18 research outputs found

    Exploring Pulmonary Rehabilitation Strategies for those with Respiratory Conditions

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    Effective rehabilitation strategies are paramount to improve physiological and psychological health in pulmonary disease. The aim of this thesis was to investigate traditional and alternative pulmonary rehabilitation strategies in those with chronic respiratory disease. Chapter Four found that traditional pulmonary rehabilitation (PR) was physiologically and psychologically effective, regardless of respiratory disease, with socioeconomic status being a key determinant of adherence. Chapter Five investigated the feasibility and acceptability of IMT. Children aged 10.8 ± 0.8 years with Cystic Fibrosis (CF) enjoyed the IMT intervention, perceiving improvements in their physical ability and psychosocial health. The care team highlighted that future interventions needed to be longer and to monitor engagement and adherence. Chapter Six assessed the effectiveness of an alternative rehabilitation strategy, using a four-week inspiratory muscle training (IMT) intervention, on lung function and heart rate variability in children with CF aged 10.8 ± 1.1 years. There were significant and clinically meaningful increases in respiratory muscle strength, a clinically meaningful decrease in sympathetic modulation, and decreases in respiratory symptoms. Subsequently, utilising the formative, physiological and psychological findings derived from Chapters Five and Six, an eight-week IMT intervention with live biofeedback, performed at 80% maximal inspiratory pressure, three times a week was implemented, with an eight-week optional IMT top-up. Overall, Chapter Seven found that eight weeks of IMT elicited significant increases in respiratory muscle strength, aerobic capacity and in CF-specific questionnaire domains in children (11.0 ± 2.2 years) with CF, which were maintained following the eight-week top-up period. Chapter Eight demonstrated significant improvements in inspiratory muscle strength and endurance after eight weeks, with sustained improvements in physiological health after 16-weeks in adults with bronchiectasis (64.5 ± 10.3 years). CF and bronchiectasis participants demonstrated high levels of adherence and reported competency and autonomy. Overall, IMT may be an effective and feasible alternative to pulmonary rehabilitation

    Models of Physical Activity: Active Lifestyle Promotion for adults and elderly people affected by Chronic Obstruction Pulmonary Disease

