Mechanisms of physical activity limitation in chronic lung diseases

Are the gains from pulmonary rehabilitation the same in idiopathic pulmonary fibrosis and other interstitial lung diseases?

INTRODUCTION

In addition to dyspnoea and cough in interstitial lung diseases (ILD), the main symptom is decreased effort capacity. Pulmonary rehabilitation (PR)is recommended besides medical treatment approaches in chronic respiratory diseases. PR programs include approaches such as exercise training, patient and family training, nutritional assessment and support, psychosocial assessment and support. COPD patients more often directed to PR programs, besides that PR is also recommended for ILD. In this study, we aimed to evaluate the PR-related gains in patinets with IPF and non-IPF ILD.

METHODS

This retrospective study that we evaluated the PR data, demographic features of the patients with ILD who completed PR program between 2017 and 2020. PR was an 8-week (2days) outpatient PR program including aerobic and strengthening exercises. The 6-minute walking test (6MWT) results, quality of life scores that were recorded at the beginning and end of the PR program were evaluated.The patients were evaluated in two groups, patinets with IPF and non-IPF ILD.

RESULTS

A total of 56 patients (30 IPF, 26 non-IPF) with mean age 62±10 were included in the study. Among IPF patients 23 (77%) of them were receiving antifibrotic drugs. Non -IPF patients were: Unclassified ILD 9(16%), nonspecific interstitial pneumonia (NSIP) 8 (14%), sarcoidosis 3(%5), fibrotic hypersensitivity pneumonitis (fHP) 3 (5%), sjogren 2 (4%), scleroderma 1(2%). Both in IPF and non-IPF groups improvement in 6MWT, SGRQ total score after PR were statistically significantly improved (p= 0.001, p=0.002), (p= 0.001, p=0.018). Inspiratory muscle evaluation, MIP statistically increased after PR both in IPF and non-IPF patients (p= 0.015, p=0.028). There no significant differences in gains after PR program in walking capacity, quality of life, maximum inspiratory pressure between IPF and non-IPF patients.

CONCLUSION

PR programs provide significant gains both in patints with IPF and non-IPF ILD. It is important that patients should be directed to PR programs in the early stages of ILD.

Intensity-specific physical activity measured by accelerometer and the risk of mortality among individuals with cardiometabolic diseases: A prospective study from the UK Biobank

BACKGROUND

While the health benefits of physical activity for general population are well-recognized, the prospective associations of physical activity volume and intensity with mortality among cardiometabolic disease individuals remain unclear.

OBJECTIVE

The objective of this study was to investigate the associations of accelerometer-measured intensity-specific physical activity with mortality risk among population with cardiometabolic disease.

DESIGN

Prospective cohort study.

SETTING

Participants were recruited from the United Kingdom (UK) across 22 assessment centers from 2006 to 2010.

PARTICIPANTS

A total of 9524 participants from the UK Biobank (median: 67.00 years, interquartile range: 61.00-70.00 years) were included in final study.

METHODS

Accelerometer-measured total volume, moderate-to-vigorous and light intensity physical activity collecting from 2013 to 2015 were quantified using a machine learning model. Multivariable restricted cubic splines and Cox proportional hazard models with hazard ratios (HRs) and 95 % confidence intervals (CIs) were employed to examine the associations of interests.

RESULTS

During the follow-up period (median: 6.87 years; interquartile range: 6.32-7.39 years), there were 659 (6.92 %) death events with 218 (2.29 %) cardiovascular disease-related deaths and 441 (4.63 %) non-cardiovascular disease-related deaths separately. In the fully adjusted models, compared with participants in the lowest quartiles of total volume, moderate-to-vigorous and light physical activities, the adjusted HRs (95 % CIs) of all-cause mortality for those in the highest quartiles were 0.40 (0.31, 0.52), 0.48 (0.37, 0.61), and 0.56 (0.44, 0.71) while those for cardiovascular diseases-related mortality were 0.35 (0.22, 0.55), 0.52 (0.35, 0.78) and 0.59 (0.39, 0.88), and for non-cardiovascular diseases-related mortality, they were 0.42 (0.30, 0.59), 0.40 (0.29, 0.54) and 0.54 (0.40, 0.73), separately. The optimal moderate-to-vigorous-intensity physical activity level for cardiovascular diseases-related mortality reduction was found to be in the third quartile (17.75-35.33 min/day). Furthermore, the observed inverse associations were mainly non-linear.

CONCLUSIONS

Promoting physical activity, regardless of intensity, is essential for individuals with cardiometabolic disease to reduce mortality risk. For both all-cause and cardiovascular disease-related and non-cardiovascular disease-related mortality, the observed decrease in risk seems to level off at a moderate level. The current findings deriving from precise device-based physical activity data provide inference for secondary prevention of cardiometabolic disease.

Characteristics of Skeletal Muscle Strength in Subjects With Interstitial Lung Disease

OBJECTIVES

To investigate muscle strength and the prevalence of muscle weakness in adults with interstitial lung diseases (ILDs) compared to healthy subjects.

DESIGN

Cross-sectional (description of clinical features).

SETTING

Public referral center (University Hospital).

PARTICIPANTS

One hundred and twelve adults with ILD (n=48, 60±10yr, 68% female) and healthy counterparts (control group, n=64, 57±10yr, 58% female) (N=112).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE(S)

Muscle strength and prevalence of muscle weakness in adults with ILD. Muscle strength was assessed via maximal isometric voluntary contraction of dominant upper and lower limb muscle groups. Data from the control group were used to generate reference equations. Muscle weakness was defined as a muscle strength value below the lower limit of normal calculated using data from the control group. Data were expressed as mean ± SD or median [interquartile range] according to the data distribution.

RESULTS

Compared to the control group, adults with ILD had lower muscle strength for all muscle groups assessed (values presented as %predicted: pectoralis major 75[57-86]%; quadriceps 72[58-87]%; latissimus dorsi 76[57-103]%; deltoid 74[64-98]%; biceps brachii 78[64-91]%; triceps brachii 84[62-101]%; P≤.001 for all). Prevalence of muscle weakness in people with ILD was 40% for pectoralis major, 25% for latissimus dorsi, 16% for triceps brachii, 20% for biceps brachii, 27% for deltoid and 46% for quadriceps.

CONCLUSIONS

Adults with ILD present a generalised reduction in peripheral Muscle strength, ranging between 20% to 46% of people depending on the muscle group assessed. and it was more prevalent in lower limb muscles.

The impact of sleep duration on physical activity in daily life in patients with idiopathic pulmonary fibrosis

BACKGROUND

Despite the high prevalence of sleep disturbances in idiopathic pulmonary fibrosis (IPF), the relationship between physical activity in daily life (PADL) and sleep in this population remains unclear.

OBJECTIVES

Investigate the impact of sleep on different domains of PADL in IPF and characterize their PADL profile.

METHODS

Sixty-seven participants (thirty-three with IPF and thirty-four healthy subjects [control group]) were included. The subjects underwent assessments of pulmonary function, exercise capacity, respiratory and peripheral muscle strength, PADL, sleep, dyspnea, and health-related quality of life. PADL and sleep measures were assessed using an activity monitor (Actigraph®, wGT3x-BT). Associations between sleep and PADL were done using correlation and regression models.

RESULTS

In the IPF, sleep duration at night associated significantly with step counts, sedentary, light, and moderate-to-vigorous physical activity (MVPA) (-0.82 ≤ R ≤ 0.43; p < .05 for all). Lung function and sleep partially explained PADL variables (0.19 ≤ R2 ≤ 0.65, p < .05 for all). Compared to controls, the IPF subjects presented lower step counts, less time spent in MVPA, standing position, and more time spent in lying position (p < .05, for all).

