The importance of addressing physical activity and exercise intolerance in our patients with COPD.

Both increased physical activity and increased exercise capacity are desired outcomes in the treatment of individuals with COPD https://bit.ly/4apLYzm.

A Cross-Sectional Study Evaluating the Association of Brachial Artery Flow Mediated Vasodilation with Physical Activity Measured by Accelerometry in Patients with the Overlap of Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in Overlap Syndrome (OS), the co-occurrence of Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease. Clustering of patients in subgroups with similar pre-clinical manifestations (ie, endothelial dysfunction) may identify relevant therapeutic phenotype categories for patients with OS who are at high risk of CVD. We therefore conducted a cross-sectional pilot study of endothelial function in 7 patients with OS (Forced Expiratory Volume in 1 second/Forced Vital Capacity < 0.7) on continuous positive airway pressure therapy (n = 7) to assess the relationship between FMD and physical activity. We found a strong association between FMD and step counts (rho = 0.77, p = 0.04); and FMD and moderate physical activity (rho = 0.9, p = 0.005). Further, larger studies are needed to confirm that FMD may identify patients with OS at high risk of CVD who benefit from increased physical activity.

COPD: Providing the right treatment for the right patient at the right time.

Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Promoting Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease, Strategies of Top-performing Systems: A Qualitative Study.

Rationale: Pulmonary rehabilitation (PR) after hospitalization for chronic obstructive pulmonary disease (COPD) is recommended by guidelines; however, few patients participate, and rates vary between hospitals. Objectives: To identify contextual factors and strategies that may promote participation in PR after hospitalization for COPD. Methods: Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States, we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th percentile, at least 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of PR rates after discharge, we identified innovative hospitals on the basis of a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes. Results: Interviews were conducted with 38 stakeholders at nine hospitals (seven high-performers and two innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR medical directors, PR managers, respiratory therapists, inpatient and outpatient providers, and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after admission for COPD in response to the Centers for Medicare and Medicaid Services/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance in overcoming barriers. Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of a larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.

Potential downside issues with telemedicine for individuals with chronic respiratory diseases.

Telemedicine refers to the use of communications technologies to provide or enhance medical care through mitigating the negative effects of patient-caregiver distance on medical evaluation and treatment. The general concept, telemedicine, can refer to a number of interventions, such as telemonitoring, tele-consultations, tele-education, tele-communication, and tele-rehabilitation. While telemedicine has seen steady growth its trajectory has increased during the COVID-19 pandemic. As a tool in health care delivery, telemedicine is often met with patient satisfaction often resulting from ease of use and accessibility.  Additionally, outcomes may improve, although the medical literature is not consistent in this regard.  However, enthusiasm over its beneficial effects should be tempered by negative aspects, including the decrease in direct patient-clinician interaction (such as loss of information from the physical examination) and potentially serious privacy risks. Finding a happy median between positive and negative features of telemedicine remains a work in progress.

The Role of Telemedicine in Extending and Enhancing Medical Management of the Patient with Chronic Obstructive Pulmonary Disease.

Medical management of a chronic obstructive pulmonary disease (COPD) patient must incorporate a broadened and holistic approach to achieve optimal outcomes. This is best achieved with integrated care, which is based on the chronic care model of disease management, proactively addressing the patient's unique medical, social, psychological, and cognitive needs along the trajectory of the disease. While conceptually appealing, integrated care requires not only a different approach to disease management, but considerably more health care resources. One potential way to reduce this burden of care is telemedicine: technology that allows for the bidirectional transfer of important clinical information between the patient and health care providers across distances. This not only makes medical services more accessible; it may also enhance the efficiency of delivery and quality of care. Telemedicine includes distinct, often overlapping interventions, including telecommunication (enhancing lines of communication), telemonitoring (symptom reporting or the transfer of physiological data to health care providers), physical activity monitoring and feedback to the patient and provider, remote decision support systems (identifying "red flags," such as the onset of an exacerbation), tele-consultation (directing assessment and care from a distance), tele-education (through web-based educational or self-management platforms), tele-coaching, and tele-rehabilitation (providing educational material, exercise training, or even total pulmonary rehabilitation at a distance when standard, center-based rehabilitation is not feasible). While the above components of telemedicine are conceptually appealing, many have had inconsistent results in scientific trials. Interventions with more consistently favorable results include those potentially modifying physical activity, non-invasive ventilator management, and tele-rehabilitation. More inconsistent results in other telemedicine interventions do not necessarily mean they are ineffective; rather, more data on refining the techniques may be necessary. Until more outcome data are available clinicians should resist being caught up in novel technologies simply because they are new.

