Static and dynamic hyperinflation during severe acute exacerbations of chronic obstructive pulmonary disease

Background: Static hyperinflation is known to be increased during moderate acute exacerbations of chronic obstructive pulmonary disease (COPD) (AECOPD), but few data exist in patients with severe exacerbations of COPD. The role of dynamic hyperinflation during exacerbations is unclear. Methods: In a prospective, observational cohort study, we recruited patients admitted to hospital for AECOPD. The following measurements were performed upon admission and again after resolution (stable state) at least 42 days later: inspiratory capacity (IC), body plethysmography, dynamic hyperinflation by metronome-paced IC measurement, health-related quality of life and dyspnea. Results: Forty COPD patients were included of whom 28 attended follow-up. The IC was low at admission (2.05 +/- 0.11 L) and increased again during resolution by 15.6%+/- 23.1% or 0.28 +/- 0.08 L (mean +/- standard error of the mean, p Conclusion: Static hyperinflation is increased during severe AECOPD requiring hospitalization compared with stable state. We could measure metronome-paced dynamic hyperinflation during severe AECOPD but found no increase

Understanding the role of long-acting muscarinic antagonists in asthma treatment

Objective: Long-acting muscarinic antagonists (LAMAs) have been used in the treatment of obstructive pulmonary diseases for years. Long-acting muscarinic antagonists were previously mainly used as bronchodilators in chronic obstructive pulmonary disease, but the use of LAMAs in the treatment of asthma has gained great interest. There is now ample evidence of the efficacy and safety of LAMAs as add-on therapy to inhaled corticosteroid (ICS) plus long-acting β 2-agonist (LABA) combinations in patients with moderate to severe uncontrolled asthma. Long-acting muscarinic antagonists have subsequently been included in asthma guidelines. This review summarizes the scientific evidence on the use of LAMAs in asthma and aims to provide a better understanding of the role of LAMAs in the asthma treatment care algorithm and the current gaps in our knowledge. Data sources: PubMed review using the following words: long-acting muscarinic antagonists, asthma, muscarinic receptors, tiotropium, glycopyrronium, umeclidinium. Study selections: This review focused on the key trials that led to the inclusion of LAMAs in asthma guidelines. In addition, we highlighted a number of studies with other study designs and populations. Results: We identified 6 major studies that led to inclusion in asthma guidelines and 3 studies with other study designs and populations. Conclusion: Long-acting muscarinic antagonists add-on therapy to ICS-LABA improves lung function, reduces exacerbations, and modestly improves asthma control in patients with moderate to severe asthma who are uncontrolled despite the use of ICS-LABA. Long-acting muscarinic antagonists are effective in all asthma phenotypes and endotypes

Initiation of home mechanical ventilation at home:A randomised controlled trial of efficacy, feasibility and costs

SummaryIntroductionHome mechanical ventilation (HMV) in the Netherlands is normally initiated in hospital, but this is expensive and often a burden for the patient. In this randomised controlled study we investigated whether initiation of HMV at home in patients with chronic respiratory failure is non-inferior to an in hospital based setting.MethodsSeventy-seven patients were included, of which 38 patients started HMV at home. All patients were diagnosed with chronic respiratory failure due to a neuromuscular or thoracic cage disease. Primary outcome was the arterial carbon dioxide (PaCO2) while quality of life and costs were secondary outcomes. Telemonitoring was used in the home group to provide therapeutic information, for example; transcutaneous carbon dioxide, oxygen saturation and ventilator information, to the caregivers. Follow-up was six months.ResultsPaCO2, improved by 0.72 (SE ± 0.16) kPa in the hospital group and by 0.91 (±0.20) in the home group, both improvements being significant and the latter clearly not inferior.There were also significant improvements in quality of life in both groups, again not being inferior with home treatment.ConclusionThis study is the first to show that initiation of HMV at home in a selective group of patients with chronic respiratory failure is as effective for gas exchange and quality of life as hospital initiation. In addition we found that it is safe, technically feasible and that more than € 3000 per patient can be saved compared to our standard care

Predicted values for the forced expiratory flow adjusted for forced vital capacity, a descriptive study

Background: The forced expiratory flows (FEFs) towards the end of the expiration may be more sensitive in detecting peripheral airways obstruction compared to the forced expiratory volume in 1 s and forced vital capacity (FVC). However, they are highly variable. A partial solution is to adjust the FEFs for FVC (FEF/FVC). Here we provide reference equations for these adjusted FEFs at 25%, 50%, 75% and 25-75% of FVC, which are currently lacking. Methods: We included pulmonary healthy, never-smoker adults; 14 472 subjects from Lifelines, a biobank for health research, and 338 subjects from the department's control cohorts (NORM and Fiddle). Reference equations were obtained by linear regression on 80% of the Lifelines dataset and validated on the remaining data. The best model was defined as the one with the highest adjusted R2-value. The difference in variability between adjusted and unadjusted FEFs was evaluated using the coefficient of variation. Results: For all adjusted FEFs, the best model contained age, height and weight. The adjustment improved the coefficient of variation of the FEF75 from 39% to 36% and from 43% to 40%, respectively, in males and females. The highest percentage of explained variance by the reference equation was obtained for FEF75/FVC, 32%-38% for males, and 41%-46% for females, depending on the validation set. Conclusion: We developed reference equations for FVC-adjusted FEF values. We demonstrated minimally yet significantly improved variability. Future studies in obstructive airway diseases should demonstrate whether it is worthwhile to use these (predicted) adjusted FEF values

Short- and long-term effects of a physical activity counselling programme in COPD:A randomized controlled trial

SummaryBackgroundWe were interested in the effects of a physical activity (PA) counselling programme in three groups of COPD patients from general practice (primary care), outpatient clinic (secondary care) and pulmonary rehabilitation (PR).MethodsIn this randomized controlled trial 155 COPD patients, 102 males, median (IQR) age 62 (54–69) y, FEV1predicted 60 (40–75) % were assigned to a 12-weeks' physical activity counselling programme or usual care. Physical activity (pedometer (Yamax SW200) and metabolic equivalents), exercise capacity (6-min walking distance) and quality of life (Chronic Respiratory Questionnaire and Clinical COPD Questionnaire) were assessed at baseline, after three and 15 months.ResultsA significant difference between the counselling and usual care group in daily steps (803 steps, p = 0.001) and daily physical activity (2214 steps + equivalents, p = 0.001)) from 0 to 3 months was found in the total group, as well as in the outpatient (1816 steps, 2616 steps + equivalents, both p = 0.007) and PR (758 steps, 2151 steps + equivalents, both p = 0.03) subgroups. From 0 to 15 months no differences were found in physical activity. However, when patients with baseline physical activity>10,000 steps per day (n = 8), who are already sufficiently active, were excluded, a significant long-term effect of the counselling programme on daily physical activity existed in the total group (p = 0.02). Differences in exercise capacity and quality of life were found only from 0 to 3 months, in the outpatient subgroup.ConclusionOur PA counselling programme effectively enhances PA level in COPD patients after three months. Sedentary patients at baseline still benefit after 15 months.ClinicalTrials.gov: registration number NCT00614796