A pilot study of trained ICU doulas providing early psychological support to critically ill patients.

BACKGROUND: Over a third of critical illness survivors suffer from mental health problems following hospitalization. Memories of delusional experiences are a major risk factor. In this project, ICU doulas delivered a unique positive suggestion intervention targeting the vulnerable time period during critical illness when these memories are formed. METHODS: Adult critically ill patients were recruited for this single-arm, prospective pilot study. These ICU patients received a positive suggestion intervention daily during their ICU stay in parallel with their medical treatment. The intervention was designed to be delivered over a minimum of two sessions. Feasibility was defined as intervention delivery on ≥ 70% of ICU days after patient enrollment. As a secondary analysis, psychometric questionnaires were compared to those of a historic control cohort of patients receiving standard care in the ICU using adjusted linear regression models. RESULTS: Of the 97 patients who received the intervention and were alive at the end of their ICU course, 54 were excluded from analyses mostly for having received only one session because of a short ICU length of stay of < 2 days, transitioning to comfort care or not wanting to answer the study questionnaires. Forty-three patients who completed 2 or more sessions of the positive therapeutic suggestion intervention provided by two trained ICU doulas received it for a median of 4 days (IQR 3, 5), with each session lasting for a median of 20 min (IQR 14, 25). The intervention was delivered on 71% of days, meeting our pre-determined feasibility goal. Compared to historical controls (N = 299), patients receiving the intervention had higher severity of illness and longer length of stay. When adjusted for baseline differences, patients both with and without mechanical ventilation who received the intervention scored lower on the Hospital Anxiety and Depression Scale (HADS)-Depression subscale. The intervention was also associated with reduced HADS-Anxiety subscale among ventilated patients. CONCLUSIONS: Positive therapeutic suggestion delivered by ICU doulas is feasible in the ICU setting. A randomized trial is warranted to better delineate the role that positive suggestion and ICU doulas may play in ongoing interprofessional efforts to humanize critical care medicine. The study was registered on clinicaltrials.gov (NCT03736954) on 03/14/2018 prior to the first patient enrollment https://clinicaltrials.gov/ct2/show/NCT03736954?cond=ICU+Doulas+Providing+Psychological+Support&draw=2&rank=1 .

Evaluating resilience as a predictor of outcomes in lung transplant candidates.

BACKGROUND: Resilience represents the capacity to adapt to adversity. Resilience can improve following behavioral interventions. We examined lung transplant candidates' resilience as a novel predictor using the Connor-Davidson Resilience Scale (RISC-10). METHODS: Waitlisted candidates at six centers were mailed questionnaires from 9/16/2015 to 10/1/2019. Follow-up surveys were collected annually and post-transplant. Outcomes were recorded through February 17, 2020. Primary outcome was pre-transplant death/delisting. Analyses included t test or chi-square for group comparisons, Pearson's correlation coefficients for strength of relationships, and Cox proportional-hazard models to evaluate associations with outcomes, adjusting for age, sex, and mood. RESULTS: Participation was 55.3% (N = 199). Baseline RISC-10 averaged 32.0 ± 5.6 and did not differ by demographics, primary transplant diagnosis, or disease severity markers. RISC-10 did not correlate to the commonly utilized Psychosocial Assessment of Candidates for Transplant [PACT] or Stanford Integrated Psychosocial Assessment for Transplantation [SIPAT] tools. Scores < 26.3 (representing > 1 standard deviation below population average) occurred in 16% and were associated with pre-transplant death or delisting, adjusted Hazard Ratio of 2.60 (95% Confidence Interval 1.23-5.77; P = .01). CONCLUSION: One in six lung candidates had low resilience, predicting increased pre-transplant death/delisting. RISC-10 did not correlate with PACT or SIPAT; resilience may represent a novel risk factor.

Mindfulness Meditation and Interprofessional Cardiopulmonary Resuscitation: A Mixed-Methods Pilot Study.

