Balance measures for fall risk screening in community-dwelling older adults with COPD: A longitudinal analysis.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) increases fall risk, but consensus is lacking on suitable balance measures for fall risk screening in this group. We aimed to evaluate the reliability and validity of balance measures for fall risk screening in community-dwelling older adults with COPD. METHODS: In a secondary analysis of two studies, participants, aged ≥60 years with COPD and 12-month fall history or balance issues were tracked for 12-month prospective falls. Baseline balance measures - Brief Balance Evaluation Systems Test (Brief BESTest), single leg stance (SLS), Timed Up and Go (TUG), and TUG Dual-Task (TUG-DT) test - were assessed using intra-class correlation (ICC2,1) for reliability, Pearson/Spearman correlation with balance-related factors for convergent validity, t-tests/Wilcoxon rank-sum tests with fall-related and disease-related factors for known-groups validity, and area under the receiver operator characteristic curve (AUC) for predictive validity. RESULTS: Among 174 participants (73 ± 8 years; 86 females) with COPD, all balance measures showed excellent inter-rater and test-retest reliability (ICC2,1 = 0.88-0.97) and moderate convergent validity (r = 0.34-0.77) with related measures. Brief BESTest and SLS test had acceptable known-groups validity (p < 0.05) for 12-month fall history, self-reported balance problems, and gait aid use. TUG test and TUG-DT test discriminated between groups based on COPD severity, supplemental oxygen use, and gait aid use. All measures displayed insufficient predictive validity (AUC<0.70) for 12-month prospective falls. CONCLUSION: Though all four balance measures demonstrated excellent reliability, they lack accuracy in prospectively predicting falls in community-dwelling older adults with COPD. These measures are best utilized within multi-factorial fall risk assessments for this population.

Improvement in upright and supine lung mechanics with bariatric surgery affects bronchodilator responsiveness and sleep quality.

Obesity and weight loss have complex effects on respiratory physiology, but these have been insufficiently studied, particularly at early time points following weight loss surgery and in the supine position. We evaluated 15 female participants with severe obesity before and 5 wk and 6 mo after bariatric surgery using the Pittsburgh Sleep Quality Index (PSQI), spirometry, plethysmography, and oscillometry to measure respiratory system mechanics. Oscillometry and spirometry were conducted in the upright and supine position and before and after bronchodilation with 200 µg of salbutamol. At 5 wk postsurgery, weight loss was 11.9 kg (SD 2.7) with no effect on spirometric outcomes and a slight effect on oscillometric outcomes. However, at 6 mo weight loss was 21.4 kg (SD 7.1) with a 14.1% (SD 6.1) and 17.8 (5.4)% reduction in upright and supine respiratory system resistance (Rrs),6, respectively. Respiratory system elastance also decreased by 25.7% (SD 9.4) and 20.2 (SD 7.2)% in the upright and supine positions. No changes were observed in spirometry, but sleep quality improved from PSQI of 8.4 (SD 3.5) to 4.1 (SD 2.9). Bronchodilator responsiveness was low at baseline but increased significantly after surgery, and this response was comparable to the improvement in Rrs produced by weight loss. Modeling the impedance spectra with a two-compartment model demonstrated that improvements in lung mechanics with weight loss begin in the upper or central compartment of the lungs and progress to include the peripheral compartment. Respiratory mechanics are impaired in individuals with severe obesity and is associated with poor sleep quality, but these improved substantially with weight loss. Our data provide new evidence that individuals with severe obesity may have poor sleep quality because of abnormal respiratory mechanics that weight loss improves.NEW & NOTEWORTHY This is the first study to quantify the degree of weight loss-induced improvements in respiratory system mechanics in both upright and supine positions, and its association with bronchodilator responsiveness and sleep quality at multiple time points. Weight loss induced large improvements in upright and supine respiratory system mechanics with corresponding improvements in bronchodilator responsiveness and sleep quality. Using mathematical modeling, we demonstrate that these improvements begin in the central airways and progress to include the lung periphery.

Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease.

INTRODUCTION: Hospital and emergency department discharge for patients with chronic obstructive pulmonary disease (COPD) is often poorly organised. We developed a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbations of COPD. METHODS: A purposeful sample of clinicians and patients were invited to participate in a two-round Delphi study (July-November 2015). In round 1, participants rated on a seven-point Likert scale (1=not at all important; 7=extremely important) the importance of 29 unique COPD care actions. Round 2 comprised items selected from round 1 based on consensus (>80% endorsement for Likert values 5-7). A list of 18 care items from round 2 was discussed in a face-to-face nominal group meeting. RESULTS: Seven care items were included in the COPD discharge bundle based on clinician and patient input: (1) ensure adequate inhaler technique is demonstrated; (2) send discharge summary to family physician and arrange follow-up; (3) optimise and reconcile prescription of respiratory medications; (4) provide a written discharge management plan and assess patient's and caregiver's comprehension of discharge instructions; (5) refer to pulmonary rehabilitation; (6) screen for frailty and comorbidities; and (7) assess smoking status, provide counselling and refer to smoking cessation programme. CONCLUSION: We present a seven-item, patient-centred, evidence-based and consensus-based discharge bundle for patients with acute exacerbations of COPD. Alignment with clinical practice guidelines and feasibility of local adaptations of the bundle should be explored to facilitate wide applicability and evaluation of the effectiveness of the COPD discharge bundle.