Association between Initiation of Pulmonary Rehabilitation and Rehospitalizations in Patients Hospitalized with Chronic Obstructive Pulmonary Disease.

Rationale: Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, less is known about PR's impact in routine clinical practice. Objectives: To evaluate the association between initiation of PR within 90 days of discharge and rehospitalization(s). Methods: We analyzed a retrospective cohort of Medicare beneficiaries (66 years of age or older) hospitalized for COPD in 2014 who survived at least 30 days after discharge. Measurements and Main Results: We used propensity score matching and estimated the risk of recurrent all-cause rehospitalizations at 1 year using a multistate model to account for the competing risk of death. Of 197,376 total patients hospitalized in 4,446 hospitals, 2,721 patients (1.5%) initiated PR within 90 days of discharge. Overall, 1,534 (56.4%) patients who initiated PR and 125,720 (64.6%) who did not were rehospitalized one or more times within 1 year of discharge. In the propensity-score-matched analysis, PR initiation was associated with a lower risk of readmission in the year after PR initiation (hazard ratio, 0.83; 95% confidence interval, 0.77-0.90). The mean cumulative number of rehospitalizations at 1 year was 0.95 for those who initiated PR within 90 days and 1.15 for those who did not (P < 0.001). Conclusions: After hospitalization for COPD, Medicare beneficiaries who initiated PR within 90 days of discharge experienced fewer rehospitalizations over 1 year. These results support findings from randomized controlled clinical trials and highlight the need to identify effective strategies to increase PR participation.

Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report.

Pulmonary rehabilitation is a highly effective treatment for people with chronic lung disease but remains underused across the world. Recent years have seen the emergence of new program models that aim to improve access and uptake, including telerehabilitation and low-cost, home-based models. This workshop was convened to achieve consensus on the essential components of pulmonary rehabilitation and to identify requirements for successful implementation of emerging program models. A Delphi process involving experts from across the world identified 13 essential components of pulmonary rehabilitation that must be delivered in any program model, encompassing patient assessment, program content, method of delivery, and quality assurance, as well as 27 desirable components. Only those models of pulmonary rehabilitation that have been tested in clinical trials are currently considered as ready for implementation. The characteristics of patients most likely to succeed in each program model are not yet known, and research is needed in this area. Health professionals should use clinical judgment to determine those patients who are best served by a center-based, multidisciplinary rehabilitation program. A comprehensive patient assessment is critical for personalization of pulmonary rehabilitation and for effectively addressing individual patient goals. Robust quality-assurance processes are important to ensure that any pulmonary rehabilitation service delivers optimal outcomes for patients and health services. Workforce capacity-building and training should consider the skills necessary for emerging models, many of which are delivered remotely. The success of all pulmonary rehabilitation models will be judged on whether the essential components are delivered and on whether the expected patient outcomes, including improved exercise capacity, reduced dyspnea, enhanced health-related quality of life, and reduced hospital admissions, are achieved.

Medical Director Responsibilities for Outpatient Pulmonary Rehabilitation Programs in the United States: 2019: A STATEMENT FOR HEALTH CARE PROFESSIONALS FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION (AACVPR).

Clinical guidelines have been developed recognizing pulmonary rehabilitation (PR) as a key component in the management of patients with chronic lung disease. The medical director of a PR program is a key player in every program and is a requirement for operation of the program. The medical director must be a licensed physician who has experience in respiratory physiology management. The purpose of this document is to provide an update regarding the clinical, programmatic, legislative, and regulatory issues that impact PR medical directors in North America. It describes the clinical rationale for physician involvement, relevant legislative and regulatory requirements, and resources available that the medical director can utilize to promote evidence-based and cost-effective PR services. All pulmonary rehabilitation (PR) programs must include a medical director. There are many clinical, programmatic, legislative, and regulatory issues that impact the PR medical director. The purpose of this document is to concentrate on the unique roles and responsibilities of the PR medical director.

Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries.

Importance: Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge. Objective: To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival. Design, Setting, and Patients: This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015. Exposures: Initiation of pulmonary rehabilitation within 90 days of hospital discharge. Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality. Results: Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01). Conclusions and Relevance: Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.

A Geographic Analysis of Racial Disparities in Use of Pulmonary Rehabilitation After Hospitalization for COPD Exacerbation.

BACKGROUND: Guidelines recommend pulmonary rehabilitation (PR) after hospitalization for an exacerbation of COPD, but few patients enroll in PR. We explored whether density of PR programs explained regional variation and racial disparities in receipt of PR. METHODS: We used Centers for Medicare & Medicaid Services data from 223,832 Medicare beneficiaries hospitalized for COPD during 2012 who were eligible for PR postdischarge. We used Hospital-Referral Regions (HRR) as the unit of analysis. For each HRR, we calculated the density of PR programs as a measure of program access and estimated risk-standardized rates of PR within 6 months of discharge overall, and for non-Hispanic, white, and black beneficiaries. We used linear regression to examine the relationship between access to PR and HRR PR rates. We tested for racial disparity in PR rates among non-Hispanic white and black beneficiaries living in the same HRRs. RESULTS: Across 306 HRRs, the median number of PR programs per 1,000 Medicare beneficiaries was 0.06 (interquartile range [IQR], 0.04-0.10). Risk-standardized rates of PR ranged from 0.53% to 6.67% (median, 1.93%). Density of PR programs was positively associated with PR rates overall and among non-Hispanic white beneficiaries (P < .001), but this relationship was not observed among black beneficiaries. Rates were higher among non-Hispanic white beneficiaries (median, 2.08%; IQR, 1.54%-2.87%) compared with black beneficiaries (median, 1.19%; IQR, 1.15%-1.20%). CONCLUSIONS: Greater PR program density was associated with higher rates of PR for non-Hispanic white but not black beneficiaries. Further research is needed to identify reasons for this discrepancy and strategies to increase receipt of PR for black patients.

Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease among Medicare Beneficiaries.

RATIONALE: Current guidelines recommend pulmonary rehabilitation (PR) after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, but little is known about its adoption or factors associated with participation. OBJECTIVES: To evaluate receipt of PR after a hospitalization for COPD exacerbation among Medicare beneficiaries and identify individual- and hospital-level predictors of PR receipt and adherence. METHODS: We identified individuals hospitalized for COPD during 2012 and recorded receipt, timing, and number of PR visits. We used generalized estimating equation models to identify factors associated with initiation of PR within 6 months of discharge and examined factors associated with number of PR sessions completed. RESULTS: Of 223,832 individuals hospitalized for COPD, 4,225 (1.9%) received PR within 6 months of their index hospitalization, and 6,111 (2.7%) did so within 12 months. Median time from discharge until first PR session was 95 days (interquartile range, 44-190 d), and median number of sessions completed was 16 (interquartile range, 6-25). The strongest factor associated with initiating PR within 6 months was prior home oxygen use (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.39-1.59). Individuals aged 75-84 years and those aged 85 years and older (respectively, OR, 0.70; 95% CI, 0.66-0.75; and OR, 0.25; 95% CI 0.22-0.28), those living over 10 miles from a PR facility (OR, 0.42; 95% CI, 0.39-0.46), and those with lower socioeconomic status (OR, 0.42; 95% CI, 0.38-0.46) were less likely to receive PR. CONCLUSIONS: Two years after Medicare began providing coverage for PR, participation rates after hospitalization were extremely low. This highlights the need for strategies to increase participation.

Incorporating telemedicine into the integrated care of the COPD patient a summary of an interdisciplinary workshop held in Stresa, Italy, 7-8 September 2017.

