Respiratory function and therapeutic expectations in DMD: families experience and perspective.

OBJECTIVE: The aim of this study was to use a structured questionnaire in a large cohort of Duchenne Muscular Dystrophy (DMD) patients to assess caregivers and patients views on respiratory function and to establish if their responses were related to the patients' age or level of functional impairment. METHODS: Questionnaires were administered to caregivers in 205 DMD patients of age between 3 and 36 years (115 ambulant, 90 non-ambulant), and to 64 DMD patients (3 ambulant, 61 non-ambulant) older than 18 years, subdivided into groups according to age, FVC, ambulatory and ventilatory status. RESULTS: Some differences were found in relation to FVC % values (p = 0.014), ambulatory (p = 0.043) and ventilatory status (p = 0.014). Nearly half of the caregivers expected deterioration over the next years, with the perspective of deterioration more often reported by caregivers of non-ambulant (p = 0.018) and ventilated patients (p = 0.004). Caregivers appeared to be aware of the relevance of respiratory function on quality of life (84%) showing willingness to enter possible clinical trials if these were aiming to stabilize the progression of respiratory function with a very high number of positive responses across the spectrum of age, FVC, ambulatory and ventilatory status. The boys older than 18 years showed similar results. CONCLUSIONS: Our study showed that the concern for respiratory function increases with age and with the reduction of FVC or the need for ventilation, but the need for intervention was acknowledged across the whole spectrum of age and functional status.

Cough reflex testing in acute stroke: A survey of current UK service provision and speech and language therapist perceptions.

BACKGROUND: Silent aspiration (SA)-airway entry of food, drink or other material without a cough response-is common post-stroke. Clinical swallowing examination misses up to 40% of dysphagic patients with SA. This may put these patients at risk of aspiration pneumonia, prolonged length of hospital stay and increased healthcare costs. After stroke, the laryngeal cough reflex is frequently impaired with significant relationships between pneumonia rates and reduced cough strength and sensitivity. There has been a significant amount of recent interest in cough reflex testing (CRT) as a potential means to improve clinical identification of patients at risk of SA. However, there is a lack of consensus regarding the methodology and protocols for use of CRT with widely varying outcomes reported in the literature. AIMS: To provide an overview of current practice in the UK with regards to clinical use of CRT by speech and language therapists (SLTs) in acute stroke settings and to explore the perceptions regarding its potential application in clinical dysphagia management and the barriers and facilitators associated with adopting CRT in clinical practice. METHODS & PROCEDURES: A cross-sectional web-based survey was developed, piloted and delivered. The survey targeted all UK-based SLTs working in acute stroke settings. OUTCOMES & RESULTS: A total of 129 SLTs with varying levels of experience of CRT from all regions of the UK responded. Only four SLT services in the UK were reported to be currently using CRT clinically with acute stroke patients. A total of 29% of respondents who were not using CRT were considering introducing CRT into their service's dysphagia protocol. Variation was reported in the procedures and protocols. Overall, users reported improved confidence in the clinical detection of SA and felt that the introduction of CRT had improved their patient-related outcomes. Issues included difficulties procuring citric acid, implications for SLT time (including service set-up and delivery of CRT) and restricted access to instrumental assessments. CONCLUSIONS & IMPLICATIONS: This survey gives valuable insight into the current practice and perceptions of SLTs in the UK working in acute stroke settings in relation to CRT. It highlights discrepancies between reported approaches and recommendations from existing guidelines and validation studies. The variation in responses indicates a need to develop a consensus statement and further research to guide practice. What this study adds What is already known on the subject CRT is gaining popularity as a screening tool for the clinical identification of SA with acute stroke patients. However, there is a lack of consensus in the literature regarding the methodology and protocols with widely varying outcomes. Further work needs to be done to standardize its use, especially if it is to be incorporated into dysphagia protocols for use in the acute stroke setting. What this paper adds to existing knowledge This survey of SLTs working in acute stroke settings highlights variability in practice in CRT service delivery in the UK, reflecting findings from the existing CRT literature. What are the potential or actual clinical implications of this work? The findings of this study support the need for further research relating to clinical screening tests for SA and standardization of methodology and protocols for CRT use if its use is to be continued clinically.

