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.

The impact of the meta-analysis of pulmonary rehabilitation by Lacasse and colleagues: transforming pulmonary rehabilitation from "art to science".

#Pulmonaryrehab was transformed in the 1990s into the standard of care for COPD: this article focuses on the impact of the 1996 meta-analysis by Lacasse and colleagues which provided the evidence to silence the sceptics https://bit.ly/3MIntBC.

Measures of physical performance in COVID-19 patients: a mapping review.

BACKGROUND AND OBJECTIVE: There is evidence of short- and long-term impairment of physical performance in patients with COVID-19 infection, but a verification of measures of physical impairment in this condition is lacking. We reviewed the measures used to assess physical performance in these patients. Secondary targets were measures of exercise or daily life activities induced symptoms. METHODS: Medline, CINAHL, and Pedro databases were searched from January 2020 to February 2021 for articles in the English language. Two investigators independently conducted the search, screened all titles and/or abstracts based on the inclusion criteria and independently scored the studies. The quality of the studies was evaluated by two reviewers according to the NIH quality assessment tool for observational cohort and cross-sectional studies. Discrepancies were resolved through consensus. RESULTS: Out of 156 potentially relevant articles, 31 observational studies (8 cross-sectional), 1 randomized controlled trial, and 1 protocol were included. The quality of most of the 31 evaluable studies was judged as low (11 studies) or fair (14 studies). Sample sizes of the studies ranged from 14 to 20,889 patients. among the 28 reported measures, Barthel Index (42.4% of studies), Six-Minute Walking Distance Test (36.4%), Short Physical Performance Battery (21.2%) and 1-Minute Sit-to-Stand (12.1%) were the most used. Fifteen% and 36% of studies reported exercise induced desaturation and dyspnoea when performing the assessments, respectively. Other exercise induced symptoms were fatigue and pain. Studies reported wide ranges of impairment in physical performance as compared to "reference" values (range of mean or median reported values vs "reference values": 11-77 vs 100 points for Barthel Index; 11-22 vs 22-37 repetitions/min for 1m-STS; 0.5-7.9 vs 11.4 ± 1.3 points for SPPB; and 45-223 vs 380-782 m for 6MWT respectively). CONCLUSION: This review found that a wide variety of functional status tests have been used, making comparisons difficult between studies. These measures show impairment in physical performance in COVID-19 patients. However, the quality of most of the studies was judged as low or fair.

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.

Muscle Strength and Physical Performance in Patients Without Previous Disabilities Recovering From COVID-19 Pneumonia.

ABSTRACT: In this cross-sectional study, we evaluated skeletal muscle strength and physical performance (1-min sit-to-stand and short physical performance battery tests), dyspnea, fatigue, and single-breath counting at discharge from a postacute COVID department, in patients recovering from COVID-19 pneumonia who had no locomotor disability before the infection.Quadriceps and biceps were weak in 86% and 73% of the patients, respectively. Maximal voluntary contraction for quadriceps was 18.9 (6.8) kg and for biceps 15.0 (5.5) kg (i.e., 54% and 69% of the predicted normal value, respectively). The number of chair rises in the 1-min sit-to-stand test was 22.1 (7.3 corresponding to 63% of the predicted normal value), whereas the short physical performance battery score was 7.9 (3.3 corresponding to 74% of the predicted normal value). At the end of the 1-min sit-to-stand test, 24% of the patients showed exercise-induced desaturation. The single-breath counting count was 35.4 (12.3) corresponding to 72% that of healthy controls. Mild-to-moderate dyspnea and fatigue were found during activities of daily living (Borg scale score, median value = 0.5 [0-2] and 1 [0-2]) and after the 1-min sit-to-stand (Borg scale score, median value = 3 [2-5] and 1 [0-3]). Significant correlations were observed between muscle strength and physical performance indices (R = 0.31-0.69).The high prevalence of impairment in skeletal muscle strength and physical performance in hospitalized patients recovering from COVID-19 pneumonia without previous locomotor disabilities suggests the need for rehabilitation programs after discharge.

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.

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.

The impact of exercise training on fatigue in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis.

