Chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD): a systematic review

The effect of physiotherapy intervention on functional outcomes among COVID-19 patients: Clinical experimental study

BACKGROUND

COVID-19 is a highly contagious virus that causes pneumonia, which quickly progresses to acute respiratory distress. In the case of COVID-19, physiotherapy is critical in non-invasive support management, postural changes, chest physiotherapy (CPT), and bed mobility. This study aims to look into the effects of physiotherapy intervention on functional outcome levels in COVID-19 patients in the acute stage.

METHODS

A total of 60 severe COVID-19 patients (54 males and 6 females) with a mean age of 50 years were studied. The intervention group (n = 30) had two daily physiotherapy sessions that included positioning, CPT, cardio exercises, breathing exercises, and early mobility, whereas the control group (n = 30) received only standard medical care. Patients were tested twice at the baseline and discharge using peripheral oxygen saturation, respiratory rate (RR) test, dyspnea rate, two-min walk test, and spirometer scores, forced vital capacity (FVC) and forced expiratory volume in one second (FEV1).

RESULTS

The two groups improved significantly between the baseline and discharge ratings. The intervention group, on the other hand, significantly improved all outcome indicators at discharge (p-value = 0.00). This study found that physiotherapy management improved oxygen saturation, RR, dyspnea, and lung function tests in COVID-19 patients except in FVC (p-value = 0.402) and FEV1(p-value = 0.114).

CONCLUSION

Physiotherapist interventions with COVID-19 patients increase respiratory function and treatment time.

Pulmonary rehabilitation and risk of fall in elderly with chronic obstructive pulmonary disease

BACKGROUND

Few data are available on the effects of pulmonary rehabilitation (PR) on risk of fall in over 80 individuals with chronic obstructive pulmonary disease (COPD). We investigated the effectiveness of PR on the risk of fall in older as compared to younger than 80 individuals.

METHODS

Parallel-group retrospective exploratory study of individuals undergone in-hospital PR. The risk of fall was defined as a gait speed ≤0.8 m/s (primary outcome). Outcome measures (exercise capacity, physical performance, symptoms, and health status) were also assessed.

RESULTS

As compared to younger, individuals over 80 suffered from more severe symptoms, a reduction in physical performance and in exercise capacity and greater risk of fall (P=0.0001). The proportion of participants at risk of fall increased with age, and after PR decreased significantly without any significant difference between age groups. However, 53.4% of older individuals were still at risk of fall, as compared to 17.5% of those under 80 (P=0.0001). After PR, both populations had improved outcomes measures, without any significant between group differences.

CONCLUSIONS

In individuals with COPD pulmonary rehabilitation reduced the risk of fall, while improving outcome measures independent of age, however, more than 50% of those over 80 were still at risk of fall. The pulmonary rehabilitation programs for individuals over 80 should include strategies effective in reducing the risk of fall.

Identification of TRPC6 as a Novel Diagnostic Biomarker of PM-Induced Chronic Obstructive Pulmonary Disease Using Machine Learning Models

Chronic obstructive pulmonary disease (COPD) was the third most prevalent cause of mortality worldwide in 2010; it results from a progressive and fatal deterioration of lung function because of cigarette smoking and particulate matter (PM). Therefore, it is important to identify molecular biomarkers that can diagnose the COPD phenotype to plan therapeutic efficacy. To identify potential novel biomarkers of COPD, we first obtained COPD and the normal lung tissue gene expression dataset GSE151052 from the NCBI Gene Expression Omnibus (GEO). A total of 250 differentially expressed genes (DEGs) were investigated and analyzed using GEO2R, gene ontology (GO) functional annotation, and Kyoto Encyclopedia of Genes and Genomes (KEGG) identification. The GEO2R analysis revealed that TRPC6 was the sixth most highly expressed gene in patients with COPD. The GO analysis indicated that the upregulated DEGs were mainly concentrated in the plasma membrane, transcription, and DNA binding. The KEGG pathway analysis indicated that the upregulated DEGs were mainly involved in pathways related to cancer and axon guidance. TRPC6, one of the most abundant genes among the top 10 differentially expressed total RNAs (fold change ≥ 1.5) between the COPD and normal groups, was selected as a novel COPD biomarker based on the results of the GEO dataset and analysis using machine learning models. The upregulation of TRPC6 was verified in PM-stimulated RAW264.7 cells, which mimicked COPD conditions, compared to untreated RAW264.7 cells by a quantitative reverse transcription polymerase chain reaction. In conclusion, our study suggests that TRPC6 can be regarded as a potential novel biomarker for COPD pathogenesis.