PROBLEM: Mindfulness training includes mindfulness meditation, which has been shown to improve both attention and self-awareness. Medical providers in the intensive care unit often deal with difficult situations with strong emotions, life-and-death decisions, and both interpersonal and interprofessional conflicts. The effect of mindfulness meditation training on healthcare providers during acute care tasks such as cardiopulmonary resuscitation remains unknown. Mindfulness meditation has the potential to improve provider well-being and reduce stress in individuals involved in resuscitation teams, which could then translate into better team communication and delivery of care under stress. A better understanding of this process could lead to more effective training approaches, improved team performance, and better patient outcomes. INTERVENTION: All participants were instructed to use a mindfulness meditation device (Muse™ headband) at home for 7 min twice a day or 14 min daily over the 4-week training period. This device uses brainwave sensors to monitor active versus relaxing brain activity and provides real-time feedback. CONTEXT: We conducted a single-group pretest-posttest convergent mixed-methods study. We enrolled 24 healthcare providers, comprising 4 interprofessional code teams, including physicians, nurses, respiratory therapists, and pharmacists. Each team participated in a simulation session immediately before and after the mindfulness training period. Each session consisted of two simulated cardiopulmonary arrest scenarios. Both quantitative and qualitative outcomes were assessed. OUTCOME: The median proportion of participants who used the device as prescribed was 85%. Emotional balance, as measured by the critical positivity ratio, improved significantly from pretraining to posttraining (p = .02). Qualitative findings showed that mindfulness meditation changed how participants responded to work-related stress, including stress in real-code situations. Participants described the value of time for self-guided practice with feedback from the device, which then helped them develop individual approaches to meditation not reliant on the technology. Time measures during the simulated scenarios improved, specifically, time to epinephrine in Scenario 1 (p = .03) and time to defibrillation in Scenario 2 (p = .02), improved. In addition, team performance, such as teamwork (p = .04), task management (p = .01), and overall performance (p = .04), improved significantly after mindfulness meditation training. Physiologic stress (skin conductance) improved but did not reach statistical significance (p = .11). LESSONS LEARNED: Mindfulness meditation practice may improve individual well-being and team function in high-stress clinical environments. Our results may represent a foundation to design larger confirmatory studies.

Analysis of nocturnal actigraphic sleep measures in patients with COPD and their association with daytime physical activity.

BACKGROUND: Sleep disturbances are common in patients with chronic obstructive pulmonary disease (COPD) with a considerable negative impact on their quality of life. However, factors associated with measures of sleep in daily life have not been investigated before nor has the association between sleep and the ability to engage in physical activity on a day-to-day basis been studied. AIMS: To provide insight into the relationship between actigraphic sleep measures and disease severity, exertional dyspnoea, gender and parts of the week; and to investigate the association between sleep measures and next day physical activity. METHODS: Data were analysed from 932 patients with COPD (66% male, 66.4±8.3 years, FEV1% predicted=50.8±20.5). Participants had sleep and physical activity continuously monitored using a multisensor activity monitor for a median of 6 days. Linear mixed effects models were applied to investigate the factors associated with sleep impairment and the association between nocturnal sleep and patients' subsequent daytime physical activity. RESULTS: Actigraphic estimates of sleep impairment were greater in patients with worse airflow limitation and worse exertional dyspnoea. Patients with better sleep measures (ie, non-fragmented sleep, sleeping bouts ≥225 min, sleep efficiency ≥91% and time spent awake after sleep onset <57 min) spent significantly more time in light (p<0.01) and moderate-to-vigorous physical activity (p<0.01). CONCLUSIONS: There is a relationship between measures of sleep in patients with COPD and the amount of activity they undertake during the waking day. Identifying groups with specific sleep characteristics may be useful information when designing physical activity-enhancing interventions.

Physical activity patterns and clusters in 1001 patients with COPD.

We described physical activity measures and hourly patterns in patients with chronic obstructive pulmonary disease (COPD) after stratification for generic and COPD-specific characteristics and, based on multiple physical activity measures, we identified clusters of patients. In total, 1001 patients with COPD (65% men; age, 67 years; forced expiratory volume in the first second [FEV1], 49% predicted) were studied cross-sectionally. Demographics, anthropometrics, lung function and clinical data were assessed. Daily physical activity measures and hourly patterns were analysed based on data from a multisensor armband. Principal component analysis (PCA) and cluster analysis were applied to physical activity measures to identify clusters. Age, body mass index (BMI), dyspnoea grade and ADO index (including age, dyspnoea and airflow obstruction) were associated with physical activity measures and hourly patterns. Five clusters were identified based on three PCA components, which accounted for 60% of variance of the data. Importantly, couch potatoes (i.e. the most inactive cluster) were characterised by higher BMI, lower FEV1, worse dyspnoea and higher ADO index compared to other clusters ( p < 0.05 for all). Daily physical activity measures and hourly patterns are heterogeneous in COPD. Clusters of patients were identified solely based on physical activity data. These findings may be useful to develop interventions aiming to promote physical activity in COPD.

