Changes in lower limb muscle function and muscle mass following exercise-based interventions in patients with chronic obstructive pulmonary disease : a review of the English-language literature

Chronic obstructive pulmonary disease (COPD) patients often experience lower limb muscle dysfunction and wasting. Exercise-based training has potential to improve muscle function and mass, but literature on this topic is extensive and heterogeneous including numerous interventions and outcomemeasures. This reviewuses a detailed systematic approach to investigate the effect of this wide range of exercise-based interventions on muscle function and mass. PUBMED and PEDro databases were searched. In all, 70 studies (n = 2504 COPD patients) that implemented an exercise-based intervention and reported muscle strength, endurance, or mass in clinically stable COPD patients were critically appraised. Aerobic and/or resistance training, high-intensity interval training, electrical or magnetic muscle stimulation, whole-body vibration, andwater-based training were investigated. Muscle strength increased in 78%, muscle endurance in 92%, and muscle mass in 88% of the cases where that specific outcome was measured. Despite large heterogeneity in exercise-based interventions and outcome measures used, most exercise-based trials showed improvements in muscle strength, endurance, and mass in COPD patients. Which intervention(s) is (are) best for which subgroup of patients remains currently unknown. Furthermore, this literature review identifies gaps in the current knowledge and generates recommendations for future research to enhance our knowledge on exercise-based interventions in COPD patients

COPD and exercise: does it make a difference?

Physical activity is defined as any bodily movement produced by skeletal muscles which results in energy expenditure. Physical activity in daily life can be categorised into occupational, sports, conditioning, household, or other activities. Exercise is a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness [1]. According to international guidelines, exercise training, widely regarded as the cornerstone of pulmonary rehabilitation, is the best available means of improving muscle function and exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) [2, 3]. It truly makes a difference in the life of patients with COPD. In this review, an overview is provided on the history of exercise training (as standalone intervention or as part of a comprehensive pulmonary rehabilitation programme), the state-of-the-art exercise training, exercise training in comorbid patients with COPD, and the impact of physical activity counselling in a clean air environment

Could a 400-μm mesh size sieve be used for Trichinella inspection at the slaughterhouse laboratory to facilitate pork export to third countries?

Trichinellosis is a zoonotic disease caused by the nematode Trichinella through ingestion of raw or undercooked meat. In the European Union, the magnetic stirrer method (EU reference method, EU-RM) according to European regulation EC 2075/2005 is used for individual carcass control for Trichinella in pork. This method has been validated for the detection of live Trichinella muscle larvae (ML) and critical control points are well described. In international pig trade, different parts of the same carcass are shipped to countries both within and outside the EU. For export to countries outside the EU (third countries), meat producers may have to comply with regulations according to the food safety authorities of those countries, including the mandatory use of alternative equipment, such as a 400-μm mesh size sieve (sieve400), instead of a sieve with a mesh size of 180 μm (sieve180). In its supervising role on the quality of Trichinella inspection at the slaughterhouse laboratories, the Dutch Reference Laboratory for Parasites (NRL-P) was asked to advise the Competent Authorities on the test sensitivity of a sieve400, the performance of which is currently unknown. We evaluated the performance of a sieve400, compared to a sieve180, using spiked pork samples (0 - 10 Trichinella muscle larvae per analytical portion) in three evaluation experiments

Determinants of polypharmacy and compliance with GOLD guidelines in patients with chronic obstructive pulmonary disease

BACKGROUND: Polypharmacy of respiratory medications is commonly observed in patients with chronic obstructive pulmonary disease (COPD). The aims of this study were to investigate determinants of polypharmacy and to study the consistency of actual respiratory drug use with current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in pulmonary rehabilitation candidates with COPD. METHODS: Data were extracted from the records of all patients with a diagnosis of COPD referred for pulmonary rehabilitation to CIRO+ between 2005 and 2009. Use of respiratory medications, self-reported COPD exacerbations, lung function, blood gases, exercise capacity, Medical Research Council (MRC) dyspnea grade, and St George's Respiratory Questionnaire (SGRQ) were recorded as part of assessment of health status. RESULTS: In total, 1859 COPD patients of mean age (+/- standard deviation) 64.3 +/- 9.7 years and with a forced expiratory volume in one second (FEV(1)) of 44.7% +/- 18.2% were included. On average, patients used 3.5 +/- 1.5 respiratory medications; this number increased with increasing GOLD stage, MRC score, and SGRQ scores. FEV(1) (% predicted), SGRQ, and number of recent exacerbations were independent determinants of polypharmacy. Use of long-acting bronchodilators and inhaled corticosteroids was substantial and comparable in all GOLD stages. Use of corticosteroids was not restricted to patients with frequent exacerbations. CONCLUSION: Polypharmacy of respiratory medications is common in COPD patients with persistent symptoms. In addition to severity of disease, health status is an independent predictor of polypharmacy. Actual drug use in COPD patients referred for pulmonary rehabilitation is partially inconsistent with current GOLD guidelines

Preliminary study on the assessment of visceral adipose tissue using dual-energy x-ray absorptiometry in chronic obstructive pulmonary disease

