Smoking cessation in pulmonary rehabilitation: goal or prerequisite?

Smoking Cessation Interventions for Patients With Chronic Obstructive Pulmonary Disease: A NARRATIVE REVIEW WITH IMPLICATIONS FOR PULMONARY REHABILITATION

PURPOSE

Reducing disease burden in patients with chronic obstructive pulmonary disease (COPD) focuses, in part, on helping patients become more functional through programs such as pulmonary rehabilitation (PR). Smoking cessation may be a prerequisite or component of PR, and determining which smoking interventions (eg, behavioral, pharmacotherapy, combination) are most effective can help guide efforts to extend them to patients with COPD. The purpose of this narrative review was to summarize evidence from studies testing smoking cessation interventions in patients with COPD and discuss how these interventions may be integrated into PR programs.

REVIEW METHODS

Searches were conducted in the PubMed and Web of Science databases. Search terms included "(smoking cessation) AND (RCT OR clinical trial OR intervention) AND (pulmonary OR chronic bronchitis OR emphysema OR COPD)." Published original studies were included if they used a prospective, experimental design, tested a smoking cessation intervention, reported smoking cessation rate, and included patients with COPD or a subgroup analysis focused on smokers with COPD.

SUMMARY

Twenty-seven distinct studies were included in the review. Most studies tested multitreatment smoking cessation interventions involving some form of counseling in combination with pharmacotherapy and/or health education. Overall, smoking cessation interventions may help promote higher rates of smoking abstinence in patients with COPD, particularly multifaceted interventions that include intensive counseling (eg, individual, group, and telephone support), smoking cessation medication or nicotine replacement therapy, and health education.

Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD: RESULTS OF A NATIONAL SURVEY

PURPOSE

Pulmonary rehabilitation (PR) improves outcomes for patients with chronic obstructive pulmonary disease (COPD); however, very few patients attend. We sought to describe strategies used to promote participation in PR after a hospitalization for COPD.

METHODS

A random sample of 323 United States based PR programs was surveyed. Using a positive deviance approach, a 39-item survey was developed based on interviews with clinicians at hospitals demonstrating high rates of participation in PR. Items focused on strategies used to promote participation as well as relevant contextual factors.

RESULTS

Responses were received from 209 programs (65%), of which 88% (n = 184) were hospital-based outpatient facilities. Most (91%, n = 190) programs described enrolling patients continuously, and 80% (n = 167) reported a wait time from referral to the initial PR visit of <4 wk. Organization-level strategies to increase referral to PR included active surveillance (48%, n = 100) and COPD-focused staff (49%, n = 102). Provider-level strategies included clinician education (45%, n = 94), provider outreach (43%, n = 89), order sets (45%, n = 93), and automated referrals (23%, n = 48). Patient-level strategies included bedside education (53%, n = 111), flyers (49%, n = 103), motivational interviewing (33%, n = 69), financial counseling (64%, n = 134), and transportation assistance (35%, n = 73). Fewer than one-quarter (18%, n = 38) of PR programs reported using both bedside education and automatic referral, and 42% (n = 88) programs did not use either strategy.

CONCLUSIONS

This study describes current practices in the United States, and highlights opportunities for improvement at the organization, provider, and patient level. Future research needs to demonstrate the effectiveness of these strategies, alone or in combination.

The Effectiveness of Cardiopulmonary Rehabilitation Programs on Psychosocial Factors in Patients With Pulmonary and Cardiac Disease

PURPOSE

Those with chronic cardiac and pulmonary diseases are predisposed to several psychosocial disorders. Tailored rehabilitation programs have been shown to improve physiological and psychosocial well-being. The purpose of this study was, first, to assess the psychosocial improvements among patients with cardiac and pulmonary diseases who have finished cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs; second, to assess the differences in psychosocial factors among those patients based on smoking status at the beginning and end of these programs.

METHODS

The CR and PR programs in hospital settings were retrospectively analyzed from 2013-2018. Before and after, all patients completed the sociodemographic characteristics along with the Psychosocial Risk Factor Survey that measures total distress, depression, anxiety, hostility, and social isolation.