Early rehabilitation program and weaning outcomes in critically ill chronic obstructed airway disease patients: a randomized trial

Background

To compare the effectiveness of early rehabilitation program on mechanical ventilated COPD patient in RICU to those using current usual care regarding diaphragm function and weaning outcomes.

Methods

The study was a randomized controlled trial. It included 108 newly admitted COPD patients to RICU, Chest Department, Assiut University Hospital, Egypt, in the period from June 2018 to May 2020. They were divided into two groups: group Ι received the usual care plus pulmonary rehabilitation program, and group II received the usual care alone. The outcomes (MV duration, rates of successful weaning, diaphragm function, and lengths of hospital and ICU stay) were recorded and evaluated. The data was analyzed using Student t-test, Mann–Whitney U-test, Wilcoxon signed-rank test, chi-square (χ2) test or Fisher Exact test, receiver operating characteristics (ROC) curve, and logistic regression analysis.

Results

One-hundred and eight COPD patients were included. Early rehabilitation program for COPD patients in the ICU shortened the duration of their MV, increases the rates of successful weaning and decreases 30-day mortality, and shortened the duration of their ICU and hospital stays, as compared to COPD patients who received usual care.

Conclusions

Management of COPD patients with early rehabilitation program is associated with better outcome with improvement of the quality of life of COPD patients.

Trial registration

Clinical trial.gov: NCT03253380

Pulmonary Rehabilitation Programmes Within Three Days of Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Objective

To evaluate the efficacy and safety of early pulmonary rehabilitation (PR) (ie, <3 days of hospitalization) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

Embase, Web of Science, PubMed and Cochrane Library were searched from their inception to 1 April 2021. Randomized controlled trials were included if they observed the efficacy of early PR in AECOPD patients. Study selection, data extraction, risk of bias and quality of evidence were assessed by two researchers independently. Assessment of the risk of bias and eidence quality were evaluated by the Cochrane Collaboration’s tool and Grading of Recommendations, Assessment, Development and Evaluation system, respectively.

Results

Fourteen trials (829 participants) were identified. Significant improvement was found in the 6-minute walk distance (6MWD; mean difference (MD): 69.64; 95% CI: 40.26 to 99.01; Z = 4.65, P < 0.0001, low quality). In the subgroup analysis, the exercise-training group showed marked improvement (MD: 96.14; 95% CI: 20.24 to 172.04; Z = 2.48, P = 0.001). The Saint George’s Respiratory Questionnaire (SGRQ) total score was low (MD: −12.77; 95% CI: −16.03 to −9.50; Z = 7.67, P < 0.0001, moderate quality). Significant effects were not found for the duration of hospital stay, quadriceps muscle strength or five times sit to stand test. Only one serious adverse event was reported in experimental group, which was not associated with early PR.

Conclusion

PR initiated <3 days of hospitalization may increase exercise capacity and improve quality of life, but the results should be interpreted prudently and dialectically, and the role of early PR in AECOPD needs further exploration.

Role of the active cycle of breathing technique combined with phonophoresis for the treatment of patients with chronic obstructive pulmonary disease (COPD): study protocol for a preliminary randomized controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease characterized by coughing, the production of excess sputum, and dyspnea. Patients with excessively thick sputum may have frequent attacks or develop more serious disease. The guidelines recommend airway clearance for patients with excessive sputum who are hospitalized with COPD. The active cycle of breathing technique is the most common non-pharmacological airway clearance technique used by physiotherapists. However, the effectiveness of the technique is not always guaranteed. Active cycle of breathing techniques require the initial dilution of the sputum, usually by inhalation drugs, which may have limited effects. Recent studies have found that phonophoresis decreases inflammation, suggesting the potential of the combined usage of active cycle of breathing techniques and phonophoresis. Therefore, the aim of this study is to explore the effectiveness and safety of combining active cycle of breathing technique and phonophoresis in treating COPD patients.

