Short-Term Health Outcomes of a Structured Pulmonary Rehabilitation Program Implemented Within Rural Canadian Sites Compared With an Established Urban Site: A Pre-Post Intervention Observational Study

OBJECTIVES

To evaluate congruence in program delivery and short-term health outcomes of a structured pulmonary rehabilitation (S-PR) program implemented at 11 Canadian rural pulmonary rehabilitation (PR) sites compared with an urban reference site.

DESIGN

Multi-center, pre- and post-intervention, comparative, observational study.

SETTING

Eleven rural Canadian PR sites and 1 urban reference PR site.

PARTICIPANTS

Adults with chronic respiratory diseases (CRDs) referred to PR.

INTERVENTION

Clinicians at the reference site worked with local clinicians to implement the S-PR program in rural sites. A PR survey evaluated site congruence with the S-PR components, with congruence defined as delivering program components ≥80% in alignment with the S-PR program. Participants were enrolled in 16 sessions of group education and supervised exercise, offered twice or thrice a week. Health outcomes were tracked using a quality assurance database.

OUTCOME MEASURES

Main outcomes were congruence in program delivery and changes in the 6-minute walk (6MW) distance and COPD Assessment Test (CAT).

RESULTS

A total of 555 participants (rural n=204 and reference n=351) were included in the analyses. There was congruence in exercise and group education; however, individual education varied. Following the S-PR program, 6MW distance increased, with greater changes observed at rural sites (51±67 m at rural sites vs 30±46 m at the reference site). CAT score was reduced by -2.6±5.4 points with no difference between reference and rural sites. Changes in 6MW distance and CAT scores were similar for participants at sites that were congruent vs noncongruent with the individual education component, and similar for patients with COPD, asthma, bronchiectasis, and interstitial lung disease.

CONCLUSION

The S-PR program components can be implemented with good congruence in Canadian rural settings, resulting in similar short-term health outcomes as in an established urban site and across CRDs.

Pulmonary rehabilitation of chronic pulmonary diseases (the review of clinical trials, national and international recommendations)

The review of data from randomized clinical trials, results of systematic reviews, international and national clinical recommendations on the problem of pulmonary rehabilitation in chronic pulmonary disease was carried out. This analysis of the studies included the databases eLibrary, Medline, PubMed and Cochrane libraries on the problem of pathophysiology and methods of physical rehabilitation of chronic pulmonary disease. The analysis took into account the opinions of expert groups of clinical recommendations developers of the Russian respiratory society, the European respiratory society, and the American thoracic society, presented in this review. The data of studies confirm the clinical effectiveness of physical rehabilitation methods for chronic pulmonary disease that take into account the unique needs of a complex patient. Pulmonary rehabilitation improves the physical activity, quality of life associated with health, reduces the incidence of exacerbations and mortality of patients with chronic pulmonary disease. Increasing the availability and improving pulmonary rehabilitation programs based on individual assessment of the patient's physical capabilities will increase the use of this method of treatment.

Effectiveness of high-flow nasal cannula on pulmonary rehabilitation in subjects with chronic respiratory failure

BACKGROUND

The effects of exercise training using both high fraction of inspired oxygen (F_IO₂) and high flow oxygen delivered through a high-flow nasal cannula (HFNC) on exercise capacity in patients with chronic respiratory failure (CRF) receiving long-term oxygen therapy (LTOT) are unknown.

METHODS

In this randomized study, 32 patients with CRF receiving LTOT were assigned to undergo 4 weeks of exercise training on a cycle ergometer using an HFNC (flow: 50 L/min) with a F_IO₂ of 1.0 (HFNC group; n = 16) or ordinary supplemental oxygen via a nasal cannula (flow: 6 L/min) (oxygen group; n = 16). A 6-min walking test and a constant-load test were performed before and after 4 weeks of exercise training.

RESULTS

Following 4 weeks of exercise training, change in the 6-min walking distance was significantly greater in the HFNC than in the oxygen group (55.2 ± 69.6 m vs. -0.5 ± 87.3 m; p = 0.04). However, there was no significant difference between the two groups in the degree of improvement in the duration of the constant-load exercise test after exercise training.

CONCLUSIONS

Considering the effect on daily activities (e.g., walking), exercise training using both high F_IO₂ and high flow through an HFNC is a potentially superior exercise training modality for patients with CRF receiving LTOT. Clinical Trial Registration - http://www.

CLINICALTRIALS

gov. Unique identifier: NCT02804243.

Effects of Pulmonary Rehabilitation on Systemic Inflammation and Exercise Capacity in Bronchiectasis: A Randomized Controlled Trial

INTRODUCTION

Bronchiectasis is a chronic condition that is becoming a global health concern.

OBJECTIVE

To examine the effects of pulmonary rehabilitation (PR) on systemic inflammation, exercise capacity, and quality of life in participants with bronchiectasis.

METHODS

Participants were randomized to receive PR (outpatient, three weekly sessions for 3 months) or control intervention (usual care + airway clearance therapy + breathing exercises). Data on laboratory (fibrinogen level) and patient-centered outcomes such as physical fitness [6-min walk test (6MWT)] and quality of life were collected.

RESULTS

A total of 41 participants were evaluated (20 in the intervention group and 21 in the control group). The magnitude of change between baseline and the end of study was greater in the PR group than in the control group-the 6MWT distance increased by a mean of 54 m (54 vs 12 m; p < 0.01), fibrinogen showed a significant reduction (fibrinogen - 92.8 versus - 47.1 mg/dl; p < 0.01), and quality of life improved according to Saint George's Respiratory Questionnaire (SGRQ) (- 7.5 vs 3.2; p < 0.01), which exceeded the minimal clinically important difference of 4 points.

