Effect of dyspnea and clinical variables on the quality of life and functional capacity in patients with chronic obstructive pulmonary disease and congestive heart failure:

Effects of Home-Based Pulmonary Rehabilitation on Dyspnea, Exercise Capacity, Quality of Life and Impact of the Disease in COPD Patients: A Systematic Review

Conventional pulmonary rehabilitation programs are used as therapies for the treatment of chronic obstructive pulmonary disease (COPD). However, this modality presents barriers that make rehabilitation difficult. For this reason, home-based pulmonary rehabilitation (HBPR) has been used to overcome these barriers. The objective was to systematically compare a structured program with HBPR or a control group for participants with COPD. The primary outcome was an improvement in symptoms in the level of dyspnea and secondary outcomes were parameters in lung function, exercise capacity, health-related quality of life (HRQoL) and the impact of the disease on the individual. The Medline (via PubMed), Virtual Health Library and Cochrane Library databases were searched until May 10, 2021. Randomized controlled trials were included without restrictions on the year of publication or language. The risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (RoB). Our results showed that there was a significant decrease in the level of dyspnea, (MD: 5.46; 95% CI: 1.97 to 8.96), increased distance covered (MD: 61.75; 95% CI: 42, 94 to 80.56, significant improvement in HRQoL (MD: -11.30; 95% CI: -19.81 to -2.79) and reduction in the impact of the disease (DM: -4.71; 95% CI: -7.95 to -1.47). All results found were comparing the intervention group versus the control group. To conclude we found a reduction in the levels of dyspnea, an increase in the distance covered on the six-minute walk test, improving HRQoL and decreasing the impact of the disease in COPD patients in home-based pulmonary rehabilitation.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.2020234 .

Dyspnea in Community-Dwelling Older Persons: A Multifactorial Geriatric Health Condition

OBJECTIVES

To evaluate the associations between a broad array of cardiorespiratory and noncardiorespiratory impairments and dyspnea in older persons.

DESIGN

Cross-sectional.

SETTING

Cardiovascular Health Study.

PARTICIPANTS

Community-dwelling persons (N = 4,413; mean age 72.6, 57.1% female, 4.5% African American, 27.2% <high school education, 54.7% ever-smokers).

MEASUREMENTS

Dyspnea severity (moderate to severe defined as American Thoracic Society Grade ≥2) and several impairments, including those established using spirometry (forced expiratory volume in 1 second (FEV₁ )), maximal inspiratory pressure (respiratory muscle strength), echocardiography, ankle-brachial index, blood pressure, whole-body muscle mass (bioelectrical impedance), single chair stand (lower extremity function), grip strength, serum hemoglobin and creatinine, Center for Epidemiologic Studies Depression Scale (CES-D), Mini-Mental State Examination, medication use, and body mass index (BMI).

RESULTS

In a multivariable logistic regression model, impairments that had strong associations with moderate to severe dyspnea were FEV₁ less than the lower limit of normal (adjusted odds ratio (aOR) = 2.88, 95% confidence interval (CI) = 2.37-3.49), left ventricular ejection fraction less than 45% (aOR = 2.12, 95% CI = 1.43, 3.16), unable to perform a single chair stand (aOR = 2.10, 95% CI = 1.61-2.73), depressive symptoms (CES-D score ≥16; aOR = 2.02, 95% CI = 1.26-3.23), and obesity (BMI ≥30; aOR = 2.07, 95% CI = 1.67-2.55). Impairments with modest but still statistically significant associations with moderate to severe dyspnea included respiratory muscle weakness, diastolic cardiac dysfunction, grip weakness, anxiety symptoms, and use of cardiovascular and psychoactive medications (aORs = 1.31-1.71).

CONCLUSION

In community-dwelling older persons, several cardiorespiratory and noncardiorespiratory impairments were significantly associated with moderate to severe dyspnea, akin to a multifactorial geriatric health condition.

Intensive symptom control of opioid-refractory dyspnea in congestive heart failure: Role of milrinone in the palliative care unit

OBJECTIVE

We describe an exemplary case of congestive heart failure (CHF) symptoms controlled with milrinone. We also analyze the benefits and risks of milrinone administration in an unmonitored setting.

METHOD

We describe the case of a patient with refractory leukemia and end-stage CHF who developed severe dyspnea after discontinuation of milrinone. At that point, despite starting opioids, she had been severely dyspneic and anxious, requiring admission to the palliative care unit (PCU) for symptom control. After negotiation with hospital administrators, milrinone was administered in an unmonitored setting such as the PCU. A multidisciplinary team approach was also provided.

RESULTS

Milrinone produced a dramatic improvement in the patient's symptom scores and performance status. The patient was eventually discharged to home hospice on a milrinone infusion with excellent symptom control.

