An official European Respiratory Society statement on physical activity in COPD

Daily Physical Activity in Patients With COPD After Hospital Discharge in a Minority Population

Background

Low physical activity in patients with chronic obstructive pulmonary disease (COPD) is associated with increased morbidity and mortality. To inform the design of a home-based physical activity promotion program for patients with COPD recently discharged from a minority-serving hospital, we conducted a cohort study to evaluate objectively measured daily physical activity and patient-reported outcomes.

Methods

This was a 12-week prospective cohort study of patients with a physician diagnosis of COPD recently hospitalized (≤ 12 weeks) for respiratory symptoms. Daily physical activity was recorded using wrist-based and "clip-on" pedometers, and analyzed as mean daily step counts averaged over 7 days.

Results

Twenty-two patients were enrolled a median (interquartile range, [IQR]) of 14 (7 to 29) days after hospital discharge. The median daily step count (IQR) in the first week after enrollment (week 1) was 3710 (1565 to 5129) steps. The median within-person change in daily step count (IQR) from week 1 to week 12 was 314 (-30 to 858) steps (p=0.28). Within-person correlation of week-to-week daily step counts was high (r ≥ 0.75). Time from hospital discharge to enrollment was not correlated with mean daily step counts on week 1 (r= -0.13) and only weakly correlated with change in mean daily step counts from week 1 to week 12 (r=0.37).

Conclusions

Daily physical activity was variable in this cohort of recently hospitalized patients with COPD, but with little within-person change over a 12-week period. These observations highlight the need for flexible physical activity promotion programs addressing the needs of a heterogeneous patient population.

[Delayed diagnosis is associated with greater disease severity of chronic obstructive pulmonary disease]

OBJECTIVE

To investigate the association of the time of initial diagnosis with the severity of chronic obstructive pulmonary disease (COPD).

METHODS

A total of 803 patients who were diagnosed to have COPD for the first time in our hospital between May 2015 to February 2018 were enrolled in this study.The diagnoses of COPD and asthma COPD overlap (ACO) were made according GOLD guidelines and european consensus definition.Lung function of the patients was graded according to the GOLD guidelines.

RESULTS

The patients with COPD had a mean age of 61.8±9.9 years,including 726 male and 77 female patients.The course of the patients (defined as the time from symptom onset to the establishment of a diagnosis) was 3(0.5,8) years.Among these patients,85.2% had a moderate disease severity (FEV1%<80%),and 48.3% had severe or very severe conditions (FEV1%<50%);47.0% of them were positive for bronchial dilation test.In the overall patients,295(36.7%) were also diagnosed to have ACO,and the mean disease course of ACO[3(1,9) years]was similar to that of COPD[3(0.5,8) years](P>0.05).A significant correlation was found between the disease course and the lung function of the patients.Multiple linear regression analysis showed that an older age and a longer disease course were associated with poorer lung functions and a greater disease severity.

CONCLUSIONS

The delay of the initial diagnosis is significantly related to the severity of COPD.

Promoting exercise training and physical activity in daily life: a feasibility study of a virtual group intervention for behaviour change in COPD

Background

Physical inactivity is associated with poor health outcomes in chronic obstructive pulmonary disease (COPD). It is therefore crucial for patients to have a physically active lifestyle. The aims of this feasibility study were to assess a tablet-based physical activity behavioural intervention in virtual groups for COPD regarding 1) patients’ acceptance 2) technology usability 3) patients’ exercise programme adherence and 4) changes in patients’ physical activity level.

Methods

We used an application with functionality for a virtual peer group, a digital exercise diary, a follow-along exercise video, and visual rewards on the home screen wallpaper. The exercise programme combined scheduled virtual group exercising (outdoor ground walking, indoor resistance and strength training) with self-chosen individual exercises. Ten participants with COPD were enrolled into two exercise training groups. Patients’ acceptance was assessed by semi-structured interviews, technology usability was assessed by the System Usability Scale, and exercise programme adherence and level of physical activity by self-reporting. The interviews were also used for the latter three aspects.

Results

The virtual peer group was experienced as motivating, helping participants to get started and be physically active. They updated their own activity status and kept track of the others’ status. Having a time schedule for the virtual group exercises helped them to avoid postponing the exercise training. All participants recorded individual exercises in the diary, the exercise video was well received and used, and most participants paid attention to the visual rewards. All participants found the technology easy both to learn and to use. The exercise programme adherence was good, with, on average, 77% attendance for the virtual group exercises, and all participants performed additional individual exercises. The average number of physical activity sessions per week was doubled from 2.9 (range 0–10, median 2) at baseline to 5.9 (range 3.3–10.33, median 4.8) during the intervention period.

Conclusion

The results indicate that the tablet-based intervention may be feasible in COPD, and that it was acceptable, encouraged a sense of peer support and fellowship in the group and motivated participants to physical activity and exercise training in daily life. Further assessment is needed on patient outcomes.

Surgical Prehabilitation: Nutrition and Exercise

Complications after major surgery account for a disproportionate amount of in-hospital morbidity and mortality. Recent efforts have focused on preoperative optimization in an attempt to modify the risk associated with major surgery. Underaddressed, but important, modifiable risk factors are physical fitness and nutritional status. Surgical patients are particularly at risk of 3 related, but distinct, conditions: frailty, sarcopenia, and reduced physical fitness. Exercise-based prehabilitation strategies have shown promise in terms of improving aerobic fitness, although their impact on key clinical perioperative outcome measures have not been fully determined. Preoperative nutritional status also has a strong bearing on perioperative outcome.

Physical activity associates with disease characteristics of severe asthma, bronchiectasis and COPD

BACKGROUND AND OBJECTIVE

Physical activity (PA) in obstructive airway diseases (OAD) is likely to be impaired but this has not been extensively studied outside of chronic obstructive pulmonary disease (COPD). We describe PA levels in severe asthma and bronchiectasis compared to moderate-severe COPD and to controls, and tested the cross-sectional associations of PA (steps/day) with shared disease characteristics in the OAD group.

METHODS

Adults with OAD (severe asthma = 62, COPD = 67, bronchiectasis = 60) and controls (n = 63) underwent a multidimensional assessment, including device-measured PA levels.

RESULTS

The OAD group included 189 participants (58.7% females), with median (interquartile range) age of 67 (58-72) years and mean forced expiratory volume in the first second (FEV₁ ) % predicted of 69.4%. Demographic characteristics differed between groups. Compared to controls (52.4% females, aged 55 (34-64) years, median 7640 steps/day), those with severe asthma, bronchiectasis and COPD accumulated less steps/day: median difference of -2255, -2289, and -4782, respectively (P ≤ 0.001). Compared to COPD, severe asthma and bronchiectasis participants accumulated more steps/day: median difference of 2375 and 2341, respectively (P ≤ 0.001). No significant differences were found between the severe asthma and bronchiectasis group. Exercise capacity, FEV₁ % predicted, dyspnoea and systemic inflammation differed between groups, but were each significantly associated with steps/day in OAD. In the multivariable model adjusted for all disease characteristics, exercise capacity and FEV₁ % predicted remained significantly associated.