CONCLUSION

PR effectively improved physical fitness, quality of life, and the degree of systemic inflammation, as reflected by changes in 6 MWT, fibrinogen levels and SGRQ scores. This study supports the inclusion of people with bronchiectasis in supervised PR programs.

Pulmonary Rehabilitation in Noncystic Fibrosis Bronchiectasis

BACKGROUND

Current guidelines for the treatment of noncystic fibrosis bronchiectasis (NCFB) recommend pulmonary rehabilitation (PR), but to date, there are few studies that have proven its effectiveness.

OBJECTIVE

The main objective of this study was to examine the effect of PR on pulmonary function tests and exercise capacity.

METHOD

The aim of this study was to systematically review the effects of PR in NCFB on (1) forced expiratory volume in the first second (FEV1) and (2) exercise capacity evaluated by the 6-min walk test (6MWT) and the incremental shuttle walk test (ISWT). This meta-analysis was undertaken according to PRISMA recommendations.

RESULTS

This pair-wise meta-analysis included data obtained from studies that enrolled 529 NCFB patients. The FEV1 assessment after PR between the active and control group did not show any significant increase (FEV1 difference 0.084 mL; CI: -0.064, +0.233; p = 0.264), and there was an increasing trend (188 mL; CI: -0 to 0.009, +0.384) at the limits of statistical significance (p = 0.061). Walked distance showed a significant increase in the PR group compared to the control group (ISWT distance difference 070.0 m; CI: 55.2, 84.8; p < 0.001), and this finding was confirmed before and after PR both by the ISWT (68.85 m greater than baseline; CI: 40.52, 97.18; p < 0.001) and by the 6MWT (37.7 m greater than baseline; CI: 20.22, 55.25; p < 0.001).

CONCLUSIONS

PR improves exercise tolerance in NCFB patients, but it has a modest impact on respiratory function.

The Deteriorating Patient: Therapies Including Lung Transplantation

In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.

A prospective study of lung disease in a cohort of early rheumatoid arthritis patients

Lung disease is common in patients with rheumatoid arthritis (RA). The onset of lung involvement in RA is not well known. The objective is to describe the features and evolution of lung involvement in early RA, its relationship with disease activity parameters, smoking and treatments. Consecutive patients with early RA without respiratory symptoms were included and tracked for 5 years. Lung assessment included clinical, radiological and pulmonary function tests at diagnosis and during follow-up. Peripheral blood parameters (erythrocyte sedimentation rate, C reactive protein, rheumatoid factor and anti-citrullinated peptide autoantibodies) and scales of articular involvement, such as DAS28-CRP, were evaluated. 40 patients were included and 32 completed the 5-year follow up. 13 patients presented lung involvement in the initial 5 years after RA diagnosis, 3 of them interstitial lung disease. Significant decrease of diffusion lung transfer capacity of carbon monoxide over time was observed in six patients, 2 of them developed interstitial lung disease. DLCO decrease was correlated with higher values of CRP and ESR at diagnosis. Methotrexate was not associated with DLCO deterioration or lung disease development. Subclinical progressive lung disease correlates with RA activity parameters. Smoking status and methotrexate were not associated with development or progression of lung disease.

Anxiety and depression in bronchiectasis: Response to pulmonary rehabilitation and minimal clinically important difference of the Hospital Anxiety and Depression Scale

The aims of the study were to evaluate the responsiveness of Hospital Anxiety and Depression Scale-Anxiety (HADS-A) subscale and HADS-Depression (HADS-D) subscale to pulmonary rehabilitation (PR) in patients with bronchiectasis compared to a matched group of patients with chronic obstructive pulmonary disease (COPD) and provide estimates of the minimal clinically important difference (MCID) of HADS-A and HADS-D in bronchiectasis. Patients with bronchiectasis and at least mild anxiety or depression (HADS-A ≥ 8 or/and HADS-D ≥ 8), as well as a propensity score-matched control group of patients with COPD, underwent an 8-week outpatient PR programme (two supervised sessions per week). Within- and between-group changes were calculated in response to PR. Anchor- and distribution-based methods were used to estimate the MCID. HADS-A and HADS-D improved in response to PR in both patients with bronchiectasis and those with COPD (median (25th, 75th centile)/mean (95% confidence interval) change: HADS-A change: bronchiectasis −2 (−5, 0), COPD −2 (−4, 0); p = 0.43 and HADS-D change: bronchiectasis −2 (−2 to −1), COPD −2 (−3 to −2); p = 0.16). Using 26 estimates, the MCID for HADS-A and HADS-D was −2 points. HADS-A and HADS-D are responsive to PR in patients with bronchiectasis and symptoms of mood disorder, with an MCID estimate of −2 points.

Non-CF bronchiectasis: Orphan disease no longer

Bronchiectasis is a complex, chronic respiratory condition, characterized by frequent cough and exertional dyspnea due to a range of conditions that include inherited mucociliary defects, inhalational airway injury, immunodeficiency states and prior respiratory infections. For years, bronchiectasis was classified as either being caused by cystic fibrosis or non-cystic fibrosis. Non-cystic fibrosis bronchiectasis, once considered an orphan disease, is more prevalent worldwide in part due to greater availability of chest computed tomographic imaging. Identification of the cause of non-cystic fibrosis bronchiectasis with the use of chest imaging, laboratory testing, and microbiologic assessment of airway secretions can lead to initiation of specific therapies aimed at slowing disease progression. Nonpharmacologic therapies such as airway clearance techniques and pulmonary rehabilitation improve patient symptoms. Inhaled corticosteroids should not be routinely prescribed unless concomitant asthma or COPD is present. Inhaled antibiotics prescribed to individuals with >3 exacerbations per year are well tolerated, reduce airway bacteria load and may reduce the frequency of exacerbations. Likewise, chronic macrolide therapy reduces the frequency of exacerbations. Medical therapies for cystic fibrosis bronchiectasis may not be effective in treatment of non-cystic fibrosis bronchiectasis.

Bronchiectasis in rheumatoid arthritis. A clinical appraisial

Bronchiectasis is defined as irreversibly damaged and dilated bronchi and is one of the most common pulmonary manifestations in patients with rheumatoid arthritis (RA). The model of RA-associated autoimmunity induced in some individuals by chronic bacterial infection in bronchiectasis is becoming increasingly acceptable, although a genetic predisposition to RA-associated bronchiectasis has also been demonstrated. Bronchiectasis should be suspected in RA patients with chronic cough and sputum production or frequent respiratory infections and the diagnosis must be confirmed by thoracic high-resolution computed tomography. Management of patients with RA-associated bronchiectasis includes a multimodal treatment approach. Similar to all patients with non-cystic fibrosis bronchiectasis, patients with RA-associated bronchiectasis benefit from a pulmonary rehabilitation program, including an exercise/muscle strengthening program and an education program with a specific session on airway clearance techniques. Prophylactic antibiotics are recommended for patients with frequent (3 or more infective exacerbations per year) or severe infections requiring hospitalization/intravenous antibiotics and inhaled corticosteroids and long-acting β2-agonists should be used in patients with non-cystic fibrosis bronchiectasis and associated airway hyper-responsiveness. In patients with RA-associated bronchiectasis the use of immunomodulatory drugs has to be carefully considered, as they are essential to control disease activity, despite being associated with an increased infectious risk. Pneumococcal and influenza vaccines are advised to all patients with RA-associated bronchiectasis in order to reduce the risk of infection. Patients with RA-associated bronchiectasis have a poorer prognosis than those with either RA or bronchiectasis alone and require regular follow-up, under the joint care of a rheumatologist and a pulmonologist.

Effects of a Long-Term Use of Carbocysteine on Frequency and Duration of Exacerbations in Patients with Bronchiectasis

BACKGROUND

The failure of mucus clearance in bronchiectasis can be improved by chest physiotherapy or/and mucoactive agents.

AIM

To assess the effects of long-term use of carbocysteine on frequency and duration of exacerbations in patients with bronchiectasis.

METHODS

We performed an observational, non-randomized, open study (a real-life study) including 64 patients with bronchiectasis divided into two groups, examined group (EG) and control group (CG). All participants were treated with appropriate treatment for the stable disease, but in the study, subjects of EG two capsules 375 mg carbocysteine three times a day was added over three months. Daily diary cards realised collection of data regarding the occurrence and duration of exacerbation in all study subjects.

RESULTS

Over the study period 43 exacerbations were documented, 17 in the EG and 26 in the CG, 10 (23.4%) of which required hospital treatment (four in the EG [23.5%] and six in the CG [23.1%]). A mean number of exacerbations over the study period was significantly lower in the EG (0.5 ± 0.1) as compared to their mean number in the CG (0.8 ± 0.2) (P = 0.0000). Mean duration of exacerbations expressed in days needed for complete resolution of symptoms or return of the symptoms to their baseline severity in the EG was significantly shorter than the mean duration of exacerbations in the CG (10.1 ± 2.6 vs 12.8 ± 2.1; P = 0.0000). The frequency of adverse effects, i.e. mild gastrointestinal manifestations and headache which did not require discontinuation of the treatment, in the EG during the study period was 15.6%.

CONCLUSION

Our findings indicated positive effects of carbocysteine regarding the frequency and duration of exacerbations, as well as its good tolerability in the patients with bronchiectasis.

Non Cystic Fibrosis Bronchiectasis-new clinical approach, management of treatment and pulmonary rehabilitation

Abstract Non-Cystic Fibrosis Bronchiectasis (NCFB) are characterised by abnormal, permanently damaged and dilated bronchi due to the innapropiate clearence of various microorganisms and recurrent chronic infections.The diagnosis is suggested by the clinical presentation and is confirmed by multiple investigations. There are some comorbidities associated with bronhciectasis, such as chronic obstructive pulmonary disease (COPD), cardiovascular disorders, gastro-esophageal reflux disease (GERD), psychological illnesses, pulmonary hypertension, obstructive apnea syndrome(OSA). The condition has a substantial socioeconomic impact because it requests a multidisciplinary management and periods of exacerbations are common. The aims of the management of bronchiectasis are to reduce symptoms (such as sputum volume and purulence, cough and dyspnea), reduce the frequency and severity of exacerbations, preserve lung function and improve health-related quality of life. The multidisciplinary approach of bronchiectasis patients require along with the medical treatment, a specific plan of nonphamarcological strategies, including balneological intervention. There are a lot of techniques improving the airway clearence, such as: active cycle of breathing techniques (which include breathing control, thoracic expansion exercises, forced expiratory technique), oscilatting possitive expiratory pressure, autogenic drainage, gravity-assisted-positioning, modified postural drainage. Together with specific medication, these techniques can diminuate symptoms and improve the quality of life. Key words: NCFB, airway clearence, physiotherapy,

