Changes in physical activity during hospital admission for chronic respiratory disease.

BACKGROUND AND OBJECTIVE: Establishing the amount of inpatient physical activity (PA) undertaken by individuals hospitalized for chronic respiratory disease is needed to inform interventions. This observational study investigated whether PA changes when a person is an inpatient, how long is required to obtain representative PA measures and whether PA varies within a day and between patients of differing lengths of stay. METHODS: A total of 389 participants were recruited as early as possible into their hospitalization. Patients wore a PA monitor from recruitment until discharge. Step count was extracted for a range of wear time criteria. Single-day intraclass correlation coefficients (ICC) were calculated, with an ICC ≥ 0.80 deemed acceptable. RESULTS: PA data were available for 259 participants. No changes in daily step count were observed during the inpatient stay (586 (95% CI: 427-744) vs 652 (95% CI: 493-812) steps/day for day 2 and 7, respectively). ICC across all wear time criteria were > 0.80. The most stringent wear time criterion, retaining 80% of the sample, was ≥11 h on ≥1 day. More steps were taken during the morning and afternoon than overnight and evening. After controlling for the Medical Research Council (MRC) grade or oxygen use, there was no difference in step count between patients admitted for 2-3 days (short stay) and those admitted for 7-14 days (long stay). CONCLUSION: Patients move little during their hospitalization, and inpatient PA did not increase during their stay. A wear time criterion of 11 waking hours on any single day was representative of the entire admission whilst retaining an acceptable proportion of the initial sample size. Patients may need encouragement to move more during their hospital stay.

"We are not worthy"--understanding why patients decline pulmonary rehabilitation following an acute exacerbation of COPD.

PURPOSE: To explore how patients who refuse referral to pulmonary rehabilitation (PR) appraise acute exacerbations of chronic obstructive pulmonary disease (COPD), in the context of having considered and declined PR. METHOD: Six participants recently hospitalized with an acute exacerbation COPD who refused a referral to PR subsequent to hospital discharge participated in in-depth interviews. Transcripts were subjected to interpretative phenomenological analysis (IPA). RESULTS: Three conceptual themes emerged comprising: "Construction of the self", reflecting the impact of the acute exacerbation on personal identity; "Relinquishing control", describing participants" struggle to maintain agency following an acute event; and "Engagement with others", embodying participants' sensitivity and responsiveness to interactions with others. CONCLUSIONS: Prominent in theses participants' narratives are self-conscious cognitions which appear founded in shame and stigmatization. These cognitions seem to reflect challenges to self-worth and appear associated with reduced help-seeking and isolation. Perceived personal culpability for COPD appears to sensitize participants' towards their interactions with health care professionals, construed as critical and judgmental which may increase avoidant behaviors, such as refusal of PR. When introducing PR, professionals should be aware of such sensitivities and facilitate open discussion which offers, time, compassion and understanding as a means of facilitating uptake. IMPLICATIONS FOR REHABILITATION: Patients who decline referral to pulmonary rehabilitation report self-conscious cognitions (i.e., shame, guilt, fear of others evaluation) associated with lowered self-worth and reduced help-seeking. When introducing pulmonary rehabilitation health care professionals need to be mindful of patients' sensitivities to being shamed which stem from perceived culpability for COPD. Professionals should facilitate an open discussion with patients which offers, time, compassion and understanding as a means of facilitating pulmonary rehabilitation uptake. Compassion focused interventions which encourage trust and safety may promote active partnership working and facilitate engagement in pulmonary rehabilitation.

'Consumed by breathing' - a critical interpretive meta-synthesis of the qualitative literature.

OBJECTIVE: To derive an improved understanding of how patients respond to, appraise, and understand the experience of an acute exacerbation of chronic obstructive pulmonary disease via a critical interpretive meta-synthesis. METHODS: Search terms - Exacerbate* OR hospital* AND 'Chronic obstructive' OR emphysema OR bronchitis AND interview* OR qualitative. Inclusion criteria - Primary research published in English of patients' experiences of an acute exacerbation of chronic obstructive pulmonary disease. Data extraction and synthesis - eight papers were identified. Data were extracted by three researchers and constructs elicited via reciprocal translational analysis. FINDINGS: Themes reflected two domains of understanding an acute exacerbation: (1) Acute effect - encompassing intense emotions, somatic awareness and patients need for rescue. (2) Sustained regulation - reflecting life as interrupted, ongoing beliefs and behaviour and help-seeking. DISCUSSION: Acute exacerbations of chronic obstructive pulmonary disease result in heightened patient arousal, vigilance and powerlessness in response to symptoms. Ongoing, psychological interventions which promote partnership working by both acknowledging patients fear and shaping their appraisals may mitigate distress, enhancing the impact of health messages and engagement in pulmonary rehabilitation.

