In-hospital pulmonary rehabilitation after completion of primary respiratory disease treatment improves physical activity and ADL performance: A prospective intervention study

INTRODUCTION

Pulmonary rehabilitation improves the physical condition of patients with chronic respiratory disease; however, there are patients who cannot leave the hospital because of their low activities of daily living (ADLs), despite the completion of primary respiratory disease treatment and rehabilitation during treatment. Therefore, this study demonstrated that those patients recovered their ADLs through in-hospital pulmonary rehabilitation after treatment completion.

METHODS

We prospectively studied 24 hospitalized patients who had some remaining symptoms and showed low ADL scores of 9 points or less on the short physical performance battery after undergoing treatment for respiratory disease in Fukujuji Hospital from October 2018 to October 2019, excluding 2 patients who had re-exacerbation and 1 patient who could not be examined using the incremental shuttle walk test (ISWT). After completion of the primary respiratory disease treatment, patients moved to the regional comprehensive care ward, and they received pulmonary rehabilitation for 2 weeks. In the ward, patients who could not yet leave the hospital could undergo pulmonary rehabilitation for up to 60 days. Data were evaluated three times: upon treatment completion (baseline), postrehabilitation, and 3 months after baseline. The main outcome was an improvement in the incremental shuttle walk test (ISWT) postrehabilitation.

RESULTS

The median age of the patients was 80 (interquartile range (IQR): 74.8-84.5), and 14 patients (58.3%) were male. The ISWT distance significantly increased postrehabilitation (median [IQR]: 60 m [18-133] vs 120 m [68-203], P < .001). The Barthel Index (BI) (P < .001), the modified Medical Research Council (P < .001), and other scale scores were also improved. Among patients with acute respiratory diseases such as pneumonia, chronic obstructive pulmonary disease, and interstitial pneumonia, ISWT and other data showed improvement at the postrehabilitation timepoint. Ten patients who could perform examinations at 3 months after baseline were evaluated 3 months after taking baseline data prior to starting rehabilitation. The ISWT showed significant improvement 3 months after baseline compared to baseline (P = .024), and the ISWT distance was maintained after rehabilitation.

DISCUSSION AND CONCLUSIONS

Physical activity, symptoms, mental health, and ADL status in patients who had not recovered after primary treatment completion for respiratory diseases could improve through in-hospital pulmonary rehabilitation.

Exercise training for bronchiectasis

BACKGROUND

Bronchiectasis is characterised by excessive sputum production, chronic cough, and acute exacerbations and is associated with symptoms of dyspnoea and fatigue, which reduce exercise tolerance and impair quality of life. Exercise training in isolation or in conjunction with other interventions is beneficial for people with other respiratory diseases, but its effects in bronchiectasis have not been well established.

OBJECTIVES

To determine effects of exercise training compared to usual care on exercise tolerance (primary outcome), quality of life (primary outcome), incidence of acute exacerbation and hospitalisation, respiratory and mental health symptoms, physical function, mortality, and adverse events in people with stable or acute exacerbation of bronchiectasis.

SEARCH METHODS

We identified trials from the Cochrane Airways Specialised Register, ClinicalTrials.gov, and the World Health Organization trials portal, from their inception to October 2020. We reviewed respiratory conference abstracts and reference lists of all primary studies and review articles for additional references.

SELECTION CRITERIA

We included randomised controlled trials in which exercise training of at least four weeks' duration (or eight sessions) was compared to usual care for people with stable bronchiectasis or experiencing an acute exacerbation. Co-interventions with exercise training including education, respiratory muscle training, and airway clearance therapy were permitted if also applied as part of usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and selected trials for inclusion, extracted outcome data, and assessed risk of bias. We contacted study authors for missing data. We calculated mean differences (MDs) using a random-effects model. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included six studies, two of which were published as abstracts, with a total of 275 participants. Five studies were undertaken with people with clinically stable bronchiectasis, and one pilot study was undertaken post acute exacerbation. All studies included co-interventions such as instructions for airway clearance therapy and/or breathing strategies, provision of an educational booklet, and delivery of educational sessions. The duration of training ranged from six to eight weeks, with a mix of supervised and unsupervised sessions conducted in the outpatient or home setting. No studies of children were included in the review; however we identified two studies as currently ongoing. No data were available regarding physical activity levels or adverse events. For people with stable bronchiectasis, evidence suggests that exercise training compared to usual care improves functional exercise tolerance as measured by the incremental shuttle walk distance, with a mean difference (MD) between groups of 87 metres (95% confidence interval (CI) 43 to 132 metres; 4 studies, 161 participants; low-certainty evidence). Evidence also suggests that exercise training improves six-minute walk distance (6MWD) (MD between groups of 42 metres, 95% CI 22 to 62; 1 study, 76 participants; low-certainty evidence). The magnitude of these observed mean changes appears clinically relevant as they exceed minimal clinically important difference (MCID) thresholds for people with chronic lung disease. Evidence suggests that quality of life improves following exercise training according to St George's Respiratory Questionnaire (SGRQ) total score (MD -9.62 points, 95% CI -15.67 to -3.56 points; 3 studies, 160 participants; low-certainty evidence), which exceeds the MCID of 4 points for this outcome. A reduction in dyspnoea (MD 1.0 points, 95% CI 0.47 to 1.53; 1 study, 76 participants) and fatigue (MD 1.51 points, 95% CI 0.80 to 2.22 points; 1 study, 76 participants) was observed following exercise training according to these domains of the Chronic Respiratory Disease Questionnaire. However, there was no change in cough-related quality of life as measured by the Leicester Cough Questionnaire (LCQ) (MD -0.09 points, 95% CI -0.98 to 0.80 points; 2 studies, 103 participants; moderate-certainty evidence), nor in anxiety or depression. Two studies reported longer-term outcomes up to 12 months after intervention completion; however exercise training did not appear to improve exercise capacity or quality of life more than usual care. Exercise training reduced the number of acute exacerbations of bronchiectasis over 12 months in people with stable bronchiectasis (odds ratio 0.26, 95% CI 0.08 to 0.81; 1 study, 55 participants). After an acute exacerbation of bronchiectasis, data from a single study (N = 27) suggest that exercise training compared to usual care confers little to no effect on exercise capacity (MD 11 metres, 95% CI -27 to 49 metres; low-certainty evidence), SGRQ total score (MD 6.34 points, 95%CI -17.08 to 29.76 points), or LCQ score (MD -0.08 points, 95% CI -0.94 to 0.78 points; low-certainty evidence) and does not reduce the time to first exacerbation (hazard ratio 0.83, 95% CI 0.31 to 2.22).

