Clusters of individuals recovering from an exacerbation of chronic obstructive pulmonary disease and response to in-hospital pulmonary rehabilitation.

INTRODUCTION AND OBJECTIVES: Due to the present low availability of pulmonary rehabilitation (PR) for individuals recovering from a COPD exacerbation (ECOPD), we need admission priority criteria. We tested the hypothesis that these individuals might be clustered according to baseline characteristics to identify subpopulations with different responses to PR. METHODS: Multicentric retrospective analysis of individuals undergone in-hospital PR. Baseline characteristics and outcome measures (six-minute walking test - 6MWT, Medical Research Council scale for dyspnoea -MRC, COPD assessment test -CAT) were used for clustering analysis. RESULTS: Data analysis of 1159 individuals showed that after program, the proportion of individuals reaching the minimal clinically important difference (MCID) was 85.0%, 86.3%, and 65.6% for CAT, MRC, and 6MWT respectively. Three clusters were found (C1-severe: 10.9%; C2-intermediate: 74.4%; C3-mild: 14.7% of cases respectively). Cluster C1-severe showed the worst conditions with the largest post PR improvements in outcome measures; C3-mild showed the least severe baseline conditions, but the smallest improvements. The proportion of participants reaching the MCID in ALL three outcome measures was significantly different among clusters, with C1-severe having the highest proportion of full success (69.0%) as compared to C2-intermediate (48.3%) and C3-mild (37.4%). Participants in C2-intermediate and C1-severe had 1.7- and 4.6-fold increases in the probability to reach the MCID in all three outcomes as compared to those in C3-mild (OR = 1.72, 95% confidence interval [95% CI] = 1.2 - 2.49, p = 0.0035 and OR = 4.57, 95% CI = 2.68 - 7.91, p < 0.0001 respectively). CONCLUSIONS: Clustering analysis can identify subpopulations of individuals recovering from ECOPD associated with different responses to PR. Our results may help in defining priority criteria based on the probability of success of PR.

Pulmonary tuberculosis in intensive care setting, with a focus on the use of severity scores, a multinational collaborative systematic review.

BACKGROUND AND AIM: Tuberculosis (TB) is associated with a high mortality in the intensive care unit (ICU), especially in subjects with Acute Respiratory Distress Syndrome (ARDS) requiring mechanical ventilation. Despite its global burden on morbidity and mortality, TB is an uncommon cause of ICU admission, however mortality is disproportionate to the advances in diagnosis and treatment made. Herein we report a systematic review of published studies. METHODS: Our Literature search was conducted to identify studies on outcomes of individuals with TB admitted to ICU. We report and review in-hospital mortality, predictors of poorer outcomes, usefulness of severity scoring systems and potential benefits of intravenous antibiotics. Searches from Pubmed, Embase, Cochrane and Medline were conducted from inception to March 2020. Only literature in English was included. RESULTS: Out of 529 potentially relevant articles, 17 were included. Mortality across all studies ranged from 29-95% with an average of 52.9%. All severity scores underestimated average mortality. The most common indication for ICU admission was acute respiratory failure (36.3%). Negative predictors of outcome included hospital acquired infections, need of mechanical ventilation and vasopressors, delay in initiation of anti-TB treatment, more than one organ failure and a higher severity score. Low income, high incidence countries showed a 23.4% higher mortality rate compared to high income, low TB incidence countries. CONCLUSION: Mortality in individuals with TB admitted to ICU is high. Earlier detection and treatment initiation is needed.

Clinical standards for the assessment, management and rehabilitation of post-TB lung disease.

BACKGROUND: Increasing evidence suggests that post-TB lung disease (PTLD) causes significant morbidity and mortality. The aim of these clinical standards is to provide guidance on the assessment and management of PTLD and the implementation of pulmonary rehabilitation (PR).METHODS: A panel of global experts in the field of TB care and PR was identified; 62 participated in a Delphi process. A 5-point Likert scale was used to score the initial ideas for standards and after several rounds of revision the document was approved (with 100% agreement).RESULTS: Five clinical standards were defined: Standard 1, to assess patients at the end of TB treatment for PTLD (with adaptation for children and specific settings/situations); Standard 2, to identify patients with PTLD for PR; Standard 3, tailoring the PR programme to patient needs and the local setting; Standard 4, to evaluate the effectiveness of PR; and Standard 5, to conduct education and counselling. Standard 6 addresses public health aspects of PTLD and outcomes due to PR.CONCLUSION: This is the first consensus-based set of Clinical Standards for PTLD. Our aim is to improve patient care and quality of life by guiding clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage PTLD.