Effect of repeated pulmonary function test training on student self-confidence in a clinical skills laboratory.

INTRODUCTION: A skills laboratory session was created to train students to perform basic pulmonary function test (PFT) assessments. The objective of this study was to evaluate whether pharmacy student confidence changed after conducting a PFT in a laboratory session and if this was enhanced by adding a second session. METHODS: A two-week educational activity was designed. For week one, each student completed a PFT with an instructor coaching to assure proper performance. Week two occurred one week later, and in pairs, students again completed an individual PFT, but the paired student served as the coach rather than the instructor. Students completed three surveys, a baseline before training, and after completing the sessions in week 1 and week 2, to assess confidence in PFT procedures on a 10-point scale. Survey results were analyzed using the sign test. A summary of instructor time and supply costs was also estimated. RESULTS: Forty-five students consented to all surveys (78.9 percent inclusion rate). There was a significant increase in confidence for all items between the first and second surveys. Between the second and third surveys, only two items increased significantly. CONCLUSIONS: The educational intervention was successful in improving student self-confidence in performing PFTs. However, limited additional confidence was gained by adding a second week of training, especially in context of resource allocation. These findings informed instructors that a one week PFT training may be sufficient and that resources needed for a second PFT training week may be better invested in another teaching opportunity.

Predictive factors over time of health-related quality of life in COPD patients.

BACKGROUND: Health-related quality of life (HRQoL) should be seen as a tool that provides an overall view of the general clinical condition of a COPD patient. The aims of this study were to identify variables associated with HRQoL and whether they continue to have an influence in the medium term, during follow-up. METHODS: Overall, 543 patients with COPD were included in this prospective observational longitudinal study. At all four visits during a 5-year follow-up, the patients completed the Saint George's Respiratory Questionnaire (SGRQ), pulmonary function tests, the 6-min walk test (6MWT), and a physical activity (PA) questionnaire, among others measurements. Data on hospitalization for COPD exacerbations and comorbidities were retrieved from the personal electronic clinical record of each patient at every visit. RESULTS: The best fit to the data of the cohort was obtained with a beta-binomial distribution. The following variables were related over time to SGRQ components: age, inhaled medication, smoking habit, forced expiratory volume in one second, handgrip strength, 6MWT distance, body mass index, residual volume, diffusing capacity of the lung for carbon monoxide, PA (depending on level, 13 to 35% better HRQoL, in activity and impacts components), and hospitalizations (5 to 45% poorer HRQoL, depending on the component). CONCLUSIONS: Among COPD patients, HRQoL was associated with the same variables throughout the study period (5-year follow-up), and the variables with the strongest influence were PA and hospitalizations.

Gender difference on the knowledge, attitude, and practice of COPD diagnosis and treatment: a national, multicenter, cross-sectional survey in China.

PURPOSE: To investigate the gender difference in knowledge, attitude, and practice of COPD diagnosis and treatment in China. PATIENTS AND METHODS: A nationwide, multicenter, cross-sectional questionnaire study was carried out to investigate patients' understanding and experience of COPD between September 2007 and December 2008. RESULTS: Two thousand and seventy-two patients were recruited from eleven centers. The final effective questionnaires were those of 1,698 cases, of which 32% were female. Women were younger, had higher body mass index, were more never smokers, and had lesser pack-years (all P<0.01). More women had under elementary education level and monthly income <1,000 RMB (about 160 USD) (all P<0.01). Women had higher ratio of FEV1/FVC (54.1±10.9 vs 50.2±11.5), FEV1% (50.0±19.1 vs 45.4±29.0), and lower short form-36 mental component summary (57.5±26.8 vs 61.3±25.0) (all P<0.01). Fewer women reported severe exacerbation (defined as an acute worsening of respiratory symptoms that results in patient's hospitalization) in the previous year (44.5% vs 51.6%, P<0.05). More women reported that they never heard of COPD before (67.0% vs 59.0%, P<0.01). Less women reported that physician had to tell them they had emphysema (50.5% vs 60.4%) or COPD (31.9% vs 37.9%). Less women had pulmonary function test (PFT) done before (65.2% vs 70.4%, P<0.05). More women reported that they would not repeat PFT annually (91.7% vs 87.6%, P<0.05) and did not know the PFT results (78.6% vs 73.1%, P<0.05). More women reported not having had pulmonary rehabilitation before (87.8% vs 83.6%, P<0.05). Fewer women reported knowing that COPD should be given combined therapy (38.3% vs 44.5%) and long-term treatment (46.1% vs 51.9%) (all P<0.05). CONCLUSION: Male and female patients had different experiences on COPD diagnosis and treatment. Physicians should pay more attention to patients' education on COPD, especially of women.

