New tools and optimization of existing tools for pulmonary rehabilitation and revalidation of patients with ventilatory impairment

La réhabilitation respiratoire (RR) est recommandée dans la prise en soin des patients atteints d’un handicap ventilatoire afin d’améliorer leur qualité de vie. Malgré une efficacité clairement établie, très peu de patients en bénéficient et les modalités optimales d’entrainement restent à définir. L’utilisation des outils existants et des nouveaux outils pour optimiser l’accès au programme et ses effets représentent des développements majeurs qui méritent d’être évalués. Dans le cadre de cette thèse, nous avons cherché à aborder ces deux problématiques (1) en tentant de proposer un modèle de RR délocalisée hors des centres tout en évaluant les freins à ce modèle et (2) en explorant la place de différents adjuvants à la RR afin d’en optimiser les bénéfices. Dans la première partie, nous avons montré, à travers plusieurs études rétrospectives et une contribution originale prospective multicentrique, que le test stepper de six minutes peut être utilisé pour prescrire l’entrainement en endurance, particulièrement pour les patients présentant une forme légère à modérée de bronchopneumopathie chronique obstructive (BPCO), mais pas pour prescrire le renforcement musculaire. Par ailleurs, nous avons montré dans une population de 105 patients adressés en RR que l’utilisation d’un dispositif de telemonitoring était faisable, valide et largement accepté. Enfin, nous avons exploré la prévalence des dysfonctions cognitives, autre conséquence systémique de la BPCO qui pourrait compromettre la délocalisation du programme, et avons montré que cette prévalence était très élevée (environ 75% des patients) mais que ces troubles cognitifs pouvaient s’améliorer après la RR et ne semblaient pas influencer l’utilisation d’un dispositif de telemonitoring. Dans la seconde partie, nous avons évalué la place de différents adjuvants à la RR utilisés pour en potentialiser les bénéfices. Dans une étude en cross-over menée chez 21 patients atteints de BPCO, nous avons montré que la ventilation non invasive ne permettait pas d’améliorer la capacité à l’exercice en endurance en raison d’une limitation technologique du ventilateur. A travers une étude contrôlée randomisée multicentrique menée chez 73 patients atteints de BPCO sévère à très sévère, nous avons montré que la stimulation électrique excito-motrice à domicile, réalisée en plus d’un programme de RR, n’apportait pas davantage de bénéfices sur la qualité de vie ou la capacité à l’exercice. Enfin, à travers une étude randomisée en cross-over et en double aveugle menée chez 10 patients, nous n’avons pas pu montrer l’intérêt de la stimulation électrique nerveuse transcutanée pour améliorer leur capacité à l’exercice en endurance. Enfin, dans la dernière partie, nous avons présenté les recherches actuellement menées au sein de notre laboratoire, faisant suite aux contributions originales décrites au cours de cette thèse, ainsi que de nouvelles pistes de recherche afin de poursuivre les thématiques explorées. Ainsi, deux revues de littérature et méta-analyses (l’une d’elle portant sur le haut débit nasal et l’autre sur l’utilisation des technologies de santé avancées pour réaliser la RR respiratoire à domicile) serviront de base pour de futurs travaux.Pulmonary rehabilitation (PR) is recommended in the management of subjects with ventilatory impairment to improve their quality of life. Although a large body of evidence support its use, only few subjects benefit from it and the optimal training modality has not been determined yet. In this context, the use of new and existing tools to optimize access as well as the effects of the program are major developments that deserve to be studied. As part of this thesis, we sought to explore these two major issues (1) by considering a rehabilitation model relocated outside the PR centres while assessing the obstacles to this model and (2) exploring the effectiveness of different add-on to PR in further optimizing the benefits of the program. In the first part, we have shown, through several retrospective studies and an original prospective multicentre contribution, that the six-minute stepper test can be used to prescribe endurance training, particularly for those patients with a mild to moderate chronic obstructive pulmonary disease (COPD), but not to prescribe muscle strengthening. Furthermore, we have shown in a cohort of 105 subjects referred for PR that the use of a remote tele monitoring device was feasible, valid and widely accepted. Finally, we explored the prevalence of cognitive dysfunction, another systemic impairment of COPD that could compromise the relocation of the program, and showed that it was a very common condition (around 75% of the subjects) but that it could improve following PR and did not seem to influence the use of a remote tele monitoring device. In the second part, we evaluated the effects of different add-on used to potentiate the benefits of the PR program. In a cross-over study of 21 COPD patients, we showed that non-invasive ventilation did not improve endurance exercise capacity due to technological limitation of the ventilator. Through a multicentre randomized controlled study carried out in 73 patients with severe to very severe COPD, we have shown that neuromuscular electrical stimulation at home, performed in addition to a PR program, did not provide further benefits on quality of life or exercise capacity. Finally, through a randomized cross-over double-blind study carried out in 10 patients, we were unable to show the effectiveness of transcutaneous nerve electrical stimulation in improving their endurance exercise capacity. Finally, in a last part, we highlighted the research currently carried out in our laboratory following the original contributions described during this thesis, as well as new area of research in order to pursue the themes explored. Thus, two systematic reviews and meta-analysis (the first about nasal high flow therapy in subjects with stable COPD and the second about the use of advanced telehealth technologies to deliver PR) will serve as a basis for future research

