The clinical utility of forced oscillation technique during hospitalisation in patients with exacerbation of COPD

Background: Forced Oscillation Technique (FOT) is an innovative tool to measure within-breath reactance at 5 Hz (ΔXrs5Hz) but its feasibility and utility in acute exacerbations of COPD (AECOPD) is understudied. Methods: A prospective observational study was conducted in 82 COPD patients admitted due to AECOPD. FOT indices were measured and the association between these indices and spirometry, peak inspiratory flow rate, blood inflammatory biomarkers and patient-reported outcomes including assessment of dyspnoea, quality of life, anxiety and depression and frailty at admission and discharge were explored. Results: All patients were able to perform FOT in both sitting and supine position. The prevalence of expiratory flow limitation (EFL) in the upright position was 39% (32 out of 82) and increased to 50% (41 out of 82) in the supine position. EFL (measured by ΔXrs5Hz) and resistance at 5 Hz (Rrs5Hz) negatively correlated with forced expiratory volume in 1 s (FEV1); those with EFL had lower FEV1 (0.74±0.30 versus 0.94±0.36 L, p = 0.01) and forced vital capacity (1.7±0.55 versus 2.1±0.63 L, p = 0.009) and higher body mass index (27 (21-36) versus 23 (19-26) kg·m-2, p = 0.03) compared to those without EFL. During recovery from AECOPD, changes in EFL were observed in association with improvement in breathlessness. Conclusion: FOT was easily used to detect EFL during hospitalisation due to AECOPD. The prevalence of EFL increased when patients moved from a seated to a supine position and EFL was negatively correlated with airflow limitation. Improvements in EFL were associated with a reduction in breathlessness. FOT is of potential clinical value by providing a noninvasive, objective and effort-independent technique to measure lung function parameters during AECOPD requiring hospital admission

Home monitoring of physiology and symptoms to detect Interstitial Lung Disease exacerbations and progression: a systematic review

BACKGROUND: Acute exacerbations and disease progression in interstitial lung disease (AE-ILD) pose important challenges to clinicians and patients. AE-ILD are variable in presentation but may result in rapid progression of ILD, respiratory failure and death. However, in many cases AE-ILD may go unrecognised so that their true impact and response to therapy is unknown. The potential for home monitoring to facilitate early, and accurate, identification of AE and/or ILD progression has gained interest. With increasing evidence available, there is a need for a systematic review on home monitoring of patients with ILD to summarise the existing data. AIMS: To systematically evaluate the evidence for use of home monitoring for early detection of exacerbations and/or progression of ILD. METHOD: We searched Ovid-EMBASE, MEDLINE, and CINAHL using MeSH terms in accordance with the PRISMA guidelines. PROSPERO registration number (CRD42020215166). RESULTS: Thirteen studies comprising 968 patients have demonstrated that home monitoring is feasible and of potential benefit in patients with ILD. Nine studies reported that mean adherence to home monitoring was greater than 75%, and where spirometry was performed there was a significant correlation (r=0.72–0.98, p<0.001) between home and hospital-based readings. Two studies suggested that home monitoring of Forced Vital Capacity (FVC) might facilitate detection of progression in idiopathic pulmonary fibrosis (IPF). CONCLUSION: Despite the fact that individual studies in this systematic review provide supportive evidence suggesting the feasibility and utility of home monitoring in ILD, further studies are necessary to quantify the potential of home monitoring to detect disease progression and/or acute exacerbations

Nutritional supplementation during pulmonary rehabilitation in COPD: A systematic review

Uptake of nutritional supplementation during pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD) has been limited by an absence of rigorous evidence-based studies supporting use. The objective was to report and summarise the current evidence supporting the use of nutritional supplementation to improve outcomes during PR in stable COPD patients. A systematic search was conducted up to 7 August 2019 (registration number CRD42018089142). The preferred reporting items for systematic reviews and meta-analyses guidelines were used. Six databases were included: Medical Literature Analysis and Retrieval System Online or MEDLARS Online, Allied and Complementary Medicine Database, the Cochrane Database of Systematic Reviews, Excerpta Medica dataBASE, Cumulative Index of Nursing and Allied Health Literature and Web of Science. This systematic search generated 580 initial matches, of which 22 studies (917 COPD participants) met the pre-specified criteria and were included. Sixteen of 19 studies that used nutritional supplements in addition to PR did not show additional benefit compared to PR alone when measuring exercise capacity. Nutritional supplements significantly increased body weight in 7 of 11 studies. Body mass index increased significantly in two of six studies. Handgrip strength did not improve, while quadriceps muscle strength significantly improved in 3 of 11 studies. Four of eight studies showed a significant improvement in inspiratory muscle function. Only 2 of 14 studies demonstrated a significant improvement in quality of life with supplementation in addition to PR. There remains insufficient evidence on the effect of nutritional supplementation on improving outcomes during PR in patients with COPD due to heterogeneity in supplements, outcome measures and PR programmes. Therefore, controversy remains and further research is needed

Once Daily Versus Overnight and Symptom Versus Physiological Monitoring to Detect Exacerbations of Chronic Obstructive Pulmonary Disease: Pilot Randomized Controlled Trial

