On the cutting edge of clinical pulmonary medicine in COPD

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Predictors for a positive QuantiFERON-TB-Gold test in BCG-vaccinated adults with a positive tuberculin skin test

SummaryBackgroundPrevention of tuberculosis (TB) in the United States usually involves testing for latent tuberculosis infection (LTBI) with a tuberculin skin test (TST), followed by offering therapy to those who have a positive test result. QuantiFERON-TB Gold assay (QFT-G) is more specific for infection with Mycobacterium tuberculosis than the TST, especially among persons vaccinated with bacillus Calmette-Guérin, thereby reducing the number of false positive tests.MethodsAdults referred to a pulmonary clinic for a positive TST result were tested with QFT-G. We assessed factors for having a positive QFT-G.ResultsAmong 100 adults who were BCG-vaccinated and had a positive TST result, 30 (30%) had a positive result using QFT-G. Persons from high-incidence countries were 8.2 times more likely to have a positive QFT-G result compared with persons from low-incidence countries (46% versus 9%). Using logistic regression to assess QFT-G positivity, strong predictors included having an abnormal chest radiograph consistent with healed TB, a TST induration of ≥16mm, and birth in a high-incidence country.ConclusionUse of QFT-G assay following a positive TST result further identifies persons who would most benefit from treatment for LTBI

There’s no place like home: Integrating pulmonary rehabilitation into the home setting

Traditional, outpatient pulmonary rehabilitation provided to stable COPD patients leads to significant improvements in dyspnea, exercise capacity and health related quality of life.  Also, when started during or shortly after a hospitalization for a COPD exacerbation, pulmonary rehabilitation improves these patient-centered outcomes and arguably reduces subsequent health care utilization and mortality.  Despite these benefits, the uptake of traditional pulmonary rehabilitation remains disappointingly poor.  Home-based pulmonary rehabilitation, a safe and effective alternative to traditional, center-based programs, can broaden access. While proven improvements in dyspnea, exercise capacity and health status justify implementation of home-based pulmonary rehabilitation, it would be helpful to know whether it can also decrease health care utilization and be cost-effective.

8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – part 2

This paper summarizes the Part 2 of the proceedings of the 8th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations. This paper (Part 2) includes sections regarding: Promoting Physical Activity across the Spectrum of COPD (Physical activity: definitions, measurements, and significance; Increasing Physical Activity through Pharmacotherapy in COPD); Pulmonary Rehabilitation in Critical Illness (Complex COPD with comorbidities and its impact during acute exacerbation; Collaborative Self-Management in COPD: A Double-Edged Sword?; and Pulmonary Rehabilitation in Critical Illness

Integrating the care of the complex COPD patient

The European Seminars in Respiratory Medicine has represented an outstanding series updating new science in respiratory disease from the 1990\u2019s up to the early beginning of this 21st century [1,2]. Its aim is to update issues and current science, focusing on the multidisciplinary approach to patients with respiratory disease. As such, it represents a unique opportunity for specialists in Respiratory Medicine involved in Basic and Clinical Research to discuss topical and debated problems in medical care, at a top level forum guided by an expert panel of authors. The structure of the seminar is based on the following pillars: \u2022 Attendance at the Seminars is strictly limited: selection of participants is based, in order of priority, on scientific curriculum, age (younger specialists are privileged), and early receipt of the application form. \u2022 Each topic is allotted considerable time for presentation and discussion. The first section is devoted to a series of presentations (with adequate time allocated for discussion) by an expert panel of researchers and clinicians. In the second section involves discussions of controversial issues, in a smaller audience format encouraging interaction between the panel and audience. \u2022 \u201cMeet the expert\u201d seminars discuss topical subjects in more depth, utilizing an interactive tutorial

COPD: The Glass is Half-Full

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A History of Pulmonary Rehabilitation: Back to the Future

Pulmonary rehabilitation is defined as “an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease” [...

The Effect of Pulmonary Rehabilitation on Pedometer-Measured Physical Activity

Background: Pulmonary rehabilitation results in favorable outcomes across multiple areas, including exercise capacity, dyspnea, and health status. The effectiveness of this intervention on increasing physical activity levels, however, has received less attention. Accordingly, we tested the potential usefulness of a commercially-available pedometer (NL-2000) as an outcome measure for pulmonary rehabilitation. This instrument, which is a uniaxial accelerometer, accurately detects walking activity in healthy adults. Methods: Fifty-five patients with COPD who were referred to participating centers in the Northeast Pulmonary Rehabilitation Consortium (mean age 69 yr, FEV1 45%) were studied after informed consent was obtained. All were given usual outpatient pulmonary rehabilitation, with pre- to post-rehabilitation assessments of the six minute walk distance (6MWD), MRC dyspnea, and health status, using a self-administered version of the Chronic Respiratory Disease Questionnaire (CRQ). Pedometer activity was measured over a ~ one-week period early in rehabilitation and again for ~ 1 week at the end of rehabilitation. The device was not worn during rehabilitation sessions. Patients recorded in a diary the exact times they wore the device. Pre- to post-rehabilitation changes in NL-2000 counts per hour worn (NL&#183;hr-1) were evaluated, as well as the standard outcome variables (6 MWD, MRC, and CRQ). Results: Improvements were observed in the 6MWD (45 m.), MRC dyspnea (- 0.54 units) and the CRQ total score (10 units) (all, P < 0.001). However, there was no change in NL&#183;hr-1 (30 counts, IP. = 0.11). NL&#183;hr-1 were lower on rehabilitation days than on non-rehabilitation days; after adding this as a covariate, changes in activity became statistically significant. Conclusion: These results suggest that either pedometer activity assessment is relatively insensitive to detecting activity in slow-moving patients with COPD and/or pulmonary rehabilitation has less effect on increasing activity than in improving exercise performance, dyspnea, or health status

Cardiopulmonary exercise testing in the assessment of exertional dyspnea

Dyspnea on exertion is a commonly encountered problem in clinical practice. It is usually investigated by resting tests such as pulmonary function tests and echocardiogram, which may at times can be non-diagnostic. Cardiopulmonary exercise testing (CPET) measures physiologic parameters during exercise which can enable accurate identification of the cause of dyspnea. Though CPET has been around for decades and provides valuable and pertinent physiologic information on the integrated cardiopulmonary responses to exercise, it remains underutilized. The objective of this review is to provide a comprehensible overview of the underlying principles of exercise physiology, indications and contraindications of CPET, methodology and interpretative strategies involved and thereby increase the understanding of the insights that can be gained from the use of CPET