A new perspective on COPD exacerbations: monitoring impact by measuring physical, psychological and social resilience

Short-term effects of home-based pulmonary rehabilitation during outpatient-managed exacerbations of COPD: a randomised controlled trial

BACKGROUND

Uncertainty exists about the beneficial effects of delivering pulmonary rehabilitation (PR) during exacerbations of chronic obstructive pulmonary disease (ECOPD). This study explored the short-term effects and self-reported impact of a home-based PR programme for people with outpatient-managed ECOPD.

METHODS

We conducted a mixed-methods randomised controlled trial in people with outpatient-managed ECOPD. Participants were randomly assigned to the control (CG, ie, usual care) or experimental (EG, ie, usual care and 3-week home-based PR) group within 48 hours of the diagnosis (baseline). Assessments were performed at baseline and after 3 weeks (post). The COPD assessment test (CAT) was the primary outcome. Secondary outcomes included measures of symptoms and functional capacity. After PR, interviews were conducted. Analyses were performed using (non-)parametric mixed analysis of variance, deductive thematic analysis and narrative integration through joint displays.

RESULTS

Fifty participants with outpatient-managed ECOPD (78% men, 70±11 years, forced expiratory volume in one second 47.4±16.4% pred) were included. Significant greater improvements in the EG compared with the CG were found for the CAT (EG Δ-12.5±7.2 vs CG Δ-5.9±7.2, p=0.002) and 12 of 13 other secondary outcome measures. A positive self-perceived impact of PR was found on symptoms, control of daily life, health, mental status and empowerment. No adverse events were reported.

CONCLUSIONS

A 3-week home-based PR programme is safe, meaningful and more effective than just standard medication in improving symptoms, functional capacity and health status, outcomes often associated with poor prognosis. This highlights the role of PR in improving the recovery process during outpatient-managed ECOPD and might contribute to a better prognosis in these individuals.

TRIAL REGISTRATION

NCT03751670.

Predictive Value of Physiological Values and Symptom Scores for Exacerbations in Bronchiectasis and Chronic Obstructive Pulmonary Disease With Frequent Exacerbations: Longitudinal Observational Cohort Study

BACKGROUND

COPD (chronic obstructive pulmonary disease) and bronchiectasis are common, and exacerbations contribute to their morbidity and mortality. Predictive factors for the frequency of future exacerbations include previous exacerbation frequency and airway colonization. Earlier treatment of exacerbations is likely to reduce severity.

OBJECTIVE

This study tested the hypothesis that, in a population with bronchiectasis, COPD, or both who have frequent exacerbations and airway colonization, changes in symptom scores or physiological variables within 10 days prior to an exacerbation would allow the prediction of the event.

METHODS

We performed a 6-month, longitudinal, observational, cohort study among 30 participants with bronchiectasis, COPD, or both; at least 2 exacerbations per year; and colonization with Pseudomonas aeruginosa or Haemophilus influenzae. Daily symptom and physiological data were collected, comprising pulse rate, blood pressure, oxygen saturation, peak flow rate, step count, weight, and temperature. Exacerbations (defined as the onset of new antibiotic use for respiratory symptoms) were collected, and predictive values for abnormal values in the 10 days prior to an exacerbation were calculated.

RESULTS

A total of 30 participants were recruited, collecting a total of 39,534 physiological and 25,334 symptom data points across 5358 participant-days; these included 78 exacerbations across 27 participants, with the remaining 3 participants not having exacerbations within the 6-month observation period. Peak flow rate, oxygen saturation, and weight were significantly different at the point of exacerbation (all P<.001), but no significant trends around exacerbation were noted and no clinically beneficial predictive value was found in the overall or individually adjusted model. Symptom scores tended to worsen for 10 days on either side of an exacerbation but were of insufficient magnitude for prediction, with area under the receiver operating characteristic curve values of ranging from 0.4 to 0.6.

CONCLUSIONS

Within this small cohort with bronchiectasis, COPD, or both and airway colonization, physiological and symptom variables did not show sufficient predictive value for exacerbations to be of clinical utility. The self-management education provided as standard of care may be superior to either of these approaches, but benefit in another or larger cohort cannot be excluded.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.6636.

