Oxygen Uptake and Heart Rate On-Kinetics during Prehabilitation in Patients with Scheduled Non-Small Cell Lung Cancer Resection.

BACKGROUND: Oxygen uptake (V̇O2) and heart rate (HR) kinetics during a constant work-rate test (CWRT) are used to evaluate the response to exercise in healthy subjects as well as subjects with various pathologies. OBJECTIVES: This study aimed to explore the feasibility of these measures and their responsiveness to a prehabilitation program in patients with non-small cell lung cancer (NSCLC). METHOD: This study is preregistered (NCT04041297) ancillary analysis of a subgroup of individuals with NSCLC included in the Preo-Dens study (NCT03936764). Thirty individuals performed a moderate-CWRT before and after a 15-session prehabilitation program between July 2019 and April 2021. V̇O2 and HR on-kinetics were extracted from the first 240 s of breath-by-breath data using Box-Jenkins transfer functions. RESULTS: Pre/post V̇O2 on-kinetic feature values were reliable for 25/30 participants, and pre/post HR kinetic feature values were reliable for 19/30. V̇O2 time constant (τ) and mean response time reduced from pre-post prehabilitation (mean difference -7.8 s; 95% CI: -14.6 to -1.0, and -8.4 s; 95% CI: -14.7 to -2.0, respectively). For HR on-kinetics, τ did not change from pre-post prehabilitation (median difference -4.0 s; 95% CI: -36.0 to +11.0). V̇O2 and HR response amplitudes reduced significatively from pre-post prehabilitation (mean difference -38.6 mL/min; 95% CI: -73.3 to -3.9, and -3.1 beats/min; 95% CI: -6.4 to -0.2, respectively). CONCLUSION: V̇O2 on-kinetic analysis during moderate-CWRT is feasible in individuals with scheduled NSCLC resection, and results are responsive to prehabilitation. These results support a true speeding of the adaptation of aerobic metabolism after a 15-session prehabilitation program.

Functional Electrical Stimulation-A New Therapeutic Approach to Enhance Exercise Intensity in Chronic Obstructive Pulmonary Disease Patients: A Randomized, Controlled Crossover Trial.

OBJECTIVE: To evaluate the effect of quadriceps functional electrical stimulation (FES)-cycling on exertional oxygen uptake (V˙o2) compared with placebo FES-cycling in patients with chronic obstructive pulmonary disease (COPD). DESIGN: A randomized, single-blind, placebo-controlled crossover trial. SETTING: Pulmonary rehabilitation department. PARTICIPANTS: Consecutive patients (N=23) with COPD Global Initiative for Chronic Obstructive Lung Disease stage 2, 3, or 4 (mean forced expiratory volume during the first second, 1.4±0.4L [50.3% predicted]) who had recently begun a respiratory rehabilitation program. INTERVENTION: Two consecutive 30-minute sessions were carried out at a constant load with active and placebo FES-cycling. MAIN OUTCOME MEASURES: The primary outcome was mean V˙o2 during the 30-minute exercise session. The secondary outcomes were respiratory gas exchange and hemodynamic parameters averaged over the 30-minute endurance session. Lactate values, dyspnea, and perceived muscle fatigue were evaluated at the end of the sessions. RESULTS: FES-cycling increased the physiological response more than the placebo, with a greater V˙o2 achieved of 36.6mL/min (95% confidence interval [CI], 8.9-64.3mL/min) (P=.01). There was also a greater increase in lactate after FES-cycling (+1.5mmol/L [95% CI, .05-2.9mmol/L]; P=.01). FES-cycling did not change dyspnea or muscle fatigue compared with the placebo condition. CONCLUSIONS: FES-cycling effectively increased exercise intensity in patients with COPD. Further studies should evaluate longer-term FES-cycling rehabilitation programs.

Home-based Neuromuscular Electrical Stimulation as an Add-on to Pulmonary Rehabilitation Does Not Provide Further Benefits in Patients With Chronic Obstructive Pulmonary Disease: A Multicenter Randomized Trial.

OBJECTIVE: To assess the additional effect of a home-based neuromuscular electrical stimulation (NMES) program as an add-on to pulmonary rehabilitation (PR), on functional capacity in subjects with chronic obstructive pulmonary disease (COPD). DESIGN: Single-blind, multicenter randomized trial. SETTING: Three PR centers. PARTICIPANTS: Subjects with severe to very severe COPD (N=73; median forced expiratory volume in 1 second, 1L (25th-75th percentile, 0.8-1.4L) referred for PR. Twenty-two subjects discontinued the study, but only 1 dropout was related to the intervention (leg discomfort). INTERVENTION: Subjects were randomly assigned to either PR plus quadricipital home-based NMES (35Hz, 30min, 5 time per week) or PR without NMES for 8 weeks. MAIN OUTCOME MEASURE: The 6-minute walk test (6MWT) was used to assess functional capacity. RESULTS: Eighty-two percent of the scheduled NMES sessions were performed. In the whole sample, there were significant increases in the distance walked during the 6MWT (P<.01), peak oxygen consumption (P=.02), maximal workload (P<.01), modified Medical Research Council dyspnea scale (P<.01), and Saint George's Respiratory Questionnaire total score (P=.01). There was no significant difference in the magnitude of change for any outcome between groups. CONCLUSIONS: Home-based NMES as an add-on to PR did not result in further improvements in subjects with severe to very severe COPD; moreover, it may have been a burden for some patients.

Comparison of Specific Prediction Equations to Estimate Peak Oxygen Uptake in Obese Women.

The aim of the current study was to compare 2 equations to predict peak oxygen uptake (V̇O2peak) in obese women, according to their obesity class. 92 maximal cardiopulmonary exercise testing sets (CPET with initial and subsequent increments set to achieve an exercise duration between 8-12 min) were retrospectively analysed. These CPET were divided into 3 groups according to the women body mass indexes (BMI): class 1 (30 kg.m-2≤BMI<35 kg.m-2, n=22), class 2 (35 kg.m-2≤BMI<40 kg.m-2, n=36) or class 3 (BMI≥40 kg.m-2, n=34). Each participant's V̇O2peak was predicted from 2 prediction equations (from Wasserman et al.'s and Debeaumont et al.'s equations) and compared with the actual V̇O2peak. Moreover, the correlations between these values were studied, and the accuracy of the predictions was analysed. Only predicted V̇O2peak from the Debeaumont et al.'s equation was not significantly different from the actual V̇O2peak in the women in obesity class 3 (p=0.89). Moreover, significant correlation was found between these values (p<0.001, r=0.68). The bias and the 95% limits of agreement represented -3.2±34.0%. In women in obesity class 3, Debeaumont et al.'s equation may be the accurate one to predict V̇O2peak. However, the accuracy of predictions is low. Consequently, to improve this accuracy, new prediction equations for obese women are required according to the obesity class.

Six-minute Stepper Test to Set Pulmonary Rehabilitation Intensity in Patients with COPD - A Retrospective Study.

Pulmonary rehabilitation (PR) improves outcomes in patients with chronic obstructive pulmonary disease (COPD). Optimal assessment includes cardiopulmonary exercise testing (CPET), but consultations are limited. Field tests could be used to individualize PR instead of CPET. The six-minute stepper test (6MST) is easy to set up and its sensitivity and reproducibility have previously been reported in patients with COPD. The aim of this study was to develop a prediction equation to set intensity in patients attending PR, based on the 6MST. The following relationships were analyzed: mean heart rate (HR) during the first (HR1-3) and last (HR4-6) 3 minutes of the 6MST and HR at the ventilatory threshold (HRvt) from CPET; step count at the end of the 6MST and workload at the Ventilatory threshold (VT) (Wvt); and forced expiratory volume in 1 second and step count during the 6MST. This retrospective study included patients with COPD referred for PR who underwent CPET, pulmonary function evaluations and the 6MST. Twenty-four patients were included. Prediction equations were HRvt = 0.7887 × HR1-3 + 20.83 and HRvt = 0.6180 × HR4-6 + 30.77. There was a strong correlation between HR1-3 and HR4-6 and HRvt (r = 0.69, p < 0.001 and r = 0.57, p < 0.01 respectively). A significant correlation was also found between step count and LogWvt (r = 0.63, p < 0.01). The prediction equation was LogWvt = 0.001722 × step count + 1.248. The 6MST could be used to individualize aerobic training in patients with COPD. Further prospective studies are needed to confirm these results.

Factors influencing participation in educational workshops as part of a pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease: a retrospective study.

BACKGROUND: Pulmonary rehabilitation (PR) (primarily composed of an exercise training program (ET) and educational workshops) is an effective intervention for patients with chronic obstructive pulmonary disease. Although factors which influence participation in the full PR program have been reported, specific data on the educational component of PR have not been published. We aimed to identify factors which predict refusal to participate in the educational component of PR. RESEARCH DESIGN AND METHODS: 201 patient charts were retrospectively included in the analysis. Patients were classified according to their acceptance or refusal to participate in the educational workshops. RESULTS: The location of ET outside the center was independently related to refusal to participate in the educational workshops (OR = 0.01 [95%CI 0.00 to 0.17]). Patients who refused the workshops were less disabled according to the number of prescriptions of noninvasive ventilation, use of medical transport, oxygen consumption and workload achieved during cardiopulmonary exercise testing. CONCLUSIONS: The location of exercise sessions during PR influences patients' decisions to refuse or accept center-based educational workshops. When center-based PR programs are limited, and the ET is relocated to the patient's home, the educational workshops should also be relocated. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov (NCT04301245).

Prehabilitation sessions can be provided more frequently in a shortened regimen with similar or better efficacy in people with non-small cell lung cancer: a randomised trial.

QUESTION: In people with non-small cell lung cancer, what is the effect of condensing 15 prehabilitation sessions into a 3-week regimen compared with a 5-week regimen? DESIGN: Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment of the primary outcome. PARTICIPANTS: People with diagnosed or suspected non-small cell lung cancer and moderate-to-high risk of postoperative complications. INTERVENTION: Fifteen supervised prehabilitation sessions delivered with either a dense regimen of five sessions/week for 3 weeks (experimental group) or a non-dense regimen of three sessions/week for 5 weeks (control group). OUTCOME MEASURES: The primary outcome was the change in cardiorespiratory fitness measured by the V̇O2peak in ml/kg/min. The secondary outcomes were the change in other variables of interest measured during cardiopulmonary exercise testing, non-invasive nutritional markers, quadriceps maximal voluntary isometric contractions, maximal inspiratory pressure, quality of life, adherence and postoperative complications. RESULTS: Changes with the experimental regimen were similar to or better than changes with the control regimen for: V̇O2peak (MD 1.2 ml/kg/min, 95% CI -0.1 to 2.6); V̇E/V̇CO2 slope (MD -3.6 points, 95% CI -8.7 to 1.5); and work rate at ventilatory threshold (MD 3.7 W, 95% CI -5.6 to 13.0). The two regimens had similar effects on: peak work rate (MD 1.3 W, 95% CI -6.4 to 9.0), V̇O2 at ventilatory threshold (MD 0.0 ml/kg/min, 95% CI -1.4 to 1.4); body mass index (MD -0.2 kg/m2, 95% CI -0.5 to 0.1); and maximal inspiratory pressure (MD -0.7 cmH2O, 95% CI -9.8 to 8.4). The relative effect was uncertain for quadriceps maximal voluntary isometric contractions, quality of life and complications. CONCLUSION: Condensing prehabilitation sessions led to similar or better improvement in cardiorespiratory fitness and did not decrease adherence or increase adverse events. This could increase the number of patients who can be referred for prehabilitation, despite short presurgical periods. TRIAL REGISTRATION: NCT03936764.

Cardiopulmonary Exercise Testing to Assess Persistent Symptoms at 6 Months in People With COVID-19 Who Survived Hospitalization: A Pilot Study.

OBJECTIVE: The aim of this pilot study was to assess physical fitness and its relationship with functional dyspnea in survivors of COVID-19 6 months after their discharge from the hospital. METHODS: Data collected routinely from people referred for cardiopulmonary exercise testing (CPET) following hospitalization for COVID-19 were retrospectively analyzed. Persistent dyspnea was assessed using the modified Medical Research Council dyspnea scale. RESULTS: Twenty-three people with persistent symptoms were referred for CPET. Mean modified Medical Research Council dyspnea score was 1 (SD = 1) and was significantly associated with peak oxygen uptake (VO2peak; %) (rho = -0.49). At 6 months, those hospitalized in the general ward had a relatively preserved VO2peak (87% [SD = 20]), whereas those who had been in the intensive care unit had a moderately reduced VO2peak (77% [SD = 15]). Of note, the results of the CPET revealed that, in all individuals, respiratory equivalents were high, power-to-weight ratios were low, and those who had been in the intensive care unit had a relatively low ventilatory efficiency (mean VE/VCO2 slope = 34 [SD = 5]). Analysis of each individual showed that none had a breathing reserve <15% or 11 L/min, all had a normal exercise electrocardiogram, and 4 had a heart rate >90%. CONCLUSION: At 6 months, persistent dyspnea was associated with reduced physical fitness. This study offers initial insights into the mid-term physical fitness of people who required hospitalization for COVID-19. It also provides novel pathophysiological clues about the underlaying mechanism of the physical limitations associated with persistent dyspnea. Those with persistent dyspnea should be offered a tailored rehabilitation intervention, which should probably include muscle reconditioning, breathing retraining, and perhaps respiratory muscle training. IMPACT: This study is the first, to our knowledge, to show that a persistent breathing disorder (in addition to muscle deconditioning) can explain persistent symptoms 6 months after hospitalization for COVID-19 infection and suggests that a specific rehabilitation intervention is warranted.

Validation of a Score for the Detection of Subjects with High Risk for Severe High-Altitude Illness.

PURPOSE: A decision tree based on a clinicophysiological score (severe high-altitude illness (SHAI) score) has been developed to detect subjects susceptible to SHAI. We aimed to validate this decision tree, to rationalize the prescription of acetazolamide (ACZ), and to specify the rule for a progressive acclimatization. METHODS: Data were obtained from 641 subjects in 15 European medical centers before and during a sojourn at high altitude. Depending on the value of the SHAI score, advice was given and ACZ was eventually prescribed. The outcome was the occurrence of SHAI at high altitude as a function of the SHAI score, ACZ prescription, and use and fulfillment of the acclimatization rule. RESULTS: The occurrence of SHAI was 22.6%, similar to what was observed 18 yr before (23.7%), whereas life-threatening forms of SHAI (high-altitude pulmonary and cerebral edema) were less frequent (2.6%-0.8%, P = 0.007). The negative predictive value of the decision tree based was 81%, suggesting that the procedure is efficient to detect subjects who will not suffer from SHAI, therefore limiting the use of ACZ. The maximal daily altitude gain that limits the occurrence of SHAI was established at 400 m. The occurrence of SHAI was reduced from 27% to 12% when the recommendations for ACZ use and 400-m daily altitude gain were respected (P < 0.001). CONCLUSIONS: This multicenter study confirmed the interest of the SHAI score in predicting the individual risk for SHAI. The conditions for an optimized acclimatization (400-m rule) were also specified, and we proposed a rational decision tree for the prescription of ACZ, adapted to each individual tolerance to hypoxia.

Evaluation of the 3-minute chair rise test as part of preoperative evaluation for patients with non-small cell lung cancer.

BACKGROUND: Peak oxygen uptake ( V˙O2peak ) measured by a cardiopulmonary exercise test (CPX) is the gold-standard for predicting surgical risk in patients with non-small cell lung cancer (NSCLC). The 3-minute chair rise test (3CRT) is a simple test requiring minimal resources. This study aimed to determine the ability of 3CRT to predict V˙O2peak in patients with NSCLC. METHODS: Retrospective data from CPX and 3CRT carried out in 36 patients with NSCLC between March 2018 and February 2019 were included. A multivariate analysis was undertaken to derive a predictive V˙O2peak equation based on performance on the 3CRT. In addition, sensitivity-specificity analysis was carried out to estimate a threshold 3CRT value for the prediction of V˙O2peak ≥ 15 mL/kg/minute. RESULTS: The following equation was obtained: V˙O2peak predicted = (0.04765 × FEV1) - (0.207 59 × BMI) - (0.115 89 × age) + (0.386 09 × vertical distance) + 16.628 69; r2 = 0.75, P < 0.01. The bias between the V˙O2peak values predicted and measured during CPX was 0.0 ± 1.7 mL/kg/minute (95% limits of agreement [-3.5 to 3.5]). A performance ≥49 chair rises predicted V˙O2peak ≥ 15 mL/kg/minute with a sensitivity of 0.75 and a specificity of 0.81. CONCLUSIONS: The level of error in the prediction of V˙O2peak from 3CRT performance was too great to recommend that 3CRT should replace CPX as the sole measurement of V˙O2peak . Nevertheless, the 3CRT could help to identify those patients that require CPX prior to lung resection surgery for NSCLC, larger prospective study is needed to confirm this hypothesis. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Cardiopulmonary exercise tests can stratify the surgical risk. Prediction of the peak oxygen uptake ( V˙O2peak ) value from the 3CRT yields an unacceptable level of error. However, a performance of 49 chair rises or more during the 3CRT could indicate a V˙O2peak ≥ 15 mL / kg / minute. WHAT THIS STUDY ADDS: The 3CRT is a useful screening tool to determine the necessity for a comprehensive cardiopulmonary exercise test, whose access is limited in clinical practice. It could also allow early screening of patients requiring specific prehabilitation programs.

