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Hasegawa T, Ochi T, Goya S, Matsuda Y, Kako J, Watanabe H, Kasahara Y, Kohara H, Mori M, Nakayama T, Yamaguchi T. Efficacy of supplemental oxygen for dyspnea relief in patients with advanced progressive illness: A systematic review and meta-analysis. Respir Investig 2023; 61:418-437. [PMID: 37105126 DOI: 10.1016/j.resinv.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/27/2023] [Accepted: 03/15/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Supplemental oxygen is widely used for dyspnea relief; however, its efficacy is yet to be verified. This study aimed to determine the efficacy of supplemental oxygen for dyspnea relief in patients with advanced progressive illness. METHODS In this systematic review, several databases, including MEDLINE and EMBASE, were searched to identify eligible randomized controlled trials (RCTs) on the topic published up to September 23, 2019. The search criteria included RCTs investigating patients with advanced progressive illness (advanced cancer, chronic obstructive pulmonary disease, and chronic heart failure). The study protocol was registered with PROSPERO (No. CRD42020161838). Separate analyses were pre-planned regarding the presence or absence of resting hypoxemia. RESULTS RCTs investigating supplemental oxygen for dyspnea relief in participants with and without resting hypoxemia (39 and five, respectively) were included in the study. Heterogeneity of supplemental oxygen for dyspnea in RCTs, including participants without resting hypoxemia was evident; hence, post-hoc analyses in four subgroups (supplemental oxygen during exercise or daily activities, short-burst oxygen, continuous supplemental oxygen, and supplemental oxygen during rehabilitation intervention) were conducted. In the meta-analysis, supplemental oxygen during exercise was found to improve dyspnea in patients without resting hypoxemia compared with that in the control (standardized mean difference = -0.57, 95% confidence interval = -0.77 to -0.38). However, supplemental oxygen for the other subgroups failed to improve patients' dyspnea. CONCLUSION The results of this systematic review do not support supplemental oxygen therapy for dyspnea relief in patients with advanced progressive illness, except during exercise.
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Affiliation(s)
- Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-0001, Japan.
| | - Takura Ochi
- Hospice, Matsuyama Bethel Hospital, 6-1229 Iwaidani, Matsuyama, Ehime 790-0833, Japan
| | - Sho Goya
- Department of Respiratory Medicine, Kinki Central Hospital of the Mutual Aid Association of Public School Teachers, 3-1 Kurumazuka, Itami, Hyogo 664-8533, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-cho, Kita-ku, Sakai, Osaka 591-8025, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, 8-2-1 Gakuen Nishimachi, Nishi-ku, Kobe, Hyogo 651-2197, Japan
| | - Hiroaki Watanabe
- Home Palliative Care Asunaro Clinic, 1-35, Joubushi, Komaki, Aichi 485-0044, Japan
| | - Yoko Kasahara
- Department of Pharmacy, Hiroshima Prefectural Hospital, 1-5-54, Ujinakanda, Minami-ku, Hiroshima 734-0004, Japan
| | - Hiroyuki Kohara
- Department of Internal Medicine, Hatsukaichi Memorial Hospital, 5-12 Yokodai, Hatsukaichi, Hiroshima 738-0060, Japan
| | - Masanori Mori
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka 433-8105, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Yoshidahonmachi, Sakyo-ku, Kyoto 606-8501, Japan
| | - Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
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Gindre D, Surpas P, Garcia-Tejero M, Decullier E, Bin S. Apport de l’hélium dans la réhabilitation respiratoire de patients BPCO sévères. Rev Mal Respir 2022; 39:676-684. [DOI: 10.1016/j.rmr.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022]
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3
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Megaritis D, Wagner PD, Vogiatzis I. Ergogenic value of oxygen supplementation in chronic obstructive pulmonary disease. Intern Emerg Med 2022; 17:1277-1286. [PMID: 35819698 PMCID: PMC9352614 DOI: 10.1007/s11739-022-03037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Patients with COPD exhibit limited exercise endurance time compared to healthy age-matched individuals. Oxygen supplementation is often applied to improve endurance time during pulmonary rehabilitation in patients with COPD and thus a comprehensive understanding of the mechanisms leading to improved endurance is desirable. This review analyses data from two studies by our research group investigating the effect of oxygen supplementation on cerebrovascular, systemic, respiratory and locomotor muscle oxygen availability on the same cohort of individuals with advanced COPD, and the mechanisms associated with improved endurance time in hyperoxia, which was essentially doubled (at the same power output). In hyperoxia at isotime (the time at which patients became exhausted in normoxia) exercise was associated with greater respiratory and locomotor muscle (but not frontal cortex) oxygen delivery (despite lower cardiac output), lower lactate concentration and less tachypnoea. Frontal cortex oxygen saturation was higher, and respiratory drive lower. Hence, improved endurance in hyperoxia appears to be facilitated by several factors: increased oxygen availability to the respiratory and locomotor muscles, less metabolic acidosis, and lower respiratory drive. At exhaustion in both normoxia and hyperoxia, only cardiac output and breathing pattern were not different between conditions. However, minute ventilation in hyperoxia exceeded the critical level of ventilatory constraints (VE/MVV > 75-80%). Lactate remained lower and respiratory and locomotor muscle oxygen delivery greater in hyperoxia, suggesting greater muscle oxygen availability improving muscle function. Taken together, these findings suggest that central haemodynamic and ventilatory limitations and not contracting muscle conditions dictate endurance time in COPD during exercise in hyperoxia.
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Affiliation(s)
- Dimitrios Megaritis
- grid.42629.3b0000000121965555Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Tyne and Wear, Newcastle upon Tyne, UK
| | - Peter D. Wagner
- grid.42629.3b0000000121965555Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Tyne and Wear, Newcastle upon Tyne, UK
- grid.266100.30000 0001 2107 4242Department of Medicine, University of California, San Diego, CA USA
| | - Ioannis Vogiatzis
- grid.42629.3b0000000121965555Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Tyne and Wear, Newcastle upon Tyne, UK
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Bamonti PM, Robinson SA, Wan ES, Moy ML. Improving Physiological, Physical, and Psychological Health Outcomes: A Narrative Review in US Veterans with COPD. Int J Chron Obstruct Pulmon Dis 2022; 17:1269-1283. [PMID: 35677347 PMCID: PMC9167842 DOI: 10.2147/copd.s339323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States (US) providing healthcare to an increasing number of middle-aged and older adults who remain at greater risk for chronic obstructive pulmonary disease (COPD) compared to their civilian counterparts. The VHA has obligated research funds, drafted clinical guidelines, and built programmatic infrastructure to support the diagnosis, treatment, and care management of Veterans with COPD. Despite these efforts, COPD remains a leading cause of morbidity and mortality in Veterans. This paper provides a narrative review of research conducted with US Veteran samples targeting improvement in COPD outcomes. We review key physiological, physical, and psychological health outcomes and intervention research that included US Veteran samples. We conclude with a discussion of directions for future research to continue advancing the treatment of COPD in Veterans and inform advancements in COPD research within and outside the VHA.
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Affiliation(s)
- Patricia M Bamonti
- Research & Development, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Stephanie A Robinson
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Emily S Wan
- Research & Development, VA Boston Healthcare System, Boston, MA, USA.,Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA.,Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Marilyn L Moy
- Research & Development, VA Boston Healthcare System, Boston, MA, USA.,Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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5
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Rozenbaum Z, Ben-Gal Y, Kapusta L, Hochstadt A, Sadeh Md B, Aviram Md G, Havakuk Md O, Shimiaie Md J, Ghermezi Md M, Laufer-Perl Md M, Shacham Md Y, Keren G, Topilsky Y. Combined Echocardiographic and Cardiopulmonary Exercise to Assess Determinants of Exercise Limitation in Chronic Obstructive Pulmonary Disease. J Am Soc Echocardiogr 2020; 34:146-155.e5. [PMID: 33187814 DOI: 10.1016/j.echo.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Current methods do not allow a thorough assessment of causes associated with limited exercise capacity in patients with chronic obstructive pulmonary disease (COPD). METHODS Twenty patients with COPD and 20 matched control subjects were assessed using combined cardiopulmonary and stress echocardiographic testing. Various echocardiographic parameters (left ventricular [LV] volumes, right ventricular [RV] area, ejection fraction, stroke volume, S', and E/e' ratio) and ventilatory parameters (peak oxygen consumption [Vo2] and A-Vo2 difference) were measured to evaluate LV and RV function, hemodynamics, and peripheral oxygen extraction (A-VO2 difference). RESULTS Significant differences (both between groups and for group-by-time interaction) were seen in exercise responses (LV volume, RV area, LV volume/RV area ratio, S', E/e' ratio, tricuspid regurgitation grade, heart rate, stroke volume, and Vo2). The major mechanisms of reduced exercise tolerance in patients with COPD were bowing of the septum to the left in 12 (60%), abnormal increases in E/e' ratio in 12 (60%), abnormal stroke volume reserve in 16 (80%), low peak A-Vo2 difference in 10 (50%), chronotropic incompetence in 13 (65%), or a combination of several mechanisms. Patients with COPD and poor exercise tolerance showed attenuated increases in stroke volume, heart rate, and A-Vo2 difference and exaggerated changes in LV/RV ratio and LV compliance (ratio of LV volume to E/e' ratio) compared with patients with COPD with good exercise tolerance. CONCLUSIONS Combined cardiopulmonary and stress echocardiographic testing can be helpful in determining individual mechanisms of exercise intolerance in patients with COPD. In patients with COPD, exercise intolerance is predominantly the result of chronotropic incompetence, limited stroke volume reserve, exercise-induced elevation in left filling pressure, and peripheral factors and not simply obstructive lung function. Limited stroke volume is related to abnormal RV contractile reserve and reduced LV compliance introduced through septal flattening and direct ventricular interaction.