CONCLUSION

PA impairment is common in OAD. The activity level was associated with shared characteristics of these diseases. Interventions to improve PA should be multifactorial and consider the level of impairment and the associated characteristics.

Residential air pollution does not modify the positive association between physical activity and lung function in current smokers in the ECRHS study

BACKGROUND

Very few studies have examined whether a long-term beneficial effect of physical activity on lung function can be influenced by living in polluted urban areas.

OBJECTIVE

We assessed whether annual average residential concentrations of nitrogen dioxide (NO₂) and particulate matter with aerodynamic diameters < 2.5 μm (PM_2.5) and <10 μm (PM₁₀) modify the effect of physical activity on lung function among never- (N = 2801) and current (N = 1719) smokers in the multi-center European Community Respiratory Health Survey.

METHODS

Associations between repeated assessments (at 27-57 and 39-67 years) of being physically active (physical activity: ≥2 times and ≥1 h per week) and forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) were evaluated using adjusted mixed linear regression models. Models were conducted separately for never- and current smokers and stratified by residential long-term NO₂, PM_2.5 mass and PM₁₀ mass concentrations (≤75th percentile (low/medium) versus >75th percentile (high)).

RESULTS

Among current smokers, physical activity and lung function were positively associated regardless of air pollution levels. Among never-smokers, physical activity was associated with lung function in areas with low/medium NO₂, PM_2.5 mass and PM₁₀ mass concentrations (e.g. mean difference in FVC between active and non-active subjects was 43.0 mL (13.6, 72.5), 49.5 mL (20.1, 78.8) and 49.7 mL (18.6, 80.7), respectively), but these associations were attenuated in high air pollution areas. Only the interaction term of physical activity and PM₁₀ mass for FEV₁ among never-smokers was significant (p-value = 0.03).

CONCLUSIONS

Physical activity has beneficial effects on adult lung function in current smokers, irrespective of residential air pollution levels in Western Europe. Trends among never-smokers living in high air pollution areas are less clear.

Dyspnea and the Varying Pathophysiologic Manifestations of Chronic Obstructive Pulmonary Disease Evaluated by Cardiopulmonary Exercise Testing With Arterial Blood Analysis

Background: Patients with chronic obstructive pulmonary disease (COPD) show varying mechanisms of exertional dyspnea with different exercise capacities. Methods: To investigate the pathophysiologic conditions related to exertional dyspnea, 294 COPD patients were evaluated using cardiopulmonary exercise testing (CPET) with arterial blood analyses, with the patients classified into two groups according to their exercise limitation: the leg fatigue group (n = 58) and the dyspnea group (n = 215). The dyspnea group was further subdivided into four groups based on peak oxygen uptake ( V ° O 2 in mL/min/kg): group A (< 11), group B (11 to < 15), group C (15 to < 21), and group D (≥21). Results: In the dyspnea group, group A (n = 28) showed the following findings: (i) the forced expiratory volume in 1 s was not correlated with the peak V ° O 2 (p = 0.288), (ii) the arterial oxygen tension (PaO₂) slope (peak minus resting PaO₂/Δ V ° O 2 ) was the steepest (p < 0.0001) among all subgroups, (iii) reduced tidal volume (V_T) was negatively correlated with respiratory frequency at peak exercise (p < 0.0001), and (iv) a break point in exertional V_T curve was determined in 17 (61%) patients in group A. In these patients, there was a significant negative correlation between bicarbonate ion ( HCO 3 - ) levels at peak exercise and V_T level when the V_T-break point occurred (p = 0.032). In group D (n = 46), HCO 3 - levels were negatively correlated with plasma lactate levels (p < 0.0001). In all subgroups, the HCO 3 - level was negatively correlated with minute ventilation. The dyspnea subgroups showed no significant differences in the overall mean pH [7.363 (SD 0.039)] and Borg scale scores [7.4 (SD, 2.3)] at peak exercise. Conclusions: During exercise, ventilation is stimulated to avoid arterial blood acidosis and hypoxemia, but ventilatory stimulation is restricted in the setting of reduced respiratory system ability. These conditions provoke the exertional dyspnea in COPD. Although symptom levels were similar, the exertional pathophysiologic conditions differed according to residual exercise performance; moreover, COPD patients showed great inter-individual variability. An adequate understanding of individual pathophysiologic conditions using CPET is essential for proper management of COPD patients.

Short and long-term effects of pulmonary rehabilitation in interstitial lung diseases: a randomised controlled trial

BACKGROUND

Few data are available on the long-term effect of pulmonary rehabilitation (PR) and on long PR programs in interstitial lung diseases (ILD). We aimed to evaluate the effects of PR on exercise capacity (6-Minute Walking Distance, 6MWD; Peak Work Rate, W_max), quality of life (St George's Respiratory Questionnaire, SGRQ), quadriceps force (QF) and objectively measured physical activity in ILD after the 6-month PR-program and after 1 year.

METHODS

60 patients (64 ± 11 years; 62% males; 23% with IPF) were randomly assigned to receive a 6 month-PR program or usual medical care.

RESULTS

Exercise capacity, quality of life and muscle force increased significantly after the program as compared to control (mean,95%CI[ll to ul]; 6MWD + 72,[36 to 108] m; W_max 19, [8 to 29]%pred; SGRQ - 12,[- 19 to - 6] points; QF 10, [1 to 18] %pred). The gain was sustained after 1 year (6MWD 73,[28 to 118] m; Wmax 23, [10 to 35]%pred; SGRQ - 11,[- 18 to - 4] points; QF 9.5, [1 to 18] %pred). Physical activity did not change.

CONCLUSIONS

PR improves exercise tolerance, health status and muscle force in ILD. The benefits are maintained at 1-year follow-up. The intervention did not change physical activity.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00882817 .

Clinician-Facilitated Physical Activity Intervention Versus Pulmonary Rehabilitation for Improving Physical Activity in COPD: A Feasibility Study

Pulmonary rehabilitation (PR) may not suit all individuals with chronic obstructive pulmonary disease (COPD) and may not result in increased physical activity. Higher levels of physical activity are associated with reduced mortality and morbidity. The aim of this study was to assess the feasibility of conducting a trial to investigate the effectiveness of a clinician-facilitated physical activity intervention (PAI) versus PR in improving physical activity in patients with COPD referred to PR. In this randomised controlled mixed methods feasibility study, all patients referred to PR who were eligible and willing were assessed at baseline and then randomised to the PAI or to PR. The assessments were repeated post-intervention and at 3-month follow-up. The main outcome was step count measured by Actigraph. Semi-structured interviews were conducted post-intervention. The N = 50 patients; mean (SD) age, 64.1(8.6) years, 24M were recruited and randomised; N = 23 (PAI) and n = 26 (PR): one patient was excluded from the analysis as that person did not meet the GOLD diagnostic criteria. Key feasibility criteria were met; recruitment was 11%, dropouts in PAI were 26% (n = 6) and 50% (n = 13/26) PR. Participants in both groups experienced a range of health benefits from their respective programmes. The PAI appears to be effective in increasing step counts in people with COPD: mean change (standard deviation) [confidence interval] for the PAI group was 972.0(3230.3)[-1080.3 to 3024.4], n = 12 and 4.3(662.7)[-440.9 to 449.5], n = 11 for the PR group. The PAI met all domains of fidelity. This study provides key information to inform a future-randomised controlled trial in physical activity.

Lifestyle interventions in prevention and comprehensive management of COPD

Chronic respiratory diseases are among the four major human chronic diseases. Tobacco smoke as well as environmental pollutants, infections, physical activity and nutritional status play a role in the prevalence, development and/or progression of chronic obstructive pulmonary disease (COPD). Changes in lifestyle are possible and may be beneficial in prevention and comprehensive management of COPD. Population-level interventions aimed at early diagnosis, promotion of vaccinations and prevention of infections, and reductions in smoking, environmental pollutants, physical inactivity, obesity and malnutrition may increase the number of life-years lived in good health.

EDUCATIONAL AIMS

To improve awareness of the influence of lifestyle on natural history of COPD.To describe the effects of some interventions to modify lifestyle in prevention and management.To provide information on the main clinical results.To define recommendations and limitations.

The all age asthma cohort (ALLIANCE) - from early beginnings to chronic disease: a longitudinal cohort study

Background

Asthma and wheezing disorders in childhood and adulthood are clinically heterogeneous regarding disease presentation, natural course, and response to treatment. Deciphering common disease mechanisms in distinct subgroups requires harmonized molecular (endo-) phenotyping of both children and adult patients with asthma in a prospective, longitudinal setting.

Methods

The ALL Age Asthma Cohort (ALLIANCE) of the German Center for Lung Research (DZL) is a prospective, multi-center, observational cohort study with seven recruiting sites across Germany. Data are derived from four sources: (a) patient history from medical records, (b) standardized questionnaires and structured interviews, (c) telephone interviews, and (d) objective measurements. Objective measurements include amongst others lung function and quantitative assessment of airway inflammation and exhaled breath, peripheral blood, skin, nasal, pharyngeal, and nasopharyngeal swabs, nasal secretions, primary nasal epithelial cells, and induced sputum. In cases, objective measurements and biomaterial collection are performed regularly, while control subjects are only examined once at baseline.

Discussion

The standardized and detailed collection of epidemiological and physiological data, and the molecular deep phenotyping of a comprehensive range of biomaterials in a considerable number of study participants across all ages are the outstanding characteristics of this multi-center cohort. Despite extensive biomaterial sampling, and a recruitment strategy that also includes pre-school children as young as 6 months, attrition is low. In children 83.9%, and in adults 90.5% attended the 12-month follow-up. The earliest time-point to include cases, however, is disease manifestation. Therefore, unraveling mechanisms that drive disease onset is limited, as this question can only be answered in a population-based birth cohort. Nonetheless, ALLIANCE offers a unique, integrative and inter-disciplinary framework with a comprehensive molecular approach in a prospective and identical fashion across ages in order to identify biomarkers and predictors for distinct childhood wheeze and asthma trajectories as well as their further course during adulthood. Ultimately, this approach aims to translate its most significant findings into clinical practice, and to improve asthma transition from adolescence to adulthood.

Trial registration

NCT02496468 for pediatric arm, NCT02419274 for adult arm.

The association between daily exacerbation symptoms and physical activity in patients with chronic obstructive pulmonary disease

Background

Evidence from longitudinal studies on the impact of exacerbation symptoms on physical activity in chronic obstructive pulmonary disease (COPD) is lacking. The aim of this first exploratory study was to assess the association between exacerbation symptoms and physical activity, and to quantify the relative influence of specific symptoms.

Methods

We recruited COPD patients at high risk for exacerbations from 2 pulmonary rehabilitation clinics and 1 acute care clinic in Switzerland. For 3 months after discharge, patients completed a daily symptom diary on a smartphone application, the EXAcerbations of Chronic pulmonary disease Tool (EXACT), and wore a pedometer to measure daily steps. We used mixed-effects models to determine the association of daily steps with exacerbation symptoms.

Results

A total of 21 patients (Global Initiative for Chronic Obstructive Lung Disease grades 2-4) were enrolled for a mean of 94.4 days (standard deviation 4.2). The baseline median number of daily steps was 3,264.6 (interquartile range [IQR]: 1,851.3-4,784.1) and EXACT score was 37.0 (IQR: 30.9-41.4). A 12-point increase in EXACT score (indicating the start of an exacerbation) was statistically significantly associated with a decrease in daily steps of 653.3 (95% CI 969.7-336.9). Chest symptoms (tightness, discomfort and congestion) were more strongly associated with change in steps than breathlessness, and cough and sputum (z-value -4.5 vs -2.9 and -3.0).

Conclusion

This is the first study to show that, in a small cohort of COPD patients, increases in exacerbation symptoms were associated with a statistically and clinically significant reduction in daily physical activity. These results underscore the importance for symptom control and exacerbation prevention in COPD patients.

Protocol for regional implementation of collaborative self-management services to promote physical activity

BACKGROUND

Chronic diseases are generating a major health and societal burden worldwide. Healthy lifestyles, including physical activity (PA), have proven efficacy in the prevention and treatment of many chronic conditions. But, so far, national PA surveillance systems, as well as strategies for promotion of PA, have shown low impact. We hypothesize that personalized modular PA services, aligned with healthcare, addressing the needs of a broad spectrum of individual profiles may show cost-effectiveness and sustainability.

METHODS

The current manuscript describes the protocol for regional implementation of collaborative self-management services to promote PA in Catalonia (7.5 M habitants) during the period 2017-2019. The protocols of three implementation studies encompassing a broad spectrum of individual needs are reported. They have a quasi-experimental design. That is, a non-randomized intervention group is compared to a control group (usual care) using propensity score methods wherein age, gender and population-based health risk assessment are main matching variables. The principal innovations of the PA program are: i) Implementation of well-structured modular interventions promoting PA; ii) Information and communication technologies (ICT) to facilitate patient accessibility, support collaborative management of individual care plans and reduce costs; and iii) Assessment strategies based on the Triple Aim approach during and beyond the program deployment.

DISCUSSION

The manuscript reports a precise roadmap for large scale deployment of community-based ICT-supported integrated care services to promote healthy lifestyles with high potential for comparability and transferability to other sites.

TRIAL REGISTRATION

This study protocol has been registered at ClinicalTrials.org ( NCT02976064 ). Registered November 24th, 2016.

