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Beaumont M, Le Tallec F, Villiot-Danger E. [Inspiratory muscle training during pulmonary rehabilitation]. Rev Mal Respir 2021; 38:754-767. [PMID: 33879382 DOI: 10.1016/j.rmr.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 04/04/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Inspiratory muscle training (IMT) is part of the management of patients with pulmonary diseases during rehabilitation. Since the last recommendations of the Société de pneumologie de langue française, several studies have focused on the role of inspiratory muscle training during pulmonary rehabilitation. BACKGROUND IMT, in comparison to standard care or sham-IMT, improves the strength and endurance of the inspiratory muscles, decreases dyspnoea during the activities of daily living, improves walking distance and quality of life. However, the different studies did not show an additional effect of IMT during a pulmonary rehabilitation program compared to a rehabilitation program without IMT, with regard to improvement of exercise capacity and quality of life. OUTLOOK One study showed an improvement in dyspnoea of effort, but these results are yet to be confirmed. Finally, it seems appropriate to associate IMT with an exercise-training program before chest or abdominal surgery, even if further studies are necessary. CONCLUSION During a pulmonary rehabilitation program, IMT does not provide additional benefits. However, when patients cannot perform a global exercise training, IMT has shown benefit. IMT provides additional benefits in pre-operative programs.
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Affiliation(s)
- M Beaumont
- Service de réhabilitation respiratoire, centre hospitalier des Pays de Morlaix, Morlaix, France; Laboratoire GETBO (EA3878), CIC Inserm 1412, centre hospitalier universitaire de Brest, Brest, France.
| | - F Le Tallec
- Service de kinésithérapie, centre hospitalier privé Saint-Grégoire, Rennes, France
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2
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Munari AB, Venâncio RS, Gulart AA, Da Silveira JA, Klein SR, Martins AC, Mayer AF. Slow chest compression acutely reduces dynamic hyperinflation in people with chronic obstructive pulmonary disease: a randomized cross-over trial. Physiother Theory Pract 2021; 38:1937-1945. [PMID: 33829946 DOI: 10.1080/09593985.2021.1907824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Strategies to minimize dynamic hyperinflation (DH) and dyspnea, such as slow chest compression (SCC), are relevant in people with chronic obstructive pulmonary disease (COPD).Objectives: To analyze the acute effects of SCC after exercise on DH and dyspnea in people with COPD and to identify responders to the technique.Methods: This is a cross-over study with 40 patients. Two six-minute step tests (6MSTs) were performed followed by a one-minute application of SCC (6MSTSCC) or rest (6MSTCONTROL), at random. End-expiratory lung volume (EELV) and dyspnea were assessed. A difference ≥76 ml in ΔEELV between SCC and control characterized the responders.Results: The performance in 6MSTSCC and 6MSTCONTROL were similar. There was a greater reduction in EELV after 6MSTSCC compared to 6MSTCONTROL (124 ± 193 ml vs. 174 ± 183 ml; p = .049), while there was no difference in change in dyspnea between the SCC and control groups. Twenty-one participants were SCC responders and had higher functional residual capacity [FRC: 5.36 ± 1.09 vs. 4.58 ± 0.94; p = .02; cutoff point: 4.56; sensitivity = 76%; specificity = 53%; AUC = 0.71 (95%CI: 0.54 to 0.87); p = .02].Conclusion: SCC applied immediately after exercise reduced DH, but did not reduce dyspnea in people with COPD. The technique is beneficial only for some patients and FRC can help to identify them.
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Affiliation(s)
- Anelise Bauer Munari
- Center for Assistance, Teaching and Research in Pulmonary Rehabilitation (Nureab), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil.,Graduate Program in Physical Therapy, Centro de Ciências da Saúde e do Esporte (CEFID), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil
| | - Raysa Silva Venâncio
- Center for Assistance, Teaching and Research in Pulmonary Rehabilitation (Nureab), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil.,Graduate Program in Physical Therapy, Centro de Ciências da Saúde e do Esporte (CEFID), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil
| | - Aline Almeida Gulart
- Center for Assistance, Teaching and Research in Pulmonary Rehabilitation (Nureab), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil.,Graduate Program in Human Movement Sciences, Centro de Ciências da Saúde e do Esporte (CEFID), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil
| | - Jaqueline Aparecida Da Silveira
- Center for Assistance, Teaching and Research in Pulmonary Rehabilitation (Nureab), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil.,Graduate Program in Physical Therapy, Centro de Ciências da Saúde e do Esporte (CEFID), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil
| | - Suelen Roberta Klein
- Center for Assistance, Teaching and Research in Pulmonary Rehabilitation (Nureab), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil.,Graduate Program in Human Movement Sciences, Centro de Ciências da Saúde e do Esporte (CEFID), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil
| | - Ana Carolina Martins
- Center for Assistance, Teaching and Research in Pulmonary Rehabilitation (Nureab), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil
| | - Anamaria Fleig Mayer
- Center for Assistance, Teaching and Research in Pulmonary Rehabilitation (Nureab), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil.,Graduate Program in Physical Therapy, Centro de Ciências da Saúde e do Esporte (CEFID), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil.,Graduate Program in Human Movement Sciences, Centro de Ciências da Saúde e do Esporte (CEFID), Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Santa Catarina, Brazil
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3
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Braghiroli A, Braido F, Piraino A, Rogliani P, Santus P, Scichilone N. Day and Night Control of COPD and Role of Pharmacotherapy: A Review. Int J Chron Obstruct Pulmon Dis 2020; 15:1269-1285. [PMID: 32606638 PMCID: PMC7283230 DOI: 10.2147/copd.s240033] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/03/2020] [Indexed: 12/30/2022] Open
Abstract
The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients' adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient's profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic "24-hour control of COPD and role of pharmacotherapy", held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine.
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Affiliation(s)
- Alberto Braghiroli
- Department of Pulmonary Rehabilitation, Sleep Laboratory, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno, NO, Italy
| | - Fulvio Braido
- Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, Azienda Policlinico IRCCS San Martino, Genoa, Italy
| | - Alessio Piraino
- Respiratory Area, Medical Affairs Chiesi Italia, Parma, Italy
| | - Paola Rogliani
- Respiratory Unit, Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Pierachille Santus
- Pierachille Santus, Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Milan, Italy
| | - Nicola Scichilone
- Department of Biomedicine and Internal and Specialistic Medicine (DIBIMIS), University of Palermo, Palermo, Italy
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4
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Wingårdh ASL, Göransson C, Larsson S, Slinde F, Vanfleteren LE. Effectiveness of Energy Conservation Techniques in Patients with COPD. Respiration 2020; 99:409-416. [PMID: 32272478 PMCID: PMC7265758 DOI: 10.1159/000506816] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) might suffer from severe dyspnea, which importantly impacts on the performance of activities of daily living (ADL). Patient training of energy conservation techniques (ECTs) might be useful to improve the tolerance and execution of these ADL, but objective studies evaluating the effect of teaching ECTs on the metabolic equivalent of task (MET) in patients with COPD are sparse. OBJECTIVES The aim of this study was to test the hypothesis that practicing ECTs after a 2-week ECT teaching period would reduce the energy expenditure (MET) in performing an activity in patients with severe COPD. METHODS Energy expenditure was assessed with a gas exchange system (OxyconTM Mobile) during one out of five standardized ADL before and after a 2-week intervention period in which ECTs were taught. These ECTs comprised a good breathing technique, an ergonomic way of performing the activity, and the use of assistive devices. RESULTS Thirty-two patients with COPD (mean FEV1: 39 ± 14%; female: n = 18; age: 68 ± 7 years) were included. A significantly lower MET (2.3 ± 0.6 to 2.1 ± 0.5; p < 0.05) and less desaturation (89.7 ± 5.2 vs. 91.1 ± 5.5% HbO2; p < 0.05) were seen while performing the same activity after the intervention. However, there was no significant difference in the time spent on the task performed (6.0 ± 3.9 vs. 6.7 ± 4.0 min; p > 0.05). CONCLUSIONS A 2-week educative program on ECTs successfully reduces the energy spent for performing ADL relevant to the patient without any significant increase in the time spent on the activity.