SIGNIFICANCE OF RESULTS

This case suggests that milrinone may be of benefit for short-term inpatient administration for dyspnea management, even in unmonitored settings and consequently during hospice in do-not-resuscitate (DNR) patients. This strategy may reduce costs and readmissions to the hospital related to end-stage CHF.

Lower Extremity Proximal Muscle Function and Dyspnea in Older Persons

OBJECTIVES

To evaluate the association between performance on a single chair stand and moderate to severe exertional dyspnea.

DESIGN

Cross-sectional.

SETTING

Cardiovascular Health Study.

PARTICIPANTS

Community-dwelling individuals aged 65 and older (N = 4,413; mean age 72.6; female, n = 2,518 (57.1%); nonwhite, n = 199 (4.5%); obese, n = 788 (17.9%); history of smoking, n = 2,410 (54.6%)).

MEASUREMENTS

Performance on single chair stand (poor (unable to rise without arm use) vs normal (able to rise without arm use)), moderate to severe exertional dyspnea (American Thoracic Society grade ≥2), age, sex, ethnicity, obesity, smoking, frailty status (Fried-defined nonfrail, prefrail, frail), high cardiopulmonary risk (composite of cardiopulmonary diseases and diabetes mellitus), spirometric impairment, arthritis, depression, stroke, and kidney disease.

RESULTS

Poor performance on the single chair stand was established in 369 (8.4%) and moderate to severe exertional dyspnea in 773 (17.5%). Prefrail status was established in 2,210 (50.1%), frail status in 360 (8.2%), arthritis in 2,241 (51.4%), high cardiopulmonary risk in 2,469 (55.9%), spirometric impairment in 1,076 (24.4%), kidney disease in 111 (2.5%), depression in 107 (2.4%), and stroke in 93 (2.1%). In multivariable regression models, poor performance on the single chair stand was associated with moderate to severe exertional dyspnea (unadjusted odds ratio (OR) = 3.48, 95% confidence interval (CI) = 2.78-4.36; adjusted OR = 1.85, 95% CI = 1.41-2.41).

CONCLUSION

Poor performance on a single chair stand was associated with an adjusted 85% greater likelihood of moderate to severe exertional dyspnea than normal performance. These results suggest that reduced proximal muscle function of the lower extremities is associated with moderate to severe exertional dyspnea, even after adjusting for multiple confounders.

Correlation between functional capacity and health-related quality of life in COPD: a case series

Objective To correlate functional capacity test scores from chronic obstructive pulmonary disease (COPD) subjects with their functional state as assessed by health-related quality of life questionnaires (one respiratory disease-specific [SGRQ] and one generic [SF-36] questionnaire). Materials and methods Study of a case series of 8 COPD patients. The following tests were performed: 1) Six-minute walk test (6-MWT); 2) Shuttle walking test (SWT); 3) Six-minute step test (6-MST); 4) Two-minute sit-to-stand test (STST); and 5) Pegboard and ring test (PBRT). Besides these tests, two health-related quality of life questionnaires were administered: The St George's Respiratory Questionnaire (SGRQ) and the Short Form 36 (SF-36) health survey questionnaire. The statistical analysis was carried out by using the Shapiro-Wilk normality test, while correlations were assessed using Pearson's (parametric data) or Spearman's (non-parametric data) rank tests, with p < 0.05. Results The 6-MWT showed strong correlation with the SF-36 scales of physical functioning, general health, vitality, social functioning and mental health. Conversely, the other functional capacity tests showed no correlation with this questionnaire. The SGRQ showed no correlation with any of the tests. Conclusions The 6-MWT may be a good test to reflect the health-related quality of life of COPD subjects.

Relationship between the functional status constructs and quality of life in COPD

Introduction Functional status is an important component of health related quality of life (QOL) in patients with chronic obstructive pulmonary disease (COPD). However there is a lack of studies aiming to evaluate the association between QOL and the different methods for assessing patient´s limitation to perform ADL. Objectives To investigate the association between QOL and functional status, measured by four different instruments: London Chest Activity of Daily Living scale (LCADL), six-minute walking test (6MWT), Glittre ADL-test (TGlittre) and assessment of physical activities in daily living (PADL). Methods Twenty-three patients with COPD, GOLD 2 to 4, were submitted to the following evaluations: spirometry, the Saint George Respiratory Questionnaire (SGRQ), LCADL, 6MWT, TGlittre and assessment of PADL. Pearson or Spearman correlation coefficients were used to verify the association between the variables. Results It was observed correlation between all domains of the SGRQ and the 6MWT, between TGlittre and ‘leisure’ domain of LCADL; and between the domain ‘activity’ of the SGRQ with the total score of LCADL (r = 0.53), LCADL% (r = 0.54), ‘self care’ (r = 0.49) and ‘leisure’ (r = 0.82). The number of steps correlated with the SGRQ (r = -0.59) and with ‘activity’ (r = -0.70) and ‘impact’ (r = -0.52) domains. The standing time correlated with the domain ‘activitiy’ (r = -0.47) of the SGRQ (p < 0.05 for all). Conclusions Both functional performance and capacity are able to reflect the impact that ADL limitation has on QOL in patients with COPD