INTRODUCTION AND OBJECTIVE: Fatigue can be divided in perceived fatigue, the feeling of exhaustion or lack of energy, and performance fatigue, the reduction in muscle force/activation during a given task. This meta-analysis evaluates the impact of exercise training on fatigue, compared with normal care in patients with COPD. MATERIAL AND METHODS: We searched randomised controlled trials on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL databases from their inception to December, 31st 2019 using the terms COPD, Fatigue, Fatigability, Muscle activation, Muscle endurance, Muscle Performance, Voluntary Activation, Motoneuron excitability, Force Development, Exercise, AND Rehabilitation. RESULTS: We evaluated 494 potential articles. Sixteen, all evaluating perceived fatigability, satisfied the inclusion criteria and were included. Twelve studies (463 patients) assessed fatigue by the Chronic Respiratory Questionnaire showing that intervention improved significantly more than the control group [SMD 0.708; 95% CI 0.510, 0.907; p < 0.001; I²â€¯= 34.3%; p = 0.116]. Two studies (68 patients) using the Fatigue Impact Scale, did not find any significant differences between groups [SMD -0.922; 95%CI -2.258, 0.413; p = 0.176; I²â€¯= 83.9%; p = 0.013]. Two studies (82 patients) assessed perceived fatigue by the Fatigue Severity Scale: the intervention improved significantly more than the control group [SMD -2.282; 95%CI -2.870, -1.699; p < 0.001; I²â€¯= 64.6%, p = 0.093]. No study evaluating performance fatigue was found. CONCLUSIONS: This study provided low-quality evidence of a positive impact of different exercise training programs on perceived fatigue in patients with COPD. Further studies are needed to assess the effects of exercise training on fatigue and to test tailored programs.

Therapist Driven Rehabilitation Protocol for Patients with Chronic Heart and Lung Diseases: A Real-Life Study.

Therapist driven protocols may help to tailor rehabilitation programs to individual patients. We aimed to test the feasibility, safety, and clinical usefulness of a therapist driven protocol for rehabilitation including exercise training of patients with heart or lung diseases. An internal audit elaborated the Cardio-Respiratory Exercise Maugeri Algorithm (CREMA) based on: (a) standardized baseline assessments, (b) decision-making pathways, and (c) frequency/intensity/time/type (FITT) of prescription for each exercise. Outpatients (n = 620) with chronic heart disease (CHD), recent myocardial revascularization (REVASC), chronic airway (Obstructive), and restrictive lung (Restrictive) diseases underwent exercise training according to CREMA during 4 years. Peripheral muscle strengthening was the most prescribed exercise (83.6%), while arm endurance training was the least frequently (0.75%). Exercise prescription varied widely among the disease groups (interval training 19-47%, balance 35-49%, lower limb muscle training 6-15%). After training, REVASC patients were the best improvers in the 6 min walking distance (+48.7 (56.1) m), maximal inspiratory pressure (+9.6 (15.4) cmH2O), and daily steps (+1087.2 (3297.1) n/day). Quadriceps and biceps strength, maximal expiratory pressure, and balance improved in all groups, without significant differences. Minor side effects were observed in 11.2% of the patients. The CREMA therapist driven protocol was feasible, safe, and useful for prescribing tailored training programs. Exercise prescriptions and training response differed among diseases.

Physical Activity in Patients with Chronic Obstructive Pulmonary Disease on Long-Term Oxygen Therapy: A Cross-Sectional Study.

