Rehabilitation of COPD patients: which training modality?

Non pharmacological therapy has been gaining more interest and has been evolving rapidly over the last decade as an essential part of therapy for COPD patients. Pulmonary Rehabilitation (PR), the most important non pharmacological treatment in patients with COPD, has a primary goal: to achieve the highest possible level of individual exercise tolerance, thus reducing the primary and/or secondary health care utilisation. The aim of the present review is to focus the role of exercise training in these patients as well as to address the question on which training methods are the most beneficial. We have therefore undertaken a MEDLINE-based search including the terms: pulmonary rehabilitation, exercise, lung disease/obstructive. Several strategies based on endurance or strength training are nowadays implemented during PR programmes in order to maximise the benefits for each patient. The impaired function of ambulation muscles causing breathlessness as one of the more frequent symptoms in many COPD, suggests that training the lower extremities is the most important goal to achieve during pulmonary rehabilitation of these patients. On the other hand, as muscle strength appears to be an independent contributor to survival and utilisation of health care resources, it seems largely justified also to include this further modality in the PR program of these patients. In conclusion, both modalities are effective and useful for COPD patients. However, whether resistance training should be administered to all COPD and which is the optimal length of strength training still needs to be elucidated

Chronic critical illness: the price of survival

BACKGROUND: The evolution of the techniques used in the intensive care setting over the past decades has led on one side to better survival rates in patients with acute conditions and severely impaired vital functions. On the other side, it has resulted in a growing number of patients who survive an acute event, but who then become dependent on one or more life support techniques. Such patients are called chronically critically ill patients. MATERIALS & METHODS: No absolute definition of the disease is currently available, although most patients are characterized by the need for prolonged mechanical ventilation. Mortality rates are still high even after dismissal from intensive care unit (ICU) and transfer to specialized rehabilitation care settings. RESULTS: In recent years, some studies have tried to clarify the pathophysiological characteristics underlying chronic critical illness (CCI), a disease that is also characterized by severe endocrine and inflammatory impairments, partly accounting for the almost constant set of symptoms. DISCUSSION: Currently, no specific treatment is available. However, a strategic early therapeutic approach on ICU admission might try to prevent the progress of the acute disease towards chronic critical illness

Commencing rehabilitation in the ICU.

Rehabilitation is an integral part of the management of patients inIntensive Care Units (ICUs).The most important aim in this area isto enhance the patient's overall functional capacity and to restorehis/her respiratory and physical independence, thus decreasing the risks of bed-rest and associated complications.The evidence for applying a weaning protocol and physiotherapytechniques (postures, percussion/vibration, limb exercise, and active mobilization) in these patients has proved to be effective according to the application rationale of each process. However, todate, there are only strong recommendations concerning the evidence-based strategies to speed weaning from mechanical ventilation.Early physiotherapy may be effective in the ICU: nonetheless,most techniques need to be further studied in a wider population.In particular, evidence supporting physiotherapy interventionsis limited as there are no studies examining the specific effectsof interventions on long-term outcomes

Platelet activation and cardiovascular co-morbidities in patients with chronic obstructive pulmonary disease.

Objective: Platelet activation in COPD patients is associated with an increased risk of cardiovascular events. Aim of the study: to assess the mean platelet volume (MPV), as an index of platelet activation, in patients with COPD both when stable or during exacerbation. Research design and methods: 478 patients with COPD (75 with exacerbation) and 72 age-matched healthy controls were enrolled. Medical history, co-morbidities, medications, pulmonary function tests, MPV and blood cell count, erythrocyte sedimentation rate (ERS) and C reactive protein (CRP) were recorded. Results: MPV was higher in COPD patients than in controls (8.7 \ub1 1.1 fL and 8.4 \ub1 0.8 fL respectively, p = 0.025) and increased across the severity of the diseases as assessed by the GOLD post bronchodilator FEV1 categorized I to IV (p>0.05). MPV was higher in COPD patients during acute exacerbation as compared with stable condition (8.7 \ub1 1.0 fL and 8.9 \ub1 1.0 fL, p = 0.021). MPV 65 10.5 fL correlated with the presence of at least one co-existing cardiovascular disease (p = 0.008) . No correlation was observed between MPV and CRP or ERS in patients or in controls. An inverse significant correlation was found between platelets count and MPV in COPD patients. Conclusions: Elevated MPV is associated with lower platelet count and with cardiovascular co-morbidity in COPD patients. MPV value is higher in more severe COPD and during acute exacerbation. Present findings warrant future studies to confirm a possible clinically relevant role for platelet activation and cardiovascular risk in the population of COPD

Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis

Background. Treatment of bronchiectasis includes drugs, oxygen therapy and bronchial clearance maneuvers. The aim of the current study was to assess safety and efficacy of IntrapulmonaryPercussive Ventilation when compared with usual Chest Physical Therapy in patients with bronchiectasis Methods. In two consecutive days, 22 patients underwent both Intrapulmonary Percussive Ventilation and Chest Physical Therapy following a randomized cross-over design. At inclusion (T0), at the end of 30-min session (T1), and after 30 min (T2) and 4 hrs (T3), side effects, heart rate, oxygen saturation rate, respiratory rate, sensation of phlegm encumbrance and dyspneameasured by visual analogue scales, were recorded. At T1, discomfort measured by visual analogue scales was also recorded. At T3, we evaluated efficacy in terms of volume (ml), and wet and dry weight (g) of sputum. Results. Side effects were not so severe as to determine study discontinuation and were similar (27%) between the two treatments. Heart rate (p<.001) and respiratory rate (p=0.047) decreased over time while sensation of phlegm encumbrance improved (p=0.026) withboth treatments. Only Intrapulmonary Percussive Ventilation improved (p=0.004) sensation of dyspnea and resulted more comfortable than Chest Physical Therapy (p=0.032). The two treatments caused important phlegm production without differences in total volume, and both wet and dry weight. Conclusions. In patients with bronchiectasis and productive cough, short-term application of Intrapulmonary Percussive Ventilation is similarly safe and effective than traditional chestPhysical Therapy with less discomfort. Further studies on cost-effectiveness of using IPV is recommended

THE PALLADIOLIBRARY GEO-MODELS: AN OPEN 3D ARCHIVE TO MANAGE AND VISUALIZE INFORMATION-COMMUNICATION RESOURCES ABOUT PALLADIO

Abstract. The paper describes objectives, methods, procedures and outcomes of the development of the digital archive of Palladio works and documentation: the PALLADIOLibrary of Centro Internazionale di Studi di Architettura Andrea Palladio di Vicenza (CISAAP). The core of the application consists of fifty-one reality-based 3D models usable and navigable within a system grounded on GoogleEarth. This information system, a collaboration of four universities bearers of specific skills returns a comprehensive, structured and coherent semantic interpretation of Palladian landscape through shapes realistically reconstructed from historical sources and surveys and treated for GE with Ambient Occlusion techniques, overcoming the traditional display mode

Interdisciplinary rehabilitation in morbidly obese subjects: an observational pilot study.

