Acute thoracoabdominal and hemodynamic responses to tapered flow resistive loading in healthy adults

We investigated the acute physiological responses of tapered flow resistive loading (TFRL) at 30, 50 and 70% maximal inspiratory pressure (PImax) in 12 healthy adults to determine an optimal resistive load. Increased end-inspiratory rib cage and decreased end-expiratory abdominal volumes equally contributed to the expansion of thoracoabdominal tidal volume (captured by optoelectronic plethysmography). A significant decrease in end-expiratory thoracoabdominal volume was observed from 30 to 50% PImax, from 30 to 70% PImax, and from 50 to 70% PImax. Cardiac output (recorded by cardio-impedance) increased from rest by 30% across the three loading trials. Borg dyspnoea increased from 2.36 ± 0.20 at 30% PImax, to 3.45 ± 0.21 at 50% PImax, and 4.91 ± 0.25 at 70% PImax. End-tidal CO2 decreased from rest during 30, 50 and 70 %PImax (26.23 ± 0.59, 25.87 ± 1.02 and 24.30 ± 0.82 mmHg, respectively). Optimal intensity for TFRL is at 50% PImax to maximise global respiratory muscle and cardiovascular loading whilst minimising hyperventilation and breathlessness

Effect of portable non-invasive ventilation on exercise tolerance in COPD: One size does not fit all

In a cross-over RCT, portable NIV (pNIV) reduced dynamic hyperinflation (DH) compared to pursed lip breathing (PLB) during recovery from intermittent exercise in COPD, but not consistently in all subjects. In this post-hoc analysis, DH response was defined as a reduction ≥4.5 % of predicted resting inspiratory capacity with pNIV compared to PLB. At exercise iso-time (where work completed was consistent between pNIV and PLB), 8/24 patients were DH non-responders (DH: 240 ± 40 mL, p = 0.001 greater using pNIV). 16/24 were DH responders (DH: 220 ± 50 mL, p = 0.001 lower using pNIV). Compared to DH responders, DH non-responders exhibited greater resting DH (RV/TLC: 65 ± 4% versus 56 ± 2%; p = 0.028) and did not improve exercise tolerance (pNIV: 30.9 ± 3.4 versus PLB: 29.9 ± 3.3 min; p = 0.603). DH responders increased exercise tolerance (pNIV: 34.9 ± 2.4 versus PLB: 27.1 ± 2.3 min; p = 0.001). Resting RV/TLC% was negatively associated with the magnitude of DH when using pNIV compared to PLB (r=-0.42; p = 0.043). Patients with profound DH were less likely to improve exercise tolerance with pNIV. Further studies using auto-adjusted ventilators are warranted

Prescribing and adjusting exercise training in chronic respiratory diseases – Expert-based practical recommendations

Background International guidelines recommend endurance (ET) and strength training (ST) in patients with chronic respiratory diseases (CRDs), but only provide rough guidance on how to set the initial training load. This may unintentionally lead to practice variation and inadequate training load adjustments. This study aimed to develop practical recommendations on tailoring ET and ST based on practices from international experts from the field of exercise training in CRDs. Methods 35 experts were invited to address a 64-item online survey about how they prescribe and adjust exercise training. Results Cycling (97%) and walking (86%) were the most commonly implemented ET modalities. Continuous endurance training (CET, 83%) and interval endurance training (IET, 86%) were the frequently applied ET types. Criteria to prescribe IET instead of CET were: patients do not tolerate CET due to dyspnoea at the initial training session (79%), intense breathlessness during initial exercise assessment (76%), and/or profound exercise-induced oxygen desaturation (59%). For ST, most experts (68%) recommend 3 sets per exercise; 62% of experts set the intensity at a specific load that patients can tolerate for a range of 8 to 15 repetitions per set. Also, 56% of experts advise patients to approach local muscular exhaustion at the end of a single ST set. Conclusions The experts´ practices were summarized to develop practical recommendations in the form of flowcharts on how experts apply and adjust CET, IET, and ST in patients with CRDs. These recommendations may guide health care professionals to optimize exercise training programs in patients with CRDs

Effect of portable noninvasive ventilation on thoracoabdominal volumes in recovery from intermittent exercise in patients with COPD

