Subject Preferences and Psychological Implications of Portable Oxygen Concentrator Versus Compressed Oxygen Cylinder in Chronic Lung Disease.

BACKGROUND: Oxygen therapy represents the elective therapy to improve the quality of life for patients with chronic respiratory diseases like COPD and interstitial lung disease. Lightweight portable oxygen concentrators (POCs) are a valid alternative to traditional systems such as portable compressed oxygen cylinders. However, patient preference and the possible psychological implications related to the use of both devices have been poorly assessed. We sought to evaluate patient preference between the ambulatory oxygen systems (ie, a POC or a small cylinder) for patients with COPD and interstitial lung disease experiencing exertional desaturation in a rehabilitation setting. Furthermore, the use of one device in comparison with the other was related to specific mechanical characteristics and related to perceived quality of life, anxiety, and depressive symptoms. METHODS: 30 subjects with COPD and interstitial lung disease, who demonstrated exertional desaturation on room air during 6-min walk test (6MWT), were recruited. Each subject performed 2 6MWTs, in random order: one breathing oxygen via a POC and one with a portable compressed oxygen cylinder. Both devices were set up to ensure oxyhemoglobin saturation between 92% and 95% during the 6MWTs. All subjects completed a questionnaire assessing anxiety, depression, and quality of life. Each device was randomly assigned to each subject for 1 week, and then replaced with the other in the following week. At the end of the trial period, all subjects completed a questionnaire evaluating several aspects of the oxygen therapy devices. RESULTS: There were no significant differences in oxygen saturation or the mean distances achieved during the 6MWTs between the 2 portable oxygen devices. The subjects expressed greater preference for the POC (73.3%), basing their choice mainly on ease of transport and lower weight. Subjects' age also correlated with preferences: younger subjects were more negatively focused on the weight of the portable compressed oxygen cylinder, whereas older subjects considered the POC easier to manage. No significant differences in preferences were present between COPD and interstitial lung disease. CONCLUSIONS: The POC and the portable compressed oxygen cylinder performed in a comparable manner during 6MWT for subjects with COPD and interstitial lung disease and exertional desaturation. Subjects preferred the POC because it was associated with better mobility.

A case scenario study on adherence to COPD GOLD recommendations by general practitioners in a rural area of southern Italy: The "progetto PADRE".

The aim of the present study was to evaluate in a sample of 200 patients diagnosed with COPD and selected from the physician database of 15 general practices from Valle Telesina (Benevento, Italy) if the diagnostic-therapeutic algorithm adopted by GPs operating in a non-urban district in Southern Italy adhered to GOLD 2018 recommendations for COPD. Each patient underwent a specialist visit by an experienced chest physician that collected anamnesis, assessed mMRC and CAT scores, and performed a spirometry. In case of diagnostic doubt, a second visit was performed at the Pulmonary Rehabilitation Unit of the Istituti Clinici Scientifici Maugeri IRCCS in Telese Terme where other diagnostic tests were performed. Our results showed that GPs participating in the study often diagnosed and empirically treated COPD without a confirmative spirometry or even despite a spirometry that was not diagnostic of obstructive lung disease. Furthermore, real-life implementation of GOLD strategy, as regards patients' ABCD categorization, was poor and many patients belonging to groups A and B (39% and 48%, respectively) were over-treated and 19% of those belonging to group D were under-treated. The discrepancy between guidelines and daily clinical practice present also in this study supports the opinion of many that those who develop guidelines for the management of COPD must seriously try to understand if and why the guidelines might not reflect real life and therefore how it could be improved.

Exhaled and nasal nitric oxide measurement in the evaluation of chronic cough.

Chronic cough is one of the most common and troublesome nonspecific respiratory symptom for which patients seek a general practitioner and specialist advice. It is conventionally defined as a cough lasting for more than 8 weeks. Exhaled nitric oxide has proven to be a specific biomarker capable to discriminate between differential diagnoses of chronic cough and simultaneously provide information about the response to specific treatment. In this review, we will discuss the potential use of exhaled and nasal nitric oxide in the diagnosis of chronic chough.

Clinical assessment of endothelial function in patients with chronic obstructive pulmonary disease: a systematic review with meta-analysis.

