Telerehabilitation Programme as a Maintenance Strategy for COPD Patients: A 12-Month Randomized Clinical Trial / Programa de telerrehabilitación como estrategia de mantenimiento para pacientes con EPOC: un ensayo clínico aleatorizado de 12 meses

Background: There is uncertainty regarding efficacy of telehealth-based approaches in COPD patients for sustaining benefits achieved with intensive pulmonary rehabilitation (PR).Research question: To determine whether a maintenance pulmonary telerehabilitation (TelePR) programme, after intensive initial PR, is superior to usual care in sustaining over time benefits achieved by intensive PR.Study design and methods: A multicentre open-label pragmatic parallel-group randomized clinical trial was conducted. Two groups were created at completion of an 8-week intensive outpatient hospital PR programme. Intervention group (IG) patients were given appropriate training equipment and instructed to perform three weekly training sessions and send performance data through an app to a web-based platform. Patients in the control group (CG) were advised to exercise regularly (usual care).Results: Ninety-four patients (46 IG, 48 CG) were randomized. The analysis of covariance showed non-significant improvements in 6-min walk distance [19.9m (95% CI ∧4.1/+43.8)] and Chronic Respiratory Disease Questionnaire • Emotion score [0.4 points (0•0.8)] in the IG. Secondary linear mixed models showed improvements in the IG in Short Form-36 mental component summary [9.7, (4.0•15.4)] and Chronic Respiratory Disease Questionnaire • Emotion [0.5, (0.2•0.9)] scores, but there was no association between compliance and outcomes. Acute exacerbations were associated with a marginally significant decrease in 6-minute walk distance of 15.8m (∧32.3/0.8) in linear models. (AU)

Contexto previo: Existe incertidumbre con respecto a la eficacia de los enfoques basados en telesalud en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) para mantener los beneficios logrados con la rehabilitación pulmonar (RP) intensiva.Pregunta de investigación: Determinar si un programa de telerrehabilitación pulmonar de mantenimiento (TeleRP), después de una RP inicial intensiva, es superior a la atención habitual para mantener en el tiempo los beneficios logrados por la RP intensiva.Diseño del estudio y métodos: Se realizó un ensayo clínico aleatorizado, pragmático, abierto, multicéntrico, de grupos paralelos. Se crearon 2 grupos al finalizar un programa de RP intensiva en rèc)gimen ambulatorio de 8 semanas de duración. A los pacientes del grupo de intervención (GI) se les proporcionó el equipo de entrenamiento apropiado y se les instruyó para realizar 3 sesiones de entrenamiento semanales y enviar los datos de rendimiento a travèc)s de una aplicación a una plataforma web. Se aconsejó a los pacientes del grupo de control (GC) que hicieran ejercicio regularmente (cuidado habitual).Resultados: Se aleatorizaron 94 pacientes (46 GI, 48 GC). El análisis de covarianza mostró mejoras no significativas en la distancia en la prueba de marcha de 6min (19,9m [IC 95%: ∧4,1/+43,8]) y el cuestionario de enfermedad respiratoria crónica-factor emocional (0,4 puntos [0-0,8]) en el GI. Los modelos lineales mixtos secundarios mostraron mejoras en el GI en las puntuaciones de la sección mental del SF-36 (9,7 [4,0-15,4]) y el cuestionario de enfermedad respiratoria crónica-factor emocional (0,5 puntos [0,2-0,9]), pero no se demostró asociación entre el cumplimiento y los resultados. Las exacerbaciones agudas se asociaron con una disminución marginalmente significativa en la distancia en la prueba de la marcha de 6min de 15,8m (∧32,3/0,8) en los modelos lineales.

Telerehabilitation Programme as a Maintenance Strategy for COPD Patients: A 12-Month Randomized Clinical Trial.