METHODS AND ANALYSIS

We propose a single-blind randomized controlled trial using 75 hospitalized patients diagnosed with COPD with excessive sputum production. The patients will be divided into three groups. The intervention group will receive active cycle of breathing techniques combined with phonophoresis. The two comparison groups will be treated with active cycle of breathing techniques and phonophoresis, respectively. The program will be implemented daily for 1 week. The primary outcomes will be changes in sputum viscosity and production, lung function, and pulse oximetry. Secondary outcomes include the assessment of COPD and anxiety, measured by the COPD Assessment Test scale and the Anxiety Inventory for Respiratory Disease, respectively; self-satisfaction; the degree of cooperation; and the length of hospital stay. All outcome measures, with the exception of sputum production and additional secondary outcomes, will be assessed at the commencement of the study and after 1 week's intervention. Analysis of variance will be used to investigate differences between the groups, and a p-value of less than 0.05 (two-tailed) will be considered statistically significant.

DISCUSSION

This study introduces a combination of active cycle of breathing techniques and phonophoresis to explore the impact of these interventions on patients hospitalized with COPD. If this combined intervention is shown to be effective, it may prove to be a better treatment for patients with COPD.

TRIAL REGISTRATION

The trial was registered prospectively on the Chinese Clinical Trial Registry on 24 December 2019.ClinicalTrials.gov ChiCTR1900028506 . Registered on December 2019.

An integrative review on the positive expiratory pressure (PEP)-bottle therapy for patients with pulmonary diseases

BACKGROUND AND PURPOSE

Positive expiratory pressure (PEP)-bottle device delivers a PEP within a range of 10-20 cmH₂ O. PEP treatment is applied to different pathological conditions also in combination with other physiotherapeutic techniques. The primary aim of the present review was to investigate the effects of PEP-bottle therapy in patients with pulmonary diseases and, secondarily, to provide a physiological analysis of its use.

METHODS

The databases PubMed, Scopus, Web of Science, Cinahl, and Cochrane Library were searched for citations published from their inception until May 2019. Adult participants (>18 years) with pulmonary disease who underwent PEP-bottle treatment, with no restriction on gender, were included in the study. There were no restrictions about the therapeutic settings and the condition of the disease (either acute or chronic).

RESULTS

The literature review returned 97 citations. After duplicates removal, the remaining 77 articles have been screened: 66 have been assessed as not eligible at first because the abstract did not meet the inclusion criteria. Eleven articles were left after the first two steps of selection: four have been excluded after full-text reading.

CONCLUSION

PEP-bottle therapy has been proved to improve lung volume, to reduce hyperinflation, and to remove secretions. The device delivers a pressure equal to the water column only if the inner diameter of the tubing and the width of the air escape orifice are equal or greater than 8 mm, and the length of tubing ranges between 20 and 80 cm. The cost of a PEP-bottle device is significantly lower if compared with other commercially available devices having the same therapeutic purposes.

Effectiveness of early rehabilitation on patients with chronic obstructive lung disease and acute respiratory failure in intensive care units: A case-control study

The effect of early rehabilitation on the outcome of patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure (ARF) in intensive care units (ICUs) remains unclear. We examined the effect of early rehabilitation on the outcomes of COPD patients requiring mechanical ventilation (MV) in the ICU. This retrospective, observational, case–control study was conducted in a medical center with a 19-bed ICU. The records of all 105 ICU patients with COPD and ARF who required MV from January to December 2011 were examined. The outcomes (MV duration, rates of successful weaning and survival, lengths of ICU and hospital stays, and medical costs) were recorded and analyzed. During the study period, 35 patients with COPD underwent early rehabilitation in the ICU and 70 demographically and clinically matched patients with similar COPD stage, cause of intubation, type of respiratory failure, and levels of disease severity who had not undergone early rehabilitation in the ICU were selected as comparative controls. Multiple regression analysis showed that early rehabilitation was significantly negatively associated with MV duration. Early rehabilitation for COPD patients in the ICU with ARF shortened the duration of their MV.

