Impact of the new ATS/ERS pulmonary function test interpretation guidelines

Validity Study for Clinical Use of Hand-Held Spirometer in Patients with Chronic Obstructive Pulmonary Disease

A spirometer is a medical device frequently used clinically for the diagnosis and prediction of lung disease. This study aimed to investigate the clinical usefulness of a hand-held spirometer (The Spirokit), compared with conventional spirometry in patients with chronic obstructive pulmonary disease (COPD). This study was conducted from February 2022 to October 2022. Measurements from 80 patients with COPD (male: 53, female: 27) were obtained using The Spirokit and PC-based pulmonary function test equipment, and the resulting values were compared and analyzed. For the concurrent validity comparison of The Spirokit, the intra-class correlation (ICC 2, 1), coefficients of variation (CVME), 95% limits of agreement (95% LOA), and Cohen's Kappa Index were analyzed. The Spirokit showed high agreement (ICC: 0.929-0.989; 95% LOA: -0.525 to 2.559; and CVME: 0.05-0.08) with the PC-based pulmonary function tester. Using the Cohen's kappa coefficients, the device showed high sensitivity, specificity, and accuracy scores of Pa: 0.90, Pc: 0.52, and K: 0.79, respectively, indicating considerable agreement. The Spirokit, a portable pulmonary function test device, is a piece of equipment with high validity and portability, with high potential for replacing PC-based pulmonary function test equipment.

Is it Possible to Use the Timed Performance Tests in Lung Transplantation Candidates to Determine the Exercise Capacity?

OBJECTIVES

Lung transplantation (LTx) candidates have severe exercise intolerance. This makes it difficult for them to complete the field tests used to determine the exercise capacity of patients. Therefore, there is a need for alternative tests that require less effort. We aimed to investigate the use of short-timed performance tests instead of 6-minute walk test (6MWT) in the determination of exercise capacity in LTx.

MATERIALS AND METHODS

A total of 63 LTx candidates were included in the study. Ten-meter walking speed test (10MWT), 5-times sit-to-stand test (5XSST), 6MWT were performed at one-hour intervals within the same day, and by the same physiotherapist in all patients. Maximal inspiratory (MIP) and expiratory pressure (MEP), peripheral muscle strengths, pulmonary function tests, and body mass index (BMI) were recorded for each patient.

RESULTS

The subjects' baseline mean 6-minute walking distance (6MWD) was 336m, 5XSST time was 11.59 sec, and 10MWT time was 8.45sec. There was a negative and moderate correlation between 6MWD and 10MWT (p<0.001, r=0.449). Similarly there was a negative but weak correlation between 6MWD and 5XSST (p=0.001, r=0.397). In addition, there was a strong relationship between 5XSST and 10MWT (p<0.001, r=0.767).

CONCLUSION

This study showed that 6MWT and short-timed performance tests were correlated in terms of exercise capacity assessment. In contrast, there was a strong relationship between 6MWT and 10MWT according to 6MWT and 5XSST. The timed performance tests may be alternative tests to determine exercise capacity in LTx candidates.

Investigation of the health effects on workers exposed to respirable crystalline silica during outdoor and underground construction projects

Chronic exposure of workers to powder containing crystalline silica (Silicon dioxide; SiO2) can lead to chronic lung diseases (lung cancer, silicosis, etc.). Aim of this study was to evaluate the exposure of Greek construction workers to SiO2 and describe their pulmonary function. The study involved 86 outdoor and underground workers. Medical and professional history was obtained, and breath samples were collected at morning hours through a mask for the determination of SiO2 levels. Pulmonary function tests, radiological examination and evaluation of radiographs were also performed. Pulmonary function examination showed that the majority of the workers were within normal range (61.4%) while the rest were diagnosed with mild (26.5%) and more severe impairment (7.24%). Working conditions (underground-outdoor) were statistically significantly related to the categorization of pulmonary function (P=0.038). During radiological examination, the type of working activity/ conditions (underground-outdoor) were statistically significantly related to the categorization of these findings (P=0.044). Of the 69 employees, 52 did not present findings (75.4%) and 5 were diagnosed with findings specific to occupational diseases (7.23%). Environmental exposure to respirable crystalline silica (RCS) was detected at 0.0125 mg/m3 in the workplace, which is not beyond the legal limits. Underground workers with more than 15 years of exposure to SiO2 are more likely to present chronic silicosis compared to the workers of outdoor activities.