Phenotypes, Etiotypes, and Endotypes of Exacerbations of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease is a major health problem with a high prevalence, a rising incidence, and substantial morbidity and mortality. Its course is punctuated by acute episodes of increased respiratory symptoms, termed exacerbations of chronic obstructive pulmonary disease (ECOPD). ECOPD are important events in the natural history of the disease, as they are associated with lung function decline and prolonged negative effects on quality of life. The present-day therapy for ECOPD with short courses of antibiotics and steroids and escalation of bronchodilators has resulted in only modest improvements in outcomes. Recent data indicate that ECOPD are heterogeneous, raising the need to identify distinct etioendophenotypes, incorporating traits of the acute event and of patients who experience recurrent events, to develop novel and targeted therapies. These characterizations can provide a complete clinical picture, the severity of which will dictate acute pharmacological treatment, and may also indicate whether a change in maintenance therapy is needed to reduce the risk of future exacerbations. In this review we discuss the latest knowledge of ECOPD types on the basis of clinical presentation, etiology, natural history, frequency, severity, and biomarkers in an attempt to characterize these events.

Impact of acute exacerbations of COPD on patients' health status beyond pulmonary function: A scoping review

This scoping review summarized the evidence regarding the impact of acute exacerbations of COPD (AECOPD) on patients' health status beyond pulmonary function. PubMed, Embase, and Web of Science were searched. Prospective cohort studies assessing the health status of patients with COPD in a stable phase of the disease and after a follow-up period (where at least one AECOPD occurred) were included. An integrated assessment framework of health status (i.e., physiological functioning, complaints, functional impairment, quality of life) was used. Twenty-two studies were included. AECOPD acutely affected exercise tolerance, quadriceps muscle strength, physical activity levels, symptoms of dyspnoea and fatigue, and impact of the disease. Long-term effects on quadriceps muscle strength, symptoms of dyspnoea and depression, and quality of life were found. Repeated exacerbations negatively impacted the fat-free mass, levels of dyspnoea, impact of the disease and quality of life. Conflicting evidence was found regarding the impact of repeated exacerbations on exercise tolerance and physical activity levels. AECOPD have well-established acute and long-term adverse effects on health status beyond pulmonary function; nevertheless, the recovery trajectory and the impact of repeated exacerbations are still poorly studied. Further prospective research is recommended to draw firm conclusions on these aspects.

Change in physical activity related to admission for exacerbation in COPD patients

INTRODUCTION

The aim of this study was to determine the impact of hospitalizations on levels of physical activity (PA) and whether other factors were associated with subsequent changes in PA.

METHODS

Prospective observational cohort study with a nested case-control study, with follow-up 60 days from the index hospital admission. Nine hospitals participated in the study. Patients were recruited consecutively. Several variables and questionnaires of the clinical baseline status of the patients were recorded including: the COPD Assessment Test (CAT), the Hospital Anxiety-Depression scale (HADS), comorbidities and the Yale Physical Activity Survey. Patients' data related to admission and up to two months after discharge were also recorded.

RESULTS

883 patients were studied: 79.7% male; FEV1 48%; Charlson index 2; 28.7% active smokers. The baseline PA level for the total sample was 23 points. A statistically significant difference in PA was found between patients readmitted up to 2 months after the index admission and those not readmitted (17vs. 27, p < 0.0001). Multivariable linear regression analysis identified the following as predictors of the decrease of PA from baseline (index admission) up to 2 months follow-up: admission for COPD exacerbation in the two months prior to the index admission; readmission up to 2 months after the index admission; baseline HAD depressive symptoms, worse CAT score, and patient-reported "need for help".

CONCLUSIONS

In a cohort of admitted COPD patients, we identified a strong relationship between hospitalization for exacerbation and PA. In addition, some other potentially modifiable factors were found associated with the change in PA level after an admission.

Next Generation Health Claims Based on Resilience: The Example of Whole-Grain Wheat

Health claims on foods are a way of informing consumers about the health benefits of a food product. Traditionally, these claims are based on scientific evaluation of markers originating from a pharmacological view on health. About a decade ago, the definition of health has been rephrased to 'the ability to adapt' that opened up the possibility for a next generation of health claims based on a new way of quantifying health by evaluating resilience. Here, we would like to introduce an opportunity for future scientific substantiation of health claims on food products by using whole-grain wheat as an example. Characterization of the individual whole wheat grain food product or whole wheat flour would probably be considered as sufficiently characterized by the European Food Safety Authority, while the food category whole grain is not specific enough. Meta-analysis provides the scientific evidence that long-term whole-grain wheat consumption is beneficial for health, although results from single 'gold standard' efficacy studies are not always straight forward based on classic measurement methods. Future studies may want to underpin the scientific argumentation that long-term whole grain wheat consumption improves resilience, by evaluating the disruption and rate of a selected panel of blood markers in response to a standardized oral protein glucose lipid tolerance test and aggregated into biomarkers with substantiated physiological benefits, to make a next-generation health claim for whole-grain wheat achievable in the near future.