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Affiliation(s)
- Zach Rozenbaum
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yanai Ben-Gal
- Sackler Faculty of Medicine, Cardiac Surgery Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Livia Kapusta
- Department of Paediatrics, Paediatric Cardiology Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Paediatric Cardiology, Amalia Children's Hospital, Radboud, University Medical Centre, Nijmegen, the Netherlands
| | - Aviram Hochstadt
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ben Sadeh Md
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Galit Aviram Md
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ofer Havakuk Md
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Jason Shimiaie Md
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Michael Ghermezi Md
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Michal Laufer-Perl Md
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yacov Shacham Md
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gad Keren
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yan Topilsky
- Sackler Faculty of Medicine, Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
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6
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Hasler ED, Saxer S, Schneider SR, Furian M, Lichtblau M, Schwarz EI, Bloch KE, Ulrich S. Effect of Breathing Oxygen-Enriched Air on Exercise Performance in Patients with Chronic Obstructive Pulmonary Disease: Randomized, Placebo-Controlled, Cross-Over Trial. Respiration 2020; 99:213-224. [PMID: 32050198 DOI: 10.1159/000505819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/06/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) experience dyspnea and hypoxemia during exercise. OBJECTIVE The aim of this study was to evaluate the effects of breathing oxygen-enriched air on exercise performance and associated physiological changes in patients with COPD. METHODS In a randomized, placebo-controlled, single-blind, cross-over trial, 20 patients with COPD (11 women, age 65 ± 6 years, FEV1 64 ± 19% pred., resting SpO2 ≥90%) performed 4 cycle ergospirometries to exhaustion using an incremental exercise test (IET) and a constant work rate (at 75% maximal workload with air) exercise test (CWRET), each with ambient (FiO2 0.21) and oxygen-enriched (FiO2 0.5) air. The main outcomes were the change in maximal workload in the IET and the change in exercise duration in the CWRET with oxygen versus air. Electrocardiogram, pulmonary gas exchange, thoracic volumes by inductance plethysmography, arterial blood gases, and cerebral and quadriceps muscle tissue oxygenation (CTO and MTO) were additionally measured. RESULTS In the IET, maximal workload increased from 96 ± 21 to 104 ± 28 W with oxygen. In the CWRET, exercise duration increased from 605 ± 274 to 963 ± 444 s with oxygen. At end-exercise with oxygen, CTO, MTO, PaO2, and PaCO2 were increased, while V'E/V'CO2 was reduced and thoracic volumes were similar. At the corresponding time to end of exercise with ambient air, oxygen decreased heart rate, respiratory rate, minute ventilation, and V'E/V'CO2, while oxygenation was increased. CONCLUSION In COPD patients without resting hypoxemia, breathing oxygen-enriched air improves exercise performance. This relates to a higher arterial oxygen saturation promoting oxygen availability to muscle and cerebral tissue and an enhanced ventilatory efficiency. COPD patients may benefit from oxygen therapy during exercise training.
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Affiliation(s)
| | - Stéphanie Saxer
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | | | - Michael Furian
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | | | - Konrad E Bloch
- Pulmonary Clinic, University Hospital Zurich and Centre for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Pulmonary Clinic, University Hospital Zurich and Centre for Integrative Human Physiology, University of Zurich, Zurich, Switzerland,
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7
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Wouters EF, Posthuma R, Koopman M, Liu WY, Sillen MJ, Hajian B, Sastry M, Spruit MA, Franssen FM. An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease. Expert Rev Respir Med 2020; 14:149-161. [PMID: 31931636 DOI: 10.1080/17476348.2020.1700796] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.Areas covered: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.Expert opinion: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.
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Affiliation(s)
- Emiel Fm Wouters
- Department of Respiratory Medicine, Maastricht University Medical Center+, The Netherlands.,CIRO+, center of expertise for chronic organ failure, Horn, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center Maastricht, The Netherlands
| | - Rein Posthuma
- Department of Respiratory Medicine, Maastricht University Medical Center+, The Netherlands.,CIRO+, center of expertise for chronic organ failure, Horn, The Netherlands
| | - Maud Koopman
- Department of Respiratory Medicine, Maastricht University Medical Center+, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center Maastricht, The Netherlands
| | - Wai-Yan Liu
- CIRO+, center of expertise for chronic organ failure, Horn, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center Maastricht, The Netherlands
| | - Maurice J Sillen
- Department of Respiratory Medicine, Maastricht University Medical Center+, The Netherlands
| | - Bita Hajian
- Department of Respiratory Medicine, Maastricht University Medical Center+, The Netherlands
| | - Manu Sastry
- Department of Respiratory Medicine, Maastricht University Medical Center+, The Netherlands
| | - Martijn A Spruit
- Department of Respiratory Medicine, Maastricht University Medical Center+, The Netherlands.,CIRO+, center of expertise for chronic organ failure, Horn, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center Maastricht, The Netherlands
| | - Frits M Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center+, The Netherlands.,CIRO+, center of expertise for chronic organ failure, Horn, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center Maastricht, The Netherlands
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Abstract
Cardiopulmonary exercise testing (CPET) in hyperoxia and hypoxia has several applications, stemming from characterization of abnormal physiological response profiles associated with exercise intolerance. As altered oxygenation can impact the performance of gas-concentration and flow sensors and pulmonary gas exchange algorithms, integrated CPET system function requires validation under these conditions. Also, as oxygenation status can influence peak [Formula: see text]o2, care should be taken in the selection of work-rate incrementation rates when CPET performance is to be compared with normobaria at sea level. CPET has been used to evaluate the effects of supplemental O2 on exercise intolerance in chronic obstructive pulmonary disease, interstitial pulmonary fibrosis, and cystic fibrosis at sea level. However, identification of those CPET indices likely to be predictive of supplemental O2 outcomes for exercise tolerance at altitude in such patients is lacking. CPET performance with supplemental O2 in respiratory patients residing at high altitudes is also poorly studied. Finally, CPET has the potential to give physiological and clinical information about acute and chronic mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema. It may also translate high-altitude acclimatization and adaptive processes in healthy individuals into intensive care medical practice.
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9
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Brugniaux JV, Coombs GB, Barak OF, Dujic Z, Sekhon MS, Ainslie PN. Highs and lows of hyperoxia: physiological, performance, and clinical aspects. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1-R27. [PMID: 29488785 DOI: 10.1152/ajpregu.00165.2017] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Molecular oxygen (O2) is a vital element in human survival and plays a major role in a diverse range of biological and physiological processes. Although normobaric hyperoxia can increase arterial oxygen content ([Formula: see text]), it also causes vasoconstriction and hence reduces O2 delivery in various vascular beds, including the heart, skeletal muscle, and brain. Thus, a seemingly paradoxical situation exists in which the administration of oxygen may place tissues at increased risk of hypoxic stress. Nevertheless, with various degrees of effectiveness, and not without consequences, supplemental oxygen is used clinically in an attempt to correct tissue hypoxia (e.g., brain ischemia, traumatic brain injury, carbon monoxide poisoning, etc.) and chronic hypoxemia (e.g., severe COPD, etc.) and to help with wound healing, necrosis, or reperfusion injuries (e.g., compromised grafts). Hyperoxia has also been used liberally by athletes in a belief that it offers performance-enhancing benefits; such benefits also extend to hypoxemic patients both at rest and during rehabilitation. This review aims to provide a comprehensive overview of the effects of hyperoxia in humans from the "bench to bedside." The first section will focus on the basic physiological principles of partial pressure of arterial O2, [Formula: see text], and barometric pressure and how these changes lead to variation in regional O2 delivery. This review provides an overview of the evidence for and against the use of hyperoxia as an aid to enhance physical performance. The final section addresses pathophysiological concepts, clinical studies, and implications for therapy. The potential of O2 toxicity and future research directions are also considered.
