Fabio Pitta

An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease

Field walking tests are commonly employed to evaluate exercise capacity, assess prognosis and evaluate treatment response in chronic respiratory diseases. In recent years, there has been a wealth of new literature pertinent to the conduct of the 6-min walk test (6MWT), and a growing evidence base describing the incremental and endurance shuttle walk tests (ISWT and ESWT, respectively). The aim of this document is to describe the standard operating procedures for the 6MWT, ISWT and ESWT, which can be consistently employed by clinicians and researchers. The Technical Standard was developed by a multidisciplinary and international group of clinicians and researchers with expertise in the application of field walking tests. The procedures are underpinned by a concurrent systematic review of literature relevant to measurement properties and test conduct in adults with chronic respiratory disease. Current data confirm that the 6MWT, ISWT and ESWT are valid, reliable and responsive to change with some interventions. However, results are sensitive to small changes in methodology. It is important that two tests are conducted for the 6MWT and ISWT. This Technical Standard for field walking tests reflects current evidence regarding procedures that should be used to achieve robust results. Technical Standard document: standard operating procedures for the 6MWT, ISWT and ESWT in chronic respiratory disease http://ow.ly/Bq2B9

An official European Respiratory Society statement on physical activity in COPD

This European Respiratory Society (ERS) statement provides a comprehensive overview on physical activity in patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary Task Force of experts representing the ERS Scientific Group 01.02 “Rehabilitation and Chronic Care” determined the overall scope of this statement through consensus. Focused literature reviews were conducted in key topic areas and the final content of this Statement was agreed upon by all members. The current knowledge regarding physical activity in COPD is presented, including the definition of physical activity, the consequences of physical inactivity on lung function decline and COPD incidence, physical activity assessment, prevalence of physical inactivity in COPD, clinical correlates of physical activity, effects of physical inactivity on hospitalisations and mortality, and treatment strategies to improve physical activity in patients with COPD. This Task Force identified multiple major areas of research that need to be addressed further in the coming years. These include, but are not limited to, the disease-modifying potential of increased physical activity, and to further understand how improvements in exercise capacity, dyspnoea and self-efficacy following interventions may translate into increased physical activity. The Task Force recommends that this ERS statement should be reviewed periodically (e.g. every 5–8 years). An official ERS statement providing a comprehensive overview on physical activity in patients with COPD http://ow.ly/C6v78

An official systematic review of the European Respiratory Society/American Thoracic Society: measurement properties of field walking tests in chronic respiratory disease

This systematic review examined the measurement properties of the 6-min walk test (6MWT), incremental shuttle walk test (ISWT) and endurance shuttle walk test (ESWT) in adults with chronic respiratory disease. Studies that report the evaluation or use of the 6MWT, ISWT or ESWT were included. We searched electronic databases for studies published between January 2000 and September 2013. The 6-min walking distance (6MWD) is a reliable measure (intra-class correlation coefficients ranged from 0.82 to 0.99 in seven studies). There is a learning effect, with greater distance walked on the second test (pooled mean improvement of 26 m in 13 studies). Reliability was similar for ISWT and ESWT, with a learning effect also evident for ISWT (pooled mean improvement of 20 m in six studies). The 6MWD correlates more strongly with peak work capacity (r=0.59–0.93) and physical activity (r=0.40–0.85) than with respiratory function (r=0.10–0.59). Methodological factors affecting 6MWD include track length, encouragement, supplemental oxygen and walking aids. Supplemental oxygen also affects ISWT and ESWT performance. Responsiveness was moderate to high for all tests, with greater responsiveness to interventions that included exercise training. The findings of this review demonstrate that the 6MWT, ISWT and ESWT are robust tests of functional exercise capacity in adults with chronic respiratory disease. Systematic review: support for use of the 6MWT, ISWT and ESWT in adults with chronic respiratory disease http://ow.ly/Bq2Mz

Resistance Training Prevents Deterioration in Quadriceps Muscle Function During Acute Exacerbations of Chronic Obstructive Pulmonary Disease