Factors affecting health status in patients with chronic obstructive pulmonary disease

The aim of this study is to determine the correlation between the quality of life (QOL) and subjective dyspnoea, subjective fatigue, sleep quality, and the forced expiratory volume in first second (FEV(1)) % predicted value and collective contribution of these variables on QOL. The study was conducted with 102 patients. Pulmonary function tests (FEV(1) % predicted value, FEV(1) /forced vital capacity), subjective dyspnoea, subjective fatigue, sleep quality were assessed. There were negative correlations between QOL total score and pulmonary function tests, positive correlations between QOL total score and subjective dyspnoea score, subjective fatigue and sleep quality total scores. In addition, subjective dyspnoea, subjective fatigue and sleep quality total scores and FEV(1) % predicted value accounted for 68.1% of the variance on QOL. As a conclusion of these findings, it has been recommended that these variables should be considered when planning an approach towards improving the QOL in chronic obstructive pulmonary disease patients.

Frequency and significance of unrecognized chronic obstructive pulmonary disease in elderly patients with stable heart failure

BACKGROUND AND AIMS

Due to prolonged life-spans and modern therapeutic approaches, there has been an increase in the number of patients aged ≥ 65 years with chronic heart failure (CHF). The duration and quality of life in elderly patients with CHF also depend on accompanying diseases. Although frequency of chronic obstructive pulmonary disease (COPD) in patients with CHF is about 30%, it is hard to find similar data in the elderly population. COPD is defined as a spirometrically assessed ratio of a post-dilatory forced expiratory volume in the first second, divided by forced vital capacity (FEV1/FVC) <70%. The aims of our study were to assess the prevalence of previously undiagnosed COPD in outpatients (≥ 65 yrs) with stable CHF and to determine the effect of the combination of COPD and CHF on patients' functional capacity as measured by a 6-minute walking test.

METHODS AND RESULTS

Of the 174 study patients, 126 (72.4%) were men. In 48 patients (27.6%) we found previously unrecognized COPD. They were significantly older (75.6 ± 5.8 vs 73 ± 4.5 years, p<0.01) and more frequently had abdominal obesity and a greater waist circumference (98.8 ± 10.2 vs 94.9 ± 9.1 cm, p<0.05). Patients with COPD had significantly shorter 6-min walking distance (275.5 ± 112.9 vs 291.3 ± 96.7 m, p<0.05). Only patient's age had a positive prognostic association with unrecognized COPD (OR=1.16; 95% CI 1.01- 1.34, p<0.01). Patients with COPD showed a significant correlation between actual/predicted FEV1 and the 6-min walking distance (r=0.39, p<0.01).

CONCLUSIONS

We found a high prevalence of unrecognized COPD in elderly patients with CHF and central obesity. Chronic obstructive pulmonary disease influenced functional capacity in CHF patients, as determined by the 6-minute walking test. Closer co-operation between pulmonologists and cardiologists is necessary to optimize management of this large proportion of CHF patients.

A classe da NYHA tem relação com a condição funcional e qualidade de vida na insuficiência cardíaca

A insuficiência cardíaca (IC) é uma síndrome que se apresenta com crescente prevalência, podendo limitar o indivíduo quanto à capacidade físico-funcional, condição pulmonar e qualidade de vida. Este estudo tem como objetivo verificar as limitações pulmonares e físicas, bem como a qualidade de vida dos pacientes e compará-las com as classes funcionais da New York Heart Association (NYHA). Estudo transversal, com amostra de 66 pacientes (45 homens). Foram aplicados uma ficha de avaliação padronizada e o questionário de qualidade de vida Short Form-36 (SF-36). Foram realizados espirometria, manovacuometria e o teste da caminhada de seis minutos (TC6M). Os pacientes (classe I: 24 indivíduos, classe II: 27 e classe III: 15) possuíam uma média de idade de 57,95±10,96 anos e representaram uma amostra com características antropométricas homogêneas. Para a condição pulmonar, observou-se diferença estatística quanto a Capacidade Vital Forçada (CVF), Pico de Fluxo Expiratório e Pressão Expiratória Máxima (Pemáx). Na distância do TC6M houve diferença entre classe I e III e entre II e III (classe I: 439,27±58,85 m, classe II: 370,96±74,41 m e classe III: 268,96±83,88 m), com p<0,001. Para o SF-36, houve decréscimo da qualidade de vida conforme o agravo das classes funcionais. Pacientes com IC apresentam diminuição da condição pulmonar, capacidade físico-funcional e qualidade de vida relacionada ao aumento da classe funcional da NYHA.