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Affiliation(s)
| | - Geoff B Coombs
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada
| | - Otto F Barak
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
| | - Zeljko Dujic
- Department of Integrative Physiology, School of Medicine, University of Split , Split , Croatia
| | - Mypinder S Sekhon
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada.,Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia , Vancouver, British Columbia , Canada
| | - Philip N Ainslie
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada
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10
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O'Donnell DE, Elbehairy AF, Faisal A, Webb KA, Neder JA, Mahler DA. Exertional dyspnoea in COPD: the clinical utility of cardiopulmonary exercise testing. Eur Respir Rev 2017; 25:333-47. [PMID: 27581832 DOI: 10.1183/16000617.0054-2016] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/01/2016] [Indexed: 02/03/2023] Open
Abstract
Activity-related dyspnoea is often the most distressing symptom experienced by patients with chronic obstructive pulmonary disease (COPD) and can persist despite comprehensive medical management. It is now clear that dyspnoea during physical activity occurs across the spectrum of disease severity, even in those with mild airway obstruction. Our understanding of the nature and source of dyspnoea is incomplete, but current aetiological concepts emphasise the importance of increased central neural drive to breathe in the setting of a reduced ability of the respiratory system to appropriately respond. Since dyspnoea is provoked or aggravated by physical activity, its concurrent measurement during standardised laboratory exercise testing is clearly important. Combining measurement of perceptual and physiological responses during exercise can provide valuable insights into symptom severity and its pathophysiological underpinnings. This review summarises the abnormal physiological responses to exercise in COPD, as these form the basis for modern constructs of the neurobiology of exertional dyspnoea. The main objectives are: 1) to examine the role of cardiopulmonary exercise testing (CPET) in uncovering the physiological mechanisms of exertional dyspnoea in patients with mild-to-moderate COPD; 2) to examine the escalating negative sensory consequences of progressive respiratory impairment with disease advancement; and 3) to build a physiological rationale for individualised treatment optimisation based on CPET.
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Affiliation(s)
- Denis E O'Donnell
- Dept of Medicine, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | - Amany F Elbehairy
- Dept of Medicine, Queen's University and Kingston General Hospital, Kingston, ON, Canada Dept of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Azmy Faisal
- Dept of Medicine, Queen's University and Kingston General Hospital, Kingston, ON, Canada Faculty of Physical Education for Men, Alexandria University, Alexandria, Egypt
| | - Katherine A Webb
- Dept of Medicine, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | - J Alberto Neder
- Dept of Medicine, Queen's University and Kingston General Hospital, Kingston, ON, Canada
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11
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Ekström M, Ahmadi Z, Bornefalk‐Hermansson A, Abernethy A, Currow D. Oxygen for breathlessness in patients with chronic obstructive pulmonary disease who do not qualify for home oxygen therapy. Cochrane Database Syst Rev 2016; 11:CD006429. [PMID: 27886372 PMCID: PMC6464154 DOI: 10.1002/14651858.cd006429.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Breathlessness is a cardinal symptom of chronic obstructive pulmonary disease (COPD). Long-term oxygen therapy (LTOT) is given to improve survival time in people with COPD and severe chronic hypoxaemia at rest. The efficacy of oxygen therapy for breathlessness and health-related quality of life (HRQOL) in people with COPD and mild or no hypoxaemia who do not meet the criteria for LTOT has not been established. OBJECTIVES To determine the efficacy of oxygen versus air in mildly hypoxaemic or non-hypoxaemic patients with COPD in terms of (1) breathlessness; (2) HRQOL; (3) patient preference whether to continue therapy; and (4) oxygen-related adverse events. SEARCH METHODS We searched the Cochrane Airways Group Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase, to 12 July 2016, for randomised controlled trials (RCTs). We handsearched the reference lists of included articles. SELECTION CRITERIA We included RCTs of the effects of non-invasive oxygen versus air on breathlessness, HRQOL or patient preference to continue therapy among people with COPD and mild or no hypoxaemia (partial pressure of oxygen (PaO2) > 7.3 kPa) who were not already receiving LTOT. Two review authors independently assessed articles for inclusion in the review. DATA COLLECTION AND ANALYSIS Two review authors independently collected and analysed data. We assessed risk of bias by using the Cochrane 'Risk of bias tool'. We pooled effects recorded on different scales as standardised mean differences (SMDs) with 95% confidence intervals (CIs) using random-effects models. Lower SMDs indicated decreased breathlessness and reduced HRQOL. We performed subanalyses and sensitivity analyses and assessed the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. MAIN RESULTS Compared with the previous review, which was published in 2011, we included 14 additional studies (493 participants), excluded one study and included data for meta-analysis of HRQOL. In total, we included in this review 44 studies including 1195 participants, and we included 33 of these (901 participants)in the meta-analysis.We found that breathlessness during exercise or daily activities was reduced by oxygen compared with air (32 studies; 865 participants; SMD -0.34, 95% CI -0.48 to -0.21; I2 = 37%; low-quality evidence). This translates to a decrease in breathlessness of about 0.7 points on a 0 to 10 numerical rating scale. In contrast, we found no effect of short-burst oxygen given before exercise (four studies; 90 participants; SMD 0.01, 95% CI -0.26 to 0.28; I2 = 0%; low-quality evidence). Oxygen reduced breathlessness measured during exercise tests (25 studies; 442 participants; SMD -0.34, 95% CI -0.46 to -0.22; I2 = 29%; moderate-quality evidence), whereas evidence of an effect on breathlessness measured in daily life was limited (two studies; 274 participants; SMD -0.13, 95% CI, -0.37 to 0.11; I2 = 0%; low-quality evidence).Oxygen did not clearly affect HRQOL (five studies; 267 participants; SMD 0.10, 95% CI -0.06 to 0.26; I2 = 0%; low-quality evidence). Patient preference and adverse events could not be analysed owing to insufficient data. AUTHORS' CONCLUSIONS We are moderately confident that oxygen can relieve breathlessness when given during exercise to mildly hypoxaemic and non-hypoxaemic people with chronic obstructive pulmonary disease who would not otherwise qualify for home oxygen therapy. Most evidence pertains to acute effects during exercise tests, and no evidence indicates that oxygen decreases breathlessness in the daily life setting. Findings show that oxygen does not affect health-related quality of life.
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Affiliation(s)
- Magnus Ekström
- Lund UniversityDepartment of Clinical Sciences, Division of Respiratory Medicine & AllergologyLundSweden
| | - Zainab Ahmadi
- Lund UniversityDepartment of Clinical Sciences, Division of Respiratory Medicine & AllergologyLundSweden
| | | | - Amy Abernethy
- Duke University Medical CenterCLHCDurhamNorth CarolinaUSA
| | - David Currow
- Flinders UniversityDepartment of Palliative and Supportive Services700 Goodwood RoadDaw ParkSAAustralia5041
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Ambrosino N, Giannini D, D'Amico I. How good is the evidence for ambulatory oxygen in chronic obstructive pulmonary disease. Chron Respir Dis 2016; 1:125-6. [PMID: 16281652 DOI: 10.1191/1479972304cd031ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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13
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Rossi A, Aisanov Z, Avdeev S, Di Maria G, Donner CF, Izquierdo JL, Roche N, Similowski T, Watz H, Worth H, Miravitlles M. Mechanisms, assessment and therapeutic implications of lung hyperinflation in COPD. Respir Med 2015; 109:785-802. [DOI: 10.1016/j.rmed.2015.03.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 03/04/2015] [Accepted: 03/23/2015] [Indexed: 02/05/2023]
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Fotheringham I, Meakin G, Punekar YS, Riley JH, Cockle SM, Singh SJ. Comparison of laboratory- and field-based exercise tests for COPD: a systematic review. Int J Chron Obstruct Pulmon Dis 2015; 10:625-43. [PMID: 25834421 PMCID: PMC4372024 DOI: 10.2147/copd.s70518] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Exercise tests are often used to evaluate the functional status of patients with COPD. However, to the best of our knowledge, a comprehensive systematic comparison of these tests has not been performed. We systematically reviewed studies reporting the repeatability and/or reproducibility of these tests, and studies comparing their sensitivity to therapeutic intervention. A systematic review identified primary manuscripts in English reporting relevant data on the following exercise tests: 6-minute walk test (6MWT) and 12-minute walk test, incremental and endurance shuttle walk tests (ISWT and ESWT, respectively), incremental and endurance cycle ergometer tests, and incremental and endurance treadmill tests. We identified 71 relevant studies. Good repeatability (for the 6MWT and ESWT) and reproducibility (for the 6MWT, 12-minute walk test, ISWT, ESWT, and incremental cycle ergometer test) were reported by most studies assessing these tests, providing patients were familiarized with them beforehand. The 6MWT, ISWT, and particularly the ESWT were reported to be sensitive to therapeutic intervention. Protocol variations (eg, track layout or supplemental oxygen use) affected performance significantly in several studies. This review shows that while the validity of several tests has been established, for others further study is required. Future work will assess the link between these tests, physiological mechanisms, and patient-reported measures.