RATIONALE Exacerbations of chronic obstructive pulmonary disease (COPD) acutely reduce skeletal muscle strength and result in long-term loss of functional capacity. OBJECTIVES To investigate whether resistance training is feasible and safe and can prevent deteriorating muscle function during exacerbations of COPD. METHODS Forty patients (FEV(1) 49 +/- 17% predicted) hospitalized with a severe COPD exacerbation were randomized to receive usual care or an additional resistance training program during the hospital admission. Patients were followed up for 1 month after discharge. Primary outcomes were quadriceps force and systemic inflammation. A muscle biopsy was taken in a subgroup of patients to assess anabolic and catabolic pathways. MEASUREMENTS AND MAIN RESULTS Resistance training did not yield higher systemic inflammation as indicated by C-reactive protein levels and could be completed uneventfully. Enhanced quadriceps force was seen at discharge (+9.7 +/- 16% in the training group; -1 +/- 13% in control subjects; P = 0.05) and at 1 month follow-up in the patients who trained. The 6-minute walking distance improved after discharge only in the group who received resistance training (median 34; interquartile range, 14-61 m; P = 0.002). In a subgroup of patients a muscle biopsy showed a more anabolic status of skeletal muscle in patients who followed training. Myostatin was lower (P = 0.03) and the myogenin/MyoD ratio tended to be higher (P = 0.08) in the training group compared with control subjects. CONCLUSIONS Resistance training is safe, successfully counteracts skeletal muscle dysfunction during acute exacerbations of COPD, and may up-regulate the anabolic milieu in the skeletal muscle. Clinical trial registered with www.clinicaltrials.gov (NCT00877084).

Perfil do nível de atividade física na vida diária de pacientes portadores de DPOC no Brasil

OBJECTIVE: To evaluate characteristics of physical activities in daily life in COPD patients in Brazil, correlating those characteristics with physiological variables. METHODS: Physical activities in daily life were evaluated in 40 COPD patients (18 males; 66 ± 8 years of age; FEV1 = 46 ± 16 % of predicted; body mass index = 27 ± 6 kg/m2) and 30 healthy age- and gender-matched subjects, using a multiaxial accelerometer-based sensor for 12 h/day on two consecutive days. We also assessed maximal and functional exercise capacity, using the incremental exercise test and the six-minute walk test (6MWT), respectively; MIP and MEP; peripheral muscle force, using the one-repetition maximum test and the handgrip test; quality of life, using the Saint Georges Respiratory Questionnaire (SGRQ); functional status, using the London Chest Activity of Daily Living questionnaire; and dyspnea sensation, using the Medical Research Council (MRC) scale. RESULTS: Mean walking time/day was shorter for COPD patients than for the controls (55 ± 33 vs. 80 ± 28 min/day; p = 0.001), as movement intensity was lower (1.9 ± 0.4 vs. 2.3 ± 0.6 m/s2; p = 0.004). The COPD patients also tended to spend more time seated (294 ± 114 vs. 246 ± 122 min/day, p = 0.08). Walking time/day correlated with the 6MWT (r = 0.42; p = 0.007) and maximal workload (r = 0.41; p = 0.009), as well as with age, MRC scale score and SGRQ activity domain score (-0.31 < r < -0.43; p < 0.05 for all). CONCLUSIONS: This sample of Brazilian patients with COPD, although more active than those evaluated in studies conducted in Europe, were less active than were the controls. Walking time/day correlated only moderately with maximal and functional exercise capacity.

Relationship between pulmonary function and physical activity in daily life in patients with COPD

BACKGROUND It remains unclear how closely the physical inactivity observed in patients with Chronic Obstructive Pulmonary Disease (COPD) relates to the severity of their airflow limitation. Furthermore, it is unknown whether spirometric variables such as maximal voluntary ventilation (MVV) and inspiratory capacity (IC) reflect the level of physical activity in daily life better than the forced expiratory volume in the first second (FEV(1)), the main spirometric variable used to determine the severity of COPD. The objective of the present study was to investigate the relationship between physical activity in daily life and the severity of COPD assessed by different spirometric variables: MVV, IC and FEV(1). METHODS Forty patients with COPD (21 men; 68+/-7 years; FEV(1) 41+/-14% predicted) were performed spirometry and assessment of the physical activity level in daily life using an accelerometer (SenseWear Armband). RESULTS MVV was significantly correlated to total energy expenditure per day, energy expenditure per day in activities demanding more than 3 metabolic equivalents (METs), number of steps per day and time spent per day in moderate and vigorous activities (0.42<or=r<or=0.52; p<0.01 for all). Correlation of these variables with IC and especially FEV(1) was more modest, borderline or not statistically significant. There was no difference in time spent in vigorous activities among patients classified according to the FEV(1)-based GOLD stages II, III and IV, differently than that observed when patients were classified in groups according to their MVV. CONCLUSION In COPD patients, MVV better reflects the physical activity level in daily life than FEV(1) and IC.

