Arietta Spinou

An update on measurement and monitoring of cough: what are the important study endpoints?

Considerable progress has been achieved in the development of tools that assess cough. The visual analogue scale (VAS) for cough severity is widely used in clinical practice because its simple and practical. The Leicester cough questionnaire (LCQ) and the cough-specific quality of life questionnaire (CQLQ) are the most widely used health status questionnaires for adults with chronic cough. They are well validated for assessing the impact of cough. Cough can be assessed objectively with challenge tests that measure the sensitivity of the cough reflex. Cough challenge tests are better used to determine the mechanism of action of therapy, rather than efficacy. Cough frequency monitoring, the preferred tool to objectively assess cough, is increasingly being used as primary end-points in clinical trials. The most widely used cough monitors are the Leicester cough monitor (LCM) and VitaloJak. They are ambulatory devices that consist of a microphone and recording device. Cough frequency monitors do not reflect the intensity or the impact of cough; hence their relationship with subjective measures of cough is weak. Cough should therefore be assessed with a combination of subjective and objective tools. There is a paucity of studies that have investigated the minimal important difference of cough frequency monitors, rendering further investigations needed.

The validity of health-related quality of life questionnaires in bronchiectasis: a systematic review and meta-analysis

Background A range of questionnaires have been used to assess health-related quality of life (HRQOL) in bronchiectasis. A systematic review was conducted to evaluate their psychometric properties and assess associations between HRQOL and clinical measures. Methods Five electronic databases were searched. Studies eligible for inclusion were those that investigated the validity of HRQOL questionnaires and/or their association with other outcomes in adults with bronchiectasis. Patients with cystic fibrosis were excluded. The identified questionnaires were assessed for convergent, discriminant and cross-cultural translation validity; missing data, floor and ceiling effects, internal consistency, responsiveness and test-retest reliability. A meta-analysis was conducted to estimate the strength of associations between HRQOL and clinical measures. Results From 1918 studies identified, 43 studies were included in the systematic review, of which 38 were suitable for the meta-analysis. Nine HRQOL questionnaires were identified, with the most widely used being: St Georges Respiratory Questionnaire, Leicester Cough Questionnaire, Quality of Life–Bronchiectasis and Short Form-36. HRQOL questionnaires had moderate to good internal consistency and good test-retest reliability. Only 8 of 18 studies that used translated HRQOL questionnaires reported or referred to the validity of the translated questionnaire. There was a stronger correlation (mean r (95% CI)) between HRQOL and subjective outcome measures, such as dyspnoea (0.55 (0.41 to 0.68)) and fatigue (0.42 (0.23 to 0.58)) compared with objective measures; exercise capacity (−0.41 (−0.54 to −0.24)), FEV1% predicted (−0.31 (−0.40 to −0.23)) and extent of bronchiectasis on CT scan (0.35 (0.03 to 0.61)); all p<0.001. Conclusions This review supports most HRQOL questionnaires used in bronchiectasis have good psychometric properties. There was a weak to moderate association between HRQOL and objective outcome measures. This suggests that HRQOL questionnaires assess a unique aspect of health not captured by objective measures.

How best to measure cough clinically

It is possible to measure cough by assessing its severity, frequency, intensity, associated urge and its impact on quality of life. Cough severity can simply be assessed with a Visual Analogue Scale. Cough frequency can be assessed objectively with cough frequency monitors. Validated cough monitors include the Leicester Cough Monitor and the VitaloJAK. Cough reflex sensitivity measurement is better used to investigate the mechanisms of action of antitussive medications, rather than assessing efficacy. Health-Related Quality of Life measures are available to assess the impact of cough; they include the validated Leicester Cough Questionnaire and Cough-specific Quality of Life Questionnaire for adult patients. It is best to assess cough with a combination of subjective and objective tools, to capture its wide-ranging impact.

The development and validation of the Bronchiectasis Health Questionnaire

Health-related quality of life or health status is significantly impaired in bronchiectasis. There is a paucity of brief, simple-to-use, disease-specific health status measures. The aim of this study was to develop and validate the Bronchiectasis Health Questionnaire (BHQ), a new health status measure that is brief and generates a single overall score. Patients with bronchiectasis were recruited from two outpatient clinics, during a clinically stable stage. The development of the questionnaire followed three phases: item generation and item reduction using Rasch analysis, validation, and repeatability testing. The BHQ was translated into 11 languages using standardised methodology. 206 patients with bronchiectasis completed a preliminary 65-item questionnaire. 55 items were removed due to redundancy or poor fit to the Rasch model. The final version of the BHQ consisted of 10 items. Internal consistency was good (Cronbachs α=0.85). Convergent validity of the BHQ with the St Georges Respiratory Questionnaire was high (r= −0.82; p<0.001) and moderate with lung function (forced expiratory volume in 1 s % predicted r= −0.27; p=0.001). There was a significant association between BHQ scores and number of exacerbations of bronchiectasis in the last 12 months (p<0.001), hospital admissions (p=0.001) and computed tomography scan bronchiectasis pulmonary lobe counts (p<0.001). BHQ scores were significantly worse in patients with sputum bacterial colonisation versus no colonisation (p=0.048). The BHQ was highly repeatable after 2 weeks (intraclass correlation coefficient 0.89). The BHQ is a brief, valid and repeatable, self-completed health status questionnaire for bronchiectasis that generates a single total score. It can be used in the clinic to assess bronchiectasis from the patients perspective. The BHQ is a brief, valid measure of health status in patients with bronchiectasis http://ow.ly/ddUJ3089LQV