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Affiliation(s)
- Iain Fotheringham
- Value Demonstration Practice, Oxford PharmaGenesis, Oxford, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Georgina Meakin
- Value Demonstration Practice, Oxford PharmaGenesis, Oxford, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Yogesh Suresh Punekar
- GlaxoSmithKline, Uxbridge, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - John H Riley
- GlaxoSmithKline, Uxbridge, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sarah M Cockle
- GlaxoSmithKline, Uxbridge, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally J Singh
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
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Brill SE, Wedzicha JA. Oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2014; 9:1241-52. [PMID: 25404854 PMCID: PMC4230177 DOI: 10.2147/copd.s41476] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (COPD) are important events in the history of this debilitating lung condition. Associated health care utilization and morbidity are high, and many patients require supplemental oxygen or ventilatory support. The last 2 decades have seen a substantial increase in our understanding of the best way to manage the respiratory failure suffered by many patients during this high-risk period. This review article examines the evidence underlying supplemental oxygen therapy during exacerbations of COPD. We first discuss the epidemiology and pathophysiology of respiratory failure in COPD during exacerbations. The rationale and evidence underlying oxygen therapy, including the risks when administered inappropriately, are then discussed, along with further strategies for ventilatory support. We also review current recommendations for best practice, including methods for improving oxygen provision in the future.
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Affiliation(s)
- Simon E Brill
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London, UK
| | - Jadwiga A Wedzicha
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London, UK
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Hill K, Holland AE. Strategies to enhance the benefits of exercise training in the respiratory patient. Clin Chest Med 2014; 35:323-36. [PMID: 24874128 DOI: 10.1016/j.ccm.2014.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Despite the well-established benefits of exercise training in people with chronic respiratory disease, there are a group of people in whom it confers minimal gains. Furthermore, there is increasing recognition of the prevalence of comorbid conditions among people with chronic obstructive pulmonary disease and other respiratory diseases, such as musculoskeletal disorders, which make participation in traditional exercise training programs challenging. This article focuses on several adjuncts or strategies that may be implemented by clinicians during exercise training, with the goal of optimizing the proportion of pulmonary rehabilitation participants who achieve significant and meaningful gains on program completion.
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Affiliation(s)
- Kylie Hill
- School of Physiotherapy and Exercise Science, Faculty of Health Science, Curtin University, GPO Box U1987, Perth, Western Australia 6845, Australia; Lung Institute of Western Australia, Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Hospital Avenue, Nedlands, Western Australia 6009, Australia; Physiotherapy Department, Royal Perth Hospital, Wellington Street, Perth, Western Australia 6000, Australia.
| | - Anne E Holland
- Department of Physiotherapy, La Trobe University, Level 4, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia; Department of Physiotherapy, Alfred Health, Commercial Road, Melbourne, Victoria 3004, Australia; Institute for Breathing and Sleep, Studley Road, Heidelberg, Victoria 3084, Australia
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Kollmann D, Hogan WK, Steidl C, Hibbs-Brenner MK, Hedin DS, Lichter PA. VCSEL based, wearable, continuously monitoring pulse oximeter. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2013:4156-9. [PMID: 24110647 DOI: 10.1109/embc.2013.6610460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We present the development of a novel pulse oximeter based on low power, low cost, Vertical Cavity Surface Emitting Laser (VCSEL) technology. This new design will help address a need to perform regular measurements of pulse oximetry for patients with chronic obstructive pulmonary disease. VCSELs with wavelengths suitable for pulse oximetry were developed and packaged in a PLCC package for a low cost solution that is easy to integrate into a pulse oximeter design. The VCSELs were integrated into a prototype pulse oximeter that is unobtrusive and suitable for long term wearable use. The prototype achieved good performance compared the Nonin Onyx II pulse oximeter at less than one fifth the weight in a design that can be worn behind the ear like a hearing aid.
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Effect of ambulatory oxygen on exertional dyspnea in IPF patients without resting hypoxemia. Respir Med 2013; 107:1241-6. [DOI: 10.1016/j.rmed.2013.05.015] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Revised: 03/26/2013] [Accepted: 05/16/2013] [Indexed: 12/14/2022]
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Inspiratory Capacity during Exercise: Measurement, Analysis, and Interpretation. Pulm Med 2013; 2013:956081. [PMID: 23476765 PMCID: PMC3582111 DOI: 10.1155/2013/956081] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 12/21/2012] [Indexed: 12/24/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is an established method for evaluating dyspnea and ventilatory abnormalities. Ventilatory reserve is typically assessed as the ratio of peak exercise ventilation to maximal voluntary ventilation. Unfortunately, this crude assessment provides limited data on the factors that limit the normal ventilatory response to exercise. Additional measurements can provide a more comprehensive evaluation of respiratory mechanical constraints during CPET (e.g., expiratory flow limitation and operating lung volumes). These measurements are directly dependent on an accurate assessment of inspiratory capacity (IC) throughout rest and exercise. Despite the valuable insight that the IC provides, there are no established recommendations on how to perform the maneuver during exercise and how to analyze and interpret the data. Accordingly, the purpose of this manuscript is to comprehensively examine a number of methodological issues related to the measurement, analysis, and interpretation of the IC. We will also briefly discuss IC responses to exercise in health and disease and will consider how various therapeutic interventions influence the IC, particularly in patients with chronic obstructive pulmonary disease. Our main conclusion is that IC measurements are both reproducible and responsive to therapy and provide important information on the mechanisms of dyspnea and exercise limitation during CPET.
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Miki K, Maekura R, Hiraga T, Kitada S, Miki M, Yoshimura K, Tateishi Y. Effects of oxygen on exertional dyspnoea and exercise performance in patients with chronic obstructive pulmonary disease. Respirology 2012; 17:149-54. [PMID: 22008208 DOI: 10.1111/j.1440-1843.2011.02086.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE The results of studies on the oxygen response in patients with COPD should provide important clues to the pathophysiology of exertional dyspnoea. We investigated the exercise responses to hyperoxia in relation to dyspnoea profile, as well as cardiopulmonary, acidotic and sympathetic parameters in 35 patients with stable COPD (mean FEV(1) 46% predicted). METHODS This was a single-blind trial, in which patients breathed 24% O(2) or compressed air (CA) in random order during two incremental cycle exercise tests. RESULTS PaO(2) and PaCO(2) were higher (P < 0.0001 and P < 0.05, respectively) at each exercise point while patients were breathing 24% O(2) compared with CA. At a standardized time point near peak exercise, use of O(2) resulted in reduced plasma lactate and plasma noradrenaline concentrations (P < 0.01). Peak minute ventilation/indirect maximum voluntary ventilation was similar while breathing 24% O(2) and CA. At peak exercise, the dyspnoea score, pH and plasma noradrenaline concentrations were similar while breathing 24% O(2) and CA. The dyspnoea-ratio (%) of Δoxygen uptake (peak minus resting oxygen uptake) curve reached a break point that occurred at a similar exercise point while breathing 24% O(2) or CA. CONCLUSIONS Regardless of whether they breathed CA or 24% O(2) , patients with COPD did not develop ventilatory compensation for exertional acidosis, and the pH values measured were similar. Hyperoxia during a standardized exercise protocol did not alter the pattern of exertional dyspnoea in these patients, compared with breathing CA, although hyperoxia resulted in miscellaneous effects.
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Affiliation(s)
- Keisuke Miki
- Department of Internal medicine, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan.
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012; 185:435-52. [PMID: 22336677 PMCID: PMC5448624 DOI: 10.1164/rccm.201111-2042st] [Citation(s) in RCA: 1064] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
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Moga AM, de Marchie M, Saey D, Spahija J. Mechanisms of non-pharmacologic adjunct therapies used during exercise in COPD. Respir Med 2012; 106:614-26. [PMID: 22341681 DOI: 10.1016/j.rmed.2012.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 01/04/2012] [Accepted: 01/12/2012] [Indexed: 11/16/2022]
Abstract
Individuals with chronic obstructive pulmonary disease (COPD) are often limited in their ability to perform exercise due to a heightened sense of dyspnea and/or the occurrence of leg fatigue associated with a reduced ventilatory capacity and peripheral skeletal muscle dysfunction, respectively. Pulmonary rehabilitation programs have been shown to improve exercise tolerance and health related quality of life. Additional therapeutic approaches such as non-invasive ventilatory support (NIVS), heliox (He-O(2)) and supplemental oxygen have been used as non-pharmacologic adjuncts to exercise to enhance the ability of patients with COPD to exercise at a higher exercise-intensity and thus improve the physiological benefits of exercise. The purpose of the current review is to examine the pathophysiology of exercise limitation in COPD and to explore the physiological mechanisms underlying the effect of the adjunct therapies on exercise in patients with COPD. This review indicates that strategies that aim to unload the respiratory muscles and enhance oxygen saturation during exercise alleviate exercise limiting factors and improve exercise performance in patients with COPD. However, available data shows significant variability in the effectiveness across patients. Further research is needed to identify the most appropriate candidates for these forms of therapies.
