Power of outcome measurements to detect clinically significant changes in pulmonary rehabilitation of patients with COPD

Defining the minimal important difference for the visual analogue scale assessing dyspnea in patients with malignant pleural effusions

Background

The minimal important difference (MID) is essential for interpreting the results of randomised controlled trials (RCTs). Despite a number of RCTs in patients with malignant pleural effusions (MPEs) which use the visual analogue scale for dyspnea (VASD) as an outcome measure, the MID has not been established.

Methods

Patients with suspected MPE undergoing a pleural procedure recorded their baseline VASD and their post-procedure VASD (24 hours after the pleural drainage), and in parallel assessed their breathlessness on a 7 point Likert scale.

Findings

The mean decrease in VASD in patients with a MPE reporting a ‘small but just worthwhile decrease’ in their dyspnea (i.e. equivalent to the MID) was 19mm (95% CI 14-24mm). The mean drainage volume required to produce a change in VASD of 19mm was 760ml.

Interpretation

The mean MID for the VASD in patients with a MPE undergoing a pleural procedure is 19mm (95% CI 14-24mm). Thus choosing an improvement of 19mm in the VASD would be justifiable in the design and analysis of future MPE studies.

Pulmonary rehabilitation for chronic obstructive pulmonary disease

BACKGROUND

Widespread application of pulmonary rehabilitation (also known as respiratory rehabilitation) in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function (health-related quality of life, functional and maximal exercise capacity) attributable to the programmes. This review updates the review reported in 2006.

OBJECTIVES

To compare the effects of pulmonary rehabilitation versus usual care on health-related quality of life and functional and maximal exercise capacity in persons with COPD.

SEARCH METHODS

We identified additional randomised controlled trials (RCTs) from the Cochrane Airways Group Specialised Register. Searches were current as of March 2014.

SELECTION CRITERIA

We selected RCTs of pulmonary rehabilitation in patients with COPD in which health-related quality of life (HRQoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. We defined 'pulmonary rehabilitation' as exercise training for at least four weeks with or without education and/or psychological support. We defined 'usual care' as conventional care in which the control group was not given education or any form of additional intervention. We considered participants in the following situations to be in receipt of usual care: only verbal advice was given without additional education; and medication was altered or optimised to what was considered best practice at the start of the trial for all participants.

DATA COLLECTION AND ANALYSIS

We calculated mean differences (MDs) using a random-effects model. We requested missing data from the authors of the primary study. We used standard methods as recommended by The Cochrane Collaboration.

MAIN RESULTS

Along with the 31 RCTs included in the previous version (2006), we included 34 additional RCTs in this update, resulting in a total of 65 RCTs involving 3822 participants for inclusion in the meta-analysis.We noted no significant demographic differences at baseline between members of the intervention group and those who received usual care. For the pulmonary rehabilitation group, the mean forced expiratory volume at one second (FEV1) was 39.2% predicted, and for the usual care group 36.4%; mean age was 62.4 years and 62.5 years, respectively. The gender mix in both groups was around two males for each female. A total of 41 of the pulmonary rehabilitation programmes were hospital based (inpatient or outpatient), 23 were community based (at community centres or in individual homes) and one study had both a hospital component and a community component. Most programmes were of 12 weeks' or eight weeks' duration with an overall range of four weeks to 52 weeks.The nature of the intervention made it impossible for investigators to blind participants or those delivering the programme. In addition, it was unclear from most early studies whether allocation concealment was undertaken; along with the high attrition rates reported by several studies, this impacted the overall risk of bias.We found statistically significant improvement for all included outcomes. In four important domains of quality of life (QoL) (Chronic Respiratory Questionnaire (CRQ) scores for dyspnoea, fatigue, emotional function and mastery), the effect was larger than the minimal clinically important difference (MCID) of 0.5 units (dyspnoea: MD 0.79, 95% confidence interval (CI) 0.56 to 1.03; N = 1283; studies = 19; moderate-quality evidence; fatigue: MD 0.68, 95% CI 0.45 to 0.92; N = 1291; studies = 19; low-quality evidence; emotional function: MD 0.56, 95% CI 0.34 to 0.78; N = 1291; studies = 19; mastery: MD 0.71, 95% CI 0.47 to 0.95; N = 1212; studies = 19; low-quality evidence). Statistically significant improvements were noted in all domains of the St. George's Respiratory Questionnaire (SGRQ), and improvement in total score was better than 4 units (MD -6.89, 95% CI -9.26 to -4.52; N = 1146; studies = 19; low-quality evidence). Sensitivity analysis using the trials at lower risk of bias yielded a similar estimate of the treatment effect (MD -5.15, 95% CI -7.95 to -2.36; N = 572; studies = 7).Both functional exercise and maximal exercise showed statistically significant improvement. Researchers reported an increase in maximal exercise capacity (mean Wmax (W)) in participants allocated to pulmonary rehabilitation compared with usual care (MD 6.77, 95% CI 1.89 to 11.65; N = 779; studies = 16). The common effect size exceeded the MCID (4 watts) proposed by Puhan 2011(b). In relation to functional exercise capacity, the six-minute walk distance mean treatment effect was greater than the threshold of clinical significance (MD 43.93, 95% CI 32.64 to 55.21; participants = 1879; studies = 38).The subgroup analysis, which compared hospital-based programmes versus community-based programmes, provided evidence of a significant difference in treatment effect between subgroups for all domains of the CRQ, with higher mean values, on average, in the hospital-based pulmonary rehabilitation group than in the community-based group. The SGRQ did not reveal this difference. Subgroup analysis performed to look at the complexity of the pulmonary rehabilitation programme provided no evidence of a significant difference in treatment effect between subgroups that received exercise only and those that received exercise combined with more complex interventions. However, both subgroup analyses could be confounded and should be interpreted with caution.

AUTHORS' CONCLUSIONS

Pulmonary rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances the sense of control that individuals have over their condition. These improvements are moderately large and clinically significant. Rehabilitation serves as an important component of the management of COPD and is beneficial in improving health-related quality of life and exercise capacity. It is our opinion that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted. Future research studies should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree of supervision and intensity of training required and how long treatment effects persist. This endeavour is important in the light of the new subgroup analysis, which showed a difference in treatment effect on the CRQ between hospital-based and community-based programmes but no difference between exercise only and more complex pulmonary rehabilitation programmes.

A prospective multicentric study of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease and different clinical phenotypes

BACKGROUND

Recently, it has been proposed that different clinical phenotypes can be recognized in patients with chronic obstructive disease (COPD), namely predominant airway disease or parenchymal destructive changes.

OBJECTIVES

The aim of this prospective multicenter study was to evaluate whether these two phenotypes may influence outcomes following a pulmonary rehabilitation program (PRP).

METHODS

We have prospectively evaluated 364 consecutive COPD patients (70 ± 8 years, 76.3% males) admitted to a standard hospital-based PRP in 6 Italian centers. According to their phenotype, the study cohort was divided into two groups: patients with airway obstructive (group 1, n = 208) or parenchymal destructive COPD (group 2, n = 156). Before and after PRP, values of 6-min walking distance, perceived breathlessness (Medical Research Council), health-related quality of life (St. George's Respiratory Questionnaire) and respiratory muscle function (maximal inspiratory and expiratory pressure) were recorded.

RESULTS

PRP resulted in significant improvements in all outcome measures without any significant differences between groups.

CONCLUSIONS

Our study confirms that COPD patients may benefit from pulmonary rehabilitation independent of their clinical phenotype.