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Affiliation(s)
- Ann Sylvia Louise Wingårdh
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carina Göransson
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven Larsson
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frode Slinde
- Department of Food and Nutrition, and Sports Science, University of Gothenburg, Gothenburg, Sweden
| | - Lowie E.G.W. Vanfleteren
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
- COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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5
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Do London Chest Activity of Daily Living Scale and St George's Respiratory Questionnaire Reflect Limitations During Activities of Daily Living in Patients With COPD? J Cardiopulm Rehabil Prev 2019; 39:274-280. [DOI: 10.1097/hcr.0000000000000355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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6
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Vaes AW, Delbressine JML, Mesquita R, Goertz YMJ, Janssen DJA, Nakken N, Franssen FME, Vanfleteren LEGW, Wouters EFM, Spruit MA. Impact of pulmonary rehabilitation on activities of daily living in patients with chronic obstructive pulmonary disease. J Appl Physiol (1985) 2018; 126:607-615. [PMID: 30496707 DOI: 10.1152/japplphysiol.00790.2018] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A high proportion of patients with chronic obstructive pulmonary disease (COPD) experience problems during the performance of activities of daily living (ADLs). We aimed to determine the effects of a comprehensive 8-wk pulmonary rehabilitation program on the physiologic response to and performance of ADLs in patients with COPD. Before and after pulmonary rehabilitation, 31 patients with COPD [71% men; mean age: 64.2 (SD 8.4) years; mean forced expiratory volume in the first second: 54.6 (SD 19.9) % predicted] performed physical function tests, the Canadian Occupational Performance Measure (COPM), and an ADL test consisting of the following: putting on socks, shoes, and vest; stair climbing; washing up four dishes, cups, and saucers; doing groceries and putting away groceries in a cupboard; folding eight towels; and vacuum cleaning for 4 min. Metabolic load, ventilation, and dynamic hyperinflation were assessed using an Oxycon mobile device. In addition, symptoms of dyspnea and fatigue and time to complete ADLs were recorded. After rehabilitation, patients with COPD used a significantly lower proportion of their peak aerobic capacity and ventilation to perform ADLs, accompanied by lower Borg scores for dyspnea and fatigue. Furthermore, patients needed significantly less time to complete ADLs. Dynamic hyperinflation occurred during the performance of ADLs, which did not change following pulmonary rehabilitation. Changes in physical function, including six-min walk distance, constant work rate test, quadriceps muscle strength, and COPM were significantly correlated with change in average total oxygen uptake during the performance of the ADL test. A comprehensive pulmonary rehabilitation program can improve the physiologic response to and actual performance of ADLs in patients with COPD. NEW & NOTEWORTHY A high proportion of patients with chronic obstructive pulmonary disease (COPD) experience problems during the performance of activities of daily living (ADLs). This study clearly demonstrated that a comprehensive pulmonary rehabilitation program can improve the performance of ADLs in patients with COPD, indicated by a significantly shorter time to perform ADLs and a lower metabolic load and dyspnea sensation.
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Affiliation(s)
- A W Vaes
- Department of Research and Education, Ciro, Horn , The Netherlands
| | | | - R Mesquita
- Department of Research and Education, Ciro, Horn , The Netherlands
| | - Y M J Goertz
- Department of Research and Education, Ciro, Horn , The Netherlands
| | - D J A Janssen
- Department of Research and Education, Ciro, Horn , The Netherlands
| | - N Nakken
- Department of Research and Education, Ciro, Horn , The Netherlands
| | - F M E Franssen
- Department of Research and Education, Ciro, Horn , The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands.,Department of Respiratory Medicine, MUMC+, Maastricht , The Netherlands
| | - L E G W Vanfleteren
- Department of Research and Education, Ciro, Horn , The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - E F M Wouters
- Department of Research and Education, Ciro, Horn , The Netherlands.,Department of Respiratory Medicine, MUMC+, Maastricht , The Netherlands
| | - M A Spruit
- Department of Research and Education, Ciro, Horn , The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands.,Department of Respiratory Medicine, MUMC+, Maastricht , The Netherlands
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7
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Ariel A, Altraja A, Belevskiy A, Boros PW, Danila E, Fležar M, Koblizek V, Fridlender ZG, Kostov K, Krams A, Milenkovic B, Somfay A, Tkacova R, Tudoric N, Ulmeanu R, Valipour A. Inhaled therapies in patients with moderate COPD in clinical practice: current thinking. Int J Chron Obstruct Pulmon Dis 2017; 13:45-56. [PMID: 29317810 PMCID: PMC5743110 DOI: 10.2147/copd.s145573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
COPD is a complex, heterogeneous condition. Even in the early clinical stages, COPD carries a significant burden, with breathlessness frequently leading to a reduction in exercise capacity and changes that correlate with long-term patient outcomes and mortality. Implementation of an effective management strategy is required to reduce symptoms, preserve lung function, quality of life, and exercise capacity, and prevent exacerbations. However, current clinical practice frequently differs from published guidelines on the management of COPD. This review focuses on the current scientific evidence and expert opinion on the management of moderate COPD: the symptoms arising from moderate airflow obstruction and the burden these symptoms impose, how physical activity can improve disease outcomes, the benefits of dual bronchodilation in COPD, and the limited evidence for the benefits of inhaled corticosteroids in this disease. We emphasize the importance of maximizing bronchodilation in COPD with inhaled dual-bronchodilator treatment, enhancing patient-related outcomes, and enabling the withdrawal of inhaled corticosteroids in COPD in well-defined patient groups.
