Does timing of initiation influence acceptance and adherence to NIV in patients with ALS

Background: The role of nocturnal non invasive ventilation (NIV) to prolong tracheostomy-free survival, is still controversial in amyotrophic lateral sclerosis (ALS) patients and the best timing to initiate NIV is unclear. Objective: As NIV acceptance and adherence can be influenced by many factors, we aimed to compare immediate acceptance and short-term NIV adherence between NIV initiated very early and NIV initiated later. Methods: This is a post hoc analysis of our previous cohort retrospective study of 88 ALS patients: 53 under later NIV (late group – LG) (forced vital capacity [FVC] 80%). We compared hours of NIV use as immediate acceptance of NIV (use ≥4 h/night) and dherence at 4 months post-initiation (defined as use ≥4 h/night or 120 h/month). Results: No differences were found between VEG and LG in use of NIV (>5 h/night in both groups), immediate acceptance (85.7% vs. 85.0%, p = 0.927) and short-term adherence (81.3% vs. 87.2%, p = 0.469); 39.7% of patients increased their NIV use (35% by >60 min/night). A decline in adherence was observed in 12.5% of patients irrespective of group affiliation. Conclusions: In ALS patients, initiation of very early NIV does not reduce its immediate acceptance or the short-term adherence. However, at least 1 in 10 patients may be at risk of reducing their adherence irrespective of early or late NIV prescription. As still under debate and not conclusive, further literature on early NIV benefit is welcomed. Keywords: Home mechanical ventilation, ALS, Motoneuron disease, NI

Physiological responses to arm exercise in difficult to wean patients with chronic obstructive pulmonary disease

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Physical activity in patients with chronic obstructive pulmonary disease on long-term oxygen therapy: a cross-sectional study

Background and aim: There are few studies evaluating physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT). Aim: To assess PA in hypoxemic COPD patients on LTOT. Methods: In this cross-sectional study, we compared lung function, arterial blood gases, respiratory and peripheral muscle strength, 6-min walking distance (6MWD), daily energy expenditure and steps, and health-related quality of life (HRQL) in COPD patients on LTOT (LTOT group) versus two groups of control patients not needing LTOT: with (HYPOX) and without (COPD) exercise-induced desaturations. Results: Groups did not differ as regards demographics, anthropometrics, peripheral or respiratory muscle strength. Compared to the other groups, LTOT patients had more severe airway obstruction and lung hyperinflation, greater number and severity of comorbidities, shorter 6MWD, as well as lower mean SpO2 during 6MWD and worse quality of life. LTOT patients had a lower daily energy expenditure, shorter time spent > 3.0 METs and longer sedentary time compared to the COPD group, and less daily steps compared to the other groups. No significant difference in any parameter of PA was found between COPD and HYPOX. In LTOT patients, daily steps showed a strong correlation with 6MWD, and a moderate correlation with airway obstruction, level of oxygenation, comorbidities and quality of life but not with peripheral and respiratory muscle strength. In COPD and HYPOX patients, daily steps were strongly correlated with 6MWD and level of oxygenation as assessed by PaO2/FiO2. There was no significant correlation between mean SpO2 and 6MWD in any group. Conclusion: COPD patients on LTOT perform less physical activity than patients not needing LTOT, both with and without exercise-induced desaturations. Patients with exercise-induced desaturations do not perform less physical activity than those without

A Pulmonary Rehabilitation Decisional Score to Define Priority Access for COPD Patients

This retrospective study aimed to evaluate, through an ad hoc 17-item tool, the Pulmonary Rehabilitation Decisional Score (PRDS), the priority access to PR prescription by respiratory specialists. The PRDS, scoring functional, clinical, disability, frailty, and participation parameters from 0 = low priority to 34 = very high priority for PR access, was retrospectively calculated on 124 specialist reports sent to the GP of subjects (aged 71 \ub1 11 years, FEV1%\u2009\u200951 \ub1 17) consecutively admitted to our respiratory outpatient clinic. From the specialist's report the final subject's allocation could be low priority (LP) (>60 days), high priority (HP) (30-60 days), or very high priority (VHP) (<30 days) to rehabilitation. The PRDS calculation showed scores significantly higher in VHP versus LP (p < 0.001) and significantly different between HP and VHP (p < 0.001). Comparing the specialist's allocation decision and priority choice based on PRDS cut-offs, PR prescription was significantly more appropriate in VHP than in HP (p = 0.016). Specialists underprescribed PR in 49% of LP cases and overprescribed it in 46% and 30% of the HP and VHP prescriptions, respectively. A multicomprehensive score is feasible being useful for staging the clinical priorities for PR prescription and facilitating sustainability of the health system

Clinical research as foundation for the advancement of respiratory physiotherapy

Associazione Riabilitatori dell’Insufficienza Respiratoria (ARIR) is pleased to announce a new editorial project by joining the Monaldi Archives of Chest Disease journal

The degree of arm elevation impacts the endurance and cardiopulmonary adaptations of COPDpatients performing upper-limb exercise: A cross-over study

In Chronic Obstructive Pulmonary Disease (COPD), upper limb exercise is widely recommended. However, how the degree of shoulder flexion may influence the exercise response is unknown

Altered vascular endothelium-dependent responsiveness in frail elderly patients recovering from {COVID}-19 pneumonia: preliminary evidence