Survey of Exercise Prescription in US Pulmonary Rehabilitation Programs

PURPOSE

Pulmonary rehabilitation (PR) is the standard of care for chronic, symptomatic lung disease. Current scientific and clinical guidelines recommend PR to improve dyspnea, functional capacity, and quality of life. Several PR guidelines provide recommendations about the mode, intensity, duration, frequency, and progression of exercise-based interventions. There are variations in the components of PR exercise prescription that may influence the response to PR, as well as variations in how the exercise prescription and its components are determined and monitored. Therefore, the purpose of this investigation was to identify current PR exercise prescription practices via survey sent to 1758 PR programs in the United States.

METHODS

The American Association of Cardiovascular and Pulmonary Rehabilitation administered surveys in 2013 and 2016 to US-based PR providers.

RESULTS

Responses were returned from 371 PR providers (vs 380 in 2013). There was an increase in responses for all options describing exercise prescription methodology in the 2016 survey, with each element (frequency, intensity, time [duration], and type [mode]; FITT) demonstrating significant increase in use. There was a significant increase in 3 methods of determining exercise goals in 2016 versus 2013: duration (P = .017), distance (P = .010), and metabolic equivalents of task (P ≤ .001).

CONCLUSIONS

The 2016 survey responses show a greater use of guideline-based exercise prescription methodology, with an increase in use of FITT methodology for exercise prescription.

Mood Monitoring Over One Year for People With Chronic Obstructive Pulmonary Disease Using a Mobile Health System: Retrospective Analysis of a Randomized Controlled Trial

Background

Comorbid anxiety and depression can add to the complexity of managing treatment for people living with chronic obstructive pulmonary disease (COPD). Monitoring mood has the potential to identify individuals who might benefit from additional support and treatment.

Objective

We used data from the sElf-management anD support proGrammE (EDGE) trial to examine: (1) the extent to which the mood-monitoring components of a mobile health system for patients with COPD were used by participants; (2) the levels of anxiety and depression symptoms among study participants; (3) the extent to which videos providing advice about coping with low mood were viewed; and (4) the characteristics of participants with differing levels of mood and utilization of mood monitoring.

Methods

A total of 107 men and women with a clinical diagnosis of COPD, aged ≥40 years old, were recruited to the intervention arm of the EDGE trial. Participants were invited to complete the Patient Health Questionnaire-8 and the Generalized Anxiety Disorder-7 test every four weeks using a tablet computer. Mood disturbance based on these measures was defined as a score ≥5 on either scale. Participants reporting a mood disturbance were automatically directed (signposted) to a stress or mood management video. Study outcomes included measures of health status, respiratory quality of life, and symptoms of anxiety and depression.

Results

Overall, 94 (87.9%) participants completed the 12-month study. A total of 80 participants entered at least one response each month for at least ten months. On average, 16 participants (range 8-38 participants) entered ≥2 responses each month. Of all the participants, 47 (50%) gave responses indicating a mood disturbance. Participants with a mood disturbance score for both scales (n=47) compared with those without (n=20) had lower health status (P=.008), lower quality of life (P=.009), and greater anxiety (P<.001) and increased depression symptoms (P<.001). Videos were viewed by 64 (68%) people over 12 months. Of the 220 viewing visualizations, 70 (34.7%) began after being signposted. Participants signposted to the stress management video (100%; IQR 23.3-100%) watched a greater proportion of it compared to those not signposted (38.4%; IQR 16.0-68.1%; P=.03), whereas duration of viewing was not significantly different for the mood management video.

Conclusions

Monitoring of anxiety and depression symptoms for people with COPD is feasible. More than half of trial participants reported scores indicating a mood disturbance during the study. Signposting participants to an advisory video when reporting increased symptoms of a mood disturbance resulted in a longer view-time for the stress management video. The opportunity to elicit measures of mood regularly as part of a health monitoring system could contribute to better care for people with COPD.

