Effects of Whole-Body Exercise Training on Body Composition and Functional Capacity in Normal-Weight Patients With COPD

Vitamin D Status and Longitudinal Changes in Body Composition in Patients with Chronic Obstructive Pulmonary Disease - A Prospective Observational Study

Background

Alterations in body weight and composition are common in patients with chronic obstructive pulmonary disease (COPD) and are independent predictors for morbidity and mortality. Low vitamin D status is also more prevalent in patients with COPD compared to controls and has been related to lower lung function, muscle atrophy and impaired musculoskeletal function. This study aimed to evaluate the association between vitamin D levels and status with body composition (BC), as well as with its changes over time.

Patients and Methods

Patients with COPD and controls without COPD, participating in the Individualized COPD Evaluation in relation to Ageing (ICE-Age) study, a prospective observational study, were included. Plasma 25-hydroxyvitamin D (25(OH)D) was measured at baseline and BC was measured by dual-energy X-ray absorptiometry scan, at baseline and after two years of follow-up. Multiple linear regression analyses were performed to assess the relationships between 25(OH)D (nmol/l) and longitudinal changes in BMI, fat-free mass index (FFMI), fat mas index (FMI) and bone mineral density (BMD).

Results

A total of 192 patients with COPD (57% males, mean ± SD age, 62 ± 7, FEV1, 49 ± 16% predicted) and 199 controls (45% males, mean ± SD age 61 ± 7) were included in this study. Vitamin D levels were significantly lower in patients with COPD (64 ± 26 nmol/L, 95% CI 60-68 nmol/L versus 75 ± 25 nmol/L, 95% CI 72-79 nmol/L) compared to controls. Both patients and controls presented a significant decline in FFMI and T-score hip, but vitamin D level or status did not determine differences in BC or changes in BC over time in either COPD or controls.

Conclusion

Vitamin D status was not associated with BC or longitudinal changes in BC. However, vitamin D insufficiency and low BMD were more prevalent in patients with COPD compared to controls.

Efficacy of Digital Therapeutics for Pulmonary Rehabilitation: A Multi-Center, Randomized Controlled Trial

BACKGROUND

This study aimed to investigate the efficacy and safety of digital therapeutics (DTx), EASYBREATH, for pulmonary rehabilitation (PR) in patients with chronic respiratory diseases (CRDs).

MATERIALS AND METHODS

This prospective randomized controlled trial was conducted at multiple centers. Participants were randomly allocated 1:1 to the DTx group (DTxG), provided with DTx using EASYBREATH. The DTxG underwent an 8-week PR program with evaluations conducted at baseline, four weeks, and eight weeks. The control group (CG) underwent one PR session and was advised to exercise and undergo the same evaluation. The primary outcome was the change in six-minute walking distance (6MWD) over eight weeks, and secondary outcomes included changes in scores of Modified Medical Research Council (mMRC), chronic obstructive pulmonary disease assessment test (CAT), and St. George's respiratory questionnaire (SGRQ).

RESULTS

The change in 6MWD after eight weeks demonstrated a significant difference between the DTxG and CG (57.68 m vs. 21.71 m, p = 0.0008). The change in mMRC scores (p = 0.0008), CAT scores (p < 0.0001), and total SGRQ scores (p = 0.0003) also showed a significant difference between the groups after eight weeks.

CONCLUSIONS

EASYBREATH significantly improved exercise capacity, alleviated dyspnea, and enhanced the overall quality of life at eight weeks. EASYBREATH is a highly accessible, time-efficient, and effective treatment option for CRD with high compliance.

Serum metabolomics using ultra-high performance liquid chromatography-Q-Exactive tandem mass spectrometry reveals the mechanism of action of exercise training on chronic obstructive pulmonary disease rats

Exercise training is the cornerstone component of pulmonary rehabilitation, which results in symptom-reducing, psychosocial, and health economic benefits for chronic obstructive pulmonary disease (COPD) patients. However, the potential mechanisms of its action are poorly understood. This study conducted serum metabolomics using ultra-high performance liquid chromatography-Q-Exactive tandem mass spectrometry to determine the metabolic changes in COPD rats, and the effects of exercise training on improvement in COPD were further investigated. Twelve differential metabolites-which are primarily related to tryptophan metabolism, sphingolipid metabolism, glycerophospholipid metabolism, riboflavin metabolism, pantothenate and CoA biosynthesis, and lysine degradation-were identified in relation to COPD. After the intervention of exercise training, the levels of most metabolites were restored, and the changes in five metabolites were statistically significant, which suggested that exercise training provided effective protection against COPD and might play its role by rebalancing disordered metabolism pathways. This work enhanced our comprehension of the protective mechanism of exercise training on COPD.

The effectiveness of the Healthworks Staying Steady community-based falls prevention exercise programme to improve physical function in older adults: a 6-year service evaluation

Background

Falls prevention exercise programmes are evidence-based and recommended for improving physical function in older adults. However, few service evaluations exist to assess the effectiveness of community-delivered interventions in practice.

Methods

We conducted a six-year, retrospective evaluation of the community-delivered Staying Steady programme (Healthworks, United Kingdom). Staying Steady is a 27-week, tailored strength and balance programme delivered in a group setting (1-h, once/week) and at home (30–40 min, 2–3 times/week). Participants were referred by healthcare professionals, or self-referred, due to a history or risk of falling. Routinely collected outcome measures (30-s chair stand, Timed Up and Go, four-stage balance test, and patient reported outcomes; including ‘fear of falling’ and ‘ability to manage health’) were analysed. Factors associated with programme completion were reported. The intervention effect on physical function was analysed in subgroups: participants used arms to chair-stand or a walking-aid at both (‘aided’), neither (‘unaided’), or one assessment timepoint (‘aided at baseline only’ or ‘aided at follow-up only’).

Results

There were 1,426 referrals; 835 (67.3%) participants enrolled on to the Staying Steady programme, 406 (32.7%) declined, 185 (13.0%) were inappropriately referred and excluded from analysis. After enrolling, 451 (54.0%) participants completed, and 384 (46.0%) dropped out. Chair stand performance improved in participants who were unaided (n = 264; median 2.0 [1.0, 4.0] repetitions; P < 0.001), or aided at baseline, follow-up or both (n = 170, P < 0.05). Timed Up and Go performance improved in the unaided (n = 387; median ˗3.1 [˗5.4, ˗1.4] s, P < 0.001), and aided at baseline only (n = 32; median ˗4.9 [˗10.8, ˗3.4] s, P < 0.001) groups. Four-stage balance performance improved (n = 295; median 1.0 [0.0, 1.0] points, P < 0.001). After programme completion, participants self-reported an improved ability to manage their health and daily activities, improved confidence, and a reduced fear of falling. Presence of chronic obstructive pulmonary disease, fear of falling, prescribed nutritional support, disability and social deprivation influenced non-completion of Staying Steady.

Conclusions

Completing Staying Steady improved physical function in older adults. Methods to encourage retention of participants from groups associated with low uptake and adherence should be investigated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13832-3.

