Patient-related outcomes in patients referred to a respiratory clinic with persisting symptoms following non-hospitalised COVID-19.

Survivors of COVID-19 can present with varied and persisting symptoms, regardless of hospitalisation. We describe the ongoing symptoms, quality of life and return to work status in a cohort of non-hospitalised COVID-19 survivors with persisting respiratory symptoms presenting to clinic, who consented and completed patient-reported outcome measures. We identified fatigue, reduced quality of life and dysregulated breathing alongside the breathlessness. Those with co-existent fatigue had worse mood and quality of life and were less likely to have returned to normal working arrangements compared to those without fatigue. For non-hospitalised people with persisting symptoms following COVID-19 referred to a respiratory assessment clinic, there was a need for a wider holistic assessment, including return to work strategies.

Longitudinal changes to quadriceps thickness demonstrate acute sarcopenia following admission to hospital for an exacerbation of chronic respiratory disease.

Acute admission to hospital for an exacerbation of chronic respiratory disease (CRD) may impair skeletal muscle mass and function. We measured quadriceps thickness (Qthick), as a surrogate marker of muscle mass, at hospital admission, discharge, 6 weeks and 3 months in 55 patients with CRD. Qthick fell by 8.3% during the period of hospitalisation, which was sustained at 6 weeks, and only partially recovered at 3 months. Sustained loss was most marked in patients readmitted during the follow-up period. Acute reduction in quadriceps muscle mass occurs during hospitalisation, with prolonged and variable recovery, which is prevented with subsequent hospital readmission.

Rehabilitation in chronic respiratory diseases: In-hospital and post-exacerbation pulmonary rehabilitation.

Exacerbations of chronic obstructive pulmonary disease (COPD) that require hospitalization are important events for patients. Functional impairment and skeletal muscle dysfunction can increase the risk of hospitalization and readmission, independent of lung function. In addition, once a patient is admitted, multiple factors can lead to worsening outcome including immobility, systemic inflammation and nutritional depletion. These non-pulmonary factors are potentially amenable to exercise therapy, as part of pulmonary rehabilitation (PR). Peri-exacerbation PR has an important role in the management of exacerbations of COPD. In this review, we explore how functional limitation and skeletal muscle dysfunction affect patients having a severe exacerbation of COPD, the systemic impact of hospitalization on patients including potential aetiologies and the role of PR around the time of an exacerbation. This includes rehabilitation during the inpatient phase, post-exacerbation rehabilitation and rehabilitation bridging hospital discharge. We also describe potential future developments in peri-exacerbation PR.

Changes in physical activity during hospital admission for chronic respiratory disease.

BACKGROUND AND OBJECTIVE: Establishing the amount of inpatient physical activity (PA) undertaken by individuals hospitalized for chronic respiratory disease is needed to inform interventions. This observational study investigated whether PA changes when a person is an inpatient, how long is required to obtain representative PA measures and whether PA varies within a day and between patients of differing lengths of stay. METHODS: A total of 389 participants were recruited as early as possible into their hospitalization. Patients wore a PA monitor from recruitment until discharge. Step count was extracted for a range of wear time criteria. Single-day intraclass correlation coefficients (ICC) were calculated, with an ICC ≥ 0.80 deemed acceptable. RESULTS: PA data were available for 259 participants. No changes in daily step count were observed during the inpatient stay (586 (95% CI: 427-744) vs 652 (95% CI: 493-812) steps/day for day 2 and 7, respectively). ICC across all wear time criteria were > 0.80. The most stringent wear time criterion, retaining 80% of the sample, was ≥11 h on ≥1 day. More steps were taken during the morning and afternoon than overnight and evening. After controlling for the Medical Research Council (MRC) grade or oxygen use, there was no difference in step count between patients admitted for 2-3 days (short stay) and those admitted for 7-14 days (long stay). CONCLUSION: Patients move little during their hospitalization, and inpatient PA did not increase during their stay. A wear time criterion of 11 waking hours on any single day was representative of the entire admission whilst retaining an acceptable proportion of the initial sample size. Patients may need encouragement to move more during their hospital stay.

Are the measurement properties of incremental exercise tests similar between patients with COPD and CHF?

