Oxygen Uptake and Heart Rate On-Kinetics during Prehabilitation in Patients with Scheduled Non-Small Cell Lung Cancer Resection.

BACKGROUND: Oxygen uptake (V̇O2) and heart rate (HR) kinetics during a constant work-rate test (CWRT) are used to evaluate the response to exercise in healthy subjects as well as subjects with various pathologies. OBJECTIVES: This study aimed to explore the feasibility of these measures and their responsiveness to a prehabilitation program in patients with non-small cell lung cancer (NSCLC). METHOD: This study is preregistered (NCT04041297) ancillary analysis of a subgroup of individuals with NSCLC included in the Preo-Dens study (NCT03936764). Thirty individuals performed a moderate-CWRT before and after a 15-session prehabilitation program between July 2019 and April 2021. V̇O2 and HR on-kinetics were extracted from the first 240 s of breath-by-breath data using Box-Jenkins transfer functions. RESULTS: Pre/post V̇O2 on-kinetic feature values were reliable for 25/30 participants, and pre/post HR kinetic feature values were reliable for 19/30. V̇O2 time constant (τ) and mean response time reduced from pre-post prehabilitation (mean difference -7.8 s; 95% CI: -14.6 to -1.0, and -8.4 s; 95% CI: -14.7 to -2.0, respectively). For HR on-kinetics, τ did not change from pre-post prehabilitation (median difference -4.0 s; 95% CI: -36.0 to +11.0). V̇O2 and HR response amplitudes reduced significatively from pre-post prehabilitation (mean difference -38.6 mL/min; 95% CI: -73.3 to -3.9, and -3.1 beats/min; 95% CI: -6.4 to -0.2, respectively). CONCLUSION: V̇O2 on-kinetic analysis during moderate-CWRT is feasible in individuals with scheduled NSCLC resection, and results are responsive to prehabilitation. These results support a true speeding of the adaptation of aerobic metabolism after a 15-session prehabilitation program.

Nasal High-Flow Therapy during Exercise in Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis.

Background: Several studies have evaluated the effect of nasal high-flow (NHF) therapy to enhance exercise performance and tolerance in patients with chronic obstructive pulmonary disease (COPD); however, results are disparate. Objective: The aim of this systematic review and meta-analysis was to assess the effect of NHF therapy as an adjuvant to exercise training on functional exercise capacity in patients with COPD. Data Sources: An electronic search was performed in the following databases: PubMed, the Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, ScienceDirect, the Web of Science, OpenGrey, ClinicalTrials.gov, and European Respiratory Society and American Thoracic Society databases. Data Extraction: Two authors independently selected relevant randomized trials (parallel-group or crossover design), extracted data, assessed the risk of bias, and rated the quality of the evidence. Synthesis: Eleven studies were included, involving 408 participants (eight full papers and three conference abstracts). Most studies had a high risk of bias or other methodological limitations. The use of NHF therapy during a single session increased functional exercise capacity (standardized mean difference, 0.36 [95% confidence interval (CI), 0.03 to 0.69]; P = 0.03, heterogeneity [I2 = 83%]). When conference abstracts were included in the pooled analysis, the estimated effect did not change (P = 0.006). The use of NHF therapy throughout a pulmonary rehabilitation program (parallel-group randomized controlled trials) increased functional exercise capacity at 4-12 weeks compared with training without NHF therapy (standardized mean difference, 0.34 [95% CI, 0.00-0.68]; P = 0.05, heterogeneity [I2 = 18%]). Conclusions: There is very-low-quality to low-quality evidence that NHF therapy improves functional exercise capacity. Patient responses to NHF therapy were highly variable and heterogeneous, with benefits ranging from clinically trivial to worthwhile.

Factors influencing participation in educational workshops as part of a pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease: a retrospective study.

BACKGROUND: Pulmonary rehabilitation (PR) (primarily composed of an exercise training program (ET) and educational workshops) is an effective intervention for patients with chronic obstructive pulmonary disease. Although factors which influence participation in the full PR program have been reported, specific data on the educational component of PR have not been published. We aimed to identify factors which predict refusal to participate in the educational component of PR. RESEARCH DESIGN AND METHODS: 201 patient charts were retrospectively included in the analysis. Patients were classified according to their acceptance or refusal to participate in the educational workshops. RESULTS: The location of ET outside the center was independently related to refusal to participate in the educational workshops (OR = 0.01 [95%CI 0.00 to 0.17]). Patients who refused the workshops were less disabled according to the number of prescriptions of noninvasive ventilation, use of medical transport, oxygen consumption and workload achieved during cardiopulmonary exercise testing. CONCLUSIONS: The location of exercise sessions during PR influences patients' decisions to refuse or accept center-based educational workshops. When center-based PR programs are limited, and the ET is relocated to the patient's home, the educational workshops should also be relocated. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov (NCT04301245).

Effects of exercise training in people with non-small cell lung cancer before lung resection: a systematic review and meta-analysis.

INTRODUCTION: Exercise training before lung resection for non-small cell lung cancer is believed to decrease postoperative complications (POC) by improving cardiorespiratory fitness. However, this intervention lacks a strong evidence base. AIM: To assess the effectiveness of preoperative exercise training compared with usual care on POC and other secondary outcomes in patients with scheduled lung resection. METHODS: A systematic search of randomised trials was conducted by two authors. Meta-analysis was performed, and the effect of exercise training was estimated by risk ratios (RR) and mean differences, with their CIs. Clinical usefulness was estimated according to minimal important difference values (MID). RESULTS: Fourteen studies involving 791 participants were included. Compared with usual care, exercise training reduced overall POC (10 studies, 617 participants, RR 0.58, 95% CI 0.45 to 0.75) and clinically relevant POC (4 studies, 302 participants, Clavien-Dindo score ≥2 RR 0.42, 95% CI 0.25 to 0.69). The estimate of the effect of exercise training on mortality was very imprecise (6 studies, 456 participants, RR 0.66, 95% CI 0.20 to 2.22). The main risks of bias were a lack of participant blinding and selective reporting. Exercise training appeared to improve exercise capacity, pulmonary function and also quality of life and depression, although the clinical usefulness of the changes was unclear. The quality of the evidence was graded for each outcome. CONCLUSION: Preoperative exercise training leads to a worthwhile reduction in postoperative complications. These estimates were both accurate and large enough to make recommendations for clinical practice.

Prehabilitation sessions can be provided more frequently in a shortened regimen with similar or better efficacy in people with non-small cell lung cancer: a randomised trial.

QUESTION: In people with non-small cell lung cancer, what is the effect of condensing 15 prehabilitation sessions into a 3-week regimen compared with a 5-week regimen? DESIGN: Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment of the primary outcome. PARTICIPANTS: People with diagnosed or suspected non-small cell lung cancer and moderate-to-high risk of postoperative complications. INTERVENTION: Fifteen supervised prehabilitation sessions delivered with either a dense regimen of five sessions/week for 3 weeks (experimental group) or a non-dense regimen of three sessions/week for 5 weeks (control group). OUTCOME MEASURES: The primary outcome was the change in cardiorespiratory fitness measured by the V̇O2peak in ml/kg/min. The secondary outcomes were the change in other variables of interest measured during cardiopulmonary exercise testing, non-invasive nutritional markers, quadriceps maximal voluntary isometric contractions, maximal inspiratory pressure, quality of life, adherence and postoperative complications. RESULTS: Changes with the experimental regimen were similar to or better than changes with the control regimen for: V̇O2peak (MD 1.2 ml/kg/min, 95% CI -0.1 to 2.6); V̇E/V̇CO2 slope (MD -3.6 points, 95% CI -8.7 to 1.5); and work rate at ventilatory threshold (MD 3.7 W, 95% CI -5.6 to 13.0). The two regimens had similar effects on: peak work rate (MD 1.3 W, 95% CI -6.4 to 9.0), V̇O2 at ventilatory threshold (MD 0.0 ml/kg/min, 95% CI -1.4 to 1.4); body mass index (MD -0.2 kg/m2, 95% CI -0.5 to 0.1); and maximal inspiratory pressure (MD -0.7 cmH2O, 95% CI -9.8 to 8.4). The relative effect was uncertain for quadriceps maximal voluntary isometric contractions, quality of life and complications. CONCLUSION: Condensing prehabilitation sessions led to similar or better improvement in cardiorespiratory fitness and did not decrease adherence or increase adverse events. This could increase the number of patients who can be referred for prehabilitation, despite short presurgical periods. TRIAL REGISTRATION: NCT03936764.

Short-term effects of menthol on walking dyspnoea in patients with COPD: a randomised, single blinded, cross-over study.

