes in 122 patients with all Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD grades selected from our database.

RESULTS

Compared with the GOLD I-II group (n = 51), peak [Formula: see text]O2 (p < 0.0001), OUES (p = 0.0161), [Formula: see text]E at peak exercise (p < 0.0001), and percutaneous oxygen saturation (SpO2) at peak exercise (p = 0.0004) were significantly lower in the GOLD III-IV group (n = 71). The GOLD III-IV group was divided into two groups by the exertional decrease in SpO2 from rest to peak exercise: 3% or less (the non-desaturation group: n = 23), or greater than 3% (the desaturation group: n = 48). OUES correlated only weakly with peak [Formula: see text]O2, [Formula: see text]E at peak exercise, and the difference between inspired and expired mean O2 concentrations (ΔFO2) at peak exercise, i.e., an indicator of oxygen consumption ability throughout the body, in the GOLD III-IV group with exertional hypoxemia. In contrast, the [Formula: see text]E-[Formula: see text]CO2 slope was significantly correlated with ΔFO2 at peak exercise, regardless of the COPD grade and exertional desaturation. Across all COPD stages, there was no correlation between the [Formula: see text]E-[Formula: see text]CO2 slope and [Formula: see text]E at peak exercise, and stepwise analysis identified peak [Formula: see text]O2 (p = 0.0345) and ΔFO2 (p < 0.0001) as variables with a greater effect on the [Formula: see text]E-[Formula: see text]CO2 slope.

CONCLUSIONS

The OUES may be less useful in advanced COPD with exertional hypoxemia. The [Formula: see text]E-[Formula: see text]CO2 slope, which is independent of [Formula: see text]E, focuses on oxygen consumption ability and exercise tolerance in COPD, regardless of the exertional hypoxemia level and COPD grade. Therefore, the [Formula: see text]E-[Formula: see text]CO2 slope might be useful in establishing or evaluating tailor-made therapies for individual patient's pathologies in COPD as an indicator focusing on oxygen consumption ability.

Living with COPD and its psychological effects on participating in community-based physical activity in Brazil: a qualitative study. Findings from the Breathe Well group

Physical activity (PA) improves dyspnoea, psychological wellbeing and quality of life (QoL) for people with COPD reducing their risk of exacerbation. However, engagement in PA is low especially amongst those with anxiety and depression, and PA programmes are limited in countries with limited resources such as Brazil. We explored perceptions of 21 people with COPD about the impact of their disease on taking part in community-based PA programmes in Sao Paulo, Brazil through semi-structured telephone interviews from October 2020 to April 2021. Discussions were audio-recorded, transcribed, and analysed using the Framework method. Five themes were identified: Knowledge about COPD and its management; Self-perception of life with COPD; Knowledge and experiences of depression and anxiety; Opinions on PA and repercussions of COVID-19. PA was considered to be important in bringing physical and mental health benefits but there were barriers in accessibility of formal PR programmes and therefore local community PA programmes were considered to be important. People with mental health conditions tended to view PA more negatively. COVID-19 had reduced PA opportunities, access to COPD treatment and social interaction, and was associated with more exacerbations and emotional suffering. In general, this study showed an urgent need to improve knowledge about COPD and its risk factors and management among both patients, the public and primary healthcare professionals. We provide important content for the formulation of public policies for the implementation of specific activity programmes for people with COPD in community spaces using local resources and intersectoral partnerships.

Physical and mental health trajectories: A longitudinal SF-36 analysis in Alpha-1 antitrypsin deficiency-associated COPD

BACKGROUND

The Short Form 36-Item Health Survey (SF-36) is a health-related quality of life (HRQoL) measure validated in people with chronic obstructive pulmonary disease (COPD). While physical health is often more impaired than mental health in people with COPD, research on alpha-1 antitrypsin deficiency (AATD)-associated COPD is limited. This longitudinal study examines changes in physical and mental health in individuals with AATD and associated factors.

METHODS

Analyses included participants of AlphaNet, a disease management program for individuals with AATD-associated lung disease who are prescribed augmentation therapy. Norm-based SF-36 scores for mental and physical component summaries (MCS and PCS) and 8 scales were analyzed. Linear mixed models evaluated mean changes in SF-36 scores over time.

RESULTS

The study included 2165 participants (mean age 56.9 ± 10.0 years, 47.0 % female). At enrollment, mean PCS score was 37.5 ± 9.6, and mean MCS score was 51.9 ± 10.5. Mean mMRC dyspnea score was 2.3 ± 1.3; 54.6 % had ≥2 exacerbations annually, and 46.5 % used oxygen regularly. Average follow-up was 6.6 ± 3.2 years. The HRQoL remained stable; MCS improved by 0.16 points/year (p < 0.0001), while the PCS score declined by 0.49 points/year (p < 0.0001). Subscales followed similar trends.

CONCLUSIONS

At baseline, mental HRQoL scores were higher than physical HRQoL scores, indicating better mental health than physical health in this cohort with AATD-associated lung disease. Stable HRQoL with a slight improvement in mental scores over time and a small decrease in physical scores may be a unique feature of this cohort. Further studies are needed to correlate these findings with disease-specific instruments and patient physiology.

Factors associated with the place of death of persons with advanced dementia: A systematic review of international literature with meta-analysis

BACKGROUND

Many individuals with advanced dementia die in hospital, despite preferring home death. Existing evidence of factors affecting their place of death is inconsistent. To inform policies/practices for meeting needs/preferences, systematically establishing the evidence is pertinent, particularly given the exponential rise in advanced dementia prevalence.

AIM

To identify factors influencing where people with advanced dementia die.

DESIGN AND DATA SOURCES

This systematic review with meta-analysis was registered on PROSPERO (CRD42022366722). Medline, CINAHL, PsycINFO, SocINDEX and a grey literature database, Overton, were searched on 21/12/2022, supplemented by hand-searching/citation tracking. Papers reporting quantitative data on factors associated with place of death in advanced dementia were included and appraised using QualSyst. Data were analysed using random effects with the certainty of evidence determined using the GRADE criteria.

RESULTS

Thirty-three papers involving >5 million individuals (mean age = 89.2 years) were included. Long-term care setting deaths were relatively common but hospice deaths were rarer. Marriage's association with home death underscores social networks' importance, while younger age's and male gender's associations with hospital death demonstrate patients' and families' interdependency. Pneumonia/COPD's opposing effects on hospital deaths with cancer/functional impairment highlight the challenges of advanced dementia care. Unlike hospital/nursing home bed availability's lack of effect, capitated funding (fixed-amount-per-patient-per-period) decreased hospital death likelihood.

CONCLUSION

This comprehensive review of place of death determinants highlight the profound challenges of advanced dementia end-of-life care. Given that bed capacity did not affect place of death, a capitation-based, integrated palliative care model would appear more likely to meet patients' needs in a resource-constrained environment.

Multicomponent services for symptoms in serious respiratory illness: a systematic review and meta-analysis

BACKGROUND

People living with serious respiratory illness experience a high burden of symptoms. This review aimed to determine whether multicomponent services reduce symptoms in people with serious illness related to respiratory disease.

METHODS

Electronic databases were searched to identify randomised controlled trials (RCTs) evaluating multicomponent services that enrolled patients due to symptoms, rather than underlying disease, and provided at least one nonpharmacological intervention. The primary outcome was chronic breathlessness and secondary outcomes were health-related quality of life (HRQoL), cough, fatigue and adverse events. At least two authors independently screened studies, assessed risk of bias and extracted data.

RESULTS

Five RCTs, involving 439 patients, were included. In comparison to usual care, multicomponent services improved breathlessness mastery (Chronic Respiratory Questionnaire (CRQ) mastery scale, mean difference (MD) 0.43 points, 95% CI 0.20-0.67, three RCTs, 327 participants) and HRQoL (CRQ total score, MD 0.24 points, 95% CI 0.04-0.40, two RCTs, 237 participants). Fatigue did not improve with multicomponent services and no studies evaluated cough. No serious adverse events were reported. The one study evaluating mortality found increased survival in those accessing a multicomponent service. The certainty of evidence was very low, mainly due to detection and reporting bias.

CONCLUSION

Multicomponent services improve breathlessness mastery and HRQoL, with minimal risk. These findings support the use of multicomponent symptom-directed services for people living with serious respiratory illness.

