Physical Activity and Hospitalization for Exacerbation of COPD

Effects of different exercise regimens on prognosis of patients with chronic obstructive pulmonary disease: a systematic reviews and meta-analysis

INTRODUCTION

Skeletal muscle dysfunction is a significant factor contributing to exercise limitation in patients with chronic obstructive pulmonary disease (COPD). Although exercise training is often recommended to enhance patient outcomes, there continues to be ongoing debate regarding its exact effects.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of endurance exercise, strength training and combined exercise on cardiorespiratory fitness (including maximal oxygen uptake, maximal minute ventilation, and the 6-minute walk test), strength of lower limbs (measured by leg press), and quality of life (using the COPD Assessment Test) in patients with COPD. By conducting a systematic review and meta-analysis of randomized controlled trials (RCTs), our objective is to provide tailored training methods and intensity recommendations for patients with COPD in order to improve their quality of life.

METHODS

The meta-analysis included 10 randomized controlled trials (RCTs) of exercise rehabilitation programs involving 180 patients with COPD that were retrieved from electronic databases (PubMed, Cochrane Library, and Embase). Two reviewers independently assessed the topical relevance, trial quality, and extracted data for the meta-analysis.

RESULTS

Meta-analysis showed that primary outcomes representing exercise endurance were elevated under different exercise interventions compared to pre-test, such as maximal oxygen uptake (VO2max (ml/kg/min)) [SMD = 0.40, 95% CI (0.15, 0.64)] and the 6-min walk test (6MWT) [MD = 33.90, 95% CI (25.25, 42.55)], and primary outcomes representing strength also increased, such as leg press (1RM) [MD = 24.59, 95% CI (16.08, 33.11)], while secondary outcomes such as assessments of life such as the COPD Assessment Test (CAT) recovered [MD = 2.51, 95% CI (2.01, 3.00)], with all differences being statistically significant (p < 0.05). However, Maximum minute ventilation (VEmax (L)) [MD = 0.91, 95%CI (3.61, 5.43)] was not statistically significant (p > 0.05) when compared with the post-test data. The sensitivity test data were stable, and the results were reliable. We subgrouped the data from different types of exercise interventions and found that different types of exercise affected the experimental results.

CONCLUSION

Exercise interventions have a positive effect on the treatment of patients with COPD, significantly improving functional capacity, aerobic capacity, and exercise tolerance, but they should be individualized and developed according to the patient's condition to achieve the best therapeutic effect.

Prevalence and prognostic importance of exercise limitation and physical inactivity in COPD

Exercise limitation and physical inactivity are separate, but related constructs. Both are commonly present in individuals with COPD, contribute to disease burden over and above the respiratory impairments, and are independently predictive of adverse outcomes. Because of this, clinicians should consider assessing these variables in their patients with COPD. Field tests of exercise performance such as the 6-min walk test and the incremental and endurance shuttle walk tests require limited additional resources, and results correlate with negative outcomes. Laboratory measures of exercise performance using a treadmill or cycle ergometer assess exercise capacity, provide prognostic information and have the advantage of explaining physiological mechanisms (and their interactions) underpinning exercise limitation. Limitations in exercise capacity (i.e. "cannot do") and physical inactivity (i.e. "do not do") are both associated with mortality; exercise limitation appears to be the more important driver of this outcome.

Advances in COPD imaging using CT and MRI: linkage with lung physiology and clinical outcomes

Recent years have witnessed major advances in lung imaging in patients with COPD. These include significant refinements in images obtained by computed tomography (CT) scans together with the introduction of new techniques and software that aim for obtaining the best image whilst using the lowest possible radiation dose. Magnetic resonance imaging (MRI) has also emerged as a useful radiation-free tool in assessing structural and more importantly functional derangements in patients with well-established COPD and smokers without COPD, even before the existence of overt changes in resting physiological lung function tests. Together, CT and MRI now allow objective quantification and assessment of structural changes within the airways, lung parenchyma and pulmonary vessels. Furthermore, CT and MRI can now provide objective assessments of regional lung ventilation and perfusion, and multinuclear MRI provides further insight into gas exchange; this can help in structured decisions regarding treatment plans. These advances in chest imaging techniques have brought new insights into our understanding of disease pathophysiology and characterising different disease phenotypes. The present review discusses, in detail, the advances in lung imaging in patients with COPD and how structural and functional imaging are linked with common resting physiological tests and important clinical outcomes.

Changes in physical activity, sedentary behaviour and sleep following pulmonary rehabilitation: a systematic review and network meta-analysis

BACKGROUND

The variety of innovations to traditional centre-based pulmonary rehabilitation (CBPR), including different modes of delivery and adjuncts, are likely to lead to differential responses in physical activity, sedentary behaviour and sleep.

OBJECTIVES

To examine the relative effectiveness of different pulmonary rehabilitation-based interventions on physical activity, sedentary behaviour and sleep.

METHODS

Randomised trials in chronic respiratory disease involving pulmonary rehabilitation-based interventions were systematically searched for. Network meta-analyses compared interventions for changes in physical activity, sedentary behaviour and sleep in COPD.

RESULTS

46 studies were included, and analyses were performed on most common outcomes: steps per day (k=24), time spent in moderate-to-vigorous physical activity (MVPA; k=12) and sedentary time (k=8). There were insufficient data on sleep outcomes (k=3). CBPR resulted in greater steps per day and MVPA and reduced sedentary time compared to usual care. CBPR+physical activity promotion resulted in greater increases in steps per day compared to both usual care and CBPR, with greater increases in MVPA and reductions in sedentary time compared to usual care, but not CBPR. Home-based pulmonary rehabilitation resulted in greater increases in steps per day and decreases in sedentary time compared to usual care. Compared to usual care, CBPR+physical activity promotion was the only intervention where the lower 95% confidence interval for steps per day surpassed the minimal important difference. No pulmonary rehabilitation-related intervention resulted in greater increases in MVPA or reductions in sedentary time compared to CBPR.

CONCLUSION

The addition of physical activity promotion to pulmonary rehabilitation improves volume of physical activity, but not intensity, compared to CBPR. High risk of bias and low certainty of evidence suggests that these results should be viewed with caution.

Short-term effects of air pollution and weather on physical activity in patients with chronic obstructive pulmonary disease (COPD)

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) accumulate low levels of physical activity. How environmental factors affect their physical activity in the short-term is uncertain.

AIM

to assess the short-term effects of air pollution and weather on physical activity levels in COPD patients.

METHODS

This multi-center panel study assessed 408 COPD patients from Catalonia (Spain). Daily physical activity (i.e., steps, time in moderate-to-vigorous physical activity (MVPA), locomotion intensity, and sedentary time) was recorded in two 7-day periods, one year apart, using the Dynaport MoveMonitor. Air pollution (nitrogen dioxide (NO2), particulate matter below 10 μm (PM10) and a marker of black carbon (absorbance of PM2.5: PM2.5ABS), and weather (average and maximum temperature, and rainfall) were estimated the same day (lag zero) and up to 5 days prior to each assessment (lags 1-5). Mixed-effect distributed lag linear regression models were adjusted for age, sex, weekday, public holidays, greenness, season, and social class, with patient and city as random effects.

RESULTS

Patients (85% male) were on average (mean ± SD) 68 ± 9 years old with a post-bronchodilator forced expiratory volume in 1 s (FEV1) of 57 ± 18% predicted. Higher NO2, PM10 and PM2.5ABS levels at lag four were associated with fewer steps, less time in MVPA, reduced locomotion intensity, and longer sedentary time (e.g., coefficient (95% CI) of -60 (-105, -15) steps per 10 μg/m3 increase in NO2). Higher average and maximum temperatures at lag zero were related to more steps and time in MVPA, and less sedentary time (e.g., +85 (15, 154) steps per degree Celsius). Higher rainfall at lag zero was related to fewer steps and more sedentary time.

CONCLUSION

Air pollution affects the amount and intensity of physical activity performed on the following days in COPD patients, whereas weather affects the amount of physical activity performed on the same day.

Exercise training initiated early during hospitalisation in individuals with chronic obstructive pulmonary disease is safe and improves exercise capacity and physical function at hospital discharge: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Earlier reviews of exercise in people during exacerbation of chronic obstructive pulmonary disease (COPD) included studies where exercise training was initiated late during hospital admission or shortly following hospital discharge. Our question was: in adults hospitalised with an exacerbation of COPD, does initiating exercise training early during an admission versus not initiating exercise training during admission, change outcomes measured at discharge?

METHODS

Systematic review and meta-analysis. Database searches of PubMed, the Cochrane Library, PEDro and EMBASE conducted in December 2021 and updated in January 2024. Studies were included if they had at least one group that was prescribed exercise training within 48 h of hospital admission (experimental) and at least one group that received usual care which did not include prescribed exercise training (control). Outcomes included exercise capacity, physical function, adverse events and uptake of outpatient pulmonary rehabilitation programs.

RESULTS

Ten studies (423 participants; mean FEV1 ranging from 26 % to 50 % predicted) were included. At discharge, compared to the control group, the experimental group demonstrated better exercise capacity (standardised mean difference (SMD) 0.58, 95 % confidence interval (CI) 0.32 to 0.83; five studies, moderate effect, low certainty evidence) and physical function (SMD -0.54, 95 % CI -0.86 to -0.22; four studies, moderate effect, low certainty evidence). No observed serious adverse events were reported. None of the studies reported uptake of pulmonary rehabilitation following discharge.

CONCLUSION

In adults with an exacerbation of COPD, exercise training prescribed within 48 h of hospitalisation was safe and improved exercise capacity and physical function.