Three Weeks of Pulmonary Rehabilitation Do Not Influence Oscillometry Parameters in Postoperative Lung Cancer Patients

Background: Thoracic surgery is a recommended treatment option for non-small cell lung cancer patients. An important part of a patient’s therapy, which helps to prevent postoperative complications and improve quality of life, is pulmonary rehabilitation (PR). The aim of this study was to assess whether the implementation of physical activity has an influence on forced oscillation technique (FOT) values in patients after thoracic surgery due to lung cancer. Methods: In this observational study, we enrolled 54 patients after thoracic surgery due to lung cancer, 49 patients with idiopathic interstitial fibrosis (IPF), and 54 patients with chronic obstructive pulmonary disease/asthma−COPD overlap (COPD/ACO). All patients were subjected to three weeks of in-hospital PR and assessed at the baseline as well as after completing PR by FOT, spirometry, grip strength measurement, and the 6-min walk test (6MWT). Results: We observed differences between FOT values under the influence of physical activity in studied groups, mostly between patients after thoracic surgery and COPD/ACO patients; however, no significant improvement after completing PR among FOT parameters was noticed in any group of patients. Improvements in the 6MWT distance, left hand strength, and right hand strength after PR were noticed (p < 0.001, 0.002, and 0.012, respectively). Conclusions: Three weeks of pulmonary rehabilitation had no impact on FOT values in patients after thoracic surgery due to lung cancer. Instead, we observed improvements in the 6MWT distance and the strength of both hands. Similarly, no FOT changes were observed in IPF and COPD/ACO patients after completing PR.

Effect of modified Total Body Recumbent Stepper training on exercise capacity and thioredoxin in COPD: a randomized clinical trial

Exercise intolerance is one of the major symptoms of chronic obstructive pulmonary disease (COPD). Exercise training can benefit COPD patients, but the underlying mechanism remains unclear. The modified Total Body Recumbent Stepper (TBRS, Nustep-T4) can benefit patients with stroke, spinal cord injury and amyotrophic lateral sclerosis. Nevertheless, the effect of TBRS training alone on pulmonary rehabilitation (PR) in COPD patients remains largely unknown. We aimed to explore the effect of TBRS training on exercise capacity and the thioredoxin system (TRXS) in COPD patients to provide a novel rehabilitation modality and new theoretical basis for PR of COPD patients. Ninety stable COPD patients were randomly divided into a control group (NC group) and a TBRS training group (TBRS group), with 45 cases in each group. Subjects in the TBRS training group were scheduled to undergo TBRS endurance training triweekly for 12 weeks under the guidance of a rehabilitation therapist. We assessed the primary outcome: exercise capacity (6-min walking distance, 6MWD); and secondary outcomes: perception of dyspnoea (mMRC, Borg), the COPD assessment test (CAT), the BODE index, pulmonary function, the number of acute exacerbations of COPD and oxidative stress (TRXS) at one-year follow-up. Compared with before the intervention and the control group, after the intervention, the TBRS training group, exhibited an increase in the 6MWD (from 366.92 ± 85.81 to 484.10 ± 71.90, 484.10 ± 71.90 vs 370.63 ± 79.87, P < 0.01), while the scores on the BORG, mMRC, BODE index, CAT, and the number of acute exacerbations of COPD were reduced, and the protein and mRNA expression levels of TRXS was significantly increased (P < 0.01). However, no differences were found in PF parameters in the comparison with before the intervention or between groups. TBRS training can effectively increase exercise capacity, while there are indications that it can alleviate COPD-related dyspnoea and reduce the number of acute exacerbations of COPD. Interestingly, long-term regular TBRS training may reduce oxidative stress associated with COPD to increase exercise capacity.

The Association between Fat-Free Mass and Exercise Test Outcomes in People with Chronic Obstructive Pulmonary Disease: A Systematic Review

People with chronic obstructive pulmonary disease (COPD) tend to have abnormally low levels of fat-free mass (FFM), which includes skeletal muscle mass as a central component. The purpose of this systematic review was to synthesise available evidence on the association between FFM and exercise test outcomes in COPD. MEDLINE, Cochrane Library, EMBASE, Web of Science, and Scopus were searched. Studies that evaluated exercise-related outcomes in relation to measures of FFM in COPD were included. Eighty-three studies, containing 18,770 (39% female) COPD participants, were included. Considerable heterogeneity was identified in the ways that FFM and exercise test outcomes were assessed; however, higher levels of FFM were generally associated with greater peak exercise capacity. This association was stronger for some exercise test outcomes (e.g. peak rate of oxygen consumption during incremental cycle exercise testing) than others (e.g. six-minute walking distance). This review identified heterogeneity in the methods used for measuring FFM and exercise capacity. There was, in general, a positive association between FFM and exercise capacity in COPD. There was also an identified lack of studies investigating associations between FFM and temporal physiological and perceptual responses to exercise. This review highlights the significance of FFM as a determinant of exercise capacity in COPD.

Isokinetic testing of quadriceps function in COPD: feasibility, responsiveness, and minimal important differences in patients undergoing pulmonary rehabilitation

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Evaluation of isokinetic quadriceps testing in COPD is needed to assess its efficacy.

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Isokinetic testing was performed incorrectly in a quarter of patients with COPD.

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Quadriceps peak torque and total work improved following pulmonary rehabilitation.

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Minimal important differences for peak torque and total work were determined.

Background

Isokinetic testing of peripheral muscle function is valid and reliable in patients with chronic obstructive pulmonary disease (COPD).

Objective

To evaluate whether and to what extent isokinetic testing of quadriceps function meets pre-defined test criteria in patients with COPD; to determine the response to pulmonary rehabilitation (PR), and to calculate minimal important differences (MIDs) of isokinetic quadriceps function.

Methods

Retrospective analysis of 2033 patients with COPD (age: 65±9 years, body mass index: 26±6 kg/m², FEV₁: 49±22% predicted) who followed a comprehensive PR program. Pre and post PR isokinetic quadriceps function was assessed with 30 maximal extension-flexion contractions at an angular speed of 90°/s on a computerized dynamometer. The chosen anchors were 6-min walk test and COPD assessment test.

Results

Pre PR, 27% of the patients performed the isokinetic test incorrectly. In male and female patients with a correct pre and post PR isokinetic test, peak torque (Δ=10±13 Nm or 9% and Δ=7±9 Nm or 10%, respectively) and total work (Δ=263±270 J or 14% and Δ=198±190 J or 15%, respectively) improved significantly. There was no change in work fatigue index following PR. Using distribution-based calculations, MID estimates for peak torque and total work ranged between 6–7 Nm and 97–135 J in males and between 4–5 Nm and 62–99 J in females.

Conclusions

Based on the current test criteria, three in four patients with COPD performed the isokinetic quadriceps test correctly during baseline PR assessment. Furthermore, peak torque and total work, but not work fatigue index, were responsive to PR and sex-specific MIDs were established.

Nutritional Status and Body Composition in Patients Suffering From Chronic Respiratory Diseases and Its Correlation With Pulmonary Rehabilitation

As part of an individualized intervention to improve the physical, emotional, and social functioning of patients with chronic respiratory diseases in general and chronic obstructive pulmonary disease in particular, awareness of the presence and consequences of changes in body composition increased enormously during the last decades, and nutritional intervention is considered as an essential component in the comprehensive approach of these patients. This review describes the prevalence and the clinical impact of body composition changes and also provides an update of current intervention strategies. It is argued that body composition, preferentially a three-component evaluation of fat, lean, and bone mass, must become part of a thorough assessment of every patient, admitted for pulmonary rehabilitation.

