Gerd Martinez

A Comparison of the Assessment of Quality of Life with CAT, CCQ, and SGRQ in COPD Patients Participating in Pulmonary Rehabilitation

Abstract Background: The aim of this study was to compare the COPD specific health-related quality of life (HR-QoL) instruments, the St Georges Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT), and COPD Clinical Questionnaire (CCQ), in terms of feasibility and correlations in COPD patients participating in pulmonary rehabilitation (PR). Methods/materials: Ninety consecutive patients with mainly severe COPD who participated in a 7-week PR programme were assessed with CAT, CCQ, SGRQ. In addition to evaluating the scores obtained by the questionnaires we also assessed the need of help and the time needed to complete the questionnaires. Results: Patients had mean FEV1 = 38.7% of predicted value and poor quality of life (mean SGRQ total score 51.1, CAT 1.81, and CCQ 26.5 units). There were good correlations between the overall scores for the three HR-QoL instruments: CAT versus CCQ, r = 0.77; CAT versus SGRQ, r = 0.73; and CCQ versus SGRQ, r = 0.75 (p < 0.001 for all correlations). The average time to complete the questionnaires was 578 seconds for SGRQ, 107 seconds for CAT, and 134 seconds for CCQ. The need for assistance while answering the questionnaire was 86.5% for SGRQ, 53.9% for CAT, and 36.0% for CCQ. Conclusions : we observed a good correlation between the SGRQ, CCQ and CAT in this group of patients with severe COPD undergoing pulmonary rehabilitation. We found that CAT and CCQ have the advantage of being easier and faster to complete than the SGRQ. The need for help with the completion of the questionnaires was especially seen in patients with low education level.

Long-term effects of 1-year maintenance training on physical functioning and health status in patients with COPD: A randomized controlled study.

PURPOSE To examine whether maintenance training (MT) for 1 year improved the long-term effects of a 7-week chronic obstructive pulmonary disease (COPD) rehabilitation program. METHODS After a 7-week outpatient rehabilitation program, 96 patients with COPD were randomized to either an MT group (n = 55) or a control group (n = 41). Both groups were requested to continue unsupervised training at home. The MT group received weekly supervised training the first 6 months, supervised training every second week the next 6 months, and finally no supervised training the last 6 months of the 18-month study period. Primary effect parameters were Endurance Shuttle Walk Test (ESWT) time and health status (St. Georges Respiratory Questionnaire, SGRQ). Secondary effect parameters were adherence to supervised training, dropout rates, and hospitalization. RESULTS Compared with the control group, the MT group had significantly better ESWT times at 3 and 6 months (+43.9 seconds; P= .03, and +75.1 seconds; P= .02) and insignificantly higher ESWT time at 12 months (+66.6 seconds; P= .40). SGRQ total score declined gradually after the 7-week program with no difference between the 2 groups, and after 18 months, the score was 1.7 units (95% confidence interval: −0.7 to 4.1) worse than at randomization. There was no difference between the 2 groups regarding dropout rates or hospitalization. DISCUSSION Weekly MT for 12 months improved walking time but had no influence on health-related quality of life or hospital admissions, compared with unsupervised daily training at home. The effect of the MT was closely related to adherence to the program.

Rehabilitation in COPD: the long-term effect of a supervised 7-week program succeeded by a self-monitored walking program.

Pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) improves exercise tolerance and health status, however, these effects have been shown to decline after termination of the rehabilitation program. This study has examined the long-term effect of a 7-week supervised rehabilitation program combined with daily self-monitored training at home on exercise tolerance and health status. Two hundred and nine consecutive COPD patients who had completed a 7-week pulmonary rehabilitation program were assessed with endurance shuttle walk test (ESWT) and the St Georges Respiratory Questionnaire (SGRQ) at baseline, 0, 3, and 12 months after the program. Sixty-eight (32.5%) patients did not attend the 1-year follow-up. Among the 141 patients who competed the 1-year evaluation, the initial improvement after the 7-week program in the ESWT time was 180 s or 101% (p = 0.001) and in SGRQ 3.4 units (p = 0.001). These effects were maintained at the 1-year evaluation (ESWT 59% above baseline; p < 0.001 and improved SGRQ 3.0 units compared with baseline; p = 0.011). The 31 patients who attended the 6-month, but not the 12-month evaluation, improved ESWT time by 96 s (p = 0.02) without any change in SGRQ +2.0 (p = 0.40). A relative simple and inexpensive 7-week supervised rehabilitation program combined with daily self-monitored training at home was able to maintain significant improvement in exercise tolerance and health status throughout 1 year. Death and hospital admissions due to acute exacerbations were the main reasons for non-attendance in the follow-up period.