We investigated whether the differences in exercise limitation between patients with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF) affect the repeatability or responsiveness of incremental exercise tests. Patients with COPD (Medical Research Council dyspnoea grade 2-5) and patients with CHF (New York Heart Association class II-IV) performed two incremental shuttle walk tests (ISWT) following familiarisation and two incremental cycle ergometer tests (ICE) within 2 weeks. Both tests were repeated on completion of a pulmonary rehabilitation (PR) programme. One hundred and twelve patients were recruited. In response to exercise, patients with COPD were more likely than patients with CHF to have a ventilatory limitation (p < 0.001) and less likely to have a cardiovascular limitation (p < 0.001). The ISWT distance and ICE peak volume of oxygen uptake (VO2Peak) were similarly repeatable (p = 0.11 and p = 0.47 for time and disease effect) and responsive to PR (p = 0.44 and p = 0.67) between diseases. There was no difference in repeatability or responsiveness with either a ventilatory or cardiovascular limitation to exercise (p > 0.20 for all comparisons). The coefficient of repeatability across the cohort was 60 m for the ISWT and 0.270 L/minute for ICE VO2Peak. The minimum important difference (MID) for the ISWT in both diseases for PR was 30 m. The repeatability and responsiveness of the ISWT distance and ICE VO2Peak are similar between patients with COPD and CHF and are unaffected by differences in exercise limitation. A change of 60 m in the ISWT or 0.270 L/minute in ICE VO2Peak is required to be 95% certain that a true change has occurred within an individual patient. For a group of patients with either COPD or CHF, the MID for the ISWT distance is estimated to be 30 m.

Bedside assessment of quadriceps muscle by ultrasound after admission for acute exacerbations of chronic respiratory disease.

RATIONALE: Hospitalization represents a major event for the patient with chronic respiratory disease. There is a high risk of readmission, which over the longer term may be related more closely to the underlying condition of the patient, such as skeletal muscle dysfunction. OBJECTIVES: We assessed the risk of hospital readmission at 1 year, including measures of lower limb muscle as part of a larger clinical trial. METHODS: Patients hospitalized with an exacerbation of chronic respiratory disease underwent measures of muscle function including quadriceps ultrasound. Independent factors influencing time to hospital readmission or death were identified. Patients were classified into four quartiles based on quadriceps size and compared. MEASUREMENTS AND MAIN RESULTS: One hundred and ninety-one patients (mean age, 71.6 [SD, 9.1] yr) were recruited. One hundred and thirty (68%) were either readmitted or died. Factors associated with readmission or death were age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.08; P = 0.015), Medical Research Council (MRC) dyspnea grade (OR, 4.57; 95% CI, 2.62-7.95; P < 0.001), home oxygen use (OR, 12.4; 95% CI, 4.53-33.77; P < 0.001), quadriceps (rectus femoris) cross-sectional area (Qcsa) (OR, 0.34; 95% CI, 0.17-0.65; P = 0.001), and hospitalization in the previous year (OR, 4.82; 95% CI, 2.42-9.58; P < 0.001). In the multivariate analyses, home oxygen use (OR, 4.80; 95% CI, 1.68-13.69; P = 0.003), MRC dyspnea grade (OR, 2.57; 95% CI, 1.44-4.59; P = 0.001), Qcsa (OR, 0.46; 95% CI, 0.22-0.95; P = 0.035), and previous hospitalization (OR, 3.04; 95% CI, 1.47-6.29; P = 0.003) were independently associated with readmission or death. Patients with the smallest muscle spent more days in hospital than those with largest muscle (28.1 [SD, 33.9] vs. 12.2 [SD, 23.5] d; P = 0.007). CONCLUSIONS: Smaller quadriceps muscle size, as measured by ultrasound in the acute care setting, is an independent risk factor for unscheduled readmission or death, which may have value both in clinical practice and for risk stratification.

High-Frequency Airway Oscillating Device for Respiratory Muscle Training in Subjects With COPD.

BACKGROUND: COPD is characterized by expiratory flow limitation, which results in symptomatic dyspnea and reduced exercise capacity. Changes in breathing mechanics mean the respiratory muscles are unable to respond to the ventilatory demands, increasing the sensation of dyspnea. A high-frequency oscillating device has been developed to improve dyspnea in patients with COPD. We conducted a feasibility trial to gain insight into the potential for recruitment, retention, and study design for a future randomized controlled trial. METHODS: Symptomatic subjects with COPD were included on the basis of a Medical Research Council (MRC) score ≥ 3 and FEV1/FVC < 0.70). Patients were excluded if they received pulmonary rehabilitation within the last 6 months. The intervention employed the device for 8 weeks, 3 times daily. Clinical outcomes included the MRC score, maximal expiratory and inspiratory pressures (PEmax/PImax), the incremental shuttle walk test (ISWT), and the endurance shuttle walk test (ESWT). RESULTS: We successfully recruited 23 subjects with established COPD (65.2% male, mean age 65 ± 5.03 y, mean % predicted FEV1 43.9 ± 16, mean FEV1/FVC ratio 0.46 ± 0.13, and median [interquartile range] MRC 4 [3-5]). There was a significant change in MRC from 4 to 3 pre to post intervention (P = .003). There was a statistically significant difference in PEmaxP < .008 and PImaxP = .044. There were no significant differences observed in the ISWT or ESWT. CONCLUSIONS: This study design appeared feasible to proceed to a clinical effectiveness trial. The use of the device for 8 weeks showed a significant improvement in PEmax, PImax, and reduced symptomatic dyspnea on the MRC dyspnea score. The results of this study should encourage a randomized controlled trial.

