Clusters of individuals recovering from an exacerbation of chronic obstructive pulmonary disease and response to in-hospital pulmonary rehabilitation

A Comparison of GOLD and STAR Severity Stages in Individuals With COPD Undergoing Pulmonary Rehabilitation

BACKGROUND

Alongside the recognized Global Initiative for Obstructive Lung Disease (GOLD) classification, the Staging of Airflow Obstruction by Ratio (STAR) severity scheme has been proposed for categorizing COPD.

STUDY QUESTION

What are the agreement and utility of the GOLD and STAR classifications in patients with severe COPD entering the rehabilitation setting?

STUDY DESIGN AND METHODS

Medical records were reviewed in this multicenter retrospective study, examining key functional variables and their changes in a large cohort of patients with COPD undergoing pulmonary rehabilitation.

RESULTS

A total of 1,516 participants (33.7% female participants; median age, 72.0 years) were included in the analysis. Compared with GOLD, the use of the STAR classification resulted in a different disease severity category for 53.4% of patients. An unweighted Cohen's kappa of 0.25 and a Bangdiwala B value of 0.24 indicated a fair agreement between the 2 classifications. Higher weighted agreement measures (0.47 and 0.78, respectively) suggested that discrepancies between the classifications mainly occurred for contiguous stages. GOLD exhibited superior discrimination between stages for chronic respiratory failure, whereas STAR exhibited better performance in detecting hyperinflation. In terms of their application within pulmonary rehabilitation settings, GOLD exhibited superior performance compared with STAR in identifying the minimal clinically important difference in 6-min walking distance and modified Medical Research Council score. Accordingly, GOLD but not STAR acted as an independent predictor for achieving a minimal clinically important difference in modified Medical Research Council score (OR, 1.48; 95% CI, 1.12-1.94; P = .005) and also independently predicted changes in the Braden scale score (β = 0.154; P = .004).

INTERPRETATION

STAR exhibited a more uniform gradation of disease severity and enhanced performance in detecting hyperinflation, but our preliminary findings do not endorse its utilization in the rehabilitation setting.

Is the Rehabilitation Complexity Scale Useful in Individuals Undergoing In-Hospital Pulmonary Rehabilitation?

OBJECTIVE

To assess validity and responsiveness of the Extended Rehabilitation Complexity Scale (RCS-E v13) to in-hospital pulmonary rehabilitation (PR) in individuals with chronic respiratory diseases (CRD).

DESIGN

Cross-sectional, multicentric study. Assessments in individuals attending units on 2 nonconsecutive days.

SETTING

Fourteen in-hospital PR units.

PARTICIPANTS

Five hundred forty-seven individuals (59.2% male, age 72y [range, 65-78y]): 317 with chronic respiratory failure because of various causes (CRF); 96 with chronic obstructive pulmonary disease without CRF (COPD), 39 tracheostomized and ventilated (TX/V), and 95 with other diseases (Miscellaneous).

INTERVENTION

Assessment of RCS-E v13 before and after the PR program.

MAIN OUTCOME MEASURES

RCS-E v13 and outcome measures: Barthel Index (BI), Barthel Index Dyspnea (BiD), Medical Research Council scale for dyspnea (MRC), COPD Assessment Test (CAT), Short Physical Performance Battery (SPPB), and 6-minute walk test (6MWT).

RESULTS

The highest RCS-E v13 admission values (median [interquartile range]) were found in TX/V (17 [15-18]) as compared with other groups (8 [7-10], 10 [9-12], and 8 [8-10] in COPD, CRF, and Miscellaneous, respectively, P<.001). At admission and discharge, RCS-E v13 correlated strongly with BI, 6MWT, and SPPB and moderately with MRC and BiD (r=.43-.60). After the program, RCS-E v13 as well as all outcome measures improved significantly in all groups (P<.001 for all). The size of improvement was different among groups according to the different variables. In the overall group, the effect size was high for changes in RCS-E v13 (Cohen's d=-2.0984), CAT (d=-1.1937), MRC (d=-1.0505), BiD (d=-.9364), and SPPB (d=.9231) whereas it was moderate for 6MWT (d=.7670) and BI (d=.6574).

CONCLUSIONS

RCS-E v13 varies according to different CRD, is responsive to PR, has good construct and concurrent validity, and correlates with most of the accepted outcome measures of PR. Its scoring may provide useful information on the care burden of individuals undergoing PR.

Effects of pulmonary rehabilitation in survivors of severe acute respiratory syndrome coronavirus 2. Role of vaccination

Survivors of severe COVID-19 requiring hospital admission may suffer from short- and long-term sequelae, including disability and reduced physical performance. Vaccination and pulmonary rehabilitation (PR) are effective tools against COVID-19 effects. While the beneficial effect of each of these treatments is known, there are no data about their combined effect. In people admitted to PR hospitals after severe COVID-19 disease, we retrospectively analyzed whether PR outcome might be influenced by vaccination status. Ninety-six individuals were studied (46 vaccinated, 50 unvaccinated). Unvaccinated individuals were younger and less comorbid than vaccinated ones and had needed more intensive care support during the previous hospitalization. Measures of disability and physical performance did not differ between groups at the beginning and at the end of the PR program. However, each group showed a statistically significant improvement in all outcome measures (6-minute walking test, short physical performance battery, Barthel Index). We conclude that vaccination status does not influence the outcome of in-patient PR programs for survivors of severe COVID-19.

