Role of physiotherapy in the management of chronic lung diseases: an overview of systematic reviews

Interprofessional peer-assisted learning for pharmacy and physical therapy students using inhalers and inhalation devices

BACKGROUND

Peer-assisted learning (PAL) is exchanging knowledge between learners often from similar professional levels. Limited evidence exists on the effectiveness of PAL between different healthcare professions. The purpose of this study is to evaluate the knowledge, confidence, and perception of students engaged in an interprofessional PAL activity with pharmacy students instructing physical therapy students on the proper technique, cleaning/storage and therapeutic knowledge on inhaler devices for treatment of pulmonary conditions.

METHODS

Pharmacy and physical therapy students completed a survey before and immediately after the PAL activity. As instructors, pharmacy students rated their experience with inhalers, their confidence if they were to assist clients on the use of inhaler devices and confidence in teaching peers. Physical therapy students completed surveys on inhaler knowledge with 10 scenario-based multiple-choice questions, and their confidence if they were to assist clients with inhaler devices. The knowledge questions were grouped into three categories: storage and cleaning of inhalers (3 questions), technique of using inhalers (4 questions), and therapeutic knowledge of drugs given by inhalation (3 questions).

RESULTS

102 physical therapy and 84 pharmacy students completed the activity and surveys. For the physical therapy students, the mean improvement of the total score for knowledge-based questions was 3.6 ± 1.8 (p < 0.001). The question with the fewest number of correct answers (13%) before the PAL activity had the highest number of correct answers post-activity (95%). Prior to the activity, no physical therapy students felt certain/very certain about their knowledge on inhalers, yet after PAL activity this proportion increased to 35%. The percent of pharmacy students reporting their confidence as "certain" and "very certain" in teaching peers increased from 46% before the activity to 90% afterwards. Pharmacy students rated the monitoring and follow-up of inhaler devices as the lowest expectation for physical therapists to play a role. Steps taken to prepare for this PAL activity were also discussed.

CONCLUSIONS

Interprofessional PAL can increase knowledge and confidence of healthcare students reciprocally learning and teaching in joint activities. Allowing such interactions facilitate students to build interprofessional relationships during their training, which can increase communication and collaboration to foster an appreciation for each other's roles in clinical practice.

Is manual therapy of the diaphragm effective for people with Obstructive Lung Diseases? A Systematic Review

BACKGROUND

Diaphragm dysfunction is common among people with obstructive lung disease (OLD). The effectiveness of manual therapy (MT) techniques specifically targeting this region remains unclear. The scope of this systematic review is to investigate the effectiveness of MT on the zone of apposition (ΖΟΑ) of the diaphragm in lung function, diaphragm excursion (DE), chest expansion, exercise capacity (EC), maximal inspiratory pressure (PImax) and dyspnea in people suffering from OLD.

METHODS

Key databases were systematically searched. Two independent reviewers screened the papers for inclusion. Methodological quality and the quality of evidence were assessed using the PEDro scale and the GRADE approach, respectively.

RESULTS

Two studies were included. One showed that diaphragmatic stretching and the manual diaphragm release technique (MDRT) improved DE and CE (p<0.001, p<0.05, respectively). The other showed that MDRT improved DE and EC (p<0.05, p<0.05, respectively).

CONCLUSION

This systematic review provides preliminary evidence on the effectiveness of MT on the ZOA of the diaphragm in people with COPD. Further research is needed in order for definitive conclusions to be drawn.

REGISTRATION NUMBER IN PROSPERO

CRD42022308595.

A national survey of oncology physiotherapy services for cancer survivors in Australia

BACKGROUND

Cancer is a leading cause of illness globally. Advancements in screening and treatment have led to improved survivorship. Physiotherapy is integral in improving survivorship for people with cancer, with strong evidence supporting the use of various physiotherapy services. However, the scope and extent of these services within clinical practice in Australia is unknown.

AIM

Identify and describe physiotherapy service provision for cancer survivors in Australia and describe the scope of physiotherapy services provided to cancer survivors.