BACKGROUND: There is uncertainty regarding efficacy of telehealth-based approaches in COPD patients for sustaining benefits achieved with intensive pulmonary rehabilitation (PR). RESEARCH QUESTION: To determine whether a maintenance pulmonary telerehabilitation (TelePR) programme, after intensive initial PR, is superior to usual care in sustaining over time benefits achieved by intensive PR. STUDY DESIGN AND METHODS: A multicentre open-label pragmatic parallel-group randomized clinical trial was conducted. Two groups were created at completion of an 8-week intensive outpatient hospital PR programme. Intervention group (IG) patients were given appropriate training equipment and instructed to perform three weekly training sessions and send performance data through an app to a web-based platform. Patients in the control group (CG) were advised to exercise regularly (usual care). RESULTS: Ninety-four patients (46 IG, 48 CG) were randomized. The analysis of covariance showed non-significant improvements in 6-min walk distance [19.9m (95% CI -4.1/+43.8)] and Chronic Respiratory Disease Questionnaire - Emotion score [0.4 points (0-0.8)] in the IG. Secondary linear mixed models showed improvements in the IG in Short Form-36 mental component summary [9.7, (4.0-15.4)] and Chronic Respiratory Disease Questionnaire - Emotion [0.5, (0.2-0.9)] scores, but there was no association between compliance and outcomes. Acute exacerbations were associated with a marginally significant decrease in 6-minute walk distance of 15.8m (-32.3/0.8) in linear models. CONCLUSIONS: The TelePR maintenance strategy was both feasible and safe but failed to show superiority over usual care, despite improvements in some HRQoL domains. Acute exacerbations may have an important negative influence on long-term physical function. CLINICALTRIALS. GOV IDENTIFIER: NCT03247933.

Programa de paseos para pacientes con EPOC: impacto clínico tras 2 años de seguimiento / Walking Program for Copd Patients: Clinical Impact After Two Years of Follow-up

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Effects of simple long-term respiratory care strategies in older men with COPD / Efeitos de estratégias de longo prazo simples de cuidados respiratórios em homens idosos com DPOC

ABSTRACT Objective: To evaluate a 24-month supervised, community-based maintenance exercise program after 3 months of pulmonary rehabilitation (PR) in comparison with a 27-month physical activity counseling program, in terms of the effects on maximal muscle strength, muscle power output, and exercise capacity, in individuals with COPD. Methods: Sixty-three men with moderate-to-severe COPD were recruited from two previous studies. Of those 63 participants, 31 were offered 3 months of PR followed by a 24-month supervised maintenance exercise program (24MME group) and 32 were offered a 27-month physical activity counseling program (27MPAC group). Measurements at 3 months and at the end of the study period included maximal strength of the upper and lower limbs, power output of the lower limbs, six-minute walk distance (6MWD), and quality of life. Results: At 27 months, the improvements in maximal strength of the upper and lower limbs were greater in the 24MME group than in the 27MPAC group (37.6 ± 28.3% and 28.4 ± 13.3%, respectively, vs. 8.8 ± 16% and 13.6 ± 16.4%, respectively; p < 0.05), as was the improvement in power output of the lower limbs (24.6 ± 18.4% vs. −2.3 ± 28.5%; p < 0.01). The increase in the 6MWD after 3 months was also greater in the 24MME group than in the 27MPAC group (33.2 ± 36.6 m vs. 2.9 ± 34.7 m; p < 0.05), although there were no differences between the two groups in terms of the Δ6MWD at 27 months (vs. baseline). Conclusions: A supervised, community-based maintenance program is a successful long-term strategy to preserve the benefits of PR on peripheral muscle function and exercise capacity in individuals with COPD. However, physical activity counseling can maintain maximal muscle strength and exercise capacity in such individuals.

