Real-world walking cadence in people with COPD.

Introduction: The clinical validity of real-world walking cadence in people with COPD is unsettled. Our objective was to assess the levels, variability and association with clinically relevant COPD characteristics and outcomes of real-world walking cadence. Methods: We assessed walking cadence (steps per minute during walking bouts longer than 10 s) from 7 days' accelerometer data in 593 individuals with COPD from five European countries, and clinical and functional characteristics from validated questionnaires and standardised tests. Severe exacerbations during a 12-month follow-up were recorded from patient reports and medical registries. Results: Participants were mostly male (80%) and had mean±sd age of 68±8 years, post-bronchodilator forced expiratory volume in 1 s (FEV1) of 57±19% predicted and walked 6880±3926 steps·day-1. Mean walking cadence was 88±9 steps·min-1, followed a normal distribution and was highly stable within-person (intraclass correlation coefficient 0.92, 95% CI 0.90-0.93). After adjusting for age, sex, height and number of walking bouts in fractional polynomial or linear regressions, walking cadence was positively associated with FEV1, 6-min walk distance, physical activity (steps·day-1, time in moderate-to-vigorous physical activity, vector magnitude units, walking time, intensity during locomotion), physical activity experience and health-related quality of life and negatively associated with breathlessness and depression (all p<0.05). These associations remained after further adjustment for daily steps. In negative binomial regression adjusted for multiple confounders, walking cadence related to lower number of severe exacerbations during follow-up (incidence rate ratio 0.94 per step·min-1, 95% CI 0.91-0.99, p=0.009). Conclusions: Higher real-world walking cadence is associated with better COPD status and lower severe exacerbations risk, which makes it attractive as a future prognostic marker and clinical outcome.

Exploring the perceptions of patients with chronic respiratory diseases and their insights into pulmonary rehabilitation in Bangladesh.

Background: Chronic respiratory diseases (CRDs) require holistic management which considers patients' preferences, appropriate pharmacotherapy, pulmonary rehabilitation, and integrated care. We aimed to understand the perceptions of people with CRDs about their condition and pulmonary rehabilitation in Bangladesh. Methods: We conducted semi-structured interviews with a maximum variation sample of people with CRDs who had participated in a feasibility study of pulmonary rehabilitation in 2021/2022. A multidisciplinary team transcribed the interviews verbatim and analysed them in Bengali using a grounded theory approach. Results: We interviewed 15 participants with chronic obstructive pulmonary disease, asthma, or post-tuberculosis. The analysis revealed three themes. The first encompassed understanding CRDs: Patients characterised their condition by the symptoms (e.g. 'Hapani' meaning 'breathlessness') rather than describing a disease entity. Some believed occupation, previous infection, or family history to be a cause. The second theme included perceptions of pulmonary rehabilitation: Exercise was counterintuitive, as it exacerbated the breathlessness symptom that defined their disease. Views varied, though many acknowledged the benefits after a few sessions. Even with home-based programmes, participants described practical barriers to finding time for the sessions and adopted strategies to overcome the challenges. The third theme focused on implementation: Participants highlighted the need for raising awareness of CRDs and the potential of pulmonary rehabilitation in the community, adapting to the local context, and establishing an accessible resourced service. Conclusions: Understanding how patients and their communities perceive their condition and the barriers (both conceptual and logistical) to acceptance is the first step to embedding this highly effective intervention into routine health care services in Bangladesh with potential benefits for the increasing number of people living with CRDs in low- and middle-income countries.

Pulmonary rehabilitation and physical interventions.

Pulmonary rehabilitation has established a status of evidence-based therapy for patients with symptomatic COPD in the stable phase and after acute exacerbations. Rehabilitation should have the possibility of including different disciplines and be offered in several formats and lines of healthcare. This review focusses on the cornerstone intervention, exercise training, and how training interventions can be adapted to the limitations of patients. These adaptations may lead to altered cardiovascular or muscular training effects and/or may improve movement efficiency. Optimising pharmacotherapy (not the focus of this review) and oxygen supplements, whole-body low- and high-intensity training or interval training, and resistance (or neuromuscular electrical stimulation) training are important training modalities for these patients in order to accommodate cardiovascular and ventilatory impairments. Inspiratory muscle training and whole-body vibration may also be worthwhile interventions in selected patients. Patients with stable but symptomatic COPD, those who have suffered exacerbations and patients waiting for or who have received lung volume reduction or lung transplantation are good candidates. The future surely holds promise to further personalise exercise training interventions and to tailor the format of rehabilitation to the individual patient's needs and preferences.