Effectiveness of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease: A systematic review and meta-analysis

AIM

To critically review and synthesize the findings of studies that evaluated the effectiveness of nursing interventions for improving breathlessness in adults with chronic obstructive pulmonary disease.

BACKGROUND

Systematic reviews of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease have not been specifically addressed.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

A systematic search of Medline, CINAHL, PsycINFO and Embase was performed for studies published between January 2000 and June 2017.

REVIEW METHODS

Risk of bias, data extraction and meta-analysis were conducted using Cochrane methodology. The quality of evidence was assessed using the GRADE approach.

RESULTS

Twenty papers were included. A meta-analysis of interventions performed at home, including two trials, showed a significant effect in favour of experimental groups for the symptom score of the St. George Respiratory Questionnaire compared with controls. A meta-analysis of interventions performed in clinics with home follow-up showed a significant effect in favour of experimental groups for the mastery and fatigue scores of the Chronic Respiratory Questionnaire compared with controls. In this category of intervention, an additional meta-analysis showed a significant effect in favour of experimental groups for the symptom, activity and total scores of the St. George Respiratory Questionnaire compared with controls. The quality of evidence was assessed to be very low to moderate.

CONCLUSION

The results are equivocal as to whether nursing interventions performed at home and nursing interventions performed in hospital with follow-up improve breathlessness in people with chronic obstructive pulmonary disease.

Hypercapnic COPD patients and NIV at home: is there any benefit? Using the CAT and BODE index in an effort to prove benefits of NIV in these patients

Introduction

The benefits of long-term noninvasive ventilation (NIV) in stable COPD with chronic hypercapnic respiratory failure (CHRF) have been debated for many years due to the conflicting results observed in these patients.

Materials and methods

We investigated the effects of domiciliary NIV in stable hypercapnic COPD patients for a period of 1 year using COPD Assessment Test (CAT), BODE Index, and the number of acute exacerbations. NIV was administered in 57 stable COPD patients with CHRF in the spontaneous/timed mode. Spirometry, 6 minute walk test, Medical Research Council dyspnea scale, arterial blood gases, number of acute exacerbations, BODE Index, and CAT were assessed. Study participants were reassessed in the 1st, 6th, and 12th months after the initial evaluation.

Results

There was a significant improvement in COPD exacerbations (p<0.001), CAT (p<0.001), PO₂ (p<0.001), PCO₂ (p<0.001), and Medical Research Council dyspnea scale (p<0.001) in 1 year of follow-up. BODE Index was improved in the first 6 months (5.8±2.2 vs 4.8±2.4, p<0.001), but the improvement was not maintained.

Conclusion

In conclusion, domiciliary NIV in stable COPD patients with CHRF has beneficial effect on CAT, arterial blood gases, and number of acute exacerbations in a year of NIV use at home. A significant improvement in BODE Index from baseline to 12 months was found in patients aged >70 years, while for those aged <70, the improvement was not maintained after the sixth month.

Outcome Measures Used in Pulmonary Rehabilitation in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review

BACKGROUND

Conflicting results about the effects of community-based pulmonary rehabilitation in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) exist, possibly because the variety of outcome measures used and the lack of appropriate measurement properties hinder the development of pulmonary rehabilitation guidelines.

PURPOSE

The purpose of this study was to identify and review the measurement properties of patient-reported outcome measures (PROMs) and clinical outcome measures of AECOPD that are used in pulmonary rehabilitation and that can be easily applied in a community setting.

DATA SOURCES

PubMed, Web of Science, Scopus, and CINAHL were searched up to July 1, 2016.