Non-pharmacological techniques for the extremes of the cough spectrum

Cough can be viewed as a continuum where extremes represent disease phenotypes. Under this unified concept, non-pharmacological treatment for the extremes of the cough spectrum includes both cough augmentation and cough control techniques. Supporting the cough motor output and exercising the cognitive control on coughing are the main directions of these techniques. Cough augmentation can be provided to patients who present low ability to generate adequate peak cough flows, with the aim to develop the sheering forces that are essential for effective airway clearance. On the other hand, individuals with high cough sensitivity or frequency can practice techniques for cough control, which incorporates a combination of education, retraining and psychological support. These techniques aim to empower patients to increase their supramedulary control on cough. Although hypotheses that are generated by the physiology of cough can support most non-pharmacological techniques, their exact mechanisms of effectiveness remain unclear.

Current physiotherapy practice in Greek intensive care units: a national study

Abstract Background: The purpose of the study was to investigate the responsibilities and frequency of clinical procedures that physiotherapists perform within the intensive care unit (ICU) in Greece, along with the level of education and training of these physiotherapists. Methods: Physiotherapists who work in general ICUs of hospitals were invited to complete a developed questionnaire. The questionnaire consisted of 83 items, of closed and opened–ended format. Items for service provision and physiotherapists’ employment were included, along with participants’ involvement in respiratory care, early mobilisation and the use of the ICU equipment. Results: One hundred forty physiotherapists completed the questionnaire. Seventy-three respondents (52%) reported working in ICU in Athens and 67 (48%) in other cities of Greece. Almost all the physiotherapists’ performed early mobilisation and respiratory techniques; although the frequency of procedures and use of equipment were variable. Sixty-one (44%) and 70 (50%) respondents participated in the weaning procedure and mobilised the patient whilst using the ventilator, respectively. Conclusion: The physiotherapists are from ICUs all over Greece. The results reflect the differences among the procedures that physiotherapists perform, regarding early mobility and respiratory physiotherapy. The results indicate the need for a national up-to-date job description of the physiotherapy services in ICUs in Greece.

P197 Physical Inactivity in Sarcoidosis

Introduction Sarcoidosis is associated with dyspnoea, arthralgia, fatigue and poor health status. Little is known about physical activity in sarcoidosis. This study aimed to: 1) objectively measure physical activity in patients with pulmonary sarcoidosis; 2) investigate the relationship between physical activity and fatigue, exercise capacity, health status and lung function. Methods 15 pulmonary sarcoidosis patients (mean age: 52.7 years; 4 males) and 14 healthy controls (mean age: 46.5 years; 4 males) were recruited. Physical activity was assessed objectively over one week, using a validated tri-axial accelerometer- ActivPalTM, and subjectively with the International Physical Activity Questionnaire (IPAQ). All participants also underwent pulmonary function tests, 6MWT and completed the Fatigue Assessment Scale (FAS), MRC Dyspnoea Scale and the King’s Sarcoidosis QOL Questionnaire (KSQ). Results Compared to controls, patients had lower mean ± SD daily step count (5624 ± 1875 steps vs. 10429 ± 2942 steps, p < 0.01, figure 1) and time spent stepping (1.18 ± 0.35 hr.day-1 vs. 1.97 ± 0.46 hr.day-1; p < 0.01). There was also a trend to reduced bouts of activity in sarcoidosis patients compared with controls, (sit-stand transitions: 49 ± 15 vs. 61 ± 20; p = 0.08). Exercise capacity was significantly reduced in patients compared to controls (6MWT distance: 375 ± 59 m vs. 487 ± 92 m; p < 0.01). There was a significant association between daily step counts, and 6MWT distance, of patients (r = 0.63, p = 0.01). Physical activity (overall) reported subjectively was not significantly different between groups (Overall IPAQ median score: 2153 vs. 3230 MET.min.week-1; p = 0.32). However, 87% of patients reported doing no vigorous physical activity compared to 50% in controls (vigorous activity IPAQ; p < 0.01). There were no significant correlations between daily step count and fatigue, dyspnoea, health status, lung function and self reported physical activity (IPAQ). Conclusion Physical activity is significantly reduced in sarcoidosis compared to healthy subjects. Objective measures of physical activity assess a unique dimension of health in the patient’s own environment that is not captured by existing clinical tools and should be further investigated. Abstract P197 Figure 1. Mean (SD) daily step count assessed with ActivPal.