Background and aim: There are few studies evaluating physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT). Aim: To assess PA in hypoxemic COPD patients on LTOT. Methods: In this cross-sectional study, we compared lung function, arterial blood gases, respiratory and peripheral muscle strength, 6-min walking distance (6MWD), daily energy expenditure and steps, and health-related quality of life (HRQL) in COPD patients on LTOT (LTOT group) versus two groups of control patients not needing LTOT: with (HYPOX) and without (COPD) exercise-induced desaturations. Results: Groups did not differ as regards demographics, anthropometrics, peripheral or respiratory muscle strength. Compared to the other groups, LTOT patients had more severe airway obstruction and lung hyperinflation, greater number and severity of comorbidities, shorter 6MWD, as well as lower mean SpO2 during 6MWD and worse quality of life. LTOT patients had a lower daily energy expenditure, shorter time spent > 3.0 METs and longer sedentary time compared to the COPD group, and less daily steps compared to the other groups. No significant difference in any parameter of PA was found between COPD and HYPOX. In LTOT patients, daily steps showed a strong correlation with 6MWD, and a moderate correlation with airway obstruction, level of oxygenation, comorbidities and quality of life but not with peripheral and respiratory muscle strength. In COPD and HYPOX patients, daily steps were strongly correlated with 6MWD and level of oxygenation as assessed by PaO2/FiO2. There was no significant correlation between mean SpO2 and 6MWD in any group. Conclusion: COPD patients on LTOT perform less physical activity than patients not needing LTOT, both with and without exercise-induced desaturations. Patients with exercise-induced desaturations do not perform less physical activity than those without.

Is Two Better Than One? The Impact of Doubling Training Volume in Severe COPD: A Randomized Controlled Study.

Patients with severe chronic obstructive pulmonary disease (COPD) are unable to exercise at high intensities for sufficiently long periods of time to obtain true physiological training effects. It therefore appears sensible to increase training duration at sub-maximal exercise intensities to optimize the benefit of exercise training. We compared the effects on exercise tolerance of two endurance cycloergometer submaximal exercise protocols with different cumulative training loads (one (G1) versus two (G2) daily 40 min training sessions) both implemented over 20 consecutive days in 149 patients with COPD (forced expiratory volume at first second (FEV1): 39% predicted) admitted to an inpatient pulmonary rehabilitation program. Patients in G2 exhibited greater improvement (p = 0.011) in submaximal endurance time (from 258 (197) to 741 (662) sec) compared to G1 (from 303 (237) to 530 (555) sec). Clinically meaningful improvements in health-related quality of life, 6MWT, and chronic dyspnea were not different between groups. Doubling the volume of endurance training is feasible and can lead to an additional benefit on exercise tolerance. Future studies may investigate the applicability and benefits of this training strategy in the outpatient or community-based pulmonary rehabilitation settings to amplify the benefits of exercise interventions.

Short-Term Effects of Normocapnic Hyperpnea and Exercise Training in Patients With Chronic Obstructive Pulmonary Disease: A Pilot Study.

OBJECTIVE: The aim of the study was to evaluate the short-term physiologic effects of respiratory muscle training with normocapnic hyperpnea added to standard exercise training on respiratory muscle endurance/strength and exercise tolerance in patients with chronic obstructive pulmonary disease. DESIGN: The study used a randomized controlled trial. Patients referred for rehabilitation were randomly assigned to 20 sessions (twice daily 5 d/wk) of either normocapnic hyperpnea (group 1, n = 12) or sham maneuvers (group 2, n = 10) in addition to individualized cycle training and abdominal, upper, and lower limb muscle exercise. At baseline and end of study, patients underwent evaluation of respiratory muscle endurance, maximum voluntary ventilation, maximal inspiratory, and expiratory pressures, and 6-min walking distance. RESULTS: After training, a significant improvement was found only for group 1 in respiratory muscle endurance time (by 654 [481] secs versus 149 [216] secs for group 2, P = 0.0108) and maximal inspiratory (group 1: from 81.2 [21.9] cmH2O to 107.6 [23.0] cmH2O, P = 0.018 versus group 2: from 75.4 [13.8] cmH2O to 81.3 [18.9] cmH2O, P = 0.139). The difference between groups for 6-min walking distance, maximum voluntary ventilation, and expiratory pressures was not significant. CONCLUSIONS: Short-term normocapnic hyperpnea training added to standard exercise, compared with exercise training alone, improves respiratory muscle endurance and strength but not exercise tolerance in patients with chronic obstructive pulmonary disease.

The degree of arm elevation impacts the endurance and cardiopulmonary adaptations of COPD patients performing upper-limb exercise: a cross-over study.