STUDY SELECTION

Phase 1 identified outcome measures used in pulmonary rehabilitation for AECOPD. Phase 2 reviewed the measurement properties of the identified outcome measures.

DATA EXTRACTION

One reviewer extracted the data and 2 reviewers independently assessed the methodological quality of the studies and the measurement properties of the outcome measures by using the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations.

DATA SYNTHESIS

Twenty-three PROMs and 18 clinical outcome measures were found. The outcome measures most used were the St George Respiratory Questionnaire (n = 15/37 studies) and the 6-minute walk test (n = 21/37 studies). Thirty-two studies described the measurement properties of 22 PROMs and 7 clinical outcome measures. The methodological quality of the studies was mostly poor, and the measurement properties were mostly indeterminate. The outcome measure exhibiting more robust properties was the COPD Assessment Test.

LIMITATIONS

A Number of studies were not found with the validated search strategy used and were included a posteriori; the fact that 3 studies presented combined results- for patients who were stable and patients with exacerbation-affected the conclusions that can be drawn.

CONCLUSIONS

A Large variety of outcome measures have been used; however, studies on their measurement properties are needed to enhance the understanding of community pulmonary rehabilitation for AECOPD.

Results of Physiotherapy Treatments in Exacerbations of Chronic Obstructive Pulmonary Disease: A Systematic Review

Purpose: The objective of this study was to review clinical trials of the effectiveness of physiotherapy compared with standard care, focused mainly on the functional status of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Methods: Search strategies were developed for each of the databases (PubMed, Scopus, and Web of Science). The study eligibility criteria were as follows: (1) The objective was to assess the effect and efficacy of physiotherapy compared with standard care (which included only medical and pharmacological treatment); (2) adults subjects had AECOPD; (3) one of the outcome measures was functional status, defined as an individual's ability to perform the normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being; (4) it was a clinical trial; (5) it was written in English; (6) it was published between January 2009 and February 2016; and (7) the full-text article was available. Results: The review revealed that for patients hospitalized for AECOPD, exercise, neuromuscular electrical stimulation, breathing exercises, and chest therapy significantly improved their functional status compared with standard care. Conclusions: A variety of physiotherapy modalities have been shown to improve functional status compared with standard care among patients hospitalized for AECOPD; other outcome measures also showed improvements.

Short-Term Pulmonary Rehabilitation for a Female Patient with Chronic Scleroderma under a Single-Case Research Design

Although previously proposed that chronic scleroderma should be cared for clinically and early rehabilitation should be performed in hospital by a chest physical therapist, little evidence is currently available on its benefits. Therefore, this study demonstrated the benefits of short-term pulmonary rehabilitation during hospitalization in a female patient with chronic scleroderma. The aim of rehabilitation was to improve ventilation and gas exchange by using airway clearance, chest mobilization, and breathing-relearning techniques, including strengthening the respiratory system and the muscles of the limbs by using the BreathMax^® device and elastic bands. Gross motor function and activities of daily life were regained by balancing, sitting, and standing practices. Data on minimal chest expansion, high dyspnea, high respiratory rate, and low maximal inspiratory mouth pressure were recorded seven days before rehabilitation or at the baseline period. But there was a clinically significant improvement in dyspnea, chest expansion, maximal inspiratory mouth pressure, and respiratory rate, when compared to baseline data, which were recorded by a chest physical therapist during seven days of rehabilitation. Furthermore, physicians decided to stop using a mechanical ventilator, and improvement in functional capacity was noted. Therefore, in the case of chronic and stable scleroderma, short-term rehabilitation during hospitalization for chest physical therapy possibly shows clinical benefits by improving both pulmonary function and physical performance.

Long-term non-invasive ventilation reduces readmissions in COPD patients with two or more episodes of acute hypercapnic respiratory failure

BACKGROUND

Chronic obstructive pulmonary disease (COPD) patients who have had an episode of acute hypercapnic respiratory failure (AHRF) have a large 1-year risk of death or readmission. Acute non-invasive ventilation (NIV) has been shown to be an effective treatment of AHRF; and long-term NIV (LTNIV) has been shown to be an effective treatment of chronic respiratory failure in stable hypercapnic COPD. We investigated the effects of LTNIV in a group of patients with severe, unstable COPD: frequent admissions and multiple previous episodes of AHRF treated with NIV.