Non-invasive techniques to assess restrictive lung disease in workers exposed to free crystalline silica

Objectives:

To compare the reliability of spirometry and body plethysmography in detecting restrictive lung disease in clay excavation workers exposed to free crystalline silica (FCS). The exhaled breath condensate (EBC) biomarkers of oxidative stress were also assessed in order to evaluate early lung damage.

Methods:

The study involved 62 workers (58 males and 4 females) at a company that extracts and processes clay.

Results:

Body plethysmography (total lung capacity below the lower normal limit) and spirometry respectively indicated restrictive pattern prevalence rates of 22.6% and 1.6%. EBC 4-hydroxynonenale levels were not sufficiently sensitive to highlight a restrictive deficit, but did distinguish low and high rates of occupational exposure. There was no correlation between plethysmography values and the intensity or duration of exposure.

Conclusions:

Only one out of 14 cases of restrictive deficit diagnosed on the basis of body plethysmography values was also identified by means of spirometry. This finding supports the need to use body plethysmography in the health surveillance of clay workers exposed to FCS.

Changes in Health-Related Quality of Life During Rehabilitation in Patients With Operable Lung Cancer: A Feasibility Study (PROLUCA)

INTRODUCTION

Surgical resection in patients with non-small cell lung cancer (NSCLC) may be associated with significant morbidity, functional limitations, and decreased quality of life.

OBJECTIVES

The objective is to present health-related quality of life (HRQoL) changes over time before and 1 year after surgery in patients with NSCLC participating in a rehabilitation program.

METHODS

Forty patients with NSCLC in disease stage I to IIIa, referred for surgical resection at the Department of Cardiothoracic Surgery RT, Rigshospitalet, were included in the study. The rehabilitation program comprised supervised group exercise program, 2 hours weekly for 12 weeks, combined with individual counseling. The study endpoints were self-reported HRQoL (Functional Assessment of Cancer Therapy-Lung, European Organization for Research and Treatment in Cancer-Quality of Life Questionnaire-QLQ-C30, Short-Form-36) and self-reported distress, anxiety, depression, and social support (National Comprehensive Cancer Network Distress Thermometer, Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support), measured presurgery, postintervention, 6 months, and 1 year after surgery.

RESULTS

Forty patients were included, 73% of whom completed rehabilitation. Results on emotional well-being ( P < .0001), global quality of life ( P = .0032), and mental health component score ( P = .0004) showed an overall statistically significant improvement during the study.

CONCLUSION

This feasibility study demonstrated that global quality of life, mental health, and emotional well-being improved significantly during the study, from time of diagnosis until 1 year after resection, in patients with NSCLC participating in rehabilitation.

Perioperative Rehabilitation in Operable Lung Cancer Patients (PROLUCA): A Feasibility Study

Introduction Surgical resection in patients with non-small cell lung cancer (NSCLC) may be associated with significant morbidity, functional limitations, and decreased quality of life. Objectives The safety and feasibility of a preoperative and early postoperative rehabilitation program in patients operated for NSCLC was determined in a nonhospital setting, with focus on high-intensity interval exercise. Methods Forty patients with biopsy-proven NSCLC stages I to IIIa referred for surgical resection at the Department of Cardiothoracic Surgery RT, Rigshospitalet, University of Copenhagen, were randomly assigned to 1 of 4 groups (3 intervention groups and 1 control group). The preoperative intervention consisted of a home-based exercise program, while the postoperative exercise program comprised a supervised group exercise program involving resistance and high-intensity interval cardiorespiratory exercise 2 hours weekly for 12 weeks combined with individual counseling. The study endpoints were inclusion rate, adherence, and number of adverse events. Results Forty patients (of 124 screened; 32%) were included and randomized into the 4 groups. The postoperative exercise was completed by 73% of the patients randomized to this intervention. No adverse events were observed, indicating that the early postoperative exercise program is safe. The preoperative home-based exercise program was not feasible due to interfering diagnostic procedures and fast-track surgery that left only 1 to 2 weeks between diagnosis and surgery. Conclusion The early postoperative exercise program for patients with NSCLC was safe and feasible, but in a fast-track set up, a preoperative home-based exercise program was not feasible for this population.

