Interval training induces clinically meaningful effects in daily activity levels in COPD

Mounting evidence suggests that daily activity levels (DAL) in patients with chronic obstructive pulmonary disease (COPD) are markedly low compared with healthy age-matched individuals and are associated with poorer health status and prognosis [1]. COPD severity negatively impacts on DAL since patients with low DAL experience greater ventilatory, central haemodynamic and peripheral muscle oxygenation constraints during activities of daily living when compared with more physically active counterparts [2, 3]. Although exercise training as part of pulmonary rehabilitation has shown to mitigate the aforementioned physiological constraints [4], there is no evidence of clinically meaningful improvements in DAL following pulmonary rehabilitation [5] as manifested by a mean increase of at least 1000 steps·day−1 [6]. This has been attributed to methodological shortfalls, such as lack of adequately controlled studies, small sample size, short duration of pulmonary rehabilitation programmes, application of activity monitors non-validated for COPD patients [5] and insufficient exercise intensities to induce true physiological training effects. Interval exercise training has been shown to allow application of intense loads to peripheral muscles that induce substantial physiological effects manifested by mitigation of respiratory and central haemodynamic limitations and partial restoration of peripheral muscle dysfunction in patients with diverse COPD severity [7, 8]. In this context, it is reasoned that application of this training modality would allow transfer of the aforementioned physiological benefits into clinically meaningful improvements in DAL [2, 3]. Accordingly, the purpose of this randomised controlled study was to investigate the effect of a 12-week high-intensity interval exercise training programme in DAL in addition to usual care in patients with COPD

Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits

Pulmonary rehabilitation (PR) remains grossly underutilised by suitable patients worldwide. We investigated whether home-based maintenance tele-rehabilitation will be as effective as hospital-based maintenance rehabilitation and superior to usual care in reducing the risk for acute chronic obstructive pulmonary disease (COPD) exacerbations, hospitalisations and emergency department (ED) visits. Following completion of an initial 2-month PR programme this prospective, randomised controlled trial (between December 2013 and July 2015) compared 12 months of home-based maintenance tele-rehabilitation (n=47) with 12 months of hospital-based, outpatient, maintenance rehabilitation (n=50) and also to 12 months of usual care treatment (n=50) without initial PR. In a multivariate analysis during the 12-month follow-up, both home-based tele-rehabilitation and hospital-based PR remained independent predictors of a lower risk for 1) acute COPD exacerbation (incidence rate ratio (IRR) 0.517, 95% CI 0.389–0.687, and IRR 0.635, 95% CI 0.473–0.853), respectively, and 2) hospitalisations for acute COPD exacerbation (IRR 0.189, 95% CI 0.100–0.358, and IRR 0.375, 95% CI 0.207–0.681), respectively. However, only home-based maintenance tele-rehabilitation and not hospital-based, outpatient, maintenance PR was an independent predictor of ED visits (IRR 0.116, 95% CI 0.072–0.185). Home-based maintenance tele-rehabilitation is equally effective as hospital-based, outpatient, maintenance PR in reducing the risk for acute COPD exacerbation and hospitalisations. In addition, it encounters a lower risk for ED visits, thereby constituting a potentially effective alternative strategy to hospital-based, outpatient, maintenance PR