This report is a summary of a workshop focusing on using telemedicine to facilitate the integrated care of chronic obstructive pulmonary disease (COPD). Twenty-five invited participants from 8 countries met for one and one-half days in Stresa, Italy on 7-8 September 2017, to discuss this topic. Participants included physiotherapists, nurses, a nurse practitioner, and physicians. While evidence-based data are always at the center of sound inference and recommendations, at this point in time the science behind telemedicine in COPD remains under-developed; therefore, this document reflects expert opinion and consensus. While telemedicine has great potential to expand and improve the care of our COPD patients, its application is still in its infancy. While studies have demonstrated its effectiveness in some patient-centered outcomes, the results are by no means consistently positive. Whereas this tool may potentially reduce health care costs by moving some medical interventions from centralized locations in to patient's home, its cost-effectiveness has had mixed results and telemonitoring has yet to prove its worth in the COPD population. These discordant results should not be unexpected in view of patient complexity and the heterogeneity of telemedicine. This is reflected in the very limited support offered by the National Health Services to a wider application of telemedicine in the integrated care of COPD patients. However, this situation should challenge us to develop the necessary science to clarify the role of telemedicine in the medical management of our patients, providing a better and definitive scientific basis to this approach.

Integrated Care in Chronic Obstructive Pulmonary Disease and Rehabilitation.

Individuals with advanced chronic obstructive pulmonary disease (COPD) often have complex medical problems that require more than simple pharmacological therapy to optimize outcomes. Comprehensive care is necessary to meet the substantial burdens, not just from the primary respiratory disease process itself, but also those imposed by its systemic manifestations and comorbidities. These problems are intensified in the peri-exacerbation period, especially for newly discharged patients. Pulmonary rehabilitation, with its interdisciplinary, patient-centered and holistic approach to management, and integrated care, adding coordination or transition of care to the chronic care model, are useful approaches to meeting these complex issues.

COPD Advanced Patient Management.

COPD is the third leading cause of death in the United States, with current rates of both morbidity and mortality persisting and contributing significantly to long-term disability. More than 11 million Americans are diagnosed with COPD, with an additional 13 million people estimated to be living with undiagnosed disease. For patients diagnosed with COPD, the turning point will be hospitalization. It is important, therefore, that new treatment techniques that manage the signs and symptoms of the COPD and impact the prevalence and severity of exacerbations, hospital admissions, quality of life, and activities of daily living, and innovative clinical management strategies that optimize hospital discharge planning, all show promise in improving outcomes for patients with COPD. In particular, readmissions following COPD hospitalization are associated with high morbidity, mortality, and costs of care, and therefore hospital readmissions are receiving close scrutiny as an opportunity to improve patient care. To this end, programs to assess the presence and severity of dyspnea, and secretion burden and clearance, through implementation of a telemedicine program, use of noninvasive ventilation or supplemental oxygen, and development of a comprehensive self-management program have all been found to be variously effective as elements of a posthospitalization treatment plan. In this series of multi-media presentations and roundtable discussions published in CHEST (available at http://journal.cme.chestnet.org/copd-advanced-patient), leading international faculties discuss some of these specific interventions in detail to provide clinicians with possible solutions to the challenges of managing their patients with advanced COPD.

Chronic Obstructive Pulmonary Disease Education in Pulmonary Rehabilitation. An Official American Thoracic Society/Thoracic Society of Australia and New Zealand/Canadian Thoracic Society/British Thoracic Society Workshop Report.

According to the 2013 American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation (PR), education to promote effective self-management is a cornerstone of this intervention. Despite education's stature within PR, there is currently limited evidence supporting its overall efficacy, and minimal evidence guiding its optimal design and delivery. This workshop was convened to focus on the current state of education in PR for patients with chronic obstructive pulmonary disease, who are the most common people referred to PR. The workshop explored the learning needs and limitations of patients participating in PR, promising design features (from work done outside of PR) that may inform our approach to education, and professional development of PR healthcare educators. Areas identified as needing development include: 1) outcome assessment for the educational component; 2) screening patients for conditions that will impede the learning process (anxiety, depression, cognitive deficits and health literacy issues); 3) tailoring content and optimizing delivery of the educational component; and 4) training PR professionals in their roles as educators. By necessity, the workshop conclusions are painted in broad strokes. However, with ongoing interest in improving quality through individualized patient assessment, educational design innovations, and scientific scrutiny comparable to that given to exercise training, the educational component of PR may achieve effective self-management, leading to successful behavior change and enhancement in health.