Self-Management Programs and the Pursuit of Behavior Change.

A self-management intervention is a personalized approach to individuals aiming to engage individuals in a behavior change to develop skills to live better with their condition. Self-management involves an iterative process between participants and providers in which goals are formulated and feedback is given. All respiratory societies advocate self-management as part of chronic care because it may improve quality of life and health-care utilization. Self-management is an integral part of pulmonary rehabilitation. Self-management interventions usually involve education and exercise prescription, and that is an asset of current programs; however, recent reports indicate that effective strategies for motivation and a behavior change focus are often missed. A recent systematic review on self-management urges the need for a specific aspect and characteristic of self-management interventions: iterative interactions between participants and health-care professionals competent in using behavior change practices to elicit participants' motivation, confidence, and competence to develop skills to better manage their disease. A recent review of self-care intervention in chronic disease states that the major deficits found in self-care interventions included a lack of attention and/or innovation to the psychological consequences of chronic illness, technology, and behavior change techniques to help patients manage symptoms. There is a need for exploration of mechanisms to explain the relationships between both anxiety and depression, and adherence to treatment in COPD. The latter is particularly appropriate for pulmonary rehabilitation, for which greater adherence is needed. This report aims to introduce basic aspects of behavior change and a proposed roadmap to introduce behavior change into pulmonary rehabilitation and chronic care programs.

Management of Patients With Kidney Disease Undergoing Bariatric Surgery: A Multidisciplinary Approach.

Bariatric surgery is increasingly recognized as a safe and effective treatment for obesity in patients with chronic kidney disease (CKD), including stages 4, 5, and 5D (on dialysis). Among the available surgical methods, sleeve gastrectomy (SG) is the most commonly performed weight loss procedure and is mainly done to facilitate kidney transplantation (KT). However, many KT candidates treated with SG remain on the transplant waiting list for months to years, with some never receiving a transplant. Therefore, appropriate candidates for SG must be selected, and post-SG management should address the unique needs of this population, with a focus on sustaining the metabolic benefits of surgery while minimizing potential side effects related to rapid weight loss which may inadvertently lead to muscle and bone catabolism. Multidisciplinary post-SG care in this population may lead to overall better health on the transplant waiting list, resulting in a higher percentage of post-SG patients ultimately receiving KT. To tailor the effective treatment for these patients, clinicians should acknowledge that patients with CKD stage 4-5D have different nutritional needs and are metabolically and psychosocially distinct from the general bariatric surgery population. Sarcopenia is highly prevalent and may be exacerbated by muscle catabolism following SG if not adequately addressed. Blood pressure, glucose, and bone metabolism are all affected by the CKD stage 4-5D, and therefore require distinct diagnostic and management approaches. Long-standing chronic disease, associated comorbidities, and low adherence to medical therapies require ongoing comprehensive psychosocial assessment and support. This paper aims to review and consolidate the existing literature concerning the intersection of CKD stage 4-5D and the consequences of SG. We also suggest future clinical outcome studies examining novel treatment approaches for this medically complex population.

Weight Loss Surgery Increases Kidney Transplant Rates in Patients With Renal Failure and Obesity.

