Respiratory rehabilitation after acute exacerbation of COPD may reduce risk for readmission and mortality -- a systematic review

Pulmonary Rehabilitation: A Look Back, a Look Forward

Pulmonary rehabilitation (PR) is a comprehensive approach to the management of patients with chronic lung disease that encompasses exercise, education, and psychosocial support. The development of PR programs began in the mid-20th century with the appreciation that exercise provided real benefit in chronic lung disease and that effective disease management involved patient education focused on medications, lifestyle changes, and lifelong regular exercise. Initially PR was primarily facility-based, but today PR is extending into the home with telemedicine, and this is encouraging a real partnership of patients and professionals supporting self-management. The evidence base supporting PR as a safe and effective modality has grown exponentially over the last 4 decades, and PR is strongly endorsed by virtually all the major professional societies. Importantly, PR has also clearly been shown to be cost-effective. Challenges remain, however. Access is still very limited for a variety of reason (logistics, financial, patient motivation) that need to be addressed. More focused and personalized exercise programs and monitoring strategies that encourage a patient's lifetime commitment to the principles of PR need to be developed and refined. The opportunity to really impact important clinical outcomes exists with PR, and this needs to be exploited.

Internet of Things-Based Home Respiratory Muscle Training for Patients with Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial

Purpose

Whether Internet of Things (IoT)-based home respiratory muscle training (RMT) benefits patients with comorbid chronic obstructive pulmonary disease (COPD) remains unclear. Therefore, this study aims to evaluate the effectiveness of IoT-based home RMT for patients with COPD.

Patients and Methods

Seventy-eight patients with stable COPD were randomly divided into two groups. The control group received routine health education, while the intervention group received IoT-based home RMT (30 inspiratory muscle training [IMT] and 30 expiratory muscle training [EMT] in different respiratory cycles twice daily for 12 consecutive weeks). Assessments took place pre-intervention and 12 weeks post-intervention, including lung function tests, respiratory muscle strength tests, the mMRC dyspnea scale, CAT questionnaires, the HAMA scale, and 6-month COPD-related readmission after intervention.

Results

Seventy-four patients with COPD were analyzed (intervention group = 38, control group = 36), and the mean age and FEV1 of the patients were 68.65 ± 7.40 years, 1.21 ± 0.54 L. Compared to those of the control population, the intervention group exhibited higher FEV1/FVC (48.23 ± 10.97 vs 54.32 ± 10.31, p = 0.016), MIP (41.72 ± 7.70 vs 47.82 ± 10.99, p = 0.008), and MEP (42.94 ± 7.85 vs 50.29 ± 15.74, p = 0.013); lower mMRC (2.00 [2.00-3.00] vs 1.50 [1.00-2.00], p < 0.001), CAT (17.00 [12.00-21.75] vs 11.00 [9.00-13.25], p < 0.001), and HAMA (7.00 [5.00-9.00] vs 2.00 [1.00-3.00], p < 0.001) scores; and a lower incidence rate of 6-month readmission (22% vs 5%, p = 0.033).

Conclusion

Compared with no intervention, IoT-based home RMT may be a more beneficial intervention for patients with COPD.

Promoting Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease, Strategies of Top-performing Systems: A Qualitative Study

Rationale: Pulmonary rehabilitation (PR) after hospitalization for chronic obstructive pulmonary disease (COPD) is recommended by guidelines; however, few patients participate, and rates vary between hospitals. Objectives: To identify contextual factors and strategies that may promote participation in PR after hospitalization for COPD. Methods: Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States, we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th percentile, at least 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of PR rates after discharge, we identified innovative hospitals on the basis of a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes. Results: Interviews were conducted with 38 stakeholders at nine hospitals (seven high-performers and two innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR medical directors, PR managers, respiratory therapists, inpatient and outpatient providers, and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after admission for COPD in response to the Centers for Medicare and Medicaid Services/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance in overcoming barriers. Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of a larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.

Chronic obstructive pulmonary disease (COPD) mortality trends worldwide: An update to 2019

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease (COPD) incidence, prevalence, mortality and socioeconomic burden are considerable and vary across countries. The aim of the present study was to update the analysis of COPD mortality worldwide using data from the World Health Organization (WHO) up to 2019.

METHODS

We obtained COPD mortality and population data for 22 European countries and the European Union (EU) as a whole, 10 American countries and six other countries from the WHO mortality database. We calculated age-standardized mortality rates in both sexes and examined trends by country with joinpoint analysis between 1994 and 2019.

RESULTS

Between 2005-2007 and 2015-2017, overall COPD mortality decreased in EU men (-16.3%) but increased in women (12.7%) to reach rates of 14.0/100,000 in men and of 6.4/100,000 in women. In the United States, mortality declined in men to 21.3/100,000 but rose in women to 18.3/100,000. Mortality declined in most Latin American countries and all Asian countries, while an increase in Australian women was observed.

CONCLUSION

A steady decrease in COPD mortality was observed in most of countries for men, whilst a different trend was observed in women in several countries. These trends are largely explained by changes in smoking habits, with an additional contribution of air pollution and occupational exposures. Despite past and ongoing tobacco control initiatives, this condition still remains a leading cause of death, in particular in countries with lower socio-demographic indices.

Pulmonary Rehabilitation Programmes Within Three Days of Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Objective

To evaluate the efficacy and safety of early pulmonary rehabilitation (PR) (ie, <3 days of hospitalization) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

Embase, Web of Science, PubMed and Cochrane Library were searched from their inception to 1 April 2021. Randomized controlled trials were included if they observed the efficacy of early PR in AECOPD patients. Study selection, data extraction, risk of bias and quality of evidence were assessed by two researchers independently. Assessment of the risk of bias and eidence quality were evaluated by the Cochrane Collaboration’s tool and Grading of Recommendations, Assessment, Development and Evaluation system, respectively.

Results

Fourteen trials (829 participants) were identified. Significant improvement was found in the 6-minute walk distance (6MWD; mean difference (MD): 69.64; 95% CI: 40.26 to 99.01; Z = 4.65, P < 0.0001, low quality). In the subgroup analysis, the exercise-training group showed marked improvement (MD: 96.14; 95% CI: 20.24 to 172.04; Z = 2.48, P = 0.001). The Saint George’s Respiratory Questionnaire (SGRQ) total score was low (MD: −12.77; 95% CI: −16.03 to −9.50; Z = 7.67, P < 0.0001, moderate quality). Significant effects were not found for the duration of hospital stay, quadriceps muscle strength or five times sit to stand test. Only one serious adverse event was reported in experimental group, which was not associated with early PR.

Conclusion

PR initiated <3 days of hospitalization may increase exercise capacity and improve quality of life, but the results should be interpreted prudently and dialectically, and the role of early PR in AECOPD needs further exploration.

Does branched-chain amino acid supplementation improve pulmonary rehabilitation effect in COPD?

BACKGROUND

Muscle wasting is frequent in chronic obstructive lung disease (COPD) and associated with low branched-chain amino acids (BCAA). We hypothesized that BCAA supplementation could potentiate the effect of a pulmonary rehabilitation program (PRP) by inducing muscular change.

MATERIALS AND METHODS

Sixty COPD patients (GOLD 2-3) were involved in an ambulatory 4-week PRP either with BCAA oral daily supplementation or placebo daily supplementation in a randomized double-blind design. Maximal exercise test including quadriceps oxygenation measurements, functional exercise test, muscle strength, lung function tests, body composition, dyspnea and quality of life were assessed before and after PRP.

RESULTS

Fifty-four patients (64.9 ± 8.3 years) completed the protocol. In both groups, maximal exercise capacity, functional and muscle performances, quality of life and dyspnea were improved after 4-week PRP (p ≤ 0.01). Changes in muscle oxygenation during the maximal exercise and recovery period were not modified after 4-week PRP in BCAA group. Contrarily, in the placebo group the muscle oxygenation kinetic of recovery was slowed down after PRP.

CONCLUSION

This study demonstrated that a 4-week PRP with BCAA supplementation is not more beneficial than PRP alone for patients. A longer duration of supplementation or a more precise targeting of patients would need to be investigated to validate an effect on muscle recovery and to demonstrate other beneficial effects.