RESULTS

There were 355 patients with cardiac and 244 patients with pulmonary disease who completed 6- to 12-wk CR or PR programs. There were significant improvements in all psychosocial symptoms among cardiac patients. Patients with pulmonary disease exhibited significant improvements in all psychosocial factors except for social isolation. Moreover, current smokers in the CR group reported elevated symptoms of several psychosocial scores.

CONCLUSION

These findings provide critical information about the effects of tailored rehabilitation programs among patients with chronic cardiac and pulmonary diseases on psychosocial levels. By using the Psychosocial Risk Factor Survey, we have found that total distress, depression, anxiety, and hostility were reduced among patients who completed the CR or PR programs. Current smokers exhibited the elevated mean scores on psychosocial symptoms in the cardiac group that may be a target for smoking cessation program. The advantages of tailored rehabilitation programs are significant, which may be of benefit for physical, social, behavioral, and psychological well-being.

The effect of pulmonary rehabilitation on smoking and health outcomes in COPD patients

OBJECTIVES

Although several positive effects of pulmonary rehabilitation (PR) are known in COPD patients, the results of PR in smoker COPD patients are unclear. We aimed to compare the effect of PR on smoking behaviour and health outcomes between COPD patients who are smoker and ex-smoker.

METHODS

In our study; 62 COPD patients (31 of them active smoker and 31 of them were ex-smoker) who completed in an 8-week outpatient PR programme were included. Pulmonary function test, blood gas analysis, mMRC Dyspnoea Scale, 6-minute walk test, St. George's Respiratory Questionnaire, SF-36 Quality of Life Questionnaire and Hospital Anxiety Depression Scale were performed. Smoking behaviour and nicotine dependence of the study group was evaluated.

RESULTS

At baseline assessment; TLCO was found to be lower in the currently smoking group (p = 0.042) and significantly increased after PR (p = 0.012). FEV₁ , PaO₂ , arterial saturation, 6-min walk distance and quality of life improved in both groups (p < 0.05). Anxiety score decreased in both groups; depression score decreased only in the ex-smoker group. When comparing changes between groups; mMRC score was observed to be decreased more in the smoker group (p = 0.01). At the end of the programme, nicotine dependence score and the daily number of cigarettes were significantly decreased in the smoker group (p < 0.001), also 2 patients completely quit smoking.

CONCLUSION

Smoker COPD patients benefited from the PR programme at least as much as the patients who do not smoke. Furthermore, nicotine dependence and amount of cigarette decreased in smoker patients. Therefore, COPD patients who smoke should be referred to the PR programmes.

Nonadherence in Home-Based Pulmonary Rehabilitation Program for COPD Patients

Background

The pulmonary rehabilitation (PR) is beneficial for COPD patients. Due to the poor rate of adherence, we evaluate the factors which will predict the nonadherence of PR.

Method

We analyzed the data from a retrospective study of COPD patients who were enrolled to attend the PR program. Patients were classified as the adherence group and the nonadherence group according to completion of over 50% sessions during the 8-week PR program. Demographic characteristics, 6-minute walking distance (6MWD), COPD assessment test (CAT), modified Medical Research Council scale (mMRC), and emotional function were compared between two groups. Univariate and multivariable analyses were performed to determine the factors of poor adherence of PR.

Results

Among 418 patients, 170 patients (40.7%) who completed less than 50% sessions of the PR program were categorized as “nonadherence.” Compared to completers, “nonadherence” patients had more cigarette consumption, higher emotional score, less 6MWD, more exacerbation, using nebulizer frequently, and higher rate of smoking at enrollment. On multivariate analysis, more exacerbation frequency (odds ratio (OR) = 1.434, 95% confidence interval (CI): 1.191∼1.796, P=0.046) and smoking at enrollment (OR = 3.349, 95% CI: 1.194∼6.302, P=0.012) were predict factors associated with nonadherence of PR.

Conclusion

COPD patients with frequent exacerbation and smoking currently were more likely to be nonadherence during PR.

Improving the uptake: Barriers and facilitators to pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation (PR) is a well-established therapeutic management programme for patients with chronic lung disease. Despite good clinical evidence, patient engagement can be poor.

AIM

The aim of the study was to determine the number of patients who are referred to PR at a District General Hospital, explore barriers and facilitators to attending and completing and identify strategies for improvement.