Vitamin D Status in Patients With Chronic Obstructive Pulmonary Disease Who Participate in Pulmonary Rehabilitation

PURPOSE Vitamin D deficiency is common in patients with chronic obstructive pulmonary disease; however, no study has evaluated the influence of vitamin D status on effects of pulmonary rehabilitation (PR). METHODS We studied 311 patients, who participated in a 7-week outpatient PR. Vitamin D status was assessed at entry and examined for association with patient characteristics, dropout from PR, and effect on endurance shuttle walk time. RESULTS Vitamin D level 25 nM was seen in 61 (19.6%) of the patients. They were significantly younger, were more frequently on long-term oxygen therapy, had higher body mass index and fat-free mass index, had worse quality of life score, tended to have lower percent predicted value for forced expiratory volume in the first second of expiration, and more frequently were current smokers. They had a 3-time higher risk of dropout from the PR program (P = .003) compared with patients with normal vitamin D status and a poorer improvement in endurance shuttle walk time (P = .03). DISCUSSION In conclusion, vitamin D deficiency was significantly associated with higher dropout rates from PR, and there was a tendency toward a poorer improvement in endurance shuttle walk time.

Validation of the i-BODE Index as a Predictor of hospitalization and Mortality in Patients with COPD Participating in Pulmonary Rehabilitation

Abstract The aim of this study was to examine the value of the i-BODE index to predict hospital admission and to confirm its usefulness to predict mortality in a Danish population. The incremental shuttle walking test (ISWT) is widely used in the UK and Europe and previous work has examined the replacement of the 6MWT with the ISWT within the BODE index for predicting the prognosis of COPD (i-BODE). The 674 patients included in the analysis participated in a 7-week pulmonary rehabilitation program from 2002 to 2011. The National Health Services Central Register ascertained vital status and provided information on all hospital admissions. The mean follow-up period was 66 months (range 11–118 months). Cox proportional hazards model was used to identify factors that significantly predicted mortality and time to first hospital admission. The i-BODE index as well as body mass index, MRC dyspnea grade, and exercise capacity (ISWT) were significantly associated with all-cause mortality. The adjusted hazard ratio for death per one point increase in the i-BODE score was 1.28 (95% confidence interval 1.20 to 1.37). The i-BODE index was also a significant predictor of hospitalization, both for all causes and COPD exacerbation. Patients in the highest i-BODE quartile had a median time to first hospitalization of 17 months compared to 51 months for patients in the lowest quartile. The i-BODE index is a significant predictor of hospital admission and thus health care utilization, and also mortality.

The long-term effect of ambulatory oxygen in normoxaemic COPD patients: A randomised study

Aim: To study the long-term benefits of ambulatory oxygen (AO) in combination with pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) patients experiencing exertional desaturation. Patients and methods: Normoxaemic COPD who participated in outpatient PR and desaturated >4% and <90% during endurance shuttle walk test (ESWT) were randomised to control (n = 23) or AO 2 L/min from a portable oxygen concentrator (n = 22) to be used during exercise. PR consisted of supervised training for 20 weeks combined with unsupervised daily training at home followed by 13 weeks without supervised training. Results: Only 45 of 165 eligible patients wanted to participate. Mean forced expiratory volume in 1 s = 32% (SD 13.8) and Medical Research Council (MRC) = 4.5 (3–5). Supplemental oxygen improved oxygen saturation during ESWT by 2.3% (95% CI: 1.2%–3.5%; p < 0.001). In the study period of 33 weeks, 10 and 6 patients withdrew from the AO group and control group, respectively. Patients spent an average of 7.9 h/week on oxygen. PR improved ESWT by 18,076 s (95% CI: 101–258 s; p < 0.001) and St. George’s Respiratory Questionnaire (SGRQ) score by 2.6 units (95% CI: 0.1–5.1 s; p = 0.04) after 7 weeks, and these gains remained at 33 weeks of evaluation. There were no differences between the AO group and control group at 33 weeks of evaluation with regard to change in ESWT (223 vs. 241 s; p = 0.32), change in SGRQ (−3.6 vs. −4.5 units, 0.91), and number of patients with acute exacerbation in COPD (AECOPD), hospital admission or dropout (17 of 22 vs. 20 of 23, p = 0.59). Conclusions: AO seems not to provide additional beneficial effects in patients with COPD participating in pulmonary rehabilitation and experiencing exertional desaturation without severe resting hypoxaemia.