RESUMO Objetivo: Avaliar um programa comunitário supervisionado de 24 meses de exercícios de manutenção precedido de 3 meses de reabilitação pulmonar (RP) em comparação com um programa de 27 meses de aconselhamento de atividade física, quanto aos efeitos na força muscular máxima, potência muscular e capacidade de exercício em indivíduos com DPOC. Métodos: Foram recrutados 63 homens com DPOC moderada a grave de dois estudos anteriores. A 31 desses 63 participantes foram oferecidos 3 meses de RP seguidos de um programa supervisionado de 24 meses de exercícios de manutenção (grupo 24MEM), e a 32, um programa de 27 meses de aconselhamento de atividade física (grupo 27MAAF). Medidas realizadas aos 3 meses e ao final do período estudado incluíram força máxima dos membros superiores e inferiores, potência dos membros inferiores, distância percorrida no teste de caminhada de seis minutos (DTC6) e qualidade de vida. Resultados: Aos 27 meses, a melhora da força máxima dos membros superiores e inferiores foi maior no grupo 24MEM que no grupo 27MAAF (37,6 ± 28,3% e 28,4 ± 13,3%, respectivamente, vs. 8,8 ± 16% e 13,6 ± 16,4%, respectivamente; p < 0,05), e houve melhora da potência dos membros inferiores (24,6 ± 18,4% vs. −2,3 ± 28,5%; p < 0,01). O aumento da DTC6 após 3 meses também foi maior no grupo 24MEM que no grupo 27MAAF (33,2 ± 36,6 m vs. 2,9 ± 34,7 m; p < 0,05), mas não houve diferenças entre os grupos quanto a ΔDTC6 aos 27 meses (vs. basal). Conclusões: Um programa comunitário supervisionado de manutenção é uma estratégia de longo prazo bem sucedida para preservar os benefícios da RP na função muscular periférica e capacidade de exercício em indivíduos com DPOC. No entanto, o aconselhamento de atividade física consegue manter a força muscular máxima e a capacidade de exercício nesses indivíduos.

Effects of simple long-term respiratory care strategies in older men with COPD.

OBJECTIVE: To evaluate a 24-month supervised, community-based maintenance exercise program after 3 months of pulmonary rehabilitation (PR) in comparison with a 27-month physical activity counseling program, in terms of the effects on maximal muscle strength, muscle power output, and exercise capacity, in individuals with COPD. METHODS: Sixty-three men with moderate-to-severe COPD were recruited from two previous studies. Of those 63 participants, 31 were offered 3 months of PR followed by a 24-month supervised maintenance exercise program (24MME group) and 32 were offered a 27-month physical activity counseling program (27MPAC group). Measurements at 3 months and at the end of the study period included maximal strength of the upper and lower limbs, power output of the lower limbs, six-minute walk distance (6MWD), and quality of life. RESULTS: At 27 months, the improvements in maximal strength of the upper and lower limbs were greater in the 24MME group than in the 27MPAC group (37.6 ± 28.3% and 28.4 ± 13.3%, respectively, vs. 8.8 ± 16% and 13.6 ± 16.4%, respectively; p < 0.05), as was the improvement in power output of the lower limbs (24.6 ± 18.4% vs. -2.3 ± 28.5%; p < 0.01). The increase in the 6MWD after 3 months was also greater in the 24MME group than in the 27MPAC group (33.2 ± 36.6 m vs. 2.9 ± 34.7 m; p < 0.05), although there were no differences between the two groups in terms of the Δ6MWD at 27 months (vs. baseline). CONCLUSIONS: A supervised, community-based maintenance program is a successful long-term strategy to preserve the benefits of PR on peripheral muscle function and exercise capacity in individuals with COPD. However, physical activity counseling can maintain maximal muscle strength and exercise capacity in such individuals.

The Relationships Between Muscle Power and Physical Activity in Older Men With Chronic Obstructive Pulmonary Disease.