Development of a performance-based toolkit of the treatable traits of functioning in hospitalised patients with exacerbation of COPD: a survey-based study protocol

Background

The management of COPD has been based on the premise of identifying problems that guide personalised treatment based on a multidimensional assessment, known as treatable traits. Exacerbation of COPD (ECOPD) results in physical and functional impairments, limitation of daily activities and negative impact on patients' quality of life and prognosis. In this context, identifying treatable traits in patients with ECOPD is essential to properly guide individualised patient care. There is a need to develop a performance-based toolkit to identify the main treatable traits of functioning in hospitalised patients with ECOPD.

Methods and analysis

This is a study protocol of a survey method observational study to develop a performance-based toolkit. The study will include the following steps: 1) definition of treatable traits by both physiotherapists who provide or have provided care to hospitalised patients with ECOPD on a regular basis, and patients who have experienced at least one ECOPD which required hospitalisation; 2) selection of the most appropriate measures (markers) for each treatable trait based on established criteria and a previous systematic review; and 3) implementation of the toolkit in a pilot/feasibility study with hospitalised patients with ECOPD.

Conclusion

The development of a feasible performance-based toolkit with the best markers for each key treatable trait of functioning in hospitalised patients with ECOPD will make it possible to create individualised patient care for the specific demands of these patients.

Impacts of regular physical activity on hospitalisation in chronic obstructive pulmonary disease: a nationwide population-based study

INTRODUCTION

Studies that comprehensively evaluate the association between physical activity (PA) levels, particularly by quantifying PA intensity, and healthcare use requiring emergency department (ED) visit or hospitalisation in patients with chronic obstructive pulmonary disease (COPD) are limited in Korea.

METHODS

The risk of all-cause and respiratory ED visit or hospitalisation according to the presence or absence of COPD and the level of PA was evaluated in a retrospective nationwide cohort comprising 3308 subjects with COPD (COPD cohort) and 293 358 subjects without COPD (non-COPD cohort) from 2009 to 2017.

RESULTS

The COPD group exhibited a higher relative risk of all-cause and respiratory ED visit or hospitalisation across all levels of PA compared with the highly active control group (≥1500 metabolic equivalents (METs)-min/week). Specifically, the highest risk was observed in the sedentary group (adjusted HR (aHR) (95% CI) = 1.70 (1.59 to 1.81) for all-cause ED visit or hospitalisation, 5.45 (4.86 to 6.12) for respiratory ED visit or hospitalisation). A 500 MET-min/week increase in PA was associated with reductions in all-cause and respiratory ED visit or hospitalisation in the COPD cohort (aHR (95% CI) = 0.92 (0.88 to 0.96) for all-cause, 0.87 (0.82 to 0.93) for respiratory cause).

CONCLUSIONS

Compared with the presumed healthiest cohort, the control group with PA>1500 METs-min/week, the COPD group with reduced PA has a higher risk of ED visit or hospitalisation.

Physical activity and outcomes in Japanese patients with chronic obstructive pulmonary disease: From the Ishinomaki COPD Network registry

BACKGROUND

Low physical activity levels are associated with an increased risk of exacerbations and all-cause mortality in patients with chronic obstructive pulmonary disease (COPD); however, evidence is limited in a population with a low frequency of exacerbations, such as the Japanese population. This study investigated the effects of physical activity on outcomes in Japanese patients with COPD.

METHODS

We conducted a prospective observational study in a cohort of Japanese patients with COPD between April 2018 and July 2020. Characteristics, frequency of exacerbations, and mortality were assessed during the 1-year follow-up period. Logistic regression analysis evaluated the relationship between physical activity and outcomes.

RESULTS

A total of 309 patients (294 males; median age, 75 years) with stable COPD were included, and 307 completed follow-up. Patients with lower levels of physical activity were older, and showed increased airflow obstruction, limited exercise capacity, increased dyspnea, depressive state, poor health status, muscle weakness, and more information needs for the disease. Patients with high levels of physical activity had a lower risk of exacerbation, including hospital admission, compared to those with low levels of activity (odds ratio [OR], 0.46; 95 % confidence interval [CI], 0.22-0.97; and OR, 0.21; 95 % CI, 0.09-0.50, respectively). High physical activity was associated with a reduced risk of all-cause mortality (OR, 0.07; 95 % CI, 0.01-0.55) and respiratory mortality (OR, 0.16; 95 % CI, 0.02-1.47).

CONCLUSIONS

These findings showed that higher physical activity is associated with better clinical outcomes, even in a COPD population with a low frequency of exacerbations.

Physical status, symptoms and health-related quality of life during a severe exacerbation of COPD: Recovery and discriminative capacity for future events

OBJECTIVE

Severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) can have a negative impact on functional capacity, symptoms and health-related quality of life (HRQOL). This study aimed to i) investigate the recovery of muscle strength, functional capacity, symptoms, and HRQOL in patients after a severe AECOPD; ii) compare with matched patients with stable COPD (SCOPD); and iii) assess whether these assessments at hospital discharge could discriminate patients' risk for future events.

METHODS

This observational study assessed patients with AECOPD during hospital discharge (T1) and one month after discharge (T2). Patients with SCOPD were assessed once. Quadriceps force, handgrip strength, short physical performance battery (SPPB), 6-min walk distance (6 MWD), COPD assessment test (CAT), London chest activity of daily living (LCADL), modified medical research council, checklist individual strength-fatigue, patient health questionnaire, and physical activity (Actigraph) were measured. Exacerbation-related readmission and mortality within six months and 1-year were collected.

RESULTS

Forty-four patients with AECOPD were matched with 44 patients with SCOPD. At T2, a significant improvement was found for the SPPB total score, 6 MWD, CAT score, and LCADL score. Compared to patients with SCOPD, a worse LCADL score was found at T2 in patients with AECOPD. Patients with AECOPD that were readmitted or died had a worse SPPB classification and five-repetition sit-to-stand test at T1.

CONCLUSION

Patients after severe AECOPD improved in functional capacity and HRQOL one month after hospital discharge, but ADL performance was still worse compared to SCOPD. Patients who were readmitted or died had significantly worse scores on functional tests at hospital discharge.

Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review

Introduction

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD.

Methods

A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035).

Results

In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility.

Conclusion

The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.

Impact of acute exacerbations of COPD on patients' health status beyond pulmonary function: A scoping review

This scoping review summarized the evidence regarding the impact of acute exacerbations of COPD (AECOPD) on patients' health status beyond pulmonary function. PubMed, Embase, and Web of Science were searched. Prospective cohort studies assessing the health status of patients with COPD in a stable phase of the disease and after a follow-up period (where at least one AECOPD occurred) were included. An integrated assessment framework of health status (i.e., physiological functioning, complaints, functional impairment, quality of life) was used. Twenty-two studies were included. AECOPD acutely affected exercise tolerance, quadriceps muscle strength, physical activity levels, symptoms of dyspnoea and fatigue, and impact of the disease. Long-term effects on quadriceps muscle strength, symptoms of dyspnoea and depression, and quality of life were found. Repeated exacerbations negatively impacted the fat-free mass, levels of dyspnoea, impact of the disease and quality of life. Conflicting evidence was found regarding the impact of repeated exacerbations on exercise tolerance and physical activity levels. AECOPD have well-established acute and long-term adverse effects on health status beyond pulmonary function; nevertheless, the recovery trajectory and the impact of repeated exacerbations are still poorly studied. Further prospective research is recommended to draw firm conclusions on these aspects.

Factors associated to physical activity in patients with COPD: An ecological approach

BACKGROUND

Physical activity (PA) is low in patients with Chronic Obstructive Pulmonary Disease (COPD). Identifying modifiable and non-modifiable correlates of PA give understanding of the individual behavior and provide future directions for PA enhancing interventions. As PA is complex and multidimensional, it should be embedded within a thorough framework.

OBJECTIVE

To identify correlates of PA in a comprehensive COPD population based on a broad ecological model, including physiological, psychological, socio-demographic and environmental dimensions.

METHODS

PA was objectively measured using the Dynaport Movemonitor and a comprehensive data collection of physiological, psychological, socio-demographic and environmental factors were collected. Bivariable and multivariable regression analyses (including principle component analysis) were executed.

RESULTS

For this cross-sectional analysis, we included 148 patients with COPD and valid PA data (mean (SD) age 68 (7) years, FEV1 57 (17) % predicted, 5613 (3596) steps per day). Significant bivariable associations were found for physiological (exercise capacity, muscle force, lung function, symptoms, comorbidities), psychological (e.g. fatigue, motivation, perceived difficulty with PA), socio-demographic (dog owning, use of activity tracker) and environmental (season, daylight, temperature) factors. Based on the multivariable regression model, exercise capacity, beliefs on motivation, importance and self-confidence regarding PA and weather conditions were independent correlates of mean steps per day (R2 = 0.35). Movement intensity during walking was only independently associated with exercise capacity and age (R2 = 0.41).

CONCLUSION

Although a wide range of potential influence factors were evaluated, variance in PA was only partly explained, supporting that PA is a complex behavior which is difficult to predict.

Glittre-ADL test without backpack: A qualitative study of perceptions of people with chronic obstructive pulmonary disease

BACKGROUND

The Glittre Activities of Daily Living (Glittre-ADL) test without backpack was recently validated to assess the functional capacity of people with chronic obstructive pulmonary disease (COPD) OBJECTIVE: To understand the perceptions of people with COPD about the Glittre-ADL test with and without backpack and the possible similarities with their activities of daily living (ADLs).