CONCLUSIONS

Sleep duration is associated with PADL in IPF. The PADL profile of patients is worse than in control subjects.

Pulmonary Diseases in Older Patients: Understanding and Addressing the Challenges

As the global population ages, pulmonary diseases among older people have emerged as a significant and growing public health concern. The increasing incidence of these conditions has led to higher rates of morbidity and mortality among older adults. This perspective study offers a thorough overview of the prevalent pulmonary diseases affecting the elderly demographic. It delves into the challenges encountered during the diagnosis and management of these conditions in older individuals, considering factors such as comorbidities, functional limitations, and medication complexities. Furthermore, innovative strategies and personalized interventions such as precision medicine, advanced therapies, telemedicine solutions, and patient-centered support systems aimed at enhancing the care provided to older individuals grappling with pulmonary disorders are thoroughly explored. By addressing the unique needs and complexities of this vulnerable population, healthcare systems can strive towards improving outcomes and enhancing the quality of life for elderly individuals affected by pulmonary diseases.

Long-term reduced functional capacity and quality of life in hospitalized COVID-19 patients

Background

Persistent symptoms and exercise intolerance have been reported after COVID-19, even months after the acute disease. Although, the long-term impact on exercise capacity and health-related quality of life (HRQoL) is still unclear.

Research question

To assess the long-term functional capacity and HRQoL in patients hospitalized due to COVID-19.

Study design and methods

This is a prospective cohort study, conducted at two centers in Brazil, that included post-discharge COVID-19 patients and paired controls. The cohort was paired by age, sex, body mass index and comorbidities, using propensity score matching in a 1:3 ratio. Patients were eligible if signs or symptoms suggestive of COVID-19 and pulmonary involvement on chest computed tomography. All patients underwent cardiopulmonary exercise testing (CPET) and a HRQoL questionnaire (SF-36) 6 months after the COVID-19. The main outcome was the percentage of predicted peak oxygen consumption (ppVO2). Secondary outcomes included other CPET measures and HRQoL.

Results

The study sample comprised 47 post-discharge COVID-19 patients and 141 healthy controls. The mean age of COVID-19 patients was 54 ± 14 years, with 19 (40%) females, and a mean body mass index of 31 kg/m2 (SD, 6). The median follow-up was 7 months (IQR, 6.5-8.0) after hospital discharge. PpVO2 in COVID-19 patients was lower than in controls (83% vs. 95%, p = 0.002) with an effect size of 0.38 ([95%CI], 0.04-0.70). Mean peak VO2 (22 vs. 25 mL/kg/min, p = 0.04) and OUES (2,122 vs. 2,380, p = 0.027) were also reduced in the COVID-19 patients in comparison to controls. Dysfunctional breathing (DB) was present in 51%. HRQoL was significantly reduced in post COVID patients and positively correlated to peak exercise capacity.

Interpretation

Hospitalized COVID-19 patients presented, 7 months after discharge, with a reduction in functional capacity and HRQoL when compared to historical controls. HRQoL were reduced and correlated with the reduced peak VO2 in our population.

Comparison of Physical Activity Patterns among Three Major Chronic Respiratory Diseases

Although the level of physical activity in daily life (PADL) plays a vital role concerning the health of subjects with chronic lung diseases, it remains uncertain how PADL patterns compare among different conditions. This study's objective was to compare the PADL levels of subjects with COPD, asthma and idiopathic pulmonary fibrosis (IPF); and to investigate PADL behaviour in different diseases' severity. Stable subjects who had not undergone pulmonary rehabilitation in the previous year were included. Subjects were divided into two subgroups according to disease severity: mild/moderate and severe/very severe. The primary outcome was time spent in moderate-to-vigorous physical activities (MVPA) (Actigraph GT3x) measured during one week over 12 h/day; other assessments included pulmonary function, peripheral muscle strength and exercise capacity. Comparisons among subgroups were corrected for age, BMI and sex. The analysis involved 119 subjects (47 asthma, 48 COPD and 24 IPF). Subjects with asthma had higher PADL levels than those with COPD and IPF (MVPA 18(14-22) vs. 8(4-12) vs. 7(1-12) min/day, respectively; p ancova = 0.002). Subjects with severe/very severe IPF had the lowest PADL level among all subgroups. Adult subjects with asthma have higher PADL levels than those with COPD and IPF, whereas patients with severe and very severe IPF are the most physically inactive subjects.

The interplay of physical and cognitive function in rehabilitation of interstitial lung disease patients: a narrative review

Background and Objective

Interstitial lung disease (ILD) encompasses several diverse pulmonary pathologies that result in abnormal diffuse parenchymal changes. When prescribing rehabilitation, several additional factors need to be considered as a result of aging, polypharmacy, and comorbidities manifested in ILD patients. This review aims to discuss issues related to frailty, skeletal muscle and cognitive function that limit physical activities in ILD patients. It will also highlight exercise training and propose complementary strategies for pulmonary rehabilitation.

Methods

A literature search was performed in MEDLINE, CINAHL (inception to October 19th, 2022) using search terms based on concepts of: idiopathic pulmonary fibrosis or interstitial lung disease; frailty; muscular atrophy; skeletal muscle dysfunction; cognitive dysfunction; sleep quality; sleep disorders; anxiety disorders; or depressive disorders. After eligible texts were screened, additional references were included from references cited in the screened articles.

Key Content and Findings

Frailty and skeletal muscle dysfunction are common in ILD. Weight loss, exhaustion, and anti-fibrotic medications can impact frailty, whereas physical inactivity, aging, corticosteroids and hypoxemia can contribute to sarcopenia (loss of muscle mass and function). Frailty is associated with worse clinical status, exercise intolerance, skeletal muscle dysfunction, and decreased quality of life in ILD. Sarcopenia appears to influence wellbeing and can potentially affect overall physical conditioning, cognitive function and the progression of ILD. Optimal assessment tools and effective strategies to prevent and counter frailty and sarcopenia need to be determined in ILD patients. Even though cognitive impairment is evident in ILD, its prevalence and underlying neurobiological model of contributing factors (i.e., inflammation, disease severity, cardiopulmonary status) requires further investigation. How ILD affects cognitive interference, motor control and consequently physical daily activities is not well defined. Strategies such as pulmonary rehabilitation, which primarily focuses on strength and aerobic conditioning have demonstrated improvements in ILD patient outcomes. Future incorporation of interval training and the integration of motor learning could improve transfer of rehabilitation strategies to daily activities.

Conclusions

Numerous underlying etiologies of ILD contribute to frailty, skeletal muscle and cognitive function, but their respective neurobiologic mechanisms require further investigation. Exercise training increases physical measures, but complementary approaches may improve their applicability to improve daily activities.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Understanding the Impact of Pulmonary Rehabilitation on Airway Resistance in Patients with Severe COPD: A Single-Center Retrospective Study

Purpose

We investigated the effect of pulmonary rehabilitation (PR) on airway resistance in chronic obstructive pulmonary disease (COPD) patients with severe airway obstruction and hyperinflation.

