Marcel A. Baltzan

Success in pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

BACKGROUND Pulmonary rehabilitation (PR) is beneficial for some, but not all, patients with chronic lung disease. OBJECTIVES To determine the success rate of a comprehensive PR program for patients with chronic obstructive pulmonary disease (COPD) and to characterize the differences between responders and nonresponders. METHODS A chart review was performed on patients with a clinical diagnosis of COPD who were referred for PR. Success was defined according to clinically important changes in St Georges Respiratory Questionnaire scores and⁄or 6 min walk test distance. RESULTS The majority of subjects were men (58%) with a mean (± SD) age of 69±10 years (n=177). Sixty-two per cent of participants had a successful outcome with PR, with proportionally more responders noting subjective improvement than objective improvement on a 6 min walk test (73% versus 51%). Subjects with poor baseline St Georges Respiratory Questionnaire scores tended to improve the most (P=0.011 [ANOVA]). Successful participants had a greater forced expired volume in 1 s (1.1 L versus 0.9 L; P<0.05) and a lower BODE index (body mass index, airflow obstruction, dyspnea, and exercise capacity index) at baseline (9.6 versus 10.3; P<0.05). Success of PR was not correlated with age, sex, chronic hypoxemic respiratory failure or other chronic conditions. Successful participants were more likely to be compliant and to experience fewer adverse events (P≤0.001). CONCLUSIONS Our study reinforced the belief that the majority of participants with COPD benefit from PR. Few baseline characteristics were predictive of success. Subjectively measured improvement occurred more frequently than objectively measured improvement and was greatest in those with the poorest baseline values.

Evidence of interrelated side effects with reduced compliance in patients treated with nasal continuous positive airway pressure

OBJECTIVES Patients treated for obstructive sleep apnea syndrome (OSAS) with nasal continuous positive airway pressure (nCPAP) often have side effects and poor compliance. Our objectives were to explore their side effects when treated with nCPAP and to validate the association of a side effect syndrome with the outcomes of sleep quality, daytime sleepiness and nCPAP compliance. METHODS Prospective exploratory and subsequent validation study using questionnaires was performed in a tertiary-care sleep-disorders clinic. Consecutive patients with polysomnographic diagnosis and nCPAP titrations treated at least 3 months with single-pressure nCPAP were studied. In the first survey, 114 patients were questioned of whom 89 (78%) qualified for exploratory analysis. In the validation survey of 122 patients, 104 (85%) were studied. Subjects were interviewed and their nCPAP meters were queried. RESULTS In the first survey, 3 side effects were often found together and each found to be correlated to compliance: mouth leak with nCPAP, nasal congestion, and taking off the mask prematurely. In the validation study, 34% of participants met a syndrome definition with at least 2 of 3 major side effects. Mean (SD) compliance was lower in patients with the syndrome: 4.97 (1.98) vs. 6.42 (1.56) hours per night (p=0.0001). Poor sleep quality and lower satisfaction with nCPAP were associated with the syndrome. CONCLUSIONS The syndrome of mouth leak, taking off the nCPAP mask prematurely and nasal congestion is frequent in patients treated with nCPAP. This is associated with lower compliance and poor sleep quality.

Pulmonary rehabilitation improves functional capacity in patients 80 years of age or older.

OBJECTIVES There is limited evidence that pulmonary rehabilitation improves exercise capacity in older patients with chronic respiratory disease. The objective of the present study was to determine whether patients 80 years of age or older gain similar benefits from pulmonary rehabilitation as do younger patients. DESIGN Outcomes were compared in 230 consecutive inpatients with moderate to severe lung disease who participated in a comprehensive pulmonary rehabilitation program during a one-year period. Outcomes included 6 min walk test distance (6MWT), the number of stairs completed in 2 min (2MST), Borg dyspnea scores after exertion and objective functional scores. RESULTS There were no differences between older (80 to 91 years, n=43) and younger patients (n=187) with respect to sex, forced expiratory volume in 1 s (mean 0.77 L versus 0.72 L) or number of chronic medical diagnoses (2.4 versus 2.7). Older patients were less frequently survivors of mechanical ventilation (2.3% versus 16%). Baseline 6MWT (133 m versus 144 m; P=0.48) and 2MST (5.2 laps versus 6.5 laps; P=0.067) were similar but global function was lower (85 versus 89; P=0.040) in older patients than in younger patients, respectively. After pulmonary rehabilitation, all outcomes improved significantly regardless of age (all before-after comparisons P<0.0001). Younger patients improved with a higher discharge 6MWT (231 m versus 185 m; P=0.004) and similar discharge 2MST (9.3 laps versus 7.9 laps; P=0.070) compared with older patients. Global function at discharge remained lower in older patients than younger patients (91 versus 94; P=0.002). The duration of rehabilitation and length of stay were similar between the two groups. CONCLUSION A comprehensive inpatient pulmonary rehabilitation program is beneficial in selected patients 80 years of age or older.