METHODS

Participants performed 2 Glittre-ADL tests with a backpack (visit 1). On visit 2, participants randomly performed the Glittre-ADL test with and without backpack and completed a semi-structured interview with questions about the tests. Interviews were analyzed according to thematic analysis.

RESULTS

Twelve participants aged between 57 and 76 years with mild to severe COPD were included. Interviews were grouped into four thematic categories: (1) Glittre-ADL test with a backpack: does the backpack make the test worse, or does it not matter?; (2) test tasks and ADL: what is in common between them?; (3) "I enjoyed taking the test": the possibility of learning and new expectations; and (4) symptoms during the Glittre-ADL tests.

CONCLUSION

The following perceptions while performing the Glittre-ADL test with and without the backpack were observed: dyspnea and fatigue sensation, difficulty using the backpack while performing tasks such as squatting, and similarities to ADLs tasks despite different perspectives regarding the degree of ease and expectations on how to perform test tasks at home.

The Effect of a Smartphone App with an Accelerometer on the Physical Activity Behavior of Hospitalized Patients: A Randomized Controlled Trial

Inactive behavior is common in hospitalized patients. This study investigated the effectiveness of using a smartphone app with an accelerometer (Hospital Fit) in addition to usual care physiotherapy on increasing patients' physical activity (PA) behavior. A randomized controlled trial was performed at Maastricht University Medical Centre. Patients receiving physiotherapy while hospitalized at the department of Pulmonology or Internal Medicine were randomized to usual care physiotherapy or using Hospital Fit additionally. Daily time spent walking, standing, and upright (standing/walking) (min) and daily number of postural transitions were measured with an accelerometer between the first and last treatment. Multiple linear regression analysis was performed to determine the association between PA behavior and Hospital Fit use, corrected for functional independence (mILAS). Seventy-eight patients were included with a median (IQR) age of 63 (56-68) years. Although no significant effects were found, a trend was seen in favor of Hospital Fit. Effects increased with length of use. Corrected for functional independence, Hospital Fit use resulted in an average increase of 27.4 min (95% CI: -2.4-57.3) standing/walking on day five and 29.2 min (95% CI: -6.4-64.7) on day six compared to usual care. Hospital Fit appears valuable in increasing PA in functionally independent patients.

Performance-based outcome measures to assess functionality in hospitalised patients with COPD exacerbations: a systematic review of the measurement properties

INTRODUCTION

Hospitalised patients with exacerbations of COPD (ECOPD) may have physical and functional impairments that impact morbidity and readmission. Therefore, it is crucial to properly identify reduced functionality in these patients to support a personalised rehabilitation. The objective of this study is to summarise and compare the measurement properties of functionality performance-based outcome measures for hospitalised patients with ECOPD.

METHODS

A systematic review based on the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) was performed. The PubMed, Embase, PEDro and Cochrane databases were searched using terms related to functionality, hospitalised patients with ECOPD and measurement properties. Studies were selected and extracted by two researchers. The COSMIN Risk of Bias checklist was applied to assess the methodological quality of the studies and measurement property results were compared with the criteria for good measurement properties. Quality of evidence was graded using a modified Grades of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

13 studies were included with nine outcome measures, namely the 6-min pegboard ring test, the de Morton mobility index, the incremental shuttle walk test (ISWT), the 6-min walk test (6MWT), maximum inspiratory pressure (MIP), the Berg balance scale, 4-m gait speed, handgrip strength and the 6-min stepper test. Construct validity was rated as sufficient, except for the ISWT. Responsiveness, assessed only for MIP, was considered insufficient and measurement errors for the ISWT and 6MWT were insufficient, with a very low quality of evidence for all measurement properties.

CONCLUSION

Measurement properties of performance-based outcome measures to assess functionality in patients hospitalised with ECOPD are still scarce, with very low evidence supporting validity and a lack of evidence of responsiveness and reliability. Further studies are needed to address this topic and guide assertive and personalised management.

Effects of pharmacological and non-pharmacological interventions on physical activity outcomes in COPD: a systematic review and meta-analysis

Rationale

The effect of pharmacological and non-pharmacological interventions on physical activity (PA) outcomes is not fully elucidated in patients with COPD. The objectives of the present study were to provide estimation of treatment effects of all available interventions on PA outcomes in patients with COPD and to provide recommendations regarding the future role of PA outcomes in pharmacological trials.

Materials and methods

This review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and reported in line with PRISMA. Records were identified through searches of 12 scientific databases; the most updated search was performed in January 2023.

Results

74 studies published from 2000 to 2021 were included, with a total of 8140 COPD patients. Forced expiratory volume in 1 s % predicted ranged between 31% and 74%, with a mean of 55%. Steps/day constituted the most frequently assessed PA outcome in interventional studies. Compared to usual care, PA behavioural modification interventions resulted in improvements in the mean (95% CI) steps/day when implemented alone (by 1035 (576-1493); p<0.00001) or alongside exercise training (by 679 (93-1266); p=0.02). Moreover, bronchodilator therapy yielded a favourable difference of 396 (125-668; p=0.004) steps/day, compared to placebo.

Conclusions

PA behavioural modification and pharmacological interventions lead to significant improvements in steps/day, compared to control and placebo groups, respectively. Compared to bronchodilator therapy, PA behavioural modification interventions were associated with a 2-fold greater improvement in steps/day. Large-scale pharmacological studies are needed to establish an intervention-specific minimal clinically important difference for PA outcomes as well as their convergent validity to accelerate qualification as potential biomarkers and efficacy end-points for regulatory approval.

Healthcare Utilization in Patients with Chronic Obstructive Pulmonary Disease Discharged from Coronavirus 2019 Hospitalization

Rationale

There is concern that patients with chronic obstructive pulmonary disease (COPD) are at greater risk of increased healthcare utilization (HCU) following Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-COV-2) infection.

Objective

To assess whether COPD is an independent risk factor for increased post-discharge HCU.

Methods

We conducted a retrospective cohort study of patients with COPD discharged home from a hospitalization due to Coronavirus Disease 2019 (COVID-19) between April 1, 2020, and March 31, 2021, using Optum's de-identified Clinformatics® Data Mart Database (CDM). COVID-19 was identified by an International Classification of Diseases, tenth revision, clinical modification (ICD-10-CM) diagnosis code of U07.1. The primary outcome was HCU (ie, emergency department (ED) visits, readmissions, rehabilitation/skilled nursing facility (SNF) visits, outpatient office visits, and telemedicine visits) nine months post-discharge after COVID-19 hospitalization (from here on "post-discharge") in patients with COPD compared to HCU of patients without COPD. Poisson regression modeling was used to calculate relative risk (RR) and confidence interval (CI) for COPD, adjusted for the other covariates.

Results

We identified a cohort of 160,913 patients hospitalized with COVID-19, with 57,756 discharged home and 14,622 (25.3%) diagnosed with COPD. Patients with COPD had a mean age of 75.48 years (±9.49); 55.5% were female and 70.9% were White. Patients with COPD had an increased risk of HCU in the nine months post-discharge after adjusting for the other covariates. Risk of ED visits, readmissions, length of stay during readmission, rehabilitation/SNF visits, outpatient office visits, and telemedicine visits were increased by 57% (RR 1.57; 95% CI 1.53-1.60), 50% (RR 1.50; 95% CI 1.46-1.54), 55% (RR 1.55; 95% CI 1.53-1.56), 18% (RR 1.18; 95% CI 1.14-1.22), 16% (RR 1.16; 95% CI 1.16-1.17), and 28% (RR 1.28; 95% CI 1.24-1.31), respectively. Younger patients (ages 18 to 65 years), women, and Hispanic patients with COPD showed an increased risk for post-discharge HCU.

Conclusion

Patients with COPD hospitalized with COVID-19 experienced increased HCU post-discharge compared to patients without COPD.

Cultural adaptation and validation of the Brazilian Portuguese version of the PROactive Physical Activity in COPD-clinical visit instrument for individuals with COPD

OBJECTIVE

To adapt the PROactive Physical Activity in COPD-clinical visit (C-PPAC) instrument to the cultural setting in Brazil and to determine the criterion validity, test-retest reliability agreement, and internal consistency of this version.

METHODS

A protocol for cultural adaptation and validation was provided by the authors of the original instrument and, together with another guideline, was applied in a Portuguese-language version developed by a partner research group from Portugal. The adapted Brazilian Portuguese version was then cross-sectionally administered twice within a seven-day interval to 30 individuals with COPD (57% were men; mean age was 69 ± 6 years; and mean FEV1 was 53 ± 18% of predicted) to evaluate internal consistency and test-retest reliability. Participants also completed the International Physical Activity Questionnaire (IPAQ), the modified Medical Research Council scale, the COPD Assessment Test, and Saint George's Respiratory Questionnaire to evaluate criterion validity.

RESULTS

The C-PPAC instrument showed good internal consistency and excellent test-retest reliability: "amount" domain = 0.87 (95% CI, 0.73-0.94) and "difficulty" domain = 0.90 (95% CI, 0.76-0.96). Bland & Altman plots, together with high Lin's concordance correlation coefficients, reinforced that agreement. Criterion validity showed moderate-to-strong correlations of the C-PPAC with all of the other instruments evaluated, especially with the IPAQ (rho = -0.63).

CONCLUSIONS

The Brazilian Portuguese version of the C-PPAC is a reliable and valid instrument for evaluating the experience of Brazilian individuals with COPD with their physical activity in daily life.