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    Background e obiettivi L\u2019intolleranza all\u2019esercizio fisico (ES), la sintomatologia e gli effetti extra-polmonari incrementano il rischio di disabilit\ue0, bassa qualit\ue0 della vita (QoL) e sedentariet\ue0 nel paziente affetto da Broncopneumopatia Cronica Ostruttiva (BPCO). In riabilitazione respiratoria l\u2019ES \ue8 considerato il principale intervento non farmacologico per incrementare la salute e la capacit\ue0 di esercizio nei pazienti. Sfortunatamente, si rilevano pochi interventi strutturati di attivit\ue0 fisica (AF). Inoltre, un numero elevato di pazienti declina la partecipazione. Le ragioni di abbandono o non partecipazione sono state poco investigate. Inoltre, esiste un considerevole dibatto riguardo l\u2019efficacia dei diversi modelli applicativi di AF nell\u2019incrementare i parametri salute correlati (PSC) dei pazienti BPCO e il loro impatto sul mantenimento a lungo termine di uno stile di vita attivo. Infine, l\u2019AF quotidiana, i PSC, la forza muscolare e la performance motoria dei pazienti BPCO sono intimamente correlati. Sebbene la disfunzione muscoolare sia presente in tutti i pazienti BPCO, \ue8 stato osservato che la contrazione eccentrica (ECC) \ue8 pi\uf9 elevata nei BPCO rispetto ai soggetti sani (HC). La maggior parte delle ricerche del settore hanno utilizzato parametri isometrici i concentrici (CON), per\uf2 poco \ue8 conosciuto riguardo all\u2019associazione tra forza ECC e alte velocit\ue0 di contrazione nei pazienti BPCO. Pertanto gli studi proposti vogliono evidenziare le motivazioni e le barriere che riducono il reclutamento e impediscono a pazienti BPCO di acquisire uno stile di vita attivo. Inoltre, si vogliono verificare le modifiche ai PSC ottenute da due modelli di attivit\ue0 fisica adattata (AFA) specifici per BPCO e il loro impatto nell\u2019acquisizione di uno stile di vita attivo. Infine si vogliono investigate le performance muscolari CON ed ECC degli arti inferiori dei pazienti BPCO a diverse velocit\ue0 di contrazione. Metodi 1\ub0 studio: single-centre, multi-practice, parallel-group trial clinico randomizzato. 269 maschi affetti da BPCO males sono stati sottoposti a screening per individuare 132 pazienti elegibili. I 38 soggetti reclutati hanno compilato il questionario EMI-2. 2\ub0 studio: trial longitudinale, randomizzato. Sono state effettuate valutazioni ad inizio (T1), dopo 3 mesi (T2), 6 mesi (T3) and a 3 mesi di follow up (T4). La composizione corporea e il contenuto minerale osseo (BMC) tramite DXA, i parametri motori (6MWT, Leg press, leg extension, chest press e biceps curl 1RM, flessibilit\ue0 del cingolo scapolo-omerale e della schiena, e l\u2019equilibrio), lo stile di vita (IPAQ e registrazione SenseWear PRO-2) e la QoL (questionario MRF-26) sono stati investigati. 3\ub0 stadio: studio osservazionale, caso/controllo, cross over. Misure di architettura muscolare, contrazione CON ed ECC del quadricipite a diverse velocit\ue0 (30deg/sec, 210 deg/sec), stile di vita e PSC di 35 pazienti con BPCO sono state confrontati con quelli rilevati in 25 soggetti sani di controllo (HC). Risultati 1\ub0 studio: la principale causa che impedisce la partecipazione \ue8 dovuta al non rispetto dei criteri di inclusione (65.53%). La mancanza di interesse (8.94%), di tempo disponibile (6.81%) e la difficolt\ue0 a raggiungere le strutture sportive (1.7%) sono le principali ragioni che inducono il paziente ad abbandonare il programma. Il reclutamento dello studio ha un\u2019aderenza molto elevata (25.7%) in confronto alla letteratura di riferimento, confermato anche dal numero esiguo di drop out (10.52%). Bassi livelli iniziali di motivazione intrinseca da parte dei pazienti con BPCO sono stati rilevati (media 81.69pt \ub148.08), sebbene miglioramenti statisticamente significativi si osservino solo nel gruppo FC dopo la partecipazione ad interventi di AF dopo 3 mesi (+43.99%, p<0.05) e 6 mesi (+47.42%, p<0.05). A 3 mesi modificano gli item socio/emotivi (p<0.01), di gestione ponderale (p<0.05) e di piacevolezza (p<0.01), riconfermandosi a 6 mesi (socio/emotivi p<0.01, piacevolezza p<0.05). 