METHODS

We conducted a retrospective analysis of 20 COPD patients treated with LTNIV after two or more episodes of AHRF during 1 year.

RESULTS

The mean number of AHRF episodes decreased from 2.44 in the year prior to LTNIV initiation to 0.44 in the year following (p<0.0001). The median number of admissions decreased from 5.19 to 1.88 (p=0.0092). Four patients (20%) died in 1 year. LTNIV tended to reduce arterial CO2. No changes were found in lung function.

CONCLUSIONS

LTNIV seems effective in reducing recurrent AHRF and readmissions in a highly select group of patients with severe, unstable COPD and frequent AHRF.

Physiotherapy Intervention During Level I of Pulmonary Rehabilitation on Chronic Obstructive Pulmonary Disease: A Systematic Review

Background:

The progressive and chronic course of COPD, characterized by difficulty in breathing, can be aggravated by periods of increased symptoms (exacerbation). The treatment often involves in-hospital care and among the interventions applied in COPD patients, physical therapy prompts good results. However the most used techniques are not properly pinpointed and there is no consensus in the literature regarding its effectiveness.

Methods:

A systematic review was performed to identify which physical therapy treatment was applied in these cases. The following bibliographic databases were consulted: PubMed, and Bireme Portal, Periódicos Capes. Controlled randomized clinical trials that is under went physical therapy intervention in patients hospitalized for exacerbated COPD without the use of NIV (non-invasive ventilation) were included in the study. The PEDro scale, which has a score of 0-10, was used to evaluate the quality of studies included in this review.

Results:

The electronic search yielded a total of 302 references published in English, of which only 6 met the criteria for inclusion and exclusion.

Conclusion:

It is possible to infer that physiotherapy’s techniques used in patients hospitalized for COPD exacerbation, based on this review, were the high frequency chest wall oscillation (HFCWO) on the chest; relaxing massage and active exercises, electrical stimulation via electro-acupuncture; strengthening of the quadriceps; the ELTGOL bronchial drainage technique (expiration with the glottis open in the lateral posture) and an incentive spirometer.

Effects of a respiratory physiotherapy session in patients with LRTI: a pre/post-test study

INTRODUCTION

The role of respiratory physiotherapy (RP) in lower respiratory tract infections (LRTI) has been questioned. However, studies have focused on hospitalised patients, and the presence/absence of an underlying disease has been neglected.

OBJECTIVES

To assess the effects of a RP session in community patients with LRTI and to explore the differences between patients with pneumonia (restrictive disease - AR) and those with exacerbations of an obstructive disease (AO).

METHODS

A pre/post-test study was conducted. A RP session was applied to patients with LRTI and crackles, wheezes, dyspnoea, perception of sputum and oxygen saturation were collected pre/post session. Comparisons were performed using paired t-tests or Wilcoxon tests.

RESULTS

Thirty patients (14 males, 55.23 ± 17.78 years) with pneumonia (AR, n = 12), exacerbations of chronic obstructive pulmonary disease, acute bronchitis and asthma (AO, n = 18) were enrolled. After treatment, the total sample presented lower wheeze rates at trachea (P = 0.02; r = -0.54) and less sputum (P = 0.01; r = -0.47). AR patients presented a decrease in the number of crackles (P < 0.05; 0.30 < d_z  < 0.26) and number and rate of wheezes at chest locations (P < 0.05; -0.56 < r < -0.48). AO patients showed an increase in the number of crackles (P < 0.05; 0.20 <d_z <0.31), wheeze frequency (P = 0.03; r = -0.27) and dyspnoea (P = 0.04; r = -0.55); and a decrease in the number of wheezes at trachea (P = 0.02; r = -0.54).