BACKGROUND: In Chronic Obstructive Pulmonary Disease (COPD), upper limb exercise is widely recommended. However, how the degree of shoulder flexion may influence the exercise response is unknown. AIM: We compared metabolic, ventilatory and symptomatic responses during constant-load supported and unsupported exercise performed at 80° and 120° arm elevation. DESIGN: Randomized cross-over study. SETTING: Pulmonary Pathophysiology Service in an Italian Respiratory Rehabilitative Division, in-patients were enrolled. METHODS: Twelve patients with moderate-to-severe COPD (FEV1 51%, BMI 26.7 ± 6.3 Kg/m2) performed 4 symptom-limited constant-load tests at 70% of their individual maximal workload: 2 supported and 2 unsupported, respectively at 80° and 120° of glenohumeral joint flexion, executed in a random order. RESULTS: Time to exhaustion (Tlim), evaluated by Kaplan-Maier curve, was shorter at 120° than 80° arm elevation in both supported (360 vs.. 486 seconds, p=0.031) and unsupported exercise (210 vs.. 375 seconds, p=0.005). No difference in dynamic hyperinflation was found between 80° and 120° elevation, even at the peak of exercise and at iso-ventilation. When normalized to Tlim, 120° arm elevation had a significantly higher metabolic cost, heart rate, minute ventilation and dyspnea/fatigue symptoms compared to 80° elevation, both in unsupported and supported conditions. CONCLUSIONS: A larger shoulder flexion shortens per se exercise endurance due to the increased metabolic, ventilatory and cardiac response, without worsening dynamic hyperinflation. CLINICAL REHABILITATION IMPACT: Arm position should be considered when prescribing individual exercise training and may be adjusted to modulate the workload.

Aerobic Exercise Training in Very Severe Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the effectiveness of exercise training in patients with very severe chronic obstructive pulmonary disease (COPD). DESIGN: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature databases using the following as search terms: COPD, Chronic Obstructive Pulmonary Disease, Exercise, and Pulmonary Rehabilitation. We included randomized controlled trials (RCTs) of subjects with forced expiratory volume in the first second of less than 35% of the predicted normal value enrolled in in-patient, outpatient, or home- or community-based training programs lasting at least 4 weeks with respect to usual care. We included RCTs with outcome measures including the 6-minute walking test and/or health-related quality of life assessed by the St. George's Respiratory Questionnaire (SGRQ). RESULTS: Of 580 articles screened, 10 were included. The programs' duration ranged from 4 to 52 weeks with 1 to 5 sessions per week lasting 15 to 40 minutes each. The intervention group improved in 6-minute walking test [weighted mean difference, 67.1 (95% confidence interval [CI], 37.897-98.927); standardized mean difference, 3.86 (95% CI, 2.04-5.67)], and St. George's Respiratory Questionnaire [weighted mean difference, -8.041 (95% CI, -15.273 to -0.809); standardized mean difference, -1.23 (95% CI, -2.14 to -0.31)]. CONCLUSIONS: Exercise training improves exercise tolerance and health-related quality of life in patients with very severe COPD. However, because few studies on severely affected patients are available and the training programs are Highly heterogeneous, larger RCTs are needed.

¿Cuál es el nivel óptimo de presión espiratoria positiva (PEP) capaz de mejorar la tolerancia a la deambulación de los pacientes con enfermedad pulmonar obstructiva cronica (EPOC) grave? / Is there an optimal level of positive expiratory pressure (PEP) to improve walking tolerance in patients with severe COPD?