METHODS

All patients invited to attend PR in the calendar year 2016 were included in an analysis (N = 281). A structured questionnaire composed of barriers and facilitators was administered to patients that did not attend (non-attenders, N = 20) and those that attended but did not complete the programme (non-completers/"drop-outs," N = 13). Improvement strategies were identified and implemented followed by analysis of patients invited to attend in 2017 and 2018.

RESULTS

Age, sex and smoking status are factors that affect both attendance and completion rates of patients attending PR. In our analysis, we were able to demonstrate that lack of awareness and low perceived benefits were important barriers for non-attendance. In addition, overall uptake rate was improved but at the expense of completion rate.

CONCLUSION

Our local non-attendance rate in 2016 was 42%, with strategies aimed at improving patient and physician information, this was reduced to 11% (2018), below the national United Kingdom average. Unexpectedly, there was a worsening of completion rates and this raises questions about both appropriateness of referrals and whether completion rate rather than non-attendance rate should be used as a performance indicator and standard.

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.

The latent trait of ICD-11 nicotine dependence criteria: Dimensional and categorical phenotypes

We aimed to identify phenotypes of DSM-ICD nicotine dependence among a representative sample of lifetime weekly smokers in the largest metropolitan area in South America. Data came from 1,387 lifetime weekly smokers in the São Paulo Megacity Mental Health Survey. We used exploratory factor analysis (EFA) and latent class analysis (LCA) on ICD-11 nicotine dependence proposed criteria to explore dimensionality and phenotypes profiles, followed by logistic regression models to examine the association between latent classes and socio-demographic, psychiatric and chronic medical conditions. Analyses were performed using Mplus taking into account the complex survey design features. An unidimensional model had the best EFA fit with high loadings on all criteria. Response patterns detected by LCA indicated class differences based on severity continuum: a "non-symptomatic class" (32.0%), a "low-moderate symptomatic class" (34.9%)-with high probability of the criterion "use in larger amounts", and a "high-moderate symptomatic class" (33.1%). We found an association between high-income and the intermediate class that differs from findings in high-income countries, and high likelihood of psychiatric comorbidity among the most symptomatic smokers. The best dimensional model that pulled together nicotine dependence criteria supported a single factor, in concordance with the changes proposed for ICD-11.

Smoking Cessation Treatment for Patients With Mental Disorders Using CBT and Combined Pharmacotherapy

OBJECTIVES

The aim of this study was to investigate smoking treatment effectiveness and retention in a population with and without mental disorders (MD). Participants received cognitive behavioral therapy (CBT) plus nicotine patch alone or in combination with other medications (i.e., gum, bupropion, or nortriptyline) for smoking cessation treatment in a Brazilian Psychosocial Care Center unit (CAPS), taking into account sociodemographics and smoking profile covariates.

METHODS

The study involved comparison of treatment success (seven-day point prevalence abstinence at the end of the treatment) and retention (presence of the individual in all of the four medical consultations and six group sessions) in two subsamples of patients with MD (n = 267) and without MD (n = 397) who were included in a six-week treatment provided by a CAPS from 2007 to 2013. The treatment protocol comprised group CBT and pharmacotherapy (nicotine patches, nicotine gums, and bupropion and nortriptyline available, prescribed by psychiatrists).

RESULTS

Within patients with MD, CBT plus nicotine patch plus bupropion (aOR = 2.00, 95% CI [1.14, 3.50], p = .015) and CBT plus nicotine patch plus gum (aOR = 2.10, 95% CI [1.04, 4.23], p = .036) were associated with treatment success. Within patients without MD, female gender (aOR = 0.60, 95% CI [0.37, 0.95], p = .031) and lower Heaviness of Smoking Index score (aOR = 0.80, 95% CI [0.65, 0.99], p = .048) were associated with treatment success. No variable was associated with dropout or retention within patients with or without MD.

CONCLUSION

Our findings support the use of CBT plus nicotine patch plus bupropion as well as CBT plus nicotine patch plus gum in samples with high rates of medical, psychiatric, and addiction disorders. These findings support those of previous studies in the general population. Pharmacological treatment associated with group CBT based on cognitive-behavioral concepts and combined with ongoing MD treatment seems to be the best option for smoking cessation treatment among patients with MD. Units that deal with patients with MD, such as CAPS in Brazil, should be encouraged to treat smoking addiction in this population. Future studies should investigate retention rates in other samples of patients with MD.

