Protocol for a feasibility trial to inform the development of a breathlessness rehabilitation programme for chronic obstructive pulmonary disease and chronic heart failure (the COHERE trial)

© 2019 Author(s). Introduction Adults with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) commonly suffer from exertional dyspnoea and fatigue. Exercise training is recommended in the management of both diseases, yet many of the outcome measures traditionally reported are disease specific and may not fully acknowledge the multimorbid older adult. Based on our previous research, a breathlessness rehabilitation programme for patients with COPD/CHF or combined disease has been introduced as a service improvement within University Hospital Leicester National Health Service Trust and has amalgamated aspects of cardiac and pulmonary rehabilitation. This has created an opportunity to expand the outcome measures assessed and introduce a holistic approach in a population that share common symptoms. Therefore, this multisite trial will explore the feasibility of collecting novel outcome markers as part of a comprehensive assessment prior to enrolment in a breathlessness rehabilitation programme for participants with COPD and/or CHF. Methods and analysis The rehabilitation programme consists of 12 sessions, twice weekly, over a 6-week period. In addition to usual rehabilitation outcome measures, the trial will collect measures of future cardiometabolic risk including arterial stiffness, body composition, physical activity/sedentary time, frailty and symptom burden in a comprehensive rehabilitation assessment. The primary outcome measures will centre around feasibility (eg, acceptability of the comprehensive rehabilitation assessment, intervention delivery and the experiences and attitudes of healthcare professionals and participants). Focus groups and interviews will be conducted to further explore barriers and facilitators to the operation and participation in a breathlessness rehabilitation programme and the trial. Thematic analysis will be used for the interpretation of all qualitative data. Ethics and dissemination The research ethics committee East Midlands Leicester-Central has provided ethical approval for the conduct of this trial. The results of the trial will be disseminated through appropriate conference proceedings and peer-reviewed journals. Trial registration number ISRCTN1163630

Submaximal eccentric cycling in people with COPD: acute whole-body cardiopulmonary and muscle metabolic responses

BackgroundEccentric cycling (ECC) may be an attractive exercise modality in COPD due to both low cardiorespiratory demand and perception of effort compared to conventional concentric cycling (CON) at matched mechanical loads. However, it is unknown whether ECC can be performed by individuals with COPD at an intensity able to cause sufficient metabolic stress to improve aerobic capacity.Research questionWhat are the cardiopulmonary and metabolic responses to ECC in people with COPD and healthy volunteers when compared to CON at matched mechanical loads?Study Designand Methods: 13 individuals with COPD (mean ± SD age 64 ± 9 years, FEV 1 %pred 45 ± 19%, BMI 24 ± 4 kg.m -2, V̇O 2peak 15 ± 3 ml.kg -1.min -1) and 9 age matched controls (FEV 1 %pred 102 ± 13%, BMI 28 ± 5 kg.m -2, V̇O 2peak 23 ± 5 ml.kg -1.min -1), performed up to six 4 min bouts of ECC and CON at matched mechanical loads of increasing intensity. In addition, 12 individuals with COPD underwent quadriceps muscle biopsies before and after 20 min of ECC and CON at 65% peak power.ResultsAt matched mechanical loads, oxygen uptake, minute ventilation, heart rate, systolic blood pressure, RER (all pInterpretationCardiopulmonary and blood lactate responses during submaximal ECC were less compared to CON at equivalent mechanical workloads in health and COPD, and this was confirmed at a muscle level in COPD. Submaximal ECC was well tolerated and allowed greater mechanical work at lower ventilatory cost. However, in people with COPD, a training intervention based on ECC is unlikely to stimulate cardiovascular and metabolic adaptation to the same extent as CON.</div

Change in V˙O_2peak in response to aerobic exercise training and the relationship with exercise prescription in people with COPD: a systematic review and meta-analysis

BACKGROUND: ▪▪▪ RESEARCH QUESTION: The goal of this study was to investigate the effect of aerobic training and exercise prescription on peak oxygen uptake (V˙O2peak) in COPD. STUDY DESIGN AND METHODS: A systematic review was performed by using MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases for all studies measuring V˙O2peak prior to and following supervised lower-limb aerobic training in COPD. A random effects meta-analysis limited to randomized controlled trials comparing aerobic training vs usual care was conducted. Other study designs were included in a secondary meta-analysis and meta-regression to investigate the influence of program and patient factors on outcome. RESULTS: A total of 112 studies were included (participants, N = 3,484): 21 controlled trials (n = 489), of which 13 were randomized (n = 288) and 91 were uncontrolled (n = 2,995) studies. Meta-analysis found a moderate positive change in V˙O2peak (standardized mean difference, 0.52; 95% CI, 0.34-0.69) with the intervention. The change in V˙O2peak was positively associated with target duration of exercise session (P = .01) and, when studies > 1 year duration were excluded, greater total volume of exercise training (P = .01). Similarly, the change in V˙O2peak was greater for programs > 12 weeks compared with those 6 to 12 weeks when adjusted for age and sex. However, reported prescribed exercise intensity (P = .77), training modality (P > .35), and mode (P = .29) did not affect V˙O2peak. Cohorts with more severe airflow obstruction exhibited smaller improvements in V˙O2peak (P < .001). INTERPRETATION: Overall, people with COPD achieved moderate improvements in V˙O2peak through supervised aerobic training. There is sufficient evidence to show that programs with greater total exercise volume, including duration of exercise session and program duration, are more effective. Reduced effects in severe disease suggest alternative aerobic training methods may be needed in this population. CLINICAL TRIAL REGISTRATION: PROSPERO; No.: CRD42018099300; URL: www.clinicaltrials.gov