Pulmonary Rehabilitation in the Management of Chronic Lung Disease

Pulmonary rehabilitation is a core component of management of patients with chronic lung disease that have exercise or functional limitations. Causes of these limitations are manifold but include loss of skeletal muscle mass, power and endurance, diminished respiratory capacity owing to respiratory muscle weakness, inefficient gas exchange, and increased work of breathing, and impaired cardiovascular functioning. Besides physical limitations, patients with chronic lung disease have high rates of depression and anxiety leading to social isolation and increased health care use. Pulmonary rehabilitation uses a comprehensive and holistic approach that has been shown to ameliorate most effects of chronic lung disease.

Pulmonary rehabilitation in bronchiectasis: a propensity-matched study

International guidelines recommend pulmonary rehabilitation for patients with bronchiectasis, supported by small trials and data extrapolated from chronic obstructive pulmonary disease (COPD). However, it is unknown whether real-life data on completion rates and response to pulmonary rehabilitation are similar between patients with bronchiectasis and COPD.Using propensity score matching, 213 consecutive patients with bronchiectasis referred for a supervised pulmonary rehabilitation programme were matched 1:1 with a control group of 213 patients with COPD. Completion rates, change in incremental shuttle walk (ISW) distance and change in Chronic Respiratory Disease Questionnaire (CRQ) score with pulmonary rehabilitation were compared between groups.Completion rate was the same in both groups (74%). Improvements in ISW distance and most domains of the CRQ with pulmonary rehabilitation were similar between the bronchiectasis and COPD groups (ISW distance: 70 versus 63 m; CRQ-Dyspnoea: 4.8 versus 5.3; CRQ-Emotional Function: 3.5 versus 4.6; CRQ-Mastery: 2.3 versus 2.9; all p>0.20). However, improvements in CRQ-Fatigue with pulmonary rehabilitation were greater in the COPD group (bronchiectasis 2.1 versus COPD 3.3; p=0.02).In a real-life, propensity-matched control study, patients with bronchiectasis show similar completion rates and improvements in exercise and health status outcomes as patients with COPD. This supports the routine clinical provision of pulmonary rehabilitation to patients with bronchiectasis.

The Effect of Pulmonary Rehabilitation on the Physical Activity Level and General Clinical Status of Patients with Bronchiectasis

OBJECTIVES

We aimed to investigate the effects of pulmonary rehabilitation (PR) on the level of physical activity (PA) and the general clinical status in adult patients with non-cystic fibrosis bronchiectasis.

MATERIALS AND METHODS

The patients were included prospectively in the study and followed a home-based PR program for 2 months comprising breathing exercises, training in chest hygiene techniques, peripheral muscle strengthening training, and self-walking. The outcomes measurements were the following: 6-minute walking distance, pulmonary function test, peripheral and respiratory muscle strength measurements, International Physical Activity Questionnaire (IPAQ), Saint George Respiratory Questionnaire, and modified Medical Research Council dyspnea scores.

RESULTS

Of the total 25 patients included in the study, six were excluded due to follow-up and adherence problems. A comparison of the outcome measures recorded before and after PR showed statistically significant improvements in the IPAQ total (p=0.015) and walking scores (p=0.011). While the proportion of patients in the low PA category was 73% (n=14) prior to PR, this rate decreased to 42% (n=8) post-PR. The proportion of patients in the moderate PA category was 26% (n=5) prior to PR and increased to 52% (n=10) post-PR. While positive improvements were seen in all clinically monitored parameters, aside from spirometric values, these changes did not reach a statistically significant level.

CONCLUSION

The majority of patients with bronchiectasis have a low level of PA. PR ensures positive improvements in the level of PA and general physical clinical status of such patients.

Effects of exercise on secretion transport, inflammation, and quality of life in patients with noncystic fibrosis bronchiectasis: Protocol for a randomized controlled trial

BACKGROUND

Bronchiectasis is characterized by pathological and irreversible bronchial dilatation caused by the inefficient mucus and microorganism clearance and progression of inflammatory processes. The most frequent characteristic is the increase in bronchial mucus production resulting in slower transport and damage to the mucociliary transport.

AIMS

To evaluate the effects of exercise on mucus transport, inflammation, and resistance of the respiratory and autonomic nervous systems and subsequent effects on quality of life in patients with bronchiectasis who are enrolled in a pulmonary rehabilitation program.

METHODS

Sixty subjects of both sexes between 18 and 60 years (30 volunteers with clinically stable bronchiectasis and 30 healthy volunteers) will be included. Participants with chronic obstructive pulmonary disease, decompensated cardiovascular or metabolic diseases, neuromuscular and musculoskeletal diseases, and active smokers will be excluded. Volunteers will be randomly allocated to the pulmonary rehabilitation or control groups. The primary outcomes will be nasal transport time as evaluated by nasal saccharin transport time, analysis of nasal lavage, enzyme immunoassay of exhaled expiration, and analysis of the mucus properties. The secondary outcomes will include pulmonary function tests, impulse oscillometry, heart rate variability analysis, and quality of life questionnaires.

DISCUSSION

In addition to the benefits for patients already described in the literature, the additional benefit of mucus removal may contribute to optimizing treatments and better control of the disease.

CONCLUSION

This protocol could provide new information about the unclear mechanisms regarding exercise to aid in the removal of secretions.

Early Career Members at the ERS International Congress 2017: highlights from the Assemblies

.@EarlyCareerERS reflect on the highlights from the #ERSCongress 2017
 http://ow.ly/klLS30gAN49.

Diagnosis and management of bronchiectasis

KEY POINTS Following a diagnosis of bronchiectasis, it is important to investigate for an underlying cause. Goals of management are to suppress airway infection and inflammation, to improve symptoms and health-related quality of life. There are now validated scoring tools to help assess disease severity, which can help to stratify management. Good evidence supports the use of both exercise training and long-term macrolide therapy in long-term disease management.

Does home-based pulmonary rehabilitation improve functional capacity, peripheral muscle strength and quality of life in patients with bronchiectasis compared to standard care?

BACKGROUND

Home-based pulmonary rehabilitation is a promising intervention that may help patients to overcome the barriers to undergoing pulmonary rehabilitation. However, home-based pulmonary rehabilitation has not yet been investigated in patients with bronchiectasis.

OBJECTIVES

To investigate the effects of home-based pulmonary rehabilitation in patients with bronchiectasis.

METHODS

An open-label, randomized controlled trial with 48 adult patients with bronchiectasis will be conducted.

INTERVENTIONS

The program will consist of three sessions weekly over a period of 8 weeks. Aerobic exercise will consist of stepping on a platform for 20min (intensity: 60-80% of the maximum stepping rate in incremental step test). Resistance training will be carried out using an elastic band for the following muscles: quadriceps, hamstrings, deltoids, and biceps brachii (load: 70% of maximum voluntary isometric contraction).

CONTROL

The patients will receive an educational manual and a recommendation to walk three times a week for 30min. All patients will receive a weekly phone call to answer questions and to guide the practice of physical activity. The home-based pulmonary rehabilitation group also will receive a home visit every 15 days.

MAIN OUTCOME MEASURES

incremental shuttle walk test, quality of life, peripheral muscle strength, endurance shuttle walk test, incremental step test, dyspnea, and physical activity in daily life. The assessments will be undertaken at baseline, after the intervention, and 8 months after randomization.

DISCUSSION

The findings of this study will determine the clinical benefits of home-based pulmonary rehabilitation and will contribute to future guidelines for patients with bronchiectasis.

TRIAL REGISTRATION

www.ClinicalTrials.gov (NCT02731482). https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S00060X6&selectaction=Edit&uid=U00028HR&ts=2&cx=1jbszg.

The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis

This is the first guideline developed by the Saudi Thoracic Society for the diagnosis and management of noncystic fibrosis bronchiectasis. Local experts including pulmonologists, infectious disease specialists, thoracic surgeons, respiratory therapists, and others from adult and pediatric departments provided the best practice evidence recommendations based on the available international and local literature. The main objective of this guideline is to utilize the current published evidence to develop recommendations about management of bronchiectasis suitable to our local health-care system and available resources. We aim to provide clinicians with tools to standardize the diagnosis and management of bronchiectasis. This guideline targets primary care physicians, family medicine practitioners, practicing internists and respiratory physicians, and all other health-care providers involved in the care of the patients with bronchiectasis.

Lung involvement in inflammatory rheumatic diseases

This chapter describes the involvement of the lung in systemic inflammatory joint disease (IJD) with a particular focus on rheumatoid arthritis, although the topics of pulmonary involvement in ankylosing spondylitis and psoriatic arthritis are also addressed. Interstitial lung disease is the most lethal pulmonary complication of IJD and the chapter describes recent advances in both our understanding of this complication and the therapeutic options that offer real hope for improved outcomes. Although less well recognised, airways disease is just as common and its association with IJD is described in some detail, with a section devoted to the recent surge in interest in bronchiectasis. Acute pulmonary infection is common in IJD and its management is reviewed in some detail. Although pleural disease is less common than it once was, its treatment is explored. We conclude by reviewing the relationship between the drug therapies employed in IJD and their effects on the lung.

Research priorities in bronchiectasis: a consensus statement from the EMBARC Clinical Research Collaboration

Bronchiectasis is a disease of renewed interest in light of an increase in prevalence and increasing burden on international healthcare systems. There are no licensed therapies, and large gaps in knowledge in terms of epidemiology, pathophysiology and therapy. The European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) is a European Respiratory Society (ERS) Clinical Research Collaboration, funded by ERS to promote high-quality research in bronchiectasis. The objective of this consensus statement was to define research priorities in bronchiectasis. From 2014 to 2015, EMBARC used a modified Delphi process among European bronchiectasis experts to reach a consensus on 55 key research priorities in this field. During the same period, the European Lung Foundation collected 711 questionnaires from adult patients with bronchiectasis and their carers from 22 European countries reporting important research priorities from their perspective. This consensus statement reports recommendations for bronchiectasis research after integrating both physicians and patients priorities, as well as those uniquely identified by the two groups. Priorities identified in this consensus statement provide the clearest possible roadmap towards improving our understanding of the disease and the quality of care for patients with bronchiectasis.