Long-term efficacy of intensive cycle ergometer exercise training program for advanced COPD patients

Background

Exercise training has been incorporated into the international guidelines for the treatment of chronic obstructive pulmonary disease (COPD). However, the long-term efficacy of the training program for patients with advanced COPD has never been evaluated in Thailand.

Purpose

To determine the long-term efficacy of intensive cycle ergometer exercise program on various clinical parameters of patients with advanced COPD.

Materials and methods

The patients with advanced COPD were separated into two groups: the intensive ergometer exercise program group and the control group. The clinical parameters of all the patients were assessed at baseline, every month for the first 3 months, and then every 3 months until they had completed the 24-month follow-up. Mann–Whitney U test was used to compare baseline mean differences between the groups. Repeated measure analysis was applied to determine the progress in all parameters during the entire follow-up period. Mean incase imputation method was applied to estimate the parameters of dropout cases.

Results

A total of 41 patients were enrolled: 27 in the intensive ergometer exercise program group and 14 in the control group. The intensive cycle ergometer exercise program group showed statistically significant improvements in muscle strength (from month 1 till the end of the study, month 24), endurance time (from month 1 till the end of measurement, month 12) and clinically significant improvements in 6-minute walk distance (from month 2 until month 9), dyspnea severity by transitional dyspnea index (from month 1 till the end of the study, month 24), and quality of life (from month 1 till the end of the study, month 24). There was no significant difference in survival rates between the groups.

Conclusion

The intensive ergometer exercise training program revealed meaningful long-term improvements in various clinical parameters for up to 2 years. These promising results should encourage health care professionals to promote exercise training for patients with advanced COPD who have limited daily activities despite optimal medication control.

Withdrawal of inhaled glucocorticoids and exacerbations of COPD

BACKGROUND

Treatment with inhaled glucocorticoids in combination with long-acting bronchodilators is recommended in patients with frequent exacerbations of severe chronic obstructive pulmonary disease (COPD). However, the benefit of inhaled glucocorticoids in addition to two long-acting bronchodilators has not been fully explored.

METHODS

In this 12-month, double-blind, parallel-group study, 2485 patients with a history of exacerbation of COPD received triple therapy consisting of tiotropium (at a dose of 18 μg once daily), salmeterol (50 μg twice daily), and the inhaled glucocorticoid fluticasone propionate (500 μg twice daily) during a 6-week run-in period. Patients were then randomly assigned to continued triple therapy or withdrawal of fluticasone in three steps over a 12-week period. The primary end point was the time to the first moderate or severe COPD exacerbation. Spirometric findings, health status, and dyspnea were also monitored.

RESULTS

As compared with continued glucocorticoid use, glucocorticoid withdrawal met the prespecified noninferiority criterion of 1.20 for the upper limit of the 95% confidence interval (CI) with respect to the first moderate or severe COPD exacerbation (hazard ratio, 1.06; 95% CI, 0.94 to 1.19). At week 18, when glucocorticoid withdrawal was complete, the adjusted mean reduction from baseline in the trough forced expiratory volume in 1 second was 38 ml greater in the glucocorticoid-withdrawal group than in the glucocorticoid-continuation group (P<0.001); a similar between-group difference (43 ml) was seen at week 52 (P=0.001). No change in dyspnea and minor changes in health status occurred in the glucocorticoid-withdrawal group.

CONCLUSIONS

In patients with severe COPD receiving tiotropium plus salmeterol, the risk of moderate or severe exacerbations was similar among those who discontinued inhaled glucocorticoids and those who continued glucocorticoid therapy. However, there was a greater decrease in lung function during the final step of glucocorticoid withdrawal. (Funded by Boehringer Ingelheim Pharma; WISDOM ClinicalTrials.gov number, NCT00975195.).

Pain in patients with COPD: a systematic review and meta-analysis

OBJECTIVES

To systematically investigate the prevalence of pain, factors related with pain and pain management interventions in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND STUDY ELIGIBILITY CRITERIA

PubMed (MEDLINE), EMBASE, CINAHL and PsychINFO from 1966 to December 2013. Studies were included if they presented clinical data on pain or symptom burden in patients with COPD, or pain as a domain of quality of life (QoL). All types of study designs were included.

RESULTS

Of the 1571 articles that were identified, 39 met the inclusion criteria and were included in this review. Fourteen studies focused on pain and symptom burden (including pain) in patients with COPD and 25 studies focused on QoL using a questionnaire that included a separate pain domain. Reported pain prevalence in high-quality studies ranged from 32 to 60%. Included studies report that pain is more prevalent in patients with COPD compared to participants from the general population. Comorbidity, nutritional status, QoL and several symptoms were related to pain. None of the included studies reported a significant relationship between lung function and pain prevalence or severity. However, studies investigating pain in patients with moderate COPD reported higher pain prevalence compared to studies in patients with severe of very severe COPD.

CONCLUSIONS

Although literature on this topic is limited and shows substantial heterogeneity, pain seems to be a significant problem in patients with COPD and is related to several other symptoms, comorbidity and QoL. Data synthesis suggests that pain is more prevalent in patients with moderate COPD compared to patients with severe or very severe COPD. Further research is needed and should focus on determining a more accurate pain prevalence, investigating the relationship between pain prevalence, disease severity and comorbidity and explore implementation and efficacy of pain management interventions in patients with COPD.

Tai chi mind-body exercise in patients with COPD: study protocol for a randomized controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic, progressively debilitating condition that is prevalent in the US and worldwide. Patients suffer from progressive dyspnea and exercise intolerance. Physical exercise is beneficial, but conventional pulmonary rehabilitation programs are underutilized. There remains a need for novel interventions that improve symptoms, quality-of-life, and functional capacity. Tai chi is an increasingly popular mind-body exercise that includes physical exercise, breathing training, mindful awareness, and stress management--components that are essential to the self-management of COPD. There are, however, limited data on the effectiveness of tai chi as a therapeutic intervention in this population.

METHODS/DESIGN

The Primary Aims are to evaluate the efficacy, safety, and feasibility of a 12-week tai chi program for patients with COPD. We utilize a randomized controlled trial design, with participants assigned in a 2:1 ratio to either a group tai chi program (N = 63) or a time/attention-matched education control (N = 31). Our primary outcomes are COPD-specific quality-of-life and exercise capacity. Secondary outcomes include dyspnea, mood, functional status, self-efficacy, and lung function. Cardiopulmonary exercise testing is done in a subset of patients (N = 50). To explore optimal training duration, a subgroup of patients in tai chi are randomly assigned to complete an additional 12 weeks training (total 24 weeks) (Exploratory Aim 1). To explore the impact of a simplified seated intervention including only a subset of tai chi's training components, a third randomly assigned group (N = 31) receives a 12- week mind-body breathing program (N = 31) (Exploratory Aim 2).

DISCUSSION

Results of the BEAM study (Breathing, Education, Awareness, Movement) will provide preliminary evidence regarding the value of tai chi for improving quality of life and exercise capacity in patients with COPD, including information regarding optimal duration. They will also inform the feasibility and potential benefit of an alternative mind-body breathing intervention, and provide insight regarding how isolated mind-body exercise components contribute to the overall effects of tai chi. Should the results be positive, tai chi and related mind-body practices may offer a novel exercise option that is potentially accessible to a large proportion of patients with COPD.

TRIAL REGISTRATION

This trial is registered in Clinical Trials.gov, ID number NCT01551953. Date of Registration March 1 2012.

