Inpatient pulmonary rehabilitation: does it make sense?

Among the nonpharmacological therapies, pulmonary rehabilitation (PR) is particularly appropriate for patients with chronic respiratory impairment who, despite any optimal drug management, are still symptomatic and experience restriction in every day activities. Pulmonary rehabilitation performed in inpatient, outpatient, or home settings demonstrates short- and long-term clinical efficacy. Although disease severity does not inherently dictate candidacy for exercise training, the degree of physiological and functional impairment may influence setting in which the training should occur. Therefore, inpatient rehabilitation is generally best-suited for the most sick and most disabled patients. The overall results from the literature confirm that the inpatient setting for a PR program is a feasible option and does not necessarily result in higher direct costs when balanced against duration and effectiveness in terms of improved outcomes

Hospital monitoring, setting and training for home non invasive ventilation.

Although in recent years guidelines have been published in order to define indications, applications and delivery of long-term home non invasive mechanical ventilation (HNMV), there is lack of information with regards to in-hospital assessment, planning and training to initiate and prescribe it. Discontinuation and lack of compliance versus HNMV may affect the follow-up of these patients adding a costly burden for care. The present review proposes an operative flow chart for optimisation of HNMV prescription from initial patient's selection to post discharge follow up including; 1. assessment of the correct choice of ventilator, interfaces, ventilation setting. 2. Timing for different physiological monitoring (arterial gases, mechanics, sleep) 3. Timing for clinical evaluation, machine adaptation, carer training and long term follow-up

Chronic respiratory abnormalities in the multi-morbid frail elderly

Two-thirds of people aged 65 65 years have multi-morbidity, with people living in the most deprived areas developing multi-morbidity 10-15 years even earlier. Multi-morbidity is associated with higher mortality, polypharmacy and high treatment burden, higher rates of adverse drug events, and much greater health services use including emergency hospital admissions. Multi-morbidity includes both physical and mental health conditions, as anxiety and depression, that almost invariably affect patients with multiple symptomatic chronic diseases. The main message of the present paper is that the management of a patient with any of the chronic diseases that are part of multi-morbidity is not just the management of that single index disease, but must include the active search and proper treatment of concomitant chronic diseases. The presence of concomitant chronic diseases should not alter the management of the index disease (eg COPD), and concomitant chronic disease should be treated according to single diseases guidelines regardless of the presence of the index disease, obviously with careful consideration that this choice implies complex management, polypharmacy and potential adverse effects. Ongoing multidisciplinary hospital and home base management programmes suggest that an olistic integrated approach might improve quality of life and reduce hospital admissions and death in these multimorbid patients

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

Advanced COPD patients under home mechanical ventilation and/or long term oxygen therapy: italian health care costs.

Introduction. Little information is available on health care costs for patients with very severe chronic obstructive pulmonary disease The aim of the current work was to evaluate Italian health care costs in these patients. Patients and Methods. Prospective 1-year analysis were assessed in three subgroups of patients; non-invasively ventilated (n=30); invasively-ventilated (n=12) and on long-term oxygen therapy (n= 41). Acute costs for care were a sum of fees for doctor\u2019s consultations, admissions to hospital (ward and intensive care unit) and emergency drugs. Chronic costs were the sum of costs for pharmacotherapy and home ventilation and/or oxygen care. Results. Mean cost/day/patient was 96\ub1112 \u20ac (range 9-526 \u20ac), with acute costs accounting for 72% and chronic costs for 28% of the total cost burden, with no significant differences in costs associated with the three subgroups. Acute costs had a non-normally distribution (range 0 to 510 \u20ac) with cost for hospitalization being the highest cost burden with greater than 30 % of acute care costs were attributed to only a small segment of patients. Chronic care costs were also unevenly distributed among the various groups (ANOVA p=0.006), with home oxygen supply being the highest cost burden. Conclusions. The current Health Care System is in urgent need for a reassessment of the high cost burden associated with hospitalizations and home oxygen supply

Comorbidities in Chronic Obstructive Pulmonary Disease from Assessment to Treatment.

Not availabl

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

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

Activity and analysis of costs in a dedicated weaning centre.

AIM: To analyse the diagnosis-related characteristics and the costs of treating patients with difficult/prolonged weaning from mechanical ventilation we have undertaken a retrospective observational study. METHODS: The study has considered all the patients admitted to our weaning unit of a regional Rehabilitation department during 3 consecutive periods since the opening date. Characteristics of the admitted patients and the DRG-related cares delivered have been recorded. A cost analysis has been obtained over time. RESULTS: The number of beds allocated to this unit (from 4 in the 1st period to 6 in the 2nd and 3rd periods) and the number of patients cared for (from 32 to 43 and to 65, respectively) increased over time. In particular, the COPD to non-COPD patient ratio (from 2.2 to 1.3 and to 1.0) and the DRG/patient weight (from 3.0 +/- 0.3 to 3.1 +/- 0.2 and to 3.3 +/- 0.2 point) changed significantly (p &lt; 0.05). The daily reimbursement per patient from the public health care system only slightly increased, whereas the operating margin (reimbursement less costs) per patient significantly improved (from -304, to +17 and +55 Euro/pt/day, respectively, p &lt; 0.05) due to a gradual restriction in the variable costs. Length of stay, mortality rate and weaning rate did not change over time. CONCLUSION: The weaning centre is a hospital area where economic burdens should be carefully evaluated. Given the actual reimbursement received on a national level for these patients, variable costs might be better spread, thus optimising the burdens without losing out on clinical outcomes