Impaired Sleep in Chronic Fatigue Syndrome How Is It Best Measured

The goal was to examine comparative efficacy of polysomnography, actigraphy, and self-report in evaluating the sleep/wake experience of individuals with chronic fatigue syndrome (CFS). Sleep parameters were evaluated by the three measurement modalities for the same night in 49 participants with CFS. Psychological and daytime functioning were measured by self-report. Results indicate that: (a) objectively measured nocturnal sleep time effectively approximated subjective experience although nocturnal wakefulness did not; (b) total sleep time and sleep efficiency differentiated individuals with and without insomnia complaints; (c) daytime sleepiness, fatigue, and non-refreshing sleep were not reflected by the objective sleep-related measures (polysomnography and actigraphy).

Oxygen desaturation during a 6 min walk test is a sign of nocturnal hypoxemia.

UNLABELLED BACKGROUND⁄ OBJECTIVES Patients with chronic obstructive pulmonary disease (COPD) may experience sleep disordered breathing with nocturnal desaturation. An exploratory study was performed to determine whether any commonly measured clinical parameters were useful in predicting nocturnal desaturation in patients with COPD. A validation study was subsequently performed to confirm the utility of the parameter identified in the exploratory study as most useful in this regard. METHODS A total of 103 (exploratory cohort) and 200 (validation cohort) consecutive patients with COPD admitted for pulmonary rehabilitation were evaluated. Standard outcome measures including nocturnal oximetry and the 6 min walk test (6MWT) on room air with continuous pulse oximetry were assessed. Patients with sleep apnea or those undergoing long-term oxygen therapy were excluded. RESULTS In the exploratory study, the mean (± SD) patient age was 70 ± 9.9 years, with forced expiratory volume in 1 s of 0.76 ± 0.34 L, which was 36 ± 16% of predicted. Body mass index, arterial oxygen tension, oxygen saturation by pulse oximetry at rest and during the 6MWT all demonstrated significant correlations with percentage of time spent with a saturation <90%. When the lowest pulse oximetry during the 6MWT was ≤88%, 10 of 21 patients demonstrated a saturation <90% for at least 30% of sleep time. This measure yielded a positive likelihood ratio of 3.77 (95% CI 1.87 to 7.62) compared with those who did not reach this threshold value. The validation study confirmed similar detection characteristics. CONCLUSIONS Results from the present study suggest that monitoring oxygen saturation changes during a 6MWT is useful in helping to identify COPD patients who may experience significant nocturnal desaturation.

Sleep Apnea and Psychological Functioning in Chronic Fatigue Syndrome

Objectives were to explore: (1) whether sleep apnea/hypopnea syndrome (SAHS) should be considered a chronic fatigue syndrome (CFS) comorbidity, rather than a diagnostic exclusion criterion; and (2) to compare sleep/wake/ psychopathology in individuals with CFS, controls and another illness. Participants (CFS, SAHS, controls) completed questionnaires and were evaluated for SAHS; 68 percent were subsequently diagnosed with SAHS. CFS participants with and without SAHS did not differ. Both clinical groups were less well adjusted than controls. We conclude that SAHS should not be an exclusion criterion for CFS and that psychological problems in CFS seem a consequence of coping with illness.

Using a virtual game system to innovate pulmonary rehabilitation: Safety, adherence and enjoyment in severe chronic obstructive pulmonary disease