CONCLUSIONS

RP seems effective in reducing wheezes and perception of sputum in patients with LRTI. However, when considering AR and AO diseases separately, further changes in respiratory sounds and dyspnoea emerged. This highlights the importance of considering subgroups of patients with LRTI to develop RP evidence-base practice.

Current care services provided for patients with COPD in the Eastern province in Saudi Arabia: a descriptive study

BACKGROUND

COPD is a leading cause of morbidity and mortality worldwide. The prevalence rate of COPD in the general Saudi population is estimated to be 2.4% and 14.2% among smokers. Not much is known about current health care services for patients with COPD in Saudi Arabia. The objective of this study was to determine the current care services for patients with COPD provided by government hospitals in the Eastern province of Saudi Arabia.

METHODS

A cross-sectional study was conducted in the Eastern province of Saudi Arabia. Directors of the Department of Internal Medicine from all 22 general government hospitals that are under the responsibility of the Ministry of Health or the Ministry of Higher Education in this region were asked to participate. Data were collected using a questionnaire.

RESULTS

The study results indicated that there are limited hospital facilities for patients with COPD: no respiratory departments in any of the included hospitals, no spirometry in 77.3% of the hospitals, no intensive care units in 63.7% of the hospitals, and no pulmonary rehabilitation program in any of the hospitals. Among the included 22 hospitals, 24 respiratory physicians, 29 respiratory therapists, and three physiotherapists were involved in COPD care.

CONCLUSION

In conclusion, current care services provided by government hospitals in the Eastern province of Saudi Arabia for patients with COPD do not meet international recommendations for COPD management. Increased awareness, knowledge, and implementation of COPD guidelines by health care providers will most probably improve COPD management in Saudi Arabia. In addition, the government could improve dissemination of information about COPD management through national programs and by offering specific education regarding respiratory diseases.

Pulmonary rehabilitation at the time of the COPD exacerbation

Pulmonary rehabilitation (PR) is associated with improvements in exercise capacity, health related quality of life, psychological symptoms and response to utilization. Acute exacerbations threaten these improvements. An awareness of the clinical sequelae of acute exacerbation of chronic obstructive pulmonary disease enables approaches, such as early post exacerbation rehabilitation to mitigate its negative effects.

Advances in airway clearance technologies for chronic obstructive pulmonary disease

Techniques to promote clearance of sputum from the airways (airway clearance techniques; ACTs) have existed in clinical practice for more than a century. This review examines current evidence and clinical recommendations regarding ACTs for individuals with chronic obstructive pulmonary disease. Comparisons between this literature and reports of current practice suggest that discrepancies may exist in relation to the clinical management of sputum in individuals with COPD. The novel application of newer technologies has enhanced our ability to assess the complex physiological processes underpinning airway clearance therapy. The potential for physiologically tailored ACT prescription may, however, depend on the capacity for translation of such technology from the research setting into the clinical environment. Future directions regarding this common form of therapy will be discussed, including identification of the key research priorities to optimize evidence-based practice in this area.

Clinical management practices adopted by physiotherapists in India for chronic obstructive pulmonary disease: A national survey

Background and Objective:

Evidence supports the use of pulmonary rehabilitation in the treatment of chronic obstructive pulmonary disease (COPD) patients both during acute exacerbation and at later stages. It is used in India; but, to date, there has been no study that has investigated the structure of pulmonary rehabilitation programs for COPD patients in India. The recent study aims to determine the current practice patterns of Indian Physiotherapists for COPD patients admitted in Intensive Care Units (ICUs) and wards in terms of assessment and treatment.

Materials and Methods:

A questionnaire-based survey was conducted across India. Questionnaires were distributed to around 800 physiotherapists via E-mail. Physiotherapists with a Master Degree and a specialization in cardiopulmonary science or a minimum of 1 year of experience in treating cardiopulmonary patients were included. The questionnaires addressed assessment measures and treatment techniques given to COPD patients.

