Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline.

Background: Despite the known benefits of pulmonary rehabilitation (PR) for patients with chronic respiratory disease, this treatment is underused. Evidence-based guidelines should lead to greater knowledge of the proven benefits of PR, highlight the role of PR in evidence-based health care, and in turn foster referrals to and more effective delivery of PR for people with chronic respiratory disease. Methods: The multidisciplinary panel formulated six research questions addressing PR for specific patient groups (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) and models for PR delivery (telerehabilitation, maintenance PR). Treatment effects were quantified using systematic reviews. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel made the following judgments: strong recommendations for PR for adults with stable COPD (moderate-quality evidence) and after hospitalization for COPD exacerbation (moderate-quality evidence), strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence), conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence), strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence), and conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence). Conclusions: These guidelines provide the basis for evidence-based delivery of PR for people with chronic respiratory disease.

Evaluation of Donor Lungs for Transplantation: The Efficacy of Screening Bronchoscopy for Detecting Donor Aspiration and Its Relationship to the Resulting Allograft Function in Corresponding Recipients.

BACKGROUND: Potential organ donors often have suffered anoxic and/or traumatic brain injury during which they may have experienced aspiration of gastric material (AGM). Evaluation of such donors typically includes a screening bronchoscopic examination during which determinations of aspiration are made. The efficacy of this visual screening and its relationship to post-transplant allograft function are unknown. METHODS: Before procurement, bronchoscopy was performed on donors in which both bronchoalveolar lavage fluid (BALF) was collected and a visual inspection made. As a marker of AGM, BALF specimens were analyzed for the presence of bile salts. Data collected on the corresponding recipients included primary graft dysfunction (PGD) score, post-transplant spirometry, acute rejection scores (ARS), and overall survival. RESULTS: Of 31 donors evaluated, bronchoscopies revealed only 2 with visual evidence of AGM, whereas BALF analysis for bile salts indicated AGM in 14. As such, screening bronchoscopy had a sensitivity of only 7.1%. Visual detection of AGM via bronchoscopy was not associated with any resulting grade of PGD (χ2 = 2.96, P = .23); however, AGM defined by detection of bile salts was associated (χ2 = 7.56, P = .02). Over the first post-transplant year, the corresponding recipients experienced a similar improvement in allograft function (χ2 = 1.63, P = .69), ARS (P = .69), and survival (P = .24). CONCLUSION: Visual inspection during a single bronchoscopic examination of lung donors underestimates the prevalence of AGM. The detection of bile salts in donor BALF is associated with early allograft dysfunction in the corresponding recipients but not with later allograft proficiency, acute rejection responses, or 1-year post-transplant survival.

De-escalation Training as Part of a Workplace Violence Prevention Program.

Workplace violence, including verbal and physical abuse, is escalating nationwide. As healthcare workers try to enforce COVID-19 prevention policies and practices, this phenomenon is exacerbated. De-escalation training is a method to prepare nurses through increased situational awareness, leading to early recognition and improved coping and confidence in dealing with aggression. Outcomes are presented, suggesting education of nurses may have a positive influence on the number of security calls and incident reports.

Pulmonary comorbidities in cardiac rehabilitation.

Patients with cardiovascular disease (CVD) benefit greatly from participation in cardiac rehabilitation programs. Many patients with CVD have a concomitant pulmonary disease, yet the latter is often not diagnosed (and thus undertreated). Means to evaluate and manage patients with concomitant cardiovascular and pulmonary disease will be addressed in this article.

Calcineurin Inhibitor-Based Maintenance Immunosuppression in Lung Transplant Recipients: Optimal Serum Levels for Managing Acute Rejection and Renal Function.

