Effect of Pulmonary Rehabilitation on COPD Assessment Test Items in Individuals Classified as GOLD Group E.

BACKGROUND: A new Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification has been proposed, based also on COPD Assessment Test (CAT). OBJECTIVES: The aim of this large, multicenter, retrospective study was to determine the impact of pulmonary rehabilitation (PR) on CAT items in individuals with COPD, GOLD group E, recovering from an exacerbation (ECOPD). As secondary aims, we evaluated whether gender, associated chronic respiratory failure (CRF), and age might influence results. METHODS: Data of 2,213 individuals with available paired pre- and post-PR CAT were analyzed. Other common outcome measures were also assessed. RESULTS: After PR, total CAT improved from 20.8 ± 7.8 to 12.4 ± 6.9 (p = 0.000), and 1,911 individuals (86.4%) reached the minimal clinically important difference (MCID). All CAT items improved significantly without any significant difference among them. However, item "confidence with disease" improved significantly more in males than in females (p = 0.009). Total CAT and six out of eight items improved significantly more in individuals with CRF than in those without (all p < 0.001). Total CAT and three items improved significantly more in younger than in older individuals (p = 0.023). Only presence of CRF was significantly associated with the probability of improving total CAT more than the MCID. CONCLUSION: In individuals with COPD, GOLD group E, recovering from ECOPD, PR improves all CAT items; however, gender, associated CRF and age may influence the effect size, suggesting the need to evaluate all items in addition to total CAT score.

Comparison among three different follow-up models for obstructive sleep apnea syndrome patients: focus on the physiotherapist's role.

In obstructive sleep apnea syndrome (OSAS) subjects different follow-up modalities have been proposed to improve adherence to the continuous positive airway pressure (CPAP) device. This retrospective study compares three different health professional approaches dedicated to caring OSAS patients in three consecutive follow-up periods of 15 months each. The three different follow-up models are: i) physician-oriented follow-up (P-F); ii) physiotherapist-oriented follow-up (PT-F); and iii) tele-titration plus PT-oriented follow-up (TT-PT-F). Health personal visits and actions delivered, patients' adherence, CPAP efficacy, and problems under CPAP use were considered for comparison. Data from 122 OSAS patients with a new prescription of CPAP were analyzed: 39 (32.0%) in the P-F, 38 (31.1%) in the PT-F, and 45 (36.9%) in the TT-PT-F period. We found a reduction over time (from 40.9% in P-F to 8.2% in TT-PT-F, p<0.001) in patients missing the 1-year follow-up visit. The PT-F and TT-PT-F lead to a reduction in physician visits in comparison to P-F (5.2% and 8.9% vs 100%, p<0.001) with no differences in time to the first follow-up visit, CPAP efficacy, and patients' adherence among the three periods. More device-related problems were found in the PT-F (57.8%), compared with the PF (25.6%) period (p<0.001); the most common troubles were mask problems evaluated in 26.2% of cases. In conclusion, different follow-up models offer similar efficacy and short-term adherence for CPAP leading to a significant reduction in physician visits under the PT-F with or without tele-titration, being mask problems as the most commonly treated. Further analysis should be useful to define the best cost-efficacy follow-up intervention.

Strategies targeting the NO pathway to counteract extra-pulmonary manifestations of COPD: A systematic review and meta-analysis.

