Intensive long-term pulmonary rehabilitation program after oesophagectomy, a reflection

UK COPD treatment: failing to progress

Health status is one of the most important outcome measures to evaluate the effects of integrated care of patients with mild to very severe chronic obstructive pulmonary disease (COPD). Indeed, to improve the health status of patients with COPD has been set as one of the main goals of effective COPD management. Pharmacological treatment has been shown to reduce the deterioration of health status over time in COPD, in comparison with placebo treatment. Nevertheless, health status appears to decrease over time even though COPD patients did receive pharmacological treatments for their respiratory symptoms. Indeed, patients with COPD suffer from multiple extrapulmonary features, which in turn may result in a reduced health status. The present review will summarize the effects of pulmonary rehabilitation, nutritional interventions and of surgical interventions on the health status in the patients with COPD. Based on the present review of the literature, the authors conclude that besides optimal pharmacological interventions, management of COPD has to consist of non-pharmacological treatments, which has been shown to positively influence patients health status. In particular, pulmonary rehabilitation programs have been shown to have positive short-term effects on health status in COPD. Keywords: Pulmonary rehabilitation, nutritional interventions, lung transplantation, lung volume reduction surgery, respiratory questionnaires

Pulmonary Rehabilitation in Patients Undergoing Lung-Volume Reduction Surgery

Pulmonary rehabilitation (PR) is a core component of the management of patients with chronic obstructive pulmonary disease (COPD). Although several types of PR programs are implemented for patients with COPD on the basis of patient preferences or clinical protocols, the clinical efficiencies of these programs may vary, with each program having its own unique purpose, procedures, benefits, challenges, and effectiveness. The aim of this study was to compare the effects of self-management and hospital-based PR programs in COPD patients. This study was prospective intervention research. Fifty-eight patients with stable COPD were randomly allocated to a hospital-based outpatient group and a self-management group before commencement of a 12-week PR program. Before and after the PR program, all patients were evaluated using the 6-min walk test, Modified Borg Scale, St. George's Respiratory Questionnaire, State-Trait Anxiety Inventory, and Standardized Mini-Mental Test. Pulmonary functions, dyspnea, quality of life, and 6MWT distance were significantly improvement the hospital-based PR than self-management PR (P < 0.05). Moreover, cognitive function significantly improved after the PR program in both groups with no significant intergroup difference (P > 0.05). Our findings suggest that PR is useful for to improvement functional capacity, quality of life, cognitive function and anxiety, in patients with COPD. A hospital-based PR is more effective than a self-management PR program.