OBJECTIVE: To describe the outcomes of kidney transplant (KT) candidates with obesity undergoing sleeve gastrectomy (SG) to meet the criteria for KT. METHODS: Retrospective analysis was conducted of electronic medical records of KT candidates with obesity (body mass index >35 kg/m2) who underwent SG in our institution. Weight loss, adverse health events, and the listing and transplant rates were abstracted and compared with the nonsurgical cohort. RESULTS: The SG was performed in 54 patients; 50 patients did not have surgery. Baseline demographic characteristics were comparable at the time of evaluation. Mean body mass index ± SD of the SG group was 41.7±3.6 kg/m2 at baseline (vs 41.5±4.3 kg/m2 for nonsurgical controls); at 2 and 12 months after SG, it was 36.4±4.1 kg/m2 and 32.6±4.0 kg/m2 (P<.01 for both). In the median follow-up time of 15.5 months (interquartile range, 6.4 to 23.9 months), SG was followed by active listing (37/54 people), and 20 of 54 received KT during a median follow-up time of 20.9 months (interquartile range, 14.7 to 28.3 months) after SG. In contrast, 14 of 50 patients in the nonsurgical cohort were listed, and 5 received a KT (P<.01). Three patients (5.6%) experienced surgical complications. There was no difference in overall hospitalization rates and adverse health outcomes, but the SG cohort experienced a higher risk of clinically significant functional decline. CONCLUSION: In KT candidates with obesity, SG appears to be effective, with 37% of patients undergoing KT during the next 18 months (P<.01). Further research is needed to confirm and to improve the safety and efficacy of SG for patients with obesity seeking a KT.

Mindfulness and motivational interviewing: two candidate methods for promoting self-management.

There is no conclusive evidence about the way to a promote behavior change in self-management programs for patients with chronic obstructive pulmonary disease (COPD). The latter is a significant knowledge gap as there is a need to promote a sustained effect in interventions like Pulmonary Rehabilitation or Supporting Programs. Embracing patient's values seems to be a key ingredient to ignite genuine motivation for behavior change. This manuscript describes two pilot qualitative studies carried out in patients with severe COPD aimed to engage the patient inner experience and promote self-management: a trial testing motivational interviewing (MI) as one style of helping patients with severe COPD make changes in their behavior and second a trial testing a mindfulness-based intervention. The MI study consisted of a 3-month program of weekly coaching phone calls after one face-to-face visit. The following themes were outstanding: patients value the supportive communication with coach and believe the MI-based coaching created increased level of awareness and accountability. They perceived an increase in physical activity and reported "feeling better" or other benefits not directly related to exercise. The Mindfulness for Health Program was a mandatory 8-week program that consisted on 2-hour classes aimed to cultivate nonjudgmental attention in the moment (through different meditative practices and sharing) plus monthly face-to-face encounters aimed to sustain practice and sharing of life experiences for 1 year. The following themes (at 1 year) were outstanding: appreciating life by seeing hardships as opportunities, valuing the self through compassion and awareness, cultivating connectedness with others, acquiring joy, and adopting healthy behaviors. In the search for the "holy grail" for self-management programs that can promote a behavior change, mindfulness and MI seem promising for cultivating a way to live a life in which people are fully present and consciously agree with.

Screening for severe physical inactivity in chronic obstructive pulmonary disease: the value of simple measures and the validation of two physical activity questionnaires.

Objectively measured severe physical inactivity (SPI) has been reported as the strongest independent predictor of mortality in patients with chronic obstructive pulmonary disease (COPD). Activity monitoring is not feasible in routine clinical practice; therefore, we set out to determine the utility of simple clinical measures for predicting SPI in patients with COPD. A total of 165 patients with COPD wore an activity monitor for 5 days to define the presence or absence of SPI. Logistic models were generated including the modified Medical Research Council (MMRC) dyspnea grade, spirometry and the age-dyspnea-airflow obstruction (ADO) index. Physical Activity Scale for the Elderly (PASE) and Stanford Brief Activity Scale (SBAS) were also tested for validity and reliability in a subgroup of 67 patients. The MMRC dyspnea grade, PASE score, ADO index and SBAS score were associated with SPI, but general self-efficacy and spirometry were not. An MMRC dyspnea grade ≥3 was the best independent predictor of SPI (AUC: 0.74; PPV: 0.83; NPV: 0.68) followed closely by a PASE score of <111. The combination of MMRC dyspnea grade and PASE score provided the most robust model (AUC: 0.83; Positive Predictive Value (PPV): 0.95; Negative Predictive Value (NPV): 0.63). The results were confirmed using 5000 bootstrapped models from the cohort of 165 patients. MMRC dyspnea grade ≥3 may be the best triage tool for SPI in patients with COPD. The combination of the MMRC and PASE score provided the most robust prediction. Our results may have significant practical applicability for clinicians caring for patients with COPD.

Understanding the Patient Experience of Home-Based Pulmonary Rehabilitation with Health Coaching for COPD: A Qualitative Interview Study.

