Multimodal nutritional rehabilitation improves clinical outcomes of malnourished patients with chronic respiratory failure: a randomised controlled trial.

BACKGROUND: In chronic respiratory failure (CRF), body composition strongly predicts survival. METHODS: A prospective randomised controlled trial was undertaken in malnourished patients with CRF to evaluate the effects of 3 months of home rehabilitation on body functioning and composition. 122 patients with CRF on long-term oxygen therapy and/or non-invasive ventilation (mean (SD) age 66 (10) years, 91 men) were included from eight respiratory units; 62 were assigned to home health education (controls) and 60 to multimodal nutritional rehabilitation combining health education, oral nutritional supplements, exercise and oral testosterone for 90 days. The primary endpoint was exercise tolerance assessed by the 6-min walking test (6MWT). Secondary endpoints were body composition, quality of life after 3 months and 15-month survival. RESULTS: Mean (SD) baseline arterial oxygen tension was 7.7 (1.2) kPa, forced expiratory volume in 1 s 31 (13)% predicted, body mass index (BMI) 21.5 (3.9) kg/m2 and fat-free mass index (FFMI) 15.5 (2.4) kg/m2. The intervention had no significant effect on 6MWT. Improvements (treatment effect) were seen in BMI (+0.56 kg/m2, 95% CI 0.18 to 0.95, p=0.004), FFMI (+0.60 kg/m2, 95% CI 0.15 to 1.05, p=0.01), haemoglobin (+9.1 g/l, 95% CI 2.5 to 15.7, p=0.008), peak workload (+7.2 W, 95% CI 3.7 to 10.6, p<0.001), quadriceps isometric force (+28.3 N, 95% CI 7.2 to 49.3, p=0.009), endurance time (+5.9 min, 95% CI 3.1 to 8.8, p<0.001) and, in women, Chronic Respiratory Questionnaire (+16.5 units, 95% CI 5.3 to 27.7, p=0.006). In a multivariate Cox analysis, only rehabilitation in a per-protocol analysis predicted survival (HR 0.27, 95% CI 0.07 to 0.95, p=0.042). CONCLUSIONS: Multimodal nutritional rehabilitation aimed at improving body composition increased exercise tolerance, quality of life in women and survival in compliant patients, supporting its incorporation in the treatment of malnourished patients with CRF. Clinical Trial number NCT00230984.

Computed tomography measurements for airway stent insertion in malignant airway obstruction.

BACKGROUND: Metallic airway stents for malignant airway obstruction are considered safe, yet are not without complications. This study reviews the role of computed tomography (CT) airway measurements for planning stent placement in malignant airway obstruction before the actual therapeutic procedure to avoid invasive diagnostic evaluation before the stent placement and to reduce complications. METHODS: This study is a retrospective review of information from a stent order database and medical records of patients receiving stents for malignant airway obstruction at a university hospital over a 12-year period. CT scans were used to determine stent diameter by calculating mean diameters of healthy adjacent zones (proximal and distal), stent length (length of diseased airway), and location and number of potential stents. Results of CT planning before bronchoscopy were judged by complication rates. RESULTS: Patient population consisted of 69 patients, 61.7±14.0 years old, 40 males, in whom 92 stents were inserted. The most frequent cause of airway obstructions was tracheobronchial cancer (32). All patients had nitinol stent placement; 66 stents were covered and 26 were uncovered. Follow-up time was 1 to 1067 days (median: 35 days). Complication rate was 10.1% and mainly involved the patients with tracheal obstruction (6). Complications included stent fractures (2), migration (2), granuloma (1), and infectious tracheitis (2). One early death within 24 hours after the procedure was not related to stent placement. Five patients required follow-up therapeutic bronchoscopy to treat the complications. CONCLUSIONS: These results suggest that prestent planning by noninvasive method of obtaining CT scan provides optimal stent size and position, possibly avoiding a diagnostic bronchoscopy and reducing complications. Further prospective study is needed to confirm these results because of limitation of this study's design.

C-reactive protein and body mass index predict outcome in end-stage respiratory failure.

STUDY OBJECTIVE: To determine the predictive factors of morbidity and mortality in patients with end-stage respiratory disease. DESIGN: Prospective, multicenter cohort study. SETTING: Thirteen outpatient chest clinics within the Association Nationale de Traitement à Domicile de l'Insuffisance Respiratoire. PARTICIPANTS: Stable adult patients with chronic respiratory failure receiving long-term oxygen therapy and/or home mechanical ventilation (n = 446; 182 women and 264 men; aged 68.5 +/- 12.1 years [+/- SD]); Respiratory diseases were COPD in 42.8%, restrictive disorders in 36.3%, mixed respiratory failure in 13.5%, and bronchiectasis in 7.4%. Recruitment was performed during the yearly examination. Patients with neuromuscular diseases and sleeping apnea were excluded. MEASUREMENTS AND RESULTS: Hospitalization days and survival were recorded during a follow-up of 14.3 +/- 5.6 months. Body mass index (BMI), serum albumin, and transthyretin levels were considered for their predictive value of outcome, together with demographic data, underlying respiratory disease, respiratory function, hemoglobin, C-reactive protein, smoking habits, oral corticosteroid use, and antibiotic treatment courses. Overall, 1.8 +/- 1.7 hospitalizations (cumulative stay, 17.6 +/- 27.1 days) were observed in 254 of 446 patients (57%). Independent predictors of hospitalization were oral corticosteroids, FEV(1), and plasma C-reactive protein. One-year and 2-year cumulative survivals were 93% and 69%, respectively. Plasma C-reactive protein, BMI, Pao(2) on room air, and oral corticosteroids independently predicted survival in multivariate analysis. CONCLUSION: Besides established prognosis factors such as FEV(1) and Pao(2), nutritional depletion as assessed by BMI and overall systemic inflammation as estimated by C-reactive protein appear as major determinants of hospitalization and death risks whatever the end-stage respiratory disease. BMI and C-reactive protein should be included in the monitoring of chronic respiratory failure. Oral corticosteroids as maintenance treatment in patients with end-stage respiratory disease are an independent risk factor of death, and should be avoided in most cases.