A longitudinal exploration of 'Four Critical Moments' during treatment trajectory in patients with operable lung cancer and the feasibility of an exercise intervention: a research protocol

AIM

This article described a research protocol for a study exploring the lived experiences of patients with operable lung cancer in daily life at 'Four Critical Moments' during the disease and treatment trajectory.

BACKGROUND

Patients with lung cancer may experience complex problems during the disease and treatment trajectory, and studies conclude this population to be at higher risk in developing emotional distress than other cancer populations. It is required to explore the supportive needs of patients with lung cancer through the treatment trajectory.

DESIGN

A longitudinal design with a method of multiple data collection. The study is performed at four time points 'Four Critical Moments'.

METHODS

The study contained three samples. Sample I and sample II explored the expected four critical moments for patients with operable lung cancer within the first 4 months following diagnosis and surgery. Sample III explored the patients' participation and the feasibility of an exercise intervention targeting patients with operable lung cancer. For all three samples, interviews will be performed: (1) 5 days following diagnosis; (2) the day after surgery; (3) 7 weeks; and (4) 4 months following surgery. Data from questionnaires for all three samples will be collected at baseline and 4 months following surgery.

DISCUSSION

The study will add new perspectives on the lived experiences of patients with lung cancer along the treatment trajectory based on empirical and theoretical findings for both the general lung cancer population and patients participating in an exercise intervention. This will provide a basis for optimizing and developing interventions for patients with lung cancer starting in the surgical context.

Perioperative rehabilitation in operation for lung cancer (PROLUCA) - rationale and design

BACKGROUND

The purpose of the PROLUCA study is to investigate the efficacy of preoperative and early postoperative rehabilitation in a non-hospital setting in patients with operable lung cancer with special focus on exercise.

METHODS

Using a 2 x 2 factorial design with continuous effect endpoint (Maximal Oxygen Uptake (VO2peak)), 380 patients with non-small cell lung cancer (NSCLC) stage I-IIIa referred for surgical resection will be randomly assigned to one of four groups: (1) preoperative and early postoperative rehabilitation (starting two weeks after surgery); (2) preoperative and late postoperative rehabilitation (starting six weeks after surgery); (3) early postoperative rehabilitation alone; (4) today's standard care which is postoperative rehabilitation initiated six weeks after surgery. The preoperative rehabilitation program consists of an individually designed, 30-minute home-based exercise program performed daily. The postoperative rehabilitation program consists of a supervised group exercise program comprising cardiovascular and resistance training two-hour weekly for 12 weeks combined with individual counseling. The primary study endpoint is VO2peak and secondary endpoints include: Six-minute walk distance (6MWD), one-repetition-maximum (1RM), pulmonary function, patient-reported outcomes (PROs) on health-related quality of life (HRQoL), symptoms and side effects of the cancer disease and the treatment of the disease, anxiety, depression, wellbeing, lifestyle, hospitalization time, sick leave, work status, postoperative complications (up to 30 days after surgery) and survival. Endpoints will be assessed at baseline, the day before surgery, pre-intervention, post-intervention, six months after surgery and one year after surgery.

DISCUSSION

The results of the PROLUCA study may potentially contribute to the identification of the optimal perioperative rehabilitation for operable lung cancer patients focusing on exercise initiated immediately after diagnosis and rehabilitation shortly after surgery.

TRIAL REGISTRATION

NCT01893580.