BACKGROUND: Although effective for curtailing alloimmune responses, calcineurin inhibitors (CNIs) have an adverse-effect profile that includes nephrotoxicity. In lung transplant (LTx) recipients, the optimal serum levels of the CNI tacrolimus necessary to control alloimmune responses and minimize nephrotoxicity are unknown. METHODS: This retrospective, single-center study reviewed tacrolimus whole blood trough levels (BTLs), grades of acute cellular rejection (ACR), acute rejection scores, and creatinine clearance (CrCl) obtained in LTx recipients within the first year after their transplant procedure. Comparisons were made between the first 90 days post LTx (when tacrolimus BTLs were maintained >10 µg/L) and the remainder of the post-LTX year (when BTLs were <10 µg/L). RESULTS: Despite tacrolimus mean BTLs being higher during the first 90 days post LTx compared with the remainder of the first post-LTx year (10.4 ± 0.3 µg/L vs 9.5 ± 0.3 µg/L, P < .0001) there was no association with lower grades of ACR (P = .24). The intensity of ACR (as determined by acute rejection scores) did not correlate with tacrolimus mean BTLs at any time during the first posttransplant year (P = .79). During the first 90 days post LTx there was a significant decline in CrCl and a correlation between increasing tacrolimus mean BTLs and declining CrCl (r = -0.26, P = .03); a correlation that was not observed during the remainder of the year (r = -0.09, P = .52). CONCLUSIONS: In LTx recipients, maintaining BTLs of the CNI tacrolimus >10µg/L did not result in superior control of acute rejection responses but was associated with declining renal function.

Medical Director Responsibilities for Outpatient Pulmonary Rehabilitation Programs in the United States: 2019: A STATEMENT FOR HEALTH CARE PROFESSIONALS FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION (AACVPR).

Clinical guidelines have been developed recognizing pulmonary rehabilitation (PR) as a key component in the management of patients with chronic lung disease. The medical director of a PR program is a key player in every program and is a requirement for operation of the program. The medical director must be a licensed physician who has experience in respiratory physiology management. The purpose of this document is to provide an update regarding the clinical, programmatic, legislative, and regulatory issues that impact PR medical directors in North America. It describes the clinical rationale for physician involvement, relevant legislative and regulatory requirements, and resources available that the medical director can utilize to promote evidence-based and cost-effective PR services. All pulmonary rehabilitation (PR) programs must include a medical director. There are many clinical, programmatic, legislative, and regulatory issues that impact the PR medical director. The purpose of this document is to concentrate on the unique roles and responsibilities of the PR medical director.

Prioritization, Development, and Validation of American Association of Cardiovascular and Pulmonary Rehabilitation Performance Measures.

BACKGROUND: In 2014, the American Association of Cardiovascular and Pulmonary Rehabilitation Quality of Care Committee was asked to develop performance measures (PMs) to assess program quality and aid in program improvement and certification. METHODS: A 3-step process was used to prioritize, develop, and then validate new PMs for both cardiac and pulmonary rehabilitation programs. First, we surveyed national leadership, medical directors, and program directors to identify and rank various American Association of Cardiovascular and Pulmonary Rehabilitation potential PM topics. Then, the face validity of the drafted PMs was assessed in a second national survey. Finally, we assessed the inter- and intrarater reliability and feasibility of each PM by abstracting patient charts at programs throughout the United States. At each step, modifications were made to refine and improve the measures for clarity, reliability, and consistency. RESULTS: Through survey answers received from 302 people (19% response rate), we identified 5 categories for PM development: optimal blood pressure control, tobacco use cessation, and improvement in functional capacity, depression, and sensation of dyspnea. After drafting the PMs, a second survey with 82 respondents (57% response rate), found that the proposed PMs had good face validity. Finally, we found excellent inter- and intrarater reliability for the blood pressure, functional capacity, depression, and dyspnea measures (κ generally >0.80.) However, validity concerns were raised about the tobacco intervention PM as written, and it continues to undergo further refinement and testing. CONCLUSIONS: We developed and validated 5 new PMs for use in cardiac and pulmonary rehabilitation program quality assessment, improvement, and certification.

Cigarette smoking following lung transplantation: effects on allograft function and recipient functional performance.

PURPOSE: Despite mandatory tobacco abstinence following lung transplantation (LTX), some recipients resume smoking cigarettes. The effect of smoking on allograft function, exercise performance, and symptomatology is unknown. METHODS: A retrospective review was conducted of LTX recipients who received allografts over an 8-year interval and who were subjected to sequential posttransplant pulmonary function testing (PFT), 6-minute walk (6MW) testing, and assessments of exertional dyspnea (Borg score). Using post-LTX PFT results, recipients were determined to have either bronchiolitis obliterans syndrome (BOS), a manifestation of chronic allograft rejection, or normal pulmonary function (non-BOS). With respect to post-LTX pulmonary function, 6MW distances, and Borg scores, comparisons were made between these recipient groups and those who resumed smoking. RESULTS: Of 34 LTX recipients identified, 13 maintained normal lung function (non-BOS), while 16 demonstrated a decline in their PFT values consistent with BOS. Five recipients began smoking at median postoperative day 365 and smoked 1 pack per day for a mean of 485.6 days. Smokers developed a deterioration of their PFT values that was similar to those with BOS (P = .47) and tended to be worse than those in the non-BOS group (P = .09). All smokers experienced a decline in 6MW distances similar to those with BOS and non-BOS but reported less exertional dyspnea (lower Borg scores) than those with BOS. CONCLUSION: Recipients of LTX who resume cigarette smoking demonstrate a decline in pulmonary function similar to those afflicted with chronic allograft rejection but do not experience a decrement in their functional performance or increased dyspnea.