2\ub0 studio: 7 pazienti abbandono il programma nei 9 mesi. A breve termine, il gruppo FC incrementa significativamente i parametri di %BMC (0.112 \ub10.029, p<0.01), Biceps curl 1RM (1.9kg \ub10.6, p<0.05), Chest press 1RM (8.1kg \ub11.7, p<0.001) ed equilibrio (48.5sec \ub114.2, p<0.05). Modificazioni significative si rilevano nel gruppo EDU, i.e. grasso corporeo (-736.4g \ub1240.0, p<0.05), BMI (-0.332 \ub10.106, p<0.05), Leg Extension 1RM (7.2kg \ub12.4, p<0.05), Chest Press 1RM (6.1kg\ub11.7, p<0.05) e mobilit\ue0 della spalla (2.7cm \ub10.7, p<0.01). Il gruppo CG modifica i parametri di BMI (-0.588 \ub10.157, p<0.01), grasso corporeo (-1086.4g \ub1365, p<0.05), and massa totale (-1849.8g \ub1494.1 p<0.01). A lungo termine, FC modifica significativamente %BMC (0.071 \ub10.024 p<0.05), Chest Press 1RM (9.8kg \ub12.4, p<0.01), equilibrio (57.0sec\ub113.3, p<0.01), quantit\ue0 di attivit\ue0 moderata (1024 \ub1272, p<0.01), tempo totale in attivit\ue0 sedentaria (-3.3 \ub10.7, p<0.01) and MRF-26 (-2.3 \ub10.7, p<0.05). Il gruppo EDU riduce la percezione di sforzo al 6MWT (-1.37 \ub10.41 p<0.05) e il tempo totale in attivit\ue0 sedentaria (-3.6 \ub10.7, p=0.000), aumentando l\u2019attivit\ue0 di cammino (618 \ub1208, p<0.05) e l\u2019MRF-26 (-2.1 \ub10.7, p<0.05). Al termine del follow up, il gruppo FC riduce i parametri di %BMC (-0.069 \ub10.020 p<0.05), 6MWT (-48.2 \ub114.8, p<0.05), Leg Extension 1RM (-9.3 \ub12.8, p<0.05), Chest Press 1RM (-11.6 \ub12.1, p=0.000), flessibilit\ue0 del busto (-3.8 \ub10.9, p<0.01) ed equilibrio (-21.0 \ub17 p<0.05). Il gruppo EDU group riduce i parametri di Leg Press 1RM (-32.6 \ub19.1, p<0.05), Leg Extension 1RM (-10+5 \ub11.9, p<0.001), Chest Press 1RM (-14.3 \ub11.3, p=0.000), flessibilit\ue0 del cingolo scapolo-omerale (-4.3 \ub11.3, p<0.05), tempo totale in attivit\ue0 sedentaria (-3.5 \ub10.9, p<0.01) and MRF-26 (-2.9 \ub10.8, p<0.05). anche il gruppo CG dimostra riduzioni al Chest Press 1RM (-10.9 \ub12.6, p<0.01). Nessuna modificazione \ue8 stata osservata con il SenseWear PRO-2. 3\ub0 studio: I soggetti del gruppo HC presentano valori pi\uf9 elevati in termini di capacit\ue0 d\u2019esercizio, i.e. 6MWT (p<0.001) e 1RM alla Leg Press (p<0.05), rispetto ai pazienti BPCO. Solo il torque CON a 30deg/s \ue8 pi\uf9 elevato nei soggetti HC rispetto ai BPCO (p<0.05). Nessuna differenza statisticamente significativa \ue8 stata rilevata tra i gruppi per i parametri di architettura muscolare, torque CON a 210 deg/sec e nei toque ECC. Differenze significative si evidenziano nel rapporto tra torque ECC e CON (30 deg/sec p<0.001; 210 deg/sec p<0.01). Correlazioni significative sono state osservate tra FEV1 e 6MWT (0.719 p<0.001), 1RM Leg Press (0.449 p<0.001), torque a 30 deg/sec (0.427 p<0.01; 0.280 p<0.05), a 210 deg/sec (0.285 p<0.05; 0.276 p<0.05) and rapporto ECC/CON di torque ad entrambe le velocit\ue0 (-0.562 p<0.001; -0.292 p<0.05). Le medesime osservazioni sono state rilevate tra FEV1/FVC e i parametri investigati. Conclusioni La principale barriera \ue8 rappresentata dai criteri di inclusione. La pratica di reclutamento effettuata da un singolo specialista sembra essere la pi\uf9 efficace. La supervisione dello specialista in AFA e l\u2019aumento della collaborazione tra clinici e specialisti AFA potrebbe incrementare la partecipazione dei pazienti BPCO. Semplici modelli applicativi di AFA possono risultano efficaci ad incrementare sia la motivazione all\u2019ES e sia alcuni dei PSC specifici per BPCO. Questi miglioramenti sembrano essere apportati prevalentemente dai \u201cwell rounded program\u201d. Il supporto dello specialista APA risulta necessario per poter mantenere a lungo termine i guadagni ottenuti con l\u2019ES. Invece, i miglioramenti di capacit\ue0 funzionale non sembrano modificare lo stile di vita. Sebbene i pazienti BPCO siano caratterizzati da basse performance dei PSC, ridotta capacit\ue0 di contrazione CON e stile di vita inattivo rispetto ai soggetti HC, sembrano