The effect of motivational lung age feedback on short-term quit rates in smokers seeking intensive group treatment: A randomized controlled pilot study.

BACKGROUND: A brief "Lung Age" feedback intervention has shown promise for personalizing the health impact of smoking and promoting cessation in unselected smokers. Now that many healthcare organizations provide face-to-face cessation services, it is reasonable to ask whether such motivational feedback of lung function tests might improve treatment compliance and cessation rates in smokers wanting to quit. This study assessed effects of baseline motivational spirometry-based "Lung Age" feedback on treatment compliance and tobacco abstinence at 28-day follow-up. METHODS: This randomized controlled pilot study took place in Penn State University-affiliated outpatient medical practices. Participants were 225 adult smokers (≥5 cigarettes/day) willing to attend tobacco dependence treatment. At assessment lung function (FEV-1) and exhaled carbon-monoxide (CO) were assessed. The Intervention group (n=120) were randomly allocated to receive motivational "Lung Age" feedback estimated by FEV-1 and on exhaled CO; Control group (n=105) received minimal feedback. Participants were offered 6 weekly group smoking cessation sessions and nicotine patches and followed-up 28 days after target quit date. The primary outcome measure was self-reported 7-day tobacco abstinence, confirmed by CO<10ppm at 28-day follow-up. RESULTS: Quit rates were similar at follow-up (Intervention 50.8%; Control 52.4%; p=0.65) after controlling for abstinence predictors. Group attendance and patch use were similar. Among those attending follow-up (n=164, 73%), a greater proportion of the Intervention group had improved lung function (67% vs. 46%; p=0.0083). CONCLUSIONS: Baseline Lung Age feedback did not improve quit rates or compliance at 28-day follow-up in smokers seeking intensive treatment.

Perception of pulmonary function and asthma control: the differential role of child versus caregiver anxiety and depression.

OBJECTIVE: To examine child and caregiver anxiety and depression as predictors of children's perception of pulmonary function, quick-relief medication use, and pulmonary function. METHOD: 97 children with asthma, ages 7 to 11 years old, reported their anxiety and depressive symptoms and completed spirometry. Caregivers completed a psychiatric interview. Children's predictions of their peak expiratory flow were compared with actual values across 6 weeks. Quick-relief medication use was assessed by Dosers. RESULTS: Children's anxiety symptoms were associated with over-perception of respiratory compromise and greater quick-relief medication use. Children's depressive symptoms were associated with greater quick-relief medication use, but not perception of pulmonary function. Children of caregivers with an anxiety or depressive disorder had lower pulmonary function than children of caregivers without anxiety or depression. CONCLUSIONS: Child anxiety was associated with a subjective pattern of over-perception. Caregiver anxiety and depression were risk factors for lower lung function assessed by objective measurement.

[Type D personality in chronic lung diseases: prevalence, psychological features].

AIM: To estimate the prevalence and impact of Type D personality on the psychological status and quality of life (QL) of patients with chronic lung diseases. SUBJECTS AND METHODS: 117 patients (105 men and 12 women; mean age 59.6 +/- 0.9 years) with chronic lung diseases were examined. The DS14 questionnaire was used to identify Type D personality. According to the test results, the patients were divided into 2 groups: 1) 39 Type D patients; 2) 78 non-Type D patients. The levels of depression and anxiety and QL were additionally determined using the SF-36 questionnaire. Clinical and laboratory parameters, spirometric data, and 6-minute walk test (6'WT) distance were estimated. RESULTS: The Type D versus non-Type D patients had higher levels of situational (46.6 +/- 1.7 and 41.2 +/- 1.2 scores; p = 0.01) and personality (47.6 +/- 1.5 and 43.7 +/- 0.9 scores; p = 0.02) anxiety and depression (42.9 +/- 1.6 and 35.9 +/- 0.8 scores; p = 0.00004), as well as lower QL levels in the vitality (42.2 +/- 2.2 and 52.2 +/- 1.9 scores; p = 0.002), emotional function (20.5 +/- 4.0 and 36.8 +/- 4.4 scores; p = 0.02), and mental health (56.2 +/- 1.9 and 63.4 +/- 1.9 scores; p = 0.006) scales. The 6'WT distance was less in the Type D patients (463.3 +/- 17.2 m)than in non-Type D patients (504.1 +/- 8.7 m); p = 0.02. CONCLUSION: Type D personality is encountered in 33% of patients with chronic lung diseases associated with the higher level of psychological distress in the patients, with the worsening of a mental component of QL, and with the reduction in exercise tolerance.