Application of Inspiratory Muscle Training to Improve Physical Tolerance in Older Patients with Ischemic Heart Failure

Regardless of the management regime for heart failure (HF), there is strong evidence supporting the early implementation of exercise-based cardiac rehabilitation (CR). Respiratory therapy is considered to be an integral part of such secondary prevention protocols. The aim of the study was to evaluate the effect of inspiratory muscle training (IMT) on exercise tolerance and the functional parameters of the respiratory system in patients with heart failure involved in cardiac rehabilitation. The study included 90 patients with HF who took part in the second-stage 8-week cycle of cardiac rehabilitation (CR). They were randomly divided into three groups: Group I underwent CR and IMT; Group II only CR; and patients in Group III underwent only the IMT. Before and after the 8-week cycle, participants were assessed for exercise tolerance and the functional parameters of respiratory muscle strength. Significant statistical improvement concerned the majority of the hemodynamic parameters, lung function parameters, and respiratory muscle strength in the first group. Moreover, the enhancement in the exercise tolerance in the CR + IMT group was accompanied by a negligible change in the HR_peak. The results confirm that the addition of IMT to the standard rehabilitation process of patients with heart failure can increase the therapeutic effect while influencing some of the parameters measured by exercise electrocardiography and respiratory function.

Development and validation of a prediction model for actionable aspects of frailty in the text of clinicians' encounter notes

OBJECTIVE

Frailty is a prevalent risk factor for adverse outcomes among patients with chronic lung disease. However, identifying frail patients who may benefit from interventions is challenging using standard data sources. We therefore sought to identify phrases in clinical notes in the electronic health record (EHR) that describe actionable frailty syndromes.

MATERIALS AND METHODS

We used an active learning strategy to select notes from the EHR and annotated each sentence for 4 actionable aspects of frailty: respiratory impairment, musculoskeletal problems, fall risk, and nutritional deficiencies. We compared the performance of regression, tree-based, and neural network models to predict the labels for each sentence. We evaluated performance with the scaled Brier score (SBS), where 1 is perfect and 0 is uninformative, and the positive predictive value (PPV).

RESULTS

We manually annotated 155 952 sentences from 326 patients. Elastic net regression had the best performance across all 4 frailty aspects (SBS 0.52, 95% confidence interval [CI] 0.49-0.54) followed by random forests (SBS 0.49, 95% CI 0.47-0.51), and multi-task neural networks (SBS 0.39, 95% CI 0.37-0.42). For the elastic net model, the PPV for identifying the presence of respiratory impairment was 54.8% (95% CI 53.3%-56.6%) at a sensitivity of 80%.

DISCUSSION

Classification models using EHR notes can effectively identify actionable aspects of frailty among patients living with chronic lung disease. Regression performed better than random forest and neural network models.

CONCLUSIONS

NLP-based models offer promising support to population health management programs that seek to identify and refer community-dwelling patients with frailty for evidence-based interventions.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO ID

CRD42017079935.

Effect of malnutrition and body composition on the quality of life of COPD patients

BACKGROUND

Pathological alterations in nutritional status may develop in Chronic Obstructive Pulmonary Disease (COPD) patients through production of inflammatory cytokines and inadequate diet.

OBJECTIVE

The aim of our study was to determine the correlation between nutritional status and quality of life of COPD patients.

METHODS

We evaluated the nutritional status of COPD patients of Hungarian National Koranyi Institute for Pulmonology using the Malnutrition Universal Screening Tool (MUST) and bioelectrical impedance analysis (BIA) between January 1 and June 1, 2019. Lung function, physical fitness, and respiratory muscle strength were included in the assessment.

RESULTS

Fifty patients (mean age was 66.3 ± 9.6 years) participated in our study. Mean body mass index (BMI) was 26.2 ± 6.1 kg/m2 and mean fat-free mass index (FFMI) was 16.8 ± 2.4 kg/m2. Overweight patients had better lung function values (FEV1ref%: 46.3 ± 15.2) than normal (FEV1ref%: 45.1 ± 20.9) and underweight patients (FEV1ref%: 43.8 ± 16.0). The Modified Medical Research Council Dyspnea Scale (mMRC) was significantly associated with various parameters; strongest correlation was found with FFMI (r = -0.537, P < 0.001), skeletal muscle mass index (SMMI) (r = -0.530, P < 0.001), and 6-minute walking distance (6MWD) (r = -0.481, P < 0.001).

CONCLUSIONS

Our results indicate that malnourished COPD patients may have reduced lung function and lower quality of life compared to normal weight patients. Thus, our findings suggest that nutritional therapy be included in the treatment of COPD patients combined with nutritional risk screening and BIA during the follow-up.

The correlation between quadriceps muscle strength and endurance and exercise performance in patients with COPD

To determine the association between quadriceps muscle strength (QMS) and endurance (QME) and exercise capacity in patients with COPD after stratification for sex and resting lung function (LF). Data were collected from 3,246 patients with COPD (60% men, 64 ± 9 yr), including measures of exercise capacity [peak aerobic capacity (peakV̇o₂), 6-min walk distance (6MWD)] and isokinetic QMS and QME. Patients were stratified for sex, forced expiratory volume in 1 s (>50/≤50% predicted), single breath carbon monoxide diffusing capacity (>50/≤50% predicted), and residual volume (>140/≤140% predicted). After stratification for resting LF, QMS and QME were significantly associated with peakV̇o₂ (r range: 0.47-0.61 and 0.49-0.65 for men and 0.53-0.66 and 0.48-0.67 for women, respectively) and 6MWD (r range: 0.29-0.42 and 0.44-0.55 for men and 0.25-0.54 and 0.34-0.55 for women, respectively) (P < 0.001). Regression models demonstrated that QMS and QME were significant determinants of peakV̇o₂ (explained variance R² range: 35.6%-48.8% for men and 36.8%-49.0% for women) and 6MWD (R² range: 24.3%-43.3% for men and 28.4%-40.3% for women), independent of age and fat-free mass. Quadriceps muscle function was significantly associated with peakV̇o₂ and 6MWD in male and female patients with COPD after stratification for resting LF, in which QME appear to be a more important determinant than QMS. This underlines the importance of systematically evaluating both quadriceps muscle strength and endurance in in all patients with COPD.NEW & NOTEWORTHY Our findings identified quadriceps muscle function as an important determinant of exercise capacity across a wide spectrum of lung function. Quadriceps muscle endurance appears to be a more important determinant than quadriceps muscle strength, underlining the importance of including both the measurement of quadriceps muscle strength and endurance in routine assessment for all patient with COPD.

Muscle metabolomics analysis reveals potential biomarkers of exercise‑dependent improvement of the diaphragm function in chronic obstructive pulmonary disease

Decreased diaphragm function is a crucial factor leading to reduced ventilatory efficiency and worsening of quality of life in chronic obstructive pulmonary disease (COPD). Exercise training has been demonstrated to effectively improve the function of the diaphragm. However, the mechanism of this process has not been identified. The emergence of metabolomics has allowed the exploration of new ideas. The present study aimed to analyze the potential biomarkers of exercise-dependent enhancement of diaphragm function in COPD using metabolomics. Sprague Dawley rats were divided into three groups: COPD + exercise group (CEG); COPD model group (CMG); and control group (CG). The first two groups were exposed to cigarette smoke for 16 weeks to establish a COPD model. Then, the rats in the CEG underwent aerobic exercise training for 9 weeks. Following confirmation that exercise effectively improved the diaphragm function, a gas chromatography tandem time-of-flight mass spectrometry analysis system was used to detect the differential metabolites and associated pathways in the diaphragm muscles of the different groups. Following exercise intervention, the pulmonary function and diaphragm contractility of the CEG rats were significantly improved compared with those of the CMG rats. A total of 36 different metabolites were identified in the comparison between the CMG and the CG. Pathway enrichment analysis indicated that these different metabolites were involved in 17 pathways. A total of 29 different metabolites were identified in the comparison between the CMG and the CEG, which are involved in 14 pathways. Candidate biomarkers were selected, and the pathways analysis of these metabolites demonstrated that 2 types of metabolic pathways, the nicotinic acid and nicotinamide metabolism and arginine and proline metabolism pathways, were associated with exercise-induced pulmonary rehabilitation.