Chewing menthol gum prior to exercise is a safe, easy-to-implement, low-cost, non-pharmacologic intervention that provides a reduction in dyspnoea in a third of patients and decreases the perception of discomfort during exercise in two-thirds of patients https://bit.ly/3FoFHp1.

Cardiopulmonary Exercise Testing to Assess Persistent Symptoms at 6 Months in People With COVID-19 Who Survived Hospitalization: A Pilot Study.

OBJECTIVE: The aim of this pilot study was to assess physical fitness and its relationship with functional dyspnea in survivors of COVID-19 6 months after their discharge from the hospital. METHODS: Data collected routinely from people referred for cardiopulmonary exercise testing (CPET) following hospitalization for COVID-19 were retrospectively analyzed. Persistent dyspnea was assessed using the modified Medical Research Council dyspnea scale. RESULTS: Twenty-three people with persistent symptoms were referred for CPET. Mean modified Medical Research Council dyspnea score was 1 (SD = 1) and was significantly associated with peak oxygen uptake (VO2peak; %) (rho = -0.49). At 6 months, those hospitalized in the general ward had a relatively preserved VO2peak (87% [SD = 20]), whereas those who had been in the intensive care unit had a moderately reduced VO2peak (77% [SD = 15]). Of note, the results of the CPET revealed that, in all individuals, respiratory equivalents were high, power-to-weight ratios were low, and those who had been in the intensive care unit had a relatively low ventilatory efficiency (mean VE/VCO2 slope = 34 [SD = 5]). Analysis of each individual showed that none had a breathing reserve <15% or 11 L/min, all had a normal exercise electrocardiogram, and 4 had a heart rate >90%. CONCLUSION: At 6 months, persistent dyspnea was associated with reduced physical fitness. This study offers initial insights into the mid-term physical fitness of people who required hospitalization for COVID-19. It also provides novel pathophysiological clues about the underlaying mechanism of the physical limitations associated with persistent dyspnea. Those with persistent dyspnea should be offered a tailored rehabilitation intervention, which should probably include muscle reconditioning, breathing retraining, and perhaps respiratory muscle training. IMPACT: This study is the first, to our knowledge, to show that a persistent breathing disorder (in addition to muscle deconditioning) can explain persistent symptoms 6 months after hospitalization for COVID-19 infection and suggests that a specific rehabilitation intervention is warranted.

Muscle weakness, functional capacities and recovery for COVID-19 ICU survivors.

BACKGROUND: Few studies have evaluated muscle strength in COVID-19 ICU survivors. We aimed to report the incidence of limb and respiratory muscle weakness in COVID-19 ICU survivors. METHOD: We performed a cross sectional study in two ICU tertiary Hospital Settings. COVID-19 ICU survivors were screened and respiratory and limb muscle strength were measured at the time of extubation. An ICU mobility scale was performed at ICU discharge and walking capacity was self-evaluated by patients 30 days after weaning from mechanical ventilation. RESULTS: Twenty-three patients were included. Sixteen (69%) had limb muscle weakness and 6 (26%) had overlap limb and respiratory muscle weakness. Amount of physiotherapy was not associated with muscle strength. 44% of patients with limb weakness were unable to walk 100 m 30 days after weaning. CONCLUSION: The large majority of COVID-19 ICU survivors developed ICU acquired limb muscle weakness. 44% of patients with limb weakness still had severely limited function one-month post weaning.

The relationship between maximal expiratory pressure values and critical outcomes in mechanically ventilated patients: a post hoc analysis of an observational study.

