Fatigue and Quality of Life after Pulmonary Rehabilitation Program

BACKGROUND. Fatigue and poor quality of life can play an important role in chronic obstructive disease and treatment outcomes. The aim of this study was to examine the levels of fatigue and quality of life (QoL) among chronic obstructive pulmonary disease patients before and after a pulmonary rehabilitation program. METHODS. In this experimental study, 31 chronic obstructive pulmonary disease patients at a large hospital of Athens were randomly followed a pulmonary rehabilitation program and completed two questionnaires pre- and post-intervention:the Fatigue Assessment Scale designed for measuring fatigue and the Missoula -Vitas Quality of Life Index-15 designed for measuring QoL. Statistical analysis of the data was performed via the Statistical Program SPSS version 19.0.The statistical significance was set up at 0.05. RESULTS. The results showed decreased levels of fatigue after the completion of the Pulmonary Rehabilitation Program compared to pre -intervention. Moreover, although QoL did not seem to change after the intervention, however the dimension "Transcendent" seemed to be increased for the majority of the participants. After the participation in the rehabilitation program a statistically significant and negative correlation was observed between mental fatigue and total score of quality of life (r= -0.436, p=0.014 <0.05) as well as between physical fatigue and the dimensions of "Interpersonal" (r= -0.470 p=0.008),"Well-Being" (r= -0.615, p=0.000), "Transcendent" (r= -0.636, p=0.000) and total score of QoL (r= -0.543, p=0.002). CONCLUSIONS. A pulmonary rehabilitation program seems to be a successful and innovative clinical prevention program leading to a lower level of fatigue for those patients who suffer from chronic obstructive pulmonary disease

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

Greater exercise tolerance in COPD during acute interval, compared to equivalent constant‐load, cycle exercise: physiological mechanisms

The relative importance of ventilatory, circulatory and peripheral muscle factors in determining tolerance to exercise in patients with COPD is not known. In twelve COPD patients (FEV1 :58 ± 17%pred.) we measured ventilation, cardiac output, dynamic hyperinflation, local muscle oxygenation, blood lactate and time to exhaustion during a) interval exercise (IE) consisting of 30 s at 100% peak work-rate alternated with 30 s at 50% and b) constant load exercise (CLE) at 75% WRpeak, designed to produce the same average work rate. Exercise time was substantially longer during IE than CLE (19.5 ± 4.8 versus 11.4 ± 2.1 min, p = 0.0001). Total work output was therefore greater during IE than CLE (81.3 ± 27.7 versus 48.9 ± 23.8 kJ, p = 0.0001). Dynamic hyperinflation (assessed by changes from baseline in inspiratory capacity-ΔIC) was less during IE than CLE at CLE exhaustion time (isotime, p = 0.009), but was similar at exhaustion (ΔICCLE : -0.38 ± 0.10 versus ΔICIE : -0.33 ± 0.12 l, p = 0.102). In contrast, at isotime, minute ventilation, cardiac output and systemic oxygen delivery did not differ between protocols (p>0.05). At exhaustion in both protocols, vastus lateralis and intercostal muscle oxygen saturation were higher in IE than CLE (p = 0.014 and p = 0.0002, respectively) and blood lactate concentrations were lower (4.9 ± 2.4 mmol/l versus 6.4 ± 2.2 mmol/l, p = 0.039). These results suggest that 1) exercise tolerance in COPD is limited by dynamic hyperinflation; and 2) cyclically lower (50%) effort intervals in IE help preserve muscle oxygenation and reduce metabolic acidosis compared to CLE at the same average work rate, but these factors do not appear to determine time to exhaustion

Αιμοδυναμικές προσαρμογές μετά την ολοκλήρωση προγράμματος αποκατάστασης σε ασθενείς με χρόνια καρδιακή ανεπάρκεια

