An innovative maintenance follow-up program after a first inpatient pulmonary rehabilitation.

Although the benefits of pulmonary rehabilitation (PR) have been demonstrated in patients with COPD, most studies suggest that short-term programs are insufficient to maintain the benefits beyond a post-discharge period of 6 months to 1 year. We were interested to evaluate the effects of an innovative maintenance intervention compared with a usual after-care. Forty moderate to severe COPD patients, who had just completed their first inpatient PR, were consecutively included in either a maintenance group (MG) or a standard after-care group. The maintenance program was coordinated within a health-care network including self-help associations, and offered weekly activities. We measured the 6-min walk distance (6MWD), the quality of life using the St George Respiratory Questionnaire (SGRQ), the dyspnea, the maximal workload and the health-care utilization. Data were collected at respiratory clinic admission and discharge, and at 6- and 12-month visits after the PR. After 12 months, we found statistically and clinically significant differences in favor of the MG in 6MWD (74 m; p < or = 0.01) and in the three domains of SGRQ: symptom (19%; p < or = 0.01), activity (27%; p < or = 0.01) and impact (32%; p < or = 0.01). The results showed no difference between groups in dyspnea and maximal workload. We also found that the number of days spent in hospital for respiratory disorders was significantly lower in the MG after 12 months (p < or = 0.03). The multidisciplinary management of COPD patients in the post-rehabilitation period within a health-care network including self-help associations seems to be an effective strategy for maintaining, and even improving, the benefits of a first initial structured program.

[Psychosocial support for pulmonary rehabilitation in patients with Chronic Obstructive Pulmonary Disease]. / L'accompagnement psychologique dans la réhabilitation des broncho-pneumopathies chroniques obstructives.

INTRODUCTION: This paper focuses on recent studies examining psychosocial support provided in pulmonary rehabilitation programmes for patients with Chronic Obstructive Pulmonary Disease (COPD). STATE OF ART: The literature shows the impact that psychological variables have on COPD consequences and on compliance with treatment. These parameters influenced rehabilitation outcomes. Psychosocial support, such as group discussions, reduces incapacity (dyspnoea control) and handicap situations (reductions in anxiety and depression, improvements in coping strategies, autonomy and social participation). PERSPECTIVES: Further studies are needed to optimise psychosocial input particularly by combining it with education sessions. CONCLUSIONS: Psychosocial support is nowadays recommended as part of pulmonary rehabilitation programmes for patients with stable COPD. It complements the other components of exercise, breathing techniques and health education.

Factor analysis of quality of life, dyspnea, and physiologic variables in patients with chronic obstructive pulmonary disease before and after rehabilitation.

OBJECTIVE: To identify the relationships between quality of life (QOL) and the clinical state using factor analysis pre- and postrehabilitation. Patients with chronic obstructive pulmonary disease (COPD) suffer from a significant physiologic impairment associated with an altered QOL. Comprehensive rehabilitative programs, including exercise training, have beneficial effects on exercise tolerance and QOL for these patients. DESIGN: Factor analysis (n = 6) was conducted using the data of 32 patients with COPD. Patients had been evaluated for QOL using the Nottingham Health Profile (NHP), spirometric values, dyspnea, and the variables assessed by an incremental exercise test at three levels of activity. All measurements were obtained pre- and postrehabilitation. RESULTS: Factor analysis showed that the following two factors characterize the pathophysiologic condition of patients with COPD: (1) the specific cardiorespiratory responses to incremental exercise test and the spirometric values; and (2) the QOL results. The factor analysis results differed with the testing time (pre, post) and the level of activity. CONCLUSIONS: QOL, as evaluated by a generic questionnaire and the clinical state of patients with COPD, was independent; this independence characterized the pathophysiologic condition of our patients. Our results reinforce the usefulness of different types of evaluation, especially pre- and postrehabilitation, because they reflect independent benefits used to understand the success and follow-up of rehabilitative programs.

Quality of life and exercise tolerance in chronic obstructive pulmonary disease: effects of a short and intensive inpatient rehabilitation program.

The quality of life and the exercise endurance of patients with chronic obstructive pulmonary disease are impaired. The aim of our study was to determine the impact of a 3-wk intensive inpatient rehabilitation program on the quality of life of patients with chronic obstructive pulmonary disease and to examine the correlation between quality-of-life measures and physiologic measures throughout rehabilitation. Thirty-two patients with chronic obstructive pulmonary disease (20 men, 12 women) were evaluated by spirometry and maximal exercise testing for exercise endurance and by the French version of the Nottingham Health Profile for quality of life. Rehabilitation components were individualized exercise at ventilatory threshold (4 hr/day), health education, and physical therapy and relaxation for 3 wk. Our results showed an improvement in the quality of life (especially in physical mobility, energy, and social isolation) and exercise endurance (increase of 14% of maximal power and symptom-limited oxygen uptake). In contrast, no significant correlations were found between the quality of life and physiologic parameters (gas exchange, cardiovascular and lung function parameters) throughout rehabilitation. Changes in the quality of life seem to be independent of the physiologic results during the course of a short and intensive inpatient rehabilitation program. Quality of life should, therefore, be more systematically evaluated to determine the psychosocial benefits, which, although subjective, are important for encouraging patients' compliance with rehabilitation programs.

[Notion of metabolic adaptation to exercise]. / Notion d'adaptation métabolique à l'exercice.