Chronic respiratory diseases are among the most important causes of morbidity and mortality worldwide. According to the Global Burden of Disease Study 2017, chronic obstructive pulmonary disease (COPD) was the third leading cause of global disability-adjusted life-years (DALY) among non-communicable diseases, with an increase of 13.5% over the last decade.1 Asthma is associated with a high burden of disease and substantial economic and societal impact.2 Interstitial lung diseases (ILD) represent a heterogeneous group of chronic and often progressive lung conditions, with limited response to pharmacotherapy, increasing disability and incremental healthcare utilization.3 Despite advances in pharmacological treatments for these and other chronic respiratory diseases, a large proportion of patients remain symptomatic and suffer from frequent exacerbations and hospitalizations, and the course of these diseases cannot be reversed. In addition, chronic respiratory diseases are characterized by extra-pulmonary features, and many patients suffer from comorbidities.4-6 In addition to smoking, physical inactivity is a well-recognized disadvantageous lifestyle factor contributing to disease progression, impaired health status and exercise capacity and increased mortality in COPD and other chronic respiratory diseases.7, 8 Unhealthy diet, extremes in body weight and low muscle mass are associated with poor outcomes in patients with COPD and ILD.9, 10 Many patients also experience difficulties coping with their disease11 and have limited knowledge about their condition and poor self-management skills.12 Thus, there is a clear clinical indication for additional, comprehensive interventions optimizing the physical and psychological condition of these patients and inducing a healthier lifestyle. Pulmonary rehabilitation (PR) offers this potential. It takes the factors contributing to the current and future burden of disease in individual patients into account. Clinically relevant improvements in health status, exercise capacity and other outcomes have been convincingly demonstrated in patients with stable disease13 and following exacerbation.14 Consequently, PR is considered an essential component of respiratory disease management and is recommended by various international guidelines.15-17 Despite the abundance of literature reporting the benefits of PR for patients with chronic respiratory diseases, this intervention is faced with numerous challenges. A very limited proportion of potential PR candidates are referred for these programmes, and adherence is low. Lack of awareness regarding access and benefits and insufficient funding and availability of PR programmes are important issues related to this underuse.18 Motivated by the lack of resources and poor uptake of traditional centre-based PR, alternative models, including home-based PR with minimal resources, have been studied.19, 20 The clinical outcomes of these programmes were positive, but they have instigated an international debate about the definition of PR and its minimal core components. Programmes consisting of exercise training only may improve physical functioning but may downsize the complexity of chronic respiratory diseases into a single dimension. Therefore, such programmes neglect the need for an integrated approach of all treatable components of these conditions. To move ahead and avoid devaluation of the term PR, international experts must come to agreement on essential organizational aspects and components of comprehensive PR or introduce alternative terminology for other approaches. Another challenge is related to non-response to PR in a proportion of patients and the current lack of ability to select the appropriate patients for PR programmes.21 In the realm of ‘precision medicine’, researchers in PR need to focus on these non-responders, identify treatable traits and determine which components of PR will be effective and use the outcomes to innovate and increase the efficacy of PR. For this review series on rehabilitation for chronic lung diseases, we have invited a group of global experts in PR to highlight the opportunities and challenges of this field and to provide the readers of this journal with a state-of-the-art update on the organization and content of PR in various respiratory conditions. With this, we aim to increase the awareness, implementation, quality, customization and outcomes of PR in different states (stable or exacerbation) and stages of severity of these diseases. Our experts will discuss the urgency of conceptual clarity and international consensus on the term PR and its essential components. They will also focus on the need for tailored programmes that meet the needs of individual patients. In addition to achieving a consensus on meaningful and sustainable outcomes, opportunities and limitations of PR programmes in different settings will be discussed and balanced against availability and costs. The invited authors will also provide expertise on selection of patients for PR and the components of an integrated assessment. Readers will be educated on the personalized exercise training and educational components of PR, along with other interventions. The effects of PR on patients with COPD and on patients with non-COPD diagnoses, including ILD, bronchiectasis, lung cancer and pulmonary hypertension, will be presented. In addition, invited authors will focus on the effects and safety of PR during acute exacerbations or recovery from these events. The experts will also describe the latest developments in PR for the most severe patients, for example by combining exercise training with (high-flow) oxygen supplementation and non-invasive ventilation. Finally, they will show us the evidence regarding maintenance programmes and inform readers of the barriers and facilitators for long-term benefits of PR. PR is a powerful intervention for patients with chronic respiratory diseases. Whilst these diseases remain incurable, PR will help support patients to live their life to the max. We truly hope that this review series in Respirology will be informative and interesting and that it will increase awareness among healthcare professionals, policymakers, payers and patients regarding the role of PR in respiratory health. We also hope that these reviews will stimulate the implementation of PR in regions of the world where it is not available and encourage scientists to explore the uncertainties in PR and ultimately advance this field.

Background and Purpose: Pulmonary rehabilitation (PR) is now considered a fundamental component of the integrated disease management of this population. The six-minute walk test (6MWT) is commonly performed to evaluate functional exercise capacity, and few studies have evaluated differences in physiological responses to 6MWT across the case mix of patients receiving PR. The purpose of this study was to compare the physiological responses to the 6MWT in patients referred to the PR program. Methods: A total of 60 patients referred to the out-patient PR program at Physical Therapy Center (National Taiwan University Hospital) were included. The 6MWT was performed according to the American Thoracic Society Statement (ATS) guidelines. Blood pressure (BP) and perceived dyspnea were measured before and after the 6MWT. Heart rate (HR) and arterial oxygen saturation (SpO_2) were continuously monitored by pulse oximetry throughout the test and during the first minute of recovery. The 6-minute walking distance (6MWD) was measured. Results: The case mix was categorized into bronchiectasis (n = 15), and stage I, II, III, and IV chronic obstructive pulmonary disease (COPD) (stage I to IV, n = 9, 17, 13, and 5 respectively). SpO_2 decreased significantly in all groups during the 6MWT (p ＜ 0.0001), with the most prominent reduction in stage III (9%) and IV (8%) COPD, and remained significantly low in stage II, III, and IV COPD one minute after the 6MWT. The percent of 6MWD predicted was significantly lower in stage III, IV, and bronchiectasis compared to stage I and II COPD (all p ＜ 0.05). Maximal HR achieved during the 6MWT was significantly higher in bronchiectasis and stage IV COPD patients compared to other groups (p = 0.03). Recovery HR in one minute remained significantly higher compare to baseline in all groups. Perceived dyspnea increased significantly in all groups during the 6MWT, and the mean increment was 2.6, 2.3, 3.3, 4.0, and 3.4 for stage I, II, III, IV COPD and bronchiectasis, respectively (p ＜ 0.0001). Conclusion: Except for stage I COPD, all patients referred to PR presented with reduced functional exercise capacity. Exercise desaturation and slow heart rate recovery was noted in all patient referred to PR. Clinical Relevance: This result provides evidence that insufficient functional exercise capacity exists in patients with chronic respiratory disease and PR should be provided to these patients if resources, reimbursement; and healthcare professional are sufficient. In addition, O_2 supplementation and careful monitor HR response is recommended during exercise training.