A retrospective study of crossover ambulatory oxygen walk testing in patients with fibrotic lung disease.

BACKGROUND: Fibrotic interstitial lung disease (ILD) comprises a group of lung conditions that are often progressive, debilitating, and life-shortening. Ambulatory oxygen therapy (AOT) is regularly prescribed to manage symptoms in patients with fibrotic ILD. In our institution, the decision to prescribe portable oxygen is made on the basis of oxygen improving exercise capacity, measured with the single-blinded, crossover ambulatory oxygen walk test (AOWT). This study aimed to investigate the characteristics and survival rates of patients with fibrotic ILD who have either positive or negative results on the AOWT. METHODS: This retrospective cohort study compared the data from 99 patients with fibrotic ILD who underwent the AOWT. These patients were classified into two groups based on whether they showed improvement in the AOWT with supplemental oxygen (positive group) or no improvement (negative group). Patient demographics for both groups were compared to determine any significant differences. A multivariate Cox proportional hazards model was used to analyze the survival rates of the two groups. RESULTS: Out of the 99 patients, 71 were in the positive group. We compared the measured characteristics between the positive and negative groups and found no significant difference, wherein the adjusted hazard ratio was 1.33 (95% confidence interval 0.69-2.60, P = 0.40). CONCLUSIONS: The AOWT can be used to rationalize AOT, but there was no significant difference in baseline characteristics or survival rates between patients whose performance was improved or not in the AOWT.

Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis.

INTRODUCTION: Despite proven effectiveness for people with chronic respiratory diseases, practical barriers to attending centre-based pulmonary rehabilitation (centre-PR) limit accessibility. We aimed to review the clinical effectiveness, components and completion rates of home-based pulmonary rehabilitation (home-PR) compared to centre-PR or usual care. METHODS AND ANALYSIS: Using Cochrane methodology, we searched (January 1990 to August 2021) six electronic databases using a PICOS (population, intervention, comparison, outcome, study type) search strategy, assessed Cochrane risk of bias, performed meta-analysis and narrative synthesis to answer our objectives and used the Grading of Recommendations, Assessment, Development and Evaluations framework to rate certainty of evidence. RESULTS: We identified 16 studies (1800 COPD patients; 11 countries). The effects of home-PR on exercise capacity and/or health-related quality of life (HRQoL) were compared to either centre-PR (n=7) or usual care (n=8); one study used both comparators. Compared to usual care, home-PR significantly improved exercise capacity (standardised mean difference (SMD) 0.88, 95% CI 0.32-1.44; p=0.002) and HRQoL (SMD -0.62, 95% CI -0.88--0.36; p<0.001). Compared to centre-PR, home-PR showed no significant difference in exercise capacity (SMD -0.10, 95% CI -0.25-0.05; p=0.21) or HRQoL (SMD 0.01, 95% CI -0.15-0.17; p=0.87). CONCLUSION: Home-PR is as effective as centre-PR in improving functional exercise capacity and quality of life compared to usual care, and is an option to enable access to pulmonary rehabilitation.

High frequency of Nichols-like strains and increased levels of macrolide resistance in Treponema pallidum in clinical samples from Buenos Aires, Argentina.

