Lauren Hogg

The COPD assessment test (CAT): response to pulmonary rehabilitation. A multicentre, prospective study

Background The COPD (chronic obstructive pulmonary disease) assessment test (CAT) is a recently introduced, simple to use patient-completed quality of life instrument that contains eight questions covering the impact of symptoms in COPD. It is not known how the CAT score performs in the context of clinical pulmonary rehabilitation (PR) programmes or what the minimum clinically important difference is. Methods The introduction of the CAT score as an outcome measure was prospectively studied by PR programmes across London. It was used alongside other measures including the St Georges Respiratory Questionnaire, the Chronic Respiratory Disease Questionnaire, the Clinical COPD Questionnaire, the Hospital Anxiety and Depression score, the Medical Research Council (MRC) dyspnoea score and a range of different walking tests. Patients completed a 5-point anchor question used to assess overall response to PR from ‘I feel much better’ to ‘I feel much worse’. Results Data were available for 261 patients with COPD participating in seven programmes: mean (SD) age 69.0 (9.0) years, forced expiratory volume in 1 s (FEV1) 51.1 (18.7) % predicted, MRC score 3.2 (1.0). Mean change in CAT score after PR was 2.9 (5.6) points, improving by 3.8 (6.1) points in those scoring ‘much better’ (n=162), and by 1.3(4.5) in those who felt ‘a little better’ (n=88) (p=0.002). Only eight individuals reported no difference after PR and three reported feeling ‘a little worse’, so comparison with these smaller groups was not possible. Conclusion The CAT score is simple to implement as an outcome measure, it improves in response to PR and can distinguish categories of response.

Effectiveness, Attendance, and Completion of an Integrated, System-Wide Pulmonary Rehabilitation Service for COPD: Prospective Observational Study

Abstract Pulmonary rehabilitation (PR) is one of the most effective treatments for COPD but not widely available. Uptake is poor and completion rates are low. In this integrated PR service we report on effectiveness, attendance, and completion of twice weekly rolling recruitment and once weekly cohort recruitment programmes in two hospital and five community PR sites. The hospital and two of the community programmes were ‘rolling’ recruitment twice weekly for 8 weeks. Three community programmes ran in once weekly cohorts for 8 weeks. Predictors of attendance, completion and effectiveness were sought. 1114 eligible COPD patients were referred. 812 (73%) attended assessment, 656 (59%) started and 441 (40%) completed. Significant improvements were seen in incremental shuttle walk test (ISWT) (mean 68.3 m; 95%CI 59.3–77.4), Chronic Respiratory Questionnaire self-report dyspnoea scale (CRQ-SR) (0.94; 0.80–1.07), Hospital Anxiety and Depression Scale anxiety (0.9; 0.5-1.2) and depression (1.1; 0.8–1.4) components, exceeding the minimum clinically important difference for ISWT and CRQ-SR. Twice weekly compared with once weekly programmes showed similar improvement. Patients were less likely to complete if they were deprived (4th quintile of deprivation 0.56; 0.33–0.94, 5th quintile 0.57; 0.34–0.85), reported MRC dyspnoea scale 4 (0.61; 0.37–0.97) or 5 (0.39; 0.16-0.93), or had been referred by their general practitioner (0.42; 0.24–0.74) (pseudo R2 0.103). PR is effective for COPD in real-world practice achieving results comparable to trials. Low rates of attendance and completion of PR were not explained by demographic characteristics, disease severity, psychological morbidity and source of referral despite the large number of participants.

An evaluation of factors associated with completion and benefit from pulmonary rehabilitation in COPD.

Background Pulmonary Rehabilitation (PR) is an important treatment for patients with chronic obstructive pulmonary disease (COPD) but it is not established whether any baseline parameter can predict response or compliance. Aim To identify whether baseline measures can predict who will complete the programme and who will achieve a clinically significant benefit from a Minimum Clinical Important Difference (MCID) in terms of exercise capacity and health-related quality of life (HRQoL). Methods Data were collected prospectively from patients with COPD at their baseline assessment for an outpatient PR programme in one of eight centres across London. ‘Completion’ was defined as attending at least 75% of the designated PR visits and return for the follow-up evaluation. The MCID for outcome measures was based on published data. Results 787 outpatients with COPD (68.1±10.5 years old; 49.6% males) were included. Patients who completed PR (n=449, 57.1%) were significantly older with less severe airflow obstruction, lower anxiety and depression scores, less dyspnoea and better HRQoL. Only baseline CAT score (OR=0.925; 95% CI 0.879 to 0.974; p=0.003) was retained in multivariate analysis. Patients with the lowest baseline walking distance were most likely to achieve the MCID for exercise capacity. No baseline variable could independently predict achievement of an MCID in HRQoL. Conclusions Patients with better HRQoL are more likely to complete PR while worse baseline exercise performance makes the achievement of a positive MCID in exercise capacity more likely. However, no baseline parameter could predict who would benefit the most in terms of HRQoL.

