Klaus Kenn

S2k-Leitlinie zur Diagnostik und Therapie von Patienten mit Asthma

The present guideline is a new version and an update of the guideline for the diagnosis and treatment of asthma, which replaces the previous version for german speaking countries from the year 2006. The wealth of new data on the pathophysiology and the phenotypes of asthma, and the expanded spectrum of diagnostic and therapeutic options necessitated a new version and an update. This guideline presents the current, evidence-based recommendations for the diagnosis and treatment of asthma, for children and adolescents as well as for adults with asthma.

Noninvasive ventilation in pulmonary rehabilitation of COPD patients

Noninvasive positive pressure ventilation (NIPPV) has been shown to improve exercise tolerance and health-related quality of life in patients with advanced COPD. This study tested the feasibility of nocturnal NIPPV as an additional tool in a hospital-based pulmonary rehabilitation program. This prospective observational trial included forty COPD patients in GOLD stage IV. NIPPV was successfully introduced and accepted during sleep by all patients. All patients received pressure support ventilation for 7.9+/-0.5h per day with an inspiratory support of 17.5+/-4.4 cmH(2)O, and an expiratory pressure of 4.5+/-0.9 cmH(2)O. The outcome of pulmonary rehabilitation in patients receiving nocturnal NIPPV was compared with the results of forty matched control patients who underwent the same program. Rehabilitation with nocturnal NIPPV resulted in the 6-minute walk test and in the longest non-stop walk distance in improvements of 82 and 89 m, respectively, while patients without nocturnal ventilatory support improved by 50 and 51 m (p<0.04 and p<0.03 between groups, respectively). Further significant improvements were found for FEV(1), lung hyperinflation, and blood gases in the NIPPV treated, but not in the control subjects. Health-related quality of life, assessed by the SF-36 questionnaire, improved moderately or largely in patients receiving NIPPV in the categories role-physical, vitality, social function, and mental health. Control subjects improved moderately in vitality only. In conclusion, nocturnal NIPPV is feasible and enhances the effects of pulmonary rehabilitation in advanced stage COPD.

Interval versus continuous training in lung transplant candidates: a randomized trial.

BACKGROUND Interval (IT) and continuous training (CT) represent well-established exercise modalities in patients with moderate to severe chronic obstructive pulmonary disease (COPD). However, their effects and feasibility in patients with end-stage COPD remain unclear. METHODS Sixty patients (53 ± 6 years, 53% women) being evaluated for lung transplantation where randomly assigned either to IT (n = 30, cycling at 100% peak work rate for 30 seconds alternating with 30 seconds of rest) or CT (n = 30, cycling at 60% of peak work rate) during a 3-week inpatient rehabilitation program. Both exercise protocols yielded an equivalent amount of total work. Patients had a mean forced expiratory volume at 1 second (FEV(1)) of 25% ± 8% of predicted value. RESULTS Patients in both groups achieved similar clinically relevant improvements in 6-minute walking distance of 35 ± 29 meters for IT and 36 ± 43 meters for CT, with a between-group difference of 0.3 meters (95% confidence interval, -18.2 to 18.8). Changes in lung function parameters were not significant. Perceived intensity of dyspnea was significantly (p < 0.05) lower in IT (Borg 6.2 ± 1.8) compared with CT (Borg 7.1 ± 1.7). Patients required a median of 5 unintended breaks (interquartile range, 2-28) during IT exercise and 29 (interquartile range, 6-68) during CT (p < 0.001). CONCLUSIONS IT is associated with a lower intensity of dyspnea during exercise and fewer unintended breaks but achieves similar improvements in exercise capacity compared with CT in pre-lung transplant COPD patients.

Inspiratory muscle training protocol for patients with chronic obstructive pulmonary disease (IMTCO study): a multicentre randomised controlled trial

Introduction Inspiratory muscle training (IMT) has been applied during pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). However, it remains unclear if the addition of IMT to a general exercise training programme leads to additional clinically relevant improvements in patients with COPD. In this study, we will investigate whether the addition of IMT to a general exercise training programme improves 6 min walking distance, health-related quality of life, daily physical activity and inspiratory muscle function in patients with COPD with inspiratory muscle weakness. Methods and analysis Patients with COPD (n=170) with inspiratory muscle weakness (Pi,max <60 cm H2O or <50%pred) will be recruited to a multicentre randomised placebo controlled trial of IMT and allocated into one of the two groups. Patients in both groups will follow a 3 month general exercise training programme, in combination with home-based IMT. IMT will be performed with a recently developed device (POWERbreathe KH1). This device applies an inspiratory load that is provided by an electronically controlled valve (variable flow resistive load). The intervention group (n=85) will undertake an IMT programme at a high intensity (≥50% of their Pi,max), whereas the placebo group (n=85) will undertake IMT at a low training intensity (≤10% of Pi,max). Total daily IMT time for both groups will be 21 min (6 cycles of 30 breaths). Improvement in the 6 min walking distance will be the primary outcome. Inspiratory muscle function, health-related quality of life and daily physical activity will be assessed as secondary outcomes. Ethics and dissemination Ethics approval has been obtained from relevant centre committees and the study has been registered in a publicly accessible clinical trial database. The results will be easily interpretable and should immediately be communicated to healthcare providers, patients and the general public. Results This can be incorporated into evidence-based treatment recommendations for clinical practice. ClinicalTrials.gov NCT01397396.

