Improvement in frailty status after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

The aim of this study, is to assess changes in prevalence and frailty score during pulmonary rehabilitation (PR) in patients with COPD

Bronchodilation improves endurance but not muscular efficiency in chronic obstructive pulmonary disease

We hypothesized that bronchodilator treatment not only improves hyperinflation and endurance capacity but also muscular efficiency in stable chronic obstructive pulmonary disease (COPD). We aimed to demonstrate that tiotropium and salmeterol improve muscular efficiency compared with placebo. Twenty-five COPD patients were studied, including 20 males of mean (standard deviation) age 62 years (7 years) with baseline forced expiratory volume in 1 second of 41% (10%) predicted, and maximal workload of 101 Watt (36 Watt). Subjects were randomized for 6-week treatment with tiotropium 18 μg once daily, salmeterol 50 μg twice daily, or placebo using a double-blind, crossover design. Muscular efficiency and endurance time were measured during cycling at 50% of maximal work load. Resting energy expenditure was measured using a ventilated hood. Muscular efficiency after tiotropium, salmeterol, and placebo treatment was 14.6%, 14.4%, and 14.4%, respectively (P > 0.05), and resting energy expenditure was 1485 kcal/24 hours, 1709 kcal/24 hours, and 1472 kcal/24 hours (P > 0.05), respectively. Endurance time after tiotropium treatment was significantly higher than that after placebo (27.0 minutes versus 19.3 minutes [P = 0.02]), whereas endurance time after salmeterol treatment was not higher than that after placebo (23.3 minutes [P = 0.22]). In this small study, we were not able to demonstrate that bronchodilator therapy improved muscular efficiency. Apparently, reduced costs of breathing relative to total energy expenditure were too small to be detected

Association between muscle thickness, fat-free mass and malnutrition in patients with copd: an exploratory study

Rationale: Malnutrition is a common problem in patients with Chronic Obstructive Pulmonary Disease (COPD). Whereas estimation of fat-free muscle mass index (FFMi) with bio-electrical impedance is often used, less is known about muscle thickness measured with ultrasound (US) as a parameter for malnutrition. Moreover, it has been suggested that in this population, loss of muscle mass is characterized by loss of the lower body muscles rather than of the upper body muscles.1 Therefore, we explored the association between FFMi, muscle thickness of the biceps brachii (BB) and the rectus femoris (RF), and malnutrition in patients with COPD. Methods: Patients were assessed at the start of a pulmonary rehabilitation program. Malnutrition was assessed with the Scored Patient-Generated Subjective Global Assessment (PG-SGA). Malnutrition was defined as PG-SGA Stage B or C. FFMi (kg/m²) was estimated with bio-electrical impedance analysis BIA 101® (Akern), using the Rutten equation. Muscle thickness (mm) of the BB and the RF was measured with the handheld BodyMetrix® device (Intelametrix). Univariate and multivariate logistic regression analyses were performed to analyse associations between FFMi and muscle thickness for BB and RF, and malnutrition. Multivariate analysis corrected for sex, age, and GOLD-stage. Odds ratios (OR) and 95% confidence intervals (CI) were presented. A p-level of <0.05 was considered significant. Results: In total, 27 COPD patients (age 64±8.1 years; female 60%, GOLD-stage 3, interquartile range=3-4, BMI 27±6.6 kg/m2) were included in the analyses. In the univariate analysis, FFMi (p=0.014; OR=0.70, 95%CI: -0.12—0.15), RF thickness (p=0.021; OR=0.79, 95%CI: -0.09—0.01), and BB thickness (p=0.006; OR=0.83, 95%CI: -0.06—0.01) were all significantly associated with malnutrition. In the multivariate analysis, FFMi (p=0.031; OR=0.59, 95%CI: -0.18—0.01) and BB thickness (p=0.017; OR=0.73, 95%CI:-0.09—0.01) were significantly associated with malnutrition. None of the co-variables were significantly associated with malnutrition. Conclusion: In this relatively small sample of patients with severe COPD, low FFMi and low BB muscle thickness were both robustly associated with increased odds of being malnourished. BB muscle thickness measured with US may provide added value to the toolbox for nutritional assessment. The results of this exploratory study suggest that upper body muscles may reflect nutritional status more closely than lower body muscles. Reference: 1 Shrikrishna D, Patel M, Tanner RJ, Seymour JM, Connolly BA, Puthucheary ZA, et al. Quadriceps wasting and physical inactivity in patients with COPD. Eur Respir J. 2012;40(5):1115–22.

Dietary resilience in patients with severe COPD at the start of a pulmonary rehabilitation program

Background: COPD may impact food-related activities, such as grocery shopping, cooking, and eating. Decreased food intake may result in an unhealthy diet, and in malnutrition, which is highly prevalent in patients with COPD. Malnutrition is known to negatively impact clinical outcome and quality of life. Aims: In this qualitative study, we aimed to explore strategies used to overcome food-related challenges, ie, dietary resilience, and whether these led to a healthy diet. Furthermore, we aimed to identify the key themes of motivation for dietary resilience in patients with severe COPD. Methods: In October 2015 to April 2016, 12 patients with severe COPD starting a pulmonary rehabilitation program were interviewed. Qualitative description and thematic analysis were performed. Results: All participants mentioned the use of strategies to overcome challenges. Key themes of motivation for dietary resilience were identified as "wanting to be as healthy as possible", "staying independent", and "promoting a sense of continuity and duty". Two out of 12 participants met the criteria for a healthy diet. Conclusion: Our study showed a variety of motivational factors and strategies reported by patients with severe COPD to overcome food-related challenges. However, the majority (n=10) of the participants did not meet the criteria for a healthy diet. The identified key themes can be used to develop education to support patients with severe COPD to improve their diet

Treatment of severe stable COPD:the multidimensional approach of treatable traits

Now that additional treatment options for severe chronic obstructive pulmonary disease (COPD) have emerged in recent years, patients with severe COPD should not be left in the rather hopeless situation of "there is nothing to improve" any more. Inertia or fatalism is a disservice to our patients. Ranging from advanced care planning to quite intense and demanding therapies such as multidisciplinary pulmonary rehabilitation, (endoscopic) lung volume reduction, chronic noninvasive ventilation and lung transplantation, caregivers should try to provide a personalised treatment for every severe COPD patient. In this review, we aim to describe the multidimensional approach to these patients at our centre along the lines of treatable traits leading to specific additional treatment modalities on top of standard care