Cardiopulmonary exercise testing characteristics in heart failure patients with and without concomitant chronic obstructive pulmonary disease

BACKGROUND

The assessment of aerobic exercise capacity is an important component in the clinical management of patients with heart failure (HF). Although a significant percentage of patients diagnosed with HF also present with chronic obstructive pulmonary disease (COPD) comorbidity, the combined impact of these chronic conditions on the aerobic exercise response is unknown and is therefore the purpose of the present investigation.

METHODS

Sixty-nine subjects with HF and COPD were matched to 69 subjects solely diagnosed with HF according to age, sex, and HF etiology. All subjects underwent resting pulmonary function and diffusion capacity testing, echocardiography with tissue Doppler imaging, and cardiopulmonary exercise testing (CPX).

RESULTS

Subjects with COPD comorbidity had significantly lower pulmonary function testing and diffusion capacity values versus HF alone (P < .05). In addition, subjects with both HF and COPD had significantly higher pulmonary artery systolic pressures (51.9 ± 9.0 vs 37.0 ± 7.8 mm Hg, P < .001) as assessed by pulsed Doppler echocardiography. Cardiopulmonary exercise testing revealed a significantly poorer response in subjects with HF and COPD by all variables that were analyzed, including peak oxygen consumption (12.1 ± 4.3 vs 16.3 ± 4.3 mL kg⁻¹ min⁻¹, P < .001), minute ventilation/carbon dioxide production slope (42.7 ± 7.4 vs 33.3 ± 6.6, P < .001) and heart rate recovery at 1 minute (12.1 ± 2.5 vs 14.2 ± 2.9 beats, P < .001).

CONCLUSIONS

Patients with HF and the comorbidity of COPD have significantly impaired CPX responses. This novel finding may impact the clinical interpretation of CPX data in patients with HF who also present with this chronic pulmonary condition.

[Chronic obstructive pulmonary disease - a review]

COPD is a preventable and treatable disease caused by exposure to tobacco smoke and poisonous gases. It is characterised by progressive obstruction of the airflow, irreversible once lesions occur in the parenchyma. This article aims to systematically review the disease and its treatment.

DISCUSSION

Smoking is the main cause of COPD and leads to decreased oxygenation via lung hyperinflation with reduced airflow as a systemic inflammatory process. This reduces resistance to fatigue of the skeletal musculature, leading to hypoxemia, decreased peripheral blood flow and also miscarriages and premature births. Inflammatory markers such as interleukins and TNF-alpha maintain the systemic picture. While smoking cessation improves hypoxemia and exercise intolerance, it does not repair damaged tissue. COPD is a serious disease which can be avoided by a wider understanding by the population of the harm smoking causes.

A health-related quality of life questionnaire in symptomatic patients with heart failure: validity and reliability of a Japanese version of the MRF28

BACKGROUND

Major characteristics of symptomatic patients with heart failure are exercise intolerance, poor prognosis, and poor quality of life (QOL). However, most QOL questionnaires are applicable for patients with mild to moderate heart failure, and are not sufficiently sensitive to discriminate between patients with NYHA classes III and IV. Therefore, it is necessary to prepare a questionnaire focused on patients with severe heart failure.

OBJECTIVES

We developed a Japanese version of the Maugeri Foundation Respiratory Failure (MRF28) questionnaire and assessed validity and reliability of MRF28 in heart failure patients.

METHODS

The MRF28 questionnaire was evaluated in 124 patients with heart failure (NYHA classes: I, 24; II, 31; III, 52; IV, 17). Reliability was evaluated by internal consistency and test-retest reliability. Validity was determined by correlation with World Health Organization Quality of Life (WHOQOL) questionnaire and physiological parameters.

RESULTS

The MRF28 showed high internal consistency and reproducibility. The total score and subscores were all increased with the progress of heart failure. The total score could differentiate patients among NYHA II, III, and IV, but could not between NYHA I and II. However, all subscores and total score changed consistently with changes in symptoms of heart failure.

CONCLUSION

MRF28 is a valid and reliable disease-specific questionnaire for assessing QOL in symptomatic patients with heart failure. Thus, this questionnaire may be useful for a QOL evaluation of patients with moderate to severe heart failure.