Globally, 94% of Treponema pallidum subsp. pallidum (TPA) clinical strains belong to the SS14-like group and 6% to the Nichols-like group, with a prevalence of macrolide resistance of 90%. Our goal was to determine whether local TPA strain distribution and macrolide resistance frequency have changed significantly since our last report, which revealed that Buenos Aires had a high frequency of Nichols-like strains (27%) and low levels of macrolide resistance (14%). Swab samples from patients with suspected syphilis were collected during 2015-2019 and loci TP0136, TP0548, TP0705 were sequenced in order to perform multilocus sequence typing. Strains were classified as Nichols-like or SS14-like. The presence of macrolide resistance-associated mutations was determined by examination of the 23S rDNA gene sequence. Of 46 typeable samples, 37% were classified as Nichols-like and 63% as SS14-like. Macrolide resistance prevalence was 45.7%. Seven allelic profiles were found, five were SS14-like and two were Nichols-like. The frequency of Nichols-like strains increased between studies (26.8% vs. 37%, p = 0.36). A dramatic increase was found in the frequency of macrolide resistant strains between studies (14.3% vs. 45.7%, p = 0.005). Our results are in agreement with international trends and underscore the need to pursue further TPA molecular typing studies in South America.

Evaluación de intervenciones durante la pandemia COVID-19: desarrollo de un modelo basado en subpoblaciones con distintas tasas de contacto / Evaluation of interventions during the COVID-19 pandemic: development of a modelbased on subpopulations with different contact rates

Resumen Si bien se han realizado múltiples intentos de modelar matemáticamente la pande-mia de la enfermedad por coronavirus 2019 (COVID-19), causada por SARS-CoV-2, pocos modeloshan sido pensados como herramientas interactivas accesibles para usuarios de distintos ámbitos.El objetivo de este trabajo fue desarrollar un modelo que tuviera en cuenta la heterogeneidadde las tasas de contacto de la población e implementarlo en una aplicación accesible, que per-mitiera estimar el impacto de posibles intervenciones a partir de información disponible. Sedesarrolló una versión ampliada del modelo susceptible-expuesto-infectado-resistente (SEIR),denominada SEIR-HL, que asume una población dividida en dos subpoblaciones, con tasas decontacto diferentes. Asimismo, se desarrolló una fórmula para calcular el número básico dereproducción (R0) para una población dividida en n subpoblaciones, discriminando las tasas decontacto de cada subpoblación según el tipo o contexto de contacto. Se compararon las pre-dicciones del SEIR-HL con las del SEIR y se demostró que la heterogeneidad en las tasas decontacto puede afectar drásticamente la dinámica de las simulaciones, aun partiendo de lasmismas condiciones iniciales y los mismos parámetros. Se empleó el SEIR-HL para mostrar elefecto sobre la evolución de la pandemia del desplazamiento de individuos desde posiciones dealto contacto hacia posiciones de bajo contacto. Finalmente, a modo de ejemplo, se aplicó elSEIR-HL al análisis de la pandemia de COVID-19 en Argentina; también se desarrolló un ejemplode uso de la fórmula del R0. Tanto el SEIR-HL como una calculadora del R0fueron implementadosinformáticamente y puestos a disposición de la comunidad.

Abstract Although multiple attempts have been made to mathematically model the currentepidemic of SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), fewmodels have been conceived as accessible interactive tools for users from various backgrounds.The goal of this study was to develop a model that took into account the heterogeneity incontact rates within the population and to implement it in an accessible application allowingto estimate the impact of possible interventions based on available information. An extendedversion of the Susceptible-Exposed-Infected-Resistant (SEIR) model, named SEIR-HL, was deve-loped, assuming a population divided into two subpopulations, with different contact rates.Additionally, a formula for the calculation of the basic reproduction number (R0) for a popula-tion divided into n subpopulations was proposed, where the contact rates for each subpopulationcan be distinguished according to contact type or context. The predictions made by SEIR-HLwere compared to those of SEIR, showing that the heterogeneity in contact rates can drama-tically affect the dynamics of simulations, even when run from the same initial conditions andwith the same parameters. SEIR-HL was used to predict the effect on the epidemic evolution ofthe displacement of individuals from high-contact positions to low-contact positions. Lastly, byway of example, SEIR-HL was applied to the analysis of the SARS-CoV-2 epidemic in Argentinaand an example of the application of the R0formula was also developed. Both the SEIR-HLmodel and an R0calculator were computerized and made available to the community.