Pulmonary Function Test: Spirometry

Spirometry is a useful tool in assessing the physiological lung function of a patient, and can be helpful in differentiating the etiology of the patient's symptoms. Indications for the test and the actual procedure are as described. Validity of a spirometry depends on patient co-operation and criteria for acceptability and repeatability must be met for useful interpretation of the results. Commonly measured parameters are described and a simple logarithm for interpretation of a spirometry result is given. Physicians must be mindful when interpreting the result in the context of extreme of ages, size or differing ethnicity as reference values for these groups of individuals are often extrapolated and not validated.

Step-down of budesonide/formoterol in early stages of asthma treatment leads to insufficient anti-inflammatory effect

OBJECTIVE

Administration of the combination of an inhaled corticosteroid (ICS) and a long-acting beta agonist (LABA) is the main treatment strategy for bronchial asthma. The ICS/LABA dosage can be reduced (stepped down) when the patient's symptoms and lung functions are well-controlled. In this study, we obtained fractional exhaled nitric oxide (FeNO) measurements to clarify whether the anti-inflammatory effect of budesonide/formoterol is shortened by step-down.

METHODS

Fifty-four patients who visited the Kawasaki Medical School Hospital with newly diagnosed asthma from November 2008 to July 2010 received budesonide/formoterol for 8 weeks or more. In 29 patients, the forced expiratory volume in 1 s% predicted increased to 80% or more, and the Asthma Control Questionnaire (ACQ) score decreased to 0.5 or less within 12 weeks. These 29 patients were randomly divided into two groups: the dosage-continued group (n = 14) and the step-down group (n = 15). Then, the impact of budesonide/formoterol step-down on ACQ score, pulmonary function and FeNO level was compared between the groups.

RESULTS

In the step-down group, the dosage was stepped down from 538 mcg/day to 331 mcg/day. In both groups, pulmonary function indicators and symptoms did not change. However, the mean FeNO level decreased significantly in the dosage-continued group (from 50.9 ppb to 45.0 ppb), and increased significantly in the step-down group (from 51.0 ppb to 65.7 ppb).

CONCLUSIONS

Clinicians should be more careful when stepping down budesonide/formoterol based solely on patients' symptoms and/or pulmonary function.

Inhaled chemotherapy in lung cancer: future concept of nanomedicine

Regional chemotherapy was first used for lung cancer 30 years ago. Since then, new methods of drug delivery and pharmaceuticals have been investigated in vitro, and in animals and humans. An extensive review of drug delivery systems, pharmaceuticals, patient monitoring, methods of enhancing inhaled drug deposition, safety and efficacy, and also additional applications of inhaled chemotherapy and its advantages and disadvantages are presented. Regional chemotherapy to the lung parenchyma for lung cancer is feasible and efficient. Safety depends on the chemotherapy agent delivered to the lungs and is dose-dependent and time-dependent. Further evaluation is needed to provide data regarding early lung cancer stages, and whether regional chemotherapy can be used as neoadjuvant or adjuvant treatment. Finally, inhaled chemotherapy could one day be administered at home with fewer systemic adverse effects.

Rationale and design of the Exercise Intensity Trial (EXCITE): A randomized trial comparing the effects of moderate versus moderate to high-intensity aerobic training in women with operable breast cancer

BACKGROUND

The Exercise Intensity Trial (EXcITe) is a randomized trial to compare the efficacy of supervised moderate-intensity aerobic training to moderate to high-intensity aerobic training, relative to attention control, on aerobic capacity, physiologic mechanisms, patient-reported outcomes, and biomarkers in women with operable breast cancer following the completion of definitive adjuvant therapy.