[Characteristics of non-pharmacological interventions in the elderly with COPD. Smoking cessation, pulmonary rehabilitation, nutritional management and patient education]

Chronic obstructive pulmonary disease (COPD) is a respiratory disorder responsible for a high mortality and disability. People older than 65 years are more commonly affected than younger people and tend to present with more symptoms and a greater level of disability. Non-pharmacological interventions play an important role in the management of all patients with COPD and this is particularly true in the elderly. Given the improvement in quality of life and risk of hospitalization, smoking cessation should be promoted to patients of all ages. Increased physical activity is associated with reduced respiratory symptoms. Tests such as the "Short Physical Performance Battery" can be useful in frailer older people with COPD, while walking tests such as the 6-minute walk test are used as an assessment before pulmonary rehabilitation. Increased physical activity should be combined with nutritional management. Screening for undernutrition by questionnaire, body mass index and albumin quantification is recommended in the elderly. In case of undernutrition, oral supplementation seems to reduce the risk of re-admission. All these measures must be included in an education program adapted to the elderly comorbidities (hearing loss, isolation…).

Positive airway pressure devices for the management of breathlessness

PURPOSE OF REVIEW

Breathlessness is a common symptom in many chronic diseases and may be refractory to pharmacotherapy. In this review, we discuss the pathophysiology of breathlessness and the role of positive airway pressure (PAP) devices to ameliorate it.

RECENT FINDINGS

Breathlessness is directly related to neural respiratory drive, which can be modified by addressing the imbalance between respiratory muscle load and capacity. Noninvasive PAP devices have been applied to patients limited by exertional breathless and, as the disease progresses, breathlessness at rest. The application of PAP is focussed on addressing the imbalance in load and capacity, aiming to reduce neural respiratory drive and breathlessness. Indeed, noninvasive bi-level PAP devices have been employed to enhance exercise capacity by enhancing pulmonary mechanics and reduce neural drive in chronic obstructive pulmonary disease (COPD) patients, and reduce breathlessness for patients with progressive neuromuscular disease (NMD) by enhancing respiratory muscle capacity. Novel continuous PAP devices have been used to maintain central airways patency in patients with excessive dynamic airway collapse (EDAC) and target expiratory flow limitation in severe COPD.

SUMMARY

PAP devices can reduce exertional and resting breathlessness by reducing the load on the system and enhancing capacity to reduce neural respiratory drive.

Improvement of physical activity in chronic obstructive pulmonary disease by pulmonary rehabilitation and pharmacological treatment

Physical activity (PA) is defined as bodily movement produced by skeletal muscles with energy expenditure beyond resting levels. PA is closely related to reduced morbidity and mortality in chronic obstructive pulmonary disease (COPD). Self-report questionnaires are often subject to recall bias, correlating poorly with objectively qualified PA, and do not provide an accurate estimate of free-living energy expenditure. PA may be objectively evaluated by newly developed tri-axial accelerometers by quantifying steps or body movements over a period of time. Low-intensity, home-based pulmonary rehabilitation (PR) using pedometer feedback improves PA. Improvement in physiological factors correlates with increased walking time in stable elderly COPD patients. This review focuses on the effects of PR and pharmacological treatment on PA in COPD patients. We selected 32 studies from our literature search evaluating the effects of PR and 11 studies examining the effects of pharmacological treatment on PA. Findings in both categories were inconsistent. Nineteen studies showed a positive effect with PR whereas 13 showed no effect. Eight studies showed a positive effect, while three revealed no effect from pharmacological intervention. As both interventions increase exercise capacity without a consistent effect on PA, counseling with behavioral changes may be necessary to achieve a significant and lasting increase in PA. Changing PA behavior in COPD patients requires an interdisciplinary approach involving specialists in respiratory medicine, rehabilitation, social, and behavioral sciences. Future research in this area is warranted to advance our knowledge in this area, specifically with regard to the interaction of pharmacological and non-pharmacological interventions.

Facilitators and barriers to physical activity following pulmonary rehabilitation in COPD: a systematic review of qualitative studies

Pulmonary rehabilitation has short-term benefits on dyspnea, exercise capacity and quality of life in COPD, but evidence suggests these do not always translate to increased daily physical activity on a patient level. This is attributed to a limited understanding of the determinants of physical activity maintenance following pulmonary rehabilitation. This systematic review of qualitative research was conducted to understand COPD patients' perceived facilitators and barriers to physical activity following pulmonary rehabilitation. Electronic databases of published data, non-published data, and trial registers were searched to identify qualitative studies (interviews, focus groups) reporting the facilitators and barriers to physical activity following pulmonary rehabilitation for people with COPD. Thematic synthesis of qualitative data was adopted involving line-by-line coding of the findings of the included studies, development of descriptive themes, and generation of analytical themes. Fourteen studies including 167 COPD patients met the inclusion criteria. Seven sub-themes were identified as influential to physical activity following pulmonary rehabilitation. These included: intentions, self-efficacy, feedback of capabilities and improvements, relationship with health care professionals, peer interaction, opportunities following pulmonary rehabilitation and routine. These encapsulated the facilitators and barriers to physical activity following pulmonary rehabilitation and were identified as sub-themes within the three analytical themes, which were beliefs, social support, and the environment. The findings highlight the challenge of promoting physical activity following pulmonary rehabilitation in COPD and provide complementary evidence to aid evaluations of interventions already attempted in this area, but also adds insight into future development of interventions targeting physical activity maintenance in COPD.

Nutritional status and muscle dysfunction in chronic respiratory diseases: stable phase versus acute exacerbations

Nutritional abnormalities are frequent in different chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic fibrosis (CF), interstitial fibrosis and lung cancer, having important clinical consequences. However, nutritional abnormalities often remained underdiagnosed due to the relative lack of awareness of health professionals. Therefore, systematic anthropometry or even better, assessment of body composition, should be performed in all patients with chronic respiratory conditions, especially following exacerbation periods when malnutrition becomes more accentuated. Nutritional abnormalities very often include the loss of muscle mass, which is an important factor for the occurrence of muscle dysfunction. The latter can be easily detected with the specific assessment of muscle strength and endurance, and also negatively influences patients' quality of life and prognosis. Both nutritional abnormalities and muscle dysfunction result from the interaction of several factors, including tobacco smoking, low physical activity-sedentarism, systemic inflammation and the imbalance between energy supply and requirements, which essentially lead to a negative balance between protein breakdown and synthesis. Therapeutic approaches include improvements in lifestyle, nutritional supplementation and training. Anabolic drugs may be administered in some cases.

Efficacy of tiotropium/olodaterol on lung volume, exercise capacity, and physical activity

Purpose

This study evaluated the efficacy of tiotropium/olodaterol vs tiotropium on lung function, exercise capacity, and physical activity in patients with COPD.

Patients and methods

A total of 184 patients aged ≥40 years with COPD (Global Initiative for Chronic Obstructive Lung Disease stage II-IV) received tiotropium/olodaterol for 6 weeks, then tiotropium for 6 weeks, or vice versa. The primary endpoint was inspiratory capacity (IC) at peak post-dose.