A Pilot Study of a Sensor Enhanced Activity Management System for Promoting Home Rehabilitation Exercise Performed during the COVID-19 Pandemic: Therapist Experience, Reimbursement, and Recommendations for Implementation

Adherence to home exercise programs (HEPs) during physical rehabilitation is usually unmonitored and is thought to be low from self-reports. This article describes exploratory implementation of a Sensor Enhanced Activity Management (SEAM) system that combines HEP management software with a movement sensor for monitoring and motivating HEP adherence. The article also presents results from attempting to gain reimbursement for home use of the system with therapist oversight using Remote Physiologic Monitoring (RPM) codes. Four therapists used the system in their regular practice during the first six months of the COVID-19 pandemic. Therapists filled out surveys, kept notes, and participated in interviews. Billing and reimbursement data were obtained from the treatment facility. Exercise data from the SEAM system were used to understand HEP adherence. Patients were active for a mean of 40% (26% SD) of prescribed days and completed a mean of 25% (25% SD) of prescribed exercises. The therapists billed 23 RPM codes (USD 2353), and payers reimbursed eight of those instances (USD 649.21). The therapists reported that remote monitoring and the use of a physical movement sensor was motivating to their patients and increased adherence. Sustained technical support for therapists will likely improve implementation of new remote monitoring and treatment systems. RPM codes may enable reimbursement for review and program management activities, but, despite COVID-19 CMS waivers, organizations may have more success if these services are billed under supervision of a physician.

Functional decline in emergency department patients with dyspnea: a register-based cohort

BACKGROUND

Functional decline is associated with frequent hospital admissions and elevated risk of death. Presumably, patients acutely admitted to hospital with dyspnea have a high risk of functional decline.

OBJECTIVE

The aim of this study was to describe patient characteristics, hospital trajectory and use of physiotherapy services by dyspneic patients in an emergency department. The study also wanted to compare readmission and death among patients with and without a functional decline and to identify predictors of functional decline.

METHODS

Data originated from a historic cohort of patients admitted to a Danish Emergency Department using prospectively collected electronic patient record data from a Business Intelligence Registry of the Central Denmark Region. The study included adult patients who were treated at the emergency department (ED) for dyspnea in 2015. The main outcome measures were readmission, death and functional decline.

RESULTS

In total, 2048 dyspneic emergency treatments were registered. Within 30 days after discharge, 20% was readmitted and 3.9% had died. Patients with functional decline had a higher rate of 30-day readmission (31.2% vs. 19.1%, P < 0.001) and mortality (9.3% vs. 3.6%, P = 0.009) as well as mortality within 1 year (36.1% vs. 13.4%, P < 0.001). Predictors of functional decline were age ≥60 years and hospital stay ≥6 days.

CONCLUSION

Patients suffering from acute dyspnea are seen at the ED at all hours. In total, one in five patients were readmitted and 3.9% died within 30 days. Patients with a functional decline at discharge seem to be particularly vulnerable.

Long-term pulmonary rehabilitation progressively reduces hospitalizations and mortality in a cohort of patients with severe and very severe copd: a 5-year follow up

BACKGROUD

Pulmonary rehabilitation (PR) is recognized as a multidisciplinary intervention designed to reduce symptoms, improve functional status, and prevent acute exacerbations in patients with chronic obstructive pulmonary disease (COPD).

AIM

This study was aimed at evaluating the effects of a long-term PR program on the hospitalization rate and mortality of patients with severe and very severe COPD.

MATERIALS AND METHODS

This was a prospective study where cohorts of 195 patients undergoing a PR program were followed up for 5 years. They were divided into 3 groups: control (PR = 0 or < 3 months), partial adherence (PR > 6 and ≤ 18 months) and adherence (PR = 24 months). All patients were evaluated every 6 months (D0, D6, D12, D18 and D24, and mapped annually concerning hospitalizations and mortality). Data were analysed by medians and interquartile ranges, and Kruskal-Wallis nonparametric comparative tests were applied. Comparisons of time to first admission and time to death were made using the Kaplan-Meier estimators, and the factors associated with these outcomes were modeled using semi-parametric Cox models.

RESULTS

The results demonstrated a significant reduction in the rate of hospitalization and mortality. The protective effect seems to be dependent on the lengths of stay of patients in the PR program.

CONCLUSIONS

A multi-disciplinary, long-term PR program with individually tailored 96-week supervised interventions, reduces hospitalization rates and mortality in patients with severe and very severe COPD in a 5-year follow-up period. This protective effect on hospitalization and mortality is obtained from at least 18 months of intervention. Patients who stay longer in the PR program appear to experience a longer protective effect at the end of treatment.

CLINICAL REHABILITATION IMPACT

This Long-term PR program for patients with severe and very severe COPD produced progressively favourable clinical effects, thus reducing the frequency of hospitalizations and mortality in this population.

Effectiveness of pulmonary rehabilitation in COVID-19 respiratory failure patients post-ICU

INTRODUCTION

Some COVID-19 patients develop respiratory failure requiring admission to intensive care unit (ICU). We aim to evaluate the effects of pulmonary rehabilitation (PR) post-ICU in COVID-19 patients.

METHODS

Twenty-one COVID-19 patients were evaluated pre- and post-PR and compared retrospectively to a non-COVID-19 group of 21 patients rehabilitated after ICU admission due to respiratory failure.

RESULTS

PR induced greater 6-min walking distance improvement in COVID-19 patients (+205 ± 121 m) than in other respiratory failure patients post-ICU (+93 ± 66 m). The sooner PR was performed post-ICU, the better patients recovered.

CONCLUSIONS

PR induced large functional improvements in COVID-19 patients post-ICU although significant physical and psychosocial impairments remained post-PR.

Telerehabilitation for chronic respiratory disease

BACKGROUND

Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in-person on an outpatient basis at a hospital or other healthcare facility (referred to as centre-based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home-based models and the use of telehealth. Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease.

OBJECTIVES

To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting abstracts.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS-I tool to assess bias in non-randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in-person (centre-based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation.

MAIN RESULTS

We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) -10.82 m to 10.94 m; 556 participants; four studies; moderate-certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD -1.26, 95% CI -3.97 to 1.45; 274 participants; two studies; low-certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40; 426 participants; three studies; low-certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in-person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI -38.89 m to 83.23 m; 94 participants; two studies; low-certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low-certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in-person rehabilitation or no rehabilitation.

AUTHORS' CONCLUSIONS

This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre-based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.

Emerging challenges in meeting physiotherapy needs during COVID-19 through telerehabilitation

Background

Physiotherapy plays a significant role in rehabilitation. However, the emergence of the coronavirus disease 2019 (COVID-19) has posed a big challenge to its practice, especially regarding the level of contact with patients. There is a dire need for the exploration of rehabilitation options, other than in-person contacts, to limit the spread of the virus. This article explores telerehabilitation, its outcomes, and the challenges involved in the continuum of care of patients by physiotherapists in the face of the pandemic.

Body

Telerehabilitation is a vital tool which utilizes technology to link practitioners to patients. With its previous history of favorable outcomes for the rehabilitation of certain conditions, telerehabilitation has been widely recommended. However, issues exist on how well it can bridge the gap of physical touch in physiotherapy, its effectiveness in terms of outcomes and satisfaction across various conditions and large population sizes, and finally, its cost and effects, especially in developing countries.

Conclusion

Telerehabilitation is a necessary adaptation to ensure continued physiotherapy service delivery during the pandemic. However, more quality studies are recommended to evaluate its effectiveness and outcomes. Also, measures to ensure that developing countries are catered for in meeting the rising demands for physiotherapy services using telerehabilitation should be carried out.

Protocol for a systematic review and meta-analysis of respiratory rehabilitation following intensive care unit discharge for COVID-19 survivors

INTRODUCTION

Both physical and mental disorders may be exacerbated in patients with COVID-19 due to the experience of receiving intensive care; undergoing prolonged mechanical ventilation, sedation, proning and paralysis. Pulmonary rehabilitation is aimed to improve dyspnoea, relieve anxiety and depression, reduce the incidence of related complications, as well as prevent and improve dysfunction. However, the impact of respiratory rehabilitation on discharged patients with COVID-19 is currently unclear, especially on patients who have been mechanically ventilated over 24 hours. Therefore, we aim to investigate the efficacy of respiratory rehabilitation programmes, initiated after discharge from the intensive care unit, on the physical and mental health and health-related quality of life in critical patients with COVID-19.