Background: We recently reported on a randomized trial of home-based pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) that showed improvement in all domains of quality of life, accelerometry-measured physical activity, and self-management. In this current study, we used a theoretical framework to help us gain an in-depth understanding of how patients experience complex, multi-component programs to help uncover factors related to behavior change and to inform program scale-up in other populations. Study Design and Methods: The parent trial was conducted with COPD patients receiving care at an academic medical center and a community health system in the upper Midwest. The 12-week PR intervention included 3 daily video-guided exercises, activity monitors, and weekly telephonic health coaching. Trial participants were eligible to participate in an individual phone interview about their experience if they completed the intervention within the prior 12 months.. Analysis of verbatim transcripts followed an inductive thematic approach followed by deductive categorization and interpretation using a theoretical model: the Capability, Opportunity, Motivation-Behavior (COM-B) model developed for linking intervention functions to aspects of behavioral change. Results: Among 32 eligible program participants,32 were approached, and 15 completed interviews between October 19, 2021, and January 13, 2022. The COM-B model and recommendations for program improvement were observed in the primary findings. Discussion: Participants' feedback highlighted how the health coaching bolstered skills and confidence among individuals with the poorest function at program enrollment and how improved physical function and mood led to motivation. It also highlighted the roles of technology and telephonic support in a home-based program. Suggestions for improvement included providing exercise variations.

Home-Based Physical Activity Program With Health Coaching for participants With Chronic Obstructive Pulmonary Disease in Sweden: A Proof-of-Concept Pilot Study.

Home-based interventions are at the center stage of current health care demands. There is a clear need to translate pulmonary rehabilitation into a home-based setting. This 8-week pilot study aimed to determine the feasibility of a home-based physical activity program for participants with chronic obstructive pulmonary disease (COPD) in Sweden. Patients with COPD, aged 40 years or older and clinically stable in the past 3 months, were recruited. The program used a fitness tracker to monitor step count, weekly health coaching calls using motivational interviewing, and video-guided mindful movements. The outcome measures were adherence to the 8-week program's video-guided exercises (number of times videos were watched), adherence to health coaching calls (minimum 8), monthly and daily step count, and quality of life (QoL) using the chronic respiratory questionnaire. Thirteen participants were enrolled, and 12 participants adhered to health coaching calls and step monitoring. We had 643 video-exercise views, which exceeded the minimum standard (576 views). The mean difference comparing total monthly steps from baseline and the 8-week time point was 47,039 steps (95% CI, -113,625 to 1623.5; P=.06). The minimal clinical improvement of 500 daily steps was found for 8 of the patients. No significant improvement was found in the QoL measures and mental health. We found the home-based physical activity program to be a feasible intervention. Patients reported high adherence to tracking step counts, health coaching calls, and video-guided exercise. No improvements in QoL or monthly step count emerged; however, we found high adherence and a positive trend in the number of monthly step counts, and improvements of at least 500 daily step counts improved in most patients with this small sample size.

How many steps are enough to avoid severe physical inactivity in patients with chronic obstructive pulmonary disease?

While prognostically valuable, physical activity monitoring is not routinely performed for patients with COPD. We aimed to determine the number of daily steps associated with severe physical inactivity (physical activity level <1.40) in this population. We found that a daily step value <4580 is associated with severe physical inactivity. Our results are of significant value for clinicians counselling patients with COPD to help avoid the morbidity of severe physical inactivity.

Adding Granularity of COPD Self-Management to Impact Quality of Life.

Background: Self-management abilities are a recognized ingredient for living well with chronic obstructive pulmonary disease (COPD), improving all outcomes. Fostering self-management requires a personalized program and patient engagement to make lifestyle decisions. While some self-management practices are proven effective, like the prompt use of a plan for COPD exacerbations, there is a guideline-recognized gap on specific self-management behaviors that can impact particular COPD symptoms and allow for tailored self-management programs. We aimed to investigate the association of well-defined self-management behaviors with the most common COPD symptoms in a large cohort of patients with COPD. Methods: We analyzed baseline data of stable COPD patients who participated in 3 National Institutes of Health-funded studies. Symptoms were defined by the 4 domains of the Chronic Respiratory Questionnaire: dyspnea-fatigue-emotions-mastery. The self-management behaviors were the individual items of the Self-Management Ability Scale-30. Lasso regression models were built to explore the association of behaviors with symptoms, adjusting for lung function and age. Results: We analyzed 512 stable COPD patients, 54% female, age mean (standard deviation [SD]) 69.6 (9.9) years and forced expiratory volume in 1 second percent predicted (FEV1%) 42.2 (19.0).Dyspnea was associated with exercising and self-efficacy for self-care. Emotion was associated with good relationships, self-efficacy for self-care, positivity, and participating in agreeable activities. Fatigue was associated with self-efficacy for self-care, doing exercise, and participating in agreeable activities. Mastery was associated with self-efficacy for self-care, positivity, exercising, and participating in agreeable activities. Discussion: Our findings provide specific self-management behaviors associated with common COPD symptoms that may inform self-management programs. Positive thinking represents a novel self-management approach to COPD emotions and mastery.