We previously showed that use of portable noninvasive ventilation (pNIV) during recovery periods within intermittent exercise improved breathlessness and exercise tolerance in patients with COPD compared with pursed-lip breathing (PLB). However, in a minority of patients recovery from dynamic hyperinflation (DH) was better with PLB, based on inspiratory capacity. We further explored this using Optoelectronic Plethysmography to assess total and compartmental thoracoabdominal volumes. Fourteen patients with COPD (means ± SD) (FEV1: 55% ± 22% predicted) underwent, in a balanced order sequence, two intermittent exercise protocols on the cycle ergometer consisting of five repeated 2-min exercise bouts at 80% peak capacity, separated by 2-min recovery periods, with application of pNIV or PLB in the 5 min of recovery. Our findings identified seven patients showing recovery in DH with pNIV (DH responders) whereas seven showed similar or better recovery in DH with PLB. When pNIV was applied, DH responders compared with DH nonresponders exhibited greater tidal volume (by 0.8 ± 0.3 L, P = 0.015), inspiratory flow rate (by 0.6 ± 0.5 L/s, P = 0.049), prolonged expiratory time (by 0.6 ± 0.5 s, P = 0.006), and duty cycle (by 0.7 ± 0.6 s, P = 0.007). DH responders showed a reduction in end-expiratory thoracoabdominal DH (by 265 ± 633 mL) predominantly driven by reduction in the abdominal compartment (by 210 ± 494 mL); this effectively offset end-inspiratory rib-cage DH. Compared with DH nonresponders, DH responders had significantly greater body mass index (BMI) by 8.4 ± 3.2 kg/m2, P = 0.022 and tended toward less severe resting hyperinflation by 0.3 ± 0.3 L. Patients with COPD who mitigate end-expiratory rib-cage DH by expiratory abdominal muscle recruitment benefit from pNIV application. NEW & NOTEWORTHY Compared with the pursed-lip breathing technique, acute application of portable noninvasive ventilation during recovery from intermittent exercise improved end-expiratory thoracoabdominal dynamic hyperinflation (DH) in 50% of patients with COPD (DH responders). DH responders, compared with DH nonresponders, exhibited a reduction in end-expiratory thoracoabdominal DH predominantly driven by the abdominal compartment that effectively offset end-expiratory rib cage DH. The essential difference between DH responders and DH nonresponders was, therefore, in the behavior of the abdomen

The effect of COVID rehabilitation for ongoing symptoms Post HOSPitalisation with COVID-19 (PHOSP-R):protocol for a randomised parallel group controlled trial on behalf of the PHOSP consortium

Introduction Many adults hospitalised with COVID-19 have persistent symptoms such as fatigue, breathlessness and brain fog that limit day-to-day activities. These symptoms can last over 2 years. Whilst there is limited controlled studies on interventions that can support those with ongoing symptoms, there has been some promise in rehabilitation interventions in improving function and symptoms either using face-to-face or digital methods, but evidence remains limited and these studies often lack a control group. Methods and analysis This is a nested single-blind, parallel group, randomised control trial with embedded qualitative evaluation comparing rehabilitation (face-to-face or digital) to usual care and conducted within the PHOSP-COVID study. The aim of this study is to determine the effectiveness of rehabilitation interventions on exercise capacity, quality of life and symptoms such as breathlessness and fatigue. The primary outcome is the Incremental Shuttle Walking Test following the eight week intervention phase. Secondary outcomes include measures of function, strength and subjective assessment of symptoms. Blood inflammatory markers and muscle biopsies are an exploratory outcome. The interventions last eight weeks and combine symptom-titrated exercise therapy, symptom management and education delivered either in a face-to-face setting or through a digital platform (www.yourcovidrecovery.nhs.uk). The proposed sample size is 159 participants, and data will be intention-to-treat analyses comparing rehabilitation (face-to-face or digital) to usual care. Ethics and dissemination Ethical approval was gained as part of the PHOSP-COVID study by Yorkshire and the Humber Leeds West Research NHS Ethics Committee, and the study was prospectively registered on the ISRCTN trial registry (ISRCTN13293865). Results will be disseminated to stakeholders, including patients and members of the public, and published in appropriate journals. Article summary Strengths and limitations of this study • This protocol utilises two interventions to support those with ongoing symptoms of COVID-19 • This is a two-centre parallel-group randomised controlled trial • The protocol has been supported by patient and public involvement groups who identified treatments of symptoms and activity limitation as a top priorit

A novel intermittent shuttle walking protocol in the context of pulmonary rehabilitation in patients with COPD