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Affiliation(s)
- A M Moga
- School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir William Osler, Montreal, Quebec H3G 1Y5, Canada
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012. [PMID: 22336677 DOI: 10.1164/rccm.201111–2042st] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
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Uronis H, McCrory DC, Samsa G, Currow D, Abernethy A. Symptomatic oxygen for non-hypoxaemic chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2011:CD006429. [PMID: 21678356 DOI: 10.1002/14651858.cd006429.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Dyspnoea is a common symptom in chronic obstructive pulmonary disease (COPD). People who are hypoxaemic may be given long-term oxygen relief therapy (LTOT) to improve their life expectancy and quality of life. However, the symptomatic benefit of home oxygen therapy in mildly or non-hypoxaemic people with COPD with dyspnoea who do not meet international funding criteria for LTOT (PaO(2)< 55 mmHg or other special cases) is unknown. OBJECTIVES To determine the efficacy of oxygen versus medical air for relief of subjective dyspnoea in mildly or non-hypoxaemic people with COPD who would not otherwise qualify for home oxygen therapy. The main outcome was patient-reported dyspnoea and secondary outcome was exercise tolerance. SEARCH STRATEGY We searched the Cochrane Airways Group Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, to November 2009, to identify randomised controlled trials. We handsearched reference lists of included articles. SELECTION CRITERIA We only included randomised controlled trials of oxygen versus medical air in mildly or non-hypoxaemic people with COPD. Two review authors independently assessed articles for inclusion. DATA COLLECTION AND ANALYSIS One review author completed data extraction and methodological quality assessment. A second review author then over-read evidence tables to assess for accuracy. MAIN RESULTS Twenty-eight trials on 702 patients met the criteria for inclusion; 18 trials (431 participants) were included in the meta-analysis. Oxygen reduced dyspnoea with a standardised mean difference (SMD) of -0.37 (95% confidence interval (CI) -0.50 to -0.24, P < 0.00001). We observed significant heterogeneity. AUTHORS' CONCLUSIONS Oxygen can relieve dyspnoea in mildly and non-hypoxaemic people with COPD who would not otherwise qualify for home oxygen therapy. Given the significant heterogeneity among the included studies, clinicians should continue to evaluate patients on an individual basis until supporting data from ongoing, large randomised controlled trials are available.
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Affiliation(s)
- Hope Uronis
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Box 3841, Durham, NC, USA, 27710
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Scorsone D, Bartolini S, Saporiti R, Braido F, Baroffio M, Pellegrino R, Brusasco V, Crimi E. Does a Low-Density Gas Mixture or Oxygen Supplementation Improve Exercise Training in COPD? Chest 2010; 138:1133-9. [DOI: 10.1378/chest.10-0120] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Mechanisms of activity-related dyspnea in pulmonary diseases. Respir Physiol Neurobiol 2009; 167:116-32. [DOI: 10.1016/j.resp.2009.01.010] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 01/30/2009] [Indexed: 01/22/2023]
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Budweiser S, Jörres RA, Pfeifer M. Treatment of respiratory failure in COPD. Int J Chron Obstruct Pulmon Dis 2009; 3:605-18. [PMID: 19281077 PMCID: PMC2650592 DOI: 10.2147/copd.s3814] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients with advanced COPD and acute or chronic respiratory failure are at high risk for death. Beyond pharmacological treatment, supplemental oxygen and mechanical ventilation are major treatment options. This review describes the physiological concepts underlying respiratory failure and its therapy, as well as important treatment outcomes. The rationale for the controlled supply of oxygen in acute hypoxic respiratory failure is undisputed. There is also a clear survival benefit from long-term oxygen therapy in patients with chronic hypoxia, while in mild, nocturnal, or exercise-induced hypoxemia such long-term benefits appear questionable. Furthermore, much evidence supports the use of non-invasive positive pressure ventilation in acute hypercapnic respiratory failure. It application reduces intubation and mortality rates, and the duration of intensive care unit or hospital stays, particularly in the presence of mild to moderate respiratory acidosis. COPD with chronic hypercapnic respiratory failure became a major indication for domiciliary mechanical ventilation, based on pathophysiological reasoning and on data regarding symptoms and quality of life. Still, however, its relevance for long-term survival has to be substantiated in prospective controlled studies. Such studies might preferentially recruit patients with repeated hypercapnic decompensation or a high risk for death, while ensuring effective ventilation and the patients’ adherence to therapy.
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Abstract
PURPOSE OF REVIEW Refractory dyspnea is a common and distressing symptom complicating respiratory illness, including chronic obstructive pulmonary disease, and life-limiting illnesses in general, including cancer. Oxygen is often prescribed for relief of dyspnea and several consensus guidelines support this practice. The goal of this review is to outline the evidence for the use of oxygen for relief of dyspnea, with specific attention to situations in which oxygen is not already funded through long-term oxygen treatment guidelines (i.e., when PaO2 is >/=55 mmHg; also known as palliative oxygen). RECENT FINDINGS Several recent systematic reviews, two focusing on people with chronic obstructive pulmonary disease and the other focusing on people with cancer, strengthen the evidence base behind the use of palliative oxygen for relief of refractory dyspnea, and support the observation that there are subgroups of people who benefit from oxygen, such as individuals with chronic obstructive pulmonary disease. SUMMARY The data highlighted in this review support the belief that certain individuals benefit from the use of palliative oxygen but continue to suggest that definitive randomized trials are required to fully establish the benefit of palliative oxygen and to delineate characteristics predictive of benefit.
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Does correction of exercise-induced desaturation by O2 always improve exercise tolerance in COPD? A preliminary study. Respir Med 2008; 102:1276-86. [DOI: 10.1016/j.rmed.2008.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Revised: 03/21/2008] [Accepted: 04/01/2008] [Indexed: 11/19/2022]
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Abstract
Since the introduction of oxygen as a therapeutic agent 70 years ago, much has been learned regarding the detrimental effects of hypoxemia and the beneficial impact of oxygen therapy. It is projected that there are close to 800,000 patients receiving long-term oxygen therapy (LTOT) in the United States, at a cost of approximately $1.8 billion annually. The large numbers of patients receiving supplemental oxygen as treatment and the high costs incurred in providing oxygen therapy necessitate the practitioner to know the indications for LTOT as well its effects on survival, pulmonary hemodynamics, sleep, and exercise capacity. It is now recognized that the basis for LTOT prescription for all patients is founded on data that are over 25 years old and that only involve a very select cohort of patients. It is clear that further studies are required to assess the effects of oxygen on patients with chronic obstructive pulmonary disease with only mild hypoxemia, not only survival but also on neurocognitive function, quality of life, exercise physiology, and sleep quality. In addition, although proven to be safe when prescribed long term to individuals with lung disease, there are some concerns about worsening carbon dioxide retention and increased oxidant injury. The goals of this article are to briefly describe the indications for chronic oxygen administration, the physiologic effects of treatment, and potential toxicities, as well as its effect on morbidity and mortality.
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Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer 2008; 17:367-77. [DOI: 10.1007/s00520-008-0479-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Accepted: 06/25/2008] [Indexed: 11/27/2022]
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Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by poorly reversible airflow limitation. The pathological hallmarks of COPD are inflammation of the peripheral airways and destruction of lung parenchyma or emphysema. The functional consequences of these abnormalities are expiratory airflow limitation and dynamic hyperinflation, which then increase the elastic load of the respiratory system and decrease the performance of the respiratory muscles. These pathophysiologic features contribute significantly to the development of dyspnea, exercise intolerance and ventilatory failure. Several treatments may palliate flow limitation, including interventions that modify the respiratory pattern (deeper, slower) such as pursed lip breathing, exercise training, oxygen, and some drugs. Other therapies are aimed at its amelioration, such as bronchodilators, lung volume reduction surgery or breathing mixtures of helium and oxygen. Finally some interventions, such as inspiratory pressure support, alleviate the threshold load associated to flow limitation. The degree of flow limitation can be assessed by certain spirometry indexes, such as vital capacity and inspiratory capacity, or by other more complexes indexes such as residual volume/total lung capacity or functional residual capacity/total lung capacity. Two of the best methods to measure flow limitation are to superimpose a flow–volume loop of a tidal breath within a maximum flow–volume curve, or to use negative expiratory pressure technique. Likely this method is more accurate and can be used during spontaneous breathing. A definitive definition of dynamic hyperinflation is lacking in the literature, but serial measurements of inspiratory capacity during exercise will document the trend of end-expiratory lung volume and allow establishing relationships with other measurements such as dyspnea, respiratory pattern, exercise tolerance, and gas exchange.
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Affiliation(s)
- Luis Puente-Maestu
- Hospital General Universitario Gregorio Marañón, Servicio de Neumologia, Madrid, Spain.