Physical activity monitoring: addressing the difficulties of accurately detecting slow walking speeds.

OBJECTIVE: To test the accuracy of a multi-sensor activity monitor (SWM) in detecting slow walking speeds in patients with chronic obstructive pulmonary disease (COPD). BACKGROUND: Concerns have been expressed regarding the use of pedometers in patient populations. Although activity monitors are more sophisticated devices, their accuracy at detecting slow walking speeds common in patients with COPD has yet to be proven. METHODS: A prospective observational study design was employed. An incremental shuttle walk test (ISWT) was completed by 57 patients with COPD wearing an SWM. The ISWT was repeated by 20 patients wearing the same SWM. RESULTS: Differences were identified between metabolic equivalents (METS) and between step-count across five levels of the ISWT (p < 0.001). Good within monitor reproducibility between two ISWT was identified for total energy expenditure and step-count (p < 0.001). CONCLUSIONS: The SWM is able to detect slow (standardized) speeds of walking and is an acceptable method for measuring physical activity in individuals disabled by COPD.

Age-specific normal values for the incremental shuttle walk test in a healthy British population.

PURPOSE: The Incremental Shuttle Walk Test (ISWT) is an important functional and prognostic marker in chronic disease. Aging has a detrimental effect on exercise performance. The objective of this study was to produce normal age-specific values for the ISWT in a healthy British population and to explore whether additional variables improve the accuracy of a predictive equation. METHODS: Healthy subjects (N = 152), aged 40 to 90 years, were recruited. Data collection occurred over 2 study visits. Anthropometric and demographic data were collected, and lung function and quadriceps maximal voluntary contraction were measured. An accelerometer was worn for 2 consecutive days at home. The Duke Activity Status Index was completed, and the greatest distance from 2 ISWTs was recorded. RESULTS: One hundred forty subjects (56 men) with mean age (SD) of 59.4 (11.0) years completed 2 ISWTs. Forced expiratory volume in 1 second (FEV(1)) was 109.1% (14.56%) predicted and ISWT distance was 737 m (183 m). Age-specific normal values for the ISWT were observed: mean (lower limit of normal)--40 to 49 years, 824 m (765 m); 50 to 59 years, 788 m (730 m); 60 to 69 years, 699 m (649 m); and 70 years and older, 633 m (562 m). A predictive equation was developed from 114 subjects. Age, body mass index, FEV(1), quadriceps maximal voluntary contraction, and Duke Activity Status Index contributed to ISWT distance predicting 50.4% of the variation in performance. CONCLUSION: We have developed age-specific normal values for performance on the ISWT in a healthy British population. However, even using practical, clinically relevant variables, it is not possible to accurately predict exercise capacity from a regression equation.

Development of the i-BODE: validation of the incremental shuttle walking test within the BODE index.

BACKGROUND: The BODE index has been shown to predict mortality in COPD. The index includes the 6 min walking test as the measure of exercise capacity. The incremental shuttle walking test (ISWT) is an alternative measure of exercise capacity which can be used to prescribe exercise and has been found to correlate well with peak VO2. The objective of the study was to evaluate the incorporation of the ISWT within the BODE index (named the i-BODE) to predict mortality in COPD. METHODS: Data was analysed from 633 patients with COPD attending pulmonary rehabilitation over an 11 year period, and mortality determined a minimum of one year on from initial assessment. An i-BODE score was calculated using ISWT(m) then Cox regression analysis evaluated the capacity of the index to predict risk of death. RESULTS: BMI, ISWT (m), MRC dyspnoea score, pack years and age were all significantly associated with mortality. Cox regression revealed the i-BODE index was an independent and significant predictor of mortality (hazard ratio 1.27 (CI 1.17-1.35), p < 0.001) and Kaplan Meier survival analysis showed each quartile increase in severity in i-BODE score was significantly associated with increased mortality (p < 0.001 by log rank test). CONCLUSION: We have found the i-BODE index to be an independent predictor of mortality in COPD, even when other strong predictors such as age and pack years are adjusted for. We conclude that the ISWT can be successfully substituted for the 6MWT as an alternative measure of exercise capacity within the BODE index.

Patterns of domestic activity and ambulatory oxygen usage in COPD.