In patients with COPD pulmonary rehabilitation (PR) delivered using minimal equipment induces clinically meaningful improvements in functional capacity and quality of life that are non inferior to PR delivered using specialist equipment. Within this PR setting, walking is simple to perform and easy to administer, hence there has been a growing interest in studies investigating the effectiveness of different walking modalities. Walking activity is typically prescribed at 70-85% of predicted VO2 peak derived from the incremental shuttle walk test (ISWT) or at 70-80% of the average walking speed recorded during the 6-min walk test(6MWT). Patients with advanced COPD are, however, unable to walk uninterruptedly at such walking paces to optimise training benefits. Intolerable symptoms of dyspnoea typically limit walking tolerance to 5-7 minutes. In these patients, intermittent compared to continuous cycling has shown to prolong endurance time secondary to lower sensations of dyspnoea. A systematic review and meta-analysis, undertaken as part of this thesis, suggested that intermittent compared to continuous cycle training leads to superior improvements in peak exercise capacity and dyspnoea sensations in patients with respiratory diseases. Accordingly, the main objective of the thesis was to evaluate whether acute implementation of an intermittent (IntSW) compared to a continuous (CSW) shuttle walking protocol could enhance walking tolerance in patients with advanced COPD. A mixed methods study design was implemented to evaluate differences in walking distance, endurance time, circulatory and symptom responses between the two walking modalities and to fully appreciate patients’ experiences of undertaking the two walking protocols. Twenty stable patients with COPD (mean age: 66±8; FEV1 % predicted: 53±22) initially undertook an ISWT. On two separate visits, 14/20 patients (FEV1 % predicted: 45±21) undertook a CSW protocol and subsequently an IntSW protocol. The CSW protocol was always performed before the IntSW protocol because walking distance was expected to be shorter during the CSW protocol; this allowed comparisons of physiological variables and symptoms at iso-distance (i.e.: the distance walked during the IntSW protocol corresponding to the distance at the limit of tolerance of the CSW protocol). Both protocols were sustained at a walking pace equivalent to 85% of predicted VO2 peak derived from the ISWT to ensure comparisons of variables were made at the same walking pace. Focus groups engaged 10/14 patients on a separate visit. At the outset of the study patients walking distance during the ISWT corresponded to 41% of that recorded from 20 healthy age-matched individuals (age: 68±3; FEV1 % predicted: 112±16). In patients with COPD, median (IQR) walking distance during the IntSW protocol [735 (375- 1107) m] was almost four times greater (p=0.001) compared to that during the CSW protocol [190 (117-360) m]. At iso-distance, the IntSW compared to the CSW protocol was associated with a lower (p=0.013) circulatory load (cardiac output: 8.6±2.6 versus 10.3±3.7 L/min) and lower (p=0.002) arterial oxygen desaturation (SpO2: 92±6% versus 90±7%) while patients experienced less intense (p=0.001) breathlessness (2.8±1.3 versus 4.9±1.4) and leg discomfort (2.3±1.7 versus 4.2±2.2; p=0.001). At the limit of tolerance, symptoms of breathlessness and leg discomfort were not different between the two modalities, suggesting that both walking modalities were limited by reaching comparable intensity of symptoms which took longer during the IntSW compared to the CSW protocol. The IntSW protocol was perceived as a simple and tolerable activity that could potentially enhance general wellbeing. Based on patients’ views, the IntSW protocol was preferable to the CSW protocol because it resembled activities of daily living. Application of intermittent walking in the PR setting may provide important training benefits to patients with advanced COPD because it allows greater work outputs with less intense exertional symptoms and lower circulatory loads

Gastrocolic fistulae; From Haller till nowadays

Gastrocolic Fistula is, in the majority of cases the pathological communication between stomach and transverse colon, because cases involved with the small intestine, pancreas and skin have been also documented, even though are rare. It occurs mostly in adults, but they can be present to infants, as well, as a result of congenital abnormalities or iatrogenic procedures (i.e. migration of PEG tube that placed before). In the Western Countries, the most common cause is the adenocarcinoma of the colon, while in Japan, adenocarcinoma of the stomach is the most frequent cause. It seldom appears, as a complication of a benign peptic ulcer, in Crohn’s disease and as a result of significant intake of steroids or NSAIDs. The typical symptoms of a gastrocolic fistula are abdominal pain, nausea-vomiting, diarrhea and weight loss. Radiology has been used for the detection of the fistulae all these years but the golden standard remained the barium enema. Barium meal and CT findings play a smaller role in the diagnosis. Although the management of gastrocolic fistulae has historically been surgical, medical treatment has recently been recommended as the first line when a malignancy can be excluded. (c) 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved