Addressing Reduced Laboratory-Based Pulmonary Function Testing During a Pandemic.

To reduce the spread of the severe acute respiratory syndrome coronavirus 2, many pulmonary function testing (PFT) laboratories have been closed or have significantly reduced their testing capacity. Because these mitigation strategies may be necessary for the next 6 to 18 months to prevent recurrent peaks in disease prevalence, fewer objective measurements of lung function will alter the diagnosis and care of patients with chronic respiratory diseases. PFT, which includes spirometry, lung volume, and diffusion capacity measurement, is essential to the diagnosis and management of patients with asthma, COPD, and other chronic lung conditions. Both traditional and innovative alternatives to conventional testing must now be explored. These may include peak expiratory flow devices, electronic portable spirometers, portable exhaled nitric oxide measurement, airwave oscillometry devices, and novel digital health tools such as smartphone microphone spirometers and mobile health technologies along with integration of machine learning approaches. The adoption of some novel approaches may not merely replace but could improve existing management strategies and alter common diagnostic paradigms. With these options comes important technical, privacy, ethical, financial, and medicolegal barriers that must be addressed. However, the coronavirus disease 19 pandemic also presents a unique opportunity to augment conventional testing by including innovative and emerging approaches to measuring lung function remotely in patients with respiratory disease. The benefits of such an approach have the potential to enhance respiratory care and empower patient self-management well beyond the current global pandemic.

Comparison of end-of-life care in people with chronic obstructive pulmonary disease or lung cancer: A systematic review.

BACKGROUND: Palliative care has been widely implemented in clinical practice for patients with cancer but is not routinely provided to people with chronic obstructive pulmonary disease. AIM: The study aims were to compare palliative care services, medications, life-sustaining interventions, place of death, symptom burden and health-related quality of life among chronic obstructive pulmonary disease and lung cancer populations. DESIGN: Systematic review with meta-analysis (PROSPERO: CRD42019139425). DATA SOURCES: MEDLINE, EMBASE, PubMed, CINAHL and PsycINFO were searched for studies comparing palliative care, symptom burden or health-related quality of life among chronic obstructive pulmonary disease, lung cancer or populations with both conditions. Quality scores were assigned using the QualSyst tool. RESULTS: Nineteen studies were included. There was significant heterogeneity in study design and sample size. A random effects meta-analysis (n = 3-7) determined that people with lung cancer had higher odds of receiving hospital (odds ratio: 9.95, 95% confidence interval: 6.37-15.55, p < 0.001) or home-based palliative care (8.79, 6.76-11.43, p < 0.001), opioids (4.76, 1.87-12.11, p = 0.001), sedatives (2.03, 1.78-2.32, p < 0.001) and dying at home (1.47, 1.14-1.89, p = 0.003) compared to people with chronic obstructive pulmonary disease. People with lung cancer had lower odds of receiving invasive ventilation (0.26, 0.22-0.32, p < 0.001), non-invasive ventilation (0.63, 0.44-0.89, p = 0.009), cardiopulmonary resuscitation (0.29, 0.18-0.47, p < 0.001) or dying at a nursing home/long-term care facility (0.32, 0.16-0.64, p < 0.001) than people with chronic obstructive pulmonary disease. Symptom burden and health-related quality of life were relatively similar between the two populations. CONCLUSION: People with chronic obstructive pulmonary disease receive less palliative measures at the end of life compared to people with lung cancer, despite a relatively similar symptom profile.

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.

Systematic Review of Postural Assessment in Individuals With Obstructive Respiratory Conditions: MEASUREMENT AND CLINICAL ASSOCIATIONS.

PURPOSE: Changes in posture in individuals with an obstructive respiratory disease have been reported, but the extent of these deviations and their clinical significance is not well understood. This study aimed to systematically review the literature of the skeletal structural alignment in children and adults with an obstructive respiratory disease, describe the measurement techniques used, and determine the clinical relevance of any alternations. METHODS: Observational cohort or cross-sectional studies of postural assessment were identified, with 2 reviewers independently assessing study quality. RESULTS: A total of 18 studies were included, 12 in cystic fibrosis (CF), 5 in asthma, and 1 in chronic obstructive pulmonary disease (COPD). The overall quality assessment rating was 12.6 out of 16. Increased thoracic kyphosis or scoliosis was found in both children and adults with CF. Increased shoulder protraction and elevation were evident in asthma and COPD, although changes in spinal curvature were variable. The clinical impact of postural changes was diverse, with an inconsistent influence on lung function. A mix of methods was applied for postural assessment. CONCLUSIONS: Skeletal structural malalignment appears to be present in some individuals with an obstructive respiratory disease, although the extent of alterations and its clinical impact is variable. Photogrammetry is used to provide a comprehensive assessment of posture in these populations.

Measurement properties of the incremental shuttle walk test. a systematic review.

Background: The incremental shuttle walk test (ISWT) was developed > 20 years ago and has been used to assess peak exercise capacity in a variety of chronic diseases. The aim of this systematic review is to describe the measurement properties of the ISWT in a clinical population.Methods: Of 800 articles identified by electronic and hand searches, 35 were included. Twenty-one articles included data on the validity of the ISWT, 18 on the reliability, four on the responsiveness,and four on the interpretability.Results: Most of the studies were conducted in patients with COPD (n = 13) or cardiac disease(n = 8). For criterion validity, comparisons between distance covered during the ISWT and peak oxygen consumption reported correlations ranging from 0.67 to 0.95 ( P <.01). Intraclass correlation coefficients for test-retest reliability ranged from 0.76 to 0.99. The ISWT was shown to be responsive to pulmonary rehabilitation and bronchodilator administration. The minimal clinically important difference (MCID) in patients with COPD was 48 m. Predictive equations for the distance in the ISWT are available for healthy individuals.Conclusions: The ISWT can be considered a valid and reliable test to assess maximal exercise capacity in individuals with chronic respiratory diseases. The ISWT has been shown to be responsive to pulmonary rehabilitation and bronchodilator use in individuals with COPD, cystic fibrosis,and asthma. Further studies examining responsiveness and the MCID of the ISWT in patients with conditions other than lung diseases are required for the interpretation of interventions in other populations.

Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care.

BACKGROUND: People with known risk factors for chronic obstructive pulmonary disease (COPD) are important targets for screening and early intervention. We sought to measure the prevalence of COPD among such individuals visiting a primary care practitioner for any reason. We also evaluated the accuracy of prior diagnosis or nondiagnosis of COPD and identified associated clinical characteristics. METHODS: We recruited patients from three primary care sites who were 40 years or older and had a smoking history of at least 20 pack-years. Participants were asked about respiratory symptoms and underwent postbronchodilator spirometry. COPD was defined as a ratio of forced expiratory volume in the first second of expiration to forced vital capacity (FEV(1)/FVC) of less than 0.7 and an FEV(1) of less than 80% predicted. RESULTS: Of the 1459 patients who met the study criteria, 1003 (68.7%) completed spirometry testing. Of these, 208 were found to have COPD, for a prevalence of 20.7% (95% confidence interval 18.3%-23.4%). Of the 205 participants with COPD who completed the interview about respiratory symptoms before spirometry, only 67 (32.7%) were aware of their diagnosis before the study. Compared with patients in whom COPD had been correctly diagnosed before the study, those in whom COPD had been over-diagnosed or undiagnosed were similar in terms of age, sex, current smoking status and number of visits to a primary care practitioner because of a respiratory problem. INTERPRETATION: Among adult patients visiting a primary care practitioner, as many as one in five with known risk factors met spirometric criteria for COPD. Underdiagnosis of COPD was frequent, which suggests a need for greater screening of at-risk individuals. Knowledge of the prevalence of COPD will help plan strategies for disease management.

Ambulatory gas usage in patients with chronic obstructive pulmonary disease and exertional hypoxemia.

PURPOSE: Nonblinded observational studies have described the use of exertional supplemental oxygen in heterogeneous study populations. This report characterizes ambulatory gas usage among patients with chronic obstructive pulmonary disease (COPD) and exertional hypoxemia. METHODS: Patients with COPD and exertional hypoxemia were included in blinded N-of-1 randomized controlled trials consisting of 3 pairs (oxygen and placebo) of 2-week treatment periods. Patient-reported and objective equipment measurements of cylinder and concentrator usage were collected. RESULTS: Patients (N = 26) self-reported using gas for a median of 1.3 hours per day; measured equipment usage was 1.2 hours per day. Median concentrator use (0.8 hour per day) was significantly greater than cylinder use (0.5 hours per day) (P = .02). Patients may underestimate use by as much 1.9 hours per day or overestimate it by as much as 2.4 hours per day. The correlation coefficient between the magnitude of gas usage and the difference between the 2 estimates was 0.63 (P = .0006). As duration of gas use increased, the discrepancy between patient-reported usage and equipment gas usage increased. Below 2 hours per day, differences between patient-reported and equipment measurements were small. CONCLUSIONS: Patients with COPD and exertional hypoxemia used little more than an hour of ambulatory oxygen daily, mostly from concentrators. Individual self-reported values are reasonably accurate under 2 hours per day but inaccurate for more prolonged use.

Smoking cessation in pulmonary rehabilitation: goal or prerequisite?

It has been more than 35 years since the Surgeon General of the United States released the first report of the Advisory Committee on Smoking and Health. Cigarette smoking has been identified as the most important source of preventable morbidity and premature mortality in North America. During the 1990s, tobacco was the largest single cause of premature death in the developed world. Smoking cessation is followed by immediate health benefits in terms of symptoms and organ function. It dramatically reduces the risk of most smoking-related diseases, including chronic obstructive pulmonary disease and lung cancer. Respiratory rehabilitation has been defined as a multidimensional continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual's maximum level of independence and functioning in the community. A European Respiratory Society task force on rehabilitation recently commented that respiratory rehabilitation must address medical management including reinforcement of smoking cessation, education of the patient and family, exercise reconditioning, physical and occupational therapy, nutritional support, and long-term oxygen therapy. Many patients have quit smoking by the time they enroll in a pulmonary rehabilitation program. Nevertheless, the inclusion of smokers in respiratory rehabilitation programs remains controversial. Among 14 trials included in a meta-analysis of respiratory rehabilitation of patients with chronic obstructive pulmonary disease (COPD), the smoking status of the patients was reported in 9 of the trials, and only 2 trials stated that smoking was an absolute exclusion criterion for enrollment. Some investigators have used a trial of smoking cessation as an index of the patient's motivation to improve his or her health status. This article describes the effect of smoking on the course of COPD and the opportunity to address smoking in the context of comprehensive rehabilitation. The authors' line of reasoning is that (1) smoking causes COPD and perpetuates the pathophysiologic processes defining the disease, (2) symptomatic COPD does not facilitate smoking cessation, (3) smoking may alter rehabilitation outcomes, and (4) if smoking cessation is not a prerequisite to pulmonary rehabilitation, then a smoking cessation intervention should at least he offered as part of such a program.