Introducción: La aplicación de dispositivos de presión espiratoria positiva (PEP) durante el ejercicio se había propuesto con el objetivo de contrarrestar la hiperinflación pulmonar, reducir la disnea y mejorar así la tolerancia al ejercicio de los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) grave. En este ensayo controlado, aleatorizado y cruzado se investigó el efecto de dos niveles de PEP (1 cm de H2O y 10 cm de H2O) sobre la distancia recorrida por pacientes con EPOC grave durante la prueba de marcha de 6 min (PM6M). Los criterios de valoración secundarios fueron los efectos de la PEP sobre variables fisiológicas y de la función pulmonar. Métodos: Se reclutaron setenta y dos pacientes con EPOC grave, hospitalizados o ambulatorios, derivados a nuestros hospitales. El primer día de este estudio aleatorizado y cruzado se efectuó la PM6M sin ningún dispositivo, y posteriormente se repitió con una PEP de 1 cm de H2O (PEP1) y de 10 cm de H2O (PEP10). Antes y después de cada PM6M se practicaron espirometrías lentas y forzadas, que incluyeron la medición de la capacidad inspiratoria. Resultados: Cincuenta pacientes (edad media 69,92 años, FEV1 medio 41,42% del previsto) finalizaron el ensayo. La PM6M mejoró significativamente con los dos niveles de PEP, en comparación con la situación inicial (323,8 m al inicio vs. 337,8 con la PEP1 y 341,8 con la PEP10; p < 0,002 y p < 0,018, respectivamente). La diferencia entre la PEP10 y la PEP1 no fue significativa. No se observaron mejorías en la función pulmonar, los síntomas ni las variables fisiológicas posteriores a la prueba PM6 M. Conclusiones: En pacientes con EPOC grave, la aplicación de una PEP de 1 cm de H2O parece mejorar la tolerancia al ejercicio, al igual que lo hace la aplicación de 10 cm H2O y con un grado similar de disnea. Deben realizarse otros estudios para investigar los efectos de los niveles bajos de PEP en los programas de entrenamiento aeróbico

Background: The application of positive expiratory pressure (PEP) devices during exercise had been proposed in order to counteract the pulmonary hyperinflation, reduce the dyspnea and thus increase the exercise tolerance in patients with severe chronic obstructive pulmonary disease (COPD). This randomized controlled crossover trial investigated the effect of two different levels of PEP (1 cmH2O and 10 cmH2O) on distance covered at 6minute walk test (6MWT) in patients with severe COPD. Secondary outcomes were the evaluation of PEP effects on physiological and pulmonary function variables. Methods: Seventy-two severe COPD patients, referred to our hospitals as in and out patients, were recruited. A basal 6MWT without devices was performed on the first day, and then repeated with PEP 1 cmH2O (PEP1) and 10 cmH2O (PEP10), with a randomized crossover design. Slow and forced spirometries, including the inspiratory capacity measure, were repeated before and after each 6MWT. Results: 50 patients (average age 69,92 year, mean FEV1 41,42% of predicted) concluded the trial. The 6 MWT improved significantly among both PEP levels and baseline (323,8 mt at baseline vs. 337,8 PEP1 and 341,8 PEP10; p < .002 and p<.018, respectively). The difference between PEP10 and PEP1 did not reach the significance. No improvements were found in pulmonary function, symptoms and physiological variables after the 6MWT. Conclusions: In patients with severe COPD, the application of 1 cmH2O of PEP seems to improve the exercise tolerance as 10 cmH2O, with similar dyspnea. Further studies should investigate the effects of low levels of PEP on aerobic training programs

Is there an optimal level of positive expiratory pressure (PEP) to improve walking tolerance in patients with severe COPD? / ¿Cuál es el nivel óptimo de presión espiratoria positiva (PEP) capaz de mejorar la tolerancia a la deambulación de los pacientes con enfermedad pulmonar obstructiva cronica (EPOC) grave?

BACKGROUND: The application of positive expiratory pressure (PEP) devices during exercise had been proposed in order to counteract the pulmonary hyperinflation, reduce the dyspnea and thus increase the exercise tolerance in patients with severe chronic obstructive pulmonary disease (COPD). This randomized controlled crossover trial investigated the effect of two different levels of PEP (1 cmH2O and 10 cmH2O) on distance covered at 6minute walk test (6MWT) in patients with severe COPD. Secondary outcomes were the evaluation of PEP effects on physiological and pulmonary function variables. METHODS: Seventy-two severe COPD patients, referred to our hospitals as in and out patients, were recruited. A basal 6MWT without devices was performed on the first day, and then repeated with PEP 1 cmH2O (PEP1) and 10 cmH2O (PEP10), with a randomized crossover design. Slow and forced spirometries, including the inspiratory capacity measure, were repeated before and after each 6MWT. RESULTS: 50 patients (average age 69,92 year, mean FEV1 41,42% of predicted) concluded the trial. The 6MWT improved significantly among both PEP levels and baseline (323,8 mt at baseline vs. 337,8 PEP1 and 341,8 PEP10; p<.002 and p<.018, respectively). The difference between PEP10 and PEP1 did not reach the significance. No improvements were found in pulmonary function, symptoms and physiological variables after the 6MWT. CONCLUSIONS: In patients with severe COPD, the application of 1 cmH2O of PEP seems to improve the exercise tolerance as 10 cmH2O, with similar dyspnea. Further studies should investigate the effects of low levels of PEP on aerobic training programs.