Background: Pulmonary rehabilitation (PR) improves quality of life and functional ability in participants with chronic obstructive pulmonary disease (COPD). It is recognised PR programs are under-utilised worldwide (Rochester et al AMRCCM 2015; 192(11)1373-86),in part due to challenges with recruiting participants into PR programs. Fear of breathlessness and exercise appear to be commonly cited reasons for not attending PR programs (Harris et al, Br J Gen Pract 2008; Oct 58(555)703-10). Aim: To pilot a multidisciplinary recruitment session for participants who previously declined to attend PR. Method: One general practice (GP) list of registered COPD participants was identified. Participants were invited to a two hour recruitment session delivered by a multidisciplinary team including Physiotherapists, Psychologists and practice nurse. The session included an open discussion about the impact of COPD on individuals lives followed with education on the aims, content and benefits of PR, linking to participants identified priorities. Results: 32 participants were identified on the GP register, who had previously declined PR. 16 agreed to attend the recruitment session, of these 9 did attend the session. 4 patients declined PR and 5 accepted referral. To date a total of 3 participants have completed initial assessment and are actively doing PR sessions. Conclusion: The pilot demonstrates the potential benefit of running multidisciplinary recruitment sessions for participants who have previously declined PR. This could be a method to recruit patients who have previously declined to attend PR however it is time consuming.

Introduction Chronic obstructive pulmonary disease (COPD) is a common worldwide problem associated with morbidity and mortality that, unlike other diseases, is increasing. Recently, COPD has become the third leading cause of death in the United States, an event that was not predicted to occur until the year 2020. Therapy for COPD focuses on smoking cessation, bronchodilators, oxygen therapy, pulmonary rehabilitation, lung volume reduction surgery (LVRS), transplantation and treatment of comorbidities. While many of these interventions may improve dyspnea and quality of life, only oxygen supplementation in those with hypoxemia at rest, smoking cessation and LVRS have been associated with improved mortality in COPD. This chapter will review the role of LVRS in the treatment of patients with advanced COPD, and also examine the current status of minimally invasive bronchoscopic techniques for lung reduction that are approved overseas but are currently under study in the United States. Rationale for lung reduction in COPD COPD is an inflammatory disease that leads to airflow obstruction secondary to a combination of airway disease and emphysema, primarily in the distal small airways of the lung. The small airways become narrowed due to airway inflammation, smooth muscle hypertrophy, peribronchial fibrosis and mucus plugging. In emphysema, the destruction of alveolar walls leads to a loss of tethering of distal small airways, predisposing the airway to expiratory collapse. Most individuals with COPD will have a mixture of small airways obstruction and emphysema, but some will have a predominance of one abnormality or the other. Lung emptying is determined by the expiratory time constant, which is the product of airway resistance and lung compliance. Because subjects with emphysema have both increased lung compliance and airways resistance, they have impaired lung emptying and are prone to hyperinflation. As emphysema progresses, total lung capacity (TLC) and residual volume (RV) both increase as a result of decreased lung compliance and unopposed chest wall recoil causing hyperinflation and gas trapping, respectively. During exertion, the respiratory rate increases, reducing the time available for lung emptying, and the end-expiratory lung volume (EELV) rises even further, leading to dynamic hyperinflation. Figure 8.1 demonstrates the rise in lung volumes that occurs during exercise in severe COPD. EELV rises during exercise, thereby limiting the normal increase in tidal volume that occurs during exercise.

