Does pulmonary rehabilitation reduce peripheral blood pressure in patients with chronic obstructive pulmonary disease?

Pulmonary rehabilitation outcomes in individuals with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

The magnitude of response to pulmonary rehabilitation (PR) is influenced by the selection of outcomes and measures.

OBJECTIVES

This systematic review aimed to review all outcomes and measures used in clinical trials of PR for individuals with chronic obstructive pulmonary disease (COPD).

METHODS

The review involved a search of Scopus, Web of Knowledge, Cochrane Library, EBSCO, Science Direct and PubMed databases for studies of stable individuals with COPD undergoing PR. Frequency of reporting for each domain, outcome and measure was synthesized by using Microsoft Excel.

RESULTS

We included 267 studies (43153 individuals with COPD). A broad range of domains (n=22), outcomes (n=163) and measures (n=217) were reported. Several measures were used for the same outcome. The most reported outcomes were exercise capacity (n=218) assessed with the 6-min walk test (n=140), health-related quality of life (n=204) assessed with the Saint George's respiratory questionnaire (n=99), and symptoms (n=158) assessed with the modified Medical Research Council dyspnea scale (n=56). The least reported outcomes were comorbidities, adverse events and knowledge.

CONCLUSIONS

This systematic review reinforces the need for a core outcome set for PR in individuals with COPD because of high heterogeneity in reported outcomes and measures. Future studies should assess the importance of each outcome for PR involving different stakeholders.

PROSPERO ID

CRD42017079935.

Molecular Characteristics and Treatment of Endothelial Dysfunction in Patients with COPD: A Review Article

Patients with chronic obstructive pulmonary disease (COPD) show systemic consequences, such as chronic systemic inflammation leading to changes in the airway, airway penetrability, and endothelial function. Endothelial dysfunction is characterized by a list of alterations of endothelium towards reduced vasodilation, proinflammatory state, detachment and apoptosis of endothelial cells, and development of atherosclerosis. COPD-induced endothelial dysfunction is associated with elevated cardiovascular risk. The increment of physical activities such as pulmonary rehabilitation (PR) training have a significant effect on COPD, thus, PR can be an integrative part of COPD treatment. In this narrative review the focus is on the function of endothelial inflammatory mediators [cytokines, chemokines, and cellular proteases] and pulmonary endothelial cells and endothelial dysfunction in COPD as well as the effects of dysfunction of the endothelium may play in COPD-related pulmonary hypertension. The relationship between smoking and endothelial dysfunction is also discussed. The connection between different pulmonary rehabilitation programs, arterial stiffness and pulse wave velocity (PWV) is presented. Endothelial dysfunction is a significant prognostic factor of COPD, which can be characterized by PWV. We discuss future considerations, like training programs, as an important part of the treatment that has a favorable impact on the endothelial function.

Outcome measures in a combined exercise rehabilitation programme for adults with COPD and chronic heart failure: A preliminary stakeholder consensus event

Combined exercise rehabilitation for chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) is potentially attractive. Uncertainty remains as to the baseline profiling assessments and outcome measures that should be collected within a programme. Current evidence surrounding outcome measures in cardiac and pulmonary rehabilitation were presented by experts at a stakeholder consensus event and all stakeholders (n = 18) were asked to (1) rank in order of importance a list of categories, (2) prioritise outcome measures and (3) prioritise baseline patient evaluation measures that should be assessed in a combined COPD and CHF rehabilitation programme. The tasks were completed anonymously and related to clinical rehabilitation programmes and associated research. Health-related quality of life, exercise capacity and symptom evaluation were voted as the most important categories to assess for clinical purposes (median rank: 1, 2 and 3 accordingly) and research purposes (median rank; 1, 3 and 4.5 accordingly) within combined exercise rehabilitation. All stakeholders agreed that profiling symptoms at baseline were 'moderately', 'very' or 'extremely' important to assess for clinical and research purposes in combined rehabilitation. Profiling of frailty was ranked of the same importance for clinical purposes in combined rehabilitation. Stakeholders identified a suite of multidisciplinary measures that may be important to assess in a combined COPD and CHF exercise rehabilitation programme.

Effectiveness of a 4-week rehabilitation program on endothelial function, blood vessel elasticity in patients with chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) may have considerable cardiovascular risk. Physical activity has a paramount role in COPD treatment. Our aim was to evaluate the applicability of arteriograph in COPD and measure the effectiveness of pulmonary rehabilitation on endothelial function.

Methods

A total of 40 patients with COPD (FEV₁: 45.43±20.20%pred, BMI: 27.99±6.98 kg/m², male: female was 21:19, age: 65.47±7.39 years) participated in a 4-week rehabilitation program. We used a patented, invasively validated Arteriograph. Blood pressure, pulse, augmentation index (AIX), pulse wave velocity (PWV), diastolic area index (DAI) were registered with functional measurements in pulmonary rehabilitation.