The purpose of this study was to determine the potential relationship between muscle power of the lower extremities and the physical activity in older men with chronic obstructive pulmonary disease (COPD). Forty-four men (70.3 ± 6.7 years old) with moderate-to-severe COPD completed the 6-min walk test (6MWT), BODE (body mass index, obstruction, dyspnea, and exercise), a one-repetition maximum strength of the quadriceps femoris (1RMQF), and muscle power at 50% and 70% 1RMQF. Physical activity was measured using an accelerometer. The 6MWT was associated with muscle power at 50% 1RMQF (r = .40; P = .013) but not muscle power at 70% 1RMQF (r = .24; P = .15) or 1RMQF (r = .13; P = .44). Light-intensity activity was positively correlated with muscle power at 50% 1RMQF (r = .52; P = .001). Lower limb muscle power is associated with the 6MWT and light-intensity activities in older men with COPD.

Transbronchial Cryobiopsy in Interstitial Lung Disease: Are We on the Right Path?

BACKGROUND: A definitive and specific diagnosis of interstitial lung disease (ILD) often requires a histologic analysis of the lung parenchyma. A transbronchial biopsy with forceps has a limited diagnostic yield for idiopathic interstitial pneumonias. The incorporation of a transbronchial lung cryobiopsy for diagnosing ILD appears to be very promising, although there are only a few published studies in this regard. Our paper shows the results of using this technique in our center. METHODS: This was a prospective study including 55 patients with ILD diagnosed from January 2012 to January 2015. The methodology used, the overall diagnostic yield, and the number and the location of samples, in addition to complications, have been reported. RESULTS: In 38 (69%), 10 (20.8%), and 7 (12.7%) cases, we obtained a certain, highly likely, and unclassifiable diagnosis of interstitial pneumonia, respectively. With 18 cases, usual interstitial pneumonia was the most common diagnosis. The most common complication was a pneumothorax in 8 patients (14.5%). CONCLUSIONS: A transbronchial lung cryobiopsy using a flexible cryoprobe has a good diagnostic yield and might be an alternative to consider in cases of diffuse ILD in which a histologic sample is required for diagnosis. This technique could avoid a large number of surgical biopsies.

Effects of Combined Resistance and Endurance Training Versus Resistance Training Alone on Strength, Exercise Capacity, and Quality of Life in Patients With COPD.

PURPOSE: To compare the effects of 12-week training periods (2 d·wk) involving resistance training only with the effects of 12-week training periods involving combined resistance (once weekly) and endurance (once weekly) training on strength, endurance performance, and quality of life. METHODS: Thirty-six patients with moderate-to-severe chronic obstructive pulmonary disease were randomized to combined training (REG), resistance training alone (RG), or control (CG) groups. Patients were tested for maximal strength of the upper and lower extremities, power output of the lower extremities, maximal (Wmax) and submaximal exercise capacity, performance on a 6-minute walk test (6MWT), and quality of life. RESULTS: REG and RG induced similar maximal strength gains. Muscle power increased 19% (P ≤ .01) and Wmax improved 13% (P < .05) in REG. Reductions (P < .05) in the heart rate and blood lactate at a given submaximal workload were observed in REG. Improvements in 6MWT and quality of life were similar in both training groups. CONCLUSIONS: Compared with a twice-weekly resistance training program, the combination of once-weekly resistance and once-weekly endurance training not only produced similar gains in maximal strength, 6MWT performance, and quality of life but also produced improvements in muscle power and endurance performance. These findings may have implications for the prescription of resistance and endurance exercise for patients with chronic obstructive pulmonary disease.

Clinical audit of COPD patients requiring hospital admissions in Spain: AUDIPOC study.