Results:

A total of 342 completed questionnaires were received, yielding a response rate of 43.8%, with a majority of responses from Karnataka, Maharashtra and Gujarat. The assessment and treatment techniques used were almost similar between ICUs and wards. More than 80% of the responders carried out the assessment of certain respiratory impairments in both ICUs and wards. An objective measure of dyspnea was taken by less than 40% of the responders, with little attention given to functional exercise capacity and health-related quality of life. Eighty-five percent of the responders used Dyspnea-relieving strategies and traditional airway clearance techniques in both ICUs and wards. Eighty-three percent of the responders were giving patients in the wards training for upper and lower extremity. Fifty percent were giving strength training in the wards.

Conclusion:

Whether patients are admitted in ICUs or Wards, the practice pattern adopted by Physiotherapists to treat them vary very little with respect to certain measures taken. Assessment predominantly focused on respiratory impairment measures, followed by dyspnea-quantifying measures, with little attention given to functional exercise capacity and health-related quality of life measures. Treatment techniques given were concentrated on dyspnea-relieving strategies, airway clearance techniques and upper and lower extremity exercises, with little attention given to strength training.

Airway clearance techniques for chronic obstructive pulmonary disease

BACKGROUND

Cough and sputum production are common in chronic obstructive pulmonary disease (COPD) and are associated with adverse clinical outcomes. Airway clearance techniques (ACTs) aim to remove sputum from the lungs, however evidence of their efficacy during acute exacerbations of COPD (AECOPD) or stable disease is unclear.

OBJECTIVES

To assess the safety and efficacy of ACTs for individuals with AECOPD and stable COPD.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials from inception to October 2011, and PEDro in October 2009.

SELECTION CRITERIA

We included randomised parallel trials and randomised cross-over trials which compared an ACT to no treatment, cough or sham ACT in participants with investigator-defined COPD, emphysema or chronic bronchitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and assessed the risk of bias. We analysed data from studies of AECOPD separately from stable COPD, and classified the effects of ACTs as 'immediate' (less than 24 hours), 'short-term' (24 hours to eight weeks) or 'long-term' (greater than eight weeks). One subgroup analysis compared the effects of ACTs that use positive expiratory pressure (PEP) to those that do not.

MAIN RESULTS

Twenty-eight studies on 907 participants were included in the review. Study sample size was generally small (range 5 to 96 people) and overall quality was generally poor due to inadequate blinding and allocation procedures. Meta-analyses were limited by heterogeneity of outcome measurement and inadequate reporting of data.In people experiencing AECOPD, ACT use was associated with small but significant short-term reductions in the need for increased ventilatory assistance (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.05 to 0.85; data from four studies on 171 people), the duration of ventilatory assistance (mean difference (MD) -2.05 days, 95% CI -2.60 to -1.51; mean duration for control groups seven days; data from two studies on 54 people) and hospital length of stay (MD -0.75 days, 95% CI -1.38 to -0.11; mean duration for control groups nine days; one study on 35 people). Data from a limited number of studies revealed no significant long-term benefits of ACTs on the number of exacerbations or hospitalisations, nor any short-term beneficial effect on health-related quality of life (HRQoL) as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (MD -2.30, 95% CI -11.80 to 7.20; one study on 59 people).In people with stable COPD, data from single studies revealed no significant short-term benefit of ACTs on the number of people with exacerbations (OR 3.21, 95% CI 0.12 to 85.20; one study on 30 people), significant short-term improvements in HRQoL as measured by the SGRQ total score (MD -6.10, 95% CI -8.93 to -3.27; one study on 15 people) and a reduced long-term need for respiratory-related hospitalisation (OR 0.27, 95% CI 0.08 to 0.95; one study on 35 participants).The magnitude of effect of PEP-based ACTs on the need for increased ventilatory assistance and hospital length of stay was greater than for non-PEP ACTs, however we found no statistically significant subgroup differences. There was one report of vomiting during treatment with postural drainage and head-down tilt.

AUTHORS' CONCLUSIONS

Evidence from this review indicates that airway clearance techniques are safe for individuals with COPD and confer small beneficial effects on some clinical outcomes. Consideration may be given to the use of airway clearance techniques for patients with COPD in both acute and stable disease, however current studies suggest that the benefits achieved may be small.