Older peoples' perception of tests used in the assessment and management of COPD and asthma.

OBJECTIVES: Outcome assessment is an important part of the management of airways disease, yet older adults may have difficulty with the burden of testing. This study evaluated the patient perception of tests used for the assessment of airways disease in older people. DATA SOURCE: Older adults (>55 years) with obstructive airway disease and healthy controls (N = 56) underwent inhaler technique assessment, skin allergy testing, venepuncture, fractional exhaled nitric oxide (FENO) and gas diffusion measurement, exercise testing, sputum induction, and questionnaire assessment. They then completed an assessment burden questionnaire across five domains: difficulty, discomfort, pain, symptoms and test duration. RESULTS: Test perception was generally favourable. Induced sputum had the greatest test burden perceived as being more difficult (mean 0.83, P = 0.001), associated with more discomfort (mean 1.3, P < 0.001), more painful (0.46, P = 0.019), longer test duration (0.84, P < 0.001) and worsening symptoms (0.55, P = 0.001) than the questionnaires. FENO had a more favourable assessment but was assessed to be difficult to perform. Inhaler technique received the most favourable assessment. CONCLUSIONS: Older adults hold favourable perceptions to a range of tests that they might encounter in the course of their care for airway disease. The newer tests of sputum induction and FENO have some observed difficulties, in particular sputum induction. The results of this study can inform current practice by including details of the test and its associated adverse effects when conducting the test, as well as providing clear explanations of the utility of tests and how the results might aid in patient care.

Smoking cessation and development of respiratory health in smokers screened with normal spirometry.

BACKGROUND: Case-finding of chronic obstructive pulmonary disease (COPD) using spirometry may deter people with normal lung function from stopping smoking. The objective of this study was to observe the percentage of smokers screened with normal lung function that quit smoking. METHODS: As part of a study on early detection of COPD, 518 smokers were screened with normal lung function (post-bronchodilator FEV(1)/FVC ≥ 70%). They were invited for a follow-up measurement after an average of 2.4 years. Non-smoking was validated by carbon monoxide (<10 ppm), and respiratory health related quality of life was measured with the Clinical COPD Questionnaire (CCQ). RESULTS: A total of 255 participants were followed up (49%). The point prevalence rate of non-smoking at follow-up was 18% (N = 47), and 9% assuming that all non-respondents were smokers. This rate was not lower than the expected rate of quitting in the Dutch population (8-9%) and primary "care as usual" in smokers screened with abnormal lung function (10%; p > 0.05 for all comparisons). The average decline in post-bronchodilator FEV(1) was 26 mL/year, which was unrelated to smoking status at follow-up. Non-smokers showed a clinically meaningful and statistically significant (p < 0.001) improvement in CCQ respiratory symptoms (-0.96) and total score (-0.51). CONCLUSIONS: Our results do not suggest that early detection of airflow limitation to motivate smoking cessation reduces the rate of quitting in smokers shown to have normal lung function. Such smokers should be advised to quit smoking on the grounds that they are likely to improve their respiratory health in the short term and reduce their risk for smoking related diseases in the long term.

Spirometry use among pediatric primary care physicians.