AUTHORS' CONCLUSIONS

This review provides low-certainty evidence suggesting improvement in functional exercise capacity and quality of life immediately following exercise training in people with stable bronchiectasis; however the effects of exercise training on cough-related quality of life and psychological symptoms appear to be minimal. Due to inadequate reporting of methods, small study numbers, and variation between study findings, evidence is of very low to moderate certainty. Limited evidence is available to show longer-term effects of exercise training on these outcomes.

Telerehabilitation for chronic respiratory disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

[The Physical Medicine and Rehabilitation Approach in COVID-19 Patients with Post-Intensive Care Syndrome in Portugal]

N/a.

Exercise training to improve exercise capacity and quality of life in people with non-malignant dust-related respiratory diseases

BACKGROUND

Non-malignant dust-related respiratory diseases, such as asbestosis and silicosis, are similar to other chronic respiratory diseases and may be characterised by breathlessness, reduced exercise capacity and reduced health-related quality of life. Some non-malignant dust-related respiratory diseases are a global health issue and very few treatment options, including pharmacological, are available. Therefore, examining the role of exercise training is particularly important to determine whether exercise training is an effective treatment option in non-malignant dust-related respiratory diseases.

OBJECTIVES

To assess the effects of exercise training for people with non-malignant dust-related respiratory diseases compared with control, placebo or another non-exercise intervention on exercise capacity, health-related quality of life and levels of physical activity.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, EMBASE, CINAHL, PEDro and AMED (all searched from inception until February 2015), national and international clinical trial registries, reference lists of relevant papers and we contacted experts in the field for identification of suitable studies.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared exercise training of at least four weeks duration with no exercise training, placebo or another non-exercise intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently assessed study eligibility and risk of bias, and extracted data. We employed the GRADE approach to assess the overall quality of evidence for each outcome and to interpret findings. We synthesized study results using a random-effects model based on the assessment of heterogeneity. We conducted subgroup analyses on participants with dust-related interstitial lung diseases (ILDs) and participants with asbestos related pleural disease (ARPD).

MAIN RESULTS

Two RCTs including a combined total of 40 participants (35 from one study and five from a second study) met the inclusion criteria. Twenty-one participants were randomised to the exercise training group and 19 participants were randomised to the control group. The included studies evaluated the effects of exercise training compared to a control group of no exercise training in people with dust-related ILDs and ARPD. The exercise training programme in both studies was in an outpatient setting for an eight-week period. The risk of bias was low in both studies. There were no reported adverse events of exercise training. Following exercise training, six-minute walk distance (6MWD) increased with a mean difference (MD) of 53.81 metres (m) (95% CI 34.36 to 73.26 m). Improvements were also seen in the domains of health-related quality of life: Chronic Respiratory Disease Questionnaire (CRQ) Dyspnoea domain (MD 2.58, 95% CI 0.72 to 4.44); CRQ Fatigue domain (MD 1.00, 95% CI 0.11 to 1.89); CRQ Emotional Function domain (MD 2.61, 95% CI 0.74 to 4.49); and CRQ Mastery domain (MD 1.51, 95% CI 0.29 to 2.72). Improvements in exercise capacity and health-related quality of life were also evident six months following the intervention period: 6MWD (MD 52.68 m, 95% CI 27.43 to 77.93 m); CRQ Dyspnoea domain (MD 3.03, 95% CI 1.41 to 4.66); CRQ Emotional Function domain (MD 5.57, 95% CI 2.34 to 8.81); and CRQ Mastery domain (MD 2.66, 95% CI 1.08 to 4.23). Exercise training did not result in improvements in the Modified Medical Research Council (MMRC) dyspnoea scale immediately following exercise training or six months following exercise training. The improvements following exercise training were similar in a subgroup of participants with dust-related ILDs and in a subgroup of participants with ARPD compared to the control group, with no statistically significant differences in treatment effects between the subgroups.

AUTHORS' CONCLUSIONS

The evidence examining exercise training in people with non-malignant dust-related respiratory diseases is of very low quality. This is due to imprecision in the results from the small number of trials and the small number of participants, the indirectness of evidence due to a paucity of information on disease severity and the data from one study being from a subgroup of participants, and inconsistency from high heterogeneity in some results. Therefore, although the review findings indicate that an exercise training programme is effective in improving exercise capacity and health-related quality of life in the short-term and at six months follow-up, we remain unsure of these findings due to the very low quality evidence. Larger, high quality trials are needed to determine the strength of these findings.

