Anastasios Palamidas

Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits

Pulmonary rehabilitation (PR) remains grossly underutilised by suitable patients worldwide. We investigated whether home-based maintenance tele-rehabilitation will be as effective as hospital-based maintenance rehabilitation and superior to usual care in reducing the risk for acute chronic obstructive pulmonary disease (COPD) exacerbations, hospitalisations and emergency department (ED) visits. Following completion of an initial 2-month PR programme this prospective, randomised controlled trial (between December 2013 and July 2015) compared 12 months of home-based maintenance tele-rehabilitation (n=47) with 12 months of hospital-based, outpatient, maintenance rehabilitation (n=50) and also to 12 months of usual care treatment (n=50) without initial PR. In a multivariate analysis during the 12-month follow-up, both home-based tele-rehabilitation and hospital-based PR remained independent predictors of a lower risk for 1) acute COPD exacerbation (incidence rate ratio (IRR) 0.517, 95% CI 0.389–0.687, and IRR 0.635, 95% CI 0.473–0.853), respectively, and 2) hospitalisations for acute COPD exacerbation (IRR 0.189, 95% CI 0.100–0.358, and IRR 0.375, 95% CI 0.207–0.681), respectively. However, only home-based maintenance tele-rehabilitation and not hospital-based, outpatient, maintenance PR was an independent predictor of ED visits (IRR 0.116, 95% CI 0.072–0.185). Home-based maintenance tele-rehabilitation is equally effective as hospital-based, outpatient, maintenance PR in reducing the risk for acute COPD exacerbation and hospitalisations. In addition, it encounters a lower risk for ED visits, thereby constituting a potentially effective alternative strategy to hospital-based, outpatient, maintenance PR. Home tele-rehabilitation reduces risk of COPD exacerbation; is effective alternative to in-hospital rehabilitation http://ow.ly/T17g30ap9cY

Impact of Hemodialysis on Dyspnea and Lung Function in End Stage Kidney Disease Patients

Background. Respiratory symptoms are usually underestimated in patients with chronic kidney disease undergoing maintenance hemodialysis. Therefore, we set out to investigate the prevalence of patients chronic dyspnea and the relationship of the symptom to lung function indices. Methods. Twenty-five clinically stable hemodialysis patients were included. The mMRC dyspnea scale was applied before and after hemodialysis. Spirometry, single breath nitrogen test, arterial blood gases, static maximum inspiratory (P imax⁡) and expiratory (P emax⁡) muscle pressures, and mouth occlusion pressure (P 0.1) were also measured. Results. Despite normal spirometry, all patients (100%) reported mild to moderate degree of chronic dyspnea pre which was reduced after hemodialysis. The sole predictor of (Δ) mMRC was the (Δ) P 0.1 (r = 0.71, P < 0.001). The P imax⁡ was reduced before and correlated with the duration of hemodialysis (r = 0.614, P < 0.001), whilst after the session it was significantly increased (P < 0.001). Finally (Δ) weight was correlated with the (Δ) P imax⁡  %pred (r = 0.533, P = 0,006) and with the (Δ) CV (%pred) (r = 0.65, P < 0.001). Conclusion. We conclude that dyspnea is the major symptom among the CKD patients that improves after hemodialysis. The neuromechanical dissociation observed probably is one of the major pathophysiologic mechanisms of dyspnea.

E- Cigarette acute effect on symptoms and airway inflammation: comparison of nicotine with a non-nicotine cigarette

Materials and methods We studied 64 subjects (aged 22-65 years, 34 men) divided in 2 groups. Group A: 12 never smokers and 29 healthy smokers smoked for 10 min a single e-cigarette containing 11mg of nicotine and Group B: 14 never smokers and 9 healthy smokers smoked a single e-cigarette containing 0mg of nicotine. The same brand of e-cig was used in both groups with similar liquid ingredients but with two different nicotine concentrations. Vital signs, symptoms questionnaire, Oxygen Saturation (SpO2), heart rate(HR)] and indices of airway inflammation (exhaled NO, and airways temperature) were assessed pre and post smoking.