The clinical symptoms of chronic obstructive pulmonary disease (COPD) disease are accompanied by severely debilitating extra-pulmonary manifestations, including vascular dysfunction and hypertension. This systematic review evaluated the current evidence for several therapeutic interventions, targeting the nitric oxide (NO) pathway on hemodynamics and, secondarily, exercise capacity in patients with COPD. A comprehensive search on COPD and NO donors was performed on online databases. Of 934 initially found manuscripts, 27 were included in the review, and 16 in the meta-analysis. The analysis indicated inconsistent effects of dietary nitrate supplementation on exercise tolerance in COPD patients. Dietary nitrate supplementation decreased systolic (-3.7 ± 4.3 mmHg; p = 0.10) and diastolic blood pressure (BP; -2.6 ± 3.2 mmHg; p = 0.05) compared with placebo. When restricted to acute studies, a clinically relevant BP lowering effect of nitrate supplementation during diastole was observed (-4.7 ± 3.2 mmHg; n = 5; p = 0.05). In contrast, inhaled NO (iNO) at doses <20 ppm (+9.2 ± 11.3 mmHg) and 25-40 ppm (-5±2 mmHg) resulted in inconsistent effects on PaO2 (p = 0.48). Data on the effect of iNO on exercise capacity were too limited and inconsistent, but preliminary evidence suggests a possible benefit of iNO on pulmonary vascular resistance during exercise in severe COPD patients. Overall, the effects of acute dietary nitrate supplementation on BP may be of clinical relevance as an adjunct therapy and deserve further investigation in large sample size studies of COPD patients with and without cardiovascular comorbidities. iNO exerted inconsistent physiological effects, with the use of high doses posing safety risks.

Relationship between perceived and neuromuscular fatigue in COPD patients with chronic respiratory failure with long-term oxygen therapy: a cross-sectional study.

PURPOSE: To evaluate perceived fatigue (PF) and neuromuscular fatigue (NMF) in patients with COPD and chronic respiratory failure (CRF) on long-term oxygen therapy (CRF-COPD group), and the relationships between PF, NMF, patient's characteristics, comparing severe patients with COPD to patients without CRF (COPD group). METHODS: This cross-sectional study compared 19 CRF-COPD patients with 10 COPD patients attending a rehabilitation program. PF was determined by Fatigue Severity Scale (FSS), while dyspnea by the Barthel Dyspnea Index (BDI). We assessed quadriceps NMF via electrical nerve stimulation during and following a Maximal Voluntary Contraction (MVC) detecting changes after a Constant Workload Cycling Test (CWCT) at 80% of the peak power output at exhaustion. RESULTS: CRF-COPD patients showed higher PF (+ 1.79 of FSS score, p = 0.0052) and dyspnea (+ 21.03 of BDI score, p = 0.0023) than COPD patients. After the fatiguing task and normalization for the total work, there was a similar decrease in the MVC (CRF-COPD -1.5 ± 2.4 vs COPD -1.1 ± 1.2% baseline kJ-1, p = 0.5819), in the potentiated resting twitch force (CRF-COPD -2.8 ± 4.7 vs COPD -2.0 ± 3.3% baseline kJ-1, p = 0.7481) and in the maximal voluntary activation (CRF-COPD -0.1 ± 3.9 vs COPD -0.9 ± 1.2 -2.0 ± 3.3% baseline kJ-1, p = 0.4354). FSS and BDI were closely related (R = 0.5735, p = 0.0011), while no correlation between PF and NMF was found. CONCLUSION: Patients with CRF-COPD develop higher levels of perceived fatigue and dyspnea than patients with COPD; while neuromuscular fatigue is similar, suggesting a mismatch between symptoms and neuromuscular dysfunction.

Predictors of Low Physical Function in Patients With COVID-19 With Acute Respiratory Failure Admitted to a Subacute Unit.

OBJECTIVE: To document the level of physical function in patients with coronavirus disease 2019 (COVID-19) recovering from acute respiratory failure and investigate which patient clinical characteristics could predict physical function assessed by the Short Physical Performance Battery (SPPB) test. DESIGN: Cross-sectional study. SETTING: Subacute unit of a Rehabilitation Institute. PARTICIPANTS: Patients with COVID-19 (N=184; aged 18 years or older) who were admitted to a subacute unit to stabilize their condition and recover from acute respiratory failure due to COVID-19. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: At admission patients underwent the SPPB test, represented by the sum of 3 functional tests, standing balance, 4-meter gait speed, and 5-repetition sit-to-stand motion. Comparisons between 2 SPPB score groups were performed by an unpaired t test; multivariate stepwise linear regression analysis was employed to detect predictors of the SPPB score considering several clinical parameters. RESULTS: Participants were 74±12 years old, 52% were men and with more than 2 comorbidities in 43% of cases. SPPB score was 3.02±3.87 denoting patients' profound physical dysfunction. Normal physical function was detected in only 12% of patients, whereas low, intermediate, and severe impairment was found in 65%, 13%, and 10%, respectively. Age, both invasive and noninvasive ventilation use, and the presence of previous disability were significant predictors of SPPB. Patients without any comorbidities (8%) also exhibited low function (SPPB: 5.67±1.12). CONCLUSIONS: The majority of survivors after COVID-19 experienced acute respiratory failure due to pneumonia and exhibited substantial physical dysfunction influenced by age, mechanical ventilation need, and previous disability. Further studies are needed to evaluate the role of rehabilitation to promote recovery and community reintegration in this population.