Housing improvements for health and associated socio-economic outcomes

BACKGROUND

The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow-up periods. Impacts on socio-economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts.

OBJECTIVES

To assess the health and social impacts on residents following improvements to the physical fabric of housing.

SEARCH METHODS

Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH-DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status.

SELECTION CRITERIA

Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross-sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio-economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language.

DATA COLLECTION AND ANALYSIS

Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non-experimental and uncontrolled studies. Health and socio-economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta-analysis was not appropriate the data were tabulated and synthesized narratively following a cross-study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model.

MAIN RESULTS

Thirty-nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty-three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non-experimental studies of warmth improvements, 12 non-experimental studies of rehousing or retrofitting, three non-experimental studies of provision of basic improvements in low or mIddle Income countries (LMIC), and three non-experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review.Very little quantitative synthesis was possible as the data were not amenable to meta-analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively.Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing-led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre-1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio-economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced.Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis.

AUTHORS' CONCLUSIONS

Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities.

Pulmonary rehabilitation at home guided by telemonitoring and access to healthcare facilities for respiratory complications in patients with neuromuscular disease

BACKGROUND

Pulmonary complications are the main cause of morbidity and mortality in neuromuscular patients. Aim of this study was to evaluate the feasibility of a home follow-up program combining telemonitoring and chest physiotherapy (CPT) in preventing acute respiratory episodes.

DESIGN

Prospective observational study in a period of 24 months, and comparison with preintervention data of the same patients.

SETTING

Outpatients and community.

POPULATION

Neuromuscular patients. Enrolment criteria were: reduced efficacy of cough, high family support, long home-to-hospital distance.

METHODS

Caregivers and patients had to register daily respiratory signs and symptoms. Each patient was equipped with a pulse oximeter with a modem for transmitting data to a remote control center, in charge of alerting the pulmonologist in case of sign and symptom deterioration. CPT interventions at home were planned after indication by the pulmonologist. The number of emergency room admissions or hospitalization following respiratory exacerbations were registered.

RESULTS

Thirteen patients were enrolled. In the first year of monitoring, 18 alerts were transmitted to the pulmonologist, average 1.38±1.38 alert/patient. In the second year, the number of alerts were 5, average 0.38±0.65 alert/patient (P<0.01). In 24 months, 241 respiratory therapists' interventions were conducted on 11 patients. In the first 12 months there were four episodes of hospitalisation, none in the following 12 months. In the year prior to the project, there were seven cases of hospitalisation and one case of emergency room admission.

CONCLUSION

The combination of telemonitoring and CPT at home is feasible in the long-term for patients with neuromuscular disease.

CLINICAL REHABILITATION IMPACT

An apparent reduction of hospitalisation and emergency room admissions for respiratory complications can justify a randomized control trial to confirm efficacy and effectiveness.

Short-term effects of combination of several physiotherapy methods on the respiratory function - a case report of adolescent idiopathic scoliosis

The aim of the study was to evaluate the positive effects of combination of several physiotherapy methods on the respiratory function on example of a case report.

MATERIAL AND METHODS

14 years old girl with an adolescent idiopathic scoliosis (AIS), right thoracic (primary curve, Cobb angle = 40°, AVR = 12°) and left lumbar (secondary curve, Cobb angle = 33°, AVR = 24°) participated in the study. She was 2 years after menarche. She underwent stationary (in-patient) treatment for 3 weeks with use of standard medical care (DoboMed). Treatment also included manual therapy (OMT Kaltenborn-Evjenth) and Dynamic Brace System (DBC) device, produced by Meditrack. Then she continued exercises at home. Respiratory system function was analyzed with use of SpiroPro electronic spirometer (Jaeger) and the strength of respiratory muscles with use of portable digital pressure meter equipped with the Omega PX 25 ± 35 kPa pressure transducer. Range of movement of the spine was examined with Rippstein V plurimeter, angle of apical trunk rotation (ATR) with the Bunnell scoliometer. Measurement was performed 4 times: before treatment, after one week and 3 weeks after the beginning of the treatment and 3 months after finalization of the treatment period.

RESULTS

Examination showed that DoboMed medical care treatment, manual therapy and use of DBC device in period of 3 weeks caused improvement of respiratory parameters (MIP - maximal inspiration pressure by 6.7%; MEP - maximal expiratory pressure by 12.6%, PEF - peak expiratory flow by 16.1%). Spinal range of lateral movement and angle of apical trunk rotation has also improved.

CONCLUSION

In short term treatment, the manual therapy aided with DBC system has improved the respiratory parameters and trunk morphology values. Such a composition of various physiotherapy methods can help to conduct further specialized exercises of DoboMed method.

Non-invasive interventions for improving well-being and quality of life in patients with lung cancer

BACKGROUND

This is an updated version of the original review published in Issue 4, 2004 of The Cochrane Library. Lung cancer is one of the leading causes of death globally. Despite advances in treatment, the outlook for the majority of patients remains grim and most face a pessimistic future accompanied by sometimes devastating effects on emotional and psychological health. Although chemotherapy is accepted as an effective treatment for advanced lung cancer, the high prevalence of treatment-related side effects as well the symptoms of disease progression highlight the need for high-quality palliative and supportive care to minimise symptom distress and to promote quality of life.

OBJECTIVES

To assess the effectiveness of non-invasive interventions delivered by healthcare professionals in improving symptoms, psychological functioning and quality of life in patients with lung cancer.