Mid-Term Effects of Pulmonary Rehabilitation on Cognitive Function in People with Severe Chronic Obstructive Pulmonary Disease.

Purpose: Cognitive dysfunction is a common impairment associated with COPD. However, little is known about 1) its prevalence among those subjects referred for pulmonary rehabilitation (PR), 2) how it may affect the benefit of PR, 3) whether PR improves cognitive function and 4) whether cognitive dysfunction affects the usability of telehealth technology usually used to deliver in-home PR. Patients and Methods: Fifty-six subjects with stable COPD (54% females, mean age 62 years (SD 9) and median FEV1 0.9 L (IQR 0.7 to 1.1)) participated in this multicenter observational study and performed 24 sessions of PR. The Montreal Cognitive Assessment tool (MoCA) was used to assess the occurrence of mild cognitive dysfunction (using a screening cutoff <26) at baseline, completion of PR and 3 months of follow-up. Results: Mild cognitive dysfunction was found in 41 subjects (73% [95% CI: 60 to 83%]). The MoCA score significantly improved following PR for those people with baseline mild cognitive dysfunction (p<0.01). There was no significant difference in clinical outcomes between those people with or without mild cognitive dysfunction following PR nor in the proportion of subjects who were autonomous in using the telemonitoring system (83% compared with 71%, p=0.60). Conclusion: Mild cognitive dysfunction is highly prevalent among those people with COPD referred for PR but does not affect the benefits of PR nor the usability of a telemonitoring system. PR may improve short- and mid-term cognitive function for those people who experience mild cognitive dysfunction at the time they are referred to PR.

Cardiopulmonary exercise testing in patients with non-small cell lung cancer: trust the V˙ O2peak?

BACKGROUND: Maximal oxygen consumption (V˙ O2max) is the most frequently used variable to determine postoperative risk in patients with non-small cell lung cancer (NSCLC), however patients frequently cannot provide the necessary maximum effort to ensure the validity of the V˙ O2 measurements. The aim of this observational study was to assess exercise-limiting factors and the rate of achievement of the currently recommended maximality criteria in patients with NSCLC who had been routinely referred for cardiopulmonary exercise testing (CPET) to assess their postoperative risk. METHODS: Patient data, including peak exercise variables and markers used to designate the exercise test as maximal, were retrospectively analysed from 203 preoperative CPET assessments that were performed at Rouen University Hospital from January 2014 until July 2019. RESULTS: Ventilatory limitation was the most common physiological cause of exercise cessation. A total of 62 patients (or 30.5%) achieved either one, or no, markers of maximality. The mean duration of the incremental phase (after the 3-minute warm-up) was 5.1±2 minutes. CONCLUSIONS: About 30% of the patients in this study did not generate maximum effort during CPET. As a result, it is likely that their V˙ O2peak was underestimated and that their post-operative risk was overestimated. It is therefore important to incorporate strategies to verify V˙ O2peak results for patients with values close to the risk threshold.

NIV Is not Adequate for High Intensity Endurance Exercise in COPD.

Noninvasive ventilation (NIV) during exercise has been suggested to sustain higher training intensity but the type of NIV interface, patient-ventilator asynchronies (PVA) or technological limitation of the ventilator may interfere with exercise. We assessed whether these parameters affect endurance exercise capacity in severe COPD patients. In total, 21 patients with severe COPD not eligible to home NIV performed three constant workload tests. The first test was carried out on spontaneous breathing (SB) and the following ones with NIV and a nasal or oronasal mask in a randomized order. PVA and indicators of ventilator performance were assessed through a comprehensive analysis of the flow pressure tracing raw data from the ventilator. The time limit was significantly reduced with both masks (406 s (197-666), 240 s (131-385) and 189 s (115-545), p < 0.01 for tests in SB, with oronasal and nasal mask, respectively). There were few PVA with an oronasal mask (median: 3.4% (1.7-5.2)) but the ventilator reached its maximal generating capacity (median flowmax: 208.0 L/s (189.5-224.8) while inspiratory pressure dropped throughout exercise (from 10.1 (9.4-11.4) to 8.8 cmH2O (8.6-10.8), p < 0.01). PVA were more frequent with nasal mask (median: 12.8% (3.2-31.6), p < 0.01). Particularly, the proportion of patients with ineffective efforts > 10% was significantly higher with nasal interface (0% versus 33.3%, p < 0.01). NIV did not effectively improve endurance capacity in COPD patients not acclimated to home NIV. This was due to a technological limitation of the ventilator for the oronasal mask and the consequence either of an insufficient pressure support or a technological limitation for the nasal mask.