Patients and Methods

This retrospective cohort study was conducted with data from severe COPD cases with those who underwent an 8-week PR program. Main inclusion criteria were having severe airflow obstruction (defined as a forced expiratory volume in one second (FEV₁) <50%) and plethysmographic evaluation findings being compatible with hyperinflation supporting the diagnosis of emphysema (presence of hyperinflation defined as functional residual capacity ratio of residual volume to total lung capacity (RV/TLC) >120%). Primary outcomes were airway resistance (R_aw) and airway conductance (G_aw) which were measured by body plethysmography, and other measurements were performed, including 6-minute walk test (6-MWT), modified Medical Research Council dyspnea scale (mMRC) and COPD assessment test (CAT).

Results

Twenty-six severe and very severe COPD patients (FEV_1, 35.0 ± 13.1%; RV/TLC, 163.5 ± 29.4) were included in the analyses, mean age 62.6 ± 5.8 years and 88.5% males. Following rehabilitation, significant improvements in total specific airway resistance percentage (sR_awtot%, p = 0.040) and total specific airway conductance percentage (sG_awtot%; p = 0.010) were observed. The post-rehabilitation mMRC scores and CAT values were significantly decreased compared to baseline results (p < 0.001 and p < 0.001, respectively). Although there were significant improvements in 6-MWT value (p < 0.001), exercise desaturation (ΔSaO₂, p = 0.026), the changes in measured lung capacity and volume values were not significant.

Conclusion

We concluded that PR may have a positive effect on airway resistance and airway conductance in COPD patients with severe airflow obstruction.

Breathlessness and exercise with virtual reality system in long-post-coronavirus disease 2019 patients

Long-post-coronavirus disease-2019 (COVID-19) patients tend to claim residual symptomatology from various systems, most importantly the respiratory and central nervous systems. Breathlessness and brain fog are the main complaints. The pulmonary function pattern is consistent with restrictive defects, which, in most cases, are self-resolved, while the cognitive profile may be impaired. Rehabilitation is an ongoing field for holistic management of long-post-COVID-19 patients. Virtual reality (VR) applications may represent an innovative implementation of rehabilitation. We aimed to investigate the effect of exercise with and without the VR system and to assess further breathlessness and functional fitness indicators in long-post-COVID-19 patients with mild cognitive impairment after self-selected exercise duration using the VR system. Twenty long-post-COVID-19 patients were enrolled in our study (age: 53.9 ± 9.1 years, male: 80%, body mass index: 28.1 ± 3.1 kg/m²). Participants' anthropometric data were recorded, and they underwent pulmonary functional test evaluation as well as sleep quality and cognitive assessment. The participants randomly exercised with and without a VR system (VR vs. no-VR) and, later, self-selected the exercise duration using the VR system. The results showed that exercise with VR resulted in a lower dyspnea score than exercise without VR. In conclusion, VR applications seem to be an attractive and safe tool for implementing rehabilitation. They can enhance performance during exercise and benefit patients with both respiratory and cognitive symptoms.

Cardiopulmonary exercise testing in patients with end-stage kidney disease: principles, methodology and clinical applications of the optimal tool for exercise tolerance evaluation

Chronic kidney disease (CKD), especially end-stage kidney disease (ESKD), is associated with an increased risk for cardiovascular events and all-cause mortality. Exercise intolerance as well as reduced cardiovascular reserve is extremely common in patients with CKD. Cardiopulmonary exercise testing (CPET) is a non-invasive, dynamic technique that provides an integrative evaluation of cardiovascular, pulmonary, neuropsychological and metabolic function during maximal or submaximal exercise, allowing the evaluation of functional reserves of these systems. This assessment is based on the principle that system failure typically occurs when the system is under stress and thus CPET is currently considered to be the gold standard for identifying exercise limitation and differentiating its causes. It has been widely used in several medical fields for risk stratification, clinical evaluation and other applications, but its use in everyday practice for CKD patients is scarce. This article describes the basic principles and methodology of CPET and provides an overview of important studies that utilized CPET in patients with ESKD, in an effort to increase awareness of CPET capabilities among practicing nephrologists.

Feasibility and acceptability of a physical activity behavioural modification tele-coaching intervention in lung transplant recipients

BACKGROUND

Despite improvements in pulmonary function following lung transplantation (LTx), physical activity levels remain significantly lower than the general population. To date, there is little research investigating interventions to improve daily physical activity in LTx recipients. This study assessed the feasibility and acceptability of a novel, 12-weeks physical activity tele-coaching (TC) intervention in LTx recipients.

METHODS

Lung transplant recipients within 2 months of hospital discharge were recruited and randomised (1:1) to TC or usual care (UC). TC consists of a pedometer and smartphone app, allowing transmission of activity data to a platform that provides feedback, activity goals, education, and contact with the researcher as required. Recruitment and retention, occurrence of adverse events, intervention acceptability and usage were used to assess feasibility.

RESULTS

Key criteria for progressing to a larger study were met. Of the 15 patients eligible, 14 were recruited and randomised to TC or UC and 12 completed (67% male; mean ± SD age; 58 ± 7 years; COPD n = 4, ILD n = 6, CF n = 1, PH n = 1): TC (n = 7) and UC (n = 5). TC was well accepted by patients, with 86% indicating that they enjoyed taking part. Usage of the pedometer was excellent, with all patients wearing it for over 90% of days and rating the pedometer and telephone contact as the most vital aspects. There were no adverse events related to the intervention. After 12 weeks, only TC displayed improvements in accelerometry steps/day (by 3475 ± 3422; p = .036) and movement intensity (by 153 ± 166 VMU; p = .019), whereas both TC and UC groups exhibited clinically important changes in physical SF-36 scores (by 11 ± 14 and 7 ± 9 points, respectively).

CONCLUSION

TC appears to be a feasible, safe, and well-accepted intervention in LTx.

Reduction of Emphysema Severity by Human Umbilical Cord-Derived Mesenchymal Stem Cells in Mice

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in chronic lung disease patients throughout the world. Mesenchymal stem cells (MSCs) have been shown to regulate immunomodulatory, anti-inflammatory, and regenerative responses. However, the effects of human-umbilical-cord-derived mesenchymal stem cells (hUC-MSCs) on the lung pathophysiology of COPD remain unclear. We aimed to investigate the role of hUC-MSCs in emphysema severity and Yes-associated protein (Yap) phosphorylation (p-Yap) in a porcine-pancreatic-elastase (PPE)-induced emphysema model. We observed that the emphysema percentages (normalized to the total lung volume) measured by chest computed tomography (CT) and exercise oxygen desaturation were significantly reduced by hUC-MSCs at 107 cells/kg body weight (BW) via intravenous administration in emphysematous mice (p < 0.05). Consistently, the emphysema index, as assessed by the mean linear intercept (MLI), significantly decreased with hUC-MSC administration at 3 × 106 and 107 cells/kg BW (p < 0.05). Changes in the lymphocytes, monocytes, and splenic cluster of differentiation 4-positive (CD4+) lymphocytes by PPE were significantly reversed by hUC-MSC administration in emphysematous mice (p < 0.05). An increasing neutrophil/lymphocyte ratio was reduced by hUC-MSCs at 3 × 106 and 107 cells/kg BW (p < 0.05). The higher levels of tumor necrosis factor (TNF)-α, keratinocyte chemoattractant (KC), and lactate dehydrogenase (LDH) in bronchoalveolar lavage fluid (BALF) were significantly decreased by hUC-MSC administration (p < 0.05). A decreasing p-Yap/Yap ratio in type II alveolar epithelial cells (AECII) of mice with PPE-induced emphysema was significantly increased by hUC-MSCs (p < 0.05). In conclusion, the administration of hUC-MSCs improved multiple pathophysiological features of mice with PPE-induced emphysema. The effectiveness of the treatment of pulmonary emphysema with hUC-MSCs provides an essential and significant foundation for future clinical studies of MSCs in COPD patients.