SEARCH STRATEGY

We ran a search in February 2011 to update the original completed review. We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 2), MEDLINE (accessed through PubMed), EMBASE, PsycINFO, AMED, British Nursing Index and Archive (accessed through Ovid) and reference lists of relevant articles; we also contacted authors.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials assessing the effects of non-invasive interventions in improving well-being and quality of life in patients diagnosed with lung cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed relevant studies for inclusion. Data extraction and risk of bias assessment of relevant studies was performed by one author and checked by a second author.

MAIN RESULTS

Fifteen trials were included, six of which were added in this update. Three trials of a nursing intervention to manage breathlessness showed benefit in terms of symptom experience, performance status and emotional functioning. Four trials assessed structured nursing programmes and found positive effects on delay in clinical deterioration, dependency and symptom distress, and improvements in emotional functioning and satisfaction with care.Three trials assessed the effect of different psychotherapeutic, psychosocial and educational interventions in patients with lung cancer. One trial assessing counselling showed benefit for some emotional components of the illness but findings were not conclusive. One trial examined the effects of coaching sensory self monitoring and reporting on pain-related variables and found that although coaching increases the amount of pain data communicated to providers by patients with lung cancer, the magnitude of the effect is small and does not lead to improved efficacy of analgesics prescribed for each patient's pain level. One trial compared telephone-based sessions of either caregiver-assisted coping skills training (CST) or education/support involving the caregiver and found that patients in both treatment conditions showed improvements in pain, depression, quality of life and self efficacy.Two trials assessed exercise programmes; one found a beneficial effect on self empowerment and the other study showed an increase in quadriceps strength but no significant changes for any measure of quality of life. One trial of nutritional interventions found positive effects for increasing energy intake, but no improvement in quality of life. Two small trials of reflexology showed some positive but short-lasting effects on anxiety and pain intensity.The main limitations of the studies included were the variability of the interventions assessed and the approaches to measuring the considered outcomes, and the lack of data reported in the trials regarding allocation of patients to treatment groups and blinding.

AUTHORS' CONCLUSIONS

Nurse follow-up programmes and interventions to manage breathlessness may produce beneficial effects. Counselling may help patients cope more effectively with emotional symptoms, but the evidence is not conclusive. Other psychotherapeutic, psychosocial and educational interventions can play some role in improving patients' quality of life. Exercise programmes and nutritional interventions have not shown relevant and lasting improvements of quality of life. Reflexology may have some beneficial effects in the short term.

[Appropriateness of hospital stays in a pulmonology department]

OBJECTIVE

To analyze the number of inappropriate stays generated by patients admitted through a pulmonology department over a 1-year period and to identify the causes and predictors of those stays.

PATIENTS AND METHODS

A representative sample of hospital stays corresponding to patients admitted by the pulmonology department at Hospital de Valme, Seville, Spain, in 2004 was analyzed retrospectively using the Appropriateness Evaluation Protocol. The review was conducted by 2 physicians who did not belong to the pulmonology department. Multiple linear regression analysis was performed to identify predictors of inappropriate stay.

RESULTS

Of the 1166 stays analyzed, 1038 (89%) were judged to be appropriate and 128 (11%) inappropriate. The most common reason for inappropriate stay was the delay in performing diagnostic tests and receiving results (64%). The main justification for appropriate stay was the need for respiratory treatment (59.6%) and parenteral treatment (46.1%). The predictive model generated by multiple linear regression analysis identified the following predictors of inappropriate stay: stay on a ward other than the pulmonology ward, diagnosis on admission, and season of the year.

CONCLUSIONS

The rate of inappropriate stay was low in comparison with other studies. The majority of inappropriate stays were attributed to delays in performing diagnostic tests and receiving results. Diagnosis on admission, season of the year, and stay on a ward other than the pulmonology ward were the strongest predictors of inappropriate stay.

[Physical and neuropsychological sequelae after intensive therapy]

Until recently, critical care therapy practitioners have focused on survival rather than on long-term outcomes. The incidence of physical and neuropsychological dysfunction has been underestimated and underreported after acute critical care illness. Current research indicates that these sequelae are common, may be permanent, and are associated with decreased quality of life. More studies investigating the effects of treatment and rehabilitation therapy on sequelae after intensive therapy are required.

Cardiopulmonary Rehabilitation and Cancer Rehabilitation. 2. Pulmonary Rehabilitation Review

Pulmonary rehabilitation includes the rehabilitation of not only patients with respiratory failure in need of ventilatory support but also patients with primary pulmonary disease. New advances in medical management now offer treatment to patients with end-stage emphysema, pulmonary hypertension, and interstitial disease, and the principles of rehabilitation can add both function and quality to the lives of these patients. New surgical approaches and better transplantation outcomes that restore pulmonary function have also been introduced. Rehabilitation professionals need to be aware of these advances and be able to incorporate this knowledge into the practice of rehabilitation medicine.

OVERALL ARTICLE OBJECTIVES

(a) To identify major categories of pulmonary disease seen in pulmonary rehabilitation, (b) to know appropriate interventions and support for patients with respiratory failure, (c) to describe the new interventions available for end-stage lung disease, and (d) to describe the appropriate pulmonary rehabilitation for people with pulmonary disease.

Do Clinical Marker States Improve Responsiveness and Construct Validity of the Standard Gamble and Feeling Thermometer: A Randomized Multi-Center Trial in Patients with Chronic Respiratory Disease

BACKGROUND

Optimizing the validity and responsiveness of utility measures will enhance their usefulness in randomized trials. We evaluated the impact of clinical marker state (CMS) rating prior to patients' rating their own health on two utility instruments (feeling thermometer (FT) and standard gamble (SG)) in patients with chronic respiratory disease (CRD).