OBJECTIVE The present pilot study tested the use of a virtual game system (VGS) for exercise training in patients with moderate to very severe chronic obstructive pulmonary disease undergoing pulmonary rehabilitation (PR). Safety, feasibility, enjoyment and adherence were assessed. METHODS VGS (Wii [2006], Nintendo, USA) games were prescreened and categorized into lower- and upper-body workouts. Patients admitted for a three- to four-week inpatient PR program exercised daily. They were provided an opportunity to individually engage in VGS sessions three times weekly, varying with length of stay. Dyspnea, oxygen saturation and heart rate were measured before, during and after game sessions. Patients were considered to be adherent if they attended at least 50% of VGS sessions. Adverse events and enjoyment were evaluated. RESULTS Thirty-two patients with a mean (± SD) age of 66±9 years and a mean forced expiratory volume in 1 s of 0.72±0.40 L participated. Among the 25 patients completing the program, adherence was 76%, with a mean attendance rate of 64±35%. Mean dyspnea score was 1.5±1.1 before and 3.2±1.2 after exercise. Mean oxygen saturation changed from 94±3% to 91±5% (P<0.001), while heart rate increased from 88±15 beats⁄min to 102±18 beats⁄min (P<0.001). One patient reported chest pain requiring nitroglycerin spray and five experienced transient desaturation below 85% with play. Patients enjoyed the program (visual analogue score 8±2.6⁄10) and most would highly recommend it to others. CONCLUSIONS Moderate exercise using a VGS was safe, feasible and enjoyed as an adjunct to inpatient PR. This modality may encourage patients to maintain physical activity after PR.

Unilateral hemidiaphragm weakness is associated with positional hypoxemia in REM sleep.

BACKGROUND Patients with unilateral diaphragmatic paralysis (UDP) have been reported to have varied respiratory symptoms and often reduced lung function. We sought to describe the polysomnographic respiratory characteristics in patients with UDP without obstructive sleep apnea. METHODS We prospectively collected 5 cases with clinical investigation regarding symptoms, lung function, and nocturnal polysomnography. The respiratory sleep characteristics were analyzed with standardized scoring of respiratory events in 30-sec epochs and comparison according to sleep-wake stages and body position with respect to oximetry. The cases were compared to 5 controls matched for age, gender, and body mass index. RESULTS Three of 5 patients had significant awake lung restriction with a mean (range) forced vital capacity of 1.89 (1.48-2.24) liters, 72% (45% to 102%) predicted. All had REM sleep with few apneas and episodes of prolonged hypopneas characterized by important desaturation noted on oximetry. These desaturations were greatest during REM sleep when the patients slept supine with a mean (SD) saturation of 90.8% (4.5%) and minimum of 64% or on the side unaffected by UDP with a mean saturation of 87.8% (5.3%) and minimum of 67% (p < 0.0001 compared to same positions awake). Other sleep stages had few, if any significant desaturations and these events rarely occurred when the patient slept in the supine position. Saturation was lower in all sleep-wake stages and sleep positions compared to controls (p < 0.0001). CONCLUSION Patients with UDP demonstrate position-dependent hypopneas in REM sleep with frequent desaturations.

Development of a Patient Needs Assessment Model for Pulmonary Rehabilitation

Patients with chronic obstructive pulmonary disease are often referred to pulmonary rehabilitation programs to manage their symptoms and the consequences of the disease on their lives. Finding ways to target programs to a specific patient’s needs could help improve individual response to the program. The purpose of this study was to develop a conceptual model for the assessment of patients’ rehabilitation needs by using a grounded theory approach. Focus groups, consultations of medical charts, and a literature review helped us develop a conceptual model characterized by the following categories: need recognition, knowledge, motivation, expectations, goals, ability to fulfill needs, and the ability for personal adjustment. Based on a content matrix reflecting the conceptual model and disease consequences, items to be included in a prototype instrument were formulated and a preliminary validation phase was conducted.

CPAP Treatment Adherence in Women with Obstructive Sleep Apnea

Untreated obstructive sleep apnea (OSA) has numerous negative health-related consequences. Continuous positive airway pressure (CPAP) is generally considered the treatment of choice for OSA, but rates of nonadherence are high. It is believed that OSA is more prevalent among men; therefore understanding how OSA presents among women is limited and treatment adherence has received little research attention. For this study, 29 women were recruited from primary care offices. They completed a questionnaire battery and underwent a night of nocturnal polysomnography (PSG) followed by a visit with a sleep specialist. Women diagnosed with OSA were prescribed CPAP; 2 years later CPAP adherence was evaluated. Results show that approximately half the sample was adherent. There were no significant differences between adherent and nonadherent women on OSA severity; however CPAP adherent women had worse nocturnal and daytime functioning scores at the time of diagnosis. Moreover, when the seven nocturnal and daytime variables were used as predictors in a discriminant analysis, they could predict 87% of adherent and 93% of the nonadherent women. The single most important predictor was nonrefreshing sleep. We discuss the implications of the findings for identifying women in primary care with potential OSA and offer suggestions for enhancing treatment adherence.