Blood Eosinophils and Outcomes in Severe Hospitalized Exacerbations of COPD.

BACKGROUND: Patients with moderate exacerbations of COPD and the eosinophilic phenotype have better outcomes with prednisolone. Whether this outcome is similar in patients hospitalized with a severe exacerbation of COPD is unclear. We investigated the rate of recovery of eosinophilic and noneosinophilic exacerbations in patients participating in a multicenter randomized controlled trial assessing health outcomes in hospitalized exacerbations. METHODS: Patients were recruited at presentation to the hospital with an exacerbation of COPD. They were stratified into groups according to eosinophilic exacerbations if the peripheral blood eosinophil count on admission was ≥ 200 cells/µL and/or ≥ 2% of the total leukocyte count. Admission details, serum C-reactive protein levels, length of stay, and subsequent rehospitalization data were compared between groups. RESULTS: A total of 243 patients with COPD (117 men) with a mean age of 71 years (range, 45-93 years) were recruited. The inpatient mortality rate was 3% (median time to death, 12 days; range, 9-16 days). The median absolute eosinophil count was 100 cells/µL (range, 10-1,500 cells/µL), and 25% met our criteria for an eosinophilic exacerbation; in this population, the mean length of stay (in days) was shorter than in patients with noneosinophilic exacerbations (5.0 [range, 1-19] vs 6.5 [range, 1-33]; P = .015) following treatment with oral corticosteroids and independent of treatment prior to admission. Readmission rates at 12 months were similar between groups. CONCLUSIONS: The study patients presenting to the hospital with a severe eosinophilic exacerbation of COPD had a shorter length of stay. The exacerbations were usually not associated with elevated C-reactive protein levels, suggesting that better treatment stratification of exacerbations can be used. TRIAL REGISTRY: http://www.isrctn.com/ISRCTN05557928.

An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial.

OBJECTIVE: To investigate whether an early rehabilitation intervention initiated during acute admission for exacerbations of chronic respiratory disease reduces the risk of readmission over 12 months and ameliorates the negative effects of the episode on physical performance and health status. DESIGN: Prospective, randomised controlled trial. SETTING: An acute cardiorespiratory unit in a teaching hospital and an acute medical unit in an affiliated teaching district general hospital, United Kingdom. PARTICIPANTS: 389 patients aged between 45 and 93 who within 48 hours of admission to hospital with an exacerbation of chronic respiratory disease were randomised to an early rehabilitation intervention (n=196) or to usual care (n=193). MAIN OUTCOME MEASURES: The primary outcome was readmission rate at 12 months. Secondary outcomes included number of hospital days, mortality, physical performance, and health status. The primary analysis was by intention to treat, with prespecified per protocol analysis as a secondary outcome. INTERVENTIONS: Participants in the early rehabilitation group received a six week intervention, started within 48 hours of admission. The intervention comprised prescribed, progressive aerobic, resistance, and neuromuscular electrical stimulation training. Patients also received a self management and education package. RESULTS: Of the 389 participants, 320 (82%) had a primary diagnosis of chronic obstructive pulmonary disease. 233 (60%) were readmitted at least once in the following year (62% in the intervention group and 58% in the control group). No significant difference between groups was found (hazard ratio 1.1, 95% confidence interval 0.86 to 1.43, P=0.4). An increase in mortality was seen in the intervention group at one year (odds ratio 1.74, 95% confidence interval 1.05 to 2.88, P=0.03). Significant recovery in physical performance and health status was seen after discharge in both groups, with no significant difference between groups at one year. CONCLUSION: Early rehabilitation during hospital admission for chronic respiratory disease did not reduce the risk of subsequent readmission or enhance recovery of physical function following the event over 12 months. Mortality at 12 months was higher in the intervention group. The results suggest that beyond current standard physiotherapy practice, progressive exercise rehabilitation should not be started during the early stages of the acute illness.Trial registration Current Controlled Trials ISRCTN05557928.