Oral supplement enriched in HMB combined with pulmonary rehabilitation improves body composition and health related quality of life in patients with bronchiectasis (Prospective, Randomised Study)

BACKGROUND & AIMS

Pulmonary Rehabilitation (PR) is recommended for bronchiectasis but there is no data about its effect on body composition. The aim of this study is to assess the effect of Pulmonary Rehabilitation (PR) for 12 weeks in normally-nourished non-cystic-fibrosis bronchiectasis patients compared with the effect of PR plus a hyperproteic oral nutritional supplement enriched with beta-hydroxy-beta-methylbutyrate (HMB) on body composition, muscle strength, quality of life and serum biomarkers.

METHODS

single center randomized controlled trial, parallel treatment design: Participants were randomly assigned to receive PR for 12 weeks or PR plus ONS (PRONS) (one can per day). Outcome assessments were performed at baseline, 12 weeks and 24 weeks: body composition (Dual-energy X-Ray Absorptiometry (DEXA), mid-arm muscle circumference (MAMC), phase angle by Bio-impedance), health related quality of life (Spanish QOL-B-V3.0, Physical Functioning Scale), handgrip strength, diet questionnaire, and plasma levels of prealbumin, myostatin and somatomedin-c.

RESULTS

Thirty patients were randomized (15 per group) without differences in clinical and respiratory variables. In the PRONS group bone mineral density (BMD), mean and maximum handgrip dynamometry, MAMC, QOLB and prealbumin were significantly increased from baseline at 12 and 24 weeks and Fat free Mass (FFM) and FFM index, at 12 weeks. In the PR group only mean handgrip dynamometry and prealbumin were significantly increased at 12 and 24 weeks. In both groups plasma myostatin was reduced at 12 weeks (without significant differences).

CONCLUSION

The addition of a hyperproteic ONS enriched with HMB to Pulmonary Rehabilitation could improve body composition, BMD, muscle strength and health related quality of life in bronchiectasis patients. Clinical Trials Number NCT02048397.

Validity and Reliability of the Chronic Respiratory Disease Questionnaire in Elderly Individuals with Mild to Moderate Non-Cystic Fibrosis Bronchiectasis

BACKGROUND

The chronic respiratory disease questionnaire (CRDQ) is designed to assess health-related quality of life (HRQOL) in chronic respiratory conditions, but its reliability, validity and responsiveness in individuals with mild to moderate non-cystic fibrosis (CF) bronchiectasis are unclear.

OBJECTIVES

This study aimed to determine measurement properties of the CRDQ in non-CF bronchiectasis.

METHODS

Participants with non-CF bronchiectasis involved in a randomised controlled trial of exercise training were recruited. Internal consistency was assessed using Cronbach's α. Over 8 weeks, reliability was evaluated using intra-class correlation coefficients and Bland-Altman analysis for measures of agreement. Convergent and divergent validity was assessed by correlations with the other HRQOL questionnaires and the Hospital Anxiety and Depression Scale (HADS). The responsiveness to exercise training was assessed using effect sizes and standardised response means.

RESULTS

Eighty-five participants were included (mean age ± SD, 64 ± 13 years). Internal consistency was adequate (>0.7) for all CRDQ domains and the total score. Test-retest reliability ranged from 0.69 to 0.85 for each CRDQ domain and was 0.82 for the total score. Dyspnoea (CRDQ) was related to St George's respiratory questionnaire (SGRQ) symptoms only (r = 0.38), with no relationship to the Leicester cough questionnaire (LCQ) or HADS. Moderate correlations were found between the total score of the CRDQ, the SGRQ (rs = -0.49) and the LCQ score (rs = 0.51). Lower CRDQ scores were associated with higher anxiety and depression (rs = -0.46 to -0.56). The responsiveness of the CRDQ was small (effect size 0.1-0.24).

CONCLUSIONS

The CRDQ is a valid and reliable measure of HRQOL in mild to moderate non-CF bronchiectasis, but responsiveness was limited.

Mucociliary clearance techniques for treating non-cystic fibrosis bronchiectasis: Is there evidence?

Non-cystic fibrosis bronchiectasis (nCFb) is an acquired condition of variable etiology. An impaired mucociliary clearance seems to be one of the mechanisms behind nCFb, and treatment involves antibiotics, mucoactive agents, and airway clearance techniques (ACTs). Traditional ACTs have four components: postural drainage, percussion, vibration of the chest wall, and coughing. Reviewing the international medical literature on the use of ACTs for patients with nCFb from 1989 to the present day, we retrieved 93 articles, of which 35 met our selection criteria for this analysis. We reviewed active cycle of breathing techniques (ACBT), forced expiration techniques (FET), autogenic drainage, postural drainage, oscillating positive expiratory pressure (OPep), high frequency chest wall oscillation (HFCWO), and exercise or pulmonary rehabilitation. Overall, ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis; where there may be improvements in sputum expectoration, selected measures of lung function, and health-related quality of life. Unfortunately, there is a lack of RCTs in nCFb patients, especially in children. Moreover, none of the studies describes long-term effects of ACTs. It should be noted that a single intervention might not reflect the longer-term outcome and there is no evidence to recommend or contest any type of ACTs in nCFb management. Multicenter RCTs are necessary to evaluate the different techniques of ACTs especially in children with nCFb.

Sedentary behaviour and physical activity in bronchiectasis: a cross-sectional study

BACKGROUND

The impact of bronchiectasis on sedentary behaviour and physical activity is unknown. It is important to explore this to identify the need for physical activity interventions and how to tailor interventions to this patient population. We aimed to explore the patterns and correlates of sedentary behaviour and physical activity in bronchiectasis.