Pulmonary rehabilitation and sleep quality: a before and after controlled study of patients with chronic obstructive pulmonary disease.

Background:Poor sleep quality is common in chronic obstructive pulmonary disease (COPD). It is associated with poor quality of life. Pulmonary rehabilitation (PR) improves quality of life, exercise capacity, and anxiety and depression. Its effect on sleep quality is uncertain.Aim:To determine whether PR improves sleep quality in COPD.Methods:A prospective controlled ‘before and after’ study of sleep quality in COPD patients attending a community PR programme was conducted. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). Lung function, disease-specific quality of life (COPD assessment test—CAT), exercise capacity (incremental shuttle walk test—ISWT), and anxiety and depression (Hospital Anxiety and Depression Scale—HADS) were measured. Change in sleep quality was compared with a COPD control group.Results:Twenty-eight participants completed PR. The control group comprised 24 patients. Prevalence of poor sleep quality (PSQI ⩾5) was 78%. There were no differences between observation and control groups in sleep quality, age or severity. Quality of life was strongly correlated with quality of sleep (r=0.64, P<0.001). PR improved the quality of life (CAT change 3.0; 95% CI, 0.7–5.3), exercise capacity (ISWT change (metres) 81.0; 15.3–146.6), anxiety (HADS score ⩾8: change 2.33; 0.45–4.22), and depression (HADS score ⩾8: change 2.90; 1.92–3.88). PR did not improve sleep quality (PSQI mean change 0.79; −0.35 to 1.93).Conclusions:PR did not improve sleep quality in COPD despite improving quality of life, exercise capacity, anxiety and depression. New strategies, independent of PR, are required to improve sleep quality in COPD.

P141 An evaluation of the acceptability of supervised ward-based exercise for patients admitted to hospital for acute exacerbation of COPD

Introduction Patients with COPD demonstrate peripheral muscle dysfunction and reduced physical activity. Both are compounded by admission for acute exacerbation (AECOPD). Supervised exercise during AECOPD has been shown to be safe and may ameliorate these deleterious physical effects. Debate remains as to the acceptability of exercise for patients admitted with AECOPD. Objective To evaluate the acceptability of supervised exercise for patients admitted with AECOPD. Methods Patients admitted with AECOPD between December 2013 and August 2014 were included if medically stable, had no other limiting factor to exercise and consented to participate. Physiotherapists prescribed a standardised progressive exercise programme comprising daily upper/lower limb strengthening exercises and walking, supervised by a physiotherapy assistant. Patients completed a self-reported Likert scale questionnaire on discharge. Data collection included MRC Dyspnoea score, COPD Assessment Test (CAT), Timed Up and Go (TUAG) and 4-metre gait speed (4MGS). Results 150 patients were screened, 78 (52%) participated. Mean (SD) age 70(10) years, 50% female, median (IQR) length of stay 7(5 -12) days, median number of exercise sessions 2(1–3). Median MRC 4(4–5) (n = 60); mean CAT at baseline 26 with a mean change of -3.7 (n = 50). 71 patients completed the questionnaire. 89% felt happy to participate in exercise when approached by a physiotherapist. 93% reported being able to undertake the exercises taught, 80% felt very or fairly confident to continue at home. 82% felt the exercise improved their ability to carry out functional tasks. 34% recalled previously completing Pulmonary Rehabilitation. Analysis of those who completed TUAG and 4MGS pre and post intervention (n = 15) showed mean baseline values of 23.7(10.7) secs and 0.44(0.21) mps respectively; mean changes of -6.8(9.45) secs and +0.08(0.16) mps respectively. Conclusions Supervised exercise is acceptable to patients admitted with AECOPD, even in those demonstrating significant frailty. However, the non-participation rate was high, reasons for which are unknown. It is unclear whether the improvement in health status and functional mobility during admission was due to exercise participation or natural recovery. Further work is required exploring the impact of initiating exercise during admission on physical activity behaviours post discharge as well as reasons for non-participation during admission.