Interactive videogame as rehabilitation tool of patients with chronic respiratory diseases: preliminary results of a feasibility study

OBJECTIVE

To evaluate the effectiveness of an interactive videogame (IV) system in addition to a supervised pulmonary rehabilitation programme (PRP) in patients with chronic respiratory diseases.

DESIGN

Randomised Controlled Trial comparing standard PRP (20 patients, control group: CG), and PRP + sessions of interactive videogame-aided exercises (20 patients, experimental group: EG). Lung and respiratory muscle function, arterial blood gases, exercise capacity, dyspnoea, health status and health-related quality of life (HRQL) and emotional response were measured before and after PRP. A questionnaire on acceptability of the PRP was administered.

RESULTS

Exercise capacity, dyspnoea and HRQL significantly improved in both groups after the PRP, whereas the EG showed a greater improvement in six-minute walk test and transitional dyspnoea index than the CG. No difference in psychological status or acceptability of PRP was observed between the two groups.

CONCLUSIONS

The addition of IV training was more effective for improving some parameters of exercise tolerance and dyspnoea, although did not result in better psychological status nor it was better accepted than the standard PRP in patients with chronic respiratory diseases.

Home-based respiratory rehabilitation in adult patients with moderate or severe persistent asthma

OBJECTIVE

We assessed retrospectively the feasibility of a home-based respiratory rehabilitation (RR) program for asthmatics under optimal pharmacological treatment, as this type of care can reduce costs and offer a more patient-friendly approach for subjects with persistent asthma.

METHODS

Fifty-two patients with persistent asthma were recruited to the RR program (20 males, 32 females, 54 ± 11 (SD) years, forced expiratory volume in one second 71 ± 33% of predicted mean value, BMI 29.9 ± 7.9 kg/m(2)). This two-month protocol comprised education sessions, respiratory physiotherapy and an exercise training program at home and in groups supervised by an adapted physical activity instructor.

RESULTS

Thirty-nine patients completed the whole RR program, i.e. 25% dropout. The dropout rate was significantly higher with respect to younger patients in employment. The number of exacerbations decreased significantly during the year following the program, regardless of whether the patients had dropped out (p < 0.02) or not (p < 0.001). The distance walked during a 6-min walking test increased by 33 m (p < 0.001). Several indices measured during a cycle ergometer test increased significantly after RR: peak oxygen uptake (10%), oxygen uptake at ventilatory threshold (12%) and maximum load (19%), all at a similar maximum heart rate. Concerning quality of life assessment, the Short-Form-36 Item Health Survey revealed a non-significant improvement in the "health change" item after RR (p < 0.07).

CONCLUSIONS

This study demonstrates the potential of a home-based program in the treatment and rehabilitation of patients with asthma. Both functional and physiologic indices improved during the follow-up period.

Exercise performance after standard rehabilitation in COPD patients with lung hyperinflation

The role of pulmonary rehabilitation (PR) in COPD patients with lung hyperinflation has not yet been fully investigated. We retrospectively evaluated the effect of a standard PR course on exercise tolerance and symptoms according to the presence or absence of associated lung hyperinflation, as defined by lung function parameters in three Italian rehabilitation centres. In a cohort of 823 COPD patients (age 71 ± 8 years, FEV1 56 ± 18% pred.) we have systematically recorded: changes (∆) in 6-minute walking test (6MWD) as the primary outcome; dyspnoea (D); muscle fatigue (F); SO2nadir during effort; perceived breathlessness score (MRC); and specific health-related quality of life (SGRQ). Outcomes were compared between patients with lung hyperinflation (n = 283, LH) or without (n = 540 No-LH). Groups were comparable for age, body mass index, baseline exercise tolerance, and breathlessness. ∆-6MWD (+72 ± 47 vs. +62 ± 42 m, p < 0.05); ∆-D (-2.3 ± 1.7 vs. -1.9 ± 1.3 point, p < 0.05) and ∆-SO2nadir (+1.4 ± 3.0 and +0.5 ± 3.3 point, p < 0.05) were greater in LH than in No-LH. Using a multivariate linear regression model, ∆-6MWD in the LH group significantly correlated with lower functional residual capacity (p = 0.021) and baseline 6MWD (p = 0.004). Tolerance, gas exchange and perceived symptoms during effort are the parameters that gain a significant benefit from standard rehabilitation in COPD patients with a lung hyperinflation condition.

Baseline regional perfusion impacts exercise response to endobronchial valve therapy in advanced pulmonary emphysema

BACKGROUND

Advanced heterogeneous emphysema with hyperinflation impacts exercise tolerance in COPD. Bronchoscopic lung volume reduction using Zephyr endobronchial valves (EBVs) has been shown to improve lung function in patients with heterogeneous emphysema. It is unclear whether the target lobe perfusion of patients receiving EBV therapy impacts exercise tolerance as measured by the 6-min walk test distance (6MWTD).

METHODS

We performed a retrospective analysis on the treatment group of the Endobronchial Valve for Emphysema Palliation Trial (VENT) to evaluate the impact of perfusion, measured by 99mTc-MAA-perfusion scintigraphy, on the 6-month improvement in 6MWTD. A mixed-model analysis was performed for the treatment outcome, adjusting for other variables such as age, target lobe position, fissure integrity, BMI, sex, destruction score, and lobar exclusion.

RESULTS

Dichotomized at the median, of the 169 patients who received EBV therapy, 88 had a low target lobe regional perfusion and 81 had high target lobe regional perfusion at baseline. Patients with a low target lobe regional perfusion had a significant improvement in 6MWTD when compared with those with a high baseline target lobe regional perfusion (30.24 m vs 3.72 m, P = .03). Shifts in perfusion after EBV therapy occurred only in patients with high baseline perfusion and did not correlate with improved 6MWTD.

CONCLUSIONS

Patients having heterogeneous emphysema with a low baseline target lobe regional perfusion benefit from EBV therapy, independent of the degree of target lobe destruction. This effect is attenuated if the EBV therapy is not occlusive. Characterization of baseline perfusion may enhance clinical results of patients with emphysema undergoing EBV therapy.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00000606; URL: www.clincialtrials.gov.

An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.

PURPOSE

The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.

METHODS

A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.

RESULTS

An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.

CONCLUSIONS

The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

Clinically important differences in the intensity of chronic refractory breathlessness

CONTEXT

Clinically important differences in chronic refractory breathlessness are ill defined but important in clinical practice and trial design.

OBJECTIVES

To estimate the clinical relevance of differences in breathlessness intensity using distribution and patient anchor methods.

METHODS

This was a retrospective data analysis from 213 datasets from four clinical trials for refractory breathlessness. Linear regression was used to explore the relationship between study effect size and change in breathlessness score (0-100mm visual analogue scale) and to estimate the change in score equivalent to small, moderate, and large effect sizes. Pooled individual blinded patient preference data from three randomized controlled trials were analyzed. The difference between the mean change in Day 4 minus baseline scores between preferred and non-preferred arms was calculated.

RESULTS

There was a strong relationship between change in score and effect size (P = 0.001; R(2) = 0.98). Values for small, moderate, and large effects were -5.5, -11.3, and -18.2mm. The participant preference change in score was -9mm (95% CI, -15.8, -2.1) (P = 0.008).

CONCLUSION

This larger dataset supports a clinically important difference of 10mm. Studies should be powered to detect this difference.