Minimal clinically important difference of the 6-min walking test in patients with asthma.

BACKGROUND: The 6-min walking test (6MWT) is responsive to physiological changes and pulmonary rehabilitation (PR) in patients with asthma. The minimal clinically important difference (MCID) has not been established yet.OBJECTIVE: To determine the MCID of 6MWT in patients with asthma.METHODS: Using the perceived change in walking ability and the modified Medical Research Council (mMRC) score as anchors, receiver operating characteristic curves and quantile regression, we evaluated 6MWT before and after PR in these patients. The St George Respiratory Questionnaire (SGRQ), the COPD assessment test (CAT) and other outcome measures were also assessed.RESULTS: Of 142 patients with asthma, 37 were enrolled. After PR, 6MWT increased from 453.4 m ± 88.8 to 493.0 m ± 97.2 (P = 0.0001); other outcome measures also increased. There was a slight correlation between baseline 6MWT and SGRQ, CAT and mMRC. No significant correlations were found between post-PR changes in 6MWT and in other outcome measures. Comparing different methods of assessment, the MCID ranged from 26 m to 27 m.CONCLUSION: The most conservative estimate of the MCID of 6MWT after PR was 26 m in patients with asthma. This estimate may be useful in clinical interpretation of data, particularly in response to intervention studies.

COVID-19 pandemic and non invasive respiratory management: Every Goliath needs a David. An evidence based evaluation of problems.

BACKGROUND AND AIM: The war against Covid-19 is far from won. This narrative review attempts to describe some problems with the management of Covid-19 induced acute respiratory failure (ARF) by pulmonologists. METHODS: We searched the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and reviewed the references of retrieved articles for additional studies. The search was limited to the terms: Covid-19 AND: acute respiratory distress syndrome (ARDS), SARS, MERS, non invasive ventilation (NIV), high flow nasal cannula (HFNC), pronation (PP), health care workers (HCW). RESULTS: Protection of Health care workers should be paramount, so full Personal Protective Equipment and Negative pressure rooms are warranted. HFNC alone or with PP could be offered for mild cases (PaO2/FiO2 between 200-300); NIV alone or with PP may work in moderate cases (PaO2/FiO2 between 100-200). Rotation and coupled (HFNC/NIV) strategy can be beneficial. A window of opportunity of 1-2h is advised. If PaO2/FIO2 significantly increases, Respiratory Rate decreases with a relatively low Exhaled Tidal Volume, the non-invasive strategy could be working and intubation delayed. CONCLUSION: Although there is a role for non-invasive respiratory therapies in the context of COVID-19 ARF, more research is still needed to define the balance of benefits and risks to patients and HCW. Indirectly, non invasive respiratory therapies may be of particular benefit in reducing the risks to healthcare workers by obviating the need for intubation, a potentially highly infectious procedure.

Strategies to relieve dyspnoea in patients with advanced chronic respiratory diseases. A narrative review.

BACKGROUND AND OBJECTIVE: The management of symptoms in patients with advanced chronic respiratory diseases needs more attention. This review summarizes the latest evidence on interventions to relieve dyspnoea in these patients. METHODS: We searched randomised controlled trials, observational studies, systematic reviews, and meta-analyses published between 1990 and 2019 in English in PubMed data base using the keywords. Dyspnoea, Breathlessness AND: pharmacological and non pharmacological therapy, oxygen, non invasive ventilation, pulmonary rehabilitation, alternative medicine, intensive care, palliative care, integrated care, self-management. Studies on drugs (e.g. bronchodilators) or interventions (e.g. lung volume reduction surgery, lung transplantation) to manage underlying conditions and complications, or tools for relief of associated symptoms such as pain, are not addressed. RESULTS: Relief of dyspnoea has received relatively little attention in clinical practice and literature. Many pharmacological and non pharmacological therapies are available to relieve dyspnoea, and improve patients' quality of life. There is a need for greater knowledge of the benefits and risks of these tools by doctors, patients and families to avoid unnecessary fears which might reduce or delay the delivery of appropriate care. We need services for multidisciplinary care in early and late phases of diseases. Early integration of palliative care with respiratory, primary care, and rehabilitation services can help patients and caregivers. CONCLUSION: Relief of dyspnoea as well as of any distressing symptom is a human right and an ethical duty for doctors and caregivers who have many potential resources to achieve this.

Videogame assisted exercise training in patients with chronic obstructive pulmonary disease: A preliminary study.