Benefits of whole body vibration training in patients hospitalised for COPD exacerbations - a randomized clinical trial

BackgroundPatients with stable COPD show improvements in exercise capacity and muscular function after the application of whole body vibration. We aimed to evaluate whether this modality added to conventional physiotherapy in exacerbated hospitalised COPD patients would be safe and would improve exercise capacity and quality of life.Methods49 hospitalised exacerbated COPD patients were randomized (1:1) to undergo physiotherapy alone or physiotherapy with the addition of whole body vibration. The primary endpoint was the between-group difference of the 6-minute walking test (day of discharge – day of admission). Secondary assessments included chair rising test, quality of life, and serum marker analysis.ResultsWhole body vibration did not cause procedure-related adverse events. Compared to physiotherapy alone, it led to significantly stronger improvements in 6-minute walking test (95.55 ± 76.29 m vs. 6.13 ± 81.65 m; p = 0.007) and St. Georges Respiratory Questionnaire (-6.43 ± 14.25 vs. 5.59 ± 19.15, p = 0.049). Whole body vibration increased the expression of the transcription factor peroxisome proliferator receptor gamma coactivator-1-α and serum levels of irisin, while it decreased serum interleukin-8.ConclusionWhole body vibration during hospitalised exacerbations did not cause procedure-related adverse events and induced clinically significant benefits regarding exercise capacity and health-related quality of life that were associated with increased serum levels of irisin, a marker of muscle activity.Trial registrationGerman Clinical Trials Register DRKS00005979. Registered 17 March 2014.

Pulmonary Rehabilitation in Patients with Idiopathic Pulmonary Fibrosis - A Review

Among the various types of interstitial lung diseases, idiopathic pulmonary fibrosis (IPF) is the most common disorder and has a poor prognosis and a limited response to pharmacological treatment. In patients with IPF, functional exercise tolerance and quality of life have been shown to be significantly decreased. Current IPF guidelines suggest only a weak recommendation for pulmonary rehabilitation (PR). However, PR is regarded as a reasonable choice for the majority of patients with IPF. This review will summarize all of the available studies that have investigated the effects of PR in patients with IPF so far. Although only a small number of studies have been published to date, most studies have found significant short-term improvements in functional exercise capacity, quality of life, and level of perceived dyspnea. Long-term improvements or maintenance strategies of PR in IPF patients have not been adequately investigated yet. Up to now there is still no sufficient evidence for the recommendation of PR in IPF. However, physical training seems to be the major component of all PR programs. The current review will discuss potential exercise training regimens for patients with IPF and suggest additional useful modalities of a specific multidisciplinary PR program for IPF patients. Based on the current literature and our own experience, this article will try to highlight the importance of PR as an additional, beneficial therapeutic option for patients with IPF.

Effect of inpatient rehabilitation on quality of life and exercise capacity in long-term lung transplant survivors: a prospective, randomized study.

BACKGROUND The purpose of this study was to examine the effect of an inpatient rehabilitation program on health-related quality of life (HRQOL) and exercise capacity (EC) in long-term (>1 year after lung transplantation) survivors (LTSs) in comparison to a control group (CG). METHODS Sixty LTSs, 4.5 ± 3.2 years after lung transplantation (LTx), were randomly assigned to two equally sized groups that were stratified for gender and underlying disease. Thirty LTSs (age 49 ± 13 years, 13 male and 17 females, 19 double LTxs, 7 BOS Stage ≥ 1) attended an inpatient rehabilitation program (intervention group, IG) for 23 ± 5 days. The CG (age 50 ± 12 years, 13 males and 17 females, 20 double LTxs, 2 BOS Stage ≥ 1) received medical standard therapy (physiotherapy). Patients were evaluated by cardiopulmonary exercise testing, 6-minute walk test (6MWT), SF-36, SGRQ and the Quality of Life Profile for Chronic Diseases questionnaire before and after (18 ± 3 days) the program. RESULTS The groups were statistically indistinguishable in terms of clinical data. Each treatment group significantly improved their sub-maximal EC (6MWT: IG, 493 ± 90 m vs 538 ± 90 m, p < 0.001; CG, 490 ± 88 m vs 514 ± 89 m, p < 0.001) and maximal EC (VO(2peak): IG, 17.0 vs 18.5 ml/min/kg, p = 0.039; CG, 18.0 vs 19.5 ml/min/kg, p = 0.005), without reaching statistical significance between the groups. In both study groups, patients HRQOL tended to improve. Significant correlations were found between EC parameters and HRQOL scales. CONCLUSIONS Our data suggest that structured physical training may improve exercise tolerance in LTS. Our study results did not demonstrate a significant benefit of an inpatient over an outpatient exercise program.