Patients with chronic obstructive pulmonary disease (COPD) have an increased cardiovascular morbidity and mortality. Flow-mediated (FMD) and nitrate-mediated dilatation (NMD) are considered non-invasive methods to assess endothelial function and surrogate markers of subclinical atherosclerosis. We performed a systematic review with meta-analysis and meta-regression to evaluate the impact of COPD on FMD and NMD. Studies were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. The random-effect method was used to take into account the variability among included studies. A total of eight studies were included in the final analysis, eight with data on FMD (334 COPD patients) and two on NMD (104 COPD patients). Compared to controls, COPD patients show a significantly lower FMD (MD -3.15%; 95% CI -4.89, -1.40; P < 0.001) and NMD (MD -3.53%; 95% CI -7.04, -0.02; P = 0.049). Sensitivity analyses substantially confirms the results. Meta-regression models show that a more severe degree of airway obstruction is associated with a more severe FMD impairment in COPD patients than in controls. Regression analyses confirm that the association between COPD and endothelial dysfunction is independent of baseline smoking status and most traditional cardiovascular risk factors. In conclusion, COPD is significantly and independently associated with endothelial dysfunction. These findings may be useful to plan adequate cardiovascular prevention strategies in this clinical setting, with particular regard to patients with a more severe disease.

Comparison of plethysmographic and helium dilution lung volumes in patients with a giant emphysematous bulla as selection criteria for endobronchial valve implant.

OBJECTIVES: To assess whether the difference in lung volume measured with plethysmography and with the helium dilution technique could differentiate an open from a closed bulla in patients with a giant emphysematous bulla and could be used as a selection criterion for the positioning of an endobronchial valve. METHODS: We reviewed the data of 27 consecutive patients with a giant emphysematous bulla undergoing treatment with an endobronchial valve. In addition to standard functional and radiological examinations, total lung capacity and residual volume were measured with the plethysmographic and helium dilution technique. We divided the patients into 2 groups, the collapse or the no-collapse group, depending on whether the bulla collapsed or not after the valves were put in position. We statistically evaluated the intergroup differences in lung volume and outcome. RESULTS: In the no-collapse group (n = 6), the baseline plethysmographic values were significantly higher than the helium dilution volumes, including total lung capacity (188 ± 14 vs 145 ± 13, P = 0.0007) and residual volume (156 ± 156 vs 115 ± 15, P = 0.001). In the collapse group, there was no significant difference in lung volumes measured with the 2 methods. A difference in total lung capacity of ≤ 13% and in residual volume of ≤ 25% measured with the 2 methods predicted the collapse of the bulla with a success rate of 83% and 84%, respectively. Only the collapse group showed significant improvement in functional data. CONCLUSIONS: Similar values in lung volumes measured with the 2 methods support the hypothesis that the bulla communicates with the airway (open bulla) and thus is likely to collapse when the endobronchial valve is implanted. Further studies are needed to validate our model.

Bronchoscopic lung volume reduction with endobronchial valves for heterogeneous emphysema: long-term results.

BACKGROUND: Bronchoscopic lung volume reduction (BLVR) with implant of one-way endobronchial valves (EBV) is a feasible treatment for management of heterogeneous emphysema (HE) with clinical benefits in the early follow-up. We aimed to evaluate the long-terms results and safety of this procedure in a consecutive series of patients with HE. METHODS: It was a retrospective single center study including all consecutive patients with HE undergoing EBV treatment and completing at least 5 years of long-term follow-up. Patients were splitted into Collapse and No-Collapse Group if a lobar collapse or not were obtained after valves implant. The difference of functional data and quality of life (QoL) before and after the procedure (measured at 3, 6, 9, 12 months from the valve implantation, and then annually up to a maximum of 5 years) were statistically evaluated to show the long-term benefits of the procedure (primary endpoint). Yet, morbidity, mortality and survival rates were also recorded to show the safe of the treatment (secondary endpoint). RESULTS: Thirty-three patients were included in the study. Of these, three patients underwent a bilateral treatment. Collapse Group patients (n=27) presented a significant improvement in FEV1% (+17%; P=0.001); in FVC% (+18%; P=0.002); in RV% (-39%; P=0.003); in 6MWT (P=0.001) and in SGRQ (P=0.001) in the early 12 months of follow-up and no significant decline was seen later. Conversely, No-Collapse Group (n=9) did not have significant benefits. No major complications and death related to the procedure were observed. The 1-,2-,3-,4- and 5-year survival rates were 100%, 90%, 78%, 71% and 71%, respectively. Collapse Group had a better survival than No-Collapse Group (45 vs. 24 months; P=0.001). CONCLUSIONS: Our study confirmed that the lobar collapse is the key success of EBV treatment and the early improvements of respiratory function could be maintained up to five years from the valves implant.