METHODS AND ANALYSIS

We have registered the protocol on PROSPERO and in the process of drafting it, we strictly followed the checklist of Preferred Reporting Items for Systematic Review and Meta-Analysis Potocols. We will search the PubMed, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WanFang, VIP information databases and Chinese Biomedical Literature Database. Additionally, ongoing trials in the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov and ISRCTN registry will be searched as well. Studies in English or Chinese and from any country will be accepted regardless of study design. Two review authors will independently extract data and assess the quality of included studies. Continuous data are described as standard mean differences (SMDs) with 95% CIs. Dichotomous data from randomised controlled trials are described as risk ratio(RR) with 95% CIs; otherwise, it is described as odds ratio(OR) with 95% CIs. I² and the Cochrane's Q statistic will be used to conduct heterogeneity assessment. The quality of evidence of main outcomes will be evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation(GRADE) criteria. When included studies are sufficient, we will conduct subgroup analysis and sensitivity analysis; the publication bias will be statistically analysed using a funnel plot analysis and Egger's test.

ETHICS AND DISSEMINATION

Our review, planning to include published studies, does not need the request to the ethical committee. The final results of this review will be published in a peer-reviewed journal after completion.

PATIENT AND PUBLIC INVOLVEMENT

No patient involved.

PROSPERO REGISTRATION NUMBER

CRD42020186791.

Efficacy of Unsupervised Home-Based Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Purpose

Pulmonary rehabilitation (PR) is a well-established treatment for chronic obstructive pulmonary disease (COPD). The standard protocol for PR requires frequent hospital visits, which can be difficult for patients. We performed this study to assess whether unsupervised home-based PR (HBPR) is effective for patients with COPD.

Patients and Methods

After assessing the outcome data, including the results of a COPD assessment test (CAT); the body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) index; a spirometry; the modified Medical Research Council (mMRC) dyspnea scale; and the 6-min walking test (6MWT), specialists imparted 1-hour education to patients regarding unsupervised HBPR at the baseline visit. This included methods for breathing, inhaler use, stretching, and exercise. On reviewing diaries after 8 weeks from the first visit, patients who exercised at least thrice per week were classified as the compliant group and the others were categorized as the noncompliant group. Changes in the outcomes were compared between the compliant and noncompliant groups.

Results

A total of 41 patients were enrolled in this study; for 8 weeks of unsupervised HBPR, there were significant improvements in CAT scores (-4.62±4.61 vs 2.40±6.73; P=0.002), BODE index (-1.00±1.06 vs -0.20±0.56; P=0.01), and forced expiratory volume in 1 s (0.05±0.19 vs -0.09±0.16; P=0.02) among patients in the compliant group, compared with the noncompliant group. Moreover, their CAT (16.46±7.80 vs 11.85±7.23; P=0.03) and mMRC scores (2.54±0.76 vs 1.81±0.63; P=0.001) improved significantly after 8 weeks, compared with those at baseline. On the other hand, patients in the noncompliant group showed no significant improvement in any of the outcomes.

Conclusion

In this study, compliant patients with unsupervised HBPR achieved favorable outcomes in 8 weeks. Thus, we recommend unsupervised HBPR for patients with COPD, even when regular hospital visits for PR are not possible.

Trial Registration

NCT03754881.

Chronic Obstructive Pulmonary Disease: A Palliative Medicine Review of the Disease, Its Therapies, and Drug Interactions

Despite significant advances in treatment, chronic obstructive pulmonary disease (COPD) remains a chronic and progressive disease that frequently leads to premature mortality. COPD is associated with a constellation of significant symptoms, including dyspnea, cough, wheezing, pain, fatigue, anxiety, depression, and insomnia, and is associated with increased morbidity. Palliative care is appropriate to support these patients. However, historically, palliative care has focused on supporting patients with malignant disease, rather than progressive chronic diseases such as COPD. Therapies for COPD often result in functional and symptomatic improvements, including health-related quality of life (HRQL), and palliative care may further improve symptoms and HRQL. Provision of usual palliative care therapies for this patient population requires understanding the pathogenesis of COPD and common disease-targeted pharmacotherapies, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes COPD and current targeted therapies and their effects on symptoms, exercise tolerance, HRQL, and survival. It is important to note that medications commonly used for symptom management in palliative care can interact with COPD medications resulting in increased risk of adverse effects, enhanced toxicity, or changes in clearance of medications. To address this, we review pharmacologic interactions with and precautions related to use of COPD therapies in conjunction with commonly used palliative care medications.

Muscle loss contributes to higher morbidity and mortality in COPD: An analysis of national trends

BACKGROUND AND OBJECTIVE

COPD is the third most common cause of death worldwide and fourth most common in the United States. In hospitalized patients with COPD, mortality, morbidity and healthcare resource utilization are high. Skeletal muscle loss is frequent in patients with COPD. However, the impact of muscle loss on adverse outcomes has not been systematically evaluated. We tested the hypothesis that patients hospitalized for COPD exacerbation with, compared to those without, a secondary diagnosis of muscle loss phenotype (all ICD-9 codes associated with muscle loss including cachexia) will have higher mortality and cost of care.

METHODS

The NIS database of hospitalized patients in 2011 (1 January-31 December) in the United States was used. The impact of a muscle loss phenotype on in-hospital mortality, LOS and cost of care for each of the 174 808 hospitalizations for COPD exacerbations was analysed.

RESULTS

Of the subjects admitted for a COPD exacerbation, 12 977 (7.4%) had a secondary diagnosis of muscle loss phenotype. A diagnosis of muscle loss phenotype was associated with significantly higher in-hospital mortality (14.6% vs 5.7%, P < 0.001), LOS (13.3 + 17.1 vs 5.7 + 7.6, P < 0.001) and median hospital charge per patient ($13 947 vs $6610, P < 0.001). Multivariate regression analysis showed that muscle loss phenotype increased mortality by 111% (95% CI: 2.0-2.2, P < 0.001), LOS by 68.4% (P < 0.001) and the direct cost of care by 83.7% (P < 0.001) compared to those without muscle loss.

CONCLUSION

In-hospital mortality, LOS and healthcare costs are higher in patients with COPD exacerbations and a muscle loss phenotype.

Identification of Patient Profiles with High Risk of Hospital Re-Admissions for Acute COPD Exacerbations (AECOPD) in France Using a Machine Learning Model

Purpose

To characterise patients with chronic obstructive pulmonary disease (COPD) who are rehospitalised for an acute exacerbation, to estimate the cost of these hospitalisations, to characterise high risk patient sub groups and to identify factors potentially associated with the risk of rehospitalisation.

Patients and Methods

This was a retrospective study using the French National Hospital Discharge Database. All patients aged ≥40 years hospitalised for an acute exacerbation of COPD between 2015 and 2016 were identified and followed for six months. Patients with at least one rehospitalisation for acute exacerbation of COPD constituted the rehospitalisation analysis population. A machine learning model was built to study the factors associated with the risk of rehospitalisation using decision tree analysis. A direct cost analysis was performed from the perspective of national health insurance.

Results

A total of 143,006 eligible patients were hospitalised for an acute exacerbation of COPD (AECOPD) in 2015-2016 (mean age: 74 years; 62.1% men). 25,090 (18.8%) were rehospitalised for another exacerbation within six months. In this study, 8.5% of patients died during or immediately following the index hospitalisation and 10.5% died during or immediately after rehospitalisation (p <0.001). The specific cost of these rehospitalisations was € 5304. The overall total cost per patient of all AECOPD-related stays was € 9623, being significantly higher in patients who were rehospitalised (€ 16,275) compared to those who were not (€ 8208). In decision tree analysis, the most important driver of rehospitalisation was hospitalisation in the previous two years (contributing 85% of the information).

Conclusion

Rehospitalisations for acute exacerbations of COPD carry a high epidemiological and economic burden. Since hospitalisation for an acute exacerbation is the most important determinant of future rehospitalisations, management of COPD needs to focus on interventions aimed at decreasing the rehospitalisation risk of in order to lower the burden of disease.