Impacts of aerobic exercise on children with asthma diagnosis: integrative review

Objective: To identify the impacts of aerobic exercise on the health of children with asthma, seeking to know protocols of rehabilitation programs and their impacts. Methods: Clinical trials published from 2010 to 2020 were selected, filtered by the descriptors: 'asthma', 'exercise' or 'physical training', 'children' OR 'adolescents' AND 'quality of life'. Results: Nineteen articles were included; the duration of the programs ranged from 4 to 24 weeks, 2 to 6 times/week, with the sessions varying from 30 min to 1h10min and intensity from 40% to 100% of the Maximum Heart Rate. The studies evaluated strength, lung capacity and function, inflammatory mediators, quality of life, and asthma control. Aerobic interventions made it possible to improve cardiorespiratory capacity, intracellular action of antioxidants, quality of life, and disease control. Significant results were found in protocols with playful exercises performed for 60 minutes, three times a week, and at least 12 weeks. Conclusion: The ease of reproducing the protocols can provide greater coverage of care and rehabilitation, which in the long term can help to reduce the hospitalization rate, cost, and hospital demand for severe exacerbations.

Management of musculoskeletal pain in patients with idiopathic pulmonary fibrosis: a review

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrotic, and fatal interstitial lung disease (ILD) of unknown etiology that primarily affects the elderly. Patients with IPF suffer from a heavy symptom burden and usually have a poor quality of life. Dyspnea and dry cough are predominant symptoms of IPF. Although pain is not considered one of the main symptoms of IPF, it can occur for a variety of reasons, such as hypoxia, coughing, muscle and nerve damage, deconditioning, and steroid use. The prevalence of pain in IPF patients varies greatly, ranging from around 30 to 80%, with the prevalence being estimated mostly among patients in the end-of-life period. It manifests itself in the form of muscle pain, joint discomfort, or back and chest pain. Approaches to the treatment of chronic musculoskeletal pain in patients with IPF include pharmacological and non-pharmacological measures that are also important to optimize the treatment of other symptoms (dyspnea and cough) and the optimal treatment of comorbidities. Given the scarcity of data on this symptom in the literature, this article summarizes what is currently known about the etiology and treatment of musculoskeletal pain in IPF.

Respiratory muscle strength, exercise capacity and physical activity in patients with primary ciliary dyskinesia: A cross-sectional study

BACKGROUND AND OBJECTIVES

The pathophysiological mechanisms of primary ciliary dyskinesia (PCD) may affect many functions, including respiratory, physical, and health status. This study aimed to compare respiratory muscle strength, inspiratory muscle endurance, muscle strength, exercise capacity, physical activity levels, and quality of life in PCD patients and controls.

METHODS

Twenty-seven patients and 28 controls were included. Respiratory muscle strength (maximal inspiratory (MIP) and maximal expiratory (MEP) pressures), inspiratory muscle endurance (incremental threshold loading test), muscle strength (quadriceps femoris, shoulder abductor, elbow flexor, handgrip), exercise capacity (6-min walk test (6MWT)), physical activity and quality of life (QOL-PCD) were evaluated.

RESULTS

MIP, inspiratory muscle endurance, quadriceps femoris, and handgrip muscle strength, 6MWT distance, total energy expenditure; childrens' (6-12 years) and their parents' physical function, upper, lower respiratory, and hearing symptoms and treatment burden QOL-PCD subscales scores were significantly lower in patients compared with controls (p < 0.05). The 66.7% of patients did not meet the optimal number of steps. MEP, shoulder abductor, and elbow flexor muscle strength, active energy expenditure, physical activity duration, average metabolic equivalents, number of steps, lying time, and sleep duration; childrens' and their parents' other subscales and adolescents' all QOL-PCD subscales scores were similar between groups (p > 0.05).

CONCLUSION

Inspiratory muscle strength and endurance, lower extremity and total muscle strength, exercise capacity, total energy expenditure, and childrens' quality of life are impaired compared to healthy controls. Decreased physical activity level is prevalent in these patients. Effects of pulmonary rehabilitation on these impaired outcomes for PCD patients should be investigated.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT03370029; December 12, 2017.

Inability to Work Fulltime, Prevalence and Associated Factors Among Applicants for Work Disability Benefit

Purpose Inability to work fulltime is an important outcome in the assessment of workers applying for a disability benefit. However, limited knowledge is available about the prevalence and degree of the inability to work fulltime, the associations between disease-related and socio-demographic factors with inability to work fulltime and whether the prevalence and the associations differ across disease groups. Methods Anonymized register data on assessments of workers with residual work capacity (n = 30,177, age 48.8 ± 11.0, 53.9% female) applying for a work disability benefit in 2016 were used. Inability to work fulltime was defined as being able to work less than 8 h per day. Results The prevalence of inability to work fulltime was 39.4%, of these 62.5% could work up to 4 h per day. Higher age (OR 1.01, 95% CI 1.01-1.01), female gender (OR 1.45, 95% CI 1.37-1.52), higher education (OR 1.44, 95% CI 1.33-1.55) and multimorbidity (OR 1.06, 95% CI 1.01-1.11) showed higher odds for inability to work fulltime. Highest odds for inability to work fulltime were found for diseases of the blood, neoplasms and diseases of the respiratory system. Within specific disease groups, different associations were identified between disease-related and socio-demographic factors. Conclusion The prevalence and degree of inability to work fulltime in work disability benefit assessments is high. Specific chronic diseases are found to have higher odds for inability to work fulltime, and associated factors differ per disease group.

Occupational Competence and Activities of Daily Living Performance in Bronchial Asthma : Compétence professionnelle et performance des activités de la vie quotidienne pour la bronchite asthmatique

Background. Activity restriction is one of the most common symptoms reported by people living with bronchial asthma. Purpose. The study aimed to determine occupational competence and values in people living with bronchial asthma and compare with the occupational competence and activities of daily living (ADL) of healthy controls. Methods. Twenty individuals with asthma and 20 healthy controls were enrolled. Occupational competence and values were assessed using the Occupational Self-Assessment (OSA) questionnaire. Restriction of ADL was determined using the London Chest ADL Scale. Findings. Occupational competence was lower, and all London Chest ADL scores were significantly higher in asthma individuals compared to controls (p < .05). The most affected parameters reported by asthma individuals on the OSA were the ability to concentrate, perform physical tasks, work toward goals, and use abilities effectively. Implications. Evaluating occupational competence in people living with bronchial asthma is important to identify their occupational problem areas and provide appropriate interventions.

Correlates of variability in endurance shuttle walk test time in patients with chronic obstructive pulmonary disease

Background

The endurance shuttle walk test (ESWT) is used to evaluate exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). The recommended pre-intervention tolerated duration (Tlim) is between 3–8 minutes for optimal interpretation of treatment effects. However, this window may be exceeded and factors determining ESWT Tlim are not completely understood. Therefore, we aimed to determine whether pulmonary function, physical and incremental shuttle walk test (ISWT) performance measures are associated with ESWT Tlim in COPD patients.

Methods

Assessment data from patients eligible for pulmonary rehabilitation was retrospectively analyzed. Inclusion criteria were: diagnosis of COPD and complete data availability regarding ESWT and ISWT. Patients performed an ESWT at 85% of ISWT speed and were divided into three groups (ESWT Tlim: <3 minutes, 3–8 minutes, >8 minutes). Subject characteristics, severity of complaints, pulmonary function, physical capacity and activity, exercise tolerance and quadriceps muscle strength were evaluated.

