The Role of Cardiopulmonary Exercise Testing (CPET) in Pulmonary Rehabilitation (PR) of Chronic Obstructive Pulmonary Disease (COPD) Patients

Detection of dynamic lung hyperinflation using cardiopulmonary exercise testing and respiratory function in patients with stable cardiac disease: a multicenter, cross-sectional study

BACKGROUND

Many patients with heart disease potentially have comorbid chronic obstructive pulmonary disease (COPD); however, there are not enough opportunities for screening, and the qualitative differentiation of shortness of breath (SOB) has not been well established. We investigated the detection rate of SOB based on a visual and qualitative dynamic lung hyperinflation (DLH) detection index during cardiopulmonary exercise testing (CPET) and assessed potential differences in respiratory function between groups.

METHODS

We recruited 534 patients with heart disease or patients who underwent simultaneous CPET and spirometry (369 males, 67.0 ± 12.9 years) to scrutinize physical functions. The difference between inspiratory and expiratory tidal volume was calculated (TV E-I) from the breath-by-breath data. Patients were grouped into convex (decreased TV E-I) and non-convex (unchanged or increased TV E-I) groups based on their TV E-I values after the start of exercise.

RESULTS

Among the recruited patients, 129 (24.2%) were categorized in the convex group. There was no difference in clinical characteristics between the two groups. The Borg scale scores at the end of the CPET showed no difference. VE/VCO2 slope, its Y-intercept, and minimum VE/VCO2 showed no significant difference between the groups. In the convex group, FEV1.0/FVC was significantly lower compared to that in the non-convex group (69.4 ± 13.1 vs. 75.0 ± 9.0%). Moreover, significant correlations were observed between FEV1.0/FVC and Y-intercept (r=-0.343), as well as between the difference between minimum VE/VCO2 and VE/VCO2 slope (r=-0.478).

CONCLUSIONS

The convex group showed decreased respiratory function, suggesting a potential airway obstruction during exercise. A combined assessment of the TV E-I and Y-intercept of the VE/VCO2 slope or the difference between the minimum VE/VCO2 and VE/VCO2 slopes could potentially detect COPD or airway obstruction.

Effects of pulmonary rehabilitation in hematopoietic stem cell transplantation recipients: a randomized controlled study

PURPOSE

During hematopoietic stem cell transplantation (HSCT), patients' exercise capacity and quality of life (QOL) are impaired. Exercise training is recommended to preserve cardiorespiratory fitness during the compelling HSCT period. However, studies investigating the effects of pulmonary rehabilitation (PR) in HSCT recipients are limited. Therefore, this study aimed to investigate the effects of two different PR programs on maximal exercise capacity, respiratory muscle strength and endurance, pulmonary function, and QOL.

METHODS

This is a prospective, randomized, controlled, triple-blinded study. Thirty hospitalized patients undergoing HSCT were randomized to the pulmonary rehabilitation plus inspiratory muscle training (PR + IMT) group and the PR group. PR group performed upper extremity aerobic exercise training (AET) and progressive resistance exercise training (PRET), PR + IMT group performed IMT in addition to the upper extremity AET and PRET. Maximal exercise capacity (cardiopulmonary exercise testing), respiratory muscle strength (mouth pressure device, (MIP and MEP)) and respiratory muscle endurance (threshold loading test), pulmonary function (spirometry), and QOL (European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) were evaluated before HSCT and after discharge.

RESULTS

Changes in pulmonary function, respiratory muscle strength and endurance, and QOL were similar within groups (p > 0.05). The MEP, peak oxygen consumption, and oxygen pulse significantly decreased in both groups (p < 0.05).

CONCLUSION

Pulmonary function, inspiratory muscle strength and endurance, and QOL preserved after HSCT. Expiratory muscle strength and maximal exercise capacity decreased even though PR during HSCT. Breathing reserve and restriction improved in the PR + IMT group. In addition, minute ventilation and dyspnea were preserved in the PR + IMT group, while these values were worsened during two structured PR programs. Therefore, PR should be applied in accordance with the patient's current clinical and hematologic status to patients undergoing HSCT.

CLINICALTRIALS

gov (19/07/2018, NCT03625063).