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Affiliation(s)
- Amnon Ariel
- Emek Medical Center, Clalit Healthcare Services, Afula, Israel
| | - Alan Altraja
- Department of Pulmonary Medicine, University of Tartu
- Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Andrey Belevskiy
- Department of Pulmonology, Russian National Research Medical University, Moscow, Russia
| | - Piotr W Boros
- Lung Pathophysiology Department, National TB and Lung Diseases Research Institute, Warsaw, Poland
| | - Edvardas Danila
- Clinic of Infectious Chest Diseases, Dermatovenereology, and Allergology, Vilnius University, Centre of Pulmonology and Allergology, Vilnius University Hospital, Vilnius, Lithuania
| | - Matjaz Fležar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Vladimir Koblizek
- Department of Pneumology, University Hospital, Hradec Králové, Czech Republic
| | - Zvi G Fridlender
- Institute of Pulmonary Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Kosta Kostov
- Clinic of Pulmonary Diseases, Military Medical Academy, Sofia, Bulgaria
| | - Alvils Krams
- Medical Faculty of Latvian University, Riga East University Hospital, Riga, Latvia
| | - Branislava Milenkovic
- Clinic for Pulmonary Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Attila Somfay
- Department of Pulmonology, University of Szeged, Deszk, Hungary
| | - Ruzena Tkacova
- Department of Respiratory Medicine and Tuberculosis, Faculty of Medicine, PJ Safarik University, Košice, Slovakia
| | - Neven Tudoric
- School of Medicine, Dubrava University Hospital, Zagreb, Croatia
| | | | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
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8
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Glittre-ADL Multiple Tasks Induce Similar Dynamic Hyperinflation With Different Metabolic and Ventilatory Demands in Patients With COPD. J Cardiopulm Rehabil Prev 2017; 37:450-453. [DOI: 10.1097/hcr.0000000000000235] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Kaminsky DA, Guntupalli KK, Lippmann J, Burns SM, Brock MA, Skelly J, DeSarno M, Pecott-Grimm H, Mohsin A, LaRock-McMahon C, Warren P, Whitney MC, Hanania NA. Effect of Yoga Breathing (Pranayama) on Exercise Tolerance in Patients with Chronic Obstructive Pulmonary Disease: A Randomized, Controlled Trial. J Altern Complement Med 2017; 23:696-704. [PMID: 28714735 DOI: 10.1089/acm.2017.0102] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Pulmonary rehabilitation improves exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). However, many patients do not have access to pulmonary rehabilitation programs. We hypothesized that an alternative to pulmonary rehabilitation to improve exercise tolerance is the practice of pranayama, or yoga breathing, which could be done independently at home. We also sought to determine whether yoga nonprofessionals could adequately teach pranayama to patients. DESIGN Proof-of-concept, randomized, double-blind, controlled pilot trial. SETTINGS/LOCATION Two academic pulmonary practices. SUBJECTS Forty-three patients with symptomatic, moderate-to-severe COPD. INTERVENTIONS Twelve weeks of pranayama plus education versus education alone. Two yoga professionals trained the research coordinators to conduct all pranayama teaching and monitored the quality of the teaching and the practice of pranayama by study participants. OUTCOME MEASURES The primary outcome was a change in the 6-min walk distance (6MWD). Secondary outcomes included changes in lung function, markers of oxidative stress and systemic inflammation, and measures of dyspnea and quality of life. RESULTS The 6MWD increased in the pranayama group (least square mean [95% confidence interval] = 28 m [-5 to 61]) and decreased in the control group (-15 m [-47 to 16]), with a nearly significant treatment effect (p = 0.06) in favor of pranayama. Pranayama also resulted in small improvements in inspiratory capacity and air trapping. Both groups had significant improvements in various measures of symptoms, but no overall differences in respiratory system impedance or markers of oxidative stress or systemic inflammation. CONCLUSION This pilot study successfully demonstrated that pranayama was associated with improved exercise tolerance in patients with COPD. Lay personnel were able to adequately teach patients to practice pranayama. These results suggest that pranayama may have significant clinical benefits for symptomatic patients with COPD, a concept that needs to be confirmed in future, larger clinical trials.
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Affiliation(s)
- David A Kaminsky
- 1 Department of Medicine, Division of Pulmonary and Critical Care, University of Vermont College of Medicine , Burlington, VT.,2 Vermont Lung Center, University of Vermont College of Medicine , Burlington, VT
| | - Kalpalatha K Guntupalli
- 3 Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine , Houston, TX
| | - Joan Lippmann
- 2 Vermont Lung Center, University of Vermont College of Medicine , Burlington, VT
| | - Stephanie M Burns
- 2 Vermont Lung Center, University of Vermont College of Medicine , Burlington, VT
| | - Melissa A Brock
- 3 Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine , Houston, TX
| | - Joan Skelly
- 4 Biostatistics Unit, University of Vermont College of Medicine , Burlington, VT
| | - Michael DeSarno
- 4 Biostatistics Unit, University of Vermont College of Medicine , Burlington, VT
| | - Heidi Pecott-Grimm
- 2 Vermont Lung Center, University of Vermont College of Medicine , Burlington, VT
| | - Ali Mohsin
- 3 Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine , Houston, TX
| | | | | | | | - Nicola A Hanania
- 3 Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine , Houston, TX
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10
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van Leuteren RW, Dijkhuis S, de Jongh FHC, van der Valk PDLPM, Tabak M, Brusse-Keizer MGJ. The Mozart study: a relation between dynamic hyperinflation and physical activity in patients with chronic obstructive pulmonary disease? Clin Physiol Funct Imaging 2017; 38:409-415. [PMID: 28402088 DOI: 10.1111/cpf.12430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 03/03/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Many patients with chronic obstructive pulmonary disease (COPD) experience dyspnoea during exercise, resulting in a reduction of physical activity (PA). Dynamic hyperinflation (DH) is seen as a major cause of dyspnoea in COPD. OBJECTIVE The objective of the current study was to investigate the relationship between DH, in terms of the amount of DH and the development and recovery rate of DH in patients with COPD, and PA. METHODS Thirty-five patients with stable COPD were included from an outpatient clinic (14 GOLD II and 21 GOLD III, median age 65). PA was assessed using an accelerometer. Subjects underwent metronome-paced tachypnoea (MPT) to induce DH. To quantify the amount of DH during MPT, a decrease in inspiratory capacity (IC) or a change in IC as percentage of total lung capacity was used. RESULTS No significant correlations were found between the parameters describing DH and PA. Secondary correlation analyses showed a negative correlation between static hyperinflation (SH) and PA (r = -0·39; P = 0·02). The pattern of breathing during MPT and the test itself showed high interpatient variability. CONCLUSIONS The absence of a significant correlation between DH and PA is contrary to previous studies. SH did show a correlation with PA. The variety in results and the technical difficulties in execution of the measurements ask for a new, more reliable, method to detect DH and investigate its relation with PA in patients with COPD.