Results

Adjusted mean IC after 6-week treatment was 1.990 L with tiotropium/olodaterol vs 1.875 L with tiotropium (difference: 115 mL; 95% CI: 77, 153; p<0.0001). Forced expiratory volume in 1 s (difference: 105 mL; 95% CI: 88, 123), forced vital capacity (difference: 163 mL; 95% CI: 130, 197), and slow vital capacity (difference: 134 mL; 95% CI: 91, 176) improved with tiotropium/olodaterol (all p<0.0001). Adjusted mean 6-min walk distance was similar between treatments in the overall population but was significantly increased with tiotropium/olodaterol in the subgroup with Global Initiative for Chronic Obstructive Lung Disease stage III/IV at baseline (difference: 18.1 m; 95% CI: 2.3, 33.9; p=0.0254). In a post hoc analysis, tiotropium/olodaterol improved the values for ≥2.0 metabolic equivalents (difference: 5.0 min; 95% CI: 0.4, 9.7; p=0.0337).

Conclusion

Tiotropium/olodaterol significantly improved IC compared with tiotropium and potentially enhanced the exercise capacity in COPD patients. A slight improvement in physical activity of relatively more than moderate intensity was also seen with tiotropium/olodaterol.

Improving physical activity, sedentary behaviour and sleep in COPD: perspectives of people with COPD and experts via a Delphi approach

Background

Little is known about how to achieve enduring improvements in physical activity (PA), sedentary behaviour (SB) and sleep for people with chronic obstructive pulmonary disease (COPD). This study aimed to: (1) identify what people with COPD from South Australia and the Netherlands, and experts from COPD- and non-COPD-specific backgrounds considered important to improve behaviours; and (2) identify areas of dissonance between these different participant groups.

Methods

A four-round Delphi study was conducted, analysed separately for each group. Free-text responses (Round 1) were collated into items within themes and rated for importance on a 9-point Likert scale (Rounds 2–3). Items meeting a priori criteria from each group were retained for rating by all groups in Round 4. Items and themes achieving a median Likert score of ≥7 and an interquartile range of ≤2 across all groups at Round 4 were judged important. Analysis of variance with Tukey’s post-hoc tested for statistical differences between groups for importance ratings.

Results

Seventy-three participants consented to participate in this study, of which 62 (85%) completed Round 4. In Round 4, 81 items (PA n = 54; SB n = 24; sleep n = 3) and 18 themes (PA n = 9; SB n = 7; sleep n = 2) were considered important across all groups concerning: (1) symptom/disease management, (2) targeting behavioural factors, and (3) less commonly, adapting the social/physical environments. There were few areas of dissonance between groups.

Conclusion

Our Delphi participants considered a multifactorial approach to be important to improve PA, SB and sleep. Recognising and addressing factors considered important to recipients and providers of health care may provide a basis for developing behaviour-specific interventions leading to long-term behaviour change in people with COPD.

Verification of a Motion Sensor for Evaluating Physical Activity in COPD Patients

Background

Objective evaluation of the physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) is important. We validated a triaxial accelerometer, Active Style Pro HJA-750C® (HJA), and evaluated the necessary conditions for obtaining reproducible data.

Methods

The PA measured by HJA was compared with that measured by two already validated accelerometers in 11 patients with COPD (age: 76.6 ± 6.9, FEV1% predicted: 57.6 ± 18.6). Then, the influence of weather and holidays on the PA and the required number of days to obtain repeatability were examined in 21 patients with COPD (age: 73.0 ± 8.0, FEV1% predicted: 58.7 ± 19.0).

Results

The PA values measured by HJA and those by DynaPort Move Monitor® (DMM) or Actimarker® (AM) were significantly correlated at all intensities (p=0.024 at ≥4.0 METs by DMM and p < 0.0001 at the rest) except at ≥4.0 METs by AM, though the values measured by HJA were higher than those by AM which was reported to underestimate PA. The durations of PA on rainy days were significantly shorter than those on nonrainy days, but those on holidays were not different from those on weekdays. The values of ICC for 3, 4, or 5 days were higher than 0.8 at all intensities. The PA measured by HJA was correlated with the dyspnea scale FVC and age and tended to correlate with FEV1.

Conclusions

The HJA was validated for evaluating the PA in patients with COPD. This trial is registered with UMIN000016363.

Home-based Physical Activity Coaching, Physical Activity, and Health Care Utilization in Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease Self-Management Activation Research Trial Secondary Outcomes

RATIONALE

Physical inactivity among patients with chronic obstructive pulmonary disease is associated with exacerbations requiring high-cost health care utilization including urgent, emergent, and hospital care.

OBJECTIVES

To examine the effectiveness of a behavioral lifestyle physical activity intervention combined with chronic obstructive pulmonary disease self-management education to prevent high-cost health care utilization.

METHODS

This was an analysis of secondary outcomes of the Chronic Obstructive Pulmonary Disease Self-Management Activation Research Trial, a two-arm randomized trial of stable adult outpatients with chronic obstructive pulmonary disease recruited from primary care and pulmonary clinics. Following a 6-week self-management education run-in period, participants were randomized to usual care or to a telephone-delivered home-based health coaching intervention over 20 weeks. Secondary outcomes of physical activity and health care utilization were determined by self-report 6, 12, and 18 months after randomization. Associations between treatment allocation arm and these secondary outcomes were examined using log-binomial and Poisson regression models.

RESULTS

A total of 325 outpatients with stable chronic obstructive pulmonary disease were enrolled in the trial. Their average age was 70.3 years (standard deviation, 9.5), and 50.5% were female; 156 were randomized to usual care and 149 to the intervention. A greater proportion of participants reported being persistently active over the 18-month follow-up period in the intervention group (73.6%) compared with the usual care group (57.8%) (mean difference, 15.8%; 95% confidence interval, 4.0-27.7%). This association varied by severity of forced expiratory volume in 1 second impairment (P for interaction = 0.09). Those in the intervention group with moderate impairment (forced expiratory volume in 1 second, 50-70% predicted), more frequently reported being persistently active compared with the usual care (86.0 vs. 65.1%; mean difference, 20.9%; 95% confidence interval, 5.7-36.1%). Patients with severe and very severe forced expiratory volume in 1 second impairment (forced expiratory volume in 1 second < 50% predicted) in the intervention group also reported being persistently active more frequently compared with usual care (63.3 vs. 50.8%; mean difference, 12.6%; 95% confidence interval, -4.7 to 29.8). The intervention was associated with a lower rate of lung-related utilization (adjusted rate ratio, 0.38; 95% confidence interval, 0.23-0.63) only among participants with severe spirometric impairment.

CONCLUSIONS

Our results demonstrate that a feasible and generalizable home-based coaching intervention may decrease sedentary behavior and increase physical activity levels. In those with severe chronic obstructive pulmonary disease, this intervention may reduce lung disease-related health care utilization. Clinical trial registered with www.clinicaltrials.gov (NCT01108991).