The concept of detection of dynamic lung hyperinflation using cardiopulmonary exercise testing

Dynamic lung hyperinflation (DLH) caused by air trapping, which increases residual air volume, is a common cause of shortness of breath on exertion in chronic obstructive pulmonary disease (COPD). DLH is commonly evaluated by measuring the decrease in maximal inspiratory volume during exercise, or using the hyperventilation method. However, only few facilities perform these methods, and testing opportunities are limited. Therefore, we investigated the possibility of visually and qualitatively detecting DLH using data from a cardiopulmonary exercise test (CPET). Four men who underwent symptom-limiting CPET were included in this study, including a male patient in his 60s with confirmed COPD, a 50s male long-term smoker, and 2 healthy men in their 20s and 70s, respectively. We calculated the difference between the inspiratory tidal volume (TV I) and expiratory tidal volume (TV E) per breath (TV E-I) from the breath-by-breath data of each CPET and plotted it against the time axis. No decrease in TV E-I was observed in either of the healthy men. However, in the patient with COPD and long-term smoker, TV E-I began to decrease immediately after the initiation of exercise. These results indicate that DLH can be visually detected using CPET data. However, this study was a validation of a limited number of cases, and a comparison with existing evaluation methods and verification of disease specificity are required.

Automatic Cardiopulmonary Endurance Assessment: A Machine Learning Approach Based on GA-XGBOOST

OBJECTIVE

Among various assessment paradigms, the cardiopulmonary exercise test (CPET) provides rich evidence as part of the cardiopulmonary endurance (CPE) assessment. However, methods and strategies for interpreting CPET results are not in agreement. The purpose of this study is to validate the possibility of using machine learning to evaluate CPET data for automatically classifying the CPE level of workers in high-latitude areas.

METHODS

A total of 120 eligible workers were selected for this cardiopulmonary exercise experiment, and the physiological data and completion of the experiment were recorded in the simulated high-latitude workplace, within which 84 sets of data were used for XGBOOST model training and36 were used for the model validation. The model performance was compared with Support Vector Machine and Random Forest. Furthermore, hyperparameter optimization was applied to the XGBOOST model by using a genetic algorithm.

RESULTS

The model was verified by the method of tenfold cross validation; the correct rate was 0.861, with a Micro-F1 Score of 0.864. Compared with RF and SVM, all data achieved a better performance.

CONCLUSION

With a relatively small number of training samples, the GA-XGBOOST model fits well with the training set data, which can effectively evaluate the CPE level of subjects, and is expected to provide automatic CPE evaluation for selecting, training, and protecting the working population in plateau areas.

Analysis of Influencing Factors for Exercise Ventilation Efficiency of COPD Patients

Dynamic pulmonary hyperinflation and abnormal air exchange are the primary causes of the exercise limitation of chronic obstructive pulmonary disease (COPD) patients. During exercise, COPD sufferers' lungs are dynamically hyperinflated. Increased inefficient ventilation reduces ventilation efficiency and causes a mismatch between ventilation volume and blood flow. The ventilatory equivalent for CO2 (VeqCO2) is a physiological parameter that can be measured using cardiopulmonary exercise testing. Therefore, the aim of this exploratory study was to perform cardiopulmonary exercise testing on people with COPD, investigate the impact of static pulmonary function on ventilation efficiency under the exercise state, and screen the predictive indicators of ventilation efficiency. Subject. The aim of this study was to look at the factors that influence the exercise ventilation efficiency of people with COPD. Method. A total of 76 people with COPD were recruited during the stable period. Age, gender, body height, body mass, and other basic information were recorded. The body mass index (BMI) was determined, and forced vital capacity (FVC), forced expiratory volume in one second (FEV1), residual volume/total lung capacity (RV/TLC), diffusing capacity of the lung for carbon monoxide (DLCO), and DLCO divided by the alveolar volume (DLCO/VA) were measured. The ventilatory equivalent for carbon dioxide (VE/VCO2) under the rest state (EqCO2rest), anaerobic threshold (EqCO2at), and maximum exercise state (EqCO2 max) were calculated to investigate the influencing factors for ventilation efficiency of people with COPD. Results. FEV1% was negatively correlated with EqCO2rest (r = -0.277, P value <0.05); FEV1/FVC % was negatively correlated with EqCO2rest and EqCO2at (r = -0.311, -0.287, P value <0.05); DLCO% was negatively correlated with EqCO2rest, EqCO2at, and EqCO2max (r = -0.408, -0.462, and -0.285, P value <0.05); DLCO/VA% was negatively correlated with EqCO2rest, EqCO2at, and EqCO2max (r = -0.390, -0.392, and -0.245, P value <0.05); RV/TLC was positively correlated with EqCO2rest and EqCO2at (r = 0.289, 0.258, P-value <0.05). The prediction equation from the multivariable regression analysis equation was Y = 40.04-0.075X (Y = EqCO2, X = DLCO/VA%). Conclusions. As the degree of ventilatory obstruction increased, the ventilation efficiency of the stable people with COPD under the exercise state showed a progressive decrease; the ventilation efficiency of the people with COPD decreased significantly under the maximum exercise state, and the ventilation capacity and diffusion capacity were the significant factors that affected the exercise ventilation efficiency. The diffusion function may predict the maximum ventilation efficiency and enable primary hospitals without exercise test equipment in developing countries to predict and screen patients at risk for current exercise based on limited information.