Sequelae of Acute Respiratory Distress Syndrome: Interest of Rehabilitation.

CASE PRESENTATION: This clinical case presents the history of a woman hospitalized for acute respiratory distress syndrome (ARDS). A 62-year-old woman, with regular physical activity and no history of respiratory disease or smoking, was hospitalized for moderate ARDS with bilateral pneumonitis. Fourteen days later, she was discharged from the intensive care unit and received respiratory physical therapy. One month later, she experienced exertional dyspnea. A regression of alveolar condensation with persistent sequelae at the pulmonary bases was noted. Three months later, the patient continued daily physical activity with satisfactory tolerance. A reduction in alveolar-capillary transfer, inappropriate hyperventilation upon exercise, and impairment of gas exchanges at maximal effort, suggestive of pulmonary shunt, were demonstrated. At the 6-month evaluation, the patient displayed exertional dyspnea with residual bilateral basal consolidations. Six months later, the dyspnea had ceased. The persistence of bilateral basal interstitial syndrome associated with bronchial dilatation and pleural-based consolidations was noted, as well as a stable impaired alveolar-capillary diffusing capacity. DISCUSSION: Upon discharge from intensive care, pulmonary follow-up should be proposed to ARDS survivors. Moreover, pulmonary function testing at rest and exercise is advised as soon as possible to evaluate the respiratory sequelae. This will help to limit the severity of complications through adapted exercise rehabilitation and then regular physical activity.

The six-minute stepper test is related to muscle strength but cannot substitute for the one repetition maximum to prescribe strength training in patients with COPD.

Purpose: There are many barriers to pulmonary rehabilitation, including a limited access to evaluation centers. To cope with these difficulties, field tests are often used to prescribe endurance training. As field tests are related to muscle strength, they could also be used to prescribe strength training and increase the access to pulmonary rehabilitation in rural area. However, their validity for this purpose has never been studied. Patients and methods: The relationship between the 6-minute stepper test (6MST), 6-minute walk test, maximal workload achieved during cardiopulmonary exercise testing (Wpeak), and one repetition maximum (1RM) was assessed in 35 patients with COPD through a retrospective chart review to derive predictive equation of the 1RM from these tests. The effectiveness of these equations to prescribe strength training at 70% of the 1RM was assessed in an independent cross-validation group of 34 patients with COPD. Results: There was a moderate relationship between the 6MST, Wpeak and the 1RM (r=0.44 and r=0.41, respectively, both P≤0.01). Whatever the test, the prescription of strength training using the estimated 1RM compared with the measured 1RM resulted in a mean absolute difference and a mean bias of about 30 kg. Conclusion: The use of the 6MST and Wpeak for the prescription of strength training would result in a clinically not acceptable error. Therefore, they should not be used as a substitute for the 1RM to prescribe strength training.

Effect of prehabilitation on ventilatory efficiency in non-small cell lung cancer patients: A cohort study.