[Evaluation of interventions during the COVID-19 pandemic: development of a model based on subpopulations with different contact rates]. / Evaluación de intervenciones durante la pandemia COVID-19: desarrollo de un modelo basado en subpoblaciones con distintas tasas de contacto.

Although multiple attempts have been made to mathematically model the current epidemic of SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), few models have been conceived as accessible interactive tools for users from various backgrounds. The goal of this study was to develop a model that took into account the heterogeneity in contact rates within the population and to implement it in an accessible application allowing to estimate the impact of possible interventions based on available information. An extended version of the Susceptible-Exposed-Infected-Resistant (SEIR) model, named SEIR-HL, was developed, assuming a population divided into two subpopulations, with different contact rates. Additionally, a formula for the calculation of the basic reproduction number (R0) for a population divided into n subpopulations was proposed, where the contact rates for each subpopulation can be distinguished according to contact type or context. The predictions made by SEIR-HL were compared to those of SEIR, showing that the heterogeneity in contact rates can dramatically affect the dynamics of simulations, even when run from the same initial conditions and with the same parameters. SEIR-HL was used to predict the effect on the epidemic evolution of the displacement of individuals from high-contact positions to low-contact positions. Lastly, by way of example, SEIR-HL was applied to the analysis of the SARS-CoV-2 epidemic in Argentina and an example of the application of the R0 formula was also developed. Both the SEIR-HL model and an R0 calculator were computerized and made available to the community.

Clinical effectiveness and components of Home-pulmonary rehabilitation for people with chronic respiratory diseases: a systematic review protocol.

INTRODUCTION: Chronic respiratory diseases (CRDs) are common and disabling conditions that can result in social isolation and economic hardship for patients and their families. Pulmonary rehabilitation (PR) improves functional exercise capacity and health-related quality of life (HRQoL) but practical barriers to attending centre-based sessions or the need for infection control limits accessibility. Home-PR offers a potential solution that may improve access. We aim to systematically review the clinical effectiveness, completion rates and components of Home-PR for people with CRDs compared with Centre-PR or Usual care. METHODS AND ANALYSIS: We will search PubMed, CINAHL, Cochrane, EMBASE, PeDRO and PsycInfo from January 1990 to date using a PICOS search strategy (Population: adults with CRDs; Intervention: Home-PR; Comparator: Centre-PR/Usual care; Outcomes: functional exercise capacity and HRQoL; Setting: any setting). The strategy is to search for 'Chronic Respiratory Disease' AND 'Pulmonary Rehabilitation' AND 'Home-PR', and identify relevant randomised controlled trials and controlled clinical trials. Six reviewers working in pairs will independently screen articles for eligibility and extract data from those fulfilling the inclusion criteria. We will use the Cochrane risk-of-bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the quality of evidence. We will perform meta-analysis or narrative synthesis as appropriate to answer our three research questions: (1) what is the effectiveness of Home-PR compared with Centre-PR or Usual care? (2) what components are used in effective Home-PR studies? and (3) what is the completion rate of Home-PR compared with Centre-PR? ETHICS AND DISSEMINATION: Research ethics approval is not required since the study will review only published data. The findings will be disseminated through publication in a peer-reviewed journal and presentation in conferences. PROSPERO REGISTRATION NUMBER: CRD42020220137.

Validity and responsiveness of the Daily- and Clinical visit-PROactive Physical Activity in COPD (D-PPAC and C-PPAC) instruments.