[Pulmonary Rehabilitation]

Reduced exercise capacity, skeletal muscle dysfunction, and a physically inactive lifestyle are linked with symptoms of fatigue and dyspnea in people suffering from chronic lung disease. Numerous such extrapulmonary manifestations have been identified as treatable aspects of pulmonary rehabilitation (PR). PR is an extensive personalized non-pharmaceutical intervention, encompassing, but not limited to, exercise training, respiratory therapy, and education. The content and goals of a PR-program are based on a comprehensive patient assessment at the time of rehabilitation admission, with personalized therapies provided by a multidisciplinary team of healthcare professionals. This article provides an overview of PR including possible indications, therapy contents (e. g. exercise training, respiratory therapy), and evidence (COPD, interstitial lung disease, COVID-19). Finally, options for pulmonary rehabilitation maintenance services in Germany are presented.

Physical Activity Profiles among Patients Admitted with Acute Exacerbations of Chronic Obstructive Pulmonary Disease

People with hospitalised acute exacerbations of chronic obstructive pulmonary disease (AECOPD) exhibit low levels of physical activity (PA) and increased risks of future exacerbations. While methods to objectively measure and express PA are established for people with stable COPD, less clarity exists for people during AECOPD. Further, the relationship between PA during AECOPD and clinically relevant outcomes remains uncertain. The purpose of the study was to evaluate how much PA (step count and intensity) people accumulate during hospitalised AECOPDs, and the effect of accumulated inpatient PA (expressed via differing metrics) on length of stay (LOS), PA recovery, and readmission risk. This study was a secondary analysis of prospective observational cohort data collected with Actigraph wActiSleep-BT devices from patients with AECOPD in a Melbourne hospital from 2016 to 2018. Step counts and PA intensity throughout the hospital admission and at one-month follow-up were collected and analysed. Sixty-eight participants were recruited for inpatient measurement, and 51 were retained for follow-up. There were no significant changes in step count or intensity across the inpatient days, but 33/51 (65%) of participants demonstrated a clinically meaningful improvement in steps per day from 3817.0 to 6173.7 at follow-up. Participants spent most time sedentary and in light PA, with both PA metrics demonstrating significant influences on LOS and follow-up PA intensity, but with generally low explanatory power (R2 value range 7-22%). Those who had LOS < 5 days spent significantly less time sedentary and more time in light PA than those with LOS ≥ 5 days (p < 0.001 for both). Time spent sedentary or in light PA appears to be the most promising metric to associate with clinically relevant outcomes related to recovery following AECOPD. These findings can inform future clinical practice for the evaluation of inpatient PA to better establish its role in the clinical management of patients with AECOPD.

Protocol for a systematic review of the associations between inflammatory markers and lung function, muscle force and exercise capacity in people with COPD

INTRODUCTION

The prevalence of chronic obstructive pulmonary disease (COPD) has been on the rise, with acute exacerbation of COPD associated with the highest burden and multiple pulmonary and systemic consequences. People with COPD have been found to have an abnormal response of systemic inflammation. To date, although limited, there are studies that suggest negative associations between inflammatory markers and important clinical outcomes such as exercise capacity and muscle force. This protocol aims to systematically review the evidence for (i) the associations between inflammatory markers and lung function, muscle force and exercise capacity and (ii) the influence of other factors (eg, hospitalisation, exercise programme) on the level of inflammatory markers in people with COPD.

METHODS AND ANALYSIS

Scopus, PubMed, Cochrane, Web of Science and ProQuest will be searched from database inception to February 2023 using PEO search strategy (Population: adults with COPD; Exposure: inflammatory markers; Outcomes: lung function, muscle force and exercise capacity). Four reviewers working in pairs will independently screen articles for eligibility and extract data that fulfilled the inclusion criteria. Depending on the design of the included studies, either Cochrane risk-of-bias version 2 or the Newcastle-Ottawa Scale tools will be used to rate the methodological quality of the included studies. Effect sizes reported in each individual study will be standardised to Cohen's d and a random effects model will be used to calculate the pooled effect size for the association.

ETHICS AND DISSEMINATION

Ethical approval is unnecessary as this study will only use publicly available data. The findings will be disseminated through publication in peer-reviewed journals and conferences.

PROSPERO REGISTRATION NUMBER

CRD42022284446.

The Role of Wearable Sensors to Monitor Physical Activity and Sleep Patterns in Older Adult Inpatients: A Structured Review

Low levels of physical activity (PA) and sleep disruption are commonly seen in older adult inpatients and are associated with poor health outcomes. Wearable sensors allow for objective continuous monitoring; however, there is no consensus as to how wearable sensors should be implemented. This review aimed to provide an overview of the use of wearable sensors in older adult inpatient populations, including models used, body placement and outcome measures. Five databases were searched; 89 articles met inclusion criteria. We found that studies used heterogenous methods, including a variety of sensor models, placement and outcome measures. Most studies reported the use of only one sensor, with either the wrist or thigh being the preferred location in PA studies and the wrist for sleep outcomes. The reported PA measures can be mostly characterised as the frequency and duration of PA (Volume) with fewer measures relating to intensity (rate of magnitude) and pattern of activity (distribution per day/week). Sleep and circadian rhythm measures were reported less frequently with a limited number of studies providing both physical activity and sleep/circadian rhythm outcomes concurrently. This review provides recommendations for future research in older adult inpatient populations. With protocols of best practice, wearable sensors could facilitate the monitoring of inpatient recovery and provide measures to inform participant stratification and establish common objective endpoints across clinical trials.

Comparison of Two Frailty Assessment Methods and Their Association with Functionality in Subjects with Exacerbation of COPD

Objectives

To verify the prevalence of frailty in patients hospitalized with acute exacerbation of COPD; to compare two frailty assessment methods: Edmonton Scale and the Fried Frailty Phenotype, and to associate frailty with functioning in these patients.

Methods

Patients hospitalized due to an acute exacerbation of COPD were included. The assessment of pulmonary function, frailty, and functioning was performed. Frailty assessment was performed by the Edmonton Scale and Fried Frailty Phenotype. Individuals were classified into "frail," "pre-frail" and "non-frail." Functioning was evaluated by the one sit-to-stand test.

Results

Thirty-five individuals were included (17 male, 69 ± 9 years; FEV1/FVC 47 ± 10%; FEV1 34 (24-52) % predicted). Participants scored 3 (3-4) points on the Edmonton Scale and 7 (5-9) points on the Fried Frailty Phenotype. According to the Fried model, 17% were considered prefrail and 83% frail and in the Edmonton scale, 20% were classified as nonfrail, 29% prefrail, and 51% frail. There was a positive moderate correlation between the two methods (r = 0.42; p=0.011); however, there was no agreement between them (p=0.20). This probably occurs because they assess the same construct, i.e., frailty; however, they are different in their components. There was a negative and moderate correlation between the Fried Frailty Phenotype and functioning (r = -0.43; p=0.009).

Conclusion

Most hospitalized individuals with exacerbated COPD with severe and very severe airflow limitation are frail and the assessment methods correlate, but there is no agreement. Additionally, there is association between frailty and functioning in this population.

Computed Tomography Lung Density Analysis: An Imaging Biomarker Predicting Physical Inactivity in Chronic Obstructive Pulmonary Disease: A Pilot Study

Physical inactivity correlates with poor prognosis in chronic obstructive pulmonary disease (COPD) and is suggested to be related to lung hyperinflation. We examined the association between physical activity and the expiratory to inspiratory (E/I) ratio of mean lung density (MLD), the imaging biomarker of resting lung hyperinflation. COPD patients (n = 41) and healthy controls (n = 12) underwent assessment of pulmonary function and physical activity with an accelerometer, as well as computed tomography at full inspiration and expiration. E/I_MLD was calculated by measuring inspiratory and expiratory MLD. Exercise (EX) was defined as metabolic equivalents × duration (hours). COPD patients had higher E/I_MLD (0.975 vs. 0.964) than healthy subjects. When dividing COPD patients into sedentary (EX < 1.5) and non-sedentary (EX ≥ 1.5) groups, E/I_MLD in the sedentary group was statistically higher than that in the non-sedentary group (0.983 vs. 0.972). E/I_MLD > 0.980 was a good predictor of sedentary behavior in COPD (sensitivity, 0.815; specificity, 0.714). Multivariate analysis showed that E/I_MLD was associated with sedentary behavior (odds ratio, 0.39; p = 0.04), independent of age, symptomology, airflow obstruction, and pulmonary diffusion. In conclusion, higher E/I_MLD scores are associated with sedentary behavior and can be a useful imaging biomarker for the early detection of physical inactivity in COPD.

Change in physical activity related to admission for exacerbation in COPD patients

INTRODUCTION

The aim of this study was to determine the impact of hospitalizations on levels of physical activity (PA) and whether other factors were associated with subsequent changes in PA.

METHODS

Prospective observational cohort study with a nested case-control study, with follow-up 60 days from the index hospital admission. Nine hospitals participated in the study. Patients were recruited consecutively. Several variables and questionnaires of the clinical baseline status of the patients were recorded including: the COPD Assessment Test (CAT), the Hospital Anxiety-Depression scale (HADS), comorbidities and the Yale Physical Activity Survey. Patients' data related to admission and up to two months after discharge were also recorded.

RESULTS

883 patients were studied: 79.7% male; FEV1 48%; Charlson index 2; 28.7% active smokers. The baseline PA level for the total sample was 23 points. A statistically significant difference in PA was found between patients readmitted up to 2 months after the index admission and those not readmitted (17vs. 27, p < 0.0001). Multivariable linear regression analysis identified the following as predictors of the decrease of PA from baseline (index admission) up to 2 months follow-up: admission for COPD exacerbation in the two months prior to the index admission; readmission up to 2 months after the index admission; baseline HAD depressive symptoms, worse CAT score, and patient-reported "need for help".