Pulmonary rehabilitation improves exercise capacity in subjects with kyphoscoliosis and severe respiratory impairment.

BACKGROUND: Patients with kyphoscoliosis and severe respiratory impairment frequently experience reduction in exercise tolerance, limitation in daily life activities, and deterioration in health-related quality of life (HRQOL). Noninvasive ventilation (NIV) as an add-on treatment to long-term oxygen therapy (LTOT) was shown to improve symptoms and HRQOL in these patients. Pulmonary rehabilitation can increase exercise capacity and HRQOL in patients with COPD, but its role in patients with restrictive thoracic disease, such as kyphoscoliosis, is uncertain. The aim of this study was to analyze the effects of combining pulmonary rehabilitation with LTOT and NIV treatments on arterial blood gases and the 6-min walk test (6MWT) in a homogeneous group of subjects with kyphoscoliosis. METHODS: Twenty-three subjects with kyphoscoliosis and respiratory failure who were being treated with both LTOT and NIV and who had been referred to a pulmonary rehabilitation program were retrospectively analyzed. Eighteen subjects were included, and there was no control group. Pulmonary rehabilitation involved educational and physical training sessions and was carried out daily for 4-6 weeks. Exercise intensity was personalized based on individual tolerance, physiologic parameters, or physiotherapist judgment. RESULTS: Upon completion of pulmonary rehabilitation, a significant improvement in 6-min walk distance was observed (P = .04). The dyspnea score at the end of the 6MWT improved as well, although the improvement did not reach statistical significance (P = .06). These changes were not confirmed at a 12-month follow-up visit. No significant effects of pulmonary rehabilitation on arterial blood gases were observed. CONCLUSIONS: A combined intervention including a tailored pulmonary rehabilitation program together with LTOT and NIV seems to be of short-term benefit in subjects with kyphoscoliosis and severe respiratory impairment.

Effects of pathological respiratory pattern on heart rate turbulence in sleep apnea.

Obstructive sleep apnea syndrome (OSAS) is characterized by recurrent episodes of partial or complete upper-airway obstruction during sleep. Although cardiac autonomic impairment is involved in the development of cardiovascular disease in OSAS, the mechanism underlying this derangement is rather unknown. It can be assessed by a recently introduced analysis of the heart rate turbulence (HRT). The aim of the paper is to describe the effects of pathological respiratory pattern on HRT in OSAS. HRT has been assessed by turbulence onset (TO) and turbulence slope (TS) indexes in 20 polysomnographic recordings of severe OSAS patients, and separately calculated during both normal (NR) and obstructive apnea (OA) respiratory pattern. Results showed that, although there is an overall depressed HRT for both indexes, while the TO during OA phases is not significantly different from those of NR epochs, the TS during OA phases is very significantly higher than in NR phases. This novel finding shows a previously unknown paradoxical increase of TS during OA episodes, followed by a marked decrease during subsequent NR phases, where OSAS patient show higher sympathetic tone. Such deeper understanding of the integrated autonomic response in different OSAS pathophysiological conditions could be useful to address an overall cardiorespiratory assessment and treatment in sleep-related breathing disorders.

Quantitative assessment of emphysematous parenchyma using multidetector-row computed tomography in patients scheduled for endobronchial treatment with one-way valves†.