BACKGROUND: Exercise training is key to the comprehensive management of patients with chronic obstructive pulmonary disease (COPD). Interactive game-based systems have been proposed to improve effectiveness and compliance with exercise training. AIM: To evaluate the effectiveness of Wii Fit balance board as an additional tool for exercise training in patients with COPD. As a secondary aim we will evaluate the costs. METHODS: In a randomized controlled trial, patients were divided into experimental (EG) and control (CG) groups. The CG performed exercise training on a cycle ergometer three times a week for 6 weeks. The EG also followed a program (yoga, strength training, aerobic exercise) using the Wii Fit system. Pre and post treatment six-minute walking distance (6MWD) test, transitional dyspnea index (TDI), the Medical Research Council (MRC) score the Saint George's Respiratory Questionnaire (SGRQ), the body max index, airflow obstruction, dyspnea, and exercise capacity index (BODE) were assessed. RESULTS: The 6MWD increased from 410.7 (105.3) to 477.5 (122.4) and from 376.6 (81.0) to 420 (77.6) meters, in CG and EG respectively, p=0.0001 without any difference between groups. Both groups experienced significant improvements in TDI and SGRQ, but not in MRC and BODE, without any significant difference between groups. CONCLUSION: A Wii Fit balance board based video game program was feasible but did not add any benefit to a well conducted standard exercise training program in patients with COPD.

Effectiveness of manual therapy in COPD: A systematic review of randomised controlled trials.

PURPOSE: Manual therapy (MT) has been proposed in pulmonary rehabilitation programmes for patients with chronic obstructive pulmonary disease (COPD), but an updated systematic review of the evidence is lacking. We aimed to systematically review the effectiveness of MT interventions, alone or added to exercise, on lung function, exercise capacity and quality of life in COPD patients, compared to other therapies (e.g. exercise alone) or no treatment. MATERIALS AND METHODS: We searched MEDLINE, EMBASE, Physiotherapy Evidence Database, and Cochrane Central Register of Controlled Trials databases, using the terms: COPD, manual therapy, manipulation, joint mobilisation, osteopathic manipulation. Only randomised controlled trials (RCT) were considered. RESULTS: Out of 555 articles screened, 6 fulfilled the inclusion criteria. The study designs were heterogeneous (with different intervention schedules) and there was a high risk of bias. No effect on lung function was found, while results on exercise capacity were contrasting. MT had no effect on quality of life, although valid measures were available only in one study. Only mild adverse events were reported. CONCLUSIONS: Few RCTs of poor methodological quality are available on the effects of MT in COPD. More and better quality RCTs are needed before this technique can be included in rehabilitation programmes for these patients.

Benefits and costs of home pedometer assisted physical activity in patients with COPD. A preliminary randomized controlled trial.

BACKGROUND AND OBJECTIVE: There are barriers to providing pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) such as the high number of patients, difficult access to health facilities and high costs of programs. Pedometers can monitor and improve physical activity (PA). The aim of this study was to evaluate benefits and costs of home pedometer assisted PA, as compared to a standard outpatient supervised exercise training program in patients with COPD. METHODS: Patients were randomly assigned either to home pedometer assisted PA (Group 1), or to a six-week outpatient standard supervised exercise training program (Group 2). Patients of Group 1 had to walk at home for 6 weeks, at least 30min daily at the fastest step pace as possible, to achieve a weekly 10% increase in their average daily steps up to more than 6500. Pre and post programs we assessed: the six minute walking distance (6MWT: primary outcome), daily steps count, the Medical Research Council scale (MRC), the COPD assessment test score, and the BODE index (body-mass index, airflow obstruction, dyspnea, exercise capacity). Costs of programs were also evaluated. RESULTS: Out of 40 patients, 18 in both groups (mean (standard deviation)) age: 68.3 (6.7) and 61.2 (6.7) years; FEV1: 1.1 (0.5) and 0.9 (0.4) liters in Group 1 and 2 respectively completed the study. At the end of the program 44.5% patients of Group 1 had reached the target daily steps, in 26.6 (9.5) days. Following the programs, both groups showed significant improvements in all outcome measures, except BODE. The home program was cheaper (p=0.0001), with a mean 76.3 euros saving per patient. CONCLUSION: Home pedometer assisted PA may be a useful and cheaper alternative to outpatient supervised exercise training programs in patients with COPD.

Multidisciplinary rehabilitation in ventilator-dependent patients: Call for action in specialized inpatient facilities.