METHODS/DESIGN

Using a single-center, randomized design, 174 postmenopausal women (58 patients/study arm) with histologically confirmed, operable breast cancer presenting to Duke University Medical Center (DUMC) will be enrolled in this trial following completion of primary therapy (including surgery, radiation therapy, and chemotherapy). After baseline assessments, eligible participants will be randomized to one of two supervised aerobic training interventions (moderate-intensity or moderate/high-intensity aerobic training) or an attention-control group (progressive stretching). The aerobic training interventions will include 150 mins.wk⁻¹ of supervised treadmill walking per week at an intensity of 60%-70% (moderate-intensity) or 60% to 100% (moderate to high-intensity) of the individually determined peak oxygen consumption (VO₂peak) between 20-45 minutes/session for 16 weeks. The progressive stretching program will be consistent with the exercise interventions in terms of program length (16 weeks), social interaction (participants will receive one-on-one instruction), and duration (20-45 mins/session). The primary study endpoint is VO₂peak, as measured by an incremental cardiopulmonary exercise test. Secondary endpoints include physiologic determinants that govern VO₂peak, patient-reported outcomes, and biomarkers associated with breast cancer recurrence/mortality. All endpoints will be assessed at baseline and after the intervention (16 weeks).

DISCUSSION

EXCITE is designed to investigate the intensity of aerobic training required to induce optimal improvements in VO₂peak and other pertinent outcomes in women who have completed definitive adjuvant therapy for operable breast cancer. Overall, this trial will inform and refine exercise guidelines to optimize recovery in breast and other cancer survivors following the completion of primary cytotoxic therapy.

TRIAL REGISTRATION

NCT01186367.

The lung cancer exercise training study: a randomized trial of aerobic training, resistance training, or both in postsurgical lung cancer patients: rationale and design

Background

The Lung Cancer Exercise Training Study (LUNGEVITY) is a randomized trial to investigate the efficacy of different types of exercise training on cardiorespiratory fitness (VO_2peak), patient-reported outcomes, and the organ components that govern VO_2peak in post-operative non-small cell lung cancer (NSCLC) patients.

Methods/Design

Using a single-center, randomized design, 160 subjects (40 patients/study arm) with histologically confirmed stage I-IIIA NSCLC following curative-intent complete surgical resection at Duke University Medical Center (DUMC) will be potentially eligible for this trial. Following baseline assessments, eligible participants will be randomly assigned to one of four conditions: (1) aerobic training alone, (2) resistance training alone, (3) the combination of aerobic and resistance training, or (4) attention-control (progressive stretching). The ultimate goal for all exercise training groups will be 3 supervised exercise sessions per week an intensity above 70% of the individually determined VO_2peak for aerobic training and an intensity between 60 and 80% of one-repetition maximum for resistance training, for 30-45 minutes/session. Progressive stretching will be matched to the exercise groups in terms of program length (i.e., 16 weeks), social interaction (participants will receive one-on-one instruction), and duration (30-45 mins/session). The primary study endpoint is VO_2peak. Secondary endpoints include: patient-reported outcomes (PROs) (e.g., quality of life, fatigue, depression, etc.) and organ components of the oxygen cascade (i.e., pulmonary function, cardiac function, skeletal muscle function). All endpoints will be assessed at baseline and postintervention (16 weeks). Substudies will include genetic studies regarding individual responses to an exercise stimulus, theoretical determinants of exercise adherence, examination of the psychological mediators of the exercise - PRO relationship, and exercise-induced changes in gene expression.

Discussion

VO_2peak is becoming increasingly recognized as an outcome of major importance in NSCLC. LUNGEVITY will identify the optimal form of exercise training for NSCLC survivors as well as provide insight into the physiological mechanisms underlying this effect. Overall, this study will contribute to the establishment of clinical exercise therapy rehabilitation guidelines for patients across the entire NSCLC continuum.

Trial Registration

NCT00018255

Spirometry: don't blow it!

Spirometry is a useful test of pulmonary function and can be safely performed in a variety of clinical situations. Although the technique for performing the maneuver is straightforward, there are many sources of variability in results. Specific criteria must be met in order for the test to be considered valid. For the best results, proper instruction and coaching is essential, and patient understanding and effort must be maximized. Appropriate interpretation of spirometry requires several steps, including recognition and reporting of technically sound maneuvers, comparison to an appropriate reference population, and finally application of a well-developed interpretation scheme utilized in the context of patient symptoms and findings. Failure at any point along this path from performance to interpretation can yield misleading results that may ultimately poorly impact patient care. A clear understanding by the provider of proper coding and billing for spirometry is necessary to receive appropriate reimbursement from payers.