BACKGROUND AND AIM: To assess the clinical effectiveness of a interdisciplinary rehabilitation programme (CR), in a population of morbidly obese subjects we have undertaken a observational study. METHODS: The study included fifty-nine adult subjects (18 M, 60+/-10 years, BMI 47+/-8) with sleep-disturbance related symptoms and disabilities. Assessment and correction of sleep disordered breathing (SDB) abnormalities, improvement of exercise tolerance, body weight and associated psychological features were the aims of this CR, which has been carried out over a 1 month period.Lung functions, apnea/hypopnea index (AHI), 6-minute walking distance (6MWD), body weight (BW), quality of life by means of Sat-P questionnaire and serum metabolic data has been recorded at baseline (TO), at the end (Ti) and 6 months after (T2) the CR. RESULTS: The percentage of patients with AHI &gt; 10 declined from 65% (at TO) to 20% (at both T1 and T2). 6MWD and BW significantly improved (p &lt; 0.005) at T1 and still maintained at T2; a significant relationship (r = 0.379, p &lt; 0.01) has been found between changes of BW and 6MWD recorded in between TO and T2. Sat-P item scores dealing with sleep efficiency, problem solving, and social interactions improved (p &lt; 0.01) at T1 and still maintained at T2. CONCLUSIONS: This hospital-based CR provides indication for effectiveness in advanced morbidly obese subjects and warrants further controlled trials to confirm the results

Length and clinical effectiveness of pulmonary rehabilitation in outpatients with chronic airway obstruction

Study objective: To assess the clinical effectiveness of pulmonary rehabilitation (PR) after 10 or 20 consecutive sessions in outpatients with chronic airway obstruction (CAO). Design: Observational prospective cohort trial. Setting: Outpatient clinic of a rehabilitation center. Patients and interventions: Twenty-five outpatients (mean age, 65 +/- 9 years [+/- SD]; FEV1, 64 +/- 12% predicted) admitted to a comprehensive PR program, including exercise training. Measurements and results: The load reached on a cycloergometer (maximal achieved load [W-max]), the maximal and isoload dyspnea and leg fatigue on a Borg scale, 6-min walk distance (6MWD), and the health-related quality of life as assessed using the St. George's Respiratory Questionnaire (SGRQ) [total and components score] have been recorded as outcome measures at baseline, after 10 sessions (T10), and after 20 sessions (T20). The predefined criteria of the clinically significant improvement were as follows: + 15% W-max, + 54 m at 6MWD, - 1 point at isoload dyspnea and leg fatigue, and - 4% at SGRQ scores. There was a mean significant difference between changes at T20 and T10 for 6MWD (- 42.96 m; 95% confidence interval [0], - 57.79 to - 28.12 m; p = 0.001), total SGRQ (4.80; 95% CI, 2.29 to 7.31; p = 0.001), activity SGRQ (3.60; 95% CI, 0.48 to 6.71; p = 0.025), and symptoms SGRQ (5.96; 95% CI, 2.72 to 9.2; p = 0.001). The percentage of patients who improved was different at T20 as compared with T 10 for W-max (68% and 48%, respectively; p = 0.025), 6MWD (76% and 20%, p = 0.001), and total SGRQ (64% and 36%, p = 0.008). Conclusions: A 10-session course of PR provides only limited clinically significant changes of outcome measures when compared with a 20-session course in outpatients with CAO of mild-to-moderate severity

Advances in Ambulatory Oxygen workshop and Longterm Oxygen therapy in real-life practice.

The practical workshop presented recent advances in the field of ambulatory oxygen (AO), with experts discussing identification of patients who would benefit from AO, as well as current trials to measure specific benefits of AO in chronic patients. In particular, AO prescription in clinical practice and developments in pulsed-dose delivery of AO as a more efficient method of oxygen delivery were extensively discussed. After audience questions, the attendees had the opportunity to handle the AO systems on display in order to gain greater insight into their functionality and wearability, which should assist them in providing the most appropriate device for each patient. The symposium addressed considerations required when prescribing long-term oxygen therapy (LTOT). Dr Kampelmacher reviewed current indications for LTOT, emphasising the importance of accurate assessment of patients for LTOT, optimisation of oxygen dose, and patient education. Dr Vivodtzev discussed the evidence for LTOT in patients with exercise-induced desaturation, the role of portable oxygen concentrators, and the optimisation necessary to benefit from their use. The symposium concluded with a health economic study presented by Dr Little, demonstrating the cost benefits of a reform of the Scottish healthcare oxygen supply service