Clinical competency guidelines for pulmonary rehabilitation professionals: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation.

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognizes that interdisciplinary health care professionals providing pulmonary rehabilitation services need to have certain core competencies. This statement updates the previous clinical competency guidelines for pulmonary rehabilitation professionals, and it complements the AACVPR's Guidelines for Pulmonary Rehabilitation Programs. These competencies provide a common core of 13 professional and clinical competencies inclusive of multiple academic and clinical disciplines. The core competencies include patient assessment and management; dyspnea assessment and management; oxygen assessment, management, and titration; collaborative self-management; adherence; medication and therapeutics; non-chronic obstructive pulmonary diseases; exercise testing; exercise training; psychosocial management; tobacco cessation; emergency responses for patient and program personnel; and universal standard precautions.

The lung allocation score and survival in lung transplant candidates with chronic obstructive pulmonary disease.

The Lung Allocation Score (LAS), devised to prioritize candidates awaiting lung transplantation (LTX), is calculated using the predicted duration of survival on the wait list while also considering the recipient's likelihood of post-transplant survival. This score is generated based, in part, on the severity of the candidate's comorbid illnesses. The actual relationship between the LAS and survival is unknown. The current study was performed to evaluate the relationship between the LAS and both wait-list survival and post-transplant survival in candidates with COPD. The study was a retrospective analysis of 41 LTX candidates with chronic obstructive pulmonary disease (COPD) as well as a cohort of 17 candidates who survived to receive a graft. The study was conducted at a university hospital transplant center. Thirty-six of 41 candidates survived to transplant. The LAS of these survivors was 32.62 +/- 1.06 and was significantly lower than the score of 34.45 +/- 1.19 of the nonsurvivors (P < 0.01). The LAS also exhibited a negative association with survival to transplant (P < 0.05, beta = -1.39). A cohort of 17 LTX recipients was chosen for post-transplant analysis in which 13 survived at least 1 year. In this cohort the LAS did not exhibit significant association with 1-year post-transplant survival (P = 0.58, beta = -0.25). As might be anticipated by virtue of its calculation being based in part on the existence and severity of comorbid conditions, a lower LAS was associated with improved survival to transplantation in LTX candidates with COPD. However, the pretransplant calculation of the LAS was not associated with actual post-transplant survival.

Implementation of handheld devices.

With the rapid introduction of technology in nursing education, information regarding its implementation in undergraduate curricula is emerging. The authors describe the implementation process used to integrate personal digital assistants into an undergraduate nursing curriculum. Barriers such as potential for device loss, issues related to patient confidentiality, and infection control are addressed.

Cardiovascular consequences of pulmonary hypertension.

Pulmonary hypertension occurs when pulmonary vascular pressures are elevated. Pulmonary arterial hypertension is associated with occlusion of the pulmonary arterial tree, while pulmonary venous hypertension is seen when pulmonary vein outflow is impeded. Cardiovascular consequences are common with pulmonary hypertension, regardless of the underlying pathogenesis and whether management is complex. However, there are a number of interventions that may improve quality of life and survival of pulmonary hypertension. This article discusses current recommendations for diagnosis and management.

Wrist actigraphy validation of exercise movement in COPD.

A wrist actigraph is a device used in sleep research studies to measure whole body movements. The purpose of this study was to evaluate the feasibility, sensitivity, and validity of wrist actigraphy during pulmonary rehabilitation (PR) upper-extremity exercise in chronic obstructive pulmonary disease (COPD) patients. In this study, 20 patients wore Octagonal Basic Motionlogger actigraphs during two 90-minute PR sessions while the investigator recorded details of the subject's upper-extremity movements. Concurrent validity with supervised exercise records was supported for upper-extremity endurance (UEE) intensity at baseline (r = .885, p < .001) and 1 week (r = .935, p < .001). Criterion validity was supported for UEE (r = .56, p = .01) and combined lower- and upper-extremity resistance (r = .72, p < .01) compared with rank-ordered type of exercise. Wrist actigraphy is shown to be a feasible, sensitive, and valid instrument to measure upper-extremity movement during PR in COPD patients.

Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines.

BACKGROUND: Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation. METHODS: The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system. RESULTS: The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD. CONCLUSIONS: There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need.

Feasibility of distractive auditory stimuli on upper extremity training in persons with chronic obstructive pulmonary disease.

OBJECTIVE: To determine the feasibility of distractive auditory stimuli (DAS) used during an upper extremity training (UET) program on perceived dyspnea, functional performance, and health-related quality of life. In addition, to determine the appropriate music tempo used during the UET. DESIGN: Experimental, randomized, 3-group design with testing at baseline and 4 weeks. SETTING: Outpatient. PATIENTS: Thirty patients (13 male and 17 female) with moderate to severe chronic obstructive pulmonary disease (FEV1 41.27% +/- 18% predicted). INTERVENTION: Moderate DAS group (n = 10) and slow DAS group (n = 10) subjects were instructed to perform UET for up to 15 minutes 3 to 5 times a week using DAS (walkman, audiocassettes). The control group (n = 10) received the same instructions, but no DAS. MEASURES AND RESULTS: Primary outcome measures were perceived dyspnea, functional performance using the 6-minute peg and ring board (6MRPB) count and health-related quality of life. In addition, all subjects recorded the time of UET performance using self-report (daily logs). A significant increase was seen in 6MRPB count (P = .002) between groups. Moderate DAS subjects increased 6MPRB count 46 +/- 21 rings and slow DAS subjects increased 46 +/- 20 rings from baseline to 4 weeks whereas control subjects increased only 5 +/- 4 rings. No significant differences were noted for the remaining variables. CONCLUSION: Subjects who used DAS (music) while performing UET improved functional performance whereas controls failed to continue improvement. The DAS is a feasible adjunct to UET that may have the potential to augment the effectiveness of pulmonary rehabilitation training.

Exercise maintenance following pulmonary rehabilitation: effect of distractive stimuli.

STUDY OBJECTIVE: To determine if distractive auditory stimuli (DAS) in the form of music would promote adherence to a walking regimen following completion of a pulmonary rehabilitation program (PRP) and, thereby, maintenance of gains achieved during the program. DESIGN: Experimental, randomized, two-group design with testing at baseline, 4 weeks, and 8 weeks. SETTING: Outpatient. PATIENTS: Twenty-four patients (4 men and 20 women) with moderate-to-severe COPD (FEV(1) 41.3 +/- 13% predicted [mean +/- SD]). INTERVENTION: Experimental group subjects (n = 12) were instructed to walk at their own pace for 20 to 45 min, two to five times a week, using DAS with a portable audiocassette player. The control group (n = 12) received the same instructions, but no DAS. MEASUREMENTS AND RESULTS: Primary outcome measures were perceived dyspnea during activities of daily living (ADL) and 6-min walk (6MW) distance. Secondary outcome measures were anxiety, depressive symptoms, health-related quality of life (QoL), global QoL, and breathlessness and fatigue at completion of the 6MW. In addition, all subjects recorded the distance and time walked using self-report (pedometers and daily logs). There was a significant decrease in perceived dyspnea during ADL (p = 0.0004) and a significant increase in 6MW distance (p = 0.0004) over time in the DAS group compared to the control group. DAS subjects increased 6MW distance 445 +/- 264 feet (mean +/- SD) from baseline to 8 weeks, whereas control subjects decreased 6MW distance to 169 +/- 154 feet. No significant differences were noted for the remaining variables. The cumulative distance walked by the DAS group was 19.1 +/- 16.7 miles compared to 15.4 +/- 8.0 miles for the control group, a 24% difference (p = 0.49). Despite this difference, self-report exercise log data were similar for the two groups. CONCLUSION: Subjects who used DAS while walking had improved functional performance and decreased perceptions of dyspnea, whereas control subjects could not maintain post-PRP gains. DAS is a simple, cost-effective strategy that may have the potential to augment the effectiveness of post-PRP maintenance training.