Pulmonary Rehabilitation in Patients Recovering from COVID-19.

BACKGROUND: In hospitalized patients recovering from the SARS-coronavirus-2 disease 19 (COVID-19), high prevalence of muscle weakness and physical performance impairment has been observed. OBJECTIVES: The aim of this study was to evaluate the effectiveness of pulmonary rehabilitation in these subjects in a real-life setting. METHODS: Retrospective data analysis of patients recovering from COVID-19, including those requiring assisted ventilation or oxygen therapy, consecutively admitted to an in-patient pulmonary rehabilitation program between April 1 and August 15, 2020. Short Physical Performance Battery (SPPB: primary outcome), Barthel Index (BI), and six-min walking distance were assessed as outcome measures. RESULTS: Data of 140 patients were analyzed. After rehabilitation, patients showed improvements in SPPB {from: (median [IQR]) 0.5 (0-7) to 7 (4-10), p < 0.001} and BI (from 55 [30-90] to 95 [65-100], p < 0.001), as well as in other assessed outcome measures. The proportion of patients unable at admission to stand, rise from a chair and walk was significantly reduced (p < 0.00). CONCLUSIONS: Pulmonary rehabilitation is possible and effective in patients recovering from COVID-19. Our findings may be useful to guide clinicians taking care of patients surviving COVID-19 infection.

Patients recovering from COVID-19 pneumonia in sub-acute care exhibit severe frailty: Role of the nurse assessment.

AIMS AND OBJECTIVES: To document the level of frailty in sub-acute COVID-19 patients recovering from acute respiratory failure and investigate the associations between frailty, assessed by the nurse using the Blaylock Risk Assessment Screening Score (BRASS), and clinical and functional patient characteristics during hospitalisation. BACKGROUND: Frailty is a major problem in patients discharged from acute care, but no data are available on the frailty risk in survivors of COVID-19 infection. DESIGN: A descriptive cross-sectional study (STROBE checklist). METHODS: At admission to sub-acute care in 2020, 236 COVID-19 patients (median age 77 years - interquartile range 68-83) were administered BRASS and classified into 3 levels of frailty risk. The Short Physical Performance Battery (SPPB) was also administered to measure physical function and disability. Differences between BRASS levels and associations between BRASS index and clinical parameters were analysed. RESULTS: The median BRASS index was 14.0 (interquartile range 9.0-20.0) denoting intermediate frailty (32.2%, 41.1%, 26.7% of patients exhibited low, intermediate and high frailty, respectively). Significant differences emerged between the BRASS frailty classes regards to sex, comorbidities, history of cognitive deficits, previous mechanical ventilation support and SPPB score. Patients with no comorbidities (14%) exhibited low frailty (BRASS: median 5.5, interquartile range 3.0-12.0). Age ≥65 years, presence of comorbidities, cognitive deficit and SPPB % predicted <50% were significant predictors of high frailty. CONCLUSIONS: Most COVID-19 survivors exhibit substantial frailty and require continuing care after discharge from acute care. RELEVANCE TO CLINICAL PRACTICE: The BRASS index is a valuable tool for nurses to identify those patients most at risk of frailty, who require a programme of rehabilitation and community reintegration.

Recovering of oxygenation, physical function and disability in patients with Covid-19.

