Mc Steiner

The plasma ammonia response to cycle exercise in COPD

The plasma ammonia response to exercise in chronic obstructive pulmonary disease (COPD) was examined and the relationship between plasma ammonia concentration and muscle adenine nucleotide metabolism was explored. In total, 25 stable COPD patients and 13 similar-aged controls underwent incremental and constant-work rate cycle exercise tests. Arterialised venous blood was sampled at rest, at 1-min intervals during exercise and ≤5 min after exercise for ammonia and lactate concentration. Peak incremental work rate was significantly less in COPD subjects (67±21 W) than similar-aged controls (156±46 W). In COPD and control subjects, plasma ammonia concentration increased during incremental exercise until 2 min post-exercise and then declined by 5 min post-exercise. However, two distinct patterns were seen in COPD subjects. In one group (n = 16), ammonia increased (42.8±3.3 μmol·L−1) by a similar magnitude as the controls (55.5±7.0 μmol·L−1). In the second COPD group (n = 9), no ammonia increase was observed despite a similar lactate increase. Ammonia change with incremental and constant-work rate exercise strongly correlated in COPD subjects. Plasma ammonia increase correlated with muscle inosine-5′–monophosphate formation after constant-work rate exercise. Plasma ammonia concentration increases during incremental and constant-work rate cycle exercise in chronic obstructive pulmonary disease subjects at lower absolute work rates compared with similar-aged controls. The plasma ammonia response may provide useful information about adenine nucleotide metabolism and, therefore, muscle fatigue during exercise in patients with chronic obstructive pulmonary disease.

Pulmonary rehabilitation using the SPACE (A Self-management Programme of Activity, Coping and Education) manual at home: A randomised controlled trial

P53 Table 1 Mean baseline and mean changes for Incremental Shuttle Walking Test (ISWT), Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire Self-Reported (CRQ-SR) Dyspnoea Domain and MRC for conventional rehabilitation and self-management groups Measure Conventional rehabilitation Self-management Baseline Mean change (95% CI) Baseline Mean change (95% CI) ISWT 277.24 54.43 (88.36 to 20.60)* 253.33 40.30 (65.13 to 15.47)* ESWT 225.00 500.62 (656.90 to 344.32)** 257.02 331.33 (483.86 to 178.81)** CRQ-SR Dyspnoea 2.61 0.64 (1.11 to 1.72)* 2.14 0.77 (1.19 to 0.34)* MRC 3.40 20.80 (20.48 to 1.12)** 3.19 20.71 (20.35 to 0.07)** *.0.01; **.0.001. Poster sessions Thorax 2009;64(Suppl IV):A75–A174 A97 on 3 December 2009 thorax.bmj.com Downloaded from

S82 Daily stepping does not recover as an inpatient: standardising the measurement of physical activity during hospitalisation for respiratory disease

Introduction and Objectives Hospitalisation for an exacerbation of chronic respiratory disease has a major impact on physical activity (PA). However, criteria to derive reliable inpatient PA data do not exist and current recommendations are unlikely to account for variations in length of hospital stay (LOHS) and the hospital environment. The aims were to identify the minimum wear time and number of days required to obtain reliable inpatient PA data; to use these criteria to determine how PA changes during recovery as an inpatient; and to compare PA across patients stratified by LOHS. Methods 259 individuals hospitalised with an exacerbation of chronic respiratory disease were recruited as part of an early rehabilitation trial previously reported (Greening et al, BMJ 2014). Participants (mean (SD) age 70.0±9.7 years, 58.3% female) wore a physical activity monitor (SenseWear) during their stay. Daily step count and walking time during waking hours was analysed. Inpatient PA was assessed across a range of minimum wear time criteria (≥1–12 hours). Repeated measures analysis of covariance was used to compare between days and between times of day. Single-day intraclass correlation coefficients (ICCs) were calculated across the range of wear time criteria. The minimum number of days required to obtain an ICC ≥0.80 was estimated using the Spearman-Brown prophecy formula. Abstract S82 Figure 1 Step count per hour as a proportion of total daily step count across an average 24 hour period. Data are reported as mean (95% CI). Results A minimum wear time of 11 hours (≥1 valid day) allowed 80% of the sample to be retained. All minimum wear time thresholds produced an ICC ≥0.80, resulting in 1 day of wear required to produce representative inpatient PA. Mornings and afternoons were more active than evenings and overnight (32.1% and 32.0% vs. 25.2% and 10.7% of steps/day, respectively, p<0.001) (figure 1). No changes in PA were observed during the hospital stay; ranging 585–707 steps/day and 72–83 min/day of walking. After controlling for wear time, patients admitted for 2–3 days took more steps on average than patients staying 7–14 days (997±125 vs. 597±91, p=0.036). Conclusions One full day (24 hours) of monitoring is required at the individual-level to obtain representative inpatient PA. A minimum wear time criteria of ≥11 waking hours is recommended for sample-level data. Wear time and LOHS should be accounted for in analyses.

S124 The effectiveness of “in-clinic” smoking cessation support in the setting of secondary care respiratory outpatient services

Introduction and aims Although two thirds of smokers wish to quit, referral, uptake and engagement with smoking cessation (SC) services are frequently poor. In Leicester, uptake of smoking cessation referred from secondary care is approximately 20% with successful quit rate at four weeks of 10%. Provision of immediate support through smoking cessation specialist advice provided at the point of clinical assessment in outpatients might enhance referral uptake and quit rates. We assessed the value of this “in-clinic” approach in specialist respiratory outpatient clinics in two secondary care centres. Methods Provision of immediate smoking cessation advice was implemented in two outpatient clinic services providing specialist care for patients with complex, chronic obstructive pulmonary disease (COPD); an Acute General Hospital (Peterborough City Hospital, PCH) and a Tertiary Care Hospital (Glenfield Hospital, GH). All current smokers were referred to an on-site smoking cessation specialist advisor by the physician, or clinic nurse, as part of their outpatient review on the same day of their clinic visit. In the Glenfield service SC was provided by a smoking cessation specialist, using a harm reduction approach with a guided patient-led tailored programme and the possibility of direct supply treatment at the initial assessment. In the PCH service, SC using psychosocial and/or pharmacological therapy was undertaken by a dedicated smoking cessation officer Follow-up visits and telephone calls were arranged separately by the smoking service and data including demographics, treatment uptake and quit rates after 4 weeks were analysed. Results A population of 122 smokers with a diagnosis of COPD were assessed for in-clinic SC over a period of twelve months in both centres. Demographic details of both cohorts, outcomes of both SC strategies including treatment uptake and quit rates are disclosed in Table 1. Conclusions Providing “in-clinic”, expert smoking cessation advice results in favourable referral uptake and four week quit rates when compared with locally available data from paper based referral routes. Reinforcing physician delivered smoking cessation advice through immediate provision of proactive cessation support may be an effective means to enhance quit rates in secondary care. Abstract S124 Table 1 Smoking cessation outcomes In-Clinic SC Approach at Peterborough Hospital In-Clinic SC Approach at Glenfield Hospital N patients referred 65 57 Age (years) (mean, [SD]) 61.3 [9] 61.1 [9] Gender 53% Male 53% Male Approach to SC Conventional Harm Reduction Treatment Uptake (% of N) 32 (49%) 29 (50%) SC managed after 4 weeks (% of N) 29 (44%) 16 (28%)

P142 Inflammatory cells in the quadriceps of COPD patients and response to resistance training

Background Physical exercise in healthy individuals leads to an acute inflammatory-cell response in skeletal muscles. In COPD, quadriceps dysfunction is an important systemic manifestation that can be offset by exercise training. However, the nature of the muscle inflammatory response in these patients to acute and chronic exercise remains unknown. We therefore measured inflammatory cell infiltration in the quadriceps of COPD patients and healthy controls, in response to a programme of lower-limb resistance training. Methods 12 COPD patients (mean (SD) age 66.7(7.0) years, BMI 26.1(7.2) kg/m2, FEV1 46.4 (20.5) % predicted, 10 males) and seven healthy controls (66.7 (5.1) years, BMI 27.7(2.4) kg/m2, FEV1 103.4 (17.0) % predicted, five males) underwent 8 weeks of bilateral lower-limb, high-intensity resistance training, thrice weekly, on an isokinetic dynamometer (Cybex II Norm). Quadriceps muscle biopsies from the dominant thigh were obtained at baseline (T0), 24-h after the 1st exercise bout (T1), and 24-h after the last exercise session following 8-weeks training (T2). Glycol methacrylate-embedded muscle biopsies were analysed using immunohistochemistry. Inflammatory cells were identified using antibodies against neutrophil elastase (NE) and CD163 (macrophages). Dual energy x-ray Absorptiometry (DEXA) was used to determine thigh muscle mass and isometric quadriceps strength was measured on the cybex. Results At T0, neutrophils were not detected in any of the healthy controls, but were present in six out of 12 patients. A significant increase in neutrophil and macrophage counts in both patients and controls was seen at T1 (Abstract P142 Table 1). At T2, inflammatory cell counts in both groups were close to baseline values. Isometric quadriceps strength (COPD: pre vs post -134.0 (44.0) vs 151.8 (47.9) Nm, p=0.002; Healthy: pre vs post 153.4 (42.4) vs 169.0 (43.1) Nm, p=0.04] and thigh lean mass (COPD: pre vs post 4.4 (1.2) vs 4.7 (1.2) kg, p=0.003; Healthy: pre vs post 4.5 (0.6) vs 4.7 (0.7) kg, p=0.004] increased significantly after training in both groups. Conclusions Acute resistance exercise in COPD leads to an inflammatory-cell response in the quadriceps that is comparable to healthy controls. Regular training results in muscle adaptation characterised by a diminished inflammatory response to a bout of exercise.Abstract P142 Table 1 T0 T1 T2 NE (cells/mm2 interstitial area) COPD (n=12) 4.1 (0.0–21.0) 137.9 (30.1–217.9)* 0.0 (0.0–15.9)‡ Healthy (n=7) 0.0 (0.0–0.0) 153.4 (13.0–305.5)† 14.2 (0.0–17.3) CD163 (cells/mm2 interstitial area) COPD (n=12) 10.4 (2.1–34.1) 90.3 (40.9–135.7)† 26.9 (12.7–72.5) Healthy (n=7) 0.0 (0.0–27.0) 146.7 (64.3–172.2)† 0.0 (0.0–59.2)§ Values presented as medians (IQR). Data at various time-points compared using nonparametric repeated measures ANOVA (Friedmans Test) and Dunns post test.* p<0.001, T1 vs T0.† p<0.05, T1 vs T0.‡ p<0.001 T2 vs T1.§ p<0.05, T2 vs T1.