METHODS

This cross-sectional study recruited physiotherapists and their respective managers involved in cancer service/s provision across Australia. Physiotherapy departments of tertiary hospitals and known oncology rehabilitation programs were contacted through a government directory and snowball sampling. The online survey included questions related to the extent and scope of service provision of physiotherapy for cancer survivors. Quantitative data were descriptively analyzed whereas open-ended responses were analyzed and presented narratively.

RESULTS

Seventy-nine physiotherapy services were identified from 159 hospitals and/or health networks. Of the 55 (70%) responses received, 87% were from metropolitan areas, whereas 13% were regionally/rurally based services. Prehabilitation services mostly offered individual programs whereas rehabilitation programs had a mix of individual and group-based programs. The service content between prehabilitation and rehabilitation were similar, comprising primarily exercise-based interventions, followed by education and impairment-based therapies.

CONCLUSION

Few designated physiotherapy services for cancer survivors exist in Australia. There is also disparity between service provision between metropolitan and regional/rural areas highlighting a need for clinicians, managers, and policy makers to invest more resources in establishing oncology physiotherapy services.

Barriers and Enablers to Pulmonary Rehabilitation in Low- and Middle-Income Countries: A Qualitative Study of Healthcare Professionals

Introduction

Low- and middle-income countries bear a disproportionately high burden of global morbidity and mortality caused by chronic respiratory diseases. Pulmonary rehabilitation is recommended as a core intervention in the management of people with chronic respiratory diseases. However, the intervention remains poorly accessed/utilised globally, especially in low- and middle-income countries.

Aim

This qualitative study explored barriers and enablers to pulmonary rehabilitation in low- and middle-income countries from the perspective of healthcare professionals with pulmonary rehabilitation experience in these settings.

Methods

Online-based semi-structured in-depth interviews with healthcare professionals were undertaken to data saturation, exploring lived barriers and enablers to pulmonary rehabilitation in their low- or middle-income country. Anonymised interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis.

Results

A total of seven healthcare professionals from seven low- and middle-income countries representing Africa, Asia, and South America were interviewed. They included five physiotherapists (four females), one family physician (male), and one pulmonologist (female). Themes for barriers to pulmonary rehabilitation included limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Themes for enablers included local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support.

Conclusion

Barriers to pulmonary rehabilitation in low- and middle-income countries include limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Enablers include local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Successful implementation of these enablers will require engagement with multiple stakeholders. The findings of this study are a necessary step towards developing strategies that can overcome the existing pulmonary rehabilitation evidence-practice gap in low- and middle-income countries and alleviating the burden of chronic respiratory diseases in these countries.

Targeting exertional breathlessness to improve physical activity: the role of primary care

Primary care physicians (PCPs) play a crucial role in the diagnosis and management of chronic obstructive pulmonary disease (COPD). By working together with patients to target exertional breathlessness and increase physical activity, PCPs have an important role to play, early in the disease course, in improving patient outcomes in both the short and long term. In this article, we consider how physical activity affects disease progression from the PCP perspective. We discuss the role of pharmacological therapy, the importance of an holistic approach and the role of PCPs in assessing and promoting physical activity. The complexity and heterogeneity of COPD make it a challenging disease to treat. Patients' avoidance of activity, and subsequent decline in capacity to perform it, further impacts the management of the disease. Improving patient tolerance of physical activity, increasing participation in daily activities and helping patients to remain active are clear goals of COPD management. These may require an holistic approach to management, including pulmonary rehabilitation and psychological programmes in parallel with bronchodilation therapy, in order to address both physiological and behavioural factors. PCPs have an important role to optimise therapy, set goals and communicate the importance of maintaining physical activity to their patients. In addition, optimal treatment that addresses activity-related breathlessness can help prevent the downward spiral of inactivity and get patients moving again, to improve their overall health and long-term prognosis.