The numbers of patients needing prolonged mechanical ventilation are growing. The rehabilitation programs to be implemented in specialized inpatient facilities are ill defined. There is a clear need to establish guidelines to define the optimal rehabilitation program in this setting. In this article we review the current evidence and propose some guidance.

Place of death in patients with amyotrophic lateral sclerosis.

UNLABELLED: Amyotrophic lateral sclerosis (ALS) is a degenerative neurological disorder that affects motor neurons. Involvement of respiratory muscles causes the failure of the ventilator pump with more or less significant bulbar troubles. ALS course is highly variable but, in most cases, this disease entails a very significant burden for patients and caregivers, especially in the end-of-life period. In order to analyze the characteristics of ALS patients who die at home (DH) and in hospital (DHosp) and to study the variability of clinical practice, a retrospective medical records analysis was performed (n=77 from five hospitals). VARIABLES: time elapsed since the onset of symptoms and the beginning of ventilation, characteristics of ventilation (device, mask and hours/day), and support devices and procedures. RESULTS: In all, 14% of patients were ventilated by tracheotomy. From the analysis, 57% of patients were of DH. Mean time since the onset of symptoms was 35.93±25.89 months, significantly shorter in patients who DHosp (29.28±19.69 months) than DH (41.12±29.04) (p=0.044). The percentage of patients with facial ventilation is higher in DHosp (11.4% vs 39.4%, p<0.005). DH or not is related to a set of elements in which health resources, physician attitudes and support resources in the community play a role in the decision-making process. There is great variability between countries and between hospitals in the same country. Given the variability of circumstances in each territory, the place of death in ALS might not be the most important element; more important are the conditions under which the process unfolds.

A sequential school based smoke prevention program in secondary school adolescents.

BACKGROUND AND AIM: The hazardous health effects of smoking and second-hand smoke are well known and have been confirmed in several studies. We wondered whether a school based programme involving media models such as those represented by famous soccer players and TV characters, was effective in prevention of smoking habit in secondary school adolescents. METHODS: Since October 2006 to May 2007 an anonymous survey was submitted to 1382 secondary schools pupils. After completing the questionnaire all students of 42 out of 70 classes selected by the school principals underwent a prevention programme consisting of 1 hour lecture on smoke healthy hazard with educational material (slides, video, leaflets). Furthermore each pupil was given card games with significant pictures. Since October 2007 to May 2008 and Since October 2008 to May 2009 pupils underwent a 1 hour interactive lesson on smoke related health hazards respectively. On December 2007 pupils in study attended a theatre event with show business characters acting to smoke dissuasion. No intervention was performed on the 568 pupils of the other classes along all the same 2 school- year period (controls). RESULTS: Among other results at the end of the 2-year program 4% pupils of study group and 14% of controls reported smoking habit (p = 0.001) whereas 7% and 27% (p = 0.001) of study and control pupils respectively ignored smoking induced dependence. CONCLUSION: A school based programme involving media models such as those represented by famous soccer players, TV characters, was effective in prevention of smoking habit in secondary school adolescents.

Unexpected death of a ventilator-dependent amyotrophic lateral sclerosis patient.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a fatal, progressive, neurodegenerative disease and most patients affected die of respiratory compromise and/or pneumonia within 2-3 years of diagnosis. As ALS progresses, ventilator assistance is required. In the end stages of the disease, patients suffer from respiratory failure and may become ventilator-dependent. Deaths due to malfunction of mechanical ventilators are reported but there are very few forensic autopsy records. We report the case of a 69-year-old ALS female ventilator-dependent, trachostomised patient who was found dead by her husband, with the ventilator in "stand-by" mode. METHOD: A forensic autopsy was performed. Samples of internal organs were taken for histological and toxicological examination. The ventilator internal memory was also analysed and tested in order to find possible malfunction. RESULTS: Gross examination did not reveal any sign of trauma but showed brain and lung congestion. Pulmonary histological examination revealed thickening of peribronchial interstitial space, alveolar over-distension, break of inter-alveolar walls and diffuse alveolar haemorrhages. Focal microhemorrhages were also detected in other organs. Analysis of the ventilator internal memory showed that during the night of death, there had been several voltage drops. Specific tests revealed malfunction of the internal battery which was unable to provide the necessary voltage, as a consequence the ventilator switched off, stopping ventilation. Battery malfunction reduced the volume of the ventilator alarm, which was not heard by the caregiver. CONCLUSION: Histological pattern, with acute pulmonary emphysema and focal polivisceral haemorrhages, is strongly suggestive of a death due to "acute" asphyxia. The authors also discuss the need for strict supervision and follow up of these ventilatory dependent patients and their devices.