Findings of a feasibility study of pre-operative pulmonary rehabilitation to reduce post-operative pulmonary complications in people with chronic obstructive pulmonary disease scheduled for major abdominal surgery

Background: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of complications and death following surgery. Pulmonary complications are particularly prominent.  Pulmonary rehabilitation is a course of physical exercise and education that helps people with COPD manage their condition.  Although proven to improve health outcomes in patients with stable COPD, it has never been formally tested as a pre-surgical intervention in patients scheduled for non-cardiothoracic surgery.  If a beneficial effect were to be demonstrated, pulmonary rehabilitation for pre-surgical patients with COPD might be rapidly implemented across the National Health Service, as pulmonary rehabilitation courses are already well established across much of the United Kingdom (UK). Methods: We performed a feasibility study to test study procedures and barriers to identification and recruitment to a randomised controlled trial testing whether pulmonary rehabilitation, delivered before major abdominal surgery in a population of people with COPD, would reduce the incidence of post-operative pulmonary complications.  This study was run in two UK centres (Oxford and Newcastle upon Tyne). Results:  We determined that a full randomised controlled trial would not be feasible, due to failure to identify and recruit participants.  We identified an unmet need to identify more effectively patients with COPD earlier in the surgical pathway.  Service evaluations suggested that barriers to identification and recruitment would likely be the same across other UK hospitals. Conclusions:  Although pulmonary rehabilitation is a potentially beneficial intervention to prevent post-operative pulmonary complications, a randomised controlled trial is unlikely to recruit sufficient participants to answer our study question conclusively at the present time, when spirometry is not automatically conducted in all patients planned for surgery.  As pulmonary rehabilitation is a recommended treatment for all people with COPD, alternative study methods combined with earlier identification of candidate patients in the surgical pathway should be considered. Trial registration: ISRCTN29696295, 31/08/2017.

Comprehensive care for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common chronic disease worldwide and incurs heavy utilization of healthcare resources. Many COPD patients have comorbidities and experience exacerbations in the course of the disease. Correct diagnosis and appropriate disease assessment are essential for clinical management. Comprehensive care for patients with different severity of disease aims to offer personalized treatment to suit individual needs. Patients with recent exacerbations also need extra care for the post-acute and rehabilitation phases. Comprehensive care consists of self-management and pulmonary rehabilitation and involves multiple healthcare providers working together closely to provide formal structured programmes for patients. The setting, professionals involved, content and the duration of programme vary a lot among different comprehensive care models. Some randomized controlled trials suggested there was improvement in quality of life, exercise capacity and reduced hospital admissions for participants in comprehensive care programmes compared with controls. However, other studies showed that such programmes might not confer benefits and might even bring harm. The reason for the differences in clinical effect of programmes might be due to differences in study design, components and subjects involved in the studies. Careful evaluation of each programme is thus mandatory. Further research is needed to evaluate the safety and effectiveness of comprehensive care management for COPD patients, both at the stable and post-acute exacerbation state.

Care bundles in the management of a COPD exacerbation

Chronic obstructive pulmonary disease (COPD), the umbrella term used to describe chronic lung diseases that cause limitations in lung airflow, is predicted to be the third leading cause of death by 2030. COPD is said to affect 3 million people in the UK, resulting in approximately 30 000 deaths each year. Related healthcare costs continue to escalate, not least because of increasing readmission rates associated with COPD emergencies. The use of care bundles to streamline care is becoming more popular in an attempt to tackle this issue. An integrative literature review was carried out to examine the effectiveness of the use of care bundles. The findings highlighted inconsistencies in the components of bundles, leading to inherent difficulties in assessing which specific component of the bundles led to positive outcomes. The results of this attempt to establish the effectiveness of care bundles in reducing readmission rates and quality of care were inconclusive. The authors recommend further research to investigate the individual components in the bundles and to introduce internationally agreed care bundles for the management of COPD.

Improving the uptake: Barriers and facilitators to pulmonary rehabilitation

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence and management of chronic breathlessness in COPD in a tertiary care center

Background

Breathlessness is the prominent symptom of chronic obstructive pulmonary disease (COPD). Despite optimal therapeutic management including pharmacological and non-pharmacological interventions, many COPD patients exhibit significant breathlessness. Chronic breathlessness is defined as breathlessness that persists despite optimal treatment of the underlying disease. Because of the major disability related to chronic breathlessness, symptomatic treatments including opioids have been recommended by several authors. The prevalence of chronic breathlessness in COPD and its management in routine clinical practice have been poorly investigated. Our aim was to examine prevalence, associated characteristics and management of chronic breathlessness in patients with COPD recruited in a real-life tertiary hospital-based cohort.

Methods

A prospective study was conducted among 120 consecutive COPD patients recruited, in stable condition, at Nancy University Hospital, France. In parallel, 88 pulmonologists of the same geographical region were asked to respond to an on-line questionnaire on breathlessness management.

Results

Sixty four (53%) patients had severe breathlessness (modified Medical Research Council scale≥3), despite optimal inhaled medications for 94% of them; 40% had undergone pulmonary rehabilitation within the past 2 years. The severity of breathlessness increased with increasing airflow limitation. Breathlessness was associated with increased symptoms of anxiety, depression and with osteoporosis. No relation was found with other symptoms, exacerbation rate, or cardiovascular comorbidities. Among the patients with chronic breathlessness and Hospitalized Anxiety and/or Depression score > 10, only 25% were treated with antidepressant or anxiolytic. Among the pulmonologists 46 (52%) answered to the questionnaire and expressed a high willingness to prescribe opioids forchronic breathlessness, which contrasted with the finding that none of these patients received such treatments against breathlessness.

Conclusion

Treatment approaches to breathlessness and associated psychological distress are insufficient in COPD. This study highlights underuse of pulmonary rehabilitation and symptomatic treatment for breathlessness.

Electronic supplementary material

The online version of this article (10.1186/s12890-019-0851-5) contains supplementary material, which is available to authorized users.

A systematic review of the content and delivery of education in pulmonary rehabilitation programmes

INTRODUCTION

Pulmonary rehabilitation (PR) is a core component of Chronic Obstructive Pulmonary Disease (COPD) management with well recognized benefits. While suggestions for educational content within pulmonary rehabilitation have been detailed in clinical guidance, it is unclear what educational content is delivered as part of pulmonary rehabilitation, who delivers it, and how it is delivered.

METHODS

A systematic review was conducted to identify what educational content is delivered as part of pulmonary rehabilitation, how is this delivered and who delivers it. Databases were searched from 1981 to 2017 using multiple search terms related to "pulmonary rehabilitation" and "education".

RESULTS

Fourteen studies were identified. This included 6 survey studies, 5 quasi-experimental studies and 3 RCTs. Five key topics that were consistently included within PR programmes were identified as: 1) Anxiety/depression and stress management. 2) Early recognition of signs of infection. 3) Dyspnea and symptom management. 4) Nutrition. 5) Techniques using inhalers and nebulizers. Broader topics such as welfare/benefits, sexuality, and advance care directives did not frequently feature. Only four studies used tools to measure knowledge or learning pre and post rehabilitation in an attempt to evaluate the effectiveness of the education delivered as part of PR.

CONCLUSIONS

The delivery of education in PR programmes is variable and does not follow suggested educational topics. Education needs to take a patient centered motivational approach to ensure effective delivery. Further research into appropriate educational outcome measures are needed, in order to evaluate the changes in behaviour associated with education.

Mobile health applications in self-management of patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of their efficacy

Background

Mobile health applications are increasingly used in patients with Chronic Obstructive Pulmonary Disease (COPD) to improve their self-management, nonetheless, without firm evidence of their efficacy. This meta-analysis was aimed to assess the efficacy of mobile health applications in supporting self-management as an intervention to reduce hospital admission rates and average days of hospitalization, etc.

Methods

PubMed, Web of Science (SCI), Cochrane Library, and Embase were searched for relevant articles published before November 14th, 2017. A total of 6 reports with randomized controlled trials (RCTs) were finally included in this meta-analysis.

Results

Patients using mobile phone applications may have a lower risk for hospital admissions than those in the usual care group (risk ratio (RR) = 0.73, 95% CI [0.52, 1.04]). However, there was no significant difference in reducing the average days of hospitalization.

Conclusion

Self-management with mobile phone applications could reduce hospital admissions of patients with COPD.

Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review

QUESTION

Are additional weekend allied health services effective and cost-effective for acute general medical and surgical wards, and subacute rehabilitation hospital wards?

DESIGN

Systematic review and meta-analysis of studies published between January 2000 and May 2017. Two reviewers independently screened studies for inclusion, extracted data, and assessed methodological quality. Meta-analyses were conducted for relative measures of effect estimates.

PARTICIPANTS

Patients admitted to acute general medical and surgical wards, and subacute rehabilitation wards.