Resistance training using different elastic components offers similar gains on muscle strength to weight machine equipment in Individuals with COPD: A randomized controlled trial

Purpose: To compare the effects of three modalities of resistance training, two using elastic components and one using conventional weight machine on peripheral muscle strength in Individuals with chronic obstructive pulmonary disease (COPD). Effects on exercise capacity, impact of disease on health status, body composition and daily level of physical activity were investigated as secondary endpoints.Methods: Forty-eight participants were randomly allocated (Trials Registry #RBR-6V9SJJ) into Elastic band group (Theraband®) (EBG), Elastic tubes training using Lemgruber® (ETG), and Conventional training with weight machine equipment (CG). Participants were evaluated before and after 12 weeks of training regarding peripheral muscle strength by dynamometry; impact of disease on health status via COPD Assessment Test, CAT; exercise capacity by 6-min walk test, 6MWT; body composition by bioelectrical impedance; and daily level of physical activities via accelerometry.Results: Inter-group comparison of training effects did not elucidate significant differences between the modalities in muscle strength (p ≥ .2). Likewise, all training modalities showed similar effects on CAT, body composition and daily physical activity variables with no statistical significance observed (p ≥ .15).Conclusions: Modalities of resistance training using elastic components presented similar effects on muscle strength, health status, exercise capacity, body composition and daily level of physical activity in individuals with COPD. The effects of elastic resistance were similar to conventional resistance training.

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.

Skeletal Muscle Dysfunction in Chronic Obstructive Pulmonary Disease. What We Know and Can Do for Our Patients

Skeletal muscle dysfunction occurs in patients with chronic obstructive pulmonary disease (COPD) and affects both ventilatory and nonventilatory muscle groups. It represents a very important comorbidity that is associated with poor quality of life and reduced survival. It results from a complex combination of functional, metabolic, and anatomical alterations leading to suboptimal muscle work. Muscle atrophy, altered fiber type and metabolism, and chest wall remodeling, in the case of the respiratory muscles, are relevant etiological contributors to this process. Muscle dysfunction worsens during COPD exacerbations, rendering patients progressively less able to perform activities of daily living, and it is also associated with poor outcomes. Muscle recovery measures consisting of a combination of pulmonary rehabilitation, optimized nutrition, and other strategies are associated with better prognosis when administered in stable patients as well as after exacerbations. A deeper understanding of this process' pathophysiology and clinical relevance will facilitate the use of measures to alleviate its effects and potentially improve patients' outcomes. In this review, a general overview of skeletal muscle dysfunction in COPD is offered to highlight its relevance and magnitude to expert practitioners and scientists as well as to the average clinician dealing with patients with chronic respiratory diseases.

Improvement in body composition following a supervised exercise-training program of adult patients with cystic fibrosis

OBJECTIVES

Maintenance of optimal nutritional status is a crucial issue for cystic fibrosis (CF) patients. Here, we evaluate the effects of an 8-week exercise training (ET) program on body composition in CF patients.

METHODS

This prospective pilot observational study was conducted in adult CF subjects in stable condition following their annual check-up. The ET program consisted of three sessions per week and included aerobic training (≥30min), muscle strengthening, circuit training, and relaxation. Exercise tolerance (6-minute walk test, 6MWT), pulmonary function, quadriceps isometric strength, and body composition (bioelectrical impedance analysis of fat-free mass [FFM], fat mass, and body cell mass) were analyzed before and immediately after the ET program. A control group of CF patients who preferred not to participate in the ET program received the same evaluations.

RESULTS

A total of 43 CF patients were enrolled and offered the ET program; 28 accepted (aged 28±5 years, forced expiratory volume in 1s [FEV₁] 48.8±19% predicted) and 15 declined the ET program but agreed to be part of the control group (matched for age and CF severity: 30.8±9 years, FEV₁ 51.8±16.5%). Pulmonary function was unchanged at the end of the ET program, but significant improvements were observed in 6MWT distance (from 520±96m to 562±105m, P<0.001) and muscle strength (331±141N to 379±168N, P<0.001). Although mean body mass index did not change, the ET group showed significantly increased FFM (43.85±8kg to 44.5±9.2kg, P=0.03) and a trend towards increased body cell mass (21.4±6 to 22.1±6.6kg, P=0.06). All other parameters were unchanged by ET. There were no significant correlations between the increase in FFM and the improvements in either 6MWT distance or muscle strength. The CF control group exhibited no significant changes in any parameters between evaluations.

CONCLUSIONS

ET significantly improved FFM, but not body mass index, in CF patients. The results illustrate the superiority of bioimpedancemetry for assessing changes in body composition and reveal the importance of ET for improving not only exercise tolerance but also nutritional status in these patients.

Ventilation distribution, pulmonary diffusion and peripheral muscle endurance as determinants of exercise intolerance in elderly patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a progressive and disabling disease that has been associated with aging. Several factors may potentially impair performance during exercise in elderly patients with COPD. This study was conducted to evaluate what characteristics related to lung function, peripheral muscle strength and endurance can predict the performance of elderly patients with COPD during cardiopulmonary exercise testing (CPET). Forty elderly patients with COPD underwent resting lung function tests, knee isokinetic dynamometry, and CPET. Three models were developed to explain the variability in peak oxygen uptake (VO(2) peak) after controlling for age as an independent confounder. The pulmonary function model showed the highest explained variance (65.6 %); in this model, ventilation distribution (p<0.001) and pulmonary diffusion (0.013) were found to be independent predictors. Finally, the models that included the muscle strength and endurance variables presented explained variances of 51 % and 57.4 %, respectively. In these models that involved muscular dysfunction, however, only the endurance variables were found to be independent predictors (p<0.05). In conclusion, ventilation distribution and pulmonary diffusion, but not the degree of airway obstruction, independently predict CPET performance in elderly patients with COPD. In addition, peripheral muscle endurance, but not strength, also predicts CPET performance in these subjects.

Frailty assessment in older adults with chronic obstructive respiratory diseases

The number of patients with chronic obstructive pulmonary disease (COPD) has been rising with continued exposure to environmental risk factors and aging of populations around the world. Frailty is a geriatric syndrome with a decline in physiological reserve and often coexists with chronic diseases such as COPD. Frailty is an independent risk factor for the development and progression of COPD, and COPD can lead to frailty; treating one might improve the other. Thus, there is an increasing interest in the assessment of frailty in patients with COPD. Furthermore, early identification and assessment of frailty in patients with COPD may affect the choice of intervention and improve its effectiveness. Based on the current literature, the intent of this review was to summarize and discuss frailty assessment tools used for COPD patients and the relevant clinical practices for predicting outcomes. We ascertain that using suitable frailty assessment tools could facilitate physicians to screen and stratify physically frail patients with COPD. Screening appropriately targeted population can achieve better intervention outcomes and pulmonary rehabilitation among frail COPD patients.

