In-Patient Pulmonary Rehabilitation to Improve Asthma Control–A Randomized Controlled Study (EPRA, Effectiveness of Pulmonary Rehabilitation for Patients with Asthma)

[Effects of pulmonary rehabilitation on dysfunctional respiratory patterns in patients with uncontrolled asthma]

PURPOSE

Dysfunctional breathing patterns (DAM) are deviations from physiologic breathing patterns. DAM seem to be associated with lower asthma control. To date, it is unclear what effect inpatient rehabilitation can have on this problem. The aim of this work is to investigate the effect of pulmonary rehabilitation (PR) on DAM.

METHODS

The data are based on a randomized controlled trial with a waiting control group. The intervention group (IG) received PR 4 weeks after application approval and the control group (KG) after 5 months. Dysfunctional breathing was assessed by Nijmegen-Questionnaire (NQ). Values ≥ 23 points indicate an existing DAM. Values at the end of rehabilitation (T2) and after three months (T3) were compared (analysis of covariance). Supplemental moderator analysis was performed to examine whether the effect of PR was related to baseline NQ scores.

RESULTS

Significant differences in NQ score are found between IG (n=202) and KG (n=210) at T2 (AMD=10.5; 95%CI [9; 12]; d=1.4; p<0.001) and at T3 (AMD=5.8; 95%CI [4.3; 7.3]; d=0.8; p<0.001). There is an interaction effect between the difference in NQ score between the groups at T2 and baseline at T0 (b=5.6; 95%CI [2.2; 11.9]; p<0.001). At T3, this interaction effect was no longer detectable (b=4.5; 95%CI [-3.1; 14.1]; p=807).

CONCLUSION

Inpatient, multimodality, and interdisciplinary PR is associated with significant and clinically relevant improvement in DAM both at discharge and 3 months later. In the short term, patients with existing DAM benefit more from PR than patients without DAM.

Can an educational intervention in the context of inpatient pulmonary rehabilitation improve asthma self-management at work? A study protocol of a randomized controlled trial

BACKGROUND

Asthma self-management (e.g., trigger avoidance or correct medication use) is a cornerstone of therapy. Its successful implementation in everyday working life is determined by psychosocial working conditions, in particular by support from superiors and colleagues and the job decision latitude (i.e., when and how to carry out which tasks). To empower individuals with asthma to modify their working conditions, employees need to use certain communication skills and acquire specific knowledge. Both could be taught as part of patient education during pulmonary rehabilitation. Therefore, the aim of the planned study is the development and multicentre implementation of an education module for individuals with asthma during their rehabilitation and to generate evidence on its effectiveness.

METHODS

Participants (n ≥ 180) will be recruited, randomized into an intervention and a control group, trained and surveyed in two rehabilitation clinics. The intervention group will receive the supplementary patient education module "Asthma and Work" while the control group will participate in a program on " Eating behaviour" (both 2 × 50 min). The effectiveness of the intervention will be examined based on pre-post measurements (T1 and T2) and a 3-month follow-up (T3). We will consider behavioural intention (T2) and asthma self-management at work (T3) as primary outcomes. Secondary outcomes will include self-management-related knowledge, self-efficacy, number of sick days, number of exacerbations, asthma control (Asthma Control Test), asthma-related quality of life (Marks Asthma Quality of Life Questionnaire), and subjective employment prognosis (Brief Scale Measuring the Subjective Prognosis of Gainful Employment). The pre-post comparisons are to be evaluated using univariate analyses of covariance.

DISCUSSION

Improving asthma self-management at work could increase the work ability and social participation of employees with asthma. This could reduce costs, e.g. in terms of asthma-related sick leave.

TRIAL REGISTRATION

German Clinical Trials Register (ID: DRKS00031843).

