Home-based pulmonary rehabilitation early after hospitalisation in COPD (early HomeBase): protocol for a randomised controlled trial.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is characterised by exacerbations of respiratory disease, frequently requiring hospital admission. Pulmonary rehabilitation can reduce the likelihood of future hospitalisation, but programme uptake is poor. This study aims to compare hospital readmission rates, clinical outcomes and costs between people with COPD who undertake a home-based programme of pulmonary rehabilitation commenced early (within 2 weeks) of hospital discharge with usual care. METHODS: A multisite randomised controlled trial, powered for superiority, will be conducted in Australia. Eligible patients admitted to one of the participating sites for an exacerbation of COPD will be invited to participate. Participants will be randomised 1:1. Intervention group participants will undertake an 8-week programme of home-based pulmonary rehabilitation commencing within 2 weeks of hospital discharge. Control group participants will receive usual care and a weekly phone call for attention control. Outcomes will be measured by a blinded assessor at baseline, after the intervention (week 9-10 posthospital discharge), and at 12 months follow-up. The primary outcome is hospital readmission at 12 months follow-up. ETHICS AND DISSEMINATION: Human Research Ethics approval for all sites provided by Alfred Health (Project 51216). Findings will be published in peer-reviewed journals, conferences and lay publications. TRIAL REGISTRATION NUMBER: ACTRN12619001122145.

Smoking Cessation Care in Cardiothoracic Surgery: A Qualitative Study Exploring the Views of Australian Clinicians.

BACKGROUND: Smoking cessation (SC) care in the perioperative period of cardiothoracic surgery is important to reduce surgical risk and help achieve long-term smoking abstinence in patients who continue to smoke. The implementation of clinical guidelines for SC care in the perioperative period has proved challenging, yet little is known of what influences the inter-disciplinary team involved in the cardiothoracic area. This qualitative study explored the views of the clinicians involved in perioperative period of cardiothoracic surgery in Australia on their SC advice and support. METHODS: Semi-structured interviews were conducted with 52 cardiothoracic surgeons, anaesthetists, nurses and physiotherapists in three public tertiary referral hospitals and three private hospitals in New South Wales (NSW). Data was thematically analysed, and categorised using the Behaviour Change Wheel "Capabilities, Opportunity, Motivation & Behaviour" (COM-B) analysis framework to understand the factors that influence clinicians' views and perceived abilities to provide SC care. RESULTS: Barriers and facilitators to providing SC care were identified. The most commonly identified barriers in capability were the lack of knowledge, training and institutional engagement. Opportunity was hindered by lack of time, hospital support and resources, yet facilitated by the existence of a collaborative, multidisciplinary team and the ability to follow-up patients long term. In motivation, clinicians' attitudes and experience negatively influenced the initiation of the cessation conversation, while intrinsic attributes of empathy and positivity were drivers to provide SC care. CONCLUSIONS: Clinicians' views, together with inadequate SC training, resources and engagement to implement clinical guidelines, contribute to inconsistent SC care. There is a need for hospitals to provide adequate SC resources and training to all clinicians to improve SC care to cardiothoracic surgery patients throughout the perioperative period.

Electronic Cigarettes and Smoking Cessation in the Perioperative Period of Cardiothoracic Surgery: Views of Australian Clinicians.

For patients who smoke, electronic cigarettes may offer a pathway to achieve tobacco abstinence and reduce the risk of postoperative complications. Clinicians have a pivotal role in supporting smoking cessation by patients with lung cancer and coronary artery disease throughout the perioperative period of cardiothoracic surgery. However, the views of Australian cardiothoracic clinicians on electronic cigarettes and smoking cessation are unknown. Semi-structured interviews were conducted with 52 cardiothoracic surgeons, anaesthetists, nurses and physiotherapists in six hospitals in Sydney and thematically analysed. Clinicians' knowledge about electronic cigarettes and the regulatory environment surrounding them was limited. Clinicians believed that: electronic cigarettes, though unlikely to be safe, were safer than tobacco cigarettes; electronic cigarettes may have a harm reduction role in public health; and electronic cigarettes were a potential smoking cessation tool for the extraordinary circumstances of surgery. The professional role of a clinician and their views about electronic cigarettes as a perioperative smoking cessation aid had an influence on future clinician-patient interactions. Electronic cigarette use is increasing in Australia and clinicians are likely to receive more frequent questions about electronic cigarettes as a cessation aid. Stronger guidance for clinicians is needed on the topic of electronic cigarettes and cardiothoracic surgery.

Use of electronic cigarettes in the perioperative period: A mixed-method study exploring perceptions of cardiothoracic patients in Australia.