The physical, mental, and social impact of COPD in a population-based sample: results from the Longitudinal Aging Study Amsterdam

Chronic obstructive pulmonary disease (COPD) is associated with substantial health impact that may already become apparent in early disease. This study aims to examine the features of subjects with COPD in a Dutch population-based sample and compare their physical status, mental status, and social status to non-COPD subjects. This study made use of Longitudinal Aging Study Amsterdam (LASA) data. Demographics, clinical characteristics, self-reported diseases, post-bronchodilator spirometry, physical, mental, and social status were assessed. A number of 810 subjects (50.5% male, mean age 60.5 ± 2.9 years) were included. Subjects with COPD (n = 68, mean FEV₁ 67.6 [IQR 60.4–80.4] %.) had a slower walking speed than non-COPD subjects, p = 0.033. When compared to non-COPD subjects, COPD subjects gave a lower rating on their health (physical subscale of SF-12: 15 [IQR 16.0–19.0] vs. 18 [IQR 11.0–17.0] points) and life (EQ5D VAS: 75 [IQR 70.0–90.0] vs. 80 points [IQR 65.0–85.5]) surveys. COPD subjects also had a more impaired disease-specific health status (CAT: 9.5 ± 5.9 vs. 6.7 ± 5.2, respectively), were less likely to have a partner (69% vs. 84%, respectively) and received emotional support less often (24% vs. 36%, respectively) compared to non-COPD subjects (All comparisons p < 0.001). In a population-based sample, subjects with COPD had a reduced physical performance, a more impaired disease-specific health status and were more socially deprived compared to non-COPD subjects. These impairments need to be taken into consideration when setting up a management program for patients with mild COPD.

Patients with early-stage chronic lung disease need holistic support to limit the physical, mental and social impacts of the condition. There is more to chronic obstructive pulmonary disease (COPD) than persistent airflow limitation; systemic effects, including loss of muscle strength and higher risk of heart conditions, mental health and social problems can manifest from the early stages. Frits Franssen at CIRO, the Netherlands, and co-workers interviewed 810 participants aged 55–65 from the Longitudinal Aging Study Amsterdam to investigate the physical, mental and social status of COPD sufferers and compare them with healthy controls. Those with COPD were more likely to walk slower, tire easily and perceive themselves as having poor overall health. Socially, COPD patients were less likely to have long-term partners and felt the need for more emotional support than their healthy peers.

Outcomes of community-based and home-based pulmonary rehabilitation for pneumoconiosis patients: a retrospective study

Background

Pneumoconiosis patients receive community-based or home-based pulmonary rehabilitation (PR) for symptom management and enhancement of physical and mental well-being. This study aimed to review the clinical benefits of community-based rehabilitation programmes (CBRP) and home-based rehabilitation programmes (HBRP) for PR of pneumoconiosis patients.

Methods

Archival data of pneumoconiosis patients who participated in CBRP and HBRP between 2008 and 2011 was analysed. There were 155 and 26 patients in the CBRP and HBRP respectively. The outcome measures used in the pre- and post-tests were Knowledge, Health Survey Short Form-12 (SF-12), Hospital Anxiety and Depression Scale (HADS), 6-Min Walk Test (6MWT), and Chronic Respiratory Questionnaire (CRQ). Paired t-tests and the Analysis of Covariance (ANCOVA) using the patients’ baseline lung functions as the covariates were performed to examine the changes in the outcomes after completing the programmes. Hierarchical multiple regression analyses were used to examine the relationships between patient’s programme participation factors and different scores of the outcome measures.

Results

After controlling for patients’ baseline lung capacities, significant improvements were revealed among patients participated in CBRP in the scores of the 6MWT, Knowledge, HADS, SF-12 PCS, and CRQ emotion and mastery. The different scores in the Knowledge and HADS were correlated with the patients’ levels of programme participation. In contrast, significant improvements were only found in the scores of the Knowledge and 6MWT among patients who participated in HBRP. The gain scores of the 6MWT were correlated with the patients’ levels of programme participation.

Conclusions

Both CBRP and HBRP benefited patients’ levels of exercise tolerance and knowledge about the disease. CBRP provided greater benefits to patients’ mental and psychosocial needs. In contrast, HBRP was found to improve patients’ physical function, but did not have significant impacts on patients’ mental health and health-related quality of life. The attendance of patients and the participation of their relatives in treatment sessions were important factors in enhancing the positive effects of CBRP and HBRP. These positive outcomes confirm the value of pulmonary rehabilitation programmes for community-dwelling pneumoconiosis patients.

Electronic supplementary material

The online version of this article (10.1186/s12890-018-0692-7) contains supplementary material, which is available to authorized users.

Nutritional status and muscle dysfunction in chronic respiratory diseases: stable phase versus acute exacerbations

Nutritional abnormalities are frequent in different chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic fibrosis (CF), interstitial fibrosis and lung cancer, having important clinical consequences. However, nutritional abnormalities often remained underdiagnosed due to the relative lack of awareness of health professionals. Therefore, systematic anthropometry or even better, assessment of body composition, should be performed in all patients with chronic respiratory conditions, especially following exacerbation periods when malnutrition becomes more accentuated. Nutritional abnormalities very often include the loss of muscle mass, which is an important factor for the occurrence of muscle dysfunction. The latter can be easily detected with the specific assessment of muscle strength and endurance, and also negatively influences patients' quality of life and prognosis. Both nutritional abnormalities and muscle dysfunction result from the interaction of several factors, including tobacco smoking, low physical activity-sedentarism, systemic inflammation and the imbalance between energy supply and requirements, which essentially lead to a negative balance between protein breakdown and synthesis. Therapeutic approaches include improvements in lifestyle, nutritional supplementation and training. Anabolic drugs may be administered in some cases.

Fat-free mass depletion in patients with COPD in Brazil: development of a new cutoff point and its relation with mortality and extrapulmonary manifestations

BACKGROUND/OBJECTIVES

None of the cutoff points for fat-free mass index (FFMI) were tested for the Brazilian population, and it is unknown whether the available ones are able to discriminate extrapulmonary disease manifestations. This cross-sectional study aims to develop and validate a cutoff point for FFM depletion based on Brazilian patients with chronic obstructive pulmonary disease (COPD) and to verify its association and of previously published cutoffs with extrapulmonary manifestations.

SUBJECTS/METHODS

A new cutoff point was obtained from the best FFMI value for discrimination of preserved exercise capacity in a sample of patients (n=57). The discriminative capacity was assessed in another sample (n=96). The new cutoff point and other previously published ones were tested to discriminate low exercise capacity, physical inactivity, sedentary lifestyle and low quality of life. A receiver operation characteristics curve with area under the curve (AUC) value was plotted and each cutoff points' discriminative capacity was calculated. Cox regression and Kaplan-Meier method assessed the association between the cutoff points and mortality.

RESULTS

The new cutoff points for FFMI were 14.65 kg/m² for women (AUC=0.744; sensitivity (Se)=0.88; specificity (Sp)=0.60) and 20.35 kg/m² for men (AUC=0.565; Se=0.36; Sp=0.81). The new cutoffs were the best to discriminate poor exercise capacity assessed by walked distance in % predicted and quality of life. Only the new cutoff point was associated with mortality (HR=2.123; 95% CI: 1.03-4.33, P=0.039, log rank P=0.035).