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

[Smoking cessation in hospitalised patients - Initiate among inpatients, continue when outpatients - A Position Paper by the German Respiratory Society (DGP) Taskforce for Smoking Cessation]

Tobacco smoking is the greatest preventable health risk. The effects are serious, both individually and societal. Nevertheless, the current prevalence of tobacco smokers in Germany is still high at around 35 %. A recent strong increase in actively smoking adolescents (14- to 17-year-olds, current prevalence approx. 16 %) and young adults (18- to 24-year-olds, current prevalence approx. 41 %) is also a cause for concern. About a third of all inpatients continue smoking while being treated. The hospitalization of active smokers in acute and rehabilitation hospitals serves as a "teachable moment" for initiation of cessation offers. An intervention that begins in hospital and continues for at least a month after discharge results in about 40 % additional smokefree patients. It is scientifically well-researched, effective and cost-efficient. After initiation in hospital these measures can be continued via ambulatory cessation programs, rehabilitation facilities, an Internet or telephone service. In Germany, there are structured and quality-assured cessation offers, both for the inpatient and for the outpatient area. The biggest obstacle to broad establishment of such offers is the lack of reimbursement. Two feasible ways to change this would be the remuneration of the existing OPS 9-501 "Multimodal inpatient treatment for smoking cessation" and the establishment of quality contracts according to § 110a SGB V. An expansion of tobacco cessation measures in healthcare facilities would reduce smoking prevalence, associated burden of disease and consecutive costs.

Implementation of an internet-based asthma patient education program in primary care: results of a single-arm trial

Asthma education programs (AEPs) for patients are known to be important to provide skills to effectively manage the disease. We developed an electronic AEP (eAEP) and assessed the extent to which patients with asthma in primary care are capable to use the eAEP and whether asthma knowledge improved after eAEP.

A single-arm pilot study was performed between November 2019 and December 2020 in 12 general practices in Upper Bavaria, Germany. Asthma knowledge was assessed by the Asthma Knowledge Test (AKT) at baseline, 2 weeks after completion of the eAEP, as well as after 3 and 6 months. AKT sum scores at baseline and follow-up were compared with each other using the Wilcoxon test.

In total, 72 patients with asthma were included, of whom all participated in the 2-week follow-up, while data on the 3- and 6-month follow-up was available in 62 and 51 patients, respectively. The eAEP was well accepted and positively evaluated by participants. The mean AKT score significantly (p < .001) increased from 22.8 ± 11.0 at baseline to 44.6 ± 8.3 two weeks after completion of the eAEP. After 3 months, the mean score was still 41.8 ± 7.6, and after 6 months it was 40.2 ± 9.3 (p < .001 each compared to baseline).

The internet-based asthma education program was well accepted by primary care patients and resulted in a major increase of asthma knowledge. Thus, it has the potential to be an important adjunct in the treatment of patients with asthma in general practice.

Factors Affecting the Success of Pulmonary Rehabilitation in Asthma

Objective: The majority of patients with asthma limit their physical activity due to the fear of exercise dyspnea. Regular exercise, on the other hand, is currently suggested as one of the non-pharmaceutical treatment alternatives for patients with asthma since it improves their quality of life and symptom control. This study aimed to investigate the indicators of success in patients with asthma receiving pulmonary rehabilitation (PR). Methods: A total of 131 patients with the diagnosis of asthma were included in the study. All patients attended an 8-week comprehensive, multidisciplinary, outpatient and individualized PR program. Results: The factors related to the gains in dyspnea perception, exercise capacity, peripheral muscle strength, respiratory muscle strength and quality of life were evaluated. In the multivariate linear regression analysis, the gain in dyspnea perception is related to baseline dyspnea. The gain in exercise capacity is related to baseline exercise capacity and the amount of smoking. The gain in peripheral muscle strength is related to gender. The gain in respiratory muscle strength is related to age, and finally the gain in quality of life is related to baseline dyspnea and anxiety levels. Conclusion: Especially men, young people, heavy smokers, and those with low initial exercise capacity, high perception of dyspnea, and high anxiety are more likely to benefit from PR.