Results

245 COPD patients (FEV₁ 38 (29–52)% predicted) were included. Median ESWT Tlim was 6.0 (3.7–10.3) minutes, 41 (17%) patients walked <3 minutes and 80 (33%) patients walked >8 minutes. Body mass index, maximal oxygen consumption, Tlim on constant work rate cycle test, physical activity level, maximal ISWT speed, dyspnoea Borg score at rest and increase of leg fatigue Borg score during ISWT independently predicted Tlim in multivariate regression analysis (R² = 0.297, p<0.001).

Conclusion

This study reported a large variability in ESWT Tlim in COPD patients. Secondly, these results demonstrated that next to maximal ISWT speed, other ISWT performance measures as well as clinical measures of pulmonary function, physical capacity and physical activity were independent determinants of ESWT Tlim. Nevertheless, as these determinants only explained ~30% of the variability, future studies are needed to establish whether additional factors can be used to better adjust individual ESWT pace in order to reduce ESWT Tlim variability.

Assessment of Exercise Intolerance in Patients with Pre-Dialysis CKD with Cardiopulmonary Function Testing: Translation to Everyday Practice

BACKGROUND

Chronic kidney disease (CKD) is often characterized by increased prevalence of cardiovascular risk factors and increased incidence of cardiovascular events and death. Reduced cardiovascular reserve and exercise intolerance are common in patients with CKD and are associated with adverse outcomes.

SUMMARY

The gold standard for identifying exercise limitation is cardiopulmonary exercise testing (CPET). CPET provides an integrative evaluation of cardiovascular, pulmonary, hematopoietic, neuropsychological, and metabolic function during maximal or submaximal exercise. It is useful in clinical setting for differentiation of the causes of exercise intolerance, risk stratification, and assessment of response to relevant treatments. A number of recent studies have used CPET in patients with pre-dialysis CKD, aiming to assess the cardiovascular reserve of these individuals, as well as the effect of interventions such as exercise training programs on their functional capacity. This review provides an in-depth description of CPET methodology and an overview of studies that utilized CPET technology to assess cardiovascular reserve in patients with pre-dialysis CKD. Key Messages: CPET can delineate multisystem changes and offer comprehensive phenotyping of factors determining overall cardiovascular risk. Potential clinical applications of CPET in CKD patients range from objective diagnosis of exercise intolerance to preoperative and long-term risk stratification and providing intermediate endpoints for clinical trials. Future studies should delineate the association of CPET indexes, with cardiovascular and respiratory alterations and hard outcomes in CKD patients, to enhance its diagnostic and prognostic utility in this population.

Six-minute stepper test in hospitalized elderly patients: Convergent validity, test-retest reliability and safety

OBJECTIVE

To evaluate the convergent validity of the six-minute stepper test (6MST) with the variables used in the diagnosis of sarcopenia (appendicular muscle mass, handgrip strength and six-meter gait speed test), as well as to evaluate test-retest reliability and safety when applied to hospitalized elderly patients. Finally, we aimed to compare the performance in the 6MST between hospitalized elderly patients and healthy elderly from the community.

MATERIALS AND METHODS

Observational and cross-sectional study. Elderly patients admitted to a private hospital and healthy elderly from the community were recruited. On the first day, the patients included underwent the following assessments: anthropometric, handgrip strength (HGS), six-meter gait speed test (6GST) and 6MST. On the second day, before breakfast, patients underwent body composition assessment. The healthy elderly were evaluated on a single day and performed only anthropometric assessment and 6MST.

RESULTS

30 hospitalized patients (age 71.0±7.9 years) and 15 healthy elderly (age 68.1±5.8 years) were included. There was a high correlation of 6MST with 6GST (r = 0.78; p<0.001), moderate correlation with HGS (r = 0.59; p<0.001) and low correlation with appendicular muscle mass (r = 0.45; p = 0.01). There was no statistical difference between the first and second 6MST performed by hospitalized elderly (196.2±91.0 cycles vs. 191.3±103.7 cycles; p = 0.66), in addition to an excellent agreement between these measures (ICC = 0.90; 95% IC 0.78-0.95). Only one adverse event (3.3%) occurred in the sample.

CONCLUSION

6MST showed convergent validity with the functional variables used in the diagnosis of sarcopenia. In addition, excellent test-retest reliability was observed, which indicates the need for a single assessment in hospitalized elderly patients. The prevalence of adverse events during the application of the test is low, without resulting in clinical symptoms; therefore, the test is considered safe for this population. In addition, hospitalized elderly patients perform worse in the 6MST compared to healthy elderly from the community.

Corticosteroids are associated with reduced skeletal muscle function in interstitial lung disease patients with mild dyspnea

BACKGROUND

Interstitial lung diseases (ILDs) patients receiving steroid treatment tend to be immobilized by dyspnea and muscle weakness as the disease progresses. We therefore expected that steroid treatment for ILDs would have a greater effect on muscle function under severe dyspnea. To test this hypothesis, we evaluated whether the effect of corticosteroid treatment on peripheral muscle force and exercise capacity varied according to patients' dyspnea severity.

METHODS

In this retrospective cross-sectional study of 87 ILD patients enrolled between 2008 and 2017, quadriceps force (QF), handgrip force (HF), and 6-min walk distance (6 MWD) were compared between a low (grades 0-2) and a high (grades 3-4) modified-Medical Research Council (mMRC) dyspnea scale score group.

RESULTS

In patients with lower levels of dyspnea, corticosteroid treatments were associated with lower QF and HF (20.0 vs. 30.0 kgf, p = 0.01; 22.5 vs. 28.4 kgf, p = 0.03, respectively) values; however, no significant differences were observed between the corticosteroid and control subgroups in the high mMRC group (QF: 18.5 vs. 17.3 kgf, p = 0.64; HF: 21.0 vs. 17.1 kgf, p = 0.24, respectively). Analysis of covariance indicated that both corticosteroid treatment and mMRC dyspnea scale interacted with QF, HF, and 6 MWD. The effects of the corticosteroid treatment varied according to the level of dyspnea (interaction β = 7.52, p = 0.034; interaction β = 8.78, p = 0.048; interaction β = 131.08, p < 0.001).

CONCLUSIONS

Muscle weakness and exercise capacity in ILD patients in the low mMRC group were associated with corticosteroid treatment.

Patients with asthma have reduced functional capacity and sedentary behavior

OBJECTIVE

The modified shuttle test is a field test that avoids the ceiling effect, and there are no reports of a multidimensional assessment concerning physical activity in asthmatic patients. Thus, the aim was to evaluate functional capacity by MST, additionally to perform a multidimensional assessment as physical activity in daily life, muscle strength, and cytokine levels in children and adolescents with asthma, and to correlate these variables.

METHOD

This cross-sectional study included volunteers aged between 6 and 18 years who were divided into two groups: asthma group (n=43) that received regular treatment and control group (n=24). Functional capacity was evaluated by distance walked during the MST; physical activity in daily life was evaluated using an accelerometer by the number of steps. Quadriceps femoris strength was evaluated by load cell.