Early detection of changes in lung mechanics with oscillometry following bariatric surgery in severe obesity.

Obesity is associated with respiratory symptoms that are reported to improve with weight loss, but this is poorly reflected in spirometry, and few studies have measured respiratory mechanics with oscillometry. We investigated whether early changes in lung mechanics following weight loss are detectable with oscillometry. Furthermore, we investigated whether the changes in lung mechanics measured in the supine position following weight loss are associated with changes in sleep quality. Nineteen severely obese female subjects (mean body mass index, 47.2 ± 6.6 kg/m(2)) were evaluated using spirometry, oscillometry, plethysmography, and the Pittsburgh Sleep Quality Index before and 5 weeks after bariatric surgery. These tests were conducted in both the upright and the supine position, and pre- and postbronchodilation with 200 µg of salbutamol. Five weeks after surgery, weight loss of 11.5 ± 2.5 kg was not associated with changes in spirometry and plethysmography, with the exception of functional residual capacity. There were also no changes in upright respiratory system resistance (Rrs) or reactance following weight loss. Importantly, however, in the supine position, weight loss caused a substantial reduction in Rrs. In addition, sleep quality improved significantly and was highly correlated with the reduction in supine Rrs. Prior to weight loss, subjects did not respond to the bronchodilator when assessed in the upright position with either spirometry or oscillometry; however, with modest weight loss, bronchodilator responsiveness returned to the normal range. Improvements in lung mechanics occur very early after weight loss, mostly in the supine position, resulting in improved sleep quality. These improvements are detectable with oscillometry but not with spirometry.

Effects of Autogenic Drainage on Sputum Recovery and Pulmonary Function in People with Cystic Fibrosis: A Systematic Review.

PURPOSE: To determine the effects of short- and long-term use of autogenic drainage (AD) on pulmonary function and sputum recovery in people with cystic fibrosis (CF). METHODS: The authors conducted a systematic review of randomized and quasi-randomized clinical trials in which participants were people with CF who use AD as their sole airway clearance technique. RESULTS: Searches in 4 databases and secondary sources using 5 key terms yielded 735 articles, of which 58 contained the terms autogenic drainage and cystic fibrosis. Ultimately, 4 studies, 2 of which were long term, were included. All measured forced expiratory volume in 1 second (FEV1) and found no change. The long-term studies were underpowered to detect change in FEV1; however, the short-term studies found a clinically significant sputum yield (≥4 g). CONCLUSION: AD has been shown to produce clinically significant sputum yields in a limited number of investigations. The effect of AD on the function of the pulmonary system remains uncertain, and questions have emerged regarding the appropriateness of FEV1 as a valid measure of airway clearance from peripheral lung regions. Further consideration should be given to the use of FEV1 as a primary measure of the effect of AD.

Objet: Déterminer les effets de l'utilisation à court et à long terme du drainage autogène (DA) sur la fonction pulmonaire et la récupération de crachat chez les personnes qui ont la fibrose kystique (FK). Méthodes: Les auteurs ont procédé à un examen systématique d'essais cliniques randomisés et quasi-randomisés où les participants étaient des personnes vivant avec la FK qui utilisent le DA comme seule méthode de dégagement des voies aériennes (DVA) Résultats: Les recherches effectuées dans quatre bases de données et des sources secondaires au moyen de cinq termes clés ont produit 735 articles dont 58 contenaient les expressions « drainage autogène ¼ et « fibrose kystique ¼. On a inclus finalement quatre études dont deux à long terme. Toutes les études ont mesuré le volume expiratoire maximum seconde (VEMS1) et n'ont constaté aucun changement. Des études de longue durée n'avaient pas le pouvoir nécessaire pour détecter tout changement du VEMS1, mais des études de courte durée ont constaté une production cliniquement significative de crachat (≥4 grammes). Conclusion: Il a été démontré, dans un nombre limité d'enquêtes, que le DA produit des volumes cliniquement significatifs de crachat. L'effet du DA sur le fonctionnement de l'appareil pulmonaire demeure incertain et des questions ont surgi au sujet de la pertinence du VEMS1 comme mesure valide du dégagement des voies aériennes à partir des régions pulmonaires périphériques. Il faudrait envisager d'utiliser le VEMS1 comme mesure première de l'effet du DA.