Nouveaux outils et optimisation des outils existants pour la réhabilitation respiratoire et la ré-autonomisation des patients atteints d'un handicap ventilatoire.

Pulmonary rehabilitation (PR) is recommended in the management of subjects with ventilatory impairment to improve their quality of life. Although a large body of evidence support its use, only few subjects benefit from it and the optimal training modality has not been determined yet. In this context, the use of new and existing tools to optimize access as well as the effects of the program are major developments that deserve to be studied. As part of this thesis, we sought to explore these two major issues (1) by considering a rehabilitation model relocated outside the PR centres while assessing the obstacles to this model and (2) exploring the effectiveness of different add-on to PR in further optimizing the benefits of the program. In the first part, we have shown, through several retrospective studies and an original prospective multicentre contribution, that the six-minute stepper test can be used to prescribe endurance training, particularly for those patients with a mild to moderate chronic obstructive pulmonary disease (COPD), but not to prescribe muscle strengthening. Furthermore, we have shown in a cohort of 105 subjects referred for PR that the use of a remote tele monitoring device was feasible, valid and widely accepted. Finally, we explored the prevalence of cognitive dysfunction, another systemic impairment of COPD that could compromise the relocation of the program, and showed that it was a very common condition (around 75% of the subjects) but that it could improve following PR and did not seem to influence the use of a remote tele monitoring device. In the second part, we evaluated the effects of different add-on used to potentiate the benefits of the PR program. In a cross-over study of 21 COPD patients, we showed that non-invasive ventilation did not improve endurance exercise capacity due to technological limitation of the ventilator. Through a multicentre randomized controlled study carried out in 73 patients with severe to very severe COPD, we have shown that neuromuscular electrical stimulation at home, performed in addition to a PR program, did not provide further benefits on quality of life or exercise capacity. Finally, through a randomized cross-over double-blind study carried out in 10 patients, we were unable to show the effectiveness of transcutaneous nerve electrical stimulation in improving their endurance exercise capacity. Finally, in a last part, we highlighted the research currently carried out in our laboratory following the original contributions described during this thesis, as well as new area of research in order to pursue the themes explored. Thus, two systematic reviews and meta-analysis (the first about nasal high flow therapy in subjects with stable COPD and the second about the use of advanced telehealth technologies to deliver PR) will serve as a basis for future research.La réhabilitation respiratoire (RR) est recommandée dans la prise en soin des patients atteints d’un handicap ventilatoire afin d’améliorer leur qualité de vie. Malgré une efficacité clairement établie, très peu de patients en bénéficient et les modalités optimales d’entrainement restent à définir. L’utilisation des outils existants et des nouveaux outils pour optimiser l’accès au programme et ses effets représentent des développements majeurs qui méritent d’être évalués. Dans le cadre de cette thèse, nous avons cherché à aborder ces deux problématiques (1) en tentant de proposer un modèle de RR délocalisée hors des centres tout en évaluant les freins à ce modèle et (2) en explorant la place de différents adjuvants à la RR afin d’en optimiser les bénéfices. Dans la première partie, nous avons montré, à travers plusieurs études rétrospectives et une contribution originale prospective multicentrique, que le test stepper de six minutes peut être utilisé pour prescrire l’entrainement en endurance, particulièrement pour les patients présentant une forme légère à modérée de bronchopneumopathie chronique obstructive (BPCO), mais pas pour prescrire le renforcement musculaire. Par ailleurs, nous avons montré dans une population de 105 patients adressés en RR que l’utilisation d’un dispositif de telemonitoring était faisable, valide et largement accepté. Enfin, nous avons exploré la prévalence des dysfonctions cognitives, autre conséquence systémique de la BPCO qui pourrait compromettre la délocalisation du programme, et avons montré que cette prévalence était très élevée (environ 75% des patients) mais que ces troubles cognitifs pouvaient s’améliorer après la RR et ne semblaient pas influencer l’utilisation d’un dispositif de telemonitoring. Dans la seconde partie, nous avons évalué la place de différents adjuvants à la RR utilisés pour en potentialiser les bénéfices. Dans une étude en cross-over menée chez 21 patients atteints de BPCO, nous avons montré que la ventilation non invasive ne permettait pas d’améliorer la capacité à l’exercice en endurance en raison d’une limitation technologique du ventilateur. A travers une étude contrôlée randomisée multicentrique menée chez 73 patients atteints de BPCO sévère à très sévère, nous avons montré que la stimulation électrique excito-motrice à domicile, réalisée en plus d’un programme de RR, n’apportait pas davantage de bénéfices sur la qualité de vie ou la capacité à l’exercice. Enfin, à travers une étude randomisée en cross-over et en double aveugle menée chez 10 patients, nous n’avons pas pu montrer l’intérêt de la stimulation électrique nerveuse transcutanée pour améliorer leur capacité à l’exercice en endurance. Enfin, dans la dernière partie, nous avons présenté les recherches actuellement menées au sein de notre laboratoire, faisant suite aux contributions originales décrites au cours de cette thèse, ainsi que de nouvelles pistes de recherche afin de poursuivre les thématiques explorées. Ainsi, deux revues de littérature et méta-analyses (l’une d’elle portant sur le haut débit nasal et l’autre sur l’utilisation des technologies de santé avancées pour réaliser la RR respiratoire à domicile) serviront de base pour de futurs travaux