INTRODUCTION: Electronic cigarettes (e-cigarettes) may reduce tobacco use and achieve tobacco abstinence in the perioperative period of cardiothoracic surgery for patients who smoke. However, research on patients' views on the role of e-cigarettes as a smoking cessation tool is lacking. This mixed-methods study explored perceptions on the use of e-cigarettes among current smokers and ex-smokers awaiting cardiothoracic surgery in Australia. METHODS: A cross-sectional study and semi-structured interviews were conducted with 62 patients who were diagnosed with coronary artery disease or lung cancer and were scheduled for elective cardiothoracic surgery at six metropolitan hospitals in Sydney. Data were collected on demographic characteristics, smoking history, surgical risk index, self-efficacy, interest in, perceived benefits of, and barriers to using e-cigarettes in the perioperative period. RESULTS: Current smokers reported significantly higher interest in the use of e-cigarettes (p=0.008), and perceived fewer barriers (p=0.048) and more health benefits (p=0.079), compared to ex-smokers. Current smokers considered e-cigarettes to be either a safer alternative to tobacco or a novel method for quitting. Recent ex-smokers, defined as those who quit 2-8 weeks, were a distinct group with high nicotine dependency, a long history of smoking, and multiple failed quit attempts. Compared to longer-term ex-smokers (8-52 weeks quit), recent ex-smokers were more interested in e-cigarettes (p=0.029) and considered e-cigarettes a useful aid to prevent relapse in the lead up to surgery and to manage their nicotine cravings. CONCLUSIONS: E-cigarettes may be considered a short-term novel aid and a bridge to evidence-based methods to reduce harm from continued tobacco use for some patients awaiting cardiothoracic surgery for coronary artery disease or lung cancer. This study presents reasons why patients awaiting cardiothoracic surgery may enquire about or use e-cigarettes, which will help clinicians identify those who need more consistent, sustained cessation support.

Relationship between field walking tests and incremental cycle ergometry in COPD.

BACKGROUND AND OBJECTIVE: Cycle ergometer training is an important component of pulmonary rehabilitation for patients with COPD. However, incremental cycle tests from which individualized cycle training intensity can be prescribed may not be readily available to clinicians. The aims of the study were to (i) investigate the physiological and psychophysical responses to the 6-min walk test (6MWT), incremental shuttle walk test (ISWT) and cycle ergometer test (CET); and (ii) determine whether the distance walked in either the 6MWT or the ISWT could be used to estimate peak work rate on a cycle ergometer. METHODS: A repeated measures study was undertaken in COPD patients in a stable condition. The 6MWT, ISWT and CET were performed in random order, and physiological responses, rate of perceived exertion and dyspnoea were measured. RESULTS: Twenty-two patients with COPD completed the study. There was no significant difference in peak oxygen uptake between the 6MWT, ISWT and CET. The significant correlation between the 6MWD and incremental shuttle walk distance with peak watts on the CET (r = 0.63, P = 0.002 and r = 0.75, P < 0.001, respectively) was strengthened by the inclusion of weight, age and gender (r = 0.89 P = 0.001 and r = 0.91, P < 0.001). Bland-Altman analysis demonstrated a strong agreement between peak work rate measured on the CET and that estimated from either the 6MWT or the ISWT. CONCLUSIONS: The significant relationships found between the three exercise tests, and the regression equations predicting peak work rate on the CET from the 6MWT or the ISWT, may allow for the estimation of intensity of cycle exercise training from walk tests in COPD patients.

Prescribing cycle training intensity from the six-minute walk test for patients with COPD.

BACKGROUND: Cycle training intensity for patients with chronic obstructive pulmonary disease (COPD) is normally based on an incremental cycle test. Such tests are expensive and not readily available to clinicians. The six-minute walk test (6MWT) has been proposed as an alternative to an incremental cycle test for this purpose, based on the findings of previous research that the peak oxygen consumption (VO2peak) for the incremental cycle test and the 6MWT was equivalent in participants with COPD. A regression equation relating distance walked on the 6MWT and peak work rate (Wpeak) on the incremental cycle test has been described. The aim of this study is to measure the physiological responses to constant load cycle exercise performed at an intensity of 60% Wpeak determined from the 6MWT in participants with stable COPD. METHODS/DESIGN: This study is a prospective, repeated measures design. Thirty-five participants with stable COPD and mild to severe lung disease will be recruited from referrals to pulmonary rehabilitation. Subjects with co-morbidities limiting exercise performance will be excluded. Two 6MWTs will be performed. The better 6MWT will be used to calculate Wpeak for cycle exercise from a regression equation. After 30 minutes rest, subjects will perform ten minutes of constant-load cycle exercise at 60% of the calculated Wpeak. During all exercise, cardiorespiratory and metabolic data (Cosmed K4b2), dyspnoea and rate of perceived exertion (RPE) will be recorded. The VO2 measured at the end of cycle exercise will be compared to VO2peak of the 6MWT (VO2bike/VO2walk). Pearson's correlation coefficient will be calculated for the relationship between VO2bike and VO2walk. A one-way analysis of variance (ANOVA), with Bonferroni correction, will be performed to determine whether the ratio of VO2bike/VO2walk is affected by disease severity. DISCUSSION: This novel study will measure the physiological responses to cycle exercise, in terms of VO2peak, performed at an intensity determined from the 6MWT in participants with COPD. Positive findings will enable clinicians to more precisely prescribe cycle training intensity by utilising a simple, reliable and inexpensive 6MWT, thus providing a better standard of care for patients with COPD referred to pulmonary rehabilitation. TRIAL REGISTRATION: ACTRNO12606000496516.