Prognostic Value of C-Reactive Protein, Leukocytes, and Vitamin D in Severe Chronic Obstructive Pulmonary Disease

Inflammatory biomarkers predict mortality and hospitalisation in chronic obstructive pulmonary disease (COPD). Yet, it remains uncertain if biomarkers in addition to reflecting disease severity add new prognostic information on severe COPD. We investigated if leukocytes, C-reactive protein (CRP), and vitamin D were independent predictors of mortality and hospitalisation after adjusting for disease severity with an integrative index, the i-BODE index. In total, 423 patients participating in a pulmonary rehabilitation programme, with a mean value of FEV1 of 38% of predicted, were included. Mean followup was 45 months. During the follow-up period, 149 deaths (35%) were observed and 330 patients (78.0%) had at least one acute hospitalisation; 244 patients (57.7%) had at least one hospitalisation due to an exacerbation of COPD. In the analysis (Cox proportional hazards model) fully adjusted for age, sex, and i-BODE index, the hazard ratio for 1 mg/L increase in CRP was 1.02 (P = 0.003) and for 1 × 109/L increase in leukocytes was 1.43 (P = 0.03). Only leukocyte count was significantly associated with hospitalisation. Vitamin D was neither associated with mortality nor hospitalisation. Leukocytes and CRP add little information on prognosis and vitamin D does not seem to be a useful biomarker in severe COPD in a clinical setting.

Characterization of serological neo-epitope biomarkers reflecting collagen remodeling in clinically stable chronic obstructive pulmonary disease.

OBJECTIVES Chronic obstructive pulmonary disease (COPD) is characterized by chronic inflammation that leads to excessive remodeling of the lung extracellular matrix (ECM), resulting in release of protein fragments (neo-epitopes) to the blood. Serological markers assessing this have previously been associated with exacerbations of COPD. However, characterization of these in individuals with clinically stable COPD is lacking. The aim of this study was to characterize the collagen remodeling in stable COPD by the serological assessment of neo-epitopes. DESIGN AND METHODS Sixty-eight subjects with clinically stable COPD were included into the study at baseline, and 27 came back for a four weeks follow-up visit. Serum and plasma levels of neo-epitopes were assessed for the evaluation of collagen type III (C3M), IV (C4M, C4Ma3, P4NP 7S), and VI (C6M, Pro-C6) remodeling. RESULTS C3M, C4M, C4Ma3, P4NP 7S, and C6M levels were significantly elevated in COPD subjects compared with healthy controls (p<0.0001 to p=0.044). Each neo-epitope biomarker was significantly correlated between serum and plasma (p<0.0001) and most biomarkers were stable in the majority of patients from baseline to week four. Serum C6M levels were weakly correlated with FEV1% predicted (r=-0.274, p=0.025) and serum Pro-C6 levels were elevated in subjects with previous exacerbations (p=0.014). C3M, C4Ma3, C6M, and P4NP 7S were weakly correlated with MRC dyspnea scores (p<0.01). No associations were seen with BMI, smoking, duration of COPD, blood oxygen saturation, shuttle walk test distance, GOLD grades, or CAT scores. CONCLUSIONS Serological biomarkers of collagen remodeling were elevated in subjects with COPD as compared with healthy individuals. Biomarker levels were significantly correlated with measures of dyspnea, indicating a relationship with degree of symptoms, while only C6M showed a weak but significant association with lung function. Biomarker levels were not related to GOLD grades, which was in line with previous studies indicating that ECM remodeling may be related to disease activity rather than severity.