Methods for Assessing Expiratory Flow Limitation during Tidal Breathing in COPD Patients

Patients with severe COPD often exhale along the same flow-volume curve during quite breathing as during forced expiratory vital capacity manoeuvre, and this has been taken as indicating expiratory flow limitation at rest (EFLT). Therefore, EFLT, namely, attainment of maximal expiratory flow during tidal expiration, occurs when an increase in transpulmonary pressure causes no increase in expiratory flow. EFLT leads to small airway injury and promotes dynamic pulmonary hyperinflation with concurrent dyspnoea and exercise limitation. In fact, EFLT occurs commonly in COPD patients (mainly in GOLD III and IV stage) in whom the latter symptoms are common. The existing up-to-date physiological methods for assessing expiratory flow limitation (EFLT) are reviewed in the present work. Among the currently available techniques, the negative expiratory pressure (NEP) has been validated in a wide variety of settings and disorders. Consequently, it should be regarded as a simple, non invasive, most practical, and accurate new technique.

Driving-Related Neuropsychological Performance in Stable COPD Patients

Background. Cognitive deterioration may impair COPD patients ability to perform tasks like driving vehicles. We investigated: (a) whether subclinical neuropsychological deficits occur in stable COPD patients with mild hypoxemia (PaO2 > 55 mmHg), and (b) whether these deficits affect their driving performance. Methods. We recruited 35 stable COPD patients and 10 normal subjects matched for age, IQ, and level of education. All subjects underwent an attention/alertness battery of tests for assessing driving performance based on the Vienna Test System. Pulmonary function tests, arterial blood gases, and dyspnea severity were also recorded. Results. COPD patients performed significantly worse than normal subjects on tests suitable for evaluating driving ability. Therefore, many (22/35) COPD patients were classified as having inadequate driving ability (failure at least in one of the tests), whereas most (8/10) healthy individuals were classified as safe drivers (P = 0.029). PaO2 and FEV1 were correlated with almost all neuropsychological tests. Conclusions. COPD patients should be warned of the potential danger and risk they face when they drive any kind of vehicle, even when they do not exhibit overt symptoms related to driving inability. This is due to the fact that stable COPD patients may manifest impaired information processing operations.

Short term use of an e-cig: Influence on clinical symptoms, vital signs and eCO levels

Materials and methods Sixty two participants (32 men) with a mean age of 45.43 years have been recruited. Sixteen smokers were suffered by COPD, 12 smokers by asthma, 24 smokers had no overt airways disease. All were current smokers with a long smoking history. A group of 10 non-smokers was also included. The same brand of e-cig was used for 10 min inhaled 11mg. Clinical symptoms, vital signs, -heart rate, oxygen saturation (SpO2) and exhaled CO, was assessed pre and post the e-cig use.

Acute effects of short term use of e-cigarettes on airways physiology and respiratory symptoms in smokers with and without airways obstructive diseases and in healthy non smokers

BACKGROUND Although the use of e-cigarettes is increasing worldwide, their short and long-term effects remain undefined. We aimed to study the acute effect of short-term use of e-cigarettes containing nicotine on lung function and respiratory symptoms in smokers with airways obstructive disease (COPD, asthma), “healthy” smokers, and healthy never smokers. METHODS Respiratory symptoms, vital signs, exhaled NO, airway temperature, airway resistance (Raw), specific airway conductance (sGaw) and single nitrogen breath test were assessed before and immediately after short term use of an e-cigarette containing 11mg of nicotine among adults with COPD, asthma, “healthy” smokers, and never-smokers. The effect of the use of nicotine-free e-cigarettes among “healthy” never smokers was also studied. RESULTS The majority of participants reported acute cough. Short term use of nicotine e-cigarettes was associated: a) with increased heart rate in all subjects except in the COPD group, b) decreased oxygen saturation in “healthy” and COPD smokers, c) increased Raw in asthmatic smokers, “healthy” smokers, and healthy never smokers, d) decreased sGaw in healthy subjects, and e) changed slope of phase III curve in asthmatic smokers. Short-term use of nicotine-free e-cigarettes increased Raw and decreased sGaw among healthy never smokers. CONCLUSIONS Short-term use of an e-cigarette has acute effects on airways physiology and respiratory symptoms in COPD smokers, asthmatic smokers, “healthy” smokers and healthy never smokers. E-cigarette use was associated with effects in “healthy” never smokers irrespectively of nicotine concentration. More studies are needed to investigate both short and long-term effects of e-cigarette use