The occurrence mechanism, assessment, and non-pharmacological treatment of dyspnea

Dyspnea is a subjective sensation often described as a feeling of respiratory effort, tightness, or air hunger. The underlying mechanisms of this symptom are multifaceted and involve factors such as respiratory centers, cardiovascular system, airways, neuromuscular components, and metabolic factors, although not fully elucidated. The classical theory of imbalance between inspiratory neural drive (IND) and the simultaneous dynamic responses of the respiratory system posits that the disruption of a normal and harmonious relationship fundamentally shapes the expression of respiratory discomfort. Assessment and comprehensive treatment of dyspnea are crucial for patient rehabilitation, including subjective self-reporting and objective clinical measurements. Non-pharmacological interventions, such as pulmonary rehabilitation, fan therapy, exercise, chest wall vibration, virtual reality technology, traditional Chinese medicine (acupuncture and acupressure), and yoga, have shown promise in alleviating dyspnea symptoms. Additionally, oxygen therapy, has demonstrated short-term benefits for patients with pre-hospital respiratory distress and hypoxemia. This review provides a comprehensive overview of dyspnea, emphasizing the importance of a multifaceted approach for its assessment and management, with a focus on non-pharmacological interventions that contribute to enhanced patient outcomes and quality of life.

Opioids for the palliation of symptoms in people with serious respiratory illness: a systematic review and meta-analysis

BACKGROUND

People living with serious respiratory illness experience a high burden of distressing symptoms. Although opioids are prescribed for symptom management, they generate adverse events, and their benefits are unclear.

METHODS

We examined the efficacy and safety of opioids for symptom management in people with serious respiratory illness. Embase, MEDLINE and the Cochrane Central Register of Controlled Trials were searched up to 11 July 2022. Reports of randomised controlled trials administering opioids to treat symptoms in people with serious respiratory illness were included. Key exclusion criteria included <80% of participants having a nonmalignant lung disease. Data were extracted regarding study characteristics, outcomes of breathlessness, cough, health-related quality of life (HRQoL) and adverse events. Treatment effects were pooled using a generic inverse variance model with random effects. Risk of bias was assessed using the Cochrane Risk of Bias tool version 1.

RESULTS

Out of 17 included trials, six were laboratory-based exercise trials (n=70), 10 were home studies measuring breathlessness in daily life (n=788) and one (n=18) was conducted in both settings. Overall certainty of evidence was "very low" to "low". Opioids reduced breathlessness intensity during laboratory exercise testing (standardised mean difference (SMD) -0.37, 95% CI -0.67- -0.07), but not breathlessness measured in daily life (SMD -0.10, 95% CI -0.64-0.44). No effects on HRQoL (SMD -0.42, 95% CI -0.98-0.13) or cough (SMD -1.42, 95% CI -3.99-1.16) were detected. In at-home studies, opioids led to increased frequency of nausea/vomiting (OR 3.32, 95% CI 1.70-6.51), constipation (OR 3.08, 95% CI 1.69-5.61) and drowsiness (OR 1.37, 95% CI 1.01-1.86), with serious adverse events including hospitalisation and death identified.

CONCLUSIONS

Opioids improved exertional breathlessness in laboratory exercise studies, but did not improve breathlessness, cough or HRQoL measured in daily life at home. There were significant adverse events, which may outweigh any benefits.

The Effect of Opioids and Benzodiazepines on Exacerbation Rate and Overall Survival in Patients with Chronic Obstructive Pulmonary Disease on Long-Term Non-Invasive Ventilation

Background: There is a growing concern that opioids and benzodiazepines can depress the respiratory drive and could contribute to worsening respiratory failure and higher exacerbation frequency in COPD. However, the relationship between the exacerbation rate and medication taken is poorly understood in patients with chronic respiratory failure due to COPD. Methods: As part of a service evaluation project, we analysed 339 patients with COPD who were established on long-term non-invasive ventilation (LT-NIV) at our tertiary centre. We investigated the relationship between benzodiazepine and opioid prescription and clinical outcomes as well as their impact on the exacerbation rate and overall survival following setup. Results: Before LT-NIV setup, 40 patients took benzodiazepines and 99 patients took opioids. Neither benzodiazepine nor opioid use was associated with changes in daytime blood gases, overnight hypoxia or annual exacerbations before NIV setup, but patients taking opioids were more breathless as assessed by modified Medical Research Council scores (3.91 ± 0.38 vs. 3.65 ± 0.73, p < 0.01). Long-term NIV significantly reduced the number of yearly exacerbations (from 3.0/2.0-5.0/ to 2.8/0.71-4.57/, p < 0.01) in the whole cohort, but the effect was limited in those who took benzodiazepines (from 3.0/2.0-7.0/ to 3.5/1.2-5.5/) or opioids (3.0/2.0-6.0/ to 3.0/0.8-5.5/). Benzodiazepine use was associated with reduced exacerbation-free survival and overall survival (both p < 0.05). However, after adjustment with relevant covariates, the relationship with exacerbation-free survival became insignificant (p = 0.12). Opioids were not associated with adverse outcomes. Conclusions: Benzodiazepines and opiates are commonly taken in this cohort. Whilst they do not seem to contribute to impaired gas exchange pre-setup, they, especially benzodiazepines, may limit the benefits of LT-NIV.

The Relevance of the Endothelium in Cardiopulmonary Disorders

The endothelium is a cell monolayer that lines vessels and separates tissues from blood flow. Endothelial cells (ECs) have a multitude of functions, including regulating blood flow and systemic perfusion through changes in vessel diameter. When an injury occurs, the endothelium is affected by altering its functions and structure, which leads to endothelial dysfunction, a characteristic of many vascular diseases. Understanding the role that the endothelium plays in pulmonary vascular and cardiopulmonary diseases, and exploring new therapeutic strategies is of utmost importance to advance clinically. Currently, there are several treatments able to improve patients' quality of life, however, none are effective nor curative. This review examines the critical role of the endothelium in the pulmonary vasculature, investigating the alterations that occur in ECs and their consequences for blood vessels and potential molecular targets to regulate its alterations. Additionally, we delve into promising non-pharmacological therapeutic strategies, such as exercise and diet. The significance of the endothelium in cardiopulmonary disorders is increasingly being recognized, making ECs a relevant target for novel therapies aimed at preserving their functional and structural integrity.

Neural Respiratory Drive During Different Dyspnea Relief Positions and Breathing Exercises in Individuals With COPD

BACKGROUND

When the work load of the respiratory muscles increases and/or their capacity decreases in individuals with COPD, respiratory muscle activation increases to maintain gas exchange and respiratory mechanics, and perception of dyspnea occurs. The present study aimed to compare diaphragm and accessory respiratory muscle activation during normal breathing, pursed-lip breathing, and breathing control in different dyspnea relief positions, supine and side lying.

METHODS

A cross-sectional study design was used. Sixteen individuals with COPD age between 40-75 y were included. Pulmonary function was evaluated by spirometry, muscle activation by surface electromyography, and dyspnea by the modified Borg scale. Muscle activation was measured in the diaphragm, scalene, sternocleidomastoid, and parasternal muscles. The evaluation was made in the dyspnea relief positions (sitting leaning forward, sitting leaning forward at a table, leaning forward with back against a wall, standing leaning forward, and high lying), seated erect, supine, and side lying.

RESULTS

There were significant differences between the 8 positions (P < .001). There was no significant difference in muscle activation between sitting leaning forward and sitting leaning forward at a table position with analyzing post hoc test results (P > .99 for each muscle). However, muscle activation was lower in these 2 positions than in the other positions (P < .001 for each muscle). Muscle activation was greater in the supine position than in the other positions (P < .001 for each muscle). No difference was observed in muscle activation between the seated erect, leaning forward with back against a wall, standing leaning forward, high-lying, or side-lying positions (P > .05 for each muscle with a minimum P value of .09).

CONCLUSIONS

The use of sitting leaning forward and sitting leaning forward at a table positions together with breathing control may help people with COPD to achieve more effective dyspnea relief and greater energy efficiency.

The Sisyphean breath: role of anxiety sensitivity and distress tolerance in dyspnea among adults with asthma and COPD

INTRODUCTION

Asthma and COPD are among the leading causes of morbidity and mortality, impacting over 260 million people and causing over 3 million deaths globally (Momtaz-Manesh, S. et al., 2023). Pulmonary symptoms can impair tolerance and increase the negative attribution of anxiety sensations. Reciprocally, anxiety associated with dyspnea can induce hyperventilation. This perpetuates a cycle of symptom exacerbation and poor treatment adherence. Managing labored breathing is challenging due to its subjective nature. Dyspnea is a sufferer's endless pursuit to breathe, rendering its experience as truly, "Sisyphean."

AIM

This study explored the role of anxiety sensitivity and distress tolerance in dyspnea among adults with asthma and COPD (N = 107). A single-group cross-sectional research design was used. Data from pulmonologist-diagnosed adults with asthma and COPD were collected across various clinics in Delhi-NCR.