Post-COVID-19 Rehabilitation: Perception and Experience of Austrian Physiotherapists and Physiotherapy Students

The rehabilitation needs of COVID-19 survivors are increasingly recognized, with a focus on combating respiratory and neuromuscular dysfunctions. The aim here was to explore the perception of Austrian physiotherapists and physiotherapy students on post-COVID-19 rehabilitation care and to identify barriers for the application of sufficient rehabilitation. We analysed current knowledge and practical skills in respiratory physiotherapy, performing a cross-sectional national survey among physiotherapists working in outpatient settings and physiotherapy students in their last academic year of bachelor-level education in Austria. Out of 255 survey participants, one-third already had inquiries to treat post-COVID-19 patients, and the majority of respondents expected a further increased inflow of patients with rehabilitation needs (64.2%). Only 11.2% of respondents reported feeling sufficiently informed about post-COVID-19 rehabilitation. A total of 68.2% of students and up to 48.1% of physiotherapists favoured a COVID-19-specific adaptation already in the basic academic education, and 74.1% of survey participants indicated interest in attending specific training. Concerning respiratory physiotherapy, our data showed discrepancies between the estimation of the importance of specific examination and treatment techniques and the level of current experience. There is a clear lack of experience in implementing effective device-based respiratory therapy. Our data indicate an urgent need to develop new education and training programs with a focus on the interdisciplinary rehabilitation of patients with post-COVID-19 syndrome.

Appropriate lung management in patients with primary antibody deficiencies

Introduction: Human primary immunodeficiency diseases (PIDs) include a broad spectrum of more than 350 disorders, involving different branches of the immune system and classified as 'rare diseases.' Predominantly antibody deficiencies (PADs) represent more than half of the PIDs diagnosed in Europe and are often diagnosed in the adulthood. Areas covered: Although PAD could first present with autoimmune or neoplastic features, respiratory infections are frequent and respiratory disease represents a relevant cause of morbidity and mortality. Pulmonary complications may be classified as infection-related (acute and chronic), immune-mediated, and neoplastic. Expert opinion: At present, no consensus guidelines are available on how to monitor and manage lung complications in PAD patients. In this review, we will discuss the available diagnostic, prognostic and therapeutic instruments and we will suggest an appropriate and evidence-based approach to lung diseases in primary antibody deficiencies. We will also highlight the possible role of promising new tools and strategies in the management of pulmonary complications. However, future studies are needed to reduce of diagnostic delay of PAD and to better understand lung diseases mechanisms, with the final aim to ameliorate therapeutic options that will have a strong impact on Quality of Life and long-term prognosis of PAD patients.

The broad spectrum of lung diseases in primary antibody deficiencies

Human primary immunodeficiency diseases (PIDs) represent a heterogeneous group of more than 350 disorders. They are rare diseases, but their global incidence is more relevant than generally thought. The underlying defect may involve different branches of the innate and/or adaptive immune response. Thus, the clinical picture may range from severe phenotypes characterised by a broad spectrum of infections to milder infectious phenotypes due to more selective (and frequent) immune defects. Moreover, infections may not be the main clinical features in some PIDs that might present with autoimmunity, auto-inflammation and/or cancer. Primary antibody deficiencies (PADs) represent a small percentage of the known PIDs but they are the most frequently diagnosed, particularly in adulthood. Common variable immunodeficiency (CVID) is the most prevalent symptomatic PAD.

PAD patients share a significant susceptibility to respiratory diseases that represent a relevant cause of morbidity and mortality. Pulmonary complications include acute and chronic infection-related diseases, such as pneumonia and bronchiectasis. They also include immune-mediated interstitial lung diseases, such as granulomatous-lymphocytic interstitial lung disease (GLILD) and cancer. Herein we will discuss the main pulmonary manifestations of PADs, the associated functional and imaging findings, and the relevant role of pulmonologists and chest radiologists in diagnosis and surveillance.

The spectrum of lung complications in primary antibody deficiency ranges from asthma or COPD to extremely rare and specific ILDs. Early diagnosis of the underlying immune defect might significantly improve patients' lung disease, QoL and long-term prognosis.http://ow.ly/5cP230kZvOB

Patient Education Provided by Physiotherapists for Patients with Chronic Obstructive Pulmonary Disease: Results of a Scoping Review