OBJECTIVE: Cardiopulmonary exercise testing (CPET) for patients awaiting lung resection for non-small cell lung cancer (NSCLC) has developed considerably in recent years. Pulmonary rehabilitation before surgery (prehabilitation) improves postoperative risk factors such as forced expiratory volume in 1 second and peak oxygen consumption (VO2peak). Ventilatory inefficiency assessed according to the linear regression of the ratio between the increase in minute ventilation and the expired carbon dioxide flow during CPET (VE/VCO2 slope) >35, is a high-risk factor for postoperative complications. Our objective was to assess the effect of prehabilitation on VE/VCO2 slope, and its relationship with VO2peak. METHODS: This retrospective cohort study was performed between January 1, 2014 and December 31, 2017 at Rouen University Hospital. One hundred fifty-two patients with NSCLC awaiting lung surgery who underwent CPET were screened. A total of 50 patients who underwent CPET before and after prehabilitation were included. RESULTS: VE/VCO2 slope did not change significantly after prehabilitation (median, 37.1 [25th-75th percentile, 33.8-43.4] vs median, 35.4 [25th-75th percentile, 31.1-40.5]; P = .09), whereas VO2peak increased significantly (from a median of 13.2 [25th-75th percentile, 11.9-14.7] to a median of 14.8 [25th-75th percentile, 13.1-16.4] mL/kg/min). The number of patients with a high risk of postoperative complications (ie, VE/VCO2 slope >35) did not change significantly after prehabilitation. Cardiorespiratory parameters improved significantly more in patients who underwent at least 15 sessions of ambulatory prehabilitation. CONCLUSIONS: VE/VCO2 slope, a known predictor of favorable surgical outcomes in patients with NSCLC, did not change with the prehabilitation program used in this study, despite clear improvements in VO2peak and other CPET measures. Larger, prospective studies are needed to confirm the results of this study.

People undertaking pulmonary rehabilitation are willing and able to provide accurate data via a remote pulse oximetry system: a multicentre observational study.

QUESTIONS: Can people referred to pulmonary rehabilitation easily learn to use a system for remote transmission of oximetry data? Do they consider remote transmission of oximetry data to be satisfactory? Are the transmitted data valid compared with locally stored data? DESIGN: Multicentre, prospective, observational study. PARTICIPANTS: One hundred and five adults with chronic respiratory disease who were referred to pulmonary rehabilitation. INTERVENTION: At an initial session, participants were taught to record and transmit their oximetry data to a remote server. At subsequent testing session(s), participants were requested to independently activate and use the oximetry monitoring system for a period of exercise on a cycle ergometer, until autonomy with the system was demonstrated. A subgroup of five participants undertook five 45-minute training sessions to generate a dataset to assess whether the transmitted data were valid compared with the locally stored data. OUTCOME MEASURES: Outcome measures included the number of sessions needed to become autonomous, participant satisfaction with the system, and measures of the validity of the transmitted data. RESULTS: Participants became autonomous quickly: 86% at the first testing session and 100% within three testing sessions. At least 98% of participants agreed that the system was easy to use and they would be willing to use it throughout pulmonary rehabilitation. The system transmitted usable data from 98% (95% CI 96 to 100) of sessions and introduced minimal artefact. Mean absolute differences were 0.365 beats/minute for heart rate and 0.133% for oxyhaemoglobin saturation. For heart rate, exact agreement was 72% (SD 9) and similar agreement (within 3 beats/minute) was 99% (SD 1). For oxyhaemoglobin saturation, exact agreement was 87% (SD 3) and similar agreement (within 3%) was 100% (SD 0). CONCLUSION: The telemonitoring system used in this study was sufficiently valid and acceptable for use in at-home pulmonary rehabilitation by people with chronic respiratory disease. STUDY REGISTRATION: ClinicalTrials.gov NCT03295474 and NCT03004716 (subgroup study).

Exercise testing in patients with diaphragm paresis.

PURPOSE: Diaphragm paresis (DP) is characterized by abnormalities of respiratory muscle function. However, the impact of DP on exercise capacity is not well known. This study was performed to assess exercise tolerance in patients with DP and to determine whether inspiratory muscle function was related to exercise capacity, ventilatory pattern and cardiovascular function during exercise. METHODS: This retrospective study included patients with DP who underwent both diaphragmatic force measurements, and cardiopulmonary exercise testing (CPET). RESULTS: Fourteen patients were included. Dyspnea was the main symptom limiting exertion (86%). Exercise capacity was slightly reduced (median VO2peak: 80% [74.5%-90.5%]), mostly due to ventilatory limitation. Diaphragm and overall inspiratory muscle function were correlated with exercise ventilation. Moreover, overall inspiratory muscle function was related with oxygen consumption (r=0.61) and maximal workload (r=0.68). CONCLUSIONS: DP decreases aerobic capacity due to ventilatory limitation. Diaphragm function is correlated with exercise ventilation whereas overall inspiratory muscle function is correlated with both exercise capacity and ventilation suggesting the importance of the accessory inspiratory muscles during exercise for patients with DP. Further larger prospective studies are needed to confirm these results.