The adoption of tobacco dependence treatment by rehabilitation clinicians

PURPOSE

Individuals with disabilities tend to smoke at rates that surpass those of the general population. The Pubic Health Service Guideline on the treatment of tobacco dependence suggests that all smokers be screened at every health care visit and counselled regarding how best to quit smoking. We review the literature on the adoption of tobacco dependence treatment by rehabilitation clinicians working with disabled individuals. Despite the deleterious health effects of smoking on individuals with disabilities, the limited data suggests that rehabilitation clinicians rarely encourage their clients who smoke to quit.

METHOD

Studies were collected using various computerized databases from 1980 to the present. Because of the paucity of literature on tobacco dependence treatment utilization among rehabilitation clinicians, we also examine research on the use of tobacco dependence treatment by health care providers in the general population and in substance abuse treatment settings.

RESULTS

Despite the efficacy of tobacco dependence treatment in smokers with disabilities, tobacco dependence treatment appears to be underutilized by rehabilitation clinicians.

CONCLUSIONS

Interventions that have successfully increased adoption by the two other clinician groups should be utilized to increase tobacco dependence treatment provision by rehabilitation clinicians. Additional research is warranted to determine how to overcome obstacles to adoption.

Drop-out and attendance in pulmonary rehabilitation: the role of clinical and psychosocial variables

BACKGROUND

In spite of the well-demonstrated benefits for patients with COPD, pulmonary rehabilitation programmes show considerable drop-out and suboptimal attendance rates. The purpose of this prospective study is to examine causes for drop-out and non-attendance during a 12 week multidisciplinary pulmonary rehabilitation programme, and to investigate whether sociodemographic and medical factors as well as patients' perception of their illness are related to drop-out and non-attendance.

METHODS

Two hundred and seventeen patients with COPD who were referred to a rehabilitation centre participated in this multicentre study. Prior to treatment, patients received a questionnaire, which included the Illness Perception Questionnaire-Revised. Clinical data were drawn from medical records. Drop-out and attendance were recorded during the programme.

RESULTS

Fifty patients (23%) did not complete the rehabilitation course, of which half was due to medical reasons (e.g. exacerbations, hospitalisations). Non-completion could not be predicted by baseline sociodemographic, clinical or psychological variables. Patients who declined treatment did not differ from patients who dropped out due to medical reasons. On average, patients attended 92% of all scheduled appointments. Of all missed appointments, approximately 20% were accountable to factors beyond patients' control (e.g. absent therapists, hospitalisations). Smoking, living alone, a lower fat free mass and lower confidence in treatment increased the chance of patients not attending an appointment during rehabilitation.

CONCLUSION

In general, adherence in rehabilitation is high. However, paying attention to patients' nutritional status and creating a positive expectation of treatment during referral and intake appear to be important if one aims to optimise patients' attendance during rehabilitation.

Involvement of nitric oxide in acute lung inflammation induced by cigarette smoke in the mouse

Short-term exposure to cigarette smoke (CS) leads to acute lung inflammation (ALI) by disturbing oxidant/antioxidant balance. Both CS exposure and lung inflammation are important risk factors in the pathogenesis of chronic obstructive pulmonary disease. Nitric oxide (NO) is an oxidant both present in CS and produced in the inflammatory response, but its role in the effects of CS exposure is unclear. Our aim was to study involvement of NO in a model of CS exposure. Groups of mice (male C57BL/6) exposed to CS (six cigarettes per day over five days) were simultaneously subjected to treatment with vehicle (CS), 60mg/kg/day omega-nitro-l-arginine methyl ester (CS+l-NAME), 20mg/kg/day nitroglycerine (CS+NTG), or 120mg/kg/day l-arginine (CS+l-arg). Bronchoalveolar lavage fluid was then aspirated to perform cell counts, and malondialdehyde (MDA), nitrite, catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidase (GPx) levels were measured in lung homogenates. Macrophage and neutrophil counts were increased in the CS (p<0.001) and CS+l-NAME groups (p<0.05 and p<0.01, respectively); the CS+NTG and CS+l-arg groups showed no differences from the control group. MDA was increased in the CS (p<0.05) and CS+l-NAME (p<0.01) groups when compared to the control group. Nitrite levels were decreased in the CS and CS+l-NAME groups (p<0.001) and increased in the CS+NTG (p<0.001) and CS+l-arg (p<0.01) groups when compared to the control. CAT, SOD and GPx activities in the CS and CS+l-NAME groups were all significantly increased compared to the control group. Our results suggest that administration of NO donors or substrates may be a useful therapy in the treatment of ALI caused by CS.