preservare la contrazione ECC e il torque nelle contrazioni ad alta velocit\ue0. Ulteriori ricerche sembrano essere necessarie.Background and aims Exercise intolerance, symptoms and extra-pulmonary effects may increase patients disabilities, affecting quality of life (QoL) and reducing maintenance of an active lifestyle. Exercise training (ExT) is considered the most effective non-pharmacological intervention to improve COPD patients health and exercise capacity. Unfortunately, there are few available health-care structured programs of physical activity (PA) and a considerable proportion of eligible patients decline participation or drop out. Reasons for decline and drop-out from ExT programs have seldom been investigated. Moreover, a considerable debate continues about what kind of model of PA and ExT intervention is more effective to improve COPD patients\u2019 health related parameters (HRQL), and to maintain long-term active lifestyle. Finally, evidences support notions that daily physical activity (DPA), HRQL, muscle strength and performance are likely intimately interlinked. Although, muscle wasting is common in COPD patients across all disease stages, it has been observed that eccentric contraction (ECC) results greater compared to healthy control subjects. Majority of COPD leg muscle function\u2019s research has used isometric or concentric (CON) quadriceps torque, but there is lack of knowledge about associa\uaction between ECC muscle strength and fast-velocity muscle contractions in COPD patients. Therefore, we would to outline motivation and barriers which reduced COPD patients recruitment in ExT program and hindered an active lifestyle acquisition. Secondly, it would be verify short and long-term modifications of several HRQL provided by two different and easily applied-field models of adapted fitness activity (APA) for COPD patients to evaluate long-term active-lifestyle maintenance. Finally, we would to investigate COPD patients lower limb strength performances as a function of contraction modalities and velocities comparing with healthy control (HC). Methods Fist study: single-centre, multi-practice, randomized, parallel-group clinical trial. 269 COPD males were screened to establish 132 eligible patients. 38 recruited COPD patients were administrated by EMI-2 questionnaire. Recruitment steps were recorded in order to assess patients\u2019 motivation of decline or drop out. Second study: longitudinal randomized controlled trial, in which baseline (T1), 3 months (T2), 6 months (T3) and 3 months of follow up (T4) evaluations were performed. Body composition and bone mass content, i.e. BMC (DXA scanner), functional health-related (6MWT, Leg press, leg extension, chest press and biceps curl 1RM, shoulder and lower back flexibility and balance), lifestyle (IPAQ questionnaire and SenseWear PRO-2 assessment) and quality of life (MRF-26 questionnaire) parameters were administrated. 38 COPD patients were randomized and assigned to one of the three evaluation groups: Fitness Center based group (FC=13), Educational PA group (EDU=12) and Control group (CG=13). Third study: case/control research, cross over and observational trial. Architectural muscle measurements, CON and ECC quadriceps contractions at different velocities (30deg/sec, 210 deg/sec), lifestyle and health-related parameters of COPD patients (N=35) and HC (N=25) subjects were recorded. Results First study: major cause of not-participation was mismatched inclusion criteria (65.53%). No-interest in exercise training (8.94%), lack of available time (6.81%) and inability to access at the PA structures (1.7%) were most commonly cited reasons to drop out. Recruitment showed higher adherence (25.7%) compared to literature, also confirmed by lower number of drop out (10.52%). Low score of intrinsic motivation towards PA were recorded (mean 81.69pt \ub148.08) and significant improvements in EMI-2 were observed after 3 months (+43.99%, p<0.05) and 6 months of ExT (+47.42%, p<0.05) by FC group. Significant increases in Socio/Emotional (p<0.01), Weight