Purpose: Physiotherapists have been acknowledged as playing a vital role in the care of people living with chronic obstructive pulmonary disease (COPD), and this care includes providing patient education (PE). Yet very little is known about the issues critical to providing this PE. The purpose of this scoping review was to identify and map out the current knowledge about the content, processes, and overall effectiveness of the PE provided by physiotherapists for people living with COPD. Method: Using the guidelines developed by Arksey and O'Malley in 2005 and by Levac in 2010, key databases were searched. A total of 447 articles were identified and screened for the following inclusion criteria: adults living with COPD, published in English or French between 1995 and 2015, and describing the PE provided by physiotherapists. Fourteen studies matched these criteria. Results: In the majority of studies, both physiotherapists and nurses provided PE to patients. Common PE topics included energy conservation, exacerbations, and breathlessness. None of the studies included measures for evaluating the effectiveness of the PE. Conclusions: Even though physiotherapists routinely provide PE to people living with COPD, this PE varies substantially. The heterogeneity of the studies and lack of measures of effectiveness prevented them from providing any evidence-based recommendations for physiotherapists.

To Be or Not to Be a Cardiorespiratory Physiotherapist: Factors That Influence Career Choice in a Sample of Canadian Physiotherapists

Purpose: This study explored the factors that influence choosing or not choosing a career in cardiorespiratory physiotherapy (CRP) from the perspective of a group of currently practising, experienced physiotherapists in Canada. Methods: A modified Dillman approach was used to distribute a cross-sectional, self-administered, online questionnaire to all eligible members of the cardiorespiratory and orthopaedic divisions of the Canadian Physiotherapy Association. A total of 438 participants-21 CRP and 417 non-CRP therapists-completed the survey. The survey response rate was 9.4%. Results: A narrow scope of practice (61.9%) and a lack of interest in CRP subject matter (50.1%) were the most influential factors deterring the respondents from making CRP their career choice. Interest in CRP (81.0%), mentorship (76.2%), access to physical resources (76.2%), and inter-professional practice (71.4%) were the most influential factors in pursuing a career in CRP. Conclusion: Increasing the awareness of the scope of practice for CRP, exposure to positive mentors, and rich practice settings are key factors in promoting physiotherapists' specialisation in CRP.

Management of COPD, equal treatment across age, gender, and social situation? A register study

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease where treatment decisions should be based on disease severity and also should be equally distributed across age, gender, and social situation. The aim of this study was to determine to what extent patients with COPD are offered evidence-based interventions and how the interventions are distributed across demographic and clinical factors in the sample. Baseline registrations of demographic, disease-related, and management-related variables of 7,810 patients in the Swedish National Airway Register are presented. One-third of the patients were current smokers. Patient-reported dyspnea and health-related quality of life were more deteriorated in elderly patients and patients living alone. Only 34% of currently smoking patients participated in the smoking cessation programs, and 22% of all patients were enrolled in any patient education program, with women taking part in them more than men. Less than 20% of the patients had any contact with physiotherapists or dieticians, with women having more contact than men. Men had more comorbidities than women, except for depression and osteoporosis. Women were more often given pharmacological treatments. With increasing severity of dyspnea, participation in patient education programs was more common. Dietician contact was more common in those with lower body mass index and more severe COPD stage. Both dietician contact and physiotherapist contact increased with deteriorated health-related quality of life, dyspnea, and increased exacerbation frequency. The present study showed that COPD management is mostly equally distributed across demographic characteristics. Only a minority of the patients in the present study had interdisciplinary team contacts. Thus, this data shows that the practical implementation of structured guidelines for treatment of COPD varies, to some extent, with regard to age and gender. Also, disease characteristics influence guideline implementation for each individual patient. Quality registers have the strength to follow-up on compliance with guidelines and show whether an intervention needs to be adapted prior to implementation in health care practice.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001588.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

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.

Adherence to a maintenance exercise program 1 year after pulmonary rehabilitation: what are the predictors of dropout?

PURPOSE

To evaluate adherence to a maintenance exercise program in patients with chronic obstructive pulmonary disease (COPD) and explore predictors for adherence.

METHODS

Seventy patients with COPD were referred to a home-care maintenance exercise program after completing pulmonary rehabilitation (PR) in the rehabilitation center. Adherence (yes/no) to the maintenance program was assessed by a self-reported questionnaire, where adherence was defined as attending the maintenance program 1 year after PR. Early dropouts received a self-reported questionnaire after 6 months and the remaining patients after 12 months. Lung function, exercise capacity, exercise self-efficacy, illness perceptions, health-related quality of life, levels of anxiety and depression, duration of PR, and the number of exacerbations were studied as possible predictors of adherence.