[In-patient smoker? - Providing appropriate intervention]

Tobacco use is the most avoidable cause of death. Other than provoking multiple diseases requiring hospitalisation, Tobacco Use is also a disease requiring management in the hospital setting, not only in terms of controlling the withdrawal symptoms of the patient, who has been abruptly prohibited from smoking, but also for fulfilling legislation which prohibits tobacco use in the health services, the only efficient way of preventing exposure of non-smokers to environmental tobacco smoke. Treating the in-patient smoker in an appropriate way also provides a window of opportunity for promoting not just a temporary but a complete smoking cessation.

Oxygen therapy during exercise training in chronic obstructive pulmonary disease

BACKGROUND

Exercise training within the context of pulmonary rehabilitation improves outcomes of exercise capacity, dyspnea and health-related quality of life in individuals with chronic obstructive pulmonary disease (COPD). Supplemental oxygen in comparison to placebo increases exercise capacity in patients performing single-assessment exercise tests. The addition of supplemental oxygen during exercise training may enable individuals with COPD to tolerate higher levels of activity with less exertional symptoms, ultimately improving quality of life.

OBJECTIVES

To determine how supplemental oxygen in comparison to control (compressed air or room air) during the exercise-training component of a pulmonary rehabilitation program affects exercise capacity, dyspnea and health-related quality of life in individuals with COPD.

SEARCH STRATEGY

All records in the Cochrane Airways Group Specialized Register of trials coded as 'COPD' were searched using the following terms: (oxygen* or O2*) AND (exercis* or train* or rehabilitat* or fitness* or physical* or activ* or endur* or exert* or walk* or cycle*). Searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE and CINAHL databases identified studies. The last search was carried out in June 2006.

SELECTION CRITERIA

Only randomized controlled trials (RCTs) comparing oxygen-supplemented exercise training to non-supplemented exercise training (control group) were considered for inclusion. Participants were 18 years or older, diagnosed with COPD and did not meet criteria for long-term oxygen therapy. No studies with mixed populations (pulmonary fibrosis, cystic fibrosis, etc) were included. Exercise training was greater than or equal to three weeks in duration and included a minimum of two sessions a week.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion in the review and extracted data. Weighted mean differences (WMD) with 95% confidence intervals (CI) were calculated using a random-effects model. Missing data were requested from authors of primary studies.

MAIN RESULTS

Five RCTs met the inclusion criteria. The maximum number of studies compared in the meta-analysis was three (31 on oxygen versus 32 control participants), because all included studies did not measure the same outcomes. When two studies were pooled, statistically significant improvements of oxygen-supplemented exercise training were found in constant power exercise time, WMD 2.68 minutes (95% CI 0.07 to 5.28 minutes). Supplemental oxygen increased the average exercise time from 6 to 14 minutes; the control intervention increased average exercise time from 6 to 12 minutes. Constant power exercise end-of-test Borg score (on a scale from 1 to 10) also showed statistically significant improvements with oxygen-supplemented exercise training, WMD -1.22 units (95% CI -2.39 to -0.06). One study showed a significant improvement in the change of Borg score after the shuttle walk test, by -1.46 units (95% CI -2.72 to -0.19). There were no significant differences in maximal exercise outcomes, functional exercise outcomes (six-minute walk test), shuttle walk distance, health-related quality of life or oxygenation status. According to the GRADE system most outcomes were rated as low quality because they were limited by study quality.

AUTHORS' CONCLUSIONS

This review provides little support for oxygen supplementation during exercise training for individuals with COPD, but the evidence is very limited. Studies with larger number of participants and strong design are required to permit strong conclusions, especially for functional outcomes such as symptom alleviation, health-related quality of life and ambulation.