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

Respiratory mechanics in liver disease

AIM: To investigate the prevalence of chronic dyspnea and its relationship to respiratory muscle function in end-stage liver disease.METHODS: Sixty-eight consecutive, ambulatory, Caucasian patients with end-stage liver disease, candidates for liver transplantation, were referred for preoperative respiratory function assessment. Forty of them (29 men) were included in this preliminary study after applying strict inclusion and exclusion criteria. Seventeen out of 40 patients (42%) had ascites, but none of them was cachectic. Fifteen out of 40 patients (38%) had a history of hepatic encephalopathy, though none of them was symptomatic at study time. All patients with known history and/or presence of co-morbidities were excluded. Chronic dyspnea was rated according to the modified Medical Research Council (mMRC) 6-point scale. Liver disease severity was assessed according to the Model for End-Stage Liver Disease (MELD). Routine lung function tests, maximum static expiratory (Pemax) and inspiratory (Pimax) mouth pressures were measured. Respiratory muscle strength (RMS) was calculated from Pimax and Pemax values. In addition, arterial blood gases and pattern of breathing (VE: minute ventilation; VT: tidal volume; VT/TI: mean inspiratory flow; TI: duration of inspiration) were measured.RESULTS: Thirty-five (88%) out of 40 patients aged (mean±SD) 52±10 yr reported various degrees of chronic dyspnea (mMRC), ranging from 0 to 4, with a mean value of 2±1.2. MELD score was 14±6. Pemax%pred was 105±35, Pimax%pred was 90±29, and RMS%pred was 97±30. These pressures were below the normal limits in 12 (30%), 15 (38%) and 14 (35%) patients, respectively. Furthermore, comparing the subgroups of ascites to non-ascites patients, all respiratory muscle indices measured were found significantly decreased in ascites patients. Patients with ascites had also significantly worse MELD score compared to non-ascites ones (p=0.006). Significant correlations were found between chronic dyspnea and respiratory muscle function indices, in all patients. Specifically, mMRC score was significantly correlated with Pemax, Pimax, and RMS (r=-0.53, p<0.001; r=-0.42, p<0.01; r=-0.51, p<0.001, respectively). These correlations were substantially closer in the non-ascites subgroup (r=-0.82, p<0.0001; r=-0.61, p<0.01; r=-0.79, p<0.0001, respectively) compared to all patients. Similar results were found for the relationship between mMRC vs MELD score, and MELD score vs respiratory muscle strength indices. In all patients the sole predictor of mMRC score is RMS (r=-0.51, p<0.001). In the subgroup of patients without ascites this relationship becomes closer (r=0.79, p<0.001), whilst this relationship breaks down in the subgroup of patients with ascites. The disappearance of such a correlation may be due to the fact that ascites acts as “confounding” factor. PaCO2 (33±4 mmHg) was decreased, whereas pH (7.49±0.04) was increased in 26 (65%) and 34 (85%) patients, respectively. PaO2 (92±10 mmHg) was within normal limits. VE (11.5±3.5 L/min), VT (0.735±0.287 L), and VT/TI (0.449±0.129 L/s) were increased signifying hyperventilation in both subgroups of patients. VT/TI was significantly higher in patients with ascites than without ascites. Significant correlations, albeit weak, were found for PaCO2 with VE and VT/TI (r=-0.44, p<0.01; r=-0.41, p<0.01, respectively).CONCLUSION: The prevalence of chronic dyspnea is 88% in end-stage liver disease. The mMRC score closely correlates with respiratory muscle strength.