CONCLUSIONS

In a cohort of admitted COPD patients, we identified a strong relationship between hospitalization for exacerbation and PA. In addition, some other potentially modifiable factors were found associated with the change in PA level after an admission.

Respiratory and peripheral muscle strength influence recovery of exercise capacity after severe exacerbation of COPD? An observational prospective cohort study

BACKGROUND

Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) have decreased exercise tolerance, which may persist for months. In this context, little is known about the associations between muscle strength and recovery of exercise capacity.

OBJECTIVE

To assess whether respiratory and peripheral muscle strength influence recovery of exercise capacity in patients hospitalized due to AECOPD.

METHODS

Twenty-seven AECOPD patients (aged 69 ± 7 years, 56% male) were included. The following assessments were performed within 24 to 72 h of hospital admission: (i) respiratory muscle strength, measured by maximal inspiratory and expiratory pressures (MIP and MEP); (ii) peripheral muscle strength, assessed by handgrip and quadriceps muscle strength; and (iii) exercise capacity, measured by 6-min walking distance (6MWD). The 6MWD was reassessed 30 days later to determine the recovery of exercise capacity.

RESULTS

After 30 days, while 63% of the patients showed clinically important improvement in the 6MWD (recovery ≥ 30 m), 37% showed no change (recovery < 30 m). During hospital stay, the non-recovered group had lower quadriceps muscle strength compared to the recovered group (15 ± 5 vs. 22 ± 6 kgf; P = 0.006), with no significant difference for MIP, MEP and handgrip strength. Only quadriceps muscle strength was associated with recovery of exercise capacity (r = 0.56; P = 0.003).

CONCLUSION

AECOPD patients with quadriceps muscle weakness during hospitalization have poor recovery of exercise capacity after 30 days. This finding suggests the importance of early rehabilitation to improve quadriceps strength and accelerate functional recovery after AECOPD.

Skeletal Muscle Mitochondrial Dysfunction in Chronic Obstructive Pulmonary Disease: Underlying Mechanisms and Physical Therapy Perspectives

Skeletal muscle dysfunction (SMD) is a prevalent extrapulmonary complication and a significant independent prognostic factor in patients with chronic obstructive pulmonary disease (COPD). Mitochondrial dysfunction is one of the core factors that damage structure and function in COPD skeletal muscle and is closely related to smoke exposure, hypoxia, and insufficient physical activity. The currently known phenotypes of mitochondrial dysfunction are reduced mitochondrial content and biogenesis, impaired activity of mitochondrial respiratory chain complexes, and increased mitochondrial reactive oxygen species production. Significant progress has been made in research on physical therapy (PT), which has broad prospects for treating the abovementioned potential mitochondrial-function changes in COPD skeletal muscle. In terms of specific types of PT, exercise therapy can directly act on mitochondria and improve COPD SMD by increasing mitochondrial density, regulating mitochondrial biogenesis, upregulating mitochondrial respiratory function, and reducing oxidative stress. However, improvements in mitochondrial-dysfunction phenotype in COPD skeletal muscle due to different exercise strategies are not entirely consistent. Therefore, based on the elucidation of this phenotype, in this study, we analyzed the effect of exercise on mitochondrial dysfunction in COPD skeletal muscle and the regulatory mechanism thereof. We also provided a theoretical basis for exercise programs to rehabilitate this condition.

Safety and Efficacy of Inpatient Pulmonary Rehabilitation for Patients Hospitalized with an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-analyses

Rationale: Pulmonary rehabilitation (PR) during hospitalization for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) occurs during a period of disease instability for the patient, and the safety and efficacy of PR, specifically during the hospitalization period, have not been established. Objective: The purpose of this review is to determine the safety and efficacy of PR during the hospitalization phase for individuals with AECOPD. Methods: Scientific databases were searched up to August 2022 for randomized controlled trials that compared in-hospital PR with usual care. PR programs commenced during the hospitalization and included a minimum of two sessions. Titles and abstracts followed by full-text screening and data extraction were conducted independently by two reviewers. The intervention effect estimates were calculated through meta-analysis using a random-effect model. Results: A total of 27 studies were included (n = 1,317). The meta-analysis showed that inpatient PR improved the 6-minute-walk distance by 105 m (P < 0.001). Inpatient PR improved the performance on the five-repetition sit-to-stand test by -7.02 seconds (P = 0.03). Quality of life (QOL), as measured by the 5-level EuroQoL Group-5 dimension version (EQ-ED-5L) and the St. George's Respiratory Questionnaire, was significantly improved by the intervention. Inpatient PR increased lower limb muscle strength by 33.35 N (P < 0.001). There was no change in the length of stay. Only one serious adverse event related to the intervention was reported. Conclusions: This review suggests that it is safe and effective to provide PR during hospitalization for individuals with AECOPD. In-hospital PR improves functional exercise capacity, QOL, and lower limb strength without prolonging the hospital length of stay.

Post-acute sequelae of SARS-CoV-2 associates with physical inactivity in a cohort of COVID-19 survivors

The aim of this study was to determine whether Post-acute Sequelae of SARS-CoV-2 Infection (PASC) are associated with physical inactivity in COVID-19 survivors. This is a cohort study of COVID-19 survivors discharged from a tertiary hospital in Sao Paulo, Brazil. Patients admitted as inpatients due to laboratory-confirmed COVID-19 between March and August 2020 were consecutively invited for a follow-up in-person visit 6 to 11 months after hospitalization. Ten symptoms of PASC were assessed using standardized scales. Physical activity was assessed by questionnaire and participants were classified according to WHO Guidelines. 614 patients were analyzed (age: 56 ± 13 years; 53% male). Frequency of physical inactivity in patients exhibiting none, at least 1, 1-4, and 5 or more symptoms of PASC was 51%, 62%, 58%, and 71%, respectively. Adjusted models showed that patients with one or more persistent PASC symptoms have greater odds of being physically inactive than those without any persistent symptoms (OR: 1.57 [95% CI 1.04-2.39], P = 0.032). Dyspnea (OR: 2.22 [1.50-3.33], P < 0.001), fatigue (OR: 2.01 [1.40-2.90], P < 0.001), insomnia (OR: 1.69 [1.16-2.49], P = 0.007), post-traumatic stress (OR: 1.53 [1.05-2.23], P = 0.028), and severe muscle/joint pain (OR: 1.53 [95% CI 1.08-2.17], P = 0.011) were associated with greater odds of being physically inactive. This study suggests that PASC is associated with physical inactivity, which itself may be considered as a persistent symptom among COVID-19 survivors. This may help in the early identification of patients who could benefit from additional interventions tailored to combat inactivity (even after treatment of PASC), with potential beneficial impacts on overall morbidity/mortality and health systems worldwide.

Determinants of acute care discharge in adults with chronic obstructive pulmonary disease

CONCLUSIONS

In adults with COPD basic mobility scores on the AM-PAC "6-clicks" measure completed at discharge had the best sensitivity and specificity for predicting discharge to home and need for rehab services.

Obstructive sleep apnea reduces functional capacity and impairs cardiac autonomic modulation during submaximal exercise in patients with chronic obstructive pulmonary disease: A follow-up study

BACKGROUND

Functional capacity and heart rate variability (HRV) are important prognostic markers in chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea syndrome (OSA). However, the impact of the overlap of these diseases and the one-year clinical follow-up has not yet been evaluated.

OBJECTIVES

To assess whether the presence of OSA can impair functional performance and cardiac autonomic control during exercise in patients with COPD; and to verify whether the overlap of these diseases could lead to worse clinical outcomes during the one-year follow-up.

METHODS

Thirty-four patients underwent pulmonary function tests, echocardiography and polysomnography for diagnostic confirmation, disease staging, exclusion of any cardiac changes, and allocation between groups. The patients underwent the six-minute walk test (6MWT) to assess functional capacity and HRV during exercise. Subsequently, patients were followed up for 12 months to record outcomes such as exacerbation, hospitalization, and deaths. At the end of this period, the patients were revaluated to verify the hypotheses of the study.

RESULTS

The OSA-COPD group showed greater functional impairment when compared to the COPD group (p=0.003) and showed worse cardiac autonomic responses during the 6MWT with greater parasympathetic activation (p=0.03) and less complexity of the autonomic nervous system, in addition to being more likely to exacerbate (p=0.03) during one year of follow-up.

CONCLUSION

OSA-COPD produces deleterious effects on functional performance and a greater autonomic imbalance that impairs clinical outcomes.

A systematic review of exercise studies for individuals hospitalized with an acute exacerbation of chronic obstructive pulmonary disease: Focus on the principles of exercise training

BACKGROUND

For exercise interventions to be effectively reproduced or applied in a "real world" clinical setting, clinical trials must thoroughly document all components of the exercise prescription and ensure that participants adhere to each component. However, previous reviews have not critically examined the quality of exercise prescription of inpatient Pulmonary Rehabilitation (PR) programs.

OBJECTIVE

The objectives of this review were to evaluate the (a) application of the principles of exercise training, (b) reporting of the frequency, intensity, time and type (FITT) components of exercise prescription, and (c) reporting of patient's adherence to the FITT components in intervention studies for patients admitted to hospital for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

METHODS

Relevant scientific databases were searched for randomized controlled trials (RCTs) that compared in-hospital PR with usual care for people hospitalized with AECOPD. Title and abstract followed by full-text screening were conducted independently by two reviewers. Data were extracted and synthesized to evaluate the application of the principles of exercise training and the reporting/adherence of the FITT components.

