Norman E. Adair

A lifestyle activity intervention in patients with chronic obstructive pulmonary disease

BACKGROUND Chronic obstructive pulmonary disease (COPD) patients have lower levels of physical activity compared to age-matched controls, and they limit physical activities requiring normal exertion. Our purpose was to compare the effectiveness of a traditional exercise therapy (TET) program with a behavioral lifestyle activity program (LAP) in promoting physical activity. METHODS Moderate physical activity (kcal/week) was assessed in 176 COPD patients using the Community Health Activities Model for Seniors questionnaire. Patients were randomized to either a three month TET program that meet thrice weekly or a LAP. The LAP was designed to teach behavioral skills that encouraged the daily accumulation of self-selected physical activities of at least moderate intensity. Interventionist contact was similar (36 h) between the two groups. Patients were assessed at baseline and 3, 6 and 12 months. RESULTS Compared to baseline values, self-reported moderate physical activity increased three months post-randomization with no significant difference (p = 0.99) found between the TET (2501 +/- 197 kcal/week) and the LAP (2498 +/- 211 kcal/week). At 6 and 12 months post-randomization, there were no significant differences (p = 0.37 and 0.69, respectively) in self-reported levels of moderate physical activity between the TET (2210 +/- 187 and 2213 +/- 218 kcal/week, respectively) and the LAP (2456 +/- 198 and 2342 +/- 232 kcal/week, respectively). CONCLUSION Although there was no difference between treatment groups, the TET and the LAP were both effective at in increasing moderate levels of physical activity at 3 months and maintaining moderate physical activity levels 12 months post-randomization. This clinical trial is registered with ClinicalTrials.gov. Its identifier is NCT00328484.

Reproducibility of the 6-Minute Walk Test for Ambulatory Oxygen Prescription

Background: Ambulatory oxygen is frequently prescribed for patients with chronic obstructive pulmonary disease (COPD) who have oxygen desaturation ≤88% during exercise. The 6-min walk test (6MWT) with continuous pulse oximetry monitoring is a common method to document this oxygen desaturation, but the reproducibility of this test in determining the need for ambulatory oxygen in patients with COPD is not well documented. Objective:The aim of this study was to establish the reproducibility of the 6MWT in determining the need for ambulatory oxygen prescription in stable COPD patients using the Centers for Medicare and Medicaid (CMS) criteria for ambulatory oxygen prescription. Methods:The study was designed as a prospective observational study in an academic health center and associated pulmonary rehabilitation program. Eighty-eight COPD patients referred to pulmonary rehabilitation underwent continuous pulse oximetry while performing standard 6MWT on 3 separate days. Results: Fifty-one (58%) of these patients desaturated by continuous pulse oximetry to an SpO2 ≤88% on a least one of the 6MWTs. Only 26 patients (30%) demonstrated consistency in meeting the criteria for ambulatory oxygen set forth by the CMS on all three 6MWT with a κ statistic of 0.62. The percent agreement between 6MWTs for ambulatory oxygen prescription was 72% and the paired observation was 51%. Conclusions: The 6MWT distance is simple and widely used as a consistent measure of functional capacity in patients with COPD; however, the 6MWT oxygen saturation has only modest reproducibility in determining the need for ambulatory oxygen in stable COPD patients undergoing pulmonary rehabilitation.