INTERVENTION

All services delivered by allied health professionals during weekends (Saturday and/or Sunday). This study limited allied health professions to: occupational therapy, physiotherapy, social work, speech pathology, dietetics, art therapy, chiropractic, exercise physiology, music therapy, oral health (not dentistry), osteopathy, podiatry, psychology, and allied health assistants.

OUTCOME MEASURES

Hospital length of stay, hospital re-admission, adverse events, discharge destination, functional independence, health-related quality of life, and cost of hospital care.

RESULTS

Nineteen articles (20 studies) were identified, comprising 10 randomised and 10 non-randomised trials. Physiotherapy was the most commonly investigated profession. A meta-analysis of randomised, controlled trials showed that providing additional weekend allied health services in subacute rehabilitation wards reduced hospital length of stay by 2.35days (95% CI 0.45 to 4.24, I²=0%), and may be a cost-effective way to improve function (SMD 0.09, 95% CI -0.01 to 0.19, I²=0%), and health-related quality of life (SMD 0.10, 95% CI -0.01 to 0.20, I²=0%). For acute general medical and surgical hospital wards, it was unclear whether the weekend allied health service model provided in the two identified randomised trials led to significant changes in measured outcomes.

CONCLUSION

The benefit of providing additional allied health services is clearer in subacute rehabilitation settings than for acute general medical and surgical wards in hospitals.

REGISTRATION

PROSPERO CRD76771. [Sarkies MN, White J, Henderson K, Haas R, Bowles J, Evidence Translation in Allied Health (EviTAH) Group (2018) Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review. Journal of Physiotherapy 64: 142-158].

Mortality in Advanced Chronic Obstructive Pulmonary Disease and Heart Failure Following Cardiopulmonary Rehabilitation

Cardiopulmonary rehabilitation (CR) improves physical function and quality of life (QoL) in chronic obstructive pulmonary disease (COPD) and heart failure (HF), but it is unknown if CR improves outcomes in very severe disease. This study's purpose was to describe functional capacity (6-min walk distance [6MWD], steps/day), symptoms (dyspnea, depression), QoL (Short-Form Health Survey-Veterans [SF-36 V]) and cardiopulmonary function ( N-terminal pro-brain natriuretic peptide [NT-proBNP], forced expiratory volume in 1 s [FEV1]), and derive predictors of mortality among patients with severe COPD and HF who participated in CR.

METHODS AND RESULTS

In this secondary analysis of a randomized controlled trial comparing two CR methods in severe COPD and HF, 90 (COPD = 63, HF = 27) male veterans, mean age 66 ± 9.24 years, 79% Caucasian, and body mass index 31 kg/m2, were followed for 12 months after CR. The COPD group had greater functional decline than the HF group (6MWD, p = .006). Dyspnea was lower ( p = .001) and QoL higher ( p = .006) in the HF group. Mean NT-proBNP was higher in the HF group at all time points. FEV1 improved over 12 months in both groups ( p = .01). Mortality was 8.9%, 16.7%, and 37.8% at 12, 24, and 60 months, respectively. One-year predictors of mortality were baseline total steps (<3,000/day), 6MWD (<229 meters), and NT-proBNP level (>2,000 mg/pg).

CONCLUSIONS

In very severe COPD and HF, risks of mortality over 12 months can predict patients unlikely to benefit from CR and should be considered at initial referral.

Acute exacerbation of COPD during pulmonary rehabilitation: outcomes and risk prediction

Purpose

This study was performed to examine acute exacerbation of COPD (AECOPD) during pulmonary rehabilitation (PR) and the usefulness of multidimensional indices (MIs) to predict AECOPD at enrolment in PR.

Patients and methods

A 4-week PR program (PRP) was implemented for 125 consecutive patients with COPD. At baseline and PRP completion, we recorded the FEV₁, 6-minute walk test, peak work rate at cardiopulmonary testing, modified Medical Research Council score, and COPD Assessment Test (CAT) score. The risk of AECOPDs at baseline was assessed using the body mass index, airway obstruction, dyspnea, Exercise capacity (BODE), dyspnea, obstruction, smoking, exacerbation (DOSE), and score to predict short-term risk of COPD exacerbations (SCOPEX) MIs.

Results

Thirty-two episodes of AECOPD occurred. The COPD status was worse in patients with than without AECOPD at baseline (lower FEV₁, 6-minute walk test, and peak work rate; higher modified Medical Research Council and CAT scores). The sensitivities of the BODE, DOSE, and SCOPEX MIs to predict the occurrence of AECOPD during PRP were 78.1%, 21.9%, and 84.4%, and the specificities were 73.6%, 87.1%, and 51.6%, respectively.

Conclusion

The BODE and SCOPEX MIs help to predict the exacerbation risk during PR.

Safety and Efficacy of Aerobic Exercise Training Associated to Non-Invasive Ventilation in Patients with Acute Heart Failure

Background

Exercise training (ET) improves functional capacity in chronic heart failure (HF). However, ET effects in acute HF are unknown.

Objective

To investigate the effects of ET alone or combined with noninvasive ventilation (NIV) compared with standard medical treatment during hospitalization in acute HF patients.

Methods

Twenty-nine patients (systolic HF) were randomized into three groups: control (Control - only standard medical treatment); ET with placebo NIV (ET+Sham) and ET+NIV (NIV with 14 and 8 cmH₂O of inspiratory and expiratory pressure, respectively). The 6MWT was performed on day 1 and day 10 of hospitalization and the ET was performed on an unloaded cycle ergometer until patients' tolerance limit (20 min or less) for eight consecutive days. For all analyses, statistical significance was set at 5% (p < 0.05).

Results

None of the patients in either exercise groups had adverse events or required exercise interruption. The 6MWT distance was greater in ET+NIV (Δ120 ± 72 m) than in ET+Sham (Δ73 ± 26 m) and Control (Δ45 ± 32 m; p < 0.05). Total exercise time was greater (128 ± 10 vs. 92 ± 8 min; p < 0.05) and dyspnea was lower (3 ± 1 vs. 4 ± 1; p < 0.05) in ET+NIV than ET+Sham. The ET+NIV group had a shorter hospital stay (17 ± 10 days) than ET+Sham (23 ± 8 days) and Control (39 ± 15 days) groups (p < 0.05). Total exercise time in ET+Sham and ET+NIV had significant correlation with length of hospital stay (r = -0.75; p = 0.01).

Conclusion

Exercise training in acute HF was safe, had no adverse events and, when combined with NIV, improved 6MWT and reduce dyspnea and length of stay.

Reducing COPD readmissions through predictive modeling and incentive-based interventions

This paper introduces a case study at a community hospital to develop a predictive model to quantify readmission risks for patients with chronic obstructive pulmonary disease (COPD), and use it to support decision making for appropriate incentive-based interventions. Data collected from the community hospital's database are analyzed to identify risk factors and a logistic regression model is developed to predict the readmission risk within 30 days post-discharge of an individual COPD patient. By targeting on the high-risk patients, we investigate the implementability of the incentive policy which encourages patients to take interventions and helps them to overcome the compliance barrier. Specifically, the conditions and scenarios are identified for either achieving the desired readmission rate while minimizing the total cost, or reaching the lowest readmission rate under incentive budget constraint. Currently, such models are under consideration for a pilot study at the community hospital.

Malnutrition and its association with readmission and death within 7 days and 8-180 days postdischarge in older patients: a prospective observational study

OBJECTIVE

The relationship between admission nutritional status and clinical outcomes following hospital discharge is not well established. This study investigated whether older patients' nutritional status at admission predicts unplanned readmission or death in the very early or late periods following hospital discharge.

DESIGN, SETTING AND PARTICIPANTS

The study prospectively recruited 297 patients ≥60 years old who were presenting to the General Medicine Department of a tertiary care hospital in Australia. Nutritional status was assessed at admission by using the Patient-Generated Subjective Global Assessment (PG-SGA) tool, and patients were classified as either nourished (PG-SGA class A) or malnourished (PG-SGA classes B and C). A multivariate logistic regression model was used to adjust for other covariates known to influence clinical outcomes and to determine whether malnutrition is a predictor for early (0-7 days) or late (8-180 days) readmission or death following discharge.

OUTCOME MEASURES

The impact of nutritional status was measured on a combined endpoint of any readmission or death within 0-7 days and between 8 and 180 days following hospital discharge.