CONCLUSIONS

Only the new cutoff point was associated with all-cause mortality, and it had the highest discriminating capacity for exercise capacity and quality of life in Brazilian patients with COPD.

Changes in lower limb muscle function and muscle mass following exercise-based interventions in patients with chronic obstructive pulmonary disease: A review of the English-language literature

Chronic obstructive pulmonary disease (COPD) patients often experience lower limb muscle dysfunction and wasting. Exercise-based training has potential to improve muscle function and mass, but literature on this topic is extensive and heterogeneous including numerous interventions and outcome measures. This review uses a detailed systematic approach to investigate the effect of this wide range of exercise-based interventions on muscle function and mass. PUBMED and PEDro databases were searched. In all, 70 studies (n = 2504 COPD patients) that implemented an exercise-based intervention and reported muscle strength, endurance, or mass in clinically stable COPD patients were critically appraised. Aerobic and/or resistance training, high-intensity interval training, electrical or magnetic muscle stimulation, whole-body vibration, and water-based training were investigated. Muscle strength increased in 78%, muscle endurance in 92%, and muscle mass in 88% of the cases where that specific outcome was measured. Despite large heterogeneity in exercise-based interventions and outcome measures used, most exercise-based trials showed improvements in muscle strength, endurance, and mass in COPD patients. Which intervention(s) is (are) best for which subgroup of patients remains currently unknown. Furthermore, this literature review identifies gaps in the current knowledge and generates recommendations for future research to enhance our knowledge on exercise-based interventions in COPD patients.

Clinical management of chronic obstructive pulmonary disease patients with muscle dysfunction

Muscle dysfunction is frequently observed in chronic obstructive pulmonary disease (COPD) patients, contributing to their exercise limitation and a worsening prognosis. The main factor leading to limb muscle dysfunction is deconditioning, whereas respiratory muscle dysfunction is mostly the result of pulmonary hyperinflation. However, both limb and respiratory muscles are also influenced by other negative factors, including smoking, systemic inflammation, nutritional abnormalities, exacerbations and some drugs. Limb muscle weakness is generally diagnosed through voluntary isometric maneuvers such as handgrip or quadriceps muscle contraction (dynamometry); while respiratory muscle loss of strength is usually recognized through a decrease in maximal static pressures measured at the mouth. Both types of measurements have validated reference values. Respiratory muscle strength can also be evaluated determining esophageal, gastric and transdiaphragmatic maximal pressures although there is a lack of widely accepted reference equations. Non-volitional maneuvers, obtained through electrical or magnetic stimulation, can be employed in patients unable to cooperate. Muscle endurance can also be assessed, generally using repeated submaximal maneuvers until exhaustion, but no validated reference values are available yet. The treatment of muscle dysfunction is multidimensional and includes improvement in lifestyle habits (smoking abstinence, healthy diet and a good level of physical activity, preferably outside), nutritional measures (diet supplements and occasionally, anabolic drugs), and different modalities of general and muscle training.

Nutritional status and its relationship with different dimensions of functional status in patients with chronic obstructive pulmonary disease

ABSTRACT Objective: To investigate whether there is a relationship between nutritional status and limitations in activities of daily living in patients with chronic obstructive pulmonary disease. Methods: A cross sectional study was conducted from July to December 2011 in Santa Catarina. Seventeen chronic obstructive pulmonary disease patients [age (years) = 67±8; forced expiratory volume in one second (% of the predicted value) = 38.6±16.1; body mass index (kg/m2) = 24.7±5.4] underwent the assessments: pulmonary function (spirometry); functional status (London Chest Activity of Daily Living scale, physical activities in daily life, and Glittre ADL-Test; nutritional status (anthropometry and dual-energy X-Ray absorptiometry). Results: The total score of the London Chest Activity of Daily Living scale correlated with fat-free mass (r=-0.50; p=0.04) and lean mass (r=-0.50; p=0.04). The lying time in physical activities in daily life correlated with bone mineral content (r=-0.50; p=0.04). Nutricional status was not correlated with time spent on Glittre ADL-test. Conclusion: Variables that reflect muscle mass depletion are related to variables of self-reported limitation in activities of daily living. Bone mineral content is correlated with time patients spend lying, reflecting the impact of inactive postures on the nutritional status of these patients.

Inpatient pulmonary rehabilitation: does it make sense?

Among the nonpharmacological therapies, pulmonary rehabilitation (PR) is particularly appropriate for patients with chronic respiratory impairment who, despite any optimal drug management, are still symptomatic and experience restriction in every day activities. Pulmonary rehabilitation performed in inpatient, outpatient, or home settings demonstrates short–and long–term clinical efficacy. Although disease severity does not inherently dictate candidacy for exercise training, the degree of physiological and functional impairment may influence setting in which the training should occur. Therefore, inpatient rehabilitation is generally best–suited for the most sick and most disabled patients. The overall results from the literature confirm that the inpatient setting for a PR program is a feasible option and does not necessarily result in higher direct costs when balanced against duration and effectiveness in terms of improved outcomes.

Frailty in Pulmonary and Critical Care Medicine

Conceptualized first in the field of geriatrics, frailty is a syndrome characterized by a generalized vulnerability to stressors resulting from an accumulation of physiologic deficits across multiple interrelated systems. This accumulation of deficits results in poorer functional status and disability. Frailty is a "state of risk" for subsequent disproportionate declines in health status following new exposure to a physiologic stressor. Two predominant models have emerged to operationalize the measurement of frailty. The phenotype model defines frailty as a distinct clinical syndrome that includes conceptual domains such as strength, activity, wasting, and mobility. The cumulative deficit model defines frailty by enumerating the number of age-related things wrong with a person. The biological pathways driving frailty include chronic systemic inflammation, sarcopenia, and neuroendocrine dysregulation, among others. In adults with chronic lung disease, frailty is independently associated with more frequent exacerbations of lung disease, all-cause hospitalization, declines in functional status, and all-cause mortality. In addition, frail adults who become critically ill are more likely develop chronic critical illness or severe disability and have higher in-hospital and long-term mortality rates. The evaluation of frailty appears to provide important prognostic information above and beyond routinely collected measures in adults with chronic lung disease and the critically ill. The study of frailty in these populations, however, requires multipronged efforts aimed at refining clinical assessments, understanding the mechanisms, and developing therapeutic interventions.

Sarcopenia in Advanced COPD Affects Cardiometabolic Risk Reduction by Short-Term High-intensity Pulmonary Rehabilitation

OBJECTIVES

Sarcopenia is common in chronic obstructive pulmonary disease (COPD) and may contribute to increased cardiometabolic risk. Interventions to reduce cardiometabolic risk in advanced COPD have been scarcely studied. We have investigated the cardiometabolic effect of a short-term high-intensity rehabilitation program in sarcopenic and nonsarcopenic patients with advanced COPD.

DESIGN

Prospective observational study.

SETTING

Inpatient 4-week short-term high-intensity pulmonary rehabilitation program at the University Clinic Golnik, Slovenia.

PARTICIPANTS

112 stable COPD patients (66 ± 8 years, 85% GOLD III/IV, 66% men).