Continuous remote monitoring of COPD patients-justification and explanation of the requirements and a survey of the available technologies

Remote patient monitoring should reduce mortality rates, improve care, and reduce costs. We present an overview of the available technologies for the remote monitoring of chronic obstructive pulmonary disease (COPD) patients, together with the most important medical information regarding COPD in a language that is adapted for engineers. Our aim is to bridge the gap between the technical and medical worlds and to facilitate and motivate future research in the field. We also present a justification, motivation, and explanation of how to monitor the most important parameters for COPD patients, together with pointers for the challenges that remain. Additionally, we propose and justify the importance of electrocardiograms (ECGs) and the arterial carbon dioxide partial pressure (PaCO2) as two crucial physiological parameters that have not been used so far to any great extent in the monitoring of COPD patients. We cover four possibilities for the remote monitoring of COPD patients: continuous monitoring during normal daily activities for the prediction and early detection of exacerbations and life-threatening events, monitoring during the home treatment of mild exacerbations, monitoring oxygen therapy applications, and monitoring exercise. We also present and discuss the current approaches to decision support at remote locations and list the normal and pathological values/ranges for all the relevant physiological parameters. The paper concludes with our insights into the future developments and remaining challenges for improvements to continuous remote monitoring systems. Graphical abstract ᅟ.

Physical activity in the morning and afternoon is lower in patients with chronic obstructive pulmonary disease with morning symptoms

Background

Patients with chronic obstructive pulmonary disease (COPD) experience symptoms that vary over the day. Symptoms at the start of the day might influence physical activity during the rest of the day. Therefore, physical activity during the course of the day was studied in patients with low and high morning symptom scores.

Methods

This cross-sectional observational study included patients with moderate to very severe COPD. Morning symptoms were evaluated with the PRO-morning COPD Symptoms Questionnaire (range 0–60); the median score was used to create two groups (low and high morning symptom scores). Physical activity was examined with an accelerometer. Activity parameters during the night, morning, afternoon and evening were compared between patients with low and high morning symptom scores using independent t-tests or Mann-Whitney U tests.

Results

Seventy nine patients were included. Patients were aged (mean ± SD) 65.6 ± 8.8 years with a mean forced expiratory volume in 1 s of 55 ± 17%predicted. Patients with low morning symptom scores (score < 17.0) took more steps in the afternoon (p = 0.015) and morning (p = 0.030). There were no significant differences during the evening and night.

Conclusion

Patients with high morning symptom scores took significantly fewer steps in the morning and afternoon than those with low morning symptom scores. Prospective studies are needed to prove causality between morning symptoms and physical activity during different parts of the day.

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0749-4) contains supplementary material, which is available to authorized users.

A Systematic Review of Associations of Physical Activity and Sedentary Time with Asthma Outcomes

BACKGROUND

Physical inactivity and high sedentary time are associated with adverse health outcomes in several diseases. However, their impact in asthma is less clear.

OBJECTIVE

We aimed to synthesize the literature characterizing physical activity and sedentary time in adults with asthma, to estimate activity levels using meta-analysis, and to evaluate associations between physical activity and sedentary time and the clinical and physiological characteristics of asthma.

METHODS

Articles written in English and addressing the measurement of physical activity or sedentary time in adults ≥18 years old with asthma were identified using 4 electronic databases. Meta-analysis was used to estimate steps/day in applicable studies.

RESULTS

There were 42 studies that met the inclusion criteria. Physical activity in asthma was lower compared with controls. The pooled mean (95% confidence interval) steps/day for people with asthma was 8390 (7361, 9419). Physical activity tended to be lower in females compared with males, and in older people with asthma compared with their younger counterparts. Higher levels of physical activity were associated with better measures of lung function, disease control, health status, and health care use. Measures of sedentary time were scarce, and indicated a similar engagement in this behavior between participants with asthma and controls. High sedentary time was associated with higher health care use, and poorer lung function, asthma control, and exercise capacity.

CONCLUSIONS

People with asthma engage in lower levels of physical activity compared with controls. Higher levels of physical activity may positively impact on asthma clinical outcomes. Sedentary time should be more widely assessed.

The effect of a regular walking program on dyspnoea severity and quality of life in normal weight, overweight, and obese patients with chronic obstructive pulmonary disease

AIM

The objective was to determine the effect of a regular walking program on physical activity (the number of steps and walking duration), dyspnoea severity, and quality of life in normal weight, overweight, and obese patients with chronic obstructive pulmonary disease.

METHOD

An experimental study; 50 patients with chronic obstructive pulmonary disease admitted to the respiratory clinic of a public hospital in Turkey between November 2014 and July 2015 were included. All the patients underwent a regular walking program (at least 30 minutes every day) using a pedometer for 16 weeks under the supervision of a nurse.

RESULTS

After the regular walking program, the respiratory function test results of the obese patients were significantly improved. The walking duration, the number of steps taken per day, and the quality of life of all participants improved significantly, and dyspnoea severity was reduced in all participants.

CONCLUSION

The regular walking program reduced dyspnoea severity and improved quality of life in all participants. Nurses' efforts to increase activity levels in all patients with chronic obstructive pulmonary disease, and particularly those with obesity, through a regular walking program may contribute to reduce the severity of dyspnoea and improve quality of life.

Effects of exercise training in water and on land in patients with COPD: a randomised clinical trial

OBJECTIVES

To compare the effects of two similar 6-month protocols of high-intensity exercise training, in water and on land, in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Randomised controlled trial.

SETTING

University-based outpatient clinic.

PARTICIPANTS

Thirty-six patients with predominantly moderate-to-severe COPD completed the study.

INTERVENTION

Patients were evaluated at baseline, at 3 months and at the end of the programme (i.e. 6 months). For both groups, the 6-month protocol consisted of high-intensity endurance and strength exercises with gradual increase in time and/or workload, totalling 60 sessions.

MAIN OUTCOMES

Objective monitoring of physical activity in daily life (PADL, primary outcome), lung function, peripheral and respiratory muscle strength, body composition, maximal and submaximal exercise capacity, functional status, quality of life, and symptoms of anxiety and depression.

RESULTS

After 6 months of training, a significant improvement in PADL was seen for both groups [mean difference (95% confidence interval): land group 993 (358 to 1628) steps/day; water group 1669 (404 to 2934) steps/day]. Significant improvements were also seen in inspiratory, expiratory and peripheral muscle strength; maximal and submaximal exercise capacity; quality of life and functional status for both groups. There were no significant improvements in lung function, body composition, and symptoms of anxiety and depression for either group. No difference was found in the magnitude of improvement between the two types of training for any outcome.

CONCLUSION

High-intensity exercise training in water generates similar effects compared with training on land in patients with moderate-to-severe COPD, rendering it an equally beneficial therapeutic option for this population.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01691131.

Associations of total and type-specific physical activity with mortality in chronic obstructive pulmonary disease: a population-based cohort study

BACKGROUND

Regular physical activity is recommended for all people with chronic obstructive pulmonary disease (COPD), but the dose of physical activity required to gain mortality benefit in this population is not yet known. This aim of this study was to examine the associations of total and type-specific physical activity with mortality risk in people with COPD.

METHODS

People with COPD aged ≥40 years were identified from the 1997 Health Survey for England and the 1998 and 2003 Scottish Health Survey cohorts. Self-reported total physical activity, moderate-vigorous intensity physical activity (MVPA), walking, domestic physical activity, and sport/exercise were assessed at baseline. Cox proportional hazards models were used to examine the associations between physical activity and mortality risk.