Analysis of the Effect of Mindfulness Behavior Intervention Combined with Progressive Breathing Training on Pulmonary Function Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease

Purpose

Studies have shown that 50%-70% of patients with chronic obstructive pulmonary disease (COPD) have fatigue in addition to respiratory symptoms, so relieving respiratory symptoms and reducing fatigue are the main treatment objectives for COPD patients. This study focuses on the effect of positive behavioral intervention combined with progressive breathing training on pulmonary function rehabilitation in patients with COPD.

Methods

86 patients who underwent COPD treatment in our hospital between August 2020 and December 2021 were selected as study subjects and were divided into control (n = 43) and study groups (n = 43) using the random number table method. Patients in the control group were given conventional care, treatment, and health guidance, while patients in the study group were given positive behavioral intervention combined with progressive breathing training on this basis. Patients in both groups were compared on the basis of Multidimensional Fatigue Inventory 20 (MFI-20) score, the Medical Coping Questionnaire (MCMQ score), the Massive Attentional Awareness Scale (MAAS) score, and pulmonary function indicators (including the percentage of forced expiratory volume one second (FEV1%), peak expiratory flow (PEF), forced vital capacity (FVC), and 6-min walk distance (6MWD)) and quality of life (MCMQ) scores before and after 12 weeks of intervention.

Results

After 12 weeks of intervention, the study group had higher MFI-20 scores (comprehensive fatigue, physical fatigue, reduced activity, decreased power, and mental fatigue), confrontation scores on the MCMQ scale, MAAS scores (observation, description, nonjudgmental to intrinsic experience, nonresponsiveness to intrinsic experience, and perceived behavior), FEV1%, PEF, FVC, and 6MWD levels than the control group (P < 0.05). The scores of avoidance and submission on the MCMQ scale, and all scores of quality of life (cough, expectoration, shortness of breath, chest tightness, housework, going out, sleep, and energy) were lower than those of the control group (P < 0.05).

Conclusion

Positive behavioral interventions combined with progressive breathing training have a strengthening effect on the clinical treatment of COPD patients. Positive behavioral interventions combined with progressive breathing training are simple to implement as individual self-regulation methods and can be practiced on their own after being familiar with certain methods and techniques, and long-term adherence helps individuals cope with the stimulation of adverse events. Trail Registration. The clinical registration number for this research is L2020083.

Effects of Exercise Intervention on Peripheral Skeletal Muscle in Stable Patients With COPD: A Systematic Review and Meta-Analysis

Objectives: Peripheral skeletal muscle dysfunction is an important extrapulmonary manifestation of chronic obstructive pulmonary disease (COPD) that can be counteracted by exercise training. This study aimed to review the effect of three major exercise training modalities, which are used in pulmonary rehabilitation to improve on skeletal muscle mass, function, and exercise capacity in COPD.

Methods: PubMed, Embase, EBSCO, Web of Science, and the PEDro database were searched on April 25, 2020. Only randomized controlled studies published in English evaluating the effects of exercise interventions on peripheral skeletal muscle mass, strength, and exercise capacity in stable COPD patients were included. The quality of included studies was evaluated using the PEDro scale. The mean difference (MD) or the standardized mean difference (SMD) with 95% CI was calculated to summarize the results. Subgroup meta-analysis was used to investigate the effects of different exercise training modalities and different outcome measures. The Grading of Recommendations Assessment, Development, and Evaluation guidelines were used to rate evidence quality.