BACKGROUNDS: AUDIPOC is a nationwide clinical audit that describes the characteristics, interventions and outcomes of patients admitted to Spanish hospitals because of an exacerbation of chronic obstructive pulmonary disease (ECOPD), assessing the compliance of these parameters with current international guidelines. The present study describes hospital resources, hospital factors related to case recruitment variability, patients' characteristics, and adherence to guidelines. METHODOLOGY/PRINCIPAL FINDINGS: An organisational database was completed by all participant hospitals recording resources and organisation. Over an 8-week period 11,564 consecutive ECOPD admissions to 129 Spanish hospitals covering 70% of the Spanish population were prospectively identified. At hospital discharge, 5,178 patients (45% of eligible) were finally included, and thus constituted the audited population. Audited patients were reassessed 90 days after admission for survival and readmission rates. A wide variability was observed in relation to most variables, hospital adherence to guidelines, and readmissions and death. Median inpatient mortality was 5% (across-hospital range 0-35%). Among discharged patients, 37% required readmission (0-62%) and 6.5% died (0-35%). The overall mortality rate was 11.6% (0-50%). Hospital size and complexity and aspects related to hospital COPD awareness were significantly associated with case recruitment. Clinical management most often complied with diagnosis and treatment recommendations but rarely (<50%) addressed guidance on healthy life-styles. CONCLUSIONS/SIGNIFICANCE: The AUDIPOC study highlights the large across-hospital variability in resources and organization of hospitals, patient characteristics, process of care, and outcomes. The study also identifies resources and organizational characteristics associated with the admission of COPD cases, as well as aspects of daily clinical care amenable to improvement.

[Spirometry in primary care in Navarre, Spain]. / La espirometría en atención primaria en Navarra.

OBJECTIVE: To analyze the use and quality of spirometry in primary care settings in Navarre, Spain. PATIENTS AND METHODS: A questionnaire was completed simultaneously by professionals responsible for spirometry in all of the primary health care centers in Navarre. Data were collected on availability, model of spirometer, frequency of use, calibration, methods, personnel responsible for testing, and training of personnel. Then, baseline spirometry without a bronchodilator test was performed in 171 patients in their primary health care center and then the test was repeated on the same day in a hospital pneumology department. Spirometry was supervised by 2 pneumologists who jointly assessed the acceptability of the flow-volume curves. The quality of spirometry was assessed according to the recommendations of the American Thoracic Society and the interpretation of spirometry results according to the criteria of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). RESULTS: A total of 90.9% of primary health care centers in Navarre have a spirometer, although 22% of those spirometers have never been used. Only 2 centers performed between 10 and 20 spirometry tests per week and none performed more than 20. In 96% of primary health care centers the spirometers were not regularly calibrated. The professionals who performed spirometry were not dedicated for that task in 51.2% of cases, and the mean period of supervised training was 10 hours. When comparisons were made between the mean values obtained in the primary care centers and the pneumology department, statistically significant differences were detected for forced vital capacity (P < .0001) and forced expiratory volume in the first second (P = .0002). Significant differences were also found between the flow-volume curves performed in the 2 different care settings for the initial and end portions of the curve as well as for the slope. The criteria for reproducibility recommended by the American Thoracic Society were not met in 76% of cases for forced vital capacity and 39.7% of cases for forced expiratory volume in the first second. Incorrect functional diagnosis occurred in 39.7% of spirometry tests and there was a tendency in the primary care settings to falsely diagnose patterns as restrictive and to inadequately classify the severity of obstruction. CONCLUSIONS: Despite the fact that spirometers are available in the majority of primary health care centers in Navarre, we found a marked underuse of these devices and little compliance with recommendations for the use of spirometry. Furthermore, the quality of the measurements performed in this care setting was very low.

La espirometría en atención primaria en Navarra / Spirometry in primary care in Navarre, Spain