RESULTS

Within 7 days following discharge, 29 (10.5%) patients had an unplanned readmission or death whereas an additional 124 (50.0%) patients reached this combined endpoint within 8-180 days postdischarge. Malnutrition was associated with a significantly higher risk of combined endpoint of readmissions or death both within 7 days (OR 4.57, 95% CI 1.69 to 12.37, P<0.001) and within 8-180 days (OR 1.98, 95% CI 1.19 to 3.28, P=0.007) following discharge and this risk remained significant even after adjustment for other covariates.

CONCLUSIONS

Malnutrition in older patients at the time of hospital admission is a significant predictor of readmission or death both in the very early and in the late periods following hospital discharge. Nutritional state should be included in future risk prediction models.

TRIAL REGISTRATION NUMBER

ACTRN No. 12614000833662; Post-results.

Physiotherapy in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Physiotherapy is an essential for the treatment of patients with chronic respiratory non-inflammatory diseases especially for chronic obstructive pulmonary disease (COPD).

AIM

To assess the effect of six months physiotherapy (PT) program on functional status in patients with COPD.

MATERIAL AND METHODS

The patients were divided into two groups according to the severity of the disease. Group A included 33 patients (mean age 68.6 ± 7.3; GOLD II - III stages). Group B included 32 patients (mean age 71.7 ± 6.9; GOLD I -II). They were referred to supervised PT program performed three times weekly for a half a year. All the patients were on standard medical care. At entry and after PT, six minutes walking test (6 MWT), Borg scale and modified Medical Research Council (mMRC) scale were assessed.

RESULTS

Significant changes in 6 MWT (p < 0.001) and mMRC scale (p < 0.001) were found after applied physical therapy program in patients of group A. Exertional dyspnoea decreased significantly in patients with group A (p < 0.001). Positive changes were found in physical tolerance in the patients of group B (p < 0.001).

CONCLUSIONS

The present study revealed the positive effect of six months physiotherapy in physical tolerance and dyspnoea in patients with COPD at different stages of the disease.

The recording and characteristics of pulmonary rehabilitation in patients with COPD using The Health Information Network (THIN) primary care database

Pulmonary rehabilitation is recommended for patients with COPD to improve physical function, breathlessness and quality of life. Using The Health Information Network (THIN) primary care database in UK, we compared the demographic and clinical parameters of patients with COPD in relation to coding of pulmonary rehabilitation, and to investigate whether there is a survival benefit from pulmonary rehabilitation. We identified patients with COPD, diagnosed from 2004 and extracted information on demographics, pulmonary rehabilitation and clinical parameters using the relevant Read codes. Thirty six thousand one hundred and eighty nine patients diagnosed with COPD were included with a mean (SD) age of 67 (11) years, 53% were male and only 9.8% had a code related to either being assessed, referred, or completing pulmonary rehabilitation ever. Younger age at diagnosis, better socioeconomic status, worse dyspnoea score, current smoking, and higher comorbidities level are more likely to have a record of pulmonary rehabilitation. Of those with a recorded MRC of 3 or worse, only 2057 (21%) had a code of pulmonary rehabilitation. Survival analysis revealed that patients with coding for pulmonary rehabilitation were 22% (95% CI 0.69-0.88) less likely to die than those who had no coding. In UK THIN records, a substantial proportion of eligible patients with COPD have not had a coded pulmonary rehabilitation record. Survival was improved in those with PR record but coding for other COPD treatments were also better in this group. GP practices need to improve the coding for PR to highlight any unmet need locally.

CHRONIC LUNG DISEASE

ROLLING OUT THE REHAB: Analysis of recent UK data suggests that more patients with chronic lung disease could benefit from lung rehabilitation programmes. During pulmonary rehabilitation (PR), patients with chronic obstructive pulmonary disease (COPD) work with specialists to learn exercises and optimise breathing techniques. The programmes are recommended under current guidelines, particularly for patients with a high breathlessness score. Despite this, when Charlotte Bolton and co-workers at the University of Nottingham analysed 36,189 patient primary care records gathered since 2004, they found only 9.8% of COPD patients had ever had a coded record of being assessed, referred for, or undertaken PR. Those patients who completed PR were 22% less likely to die that those who didn't, although appeared they had also received better overall COPD care. Current smokers, those suffering from co-morbidities and younger patients were more likely to receive PR than other patient groups.

Joint statement for the diagnosis, management, and prevention of chronic obstructive pulmonary disease for Gulf Cooperation Council countries and Middle East-North Africa region, 2017

Smoking and subsequent development of COPD is an ever-increasing epidemic in Arabian Gulf and Middle East countries, with no signs of decline. The important fact to be highlighted is that this COPD epidemic of increasing incidence and prevalence is mostly unrecognized by patients, due to the common attribution of symptoms to "smoker's cough", and the underdiagnosis and undertreatment by physicians because the common signs and symptoms masquerade as asthma. Consequently, there are long-term adverse effects of missing the diagnosis. The purpose of this review article is to focus upon the status of COPD in Arabian Gulf and Middle East countries, stressing the increasing burden of smoking and COPD, to emphasize the specific factors leading to rise in prevalence of COPD, to bring to light the underdiagnosis and undermanagement of COPD, and to treat COPD in conformity with standard guidelines with local and regional modifications. This review ends with suggestions and recommendations to the health department to formulate policies and to generate awareness among the general public about the side effects of smoking and consequences of COPD.

Impact and prevention of severe exacerbations of COPD: a review of the evidence

Severe exacerbations of COPD, ie, those leading to hospitalization, have profound clinical implications for patients and significant economic consequences for society. The prevalence and burden of severe COPD exacerbations remain high, despite recognition of the importance of exacerbation prevention and the availability of new treatment options. Severe COPD exacerbations are associated with high mortality, have negative impact on quality of life, are linked to cardiovascular complications, and are a significant burden on the health-care system. This review identified risk factors that contribute to the development of severe exacerbations, treatment options (bronchodilators, antibiotics, corticosteroids [CSs], oxygen therapy, and ventilator support) to manage severe exacerbations, and strategies to prevent readmission to hospital. Risk factors that are amenable to change have been highlighted. A number of bronchodilators have demonstrated successful reduction in risk of severe exacerbations, including long-acting muscarinic antagonist or long-acting β2-agonist mono- or combination therapies, in addition to vaccination, mucolytic and antibiotic therapy, and nonpharmacological interventions, such as pulmonary rehabilitation. Recognition of the importance of severe exacerbations is an essential step in improving outcomes for patients with COPD. Evidence-based approaches to prevent and manage severe exacerbations should be implemented as part of targeted strategies for disease management.

Effect of a rehabilitation-based chronic disease management program targeting severe COPD exacerbations on readmission patterns

Background

Pulmonary rehabilitation (PR) is recommended after a severe COPD exacerbation, but its short- and long-term effects on health care utilization have not been fully established.

Aims

The aims of this study were to evaluate patient compliance with a chronic disease management (CDM) program incorporating home-based exercise training as the main component after a severe COPD exacerbation and to determine its effects on health care utilization in the following year.

Materials and methods

COPD patients with a severe exacerbation were included in a case-cohort study at admission. An intervention group participated in a nurse-supervised CDM program during the 2 months after discharge, comprising of home-based PR with exercise components directly supervised by a physiotherapist, while the remaining patients followed usual care.

Results

Nineteen of the twenty-one participants (90.5%) were compliant with the CDM program and were compared with 29 usual-care patients. Compliance with the program was associated with statistically significant reductions in admissions due to respiratory disease in the following year (median [interquartile range]: 0 [0–1] vs 1 [0–2.5]; P=0.022) and in days of admission (0 [0–7] vs 7 [0–12]; P=0.034), and multiple linear regression analysis confirmed the protective effect of the CDM program (β coefficient −0.785, P=0.014, and R²=0.219).

Conclusion

A CDM program incorporating exercise training for COPD patients without limiting comorbidities after a severe exacerbation achieves high compliance and reduces admissions in the year following after the intervention.

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Guidelines have provided positive recommendations for pulmonary rehabilitation after exacerbations of chronic obstructive pulmonary disease (COPD), but recent studies indicate that postexacerbation rehabilitation may not always be effective in patients with unstable COPD.

OBJECTIVES

To assess effects of pulmonary rehabilitation after COPD exacerbations on hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life (HRQL) and exercise capacity).