Training in and Experience with Endobronchial Ultrasound

Background: Diagnosing mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) are on the rise, but uncertainty surrounds the optimal number of cases needed to achieve acceptable yields. Objectives: To determine the threshold at which EBUS-TBNA reaches adequate yields among trainees and skilled bronchoscopists. Methods: We reviewed all EBUS-TBNAs performed at our medical center since implementing the use of EBUS (n = 222). Results: EBUS-TBNAs were performed in 222 patients (344 nodes). The percentage of adequate specimens sampled (diagnostic specimens or nodal tissue) rose from 66% in 2008 to 90% in 2012 (p < 0.01) and cancer yield improved from 34% in 2008 to 48% in 2012 (p < 0.01). Attending physicians who performed an average of more than 10 procedures per year had higher yields compared to those who performed fewer than 10 procedures per year (86 vs. 68%, p < 0.01). The yield of trainees also improved with every 10 procedures (79, 90 and 95%, p < 0.001) and that of attending physicians with experience (1-25 procedures: 78% yield, 26-50 procedures: 87% yield and 50+ procedures: 90% yield; p < 0.01). Among trainees, failure rates declined steadily. Conclusion: EBUS-TBNA yield (malignant and benign) increases with increasing experience amongst experienced bronchoscopists and trainees as early as the first 20-25 procedures. Pulmonary trainees had a rapid decline in failure rates. These findings suggest that in an academic environment a minimum of 20-25 procedures is needed to achieve acceptable yields.

Endobronchial ultrasound in the evaluation of lung cancer: a practical review and cost analysis for the practicing pulmonologist.

Flexible bronchoscopy remains an important tool in the staging, diagnosis, and treatment of primary and metastatic lung malignancies. Endobronchial ultrasound is a new technology utilized with bronchoscopy that has been shown to identify bronchial wall invasion by malignant tumors, aid in the fine needle aspiration of peripheral lung lesions and mediastinal/hilar lymph nodes, and determine the course of treatment in patients with pulmonary carcinoma in situ. The decision to invest both time and money in this technology is determined by several factors such as the cost of the equipment, reimbursement for the procedure, availability of training, the number of bronchoscopies one performs in a year, and access to endoscopic ultrasound and mediastinoscopy. This article reviews the literature to determine the utility of endobronchial ultrasound in the management of patients with lung cancer and to provide information to practicing pulmonologists that may aid in determining whether and where this technology fits into their clinical armamentarium.

Conventional and endobronchial ultrasound-guided transbronchial needle aspiration: complementary procedures.

Objective The diagnosis of mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are on the rise. Most reports have demonstrated high yields with EBUS-TBNA and superiority of this procedure over conventional TBNA (cTBNA), but the relative roles of these procedures remain undefined. We present a comprehensive comparison of EBUS-TBNA to cTBNA. Methods We reviewed all of the bronchoscopies performed at our medical center from January 2009 through December 2010. We collected data on 82 EBUS-TBNAs and 209 cTBNAs performed. A cost analysis was subsequently performed. Results EBUS-TBNA was performed more often in patients with known prior cancer and suspicion of recurrence or staging compared with cTBNA (42% vs 18%, P < 0.001). cTBNA was more likely to be performed in patients suspected of having malignancy and needing diagnostic specimens (70% vs 46%, P = 0.009). The overall yield in which a diagnostic specimen or lymphoid tissue was obtained was not different in each group: EBUS 84% vs cTBNA 86% (P = 0.75). The cancer yield was 57% in cTBNAs compared with 44% in EBUS-TBNAs (P < 0.0001), with EBUS-TBNA more often targeting smaller nodes (mean 15 ± 7 mm vs 21 ± 11 mm; P < 0.0001) and paratracheal sites (67% vs 49%, P = 0.003). Per-procedure cost using a Medicare scale was higher for EBUS than it was for cTBNA (

Increased ventilation in runners during running as compared to walking at similar metabolic rates

1195 vs

TECHNIQUES TO ASSIST SELECTION OF APPROPRIATE THERAPY FOR PATIENTS WITH OBSTRUCTIVE SLEEP APNEA

808; P < 0.001). Conclusions EBUS-TBNA and cTBNA are complementary bronchoscopic procedures, and the appropriate diagnostic modality can be selected in a cost-effective manner based upon the primary indication for TBNA, lymph node size, and lymph node location.

Pulmonary Infiltrates After Intravesical Bacille Calmette-Guerin: Two Cases and Review of the Literature

AbstractAt similar levels of carbon dioxide production (

Contents Vol. 88, 2014

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