management (p<0.05) and Enjoyment items (p<0.01) were recorded after 3 months. Socio/Emotional aspects (p<0.01) and Enjoyment items (p<0.05) improved after 6 months. Second study: 7 patients dropped out. At short term, FC group shows significant improvement in %BMC (0.112 \ub10.029, p<0.01), Biceps curl 1RM (1.9kg \ub10.6, p<0.05), Chest press 1RM (8.1kg \ub11.7, p<0.001) and Balance test (48.5sec \ub114.2, p<0.05). EDU group shows significant modification in Fat (-736.4g \ub1240.0, p<0.05), BMI (-0.332 \ub10.106, p<0.05), Leg Extension 1RM (7.2kg \ub12.4, p<0.05), Chest Press 1RM (6.1kg\ub11.7, p<0.05) and Shoulder flexibility (2.7cm \ub10.7, p<0.01). The CG group shows significant differences in BMI (-0.588 \ub10.157, p<0.01), Fat (-1086.4g \ub1365, p<0.05), and Total Body Mass (-1849.8g \ub1494.1 p<0.01). At long-term, FC modified significantly %BMC (0.071 \ub10.024 p<0.05), Chest Press 1RM (9.8kg \ub12.4, p<0.01), Balance (57.0sec\ub113.3, p<0.01), IPAQ moderate activity (1024 \ub1272, p<0.01), IPAQ sedentary hours (-3.3 \ub10.7, p<0.01) and MRF-26 (-2.3 \ub10.7, p<0.05). EDU group recorded modifications in 6MWT Borg scale (-1.37 \ub10.41 p<0.05), IPAQ walking activity (618 \ub1208, p<0.05), IPAQ sedentary hours (-3.6 \ub10.7, p=0.000) and MRF-26 (-2.1 \ub10.7, p<0.05). CG group did not shows significant differences. At follow up, FC shows significant changes in %BMC (-0.069 \ub10.020 p<0.05), 6MWD (-48.2 \ub114.8, p<0.05), Leg Extension 1RM (-9.3 \ub12.8, p<0.05), Chest Press 1RM (-11.6 \ub12.1, p=0.000), Sit & Reach (-3.8 \ub10.9, p<0.01), Balance (-21.0 \ub17 p<0.05). EDU group shows significant modification in 6MWT Borg score (-1.36 \ub10.41 p<0.05), Leg Press 1RM (-32.6 \ub19.1, p<0.05), Leg Extension 1RM (-10+5 \ub11.9, p<0.001), Chest Press 1RM (-14.3 \ub11.3, p=0.000), Back Scratch (-4.3 \ub11.3, p<0.05), IPAQ sedentary hours (-3.5 \ub10.9, p<0.01) and MRF-26 (-2.9 \ub10.8, p<0.05). CG group shows significant difference in Chest Press 1RM (-10.9 \ub12.6, p<0.01). No significant modification were observed in SenseWear PRO-2 administration. Third study: HC subjects were significantly different in exercise capacity, i.e. 6MWT (p<0.001) and 1RM Leg Press (p<0.05), than COPD patients. Only CON 30deg/s peak torque was significantly higher in HC compared to COPD (p<0.05). No differences in muscle architecture, fast CON and/or e ECC torque were observed between groups. Significant differences were found between groups in ECC/CON torque ratio (30 deg/sec p<0.001; 210 deg/sec p<0.01). Finally, significant correlations were found between FEV1 and 6MWT (0.719 p<0.001), 1RM Leg Press (0.449 p<0.001), peak torque contraction at 30 deg/sec (0.427 p<0.01; 0.280 p<0.05), at 210 deg/sec (0.285 p<0.05; 0.276 p<0.05) and ECC/CON peak torque ratio at both velocities (-0.562 p<0.001; -0.292 p<0.05). Same results were observed between FEV1/FVC and parameters assessed. Conclusions Recruit COPD patients becomes very challenging. Cause of not-participation was related to mismatched inclusion criteria. Great effort practice of recruitment, managed by only one person, seems to be more effective. Supervision of ExT specialist and incresed level of liaison between specialist physicians and healthcare professionals could be useful to increase participation. An easily applied-field models of COPD specific APA training could be efficient in order to improve some of COPD-specific HRQL. These improvements seem to be better provide by a \u201cwell rounded\u201d APA program. APA exercise specialist support is necessary to maintain long-term significant health\u2019s gains. Whereas, improvement in functional exercise capacity does not automatically turn into a more active lifestyle. COPD patients are characterized by lower health related parameters and lifestyle. Also COPD performed lower CON contraction compared to HC. COPD preserved ECC contractions and fast concentric torque. We hypothesize that COPD males develop a favorable profile to minimize strength loss likely due to neural-muscular modification. Further studies are aimed