The impact of chronic obstructive pulmonary disease-related fears on disease-specific disability

Anxiety is frequently observed in persons with chronic obstructive pulmonary disease (COPD). Although anxiety in persons with COPD is multifaceted, it is mostly assessed as a general psychopathological condition. Consequently, the objectives of this study were to revise an existing questionnaire assessing relevant anxieties for use in clinical practice and research, to examine the association between COPD-related fears and disability, and finally to develop norms for COPD-related fears. Disease severity (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, use of long-term oxygen), sociodemographic characteristics, COPD-specific disability (COPD assessment test), and psychopathology (depression, general anxiety, somatoform symptoms, and disease-related fears) were obtained from a sample of 1025 individuals with COPD via the Internet. We used the COPD Anxiety Questionnaire (German: CAF) for the assessment of different fears that have been found to be relevant in COPD: fear of dyspnea, fear of physical activity, fear of progression, fear of social exclusion, and sleep-related worries. Mean COPD-specific disability was high (22.87). After explanatory and confirmatory factor analyses, a revised version of the CAF was constructed. The economical and user-friendly CAF-R showed adequate reliability and expected correlations with convergent and discriminant constructs. Gender-specific norms are provided for use in clinical practice and research. Even after controlling for GOLD stage, sociodemographic variables, and psychopathology, COPD-related fears contributed incrementally to disease-specific disability. The CAF-R is an economical and reliable tool to assess different specific fears in COPD. Results indicate that disease-specific fears have an impact on disability, supporting the assumption that detailed assessment of anxiety in COPD should be included in clinical practice.

Der COPD-Angst-Fragebogen (CAF): Ein neues Instrument zur Erfassung krankheitsspezifischer Ängste bei COPD-Patienten

The study aimed to construct a questionnaire for COPD specific anxiety. Anxiety is a prevalent comorbid complication in COPD; however, assessment has focused on anxiety questionnaires in general and not on COPD related fears. Ninety-six patients with COPD (GOLD III/IV) participated in the study. Results of a principal component analysis with Varimax-rotation suggested 5 factors, jointly explaining 64.7% of variance. These factors depict: fear of social isolation, dyspnea related fear, fear of movement, fear of progression of disease, anxiety in relationships, and fear of LTOT. Satisfying internal consistencies (a=0.77-0.89) resulted for all factors. Validity analyses confirmed discriminant and convergent associations, as well as correlations with functional tests. Overall, the COPD-Anxiety-Questionnaire constitutes a reliable and valid measure to assess COPD-related fears. Moreover, it enables the early identification of COPD patients suffering from disease related anxiety.

Predictors of success for pulmonary rehabilitation in patients awaiting lung transplantation.

Background Numerous studies have shown the effectiveness of comprehensive pulmonary rehabilitation (PR) programs in chronic obstructive pulmonary disease (COPD). At present, it is uncertain whether PR is also effective in the management of patients with various diseases awaiting lung transplantation (LTx). Methods In a retrospective clinical preanalysis and postanalysis, we investigated the effects of a 5-week inpatient PR in LTx candidates. We compared data of patients with COPD, &agr;-1-antitrypsin deficiency, interstitial lung disease, or cystic fibrosis before and after PR with regard to exercise capacity (6-min walking distance [6MWD]) and health-related quality of life (HRQL; SF36). Multivariate stepwise regression analysis was performed to detect predictors of PR outcome. Results Eight hundred eleven data sets from consecutive patients referred to our PR center before LTx could be analysed (COPD, 360; &agr;-1-antitrypsin deficiency, 127; interstitial lung disease, 195; cystic fibrosis, 69; other, 60). After PR 6MWD increased by 56 ± 58 m (P < 0.001), the physical summary component of SF36 (0–100) improved by 1.9 ± 8.5 points (P < 0.001), the mental summary component of SF36 by 8.7 ± 13.5 points (P < 0.001). Stepwise regression analysis yielded no relevant predictors of success or nonsuccess of PR with regard to age, sex, disease, body mass index, 6MWD, and HRQL on admission. Conclusion Short-term comprehensive PR can significantly improve exercise capacity and HRQL in LTx candidates to a clinically relevant extent independent of the underlying lung disease. No relevant predictor influencing PR outcome could be detected. Further research is needed to evaluate the relevance of PR before LTx and its impact on clinical outcome after transplantation.