Results: A total of 30 randomized controlled trials involving 1,317 participants were included. Data from trials investigating endurance exercise (EE), resistance exercise (RE), and combined aerobic and resistance exercise (CE) were pooled into a meta-analysis, and the differences compared with the non-exercising COPD control were improvement in the muscle strength and exercise capacity in stable COPD patients. Subgroup meta-analysis for different exercise training modalities showed that RE significantly improved muscle strength (SMD = 0.6, 95% CI 0.35–0.84, I² = 61%), EE and CE significantly increased VO_2peak (EE: MD = 3.5, 95% CI 1.1–5.91, I² = 92%; CE: MD = 1.66, 95% CI 0.22–3.1, I² = 1%). Subgroup meta-analysis for different outcome measures showed that only isotonic strength was improved after exercise interventions (SMD = 0.89, 95% CI 0.51–1.26, I² = 71%).

Conclusion: Moderate evidence supports that exercise training in stable COPD patients has meaningful and beneficial effects on peripheral skeletal muscle strength and exercise capacity. Peripheral skeletal muscle shows a higher response to RE, and the isotonic test is relatively sensitive in reflecting muscle strength changes. The proportion of aerobic and resistance exercise components in a combined exercise program still needs exploration.

Systematic Review Registration: The review was registered with the PROSPERO: (The website is https://www.crd.york.ac.uk/PROSPERO/, and the ID is CRD42020164868).

Effects of a Rehabilitation Programme Using a Nasal Inspiratory Restriction Device in COPD

Chronic obstructive pulmonary disease (COPD) patients are characterised for presenting dyspnea, which reduces their physical capacity and tolerance to physical exercise. The aim of this study was to analyse the effects of adding a Feel-Breathe (FB) device for inspiratory muscle training (IMT) to an 8-week pulmonary rehabilitation programme. Twenty patients were randomised into three groups: breathing with FB (FBG), oronasal breathing without FB (ONBG) and control group (CG). FBG and ONBG carried out the same training programme with resistance, strength and respiratory exercises for 8 weeks. CG did not perform any pulmonary rehabilitation programme. Regarding intra group differences in the value obtained in the post-training test at the time when the maximum value in the pre-training test was obtained (Post_PRE), FBG obtained lower values in oxygen consumption (VO₂, mean = -435.6 mL/min, Bayes Factor (BF₁₀) > 100), minute ventilation (VE, -8.5 L/min, BF₁₀ = 25), respiratory rate (RR, -3.3 breaths/min, BF₁₀ = 2), heart rate (HR, -13.7 beats/min, BF₁₀ > 100) and carbon dioxide production (VCO₂, -183.0 L/min, BF₁₀ = 50), and a greater value in expiratory time (Tex, 0.22 s, BF₁₀ = 12.5). At the maximum value recorded in the post-training test (Post_FINAL), FBG showed higher values in the total time of the test (T_t, 4.3 min, BF₁₀ = 50) and respiratory exchange rate (RER, 0.05, BF₁₀ = 1.3). Regarding inter group differences at Pre_POST, FBG obtained a greater negative increment than ONBG in the ventilatory equivalent of CO₂ (EqCO₂, -3.8 L/min, BF₁₀ = 1.1) and compared to CG in VE (-8.3 L/min, BF₁₀ = 3.6), VCO₂ (-215.9 L/min, BF₁₀ = 3.0), EqCO2 (-3.7 L/min, BF₁₀ = 1.1) and HR (-12.9 beats/min, BF₁₀ = 3.4). FBG also showed a greater Pre_POST positive increment in Tex (0.21 s, BF₁₀ = 1.4) with respect to CG. At Pre_FINAL, FBG presented a greater positive increment compared to CG in T_t (4.4 min, BF₁₀ = 3.2) and negative in VE/VCO₂ intercept (-4.7, BF₁₀ = 1.1). The use of FB added to a pulmonary rehabilitation programme in COPD patients could improve tolerance in the incremental exercise test and energy efficiency. However, there is only a statically significant difference between FBG and ONBG in EqCO₂. Therefore, more studies are necessary to reach a definitive conclusion about including FB in a pulmonary rehabilitation programme.