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Affiliation(s)
- R W van Leuteren
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, The Netherlands.,Technical Medicine, University of Twente, Enschede, The Netherlands
| | - S Dijkhuis
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - F H C de Jongh
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - M Tabak
- Telemedicine group, Roessingh Research and Development, Enschede, The Netherlands
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11
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Santos KD, Gulart AA, Munari AB, Karloh M, Mayer AF. Ventilatory demand and dynamic hyperinflation induced during ADL-based tests in Chronic Obstructive Pulmonary Disease patients. Braz J Phys Ther 2016; 20:441-450. [PMID: 27333482 PMCID: PMC5123259 DOI: 10.1590/bjpt-rbf.2014.0170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/15/2016] [Indexed: 11/22/2022] Open
Abstract
Background Airflow limitation frequently leads to the interruption of activities of daily living (ADL) in patients with Chronic Obstructive Pulmonary Disease (COPD). These patients commonly show absence of ventilatory reserve, reduced inspiratory reserve volume, and dynamic hyperinflation (DH). Objective To investigate ventilatory response and DH induced by three ADL-based protocols in COPD patients and compare them to healthy subjects. Method Cross-sectional study. COPD group: 23 patients (65±6 years, FEV1 37.2±15.4%pred); control group: 14 healthy subjects (64±4 years) matched for age, sex, and body mass index. Both groups performed all three tests: Glittre-ADL test; an activity test that involved moving objects on a shelf (TSHELF); and a modified shelf protocol isolating activity with upper limbs (TSHELF-M). Ventilatory response and inspiratory capacity were evaluated. Results Baseline ventilatory variables were similar between groups (p>0.05). The ventilatory demand increased and the inspiratory capacity decreased significantly at the end of the tests in the COPD group. Ventilatory demand and DH were higher (p<0.05) in the TSHELF than in the TSHELF-M in the COPD group (p<0.05). There were no differences in DH between the three tests in the control group (p>0.05) and ventilatory demand increased at the end of the tests (p<0.05) but to a lower extent than the COPD group. Conclusion The TSHELF induces similar ventilatory responses to the Glittre-ADL test in COPD patients with higher ventilatory demand and DH. In contrast, the ventilatory response was attenuated in the TSHELF-M, suggesting that squatting and bending down during the Glittre-ADL test could trigger significant ventilatory overload.
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Affiliation(s)
- Karoliny Dos Santos
- Núcleo de Assistência, Ensino e Pesquisa em Reabilitação Pulmonar, Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC, Brazil.,Programa de Pós-graduação em Fisioterapia, Centro de Ciências da Saúde e do Esporte (CEFID), UDESC, Florianópolis, SC, Brazil
| | - Aline A Gulart
- Núcleo de Assistência, Ensino e Pesquisa em Reabilitação Pulmonar, Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC, Brazil.,Programa de Pós-graduação em Fisioterapia, Centro de Ciências da Saúde e do Esporte (CEFID), UDESC, Florianópolis, SC, Brazil
| | - Anelise B Munari
- Núcleo de Assistência, Ensino e Pesquisa em Reabilitação Pulmonar, Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC, Brazil.,Programa de Pós-graduação em Fisioterapia, Centro de Ciências da Saúde e do Esporte (CEFID), UDESC, Florianópolis, SC, Brazil
| | - Manuela Karloh
- Núcleo de Assistência, Ensino e Pesquisa em Reabilitação Pulmonar, Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC, Brazil
| | - Anamaria F Mayer
- Núcleo de Assistência, Ensino e Pesquisa em Reabilitação Pulmonar, Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC, Brazil.,Programa de Pós-graduação em Fisioterapia, Centro de Ciências da Saúde e do Esporte (CEFID), UDESC, Florianópolis, SC, Brazil
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12
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Dubé BP, Guerder A, Morelot-Panzini C, Laveneziana P. The clinical relevance of the emphysema-hyperinflated phenotype in COPD. ACTA ACUST UNITED AC 2016. [DOI: 10.1186/s40749-015-0017-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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13
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Felipe C, Bartolome C, Miguel D, Victor PP. Longitudinal changes in handgrip strength, hyperinflation, and 6-minute walk distance in patients with COPD and a control group. Chest 2016; 148:986-994. [PMID: 25996450 DOI: 10.1378/chest.14-2878] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In COPD, a decreased inspiratory capacity to total lung capacity ratio (IC/TLC) is associated with dynamic hyperinflation and poor exercise capacity. The association with upper-extremity force measured by handgrip strength (HGS) and 6-min walk distance (6MWD) has not been previously described. We hypothesized that IC/TLC affects muscle strength in the upper and lower extremities, affecting HGS and 6MWD. METHODS We prospectively measured lung function, HGS, and 6MWD in 27 patients with COPD and 12 healthy nonsmokers twice, 1 year apart. The patients were classified according to level of hyperinflation: IC/TLC > 25% or IC/TLC ≤ 25%. RESULTS Patients with COPD had reduced lung function, static hyperinflation, and reduced HGS and 6MWD compared with the control subjects on both evaluations (P < .01). There was a statistically significant deterioration in HGS, IC/TLC, and 6MWD after 1-year follow-up in the COPD compared with the control group (P < .001). More hyperinflation (IC/TLC < 0.25) was associated with lower HGS and 6MWD (P < .001). Changes in IC/TLC correlated with changes in HGS (r = 0.429, P < .05). Multivariate analysis determined that IC/TLC is an independent factor associated with HSG and 6MWD. CONCLUSIONS HGS and 6MWD are reduced in patients with COPD, particularly in those with hyperinflation and evidence of longitudinal deterioration not seen in control subjects. This finding suggests that resting hyperinflation may exert a detrimental effect on cardiac function and plays a role in reduced exercise performance in patients with COPD.
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Affiliation(s)
- Cortopassi Felipe
- Pulmonary Function and Exercise Physiology Laboratory, Respiratory Care Department, University of Arizona, Tucson, AZ; Division of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Celli Bartolome
- Division of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Divo Miguel
- Division of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Pinto-Plata Victor
- Division of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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14
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Rossi A, Aisanov Z, Avdeev S, Di Maria G, Donner CF, Izquierdo JL, Roche N, Similowski T, Watz H, Worth H, Miravitlles M. Mechanisms, assessment and therapeutic implications of lung hyperinflation in COPD. Respir Med 2015; 109:785-802. [DOI: 10.1016/j.rmed.2015.03.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 03/04/2015] [Accepted: 03/23/2015] [Indexed: 02/05/2023]
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15
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Zhao L, Peng L, Wu B, Bu X, Wang C. Effects of dynamic hyperinflation on exercise capacity and quality of life in stable COPD patients. CLINICAL RESPIRATORY JOURNAL 2015; 10:579-88. [PMID: 25620462 DOI: 10.1111/crj.12260] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 12/11/2014] [Accepted: 01/14/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Dynamic hyperinflation (DH) is an important pathophysiological characteristic of chronic obstructive pulmonary disease (COPD). There is increasing evidence that DH has negative effects on exercise performance and quality of life. The objective of this study was to explore effects of DH on exercise capacity and quality of life in stable COPD patients. METHODS Fifty-eight COPD patients and 20 matched healthy individuals underwent pulmonary function test, 6-min walk test and symptom-limited cardiopulmonary exercise test (CPET). End-expiratory lung volume/total lung capacity ratio (EELVmax/TLC) at peak exercise of CPET was evaluated, and EELVmax/TLC ≥ 75% was defined as 'severe dynamic hyperinflation (SDH)'. RESULTS Of the 58 patients studied, 29 (50.0%) presented with SDH (SDH+ group, EELVmax/TLC 79.60 ± 3.60%), having worse maximal exercise capacity reflected by lower peakload, maximal oxygen uptake (VO2 max), maximal carbon dioxide output (VCO2 max) and maximal minute ventilation (VEmax) than did those without SDH (SDH- group, EELVmax/TLC 67.44 ± 6.53%). The EELVmax/TLC ratio at peak exercise had no association with variables of pulmonary function and 6-min walk distance (6MWD), but correlated inversely with peakload, VO2 max, VCO2 max and VEmax (r = -0.300~-0.351, P < 0.05). Although no significant differences were observed, patients with EELVmax/TLC ≥ 75% tended to have higher COPD assessment test score (15.07 ± 6.55 vs 13.28 ± 6.59, P = 0.303). CONCLUSIONS DH develops variably during exercise and has a greater impact on maximal exercise capacity than 6MWD, even in those with the same extent of pulmonary function impairment at rest.