Research Trends on Pulmonary Rehabilitation: A Bibliometric Analysis From 2011 to 2020

Background and Objective

A mounting body of evidence suggests that lung function may deteriorate over time with the development of chronic lung diseases (CRDs). Pulmonary rehabilitation has been proved to improve exercise capacity and quality of life in individuals with CRDs. However, PR remains grossly underutilized all around the world. This study aimed to analyze the research trends on PR over the past 10 years.

Methods

The publications related to pulmonary rehabilitation in the Web of Science Core Collection (WoSCC) from 2011 to 2020 were searched. VOSviewer (1.6.15) and CiteSpace Software (5.5.R2) were used to analyze authors and co-cited authors, countries and institutions, journals and co-cited journals, co-cited references, and keywords.

Results

A total of 4,521 publications were retrieved between 2011 and 2020, and the number of annual publications on pulmonary rehabilitation has shown an overall upward trend in the past decade. The USA was the most productive country, the University of Toronto from Canada was both the first in publications and citations. Spruit MA was both the most productive author and the one with the highest number of co-citations. The first productive journal was the International Journal of Chronic Obstructive Pulmonary Disease, while the first co-cited journal was the American Journal of Respiratory and Critical Care Medicine. The hot keywords were grouped into three clusters, while “Asthma” and “Respiratory society statement” were determined as the frontier topics.

Conclusions

The present study successfully revealed the research status and development trends of pulmonary rehabilitation from 2011 to 2020 by using bibliometric analysis, which may help researchers explore and discover new research directions in the future.

Pulmonary rehabilitation in long COVID: more than just natural recovery!?

We thank A. Hussain and co-workers for their correspondence regarding our study on the benefits of pulmonary rehabilitation (PR) in coronavirus disease 2019 (COVID-19) [1].

In the light of missing randomised controlled trials, some arguments suggest that pulmonary rehabilitation has beneficial effects beyond natural recoveryhttps://bit.ly/3ze2xvw

Effectiveness of a Three-Week Inpatient Pulmonary Rehabilitation Program for Patients after COVID-19: A Prospective Observational Study

For COVID-19 patients who remain symptomatic after the acute phase, pulmonary rehabilitation (PR) is recommended. However, only a few studies have investigated the effectiveness of PR, especially considering the duration between the acute phase of COVID-19 and the onset of rehabilitation, as well as the initial severity. This prospective observational study evaluated the efficacy of PR in patients after COVID-19. A total of 120 still-symptomatic patients referred for PR after overcoming acute COVID-19 were asked to participate, of whom 108 (mean age 55.6 ± 10.1 years, 45.4% female) consented. The patients were assigned to three groups according to the time of referral and initial disease severity (severe acute; severe after interval; mild after interval). The primary outcome was dyspnea. Secondary outcomes included other respiratory disease symptoms, physical capacity, lung function, fatigue, quality of life (QoL), depression, and anxiety. Furthermore, patients rated the overall effectiveness of PR and their subjective change in health status. At the end of PR, we detected improvements with large effect sizes in exertional dyspnea, physical capacity, QoL, fatigue, and depression in the overall group. Other parameters changed with small to medium effect sizes. PR was effective after acute COVID-19 in all three groups analyzed.

[Pulmonary Rehabilitation in Patients with Chronic Obstructive Airway Diseases]

Pulmonary rehabilitation of asthma and COPD patients can improve their physical performance and quality of life, maintain participation in social and professional life and actively promote self-help. In addition, the resources for acute medical treatment can be spared. In case of COPD, rehabilitation directly after exacerbation can also improve the poor survival prognosis and reduce the risk of emergency hospital readmission. Therefore, pulmonary rehabilitation is an essential component of evidence-based long-term management of both bronchial asthma and, in particular, COPD. In the German healthcare system, however, pneumological rehabilitation is offered only for a small fraction of patients. Despite a very good evidence of pulmonary rehabilitation, especially in COPD patients, their share in all rehabilitation services is remarkably low. It does not even amount to 3 % of all medical rehabilitation measures approved by the German Pension Insurance.