RESULTS

It was found that anxiety sensitivity, distress tolerance and dyspnea were strongly correlated. Also, an increase in anxiety sensitivity was strongly predictive of dyspnea severity. Further, distress tolerance acted as a partial mediator between anxiety sensitivity and dyspnea.

CONCLUSIONS

Improving distress tolerance can act as an adjuvant in effective dyspnea management.

Navigating Pediatric Cor Pulmonale: A Comprehensive Review of Diagnosis and Management

Pediatric cor pulmonale, characterized by right ventricular dysfunction due to chronic pulmonary hypertension, presents significant diagnostic and management challenges. This comprehensive review delves into this complex condition's etiology, clinical presentation, diagnostic strategies, and management. Key etiological factors include congenital heart defects, chronic lung diseases, and pulmonary vascular disorders. Early diagnosis, facilitated by imaging, hemodynamic assessments, and laboratory investigations, is crucial for effective intervention. Pediatric cor pulmonale management encompasses pharmacological treatments, such as vasodilators, diuretics, and inotropic agents, and non-pharmacological interventions, including oxygen therapy, mechanical ventilation, and surgical options. Long-term follow-up is essential to monitor disease progression and adjust treatment strategies accordingly. Multidisciplinary care involving pediatric cardiologists, pulmonologists, and critical care specialists is paramount to address the multifaceted needs of these patients. The review highlights the importance of early recognition and comprehensive care, offering insights into current best practices and future research and clinical practice directions. Advances in understanding the pathophysiology of pediatric cor pulmonale and emerging therapies promise to improve patient outcomes, underscoring the need for continued collaboration and innovation in this field.

Dyspnea and Palliative Care in Advanced Chronic Obstructive Pulmonary Disease: A Rapid Review

Dyspnea is the most common and activity-limiting symptom for those with chronic obstructive pulmonary disease (COPD). Treatment is complex, palliative care (PC) dyspnea relief interventions are poorly understood, and PC remains underutilized in COPD despite national guidelines and recommendations. The purpose of this rapid review was to explore the concept of dyspnea and role of PC through the lens of providers, caregivers, and patients with COPD. A systematic approach for synthesis was used to identify 13 articles published between January 2018 and October 2023. Team members compared data via visualization and theme clustering to identify key conclusions describing operationalization of dyspnea, management, and PC implications. Dyspnea operationalization was challenging, with inconsistent measurement and terminology. Dyspnea was a significant burden in COPD and contributed to complexity of treatment. Opioids were used most often to treat dyspnea, but provider perspectives and biases can influence treatment decisions and perceptions of opioid therapy by the patient and caregiver. Evidence-based clinical practice guidelines and policies are needed to clarify the use of opioid therapy for dyspnea management to reduce stigmatization and barriers to treatment. Provider education should emphasize a multipronged approach to treatment of dyspnea in COPD with integration of PC early in the care continuum.

Obesity Impact on Dyspnea in COPD Patients

Background

The role of obesity on dyspnea in chronic obstructive pulmonary disease (COPD) patients remains unclear. We aimed to provide an assessment of dyspnea in COPD patients according to their Body Mass Index (BMI) and to investigate the impact of obesity on dyspnea according to COPD severity.

Methods

One hundred and twenty seven COPD patients with BMI ≥ 18.5 kg/m² (63% male, median (interquartile range) post bronchodilator forced expiratory volume of 1 second (post BD FEV1) at 51 (34-66) % pred) were consecutively included. Dyspnea was assessed by mMRC (Modified medical research council) scale. Lung function tests were recorded, and emphysema was quantified on CT-scan (computed tomography-scan).

Results

Twenty-five percent of the patients were obese (BMI ≥ 30kg/m²), 66% of patients experienced disabling dyspnea (mMRC ≥ 2). mMRC scores did not differ depending on BMI categories (2 (1-3) for normal weight, 2 (1-3) 1 for overweight and 2 (1-3) for obese patients; p = 0.71). Increased mMRC scores (0-1 versus 2-3 versus 4) were associated with decreased post BD-FEV1 (p < 0.01), higher static lung hyperinflation (inspiratory capacity/total lung capacity (IC/TLC), p < 0.01), reduced DLCO (p < 0.01) and higher emphysema scores (p < 0.01). Obese patients had reduced static lung hyperinflation (IC/TLC p < 0.01) and lower emphysema scores (p < 0.01) than non-obese patients. mMRC score increased with GOLD grades (1-2 versus 3-4) in non-obese patients but not in obese patients, in association with a trend towards reduced static lung hyperinflation and lower emphysema scores.

Conclusion

By contrast with non-obese patients, dyspnea did not increase with spirometric GOLD grades in obese patients. This might be explained by a reduced lung hyperinflation related to the mechanical effects of obesity and a less severe emphysema in severe COPD patients with obesity.

Respiratory diseases and gut microbiota: relevance, pathogenesis, and treatment

Preclinical evidence has firmly established a bidirectional interaction among the lung, gut, and gut microbiome. There are many complex communication pathways between the lung and intestine, which affect each other's balance. Some metabolites produced by intestinal microorganisms, intestinal immune cells, and immune factors enter lung tissue through blood circulation and participate in lung immune function. Altered gut-lung-microbiome interactions have been identified in rodent models and humans of several lung diseases such as pulmonary fibrosis, chronic obstructive pulmonary disease, lung cancer, asthma, etc. Emerging evidence suggests that microbial therapies can prevent and treat respiratory diseases, but it is unclear whether this association is a simple correlation with the pathological mechanisms of the disease or the result of causation. In this review, we summarize the complex and critical link between the gut microbiota and the lung, as well as the influence and mechanism of the gut microbiota on respiratory diseases, and discuss the role of interventions such as prebiotics and fecal bacteria transplantation on respiratory diseases. To provide a reference for the rational design of large-scale clinical studies, the direct application of microbial therapy to respiratory-related diseases can reduce the incidence and severity of diseases and accompanying complications.

What kind of non-pharmacological strategy for reducing sedentary behavior in COPD? Data from a scoping review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is usually associated with sedentary behavior (SB). Literature reports a harmful impact of SB on the physical, mental, and social health of individuals with COPD. However, Pulmonary Rehabilitation (PR) programs seem to have no clear effect on changing SB. Therefore, our study aimed to identify the strategies used in the literature to reduce SB among individuals with COPD.

METHOD

A scoping review was conducted to summarize the current literature regarding the proposed strategies to reduce SB in individuals with COPD. Searches were conducted in PUBMED; SCOPUS and COCHRANE LIBRARY for studies published from 2010 to march 2024.

RESULTS

Twenty four articles were retained for our review. Most of the identified strategies in the literature (21/24 articles) are based on behavioral approaches, with various forms: promoting self-efficacy, self-management and self-regulation of one's own behavior (12 articles), goal setting (10 articles), constant feedback (11 articles), therapeutic education (8 articles), motivational strategies (6 articles), re-engagement in meaningful activities (4 articles), promoting light intensity physical activity (LPA) (6 articles) and social support (6 articles). In association with the behavioral strategies, wearable connected technologies have been used in 4 articles, alone or combined with physical exercise programs included or not in a PR program. The home is associated with 83 % of interventions as a place for initial and continuous implementation of behavioral strategies.

CONCLUSION

It would seem appropriate to focus on combined strategies to reduce SB in individuals with COPD (improvement of physical abilities and behavioral strategies). Further research is needed to only target the reduction of SB and to evaluate the effects of various interventions.

Unravelling the complex interplay of factors behind exercise limitations and physical inactivity in COPD

Exercise limitation and physical inactivity are known treatable traits for people with COPD. Maximising exercise capacity and keeping people physically active improves health status and survival rates among people with COPD. However, managing these two treatable traits can be extremely challenging for clinicians due to the complex intersectionality of factors influencing an individual's capacity, opportunity and motivation to engage in physical activity. This review presents the complex factors influencing exercise capacity ("can do"), levels of physical activity ("do do") and sedentary behaviours amongst people with COPD and provides practical recommendations on how clinicians can address some of these factors in practice. Most importantly, it highlights the importance of referring to pulmonary rehabilitation as a way to improve exercise capacity among people with COPD.

Residual reversibility in COPD patients already on long-acting bronchodilator: The OscilloRevers Study

BACKGROUND

Dyspnea is a complex symptom of chronic obstructive pulmonary disease (COPD) which is not strongly correlated with lung function measures. Long-acting bronchodilators (LAB) may reduce this dyspnea, but some patients report persistent chronic dyspnea despite this treatment. This study aims to assess residual reversibility and clinical response after short-acting bronchodilator (SAB) in COPD patients already treated by LAB and reporting persistent dyspnea.