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Abstract
Long-term oxygen therapy (LTOT) is the treatment proven to improve survival in chronic obstructive pulmonary disease (COPD) patients with chronic respiratory failure. It also appears to reduce the number of hospitalizations, increase effort capacity, and improve health-related quality of life. Standard LTOT criteria are related to COPD patients who have PaO2 < 60 mmHg, are in a clinical stable situation, and are receiving optimal pharmacological treatment. According to LTOT guidelines, oxygen should be prescribed for at least 18 hours per day although some authors consider 24 hours would be more beneficial. The benefits of LTOT depend on correction of hypoxemia. Arterial blood gases should be measured at rest. During exercise, an effort test should be done to assure adequate SaO2. During sleep, continuous monitoring of SaO2 and PaCO2 should be performed to confirm correction of SaO2 overnight. An arterial blood gas sample should be taken at awakening to assess PaCO, in order to prevent hypoventilation from the oxygen therapy. Several issues that need to be addressed are the use of LTOT in COPD patients with moderate hypoxemia, the efficacy of LTOT in patients who desaturate during exercise or during sleep, the optimal dosage of oxygen supplementation, LTOT compliance, and the LTOT prescription in diseases other than COPD.
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Affiliation(s)
- Rosa Güell Rous
- Departament de Pneumologia, Hospital de la Santa Creu I de Sant Pau, Barcelona, Spain.
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Mahler DA, Waterman LA, Ward J, Baird JC. Responsiveness of patient-reported breathlessness during exercise in persistent asthma. Chest 2007; 131:195-200. [PMID: 17218575 DOI: 10.1378/chest.06-1366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The purpose of the study was to examine the responsiveness of a computerized system whereby the patient reports spontaneously any change in the intensity of breathlessness during exercise. The hypotheses were that hypercapnia would increase and hyperoxia would decrease the slope of power production-breathlessness ratings compared with a control condition during cycle ergometry. METHODS Thirty adult subjects (15 women and 15 men) with persistent asthma (mean [+/- SD] FEV(1)/FVC ratio, 57 +/- 10%) completed an initial familiarization visit and three study visits. All subjects inhaled two puffs of albuterol (180 microg) in order to standardize lung function prior to exercise. At visits 2 to 4, subjects breathed one of the three gas mixtures administered in a random order while performing a ramp exercise test. The experimental conditions were as follows: hypercapnia (5% carbon dioxide); hyperoxia (40% oxygen); and control (room air). RESULTS Lung function was the same before and after exercise with the three experimental conditions. With hypercapnia, peak ventilation was increased, peak oxygen consumption, and power production were reduced, the slope of power-breathlessness was increased, and 25 patients (83%) reported breathlessness as the limiting symptom. With hyperoxia, peak ventilation was decreased, peak power production and the slope of power-breathlessness were unchanged, and 16 patients (53%) reported leg discomfort as the limiting symptom. CONCLUSIONS Breathing 5% carbon dioxide altered physiologic responses and the slope of power production-breathlessness during exercise. The responses to hyperoxia were inconsistent. The continuous method for patient-reported breathlessness was responsive to hypercapnia, but not to hyperoxia, during incremental exercise.
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Affiliation(s)
- Donald A Mahler
- Section of Pulmonary & Critical Care Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756-0001, USA.
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Bradley JM, Lasserson T, Elborn S, Macmahon J, O'neill B. A systematic review of randomized controlled trials examining the short-term benefit of ambulatory oxygen in COPD. Chest 2007; 131:278-85. [PMID: 17218587 DOI: 10.1378/chest.06-0180] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
AIM To systematically review the short-term efficacy of ambulatory oxygen from single-assessment studies in COPD. METHODS Searches for relevant randomized controlled trials using predefined search terms were conducted on the Cochrane Airways Group Specialized Register of RCTs, the Cochrane Central Register of Controlled Trials, and other electronically available journals, databases, and search engines. All databases were searched from their inception until December 2004. Two reviewers (J.B., B.O.) independently assessed eligibility and extracted data. All trial data were combined using RevMan analyses 4.2.8 (Cochrane Collaboration; www.cochrane.org). Due to the crossover design of the studies, data were entered using the generic inverse variance method. Fixed-effect or random-effect models were used depending on the level of statistical heterogeneity observed. RESULTS Thirty-one studies (33 data sets; 534 participants) met the inclusion criteria of the review. Oxygen improved the primary outcomes relating to endurance and maximal exercise capacity. For the secondary outcomes of breathlessness, arterial oxygen saturation (Sao(2)), and minute ventilation (Ve), comparisons were made at isotime. Oxygen improved breathlessness, Sao(2)/Pao(2), and Ve at isotime with endurance exercise testing. For maximal exercise testing, data were not available in a format suitable for metaanalysis for breathlessness, but the improvement in Sao(2)/Pao(2) and Ve at isotime was significant. CONCLUSION This review provides evidence from single-assessment studies that ambulatory oxygen improves exercise performance in COPD; however, the clinical importance of this size of improvement is unclear. Prior to widespread prescription of ambulatory oxygen, future research is required to establish the net long-term benefit of ambulatory oxygen in patients with different levels of hypoxemia or exercise-induced desaturation.
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Affiliation(s)
- Judy M Bradley
- Department of Respiratory Medicine, Belfast City Hospital, Belfast, Northern Ireland, BT9 7AB.
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Taveira-DaSilva AM, Hathaway OM, Sachdev V, Shizukuda Y, Birdsall CW, Moss J. Pulmonary artery pressure in lymphangioleiomyomatosis: an echocardiographic study. Chest 2007; 132:1573-8. [PMID: 17890459 PMCID: PMC2946895 DOI: 10.1378/chest.07-1205] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Exercise-induced hypoxemia is frequent in patients with lymphangioleiomyomatosis (LAM) and could be associated with pulmonary hypertension. The aims of this study were to determine the prevalence of pulmonary hypertension in patients with LAM, to identify physiologic parameters associated with its occurrence, and to evaluate the effect of oxygen on response to exercise. METHODS Studies were performed in 120 patients. Complete data, including exercise echocardiography, pulmonary function testing, and standard cardiopulmonary exercise testing, were obtained in 95 patients. RESULTS Resting pulmonary artery pressure (PAP) was 26+/-0.7 mm Hg (mean+/-SEM). Eight patients had pulmonary hypertension (43+/-3 mm Hg), and two patients had right ventricular dilatation. Ninety-five patients exercised (room air, n=64; oxygen, n=31) to a power of 58+/-2 W (49% of predicted) and an estimated peak oxygen uptake of 938+/-30 mL/min (56% of predicted). Sixty-one patients had a decline in arterial oxygen saturation (SaO2)>3%, and 56 patients had an elevation in PAP>40 mm Hg. Peak exercise PAP was negatively correlated with exercise Sao2 (p=0.0005). Multivariate analysis showed that exercise SaO2 was the best predictor of exercise PAP (p=0.012). CONCLUSIONS Although resting pulmonary hypertension is rare in patients with LAM, a rise in PAP at low exercise levels occurs frequently, in part related to exercise-induced hypoxemia. Optimization of oxygen administration during activities of daily living should be undertaken in patients with LAM to prevent hypoxemia and exercise-induced pulmonary hypertension.
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Affiliation(s)
- Angelo M Taveira-DaSilva
- Pulmonary-Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10, Room 6D05, MSC 1590, Bethesda, MD 20892-1590, USA.
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Nonoyama ML, Brooks D, Lacasse Y, Guyatt GH, Goldstein RS. Oxygen therapy during exercise training in chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007; 2007:CD005372. [PMID: 17443585 PMCID: PMC8885311 DOI: 10.1002/14651858.cd005372.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Exercise training within the context of pulmonary rehabilitation improves outcomes of exercise capacity, dyspnea and health-related quality of life in individuals with chronic obstructive pulmonary disease (COPD). Supplemental oxygen in comparison to placebo increases exercise capacity in patients performing single-assessment exercise tests. The addition of supplemental oxygen during exercise training may enable individuals with COPD to tolerate higher levels of activity with less exertional symptoms, ultimately improving quality of life. OBJECTIVES To determine how supplemental oxygen in comparison to control (compressed air or room air) during the exercise-training component of a pulmonary rehabilitation program affects exercise capacity, dyspnea and health-related quality of life in individuals with COPD. SEARCH STRATEGY All records in the Cochrane Airways Group Specialized Register of trials coded as 'COPD' were searched using the following terms: (oxygen* or O2*) AND (exercis* or train* or rehabilitat* or fitness* or physical* or activ* or endur* or exert* or walk* or cycle*). Searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE and CINAHL databases identified studies. The last search was carried out in June 2006. SELECTION CRITERIA Only randomized controlled trials (RCTs) comparing oxygen-supplemented exercise training to non-supplemented exercise training (control group) were considered for inclusion. Participants were 18 years or older, diagnosed with COPD and did not meet criteria for long-term oxygen therapy. No studies with mixed populations (pulmonary fibrosis, cystic fibrosis, etc) were included. Exercise training was greater than or equal to three weeks in duration and included a minimum of two sessions a week. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion in the review and extracted data. Weighted mean differences (WMD) with 95% confidence intervals (CI) were calculated using a random-effects model. Missing data were requested from authors of primary studies. MAIN RESULTS Five RCTs met the inclusion criteria. The maximum number of studies compared in the meta-analysis was three (31 on oxygen versus 32 control participants), because all included studies did not measure the same outcomes. When two studies were pooled, statistically significant improvements of oxygen-supplemented exercise training were found in constant power exercise time, WMD 2.68 minutes (95% CI 0.07 to 5.28 minutes). Supplemental oxygen increased the average exercise time from 6 to 14 minutes; the control intervention increased average exercise time from 6 to 12 minutes. Constant power exercise end-of-test Borg score (on a scale from 1 to 10) also showed statistically significant improvements with oxygen-supplemented exercise training, WMD -1.22 units (95% CI -2.39 to -0.06). One study showed a significant improvement in the change of Borg score after the shuttle walk test, by -1.46 units (95% CI -2.72 to -0.19). There were no significant differences in maximal exercise outcomes, functional exercise outcomes (six-minute walk test), shuttle walk distance, health-related quality of life or oxygenation status. According to the GRADE system most outcomes were rated as low quality because they were limited by study quality. AUTHORS' CONCLUSIONS This review provides little support for oxygen supplementation during exercise training for individuals with COPD, but the evidence is very limited. Studies with larger number of participants and strong design are required to permit strong conclusions, especially for functional outcomes such as symptom alleviation, health-related quality of life and ambulation.