An implementation protocol for noninvasive ventilation prescription: the physiotherapist's role in an Italian hospital.

BACKGROUND: For patients with chronic respiratory failure or sleep breathing disorders, adaptation and training are important prerequisites for successful home noninvasive ventilation (NIV) and CPAP. In Europe, management of NIV/CPAP is sometimes performed by physiotherapists (PTs). However, their role within the NIV/CPAP management team is not well defined. OBJECTIVE: To describe the implementation of a standardized protocol to NIV adaptation for patients with chronic respiratory disease. Secondary outcomes were to evaluate the PT's role and time-consumption. METHODS: We enrolled 201 patients with chronic respiratory disease, referred to the cardiopulmonary rehabilitation service (CPRS). Anthropometric and clinical data, adaptation sessions, ventilator typology, side effects, plus activities conducted by the CPRS were recorded. The time spent on a single protocol task plus total time spent on the entire management procedure for NIV/CPAP adaptation was also documented. RESULTS: Adaptation to NIV/CPAP was completed in 8.2 ± 3.2 sessions, lasting 17.2 ± 15.4 min/session. Total CPRS activity included 61% adaptation procedures, 22% educational sessions, 8% evaluation, 7% monitoring and follow-up, and 2% administrative activities. CPRS time-consumption per patient was 149.5 ± 113.7 min. Total CPRS time-consumption was 28,870 min, corresponding to 1.52 hours/working day and 21% of total PT daily activity. After protocol implementation, PTs were able to cover 65% and 35% of the time devoted to ventilation procedures typically carried out by physicians and nurses, respectively. Amyotrophic lateral sclerosis/neuromuscular patients required more time for adaptation and education, compared to patients with obstructive sleep apnea syndrome (P < .001) and pulmonary restrictive disease (P < .001). CONCLUSIONS: Our study has demonstrated that the PTs can play a key role in the respiratory care management of patients with chronic respiratory disease and sleep breathing disorders with neuromuscular diseases requiring higher time consumption, and the inclusion of PTs in the NIV/CPAP management procedure reduces the time spent by other health professionals. The cost effectiveness of this management needs to be verified in larger clinical trial settings.

Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis.

BACKGROUND: Treatment of bronchiectasis includes drugs, oxygen therapy, and bronchial-clearance maneuvers. OBJECTIVE: To assess the safety and efficacy of intrapulmonary percussive ventilation (IPV) compared to traditional standard chest physical therapy in patients with bronchiectasis and productive cough. METHODS: In a randomized crossover study, 22 patients underwent, on consecutive days, IPV and chest physical therapy. Before each treatment session, immediately after the session, 30 min after the session, and 4 hours after the session we measured S(pO(2)), heart rate, respiratory rate, and (with a visual analog scale) the patient's subjective sensation of phlegm encumbrance and dyspnea. Immediately after each treatment session we also measured (via visual analog scale) the patient's discomfort. We also measured the volume and wet and dry weight of collected sputum. RESULTS: No adverse effects were so severe as to require discontinuation of treatment, and the incidence of adverse effects was similar in the groups (27%). Heart rate (P = .002) and respiratory rate (P = .047) decreased during treatment, and sensation of phlegm encumbrance improved (P = .03) with both treatments. Only IPV improved (P = .004) the sensation of dyspnea. The patients found IPV more comfortable than our traditional standard chest physical therapy (P = .03). Both treatments caused important phlegm production, but there were no differences in sputum volume, wet weight, or dry weight. CONCLUSIONS: In patients with bronchiectasis and productive cough, short-term IPV was as safe and effective as traditional chest physical therapy, with less discomfort.