Integrated Brief Cognitive Behavioral Therapy Improves Illness Intrusiveness in Veterans With Chronic Obstructive Pulmonary Disease

Background

Progressive illnesses such as chronic obstructive pulmonary disease (COPD) impart a high level of physical and psychological burden. Evidence-based psychotherapies hold the potential to improve perceptions of physical health impairment, yet few studies have documented these effects.

Purpose

To evaluate the effect of brief cognitive behavioral therapy (bCBT) on disease-related illness intrusiveness.

Methods

Participants were 175 Veterans with COPD and clinically elevated symptoms of depression and/or anxiety enrolled in a larger randomized trial (n = 99 randomized to bCBT, n = 76 to enhanced usual care; EUC). bCBT included up to six treatment sessions and optional booster sessions over a 4-month period. EUC entailed an assessment with documentation in the medical record. Primary outcomes focused on posttreatment changes on the Illness Intrusiveness Rating Scale (IIRS), an established measure of perceived impairment from a chronic health condition.

Results

Illness intrusiveness improved for bCBT participants relative to EUC, after controlling for baseline IIRS scores, depression, and anxiety (p = .03, partial η2 = .03). Specific improvement was observed in the Instrumental subscale (p = .02), encompassing improved intrusiveness of COPD on daily activities and daily functioning. IIRS scores improved in the absence of changes in physical functioning.

Conclusions

Illness intrusiveness was high among Veterans with COPD but improved over the course of bCBT. Integrated behavioral health interventions hold the potential to reduce disease intrusiveness. The IIRS may be a valuable tool to augment traditional assessment and measurement-based care approaches of behavioral health interventions for medically ill patients.

The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care

The new COPD-GRIP (Chronic Obstructive Pulmonary Disease - Guidance, Research on Illness Perception) intervention translates evidence regarding illness perceptions and health-related quality of life (HRQoL) into a nurse intervention to guide COPD patients and to improve health outcomes. It describes how to assess and discuss illness perceptions in a structured way. This study aimed to assess the effectiveness of the intervention in primary care. A cluster randomised controlled trial was conducted within 30 general practices and five home-care centres, including 204 COPD patients. 103 patients were randomly assigned to the intervention group and 101 patients to the usual-care group. To assess differences, repeated multilevel linear mixed modelling analyses were used. Primary outcome was change in health status on the Clinical COPD Questionnaire (CCQ) at 9 months. Secondary outcomes were HRQoL, daily activities, health education impact and changes in illness perceptions. There was no significant difference between the groups in the CCQ at 9 months. We found a significant increase in health-directed behaviour at 6 weeks (p=0.024) and in personal control (p=0.005) at 9 months in favour of the intervention group. The COPD-GRIP intervention, practised by nurses, did not improve health status in COPD patients in primary care. However, the intervention has benefits in improving the ability to control the disease and health-related behaviours in the short term. Therefore, taking illness perceptions into account when stimulating healthy behaviours in COPD patients should be considered. Further study on influencing the health status and HRQoL is needed.

Factors influencing exacerbation-related self-management in patients with COPD: a qualitative study

BACKGROUND

In patients with COPD, self-management skills are important to reduce the impact of exacerbations. However, both detection and adequate response to exacerbations appear to be difficult for some patients. Little is known about the underlying process of exacerbation-related self-management. Therefore, the objective of this study was to identify and explain the underlying process of exacerbation-related self-management behavior.

METHODS

A qualitative study using semi-structured in-depth interviews was performed according to the grounded theory approach, following a cyclic process in which data collection and data analysis alternated. Fifteen patients (male n=8; age range 59-88 years) with mild to very severe COPD were recruited from primary and secondary care settings in the Netherlands, in 2015.

RESULTS

Several patterns in exacerbation-related self-management behavior were identified, and a conceptual model describing factors influencing exacerbation-related self-management was developed. Acceptance, knowledge, experiences with exacerbations, perceived severity of symptoms and social support were important factors influencing exacerbation-related self-management. Specific factors influencing recognition of exacerbations were heterogeneity of exacerbations and habituation to symptoms. Feelings of fear, perceived influence on exacerbation course, patient beliefs, ambivalence toward treatment, trust in health care providers and self-empowerment were identified as specific factors influencing self-management actions.

CONCLUSION

This study provided insight into factors influencing exacerbation-related self-management behavior in COPD patients. The conceptual model can be used as a framework for health care professionals providing self-management support. In the development of future self-management interventions, factors influencing the process of exacerbation-related self-management should be taken into account.