RESULTS

Twenty-seven RCTs were included. Only two applied all principles of exercise training. Specificity was applied by 70%, progression by 48%, overload by 37%, initial values by 89% and diminishing returns and reversibility by 37% of trials. Ten trials adequately reported all FITT components. Frequency and type were the components most reported (85% and 81%, respectively), while intensity was less frequently reported (52%). Only three trials reported on the patient's adherence to all four components.

CONCLUSIONS

Studies have not adequately reported the exercise prescription in accordance with the principles of exercise training nor reported all the FITT components of the exercise prescription and patient's adherence to them. Therefore, interpretation of the current literature is limited and information for developing exercise prescriptions to individuals hospitalized with an AECOPD is lacking.

A Call for Action on Chronic Respiratory Diseases within Physical Activity Policies, Guidelines and Action Plans: Let's Move!

Global policy documents for the promotion of physical activity (PA) play an important role in the measurement, evaluation, and monitoring of population PA levels. The World Health Organisation (WHO) guidelines include, for the first time, recommendations for specific populations, including individuals living with a range of non-communicable diseases. Of note, is the absence of any chronic respiratory diseases (CRDs) within the recommendations. Globally, CRDs are highly prevalent, are attributable to significant individual and societal burdens, and are characterised by low PA. As a community, there is a need to come together to understand how to increase CRD representation within global PA policy documents, including where the evidence gaps are and how we can align with PA research in other contexts. In this commentary, the potential for synergy between evidence into the relationships between PA in CRDs globally and the relevance to current policies, guidelines and action plans on population levels of PA are discussed. Furthermore, actions and considerations for future research, including the need to harmonize and promote PA assessment (particularly in low- and middle-income countries) and encompass the synergistic influences of PA, sedentary behaviour and sleep on health outcomes in CRD populations are presented.

Flourishing despite Chronic Obstructive Pulmonary Disease (COPD): Findings from a Nationally Representative Survey of Canadians Aged 50 and Older

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of mortality and is often associated with serious disability and depression. Little is known about the characteristics of those who are in complete mental health (CMH) despite having COPD. This study’s objectives are to: (1) estimate the prevalence and odds of absence of psychiatric disorders (APD) and CMH among older adults that reported having COPD, compared to their peers that did not; (2) identify factors associated with APD and with CMH. Bivariate and logistic regression analyses were conducted using the nationally representative Canadian Community Health Survey—Mental Health. The results indicate that there was a significantly (p < 0.001) lower prevalence of APD (86.7% vs. 95.0%) and CMH (66.7% vs. 77.0%) among older adults aged 50+ with COPD (n = 703) compared to those without COPD (n = 10,189). Half of the sample was female (50.5%) and the majority of whom were under age 70 (62.5%). Factors significantly (p < 0.05) associated with higher odds of APD and of CMH among older adults with COPD include being married, having a confidant, being physically active, and having no lifetime history of major depressive disorder or generalized anxiety disorder. For every additional adverse childhood experience, the odds of APD declined by 31%. The majority of those with COPD are mentally flourishing despite having this disabling and life-threatening disorder. These findings underline the importance of targeted interventions and outreach to those most vulnerable to poorer mental health outcomes including the socially isolated.

The effect of comprehensive multidisciplinary pulmonary rehabilitation on 5-year survival in COPD: does maintaining a home exercise program improve survival?

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is one of the most common causes of death worldwide. Therefore, optimizing medical therapy in the comprehensive management of the disease, as well as including pulmonary rehabilitation (PR) in the treatment, is essential. The goal of our study was to determine the impact of PR on the survival of COPD patients.

METHODS

Between 2007-2015, 509 COPD patients who completed the PR constituted the PR group, while 167 patients who applied but could not complete it after the initial evaluations formed the control group. In the PR group, dyspnea perception, exercise capacity, muscle strength, body composition, quality of life, psychosocial status, and i-BODE scores were assessed at the beginning and end of the program, whereas in the control group, these assessments could only be conducted at the beginning. Also, after PR, our PR participants have prescribed a home exercise program, and they were recalled to the hospital at the 3rd, 6th, 12th, 18th, and 24th months for follow-up visits.

RESULTS

A statistically significant improvement was found in almost all the data (except FEV1/FVC, BORG after exercise, and FFMI) after PR. There was a statistically significant difference in 5-year survival in favor of the PR group (p = 0.006), and in PR patients who accompanied the home exercise program vs. those who did not (p = 0.000). Also the gains in MRC (p = 0.003; OR: 2.20; CI: 1.319- 3.682), MEP (p = 0.041; OR: 1.02; CI: 1.001-1.035), and i-BODE (p = 0.006; OR: 0.914; CI: 0.857-0.974) increased the survival.

DISCUSSION

Apart from incorporating PR into treatment in the comprehensive management of COPD, we demonstrated that maintaining a home exercise program for at least two years following PR increased 5-year survival significantly.

Might Dog Walking Reduce the Impact of COPD on Patients' Life?

Low levels of physical activity (PA) lead to a worsening of physical condition and contributes to multimorbidity in Chronic Obstructive Respiratory Disease (COPD). Unsupervised PA related to dog ownership may contribute to reducing sedentary behavior. We aimed to investigate the relationship between dog walking, patient-reported outcomes (PROs) and exacerbations in COPD. A pre-defined sample of 200 COPD patients (dog owners and non-dog owners) with symptomatic COPD was sourced from a database representative of the Italian population. A computer-assisted personal interview was used to assess health status impairment (CAT), fatigue (FACIT), health-related quality of life (HRQoL) (EQ-5D), and PA frequency. In the whole sample, PA was associated with better CAT, EQ-5D, VAS, FACIT scores and reduced number of exacerbation (p < 0.001). Under the same CAT scores, dog-walking duration was associated with a better HRQoL (EQ5D, p = 0.015) and less fatigue (FACIT, p = 0.017). In an adjusted regression model, walking dogs >30 min was associated with lower fatigue (FACIT) than having no dogs and walking dogs <15 min (p = 0.026 and p = 0.009, respectively). Motivation related to dog walking could modify patients’ tendency to focus on symptoms during PA and, therefore, to perceive the fatigue. Dog walking may be effective for increasing and maintaining regular PA, reducing the subjective impact of COPD.

Comparing cardiac function and structure and their relationship with exercise capacity between patients with stable COPD and recent acute exacerbation: a cross-sectional study

OBJECTIVE

Patients with COPD are prone to cardiac remodeling; however, little is known about cardiac function in patients recovering from an acute exacerbation of COPD (AECOPD) and its association with exercise capacity. The aim of this study was to evaluate the cardiac function and structure and to compare their relationship with exercise capacity in patients with a recent AECOPD and patients with clinically stable COPD.

METHODS

This was a cross-sectional study including 40 COPD patients equally divided into two groups: recent AECOPD group (AEG) and clinically stable COPD group (STG). Echocardiography was performed to assess cardiac function and chamber structure. The six-minute walk distance (6MWD) and the Duke Activity Status Index (estimated Vo2) were used in order to assess exercise capacity.

RESULTS

No significant differences in cardiac function and structure were found between the groups. The 6MWD was associated with early/late diastolic mitral filling velocity ratio (r = 0.50; p < 0.01), left ventricular posterior wall thickness (r = -0.33; p = 0.03), and right atrium volume index (r = -0.34; p = 0.04), whereas Vo2 was associated with right atrium volume index (r = -0.40; p = 0.02).

CONCLUSIONS

Regardless of the clinical condition (recent AECOPD vs. stable COPD), the cardiac function and structure were similar between the groups, and exercise capacity (determined by the 6MWD and Vo2) was associated with cardiac features.

Osteosarcopenia in Patients with Chronic Obstructive Pulmonary Diseases: Which Pathophysiologic Implications for Rehabilitation?

Chronic obstructive pulmonary disease (COPD) is a burdensome condition affecting a growing number of people worldwide, frequently related to major comorbidities and functional impairment. In these patients, several factors might have a role in promoting both bone and muscle loss, including systemic inflammation, corticosteroid therapies, sedentary behaviours, deconditioning, malnutrition, smoking habits, and alcohol consumption. On the other hand, bone and muscle tissues share several linkages from functional, embryological, and biochemical points of view. Osteosarcopenia has been recently defined by the coexistence of osteoporosis and sarcopenia, but the precise mechanisms underpinning osteosarcopenia in patients with COPD are still unknown. In this scenario, a deeper understanding of the molecular basis of osteosarcopenia might guide clinicians in a personalized approach integrating skeletal muscle health with the pulmonary rehabilitation framework in COPD. Taken together, our results summarized the currently available evidence about the multilevel interactions between osteosarcopenia and COPD to pave the way for a comprehensive approach targeting the most common risk factors of these pathological conditions. Further studies are needed to clarify the role of modern clinical strategies and telemedicine solutions to optimize healthcare delivery in patients with COPD, including osteopenia, osteoporosis, and sarcopenia screening in these subjects.

Promotion of physical activity after hospitalization for COPD exacerbation: A randomized control trial

BACKGROUND AND OBJECTIVE

Physical activity worsens during exacerbations of chronic obstructive pulmonary disease (COPD) and notably after hospitalizations. Pedometer-based interventions are useful to increase physical activity in stable patients with COPD. However, there is little information concerning the implementation of such programs following severe exacerbation. This study assessed the efficacy of a physical activity program after hospitalization for a COPD exacerbation.