BACKGROUND: The aim of this study was to examine patterns of domestic activity and ambulatory oxygen usage in patients with COPD in their domestic environment. METHODS: Twenty patients (14 men; mean age, 73.4 years [SD, 6.8 years]; FEV1, 1.0 L [SD, 0.5 L]) with stable COPD were recruited after completing a 7-week pulmonary rehabilitation program. Patients were either hypoxic at rest or had desaturation during exercise. Patients were randomized to an 8-week, double-blind, placebo-controlled trial of cylinder oxygen vs cylinder air. Total domestic physical activity and health-related quality of life (HRQL) measures were recorded before and after intervention. RESULTS: There were no significant changes in domestic activity or HRQL measures after the intervention for either cylinder oxygen or cylinder air, except for a worsening of the Chronic Respiratory Questionnaire dyspnea domain on cylinder air. There was a significant increase in mean duration (minutes per day) of cylinder use (p < 0.05) between weeks 1 vs 7 and weeks 1 vs 8 for the oxygen group. However, when comparing the two groups together, there were no between-group differences in cylinder use or time spent outside the home. Over the 8 weeks the majority of patients were using the cylinders in the home rather than outside, however, the number of times patients reported using the cylinders outside the home increased over the 8 weeks for the oxygen group. CONCLUSION: In the short term, ambulatory oxygen therapy is not associated with improvements in physical activity, HRQL, or time spent away from home. However, the use of cylinder oxygen increased over the 8 weeks compared to cylinder air. Patients need time to learn how to use oxygen, and ambulatory oxygen appears to enhance activities rather than increase them.

A prospective analysis of the inter-relationship between lung volume reduction surgery and body mass index.

OBJECTIVES: LVRS is thought to result in significant improvements in BMI. Patients with a higher BMI at the time of diagnosis of COPD are known to have better survival, and those with a low BMI prior to LVRS have significantly worse perioperative morbidity. We aimed to assess the influence of BMI on the outcome of LVRS in our own experience. METHODS: Complete preoperative BMI data was available in 114 of 131 consecutive patients who have undergone LVRS since 1995. These patients were arbitrarily classified into three categories: underweight (BMI26 kg/m2). The in-hospital course and perioperative change in BMI at 3, 6, 12, 24 and 36 months were prospectively recorded for each category and compared. RESULTS: There were no significant differences in preoperative variables except BMI. There were significantly more postoperative ITU admissions among the lowest two BMI groups (12/29, 18/58 and 3/27 patients, respectively, p=0.02), and significantly shorter hospital stay in overweight patients [16 days (5-79) vs 18 days (6-111) vs 13 days (6-25), respectively, p=0.005, expressed as median (range)]. However, there was no difference in survival between the three groups (p=0.21). Postoperative physiological improvements in the first year were related to preoperative BMI for both FEV1 (r=0.29, p=0.02) and DLCO (r=0.33, p=0.02). Postoperative BMI significantly increased in the underweight yet significantly decreased in the overweight at all time points. CONCLUSIONS: The perioperative course of LVRS and its physiological benefits are influenced by preoperative BMI. Whilst the treatment of the underweight is more complicated, LVRS may be the only way of increasing their BMI. Future work is needed to explore the roles of changing energy requirements and body composition following LVRS.

Comparison of the peak exercise response measured by the ramp and 1-min step cycle exercise protocols in patients with exertional dyspnea.

STUDY OBJECTIVES: To compare the peak exercise response and determine the limits of agreement between the ramp and the 1-min step cycle protocols in a representative population of patients with exertional breathlessness attending a respiratory outpatient clinic. DESIGN: Crossover with the test order double blinded and randomized. SETTING: Outpatient exercise physiology laboratory. PATIENTS: Twenty-two patients (12 men; mean [SD] age, 59 [8] years; FEV(1), 71% [21%]) with lung disease and/or exertional breathlessness. INTERVENTION: Symptom-limited, maximum cycle exercise tests using a ramp and a 1-min step work rate (WR) protocols. The two protocols were assigned to subjects in a randomized manner. MEASUREMENTS AND RESULTS: Oxygen uptake (O(2)), minute ventilation (E), heart rate (HR), WR, exercise time, and Borg scores were compared at symptom-limited peak exercise. The mean (SD) peak values for the ramp and the step protocols, respectively, were as follows: peak O(2), 1.51 (0.44) L/min and 1.49 (0.43) L/min; peak E, 50.8 (12.9) L/min and 49.9 (14.5) L/min; and peak HR, 133 (24) beats/min and 131 (22) beats/min (p > 0.05). There were no significant differences between breathlessness and perceived exertion at peak exercise. Peak WR (WRpeak) and exercise time were significantly higher using the ramp protocol: 110.5 (37.1) W vs 105.6 (35.6) W, and 8.2 (2.0) min vs. 7.6 (1.9) min, respectively. CONCLUSIONS: The ramp protocol leads to a higher WRpeak, and this may have implications for exercise prescription. However, there were no significant differences between the two protocols for the peak physiologic responses. The choice of protocol for the measurement of maximal exercise capacity remains one of laboratory preference.