BACKGROUND: The Daily-PROactive and Clinical visit-PROactive Physical Activity (D-PPAC and C-PPAC) instruments in chronic obstructive pulmonary disease (COPD) combines questionnaire with activity monitor data to measure patients' experience of physical activity. Their amount, difficulty and total scores range from 0 (worst) to 100 (best) but require further psychometric evaluation. OBJECTIVE: To test reliability, validity and responsiveness, and to define minimal important difference (MID), of the D-PPAC and C-PPAC instruments, in a large population of patients with stable COPD from diverse severities, settings and countries. METHODS: We used data from seven randomised controlled trials to evaluate D-PPAC and C-PPAC internal consistency and construct validity by sex, age groups, COPD severity, country and language as well as responsiveness to interventions, ability to detect change and MID. RESULTS: We included 1324 patients (mean (SD) age 66 (8) years, forced expiratory volume in 1 s 55 (17)% predicted). Scores covered almost the full range from 0 to 100, showed strong internal consistency after stratification and correlated as a priori hypothesised with dyspnoea, health-related quality of life and exercise capacity. Difficulty scores improved after pharmacological treatment and pulmonary rehabilitation, while amount scores improved after behavioural physical activity interventions. All scores were responsive to changes in self-reported physical activity experience (both worsening and improvement) and to the occurrence of COPD exacerbations during follow-up. The MID was estimated to 6 for amount and difficulty scores and 4 for total score. CONCLUSIONS: The D-PPAC and C-PPAC instruments are reliable and valid across diverse COPD populations and responsive to pharmacological and non-pharmacological interventions and changes in clinically relevant variables.

Patterns of Physical Activity Progression in Patients With COPD.

INTRODUCTION: Although mean physical activity in COPD patients declines by 400-500steps/day annually, it is unknown whether the natural progression is the same for all patients. We aimed to identify distinct physical activity progression patterns using a hypothesis-free approach and to assess their determinants. METHODS: We pooled data from two cohorts (usual care arm of Urban Training [NCT01897298] and PROactive initial validation [NCT01388218] studies) measuring physical activity at baseline and 12 months (Dynaport MoveMonitor). We identified clusters (patterns) of physical activity progression (based on levels and changes of steps/day) using k-means, and compared baseline sociodemographic, interpersonal, environmental, clinical and psychological characteristics across patterns. RESULTS: In 291 COPD patients (mean±SD 68±8 years, 81% male, FEV1 59±19%pred) we identified three distinct physical activity progression patterns: Inactive (n=173 [59%], baseline: 4621±1757 steps/day, 12-month change (Δ): -487±1201 steps/day), ActiveImprovers (n=49 [17%], baseline: 7727±3275 steps/day, Δ:+3378±2203 steps/day) and ActiveDecliners (n=69 [24%], baseline: 11 267±3009 steps/day, Δ: -2217±2085 steps/day). After adjustment in a mixed multinomial logistic regression model using Active Decliners as reference pattern, a lower 6-min walking distance (RRR [95% CI] 0.94 [0.90-0.98] per 10m, P=.001) and a higher mMRC dyspnea score (1.71 [1.12-2.60] per 1 point, P=.012) were independently related with being Inactive. No baseline variable was independently associated with being an Active Improver. CONCLUSIONS: The natural progression in physical activity over time in COPD patients is heterogeneous. While Inactive patients relate to worse scores for clinical COPD characteristics, Active Improvers and Decliners cannot be predicted at baseline.

Systematic review of clinical effectiveness, components, and delivery of pulmonary rehabilitation in low-resource settings.

Pulmonary rehabilitation (PR) is a guideline-recommended multifaceted intervention that improves the physical and psychological well-being of people with chronic respiratory diseases (CRDs), though most of the evidence derives from trials in high-resource settings. In low- and middle-income countries, PR services are under-provided. We aimed to review the effectiveness, components and mode of delivery of PR in low-resource settings. Following Cochrane methodology, we systematically searched (1990 to October 2018; pre-publication update March 2020) MEDLINE, EMBASE, CABI, AMED, PUBMED, and CENTRAL for controlled clinical trials of adults with CRD (including but not restricted to chronic obstructive pulmonary disease) comparing PR with usual care in low-resource settings. After duplicate selection, we extracted data on exercise tolerance, health-related quality of life (HRQoL), breathlessness, included components, and mode of delivery. We used Cochrane risk of bias (RoB) to assess study quality and synthesised data narratively. From 8912 hits, we included 13 studies: 11 were at high RoB; 2 at moderate RoB. PR improved functional exercise capacity in 10 studies, HRQoL in 12, and breathlessness in 9 studies. One of the two studies at moderate RoB showed no benefit. All programmes included exercise training; most provided education, chest physiotherapy, and breathing exercises. Low cost services, adapted to the setting, used limited equipment and typically combined outpatient/centre delivery with a home/community-based service. Multicomponent PR programmes can be delivered in low-resource settings, employing a range of modes of delivery. There is a need for a high-quality trial to confirm the positive findings of these high/moderate RoB studies.