Background: Earlier detection of chronic obstructive pulmonary disease (COPD) exacerbations may facilitate more rapid treatment with reduced risk of hospitalization. Changes in pulse oximetry may permit early detection of exacerbations. We hypothesized that overnight pulse oximetry would be superior to once-daily monitoring for the early detection of exacerbations. / Objective: This study aims to evaluate whether measuring changes in heart rate and oxygen saturation overnight is superior to once-daily monitoring of both parameters and to assess symptom changes in facilitating earlier detection of COPD exacerbations. / Methods: A total of 83 patients with COPD were randomized to once-daily or overnight pulse oximetry. Both groups completed the COPD assessment test questionnaire daily. The baseline mean and SD for each pulse oximetry variable were calculated from 14 days of stable monitoring. Changes in exacerbation were expressed as Z scores from this baseline. / Results: The mean age of the patients was 70.6 (SD 8.1) years, 52% (43/83) were female, and the mean FEV1 was 53.0% (SD 18.5%) predicted. Of the 83 patients, 27 experienced an exacerbation. Symptoms were significantly elevated above baseline from 5 days before to 12 days after treatment initiation. Day-to-day variation in pulse oximetry during the stable state was significantly less in the overnight group than in the once-daily group. There were greater relative changes at exacerbation in heart rate than oxygen saturation. An overnight composite score of change in heart rate and oxygen saturation changed significantly from 7 days before initiation of treatment for exacerbation and had a positive predictive value for exacerbation of 91.2%. However, this was not statistically better than examining changes in symptoms alone. / Conclusions: Overnight pulse oximetry permits earlier detection of COPD exacerbations compared with once-daily monitoring. Monitoring physiological variables was not superior to monitoring symptoms, and the latter would be a simpler approach, except where there is a need for objective verification of exacerbations. / Trial Registration: ClinicalTrials.gov NCT03003702; https://clinicaltrials.gov/ct2/show/NCT0300370

Global use, utility, and methods of tele-health in COPD: a health care provider survey

Introduction: Advances in technology offer various solutions that might help optimize the care provided to patients living with chronic non-communicable diseases such as chronic obstructive pulmonary disease (COPD). However, the efficacy of tele-health in COPD is still controversial. Despite this, there appears to be widespread adoption of this technology. // Aim: To explore the international use of tele-heath for COPD, to assess the perceptions of clinicians employing tele-health in COPD, and to summarize the techniques that have been used by health care providers to personalize alarm limits for patients with COPD enrolled on tele-health programs. // Methods: A cross-sectional survey consisting of 15 questions was distributed and advertised to health care professionals worldwide. Questions were designed to cover five different aspects of tele-health in COPD: purpose of use, equipment type, clinician perceptions, variables monitored, and personalization of alarm limits. // Results: A total of 138 participants completed the survey from 29 different countries. As high as 59% of the participants had ever used tele-health for COPD, and 33% still provided tele-health services to patients with COPD. Tele-health was most commonly used for baseline monitoring, with 90% believing it to be effective. The three most commonly monitored variables were oxygen saturation, heart rate, and the use of rescue medication. // Conclusion: Twenty-nine different countries use tele-health for managing COPD and therefore there is widespread international use of tele-health in COPD. The majority of providers thought tele-health was effective despite evidence to the contrary

Pulmonary rehabilitation, physical activity and aortic stiffness in COPD

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have elevated cardiovascular risk, and cardiovascular disease is a major cause of death in COPD. The current literature indicates that changes in cardiovascular risk during pulmonary rehabilitation (assessed using aortic stiffness) are heterogeneous suggesting that there may be sub-groups of patients who do and do not benefit. OBJECTIVES: To investigate the characteristics of COPD patients who do and do not experience aortic stiffness reduction during pulmonary rehabilitation, examine how changes relate to physical activity and exercise capacity, and assess whether changes in aortic stiffness are maintained at 6 weeks following rehabilitation. METHODS: We prospectively measured arterial stiffness (aortic pulse-wave velocity), exercise capacity (Incremental Shuttle Walk Test) and physical activity (daily step count) in 92 COPD patients who started a six week pulmonary rehabilitation programme, 54 of whom completed rehabilitation, and 29 of whom were re-assessed six weeks later. RESULTS: Whilst on average there was no influence of pulmonary rehabilitation on aortic stiffness (pre- vs. post pulse-wave velocity 11.3 vs. 11.1 m/s p = 0.34), 56% patients responded with a significant reduction in aortic stiffness. Change in aortic stiffness (absolute and/or percentage) during rehabilitation was associated with both increased physical activity (rho = - 0.30, p = 0.042) and change in exercise capacity (rho = - 0.32, p = 0.02), but in multivariable analysis most closely with physical activity. 92% of the responders who attended maintained this response six weeks later. CONCLUSION: Elevated aortic stiffness in COPD is potentially modifiable in a subgroup of patients during pulmonary rehabilitation and is associated with increased physical activity. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03003208. Registered 26/12/ 2016

'Caution, this treatment is a placebo. It might work, but it might not': why emerging mechanistic evidence for placebo effects does not legitimise complementary and alternative medicines in sport

Complementary and alternative medicines (CAM) are treatments for which either evidence is lacking, or for which evidence suggests no effect over a placebo treatment. When a non-evidence-based treatment is used alongside conventional medicine, it is considered ‘complementary’. When a non- evidence-based treatment is used instead of conventional medicine, it is considered ‘alternative’. Many forms of CAM have origins and/or a history of use beyond evidence-based medicine. Further, many CAM treatments are based on principles and/or evidence that are not recognised by the majority of independent scientists. When a person uses CAM and experiences an improvement in symptoms, this may be due to the placebo effect.Published versio