We evaluated vascular dysfunction with the single passive leg movement test (sPLM) in 22 frail elderly patients at 84 + 31 days after hospitalization for COVID-19 pneumonia, compared to 22 age-, sex- and comorbidity-matched controls (CTRL). At rest, all COVID-19 patients were in stable clinical condition without severe comorbidities. Patients (aged 72 ± 6 years, 73% male) had moderate disability (Barthel index score 77 ± 26), hypoxemia and normocapnia at arterial blood gas analysis and mild pulmonary restriction at spirometry. Values of circulating markers of inflammation (C-reactive protein: CRP; erythrocyte sedimentation rate: ESR) and coagulation (D-dimer) were: 27.13 ± 37.52 mg/dL, 64.24 ± 32.37 mm/1 h and 1043 ± 729 ng/mL, respectively. At rest, femoral artery diameter was similar in COVID-19 and CTRL (p = 0.16). On the contrary, COVID-19 infection deeply impacted blood velocity (p = 0.001) and femoral blood flow (p < 0.0001). After sPLM, peak femoral blood flow was dramatically reduced in COVID-19 compared to CTRL (p = 0.001), as was blood flow ∆peak (p = 0.05) and the area under the curve (p < 0.0001). This altered vascular responsiveness could be one of the unknown components of long COVID-19 syndrome leading to fatigue, changes in muscle metabolism and fibers’ composition, exercise intolerance and increased cardiovascular risk. Impact of specific treatments, such as exercise training, dietary supplements or drugs, should be evaluated

Predictors of low physical function in patients with COVID-19 with acute respiratory failure admitted to a sub-acute unit

Objective: To document the level of physical function in patients with COVID-19 recovering from Acute Respiratory Failure (ARF) and investigate which patient clinical characteristics could predict physical function assessed by the Short Physical Performance Battery (SPPB) test. Design: Cross-sectional study. Setting: Sub-acute unit of a Rehabilitation Institute. Participants: 184 patients with COVID-19 (aged 18 years or older) who were admitted to a sub-acute unit to stabilize their condition and recover from acute respiratory failure due to COVID-19. Interventions: Not applicable. Main Outcome Measure: At admission patients underwent the SPPB test, represented by the sum of three functional tests: standing balance, 4-meter gait speed (4-MGS), and five-repetition sit-to-stand (5-STS) motion. Comparisons between two SPPB score groups were performed by an unpaired t-test; multivariate stepwise linear regression analysis was employed to detect predictors of the SPPB score considering several clinical parameters. Results: Participants were 74±12 years old, 52% were male and with more than two comorbidities in 43% of cases. SPPB score was 3.02±3.87 denoting patients’ profound physical dysfunction. Normal physical function was detected in only 12% of patients, whereas low, intermediate and severe impairment was found in 65%, 13% and 10% respectively. Age, both invasive and non-invasive ventilation use, and the presence of previous disability were significant predictors of SPPB. Patients without any comorbidities (8%) also exhibited low function (SPPB: 5.67±1.12). Conclusions: The majority of survivors after COVID-19 experienced ARF due to pneumonia and exhibited substantial physical dysfunction influenced by age, mechanical ventilation need and previous disability. Further studies are needed to evaluate the role of rehabilitation to promote recovery and community reintegration in this population

Attitudes and preferences of home mechanical ventilation users from four European countries: an ERS/ELF survey

Home mechanical ventilation is increasingly used by people with chronic respiratory failure. However, there are few reports on attitudes towards treatment. A web-based survey in eight languages was disseminated across 11 European countries to evaluate the perception of home mechanical ventilation provision in ventilator-assisted individuals and caregivers. Out of 787 responders from 11 European countries, 687 were patients and 100 were caregivers. 95% of patients and 94% of caregivers were from only 4 countries (Germany, the Netherlands, Italy, Spain). The majority of respondents were male and aged 46-65\u2005years. Obstructive lung diseases were proportionally more represented among respondent patients (46%), and neuromuscular diseases (65%) were more represented among patients of respondent caregivers. About 20% of respondent patients and caregivers were not sure of the modality of ventilation. Different interfaces were used, with a minority of respondents in all countries using invasive home mechanical ventilation by tracheostomy. These results may be useful for healthcare providers and policy makers to improve the quality of patients' daily lives

Comparison among three different follow-up models for obstructive sleep apnea syndrome patients: focus on the physiotherapist’s role

In obstructive sleep apnea syndrome (OSAS) subjects different follow-up modalities have been proposed to improve adherence to the continuous positive airway pressure (CPAP) device. This retrospective study compares three different health professional approaches dedicated to caring OSAS patients in three consecutive follow-up periods of 15 months each. The three different follow-up models are: i) physician-oriented follow-up (P-F); ii) physiotherapist-oriented follow-up (PT-F); and iii) tele-titration plus PT-oriented follow-up (TT-PT-F). Health personal visits and actions delivered, patients' adherence, CPAP efficacy, and problems under CPAP use were considered for comparison. Data from 122 OSAS patients with a new prescription of CPAP were analyzed: 39 (32.0%) in the P-F, 38 (31.1%) in the PT-F, and 45 (36.9%) in the TT-PT-F period. We found a reduction over time (from 40.9% in P-F to 8.2% in TT-PT-F, p<0.001) in patients missing the 1-year follow-up visit. The PT-F and TT-PT-F lead to a reduction in physician visits in comparison to P-F (5.2% and 8.9% vs 100%, p<0.001) with no differences in time to the first follow-up visit, CPAP efficacy, and patients’ adherence among the three periods. More device-related problems were found in the PT-F (57.8%), compared with the PF (25.6%) period (p<0.001); the most common troubles were mask problems evaluated in 26.2% of cases. In conclusion, different follow-up models offer similar efficacy and short-term adherence for CPAP leading to a significant reduction in physician visits under the PT-F with or without tele-titration, being mask problems as the most commonly treated. Further analysis should be useful to define the best cost-efficacy follow-up intervention