The present case report describes middle-time course of respiratory and physical variables in eight Covid-19 patients who were transferred from ICU of Covid Hub in our subacute Covid-19 unit. Secondly they were admitted in a pulmonary rehabilitation unit and, at discharge, a tele-rehabilitation program was provided as a continuum of care at home. Time course of oxygenation, physical function and disability were recorded. As expected, the acute event produced in these patients a dramatic worsening in oxygenation and physical activities, with a substantial improvement in oxygenation and mild disability after the sub-acute stay. After rehabilitation program, the patients showed additional improvement in particular in physical function. Anyway, this recover was not complete for all patients. The majority of Covid-19 survivors experienced ARF recovered oxygenation, physical function and disability within a median time of 137 days. A minority needs further follow up and rehabilitation maintenance due to incomplete recovery.

The Maugeri daily activity profile: a tool to assess physical activity in patients with chronic obstructive pulmonary disease.

Patients with chronic obstructive pulmonary disease (COPD) report reduced physical activity (PA). There are only few tools available to assess PA and sedentary behavior in these patients, and none of them aims to differentiate between sedentary and active patterns. The aim of the study was to evaluate an easy tool to profile daily activity time in a cohort of patients with COPD, compared to healthy subjects; the study was set at the Istituti Clinici Scientifici Maugeri (ICS), IRCCS of Tradate and Lumezzane, Italy, and at the Ente Ospedaliero Cantonale Novaggio, Switzerland (Italian Speaking). The populations were inpatients with COPD, healthy subjects. The items of the Maugeri Daily Activity (MaDA) profile were chosen based on literature, interviews with patients and health professionals. Time spent during sleep (ST), when awake (AT), active (ACT) or in sedentary behavior (SET) were recorded. Lung function tests, arterial blood gases, the modified Medical Research Council (mMRC), the six-minute walking distance test (6MWD), the COPD Assessment Test (CAT), and the body-mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) index were also assessed in patients. Sixty patients with COPD and 60 healthy controls filled in the questionnaire. As compared to controls, patients showed longer AT and SET. Active time of patients was significantly correlated with mMRC, CAT, Bode Index and 6MWD, but not with demographics, anthropometrics or stages of disease. Using this tool, we found that patients with COPD spent longer time awake and in sedentary behavior. The MaDA may be useful to evaluate PA in patients with COPD.

Respiratory rehabilitation for patients with COVID-19 infection and chronic respiratory failure: a real-life retrospective study by a Lombard network.

The Lombardy region has been one of the areas most affected by the COVID-19 pandemic since the first months of 2020, providing real-life experiences in the acute phase. It is unclear how the respiratory rehabilitation network responded to this emergency. The aims of this retrospective study were: i) to analyze clinical, functional, and disability data at admission; ii) describe assessment tools and rehabilitative programs; iii) evaluate improvement after rehabilitation. The study was conducted on data collected from ten pulmonary rehabilitation centers in Lombardy, between the period of March 1st 2020 to March 1st 2021, in patients with respiratory failure recovering from COVID-19 both at admission and discharge. The study included demographics, comorbidities, nutritional status, risk of falls, disability status (Barthel index; Short Physical Performance Battery (SPPB); 6 minutes walking test (6MWT), symptoms (dyspnoea with Barthel Dyspnoea and MRC Dyspnoea Scale), length of stay, discharge destination, need for mechanical ventilation, respiratory function, assessment/outcomes indices, and prescribed rehabilitative programs. 413 patients were analyzed. Length of stay in acute and rehabilitative units was less than 30 days. Fifty % of patients used non-invasive ventilation during their stay. Functional status was mildly compromised for forced volumes and oxygenation, while severely compromised for diffusion capacity. Independency was low while physical performance status very low.  At discharge, 318 (77%) patients were sent home, 83 (20.1%) were transferred to an acute unit and 12 (2.9%) passed away. Barthel Index and 6MWT were the most used, while MRC score was the least used outcome parameter. The 5 main rehabilitative activities were walking (90.8 %), transfer from bed to armchair (77.5%), limb mobilization in bed (76%), balance (71.2%), and cycle-ergometer or treadmill (43.1%). A huge difference was found in admission, discharge, and delta change among different rehabilitative centers. When available, all outcomes showed a significant improvement. With the limitation of a retrospective study with a clear amount of missing data, COVID-19 subjects admitted to rehabilitative centers presented a reduced physical performance, symptoms of dyspnoea, and severe disability. The 6MWT and Barthel index were the most used measurement.