Evidence-based risk assessment and recommendations for physical activity clearance: respiratory disease

The 2 most common respiratory diseases are chronic obstructive pulmonary disease (COPD) and asthma. Growing evidence supports the benefits of exercise for all patients with these diseases. Due to the etiology of COPD and the pathophysiology of asthma, there may be some additional risks of exercise for these patients, and hence accurate risk assessment and clearance is needed before patients start exercising. The purpose of this review was to evaluate the available literature regarding the risks of exercise for patients with respiratory disease and provide evidence-based recommendations to guide the screening process. A systematic review of 4 databases was performed. The literature was searched to identify adverse events specific to exercise. For COPD, 102 randomized controlled trials that involved an exercise intervention were included (n = 6938). No study directly assessed the risk of exercise, and only 15 commented on exercise-related adverse events. For asthma, 30 studies of mixed methodologies were included (n = 1278). One study directly assessed the risk of exercise, and 15 commented on exercise-related adverse events. No exercise-related fatalities were reported. The majority of adverse events in COPD patients were musculoskeletal or cardiovascular in nature. In asthma patients, exercise-induced bronchoconstriction and (or) asthma symptoms were the primary adverse events. There is no direct evidence regarding the risk of exercise for patients with COPD or asthma. However, based on the available literature, it would appear that with adequate screening and optimal medical therapy, the risk of exercise for these respiratory patients is low.

COPD management: role of symptom assessment in routine clinical practice

Patients with chronic obstructive pulmonary disease (COPD) present with a variety of symptoms that significantly impair health-related quality of life. Despite this, COPD treatment and its management are mainly based on lung function assessments. There is increasing evidence that conventional lung function measures alone do not correlate well with COPD symptoms and their associated impact on patients' everyday lives. Instead, symptoms should be assessed routinely, preferably by using patient-centered questionnaires that provide a more accurate guide to the actual burden of COPD. Numerous questionnaires have been developed in an attempt to find a simple and reliable tool to use in everyday clinical practice. In this paper, we review three such patient-reported questionnaires recommended by the latest Global Initiative for Chronic Obstructive Lung Disease guidelines, ie, the modified Medical Research Council questionnaire, the clinical COPD questionnaire, and the COPD Assessment Test, as well as other symptom-specific questionnaires that are currently being developed.

The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial

BACKGROUND

Positive expiratory pressure (PEP) is a technique used to enhance sputum clearance during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The impact of PEP therapy during acute exacerbations on clinically important outcomes is not clear. This study sought to determine the effect of PEP therapy on symptoms, quality of life and future exacerbations in patients with AECOPD.

METHODS

90 inpatients (58 men; mean age 68.6 years, FEV(1) 40.8% predicted) with AECOPD and sputum expectoration were randomised to receive usual care (including physical exercise)±PEP therapy. The Breathlessness, Cough and Sputum Scale (BCSS), St George's Respiratory Questionnaire (SGRQ) and BODE index (Body mass index, airflow Obstruction, Dyspnoea, Exercise tolerance) were measured at discharge, 8 weeks and 6 months following discharge, and analysed via linear mixed models. Exacerbations and hospitalisations were recorded using home diaries.

RESULTS

There were no significant between-group differences over time for BCSS score [mean (SE) at discharge 5.2 (0.4) vs 5.0 (0.4) for PEP and control group, respectively; p=0.978] or SGRQ total score [41.6 (2.6) vs 40.8 (2.8) at 8 weeks, p=0.872]. Dyspnoea improved more rapidly in the PEP group over the first 8 weeks (p=0.006), however these benefits were not observed at 6 months. Exacerbations (p=0.986) and hospitalisations (p=0.359) did not differ between groups.

CONCLUSIONS

We found no evidence that PEP therapy during AECOPD improves important short-term or long-term outcomes. There does not appear to be a routine role for PEP therapy in the management of such individuals.

Patient-reported outcome measures for chronic obstructive pulmonary disease : the exclusion of people with low literacy skills and learning disabilities

BACKGROUND

Patient-reported outcome measures (PROMs) are intended to reflect outcomes relevant to patients. They are increasingly used for healthcare quality improvement. To produce valid measures, patients should be involved in the development process but it is unclear whether this usually includes people with low literacy skills or learning disabilities. This potential exclusion raises concerns about whether these groups will be able to use these measures and participate in quality improvement practices.

METHODS

Taking PROMs for chronic obstructive pulmonary disease (COPD) as an exemplar condition, our review determined the inclusion of people with low literacy skills and learning disabilities in research developing, validating, and using 12 PROMs for COPD patients. The studies included in our review were based on those identified in two existing systematic reviews and our update of this search.

RESULTS

People with low literacy skills and/or learning disabilities were excluded from the development of PROMs in two ways: explicitly through the participant eligibility criteria and, more commonly, implicitly through recruitment or administration methods that would require high-level reading and cognitive abilities. None of the studies mentioned efforts to include people with low literacy skills or learning disabilities.

CONCLUSION

Our findings suggest that people with low literacy skills or learning disabilities are left out of the development of PROMs. Given that implicit exclusion was most common, researchers and those who administer PROMs may not even be aware of this problem. Without effort to improve inclusion, unequal quality improvement practices may become embedded in the health system.

Combined therapy with tiotropium and formoterol in chronic obstructive pulmonary disease: effect on the 6-minute walk test

Combined therapy with tiotropium and long-acting beta 2 agonists confers additional improvement in symptoms, lung function and aspects of health-related quality of life (QOL) compared with each drug alone in patients with COPD. However, the efficacy of combined therapy on walking distance, a surrogate measure of daily functional activity and morbidity remains unclear. The aim was, therefore, to quantify the benefit of this therapy on the six minute walk test. Secondary outcomes included change in lung function, symptoms, the BODE index and QOL. In a double-blind, crossover study, 38 participants with moderate to severe COPD on tiotropium were randomised to receive either formoterol or placebo for 6 weeks. Following a 2-week washout period, participants crossed over to the alternate arm of therapy for a further 6 weeks. Thirty-six participants, with an average age of 64.3 years and FEV1 predicted of 53%, completed the study. Combined therapy improved walking distance by a mean of 36 metres [95% CI: 2.4, 70.1; p = 0.04] compared with tiotropium. FEV1 increased in both groups (160 mL combination therapy versus 30 mL tiotropium) with a mean difference of 110 mL (95% CI: -100, 320; p = 0.07) between groups, These findings further support the emerging advantages of combined therapy in COPD. Australian New Zealand Clinical Trials.

Longitudinal changes in patient-reported dyspnea in patients with COPD

BACKGROUND

Although guidelines recommend monitoring symptoms in patients with chronic obstructive pulmonary disease (COPD), there is limited information on the longitudinal changes in patient-reported dyspnea (PRD) related to activities of daily living. The hypothesis was that PRD scores on the modified Medical Research Council (mMRC) scale, the self-administered computerized (SAC) transition dyspnea index (TDI), and the University of California San Diego Shortness of Breath questionnaire (UCSD SOBQ) would demonstrate progression over two years.

METHODS

Observational cohort study of symptomatic patients with stable COPD evaluated every 6 months for 2 years. Patients rated the impact of activities of daily living on dyspnea using three patient-reported instruments presented in random order, and then performed post-bronchodilator (pBD) spirometry.

RESULTS

Seventy patients (37 female/33 male; age: 66 ± 9 years; and pBD forced expiratory volume in one second [(FEV1): 51 ± 16% predicted] participated. Using fixed effects regression modeling, there was significant worsening in the PRD scores with the SAC TDI (-0.9 ± 2.7; p = 0.03) and UCSD SOBQ (+5.7 ± 18.3; p = 0.001), but not with the mMRC scale (p = 0.52). Both pBD FEV1 (p = 0.19) and pBD forced vital capacity (p = 0.65) were unchanged.

CONCLUSIONS

Multidimensional instruments (SAC TDI and UCSD SOBQ) demonstrated the frequently observed decline in PRD experienced by patients with COPD. The progression in PRD occurred despite stable lung function. Monitoring PRD provides unique clinical information and should be considered along with measuring lung function to assess patient status over time.

Responsiveness of three instruments to assess self-reported functional status in patients with COPD

The study aimed to compare the responsiveness of three instruments to assess self-reported changes in functional status after exercise training in patients with COPD: Pulmonary Functional Status and Dyspnea Questionnaire -modified version (PFSDQ-M), London Chest Activity of Daily Living (LCADL) and Medical Research Council scale (MRC). Twenty-two patients (11 female, 66[62-71] years, FEV1 42[33-61]%predicted) participated in a 3-month high-intensity exercise program. The three instruments were applied pre- and post-program, as well as assessment of lung function, muscle strength, exercise capacity (6-minute walking test, 6MWT) and quality of life (St. George's Respiratory Questionnaire, SGRQ). SGRQ, 6MWT and quadriceps femoris, biceps and triceps brachialis strength improved significantly after the program (p < 0.05 for all). Training also yielded significant improvement in the LCADL total score and self-care, domestic and leisure domains and in the PFSDQ-M 'change in activities' domain, with no improvement in the MRC (p = 0.11). Calculation of effects sizes also indicated higher responsiveness in the LCADL than the other instruments. There were no significant correlations between changes in the three instruments and changes in lung function, SGRQ or 6MWT. In conclusion, PFSDQ-M's 'change in activity' domain and specially the LCADL (to a higher extent) showed responsiveness to detect changes in functional status after three months of high-intensity exercise training in patients with COPD, whereas the MRC scale did not. In this population, the improvement in functional status was not related with improvement in exercise capacity, lung function or quality of life.

Functional and psychosocial effects of health qigong in patients with COPD: a randomized controlled trial

CONTEXT

The initial gain from a Pulmonary Rehabilitation Program (PRP) among patients with chronic obstructive pulmonary disease (COPD) begins to fade away 6 months after the completion of a rehabilitation program. One possible reason may be due to the poor compliance of the patients to the existing forms of home exercise program (e.g., walking, weight training activities, etc.).

OBJECTIVES

This study tested the efficacy of health qigong (HQG), a traditional Chinese exercise, as an adjunct home exercise program in optimizing the gains obtained from PRP until 6 months after discharge.

DESIGN

This was a randomized controlled trial (RCT) on a mind-body exercise intervention.

PARTICIPANTS

Eighty (80) patients with COPD receiving conventional PRP pulmonary rehabilitation program were randomized to the HQG intervention group (n = 40) and control group (n = 40).

OUTCOME MEASURES

Assessments were undertaken by blinded assessors at baseline, discharge from training, and follow-up (FU) at 3 and 6 months. Primary outcomes involved functional capacity scales and secondary outcomes involved quality-of-life scales.

RESULTS

Intention-to-treat analysis identified trends of improvement in all outcome measures in the HQG group, whereas lesser improvement and trends of deteriorations were identified in the control group. Ancillary analysis using a per-protocol method, however, identified significantly better improvements in functional capacity measures among the HQG at the 6-month FU.

CONCLUSIONS

This RCT provided some evidence to support the positive effect of HQG as an adjunct home exercise for rehabilitation among people with COPD and to support further related research.

Effects of pulmonary rehabilitation in bronchiectasis: A retrospective study

There is limited information about the benefits of pulmonary rehabilitation (PR) in patients with bronchiectasis. This study aimed to evaluate the effects of an out-patient PR program in patients with a primary diagnosis of bronchiectasis and to compare them with a matched COPD group who completed the same PR program. A retrospective review was conducted of patients with bronchiectasis or COPD who completed 6 to 8 weeks of PR at two tertiary institutions. The outcome measures were the 6-minute walk distance (6MWD) and Chronic Respiratory Disease Questionnaire (CRQ). Ninety-five patients with bronchiectasis completed the PR (48 male; FEV1 63 [24] % predicted; age 67 [10] years). Significant improvements in 6MWD (mean change 53.4 m, 95% CI 45.0 to 61.7) and CRQ total score (mean change 14.0 units, 95% CI 11.3 to 16.7) were observed immediately following PR. In patients with complete follow-up (n = 37), these improvements remained significantly higher than baseline at 12 months (20.5 m, 95% CI 1.4 to 39.5 for 6MWD; 12.1 points, 95% CI 5.7 to 18.4 for CRQ total score). The time trend and changes in the 6MWD and CRQ scores were not significantly different between the bronchiectasis and the COPD groups (all p > 0.05). This study supports the inclusion of patients with bronchiectasis in existing PR programs. Further prospective RCTs are warranted to substantiate these findings.

Air quality influence on chronic obstructive pulmonary disease (COPD) patients' quality of life

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death. The relationship between urban air pollution and its short-term health effects on patients suffering from COPD is confirmed. However, information about the impact of air pollutants upon the quality of life (QOL) in patients with COPD is lacking. Through a cross-sectional survey, this study investigates such impact in terms of the scores of the (Chinese) chronic respiratory questionnaire (CCRQ) and the measurements of indoor air quality (IAQ), lung function and Moser's activities of daily living (ADL). Using Yule's Q statistic with a cutoff |Q|>0.7 to identify the strong relationships between environmental parameters and CRQ sub-scores, this study reveals that patient emotion is strongly associated with indoor environmental quality although the evidence of a causal relationship between them needs further research.

PRACTICAL IMPLICATIONS

As QOL in patients with COPD and indoor environmental parameters are strongly associated, indoor air pollutants must be monitored for related studies in the future.

Measures of dyspnea in pulmonary rehabilitation

Dyspnea is the main symptom perceived by patients affected by chronic respiratory diseases. It derives from a complex interaction of signals arising in the central nervous system, which is connected through afferent pathway receptors to the peripheral respiratory system (airways, lung, and thorax). Notwithstanding the mechanism that generates the stimulus is always the same, the sensation of dyspnea is often described with different verbal descriptors: these descriptors, or linguistic 'clusters', are clearly influenced by socio-individual factors related to the patient. These factors can play an important role in identifying the etiopathogenesis of the underlying cardiopulmonary disease causing dyspnea. The main goal of rehabilitation is to improve dyspnea; hence, quantifying dyspnea through specific tools (scales) is essential in order to describe the level of chronic disability and to assess eventual changes after intervention. Improvements, even if modest, are likely to determine clinically relevant changes (minimal clinically important difference, MCID) in patients.

Currently there exist a large number of scales to classify and characterize dyspnea: the most frequently used in everyday clinical practice are the clinical scales (e.g. MRC or BDI/TDI, in which information is obtained directly from the patients through interview) and psychophysical scales (such as the Borg scale or VAS, which assess symptom intensity in response to a specific stimulus, e.g. exercise).

It is also possible to assess the individual's dyspnea in relation to specific situations, e.g. chronic dyspnea (with scales that classify patients according to different levels of respiratory disability); exertional dyspnea (with tools that can measure the level of dyspnea in response to a physical stimulus); and transitional (or 'follow up') dyspnea (with scales that measure the effect in time of a treatment intervention, such as rehabilitation).