Correspondence: High positive airway pressure could shorten the drainage period in haemothorax but not physiotherapy intervention.

Dos Santos et al conducted a thorough randomised controlled trial with high methodological quality, in which they attempted to evaluate whether mobilisation and respiratory techniques shorten the drainage period and length of hospital stay in patients with pleural effusion. Their second objective was to evaluate whether such a strategy combined with continuous positive airway pressure (CPAP) could further improve the benefits. [...

Programme d'éducation thérapeutique destiné aux patients atteints de BPCO dans le cadre d'un programme de réhabilitation respiratoire : bilan de la première année d'activité

Introduction : La bronchopneumopathie chronique obstructive (BPCO) est une maladie respiratoire progressive, non réversible et invalidante. Le contrôle des facteurs de risque initiaux ou aggravants, associé à une bonne hygiène de vie et un traitement médicamenteux, permet d'en stabiliser l'évolution. Dans ce contexte, l'Éducation Thérapeutique du Patient (ETP) s'inscrit dans la prise en charge globale de la BPCO. Objectif : Évaluer la première année d'activité d'un programme d'ETP destiné aux patients BPCO adressés pour réentraînement à l'effort (REE). Méthode : Analyse rétrospective des dossiers traités par le programme d'ETP du 1er juillet 2015 au 30 juin 2016. Résultats : Cinquante-six patients BPCO ont été adressés pour REE sur cette période. Vingt-six ont refusé le programme d'ETP. Trente patients [62,5 (7,6) ans / VEMS 41,0 (25,3–54,0) %] ont été inclus. Vingt ont complété l'intégralité du programme d'ETP. Les questionnaires rapportent une amélioration significative des connaissances acquises au cours des ateliers. Les objectifs éducatifs sont atteints pour 63 % des patients. Le principal frein est la difficulté à sensibiliser les patients ne réalisant pas leur REE en centre (domicile ou kinésithérapeute de ville). Conclusion : Ce premier bilan rapporte des résultats qualitatifs encourageants malgré un effectif d'inclusion limité. Il permet en outre de cerner le profil des patients ciblés ainsi que de dégager les pistes d'améliorations nécessaires

Enhanced Recovery after Surgery (ERAS) Implementation and Barriers among Healthcare Providers in France: A Cross-Sectional Study

The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the “Environmental context and resources” domain (57.6%, 95%CI: 49.5–65.4), e.g., lack of professionals, funding, and coordination, and the “Knowledge” domain (52.8%, 95%CI: 44.7–60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS

Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study

International audienceBackground: Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving transcutaneous electrical stimulation of the diaphragm (TEDS) is increasing but none report results for diaphragmatic measurements, and they lack power. We hypothesised that the use of TEDS would decrease diaphragmatic dysfunction and improve respiratory muscle strength in patients in ICU. Methods: We conducted a controlled trial to assess the impact of daily active electrical stimulation versus sham stimulation on the prevention of diaphragm dysfunction during the weaning process from mechanical ventilation. The evaluation was based on ultrasound measurements of diaphragm thickening fraction during spontaneous breathing trials. We also measured maximal inspiratory muscle pressure (MIP), peak cough flow (PEF) and extubation failure. Results: Sixty-six patients were included and randomised using a 1:1 ratio. The mean number of days of mechanical ventilation was 10 ± 6.8. Diaphragm thickening fraction was > 30% at the SBT for 67% of participants in the TEDS group and 54% of the Sham group (OR1.55, 95% CI 0.47–5.1; p = 0.47). MIP and PEF were similar in the TEDS and Sham groups (respectively 35.5 ± 11.9 vs 29.7 ± 11.7 cmH20; p = 0.469 and 83.2 ± 39.5 vs. 75.3 ± 34.08 L/min; p = 0.83). Rate of extubation failure was not different between groups. Conclusion: TEDS did not prevent diaphragm dysfunction or improve inspiratory muscle strength in mechanically ventilated patients. Trial registration: Prospectively registered on the 20th November 2019 on ClinicalTrials.gov Identifier NCT04171024

Clinimetric evaluation of muscle function tests for individuals with cystic fibrosis: A systematic review.

Accurate testing of muscle function is essential in individuals with cystic fibrosis (CF). A literature search was conducted in MEDLINE, CENTRAL, CINAHL, PEDro, ScienceDirect and Web of Science according to PRISMA and COSMIN guidelines from inception to September 2019 to investigate the clinimetric properties of muscle tests in individuals with CF. The search identified 37 studies (1310 individuals) and 34 different muscle tests. Maximal inspiratory pressure, inspiratory work capacity and quadriceps strength measured by computerised dynamometry were identified as reliable tests of muscle function. The one-minute sit-to-stand test was found to have high reliability but its validity to measure quadriceps strength is unknown. The clinimetric properties of other routinely used tests have not been reported in people with CF. Very different measurement procedures were identified. Inspiratory muscle and quadriceps testing can be considered as reliable but high-quality studies evaluating tests of other muscles function (e.g. muscle endurance) are lacking

ICU outcomes can be predicted by non invasive muscle evaluation ::a meta-analysis

Background The relationship between muscle function in critically ill patients assessed using bedside techniques and clinical outcomes has not been systematically described. We aimed to evaluate the association between muscle weakness assessed by bedside evaluation and mortality or weaning from mechanical ventilation, and the capacity of each evaluation tool to predict outcomes. Methods Five databases (PubMed, EMBASE, CINAHL, Cochrane library, Science Direct) were searched from January 2000 to December 2018. Data were extracted and random effects meta-analyses were performed. Results Sixty studies were analysed, including 4382 patients. ICU-related muscle weakness was associated with an increase in overall mortality with odds ratios ranging from 1.2 [95% CI 0.60 to 2.40] to 4.48 [95% CI 1.49 to 13.42]. Transdiaphragmatic twitch pressure had the highest predictive capacity for overall mortality, with a sensitivity of 0.87 [95%CI 0.76 to 0.93] and a specificity of 0.36 [95%CI 0.27–0.43]. The area under the curve (AUC) was 0.74 [95%CI 0.70 to 0.78]. Muscle weakness was associated with an increase in mechanical ventilation weaning failure rate with an odds ratio ranging from 2.64 [95% CI 0.72 to 9.64] to 19.07 [95% CI 9.35 to 38.9]. Diaphragm thickening fraction had the highest predictive capacity for weaning failure with a sensitivity of 0.76 [95%CI 0.67 to 0.83] and a specificity of 0.86 [95%CI 0.78 to 0.92]. The AUC was 0.86 [95%CI 0.83 to 0.89]. Conclusion ICU-related muscle weakness detected by bedside techniques is a serious issue associated with a high risk of death or prolonged mechanical ventilation. Evaluating diaphragm function should be a clinical priority in the ICU

Video abstracts are associated with an increase in research reports citations, views and social attention: a cross-sectional study

International audienc