METHODS

Physical activity was assessed in 63 patients with bronchiectasis using an ActiGraph GT3X+ accelerometer over seven days. Patients completed: questionnaires on health-related quality-of-life and attitudes to physical activity (questions based on an adaption of the transtheoretical model (TTM) of behaviour change); spirometry; and the modified shuttle test (MST). Multiple linear regression analysis using forward selection based on likelihood ratio statistics explored the correlates of sedentary behaviour and physical activity dimensions. Between-group analysis using independent sample t-tests were used to explore differences for selected variables.

RESULTS

Fifty-five patients had complete datasets. Average daily time, mean(standard deviation) spent in sedentary behaviour was 634(77)mins, light-lifestyle physical activity was 207(63)mins and moderate-vigorous physical activity (MVPA) was 25(20)mins. Only 11% of patients met recommended guidelines. Forced expiratory volume in one-second percentage predicted (FEV1% predicted) and disease severity were not correlates of sedentary behaviour or physical activity. For sedentary behaviour, decisional balance 'pros' score was the only correlate. Performance on the MST was the strongest correlate of physical activity. In addition to the MST, there were other important correlate variables for MVPA accumulated in ≥10-minute bouts (QOL-B Social Functioning) and for activity energy expenditure (Body Mass Index and QOL-B Respiratory Symptoms).

CONCLUSIONS

Patients with bronchiectasis demonstrated a largely inactive lifestyle and few met the recommended physical activity guidelines. Exercise capacity was the strongest correlate of physical activity, and dimensions of the QOL-B were also important. FEV1% predicted and disease severity were not correlates of sedentary behaviour or physical activity. The inclusion of a range of physical activity dimensions could facilitate in-depth exploration of patterns of physical activity. This study demonstrates the need for interventions targeted at reducing sedentary behaviour and increasing physical activity, and provides information to tailor interventions to the bronchiectasis population.

TRIAL REGISTRATION

NCT01569009 ("Physical Activity in Bronchiectasis").

Management of bronchiectasis in adults

Formerly regarded as a rare disease, bronchiectasis is now increasingly recognised and a renewed interest in the condition is stimulating drug development and clinical research. Bronchiectasis represents the final common pathway of a number of infectious, genetic, autoimmune, developmental and allergic disorders and is highly heterogeneous in its aetiology, impact and prognosis. The goals of therapy should be: to improve airway mucus clearance through physiotherapy with or without adjunctive therapies; to suppress, eradicate and prevent airway bacterial colonisation; to reduce airway inflammation; and to improve physical functioning and quality of life. Fortunately, an increasing body of evidence supports interventions in bronchiectasis. The field has benefited greatly from the introduction of evidence-based guidelines in some European countries and randomised controlled trials have now demonstrated the benefit of long-term macrolide therapy, with accumulating evidence for inhaled therapies, physiotherapy and pulmonary rehabilitation. This review provides a critical update on the management of bronchiectasis focussing on emerging evidence and recent randomised controlled trials.

Principles of rehabilitation and reactivation

Skeletal muscle dysfunction and physical inactivity are two clinically important features of a wide range of acute and chronic respiratory conditions. Optimisation of both of these features is important in order to improve physical function, prevent clinical deterioration and maximise community participation. One of the most potent and evidence-based interventions to address these physical deficits is pulmonary rehabilitation (PR). Whilst the majority of PR research has been conducted in patients with chronic obstructive pulmonary disease, there is widespread recognition that PR can benefit many other respiratory patient groups. These include patients with interstitial lung diseases, asthma, pulmonary hypertension, pre-/post-lung surgery (e.g. lung cancer, transplantation) and cystic fibrosis to name a few. Exercise training must be appropriately prescribed by a skilled healthcare professional with comprehensive knowledge of the pathology and physiology of these conditions, as well as a sound understanding of the exercise physiology and core principles of exercise prescription, monitoring and progression. It has also become increasingly recognised that people with respiratory conditions, particularly those with chronic disease, are considerably less active than those of good health. PR should therefore aim to induce behavioural change to facilitate the adoption and maintenance of an active lifestyle. In addition, PR should pay attention to the psychological well-being of patients and self-management of their lung disease in all its aspects. To that end, multidisciplinary individualised programs should be offered. This review sets the scene of PR principles for a series of papers that will focus on specific diseases other than chronic obstructive pulmonary disease where rehabilitation may offer a clinically important aspect of care over and above conventional pharmacological treatment.

Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease

Pulmonary rehabilitation (PR) is an important therapeutic intervention that should no longer be considered suitable only for patients with chronic obstructive pulmonary disease (COPD). A strong rationale exists for providing PR to persons with a broad range of respiratory disorders other than COPD. Evidence shows that PR for these patients is feasible, safe and effective. A disease-relevant approach should be undertaken, based on individual patients' needs. Further research is needed to better understand the optimal program content, duration and outcomes measures, to enable diverse patients to achieve maximal benefits of PR.

Minimal important difference in field walking tests in non-cystic fibrosis bronchiectasis following exercise training

BACKGROUND

The 6-min walk distance (6MWD) and incremental shuttle walk distance (ISWD) are clinically meaningful measures of exercise capacity in people with non-cystic fibrosis (CF) bronchiectasis, but the change in walking distance which constitutes clinical benefit is undefined. This study aimed to determine the minimal important difference for the 6MWD and ISWD in non-CF bronchiectasis.