RESULTS

Distance walked was lower for the asthma group (790m [222m]) when compared with the control group (950m [240m]; p=0.007); however, the number of steps was similar between the two groups (asthma group: 7743 [3075]; control group: 7181 [3040]; p=0.41), and both groups were classified as sedentary behavior. There was no difference in muscle strength. Tumor necrosis factor-α differed, but interleukin levels were similar between groups. Quadriceps strength was correlated to distance walked (r=0.62; p<0.001) and tumor necrosis factor-α to the number of steps taken (r=-0.54, p=0.005).

CONCLUSION

Children and adolescents undergoing regular asthma treatment showed reduced functional capacity and sedentary behavior. The lower the quadriceps strength, the shorter the distance walked; the higher the tumor necrosis factor-α levels, the lower their daily physical activity levels.

Physical activity of patients with bronchiectasis compared with healthy counterparts: A cross-sectional study

BACKGROUND

A few studies have implied that patients with bronchiectasis have a more inactive lifestyle than healthy counterparts do. The main objective of this study was to compare physical activity (PA) levels subjectively and objectively between patients with bronchiectasis and healthy individuals using an accelerometer and a questionnaire.

METHODS

The study included 41 patients with bronchiectasis aged 18-65 years and 35 healthy age- and sex-matched control subjects. The PA level was assessed objectively using a multisensorial PA monitor, the SenseWear Armband (SWA), and subjectively with the International Physical Activity Questionnaire (IPAQ). All participants performed the incremental shuttle walk test (ISWT) for the assessment of exercise capacity. Pulmonary function, dyspnea, severity of bronchiectasis, respiratory and peripheral muscle strength, and quality of life were assessed.

RESULTS

The pulmonary function test parameters, respiratory and peripheral muscle strength, exercise capacity, step count, moderate- and vigorous-intensity PA duration were significantly lower in patients with bronchiectasis than in the healthy control group (p < 0.05). Sedentary, moderate, vigorous, and total PA duration measured using the SWA were higher than those obtained using the IPAQ (p < 0.05).

CONCLUSIONS

Patients with bronchiectasis have a reduced PA level compared with healthy counterparts. The IPAQ (based on the subjective estimation of PA) outcomes differed from the SWA outcomes, reinforcing the necessity for a disease-specific PA questionnaire. IPAQ underestimates the physical activity level compared with objective measurements.

Physical activity of UK adults with chronic disease: cross-sectional analysis of accelerometer-measured physical activity in 96 706 UK Biobank participants

BACKGROUND

Physical inactivity is associated with an increased risk of major chronic diseases, although uncertainty exists about which chronic diseases, themselves, might contribute to physical inactivity. The objective of this study was to compare the physical activity of those with chronic diseases to healthy individuals using an objective measure of physical activity.

METHODS

We conducted a cross-sectional analysis of data from 96 706 participants aged 40 years or older from the UK Biobank prospective cohort study (2006-10). Diagnoses were identified through ICD 9 and 10 coding within hospital admission records and a cancer registry linked to UK Biobank participants. We extracted summary physical activity information from participants who wore a wrist-worn triaxial accelerometer for 7 days. Statistical analyses included computation of adjusted geometric means and means using general linear models.

RESULTS

Participants with chronic disease undertook 9% or 61 minutes (95% confidence interval: 57.8-64.8) less moderate activity and 11% or 3 minutes (95% confidence interval: 2.7-3.3) less vigorous activity per week than individuals without chronic disease. Participants in every chronic-disease subgroup undertook less physical activity than those without chronic disease. Sixty-seven diagnoses within these subgroups were associated with lower moderate activity.

CONCLUSIONS

The cross-sectional association of physical activity with chronic disease is broad. Given the substantial health benefits of being physically active, clinicians and policymakers should be aware that their patients with any chronic disease are at greater health risk from other diseases than anticipated because of their physical inactivity.

Visual analogue scales for interstitial lung disease: a prospective validation study

BACKGROUND

Visual analogue scales (VAS) are simple symptom assessment tools which have not been validated in interstitial lung disease (ILD). Simple measures of ILD disease burden would be valuable for non-specialist clinicians monitoring disease away from ILD specialist centres.

OBJECTIVE

To validate VAS to assess change in dyspnoea, cough and fatigue in ILD, and to define the minimal clinically important difference (MCID) for change in these.

METHODS

Patients of 64 with ILD completed VAS for dyspnoea, cough and fatigue. Baseline King's Brief ILD questionnaire (K-BILD) scores, lung function and 6-min walk test results were collected. Tests were repeated 3-6 months later, in addition to a seven-point Likert scale. The MCID was estimated using median change in VAS in patients who reported 'small but just worthwhile change' in symptoms at follow-up. Methods were repeated in a validation cohort of 31 ILD patients to confirm findings.

RESULTS

VAS scores were significantly higher for patients who reported a 'small but just worthwhile change' in symptoms vs. 'no change' or 'not worthwhile change' (P < 0.01). The MCID for VAS Dyspnoea was estimated as 22.0 mm and 14.5 mm for VAS Fatigue. These results were reproducible in the validation cohort. Results were not significant for VAS Cough. Change in VAS Dyspnoea correlated with change in K-BILD (r = -0.51, P < 0.01), forced vital capacity (r = -0.32, P = 0.01) and 6-min walking distance (r = -0.37, P = 0.01).

CONCLUSION

The VAS is valid for assessing change in dyspnoea and fatigue in ILD. The MCID is estimated as 22.0 mm for dyspnoea and 14.5 mm for fatigue. This could be used to monitor disease in settings away from ILD specialist review.

MESH DESCRIPTORS

Lung Diseases, Interstitial, Dyspnoea, Fatigue, Cough.

Cerebral oxygen availability during exercise in COPD patients with cognitive impairment

Insufficient cerebral blood flow regulation to meet increasing metabolic demand during physical exertion could be associated with cognitive impairment. We compared cerebral oxygen availability during exercise in cognitively impaired (CI) to cognitively normal (CN) COPD patients. Fifty-two patients (FEV₁: 51 ± 16%) were classified as CN or CI according to the Montreal Cognitive Assessment. Patients performed cycle-ergometry at 75% peak capacity with continuous measurement of Near-Infrared Spectroscopy frontal-cortex Tissue oxygen Saturation Index (TSI), cerebral haemoglobin indices (oxy/deoxy/total- Hb), transcutaneous carbon-dioxide partial pressure (TcPCO₂), and arterial oxygen saturation (SpO₂). Twenty-one patients (40%) presented evidences of CI. During exercise, CN and CI patients exhibited mild to moderate SpO₂decline (nadir[Δ]≥ -3 ± 2% and -5 ± 3%, respectively) but preserved baseline frontal-cortex TSI levels, whilst presenting small TcPCO₂ perturbations and increased cerebral total-Hb (post [Δ]≥ 2.0 ± 3 μM sec^-1). CI patients preserve the capacity to adequately maintain cerebral oxygen availability during submaximal exercise. Therefore, rehabilitative exercise training in CI patients with COPD exhibiting mild to moderate exercise-induced SpO₂ decline does not appear to lead to reduced cerebral oxygen availability.

ERS International Congress 2017: a peek of outstanding abstracts from the clinical assembly

This review highlights a selection of abstracts from the 2017 ERS International Congress in Milan presented by the clinical assembly's groups of interventional pulmonology, general practice and primary care and rehabilitation and chronic care. Attention is brought to the increasing burden of disease of COPD and end-stage emphysema patients in China. The considerable efforts of Chinese pulmonary centers to conduct multicenter, randomized and controlled trials, investigating the possibilities of bronchoscopic lung volume reduction is underlined in the review. Furthermore, the key objectives of asthma management are stressed. We point out presentations emphasizing on achieving good control of daily symptoms and reducing the risk of asthma exacerbations. The findings of a randomized clinical trial evaluating the role of oxygen supplementation in rehabilitation therapy of COPD patients are analyzed. Additionally, another randomized clinical trial researching the influence of whole body vibration training (WBVT) in long-term (>1 year) lung transplant patients are discussed.