MEASUREMENTS

Blood biomarkers were assessed at baseline and after rehabilitation. Sarcopenia was assessed at baseline (skeletal muscle index <7.23 kg/m(2) for men and <5.67 kg/m(2) for women, as measured by whole-body dual energy X-ray absorptiometry. Insulin resistance (IR) was defined as homeostasis model assessment of insulin resistance (HOMA-IR) above 2.5.

RESULTS

IR and sarcopenia were detected in 59% and 55% of patients, respectively. In contrast to sarcopenic patients, rehabilitation decreased HOMA-IR (2.8 to 1.9, P = .031), fat mass index (10.1 to 9.7 kg/m(2), P = .013), waist circumference (103 to 101 cm, P = .002), and low-density lipoprotein cholesterol (3.2 to 3.0 mmol/L, P = .034) in nonsarcopenic patients. A decrease in total cholesterol levels was observed in both groups.

CONCLUSIONS

Sarcopenia affects the modification of cardiometabolic risk markers by short-term high-intensity pulmonary rehabilitation in advanced COPD patients.

Management of chronic obstructive pulmonary disease beyond the lungs

Chronic obstructive pulmonary disease (COPD) is an umbrella term that covers many clinical subtypes with clearly different pulmonary and extra-pulmonary characteristics, but with persistent airflow limitation in common. This insight has led to the development of a more personalised approach in bronchodilator therapy, prevention of exacerbations, and advanced treatments (such as non-invasive ventilation and lung volume reduction techniques). However, systemic manifestations and comorbidities of COPD also contribute to different clinical phenotypes and warrant an individualised approach as part of integrated disease management. Alterations in bodyweight and composition, from cachexia to obesity, demand specific management. Psychological symptoms are highly prevalent, and thorough diagnosis and treatment are necessary. Moreover, prevention of exacerbations requires interventions beyond the lungs, including treatment of gastro-oesophageal reflux disease, reduction of cardiovascular risks, and management of dyspnoea and anxiety. In this Review, we discuss the management of COPD beyond the respiratory system and propose treatment strategies on the basis of the latest research and best practices.

[Impact of physical exercise in cystic fibrosis patients: A systematic review]

INTRODUCTION

Beneficial effects of physical exercise have been previously demonstrated in patients with chronic obstructive pulmonary disease. The aim of this systematic review was to summarize the evidence supporting physical exercise to improve on lung function, exercise capacity and quality of life in cystic fibrosis patients.

METHODS

Medline database was used to search clinical studies from 2000 to 2015. We also analyzed the bibliographic section of the included studies, in order to identify additional references.

RESULTS

A total of 17 studies were identified. A great disparity was found in the results of the different studies. No systematic benefit was found on lung function, exercise capacity or quality of life. No relationship between the type of program and the benefits achieved was observed.

CONCLUSIONS

Evidence that physical exercise benefits lung function, exercise capacity and quality of life in cystic fibrosis patient is inconsistent and evidence does not support a particular standardized program for all patients.

Differences in change in coping styles between good responders, moderate responders and non-responders to pulmonary rehabilitation

INTRODUCTION

Pulmonary rehabilitation (PR) improves exercise tolerance and health status in patients with chronic obstructive pulmonary disease (COPD). Data on the effects of PR on coping styles are limited. Aim of the present study was to compare changes in coping styles between patients who had a good, moderate and no improvement in either exercise tolerance or health status after PR.

METHODS

Coping styles of 439 COPD patients undergoing PR were assessed by the Utrecht Coping List (UCL) at baseline and after PR. Patients' pulmonary function, six-minute walking distance (6MWD), St. George's Respiratory Questionnaire (SGRQ) and Hospital Anxiety and Depression Scale (HADS-A and HADS-D) were recorded. Good, moderate and non-responders were defined on the basis of minimally clinically important difference (MCID) for SGRQ total score and/or 6MWD.

RESULTS

Overall, 54.0% of the patients fulfilled the criteria for good responders, while 22.1% were moderate responders. Change in passive reaction pattern coping style differed significantly between good responders and non-responders following PR (p < 0.001). Moreover, within the groups, changes in coping styles after PR occurred among the good responders, whereas the majority of moderate responders' and non-responders' coping styles were not significantly influenced by PR.

CONCLUSION

Good responders decreased their passive reaction pattern coping style in contrast to non-responders after PR. In general, PR did not change the coping among moderate and non-responders. Further research is warranted to determine whether including interventions targeting coping styles may modify coping behaviour of COPD patients, as well as improvement in exercise tolerance or health status after PR.

Genome-wide mRNA expression profiling in vastus lateralis of COPD patients with low and normal fat free mass index and healthy controls

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) has significant systemic effects beyond the lungs amongst which muscle wasting is a prominent contributor to exercise limitation and an independent predictor of morbidity and mortality. The molecular mechanisms leading to skeletal muscle dysfunction/wasting are not fully understood and are likely to be multi-factorial. The need to develop therapeutic strategies aimed at improving skeletal muscle dysfunction/wasting requires a better understanding of the molecular mechanisms responsible for these abnormalities. Microarrays are powerful tools that allow the investigation of the expression of thousands of genes, virtually the whole genome, simultaneously. We aim at identifying genes and molecular pathways involved in skeletal muscle wasting in COPD.

METHODS

We assessed and compared the vastus lateralis transcriptome of COPD patients with low fat free mass index (FFMI) as a surrogate of muscle mass (COPDL) (FEV1 30 ± 3.6%pred, FFMI 15 ± 0.2 Kg.m(-2)) with patients with COPD and normal FFMI (COPDN) (FEV1 44 ± 5.8%pred, FFMI 19 ± 0.5 Kg.m(-2)) and a group of age and sex matched healthy controls (C) (FEV1 95 ± 3.9%pred, FFMI 20 ± 0.8 Kg.m(-2)) using Agilent Human Whole Genome 4x44K microarrays. The altered expression of several of these genes was confirmed by real time TaqMan PCR. Protein levels of P21 were assessed by immunoblotting.

RESULTS

A subset of 42 genes was differentially expressed in COPDL in comparison to both COPDN and C (PFP < 0.05; -1.5 ≥ FC ≥ 1.5). The altered expression of several of these genes was confirmed by real time TaqMan PCR and correlated with different functional and structural muscle parameters. Five of these genes (CDKN1A, GADD45A, PMP22, BEX2, CGREF1, CYR61), were associated with cell cycle arrest and growth regulation and had been previously identified in studies relating muscle wasting and ageing. Protein levels of CDKN1A, a recognized marker of premature ageing/cell cycle arrest, were also found to be increased in COPDL.

CONCLUSIONS

This study provides evidence of differentially expressed genes in peripheral muscle in COPD patients corresponding to relevant biological processes associated with skeletal muscle wasting and provides potential targets for future therapeutic interventions to prevent loss of muscle function and mass in COPD.