METHODS

We performed a prospective, 12-week, parallel group, assessor-blinded, randomized control trial in COPD patients hospitalized for an exacerbation. After discharge, physical activity and other secondary variables were assessed. Patients were allocated (1:1) to a physical activity promotion program (intervention group, IG) or usual care (control group, CG). Based on a motivational interview and accelerometer physical activity assessment, a patient-tailored, pedometer-based, progressive and target-driven program was designed. Linear mixed effect models were used to analyse between-group differences.

RESULTS

Forty-six out of 61 patients recruited were randomized and 43 (IG = 20, CG = 23) completed the study. In-hospital and baseline characteristics were similar in both groups. After 12 weeks of intervention, the mean steps difference between groups was 2093 steps/day, p = 0.018, 95% CI 376-4012, favouring the IG. Only the IG significantly increased the number of steps/day compared to baseline (mean difference [95% CI] 2932 [1069-4795] steps; p = 0.004). There were no other between-group differences.

CONCLUSION

After hospitalization for a COPD exacerbation, a patient-tailored physical activity program based on a motivational interview and the use of pedometers, with progressive and customized targets, improved the number of steps/day.

Pathogenesis of sarcopenia in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common pulmonary disease characterized by persistent respiratory symptoms and airflow obstruction. In addition to lung diseases, chronic obstructive pulmonary disease (COPD) is often associated with other organ diseases, and sarcopenia is one of the common diseases. In recent years, multiple factors have been proposed to influence muscle dysfunction in COPD patients, including systemic and local inflammation, oxidative stress, hypoxia, hypercapnia, protein synthesis, catabolic imbalance, nutritional changes, disuse, ageing, and the use of medications such as steroids. These factors alone or in combination can lead to a reduction in muscle mass and cross-sectional area, deterioration of muscle bioenergy metabolism, defects in muscle repair and regeneration mechanisms, apoptosis and other anatomical and/or functional pathological changes, resulting in a decrease in the muscle’s ability to work. This article reviews the research progress of possible pathogenesis of sarcopenia in COPD.

The Six-Minute Stepper Test Is Valid to Evaluate Functional Capacity in Hospitalized Patients With Exacerbated COPD

Background: The six-minute stepper test (6MST) is a self-paced test considered a valid tool to assess functional capacity in stable COPD patients. However, a high floor effect, where a large proportion of participants reach the minimum score when using the measurement instrument, might compromise the test validity in the hospital setting. Therefore, this study aimed at verifying the concurrent validity of 6MST in hospitalized patients with acute exacerbation of COPD (AECOPD).

Methods: A cross-sectional study was conducted in a tertiary hospital. Patients who were hospitalized due to AECOPD were considered for inclusion. On the first day, when patients reached minimum clinical criteria considered as the use of non-invasive ventilation less than 2 h for 6 h/period, dyspnea at rest less than 7 (very severe) on the modified Borg scale, a respiratory rate less than 25 breaths per minute, oxygen pulse saturation greater than 88% (considering use of supplemental oxygen) and absence of paradoxical breathing pattern, they underwent a lung function evaluation and answered three questionnaires: Chronic Respiratory Questionnaire (CRQ), Modified Medical Research Council Dyspnea Scale (MMRC), and COPD Assessment Test (CAT). Then, on two consecutive days, patients performed 6MST or six-minute walk test (6MWT), in random order. Each test was performed twice, and the best performance was recorded. Also, the patient’s severity was classified according to the BODE index. Inspiratory capacity measurements were performed before and after each test execution.

Results: Sixteen patients (69.4 ± 11.4 years) with a mean FEV₁ of 49.4 ± 9.9% predicted were included (9 females). There was a strong correlation of the performance in 6MST (number of cycles) with 6MWT (distance walked in meters) in absolute values (r = 0.87, p < 0.001) as well as with the percentage of predicted normal 6MWT (r = 0.86, p < 0.001). There was a strong correlation between the performance in 6MST with the dynamic hyperinflation (r = 0.72, p = 0.002) and a moderate correlation between 6MST with the percentage of reduction of inspiratory capacity (r = 0.68, p = 0.004). We also identified that 6MST showed moderate negative correlations with CAT (r = −0.62, p = 0.01) and BODE index (r = −0.59, p = 0.01).

Conclusion: It could be concluded that 6MST is valid for evaluating functional capacity in hospitalized patients with exacerbated COPD.

"Can Do, Do Do" Quadrants and 6-Year All-Cause Mortality in Patients With COPD

BACKGROUND

Physical capacity (PC; "can do") and physical activity (PA; "do do") are prognostic indicators in COPD and can be used to subdivide patients with COPD into four exclusive subgroups (the so-called "can do, do do" quadrants). This concept may be useful to understand better the impact of PC and PA on all-cause mortality in patients with COPD.

RESEARCH QUESTION

What is the 6-year all-cause mortality risk of the "can do, do do" quadrants of patients with COPD?

STUDY DESIGN AND METHODS

This retrospective study used data from patients with COPD who underwent a comprehensive assessment at their first-ever outpatient consultation. PC was assessed using the 6-min walk distance and physical activity was assessed using an accelerometer (steps per day). All-cause mortality data were obtained from the Municipal Personal Records Database. Receiver operating characteristic curves were used to determine threshold values for PC and PA to predict 6-year all-cause mortality. Using the derived threshold values, male and female patients were divided into the four "can do, do do" quadrants.

RESULTS

Data from 829 patients were used for analyses. Best discriminatory values for 6-year mortality were 404 m and 4,125 steps/day for men and 394 m and 4,005 steps/day for women. During a median follow-up of 55 months (interquartile range, 37-71 months), 129 patients (15.6%) died. After controlling for established prognostic factors, patients in the "can do, don't do" quadrant and "can do, do do" quadrant showed significantly lower mortality risk compared with patients in the "can't do, don't do" quadrant: hazard ratios of 0.36 (95% CI, 0.14-0.93) and 0.24 (95% CI, 0.09-0.61) for men and 0.37 (95% CI, 0.38-0.99) and 0.29 (95% CI, 0.10-0.87) for women, respectively. No significant differences were found between the "can't do, do do" and "can't do, don't do" quadrants.

INTERPRETATION

Patients with COPD with a preserved PC seem to have a significantly lower 6-year mortality risk compared with patients with a decreased PC, regardless of physical activity level.

COVID-19 Postacute Sequela Rehabilitation: A Look to the Future Through the Lens of Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation

Post-COVID-19 condition is characterized by a myriad of persistent symptoms experienced up to 60 days after the acute infection, not only in those hospitalized, but also in patients with mild to moderate acute symptoms. The overwhelming evidence on multisystem involvement in post-COVID-19 condition brings to attention the need for integrated delivery models to address health care needs of this population. The World Health Organization recently highlighted critical gaps in adequately providing the level of integrative care required to address the multisystem needs of this population in current health care delivery models and recommended development of new innovative models of delivery. This article presents a novel approach to addressing these gaps from a rehabilitation perspective.

Magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic and progressive disease, often punctuated by recurrent flare-ups or exacerbations. Magnesium sulfate, having a bronchodilatory effect, may have a potential role as an adjunct treatment in COPD exacerbations. However, comprehensive evidence of its effects is required to facilitate clinical decision-making.

OBJECTIVES

To assess the effects of magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease in adults.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) trials portal, EU Clinical Trials Register and Iranian Registry of Clinical Trials. We also searched the proceedings of major respiratory conferences and reference lists of included studies up to 2 August 2021.

SELECTION CRITERIA

We included single- or double-blind parallel-group randomised controlled trials (RCTs) assessing magnesium sulfate in adults with COPD exacerbations. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. The primary outcomes were: hospital admissions (from the emergency room); need for non-invasive ventilation (NIV), assisted ventilation or admission to intensive-care unit (ICU); and serious adverse events. Secondary outcomes were: length of hospital stay, mortality, adverse events, dyspnoea score, lung function and blood gas measurements. We assessed confidence in the evidence using GRADE methodology. For missing data, we contacted the study investigators.