METHODS

We randomized 182 patients with CRD to complete the FT (self-administered) and SG with CMS (FT+/SG+, n=91) or without marker states (FT-/SG-, n=91) before and after undergoing respiratory rehabilitation in a multi-center trial.

RESULTS

Use of CMS did not influence baseline utility scores. Improvement after therapy on the scale from 0 (dead) to 1.0 (full health) was 0.04 both in FT+ (p=0.03) and FT- (p=0.02; the difference between FT+ and FT- was 0.00, p=0.83). Improvement on the SG was 0.05 in both SG+ (p=0.08) and SG- (p=0.04; difference between SG+ and SG- 0.00, p=0.95). Correlations with other health related quality of life scores were highest for FT+.

CONCLUSION

Administration of CMS did not improve responsiveness of the FT but may have improved construct validity. The SG showed limited construct validity and responsiveness that was not influenced by CMS use.

[Perceived self-efficacy and respiratory rehabilitation]

AIMS

To analyse if rehabilitation treatment can enhance perceived self-efficacy in performance of daily living activities in patients affected by chronic respiratory diseases (prevalently over 65 years of age and living in a poor socio-cultural context). METHODS. One-hundred and fifteen inpatients undergoing rehabilitation in hospital were administered two questionnaires: the A-D scale which evaluates state anxiety and depressive symptoms, and the Self-Efficacy and Independent Daily Living (SEIDL) questionnaire which evaluates expected self-efficacy in performing daily living activities. SEIDL was re-administered by phone after patients' discharge home, asking about their perceived actual self-efficacy in that moment.

RESULTS

Subjects showed significantly higher scores on the A-D scale compared to the Italian normative sample. Females had lower expectations of self-efficacy than males (p = 0.000) and had a lower perception of their effective self-efficacy at follow-up (p = 0.01). State anxiety and depressive symptoms showed a significant negative correlation with expected self-efficacy and perceived self-efficacy at follow-up.

CONCLUSIONS

Adequate psychological assessment is necessary before the start of rehabilitation treatment, as emotional disturbances can cancel the beneficial effects of rehabilitation. The creation of community day-centres would also be opportune, to support people affected by chronic respiratory diseases who may experience increased emotional disturbances when family support is lacking or insufficient.

[Intermittent normobaric hypoxia in rehabilitation of young seamen with respiratory diseases]

The article presents the results of multimodality rehabilitation of 120 young seamen suffering from respiratory diseases. It is shown that intermittent normobaric hypoxia as a component of rehabilitation treatment prevents maladaptation, corrects compromised immunity. The data of 6-month follow-up reports reduction in morbidity and temporary disability.

Non-invasive interventions for improving well-being and quality of life in patients with lung cancer

BACKGROUND

Lung cancer is one of the leading causes of death globally. Despite advances in treatment, outlook for the majority of patients remains grim and most face a pessimistic outlook accompanied by sometimes devastating effects on emotional and psychological health. Although chemotherapy is accepted as an effective treatment for advanced lung cancer, the high prevalence of treatment-related side effects as well the symptoms of disease progression highlight the need for high quality palliative and supportive care to minimise symptom distress and to promote quality of life.

OBJECTIVES

To assess the effectiveness of non-invasive interventions delivered by healthcare professionals in improving symptoms, psychological functioning and quality of life in patients with lung cancer.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), MEDLINE (1966-March 2003), EMBASE (1974-March 2003), CINAHL (1982-September 2002), CancerLit (1975-October 2002), PsycINFO (1873-March 2003), reference lists of relevant articles and contact with authors.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials assessing the effects of non-invasive interventions in improving well-being and quality of life in patients diagnosed with lung cancer.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed relevant studies for inclusion. Data extraction and quality assessment of relevant studies was performed by one reviewer and checked by a second reviewer.

MAIN RESULTS

Nine trials were included and categorised into six groups. Two trials of a nursing intervention to manage breathlessness showed benefit on symptom experience, performance status and emotional functioning. Three trials assessed structured nursing programmes and found positive effects on delay in clinical deterioration, dependency and symptom distress, and improvements in emotional functioning and satisfaction with care. One trial assessing counselling showed benefit on some emotional components of the illness but findings were not conclusive. One trial assessing an exercise programme, found a beneficial effect on self-empowerment. One trial of nutritional interventions found positive effects for increasing energy intake, but no improvement in quality of life. One trial of reflexology showed some positive, but short-lasting effects on anxiety.

REVIEWERS' CONCLUSIONS

Nurse follow-up programmes and a nurse intervention to manage breathlessness may produce beneficial effects. Psychotherapeutic study indicates that counselling may help patients cope more effectively with emotional symptoms, but the evidence is not conclusive. Findings from the included studies reinforce the necessity for increased training and education of healthcare professionals giving in these interventions. More research, of higher methodological quality is needed in this area to explore possible underlying explanatory mechanisms.