ERS statement on standardisation of cardiopulmonary exercise testing in chronic lung diseases.

The objective of this document was to standardise published cardiopulmonary exercise testing (CPET) protocols for improved interpretation in clinical settings and multicentre research projects. This document: 1) summarises the protocols and procedures used in published studies focusing on incremental CPET in chronic lung conditions; 2) presents standard incremental protocols for CPET on a stationary cycle ergometer and a treadmill; and 3) provides patients' perspectives on CPET obtained through an online survey supported by the European Lung Foundation. We systematically reviewed published studies obtained from EMBASE, Medline, Scopus, Web of Science and the Cochrane Library from inception to January 2017. Of 7914 identified studies, 595 studies with 26 523 subjects were included. The literature supports a test protocol with a resting phase lasting at least 3 min, a 3-min unloaded phase, and an 8- to 12-min incremental phase with work rate increased linearly at least every minute, followed by a recovery phase of at least 2-3 min. Patients responding to the survey (n=295) perceived CPET as highly beneficial for their diagnostic assessment and informed the Task Force consensus. Future research should focus on the individualised estimation of optimal work rate increments across different lung diseases, and the collection of robust normative data.

Progression of physical inactivity in COPD patients: the effect of time and climate conditions - a multicenter prospective cohort study.

Purpose: Longitudinal data on the effect of time and environmental conditions on physical activity (PA) among COPD patients are currently scarce, but this is an important factor in the design of trials to test interventions that might impact on it. Thus, we aimed to assess the effect of time and climate conditions (temperature, day length and rainfall) on progression of PA in a cohort of COPD patients. Patients and methods: This is a prospective, multicenter, cohort study undertaken as part of the EU/IMI PROactive project, in which we assessed 236 COPD patients simultaneously wearing two activity monitors (Dynaport MiniMod and Actigraph GT3X). A multivariable generalized linear model analysis was conducted to describe the effect of the explanatory variables on PA measures, over three time points (baseline, 6 and 12 months). Results: At 12 months (n=157; FEV1% predicted=57.7±21.9) there was a significant reduction in all PA measures (Actigraph step count (4284±3533 vs 3533±293)), Actigraph moderate- to vigorous-intensity PA ratio (8.8 (18.8) vs 6.1 (15.7)), Actigraph vector magnitude units (374,902.4 (265,269) vs 336,240 (214,432)), MiniMod walking time (59.1 (34.9) vs 56.9 (38.7) mins) and MiniMod PA intensity (0.183 (0) vs 0.181 (0)). Time had a significant, negative effect on most PA measures in multivariable analysis, after correcting for climate factors, study center, age, FEV1% predicted, 6MWD and other disease severity measures. Rainfall was the only climate factor with a negative effect on most PA parameters. Conclusion: COPD patients demonstrate a significant decrease in PA over 1 year follow-up, which is further affected by hours of rainfall, but not by other climate considerations.

Recomendaciones en rehabilitación respiratoria 2018: Sección Rehabilitación Respiratoria Asociación Argentina Medicina Respiratoria / Recommendations in Respiratory Rehabilitation 2018: Respiratory Rehabilitation Section Argentine Association of Respiratory Medicine