    CHOICE: Choosing Health Options In Chronic Care Emergencies

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    Background Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation. Objectives The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs). Design A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team. Setting Primary care. Manchester and London. Participants People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff. Results Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling. Limitations The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD. Conclusions Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness. Future work The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention

    Chinese herbal medicine for chronic obstructive pulmonary disease (COPD): systematic analyses of modern and classical approaches.

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    Chronic obstructive pulmonary disease (COPD) is a lung disorder characterised by irreversible airflow limitation with symptoms such as chronic cough, sputum production, dyspnea and chest tightness. It is divided into stable and exacerbation phases. Exacerbations of COPD involving deterioration of symptoms are major causes of morbidity, hospitalization and mortality and affect health-related quality of life (HRQoL). Conventional pharmacotherapy involving bronchodilators and corticosteroids has side effects and provides only temporary relief. Therefore, Chinese herbal medicines are increasingly being used internationally following recent publications and reviews of randomised controlled trials (RCTs) that evaluated the benefits of oral CHM formulae and herbal extracts for stable COPD and experimental studies demonstrating anti-inflammatory and immune effects relevant to COPD of some Chinese herbs and formulae. These reviews, however, did not adequately represent the large volume of non-English studies despite the fact that in China. CHMs have been used to treat COPD-like lung diseases since ancient times and in the contemporarily management of COPD along with conventional pharmacotherapy. Therefore, this study aims to review English and Chinese databases to assess potentially efficacious and safe CHMs in the treatment of COPD. The study (1) reviewed current concepts and treatment of COPD in both conventional and Chinese medicines, (2) analysed COPD-like disorders in classical Chinese medicine books, (3) identified main herbal formulae and individual herbs used for COPD-like disorders, (4) conducted systematic searches of RCTs on CHM for COPD, meta-analyzed results of each main outcome measure and calculated usage frequencies of each herbal formulae and individual herbs, and (5) identified the likely mechanisms of action of the shortlisted herbs. English and Chinese databases were searched in three separate systematic reviews (SRs) based on Cochrane Handbook for Systematic Reviews of Interventions. Findings of reviews and meta-analysis supported the effectiveness of CHM either used independently or as an adjunct to routine pharmacotherapy in preventing decline of FEV1% predicted of stable COPD patients, improving QoL and exercise tolerance, reducing COPD exacerbation frequency and relieving a range of COPD symptoms. Other RCTs found that CHMs lower levels of TNF-α and IL-8 in sputum and serum, and regulate levels of T lymphocyte subsets and immunoglobulins. These effects were confirmed in some experimental studies. The Classical Chinese literature and modern RCTs identified several promising herbal formulae including Liu Jun Zi Tang (Six Gentleman Decoction), Bu Fei Tang (Tonify Lungs Decoction) and Shen Ge San (Ginseng and Gecko Powder) and a number of frequently used individual herbs for COPD including Ren shen (Panax ginseng), Dang shen (Codonopsis pilosula), Huang qi (Astragalus membranaceus), Bai zhu