Home mechanical ventilation for restrictive thoracic diseases: effects on patient quality-of-life and hospitalizations

Forty-five patients with restrictive respiratory diseases, including thoracic wall diseases (TWD, n = 27) and neuromuscular diseases (NMD, n = 18), underwent 18 months of home mechanical ventilation (HMV) treatment. Treatment consisted of a two-level pressure system for 7h at night, with oxygen available if needed. Questionnaire-based assessments of health-related quality-of-life (HRQL) were evaluated before treatment and at 3, 6, 9, 12 and 18 months of follow-up. Hospitalization rates pre- and post-treatment were recorded, and the numbers need to treat (NNT) to avoid hospitalization and absolute risk reduction (ARR) rates were calculated. Several categories of HRQL, including physical function and vitality, improved significantly with treatment in both groups of patients; these improvements persisted over the entire 18 months. In contrast, other categories such as social function and mental health improved initially and declined subsequently. Hospitalizations decreased significantly with treatment. NNT calculations indicated that treatment would be needed for two TWD patients (ARR 63%) and one NMD patient (ARR 78%) to prevent one hospitalization per year per disease group. We conclude that improved quality-of-life and decreased hospitalizations make home non-invasive mechanical ventilation an useful treatment for patients with restrictive respiratory disorders.

Obstructive and restrictive lung disease and functional limitation: data from the Third National Health and Nutrition Examination

OBJECTIVE

To determine functional limitations in adults with obstructive or restrictive lung disease or respiratory symptoms.

DESIGN

Cross-sectional study.

SUBJECTS

Adult participants in phase 2 of the Third National Health and Nutrition Examination Survey, 1991-94.

METHODS

We classified subjects using spirometric criteria into the following mutually exclusive categories using the forced expiratory volume in 1 s (FEV1), the forced vital capacity (FVC), the FEV1/FVC ratio and the presence of respiratory symptoms: severe obstruction, moderate obstruction, mild obstruction, respiratory symptoms only, restrictive lung disease and no lung disease. We developed regression models to predict functional limitations (unable to walk a quarter of a mile, unable to lift 10 pounds, needs help with daily activities) that controlled for age, race, sex, education, smoking status, body mass index and comorbid conditions.

RESULTS

Severe and moderate obstruction were associated with an increased risk of being unable to walk a quarter of a mile [odds ratio (OR) 8.4, 95% confidence interval (CI) 3.6, 19.9 and OR 2.4, 95% CI 1.4, 4.0]. Restrictive lung disease and the presence of respiratory symptoms in the absence of lung function impairment were also associated with an increased risk of this outcome (OR 2.8, 95% CI 1.4, 5.6 and OR 2.8, 95% CI 2.0, 3.9). Similar results were obtained for the outcomes of being unable to lift 10 pounds or needing help with daily activities.

CONCLUSIONS

The presence of obstructive or restrictive lung disease, or respiratory symptoms in the absence of lung function impairment is associated with increased functional impairment.

Extubation failure: diagnostic value of occlusion pressure (P0.1) and P0.1-derived parameters

OBJECTIVE

To evaluate the ability of the new, built-in occlusion pressure (P0.1) measurement to predict extubation failure.

DESIGN AND SETTING

Prospective observational multicentre study in the ICU of five general hospitals.

PATIENTS

Hundred thirty patients on mechanical ventilation longer than 48 h when considered ready for weaning.

MEASUREMENTS AND RESULTS

Patients underwent a 30-min spontaneous breathing trial with simultaneous monitoring of occlusion pressure (P0.1) and breathing pattern (f/Vt). Sixteen patients (12%) failed the weaning trial and full ventilatory support was resumed, while 114 tolerated the trial and were extubated. Twenty-one (18%) required reintubation within 48 h. The area under the ROC curve for diagnosing extubation failure was 0.53 for f/Vt, 0.59 for P0.1 and 0.61 for P0.1*f/Vt (p=NS). Accordingly, P0.1*f/Vt more than 100 detected extubation failure with a sensitivity of 0.89, specificity of 0.35, positive predictive value of 0.21 and negative predictive value of 0.94.

CONCLUSION

During a first trial of spontaneous breathing on pressure support ventilation (PSV), bedside P0.1 and P0.1*f/Vt are of little help, if any, for predicting extubation failure.

Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial

BACKGROUND

Functional breathing disorders may complicate asthma and impair quality of life. This study aimed to determine the effectiveness of physiotherapy based breathing retraining for patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing.

METHODS

33 adult patients aged 17-65 with diagnosed and currently treated asthma and Nijmegen questionnaire scores > or =23 were recruited to a randomised controlled trial comparing short physiotherapy breathing retraining and an asthma nurse education control. The main outcome measures were asthma specific health status (Asthma Quality of Life questionnaire) and Nijmegen questionnaire scores

RESULTS

Of the 33 who entered the study, data were available on 31 after 1 month and 28 at 6 months. The median (interquartile range) changes in overall asthma quality of life score at 1 month were 0.6 (0.05-1.12) and 0.09 (-0.25-0.26) for the breathing retraining and education groups, respectively (p=0.018), 0.42 (0.11-1.17) and 0.09 (-0.58-0.5) for the symptoms domain (p=0.042), 0.52 (0.09-1.25) and 0 (-0.45-0.45) for the activities domain (p=0.007), and 0.50 (0-1.50) and -0.25 (-0.75-0.75) for the environment domain (p=0.018). Only the change in the activities domain remained significant at 6 months (0.83 (-0.10-1.71) and -0.05 (-0.74-0.34), p=0.018), although trends to improvement were seen in the overall score (p=0.065), the symptoms domain (p=0.059), and the environment domain (p=0.065). There was a correlation between changes in quality of life scores and Nijmegen questionnaire scores at 1 month and at 6 months. The number needed to treat to produce a clinically important improvement in health status was 1.96 and 3.57 at 1 and 6 months.

CONCLUSION

Over half the patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing show a clinically relevant improvement in quality of life following a brief physiotherapy intervention. This improvement is maintained in over 25% 6 months after the intervention.