RESULTS

Ten patients died or were lost to followup. Of the remaining 60 patients, 73.3% and 63.3% were adherent to the maintenance exercise program after 6 and 12 months, respectively. Forced expiratory volume in 1 second (FEV1) (P = .021), Hospital Anxiety and Depression Scale depression score (P = .025), and duration of PR (P = .018) were significant predictors of adherence to the maintenance program.

CONCLUSION

Adherence to the maintenance exercise program included a 36.7% drop-out rate during the first year after completing PR. Experiencing exacerbations was the most reported reason for dropout. Poorer lung function, shorter initial PR course measured by reviewing patient records, and higher level of depressive symptoms were predictive of drop-out to the maintenance program. Adherence to the maintenance program needs to be improved for patients with lower FEV1, with signs of depression, or with a shorter initial PR course.

A review on guidelines for management and treatment of common variable immunodeficiency

Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in adults. As symptoms of CVID are usually heterogeneous and unspecific, diagnosis and follow-up of CVID can be challenging. In light of this, a broad review of advances in management and treatment of CVID is performed here in order to reach a distinct protocol. However, it should be noted that owing to the nature of the disease, it can only be treated symptomatically but not cured. There is little evidence to guide appropriate or universal guidelines to improve the current status of management of the disease. The most satisfactory treatments of CVID could be achieved by the use of immunoglobulin replacement, antibiotics, immunosuppressants and hematopoietic stem cell transplantation. This review is written based on the importance of clinical surveillance of asymptomatic CVID cases and early recognition of different clinical complications. Moreover, for each complication, appropriate interventions for improving outcomes are mentioned.

Lungsounds@UA Interface and Multimedia Database

The development of graphical user interfaces (GUIs) has been an emergent demand in the area of healthcare technologies. Specifically for respiratory healthcare there is a lack of tools to produce a complete multimedia database, where respiratory sounds and other clinical data are available in a single repository. This is essential for a complete patients' assessment and management in research/clinical settings. Therefore, this study aimed to develop a usable interface to collect and organise respiratory-related data in a single multimedia database. A GUI, named LungSounds@UA, composed by a multilayer of windows, was developed. The usability of the user-centred interface was assessed in a pilot study and in an evaluation session. The users testified the utility of the application and its great potential for research/clinical settings. However, some drawbacks were identified, such as a certain difficulty to intuitively navigate in the great amount of the available information, which will inform future developments.

An assessment of the effects of Iyengar yoga practice on the health-related quality of life of patients with chronic respiratory diseases: a pilot study

OBJECTIVE

To assess the effects of an Iyengar yoga program (IYP) on patients with chronic respiratory diseases.

METHODS

Patients attending lung transplant clinics in a tertiary institution were invited to participate in a two-phase, 12-week IYP that included 2 h biweekly classes. Doctors completed a formal physical and clinical assessment on candidates before enrollment. Patients with New York Association Class III or IV, or dyspnea grade IV were excluded. At baseline and at the end of 12-weeks, patients completed the Hospital Anxiety and Depression Scale (HADS), Chronic Respiratory Questionnaire (CRQ) and Health Utilities Index (HUI). Medication(s), 6 min walk test results and other clinical parameters were also recorded. Patients recorded the effects of the IYP on their daily living in journals. Nonparametric and qualitative methods were used to analyze the data.

RESULTS

Twenty-five patients diagnosed with pulmonary arterial hypertension and chronic obstructive pulmonary disease (mean age 60 years) were invited to participate. At the end of the 12-week period, changes in HADS anxiety and CRQ fatigue scores were statistically significant (P<0.05) and changes in HUI ambulation, pain, emotion and overall score were clinically important. The content of the journals revealed patients' improvement in breathing capacity, mobility, energy, sleep and included positive feedback such as: "increased tidal volume with slowing expiration", "I have an overall feeling of wellbeing" and "excellent amount of energy".

CONCLUSIONS

The findings suggest that yoga has significant potential to produce benefits. Potential benefits will be further explored in a national multisite study.