Intrinsic Dynamic Positive End-Expiratory Pressure in Stable Patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND: Assessment of intrinsic dynamic positive end-expiratory pressure (PEEPi,dyn) may be clinically important in stable patients with chronic obstructive pulmonary disease (COPD), but epidemiological data are scant. OBJECTIVES: The aim of our study was (i) to assess the PEEPi,dyn in a large population of stable patients with COPD and (ii) to evaluate the correlations with some noninvasive measurements routinely assessed. METHOD: Retrospective analysis of lung mechanics, dynamic volumes, arterial blood gases, dyspnoea by means of the Medical Research Council (MRC) scale, the COPD Assessment Test score, and maximal inspiratory/expiratory pressures in 87 hypercapnic and 62 normocapnic patients. RESULTS: The mean PEEPi,dyn was significantly higher in hypercapnic than normocapnic patients (2.8 ± 2.2 vs. 1.9 ± 1.6 cm H2O, respectively, p = 0.0094). PEEPi,dyn did not differ according to Global Initiative for Chronic Obstructive Lung Disease stage, MRC score, or use or not of long-term oxygen therapy. There were significant although weak correlations between PEEPi,dyn and airway obstruction, hyperinflation, respiratory muscle function, arterial CO2 tension, and number of exacerbations/year. The transdiaphragmatic pressure was the strongest variable associated to PEEPi,dyn (R = 0.5713, p = 0.001). CONCLUSION: In stable patients with COPD, PEEPi,dyn is higher in hypercapnic patients and weakly correlated to noninvasive measures of lung and respiratory muscle function.

Joint Statement on the Role of Respiratory Rehabilitation in the COVID-19 Crisis: The Italian Position Paper.

Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.

How the COVID-19 infection tsunami revolutionized the work of respiratory physiotherapists: an experience from Northern Italy.

Due to COVID-19 outbreak, to lighten the burden of acute and critical care hospitals, some respiratory rehabilitation departments have been used to host patients with COVID-19 in the post-acute phase. This new and unexpected situation required a change of roles and scheduling of the rehabilitation teams. In this manuscript we describe the unexpected and urgent organizational change of the Cardio-Pulmonary Rehabilitation (CPR) service during the COVID-19 emergency in a Northern Italian rehabilitation hospital, focusing on the Respiratory Physiotherapists' (RPTs) role. A quick three-days complete reorganization of the entire hospital was needed. A COVID-19 care team including a multidisciplinary panel of physicians, nurses, and RPTs was quickly performed to manage 90 beds for post acute patients with COVID-19. Within the team, the RPTs changed their shifts, so as to be available 16h per day, 7 days out of 7. Remodelled tasks in charge of RPTs were: oxygen therapy daily monitoring, non invasive ventilation (NIV) and continuous positive airways pressure (CPAP) delivery, pronation and postural changes to improve oxygenation, reconditioning with leg/arm cranking and exercises, initial and final patients' functional assessment by short-physical performance battery (SPPB) and 1-minute sit-to-stand test (1-STS) to evaluate motor conditions and exercise-induced oxygen desaturation. Three "what-to-do" algorithms were developed to guide: i) oxygen de-escalation by reducing inhaled fraction of oxygen (FiO2); ii) oxygenation improvement through the use of Venturi mask; iii) reconditioning and physical activity. One-hundred seventy patients were treated in one month. As main topics, RPTs have been involved in oxygen therapy management in almost a third of the admitted patients, reconditioning exercises in 60% of the cases, and initial and final functional motor capacity assessment in all patients. Details of activities performed by the RPT in one typical working day are also shown. Our reorganization has exploited the professional skills and clinical expertise of the RPTs. This re-organization can provide practical insights to other facilities that are facing this crisis, and may be a starting point for implementing post-COVID-19 rehabilitation. Future studies will have to improve and review this organization.