[Infantile bilateral striate necrosis]

INTRODUCTION

Necrosis of the basal ganglia (NBG) is an uncommon condition in childhood. Cases of NBG have been reported in connection with metabolic disorders, infections, degenerative conditions, intoxications, head injuries and hypoxic-ischemic encephalopathies. The commonest clinical features include alteration of consciousness, chorea-athetoic or dystonic movements, spasticity, contractures of the limbs and convulsions.

CLINICAL CASE

We describe the case of an eight year old girl, who after having clinical gastroenteritis, developed acute neurological dysfunction, associated with images on cranial computerized axial tomography (CAT) showing a possible intracranial tumour and magnetic resonance (MR) studies showing bilateral hypodensity of the basal ganglia. Three months later magnetic resonance showed that these lesions had almost completely disappeared. This supports the diagnosis of post-infectious lesions.

CONCLUSIONS

The clinical course is very variable. Cases with a previous history of infection have a better prognosis. In our patient treatment was started with corticosteroids. She made a good recovery and was sent home with no sequelae five days later. The new imaging techniques (CAT and MR) have led to more cases of selective involvement of the basal ganglia being diagnosed. MR is the most specific technique for diagnosis in these patients. Although there is no effective specific treatment, treatment with biperidine, thyrotropic hormone and corticosteroids have been used with no apparent effect on the course of the disorder.

Upgrading rural Japanese nurses' respiratory rehabilitation skills through videoconferencing

We examined the effect of distance learning on nurses' clinical skills in a rural Japanese hospital. The subject matter was respiratory rehabilitation. After one face-to-face session, who 30 min sessions were delivered by videoconferencing to staff nurses working in a 100-bed rural hospital 250 miles (400 km) from Sapporo Medical University. A self-rating questionnaire was distributed before and after the sessions. Responses were collected from 15 out of 32 nurses participating in the face-to-face session (47%). Before the first videoconferencing session, 'always use' and 'sometime use' the new skills were rated by 67% of nurses, but after the second videoconferencing session 'always use' and 'sometimes use' were rated by 73% and 'never use' at 0%. This implies that there was increased use of new skills after the second session, although the difference was not significant. The nurses' opinions about the effectiveness for patients increased from 8% to 27% after the second session, which was significant. The pilot project indicated the usefulness of distance learning for upgrading nurses' clinical practice in one rural Japanese hospital and suggested ways in which videoconferencing can be used in future.

Primitive pharyngeal dyskinesia associated with upper airway collapse in an infant

We report a case of total collapse of the upper pharyngeal airway in a slightly premature baby, resulting in a noisy breathing disorder. Primary immaturity of the central nervous system contributing to pharyngeal muscle hypotonia has been implicated in association with the increase in nasal pressure. The infant experienced complete resolution of symptoms a few weeks after the placement of a nasopharyngeal tube. This case report demonstrates the difficulty in diagnosis and management. The developmental spectrum and exploration are reviewed.

[Extracorporeal membrane oxygenation (ECMO). II. The development of an experimental model in newborn lambs]

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) is a technique used for cardiorespiratory support in the treatment of newborns with severe respiratory insufficiency. ECMO has not been used yet in newborns in Spain. The aim of this work was to develop an experimental veno-arterial ECMO model in newborn lambs for training the NICU medical and nursing staff before the clinical application of this technique.

MATERIAL AND METHODS

Six newborn lambs were anesthetized, traqueotomized and connected to a neonatal ventilator. The right jugular vein and left carotid artery were cannulated and the catheters were located in the right atrium and aortic arch, respectively. A venous-arterial ECMO was performed during three hours, with an experimental ECMO circuit developed by us. Arterial pH and blood gases, systemic and airway pressures, heart rate, and rectal temperature were monitored.

RESULTS

The experimental ECMO circuit developed by use had a very low cost, but was capable of maintaining adequate gas exchange, acid-base balance and a normal rectal temperature.

CONCLUSIONS

The development of an experimental ECMO model in newborn lambs may allow the establishment of an initial training program and to maintain the expertise of the NICU staff of a perinatal center planning to start an ECMO program.

[Extracorporeal membrane oxygenation (ECMO). I. Is it really needed in Spain?]

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) is a cardiorespiratory support technique used to treat newborns with severe respiratory insufficiency. ECMO has not been used yet in newborns in Spain, with its necessity being question. The aim of this study was to evaluate the need for ECMO for respiratory or cardiac cases in our neonatal population, as well as to study the predictive capacity of several respiratory indices.

PATIENTS AND METHODS

A retrospective observational study was carried out. Data from 2,133 newborns admitted during a 48 month period was reviewed. Babies were considered ECMO candidates if they died of respiratory failure or after surgery for a cardiac defect and if they had no ECMO exclusion criteria. The capacity of several respiratory indices to predict mortality was analyzed.

RESULTS

We considered 16 babies who died to be ECMO candidates, 6 with respiratory failure (1/3,028 live births) and 10 with cardiac defects 3 of them inborn (1/6,057). The total ECMO need was 1/2019 live births. None of the oxygenation indices studied accurately predicted the 80% mortality rate.

CONCLUSIONS

In Spain, it is necessary to start several neonatal ECMO programs since some 200 newborn infants with severe respiratory failure or cardiac defects could benefit from such a program annually.