Comparative study of PEP mask and Flutter on expectoration in cystic fibrosis patients

The objective of the study was to investigate the effect of positive expiratory pressure (PEP) and Flutter on expectoration in cystic fibrosis (CF) patients. Data was gathered through 260 treatments with 10 patients (5 female; 19.2 years; BMI: 18.0). Two methods were used alternately, first the patients started with Flutter and proceeded with PEP, and the next occasion they exercised in the reverse order, starting with PEP then continuing with Flutter. During each phase, 5 sets of 10 exhalations were performed. Sputum weight was measured after the use of the first device, and at the end of the treatment. During sessions starting with Flutter 4.0 ± 4.0 g sputum was expectorated, continuing with PEP, an additional 5.2 ± 5.0 g was produced, altogether 9.2 ± 8.2 g. At sessions starting with PEP 7.4 ± 3.7 g was expectorated, continuing with Flutter an additional 0.8 ± 1.4 g, that is 8.2 ± 4.1 g. Comparing the two devices by themselves, PEP proved to be significantly more efficient then Flutter. Comparing the two treatment types it is statistically not proven, which one is preferable using both devices. Conclusively, PEP is significantly more efficient than the Flutter in sputum expectoration among CF patients. The Flutter is a useful supplementary device.

Evaluation of the effectiveness of manual chest physiotherapy techniques on quality of life at six months post exacerbation of COPD (MATREX): a randomised controlled equivalence trial

BACKGROUND

Manual chest physiotherapy (MCP) techniques involving chest percussion, vibration, and shaking have long been used in the treatment of respiratory conditions. However, methodological limitations in existing research have led to a state of clinical equipoise with respect to this treatment. Thus, for patients hospitalised with an exacerbation of Chronic Obstructive Pulmonary Disease (COPD), clinical preference tends to dictate whether MCP is given to assist with sputum clearance. We standardised the delivery of MCP and assessed its effectiveness on disease-specific quality of life.

METHODS

In this randomised, controlled trial powered for equivalence, 526 patients hospitalised with acute COPD exacerbation were enrolled from four centres in the UK. Patients were allocated to receive MCP plus advice on airway clearance or advice on chest clearance alone. The primary outcome was a COPD specific quality of life measure, the Saint Georges Respiratory Questionnaire (SGRQ) at six months post randomisation. Analyses were by intention to treat (ITT). This study was registered, ISRCTN13825248.

RESULTS

All patients were included in the analyses, of which 372 (71%) provided evaluable data for the primary outcome. An effect size of 0·3 standard deviations in SGRQ score was specified as the threshold for superiority. The ITT analyses showed no significant difference in SGRQ for patients who did, or did not receive MCP (95% CI -0·14 to 0·19).

CONCLUSIONS

These data do not lend support to the routine use of MCP in the management of acute exacerbation of COPD. However, this does not mean that MCP is of no therapeutic value to COPD patients in specific circumstances.

Reduced hypoxia risk in a systemic sclerosis patient with interstitial lung disease after long-term pulmonary rehabilitation

Pulmonary rehabilitation is effective for improving exercise capacity in patients with interstitial lung disease (ILD), and most programs last about 8 weeks. A 43-year-old male patient with systemic sclerosis and oxygen saturation (SpO₂) declining because of severe ILD was hospitalized for treatment of chronic skin ulcers. During admission, he completed a 27-week walking exercise program with SpO₂ monitoring. Consequently, continuous walking distance without severe hypoxia (SpO₂ > 90%) increased from 60 m to 300 m after the program, although his six-minute walking distance remained the same. This suggests that walking exercise for several months may reduce the risk of hypoxia in patients with ILD, even though exercise capacity does not improve.

Influência do treinamento da musculatura respiratória e de membros inferiores no desempenho funcional de indivíduos com DPOC