METHODS

COPD patients with a persistent dyspnea (modified Medical Research Council scale (mMRC) ≥1) despite current stable treatment with at least one LAB were included. Spirometry, plethysmography and impulse oscillometry (IOS) were performed at peak effect of their LAB and repeat 45 min after the intake of two SAB (400 µg of salbutamol and 80 µg of ipratropium). Dyspnea improvement was assessed at 45 min after SAB through a comparative two-sided VAS (-100 mm for maximal improvement; +100 mm for maximal degradation).

RESULTS

Twenty-two COPD patients were analyzed, mainly men (59.1 %) with a mean age of 60.6 years and a median FEV1 of 54 % of predicted values. Fifty percent of patients reported a severe basal dyspnea (mMRC ≥2). After SAB, spirometric and plethysmographic measurements were statistically improved. For IOS measurement, reactance at 5 Hz (X5) and area of reactance (AX) were also improved. Fifty percent of patients reported a clinically relevant improvement of their resting dyspnea. However, no correlation was found between dyspnea improvement and functional measures.

CONCLUSIONS

Fifty percent of COPD patients regularly treated with one or two LAB still report a relevant improvement of resting dyspnea after the adjunctive intake of double short-acting bronchodilators. Physiological mechanisms associated with this improvement remain to be determined.

CLINICAL TRIAL REGISTRATION

NCT02928744.

Acupuncture for dyspnea and breathing physiology in chronic respiratory diseases: A systematic review and meta-analysis of randomized controlled trials

Background

Dyspnea, a common symptom of chronic respiratory diseases (CRDs), is closely linked to higher levels of functional impairment and death, leading to significant societal and financial challenges. Despite numerous clinical trials and systematic reviews suggested the potential benefits of acupuncture for chronic obstructive pulmonary disease (COPD) and lung cancer, there is currently insufficient evidence to conclusively prove its effectiveness in alleviating dyspnea in patients with CRDs.

Methods

To compile and evaluate the existing data on the effectiveness and safety of acupuncture for managing dyspnea in CRDs. Randomized controlled trials investigating acupuncture for the treatment of dyspnea in patients with CRDs, such as COPD, lung cancer, asthma, bronchiectasis, interstitial lung disease, chronic pulmonary heart disease and bronchitis, were searched and retrieved from five electronic databases in English or Chinese.

Results

A total of 23 studies meeting the inclusion criteria were found in databases, covering various CRDs such as COPD, lung cancer, and asthma. A meta-analysis that compared acupuncture to a control group (which included no acupuncture and sham acupuncture) found significant advantages for acupuncture in reducing dyspnea severity (P = 0.0003), increasing 6MWD (P < 0.00001), improving quality of life measured by St. George's Respiratory Questionnaire (P = 0.03) and karnofsky performance status score (P < 0.00001). No significance was found in breathing physiology represented by FEV1 (P = 0.34) and FVC (P = 0.15). There was a comparable incidence of negative outcomes in both groups (P = 0.07). Results were consistent when compared to sham acupuncture. In addition, subgroup analyses were also consistent when different diseases or types of acupuncture were analyzed.

Conclusions

Acupuncture may be an effective and safe non-pharmacological complementary intervention to relief dyspnea for patients with CRDs. Nevertheless, research with high quality and large sample sizes is needed for further investigation.

Pulmonary Rehabilitation: Mechanisms of Functional Loss and Benefits of Exercise

Exercise limitation is a characteristic feature of chronic respiratory diseases such as COPD and is associated with poor outcomes including decreased functional status and health-related quality of life and increased mortality. The mechanisms responsible for exercise limitation are complex and include ventilatory limitation, cardiovascular impairment, and skeletal muscle dysfunction. In addition, comorbidities such as cardiovascular disease are common in this population and can further impact exercise capacity. Exercise training, a core component of pulmonary rehabilitation, improves exercise capacity by addressing many of these mechanisms that, in turn, can potentially slow the decline of lung function, reduce the frequency of exacerbations, and decrease mortality. This article will discuss the mechanisms of exercise limitation in individuals with chronic respiratory disease, primarily focusing on COPD, and provide an overview of exercise training and its benefits in this patient population.

Advances in COPD imaging using CT and MRI: linkage with lung physiology and clinical outcomes

Recent years have witnessed major advances in lung imaging in patients with COPD. These include significant refinements in images obtained by computed tomography (CT) scans together with the introduction of new techniques and software that aim for obtaining the best image whilst using the lowest possible radiation dose. Magnetic resonance imaging (MRI) has also emerged as a useful radiation-free tool in assessing structural and more importantly functional derangements in patients with well-established COPD and smokers without COPD, even before the existence of overt changes in resting physiological lung function tests. Together, CT and MRI now allow objective quantification and assessment of structural changes within the airways, lung parenchyma and pulmonary vessels. Furthermore, CT and MRI can now provide objective assessments of regional lung ventilation and perfusion, and multinuclear MRI provides further insight into gas exchange; this can help in structured decisions regarding treatment plans. These advances in chest imaging techniques have brought new insights into our understanding of disease pathophysiology and characterising different disease phenotypes. The present review discusses, in detail, the advances in lung imaging in patients with COPD and how structural and functional imaging are linked with common resting physiological tests and important clinical outcomes.

Clinical utilization of airway inflammatory biomarkers in the prediction and monitoring of clinical outcomes in patients with chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) accounts for 545 million people living with chronic respiratory disorders and is the third leading cause of morbidity and mortality around the world. COPD is a progressive disease, characterized by episodes of acute worsening of symptoms such as cough, dyspnea, and sputum production.

AREAS COVERED

Airway inflammation is a prominent feature of COPD. Chronic airway inflammation results in airway structural remodeling and emphysema. Persistent airway inflammation is a treatable trait of COPD and plays a significant role in disease development and progression. In this review, the authors summarize the current and emerging biomarkers that reveal the heterogeneity of airway inflammation subtypes, clinical outcomes, and therapeutic response in COPD.

EXPERT OPINION

Airway inflammation can be broadly categorized as eosinophilic (type 2 inflammation) and non-eosinophilic (non-type 2 inflammation) in COPD. Currently, blood eosinophil counts are incorporated in clinical practice guidelines to identify COPD patients who are at a higher risk of exacerbations and lung function decline, and who are likely to respond to inhaled corticosteroids. As new therapeutics are being developed for the chronic management of COPD, it is essential to identify biomarkers that will predict treatment response.

Haemodynamic compensations for exercise tissue oxygenation in early stages of COPD: an integrated cardiorespiratory assessment study

BACKGROUND

Cardiovascular comorbidities are increasingly being recognised in early stages of chronic obstructive pulmonary disease (COPD) yet complete cardiorespiratory functional assessments of individuals with mild COPD or presenting with COPD risk factors are lacking. This paper reports on the effectiveness of the cardiocirculatory-limb muscles oxygen delivery and utilisation axis in smokers exhibiting no, or mild to moderate degrees of airflow obstruction using standardised cardiopulmonary exercise testing (CPET).

METHODS

Post-bronchodilator spirometry was used to classify participants as 'ever smokers without' (n=88), with 'mild' (n=63) or 'mild-moderate' COPD (n=56). All underwent CPET with continuous concurrent monitoring of oxygen uptake (V'O2) and of bioimpedance cardiac output (Qc) enabling computation of arteriovenous differences (a-vO2). Mean values of Qc and a-vO2 were mapped across set ranges of V'O2 and Qc isolines to allow for meaningful group comparisons, at same metabolic and circulatory requirements.

RESULTS

Peak exercise capacity was significantly reduced in the 'mild-moderate COPD' as compared with the two other groups who showed similar pulmonary function and exercise capacity. Self-reported cardiovascular and skeletal muscle comorbidities were not different between groups, yet disease impact and exercise intolerance scores were three times higher in the 'mild-moderate COPD' compared with the other groups. Mapping of exercise Qc and a-vO2 also showed a leftward shift of values in this group, indicative of a deficit in peripheral O2 extraction even for submaximal exercise demands. Concurrent with lung hyperinflation, a distinctive blunting of exercise stroke volume expansion was also observed in this group.

CONCLUSION

Contrary to the traditional view that cardiovascular complications were the hallmark of advanced disease, this study of early COPD spectrum showed a reduced exercise O2 delivery and utilisation in individuals meeting spirometry criteria for stage II COPD. These findings reinforce the preventive clinical management approach to preserve peripheral muscle circulatory and oxidative capacities.