La Rehabilitación Respiratoria (RR), dirigida a las personas con enfermedad respiratoria crónica, reduce las exacerbaciones y hospitalizaciones, mejora los síntomas, la tolerancia al ejercicio y calidad de vida. Miembros de la Sección de RR de la Asociación Argentina de Medicina Respiratoria, se reunieron con el objetivo de preguntarse cuáles son los temas principales de controversia para dar respuesta desde la medicina basada en evidencia (sistema GRADE). Se eligieron diez preguntas. Resultados: La RR se debe indicar en pacientes con EPOC estadio GOLD 1 (1C). La adherencia es fundamental y se relaciona a sus beneficios (1C). La actividad física debe ser evaluada y estimulada (1B). Los beneficios de la RR dentro del mes posterior a una exacerbación de EPOC, reduce los síntomas y exacerbaciones y mejora la calidad de vida (1B). La RR está indicada en algunas enfermedades respiratorias crónicas no-EPOC (1B). Se deben indicar estrategias de entrenamiento especiales en desnutridos (3B) y obesos (3C). Los pacientes deben ser evaluados con prueba de ejercicio, escalas de disnea y calidad de vida (1A). El rol del entrenador de salud es novedoso ya que disminuye hospitalizaciones y mejora la calidad de vida (2C). Las comorbilidades afectan el resultado de la RR (3B). La RR reduce la mortalidad (1B) y la ansiedad-depresión (2B). La RR domiciliaria es efectiva (1A). La RR es fundamental en el tratamiento de enfermedades respiratorias crónicas. Se han actualizado las recomendaciones en RR en base a la evidencia científica con el objetivo que la RR pueda aplicarse en nuestro país.

Respiratory Rehabilitation (RR) is indicated in patients with chronic pulmonary diseases to reduce exacerbations and hospitalizations, and to improve symptoms, exercise tolerance and quality of life. Members of RR Section of the Asociación Argentina de Medicina Respiratoria, joined to review critical issues and controversies by an evidence-based system (GRADE). Ten questions were elected.213 Results: RR must be indicated in GOLD 1 COPD (1C). Adherence in RR is critical and related to benefits (1C). Physical activity must be evaluated and stimulated (1B). RR implemented after one month of COPD exacerbation hospitalization, reduces symptoms and exacerbations and improves quality of life(1B). RR is indicated in some no-COPD chronic respiratory diseases (1B). Special training strategies must be used in undernourished (3B) and obeses patients (3C). Exercise tests, dyspnea and quality of life questionnaires must be used to evaluate patients (1A). Health trainer is an original strategy to reduce hospitalizations and improve quality of life (2C). Comorbilities impacts on RR outcomes (3B). RR reduces mortality (1B) and ansiety-depression (2B). Domiciliary RR is efective (1A). RR is a key component of chronic pulmonary diseases treatment. Based in new scientific evidence, local recomendations have been done regarding to improve access in our country.

The Relevance of Limb Muscle Dysfunction in Chronic Obstructive Pulmonary Disease: A Review For Clinicians.

"Chronic obstructive pulmonary disease (COPD) is often accompanied by extrapulmonary manifestations such as limb muscle dysfunction. This term encompasses several features, including atrophy, weakness, and reduced oxidative capacity. Clinicians should become accustomed with this manifestation of COPD because of its relevance for important outcomes such as exercise tolerance and survival. Measuring muscle strength and mass can be performed with simple and valid tools that could be implemented in clinical practice. One identified, limb muscle dysfunction is amenable to therapy such as exercise training that has been repeatedly shown to improve muscle mass, strength, and oxidative capacity in COPD."

ERS statement on respiratory muscle testing at rest and during exercise.

Assessing respiratory mechanics and muscle function is critical for both clinical practice and research purposes. Several methodological developments over the past two decades have enhanced our understanding of respiratory muscle function and responses to interventions across the spectrum of health and disease. They are especially useful in diagnosing, phenotyping and assessing treatment efficacy in patients with respiratory symptoms and neuromuscular diseases. Considerable research has been undertaken over the past 17 years, since the publication of the previous American Thoracic Society (ATS)/European Respiratory Society (ERS) statement on respiratory muscle testing in 2002. Key advances have been made in the field of mechanics of breathing, respiratory muscle neurophysiology (electromyography, electroencephalography and transcranial magnetic stimulation) and on respiratory muscle imaging (ultrasound, optoelectronic plethysmography and structured light plethysmography). Accordingly, this ERS task force reviewed the field of respiratory muscle testing in health and disease, with particular reference to data obtained since the previous ATS/ERS statement. It summarises the most recent scientific and methodological developments regarding respiratory mechanics and respiratory muscle assessment by addressing the validity, precision, reproducibility, prognostic value and responsiveness to interventions of various methods. A particular emphasis is placed on assessment during exercise, which is a useful condition to stress the respiratory system.