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Affiliation(s)
- M L Nonoyama
- West Park Healthcare Centre, Graduate Department of Rehabilitation Science, 82 Buttonwood Avenue, Toronto, Ontario, Canada, M6M 2J5.
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Ozalevli S, Ozden A, Gocen Z, Cimrin AH. Comparison of six-minute walking tests conducted with and without supplemental oxygen in patients with chronic obstructive pulmonary disease and exercise-induced oxygen desaturation. Ann Saudi Med 2007; 27:94-100. [PMID: 17356317 PMCID: PMC6077033 DOI: 10.5144/0256-4947.2007.94] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There are contradictory reports in the literature on the effects of supplemental oxygen administered before or after exercise tests. In light of this, we compared the results of 6-minute walking tests performed in room-air conditions (A6MWT) and with supplemental oxygen (O6MWT) in patients with chronic obstructive pulmonary disease (COPD) and exercise-induced oxygen desaturation. PATIENTS AND METHODS Thirty-one patients with COPD were included in the study. The A6MWT and O6MWT were performed in randomized order on each patient. During the tests, severity of dyspnea and tiring of the leg were evaluated by the Modified Borg Scale. Heart rate and pulsed oxygen saturation and blood pressure were measured by pulse oximeter. RESULTS Walking distance was longer with the O6MWT than with the A6MWT (P=0.001). The O6MWT resulted in a smaller increase in dyspnea, leg fatigue, and heart rate and a smaller drop in pulsed saturation than the A6MWT (P<0.05). The walking distance with the O6MWT correlated with respiratory function and hemodynamic parameters (P<0.05). CONCLUSION The O6MWT, which produced less hemodynamic stress and was safer than the A6MWT, might provide more accurate information on exercise limitation for patients with COPD. These results suggest that the O6MWT can be used as a standard walking exercise test for patients with COPD and exercise-induced oxygen desaturation.
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Affiliation(s)
- Sevgi Ozalevli
- Doluz Eylul University, School of Physical Therapy and Rehabillitation, Izmir, Turkey.
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Abstract
Dyspnea is a nonspecific symptom of any disease involving the respiratory system. Although diseases of the lungs, chest wall, pleura, diaphragm, upper airway, and heart are most common, diseases of many other organ systems (eg, neuromuscular, skeletal, renal, endocrine, rheumatologic, hematologic, and psychiatric) may involve the respiratory system and present with dyspnea. Dyspnea should be evaluated systematically, and a thorough history and physical examination and baseline tests of heart and lung function are necessary to establish a complete database. More sophisticated testing may be needed when the cause is not readily apparent from the initial work-up. Treatment is best and most effective when geared toward a specific etiology, but if this is not possible, nonspecific treatment of the symptom pf dyspnea may afford the patient some benefit.
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Affiliation(s)
- Saiyad Sarkar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, 10 N. Greene Street 3D-122, Baltimore, MD 21201, USA
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Spruit MA, Wouters EFM. New Modalities of Pulmonary Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease. Sports Med 2007; 37:501-18. [PMID: 17503876 DOI: 10.2165/00007256-200737060-00004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Pulmonary rehabilitation has been shown to be an important part of the management of patients with chronic obstructive pulmonary disease (COPD). Exercise training is the corner stone of a comprehensive, multidisciplinary pulmonary rehabilitation in COPD and has been shown to improve health-related quality of life and exercise capacity. Nevertheless, not every COPD patient responds well to pulmonary rehabilitation. Future trials should focus on new additions to conventional pulmonary rehabilitation programmes to optimise its effects on health-related quality of life, exercise capacity, body composition and muscle function in patients with COPD. Therefore, a patient-tailored approach is inevitable. Advantages and disadvantages of new modalities of pulmonary rehabilitation will be outlined in detail, including the following: endurance training and long-acting bronchodilatators; endurance training and technical modalities (inspiratory pressure support and inspiratory muscle training); interval training; resistance training; transcutaneous neuromuscular electrical stimulation; and exercise training and supplements (oxygen, oral creatine, anabolic steroids and polyunsaturated fatty acids). Based on well defined baseline characteristics, patients should most probably be individually selected. At present, these new modalities of pulmonary rehabilitation have been shown to improve body composition, skeletal muscle function and sometimes also exercise capacity. However, the translation to an improved health-related quality of life is mostly lacking, and cost effectiveness and long-term effects have not been studied. Moreover, future trials should study the effects of pulmonary rehabilitation in elderly patients with restrictive pulmonary diseases.
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Affiliation(s)
- Martijn A Spruit
- Department of Research Development and Education, Centre for Integrated Rehabilitation of Organ Failure, Horn, The Netherlands.
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Eves ND, Petersen SR, Haykowsky MJ, Wong EY, Jones RL. Helium-Hyperoxia, Exercise, and Respiratory Mechanics in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2006; 174:763-71. [PMID: 16840742 DOI: 10.1164/rccm.200509-1533oc] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Hyperoxia and normoxic helium independently reduce dynamic hyperinflation and improve the exercise tolerance of patients with chronic obstructive pulmonary disease (COPD). Combining these gases could have an additive effect on dynamic hyperinflation and a greater impact on respiratory mechanics and exercise tolerance. OBJECTIVE To investigate whether helium-hyperoxia improves the exercise tolerance and respiratory mechanics of patients with COPD. METHODS Ten males with COPD (FEV(1) = 47 +/- 17%pred [mean +/- SD]) performed randomized constant-load cycling at 60% of maximal work rate breathing air, hyperoxia (40% O(2), 60% N(2)), normoxic helium (21% O(2), 79% He), or helium-hyperoxia (40% O(2), 60% He). MEASUREMENTS Exercise time, inspiratory capacity (IC), work of breathing, and exertional symptoms were measured with each gas. RESULTS Compared with air (9.4 +/- 5.2 min), exercise time was increased with hyperoxia (17.8 +/- 5.8 min) and normoxic helium (16.7 +/- 9.1 min) but the improvement with helium-hyperoxia (26.3 +/- 10.6 min) was greater than both these gases (p = 0.019 and p = 0.007, respectively). At an isotime during exercise, all three gases reduced dyspnea and both helium mixtures increased IC and tidal volume. Only helium-hyperoxia significantly reduced the resistive work of breathing (15.8 +/- 4.2 vs. 10.1 +/- 4.1 L . cm H(2)O(-1)) and the work to overcome intrinsic positive end-expiratory pressure (7.7 +/- 1.9 vs. 3.6 +/- 2.1 L . cm H(2)O(-1)). At symptom limitation, tidal volume remained augmented with both helium mixtures, but IC and the work of breathing were unchanged compared with air. CONCLUSION Combining helium and hyperoxia delays dynamic hyperinflation and improves respiratory mechanics, which translates into added improvements in exercise tolerance for patients with COPD.
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Affiliation(s)
- Neil D Eves
- Rehabilitation Medicine, University of Calgary, Calgary, AB, Canada T2N 1N4.