Atrial Myxoma in a Patient With Chronic Obstructive Pulmonary Disease (COPD): Unmasking Overlapping Symptomatology

Atrial myxoma, though the most common primary cardiac tumor, often presents with nonspecific symptoms that can obscure its diagnosis. This case report details an unusual presentation of dyspnea on exertion (DOE) in a patient initially considered to have chronic obstructive pulmonary disease (COPD), a common pulmonary etiology of DOE. The diagnostic journey underscores the critical importance of considering atrial myxoma in patients with DOE, especially when symptoms are not fully explained by apparent pulmonary conditions. Our findings highlight the necessity of a comprehensive diagnostic approach, including the early use of resting transthoracic echocardiogram, to unveil less common causes like atrial myxoma. This case reinforces the pivotal role of considering alternative diagnoses in complex presentations of DOE, thereby guiding more accurate and tailored patient management.

The effect of cognition in combination with an ACBT on dyspnea-related kinesiophobia in patients with moderate to severe COPD: Quasirandomized controlled trial study

Patients with moderate to severe COPD frequently experience dyspnea, which causes these patients to acquire a fear of dyspnea and a fear of activity. This study developed a cognitive intervention combined with active cycle of breathing technique (ACBT) intervention program based on the fear-avoidance model, with the goal of evaluating the program's effectiveness in improving dyspnea-related kinesiophobia in patients with moderate to severe COPD. This study had a total of 106 participants. For 8 weeks, the intervention group (N=53) received cognitive combined with ACBT, while the control group (N=53) received standard care. The findings of the four times the dyspnea belief questionnaire were collected indicated that the combined intervention had a better impact on reducing dyspnea-related kinesiophobia than did routine nursing (P<0.05), and the impact persisted even after the intervention. Additionally, it may enhance dyspnea and quality of life, increase exercise capacity, and lower the BODE index.

ERS International Congress 2023: highlights from the Allied Respiratory Professionals Assembly

This article summarises some of the outstanding sessions that were (co)organised by the Allied Respiratory Professionals Assembly during the 2023 European Respiratory Society International Congress. Two sessions from each Assembly group are outlined, covering the following topics: Group 9.01 focuses on respiratory physiology techniques, specifically on predicted values and reference equations, device development and novel applications of cardiopulmonary exercise tests; Group 9.02 presents an overview of the talks given at the mini-symposium on exercise training, physical activity and self-management at home and outlines some of the best abstracts in respiratory physiotherapy; Group 9.03 highlights the nursing role in global respiratory health and presents nursing interventions and outcomes; and Group 9.04 provides an overview of the best abstracts and recent advances in behavioural science and health psychology. This Highlights article provides valuable insight into the latest scientific data and emerging areas affecting the clinical practice of Allied Respiratory Professionals.

Impact of Frailty on Symptom Burden in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD), the sixth leading cause of death in the United States in 2022 and the third leading cause of death in England and Wales in 2022, is associated with high symptom burden, particularly dyspnoea. Frailty is a complex clinical syndrome associated with an increased vulnerability to adverse health outcomes. The aim of this review was to explore the current evidence of the influence of frailty on symptoms in patients with a confirmed diagnosis of COPD according to GOLD guidelines. Fourteen studies report a positive association between frailty and symptoms, including dyspnoea, assessed with the COPD Assessment Test (CAT) and the modified Medical Research Council (mMRC) scale. Data were analysed in a pooled a random-effects meta-analysis of mean differences (MDs). There was an association between COPD patients living with frailty and increased CAT score versus COPD patients without frailty [pooled SMD, 1.79 (95% CI 0.72-2.87); I2 = 99%]. A lower association was found between frailty and dyspnoea measured by the mMRC scale versus COPD patients without frailty [pooled SMD, 1.91 (95% CI 1.15-2.66); I2 = 98%]. The prevalence of frailty ranged from 8.8% to 82% and that of pre-frailty from 30.4% to 73.7% in people living with COPD. The available evidence supports the role of frailty in worsening symptom burden in COPD patients living with frailty. The review shows that frailty is common in patients with COPD. Future research is needed to have further details related to the data from CAT to improve our knowledge of the frailty impact in this population.

The short- and long-term effects of lower limb endurance training on outpatients with chronic obstructive pulmonary disease

OBJECTIVE

To explore the short- and long-term effects of lower-limb endurance training on chronic obstructive pulmonary disease outpatients.

DESIGN

Prospective quasi-experimental study.

SETTING

1383-bed teaching hospital in Taiwan.

PARTICIPANTS

Overall, 69 outpatients diagnosed with chronic obstructive pulmonary disease were enrolled. A total of 60 patients completed the study.

INTERVENTION

Training group: Lower-limb endurance training; control group: Education only.

MAIN MEASURES

The modified medical research council score, chronic obstructive pulmonary disease assessment test score, pulmonary function test, and number of acute exacerbation within a year.

RESULTS

The training group showed significant improvement in the chronic obstructive pulmonary disease assessment test total score, modified medical research council score (both P < 0.001) at third month sustaining to 12th month (P < 0.001) and presented less events of acute exacerbation (P = 0.011) at 12th month. The chronic obstructive pulmonary disease assessment test decreased by 8 points sustaining to 12th month. The training group presented significant post-training functional capacity improvements in 6-min walking distance, lowest oxygen saturation during 6-min walking test, peak workload, maximum inspiratory/ expiratory pressures, and calf circumference.

CONCLUSIONS

The lower-limb endurance training improved perceived dyspnea in daily activity and health status after completion of training and sustaining for a year. The lower-limb endurance training alleviated disease impacted on reduced acute exacerbations.

Relevance of multidimensional dyspnea assessment in the context of pulmonary rehabilitation

Objectives: While dyspnea is the main symptom in chronic obstructive pulmonary disease (COPD), it is often inadequately evaluated in pulmonary rehabilitation (PR), as it is typically measured using only the impact dimension (ID). However, dyspnea is a multidimensional construct including perception (PD) and emotional (ED) domains. Our work aimed to study the complementarity of dyspnea dimensions and their respective ability to identify different evolutions during PR. Methods: 145 people with COPD attending PR were included in this retrospective study. Dyspnea scores from the modified Medical Research Council scale (ID) and the Multidimensional Dyspnea Profile questionnaire (PD/ED), exercise capacity, quality of life at the start (T1) and the end of PR (T2) were collected from existing databases/medical files. The evolution of each dyspnea dimension was evaluated using the delta score between T2-T1. PR response was defined using the minimal clinically important difference. Results: Our results show that each dyspnea dimension was associated with different health-outcomes. Positive correlations were found between PD-ED at baseline and between their T2-T1 delta score (ρ = 0.51; ρ = 0.41 respectively, p < .01), but there was no significant correlation between ID-PD or -ED (p > .05). 51% of the patients did not respond on ID, but 85% of them nonetheless responded on either PD or ED. Finally, 92% of patients responded on at least one dimension after PR. Discussion: Our study emphasizes the significance of assessing each dimension of dyspnea independently and complementary, as dimensions are associated with different elements and evolve differently under PR effects. This approach is crucial to identifying weak points and allows professionals to focus on program elements that most effectively address the specific dimension causing problems.

Effects of symptom management program on selected health outcomes among older people with chronic obstructive pulmonary disease: a quasi-experimental study

Older adults have limitations from their aging process and chronic disease, so developed interventions must pay attention and concern to their aging degeneration and needs. This study aims to study the effects of a symptom management program on selected health outcomes among older people with chronic obstructive pulmonary disease. The quasi-experimental research included the 15 older patients in the control group receiving routine nursing care, while the other 15 in the experimental group received a 4-week symptom management program. First, the general information was analyzed using descriptive statistics. Next, the average health outcomes were analyzed using independent and dependent t-tests, Mann-Whitney U Test, and Wilcoxon Signed Ranks Test. In addition, the readmission rate was compared using Fisher's Exact Test. Results revealed that most of the older patients were men (96.7%), aged 60-88 years (Mean = 71.57, SD = 7.75), with a smoking history (93.3%). The improvements were found in dyspnea (p < .01), its severity during activities (p < .01), and the quality of life (p = .04) among patients who attended the program. However, both groups did not have a different pulmonary function (p = .25) and the proportion of readmission within 28 days (p = .50). This study shows that the symptom management program can reduce dyspnea and severity during activities and improve the quality of life. Older people suffer from chronic obstructive pulmonary disease, especially when experiencing dyspnea. Therefore, it is crucial to have a symptom management program for older patients, especially a program developed to respond to changes in the aging process and the limitations of older people. This developed program was age-friendly to deal with symptoms and improve quality of life. However, this program should be explored in typical situations without the effects of the coronavirus disease (COVID-19) pandemic. In addition, more extensive population-based studies and randomized controlled trials should be adopted to increase credibility and ensure generalization.Clinical Trial Registration Number: https://osf.io/6sj7y (October 4, 2021).