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Affiliation(s)
- Li Zhao
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing, China.,Department of Surgery Intensive Care Unit, State Key Laboratory of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liyue Peng
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing, China.,Department of Surgery Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
| | - Baomei Wu
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing, China
| | - Xiaoning Bu
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing, China.
| | - Chen Wang
- Department of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, National Clinical Research Center for Respiratory Medicine, Beijing, China.
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16
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Smith SMS, Sonego S, Ketcheson L, Larson JL. A review of the effectiveness of psychological interventions used for anxiety and depression in chronic obstructive pulmonary disease. BMJ Open Respir Res 2014; 1:e000042. [PMID: 25478188 PMCID: PMC4242084 DOI: 10.1136/bmjresp-2014-000042] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 10/12/2014] [Accepted: 10/14/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Anxiety and depression are recognised co-morbidities associated with COPD and have been related to poor health outcomes. Therapies to relieve anxiety and depression are currently not detailed in clinical guidelines. METHODS A systematic review of psychological interventions for anxiety and depression in adults with COPD was conducted. Meta-analysis utilising the random effects model was undertaken for 4 studies that employed the same psychological intervention type, Cognitive Behavioural Therapy (CBT). RESULTS Seven studies met the inclusion criteria. Four studies used CBT. Included studies utilised psychotherapy, uncertainty management and minimal psychological therapy. 70% of participants were male. Many studies had poor methodological quality. The meta-analysis showed a small decrease in symptoms for both anxiety (SMD -0.49, 95% CI -1.04, 0.06, P=0.08, n=193) and depression (SMD -0.37, 95% CI -0.86, 0.11, P=0.13, n=193). No change occurred when sensitivity analyses were conducted. CONCLUSION Anxiety and depression in COPD patients are known to impact on health outcomes. Effective psychological interventions such as CBT may assist people with COPD in reducing psychological burden. There remains a need for well-designed studies to provide substantive evidence for the use of psychological interventions in this patient population.
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Affiliation(s)
- Sheree M S Smith
- School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
- Centre for Pharmacology and Therapeutics, Imperial College, Chelsea and Westminster Campus, London, UK
| | - Sandra Sonego
- School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
| | - Leah Ketcheson
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Janet L Larson
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
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17
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Alves GRT, Marchiori E, Irion KL, Teixeira PJZ, Berton DC, Rubin AS, Hochhegger B. The effects of dynamic hyperinflation on CT emphysema measurements in patients with COPD. Eur J Radiol 2014; 83:2255-2259. [PMID: 25271068 DOI: 10.1016/j.ejrad.2014.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 08/20/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Dynamic hyperinflation (DH) significantly affects dyspnea and intolerance to exercise in patients with chronic obstructive pulmonary disease (COPD). Quantitative computed tomography (QCT) of the chest is the modality of choice for quantification of the extent of anatomical lung damage in patients with COPD. The purpose of this article is to assess the effects of DH on QCT measurements. METHODS The study sample comprised patients with Global initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV COPD referred for chest CT. We examined differences in total lung volume (TLV), emphysema volume (EV), and emphysema index (EI) determined by QCT before and after DH induction by metronome-paced tachypnea (MPT). Initial (resting) and post-MPT CT examinations were performed with the same parameters. RESULTS Images from 66 CT scans (33 patients) were evaluated. EV and EI, but not TLV, increased significantly (p<0.0001) after DH induction. CONCLUSION QCT showed significant increases in EV and EI after MPT-induced DH in patients with GOLD stages III and IV COPD. For longitudinal assessment of patients with COPD using QCT, we recommend the application of a pre-examination rest period, as DH could mimic disease progression. QCT studies of the effects of DH-preventive therapy before exercise could expand our knowledge of effective measures to delay DH-related progression of COPD.
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Affiliation(s)
| | - Edson Marchiori
- Post-graduation Program in Medicine (Radiology), Federal University of Rio de Janeiro, Brazil
| | | | | | | | - Adalberto Sperb Rubin
- Pulmonology Department, Federal University of Health Sciences of Porto Alegre, Brazil
| | - Bruno Hochhegger
- Post-graduation Program in Medicine (Radiology), Federal University of Rio de Janeiro, Brazil
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18
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ACCORD COPD II: a randomized clinical trial to evaluate the 12-week efficacy and safety of twice-daily aclidinium bromide in chronic obstructive pulmonary disease patients. Clin Drug Investig 2014; 33:893-904. [PMID: 24085591 DOI: 10.1007/s40261-013-0138-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Aclidinium bromide is a long-acting muscarinic antagonist approved for the long-term maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD). This 12-week phase III study evaluated efficacy and tolerability of aclidinium 200 or 400 μg in patients with moderate-to-severe COPD. METHODS In this double-blind study, 544 patients with COPD were randomized to placebo or twice-daily aclidinium 200 or 400 μg administered by Genuair(®)/Pressair(®). Lung function, health status [measured by the St. George's Respiratory Questionnaire (SGRQ)], dyspnea [measured using the Transition Dyspnea Index (TDI)], and safety were assessed throughout the study. RESULTS Mean changes from baseline in morning trough forced expiratory volume in 1 s (FEV(1)) at week 12 (primary endpoint) were significantly higher for aclidinium than for placebo (200 μg, 51 mL; 400 μg, 72 mL; both p < 0.05). Aclidinium also significantly improved other lung function outcomes. At week 12, improvements from baseline were observed with aclidinium in SGRQ total score (200 μg, -6.0; 400 μg, -5.4) and TDI focal score (200 μg, 1.0; 400 μg, 1.3). Furthermore, clinically important improvements in SGRQ total and TDI focal scores were achieved by 45 and 51 % of patients, respectively, who received aclidinium 400 μg, with a significant difference versus placebo for TDI (p < 0.05). Anticholinergic-related adverse events (e.g., dry mouth) were infrequent, occurring <2 % for any event in any treatment group. Both aclidinium doses were well tolerated. CONCLUSION This study demonstrates efficacy and safety of aclidinium in COPD patients. Unexpected baseline imbalances between treatment groups may have impacted the aclidinium treatment benefit in this study.