Outcome measures in chronic obstructive pulmonary disease (COPD): strengths and limitations

Current methods for assessing clinical outcomes in COPD mainly rely on physiological tests combined with the use of questionnaires. The present review considers commonly used outcome measures such as lung function, health status, exercise capacity and physical activity, dyspnoea, exacerbations, the multi-dimensional BODE score, and mortality. Based on current published data, we provide a concise overview of the principles, strengths and weaknesses, and discuss open questions related to each methodology. Reviewed is the current set of markers for measuring clinically relevant outcomes with particular emphasis on their limitations and opportunities that should be recognized when assessing and interpreting their use in clinical trials of COPD.

The six-minute walk test: a useful metric for the cardiopulmonary patient

Measurement of exercise capacity is an integral element in assessment of patients with cardiopulmonary disease. The 6-min walk test (6MWT) provides information regarding functional capacity, response to therapy and prognosis across a range of chronic cardiopulmonary conditions. A distance less than 350 m is associated with increased mortality in chronic obstructive pulmonary disease, chronic heart failure and pulmonary arterial hypertension. Desaturation during a 6MWT is an important prognostic indicator for patients with interstitial lung disease. The 6MWT is sensitive to commonly used therapies in chronic obstructive pulmonary disease such as pulmonary rehabilitation, oxygen, long-term use of inhaled corticosteroids and lung volume reduction surgery. However, it appears less reliable to detect changes in clinical status associated with medical therapies for heart failure. A change in walking distance of more than 50 m is clinically significant in most disease states. When interpreting the results of a 6MWT, consideration should be given to choice of predictive values and the methods by which the test was carried out.

Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease

OBJECTIVE

To establish the minimal important difference (MID) for the six-minute walk distance (6MWD) in persons with chronic obstructive pulmonary disease (COPD).

DESIGN

Analysis of data from an observational study using distribution- and anchor-based methods to determine the MID in 6MWD.

SETTING

Outpatient pulmonary rehabilitation program at 2 teaching hospitals.

PARTICIPANTS

Seventy-five patients with COPD (44 men) in a stable clinical state with mean age 70 years (SD 9 y), forced expiratory volume in one second 52% (SD 21%) predicted and baseline walking distance 359 meters (SD 104 m).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed the six-minute walk test before and after a 7-week pulmonary rehabilitation program. Participants and clinicians completed a global rating of change score while blinded to the change in 6MWD.

RESULTS

The mean change in 6MWD in participants who reported themselves to be unchanged was 17.7 meters, compared with 60.2 meters in those who reported small change and 78.4 meters in those who reported substantial change (P=.004). Anchor-based methods identified an MID of 25 meters (95% confidence interval 20-61 m). There was excellent agreement with distribution-based methods (25.5-26.5m, kappa=.95). A change in 6MWD of 14% compared with baseline also represented a clinically important effect; this threshold was less sensitive than for absolute change (sensitivity .70 vs .85).

CONCLUSIONS

The MID for 6MWD in COPD is 25 meters. Absolute change in 6MWD is a more sensitive indicator than percentage change from baseline. These data support the use of 6MWD as a patient-important outcome in research and clinical practice.

Randomized controlled trial of mindfulness-based therapy for dyspnea in chronic obstructive lung disease

OBJECTIVES

Patients with chronic obstructive lung disease (COPD) suffer from significant dyspnea and may benefit from complementary and alternative medicine (CAM) therapies aimed at mitigating symptoms. The objective of this study was to test the efficacy of a mindfulness-based breathing therapy (MBBT) on improving symptoms and health-related quality of life in those with COPD.

DESIGN

We conducted a randomized controlled trial of 8-week mindfulness-based breathing therapy (MBBT) compared to support groups to test efficacy on improving symptoms and health-related quality of life in those with COPD.

SETTING

The setting for this study was an academic-affiliated veterans healthcare system.

SUBJECTS

The subjects consisted of 86 patients with COPD.

INTERVENTIONS

MBBT included weekly meetings practicing mindfulness mediation and relaxation response.

OUTCOME MEASURES

The main outcome measure was a post 6-minute-walk test (6MWT) Borg dyspnea assessment. Other outcome measures included health-related quality of life measures, 6MWT distance, symptom scores, exacerbation rates, and measures of stress and mindfulness. Analysis of covariance compared differences in outcomes between groups; paired t test evaluated changes within groups.

RESULTS

Participants were predominantly elderly men with moderate to severe COPD. We found no improvements in dyspnea (post 6MWT Borg difference between the MBBT and support group was 0.3 (95% confidence interval [CI]: -1.1, 1.7). We found no differences between groups in almost all other outcome measures by either intention-to-treat analysis or within the subset that completed assigned group sessions. For the physical summary scale of the generic Short Form-36 for Veterans, the difference between outcomes favored the support group (4.3, 95% CI: 0.4, 8.1). Participant retention was low compared to mind-body trials that randomize from CAM wait lists.

CONCLUSIONS

This trial found no measurable improvements in patients with COPD receiving a mindfulness-based breathing CAM therapy compared to a support group, suggesting that this intervention is unlikely to be an important therapeutic option for those with moderate-to-severe COPD.

Minimally Clinically Important Difference for the UCSD Shortness of Breath Questionnaire, Borg Scale, and Visual Analog Scale

Dyspnea is a primary symptom of chronic lung disease and an important outcome measure for clinical trials. Several standardized measures have been developed to evaluate this important symptom and are being used increasingly in clinical trials. The minimally clinically important difference (MCID) is not well defined for these measures but is important in interpreting the clinical meaning of results of studies in this area. The purpose of this paper is to evaluate the MCID for three commonly used measures to assess dyspnea in chronic lung disease: UCSD Shortness of Breath Questionnaire (SOBQ), Borg Scale (Borg), and Visual Analog Scale (VAS). The analysis is based on a retrospective review of published trials evaluating the response to a pulmonary rehabilitation or exercise intervention that is known to produce modest, but clinically meaningful changes for such patients. Using a distribution-based approach based primarily on effect size, the recommended MCID for these measures are: 5-units for the SOBQ, 1-unit for the Borg scale, and approximately 10 to 20 units for the VAS.

Patient-reported dyspnea in COPD reliability and association with stage of disease

BACKGROUND

Although questionnaires are used frequently with patients to self-report the severity of dyspnea as related to activities of daily living, the reliability of these instruments has not been established. The two purposes of this study were to examine the test-retest reliability of three widely used dyspnea instruments and to compare dyspnea scores at different stages of disease.

METHODS

At paired baseline visits, 101 stable patients with COPD were tested; at paired follow-up visits at 3 months, 89 of these patients were tested. At each visit, patients rated dyspnea with three instruments presented in random order and then performed post-bronchodilator therapy lung function tests.

RESULTS

Patient-reported dyspnea scores and lung function were similar at baseline (interval, 6 +/- 5 days) and follow-up visits (interval, 4 +/- 2 days). Intraclass correlation coefficients at baseline and at follow-up were 0.82 and 0.82, respectively, for the modified Medical Research Council scale; 0.90 and 0.84, respectively, for the self-administered computerized versions of the baseline dyspnea index and transition dyspnea indexes; and 0.95 and 0.89 for the University of San Diego Shortness of Breath Questionnaire results. Dyspnea ratings were significantly related to the stage of disease severity based on percent predicted FEV(1) (p < 0.001).

CONCLUSIONS

Test-retest reliability was acceptable for patient-reported dyspnea scores using three clinical instruments at baseline and at the 3-month follow-up. Our results demonstrate for the first time that patient-reported dyspnea ratings are related to the stage of disease severity.