Strategies implemented by informal caregivers to facilitate self-care in patients with chronic obstructive pulmonary disease (COPD): a scoping review protocol

BACKGROUND AND AIM

Chronic obstructive pulmonary disease (COPD) is a disease characterized by persistent respiratory symptoms and airflow limitation. COPD is a significant social and economic burden, and hospital admissions contribute to increased costs. Informal caregivers play a crucial role in supporting COPD patients in their self-care efforts. Therefore, understanding informal caregiver interventions to improve self-care may be helpful in reducing hospitalizations. This is the protocol for a scoping review that aims to map the literature on informal caregiver interventions to facilitate self-care in COPD patients.

RESEARCH QUESTION

What are the strategies implemented by informal caregivers to facilitate self-care for patients with COPD?

METHODS

The review will adhere to the methodology outlined by the JBI. A comprehensive search strategy will be executed in PubMed, CINAHL, Embase, Web of Science, Scopus, Cochrane, and PsycINFO. Additionally, grey literature and relevant unpublished documents will be searched to minimize publication bias. Studies describing strategies/actions implemented by informal caregivers to promote self-care in COPD patients from all countries will be included. We will exclude abstracts, editorials, articles on paid caregivers and social and healthcare workers. Two independent reviewers will screen titles, abstracts, and full-text articles based on inclusion criteria. Key data from the selected studies will be extracted using a predefined data extraction table. The results will be aggregated into themes and described qualitatively, figures and graphs may also be presented. The results will be presented according to the PRISMA-ScR.

REVIEW REGISTRATION

Open Science Framework https://doi.org/10.17605/OSF.IO/4TWRM.

Utility of Cardiopulmonary Exercise Testing in Chronic Obstructive Pulmonary Disease: A Review

Chronic obstructive pulmonary disease (COPD) is a disease defined by airflow obstruction with a high morbidity and mortality and significant economic burden. Although pulmonary function testing is the cornerstone in diagnosis of COPD, it cannot fully characterize disease severity or cause of dyspnea because of disease heterogeneity and variable related and comorbid conditions affecting cardiac, vascular, and musculoskeletal systems. Cardiopulmonary exercise testing (CPET) is a valuable tool for assessing physical function in a wide range of clinical conditions, including COPD. Familiarity with measurements made during CPET and its potential to aid in clinical decision-making related to COPD can thus be useful to clinicians caring for this population. This review highlights pulmonary and extrapulmonary impairments that can contribute to exercise limitation in COPD. Key elements of CPET are identified with an emphasis on measurements most relevant to COPD. Finally, clinical applications of CPET demonstrated to be of value in the COPD setting are identified. These include quantifying functional capacity, differentiating among potential causes of symptoms and limitation, prognostication and risk assessment for operative procedures, and guiding exercise prescription.

Psychophysical and Social Functioning of Patients with Chronic Obstructive Lung Disease and Depression

The relationship between depression and chronic obstructive pulmonary disease (COPD) is not fully understood. The comorbidity rate ranges from 18 to 84%, and depression is closely related to chronic inflammation, which affects how patients and the people around them perceive their condition. This study aims to examine the relationship between the psychophysical and social functioning of COPD patients who have been diagnosed with depression and the therapeutic benefits of selective serotonin reuptake inhibitors (SSRIs). This prospective study enrolled primary care patients diagnosed with COPD and depression. The entire period of this research was 3 years. The research was conducted at the Primary Health Center, Kragujevac, Serbia, in 87 patients for 8 weeks. The Hamilton Depression Scale (HAM-D) and Questionnaire for Quality of Life and Life Satisfaction Short Form (Q-LES-Q-SF) were used for psychiatric assessment. A positive correlation was found between the psychophysical and social functioning of the participants after 8 weeks of treatment with SSRIs. Based on the value of the phi correlation coefficient (phi = 0.5) obtained using the χ2 test, a large influence was observed in terms of life satisfaction and physical health (p < 0.05). In terms of physical functioning by gender, based on the value of the Pearson's coefficient (r) obtained with the χ2 test, it was shown that physical functioning was superior in the female respondents (p < 0.05). Treatment was found to improve depression in COPD after 8 weeks of therapy.

[Patient-Reported Outcomes (PROs) 3 and 6 Months After Pulmonary Rehabilitation Following COVID-19]

PURPOSE

If COVID-19 disease sequelae also (co-)affect the respiratory organs, national and international guidelines recommend pulmonary rehabilitation (PR). So far, however, no studies are available from Germany on the course after PR, nor on possible course differences between the two Long COVID subgroups "Ongoing symptomatic COVID-19" and "Post-COVID-19 syndrome" (PCS).

METHODS

  In a prospective observational study, patient-reported outcomes (PROs) regarding exertional dyspnea, quality of life, pain, fatigue, depression, and anxiety were assessed at the beginning of PR (T1), end of PR (T2), and after 3 (T3) and 6 months (T4). Statistical analyses were performed using latent difference models.

RESULTS

  There were 224 rehabilitation patients (MAge=54.4; SDAge=10.4; 42.0% female) included in the study. During PR, all PROs improved significantly. After PR, improvements either persisted with large pre-post effect sizes (exertional dyspnea, quality of life), decreased slightly to small pre-post effect sizes (depression, fatigue), or decreased to baseline levels (anxiety, pain). PCS patients had greater burdens in depression, fatigue, and pain at baseline, but did not differ in trajectories. Indicators of the severity of the preceding acute phase (oxygen therapy, ICU treatment, ventilation) were associated with higher burdens at T0 in depression, fatigue, and pain, but not with the courses during and after PR. In contrast, female patients showed higher burdens in both depression and fatigue at T1 and higher pre-post effects than male patients.

CONCLUSION

  The fact that improvements in PROs occurred in both subgroups only during PR, but not during the follow-up period suggests that the changes are not due to the natural healing process but at least partly due to PR. Moreover, the results suggest that both patient groups may benefit from PR. Persisting improvements in exertional dyspnea and quality of life and, to a reduced extent, in depression and fatigue until 6 months after PR, but not in pain and anxiety warrant study of additional multimodal interventions that may be needed to maintain these effects.

Cough Assessment and Management in Pulmonary Rehabilitation- A Canadian Survey

Pulmonary rehabilitation is a cornerstone intervention for controlling respiratory symptoms in people with chronic respiratory diseases. Chronic cough affects up to 90% of people with chronic respiratory diseases, however, it is currently unknown whether chronic cough is assessed and/or managed in pulmonary rehabilitation. This study aimed to determine if and how chronic cough is assessed and managed in pulmonary rehabilitation. This was a cross-sectional study. Pulmonary rehabilitation programs in Canada were identified via online websites. A representative from each program was invited to complete an online survey including the following topics: program demographics, assessment and management practices, and barriers and facilitators. Of 133 programs contacted, 31 returned a completed survey (23% response rate). Approximately half (52%) of respondents reported enrolling patients with chronic cough. Of those, 45% reported assessing and 62% reported intervening in chronic cough. Inadequate knowledge of assessment and management techniques was commonly identified to be a barrier and increased education was suggested as a possible facilitator. Based on pulmonary rehabilitation programs that responded to our survey, chronic cough is a prevalent symptom; however, it is scarcely assessed and managed. A need for structured education and the use of standardised strategies were reported as facilitators to the assessment and management of chronic cough in pulmonary rehabilitation.

Capnography-Assisted Learned, Monitored (CALM) breathing therapy for dysfunctional breathing in COPD: A bridge to pulmonary rehabilitation

BACKGROUND

Although dyspnea is a primary symptom of chronic obstructive pulmonary disease (COPD), its treatment is suboptimal. In both COPD and acute anxiety, breathing patterns become dysregulated, contributing to abnormal CO2, dyspnea, and inefficient recovery from breathing challenges. While pulmonary rehabilitation (PR) improves dyspnea, only 1-2% of patients access it. Individuals with anxiety who use PR have worse outcomes.

METHODS

We present the protocol of a randomized controlled trial designed to determine the feasibility and acceptability of a new, four-week mind-body intervention that we developed, called "Capnography-Assisted Learned, Monitored (CALM) Breathing," as an adjunct to PR. Eligible participants are randomized in a 1:1 ratio to either CALM Breathing program or Usual Care. CALM Breathing consists of 10 core, slow breathing exercises combined with real time biofeedback (of end-tidal CO2, respiratory rate, and airflow) and motivational interviewing. CALM Breathing promotes self-regulated breathing, linking CO2 changes to dyspnea and anxiety symptoms and targeting breathing efficiency and self-efficacy in COPD. Participants are randomized to CALM Breathing or a Usual Care control group.