Influence of resting lung diffusion on exercise capacity in patients with COPD

Background

Lung diffusing capacity for carbon monoxide (DLCO) gives an overall assessment of functional lung surface area for gas exchange and can be assessed using various methods. DLCO is an important factor in exercise intolerance in patients with chronic obstructive pulmonary disease (COPD). We investigated if the intra-breath (IBDLCO) method may give a more sensitive measure of available gas exchange surface area than the more typical single breath (SBDLCO) method and if COPD subjects with the largest resting DLCO relative to pulmonary blood flow (Qc) would have a more preserved exercise capacity.

Methods

Informed consent, hemoglobin, spirometry, SBDLCO, IBDLCO, and Qc during IBDLCO were performed in moderate to severe COPD patients, followed by progressive cycle ergometry to exhaustion with measures of oxygen saturation (SaO₂) and expired gases.

Results

Thirty two subjects (47% female, age 66 ± 9 yrs., BMI 30.4 ± 6.3 kg/m², smoking hx 35 ± 29 pkyrs, 2.3 ± 0.8 on the 0-4 GOLD classification scale) participated. The majority used multiple inhaled medications and 20% were on oral steroids. Averages were: FEV₁/FVC 58 ± 10%Pred, peak VO₂ 11.4 ± 3.1 ml/kg/min, and IBDLCO 72% of the SBDLCO (r = 0.88, SB vs IB methods). Using univariate regression, both the SB and IBDLCO (% predicted but not absolute) were predictive of VO₂peak in ml/kg/min; SBDLCO/Qc (r = 0.63, p < 0.001) was the best predictor of VO₂peak; maximal expiratory flows over the mid to lower lung volumes were the most significantly predictive spirometric measure (r = 0.49, p < 0.01). However, in multivariate models only BMI added additional predictive value to the SBDLCO/Qc for predicting aerobic capacity (r = 0.73). Adjusting for current smoking status and gender did not significantly change the primary results.

Conclusion

In patients with moderate to severe COPD, preservation of lung gas exchange surface area as assessed using the resting SBDLCO/Qc appears to be a better predictor of exercise capacity than more classic measures of lung mechanics.

Daily physical activity affects exercise capacity in patients with idiopathic pulmonary fibrosis

[Purpose] The aim of this study was to determine which factors, including pulmonary, physical, and mental functions; dyspnea; and daily physical activity (PA) affect the 6-minute walk distance (6MWD) in IPF patients. [Subjects and Methods] The pulmonary, physical, and mental functions; dyspnea; PA; and 6MWD were assessed in 38 outpatients with IPF. PA was represented by the mean number of steps per day. [Results] The mean 6MWD was 443.8 m (SD, 98.5), and the mean number of steps per day showing PA was 5148.4 (SD, 3295.7). The 6MWD was correlated with age, base dyspnea index, vital capacity (VC), diffusion capacity of carbon monoxide, quadriceps force (QF), dyspnea during the 6-minute walk test, and PA. Stepwise multiple regression analysis revealed that VC (β=0.382), QF (β=0.272), and PA (β=0.574) were contributing factors of the 6MWD. [Conclusion] In patients with IPF, PA has a greater effect on the 6MWD than VC and QF. The evaluation of daily PA, in addition to physiological and muscle functions, is important in patients with IPF.

Chronic allergic pulmonary inflammation is aggravated in angiotensin-(1-7) Mas receptor knockout mice

The angiotensin-(1-7) [ANG-(1-7)]/Mas receptor pathway is currently recognized as a counterbalancing mechanism of the renin-angiotensin system in different pathophysiological conditions. We have previously described that treatment with ANG-(1-7) attenuates lung inflammation and remodeling in an experimental model of asthma. In the present study, we investigated whether lack of the Mas receptor could alter the inflammatory response in a model of chronic allergic lung inflammation induced by ovalbumin (OVA). Mas receptor wild-type (MasWT) and knockout (MasKO) mice were subjected to four doses of OVA (20 μg/mice ip) with a 14-day interval. At the 21st day, nebulization with OVA (1%) was started, three times per week until the 46th day. Control groups received saline (0.9% ip) and were nebulized with saline (0.9%). MasWT-OVA developed a modest inflammatory response and minor pulmonary remodeling to OVA challenge. Strikingly, MasKO-OVA presented a significant increase in inflammatory cell infiltrate, increase in extracellular matrix deposition, increase in thickening of the alveolar parenchyma, increase in thickening of the smooth muscle layer of the pulmonary arterioles, increase in proinflammatory cytokine and chemokine levels in the lungs, characteristic of chronic asthma. Additionally, MasKO-OVA presented an increase in ERK1/2 phosphorylation compared with MasWT-OVA. Furthermore, MasKO-OVA showed a worse performance in a test of maximum physical exercise compared with MasWT-OVA. Our study shows that effects triggered by the Mas receptor are important to attenuate the inflammatory and remodeling processes in a model of allergic lung inflammation in mice. Our data indicate that impairment of the ANG-(1-7)/Mas receptor pathway may lead to worsening of the pathophysiological changes of asthma.

Determinants of exercise-induced oxygen desaturation including pulmonary emphysema in COPD: Results from the ECLIPSE study

Exercise-induced oxygen desaturation (EID) is related to mortality in patients with chronic obstructive pulmonary disease (COPD). We investigated: (1) the prevalence of EID; (2) the relative-weight of several physiological determinants of EID including pulmonary emphysema, and (3) the relationship of EID with certain patients' clinical characteristics. Data from 2050 COPD patients (age: 63.3 ± 7.1years; FEV₁: 48.7 ± 15.7%pred.) were analyzed. The occurrence of EID (SpO₂post ≤88%) at the six-minute walking test (6MWT) was investigated in association with emphysema quantified by computed-tomography (QCT), and several clinical characteristics. 435 patients (21%) exhibited EID. Subjects with EID had more QCT-emphysema, lower exercise capacity and worse health-status (BODE, ADO indexes) compared to non-EID. Determinant of EID were obesity (BMI≥30 kg/m²), impaired FEV₁ (≤44%pred.), moderate or worse emphysema, and low SpO₂ at rest (≤93%). Linear regression indicated that each 1-point increase on the ADO-score independently elevates odds ratio (≤1.5fold) for EID. About one in five COPD patients in the ECLIPSE cohort present EID. Advanced emphysema is associated with EID. In addition, obesity, severe airflow limitation, and low resting oxygen saturation increase the risk for EID. Patients with EID in GOLD stage II have higher odds to have moderate or worse emphysema compared those with EID in GOLD stage III-IV. Emphysematous patients with high ADO-score should be monitored for EID.

Activity limitation and exertional dyspnea in adult asthmatic patients: What do we know?

Limitation of activity is the most cited symptom described by uncontrolled asthma patients. Assessment of activity limitation can be undertaken through several ways, more or less complex, subjective or objective. Yet little is known about the link between patients sensations and objective measurements. The present review reports the current knowledge regarding activity limitation and symptom perception (i.e., exertional dyspnea) in adult patients with asthma. This work is based on references indexed by PubMed, irrespective of the year of publication. Overall, patients with stable asthma do not have a more sedentary lifestyle than healthy subjects. However, during a cycle ergometric test, the maximal load is reduced when FEV1, FVC and muscle strengths are decreased. Additionally, during the six-minute walking test, mild asthma patients walk less than healthy subjects even if the minimal clinically important difference is not reached. The major complaint of asthma patients when exercising is dyspnea that is mainly related to the inspiratory effort and also to dynamic hyperinflation in some circumstances. Finally, the administration of bronchodilator does not improve the ventilatory pattern and the exercise capacity of asthma patients and little is known on its effect on exertional dyspnea. The present review allows to conclude that until now there is no gold standard test allowing the objective assessment of "activity limitation and exertional dyspnea" in asthma patients.

Safety of Nurse-Led Ambulation for Patients on Venovenous Extracorporeal Membrane Oxygenation

PURPOSE

Venovenous extracorporeal membrane oxygenation (VV ECMO) is an effective therapy in patients with acute lung injury and end-stage lung disease. Although immobility increases the risk of complications, ambulation of patients on VV ECMO is not the standard of care in many institutions. Staff concerns for patient safety remain a barrier to ambulation. In this case series, we present our experience utilizing a nurse-driven ambulatory VV ECMO process to safely rehabilitate patients.

METHODS

We retrospectively reviewed all VV ECMO cases at our institution between January 1, 2011, and November 1, 2013. Inclusion criteria for this study required patients to be cannulated in the right internal jugular vein and ambulated while on VV ECMO.

RESULTS

During the period from January 1, 2011, to November 1, 2013, 18 patients (mean age 49 ± 15 years, 12 male) were ambulated while on ECMO. Eight received a transplant and survived to discharge. Of the remaining patients, 4 were successfully weaned from VV ECMO and 6 died following decisions by the family to withdraw care. The mean duration of VV ECMO support was 18 ± 16 days with the maximum duration being 61 days. All patients received physical therapy, range of motion at the bedside, and ambulated in the hospital. There were no patient falls, decannulations, or any other complications related to ambulation.

CONCLUSION

The adoption of a nurse-driven program to ambulate patients on VV ECMO is safe and may reduce other complications associated with immobility.

Effects of a pulmonary rehabilitation program on physical capacity, peripheral muscle function and inflammatory markers in asthmatic children and adolescents: study protocol for a randomized controlled trial

Background

Individuals with chronic lung disease are more susceptible to present reduction in exercise tolerance and muscles strength not only due to pulmonary limitations but also due systemic repercussions of the pulmonary disease.

The aim of this study is to assess the physical capacity, peripheral muscle function, physical activity in daily life, and the inflammatory markers in children and adolescents with asthma after pulmonary rehabilitation program.

Method

This is a study protocol of randomized controlled trial in asthmatic patients between 6 to 18 years old. The assessments will be conducted in three different days and will be performed at the beginning and at the end of the protocol. First visit: quality of life questionnaire, asthma control questionnaire, pre- and post-bronchodilator spirometry (400 μcg salbutamol), inflammatory assessment (blood collection), and cardiopulmonary exercise test on a cycle ergometer to determine aerobic capacity. Second visit: assessment of strength and endurance of the quadriceps femoris and biceps brachii muscles with concomitant electromyography to assess peripheral muscle strength. Third visit: incremental shuttle walk test (ISWT) and accelerometer to evaluate functional capacity and physical activity in daily life during 7 days. Then, the volunteers will be randomized to receive pulmonary rehabilitation program (intervention group) or chest physiotherapy + stretching exercises (control group). Both groups will have a supervised session, twice a week, each session will have 60 minutes duration, with minimum interval of 24 hours, for a period of 8 weeks. Intervention group: aerobic training (35 minutes) intensity between 60 to 80 % of the maximum workload of cardiopulmonary exercise testing or of ISWT; strength muscle training will be applied to the quadriceps femoris, biceps brachii and deltoid muscles (intensity: 40 to 70 % of maximal repetition, 3 x 8 repetition); finally the oral high-frequency oscillation device (Flutter®) will be used for 5 minutes. The control group: oral high-frequency oscillation device (Flutter®) for 10 minutes followed by the stretching of upper and lower limbs for 40 minutes. It is expected to observe the improvement in aerobic capacity, physical activity in daily life, muscle strength and quality of life of patients in the intervention group, and reduction in inflammatory markers.

Trial registration

Clinical Trial Number: NCT02383069. Data of registration: 03/03/2015

Noninvasive tests for the diagnostic evaluation of dyspnea among outpatients: the Multi-Ethnic Study of Atherosclerosis lung study

BACKGROUND

Dyspnea on exertion is a common and debilitating symptom, yet evidence for the relative value of cardiac and pulmonary tests for the evaluation of chronic dyspnea among adults without known cardiac or pulmonary disease is limited.

METHODS

The Multi-Ethnic Study of Atherosclerosis (MESA) enrolled participants aged 45 to 84 years who were free of clinical cardiovascular disease from 6 communities; participants with clinical pulmonary disease were excluded from this report. Dyspnea on exertion was assessed via structured interview. Tests included electrocardiograms, cardiac computed tomography (CT) for coronary artery calcium, cardiac magnetic resonance imaging, spirometry, percent emphysema (percent of lung regions <-950 HU) on CT, inflammatory biomarkers, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Logistic regression was used to identify independent correlates of dyspnea after adjustment for age, sex, body mass index, physical activity, anxiety, and leg pain.

RESULTS

Among 1969 participants without known cardiopulmonary disease, 9% had dyspnea. The forced expiratory volume in 1 second (FEV1) (P < .001), NT-proBNP (P = .004), and percent emphysema on CT (P = .004) provided independent information on the probability of self-reported dyspnea. Associations with the FEV1 were stronger among smokers and participants with other recent respiratory symptoms or seasonal allergies; associations with NT-proBNP were present only among participants with coexisting symptoms of lower-extremity edema. Only the FEV1 provided a significant improvement in the receiver operating curve.

CONCLUSIONS

Among adults without known cardiac or pulmonary disease reporting dyspnea on exertion, spirometry, NT-proBNP, and CT imaging for pulmonary parenchymal disease were the most informative tests.

Associations of the antioxidant capacity and hemoglobin levels with functional physical performance of the upper and lower body limbs

Herein we considered the role of oxidative stress on deficiencies of functional physical performance that could affect a future pre-frailty condition. Using principal component analyses (PCA), we created new variables to better describe the functionality regarding the physical performance of the upper and lower body limbs. Gait speed and the Short Physical Performance Battery (SPPB) score were classified by PCA to describe functional performance of the lower body limbs. Variables describing the general physical status, including weekly consumption of kilocalories and the musculoskeletal index, were classified together with grip strength of the dominant hand as indicators of functional performance of the upper body limbs. An intimate association between the functional physical performance of the upper body limbs and the total antioxidant capacity was observed in older subjects. Low levels of total antioxidant capacity were found in women 76 years or younger with deficiencies in the physical performance of both upper and lower body limbs. Similarly, we observed a close association between the functional physical performance of the lower body limbs and the levels of hemoglobin. In particular, low levels of hemoglobin were mostly found in men older than 76 years of age, showing impaired functional physical performance. In addition, the physical performance of the lower body limbs was shown to be more important than that of the upper body limbs in the statistical association with pre-frailty in the elderly. Therefore, specific low levels of hemoglobin and deficient oxidative defense in the elderly could significantly affect the functional physical performance and future outcomes of pre-frailty.