Objetivo: Analizar la utilización y calidad de la espirometría por parte de atención primaria en Navarra. Pacientes y métodos: Se realizó una encuesta simultánea a los profesionales responsables de las espirometrías de todos los centros de salud (CS) de Navarra recogiendo datos sobre la disponibilidad, modelo de espirómetro, frecuencia de realización, calibración, metodología, personal encargado de las pruebas y su preparación. Posteriormente a 171 pacientes, a los que se había realizado una espirometría basal sin prueba de broncodilatación en su CS, se les repitió la prueba el mismo día en el laboratorio de neumología; a la hora de la inclusión de los datos, 2 neumólogos supervisaron todas las espirometrías y valoraron conjuntamente la aceptabilidad de las curvas flujo-volumen. La calidad de las espirometrías se determinó siguiendo las recomendaciones de la American Thoracic Society y la interpretación de éstas según los criterios de la Sociedad Española de Neumología y Cirugía Torácica. Resultados: El 90,9% de los CS de nuestra comunidad disponía de espirómetros y el 22% de ellos no los utilizaba nunca. Sólo 2 CS realizaban entre 10 y 20 espirometrías a la semana y ninguno más de 20. El 96% de los centros de atención primaria no calibraba de forma reglada los aparatos y el 51,2% de los profesionales que realizaban las espirometrías no eran fijos, con 10 h de media de aprendizaje supervisado. Se detectaron diferencias estadísticamente significativas al comparar las medias de los valores de la capacidad vital forzada y del volumen espiratorio forzado en el primer segundo obtenidos en atención primaria y en la consulta de neumología (p < 0,0001 y p = 0,0002, respectivamente); también fueron significativas las diferencias encontradas en la realización de las curvas flujo-volumen entre los 2 niveles asistenciales, tanto en su inicio como en su pendiente o en su finalización. Se pudo comprobar, en un 76% de los casos para la capacidad vital forzada y en un 39,7% para el volumen espiratorio forzado en el primer segundo, un incumplimiento de los criterios de reproducibilidad recomendados por la American Thoracic Society. Se realizaron diagnósticos funcionales erróneos en el 39,7% de las espirometrías, con una tendencia a diagnosticar patrones falsamente "restrictivos" y a clasificar inadecuadamente la gravedad de la obstrucción en atención primaria. Conclusiones: Pese a que la mayoría de los CS de nuestra comunidad dispone de espirómetros, hemos observado una acusada infrautilización de éstos, un escaso seguimiento de las recomendaciones para la realización de la espirometría por parte de atención primaria y escasa calidad de la efectuada en este medio asistencial

Objective: To analyze the use and quality of spirometry in primary care settings in Navarre, Spain. Patients and methods: A questionnaire was completed simultaneously by professionals responsible for spirometry in all of the primary health care centers in Navarre. Data were collected on availability, model of spirometer, frequency of use, calibration, methods, personnel responsible for testing, and training of personnel. Then, baseline spirometry without a bronchodilator test was performed in 171 patients in their primary health care center and then the test was repeated on the same day in a hospital pneumology department. Spirometry was supervised by 2 pneumologists who jointly assessed the acceptability of the flow-volume curves. The quality of spirometry was assessed according to the recommendations of the American Thoracic Society and the interpretation of spirometry results according to the criteria of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). Results: A total of 90.9% of primary health care centers in Navarre have a spirometer, although 22% of those spirometers have never been used. Only 2 centers performed between 10 and 20 spirometry tests per week and none performed more than 20. In 96% of primary health care centers the spirometers were not regularly calibrated. The professionals who performed spirometry were not dedicated for that task in 51.2% of cases, and the mean period of supervised training was 10 hours. When comparisons were made between the mean values obtained in the primary care centers and the pneumology department, statistically significant differences were detected for forced vital capacity (P<.0001) and forced expiratory volume in the first second (P=.0002). Significant differences were also found between the flow-volume curves performed in the 2 different care settings for the initial and end portions of the curve as well as for the slope. The criteria for reproducibility recommended by the American Thoracic Society were not met in 76% of cases for forced vital capacity and 39.7% of cases for forced expiratory volume in the first second. Incorrect functional diagnosis occurred in 39.7% of spirometry tests and there was a tendency in the primary care settings to falsely diagnose patterns as restrictive and to inadequately classify the severity of obstruction. Conclusions: Despite the fact that spirometers are available in the majority of primary health care centers in Navarre, we found a marked underuse of these devices and little compliance with recommendations for the use of spirometry. Furthermore, the quality of the measurements performed in this care setting was very lo