OBJECTIVE: This study explores the use of spirometry in primary care settings. METHODS: A 4-page survey was mailed to a national, random sample of office-based family physicians and pediatricians. Survey items addressed knowledge, attitudes, and practices regarding spirometry and standardized clinical vignettes. Data were analyzed by using χ2 tests and multivariate logistic regression. RESULTS: Among the 360 respondents who provided care to children with asthma, 52% used spirometry in clinical practice, whereas 80% used peak flow meters and 10% used no lung function tests. Only 21% routinely used spirometry for all guideline-recommended clinical situations. More family physicians than pediatricians reported using spirometry (75% vs 35%; P<.0001), and family physicians were more comfortable in interpreting spirometric results (50% vs 25%; P<.0001). Only one-half of respondents interpreted correctly the spirometric results in a standardized clinical vignette, and the frequency of underrating asthma severity increased with the inclusion of spirometric results. The most common barriers to the use of spirometry, that is, time and training, were cited more often by physicians who did not use spirometry. Two-thirds of respondents agreed that they would want additional training regarding implementing spirometry in their clinical practices. CONCLUSIONS: The use of spirometry in primary care settings for children with asthma does not conform to national guidelines. Widespread implementation of national asthma guidelines likely would require a major educational initiative to address deficiencies in spirometry interpretation and other barriers.

[PFTing in children aged 3-5 years : which material, which measurements]. / Epreuves fonctionnelles respiratoires de l'enfant de 3 à 5 ans : quel matériel, quelles mesures ?

Lung function testing in children 3 to 5years of age is possible using equipment and techniques suitable for this age group. The use of different techniques will depend on the child's ability as well as on the technician's skill to use specific techniques. This review will detail the techniques that are easily available for routine lung function assessment in private practice or in hospital laboratory.

Lung function, sociodemographic characteristics, and psychological reaction to transplant associated with chronic stress among lung recipients.

Chronic stress is a well-known consequence of somatic diseases. In this study, we investigated whether physical, sociodemographic, or transplant-related psychological factors were associated with the patient's chronic stress level. A cross-sectional study enrolling 76 patients measured chronic stress (Screening Scale, Screening Subscale of Chronic Stress of the Trier Inventory for the Assessment of Chronic Stress) and the emotional effects of the transplant (Transplant Effects Questionnaire), as well as physical and sociodemographic conditions (lung function, bronchiolitis obliterans syndrome, working status, and parenting). Chronic stress after a lung transplant was significantly lower than in a normal community sample. In the multiple regression analysis, worries concerning the transplant were significantly associated with the patient's chronic stress, but not with physical or sociodemographic parameters, nor with interactions between physical and psychological parameters. These results underscore the importance of transplant-related worries, regardless of the patient's current state of health.

Lung function testing influences the attitude toward smoking cessation.

INTRODUCTION: Smoking cessation is the single most effective way to prevent or delay the development of airflow limitation or to reduce its progression in subjects with chronic obstructive pulmonary disease (COPD). The aim of the study was to explore whether performing a spirometry changes attitudes toward smoking cessation. METHOD: A random sample of 513 smokers, of whom 77 had COPD, answered a questionnaire before, shortly after (less than 4 weeks), and 3 months after performing a lung function test. RESULTS: Prior to spirometry, 57% of the smokers with COPD and 52% of those with normal spirometry claimed that they were not planning to quit smoking within the next 6 months. After the spirometry, 9% (p < .0001) of those with COPD and 38% (p = .009) of those with normal spirometry had no intention to stop smoking. Three months later, corresponding figures were 28% in COPD and 48% in smokers with normal spirometry, and the point prevalence of quitters was 30% for the COPD group and 14% for the normal group (p = .02). DISCUSSION: We conclude that performing spirometry changes the attitude toward smoking for a short time. We hypothesize that smokers may be more susceptible to smoking cessation activities during this period.

Do asthma patients prefer to monitor symptoms or peak flow?

We administered a 65-item survey to patients to assess preference of symptoms and peak flow to detect worsening asthma and to collect information about asthma triggers, asthma knowledge sources, and barriers to peak flow meter use. It was completed by 139 asthma patients. Survey responses were comparable for adult and pediatric patients and for those who owned peak flow meters and those who did not. But patients who owned a peak flow meter reported more severe asthma than others. On average, the patients preferred symptoms to peak flow for assessing worsening asthma. It is likely that the preference for symptom over peak flow monitoring was effort related: Patients preferred symptom monitoring because it was the easier of the two to conduct.

The influence of a mouthpiece and noseclip on breathing pattern at rest is reduced at high altitude.