The effect of acupoint application of traditional Chinese medicine for the treatment of chronic obstructive pulmonary disease: A protocol for systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a public threat, leading to progressive physical activity and poor quality of life. Although modern medicine has excellent achievement of COPD, the recurrence rate of stable COPD and the mortality of acute exacerbation COPD remain high. As one of the external therapy of traditional Chinese medicine, acupoint application has been treated COPD in China for a long time. Nevertheless, study evaluating the effect of acupoint application for COPD could not satisfy needs for clinic.

METHOD

Randomized controlled trials meeting the inclusion criteria will be collected by the 2 reviewers. We choose the following electronic databases of Web of Science, Pub Med, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wan Fang, Chinese Scientific Journals Database, and Chinese Biomedical Database as our retrieval tool. The retrieval time was from inception to March 2020. The key to evaluation criteria is total clinical efficacy rate and lung function will be measured. Secondary outcomes include assessment scales and adverse reactions. The studies extracted will be assessed. The merging analysis will be carried out by Review Manager Software.

RESULT

A scientific evidence of efficacy and safety of acupoint application for COPD will be found.

CONCLUSION

The evaluation of the efficacy and safety of acupoint application for COPD will be presented.

INPLASY REGISTRATION NUMBER

INPLASY202090023.

Cardiopulmonary exercise testing in chronic obstructive pulmonary disease: An update on its clinical value and applications

Chronic obstructive pulmonary disease is a debilitating disorder, characterized by airflow limitation, exercise impairment, reduced functional capacity and significant systemic comorbidity, which complicates the course of the disease. The critical inspiratory constraint to tidal volume expansion during exercise (that may be further complicated by the presence of dynamic hyperinflation), abnormalities in oxygen transportation and gas exchange abnormalities are the major pathophysiological mechanisms of exercise intolerance in COPD patients, and thus, exercise testing has been traditionally used for the functional evaluation of these patients. Compared to various laboratory and field exercise tests, cardiopulmonary exercise testing (CPET) provides a thorough assessment of exercise physiology, involving the integrative respiratory, cardiovascular, muscle and metabolic responses to exercise. This review highlights the clinical utility of CPET in COPD patients, as it provides important information for the determination of the major factors that limit exercise among patients with several comorbidities, allows the assessment of the severity of dynamic hyperinflation, provides valuable prognostic information and can be used to evaluate the response to several therapeutic interventions.

Exercise Training Modalities for People with Chronic Obstructive Pulmonary Disease

Exercise training confers health benefits for people with chronic obstructive pulmonary disease (COPD). This article reviews the evidence for several exercise training modalities shown to be beneficial among individuals with COPD. These modalities include aerobic, resistance, nonlinear periodized, upper limb and balance training, as well as yoga, Tai Chi, inspiratory muscle training, whole body vibration training and neuromuscular electrical stimulation. The literature pertaining to each modality was critically reviewed, and information on the rationale, mechanism(s) of action (where known), benefits, and exercise prescription is described to facilitate easy implementation into clinical practice.

Patient assessment and selection for pulmonary rehabilitation

Pulmonary rehabilitation (PR) is beneficial for people with several forms of chronic respiratory disease. Given the existing limitations on availability of PR services, it is important to identify participants who are most likely to benefit from it. Identification of criteria for patient referral to PR is challenging, as chronic respiratory diseases and their medical and psychosocial co-morbidities place a complex and multifaceted burden on patients. Although research studies have attempted to identify key parameters predictive of 'responsiveness to PR', to date no firm physiological, psychosocial or other criteria exist by which optimal patient candidacy can be determined. Moreover, individual factors do not reliably predict successful multidimensional PR outcomes. In general, individuals who remain symptomatic with dyspnoea, fatigue and exercise intolerance; who have difficulty performing activities of daily living (ADL); and who are having difficulty coping with or managing their disease despite optimized pharmacological therapy are potential candidates for PR. Patient assessment and outcome measurement are core essential features of PR. To be considered as a PR programme, rehabilitation programmes must demonstrate, at a minimum, assessment and outcome measurement in regard to exercise capacity, dyspnoea and health-related quality of life. Additional parameters, including physical activity, nutritional status, tobacco use status, patient knowledge and self-efficacy, performance of ADL, fatigue, disease exacerbations, hospitalizations and other urgent healthcare utilization, and behavioural outcomes, including coping styles, patient satisfaction and programme metrics, are other relevant and important aspects of patient assessment and outcome measurement that should be considered and undertaken in PR, where feasible.