BACKGROUND: Little interest has been paid to expiratory muscle strength, and the impact of expiratory muscle weakness on critical outcomes is not known. Very few studies assessed the relationship between maximal expiratory pressure (MEP) and critical outcomes. The aim of this study was to investigate the relationship between MEP and critical outcomes. METHODS: This work was a secondary analysis of a prospective, observational study of adult patients who required mechanical ventilation for ≥ 24 h in an 18-bed ICU. MEP was assessed before extubation after a successful, spontaneous breathing trial. The relationships between MEP and extubation failure, and short-term (30 days) mortality, were investigated. Univariate logistic regressions were computed to investigate the relationship between MEP values and critical outcomes. Two multivariate analyses, with and without maximal inspiratory pressure (MIP), both adjusted using principal component analysis, were undertaken. Unadjusted and adjusted ROC curves were computed to compare the respective ability of MEP, MIP and the combination of both measures to discriminate patients with and without extubation failure or premature death. RESULTS: One hundred and twenty-four patients were included. Median age was 66 years (IQR 18) and median mechanical ventilation duration was 7 days (IQR 6). Extubation failure rate was 15% (18/124 patients) and the rate for 30-day mortality was 11% (14/124 patient). Higher MEP values were significantly associated with a lower risk of extubation failure in the univariate analysis [OR 0.96 95% CI (0.93-0.98)], but not with short-term mortality. MEP was independently linked with extubation failure when MIP was not included in the multivariate model, but not when it was included, despite limited collinearity between these variables. This study was not able to differentiate the respective abilities of MEP, MIP, and their combination to discriminate patients with extubation failure or premature death (adjusted AUC for the combination of MEP and MIP: 0.825 and 0.650 for extubation failure and premature death, respectively). CONCLUSIONS: MEP is related to extubation failure. But, the results did not support its use as a substitute for MIP, since the relationship between MEP and critical outcomes was no longer significant when MIP was included. The use of MIP and MEP measurements combined did not reach higher discriminative capacities for critical outcomes that MEP or MIP alone. Trial Registration This study was retrospectively registered at https://clinicaltrials.gov/ct2/show/NCT02363231?cond=NCT02363231&draw=2&rank=1 (NCT02363231) in 13 February 2015.

Urinary Incontinence in People Referred for Pulmonary Rehabilitation: An Undisclosed Issue but a Real Problem.

Pulmonary rehabilitation (PR) is an evidence-based intervention to manage symptoms related to chronic obstructive respiratory diseases (CORD). Paradoxically, few people with CORD actually engage in PR, and of those, up to one-third do not complete the program. Additionally, some of those who complete the program do not achieve worthwhile benefits. Therefore, the main challenge for the next decades is to offer PR to as many people (that would potentially benefit from it) as possible. This raises questions about factors influencing participation, completion, and responsiveness to PR programs. Among these factors, urinary incontinence (UI) is highly prevalent among people with CORD (much more than in the general population) and may worsen during PR exercise sessions. Paradoxically, UI is poorly explored in routine and scarcely assessed in research, and none of the actual guidelines about PR mention it. However, its potential influence on engagement, completion, and response to PR is of real concern. Therefore, the aim of this perspective is to describe the mechanisms of UI, particularly in the context of CORD, as well as to highlight its prevalence among people with CORD, their burden, and how it could affect a PR approach based on sustained and regular physical activity.

Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review.

QUESTIONS: How effective is home-based exercise therapy delivered using advanced telehealth technology (ATT-ET) for people with chronic obstructive pulmonary disease (COPD) compared with: no exercise therapy (ET), in/outpatient ET, and home-based ET without ATT? DESIGN: Systematic review and meta-analysis of randomised trials. PARTICIPANTS: People with stable COPD referred for ET. INTERVENTION: ATT-ET. OUTCOME MEASURES: Exercise capacity, quality of life, functional dyspnoea, cost-effectiveness and various secondary outcomes. RESULTS: Fifteen eligible trials involved 1,522 participants. Compared with no ET, ATT-ET improved exercise capacity (four studies, 6-minute walk test MD 15 m, 95% CI 5 to 24) and probably improved quality of life (four studies, SMD 0.22, 95% CI 0.00 to 0.43) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had a similar effect as in/outpatient ET on functional dyspnoea (two studies, SMD -0.05, 95% CI -0.39 to 0.29) and a similar or better effect on quality of life (two studies, SMD 0.23, 95% CI -0.04 to 0.50) but its relative effect on exercise capacity was very uncertain (three studies, 6-minute walk test MD 6 m, 95% CI -26 to 37). ATT-ET had a similar effect as home-based ET without ATT on exercise capacity (three studies, 6-minute walk test MD 2 m, 95% CI -16 to 19) and similar or better effects on quality of life (three studies, SMD 0.79, 95% CI -0.04 to 1.62) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had effects on most secondary outcomes that were similar to or better than each comparator. CONCLUSION: ATT-ET improves exercise capacity, functional dyspnoea and quality of life compared with no ET, although some benefits may be small. Its benefits are generally similar to in/outpatient ET and similar to or better than home-based ET without ATT. REGISTRATION: PROSPERO CRD42020165773.