Differences in Sedentary Time, Light Physical Activity, and Steps Associated with Better COPD Quality of Life.

INTRODUCTION: There is a knowledge gap about how much physical activity is recommended to patients with chronic obstructive pulmonary disease (COPD). We asked, what is the average difference in sedentary time and physical activity associated with clinically meaningful differences in symptoms in a large, well-characterized cohort of patients with advanced COPD? STUDY DESIGN AND METHODS: We conducted a cross-sectional analysis of daily activity data in 292 patients with stable COPD. Activity measure coefficients from multivariable linear models were used to predict the average difference in activity between patients with twice the minimal clinically important difference in reported symptoms. RESULTS: Symptoms were assessed with the Chronic Respiratory Disease Questionnaire subdomains - dyspnea, fatigue, mastery, and emotions. Daily steps, minutes in light physical activity, and sedentary time were measured by triaxial accelerometers. Average sedentary time, light physical activity, and steps were 767.6 minutes, 177.7 minutes, and 2960 steps, respectively. Individuals with 1-point better dyspnea scores averaged 24.5 (8.4-40.5) minutes less sedentary time per day. Individuals with 1-point better dyspnea and fatigue scores averaged 21.5 (10.9-32.3) minutes or 12.5 (2.0-23.2) minutes more light physical activity per day, respectively. Individuals with 1-point better dyspnea, fatigue, mastery, and emotions scores averaged 762 (546-984), 579 (351-814), 418 (207-636), and 392 (157-634) more steps per day, respectively. CONCLUSIONS: We provide guidance to clinicians counseling patients with severe COPD in activity-related goal setting on sedentary time, light physical activity, and steps associated with better symptoms.

Examining Burnout in Interprofessional Intensive Care Unit Clinicians Using Qualitative Analysis.

BACKGROUND: Health care professionals working in intensive care units report a high degree of burnout, but this topic has not been extensively studied from an interdisciplinary perspective. OBJECTIVE: To characterize experiences of burnout among members of interprofessional intensive care unit teams and identify possible contributing factors. METHODS: This qualitative study involved interviews of registered nurses, respiratory therapists, physicians, pharmacists, and a personal care assistant working in multiple intensive care units of a single academic medical center to assess work stressors. RESULTS: Team composition was a factor in burnout, particularly when nonphysician team members felt that their opinions were not valued despite the institution's emphasis on a multidisciplinary team-based model of care. This was especially true when roles were not well defined at the outset of a code situation. Members of nearly all disciplines stated that there was not enough time in a day to complete all the required tasks. CONCLUSIONS: Multiple factors contribute to work-related stress and burnout across different professions in the intensive care unit. Improved communication and increased receptivity to diverse opinions among members of the multidisciplinary team may help reduce stress.

Feasibility of a Health Coaching and Home-Based Rehabilitation Intervention With Remote Monitoring for COPD.