The Relationship Between Exercise Tolerance and Other Outcomes in COPD

Exercise training has been shown to be a clinically effective therapeutic intervention for COPD patients resulting in a myriad of beneficial effects. These include improvements in exercise tolerance, health-related quality of life and activity levels. Activity levels can be assessed using health-related quality of life instruments or instruments designed especially for this purpose. Previous studies show that the relationships between activities of daily living, assessed using generic health-related quality of life instruments, and exercise vary considerably with correlations ranging from 0.18-0.72. The relationships between activities of daily living, assessed using disease specific health-related quality of life instruments, and exercise also vary considerably with correlations ranging from 0.14-0.59. The relationships between activities of daily living, assessed using activities of daily living instruments, and exercise are less variable and generally stronger with correlations ranging from 0.34-0.83. Relationships between generic health-related quality of life instruments and exercise vary considerably (0.19-0.65) as do relationships between disease specific health-related quality of life instruments and exercise (0.18-0.61). The correlations between changes in activities of daily living and changes in exercise following pulmonary rehabilitation are generally weak (0.13-0.28). The correlations between changes in health-related quality of life and changes in exercise following pulmonary rehabilitation are also generally weak. The fact that these outcomes are not tightly associated is due, in part, to the variability in responses to the instruments used and the fact that the various instruments were often designed to assess different constructs.

A structured exercise program for patients with advanced non-small cell lung cancer

INTRODUCTION

Exercise improves functional outcome and symptoms for certain cancer populations, but the feasibility, efficacy, and safety of structured exercise in patients with lung cancer is unknown. In this study, we examined the feasibility of a hospital-based exercise program for patients with advanced non-small cell lung cancer.

METHODS

This study included patients with newly diagnosed advanced stage non-small cell lung cancer and Eastern Cooperative Oncology Group performance status 0-1. A physical therapist facilitated twice-weekly sessions of aerobic exercise and weight training over an 8-week period. The primary end point was feasibility of the intervention, defined as adherence to the exercise program. Secondary endpoints included functional capacity, measured by the 6-minute walk test and muscle strength, as well as quality of life, lung cancer symptoms and fatigue, measured by the Functional Assessment of Cancer Therapy-lung and Functional Assessment of Cancer Therapy-fatigue scales.

RESULTS

Between October 2004 and August 2007, 25 patients enrolled in the study. All participants received anticancer therapy during the study period. Twenty patients (80%) underwent the baseline physical therapy evaluation. Eleven patients (44%) completed all 16 sessions. An additional 6 patients attended at least 6 sessions (range, 6-15), and 2 patients only attended one session. Study completers experienced a significant reduction in lung cancer symptoms and no deterioration in their 6-minute walk test or muscle strength.

CONCLUSIONS

Although the majority of participants attempted the exercise program, less than half were able to complete the intervention. Those who completed the program experienced an improvement in their lung cancer symptoms. Community-based or briefer exercise interventions may be more feasible in this population.

Effects of interval-load versus constant-load training on the BODE index in COPD patients

The BODE index is frequently used to assess functional capacity in patients with COPD. The aim of this study was to investigate the effectiveness of interval-load training (ILT) to improve the BODE index in comparison to the commonly implemented constant-load training (CLT). Forty-two patients with COPD [FEV(1): (mean+/-SEM) 42+/-3% predicted] were randomly allocated to either ILT (n=21) or CLT (n=21). The training program consisted of cycling exercise 3 days/week for 10 weeks. Patients assigned to ILT exercised at a mean intensity of 126+/-4% of baseline peak work rate (Wpeak) with 30-s work periods alternated with 30-s rest periods for 45 min per day, whereas patients allocated to CLT exercised at a mean intensity of 76+/-5% of baseline Wpeak for 30 min per day. The BODE index and its components: body mass index, FEV(1), MMRC dyspnea score and the 6-min walk test (6-MWT) as well as cycling Wpeak were assessed before and after both exercise training regimes. Both ILT and CLT significantly (p<0.001) decreased the BODE index (from 4.8+/-0.5 to 4.0+/-0.5 units and from 4.4+/-0.5 to 3.8+/-0.5 units, respectively). In addition, both ILT and CLT significantly decreased the MMRC dyspnea score by 0.4+/-0.1 units and increased the 6-MWT (by 52+/-16 and 44+/-12 m, respectively) as well as cycling Wpeak (by 14+/-2 and 10+/-2W, respectively). The magnitude of these changes was not significantly different between ILT and CLT. Consequently, ILT is equally effective to CLT in terms of improving the BODE index in patients with COPD and as such it may constitute an alternative rehabilitative modality in COPD.

Living with chronic obstructive pulmonary disease: developing conscious body management in a shrinking life-world

AIM

This paper is a report of a study to explore the changes experienced by the person living in a body with chronic obstructive pulmonary disease.

BACKGROUND

Chronic obstructive pulmonary disease is the world's fourth leading cause of death, and the World Health Organisation predicts further increases in prevalence and mortality. Despite a growing body of associated knowledge, there remains much to learn about patient and family-driven goals for medical and surgical treatment to guide nursing practice, to support self-management strategies, and to provide a context for therapeutic outcomes.

METHODS

Merleau-Ponty's philosophy of the body provided a framework for this Heideggerian phenomenological inquiry with 15 people with emphysema and 14 of their family members. The participants were drawn from three Australian teaching hospitals. Hermeneutic analysis was used to interpret 58 in-depth interviews conducted between 2003 and 2005.

FINDINGS

People with severe emphysema experience a shrinking life-world shaped by breathlessness. This diminishes the predictability and automatic nature of their bodies and their perceived effectiveness as a person. They develop a number of strategies of conscious body management to facilitate breathing, mobility and task completion.

CONCLUSION

Understanding of the person's changed body and the resulting expertise that those living with chronic illness bring into care and assessing and facilitating this expertise are central to planning sensitive and appropriate care and evaluating outcomes for medical or surgical therapies that are perceived as meaningful to the person.

Different short-term and longitudinal results on perceived health status for asthma and COPD patients after pulmonary rehabilitation. Patients living alone have the largest improvements in perceived quality of life

A combined sample (n = 132) of asthma (70%, n = 92) and chronic obstructive pulmonary disease (COPD) (30%, n = 40) patients was assessed for short-term and longitudinal changes in perceived health status (HS), quality of life (QoL), and trait anxiety after a 4-week inpatient pulmonary rehabilitation program (PRP). The total sample improved on HS (P = 0.009 effect size (ES) = 0.12) and QoL (P = 0.011, ES = 0.16) immediately after rehabilitation but improvements diminished at 6 months follow-up. Trait anxiety scores changed very little. The COPD group improved on HS immediately after the rehabilitation program (P = 0.005, ES = 0.16) but scores had deteriorated at follow-up. The asthma group had only a small and non-significant HS improvement immediately after the program but got better during the follow-up period and improved significantly on HS (P = 0.040, ES = 0.21) from before rehabilitation to follow-up 6 months after the program. Within both diagnosis groups, patients who were living alone had the largest improvements in QoL scores. PRP may have different longitudinal effects for patients with asthma and COPD. After-care procedures are probably important in rehabilitation of patients with COPD.

[Discriminative properties and validity of a health status questionnaire in obstructive airway disease patients: the Airway Questionnaire 20]

OBJECTIVE

To evaluate the discriminative properties and validity of the Airways Questionnaire 20 (AQ20) in a sample of patients with airway obstruction and to compare its properties with those of the St George's Respiratory Questionnaire (SGRQ) and the Short Form 36 (SF-36).