Background: Visceral adipose tissue (VAT) was shown to be increased in patients with chronic obstructive pulmonary disease (COPD) compared to control subjects with comparable body mass index (BMI). Our aim was to determine the relation of VAT by dual-energy x-ray absorptiometry (DEXA) in patients with COPD by disease severity, BMI, other indices of body composition and static lung volumes. Methods: 294 COPD patients admitted for rehabilitation were studied. Lung function, static lung volumes and body composition (i.e. BMI, waist circumference, fat-free mass, fat mass and fat distribution between android and gynoid fat mass) were assessed before entering pulmonary rehabilitation. VAT was estimated within the android region by using DEXA. Patients were stratified for gender, BMI (cut-off of 25 kg/m2) and GOLD stage. To assess the impact of VAT on lung volumes, patients were also stratified for VAT less and above 50th percentile. Results: Both male and female patients with more severe airflow limitation had significantly lower VAT values, but these differences disappeared after stratification for BMI. VAT was significantly and strongly correlated with other body composition parameters (all p < 0.001). Patients with moderate to severe airflow limitation and lower VAT had increased static lung hyperinflation and lower diffusing capacity for carbon monoxide. Nevertheless, multivariate stepwise regression models including for BMI, age, gender and forced expiratory volume in 1 s (FEV1) as confounders did not confirm an independent role for VAT on static lung hyperinflation and diffusion capacity. Conclusion: After stratification for BMI, VAT is comparable in moderate to very severe COPD patients. Furthermore, BMI and demographics, but not VAT, were independent predictors of static lung hyperinflation and diffusing capacity in COPD

ERS statement on standardisation of cardiopulmonary exercise testing in chronic lung diseases

The objective of this document was to standardise published cardiopulmonary exercise testing (CPET) protocols for improved interpretation in clinical settings and multicentre research projects. This document: 1) summarises the protocols and procedures used in published studies focusing on incremental CPET in chronic lung conditions; 2) presents standard incremental protocols for CPET on a stationary cycle ergometer and a treadmill; and 3) provides patients’ perspectives on CPET obtained through an online survey supported by the European Lung Foundation. We systematically reviewed published studies obtained from EMBASE, Medline, Scopus, Web of Science and the Cochrane Library from inception to January 2017. Of 7914 identified studies, 595 studies with 26 523 subjects were included. The literature supports a test protocol with a resting phase lasting at least 3 min, a 3-min unloaded phase, and an 8- to 12-min incremental phase with work rate increased linearly at least every minute, followed by a recovery phase of at least 2–3 min. Patients responding to the survey (n=295) perceived CPET as highly beneficial for their diagnostic assessment and informed the Task Force consensus. Future research should focus on the individualised estimation of optimal work rate increments across different lung diseases, and the collection of robust normative data.The document facilitates standardisation of conducting, reporting and interpreting cardiopulmonary exercise tests in chronic lung diseases for comparison of reference data, multi-centre studies and assessment of interventional efficacy. http://bit.ly/31SXeB

ERS International congress, Madrid, 2019: Highlights from the General Pneumology Assembly

This article contains highlights and a selection of the scientific advances from the European Respiratory Society's General Pneumology Assembly that were presented at the 2019 European Respiratory Society International Congress in Madrid, Spain. The most relevant topics from the different groups will be discussed, covering a wide range of areas including rehabilitation and chronic care, general practice and primary care and M-health and E-health. In this review, the newest research and actual data as well as award-winning abstracts and highlight sessions will be discussed

Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations

Chronic obstructive pulmonary disease; Discharge protocol; ExacerbationMalaltia pulmonar obstructiva crònica; Protocol d'alta; ExacerbacióEnfermedad pulmonar obstructiva crónica; Protocolo de alta; ExacerbaciónDischarge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient’s discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.This article was funded by AstraZeneca

The independent and combined effects of smoking and chronic obstructive pulmonary disease on body mass index trajectories

Low body mass index (BMI) is a common feature of severe chronic obstructive pulmonary disease (COPD) but in the general population, cigarette smoking is also associated with low body weight. Many people with COPD remain smokers after diagnosis, and it is unclear whether low BMI is because of the disease itself or its most common risk factor. We aim to assess the independent and combined effects of smoking and COPD on BMI trajectories. 27,651 patients without COPD and 25,990 with COPD from The Health Improvement Network (2005-2019) were grouped into: never-smokers, former smokers, sustained quitters, intermittent smokers, and continuous smokers (ten total COPD-smoking status groups). BMI trajectories over 10-year time horizon were modeled by these status groups using multivariable mixed-effect models adjusted for age (in continuous years), sex, Townsend score (a measure of material deprivation), alcohol consumption (yes/no), exacerbation history (yes/no, only for COPD patients) and any history of asthma, cancer, chronic kidney disease, diabetes, or cardiovascular disease (yes/no). Individuals with COPD who smoked at baseline (intermittent, sustained quitter, or continuous smokers) had a lower initial BMI (27.1 kg/m² [26.9-27.3]; 26.6 [26.4-26.9]; 26.2 [26.0-26.4], respectively) than non-COPD controls in the same smoking categories (28.0 [26.6-28.2]; 27.6 [27.2-27.9]; 26.7 [26.4-26.9]). Current smokers had lower initial BMIs than never and former smokers, regardless of COPD status. In individuals with COPD, compared to former smokers, continuous smokers lost weight faster (-0.071 kg/m²/year [-0.097 to -0.045]; p &lt; 0.001), while quitters gained weight (0.266 [0.233 to 0.298]; p &lt; 0.001). Non-COPD controls showed similar but less pronounced patterns when continuous smokers and quitters (-0.059 [-0.090 to -0.028] and 0.213 [0.173 to 0.254], respectively; both p &lt; 0.001) were compared to former smokers. Those with a baseline BMI of &lt; 30 also showed a decrease in longitudinal BMI, especially among COPD patients. COPD patients had lower baseline BMI than controls, but BMI trajectories were similar between groups, with continuous smokers losing weight faster and quitters gaining weight. These findings suggest that smoking behaviour significantly influences weight loss in COPD, emphasizing its importance in clinical evaluations and nutritional support consultations.</p