Use of inhaled devices during a hospital exacerbation of COPD: a summary of an interdisciplinary audit held at ICS Maugeri Pavia, Italy (March-June 2019).

To date treatment protocols in Respiratory and or Internal departments across Italy for treatment of chronic obstructive pulmonary disease (COPD) patients at hospital admission with relapse due to exacerbation do not find adequate support in current guidelines. Here we describe the results of a recent clinical audit, including a systematic review of practices reported in literature and an open discussion comparing these to current real-life procedures. The process was dived into two 8-hour-audits 3 months apart in order to allow work on the field in between meeting and involved 13 participants (3 nurses, 1 physiotherapist, 2 internists and 7 pulmonologists). This document reports the opinions of the experts and their consensus, leading to a bundle of multidisciplinary statements on the use of inhaled drugs for hospitalized COPD patients. Recommendations and topics addressed include: i) monitoring and diagnosis during the first 24 h after admission; ii) treatment algorithm and options (i.e., short and long acting bronchodilators); iii) bronchodilator dosages when switching device or using spacer; iv) flow measurement systems for shifting to LABA+LAMA within 48 h; v) when nebulizers are recommended; vi) use of SMI to deliver LABA+LAMA when patient needs SABA <3 times/day independently from flow limitation; vii) use of DPI and pre-dosed MDI to deliver LABA+LAMA or TRIPLE when patient needs SABA <3 times/day, with inspiratory flow > 30 litres/min; viii) contraindication to use DPI; ix) continuation of LABA-LAMA when patient is already on therapy; x) possible LABA-LAMA dosage increase; xi) use of SABA and/or SAMA in addition to LABA+LABA; xii) use of SABA+SAMA restricted to real need; xiii) reconciliation of drugs in presence of comorbidities; xiv) check of knowledge and skills on inhalation therapy; xv) discharge bundle; xvi) use of MDI and SMI in tracheostomized patients in spontaneous and ventilated breathing.

Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR).

Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR) On February 2020, Italy, especially the northern regions, was hit by an epidemic of the new SARS-Cov-2 coronavirus that spread from China between December 2019 and January 2020. The entire healthcare system had to respond promptly in a very short time to an exponential growth of the number of subjects affected by COVID-19 (Coronavirus disease 2019) with the need of semi-intensive and intensive care units.

Italian suggestions for pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process.

There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 after discharge from acute care. To facilitate the knowledge of the evidence and its translation into practice, we developed suggestions based on experts' opinion. A steering committee identified areas and questions sent to experts. Other international experts participated to a RAND Delphi method in reaching consensus and proposing further suggestions. Strong agreement in suggestions was defined when the mean agreement was >7 (1 = no agreement and 9 = maximal agreement). Panelists response rate was >95%. Twenty-three questions from 4 areas: Personnel protection equipment, phenotypes, assessments, interventions, were identified and experts answered with 121 suggestions, 119 of which received high level of concordance. The evidence-based suggestions provide the clinicians with current evidence and clinical experts opinion. This framework can be used to facilitate clinical decision making within the context of the individual patient. Further studies will evaluate the clinical usefulness of these suggestions.

Clinical research as foundation for the advancement of respiratory physiotherapy.

Associazione Riabilitatori dell'Insufficienza Respiratoria (ARIR) is pleased to announce a new editorial project by joining the Monaldi Archives of Chest Disease journal.

[The new concept of rehabilitation space in the era of the Digital Health in cardio-respiratory rehabilitation]. / Nuovo concetto di spazio riabilitativo nell'era della Digital Health in riabilitazione cardio-respiratoria.