BACKGROUND: Pulmonary rehabilitation is an effective treatment for patients with COPD, but patient uptake and adherence to the current offering of center-based pulmonary rehabilitation is modest due to transportation, access, poverty, and frailty, and even more so in the context of the COVID pandemic. Home-based options have been proposed and were found noninferior to center-based rehabilitation; however, there is a lack of home-based programs, and more understanding is needed. We aimed to test the feasibility, uptake, and adherence to a home-based program for COPD rehabilitation with health coaching. METHODS: We conducted a randomized trial with a wait-list controlled design to evaluate the effects of a home-based program with health coaching on breathlessness in subjects with moderate to severe COPD unable to attend the regular pulmonary rehabilitation program. The 8-week intervention consisted of video-guided exercises to be done 6 times a week and captured with a computer tablet. Health coaching was done weekly over the telephone to review subject activity and symptoms and to provide an opportunity for the subject to define their weekly goals. The primary outcomes were uptake, adherence, and Chronic Respiratory Questionnaire (CRQ) Dyspnea Domain. Secondary outcomes were self-management abilities and CRQ Emotions-Mastery-Fatigue. RESULTS: 154 subjects with moderate to severe COPD were randomized. Subject adherence was 86% to the proposed 6-times a week exercise routine. There (P = .062) was no significant difference in breathlessness (CRQ dyspnea). There was a significant improvement in self-management abilities (P < .001). The results of the qualitative interviews showed high levels of acceptability of the program. CONCLUSIONS: The tested home-based rehabilitation program with health coaching was feasible, highly acceptable, showed a high degree of adherence, and improved self-management abilities. This study offers seminal information for home-based rehabilitation programs to design alternative options of rehabilitation to individuals with COPD that cannot attend to the well-established center-based pulmonary rehabilitation. (ClinicalTrials.gov registration NCT02557178.).

Oxygen consumption, shuttle walking test and the evaluation of lung resection.

BACKGROUND: Assessment of peak oxygen uptake (VO(2)) is recommended in the evaluation of patients with borderline pulmonary function as VO(2) is the strongest independent predictor of postoperative pulmonary complications. However, the measurement of VO(2) requires expensive equipment not available in many medical facilities. The shuttle walking test (SWT) has been proposed to be used as a screening tool prior to performing a cardiopulmonary exercise test. Although an association exists between SWT distance and VO(2), only one small study directly measured VO(2) during the SWT. OBJECTIVES: The aim of this study was to further validate the VO(2)-SWT association by directly measuring VO(2) during SWT in a larger cohort of patients with stable chronic obstructive pulmonary disease (COPD). METHODS: Fifty stable COPD patients with mild/severe disease were studied. Each patient performed an SWT while wearing a validated portable metabolic monitor. RESULTS: Mean VO(2) (ml/kg/min) measured after each finalized minute of the SWT was (95% confidence interval): 6 (5-7), 9 (8-10), 11 (10-12), 13 (11-14), 15 (14-16), 18 (16-20) and 21 (18-26) for minutes 1-7, respectively. Patients that completed the British Thoracic Society-recommended 25 shuttles (5 min or 250 m) in the SWT had a mean VO(2) of 15 (14-16). The positive predictive value for walking 25 shuttles (predicting a VO(2) of >or=15ml/kg/min) was 90% and the negative predictive value was 90%. CONCLUSIONS: Our findings validate the association between VO(2) and SWT distance and facilitate the interpretation of the test in general practice, particularly when deciding the candidacy of a patient for surgical resection.

Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of death and 70% of the cost of COPD is due to hospitalizations. Self-reported daily physical activity and health status have been reported as predictors of a hospitalization in COPD but are not routinely assessed. OBJECTIVES: We tested the hypothesis that self-reported daily physical activity and health status assessed by a simple question were predictors of a hospitalization in a well-characterized cohort of patients with severe emphysema. METHODS: Investigators gathered daily physical activity and health status data assessed by a simple question in 597 patients with severe emphysema and tested the association of those patient-reported outcomes to the occurrence of a hospitalization in the following year. Multiple logistic regression analyses were used to determine predictors of hospitalization during the first 12 months after randomization. RESULTS: The two variables tested in the hypothesis were significant predictors of a hospitalization after adjusting for all univariable significant predictors: >2 h of physical activity per week had a protective effect [odds ratio (OR) 0.60; 95% confidence interval (95% CI) 0.41-0.88] and self-reported health status as fair or poor had a deleterious effect (OR 1.57; 95% CI 1.10-2.23). In addition, two other variables became significant in the multivariate model: total lung capacity (every 10% increase) had a protective effect (OR 0.88; 95% CI 0.78-0.99) and self-reported anxiety had a deleterious effect (OR 1.75; 95% CI 1.13-2.70). CONCLUSION: Self-reported daily physical activity and health status are independently associated with COPD hospitalizations. Our findings, assessed by simple questions, suggest the value of patient-reported outcomes in developing risk assessment tools that are easy to use.