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Chuang ML, Lin IF, Vintch JRE, Ho BSJ, Chao SW, Ker JJW. Significant exercise-induced hypoxaemia with equivocal desaturation in patients with chronic obstructive pulmonary disease. Intern Med J 2006; 36:294-301. [PMID: 16650194 DOI: 10.1111/j.1445-5994.2006.01069.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The wide 95% confidence interval for S(a)O2 measured by pulse oximetry (S(P)O2) and the inherent characteristics of the oxyhaemoglobin dissociation curve can lead to modest but significant decreases in P(a)O2 (deltaP(a)O2 > or = 5 mmHg) that may be under-appreciated. AIM To avoid missing potentially significant deltaP(a)O2 by using S(P)O2, this study establishes a threshold of deltaS(P)O2 to detect deltaP(a)O2 by examining the correlation between deltaS(P)O2 and deltaP(a)O2. METHODS We enrolled 29 elderly patients with moderate to severe chronic obstructive pulmonary disease as assessed by lung function testing. Arterial blood gases and S(P)O2 measurements were carried out during maximal exercise testing. The patients were assigned to groups based on P(a)O2 measurements: group 1 had P(a)O2 at peak exercise (P(a)O2peak) > or = 60 mmHg without a deltaP(a)O2; group 2 had P(a)O2peak > or = 60 mmHg with a deltaP(a)O2; group 3 had P(a)O2peak < 60 mmHg without a deltaP(a)O2; and group 4 had P(a)O2peak < 60 mmHg with a deltaP(a)O2. RESULTS The study population was evenly distributed between groups 1, 2 and 4. However, group 3 did not have any patients enrolled in this study that met group 3 criteria. The sensitivity of pulse oximetry required to detect S(a)O2 below 90% was 19%. DeltaS(P)O2 of 3% may increase the low sensitivity of S(P)O2 and was shown by a 92% positive predictive value for deltaP(a)O2 > or = 5 mmHg. CONCLUSION This study suggests that important changes in oxygenation may be avoided if using deltaS(P)O2 rather than absolute values of S(P)O2 in patients with chronic obstructive pulmonary disease undergoing exercise testing to detect exercise-induced hypoxaemia.
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Affiliation(s)
- M-L Chuang
- Division of Pulmonary and Critical Care Medicine, Buddhist Taipei Tzu Chi General Hospital, Xindian City, Taiwan, ROC.
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O'Neill B, Mahon JM, Bradley J. Short-burst oxygen therapy in chronic obstructive pulmonary disease. Respir Med 2006; 100:1129-38. [PMID: 16737805 DOI: 10.1016/j.rmed.2006.03.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Revised: 03/20/2006] [Accepted: 03/31/2006] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Despite widespread prescription, the efficacy of short-burst oxygen therapy has not been established. AIM To systematically review the available evidence for short-burst oxygen therapy in patients with chronic obstructive pulmonary disease (COPD). METHOD Retrieval of randomized-controlled trials comparing short-burst oxygen (oxygen for breathlessness at rest, before exercise and after exercise) with placebo in patients with COPD. Data were extracted and, where possible, outcome measures were combined using RevMan analyses 4.2. The methodological quality of each trial was assessed using the PEDro scale. RESULTS Studies differed in the type of exercise test used, the amount of oxygen delivered and in the length of time for pre- or post-dosing. Quality of the included studies as rated by the PEDro scale was good. For many outcome measures, data could not be pooled for meta-analysis. Short-burst oxygen is primarily indicated for the symptomatic relief of breathlessness, and the bulk of evidence from this review suggests that short-burst oxygen therapy does not reduce breathlessness. For secondary outcome measures (exercise capacity, oxygen saturation [SaO(2)], other ventilatory parameters), the results are not consistent. CONCLUSION The studies in this review suggest that the widespread prescription of short-burst oxygen is not evidence-based. If prescription is to continue, the scientific rationale for short-burst oxygen therapy must be established.
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Affiliation(s)
- Brenda O'Neill
- Health and Rehabilitation Research Institute, School of Health Sciences, University of Ulster, Shore Rd Newtownabbey, Co Antrim, BT37 OQB, Northern Ireland.
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Zhu Z, Barnette RK, Fussell KM, Michael Rodriguez R, Canonico A, Light RW. Continuous oxygen monitoring--a better way to prescribe long-term oxygen therapy. Respir Med 2006; 99:1386-92. [PMID: 15878655 DOI: 10.1016/j.rmed.2005.03.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Accepted: 03/09/2005] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE The purpose of this study was to determine if an oxygen prescription based on continuous oximetry monitoring, would result in an increased percentage of time spent within an SpO2 level between 88% and 92%. METHODS We conducted a prospective, cohort study in an outpatient, pulmonary setting in a tertiary care referral center, on 17 patients with stable chronic obstructive pulmonary disease (COPD) who had previously been prescribed long-term oxygen therapy. The patients were monitored for approximately 24h with a portable oximeter that recorded SpO2 and EKG readings. During the initial 24h of monitoring, the patients were on their previous oxygen prescription. Their oxygen prescription was then altered based on a predetermined protocol described below. The patients were then monitored for an additional 24h. RESULTS Sixteen patients completed the study. Based on the initial continuous oximetry, the median oxygen prescription was reduced from 2.5 to 1.2 L/min (P < 0.001). The oxygen prescription during exercise, rest, and sleep decreased from 3.0 +/- 0.9 to 1.8 +/- 1.3 L/min (P < 0.001), 2.2+/-0.4 to 0.8 +/- 0.7 L/min (P < 0.001), and 2.2 +/- 0.4 to 0.9 +/- 0.8 L/min (P < 0.001) respectively. After the oxygen prescription was adjusted, the percentage of the time that the SpO2 was between 88 and 92% increased from 24.8 +/- 21.7% to 52.8 +/- 25.0% (P = 0.001), but the percentage of time that the SpO2 was below 88% did not change significantly (2.8 +/- 6.1% to 4.3 +/- 8.1%). CONCLUSIONS This study demonstrates that an oxygen prescription based on continuous oximetry monitoring results in (1) a significant increase in the percentage of time that the SpO2 is between 88% and 92%, (2) a significant decrease in the amount of oxygen prescribed, (3) a slight increase in the amount of time that the SpO2 is below 88% that was not statistically significant.
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Affiliation(s)
- Zhiwen Zhu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
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O'Neill B, Dodd ME. Oxygen on the move: practical considerations for physiotherapists. PHYSICAL THERAPY REVIEWS 2006. [DOI: 10.1179/108331906x98903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Peters MM, Webb KA, O'Donnell DE. Combined physiological effects of bronchodilators and hyperoxia on exertional dyspnoea in normoxic COPD. Thorax 2006; 61:559-67. [PMID: 16467067 PMCID: PMC2104668 DOI: 10.1136/thx.2005.053470] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Studies examining the physiological interactions of oxygen (O(2)) and bronchodilators (BD) during exercise in chronic obstructive pulmonary disease (COPD) should provide new insights into mechanisms of exercise intolerance. We examined the effects of O(2) and BD, alone and in combination, on dyspnoea, ventilation (e), breathing pattern, operating lung volumes, and exercise endurance. METHODS In a randomised, double blind, crossover study, 16 patients with COPD (mean (SE) FEV(1) 43(3)% predicted) performed pulmonary function tests and an incremental exercise test, then completed four visits in which they received either nebulised BD (ipratropium 0.5 mg + salbutamol 2.5 mg) or placebo (PL) with either 50% O(2) or room air (RA). After 90-105 minutes the patients performed pulmonary function tests, then breathed RA or O(2) during symptom limited constant load exercise at 75% peak work rate. RESULTS With BD the mean (SE) increase in inspiratory capacity (IC) was 0.3 (0.1) l (p<0.05) at rest and during exercise, permitting greater tidal volume (Vt) expansion during exercise and a greater peak e. With O(2), e decreased during exercise as a result of decreased breathing frequency (F), with no significant change in IC. During exercise with BD+O(2), IC and Vt increased, F decreased, and e did not change. Dyspnoea decreased with all interventions at a standardised time during exercise compared with PL+RA (p<0.05). Endurance time was significantly (p<0.05) greater with BD+O(2) (10.4 (1.6) min) than with O(2) (8.5 (1.4) min), BD (7.1 (1.3) min) and PL+RA (5.4 (0.9) min). CONCLUSION By combining the benefits of BD (reduced hyperinflation) and O(2) (reduced ventilatory drive), additive effects on exercise endurance were observed in patients with normoxic COPD.
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Affiliation(s)
- M M Peters
- Department of Medicine, Respiratory Investigation Unit, Queen's University, Kingston, Ontario, Canada
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O'Neill B, Bradley JM, McKevitt AM, Bradbury I, Riley M, Macmahon J. Do patients prescribed short-burst oxygen therapy meet criteria for ambulatory oxygen? Int J Clin Pract 2006; 60:146-9. [PMID: 16451284 DOI: 10.1111/j.1742-1241.2006.00762.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to determine whether patients (n = 40) with chronic obstructive pulmonary disease (COPD) currently receiving short-burst oxygen therapy meet existing criteria for ambulatory oxygen. A prospective randomised balanced double-blind crossover design was used. Criterion (i) for ambulatory oxygen (desaturation by 4% to below 90% on the practice walk) was met in 21 patients; 15 of these 21 patients also met criterion (ii) (10% improvement in distance and/or breathlessness score with oxygen). Despite no evidence of desaturation in 19/40 patients, 9/19 improved their distance and/or breathlessness score with oxygen. This study has shown that many patients on short-burst oxygen meet existing criteria for ambulatory oxygen and may have been receiving suboptimal therapy. It supports recent proposals for the development of comprehensive assessment services which incorporate assessment for all categories of oxygen.
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Affiliation(s)
- B O'Neill
- Health and Rehabilitation Sciences Research Institute, University of Ulster, Northern Ireland.
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