Kris Ides

Airway clearance in COPD : need for a breath of fresh air? A systematic review

Background: Airway clearance is a key component of respiratory physiotherapy management for patients with excess secretions, including patients with chronic obstructive pulmonary disease (COPD). The aim of this review is to give an overview of the available evidence for the use of different airway clearance techniques (ACT) and their effects in patients with COPD. Methods: A systematic literature search was performed on CEBAM, PUBMED, Cochrane CT, Science Direct and Biomed central data bases. After screening, a total of 26 articles were included. Results: Studies that provide solid evidence of the effectiveness of different airway clearance techniques in patients with COPD are rather scarce. The available evidence indicates that active breathing techniques, such as active cycle of breathing techniques, autogenic drainage and forced expiration, can be effective in the treatment of COPD. The evidence for passive techniques such as postural drainage and percussion is low. Supporting techniques such as intrapulmonary percussive ventilation, positive expiratory pressure and non-invasive ventilation have little evidence because of the small number of studies. Little evidence is found for the combined use of active techniques and supporting techniques such as (oscillating) positive expiratory pressure, postural drainage and vibration in COPD patients. There is clearly a need for well-powered controlled clinical trials on the long-term effects of (combined) airway clearance techniques in COPD.

The effects of long-term noninvasive ventilation in hypercapnic COPD patients: a randomized controlled pilot study

Introduction Noninvasive ventilation (NIV) is a well-established treatment for acute-on- chronic respiratory failure in hypercapnic COPD patients. Less is known about the effects of a long-term treatment with NIV in hypercapnic COPD patients and about the factors that may predict response in terms of improved oxygenation and lowered CO2 retention. Methods In this study, we randomized 15 patients to a routine pharmacological treatment (n = 5, age 66 [standard deviation ± 6] years, FEV1 30.5 [±5.1] %pred, PaO2 65 [±6] mmHg, PaCO2 52.4 [±6.0] mmHg) or to a routine treatment and NIV (using the Synchrony BiPAP device [Respironics, Inc, Murrsville, PA]) (n = 10, age 65 [±7] years, FEV1 29.5 [±9.0] %pred, PaO2 59 [±13] mmHg, PaCO2 55.4 [±7.7] mmHg) for 6 months. We looked at arterial blood gasses, lung function parameters and performed a low-dose computed tomography of the thorax, which was later used for segmentation (providing lobe and airway volumes, iVlobe and iVaw) and post-processing with computer methods (providing airway resistance, iRaw) giving overall a functional image of the separate airways and lobes. Results In both groups there was a nonsignificant change in FEV1 (NIV group 29.5 [9.0] to 38.5 [14.6] %pred, control group 30.5 [5.1] to 36.8 [8.7] mmHg). PaCO2 dropped significantly only in the NIV group (NIV: 55.4 [7.7] → 44.5 [4.70], P = 0.0076; control: 52.4 [6.0] → 47.6 [8.2], NS). Patients actively treated with NIV developed a more inhomogeneous redistribution of mass flow than control patients. Subsequent analysis indicated that in NIV-treated patients that improve their blood gases, mass flow was also redistributed towards areas with higher vessel density and less emphysema, indicating that flow was redistributed towards areas with better perfusion. There was a highly significant correlation between the % increase in mass flow towards lobes with a blood vessel density of >9% and the increase in PaO2. Improved ventilation–perfusion match and recruitment of previously occluded small airways can explain the improvement in blood gases. Conclusion We can conclude that in hypercapnic COPD patients treated with long-term NIV over 6 months, a mass flow redistribution occurs, providing a better ventilation–perfusion match and hence better blood gases and lung function. Control patients improve homogeneously in iVaw and iRaw, without improvement in gas exchange since there is no improved ventilation/perfusion ratio or increased alveolar ventilation. These differences in response can be detected through functional imaging, which gives a more detailed report on regional lung volumes and resistances than classical lung function tests do. Possibly only patients with localized small airway disease are good candidates for long-term NIV treatment. To confirm this and to see if better arterial blood gases also lead to better health related quality of life and longer survival, we have to study a larger population.

The Effect of Whole Body Vibration Short-Term Exercises on Respiratory Gas Exchange in Overweight and Obese Women

Abstract Aims: To assess the effect of whole body vibration on oxygen uptake and carbon dioxide production among overweight and obese women. Methods: In a randomized controlled trial, anthropometric measurements were taken in 20 adult overweight women. Ventilation of oxygen, carbon dioxide, and heart rate were measured using a portable gas-analysis system. After each exercise, a Borgs scale score was assessed. Exercises were performed on a vibration platform with a frequency of 35 Hz and with the intensity set on “high” (amplitude of 4 mm). Two dynamic exercises (squatting and calf raises) and one static exercise (standing) were performed during 3 minutes with and without vibration in a randomized order, with 10 minutes rest between exercises. Mean values of the third minute of exercise were compared. Results: Ventilation of oxygen and carbon dioxide were consistently, significantly higher in the exercises with vibration compared with the exercises without vibration. Borgs scale scores only showed a significant difference between calf raises with and without vibration. Conclusion: The addition of whole body vibration to both static and dynamic exercises appears to significantly increase oxygen uptake in overweight and obese women. More research is needed to determine the physiological pathway and clinical relevance of this increase.