Pulmonary rehabilitation and risk of fall in elderly with chronic obstructive pulmonary disease

BACKGROUND

Few data are available on the effects of pulmonary rehabilitation (PR) on risk of fall in over 80 individuals with chronic obstructive pulmonary disease (COPD). We investigated the effectiveness of PR on the risk of fall in older as compared to younger than 80 individuals.

METHODS

Parallel-group retrospective exploratory study of individuals undergone in-hospital PR. The risk of fall was defined as a gait speed ≤0.8 m/s (primary outcome). Outcome measures (exercise capacity, physical performance, symptoms, and health status) were also assessed.

RESULTS

As compared to younger, individuals over 80 suffered from more severe symptoms, a reduction in physical performance and in exercise capacity and greater risk of fall (P=0.0001). The proportion of participants at risk of fall increased with age, and after PR decreased significantly without any significant difference between age groups. However, 53.4% of older individuals were still at risk of fall, as compared to 17.5% of those under 80 (P=0.0001). After PR, both populations had improved outcomes measures, without any significant between group differences.

CONCLUSIONS

In individuals with COPD pulmonary rehabilitation reduced the risk of fall, while improving outcome measures independent of age, however, more than 50% of those over 80 were still at risk of fall. The pulmonary rehabilitation programs for individuals over 80 should include strategies effective in reducing the risk of fall.

Predicting Response to In-Hospital Pulmonary Rehabilitation in Individuals Recovering From Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND

Predicting the response to pulmonary rehabilitation (PR) could be valuable in defining admission priorities. We aimed to investigate whether the response of individuals recovering from a COPD exacerbation (ECOPD) could be forecasted using machine learning approaches.

METHOD

This multicenter, retrospective study recorded data on anthropometrics, demographics, physiological characteristics, post-PR changes in six-minute walking distance test (6MWT), Medical Research Council scale for dyspnea (MRC), Barthel Index dyspnea (BId), COPD assessment test (CAT) and proportion of participants reaching the minimal clinically important difference (MCID). The ability of multivariate approaches (linear regression, quantile regression, regression trees, and conditional inference trees) in predicting changes in each outcome measure has been assessed.

RESULTS

Individuals with lower baseline 6MWT, as well as those with less severe airway obstruction or admitted from acute care hospitals, exhibited greater improvements in 6MWT, whereas older as well as more dyspnoeic individuals had a lower forecasted improvement. Individuals with more severe CAT and dyspnea, and lower 6MWT had a greater potential improvement in CAT. More dyspnoeic individuals were also more likely to show improvement in BId and MRC. The Mean Absolute Error estimates of change prediction were 44.70m, 3.22 points, 5.35 points, and 0.32 points for 6MWT, CAT, BId, and MRC respectively. Sensitivity and specificity in discriminating individuals reaching the MCID of outcomes ranged from 61.78% to 98.99% and from 14.00% to 71.20%, respectively.

CONCLUSION

While the assessed models were not entirely satisfactory, predictive equations derived from clinical practice data might help in forecasting the response to PR in individuals recovering from an ECOPD. Future larger studies will be essential to confirm the methodology, variables, and utility.

Effect of Pulmonary Rehabilitation on COPD Assessment Test Items in Individuals Classified as GOLD Group E

BACKGROUND

A new Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification has been proposed, based also on COPD Assessment Test (CAT).

OBJECTIVES

The aim of this large, multicenter, retrospective study was to determine the impact of pulmonary rehabilitation (PR) on CAT items in individuals with COPD, GOLD group E, recovering from an exacerbation (ECOPD). As secondary aims, we evaluated whether gender, associated chronic respiratory failure (CRF), and age might influence results.

METHODS

Data of 2,213 individuals with available paired pre- and post-PR CAT were analyzed. Other common outcome measures were also assessed.

RESULTS

After PR, total CAT improved from 20.8 ± 7.8 to 12.4 ± 6.9 (p = 0.000), and 1,911 individuals (86.4%) reached the minimal clinically important difference (MCID). All CAT items improved significantly without any significant difference among them. However, item "confidence with disease" improved significantly more in males than in females (p = 0.009). Total CAT and six out of eight items improved significantly more in individuals with CRF than in those without (all p < 0.001). Total CAT and three items improved significantly more in younger than in older individuals (p = 0.023). Only presence of CRF was significantly associated with the probability of improving total CAT more than the MCID.

CONCLUSION

In individuals with COPD, GOLD group E, recovering from ECOPD, PR improves all CAT items; however, gender, associated CRF and age may influence the effect size, suggesting the need to evaluate all items in addition to total CAT score.