An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation

RATIONALE Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients. OBJECTIVES The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide. METHODS Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS. MAIN RESULTS This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR. CONCLUSIONS The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.

Differences in content and organisational aspects of pulmonary rehabilitation programmes

The aim was to study the overall content and organisational aspects of pulmonary rehabilitation programmes from a global perspective in order to get an initial appraisal on the degree of heterogeneity worldwide. A 12-question survey on content and organisational aspects was completed by representatives of pulmonary rehabilitation programmes that had previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Rehabilitation and Chronic Care and/or Physiotherapists Scientific Groups, all members of the American Association of Cardiovascular and Pulmonary Rehabilitation, and all American Thoracic Society Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings. The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programmes across continents for all aspects that were surveyed, including the setting, the case mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral and types of reimbursement. The current findings stress the importance of future development of processes and performance metrics to monitor pulmonary rehabilitation programmes, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice. Differences in aspects of pulmonary rehabilitation programmes suggest caution in generalisation of research findings http://ow.ly/qOJhl

Reference equations for the six-minute walk distance based on a Brazilian multicenter study

Background It is important to include large sample sizes and different factors that influence the six-minute walking distance (6MWD) in order to propose reference equations for the six-minute walking test (6MWT). Objective To evaluate the influence of anthropometric, demographic, and physiologic variables on the 6MWD of healthy subjects from different regions of Brazil to establish a reference equation for the Brazilian population. Method In a multicenter study, 617 healthy subjects performed two 6MWTs and had their weight, height, and body mass index (BMI) measured, as well as their physiologic responses to the test. Delta heart rate (∆HR), perceived effort, and peripheral oxygen saturation were calculated by the difference between the respective values at the end of the test minus the baseline value. Results Walking distance averaged 586±106m, 54m greater in male compared to female subjects (p<0.001). No differences were observed among the 6MWD from different regions. The quadratic regression analysis considering only anthropometric and demographic data explained 46% of the variability in the 6MWT (p<0.001) and derived the equation: 6MWDpred=890.46-(6.11×age)+(0.0345×age2)+(48.87×gender)-(4.87×BMI). A second model of stepwise multiple regression including ∆HR explained 62% of the variability (p<0.0001) and derived the equation: 6MWDpred=356.658-(2.303×age)+(36.648×gender)+(1.704×height)+(1.365×∆HR). Conclusion The equations proposed in this study, especially the second one, seem adequate to accurately predict the 6MWD for Brazilians.

Comparison of daily physical activity between COPD patients from Central Europe and South America

BACKGROUND In healthy elderly and adults, lower physical activity level in daily life has been associated with lower socio-economic level and non-Caucasian race. The objective of this study was to determine if this is also applicable in chronic obstructive pulmonary disease (COPD) by comparing physical activity levels in daily life in stable patients from two countries (Austria and Brazil) with different socio-economic and ethnic characteristics. METHODS Physical activity in daily life was objectively assessed in 40 Austrian and 40 Brazilian COPD patients. Groups were matched for age, gender, body mass index, disease severity, smoking history, presence of concomitant heart disease, lung function, dyspnea and functional exercise capacity. In addition, climatic conditions were similar during the period of data collection in the two groups. RESULTS In comparison to Brazilian patients, Austrian patients had a significantly lower walking time (p=0.04), higher sitting time (p=0.02) and lower movement intensity (p=0.0001). The proportion of patients who did not reach an average of 30min of walking per day was 48% in the Austrian group and 23% in the Brazilian group. CONCLUSIONS Austrian patients with COPD showed a significantly lower daily physical activity level in comparison to matched Brazilian patients. Socio-economic and ethnic factors appear to influence stable COPD patients differently than described in previous studies including healthy subjects.