    Effect of intravenous morphine bolus on respiratory drive in ICU patients

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    Assessment and interpretation of aerobic exercise (dys)function in paediatric patients with cystic fibrosis

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    The purpose of this thesis was to extend our understanding of the assessment and interpretation of aerobic exercise function of paediatric patients with cystic fibrosis (CF). The first investigation sought to establish (1) the validity of traditional criteria to verify maximal oxygen (V ̇O2max) during a maximal cardiopulmonary exercise test (CPET); and (2) the utility of supramaximal verification (Smax) to confirm V ̇O2max. Traditional criteria significantly underreported V ̇O2max, whilst Smax was shown to provide a valid measurement in this patient group. The reproducibility of this CPET protocol, over the short- (48 h) and medium- (4-6 weeks) term, was then established in study two. V ̇O2max was repeatedly determined with no learning effect over 48 h (typical error (TE): ∆150 mL; ∆9.3%) and 4-6 weeks (TE: ∆160 mL; ∆13.3%). Supplementary maximal and submaximal CPET parameters should be incorporated for a comprehensive evaluation of a patient, however they are characterised by greater variability over time. The influence of mild-to-moderate CF on aerobic exercise function and the matching of muscle O2 delivery-to-O2 utilisation during ramp incremental exercise to exhaustion were then examined in study three. Aerobic function was impaired in CF, indicated by very likely reduced fat-free mass normalised V ̇O2max (mean difference, ±90% CI: -7.9 mL∙kg-1∙min-1, ±6.1), very likely lower V ̇O2 gain (-1.44 mL∙min-1∙W-1, ±1.12) and a likely slower V ̇O2 mean response time (MRT) (11 s, ±13). Arterial oxygen saturation was lower in CF, supporting the notion that centrally mediated O2 delivery may be impaired during ramp incremental exercise. Although a faster rate of fractional O2 extraction would be expected in the face of reduced O2 delivery, this was not observed, suggesting additional impairment in O2 extraction and utilisation at the periphery in CF. The fourth study then demonstrated the clinical utility of CPET to assess the response to 12 weeks treatment with Ivacaftor, using a case-based design. Whilst one patient with relatively mild disease demonstrated no meaningful change in V ̇O2max, the second demonstrated a 30% improvement in V ̇O2max, due to increased O2 delivery and extraction. Furthermore, changes in aerobic function were detected earlier than spirometric indices of pulmonary function. This study demonstrated that CPET represents an important and comprehensive clinical assessment tool and its use as an outcome measure in the functional assessment of patients is encouraged. Study five investigated the V ̇O2 kinetics in this patient group. During moderate intensity cycling, the phase II V ̇O2 time constant (τ) (p = 0.84, effect size (ES) = 0.11) and overall MRT (p = 0.52, ES=0.33) were not slower in CF. However, both were slowed during very heavy intensity cycling (p = 0.02, ES = 1.28 and p = 0.01, ES = 1.40, respectively) in CF. Cardiac output and muscle deoxygenation dynamics were unaltered in CF, however, the arterial-venous O2 content difference (C(a-v ̅)O2) was reduced (p=0.03) during VH and ∆C(a-v ̅)O2 correlated with the phase II τ (r= -0.85; p=0.02) and MRT (r = -0.79; p=0.03) in CF. This study showed that impaired oxidative muscle metabolism in this group is exercise intensity-dependent and mechanistically linked to an intrinsic intramuscular impairment, which limits O2 extraction and utilisation. In conclusion, this thesis has provided guidelines for a valid and reproducible CPET protocol for children and adolescents with mild-to-moderate CF, demonstrated the utility of CPET as clinical outcome measure and furthered our understanding of the factors responsible for impaired aerobic exercise function in this patient group.Royal Devon and Exeter NHS Foundation TrustUniversity of Exete

    POSTER SESSIONS

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