RESULTS

Primary outcomes include feasibility and acceptability metrics of recruitment efficiency, participant retention, intervention adherence and fidelity, PR facilitation, patient satisfaction, and favorable themes from interviews. Secondary outcomes include breathing biomarkers, symptoms, health-related quality of life, six-minute walk distance, lung function, mood, physical activity, and PR utilization and engagement.

CONCLUSION

By disrupting the cycle of dyspnea and anxiety, and providing a needed bridge to PR, CALM Breathing may address a substantive gap in healthcare and optimize treatment for patients with COPD.

Endobronchial valve treatment in chronic obstructive pulmonary disease: A qualitative study of patients' expectations

Objectives

Endobronchial valve (EBV) treatment is a treatment option for selected patients with severe chronic obstructive pulmonary disease (COPD) to reduce dyspnea and improve quality of life. However, the procedure is associated with risk of complications, and not all patients achieve the expected outcomes. The present study explores patients' expectations while waiting for EBV treatment.

Methods

Fifteen patients accepted for EBV treatment at Aarhus University Hospital in Denmark from October 2020 to June 2021 participated in a 30-min, semi-structured interview about (1) the experience of living with COPD and (2) expectations regarding EBV.

Results

Four themes were identified: a life of reduced quality; hopes and expectations; information about EBV; and perception of risks. Most patients described their lives as not worth living, and they hoped that EBV would give them their physical and social lives back, while also being aware that EBV would probably not work miracles. Patients' information seeking was influenced by their hopes and expectations to the treatment. They filtered out negative information, focusing on the hope for a positive outcome. This made them willing to run the risk of complications.

Conclusion

Living a life of considerably reduced quality, patients might have an increased focus on potential positive effects of EBV treatment while filtering out information about potential side effects. This might bias their decision-making process.

Respiratory System Dynamics

While static mechanical forces govern resting lung volumes, dynamic forces determine tidal breathing, airflow, and changes in airflow and lung volume during normal and abnormal breathing. This section will examine the mechanisms, measurement methodology, and interpretation of the dynamic changes in airflow and lung volume that occur in health and disease. We will first examine how the total work of breathing can be described by the parameters of the equation of motion, which determine the pressure required to move air into and out of the lung. This will include a detailed description of airflow characteristics and airway resistance. Next, we will review the changes in pressure and flow that determine maximal forced inspiration and expiration, which result in the maximal flow-volume loop and the clinically important forced expired volume in 1 second. We will also assess the mechanisms and interpretation of bronchodilator responsiveness, dynamic hyperinflation, and airways hyperresponsiveness.

Effectiveness and safety of opioids on breathlessness and exercise endurance in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Opioids are recommended to treat advanced refractory dyspnoea despite optimal therapy by the American Thoracic Society clinical practice guidelines, while newly published randomised controlled trials of opioids in chronic obstructive pulmonary disease yield conflicting results.

AIM

This study aimed to evaluate the effectiveness and safety of opioids for patients with chronic obstructive pulmonary disease.

DESIGN

Systematic review and meta-analysis (PROSPERO CRD42021272556).

DATA SOURCES

Databases of PubMed, EMBASE and CENTRAL were searched from inception to 2022 for eligible randomised controlled trials.

RESULTS

Twenty-four studies including 975 patients, were included. In cross-over studies, opioids improved breathlessness (standardised mean difference, -0.43; 95% CI, -0.55 to -0.30; I2 = 18%) and exercise endurance (standardised mean difference, 0.22; 95% CI, 0.02-0.41; I2 = 70%). However, opioids failed to improve dyspnoea (standardised mean difference, -0.02; 95% CI, -0.22 to 0.19; I2 = 39%) and exercise endurance (standardised mean difference, 0.00; 95% CI, -0.27 to 0.27; I2 = 0%) in parallel control studies that administered sustained-release opioids for more than 1 week. The opioids used in most crossover studies were short-acting and rarely associated with serious adverse effects. Only minor side effects such as dizziness, nausea, constipation and vomiting were identified for short-acting opioids.

CONCLUSIONS

Sustained-release opioids did not improve dyspnoea and exercise endurance. Short-acting opioids appeared to be safe, have potential to lessen dyspnoea and improve exercise endurance, supporting benefit in managing episodes of breathlessness and providing prophylactic treatment for exertional dyspnoea.

Prevalence and Impact of Social Frailty in Patients with Chronic Obstructive Pulmonary Disease

Background

Patients with chronic obstructive pulmonary disease (COPD) are more inclined to have a high level of social vulnerability due to their physical and psychological burden. However, to date, there have been no study on social frailty in patients with COPD. This study aimed to investigate the prevalence, characteristics, and impact of social frailty in patients with COPD.

Methods

Social frailty was assessed using five items in a questionnaire. A patient was diagnosed with social frailty if responses to two or more items were positive. Four hundred and five patients with COPD were assessed for social frailty, dyspnea, and appetite. We also prospectively examined the number of acute exacerbation and unexpected hospitalization for 1 year.

Results

Thirty-six percent of patients with COPD had social frailty. They had reduced appetite and more severe dyspnea [Simplified Nutritional Appetite Questionnaire score: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.69‒0.95, p < 0.01; modified Medical Research Council score: OR 1.42, 95% CI 1.05‒1.93, P = 0.02] than patients without social frailty. Social frailty was not a risk factor for moderate acute exacerbation of COPD but a risk factor for severe acute exacerbation and all-cause unexpected hospitalization (severe acute exacerbation: β, standardized regression coefficient: 0.13, 95% CI 0.01‒0.25, P = 0.04, unexpected hospitalization: β 0.17, 95% CI 0.05‒0.29, P = 0.01).

Conclusion

The prevalence of social frailty is 36%; however, social frailty has a marked clinical impact in patients with COPD.

The Effectiveness of Home-Based Inspiratory Muscle Training on Small Airway Function and Disease-Associated Symptoms in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitations, occurring mainly in the small airways. Weakness in the respiratory muscles contributes to dyspnea and a decreased exercise capacity in COPD patients. This study aimed to investigate the effectiveness of home-based inspiratory muscle training (IMT) on small airway function and symptoms in COPD patients. This research adopted a non-randomized controlled-study quasi-experimental design. The IMT program consisted of two 15 min sessions·d-1, 5 d·wk-1, with 40% of the maximal inspiratory pressure (PImax) on each participant's assessment results and lasted for 12 weeks. Small airway function was assessed using plethysmography at baseline and after 12 weeks. The modified British Medical Research Council (mMRC), COPD assessment test (CAT), PImax, and 6 min walking distance (6MWD) were recorded at baseline as well as four, eight, and twelve weeks. Twenty-three participants with at least moderate COPD were enrolled in IMT (n = 16) or in the control group (n = 7) in this study. The study participants were mostly male (82.6%), and the average age was 68.29 ± 10.87 years, with a mean body mass index (BMI) of 23.54 ± 4.79. After 12 weeks, the ratios of the first second of forced expiration to the forced vital capacity (FEV1/FVC%) (B coefficient [95% Wald confidence interval] of 5.21 [0.46 to 9.96], p = 0.032), forced expiratory flow (FEF25-75%) (0.20 [0.04 to 0.35] L/s, p = 0.012), and FEF50% (0.26 [0.08 to 0.43] L/s, p = 0.004) in the IMT group were significantly better than in the control group. The IMT group showed significantly lower CAT scores at week 8 (-5.50 [-10.31 to -0.695] scores, p = 0.025) than the control group. The mMRC grade, CAT score, PImax, and 6MWD were significantly improved compared to their values at baseline in the IMT group. Home-based IMT effectively improved post-bronchodilator small airway function and disease-associated symptoms in COPD patients.

Multiform-based Baduanjin exercise prevention and treatment for idiopathic pulmonary fibrosis: study protocol for a randomized controlled trial

INTRODUCTION

In this study, we will combine the traditional Baduanjin with Yijin Jing and Wuqinxi to create an optimized Baduanjin exercise program with three different forms (vertical, sitting, and horizontal) to adapt to idiopathic pulmonary fibrosis (IPF) patients in vairous stages of the disease. The purpose of this study is to explore and compare the therapeutic effects of this multi-form Baduanjin, traditional Baduanjin, and resistance training on lung function and limb motor function in IPF patients. The goal of this study is to prove a novel optimal exercise prescription strategy of Baduanjin exercise for improving and protecting lung function in IPF patients.