[Clinical and spirometric alterations in patients with Duchenne muscular dystrophy]

In 36 patients with Duchenne muscular dystrophy we studied the growth pattern, the type and severity of the spirometric abnormalities, the evolution of the Motor Functional Class (MFC), the infectious complications and treatments. Their age ranged from 6 to 19 years and the MFC was from 1 to 9. Regarding height, up to 12 years we verified a slope of 5.69 +/- 0.58 cm/year (r 0.872 p < 0.001) and a posterior detention was observed. Of the 36 patients, 24 were below the percentile 5. The restrictive disorder prevailed. The forced vital capacity (FVC) expressed in % of the theoretical value showed a lineal fall with age, with a negative correlation (r 0.51, p < 0.01) of -3.5 +/- 0.83%/year. The deterioration of the MFC was marked starting from 6 years; with a slope of 0.84 +/- 0.14 points between 6 to 12 years (r 0.73 p x 0.001). Up to 14 years, the slope was 0.212 +/- 0.084 (r 0.49, p < 0.05). Patients older than 14 years had reached a greater CFM of 7; starting from this MFC a progressive fall of the VC was observed with a slope of -15.29 +/- 3.39% of CVF/CF (r 0.56, p < 0.001). Nine patients with respiratory infections were documented. Four were pneumonia and 3 of them required mechanical ventilation and died. Only 50% of the patients accepted rehabilitating treatment. Four patients accepted surgery of the alterations of the feet while the patients with deformation of the column underwent spinal stabilization.

A cost-utility analysis of intensive therapy. II: Quality of life in survivors

A questionnaire designed to assess changes in quality of life was sent to 56 survivors of critical illness one year after their admission to an intensive therapy unit. Forty-one patients completed the questionnaire, and for the majority, quality of life remained unchanged (n = 25). However significant decreases in quality of life were found in those patients who previously enjoyed a good quality of life or were admitted with respiratory problems. Survivors also recorded significant decreases in five aspects of their perceived quality of life (ability to think and remember, seeing family, their contribution to society, activities outside work and income). As part of a previous study, the costs incurred by each of these patients had been measured so that changes in quality of life detected in this study could be combined to the individual costs and expressed as cost per quality adjusted life year. The cost of intensive therapy for a patient surviving for one year after acute respiratory or cardiovascular disease was 2600 pounds. The total hospital cost per quality adjusted life year was estimated at 7500 pounds, which places intensive therapy at the higher end of health programme costs. If the costs of nonsurvivors are included in the cost per quality adjusted life year calculation, the cost of intensive care increases considerably.

Long-term outcome after respiratory rehabilitation

To determine the long-term effect of respiratory rehabilitation, we followed up for 6 months after discharge 31 consecutive patients enrolled in a multidisciplinary inpatient rehabilitation program lasting 4 to 6 weeks. Of the 31, 24 showed improvement in quality of life (as measured with a previously validated questionnaire) and in functional exercise capacity (as measured with the 6-minute walk test) 2 weeks after discharge. The improvement was sustained for 6 months in 11 of the 24. Other investigators have found higher response rates than those that we report. The differences are likely due to our enrolment of consecutive patients, the length and completeness of follow-up, and the objective measurement of quality of life by an interviewer not associated with the rehabilitation program. Controlled trials of respiratory rehabilitation measuring both costs and benefits are warranted. In the meantime, strategies to maintain the initial improvement seen after rehabilitation should be developed and studied.

Bilateral vocal cord paralysis in Shy-Drager syndrome

A patient with a permanent tracheostomy was seen and noted to have bilateral abductor vocal cord paralysis. He was being investigated neurologically and was found to have several types of autonomic failure, specifically including postural hypotension. It was felt that he had Shy-Drager syndrome. A review of the literature showed that bilateral vocal cord paralysis is a recognized abnormality in this condition for which permanent speaking tracheostomy is the treatment of choice. Reflux esophagitis due to lax cardiac sphincter may be a factor in the laryngeal symptomatology.

Psychological changes during a controlled trial of rehabilitation in chronic respiratory disability

Thirty-four men with chronic respiratory disability took part in a randomised, controlled trial of physical training. The control group also undertook exercise training after their control period. During the study measurements were made of exercise tolerance (12-minute walking distance) and the men completed two psychology questionnaires. Walking distance improved significantly more in the treatment group than in the control group. Both groups recorded scores suggesting psychological "improvement" and the changes in the two groups were not significantly different from each other. There were no consistent associations between the increase in walking distance and changes in psychological scores. Initial psychological scores were not useful in predicting changes in walking distance. The results suggest that the effect of treatment on walking distance was not psychological.

[Functional respiratory rehabilitation in exudative pleuritis]

The rehabilitation of respiratory function in exudative pleurisy has two objectives, namely the prevention of adhesions, or, when this is no longer possible, to limit their influences on respiratory function. Stress is laid on the importance of the moment when rehabilitation management begins. The main moments of the treatment programme are reviewed, and an explanation is offered of the techniques adopted, and the functional tests best suited for assessment of the results. Lastly, reference is made to the satisfactory results observed in 50 patients.

The use of operant conditioning techniques in the respiratory rehabilitation of the tetraplegic

This paper discusses the development of a pilot project in respiratory rehabilitation as part of the total rehabilitation of the tetraplegic and high paraplegic. The principles of neuromuscular exercise and of behaviouristic psychology introduce the subject of operant learning in the rehabilitation setting. Incentive spirometry is described as the basic element in the development of a respiratory rehabilitation programme. The preliminary results are analysed and a recommendation made that such a programme materially increases the respiratory function of the tetraplegic, and, not least, assists in his ability to combat intercurrent respiratory infection.