PATIENTS AND METHODS

A convenience sample of 47 subjects was recruited from among 61 consecutive patients referred to an outpatient clinic specialized in obstructive airway diseases. All subjects completed the AQ20, SGRQ, and SF-36. Other measures were the baseline dyspnea index (BDI), 6-minute walk test (6MWT) distance, spirometry, results of arterial blood gas analysis, and body mass index.

RESULTS

The AQ20 showed very good correlation with the SGRQ total score (rho=0.84, P< .001) and moderate correlation with all SF-36 domains (physical capacity, rho=-0.53; physical functioning, rho=-0.61; bodily pain, rho=-0.55; general health, rho=-0.59; vitality, rho=-0.55; social functioning, rho=-0.57; emotional role functioning, rho=-0.51; mental health, rho=-0.61; all P< .001). The BDI and the 6MWT distance were the best predictors of AQ20 score (r2=0.31) in the regression model. An area under the receiver operating characteristic curve of 0.91 (P< .001) indicated a high level of accuracy for the AQ20, using the SGRQ as the gold standard.

CONCLUSION

This study shows that the AQ20 is an accurate health status questionnaire in patients with moderate-to-severe airway obstruction. It could be an alternative to longer, traditional questionnaires such as the SGRQ.

Effects of 3-week outpatient pulmonary rehabilitation on exercise capacity, dyspnea, and quality of life in COPD

The effects of intensive 3-week outpatient pulmonary rehabilitation (PR) on exercise capacity, dyspnea, and health-related quality of life (HRQL) were investigated in patients with COPD. Two hundred ten patients with COPD (mean FEV(1) = 54%pred) underwent PR consisting of exercise training, patient and psychosocial education, breathing and relaxation therapy, nutrition counseling, and smoking cessation support. Before and after PR, exercise capacity was assessed with 6-min walking tests (6MWT) and constant cycle ergometer exercise (CEE). Dyspnea was measured after 6MWTs with a Borg scale and after PR with the Transition Dyspnoea Index (TDI). HRQL was examined with the Medical Outcomes Study Short Form 36 (SF-36). Results showed improvements in the 6MWT (+39 m, p < 0.001) and CEE (+241 W x min, p < 0.001) after PR, paralleled by decreased dyspnea during the 6MWT (-0.5, p < 0.001) and during activities (TDI score = 3.6). Increases in all SF-36 subscales reflected improved HRQL after PR (p < 0.001). No gender differences were found. Patients with milder versus more severe COPD improved similarly in most outcomes. Regression analyses revealed that TDI scores were the most important predictor of improvements in HRQL. The results suggest that intensive 3-week outpatient PR is associated with improvements in exercise capacity, dyspnea, and HRQL in male and female patients with COPD irrespective of COPD severity. Reduced dyspnea during activities contributed the most to improvements in HRQL.

[Relationship between degree of dyspnoea and health-related quality of life in patients with chronic obstructive pulmonary disease]

INTRODUCTION

Dyspnoea is a characteristic symptom of chronic obstructive pulmonary disease (COPD), which impairs everyday functioning of patients.

OBJECTIVE

The aim of our study was to evaluate the relationship between the degree of dyspnoea of COPD patients and their health-related quality of life.

METHOD

We measured the degree of dyspnoea and health-related quality of life in 85 COPD outpatients (46 male; mean age was 58 +/- 12 years; mean forced expiratory volume in one second (FEV,) was 47.9 +/- 18.6% predicted). The degree of dyspnoea was assessed by Baseline Dyspnoea Index (BDI), List of Daily Activities (DAL), Visual Analogue Scale (VAS), Modified MRC Dyspnoea Scale, and Borg Category Scale (BCS). The patients filled two standardized questionnaires for measuring health-related quality of life: the generic one--15D, and the respiratory specific one--the St. George's Respiratory Questionnaire (SGRQ). Total 15D and SGRQ scores, as well as the scores for individual domains of SGRQ (symptoms, activity and impact scores) for each patient were calculated. In 40 out of 85 patients, the same procedure was repeated at the follow-up, with a mean 4-week interval between the visits.

RESULTS

There were statistically highly significant correlations (p < 0.01) between values of all dyspnoea scale scores evaluated and all the health-related quality of life scores. The highest degree of correlation of both total SGRQ and 15D scores was found for the values of BCS (r = 0.731 and -0.776, respectively). A statistically significant correlation between the changes of all SGRQ (but not 15D) scores and all dyspnoea score changes (except for MRC) were also recorded.

CONCLUSION

The degree of dyspnoea of COPD outpatients that could be well-determined by the scales used in our study clearly reflects the impairment of their health-related quality of life as assessed by the instruments used. All of the questionnaires we used in this study have good measurement properties for their purposes.

Monitoring of patients with COPD: a review of current guidelines' recommendations

BACKGROUND

The goals for the management of COPD are to delay the process of disease progression and alleviate its manifestations. The follow-up of the patients' physical and mental condition is part of best practice management when monitoring routines results in information that contributes to the achievement of management goals. However, the recommendations on monitoring procedures may differ between guidelines and may not be based on scientific evidence. The aim of this article is to review the current guideline recommendations on monitoring routines for COPD.

METHODS

Clinical practice guidelines on the management of COPD were identified by a Medline search, Internet search and expanded by experts in the respiratory field. Guidelines on the management of COPD were analysed on recommended monitoring routines, recommended frequency of monitoring.

RESULTS

Eighteen clinical practice guidelines on the management of COPD were analysed. The follow-up of lung function indices was the most frequently recommended monitoring routine. Moreover, monitoring of symptoms, exercise tolerance, comorbidity, and smoking habits were recommended regularly. In none of the guidelines, the recommended monitoring routines were evidence based. Only one guideline provides a different set of monitoring parameters for advanced COPD compared to mild and moderate COPD.

CONCLUSION

Some monitoring routines were recommended frequently, especially follow-up of lung function indices. However, evidence to support the guideline recommendations for the monitoring of patients with COPD is missing. The effect of monitoring on care process and outcomes should be assessed.

Extra-pulmonary features in COPD patients entering rehabilitation after stratification for MRC dyspnea grade

Experts have stated that referral for rehabilitation of patients with chronic obstructive pulmonary disease (COPD) becomes appropriate when these patients become aware of their disability (e.g. usually grade 3 to 5 on the Medical Research Council (MRC) dyspnea scale). However, patients with MRC dyspnea grade 1/2 may also suffer from extra-pulmonary features, such as abnormal body composition, exercise intolerance and reduced disease-specific health status. In the present study, we have studied whether and to what extent chronic obstructive pulmonary disease (COPD) patients with MRC dyspnea grade 1/2 have extra-pulmonary features compared to patients with grade 3, 4 or 5? Pulmonary function, body composition, 6-min walking distance, peak exercise capacity, anxiety, depression and disease-specific health status have been assessed in 333 outpatients who had been referred for pulmonary rehabilitation. On average, patients with MRC dyspnea grade 1/2 had a better exercise tolerance and disease-specific health status compared to patients with grade 4 or 5. Nevertheless, grade 1/2 patients had a higher prevalence of muscle mass depletion. In addition, these patients did still have aberrant values in one or more of the aforementioned outcomes. On average, patients with MRC dyspnea grade 1/2 may clearly suffer from extra-pulmonary features, indicating the necessity to refer these patients for rehabilitation. Therefore, MRC dyspnea scale alone does not appear to be a suitable measure to identify most patients with COPD who have to be referred for rehabilitation.