Σκοπός: Ο καθορισμός της επίπτωση της χρόνιας δύσπνοιας και της αλληλεξάρτηση της με την λειτουργία των αναπνευστικών μυών σε ασθενείς με ηπατική νόσο τελικού σταδίου.Μέθοδος: Η μελέτη διενεργήθηκε σε εξήντα οκτώ (68) περιπατητικούς, Καυκάσιους ασθενείς με ηπατική νόσο τελικού σταδίου οι οποίοι ήταν υποψήφιοι για μεταμόσχευση ήπατος και είχαν παραπεμφθεί για προεγχειρητική εκτίμηση της αναπνευστικής λειτουργίας. Σαράντα (29 άνδρες) έλαβαν μέρος στην μελέτη λόγω αυστηρών κριτηρίων εισαγωγής/ αποκλεισμού. Δεκαεπτά από τους 40 ασθενείς είχαν ασκίτη, όμως κανένας δεν ήταν καχεκτικός. Δεκαπέντε από τους 40 ασθενείς είχαν ιστορικό ηπατικής εγκεφαλοπάθειας, όμως κανένας δεν ήταν συμπτωματικός κατά την διάρκεια της μελέτης. Όλοι οι ασθενείς που είχαν συννοσηρότητες αποκλείστηκαν. Η χρόνια δύσπνοια βαθμολογήθηκε σύμφωνα με την mMRC (modified Medical Research Council) 6-βαθμών κλίμακα. Η βαρύτητα της ηπατικής νόσου εκτιμήθηκε με το μοντέλο για τελικού σταδίου ηπατική νόσο (MELD, Model for End-Stage Liver Disease). Λειτουργικός έλεγχος ρουτίνας, και η μέγιστη στατική εκπνευστική (Pemax) και εισπνευστική (Pimax) πίεση στο στόμα μετρήθηκαν. Η ισχύς των αναπνευστικών μυών (RMS) υπολογίστηκε από τις τιμές των Pemax και Pimax. Επιπλέον, μετρήθηκαν τα αέρια αίματος και ο τύπος της αναπνοής (VE: κατά λεπτό αερισμός, VT: αναπνεόμενος όγκος, VT/TI: μέση εισπνευστική ροή, TI: διάρκεια εισπνοής). Αποτελέσματα: Τριάντα πέντε (88%) από τους 40 ασθενείς, ηλικίας (mean±SD) 52±10 yr, ανέφεραν διαφόρου βαθμού χρόνια δύσπνοια (mMRC), με εύρος από 0 έως 4 και με μία μέση τιμή 2±1.2. Η βαθμολογία του MELD ήταν 14±6. Το Pemax%pred ήταν 105±35, το Pimax%pred ήταν 90±29, και το RMS%pred ήταν 97±30. Οι πιέσεις αυτές ήταν παθολογικές σε 12 (30%), 15 (38%), και 14 (35%) ασθενείς, αντίστοιχα. Επιπλέον, συγκρίνοντας την υποομάδα των ασθενών με ασκίτη με αυτή των μη-ασκιτικών ασθενών, όλοι οι δείκτες λειτουργίας των αναπνευστικών μυών ήταν σημαντικά μειωμένοι στους ασθενείς με ασκίτη. Οι ασθενείς με ασκίτη είχαν σημαντικά χειρότερο MELD σε σχέση με τους μη-ασκιτικούς (p=0.006). Σημαντικές συσχετίσεις ανευρέθηκαν μεταξύ της χρόνιας δύσπνοιας και των δεικτών λειτουργίας των αναπνευστικών μυών. Συγκεκριμένα, το mMRC συσχετίστηκε σημαντικά με τα Pemax, Pimax, και RMS (r=-0.53, p<0.001; r=-0.42, p<0.01; r=-0.51, p<0.001, αντίστοιχα). Οι συσχετίσεις αυτές ήταν σημαντικά πιο ισχυρές στην υποομάδα των μη-ασκιτικών ασθενών (r=-0.82, p<0.0001; r=-0.61, p<0.01; r=-0.79, p<0.0001, αντίστοιχα). Παρόμοια ήταν τα αποτελέσματα της σχέσης του mMRC με το MELD, και του MELD με τους δείκτες λειτουργίας των αναπνευστικών μυών. Σε όλους τους ασθενείς ο μόνος προγνωστικός παράγοντας της mMRC ήταν το RMS (r=-0.51, p<0.001). Στην υποομάδα των ασθενών χωρίς ασκίτη η προγνωστική ισχύς του RMS ήταν μεγαλύτερη (r=-0.79, p<0.001), ενώ η συσχέτιση αυτή καταρρέει στην ασκιτική υποομάδα. Αυτό υποδεικνύει ότι η ύπαρξη του ασκίτη δρα ως «συγχυτικός» παράγοντας. Το PaCO2 ήταν μειωμένο (33±4 mmHg) και το pH ήταν αυξημένο (7.49±0.04) σε 26 (65%) και 34 (85%) ασθενείς, αντίστοιχα. Το PaO2 (92±10 mmHg) ήταν εντός των φυσιολογικών ορίων. Τα VE (11.5±3.5 L/min), VT (0.735±0.287 L), και VT/TI (0.449±0.129 L/s) ήταν αυξημένα υποδηλώνοντας υπεραερισμό και στις δύο υποομάδες ασθενών. Το VT/TI ήταν σημαντικά μεγαλύτερο στους ασθενείς με ασκίτη σε σχέση με αυτούς χωρίς. Σημαντικές συσχετίσεις, αν και ασθενείς, βρέθηκαν για το PaCO2 με τα VE και VT/TI (r=-0.44, p<0.01; r=-0.41, p<0.01, αντίστοιχα). Συμπεράσματα: Η επίπτωση της χρόνιας δύσπνοιας στους ασθενείς με ηπατική νόσο τελικού σταδίου είναι 88%. Η βαθμολογία της κλίμακας mMRC συσχετίζεται στενά με την ισχύ των αναπνευστικών μυών