The effects of the instrumentation by a mouthpiece (MP) and a noseclip (NC) on the ventilatory response to short time hypobaric hypoxia were studied in 10 healthy volunteers at rest. The subjects were exposed to simulated altitude of 500 m, 3000 m, 4000 m and again 500 m, each altitude being applied for 30 min in a hypobaric chamber. Resting minute ventilation (VE), tidal volume (VT) and respiratory frequency (fR) using inductive plethysmography were continuously measured in all subjects in a standardized half lying position. The recordings were carried out at each altitude during the first 10 min without MP and NC, then 10 min with them, and the last 10 min again without them. At 500 m during MP+NC breathing VE and VT were increased, whereas fR was not significantly changed. At 3000 m, the VE increase with MP+NC was no more significant and fR was decreased. These effects of MP+NC on respiration disappeared at 4000 m and reappeared after the descent to 500 m. Furthermore, with and without MP and NC the variability of VE at 4000 m was significantly higher than at 500 m before ascent, and in all altitudes the variability of VT was significantly reduced by the MP+NC. It is concluded that the influence of MP+NC on VE, VT and fR is reduced or even abolished at high altitude, whereas the hypoxia induced increase of VE variability is not affected by the instrumentation.

Effect of viewing a humorous vs. nonhumorous film on bronchial responsiveness in patients with bronchial asthma.

The effect of viewing a humorous film on bronchial responsiveness to methacholine [methacholine study: 20 healthy participants and 20 patients with house dust mite (HDM)-allergic bronchial asthma (BA)] or to epigallocatechin gallate (EGCg; EGCg study: 15 normal participants and 15 EGCg-allergic BA patients) was studied. At baseline, bronchial challenge test to methacholine (20 normal participants and 20 HDM-allergic BA patients) or EGCg (15 normal participants and 15 EGCg-allergic BA patients) were performed. After 2 weeks, patients and healthy participants were randomly assigned to watch a humorous or a nonhumorous film. Two weeks later, the alternate film was watched. Immediately after viewing, bronchial challenge test to methacholine or ECGg to each study group were performed. Viewing a humorous film significantly reduced bronchial responsiveness to methacholine or EGCg, while viewing a nonhumorous film failed to do so in BA patients without affecting bronchial responsiveness to methacholine or EGCg in healthy participants. These findings indicate that viewing a humorous film may be useful in the treatment and study of BA.

Adverse reactions to peak flow monitoring. Report of 5 patients.

Five patients with adverse reactions to peak flow monitoring are presented: 2 patients had herniation of abdominal content, while the others presented with vasovagal syncope, minor depression and neurotic preoccupation with peak flow values, respectively. As a result, 3 of the 5 patients became noncompliant. For nonpsychological somatic adverse reactions, we calculated an incidence of 1.1 cases/1,000 patients started on peak flow monitoring. Adverse reactions with a psychological background may be more frequent. Clinicians should bear in mind that patients noncompliant with peak flow monitoring may have discontinued because of adverse reactions.

Behavioral task-induced bronchodilation in asthma during active and passive tasks: a possible cholinergic link to psychologically induced airway changes.

This study investigated pulmonary and autonomic reactions to active and passive behavioral laboratory tasks among asthmatic subjects. It also examined the relationship between airway irritability, as measured by the methacholine challenge test (MCT), and autonomic activity and reactivity to these tasks. Fifty-one asthmatic and 37 nonasthmatic subjects were exposed to psychological laboratory tasks involving either active (mental arithmetic and reaction time) or passive (films depicting shop accidents and thoracic surgery) response. The MCT was given to asthmatics in a separate session. Active tasks reduced respiratory impedance, as measured by forced oscillation pneumography. They also increased heart rate and appeared to block vagal activity, as measured by respiratory sinus arrhythmia (RSA). Airway irritability as assessed by the MCT was positively related to amplitude of RSA and to skin conductance levels. Our data suggest that active and passive behavioral tasks may produce different pulmonary effects among both asthmatic and nonasthmatic individuals. Engaging in tasks requiring active responses may produce temporary improvements in pulmonary function. No autonomic differences were obtained between asthmatics and nonasthmatics in physiological response to stress, but greater cholinergic receptor sensitivity was suggested among high responders to methacholine.