OBJECTIVES: To investigate the role of volume quantitative assessment using multidetector-row computed tomography to select patients scheduled for endobronchial one-way valves treatment. METHODS: Twenty-five consecutive patients (15 with heterogeneous emphysema and 10 with giant emphysematous bulla) undergoing endobronchial valves treatment were enrolled. All patients were studied pre- and postoperatively with standard pulmonary functional tests and quantitative volume assessment of target lobe and entire lung. Emphysematous parenchyma was obtained applying density thresholds of -1.024/-950 Hounsfield units. Among different subtype of patients, we evaluated: (i) the differences between preoperative versus postoperative data; (ii) the correlation between functional and volumetric quantification changes and (iii) the critical threshold value of volumetric quantification of the target lobe in close association with clinical effects. RESULTS: Among heterogeneous emphysematous and giant emphysematous bulla patients, a significant improvement of flow-expiratory volume in 1 s (from 36.9 ± 15.3 to 43.9 ± 10.4; P = 0.01; and from 35.8 ± 6.0 to 47.5 ± 7.9; P < 0.0001, respectively); and of forced vital capacity (from 41.9 ± 5.9 to 47.3 ± 9.3; P = 0.0009 and from 40.7 ± 5.9 to 48.8 ± 4.9; P = 0.0002, respectively); and a significant reduction of residual volume (from 185 ± 14 to 157 ± 14.7; P = 0.005; and from 196 ± 13.5 to 137 ± 21; P < 0.0001, respectively) and of total lung volume (from 166.7 ± 13 to 137 ± 18 ; P = 0.0003, and from 169 ± 15 to 134 ± 18; P < 0.0001, respectively) were seen after treatment. The volumetric measurements showed a reduction of volume of the treated lobe among heterogeneous emphysematous patients (from 1448 ± 204 to 1076 ± 364; P = 0.0008); and in those with giant emphysematous bulla (from 1668 ± 140 to 864 ± 199; P < 0.0001). The entire lung and target lobe volume changes were inversely correlated with change in forced expiratory volume in 1 s in patients with heterogeneous emphysematous (r = -0.7; P = 0.0006; and r = -0.7; P = 0.0009, respectively) and giant emphysematous bulla (r = -0.8; P = 0.001; and r = -0.7; P = 0.009, respectively). Among patients with heterogenous emphysematous and giant emphysematous bulla, the value of sensitivity and specificity were 66.6 and 83%, respectively (for a volumetric qunatification >1.5239), and of 60 and 100%, respectively (for a volumetric qunatification >1.762). CONCLUSIONS: Our study showed that the volumetric quantification adds further informations to the routine evaluation for optimizing the selection of patients scheduled for endobronchial valve treatment.

Diagnostic decision support of heart rate turbulence in sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is characterized by repeated upper-airway obstruction during sleep. It is diagnosed by polysomnographic studies, scoring OSAS severity by an apneas/hypopneas index associated to worse prognosis, mainly for an increased cardiovascular morbidity. Cardiac autonomic impairments involved in the development of cardiovascular disease in OSAS can be assessed by heart rate turbulence (HRT) analysis and aim of the paper is to show the increased medical decision support by HRT evaluation in OSAS patients. HRT has been assessed in 274 polysomnographic recordings of mild-to-severe OSAS patients and an overall cardiorespiratory risk scoring (CRRIS) index has been proposed on the base of both OSAS severity and HRT assessment. Results showed that, while the only polysomnografic analysis would have equally ranked OSAS patients within their mild-to-severe classification, CRRIS index allows to identify a 19% of severe-OSAS patients at very high risk of sudden cardiac death, a 13% of moderate-OSAS patients with a risk level comparable to those of severe, and a 17% of mild-OSAS patients with evidence of an autonomic impairment. CRRIS index, detecting patients at greater probability of worsening could give to the physician a very useful medical decision support in the follow up of this particular chronic disease.

Ultradian rhythms during day and night in normal and COPD subjects.

The analysis of heart rate variability (HRV) is a powerful tool in the study of the autonomic control of the heart. While circadian HRV rhythms have widely been characterized by traditional spectral measures, ultradian oscillations are not commonly investigated. In this study the identification of HRV ultradian rhythms is assigned to a quantitative measure characterizing the fractal-like behavior of the time series: the fractal dimension (FD). In order to assess ultradian regulation in Chronic Obstructive Pulmonary Disease (COPD) 24-h Holter ECG recordings of 52 COPD and 10 normal (healthy) subjects were analyzed. The FD was calculated by Higuchi's algorithm both during daytime and nighttime to highlight possible wake-sleep states differences. All subjects showed a similar common rhythm (0.06mHz) that persists with generally higher amplitude during night-time. A further rhythm becomes predominant in normal subjects in the day-to-night transition (0.15mHz), probably under the influence of the REM/non-REM ultradian sleep cycle. A very large difference between night and day amplitudes of this rhythm and of the next one (at about 0.22mHz) characterize the HRV fractal dimension of the Normal in respect of COPD. In conclusion, the FD could be used as a marker of ultradian cardiac autonomic regulation providing new insights into autonomic physiology of normal and COPD patients.