Fatores associados à melhora da composição corporal em indivíduos com DPOC após treinamento físico

Introdução A redução da massa magra corpórea (MMC) é um fator independente de mortalidade em pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC) e a literatura mostra que exercícios físicos aumentam a MMC. Objetivo Identificar fatores associados à melhora da composição corporal em indivíduos com DPOC após treinamento físico de alta intensidade. Métodos 37 pacientes com DPOC (19 H; 66 ± 7 anos; IMC = 27 ± 6 kg/m2; VEF1 = 38 ± 16 %pred) foram avaliados segundo sua composição corporal, função pulmonar, força muscular respiratória e periférica, capacidade funcional de exercício (teste de caminhada dos seis minutos, TC6M), nível de atividade física diária (DynaPort®), sensação subjetiva de dispneia (escala Medical Research Council) e qualidade de vida (Saint George Respiratory Questionnaire). O treinamento conteve exercícios de endurance e força muscular (3 vezes por semana por três meses). Após três meses, os pacientes foram reavaliados. Aqueles que apresentaram incremento de MMC incorporaram à estatística. Resultados No pré-treinamento, a MMC se correlacionou significativamente (p ≤ 0,05) com gasto energético total (r = 0,57), TC6M em %predito (r = 0,46), pressão expiratória máxima (PEmax) (r = 0,57), volume expiratório forçado no primeiro segundo em %predito (r = 0,47), força muscular de quadríceps femoral (r = 0,54), bíceps (r = 0,62) e tríceps braquial (r = 0,63). Contudo, o incremento da MMC após treinamento correlacionou-se significativamente somente com a melhora das escalas MRC (r = 0,4; p = 0,05) e PEmax (r = 0,35; p = 0,04). Conclusão Apesar de a MMC de pacientes com DPOC estar relacionada com a capacidade funcional de exercício, força muscular respiratória e periférica, obstrução pulmonar e gasto energético no pré-tratamento, a melhora da composição corporal está relacionada somente ao incremento da força muscular expiratória e sensação de dispneia após treinamento físico de alta intensidade.

Effects of exercise training on pulmonary vessel muscularization and right ventricular function in an animal model of COPD

BACKGROUND

Right ventricular dysfunction in COPD is common, even in the absence of pulmonary hypertension. The aim of the present study was to examine the effects of high intensity interval training (HIIT) on right ventricular (RV) function, as well as pulmonary blood vessel remodeling in a mouse model of COPD.

METHODS

42 female A/JOlaHsd mice were randomized to exposure to either cigarette smoke or air for 6 hours/day, 5 days/week for 14 weeks. Mice from both groups were further randomized to sedentariness or HIIT for 4 weeks. Cardiac function was evaluated by echocardiography and muscularization of pulmonary vessel walls by immunohistochemistry.

RESULTS

Smoke exposure induced RV systolic dysfunction demonstrated by reduced tricuspid annular plane systolic excursion. HIIT in smoke-exposed mice reversed RV dysfunction. There were no significant effects on the left ventricle of neither smoke exposure nor HIIT. Muscularization of the pulmonary vessels was reduced after exercise intervention, but no significant effects on muscularization were observed from smoke exposure.

CONCLUSIONS

RV function was reduced in mice exposed to cigarette smoke. No Increase in pulmonary vessel muscularization was observed in these mice, implying that other mechanisms caused the RV dysfunction. HIIT attenuated the RV dysfunction in the smoke exposed mice. Reduced muscularization of the pulmonary vessels due to HIIT suggests that exercise training not only affects the heart muscle, but also has important effects on the pulmonary vasculature.

Effects of anabolic steroids on chronic obstructive pulmonary disease: a meta-analysis of randomised controlled trials

Background

Anabolic steroids are known to improve body composition and muscle strength in healthy people. However, whether anabolic steroids improve the physical condition and function in patients with chronic obstructive pulmonary disease (COPD) remains undetermined. A meta-analysis was conducted to review the current evidence regarding the effects of anabolic steroids on COPD patients.

Methods

A comprehensive literature search of PubMed and EMBASE was performed to identify randomised controlled trials that examine the effects of anabolic steroids on COPD patients. Weighted mean differences (WMDs) with 95% confidence intervals were calculated to determine differences between anabolic steroid administration and control conditions.

Results

Eight eligible studies involving 273 COPD patients were identified in this meta-analysis. Significant improvements were found in body weight (0.956 kg), fat-free mass (1.606 kg), St. George's Respiratory Questionnaire total score (−6.336) and symptom score (−12.148). The apparent improvements in maximal inspiratory pressure (2.740 cmH₂O) and maximal expiratory pressure (12.679 cmH₂O) were not significant. The effects on handgrip strength, forced expiratory volume in one second (FEV₁), predicted FEV₁ percent, PaO₂, PaCO₂ and six-min walk distance were negative, with WMDs of −0.245 kg, −0.096 L/sec, −1.996% of predicted, −1.648 cmHg, −0.039 cmHg and −16.102 meters, respectively.

Conclusions

Limited evidence available from the published literature suggests that the benefit of anabolic steroids on COPD patients cannot be denied. However, further studies are needed to identify the specific benefits and adverse effects of anabolic steroids on COPD patients and to determine the optimal populations and regimes of anabolic steroids in COPD patients.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Coping styles in patients with COPD before and after pulmonary rehabilitation

INTRODUCTION

Pulmonary rehabilitation (PR) improves physical and psychological symptoms in COPD patients. Patients' coping with daily symptoms and limitations may have more influence on important patient-centred outcomes than the impaired lung function. To date, it remains unknown whether and to what extent coping styles change following PR, and whether coping styles are associated with the outcomes of a comprehensive PR.

METHODS

Coping styles were assessed in 303 COPD patients before and after a PR programme using the Utrecht Coping List (UCL). Additionally, lung function, St. George's Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale, anxiety (HADS-A) and depression (HADS-D) subscales and six-minute walking distance (6MWD) were recorded.

RESULTS

The level of active confronting coping style increased (p < 0.05), whereas the levels of avoidance (p < 0.05), passive reaction pattern and reassuring thoughts coping styles decreased following PR (both p < 0.001). More than 50% of the patients changed their level of active confronting, passive reaction pattern or expressing emotions coping style. Coping styles and/or changes in coping styles after PR were related to changes in exercise tolerance, anxiety and depression, but were not related to changes in health status. Following PR, SGRQ total score, HADS-A and HADS-D scores decreased (all p < 0.001), while 6MWD increased (p < 0.05).

CONCLUSION

Comprehensive PR results in change in coping styles of COPD patients. Coping styles are related to improvements in exercise tolerance, anxiety and depression, but they are not related with changes in health status after PR. Further studies are needed to evaluate the outcome of interventions actively targeting coping styles.

Does body mass index influence the outcomes of a Waking-based pulmonary rehabilitation programme in COPD?

Body mass index (BMI) is an important prognostic measure in chronic obstructive pulmonary disease (COPD). However, its effects on pulmonary rehabilitation (PR) are unknown. This study aimed to evaluate the effectiveness of a walking-based PR programme across the BMI range and the impact of BMI on exercise performance and health status. A total of 601 patients with COPD completed a PR programme. The effects of BMI on exercise capacity (incremental and endurance shuttle walk tests (ISWT and ESWT)) and health status (chronic respiratory questionnaire (CRQ)) before and after PR were evaluated. 16% of patients were underweight, with 53% overweight or obese. At baseline, the obese had worse ISWT (−54 m ± 14 m; p = 0.001) despite a higher predicted forced expiratory volume in 1 s (7.4m ± 1.6%; p < 0.001). Patients in all BMI categories made clinically important improvements in ISWT distance: BMI <21, 62 m; 21–25, 59 m; 25–30, 59 m; >30, 65 m ( p = < 0.001). All four domains of the CRQ increased above the level of clinical significance for all BMI categories (all p < 0.001). The majority of patients with COPD were overweight associated with a lower walking capacity. A walking-based PR programme was comparably effective across the BMI spectrum. Patients with COPD should be referred for standard PR, independent of BMI.