Acute effects of intrapulmonary percussive ventilation in COPD patients assessed by using conventional outcome parameters and a novel computational fluid dynamics technique

Objective: Chest physiotherapy enhances sputum evacuation in COPD patients. It can be applied as a single technique or as a combination of techniques including intrapulmonary percussive ventilation (IPV). Recently developed assessment techniques may provide new insights into the effect of airway clearance techniques. Participants: Five moderate to severe COPD patients (three females and two males; mean forced expiratory volume in 1 second of 39.49% predicted) who were admitted in the hospital for an acute exacerbation were included in this study. Methods: A novel imaging technique was used, together with other conventional techniques, to visualize the short-term effects of a single IPV treatment in COPD patients. Results: No significant changes were noted in the lung function parameters or arterial blood gases measured within 1 hour after the end of the IPV session. Computed tomography images detected changes in the airway patency after the IPV treatment compared with before treatment. Local resistances, calculated for the three-dimensional models, showed local changes in airway resistance. Conclusion: The effects of a single IPV session can be visualized by functional imaging. This functional imaging allows a calculation of changes in local airway resistance and local changes in airway volume in COPD patients without affecting conventional lung function parameters.

Pulmonary rehabilitation and non-invasive ventilation in COPD.

Abstract A multidisciplinary pulmonary rehabilitation program has become an important part of the treatment of chronic obstructive pulmonary disease. It can improve both exercise tolerance and health related quality of life in these patients (1). Exercise training has to be included for the program to be successful (2,3). The intensity of the training is of great importance: there is more physiological benefit in high-intensity training, compared to moderate-intensity training (4). High-intensity training results in reduced levels of blood lactate and pulmonary ventilation at a given heavy work rate (5). High-intensity training is limited in COPD patients because of exercise-induced dyspnoea. Flow limitation, as a consequence of increased ventilatory demands of exercise, causes a breathing pattern with greater demands on their inspiratory muscles: this results in a pattern of low tidal volume and high-frequency breathing. Increased inspiratory muscle work causes dyspnoea and limitation in exercise intensity (6). Artificial ventilatory assistance could improve exercise tolerance and hence help severe COPD patients to achieve a higher level of training (7). It could help to unload and assist the overburdened ventilatory muscles and give a possibility for higher levels of exercise intensity. In this review article we will discuss the effectiveness and feasibility of training with ventilatory aids.

The effect of intrapulmonary percussive ventilation in pediatric patients: A systematic review

Intrapulmonary percussive ventilation (IPV) is frequently used in clinical practice to enhance sputum evacuation and lung recruitment. However, the evidence in different respiratory pathologies, especially in children, is still lacking. This systematic review aims to enlist the effectiveness of IPV as an airway clearance technique in pediatric patients.

S108 The Effect of an Interdisciplinary Rehabilitation Programme on Daily Physical Activity For Patients with Less Advanced COPD in a Primary Care Setting: A Systematic Review

Introduction The natural course of COPD is characterised by progressive airflow limitation and complicated by the development of systemic consequences and co-morbidities. Daily physical inactivity (DPA) is believed to mediate those systemic consequences or co-morbidities. Recent research demonstrates that even in the early stages of COPD, DPA plays a role in developing systemic consequences and co-morbidities. Hence, interventions that enhance or maintain DPA in this population, such as pulmonary rehabilitation (PR), should be considered. Due to the low accessibility and high cost of PR in a specialised care setting, rehabilitation in primary care could be an added value for patients with less advanced COPD. related problems. Despite the widespread believe in the benefits of PR in a primary care setting, it remains unclear if such PR programmes are (cost) effective for patients with less advanced COPD Objective To evaluate data from clinical trials assessing the effect of PR in primary care for patients with less advanced COPD on DPA, exercise capacity (EC) and quality-of-life (QoL). Methods The electronic databases PEDro, CENTRAL, Pubmed and EMBASE were searched. Only randomised and controlled clinical trials were eligible for inclusion, provided they investigated the effects of interdisciplinary PR in primary care for patients with less advanced COPD (GOLD I-II). Independent data extraction was performed by two authors. Risk of bias was rated using the Cochrane Collaboration ‘Risk of bias’ tool. Primary outcome is the level of DPA, secondary outcomes are EC and QoL. Results Eight studies were found and methodological quality is displayed in table 1. One study objectively measured DPA by a pedometer and showed a significant improvement in DPA. EC was significantly improved in 7/8 studies. QoL is measured in all 8 studies, 3/8 had a significant improvement and two revealed to have clinical relevant effect on QoL. Abstract S108 Table 1 Conclusions PR in primary care for patients with less advanced COPD improves EC and QoL and could be beneficial in improving DPA. Since recent insights in the systemic burden of COPD and the role of DPA in this matter, future research must focus on the transfer of PR benefits to DPA, including a cost-effective analysis.