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19
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Perez T, Garcia G, Roche N, Bautin N, Chambellan A, Chaouat A, Court-Fortune I, Delclaux B, Guenard H, Jebrak G, Orvoen-Frija E, Terrioux P. Société de pneumologie de langue française. Recommandation pour la pratique clinique. Prise en charge de la BPCO. Mise à jour 2012. Exploration fonctionnelle respiratoire. Texte long. Rev Mal Respir 2014; 31:263-94. [DOI: 10.1016/j.rmr.2013.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Ben Saad H, Ben Amor L, Ben Mdalla S, Ghannouchi I, Ben Essghair M, Sfaxi R, Garrouche A, Rouatbi N, Rouatbi S. Place de la distension pulmonaire dans l’exploration des gros fumeurs de cigarettes. Rev Mal Respir 2014; 31:29-40. [DOI: 10.1016/j.rmr.2013.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 04/16/2013] [Indexed: 12/20/2022]
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21
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Castro AAM, Porto EF, Iamonti VC, de Souza GF, Nascimento OA, Jardim JR. Oxygen and ventilatory output during several activities of daily living performed by COPD patients stratified according to disease severity. PLoS One 2013; 8:e79727. [PMID: 24278164 PMCID: PMC3835796 DOI: 10.1371/journal.pone.0079727] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 10/03/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To measure the oxygen and ventilatory output across all COPD stages performing 18 common ADL and identify the activities that present the highest metabolic and ventilatory output as well as to compare the energy expenditure within each disease severity. MATERIALS AND METHODS Metabolic (VO2 and VCO2), ventilatory (f and VE), cardiovascular (HR) and dyspnea (Borg score) variables were assessed in one hundred COPD patients during the completion of eighteen ADL grouped into four activities domains: rest, personal care, labor activities and efforts. RESULTS The activities with the highest proportional metabolic and ventilatory output (VO2/VO2max and VE/MVV) were walking with 2.5 Kg in each hand and walking with 5.0 Kg in one hand. Very severe patients presented the highest metabolic, ventilatory output and dyspnea than mild patients (p<0.05). CONCLUSIONS COPD patients present an increased proportion of energy expenditure while performing activities of daily living. The activities that developed the highest metabolic and ventilatory output are the ones associated to upper and lower limbs movements combined. Very severe patients present the highest proportional estimated metabolic and ventilatory output and dyspnea. Activities of daily living are mainly limited by COPD's reduced ventilatory reserve.
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Affiliation(s)
- Antonio A. M. Castro
- Pulmonary Rehabilitation Center of Federal University of São Paulo – Unifesp, São Paulo, São Paulo, Brazil
- Federal University of Pampa (Unipampa), Uruguaiana, Rio Grande do Sul, Brazil
| | - Elias F. Porto
- Pulmonary Rehabilitation Center of Federal University of São Paulo – Unifesp, São Paulo, São Paulo, Brazil
- Adventist University, São Paulo, São Paulo, Brazil
| | - Vinícius C. Iamonti
- Pulmonary Rehabilitation Center of Federal University of São Paulo – Unifesp, São Paulo, São Paulo, Brazil
| | - Gérson F. de Souza
- Pulmonary Rehabilitation Center of Federal University of São Paulo – Unifesp, São Paulo, São Paulo, Brazil
- Nove de Julho University, São Paulo, São Paulo, Brazil
| | | | - José R. Jardim
- Professor of Respiratory Diseases and Director of the Pulmonary Rehabilitation Center of Unifesp, São Paulo, São Paulo, Brazil
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22
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Lahaije A, van Helvoort H, Dekhuijzen R, Heijdra Y. Can COPD patients who hyperinflate during daily life activities be identified by laboratory tests? ACTA ACUST UNITED AC 2013; 86:237-42. [PMID: 23989464 DOI: 10.1159/000351108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 03/28/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Identification of patients with chronic obstructive pulmonary disease (COPD) who develop dynamic hyperinflation (DH) during activities in daily life (ADL) is important, because of the association between DH and dyspnea and exercise limitation. OBJECTIVE We aimed to answer the question whether measurements of DH during metronome-paced tachypnea (MPT) or cardiopulmonary exercise testing (CPET) can be used to identify patients who develop DH during ADL. METHODS DH was measured by tracking changes in inspiratory capacity during CPET, MPT and ADL. Bland-Altman plots were used to evaluate agreement in DH between methods. With a receiver operating characteristic (ROC) analysis, the overall accuracy of MPT and CPET to identify patients who hyperinflate during ADL was assessed. RESULTS There are broad limits of agreement in DH between methods. ROC curve analyses showed good overall accuracy of both CPET and MPT to identify patients who hyperinflate during ADL. For CPET, area under the curve (AUC) = 0.956 (95% CI 0.903-1.009). For MPT, AUC = 0.840 (95% CI 0.699-0.981). Sensitivity and specificity to identify patients who hyperinflate during ADL with CPET were 96 and 83%, respectively, and with MPT, they were 89 and 77%, respectively. CONCLUSION Both CPET and MPT can serve as screening tools to identify patients who are susceptible to developing DH during ADL. In practice, MPT is the most simple and inexpensive surrogate. However, the sensitivity of MPT is not optimal. When DH does not occur during CPET, it is unlikely to occur during ADL.
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Affiliation(s)
- A Lahaije
- Radboud University Nijmegen Medical Centre, Department of Pulmonary Diseases, Nijmegen, The Netherlands
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23
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Lahaije AJ, van Helvoort HA, Dekhuijzen PR, Vercoulen JH, Heijdra YF. Resting and ADL-induced dynamic hyperinflation explain physical inactivity in COPD better than FEV1. Respir Med 2013; 107:834-40. [DOI: 10.1016/j.rmed.2013.02.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/19/2013] [Accepted: 02/22/2013] [Indexed: 11/27/2022]
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24
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Díaz AA, Morales A, Díaz JC, Ramos C, Klaassen J, Saldías F, Aravena C, Díaz R, Lisboa C, Washko GR, Díaz O. CT and physiologic determinants of dyspnea and exercise capacity during the six-minute walk test in mild COPD. Respir Med 2013; 107:570-9. [DOI: 10.1016/j.rmed.2012.12.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 12/14/2012] [Accepted: 12/17/2012] [Indexed: 10/27/2022]
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Thomas M, Decramer M, O'Donnell DE. No room to breathe: the importance of lung hyperinflation in COPD. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:101-11. [PMID: 23429861 PMCID: PMC6442765 DOI: 10.4104/pcrj.2013.00025] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/19/2012] [Accepted: 12/22/2012] [Indexed: 11/17/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) are progressively limited in their ability to undertake normal everyday activities by a combination of exertional dyspnoea and peripheral muscle weakness. COPD is characterised by expiratory flow limitation, resulting in air trapping and lung hyperinflation. Hyperinflation increases acutely under conditions such as exercise or exacerbations, with an accompanying sharp increase in the intensity of dyspnoea to distressing and intolerable levels. Air trapping, causing increased lung hyperinflation, can be present even in milder COPD during everyday activities. The resulting activity-related dyspnoea leads to a vicious spiral of activity avoidance, physical deconditioning, and reduced quality of life, and has implications for the early development of comorbidities such as cardiovascular disease. Various strategies exist to reduce hyperinflation, notably long-acting bronchodilator treatment (via reduction in flow limitation and improved lung emptying) and an exercise programme (via decreased respiratory rate, reducing ventilatory demand), or their combination. Optimal bronchodilation can reduce exertional dyspnoea and increase a patient's ability to exercise, and improves the chance of successful outcome of a pulmonary rehabilitation programme. There should be a lower threshold for initiating treatments appropriate to the stage of the disease, such as long-acting bronchodilators and an exercise programme for patients with mild-to-moderate disease who experience persistent dyspnoea.