SUMMARY: Rehabilitation Specialized Medicine offers new developments in relation to the new technologies, new demography, life expectation and chronicity. The same attention that in modern health systems is given to quality process and outcome, should also concern the hospital structural aspects, in order to humanize these spaces. In this perspective, the definition of a structure easy to access with well-defined areas within it, such us an external waiting area, reception area and work area, represents an integration which allows to achieve the goal of providing quality performance. The need of a new concept of rehabilitation space in the cardio-respiratory area, especially that of the Gymnasium, must be developed keeping in consideration the main scientific guidelines in cardio-respiratory field. Consequently, this will have four dedicated areas respectively to evaluation, aerobic training, strength training and educational, each one characterized by different colors. The abstract idea of "digital comprehensive rehabilitation", in which are inserted all rehabilitative services facilitated by the gym digitalization, are located in this context, and their main aim is to answer to the patient needs.

Home-based telerehabilitation in older patients with chronic obstructive pulmonary disease and heart failure: a randomised controlled trial.

Background: chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) frequently coexist in older people, reducing patients' quality of life (QoL) and increasing morbidity and mortality. Objective: we studied the feasibility and efficacy of an integrated telerehabilitation home-based programme (Telereab-HBP), 4 months long, in patients with combined COPD and CHF. The primary outcome was exercise tolerance evaluated at the 6-min walk test (6MWT). Secondary outcomes were time-to-event (hospitalisation and death), dyspnoea (MRC), physical activity profile (PASE), disability (Barthel) and QoL (MLHFQ and CAT). Study design: randomised, open, controlled, multicenter trial. Methods: the Telereab-HBP included remote monitoring of cardiorespiratory parameters, weekly phone-calls by the nurse, and exercise programme, monitored weekly by the physiotherapist. All outcomes were studied again after 2 months of a no-intervention period. Results: in total, 112 patients were randomised, 56 per group. Their mean (SD) age was 70 (9) years, and 92 (82.1%) were male. After 4 months, the IG were able to walk further than at baseline: mean (95% CI) Δ6MWT was 60 (22.2,97.8) m; the CG showed no significant improvement: -15 (-40.3,9.8) m; P = 0.0040 between groups. In IG, the media time to hospitalisation/death was 113.4 days compared with 104.7 in the CG (P = 0.0484, log-rank test). Other secondary outcomes: MRC (P = 0.0500), PASE (P = 0.0015), Barthel (P = 0.0006), MLHFQ (P = 0.0007) and CAT (P = 0.0000) were significantly improved in the IG compared with the CG at 4 months. IG maintained the benefits acquired at 6 months for outcomes. Conclusions: this 4-month Telereab-HBP was feasible and effective in older patients with combined COPD and CHF.

Non-invasive ventilation during cycle exercise training in patients with chronic respiratory failure on long-term ventilatory support: A randomized controlled trial.

BACKGROUND AND OBJECTIVE: The role of non-invasive ventilation (NIV) during exercise training (ET) in patients with chronic respiratory failure (CRF) is still unclear. The aim of this study was to test whether NIV during ET had an additional effect in increasing the 6-min walking distance (6MWD) and cycle endurance time compared with ET alone. METHODS: All patients underwent 20 sessions of cycle training over 3 weeks and were randomly assigned to ET with NIV or ET alone. Outcome measures were 6MWD (primary outcome), incremental and endurance cycle ergometer exercise time, respiratory muscle function, quality of life by the Maugeri Respiratory Failure questionnaire (MRF-28), dyspnoea (Medical Research Council scale) and leg fatigue at rest. RESULTS: Forty-two patients completed the study. Following training, no significant difference in 6MWD changes were found between groups. Improvement in endurance time was significantly greater in the NIV group compared with the non-NIV training group (754 ± 973 vs 51 ± 406 s, P = 0.0271); dyspnoea improved in both groups, while respiratory muscle function and leg fatigue improved only in the NIV ET group. MRF-28 improved only in the group training without NIV. CONCLUSION: In CRF patients on long-term NIV and long-term oxygen therapy (LTOT), the addition of NIV to ET sessions resulted in an improvement in endurance time, but not in 6MWD.