Pulmonary rehabilitation (PR) is a recommended intervention in the management of individuals with chronic lung disease. It is important to study the characteristics and capacity of programs in Canada to confirm best practices and identify future areas of program improvement and research. To identify all Canadian PR programs, regardless of setting, and to comprehensively describe all aspects of PR program delivery. The present article reports the results of the survey related to type of program, capacity and program characteristics. All hospitals in Canada were contacted to identify PR programs. A representative from each program completed a 175-item online survey encompassing 16 domains, 10 of which are reported in the present article. A total of 155 facilities in Canada offered PR, of which 129 returned surveys (83% response rate). PR programs were located in all provinces, but none in the three territories. Most (60%) programs were located in hospital settings, 24% were in public health units and 8% in recreation centres. The national capacity of programs was estimated to be 10,280 patients per year, resulting in 0.4% of all Canadians with chronic obstructive pulmonary disease (COPD) and 0.8% of Canadians with moderate to severe COPD having access to PR. COPD, interstitial lung disease, and asthma were the most common diagnoses of patients. The majority of programs had at least four health care professionals involved; 9% had only one health care professional involved. The present comprehensive survey of PR in Canada reports an increase in the number of programs and the total number of patients enrolled since the previous survey in 2005. However, PR capacity has not kept pace with demand, with only 0.4% of Canadians with COPD having access.

Pulmonary rehabilitation (PR) is recommended internationally for individuals with chronic obstructive pulmonary disease (COPD), but there is limited evidence and practice of PR in Sri Lanka. Key challenges for PR such as poor accessibility, uptake and completion need to be addressed when designing and delivering new PR programmes. Accordingly, this study determined the feasibility and acceptability of culturally adapted PR for adults with COPD in Sri Lanka. A randomized controlled feasibility trial was conducted with 50 adults living with COPD in Colombo, Sri Lanka. A culturally adapted PR comprised a 6-week rolling programme with sessions conducted twice every week. Sessions involved endurance and resistance exercise training, education and cultural adaptations of nutritional support and group singing. The control group received usual care, which did not include any form of PR or exercise training. Feasibility was determined by uptake (≥60% of eligible participants consented) and completion (≥70% of recruited participants). Acceptability was explored by focus group discussions (FGDs) analysed thematically. Seventy-nine eligible individuals (94% of screened) were referred in order to recruit 50 participants (63% uptake). The majority of participants in both intervention (72%, n=18) and control (64%, n=16) groups completed the study. Based on qualitative focus group discussions four themes emerged: (1) Increased knowledge following PR, including dispelling misbeliefs about COPD and improving medication adherence; (2) Perceived improvements in health following PR, including improved walking ability and reduced breathlessness (3) Enjoyment and benefits of cultural adaptations to PR, and (4) Challenges during PR, including adherence to exercise and travel requirements. Culturally adapted PR was feasible and acceptable to adults with COPD in Sri Lanka. A fully powered trial is warranted for evaluating clinical and cost-effectiveness of culturally adapted PR.

Field exercise tests have been increasingly used for pulmonary risk assessment. The 6-min walking distance (6MWD) is a field test commonly employed in clinical practice; however, there is limited evidence supporting its use as a risk assessment method in abdominal surgery. The aim was to assess if the 6MWD can predict the development of post-operative pulmonary complications (PPCs) in patients having upper abdominal surgery (UAS). This prospective cohort study included 137 consecutive subjects undergoing elective UAS. Subjects performed the 6MWD on the day prior to surgery, and their performance were compared with predicted values of 6MWD (p6MWD) using a previously validated formula. PPCs (including pneumonia, tracheobronchitis, atelectasis with clinical repercussions, bronchospasm and acute respiratory failure) were assessed daily by a pulmonologist blinded to the 6MWD results. 6MWD and p6MWD were compared between subjects who developed PPC (PPC group) and those who did not (no PPC group) using Student's t-test. Ten subjects experienced PPC (7.2%) and no significant difference was observed between the 6MWD obtained in the PPC group and no PPC group (466.0 ± 97.0 m vs. 485.3 ± 107.1 m; P = 0.57, respectively). There was also no significant difference observed between groups for the p6MWD (100.7 ± 29.1% vs. 90.6 ± 20.9%; P > 0.05). The results of the present study suggest that the 6-min walking test is not a useful tool to identify subjects with increased risk of developing PPC following UAS.