Quality of life in patients with chronic respiratory failure on home mechanical ventilation

Home mechanical ventilation (HMV) is a treatment for chronic respiratory failure that has shown clinical and cost effectiveness in patients with underlying COPD, obesity-related respiratory failure and neuromuscular disease (NMD). By treating chronic respiratory failure with adequate adherence to HMV, improvement in patient-reported outcomes including health-related quality of life (HRQoL) have been evaluated using general and disease-specific quantitative, semi-qualitative and qualitative methods. However, the treatment response in terms of trajectory of change in HRQoL is not uniform across the restrictive and obstructive disease groups. In this review, the effect of HMV on HRQoL across the domains of symptom perception, physical wellbeing, mental wellbeing, anxiety, depression, self-efficacy and sleep quality in stable and post-acute COPD, rapidly progressive NMD (such as amyotrophic lateral sclerosis), inherited NMD (including Duchenne muscular dystrophy) and obesity-related respiratory failure will be discussed

Role of quantitative CT in predicting postoperative FEV1 and chronic dyspnea in patients undergoing lung resection

Lung resection is the mainstay of treatment in patients with early stage non-small cell lung cancer. However, lung cancer patients often suffer from comorbidities and the respiratory reserve should be carefully evaluated preoperatively in order to avoid postoperative complications. Forced expiratory volume in 1 second (FEV1) is considered to be an index that depicts the patient’s respiratory efficacy and its prediction has a key role in the preoperative evaluation of lung cancer patients with impaired lung function. Prediction of postoperative FEV1 is currently possible with the use of perfusion radionuclide lung scanning. Quantitative CT is the analysis of data acquired during normal chest CT scan using the system’s software. By applying a dual threshold of -500 to -910 Hounsfield Units, functional lung volumes are estimated and postoperative FEV1 can be predicted by reducing the preoperative measurement by the fraction of the part to be resected. Studies have shown that preoperative predictions correlate well with the actual postoperative measurements. Additionally, quantitative CT results are in good agreement with perfusion scintigraphy predictions. Newer radiological techniques such as perfusion MRI and co-registered SPECT/CT have also been used in the preoperative evaluation with similar results. In conclusion, chest CT which is obligatory for staging, can be used for quantitative analysis of the already available data. It is technically simple, providing an accurate prediction of postoperative FEV1. Thus, quantitative CT appears to be a useful tool in the preoperative evaluation of lung cancer patients undergoing lung resection

Role of quantitative CT in predicting postoperative FEV1 and chronic dyspnea in patients undergoing lung resection

Lung resection is the mainstay of treatment in patients with early stage non-small cell lung cancer. However, lung cancer patients often suffer from comorbidities and the respiratory reserve should be carefully evaluated preoperatively in order to avoid postoperative complications. Forced expiratory volume in 1 second (FEV(1)) is considered to be an index that depicts the patient's respiratory efficacy and its prediction has a key role in the preoperative evaluation of lung cancer patients with impaired lung function. Prediction of postoperative FEV(1 )is currently possible with the use of perfusion radionuclide lung scanning. Quantitative CT is the analysis of data acquired during normal chest CT scan using the system's software. By applying a dual threshold of -500 to -910 Hounsfield Units, functional lung volumes are estimated and postoperative FEV(1 )can be predicted by reducing the preoperative measurement by the fraction of the part to be resected. Studies have shown that preoperative predictions correlate well with the actual postoperative measurements. Additionally, quantitative CT results are in good agreement with perfusion scintigraphy predictions. Newer radiological techniques such as perfusion MRI and co-registered SPECT/CT have also been used in the preoperative evaluation with similar results. In conclusion, chest CT which is obligatory for staging, can be used for quantitative analysis of the already available data. It is technically simple, providing an accurate prediction of postoperative FEV(1). Thus, quantitative CT appears to be a useful tool in the preoperative evaluation of lung cancer patients undergoing lung resection