RESULTS

Two thousand three hundred ninety-eight participants with COPD were included in the analysis and followed up for a mean 8.5 (SD 3.9) years. For both total physical activity and MVPA, we observed dose-response associations with all-cause and cardiovascular disease (CVD) mortality risk, and with respiratory mortality risk to a lesser extent. Compared to those who reported no physical activity, participants who met the physical activity guidelines demonstrated the greatest reductions in all-cause (HR 0.56, 95% CI 0.45-0.69), CVD (HR 0.48, 95% CI 0.32-0.71) and respiratory mortality risk (HR 0.40, 95% CI 0.24-0.67). Participants who reported a level of physical activity of at least half the dosage recommended by the guidelines also had a reduced risk of all-cause (HR 0.75, 95% CI 0.56-1.00) and CVD mortality (HR 0.48, 95% CI 0.26-0.88). Dose-response associations with mortality risk were demonstrated for walking and sport/exercise, but not domestic physical activity.

CONCLUSIONS

We found a dose-response association between physical activity and all-cause and CVD mortality risk in people with COPD, with protective effects appearing at levels considerably lower than the general physical activity recommendations. People with COPD may benefit from engagement in low levels of physical activity, particularly walking and structured exercise.

Do not do in COPD: consensus statement on overuse

Background

To identify practices that do not add value, cause harm, or subject patients with chronic obstructive pulmonary disease (COPD) to a level of risk that outweighs possible benefits (overuse).

Methods

A qualitative approach was applied. First, a multidisciplinary group of healthcare professionals used the Metaplan technique to draft and rank a list of overused procedures as well as self-care practices in patients with stable and exacerbated COPD. Second, in successive consensus-building rounds, description files were created for each "do not do" (DND) recommendation, consisting of a definition, description, quality of supporting evidence for the recommendation, and the indicator used to measure the degree of overuse. The consensus group comprised 6 pulmonologists, 2 general practitioners, 1 nurse, and 1 physiotherapist.

Results

In total, 16 DND recommendations were made for patients with COPD: 6 for stable COPD, 6 for exacerbated COPD, and 4 concerning self-care.

Conclusion

Overuse poses a risk for patients and jeopardizes care quality. These 16 DND recommendations for COPD will lower care risks and improve disease management, facilitate communication between physicians and patients, and bolster patient ability to provide self-care.

Leisure-time vigorous physical activity is associated with better lung function: the prospective ECRHS study

OBJECTIVE

We assessed associations between physical activity and lung function, and its decline, in the prospective population-based European Community Respiratory Health Survey cohort.

METHODS

FEV₁ and FVC were measured in 3912 participants at 27-57 years and 39-67 years (mean time between examinations=11.1 years). Physical activity frequency and duration were assessed using questionnaires and used to identify active individuals (physical activity ≥2 times and ≥1 hour per week) at each examination. Adjusted mixed linear regression models assessed associations of regular physical activity with FEV₁ and FVC.

RESULTS

Physical activity frequency and duration increased over the study period. In adjusted models, active individuals at the first examination had higher FEV₁ (43.6 mL (95% CI 12.0 to 75.1)) and FVC (53.9 mL (95% CI 17.8 to 89.9)) at both examinations than their non-active counterparts. These associations appeared restricted to current smokers. In the whole population, FEV₁ and FVC were higher among those who changed from inactive to active during the follow-up (38.0 mL (95% CI 15.8 to 60.3) and 54.2 mL (95% CI 25.1 to 83.3), respectively) and who were consistently active, compared with those consistently non-active. No associations were found for lung function decline.

CONCLUSION

Leisure-time vigorous physical activity was associated with higher FEV₁ and FVC over a 10-year period among current smokers, but not with FEV₁ and FVC decline.

Telerehabilitation for Chronic Obstructive Pulmonary Disease Patients: An Underrecognized Management in Tertiary Care

Pulmonary rehabilitation (PR) is proved to be best supportive management in chronic obstructive pulmonary disease (COPD) individuals. The literature claims the reduction of dyspnea, fatigue, exacerbations, and improved functional capacity and quality of life. Home-based PR is being prescribed widely than hospital-based rehab due to be less cost and ease of caregiver burden, but efficacy is usually questioned. The poor efficacy may be probably due to recurrent exacerbation and poor quality of life even after years of home rehabilitation. Telerehabilitation is an excellent rehab measure where the COPD patients exercise at his home, while expertise from the tertiary care centers monitors the rehab sessions remotely. In India, the tele-PR is at its budding state. This review shall enable the readers with the basics of telerehabilitation in comparison with the other available rehab measures and evidence in the management of COPD.

Factors associated with low-level physical activity in elderly patients with chronic obstructive pulmonary disease

BACKGROUND/AIMS

In patients with chronic obstructive pulmonary disease (COPD), the extent of physical activity (PA) is correlated with disease severity and prognosis. However, factors associated with low-level PA in elderly COPD patients are not known. We assessed the levels of PA and clinical factors associated with low-level of PA in elderly COPD patients.

METHODS

This was a secondary analysis of a multicenter, prospective study of 245 patients with COPD. Among them, 160 patients with 65 years or more were included. Three PA groups were defined with respect to daily activity time (low, moderate, and high). Health related quality of life (HRQL) was measured using St. George's respiratory questionnaire (SGRQ) and 36-item short-form health survey. Anxiety and depression status were assessed employing the hospital anxiety and depression scale (HADS). Multivariate logistic regression was performed to identify independent predictors of low-level PA in elderly COPD patients.

RESULTS

Of all the 160 patients, 103 (64.4%) engaged in low-level PA. Upon univariate analysis, a decreased exercise capacity (6-minute walk test < 250 m), an increased dyspnea (the modified medical research council [MMRC] dyspnea scale ≥ 2), a decreased HRQL (total SGRQ score), and a presence of depression (HADS-D ≥ 8) were significantly associated with low-level PA. Upon multivariate analysis, an MMRC grade ≥ 2 (hazard ratio [HR], 2.550; p = 0.034), and HADS-D ≥ 8 (HR, 2.076; p = 0.045) were independently associated with low-level PA in elderly COPD patients.

CONCLUSIONS

Two-thirds of elderly patients with COPD reported low-level of PA. More severe dyspnea and a presence of depression were independently associated with low-level PA in elderly COPD patients.

The association between leisure-time physical activity and lung function in older adults: The English longitudinal study of ageing

The longitudinal association between physical activity and lung function is unclear. Therefore, we examined said association over eight years. This study included data from 2966 participants in English Longitudinal Study of Ageing (63±7years [mean±SD]), a prospective study of initially healthy, community dwelling adults. Physical activity was assessed using an interview and lung function using a spirometer at baseline (2004-5) and follow-up (2012-13). General linear regression was used to assess associations between activity and lung function. Logistic regression was used to assess the odds of new cases of abnormal lung function. Some 14% of participants were defined as physically inactive at baseline, 50% were classified into the moderate group, and 36% into the vigorous group. In comparison with remaining inactive at follow-up, remaining active was positively associated with forced vital capacity (FVC) (β=0.09, 95% confidence interval [CI]: 0.01, 0.17; p=0.02) and forced expiratory volume in one second (FEV-1) (β=0.09, 95% CI: 0.02, 0.15; p=0.01) after adjustment for baseline lung function score and other covariates. Using the fifth centile to define the lower limit of normal (that is, -1.64 z scores), there were lower odds of incident abnormal lung function in participants who remained physically active compared to those who remained inactive (FVC odds ratio=0.31, 95% CI: 0.17, 0.55. FEV-1 odds ratio=0.43, 95% CI: 0.26, 0.72). Similar associations were observed in those who became active. This study suggests that remaining physically active or becoming active in older age is positively associated with lung function and reduced odds of abnormal lung function.