A doença pulmonar obstrutiva crônica (DPOC) caracteriza-se pela obstrução ou limitação crônica do fluxo aéreo, gerando uma desvantagem mecânica, causando fraqueza muscular e recrutamento da musculatura inspiratória acessória. A disfunção muscular esquelética é uma importante manifestação extrapulmonar, que leva à diminuição da capacidade funcional. O objetivo do estudo foi verificar a eficácia de um treinamento da musculatura respiratória e de quadríceps no desempenho funcional de indivíduos com DPOC. De nove indivíduos com idades entre 49 e 76 anos foram avaliadas as pressões respiratórias máximas (por manovacuometria), força muscular de membros inferiores (por repetição máxima), capacidade funcional (pelo teste de caminhada com carga progressiva, shuttle test) e qualidade de vida (pelo questionário de qualidade de vida SF-36), antes e depois da aplicação de protocolo de fortalecimento da musculatura inspiratória, dos músculos quadríceps e abdominais. As sessões de exercícios foram realizadas duas vezes por semana durante dois meses. Foi verificada melhora em todas as variáveis avaliadas, com diferença significativa na pressão inspiratória máxima (p<0,05). O treinamento da musculatura respiratória e de quadríceps proposto mostrou-se benéfico ao desempenho funcional de indivíduos com DPOC, sugerindo a utilização do fortalecimento muscular respiratório e periférico como recurso coadjuvante no tratamento desses indivíduos.

Effect of airway clearance techniques in patients experiencing an acute exacerbation of chronic obstructive pulmonary disease: A systematic review

Answers were sought to the following question: Are techniques, applied predominantly with the aim of clearing secretions from the airways, to patients during an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), safe and effective? A systematic review was undertaken of studies that (i) were either randomized controlled or randomized cross-over trials, (ii) recruited patients during an AECOPD, (iii) reported the results of between-group analyses and (iv) investigated the effect of techniques applied primarily with the aim of clearing secretions from the airways. Studies that examined non-invasive positive pressure ventilation (NIPPV) and early rehabilitation were excluded. Data were extracted pertaining to resting lung function, gas exchange, sputum expectoration, symptoms, NIPPV use and hospital stay. Five studies were included with a mean Physiotherapy Evidence Database (PEDro) score of 4.4 ± 1.1 (range: 3—6). The main findings were that (i) airway clearance techniques did not improve measures of resting lung function or produce any consistent change in measures of gas exchange, (ii) the application of 5 min of continuous chest wall percussion reduced forced expiratory volume in 1 second (FEV 1), (iii) in people with copious secretions, mechanical vibration, and non-oscillating positive expiratory pressure (PEP) mask therapy increased sputum expectoration and (iv) in patients with hypercapnic respiratory failure, intrapulmonary percussive ventilation (IPV) and PEP mask therapy reduced the need for, and duration of, NIPPV, respectively. With the exception of continuous chest wall percussion, airway clearance techniques were safe in patients during an AECOPD. Vibration and non-oscillating PEP facilitated sputum expectoration in patients characterized by copious airway secretions. In patients with respiratory failure, techniques that apply a positive pressure to the airways may reduce either the need for, or duration of, NIPPV and hospital length of stay.

Aerobic exercise training improves autonomic nervous control in patients with COPD

OBJECTIVES

Autonomic modulation is adversely impacted in patients with chronic obstructive pulmonary disease (COPD). The purpose of the present investigation is to assess the effects of a 6-week aerobic exercise training program on autonomic modulation of heart rate in patients with COPD.

METHODS

Forty patients of both sexes with moderate-to-severe COPD were randomly allocated to aerobic exercise training (PT, n=20) or to usual care (Control, n=20). The training program consisted of lower and upper limb stretching and 30 min of treadmill exercise, 3 times per week for a 6-week period. Physiological data during symptom-limited exercise testing and the six-minute walk test (6MWT) were assessed. In addition, R-R intervals were obtained at rest and during the 6MWT. Heart rate variability was analyzed by time (rMSSD and SDNN index) and frequency domains (high frequency--HF, low frequency--LF and HF/LF ratio).

RESULTS

Peak oxygen consumption significantly improved in the training group only (p<0.05). Moreover, the training group demonstrated significant improvements (p<0.05) in blood lactate, minute ventilation, dyspnea at peak exercise, sympathetic activity, and parasympathetic activity at rest and during submaximal exercise. Lastly, a positive and significant correlation was found between change in 6MWT distance and rMSSD index (r=0.65 and p=0.001).

CONCLUSIONS

Neural control of heart rate, in addition to other clinically valuable measures, is positively altered in moderate-severe COPD patients following 6 weeks of aerobic exercise training. The improvement in submaximal performance after exercise training was associated with parasympathetic activity.