SEARCH METHODS

We identified studies through searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PEDro (Physiotherapy Evidence Database) and the Cochrane Airways Review Group Register of Trials. Searches were current as of 20 October 2015, and handsearches were run up to 5 April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing pulmonary rehabilitation of any duration after exacerbation of COPD versus conventional care. Pulmonary rehabilitation programmes had to include at least physical exercise (endurance or strength exercise, or both). We did not apply a criterion for the minimum number of exercise sessions a rehabilitation programme had to offer to be included in the review. Control groups received conventional community care without rehabilitation.

DATA COLLECTION AND ANALYSIS

We expected substantial heterogeneity across trials in terms of how extensive rehabilitation programmes were (i.e. in terms of number of completed exercise sessions; type, intensity and supervision of exercise training; and patient education), duration of follow-up (< 3 months vs ≥ 3 months) and risk of bias (generation of random sequence, concealment of random allocation and blinding); therefore, we performed subgroup analyses that were defined before we carried them out. We used standard methods expected by Cochrane in preparing this update, and we used GRADE for assessing the quality of evidence.

MAIN RESULTS

For this update, we added 11 studies and included a total of 20 studies (1477 participants). Rehabilitation programmes showed great diversity in terms of exercise training (number of completed exercise sessions; type, intensity and supervision), patient education (from none to extensive self-management programmes) and how they were organised (within one setting, e.g. pulmonary rehabilitation, to across several settings, e.g. hospital, outpatient centre and home). In eight studies, participants completed extensive pulmonary rehabilitation, and in 12 studies, participants completed pulmonary rehabilitation ranging from not extensive to moderately extensive.Eight studies involving 810 participants contributed data on hospital readmissions. Moderate-quality evidence indicates that pulmonary rehabilitation reduced hospital readmissions (pooled odds ratio (OR) 0.44, 95% confidence interval (CI) 0.21 to 0.91), but results were heterogenous (I² = 77%). Extensiveness of rehabilitation programmes and risk of bias may offer an explanation for the heterogeneity, but subgroup analyses were not statistically significant (P values for subgroup effects were between 0.07 and 0.11). Six studies including 670 participants contributed data on mortality. The quality of evidence was low, and the meta-analysis did not show a statistically significant effect of rehabilitation on mortality (pooled OR 0.68, 95% CI 0.28 to 1.67). Again, results were heterogenous (I² = 59%). Subgroup analyses showed statistically significant differences in subgroup effects between trials with more and less extensive rehabilitation programmes and between trials at low and high risk for bias, indicating possible explanations for the heterogeneity. Hospital readmissions and mortality studies newly included in this update showed, on average, significantly smaller effects of rehabilitation than were seen in earlier studies.High-quality evidence suggests that pulmonary rehabilitation after an exacerbation improves health-related quality of life. The eight studies that used St George's Respiratory Questionnaire (SGRQ) reported a statistically significant effect on SGRQ total score, which was above the minimal important difference (MID) of four points (mean difference (MD) -7.80, 95% CI -12.12 to -3.47; I² = 64%). Investigators also noted statistically significant and important effects (greater than MID) for the impact and activities domains of the SGRQ. Effects were not statistically significant for the SGRQ symptoms domain. Again, all of these analyses showed heterogeneity, but most studies showed positive effects of pulmonary rehabilitation, some studies showed large effects and others smaller but statistically significant effects. Trials at high risk of bias because of lack of concealment of random allocation showed statistically significantly larger effects on the SGRQ than trials at low risk of bias. High-quality evidence shows that six-minute walk distance (6MWD) improved, on average, by 62 meters (95% CI 38 to 86; I² = 87%). Heterogeneity was driven particularly by differences between studies showing very large effects and studies showing smaller but statistically significant effects. For both health-related quality of life and exercise capacity, studies newly included in this update showed, on average, smaller effects of rehabilitation than were seen in earlier studies, but the overall results of this review have not changed to an important extent compared with results reported in the earlier version of this review.Five studies involving 278 participants explicitly recorded adverse events, four studies reported no adverse events during rehabilitation programmes and one study reported one serious event.

AUTHORS' CONCLUSIONS

Overall, evidence of high quality shows moderate to large effects of rehabilitation on health-related quality of life and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of rehabilitation on hospital readmissions and mortality and introduced heterogeneity as compared with the last update of this review. Such heterogeneity of effects on hospital readmissions and mortality may be explained to some extent by the extensiveness of rehabilitation programmes and by the methodological quality of the included studies. Future researchers must investigate how the extent of rehabilitation programmes in terms of exercise sessions, self-management education and other components affects the outcomes, and how the organisation of such programmes within specific healthcare systems determines their effects after COPD exacerbations on hospital readmissions and mortality.

Depression Is Associated with Readmission for Acute Exacerbation of Chronic Obstructive Pulmonary Disease

RATIONALE

Hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD) is associated with significant morbidity and health care costs, and hospitals in the United States are now penalized by the Centers for Medicare and Medicaid Services for excessive readmissions. Identifying patients at risk of readmission is important, but modifiable risk factors have not been clearly established, and the potential contributing role of psychological disease has not been examined adequately. We hypothesized that depression and anxiety would increase the risk of both short- and long-term readmissions for acute exacerbation of COPD.

OBJECTIVES

To characterize the associations between depression and anxiety and COPD readmission risk.

METHODS

We examined the medical records for all patients with a primary diagnosis of acute exacerbation of COPD by International Classification of Diseases, Ninth Revision codes admitted to the University of Alabama at Birmingham Hospital between November 2010 and October 2012. Those who did not meet the standardized study criteria for acute exacerbation of COPD and those with other respiratory illnesses as the primary diagnosis were excluded. Comorbidities were recorded on the basis of physician documentation of the diagnosis and/or the use of medications in the electronic medical record. Multivariable regression analyses identified factors associated with readmission for acute exacerbation of COPD at 1 year and within 30 and 90 days.

MEASUREMENTS AND MAIN RESULTS

Four hundred twenty-two patients were included, with 132 readmitted in 1 year. Mean age was 64.8 ± 11.7 years, and mean percent predicted FEV1 was 48.1 ± 18.7%. On univariate analysis, readmitted patients had lower percent predicted FEV1 (44.9 ± 17.3% vs. 50.2 ± 19.4%; P = 0.05) and a higher frequency of depression (47.7% vs. 23.4%; P < 0.001). On multivariable analysis, 1-year readmission was independently associated with depression (adjusted odds ratio [OR], 2.67; 95% confidence interval [CI], 1.59-4.47) and in-hospital tobacco cessation counseling (adjusted OR, 0.34; 95% CI, 0.18-0.66). Depression also predicted readmission at 30 days (adjusted OR, 3.83; 95% CI, 1.84-7.96) and 90 days (adjusted OR, 2.47; 95% CI, 1.34-4.55).

CONCLUSIONS

Depression is an independent risk factor for both short- and long-term readmissions for acute exacerbation of COPD and may represent a modifiable risk factor. In-hospital tobacco cessation counseling was also associated with reduced 1-year readmission.

A Patient-Centered Walking Program for COPD

Background: Pulmonary rehabilitation programs improve dyspnea and health status associated with chronic obstructive pulmonary disease (COPD), but benefits wane when patients return to a sedentary lifestyle. This study tested a simple, low-resource, low-cost home walking program. Methods: In this single center, 3-month study, 115 COPD patients were randomized to a control cohort or a goal setting cohort. Each patient met with study staff and received 5 telephone calls at 2-week intervals. During these contacts, the Goal group was assisted by a wellness coach who helped them set personal activity goals. All patients wore a pedometer to record daily steps, the primary study outcome. Results: Over the 12-week interval, the average step-per-days was 36% higher for the Goal cohort patients (Week 12 mean = 4390) than for Control patients (mean = 3790). No group differences emerged on the modified Medical Research Council (mMRC) dyspnea scale, the COPD Assessment Test, or the St. George's Respiratory Questionnaire. Secondary analyses indicated that even patients with greater disease severity, including those with an mMRC score >2 or forced expiratory volume in 1 second (FEV₁) % predicted below 50%, increased their walking relative to Control patients. Almost half (48%) of Goal patients successfully reached at least one personal goal such as increasing stamina and activity, or decreasing shortness of breath or weight. Conclusions: A relatively low-resource wellness coaching, goal-setting intervention resulted in a small improvement in the activity level of COPD patients over a 12-week period including those with marked pulmonary impairment. Further investigation should be directed at understanding the optimal blend of in person and remote coaching needed to produce the greatest cost-to-benefit ratio.

