Normativa sobre la rehabilitación respiratoria

Pulmonary rehabilitation. Sociedad Española de Neumología y Cirugía Torácica (SEPAR)

Pulmonary rehabilitation (PR) has been shown to improve dyspnea, exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). PR has also shown benefits in diseases other than COPD but the level of evidence is lower. The fundamental components of PR programs are muscle training, education and chest physiotherapy. Occupational therapy, psychosocial support and nutritional intervention should also be considered. Home programs have been shown to be as effective as hospital therapy. The duration of rehabilitation programs should not be less than 8 weeks or 20 sessions. Early initiation of PR, even during exacerbations, has proven safe and effective. The use of oxygen or noninvasive ventilation during training is controversial and dependent on the patient's situation. At present, the best strategy for maintaining the benefits of PR in the long term is unknown. Longer PR programs or telemedicine could play a key role in extending the results obtained.

[Survival in a cohort of patients with chronic obstructive pulmonary disease: comparison between primary and tertiary levels of care]

OBJECTIVE

To compare the cumulative probability of survival in a cohort of patients with chronic obstructive pulmonary disease (COPD) attended at primary and tertiary levels of health care.

PATIENTS AND METHOD

A cohort study was carried out at the Department of Pneumology of the Centro Medico Nacional La Raza (Mexico DF) on 87 of the 114 patients with confirmed diagnosis of COPD. All patients followed a 6-month physical activity and educational program. Patients underwent the COPD diagnostic tests recommended by the American Thoracic Society and were randomized and distributed in 2 groups: Group A had 44 patients who received tertiary care, and Group B had 43 who received primary care. Follow up lasted from 1993 to 2001. Exacerbations, hospital admissions, exercise duration, hospital stay, and death or study abandonment were recorded for all patients. Respiratory function tests were performed annually. Annual and total mortality, distribution by sex, loss in life expectancy, mean age at death, and cumulative probability of survival were analyzed.

RESULTS

No differences were found between the groups in population or initial characteristics. Respiratory function declined in both groups, although the decline was smaller in Group A: mean (SD) forced expired volume in 1 second, 8.93% (8.72%) compared with 17.71% (2.51%) and annual drop in blood pressure of 1.39 mm Hg compared with 1.95 mm Hg. Annual exacerbations were 0.23 in Group A compared with 2.07 in Group B; hospitalizations, 0.06 compared with 0.92, and length of stay, 15.76 days compared with 17.32 days. Mean age at death was 66.12 compared with 60.6; loss of life expectancy was 13.88 years lost compared with 19.4, and the cumulative probability of survival was 0 compared with 0.224.

CONCLUSIONS

There are many reasons for the differences found: better medical management, health education, and family involvement at the tertiary level. These factors, included in international COPD guidelines, must be incorporated into primary health care.

[Effectiveness of a recuperative primary care intervention in patients with chronic obstructive pulmonary disease]

OBJECTIVES

The main objective is to assess the effect of a respiratory rehabilitation programme on the quality of life of patients with COPD. Secondary aims are to determine whether the intervention, as against the habitual monitoring, improves tolerance to exercise and pulmonary function, and reduces dyspnoea, the number of crises and hospital admissions due to COPD and the medication used to control the disease.

DESIGN

Pragmatic cluster-randomised clinical trial.

SETTING

Clinics of 16 PC teams in various health areas of the Community of Madrid.

PARTICIPANTS

476 patients with light-moderate COPD, who sign their informed consent.

VARIABLES

Quality of life, number of crises, packages of medicines used to control the disease, unscheduled attendance, pulmonary function, dyspnoea and tolerance to exercise.

METHOD

The consultations will be assigned to the control and intervention groups at random. At each clinic there will be a randomised selection from all patients with COPD and in a stable clinical condition. 238 patients are needed in each group, in order to detect a minimum difference of 4 points in quality of life, assuming a standard deviation of 16, 95% confidence level, 80% power and 20% losses. The effect between each factor and the variables evaluated through multivariate analysis will be calculated.

DISCUSSION

This research project aims to show that a basic recuperative intervention, which is feasible and primary care-based, can achieve improvements in the quality of life of patients with COPD.

Quality control of mechanical ventilation at the patient's home

OBJECTIVE

During home mechanical ventilation the prescribed settings are applied without permanent supervision of health professionals. After a long-time period of unattended operation at home the ventilator may not apply the ventilation parameters prescribed. This quality control study of home mechanical ventilation assessed whether tidal volume (V(T)), frequency (f), and minute ventilation (V'(E)) actually applied by the ventilator coincide with the values set on the ventilator control panel and with those prescribed.

MEASUREMENTS

Actual V(T), f, and V'(E) applied by the ventilator in 30 patients on nocturnal HMV were measured at the patients' homes. The patients were subjected to volume targeted assist ventilation through nasal mask (n=28) or tracheostomy (n=2). The values of V(T), f, and V'(E) set at the ventilator were recorded. The actual and set V(T), f, and V'(E) values were compared with those prescribed.

RESULTS

Considerable differences were found between actual, set and prescribed V(T), f, and V'(E). Actual V'(E) was significantly lower than V'(E) set: mean difference was 0.82 l/min, with considerable individual differences. Differences between actual and prescribed V'(E) were caused both by a poor performance of the ventilator and by a discrepancy between the values prescribed and those set at the ventilator control panel.

CONCLUSIONS

Regularly assessing the actual performance of ventilators at the patient's home is a quality control procedure useful for detecting malfunctions which could improve compliance and outcome of home mechanical ventilation.