MAIN RESULTS

We identified 11 RCTs (10 double-blind and 1 single-blind) with a total 762 participants. The mean age of participants ranged from 62 to 76 years. Trials were single- or two-centre trials conducted in Iran, New Zealand, Nepal, Turkey, the UK, Tunisia and the USA between 2004 and 2018. We judged studies to be at low or unclear risk of bias for most of the domains. Three studies were at high risk for blinding and other biases.  Intravenous magnesium sulfate versus placebo Seven studies (24 to 77 participants) were included. Fewer people may require hospital admission with magnesium infusion compared to placebo (odds ratio (OR) 0.45, 95% CI 0.23 to 0.88; number needed to treat for an additional beneficial outcome (NNTB) = 7; 3 studies, 170 participants; low-certainty evidence). Intravenous magnesium may result in little to no difference in the requirement for non-invasive ventilation (OR 0.74, 95% CI 0.31 to 1.75; very low-certainty evidence). There were no reported cases of endotracheal intubation (2 studies, 107 participants) or serious adverse events (1 study, 77 participants) in either group. Included studies did not report intensive care unit (ICU) admission or deaths. Magnesium infusion may reduce the length of hospital stay by a mean difference (MD) of 2.7 days (95% CI 4.73 days to 0.66 days; 2 studies, 54 participants; low-certainty evidence) and improve dyspnoea score by a standardised mean difference of -1.40 (95% CI -1.83 to -0.96; 2 studies, 101 participants; low-certainty evidence). We were uncertain about the effect of magnesium infusion on improving lung function or oxygen saturation. For all adverse events, the Peto OR was 0.14 (95% CI 0.02 to 1.00; 102 participants); however, the event rate was too low to reach a robust conclusion.  Nebulised magnesium sulfate versus placebo Three studies (20 to 172 participants) were included. Magnesium inhalation may have little to no impact on hospital admission (OR 0.77, 95% CI 0.21 to 2.82; very low-certainty evidence) or need for ventilatory support (NIV or mechanical ventilation) (OR 0.33, 95% CI 0.01 to 8.20; very low-certainty evidence). It may result in fewer ICU admissions compared to placebo (OR 0.39, 95% CI 0.15 to 1.00; very low-certainty evidence) and improvement in dyspnoea (MD -14.37, 95% CI -26.00 to -2.74; 1 study, 20 participants; very low-certainty evidence). There were no serious adverse events reported in either group. There was one reported death in the placebo arm in one trial, but the number of participants was too small for a conclusion. There was limited evidence about the effect of magnesium inhalation on length of hospital stay, lung function outcomes or oxygen saturation. Included studies did not report adverse events.  Magnesium sulfate versus ipratropium bromide  A single study with 124 participants assessed nebulised magnesium sulfate plus intravenous magnesium infusion versus nebulised ipratropium plus intravenous normal saline. There was little to no difference between these groups in terms of hospital admission (OR 1.62, 95% CI 0.78 to 3.37), endotracheal intubation (OR 1.69, 95% CI 0.61 to 4.71) and length of hospital stay (MD 1.10 days, 95% CI -0.22 to 2.42), all with very low-certainty evidence. There were no data available for non-invasive ventilation, ICU admission and serious adverse events. Adverse events were not reported.  AUTHORS' CONCLUSIONS: Intravenous magnesium sulfate may be associated with fewer hospital admissions, reduced length of hospital stay and improved dyspnoea scores compared to placebo. There is no evidence of a difference between magnesium infusion and placebo for NIV, lung function, oxygen saturation or adverse events. We found no evidence for ICU admission, endotracheal intubation, serious adverse events or mortality. For nebulised magnesium sulfate, we are unable to draw conclusions about its effects in COPD exacerbations for most of the outcomes. Studies reported possibly lower ICU admissions and a lesser degree of dyspnoea with magnesium inhalation compared to placebo; however, larger studies are required to yield a more precise estimate for these outcomes. Similarly, we could not identify any robust evidence for magnesium sulfate compared to ipratropium bromide. Future well-designed multicentre trials with larger samples are required, including subgroups according to severity of exacerbations and COPD phenotypes.

Respiratory Oscillometry in Chronic Obstructive Pulmonary Disease: Association with Functional Capacity as Evaluated by Adl Glittre Test and Hand Grip Strength Test

Purpose

Respiratory oscillometry has emerged as a powerful method for detecting respiratory abnormalities in COPD. However, this method has not been widely introduced into clinical practice. This limitation arises, at least in part, because the clinical meaning of the oscillometric parameters is not clear. In this paper, we evaluated the association of oscillometry with functional capacity and its ability to predict abnormal functional capacity in COPD.

Patients and Methods

This cross-sectional study investigated a control group formed by 30 healthy subjects and 30 outpatients with COPD. The subjects were classified by the Glittre‑ADL test and handgrip strength according to the functional capacity.

Results

This study has shown initially that subjects with abnormal functional capacity had a higher value for resistance (p < 0.05), reactance area (Ax, p < 0.01), impedance modulus (Z4, p < 0.05), and reduced dynamic compliance (Cdyn, p < 0.05) when compared with subjects with normal functional capacity. This resulted in significant and consistent correlations among resistive oscillometric parameters (R=−0.43), Cdyn (R=−0.40), Ax (R = 0.42), and Z4 (R = 0.41) with exercise performance. Additionally, the effects of exercise limitation in COPD were adequately predicted, as evaluated by the area under the curve (AUC) obtained by receiver operating characteristic analysis. The best parameters for this task were R4-R20 (AUC = 0.779) and Ax (AUC = 0.752).

Conclusion

Respiratory oscillometry provides information related to functional capacity in COPD. This method is also able to predict low exercise tolerance in these patients. These findings elucidate the physiological and clinical meaning of the oscillometric parameters, improving the interpretation of these parameters in COPD patients.

Environmental Correlates of Physical Activity, Sedentary Behavior, and Self-Rated Health in Chronic Obstructive Pulmonary Disease

PURPOSE

Physical activity (PA) predicts important health outcomes in chronic obstructive pulmonary disease (COPD). In the general population, environmental factors have the potential to influence PA; however, data are limited in this clinical population. Therefore, we sought to investigate associations between the environment and PA, sedentary behavior, and self-rated health in COPD.

METHODS

Sociodemographic, PA, sedentary behavior, and self-rated health data were collected from a prospective cohort of 418 individuals with COPD (65% female; 58 ± 8 yr), while environmental data were drawn from a national environmental data repository and individually matched to participant postal code. Environmental variables included social and material deprivation, urban form index, surrounding greenness, and air quality (concentrations of air pollution for fine particles, nitrogen dioxide, ozone, and sulphur dioxide). Logistic and multivariate linear regression models were used to investigate the strongest environmental predictors.

RESULTS

The models showed a statistically significant negative correlation between PA level and ozone pollution (P = .023; adjusted OR = 0.85: 95% CI, 0.74-0.98). Urban form index was also significantly associated with sedentary behavior (β = 0.113; t value = 1.71; P = .011). Self-rated health was significantly positively correlated with PA level (P = .006; adjusted OR = 2.22: 95% CI, 1.25-3.94), and significantly inversely correlated with sedentary behavior (β = -0.159; t value =-2.42; P = .016).

CONCLUSION

These new data may identify barriers to PA and assist clinicians in the prescription of exercise for individuals living with COPD.

A proof of concept for continuous, non-invasive, free-living vital signs monitoring to predict readmission following an acute exacerbation of COPD: a prospective cohort study

Background

The use of vital signs monitoring in the early recognition of an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) post-hospital discharge is limited. This study investigated whether continuous vital signs monitoring could predict an AECOPD and readmission.

Methods

35 people were recruited at discharge following hospitalisation for an AECOPD. Participants were asked to wear an Equivital LifeMonitor during waking hours for 6 weeks and to complete the Exacerbations of Chronic Pulmonary Disease Tool (EXACT), a 14-item symptom diary, daily. The Equivital LifeMonitor recorded respiratory rate (RR), heart rate (HR), skin temperature (ST) and physical activity (PA) every 15-s. An AECOPD was classified as mild (by EXACT score), moderate (prescribed oral steroids/antibiotics) or severe (hospitalisation).

Results

Over the 6-week period, 31 participants provided vital signs and symptom data and 14 participants experienced an exacerbation, of which, 11 had sufficient data to predict an AECOPD. HR and PA were associated with EXACT score (p < 0.001). Three days prior to an exacerbation, RR increased by mean ± SD 2.0 ± 0.2 breaths/min for seven out of 11 exacerbations and HR increased by 8.1 ± 0.7 bpm for nine of these 11 exacerbations.

Conclusions

Increased heart rate and reduced physical activity were associated with worsening symptoms. Even with high-resolution data, the variation in vital signs data remains a challenge for predicting AECOPDs. Respiratory rate and heart rate should be further explored as potential predictors of an impending AECOPD.

Trial registration: ISRCTN registry; ISRCTN12855961. Registered 07 November 2018—Retrospectively registered, https://www.isrctn.com/ISRCTN12855961

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02018-5.

Systematic Review of Physical Activity, Sedentary Behaviour and Sleep Among Adults Living with Chronic Respiratory Disease in Low- and Middle-Income Countries

Abstract

Physical activity (PA), sedentary behaviour (SB) and sleep are important lifestyle behaviours associated with chronic respiratory disease (CRD) morbidity and mortality. These behaviours need to be understood in low- and middle-income countries (LMIC) to develop appropriate interventions.

Purpose

Where and how have free-living PA, SB and sleep data been collected for adults living with CRD in LMIC? What are the free-living PA, SB and sleep levels of adults living with CRD?

Patients and Methods

The literature on free-living PA, SB and sleep of people living with CRD in LMIC was systematically reviewed in five relevant scientific databases. The review included empirical studies conducted in LMIC, reported in any language. Reviewers screened the articles and extracted data on prevalence, levels and measurement approach of PA, SB and sleep using a standardised form. Quality of reporting was assessed using bespoke criteria.

Results

Of 89 articles, most were conducted in Brazil (n=43). PA was the commonest behaviour measured (n=66). Questionnaires (n=52) were more commonly used to measure physical behaviours than device-based (n=37) methods. International Physical Activity Questionnaire was the commonest for measuring PA/SB (n=11). For sleep, most studies used Pittsburgh Sleep Quality Index (n=18). The most common ways of reporting were steps per day (n=21), energy expenditure (n=21), sedentary time (n=16), standing time (n=13), sitting time (n=11), lying time (n=10) and overall sleep quality (n=32). Studies revealed low PA levels [steps per day (range 2669-7490steps/day)], sedentary lifestyles [sitting time (range 283-418min/day); standing time (range 139-270min/day); lying time (range 76-119min/day)] and poor sleep quality (range 33-100%) among adults with CRD in LMIC.

Conclusion

Data support low PA levels, sedentary lifestyles and poor sleep among people in LMIC living with CRDs. More studies are needed in more diverse populations and would benefit from a harmonised approach to data collection for international comparisons.