A Lifestyle Physical Activity Intervention for Patients with Chronic Obstructive Pulmonary Disease. A Randomized Controlled Trial

RATIONALE

Physical inactivity is associated with poor outcomes among patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To determine effectiveness of a behavioral intervention intended to increase daily physical activity with the goal of improving health-related quality of life and functional performance.

METHODS

We conducted a randomized trial among patients with COPD cared for in primary care and pulmonary clinics. The patients were at least 45 years of age and eligible for pulmonary rehabilitation. All patients received self-management education during a 6-week run-in period. Subsequently, patients were randomized to usual care or the intervention delivered over 20 weeks.

MEASUREMENTS AND MAIN RESULTS

Co-primary outcomes were change from baseline in Chronic Respiratory Questionnaire dyspnea domain score and 6-minute-walk distance measured at 6, 12, and 18 months after randomization. A total of 325 patients were enrolled, with 156 randomized to receive usual care and 149 to receive the intervention. At 18 months, there was no overall statistical or clinically significant change in the dyspnea domain in either group. However, for 6-minute-walk distance, there were statistically significant declines in both groups. In contrast, 6-minute-walk distance remained stable (5.3 m; P = 0.54) among patients in the intervention group with moderate spirometric impairment, but it was associated with clinically and statistically significant declines (-28.7 m; P = 0.0001) among usual care patients with moderate spirometric impairment. Overall, there was no increase in adverse events associated with the intervention, which was associated with a lower prevalence of hospitalization for COPD exacerbations (28.3%) compared with usual care (49.5%).

CONCLUSIONS

During this 18-month trial among outpatients with COPD, a health coach-based behavioral intervention did not improve scores in the dyspnea domain of the Chronic Respiratory Questionnaire or 6-minute-walk test distance. However, subgroup analyses suggested that there may be differential effects for specific outcomes that vary with severity of COPD. Specifically, benefits of this low-intensity intervention may be limited to 6-minute walk distance among patients with moderate spirometric impairment. Clinical trial registered with www.clinicaltrials.gov (NCT1108991).

How is physical activity measured in lung cancer?A systematic review of outcome measures and their psychometric properties

Physical activity (PA) levels are low in patients with lung cancer. Emerging evidence supports the use of interventions to increase PA in this population. We aimed to (1) identify and synthesize outcome measures which assess PA levels in patients with lung cancer and (2) to evaluate, synthesize and compare the psychometric properties of these measures. A systematic review of articles from searches was conducted of five electronic databases and personal records. Eligible studies were those which assessed PA using either performance-based or patient-reported measures. For aim 2, studies identified in aim 1 reporting on at least one psychometric property (validity, reliability, responsiveness or measurement error) were included. Two independent reviewers assessed eligibility and risk of bias with the COnsensus-based Standards for the selection of health status Measurement INstruments. Thirty-four studies using 21 different measures of PA were identified. Seventeen studies used performance-based measures. The Godin Leisure Time Exercise Questionnaire (GLTEQ) was the most frequently used patient-reported measure. Psychometric properties were reported for 13 of these measures and most frequently for movement sensors. Two studies reported on properties of the GLTEQ. Quality ratings for risk of bias were low. There is significant heterogeneity amongst studies regarding method of PA measurement along the lung cancer continuum. Greater consensus could be achieved by using a consensus approach such as a Delphi process. Future studies should include assessment of psychometric properties of the measurement tool being used. Currently, it is recommended where feasible, both performance-based and patient-reported measurements of PA should be undertaken.

Agreement of different reference equations to classify patients with COPD as having reduced or preserved 6MWD

BACKGROUND

Interpretation of the six-minute walk distance (6MWD) is enhanced by using recommended reference equations. Whenever possible, the choice of equation should be region-specific. A potential problem is that different equations for the 6MWD may have been developed for the same population, and it may be complicated to choose the most suitable.

OBJECTIVE

To verify the agreement of different reference equations in classifying patients with Chronic Obstructive Pulmonary Disease (COPD) as having reduced or preserved 6MWD.

METHODS

159 patients with COPD performed the six-minute walk test according to international standardization. They were classified as having reduced 6MWD if it was below the lower limit of normal. Five Brazilian equations (Iwama; Britto1; Britto2; Dourado; Soares) and the two non-Brazilian equations most cited worldwide (Troosters; Enright) were used. The agreement for patients classified as reduced or preserved 6MWD was verified by Cohen's Kappa (pair-to-pair) analysis. The proportion of patients classified as having reduced walked distance was compared by the Chi-squared test.

RESULTS

Agreement between equations varied largely in classifying subjects as having reduced or preserved 6MWD (Kappa: 0.10-0.82). Brazilian equations with the highest agreement were Iwama, Britto1 and Britto2 (Kappa>0.75). The proportion of patients classified as having reduced 6MWD was statistically similar only between equations in which the agreement was higher than 0.70.

CONCLUSION

Even reference equations from the same country vary considerably in the classification of reduced or preserved 6MWD, and it is recommended that the region-specific ones be used as they give with higher agreement for similar and comparable interpretation of the patients' functional exercise capacity.

Oxygen Desaturation in Daily Life and During a Laboratory-Based Protocol of Activities of Daily Living in COPD: Is There Relationship?

PURPOSE

To analyze the relationship between oxygen desaturation episodes during a laboratory-based ADL protocol and in real-life routine in patients with stable chronic obstructive pulmonary disease (COPD).

METHODS

Twenty patients with stable COPD (12 men, 70 ± 7 years, FEV₁% 54 ± 15 predicted) with no indication for long-term oxygen therapy (LTOT) were submitted to assessments including ADL performance by the Londrina ADL Protocol (LAP) and level of physical activity in daily life, both while submitted to simultaneous activity and pulse oximeter monitoring.

RESULTS

Episodes of desaturation ≥ 4% (ED ≥ 4%) during the LAP were correlated both with ED ≥ 4% in daily life (r = 0.45) and number of episodes of SpO₂ under 88% (ED < 88%) in daily life (r = 0.59). ED < 88% during the LAP was also correlated with ED < 88% in daily life (r = 0.51), explaining 43% of its variance.

CONCLUSION

In stable patients with COPD and no indication of LTOT, episodes of desaturation during a lab-based ADL protocol are moderately related to episodes of desaturation in daily (real) life, especially those episodes under 88%.