Alex J. van 't Hul

Outcome of pulmonary rehabilitation in COPD patients with severely impaired health status

Introduction Effects of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) patients with severely impaired health status are poorly documented since these patients are usually excluded from clinical trials. This retrospective, observational study aims to study the impact of disease on health status and the effects of PR on COPD patients referred to a tertiary center for PR in The Netherlands. Methods Between June 2006 and June 2010, 437 patients with COPD were allocated to our intensive, comprehensive PR program. Patients participated in this interdisciplinary program for 12 weeks for a weekly average of 20–25 hours. Before and directly after, several measures of physical performance and health-related quality of life were determined. Results At baseline, most patients (75%) had a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage of III–IV. Peak exercise performance on a cycle ergometer was on average reduced to 43 ± 29 Watt, and health-related quality of life was significantly impaired, with a total score on the St George’s Respiratory Questionnaire (SGRQ) of 66. Health-care utilization in the year preceding PR was very high. After rehabilitation, all outcome measures improved statistically significantly (P < 0.001). Exercise performance measured with the 6 minute walking distance test improved clinically significantly in 68% of the patients, whereas 75% of the patients showed a clinically meaningful improvement in quality of life as measured with the SGRQ. Multiple regression analysis revealed that 19% of the variation in responses on the 6 minute walking distance test and the SGRQ could be explained on the basis of baseline characteristics. Conclusion The present study provides data to indicate that COPD patients may substantially benefit from rehabilitation in a tertiary pulmonary rehabilitation center, despite a severely impaired health status and high level of health-care utilization, in which prior treatment in primary and secondary care have failed to improve health status. Individual rehabilitation responses can only partially be predicted on the basis of baseline characteristics. Consequently, no firm conclusions can be drawn from this study with respect to the selection of candidates that could be deemed eligible for this rehabilitation program when entering the program.

Inaccuracy of Estimating Peak Work Rate from Six-Minute Walk Distance in Patients with COPD

Abstract Introduction. The cardiopulmonary exercise test (CPET) and the 6-minute walk test (6MWT) are used to prescribe the appropriate training load for cycling and walking exercise in patients with chronic obstructive pulmonary disease (COPD). The primary aims were: (i) to compare estimated peak work rate (Wpeakestimated) derived from six existing Wpeak regression equations with actual peak work rate (Wpeakactual); and (ii) to derive a new Wpeak regression equation using six-minute walk distance (6MWD) and conventional outcome measures in COPD patients. Methods. In 2906 patients with COPD, existing Wpeak regression equations were used to estimate Wpeak using 6MWD and a new equation was derived after a stepwise multiple regression analysis. Results. The 6 existing Wpeak regression equations were inaccurate to predict Wpeakactual in 82% of the COPD patients. The new Wpeak regression equation differed less between Wpeakestimated and Wpeakactual compared to existing models. Still, in 74% of COPD patients Wpeakestimated and Wpeakactual differed more than (±) 5 watts. Conclusion. In conclusion, estimating peak work load from 6MWD in COPD is inaccurate. We recommend assessment of Wpeak using CPET during pre-rehabilitation assessment in addition to 6MWT.

Development of an integral assessment approach of health status in patients with obstructive airway diseases: the CORONA study

Background Traditional assessment of patients with obstructive lung diseases (asthma and chronic obstructive pulmonary disease; COPD) relies on physiological tests. The COPD and Asthma Rotterdam Integrated Care Approach (CORONA) study aims to develop a diagnostic pathway with a more comprehensive approach to the assessment of patients with asthma and COPD in secondary care. Methods An eight-step method was used to develop and implement the pathway for patients with asthma or COPD referred to an outpatient hospital setting. Results The diagnostic pathway consists of an evidence-based set of measurements prioritized by a Delphi procedure. The pathway incorporates three innovative diagnostics: the metronome-paced hyperventilation test to measure dynamic hyperinflation, an activity monitor to objectively evaluate physical activity in daily life, and the Nijmegen Clinical Screening Instrument as a comprehensive assessment tool to acquire detailed insight into symptoms, functional limitations, and quality of life. Conclusion An innovative diagnostic pathway was developed and implemented for patients with obstructive lung diseases referred to secondary care. As this pathway aims to provide a comprehensive analysis of health status, it focuses on biomedical aspects and also reviews behavioral aspects that further elucidate the patient’s health status. The added value of the diagnostic pathway needs to be determined from both an organizational perspective and from the individual patient’s viewpoint.

The COPDnet integrated care model

Introduction This research project sets out to design an integrated disease management model for patients with COPD who were referred to a secondary care setting and who qualified for pharmacological and nonpharmacological intervention options. Theory and methods The integrated disease management model was designed according to the guidelines of the European Pathway Association and the content founded on the Chronic Care Model, principles of integrated disease management, and knowledge of quality management systems. Results An integrated disease management model was created, and comprises 1) a diagnostic trajectory in a secondary care setting, 2) a nonmedical intervention program in a primary care setting, and 3) a pulmonary rehabilitation service in a tertiary care setting. The model also includes a quality management system and regional agreements about exacerbation management and palliative care. Discussion In the next phase of the project, the COPDnet model will be implemented in at least two different regions, in order to assess the added value of the entire model and its components, in terms of feasibility, health status benefits, and costs of care. Conclusion Based on scientific theories and models, a new integrated disease management model was developed for COPD patients, named COPDnet. Once the model is stable, it will be evaluated for its feasibility, health status benefits, and costs.

The Use of Regression Equations to Estimate Peak Work Rate in People with COPD - Reply from the Authors

1. Program Development Centre; CIRO+, centre of expertise for chronic organ failure; Horn, the Netherlands2. Department of Medical Psychology; Radboud University Nijmegen Medical Centre; Nijmegen, the Netherlands3. Department of Pulmonary Diseases; Radboud University Nijmegen Medical Centre; Nijmegen, the Netherlands4. Rehabilitation Centre Breda; Revant Rehabilitation Centre; Breda, the Netherlands5. Department of pulmonary diseases, VU Medical Centre, Amsterdam, the Netherlands6. Asthma Centre Heideheuvel; Merem Behandelcentra; Hilversum, the Netherlands7. Director; CIRO+, centre of expertise for chronic organ failure; Horn, the Netherlands8. Department of Respiratory Medicine; Maastricht University Medical Centre (MUMC+); Maastricht, the Netherlands9. Department of Respiratory Medicine; Erasmus Medical Center; Rotterdam, the Netherlands10. Sports Training; CIRO+, centre of expertise for chronic organ failure; Horn, the Netherlands