Results

Pulmonary rehabilitation was effective in 6 minutes walking distance (6MWD: 335.32±110.43 vs. 398.32±126.21 m), maximal inspiratory pressure (MIP: 57.72±22.69 vs. 63.63±18.01 cmH₂O), chest wall expansion (CWE: 2.84±1.26 vs. 4.00±1.76 cm), breath holding time (BHT: 25.77±10.63 to 29.21±11.60 sec) and grip strength (GS: 24.87±11.88 vs. 27.03±11.43 kg) (P<0.05). Improvement in quality of life was monitored by COPD assessment test marker (CAT: 17.00±8.49 vs. 11.89±7.31, P<0.05). Systolic (133.38±22.15 vs. 126.48±20.22 mmHg) and diastolic blood pressure (76.95±14.37 vs. 75.4±12.7 mmHg) showed a reduction tendency. Pulse also decreased (76.95±14.37 vs. 72.53±13.65 bpm). AIX levels showed slight improvement (3.54±35.59% vs. 2.93±30.79%); 23 patients peripheral circulation progressed. The PWV data showed abnormal elasticity with minimal change (11.74±2.13 vs. 11.4±2.73 m/s); although 20 patients showed improvement. DAI detected slightly diminished coronary circulation with moderate improvement (43.32±6.81 vs. 47.1±7.01 m/s).

Conclusions

Elevated arterial stiffness, high PWV turned the COPD patients to the high/very high-risk cluster. Rehabilitation resulted significant improvement in MIP, CWE, BHT, 6MWD, CAT with mild, but favorable changes in blood pressure, pulse, AIX, PWV. As a consequence of the four weeks rehabilitation period overall quality of life improved and cardiovascular risk showed a reduction tendency in COPD.

Impaired training-induced adaptation of blood pressure in COPD patients: implication of the muscle capillary bed

Background and aims

Targeting the early mechanisms in exercise-induced arterial hypertension (which precedes resting arterial hypertension in its natural history) may improve cardiovascular morbidity and mortality in COPD patients. Capillary rarefaction, an early event in COPD before vascular remodeling, is a potential mechanism of exercise-induced and resting arterial hypertension. Impaired training-induced capillarization was observed earlier in COPD patients; thus, this study compares the changes in blood pressure (BP) during exercise in COPD patients and matches control subjects (CSs) after a similar exercise training program, in relationship with muscle capillarization.

Methods

Resting and maximal exercise diastolic pressure (DP) and systolic pressure (SP) were recorded during a standardized cardiopulmonary exercise test, and a quadriceps muscle biopsy was performed before and after training.

Results

A total of 35 CSs and 49 COPD patients (forced expiratory volume in 1 second =54%±22% predicted) completed a 6-week rehabilitation program and improved their symptom-limited maximal oxygen uptake (VO_2SL: 25.8±6.1 mL/kg per minute vs 27.9 mL/kg per minute and 17.0±4.7 mL/kg per minute vs 18.3 mL/kg per minute; both P<0.001). The improvement in muscle capillary-to-fiber (C/F) ratio was significantly greater in CSs vs COPD patients (+11%±9% vs +23%±21%; P<0.05). Although maximal exercise BP was reduced in CSs (DP: 89±10 mmHg vs 85±9 mmHg; P<0.001/SP: 204±25 mmHg vs 196±27 mmHg; P<0.05), it did not change in COPD patients (DP: 94±14 mmHg vs 97±16 mmHg; P=0.46/SP: 202±27 mmHg vs 208±24 mmHg; P=0.13). The change in muscle C/F ratio was negatively correlated with maximal exercise SP in CSs and COPD patients (r=−0.41; P=0.02).

Conclusion

COPD patients showed impaired training-induced BP adaptation related to a change in muscle capillarization, suggesting the possibility of blunted angiogenesis.

The EQ-5D-5L health status questionnaire in COPD: validity, responsiveness and minimum important difference

Background

The EQ-5D, a generic health status questionnaire that is widely used in health economic evaluation, was recently expanded to the EQ-5D-5L to address criticisms of unresponsiveness and ceiling effect.

Aims

To describe the validity, responsiveness and minimum important difference of the EQ-5D-5L in COPD.

Methods

Study 1: The validity of the EQ-5D-5L utility index and visual analogue scale (EQ-VAS) was compared with four established disease-specific health status questionnaires and other measures of disease severity in 616 stable outpatients with COPD. Study 2: The EQ-5D-5L utility index and EQ-VAS were measured in 324 patients with COPD before and after 8 weeks of pulmonary rehabilitation. Distribution and anchor-based approaches were used to estimate the minimum important difference.

Results

There were moderate-to-strong correlations between utility index and EQ-VAS with disease-specific questionnaires (Pearson's r=0.47–0.72). A ceiling effect was seen in 7% and 2.6% of utility index and EQ-VAS. Utility index decreased (worsening health status) with indices of worsening disease severity. With rehabilitation, mean (95% CI) changes in utility index and EQ-VAS were 0.065 (0.047 to 0.083) and 8.6 (6.5 to 10.7), respectively, with standardised response means of 0.39 and 0.44. The mean (range) anchor estimates of the minimum important difference for utility index and EQ-VAS were 0.051 (0.037 to 0.063) and 6.9 (6.5 to 8.0), respectively.

Conclusions

The EQ-5D-5L is a valid and responsive measure of health status in COPD and may provide useful additional cost-effectiveness data in clinical trials.