METHODS

Thirty-seven participants with mean FEV1 70% predicted completed both field walking tests before and after an 8-week exercise program. The minimal important difference was calculated using a distribution-based and anchor-based method, with the global rating of change scale used.

RESULTS

The mean change in 6MWD in participants who reported themselves to be unchanged was 10 m, compared to 36 m (small change) and 45 m (substantial change) (p = 0.01). For the ISWD, the mean change in participants who reported themselves to be unchanged was 33 m, compared to 54 m (small change) and 73 m (substantial change) (p = 0.04). The anchor-based method defined the minimal important difference for 6MWD as 24.5 m (AUC 0.76, 95% CI 0.61-0.91) and for ISWD as 35 m (AUC 0.88, 95% CI 0.73-0.99), based on participant's global rating of change. The distribution-based method indicated a value of 22.3 m for the 6MWD and 37 m for the ISWD. There was excellent agreement between the two methods for the 6MWD (kappa = 0.91) and the ISWD (kappa = 0.92).

CONCLUSIONS

Small changes in 6MWD and ISWD may represent clinically important benefits in people with non-CF bronchiectasis. These data are likely to assist in the interpretation of change in exercise capacity following intervention.

The short and long term effects of exercise training in non-cystic fibrosis bronchiectasis--a randomised controlled trial

BACKGROUND

Exercise training is recommended for non-cystic fibrosis (CF) bronchiectasis, but the long-term effects are unclear. This randomised controlled trial aimed to determine the effects of exercise training and review of airway clearance therapy (ACT) on exercise capacity, health related quality of life (HRQOL) and the incidence of acute exacerbations in people with non-CF bronchiectasis.

METHODS

Participants were randomly allocated to 8 weeks of supervised exercise training and review of ACT, or control. Primary outcomes of exercise capacity and HRQOL (Chronic respiratory disease questionnaire) and secondary outcomes of cough-related QOL (Leicester cough questionnaire) and psychological symptoms (Hospital anxiety and depression scale) were measured at baseline, following completion of the intervention period and at 6 and 12 months follow up. Secondary outcomes of the exacerbation rate and time to first exacerbation were analysed over 12 months.

RESULTS

Eighty-five participants (mean FEV1 74% predicted; median Modified Medical Research Council Dyspnoea grade of 1 (IQR [1-3]) were included. Exercise training increased the incremental shuttle walk distance (mean difference to control 62 m, 95% CI 24 to 101 m) and the 6-minute walking distance (mean difference to control 41 m, 95% CI 19 to 63 m), but these improvements were not sustained at 6 or 12 months. Exercise training reduced dyspnoea (p = 0.009) and fatigue (p = 0.01) but did not impact on cough-related QOL or mood. Exercise training reduced the frequency of acute exacerbations (median 1[IQR 1-3]) compared to the control group (2[1-3]) over 12 months follow up (p = 0.012), with a longer time to first exacerbation with exercise training of 8 months (95% CI 7 to 9 months) compared to the control group (6 months [95% CI 5 to 7 months], p = 0.047).

CONCLUSIONS

Exercise training in bronchiectasis is associated with short term improvement in exercise capacity, dyspnoea and fatigue and fewer exacerbations over 12 months.

TRIAL REGISTRY

ClinicalTrials.gov (NCT00885521).

An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.

PURPOSE

The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.

METHODS

A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.

RESULTS

An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.

CONCLUSIONS

The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

Non-cystic fibrosis bronchiectasis

Bronchiectasis is a chronic debilitating condition with considerable phenotypic diversity. A vicious cycle of infection and inflammation exists in damaged airways with patients suffering from persistent cough, purulent sputum production, recurrent chest infections and general malaise. The associated burden of disease in terms of increased morbidity, reduced quality of life and the socioeconomic cost of long-term management is significant. Further research is essential to improve our understanding of the development and progression of this disease. This article reviews what is currently known about bronchiectasis, its pathophysiology, aetiology and management strategies.

A pilot study of pulmonary rehabilitation and chest physiotherapy versus chest physiotherapy alone in bronchiectasis

AIM

The aim of our study was to assess the efficacy of pulmonary rehabilitation in addition to regular chest physiotherapy in non cystic fibrosis bronchiectasis.

METHODS

Thirty patients with clinically significant bronchiectasis and limited exercise tolerance were randomized into either the control group receiving chest physiotherapy (8 weeks) or into the intervention group, receiving pulmonary rehabilitation in addition to chest physiotherapy (8 weeks). Both groups were encouraged to maintain their exercise program and or chest physiotherapy, following completion of the study.

RESULTS

End of training (8 weeks) No improvement in control group. In the intervention group, incremental shuttle walk test (ISWT) improved by 56.7 m (p = 0.03), endurance walk test (EWT) by 193.3 m (p = 0.01), Leicester Cough Questionnaire (LCQ) improved by 2.6 units (p < 0.001) and St. George's Respiratory Questionnaire (SGRQ) by 8 units (p < 0.001). At 20 weeks (12 weeks post end of training) No improvement in control group. In the intervention group, ISWT improved by 80 m (p = 0.04) and EWT by 247.5 m (p = 0.003). LCQ improved by 4.4 units (p < 0.001) and SGRQ by 4 units (p < 0.001).

CONCLUSION

Pulmonary rehabilitation in addition to regular chest physiotherapy, improves exercise tolerance and health related quality of life in non cystic fibrosis bronchiectasis and the benefit was sustained at 12 weeks post end of pulmonary rehabilitation. Clinical trials regn no. NCT00868075.