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Affiliation(s)
- Mike Thomas
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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26
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Dynamic hyperinflation correlates with exertional oxygen desaturation in patients with chronic obstructive pulmonary disease. Lung 2013; 191:177-82. [PMID: 23283384 DOI: 10.1007/s00408-012-9443-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 12/07/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Dynamic hyperinflation (DH) causes exercise limitation and exertional dyspnea in patients with chronic obstructive pulmonary disease (COPD). Exertional desaturation (ED) also occurs commonly in COPD but neither routine physiologic parameters nor imaging predict ED accurately. In this study we evaluated the relationship between DH and ED during 6-min walk testing (6MWT). METHODS We measured ED and DH in patients with stable COPD. SpO2 was measured by continuous pulse oximetry during 6MWT. ED was defined as a decline in SpO2 (ΔSpO2) ≥4 %. DH was determined by measuring inspiratory capacity (IC) before and after the 6MWT using a handheld spirometer. DH was defined as ΔIC >0.0 L. We correlated DH and ED with clinical and pulmonary physiologic variables by regression analysis, χ (2), and receiver operator curve (ROC) analysis. RESULTS Thirty males [age = 65 ± 9.4 years, FEV1 % predicted = 48 ± 14 %, and DLCO % predicted = 50 ± 21 % (mean ± SD)] were studied. ΔSpO2 correlated with ΔIC (r = 0.49, p = 0.005) and age (r = 0.39, p = 0.03) by univariate analysis; however, only ΔIC correlated on multivariate regression analysis (p = 0.01). ΔSpO2 did not correlate with FEV1, FVC, FEF25-75, RV, DLCO % predicted, BMI, smoking, BORG score, or distance covered in 6MWT. DH strongly correlated with ED (p = 0.001). On ROC analysis, DH had an area under the curve of 0.92 for the presence of ED (sensitivity = 90 %; specificity = 77 %, p < 0.001). CONCLUSION Routine pulmonary function test results and clinical variables did not correlate with ED in patients with stable COPD. Dynamic hyperinflation strongly correlates with exertional desaturation and could be a reason for this desaturation.
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Scichilone N, Gelb AF. Why Chronic Obstructive Pulmonary Disease Patients Get So Short of Breath with Limited Activity. Respiration 2013; 86:177-8. [DOI: 10.1159/000352049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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28
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Lahaije AJMC, Willems LM, van Hees HWH, Dekhuijzen PNR, van Helvoort HAC, Heijdra YF. Diagnostic accuracy of metronome-paced tachypnea to detect dynamic hyperinflation. Clin Physiol Funct Imaging 2012; 33:62-9. [DOI: 10.1111/j.1475-097x.2012.01164.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 07/17/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Anke J. M. C. Lahaije
- Radboud University Nijmegen Medical Centre; of Pulmonary Diseases; Nijmegen; The Netherlands
| | - Laura M. Willems
- Radboud University Nijmegen Medical Centre; of Pulmonary Diseases; Nijmegen; The Netherlands
| | | | | | | | - Yvonne F. Heijdra
- Radboud University Nijmegen Medical Centre; of Pulmonary Diseases; Nijmegen; The Netherlands
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Vaes AW, Franssen FME, Meijer K, Cuijpers MWJ, Wouters EFM, Rutten EPA, Spruit MA. Effects of body mass index on task-related oxygen uptake and dyspnea during activities of daily life in COPD. PLoS One 2012; 7:e41078. [PMID: 22815922 PMCID: PMC3398871 DOI: 10.1371/journal.pone.0041078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 06/18/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Patients with COPD use a higher proportion of their peak aerobic capacity during the performance of domestic activities of daily life (ADLs) compared to healthy peers, accompanied by a higher degree of task-related symptoms. To date, the influence of body mass index (BMI) on the task-related metabolic demands remains unknown in patients with COPD. Therefore, the aim of our study was to determine the effects of BMI on metabolic load during the performance of 5 consecutive domestic ADLs in patients with COPD. METHODOLOGY Ninety-four COPD patients and 20 healhty peers performed 5 consecutive, self-paced domestic ADLs putting on socks, shoes and vest; folding 8 towels; putting away groceries; washing up 4 dishes, cups and saucers; and sweeping the floor for 4 min. Task-related oxygen uptake and ventilation were assessed using a mobile oxycon, while Borg scores were used to assess task-related dyspnea and fatigue. PRINCIPAL FINDINGS 1. Relative task-related oxygen uptake after the performance of domestic ADLs was increased in patients with COPD compared to healthy elderly, whereas absolute oxygen uptake is similar between groups; 2. Relative oxygen uptake and oxygen uptake per kilogram fat-free mass were comparable between BMI groups; and 3. Borg symptom scores for dyspnea en fatigue were comparable between BMI groups. CONCLUSION Patients with COPD in different BMI groups perform self-paced domestic ADLs at the same relative metabolic load, accompanied by comparable Borg symptom scores for dyspnea and fatigue.
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Affiliation(s)
- Anouk W Vaes
- Program Development Centre, CIRO +, Horn, The Netherlands.