Effect of pulmonary rehabilitation on tidal expiratory flow limitation at rest and during exercise in COPD patients

We hypothesized that severe COPD patients who present with the disadvantageous phenomenon of Expiratory Flow Limitation (EFL) may benefit as COPD patients without EFL do after implementation of a Pulmonary Rehabilitation (PR) program. Forty-two stable COPD patients were studied at rest and during exercise. EFL and dynamic hyperinflation (DH) were documented using the negative expiratory pressure (NEP) technique and inspiratory capacity (IC) maneuvers, respectively. Patient centered outcomes were evaluated by the Saint-Georges Respiratory Questionnaire (SGRQ) and the mMRC dyspnea scale. Before PR, 16 patients presented with EFL at rest and/or during exercise. After PR, EFL was abolished in 15 out of those 16 EFL patients who exhibited a significant increase in IC values. These were mainly accomplished through a modification of the breathing pattern. In the 26 NFL patients no increase was noted in their IC or a modification of their breathing pattern. However, both NFL and EFL COPD patients improved exercise capacity and patients centered outcomes undergoing the same PR program.

S98 Effectiveness of home maintenance tele-rehabilitation on COPD exacerbations

Acute exacerbations are cardinal events in the natural history of chronic obstructive pulmonary disease (COPD) and are associated with increased morbidity and mortality. Tele-monitoring interventions are a relatively new field in COPD research and management. Furthermore, the effect of home tele-rehabilitation on COPD exacerbation has not been thoroughly studied. Therefore, we set out to investigate whether a home tele-rehabilitation program would be as beneficial as an outpatient maintenance rehabilitation program, in the context of COPD exacerbations, following completion of a 3-month course of supervised pulmonary rehabilitation. We studied 137 Caucasian, ambulatory COPD patients. Forty seven patients were assigned to home maintenance tele-rehabilitation (FEV1,%pred = 50 ± 22, mean±SD). Fifty patients were assigned to twice weekly hospital-based maintenance rehabilitation (FEV1,%pred = 52 ± 17). Forty COPD patients (FEV1, %pred = 52 ± 21), were not assigned to any rehabilitation program and served as controls. Tele-rehabilitation included home exercise reconditioning, self-management techniques, dietary, and psychological advice. Patients were provided with tablets and wireless devices to record and transmit data, related to symptoms, lung function, and vital signs, to a tele-health platform. Patients were followed up for 12 months. At baseline there were no significant differences amongst the tele-rehabilitation (3.3 ± 3.1), hospital-based rehabilitation (3.4 ± 1.9), or control (3.3 ± 1.6), groups in terms of COPD exacerbations. After 12 months, COPD exacerbations in the group of home tele-rehabilitation were significantly reduced to 1.7 ± 1.7. In the group of hospital-based rehabilitation COPD exacerbations were also significantly reduced to 1.8 ± 1.4. In contrast, in the control group COPD exacerbations remained unchanged (3.5 ± 1.7). There were significant difference amongst the two rehabilitation groups (tele-rehabilitation and hospital-based) and the control group in terms of COPD exacerbations (p < 0.001). In conclusion, ongoing home tele-rehabilitation with the use of tele-monitoring could significantly reduce COPD exacerbations and seems to be as beneficial as an outpatient hospital-based maintenance rehabilitation program in the context of COPD exacerbations. Thus, tele-rehabilitation may constitute a satisfactory alternative rehabilitative strategy to diminish health care costs.