METHODS/DESIGN

A single-blind and randomized controlled trial is used to conduct this study, while the randomization list will be generated using a computerized random number generator and opaque sealed envelopes with group allocation will be prepared. It will be strictly followed to blind the outcome assessors. and until the experiment's conclusion, participants won't know which group they are enrolled in. Patients between the ages of 35 and 80 who have stable diseases and have not regularly practiced Baduanjin exercise in the past will be included. They are divvied up into the following five groups at random: (1) The conventional care group (control group, CG), (2) The traditional Baduanjin exercise group (TG), (3) The modified Baduanjin exercise group (IG), (4) The resistance exercise group (RG) (5) The modified Baduanjin exercise combined with resistance exercise group (IRG). Those CG participants only received the usual treatment, while TC, IG, and RG participants exercised 1 h twice a day for 3 months. MRG participants will have a 3-month intervention with 1 h of Modified Baduanjin Exercise and 1 H of Resistance Training for each day. Every week, all groups underwent will supervis one-day training, with the exception of the control group. The Pulmonary Function Testing (PFT), HRCT, and 6MWT are the main outcome variables. The St. George Respiratory Questionnaire and mMRC are used as secondary outcome measures.

DISCUSSION

This study may produce a new Baduanjin exercise prescription that is user-friendly, simple to execute, more targeted, and adaptable. Because it consists of three forms, including vertical, sitting, and horizontal, it is more adaptable to the various disease stages and actual situations of IPF patients and may compensate for the shortcomings of conventional pulmonary rehabilitation and traditional Baduanjin.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200055559 . Registered on 12 January 2022.

A systematic review of behaviour change techniques in pharmacist-delivered self-management interventions towards patients with chronic obstructive pulmonary disease

BACKGROUND

Self-management interventions often employ behaviour change techniques in order to produce desired target behaviours that are necessary for day-to-day living with a chronic disease. Despite the large number of self-management interventions for patients with chronic obstructive pulmonary disease (COPD), previously reported interventions have been typically delivered by healthcare providers other than the pharmacist.

OBJECTIVE

This systematic review examined the components of pharmacists-delivered COPD self-management interventions according to an established taxonomy of behaviour change techniques (BCTs).

METHODS

A systematic search was conducted on PubMed, ScienceDirect, OVID, and Google Scholar from January 2011 to December 2021 for studies of pharmacist-delivered self-management interventions in COPD patients.

RESULTS

A total of seventeen studies of intervention were eligible for inclusion in the narrative review. Interventions were educational and were delivered individually and face-to-face for the first session. Across studies, pharmacists spent an average of 35 min on the first meeting and had an average of 6 follow-up sessions. Recurrent BCTs in pharmacist interventions were "Information on the health consequence", "Feedback on behaviour", "Instruction on how to perform a behaviour", "Demonstration of the behaviour" and "Behavioural practice/rehearsal".

CONCLUSIONS

Pharmacists have provided interventions towards improving health behaviours, especially on adherence and usage of inhaler devices for patients with COPD. Future self-management interventions should be designed using the identified BCTs for the improvement of COPD self-management and disease outcomes.

Test-retest reliability of a 30-min fixed perceived effort cycling exercise

PURPOSE

Using exercise protocols at a fixed rating of perceived effort (RPE) is a useful method for exploring the psychophysical influences on exercise performance. However, studies that have employed this protocol have arbitrarily selected RPE values without considering how these values correspond to exercise intensity thresholds and domains. Therefore, aligning RPE intensities with established physiological thresholds seems more appropriate, although the reliability of this method has not been assessed.

METHODS

Eight recreationally active cyclists completed two identical ramped incremental trials on a cycle ergometer to identify gas exchange threshold (GET). A linear regression model plotted RPE responses during this test alongside gas parameters to establish an RPE corresponding to GET (RPE_GET) and 15% above GET (RPE_+15%GET). Participants then completed three trials at each intensity, in which performance, physiological, and psychological measures were averaged into 5-min time zone (TZ) intervals and 30-min 'overall' averages. Data were assessed for reliability using intraclass correlation coefficients (ICC) and accompanying standard error measurements (SEM), 95% confidence intervals, and coefficient of variations (CoV).

RESULTS

All performance and gas parameters showed excellent levels of test-retest reliability (ICCs =  > .900) across both intensities. Performance, gas-related measures, and heart rate averaged over the entire 30-min exercise demonstrated good intra-individual reliability (CoV =  < 5%).

CONCLUSION

Recreationally active cyclists can reliably replicate fixed perceived effort exercise across multiple visits when RPE is aligned to physiological thresholds. Some evidence suggests that exercise at RPE_+15%GET is more reliable than RPE_GET.

Female sexual dysfunction in chronic obstructive pulmonary disease

Background

Sexual life of women with chronic obstructive pulmonary disease (COPD) can be affected by breathing difficulties, a decrease in functional status, depressive mood and fatigue.

Objetive

To evaluate the sexual dysfunction in female COPD patients and the possible explanatory mechanisms or correlations between these conditions.

Methods

The study included 70 female patients with COPD aged between 36-65 and 70 age-matched controls. All the subjects completed questionnaires for the Female Sexual Functional Index (FSFI), BECK depression inventory and, spirometry.

Results

Statistically significant sexual dysfunction was noted in COPD patients compared to the non-COPD group (p<0.001). BECK depression inventory scores of the COPD patients were also significantly lower (p<0.001). no correlation between FSFI and BECK depression scores in 'patients' characteristics (r=-0.055, p=0.651). No significant difference was found in age, forced expiratory volume (FEV)1%, and exacerbation history of the previous year according to severity of depression (p>0.005). In linear regression analysis determining depression, no statistically significant factor was found among age, number of comorbidities, and FEV1/ forced vital capacity (FVC) % predicted (p>0.05). In multivariable analysis, only fatigue during intercourse was found to be a statistically significant factor in predicting sexual dysfunction among factors like age, presence of comorbidities, duration of the disease, smoking status, FEV1%, m MRCpoints, 6-minutes walk test, BECK depression scores (p=0.008).

Conclusion

Sexual dysfunction is reported in many COPD females and seems to be related not to spirometric measures or exercise capacity but to fatigue. Depression is also a common comorbidity, of which both disorders are often neglected.

Breathing Control Exercises Delivered in a Group Setting for Patients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

Breathing control exercises are an important component of occupational therapy in patients with chronic obstructive pulmonary disease (COPD). Delivering these exercises in group settings may enhance their benefits. Therefore, this study assessed the effectiveness of breathing control exercises delivered in a group format to patients with severe COPD remitting from an acute pulmonary exacerbation. This randomized controlled trial of 6 weeks’ duration compared the addition of breathing exercise sessions delivered in a group setting to a standard exercise inpatient rehabilitation program (usual care) versus usual care alone. The standard exercise program consisted of endurance and strength training and therapeutic patient education. The intervention group received, in addition to usual care, 20 sessions of 30 min duration of breathing control exercises in a group setting. The primary outcome was quality of life (Saint George’s Respiratory Questionnaire). Secondary outcomes were the COPD assessment test, modified Borg scale, handgrip strength test, and five-time sit-to-stand test. Thirty-seven patients aged 69 ± 7 years were recruited. After the 6-week period, all outcomes significantly improved and exceeded the minimal clinically important difference in the intervention group only. Between-group changes were significant for each outcome. Conclusions: breathing control exercises in a group setting provide clinically relevant benefits in patients with severe COPD who are remitting from an acute pulmonary exacerbation.

Caring for patients with advanced COPD: beyond the inhalers…

COPD affects millions of people worldwide. Patients with advanced COPD have a high symptom burden. Breathlessness, cough and fatigue are frequent daily symptoms. Guidelines often focus on pharmacological treatment, especially inhaler therapy, but other approaches in combination with medications offer symptomatic benefit. In this review, we take a multidisciplinary approach with contributions from pulmonary physicians, cardiothoracic surgeons and a physiotherapist. The following areas are addressed: oxygen therapy and noninvasive ventilation (NIV), dyspnoea management, surgical and bronchoscopic options, lung transplantation and palliative care. Oxygen therapy prescribed within guidelines improves mortality in patients with COPD. NIV guidelines offer only low-certainty instruction on the use of this therapy on the basis of the limited available evidence. Dyspnoea management can take place through pulmonary rehabilitation. Specific criteria aid decisions on referral for lung volume reduction treatments through surgical or bronchoscopic approaches. Lung transplantation requires precise disease severity assessment to determine which patients have the most urgent need for lung transplantation and are likely to have the longest survival. The palliative approach runs in parallel with these other treatments, focusing on symptoms and aiming to improve the quality of life of patients and their families facing the problems associated with life-threatening illness. In combination with appropriate medication and an individual approach to symptom management, patients' experiences can be optimised.

Educational aims

To understand the multidisciplinary approach to management of patients with advanced COPD.To recognise the parallel approaches to oxygen, NIV and dyspnoea management with consideration of more interventional options with lung volume reduction therapy or lung transplantation.To understand the high level of symptomatology present in advanced COPD and the relevance of palliative care alongside optimal medical management.