Baseline exercise tolerance and perceived dyspnea to identify the ideal candidate to pulmonary rehabilitation: a risk chart in COPD patients.

Background The appropriate criteria for patient selection are still a key issue in the clinical management of patients referred to pulmonary rehabilitation (PR). Methods We retrospectively analyzed the records of a wide population of 1470 outpatient or inpatients with chronic obstructive pulmonary disease (COPD) referred to standard PR at two specialized Italian centers. Two models of multivariate logistic regression were developed to test the predictive powers of baseline exercise tolerance, namely the distance walked in 6 minutes (6MWD), and of baseline dyspnea on exertion, measured by the modified Medical Research Council scale (mMRC), versus the minimal clinically important difference (MCID) for the same outcomes. Results- (p<0.001) of predicting a MCID change. Compared to the category of individuals with mMRC 0-1point, all the other categories (2, 3, and 4) also showed a higher probability (p<0.001) of predicting a MCID change. The incorporation of baseline categories of 6MWD and mMRC in a risk chart showed that the percentage of patients reaching MCID in both variables increased as the baseline level of 6MWD decreased and of mMRC increased. Conclusion- This study demonstrates that lower levels of exercise tolerance and greater perceived dyspnea on exertion predict achieving clinically meaningful changes for both these treatment outcomes following PR. A specific risk chart that integrates these two variables may help clinicians to select ideal candidates and best responders to PR

Erratum: Subjective sleep quality during Average Volume Assured Pressure Support (AVAPS) ventilation in patients with hypercapnic COPD: A physiological pilot study (Lung (2009) 187: 5 (299-305) DOI: 10.1007/s00408-009-9167-1)

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Functional recovery following physical training in tracheotomised and chronically ventilated patients. An observational prospective cohort study.

Background: Rehabilitation is a non-pharmacological therapy able to restore health status and reversing the patient\u2019s disability. Since the efficacy of this treatment in critically ill patients is not enough documented, the present study aimed to assess whether the degree of change in individual\u2019s functional status after comprehensive rehabilitation may influences the in-hospital clinical outcomes in a population of long-term ventilated patients.Methods: In a prospective cohort study we observed 77 tracheotomized patients (aged 75\ub17 yrs) admitted for difficult weaning in a regional weaning centre (RICU). Care plan including peripheral muscle training was delivered on a daily basis. Demographic, anthropometric and functional characteristics were measured at admission in all patients. Pre-to-post change in basic activity of daily living score (\u394-BADL), survival and weaning success rate were recorded as clinical outcomes. Pearson\u2019s correlation analysis and a linear regression model with \u394-BADL as the dependent variable were performed to test the predictive power of any measurement taken at baseline.Results: Sixty-seven patients (87%) survived whereas 55 of them (74%) succeded weaning during stay in RICU. \u394-BADL was +2.53 point (SD 2.03, median 2). Performance of the broadest muscle of back (BMB) at baseline predicted \u394-BADL (\u3b2 0.388, 95% CI 0.111-1,664, p=0.026). Probability to remain ventilator-free (p=0.043) and to survive (p=0.001) differed across the categories of \u394-BADL (0=no change, 1-2=least improvement, and >2=improvement above median change). Conclusions: Mortality rate and weaning success vary according to the degree of change in basic activities following active training in tracheotomised, ventilated and difficult-to-wean patients. Broadest muscle of back performance was the only significant predictor of change in these activities

Intrapulmonary percussive ventilation in tracheostomized patients: A randomized controlled trial

Objective: To investigate whether the addition of intrapulmonary percussive ventilation to the usual chest physiotherapy improves gas exchange and lung mechanics in tracheostomized patients. Design and setting: Randomized multicenter trial in two weaning centers in northern Italy. Patients and participants: 46 tracheostomized patients (age 70 ± 7 years, 28 men, arterial blood pH 7.436 ± 0.06, PaO2/FIO2 238 ± 46) weaned from mechanical ventilation. Interventions: Patients were assigned to two treatment groups performing chest physiotherapy (control), or percussive ventilation (IMP2 Breas, Sweden) 10 min twice/day in addition to chest physiotherapy (intervention). Measurements and results: Arterial blood gases, PaO2/FIO2 ratio, and maximal expiratory pressure were assessed every 5th day for 15 day. Treatment complications that showed up in 1 month of follow-up were recorded. At 15 days the intervention group had a significantly better PaO2/FIO2 ratio and higher maximal expiratory pressure; after follow-up this group also had a lower incidence of pneumonia. Conclusions: The addition of percussive ventilation to the usual chest physiotherapy regimen in tracheostomized patients improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia. © 2006 Springer-Verlag

Subjective sleep quality during average volume assured pressure support (AVAPS) ventilation in patients with hypercapnic COPD. A Physiological Pilot Study.

Non-invasive Positive Pressure Ventilation (NPPV) is an advanced treatment (1) aimed to improve both physiological (2-4) and clinical outcomes (5-7), including sleep (8-10), during the long-term management of patients with Chronic Respiratory Failure (CRF) due to severe hypercapnic Chronic Obstructive Pulmonary Disease (COPD). Several studies evaluating the nocturnal application of mask ventilation in stable COPD patients (11-13) have shown a limited effectiveness of pressure based modes of NPPV in this patient group. However, further studies have shown that compliance to ventilation may influence the long-term efficacy of this treatment as patients who are compliant with NPPV are able to maintain arterial blood gase (ABG) improvements over 6-months when compared with those who discontinued this therapy (14).A new NPPV modality, called Average Volume Assured Pressure Support (AVAPS), combines both the pressure and volume characteristics of ventilation and, accordingly, delivers a range of inspiratory pressures to guarantee a pre-fixed inspiratory tidal volume. This hybrid mode of ventilation has been studied in intubated patients with acute respiratory failure (15) and in patients with chronic hypoventilation linked to obesity (16,17) and other conditions (16). Under these circumstances AVAPS is able to induce high pulmonary volumes and reduce muscle workload, thus providing physiological benefits and comfort similar to those achieved by pressure support (PS) modes. However, positive effects on sleep quality have not yet been confirmed.This pilot evaluated short-term compliance, night-time efficacy and physiological responses to Average Volume Assured Pressure Support (AVAPS) ventilation in patients with stable hypercapnic COPD

Intrapulmonary percussive ventilation in tracheostomized patients: a randomized controlled trial.

OBJECTIVE: To investigate whether the addition of intrapulmonary percussive ventilation to the usual chest physiotherapy improves gas exchange and lung mechanics in tracheostomized patients. DESIGN AND SETTING: Randomized multicenter trial in two weaning centers in northern Italy. PATIENTS AND PARTICIPANTS: 46 tracheostomized patients (age 70 +/- 7 years, 28 men, arterial blood pH 7.436 +/- 0.06, PaO(2)/FIO(2) 238 +/- 46) weaned from mechanical ventilation. INTERVENTIONS: Patients were assigned to two treatment groups performing chest physiotherapy (control), or percussive ventilation (IMP2 Breas, Sweden) 10 min twice/day in addition to chest physiotherapy (intervention). MEASUREMENTS AND RESULTS: Arterial blood gases, PaO(2)/FIO(2) ratio, and maximal expiratory pressure were assessed every 5th day for 15 day. Treatment complications that showed up in 1 month of follow-up were recorded. At 15 days the intervention group had a significantly better PaO(2)/FIO(2) ratio and higher maximal expiratory pressure; after follow-up this group also had a lower incidence of pneumonia. CONCLUSIONS: The addition of percussive ventilation to the usual chest physiotherapy regimen in tracheostomized patients improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia