Nola Cecins

Maintaining exercise capacity and quality of life following pulmonary rehabilitation

Objective:  The optimum method for sustaining the benefits gained from pulmonary rehabilitation (PR) has not been determined. In this report the authors describe the 4‐year referral and uptake patterns to a hospital‐based outpatient PR programme, and the sustained benefits of PR in patients with COPD attending a community‐based maintenance exercise programme.

State of the art : How to set up a pulmonary rehabilitation program

Pulmonary rehabilitation plays an essential role in the management of symptomatic patients with COPD. The benefits of rehabilitation include a decrease in dyspnoea and fatigue, and improvements in exercise tolerance and health‐related quality of life. Importantly, rehabilitation reduces hospitalization for acute exacerbations and is cost‐effective. Although most of the evidence for pulmonary rehabilitation has been obtained in patients with COPD, symptomatic individuals with other respiratory diseases have been shown to benefit. In this review we outline a stepwise approach to establish, deliver and evaluate a pulmonary rehabilitation program (PRP) that would be feasible in most settings. Throughout the review we have specified the minimum requirements for a PRP to facilitate the establishment of programs using limited resources. Recommendations for staffing and other resources required for a PRP are presented in the first section. Exercise training is a focus of the section on program delivery as this is the component of rehabilitation that has the strongest level of evidence for benefit. Program considerations for patients with respiratory conditions other than COPD are described. Different approaches for delivering the education component of a PRP are outlined and recommendations are made regarding topics for group and individual sessions. The problems commonly encountered in pulmonary rehabilitation, together with recommendations to avoid these problems and strategies to assist in their resolution, are discussed. The review concludes with recommendations for evaluating a PRP.

Reduction in Hospitalisation Following Pulmonary Rehabilitation in Patients with COPD

OBJECTIVES Pulmonary rehabilitation (PR) improves exercise capacity and health-related quality of life (HRQoL), and reduces health care utilisation. This study quantified outcomes of a PR program over a 6-year period and determined the effects of PR on hospitalisation. METHODS Patients with chronic obstructive pulmonary disesae (COPD) who entered an 8-week outpatient PR program from 1998 to 2003 were included. Functional exercise capacity (6-minute walk distance [6MWD]) and HRQoL (Chronic Respiratory Disease Questionnaire) were measured before and following PR. The number of hospital admissions and total bed-days due to a COPD exacerbation in the 12 months before and following PR were recorded. SETTING Physiotherapy Department, Sir Charles Gairdner Hospital, Western Australia. RESULTS 187 (73%) of the 256 patients who entered PR completed the program. Improvements in 6MWD (404.2 +/- 114.6 m to 439.6 +/- 115.0m, P < 0.001) and HRQoL (4.1 +/- 0.9 points per item to 4.9 +/- 0.9 points per item, P < 0.001) occurred following PR. There was a 46% reduction in the number of patients admitted to hospital (71 to 38) with a COPD exacerbation and a 62% reduction in total bed-days (1131 to 432) following PR. CONCLUSION Pulmonary rehabilitation provided in an Australian teaching hospital was associated with a reduction in COPD hospitalisation, and the resultant savings outweighed the costs of providing the program.

Inspiratory Muscle Training for Patients With Chronic Obstructive Pulmonary Disease: A Practical Guide for Clinicians

Reduced inspiratory muscle strength is common in people with chronic obstructive pulmonary disease (COPD) and is associated with dyspnea and decreased exercise capacity. Most studies of inspiratory muscle training (IMT) in COPD have demonstrated increased inspiratory muscle strength. Many have also shown improvements in dyspnea and exercise capacity. However, a persisting challenge when translating and applying the findings of these studies in clinical practice is the disparity in training loads, modalities, and outcomes measures used in the different studies. This commentary summarizes our clinical and research experience with a threshold IMT device with the aim of providing clinicians interested in prescribing IMT in this population with practical recommendations regarding patient selection, assessment, and implementation of training. We propose using an interval-based high-intensity threshold IMT program for people who are unable to participate fully in whole-body exercise training because of comorbidities such as severe musculoskeletal problems. Initial training loads equivalent to at least 30% of a persons maximum inspiratory pressure (PImax) are required for all people undertaking IMT. Supervision, which includes monitoring of oxygen saturation throughout the first training session, is recommended, and patients are warned to expect transient delayed-onset muscle soreness, a consequence of muscle adaptation to an unaccustomed activity. We recommend training be undertaken 3 times a week for 8 weeks, with loads progressively increased as symptoms permit. It is prudent to exclude people at risk of pneumothorax or spontaneous rib fracture. Evaluation of IMT should include measures of PImax, dyspnea, health-related quality of life, and exercise capacity.

Six-minute walk test in pulmonary rehabilitation: Do all patients need a practice test?

Background and objective:  The six‐minute walk test (6MWT) is widely used as an outcome measure in pulmonary rehabilitation programs (PRP). A learning effect for the test has been reported in COPD; however, limited data exist in patients with other respiratory diagnoses. The objectives of this study were to: (i) report the magnitude of change in 6MWD with test repetition in patients referred to an outpatient PRP, and (ii) compare the magnitude of change in 6MWD with test repetition in patients with COPD, interstitial lung disease (ILD), bronchiectasis and asthma.

The effects of pulmonary rehabilitation in patients with non-cystic fibrosis bronchiectasis: protocol for a randomised controlled trial

BackgroundNon-cystic fibrosis bronchiectasis is characterised by sputum production, exercise limitation and recurrent infections. Although pulmonary rehabilitation is advocated for this patient group, its effects are unclear. The aims of this study are to determine the short and long term effects of pulmonary rehabilitation on exercise capacity, cough, quality of life and the incidence of acute pulmonary exacerbations.Methods/DesignThis randomised controlled trial aims to recruit 64 patients with bronchiectasis from three tertiary institutions. Participants will be randomly allocated to the intervention group (supervised, twice weekly exercise training with regular review of airway clearance therapy) or a control group (twice weekly telephone support). Measurements will be taken at baseline, immediately following the intervention and at six and 12 months following the intervention period by a blinded assessor. Exercise capacity will be measured using the incremental shuttle walk test and the six-minute walk test. Quality of life and health status will be measured using the Chronic Respiratory Questionnaire, Leicester Cough Questionnaire, Assessment of Quality of Life Questionnaire and the Hospital Anxiety and Depression Scale. The rate of hospitalisation will be captured as well as the incidence of acute pulmonary exacerbations using a daily symptom diary.DiscussionResults from this study will help to determine the efficacy of supervised twice-weekly pulmonary rehabilitation upon exercise capacity and quality of life in patients with bronchiectasis and will contribute to clinical practice guidelines for physiotherapists in the management of this population.Trial registrationThis study protocol is registered with ClinicalTrials.gov (NCT00885521).

Ground-based walking training improves quality of life and exercise capacity in COPD

This study was designed to determine the effect of ground-based walking training on health-related quality of life and exercise capacity in people with chronic obstructive pulmonary disease (COPD). People with COPD were randomised to either a walking group that received supervised, ground-based walking training two to three times a week for 8–10 weeks, or a control group that received usual medical care and did not participate in exercise training. 130 out of 143 participants (mean±sd age 69±8 years, forced expiratory volume in 1 s 43±15% predicted) completed the study. Compared to the control group, the walking group demonstrated greater improvements in the St George’s Respiratory Questionnaire total score (mean difference -6 points (95% CI -10– -2), p<0.003), Chronic Respiratory Disease Questionnaire total score (mean difference 7 points (95% CI 2–11), p<0.01) and endurance shuttle walk test time (mean difference 208 s (95% CI 104–313), p<0.001). This study shows that ground-based walking training is an effective training modality that improves quality of life and endurance exercise capacity in people with COPD. Walking training improves quality of life and endurance exercise capacity compared to usual medical care in COPD http://ow.ly/zHs5u

Outcomes and direct costs of a pulmonary rehabilitation service

This study describes an analysis of referrals and the direct costs to a physiotherapy department (i.e., physiotherapy salaries and consumables) of an outpatient pulmonary rehabilitation service. The effects of an eight-week exercise program on exercise capacity (incremental shuttle walking test and distance walked in 20 minutes) and quality of life (QOL, Chronic Respiratory Disease Questionnaire, and the SF-36) also were evaluated. One hundred and nineteen patients with chronic lung disease (CLD) were referred to the service during 1998. Seventy-two patients entered the eight-week exercise program and 57 completed (20.8% attrition). Significant increases in exercise capacity and QOL occurred following the program ( P < 0.05). The cost of the program was

Questioning the use of heart rate and dyspnea in the prescription of exercise in subjects with chronic obstructive pulmonary disease.

A249 (Australian dollars) per patient. Increased exercise capacity and QOL occurred in patients with CLD following the eight-week exercise program, and this type of program can be provided at modest cost.

Comparing finger and forehead sensors to measure oxygen saturation in people with chronic obstructive pulmonary disease

PURPOSE This study examined the heart rate and dyspnea responses during constant submaximal lower limb endurance exercise in subjects with chronic obstructive pulmonary disease (COPD) to determine the appropriateness of using target heart rate or dyspnea for the prescription of endurance exercise intensity. METHODS The study participants were 15 men, ages 55 to 75 years, with stable moderate to severe COPD (forced expiratory volume in 1 second, 38.7 +/- 15.6% pred). All the participants completed the incremental shuttle walking test (ISWT) to estimate peak oxygen consumption (VO(2peak)), followed by the endurance shuttle walking test (ESWT) at an intensity equivalent to 60% VO(2peak). Heart rate and dyspnea were monitored before, immediately after, and at 1-minute intervals during each test. RESULTS The study was completed by 11 subjects. Heart rate and dyspnea increased significantly between 4.5 and 20 minutes during the ESWT (P <.01) despite walking at a constant submaximal workload. Heart rate and dyspnea attained at the end of the ESWT exceeded levels observed during the ISWT at the equivalent workload (P <.05). Four subjects were unable to walk for at least 10 minutes on the ESWT because of severe dyspnea and were withdrawn. CONCLUSIONS Setting heart rate and dyspnea targets for endurance training at an intensity equivalent to 60% VO(2peak) may be inappropriate for subjects with moderate to severe COPD because heart rate and dyspnea increase independently of workload at this intensity.