Effectiveness of interventions utilising telephone follow up in reducing hospital readmission within 30 days for individuals with chronic disease: a systematic review

BACKGROUND

Rates of readmission to hospital within 30 days are highest amongst those with chronic diseases. Effective interventions to reduce unplanned readmissions are needed. Providing support to patients with chronic disease via telephone may help prevent unnecessary readmission. This systematic review aimed to determine the methodological quality and effectiveness of interventions utilising telephone follow up (TFU) alone or in combination with other components in reducing readmission within 30 days amongst patients with cardiovascular disease, chronic respiratory disease and diabetes.

METHODS

A systematic search of MEDLINE, the Cochrane Library and EMBASE were conducted for articles published from database inception to 19(th) May 2015. Interventions which included TFU alone, or in combination with other components, amongst patients with chronic disease, reported 30 day readmission outcomes and met Effective Practice and Organisation of Care design criteria were included. The titles and abstracts of all identified articles were initially assessed for relevance and rejected on initial screening by one author. Full text articles were assessed against inclusion criteria by two authors with discrepancies resolved through discussion.

RESULTS

Ten studies were identified, of which five were effective in reducing readmissions within 30 days. Overall, the methodological quality of included studies was poor. All identified studies combined TFU with other intervention components. Interventions that were effective included three studies which provided TFU in addition to pre-discharge support; and two studies which provided TFU with both pre- and post-discharge support which included education, discharge planning, physical therapy and dietary consults, medication assessment, home visits and a resident curriculum. There was no evidence that TFU and telemedicine or TFU and post-discharge interventions was effective, however, only one to two studies examined each of these types of interventions.

CONCLUSIONS

Evidence is inconclusive for the effectiveness of interventions utilising TFU alone or in combination with other components in reducing readmissions within 30 days in patients with chronic disease. High methodological quality studies examining the effectiveness of TFU in a standardised way are needed. There is also potential importance in focusing interventions on enhancing provider skills in patient education, transitional care and conducting TFU.

The effect of pulmonary rehabilitation on COPD exacerbation frequency per year

OBJECTIVE

We aimed to investigate the effect of pulmonary rehabilitation (PR) on the number of exacerbations in chronic obstructive pulmonary diseases (COPD) patients.

METHODS

The study included 82 patients referred to our hospital's PR Unit between June 2013 and June 2014. Patients were divided into two groups, including those with low exacerbation risk (low number of exacerbations) (Groups A + B) and those experiencing frequent exacerbations (Groups C+ D) according to the combined COPD assessment.

RESULTS

Patients were included in a PR program that consisted of 16 sessions in total, held twice a week over a period of 2 months. After one year, patients were called to find out about their COPD exacerbation frequency. Groups presented similar characteristics in terms of age, BMI and smoking duration prior to the PR program (P > .05). The frequent exacerbators had lower scores in exercise capacity, arterial oxygenation, health-related quality of life and anxiety (P < .05). However, both groups exhibited significantly improved scores in the perceived dyspnea, FEV1 percentage, arterial oxygenation, exercise capacity, quality of life and anxiety after pulmonary rehabilitation (P < .05). The number of post-PR emergency referrals and hospitalization (P < .0001, P = .04), and depression score decreased significantly among the frequent exacerbators. Group 1 presented insignificant changes in the number of emergency referrals and hospitalizations (P < .05).

CONCLUSION

Notwithstanding disease severity, PR treatment is reported to have positive effects on COPD patients in terms of perceived dyspnea, exercise capacity, arterial oxygenation, quality of life, anxiety and depression. This study found reduced number of emergency referrals and hospitalization among COPD patients with frequent exacerbations after PR.

Exploring Novel Medicare Readmission Risk Variables in Chronic Obstructive Pulmonary Disease Patients at High Risk of Readmission within 30 Days of Hospital Discharge

RATIONALE

New risk factors for readmission within 30 days of hospital discharge for patients with chronic obstructive pulmonary disease (COPD) need to be identified in view of the lack of efficacy of current interventions for preventing readmission.

OBJECTIVES

To identify novel risk predictors for 30-day readmission among COPD index admissions at high risk of readmission.

METHODS

For this analysis, we used the fiscal year 2015 hospital-specific Medicare Hospital Readmissions Reduction Program workbook for Staten Island University Hospital (Staten Island, NY). We analyzed 41 variables, each with a risk-variable score. A predicted probability of readmission was calculated for each case by using the risk-variable regression coefficient and a hospital-specific effect. A predicted probability greater than 0.4 was used to identify patients with COPD with a high risk of readmission in both the readmitted and nonreadmitted groups. A percent ratio of the readmission percentage divided by the nonreadmission percentage was generated for each risk variable for patients with a predicted probability of readmission greater than 0.4. A percent ratio greater than 3 was used to identify high-risk variables predictive of readmission. A risk index was defined as the number of high-risk variables present for each index admission.

MEASUREMENTS AND MAIN RESULTS

Nine high-risk variables were identified. A risk index greater than 3 for all index admissions identified 54 (22.7%) of 238 readmitted patients versus 41 (6.5%) of 630 nonreadmitted patients (P < 0.0001; positive predictive value, 0.56; specificity, 0.93). A risk index greater than 2 for multiple-admission patients identified 56 (65.1%) of 86 readmitted patients versus 135 (40.7%) of 332 nonreadmitted patients (P < 0.0001; positive predictive value, 0.65; specificity, 0.86). Over 30% of readmitted patients meeting the risk index criteria were discharged to home without organized home care. Sleep apnea, vertebral fractures, and electrolyte and acid-base disorders were newly identified predictors of readmission.

CONCLUSIONS

This study developed a risk index based upon the 2015 Hospital Readmissions Reduction Program worksheet for one hospital to explore risk variables predictive of 30-day readmissions for patients with COPD at high risk of readmission (>0.4). Because most currently used interventions lack efficacy in preventing 30-day readmission, interventions based upon the newly identified variables should be validated with larger validation cohorts.

Physical activity and exercise capacity in patients with moderate COPD exacerbations

Little is known about changes in physical activity during moderate (out-patient managed) exacerbations.

6-min walking distance (6MWD) was measured during 50 exacerbations when the patients were stable, and at 3 and 7 days post-exacerbation presentation. At similar time points, quadriceps maximum voluntary contraction (QMVC) was measured during 47 different exacerbations. Physical activity (SenseWear; Bodymedia Inc., Pittsburgh, PA, USA) was recorded over 2 consecutive-week periods post-presentation.

6MWD fell from a median 422 m when stable to 373 m on day 3 (p=0.001). Similarly, QMVC fell from 32.6 versus 29.7 kg (p=0.026). Falls in 6MWD were associated with a rise in C-reactive protein (r= −0.364; p=0.041) and increased Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F) (r= −0.44; p=0.013). Light physical activity was 2.18 h·day−1 during the first week post-exacerbation and was less over week 2 (1.98 h·day−1; p=0.009). Patients who had attended pulmonary rehabilitation had smaller changes in 6MWD than those who had not attended (−35.0 versus −114.9 m; p=0.013). Falls in physical activity were correlated with higher depression scores (rho= −0.51; p=0.006).

These findings indicate that exercise capacity and muscle strength fall at exacerbation in chronic obstructive pulmonary disease patients who are treated at home and are free to maintain normal activity.

The effect of pulmonary rehabilitation on mortality, balance, and risk of fall in stable patients with chronic obstructive pulmonary disease

The aim of this study is to conduct a systematic review of published studies that evaluate the impact of pulmonary rehabilitation (PR) on survival and fall (including balance) in patients with chronic obstructive pulmonary disease at stability. OVID, Medline, EMBASE, and Cochrane collaboration library were searched for literature dating from January 1980 up to November 2014 as well as an update in October 2015. Two reviewers screened titles, abstracts and full text records, extracted data, and assessed studies for risk of bias; any disagreements were resolved by a third member of the team, and consensus was always sought. Initial searches yielded 3216 records but after review only seven studies were included and there were no studies focused solely on falls. Two cohort studies found some positive benefits of PR on balance, but the results were inconsistent across the studies. Regarding survival, two randomized controlled trials were conducted; one study showed significant survival benefit at 1 year, while the other one showed nonsignificant survival benefit at 3 years. Neither were adequately powered and in both, survival was a secondary outcome. There was only limited inconclusive evidence to show that PR has a significant beneficial effect on balance or survival.