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Lahaije AJ, Heijdra YF, Willems LM, van Helvoort HA, Dekhuijzen PR. COPD Anno 2011: Emphasis on Bronch(iol)odilation. J Aerosol Med Pulm Drug Deliv 2012; 25:148-53. [DOI: 10.1089/jamp.2011.0922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anke J.M.C. Lahaije
- Radboud University Nijmegen Medical Centre, Department of Pulmonary Diseases, 454, Geert Grooteplein Zuid 8, 6500 HB Nijmegen, The Netherlands
| | - Yvonne F. Heijdra
- Radboud University Nijmegen Medical Centre, Department of Pulmonary Diseases, 454, Geert Grooteplein Zuid 8, 6500 HB Nijmegen, The Netherlands
| | - Laura M. Willems
- Radboud University Nijmegen Medical Centre, Department of Pulmonary Diseases, 454, Geert Grooteplein Zuid 8, 6500 HB Nijmegen, The Netherlands
| | - Hanneke A.C. van Helvoort
- Radboud University Nijmegen Medical Centre, Department of Pulmonary Diseases, 454, Geert Grooteplein Zuid 8, 6500 HB Nijmegen, The Netherlands
| | - P.N. Richard Dekhuijzen
- Radboud University Nijmegen Medical Centre, Department of Pulmonary Diseases, 454, Geert Grooteplein Zuid 8, 6500 HB Nijmegen, The Netherlands
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Miravitlles M, Calle M, Soler-Cataluña JJ. Clinical Phenotypes of COPD: Identification, Definition and Implications for Guidelines. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.arbr.2012.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Miravitlles M, Calle M, Soler-Cataluña JJ. Clinical phenotypes of COPD: identification, definition and implications for guidelines. Arch Bronconeumol 2011; 48:86-98. [PMID: 22196477 DOI: 10.1016/j.arbres.2011.10.007] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 09/29/2011] [Accepted: 10/20/2011] [Indexed: 02/02/2023]
Abstract
The term phenotype in the field of COPD is defined as "a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes". Among all phenotypes described, there are three that are associated with prognosis and especially are associated with a different response to currently available therapies. There phenotypes are: the exacerbator, the overlap COPD-asthma and the emphysema-hyperinflation. The exacerbator is characterised by the presence of, at least, two exacerbations the previous year, and on top of long-acting bronchodilators, may require the use of antiinflammatory drugs. The overlap phenotype presents symptoms of increased variability of airflow and incompletely reversible airflow obstruction. Due to the underlying inflammatory profile, it uses to have a good therapeutic response to inhaled corticosteroids in addition to bronchodilators. Lastly, the emphysema phenotype presents a poor therapeutic response to the existing antiinflammatory drugs and long-acting bronchodilators together with rehabilitation are the treatments of choice. Identifying the peculiarities of the different phenotypes of COPD will allow us to implement a more personalised treatment, in which the characteristics of the patients, together with their severity will be key to choose the best treatment option.
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Affiliation(s)
- Marc Miravitlles
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Ciber de Enfermedades Respiratorias, Hospital Clínic, Barcelona, Spain.
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Vaes AW, Wouters EF, Franssen FM, Uszko-Lencer NH, Stakenborg KH, Westra M, Meijer K, Schols AM, Janssen PP, Spruit MA. Task-Related Oxygen Uptake During Domestic Activities of Daily Life in Patients With COPD and Healthy Elderly Subjects. Chest 2011; 140:970-979. [DOI: 10.1378/chest.10-3005] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Rambod M, Porszasz J, Make BJ, Crapo JD, Casaburi R. Six-minute walk distance predictors, including CT scan measures, in the COPDGene cohort. Chest 2011; 141:867-875. [PMID: 21960696 DOI: 10.1378/chest.11-0870] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Exercise tolerance in COPD is only moderately well predicted by airflow obstruction assessed by FEV(1). We determined whether other phenotypic characteristics, including CT scan measures, are independent predictors of 6-min walk distance (6MWD) in the COPDGene cohort. METHODS COPDGene recruits non-Hispanic Caucasian and African American current and ex-smokers. Phenotyping measures include postbronchodilator FEV(1) % predicted and inspiratory and expiratory CT lung scans. We defined % emphysema as the percentage of lung voxels < -950 Hounsfield units on the inspiratory scan and % gas trapping as the percentage of lung voxels < -856 Hounsfield units on the expiratory scan. RESULTS Data of the first 2,500 participants of the COPDGene cohort were analyzed. Participant age was 61 ± 9 years; 51% were men; 76% were non-Hispanic Caucasians, and 24% were African Americans. Fifty-six percent had spirometrically defined COPD, with 9.3%, 23.4%, 15.0%, and 8.3% in GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages I to IV, respectively. Higher % emphysema and % gas trapping predicted lower 6MWD (P < .001). However, in a given spirometric group, after adjustment for age, sex, race, and BMI, neither % emphysema nor % gas trapping, or their interactions with FEV(1) % predicted, remained a significant 6MWD predictor. In a given spirometric group, only 16% to 27% of the variance in 6MWD could be explained by age, male sex, Caucasian race, and lower BMI as significant predictors of higher 6MWD. CONCLUSIONS In this large cohort of smokers in a given spirometric stage, phenotypic characteristics were only modestly predictive of 6MWD. CT scan measures of emphysema and gas trapping were not predictive of 6MWD after adjustment for other phenotypic characteristics.
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Affiliation(s)
- Mehdi Rambod
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Janos Porszasz
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | | | | | - Richard Casaburi
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA.
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HANNINK JORIENDC, VAN HELVOORT HANNEKEAC, DEKHUIJZEN PNRICHARD, HEIJDRA YVONNEF. Similar Dynamic Hyperinflation during Arm and Leg Exercise at Similar Ventilation in Chronic Obstructive Pulmonary Disease. Med Sci Sports Exerc 2011; 43:996-1001. [DOI: 10.1249/mss.0b013e318205e2be] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Maurer J. Dynamic Hyperinflation During Daily Activities: Does COPD Global Initiative for Chronic Obstructive Lung Disease Stage Matter? ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.ypdi.2010.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Odigie-Okon E, Jordan B, Dijeh S, Wolff A, Dadu R, Lall P, Zarich S, Amoateng-Adjepong Y, Manthous CA. Cardiac injury in patients with COPD presenting with dyspnea: a pilot study. Int J Chron Obstruct Pulmon Dis 2010; 5:395-9. [PMID: 21103406 PMCID: PMC2981154 DOI: 10.2147/copd.s11975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The aim of this pilot study was to test the hypothesis that myocardial ischemia complicates the management of some patients with chest-pain-free chronic obstructive pulmonary disease (COPD) exacerbations. METHODS In this prospective, observational, cohort study, patients admitted to a 350-bed community teaching hospital, with dyspnea and a primary diagnosis of COPD exacerbation, were followed for enzymatic and electrocardiographic evidence of myocardial ischemia for the first 24 hours of hospital admission. RESULTS A total of 114 patients were studied. Overall, four patients had definite myocardial infarctions, one had definite myocardial ischemia and 14 had possible myocardial ischemia. In multiple logistic regression models, age, number of coronary risk factors, and amount of administered albuterol were not associated with myocardial injury. CONCLUSION While unrecognized myocardial injury is relatively rare in patients with an exacerbation of COPD, it occurs frequently enough to warrant some caution since beta-agonists are the mainstays of therapy.
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Affiliation(s)
- Esosa Odigie-Okon
- Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT, USA
| | - Bryan Jordan
- Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT, USA
| | - Sylvester Dijeh
- Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT, USA
| | - Armand Wolff
- Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT, USA
| | - Razvan Dadu
- Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT, USA
| | - Priyanka Lall
- Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT, USA
| | - Stuart Zarich
- Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT, USA
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