Systematic review (protocol) of clinical effectiveness and models of care of low-resource pulmonary rehabilitation.

More than half of the people with chronic respiratory diseases (CRDs) live in low- and middle-income countries (LMICs). The increasing disability, reduced productivity, associated anxiety and depression from CRDs result in social isolation and economic hardship for patients and their families. Pulmonary rehabilitation (PR) is a guideline-recommended multidisciplinary and multifaceted intervention that improves the physical and psychological condition of people with CRD. However, PR services are underprovided and uptake is poor in LMICs, especially in low-resourced setting. We aim to systematically assess the effectiveness, applicable components and mode of delivery of PR. We will search MEDLINE, EMBASE, CABI, AMED and CENTRAL from January 1990 using a PICOS search strategy (Population: adults with CRD (including chronic obstructive pulmonary disease, post-tuberculosis, remodelled asthma); Intervention: PR; Comparator: usual care; Outcomes: functional exercise capacity and Health-Related Quality-of-Life; Setting: low-resource settings). Two reviewers will independently screen titles/abstracts and full texts for eligibility and extract data from included papers. We will use the Cochrane Risk-of-Bias tool, rating the quality of evidence using GRADE. We will use narrative synthesis to answer our three objectives: What is the effectiveness of PR in low-resource settings? What components are used in effective studies? What models of service delivery are used? This systematic review will inform the potential impact and practical models of low-resource PR for the betterment of patients with CRDs to improve their substantial health-care burden and address poor quality of life.

Smartphone-Based Physical Activity Telecoaching in Chronic Obstructive Pulmonary Disease: Mixed-Methods Study on Patient Experiences and Lessons for Implementation.

BACKGROUND: Telecoaching approaches can enhance physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD). However, their effectiveness is likely to be influenced by intervention-specific characteristics. OBJECTIVE: This study aimed to assess the acceptability, actual usage, and feasibility of a complex PA telecoaching intervention from both patient and coach perspectives and link these to the effectiveness of the intervention. METHODS: We conducted a mixed-methods study based on the completers of the intervention group (N=159) included in an (effective) 12-week PA telecoaching intervention. This semiautomated telecoaching intervention consisted of a step counter and a smartphone app. Data from a project-tailored questionnaire (quantitative data) were combined with data from patient interviews and a coach focus group (qualitative data) to investigate patient and coach acceptability, actual usage, and feasibility of the intervention. The degree of actual usage of the smartphone and step counter was also derived from app data. Both actual usage and perception of feasibility were linked to objectively measured change in PA. RESULTS: The intervention was well accepted and perceived as feasible by all coaches present in the focus group as well by patients, with 89.3% (142/159) of patients indicating that they enjoyed taking part. Only a minority of patients (8.2%; 13/159) reported that they found it difficult to use the smartphone. Actual usage of the step counter was excellent, with patients wearing it for a median (25th-75th percentiles) of 6.3 (5.8-6.8) days per week, which did not change over time (P=.98). The smartphone interface was used less frequently and actual usage of all daily tasks decreased significantly over time (P<.001). Patients needing more contact time had a smaller increase in PA, with mean (SD) of +193 (SD 2375) steps per day, +907 (SD 2306) steps per day, and +1489 (SD 2310) steps per day in high, medium, and low contact time groups, respectively; P for-trend=.01. The overall actual usage of the different components of the intervention was not associated with change in step count in the total group (P=.63). CONCLUSIONS: The 12-week semiautomated PA telecoaching intervention was well accepted and feasible for patients with COPD and their coaches. The actual usage of the step counter was excellent, whereas actual usage of the smartphone tasks was lower and decreased over time. Patients who required more contact experienced less PA benefits. TRIAL REGISTRATION: ClinicalTrials.gov NCT02158065; http://clinicaltrials.gov/ct2/show/NCT02158065 (Archived by WebCite at http://www.webcitation.org/73bsaudy9).