BACKGROUND: Pulmonary rehabilitation has become a cornerstone in the management of patients with stable Chronic Obstructive Pulmonary Disease (COPD). Systematic reviews have shown large and important clinical effects of pulmonary rehabilitation in these patients. However, in unstable COPD patients who have recently suffered an exacerbation, the effects of pulmonary rehabilitation are less established. OBJECTIVES: To assess the effects of pulmonary rehabilitation after COPD exacerbations on future hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life and exercise capacity). SEARCH STRATEGY: Trials were identified from searches of CENTRAL, MEDLINE, EMBASE, PEDRO and the Cochrane Airways Group Register of Trials. Searches were current as of March 2010. SELECTION CRITERIA: Randomized controlled trials comparing pulmonary rehabilitation of any duration after exacerbation of COPD with conventional care. Pulmonary rehabilitation programmes needed to include at least physical exercise. Control groups received conventional community care without rehabilitation. DATA COLLECTION AND ANALYSIS: We calculated pooled odds ratios and weighted mean differences (MD) using random-effects models. We requested missing data from the authors of the primary studies. MAIN RESULTS: We identified nine trials involving 432 patients. Pulmonary rehabilitation significantly reduced hospital admissions (pooled odds ratio 0.22 [95% CI 0.08 to 0.58], number needed to treat (NNT) 4 [95% CI 3 to 8], over 25 weeks) and mortality (OR 0.28; 95% CI 0.10 to 0.84), NNT 6 [95% CI 5 to 30] over 107 weeks). Effects of pulmonary rehabilitation on health-related quality of life were well above the minimal important difference when measured by the Chronic Respiratory Questionnaire (MD for dyspnea, fatigue, emotional function and mastery domains between 0.81 (fatigue; 95% CI 0.16 to 1.45) and 0.97 (dyspnea; 95% CI 0.35 to 1.58)) and the St. Georges Respiratory Questionnaire total score (MD -9.88; 95% CI -14.40 to -5.37); impacts domain (MD -13.94; 95% CI -20.37 to -7.51) and for activity limitation domain (MD -9.94; 95% CI -15.98 to -3.89)). The symptoms domain of the St. Georges Respiratory Questionnaire showed no significant improvement. Pulmonary rehabilitation significantly improved exercise capacity and the improvement was above the minimally important difference (six-minute walk test (MD 77.70 meters; 95% CI 12.21 to 143.20) and shuttle walk test (MD 64.35; 95% CI 41.28 to 87.43)). No adverse events were reported in three studies. AUTHORS' CONCLUSIONS: Evidence from nine small studies of moderate methodological quality, suggests that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD patients who have recently suffered an exacerbation of COPD.

Introduction: Chronic obstructive pulmonary disease (COPD) is a chronic lung disease that results in increasing breathlessness in addition to systemic effects on the body and has significant impact on mortality and morbidity. Context: Pulmonary rehabilitation is recognised as an important facet of COPD management and, based on high level of evidence has been shown to decrease dyspnoea, decrease anxiety and depression, increase exercise tolerance and reduce hospitalisations and health care costs. Pulmonary rehabilitation is defined as “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education and behaviour change, designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote the long term adherence of health enhancing behaviours”2. Target population: In Australia, it is estimated that almost 13% or one in seven Australians aged 40 years or over are affected by COPD1 . Change implemented: Western Sydney Local Health District has developed an innovative pulmonary rehabilitation service (Respiratory Ambulatory Care) that provides integrated care to patients with COPD across the disease trajectory within a pulmonary rehabilitation program. Respiratory Ambulatory Care recognise that patients with COPD often have a range of unmet health needs due to the complexity of their disease and comorbidities. Patients referred to Respiratory Ambulatory Care undergo a comprehensive holistic multidisciplinary assessment and based on clinical findings, are linked into a range of services including clinical psychology, dietetics, speech pathology, home monitoring and support / outreach, smoking cessation, single point of contact for advice during acute exacerbations (Respiratory Hotline) and end of life support. Referrals are coordinated and followed up during the rehabilitation program to ensure patients are successfully linked into required services. Case conferences and care planning is arranged by staff to ensure all members of the patient’s health care team are invited to contribute to the patient’s care. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116596– http://www.ijic.org/ Patients are supported in behaviour change through coaching and self-management support and are encouraged to become active participants in their healthcare decision-making. Communication between services is assisted by Respiratory Ambulatory Care’s use of the electronic medical record. Other providers within the local health district can access Respiratory Ambulatory Care’s assessments to reduce duplication of tests. General practitioners and non-hospital based services are faxed results of clinical assessment and progress within 24 hours of completion. Outcomes: A retrospective chart review of 141 patients who had participated in the pulmonary rehabilitation program revealed an improvement of health related quality of life (as measured by the St George Respiratory Questionnaire) of 7± 11 unit points (minimal clinical important difference (MCID) is 4 units) and an improvement in functional capacity as measured by 6 minute walk test of 58 ± 68 m (MCID 30m). Pulmonary rehabilitation services play a critical role in care integration for patients with COPD. Similar chronic disease rehabilitation programs could easily provide similar services ensuring patients care is coordinated, seamless and integrated.

Predictors of premature discontinuation and prevalence of dropouts from a pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease

Background: Active mind‐body movement therapies (AMBMTs), including but not limited to yoga, tai chi, and qigong, have been applied as exercise modalities for people with chronic obstructive pulmon ...