During muscular exercise, adenosine triphosphate (ATP) must be resynthesized in order to allow subsequent muscle contraction. ATP can be immediately resynthesized from adenosine diphosphate (ADP) and from creatine phosphate (CP). However, such resynthesis from phosphorylated compounds is not possible in very short-duration exercise. For further exercise an energy source, mainly carbohydrates and lipids, is needed. While anaerobic (glycolysis and glycogenolysis) and aerobic (mitochondrial oxidation) pathways are used for carbohydrates, lipids can only undergo oxidation. Carbohydrates are used preferentially with rising exercise intensity because of increased muscle uptake, progressive recruitment of type II fibers and catecholamine release. Lipid oxidation rises with the duration of exercise and falls with increasing intensity. The observation that training plays an important role in the use of these energy substrates has led to the development of the crossover theory by which the use of carbohydrates and lipids in all individuals depends at all times on the combined effect of training and exercise intensity. Training facilitates lipid oxidation but, by allowing higher intensity, also implies inevitable use of carbohydrates. Thus there is an exercise level, or a crossover point, at which carbohydrate energy predominates over lipid energy. Beyond this point, increasing energy requirements are satisfied by preferential use of carbohydrates. Finally, although it was incorrectly thought that proteins play a very minor role, actually amino acids coming from the voluminous tissue mass provide an important source of energy during prolonged exercise.

[Common and current measurement parameters]. / Les paramètres de mesure usuels et actuels.

The different parameters used in cardiopneumologic exercise tests allow an assessment of exercise tolerance on the basis of the subject's ventilatory response, cardiac and metabolic adaptation and gas exchanges during exercise. VO2max and dyspnea are indicators of good or poor exercise tolerance. Normal values established for adults in three reference articles depend on age, body weight and height. In a 20-year-old non sedentary subject, VO2max is approximately 45 ml/mn/kg and decreases to 25 ml/mn/kg at 65 years of age. Dyspnea is measured on two types of scales, categorical and visual analogue scales. "Minimal dyspnea" at maximal effort is normal in a healthy subject but becomes "very severe" in diseased subjects. A dyspnea threshold can be determined from the evolution of dyspnea during the test and is useful for retraining in patients with chronic obstructive lung disease. The normal ventilatory response always leaves a ventilatory reserve equal to 30% of the theoretical maximal ventilatory output. If the reserve is diminished, exercise is limited by ventilatory capacity. Gas exchanges reflect muscle adaptation to exercise and the homogeneous nature of alveolar ventilation compared with pulmonary perfusion (VA/Q). This depends on the physiological dead space (VD/VT) which is approximately 1/3 at rest decreasing to 1/4 or 1/5 at maximal exercise. VD/VT is high at rest and stays high during exercise in interstitial lung disease and vascular lung disease. VA/Q also depends on the alveo-arterial oxygen differential (P(A-a)O2) which increases two-fold during exercise. Expired gas and arterial gas must be measured simultaneously for the calculation. To measure cardiac adaptation, the ECG, heart rate and oxygen pulse (VO2/HR) must be recorded. The kinetics of oxygen pulse is more important than its maximal value, a decrease with unchanged heart rate suggests early-stage cardiomyopathy. Finally, blood lactate, the metabolic response to exercise, is used to determine the lactate threshold or the anaerobic threshold. Measurement of the ventilatory threshold is less invasive, ventilatory outflow increasing with increasing lactate level as described by the Beaver or Wassermann model. These thresholds indicate the subject's aerobic capacity. The exercise test has diagnostic value but can also be useful for individual patient management, particularly cardiorespiratory rehabilitation.

Comparison of two training programmes in chronic airway limitation patients: standardized versus individualized protocols.

This study tested the effect of two methods of training, one individualized at the heart rate corresponding to the gas exchange threshold (GET) and the other at the heart rate corresponding to 50% of maximal heart rate reserve, on maximal and submaximal cardiorespiratory response in 24 patients with chronic airway limitation (CAL). The patients were randomly assigned to either the individualized training group (IT; n = 12) or the standardized training group (ST; n = 12). The training programme consisted of 4 weeks of stationary bicycle exercise, 5 days.week-1. Before reconditioning began, the target level based on heart rate was not significantly different between groups (109 +/- 4 versus 110 +/- 3 beats.min-1, in IT and ST, respectively). Post-training, a significant increase in symptom-limited oxygen uptake (V'O2.sl) and maximal O2 pulse was found in IT, whereas ST exhibited no significant change. In each group, GET was statistically increased in much the same way as V'O2,sl, with a higher increase in IT (p < 0.01) than ST (p < 0.05). Nevertheless, IT exhibited a concomitant and gradual decrease in minute ventilation (V'E), carbon dioxide production (V'CO2), and venous lactate concentration ([La]), whereas ST presented no significant change in these parameters (intergroup p < 0.01). Breathing pattern was also altered after IT, at the same metabolic level and at the same ventilation level (intergroup p < 0.05). Cardiac responses were modified in the two groups. At the same metabolic level, a significantly lower cardiac frequency was found both for IT and ST (intragroup p < 0.05 after training). In contrast, the increase in O2 pulse was only significantly higher in It after training. These data show the greater efficiency of an individualized training protocol based on determination of gas exchange threshold as compared to a standardized protocol, in improving exercise performance, when applied to a patient group. Despite an apparently similar target training level, the individualized method clearly optimized the physiological training effects in patients with chronic airway limitation and, more particularly, decreased their ventilatory requirement.

[Tracheal neurofibroma and Recklinghausen's disease]. / Neurofibrome trachéal et maladie de Recklinghausen.

Neurogenic tumours arising in the trachea are rare; the association with Von Recklinghausen's disease is exceptional. Only two cases of tracheal neurofibroma with neurofibromatosis have been reported. We report on another patient, a thirty year old man, who presented with acute shortness of breath; laser resection was performed via an endotracheal approach, then, a few days later, resection of the exotracheal tumor and tracheal segment was performed. Postoperatively, the patient did well for nine years without any respiratory complaint or neurofibromatosis relapse.