Οι ασθενείς με Χρόνια Καρδιακή Ανεπάρκεια (ΧΚΑ) εμφανίζουν περιορισμένη ικανότητα για άσκηση καθώς αδυνατούν να αυξήσουν τη καρδιακή παροχή, σε ικανοποιητικό βαθμό κατά την εκτέλεση αυξανόμενης έντασης σωματικού έργου. Μελέτες καταδεικνύουν ότι η ικανότητα έργου και η κορυφαία τιμή της καρδιακής παροχής μετά από πρόγραμμα αποκατάστασης αυξάνεται στους ασθενείς με ΧΚΑ. Το ερώτημα που τίθεται είναι αν η βελτίωση της οξειδωτικής ικανότητας των περιφερικών μυών είναι υπεύθυνη για τη βελτίωση της ικανότητας για έργο και κατ’ επέκταση για την αύξηση της κορυφαίας τιμής της καρδιακής παροχής ή αντιστρόφως η βελτίωση της καρδιακής παροχής αποτελεί τον βασικό μηχανισμό βελτίωσης της ικανότητας για έργο. Ο σκοπός λοιπόν αυτής της μελέτης ήταν: α) να διερευνήσει την επίδραση της διαλειμματικής προπόνησης στην απόκριση της καρδιακής παροχής, της καρδιακής συχνότητας και του όγκου παλμού σε υπομέγιστες δοκιμασίες άσκησης σταθερού φορτίου σε ασθενείς με ΧΚΑ και β) να το διερευνήσει αυτό όχι μόνο με την εργαστηριακή υπομέγιστη δοκιμασία σταθερού έργου σε κυκλοεργόμετρο αλλά και με την κλινική δοκιμασία εξάλεπτης βάδισης που χρησιμοποιείται ευρέως από τους καρδιολόγους για τη διερεύνηση αποτελεσματικότητας θεραπευτικών μεθόδων. Μελετήθηκαν σαράντα ασθενείς με ΧΚΑ με βαρύτητα νόσου Ι έως και ΙΙ σύμφωνα με την κλίμακα Νew York Heart Association (NYHA). Οι 30 ασθενείς συμμετείχαν στο πρόγραμμα Καρδιακής Αποκατάστασης (ομάδα προπόνησης) και οι 10 αποτέλεσαν την ομάδα ελέγχου. Η ομάδα προπόνησης συμμετείχε σε πρόγραμμα αποκατάστασης διαλειμματικής προπόνησης 12 εβδομάδων, με συχνότητα 3 φορές την εβδομάδα, διάρκειας 30 λεπτών, με περιόδους 30 δευτερολέπτων άσκησης και 30 δευτερολέπτων ενεργητικής ανάπαυλας, ενώ η ομάδα ελέγχου δε πραγματοποίησε κανενός είδους προπόνηση. Όλοι οι ασθενείς πριν και μετά το πέρας των 12 βδομάδων πραγματοποίησαν μια μέγιστη δοκιμασία άσκησης προοδευτικά αυξανόμενης έντασης στο κυκλοεργόμετρο, μια υπομέγιστη δοκιμασία άσκησης σταθερού φορτίου στο κυκλοεργόμετρο στο 75% του μέγιστου έργου και μια εξάλεπτη δοκιμασία βάδισης. Κατά τη διάρκεια αυτών των δοκιμασιών καταγραφόταν η καρδιακή παροχή, η καρδιακή συχνότητα και ο όγκος παλμού μη επεμβατικά με τη μέθοδο της βιοηλεκτρικής αγωγιμότητας (PhysioFlow, Enduro) για τον προσδιορισμό του μέσου χρόνου απόκρισης κατά τη φάση έναρξης και κατά τη φάση ανάκαμψης, η πρόσληψη οξυγόνου και το παραγόμενο έργο. Μετά το πέρας των 12 εβδομάδων η αερόβια διαλειμματική άσκηση φάνηκε ότι αλλάζει την κλινική βαρύτητα της νόσου της ΧΚΑ κατά ΝΥΗΑ και βελτιώνει τη λειτουργική ικανότητα των ασθενών και επιφέρει σημαντικές αιμοδυναμικές και μεταβολικές προσαρμογές που αφορούν τη βελτίωση της ικανότητας για μέγιστη και υπομέγιστη άσκηση. Επίσης, η αερόβια διαλειμματική άσκηση είναι αποτελεσματική στους ασθενείς με ΧΚΑ όσον αφορά την επιτάχυνση της απόκρισης της καρδιακής παροχής και καρδιακής συχνότητα σε δοκιμασία σταθερού φορτίου όχι όμως την απόκριση του όγκου παλμού. Τέλος η βελτίωση του μέσου χρόνου απόκρισης της καρδιακής παροχής και της καρδιακής συχνότητας στην υπομέγιστη δοκιμασία άσκησης στο 75% του παραγόμενου έργου στο κυκλοεργόμετρο σε ασθενείς με ΧΚΑ μετά την ολοκλήρωση προγράμματος αποκατάστασης αναπαράγεται στην εξάλεπτη δοκιμασία βάδισης με αποτέλεσμα την πιθανή εφαρμογή της εξάλεπτης δοκιμασίας ως εύχρηστης ασφαλούς και ανέξοδης δοκιμασίας

Cardiac output measurement during exercise in COPD : A comparison of dye dilution and impedance cardiography

Introduction: Impedance cardiography (IC) derived from morphological analysis of the thoracic impedance signal is now commonly used for noninvasive assessment of cardiac output (CO) at rest and during exercise. However, in Chronic Obstructive Pulmonary Disease (COPD), conflicting findings put its accuracy into question. Objectives: We therefore compared concurrent CO measurements captured by IC (PhysioFlow: CO IC ) and by the indocyanine green dye dilution method (CO DD ) in patients with COPD. Methods: Fifty paired CO measurements were concurrently obtained using the two methods from 10 patients (FEV 1 : 50.5 ± 17.5% predicted) at rest and during cycling at 25%, 50%, 75% and 100% peak work rate. Results: From rest to peak exercise CO IC and CO DD were strongly correlated (r = 0.986, P < 0.001). The mean absolute and percentage differences between CO IC and CO DD were 1.08 L/min (limits of agreement (LoA): 0.05-2.11 L/min) and 18 ± 2%, respectively, with IC yielding systematically higher values. Bland-Altman analysis indicated that during exercise only 7 of the 50 paired measurements differed by more than 20%. When data were expressed as changes from rest, correlations and agreement between the two methods remained strong over the entire exercise range (r = 0.974, P < 0.001, with no significant difference: 0.19 L/min; LoA: −0.76 to 1.15 L/min). Oxygen uptake (VO 2 ) and CO DD were linearly related: r = 0.893 (P < 0.001), CO DD = 5.94 × VO 2 + 2.27 L/min. Similar results were obtained for VO 2 and CO IC (r = 0.885, P < 0.001, CO IC = 6.00 × VO 2 + 3.30 L/min). Conclusions: These findings suggest that IC provides an acceptable CO measurement from rest to peak cycling exercise in patients with COPD