The Beneficial Impact of Pulmonary Rehabilitation in Idiopathic Pulmonary Fibrosis: A Review of the Current Literature.

Idiopathic pulmonary fibrosis (IPF) is a chronic and irreversible fibrotic disease whose natural history is characterised by a progressive worsening of the pulmonary function, exertional dyspnoea, exercise intolerance, reduced physical activity, and health-related quality of life (HRQOL) impairment. Pulmonary rehabilitation (PR) is a comprehensive, multi-disciplinary programme that uses a combination of strength training, teaching, counselling, and behaviour modification techniques to reduce symptoms and optimise functional capacity in patients with chronic lung disease. Based on the well-documented effectiveness of PR in chronic obstructive pulmonary disease (COPD), over the years supportive evidence of its benefits for other respiratory diseases has been emerging. Although the latest rehabilitation guidelines recognised PR's efficacy for interstitial lung disease (ILD) and IPF in particular, this comprehensive approach remains underused and under-resourced. In this review, we will discuss the advantages and beneficial effects of PR on IPF, analysing its impact on exercise capacity, disease-related symptoms, cardiovascular outcomes, body composition, and HRQOL.

Home-based exercise program for people with residual disability following hospitalization for COVID-19: Randomized control trial.

BACKGROUND: The best exercise program for individuals with effort intolerance or hypoxia at rest and/or during exercise post-COVID-19 treatment who have already had in-hospital rehabilitation remains unknown. OBJECTIVE: We evaluated the efficacy of a home-based rehabilitation exercise program intervention that included teleconsultations with a specialist nurse. METHODS: This was a multicenter randomized controlled trial for individuals who had been diagnosed with, and treated for, COVID-19. Despite inpatient rehabilitation they still had effort intolerance; this was defined as being a) only able to walk <70 % of the predicted distance during the six-minute walking test (6MWT) and/or b) oxygen desaturation all day long/during effort. The primary outcome was effort tolerance, as evaluated by the 6MWT. Secondary outcomes were dyspnea, fatigue, spirometry, respiratory muscle evaluations, and oxygenation. The Intervention group performed 4 weeks of a self-directed exercise program with bi-weekly physiotherapist video calls; the Control group participated in physical activity howsoever they wished. Exercises were divided into 4 intensity levels according to disability and oxygen desaturation. The program progressively increased from low (walking, free-body exercise, sit-to-stand, and balance exercises) to high (speed walking with a pedometer, cycle ergometer, and strengthening exercises). RESULTS: We included 79 participants: 40 in the Intervention and 39 in the Control group. Mean (SD) age was 67.1 (10.3) years; 72 % (n = 57) were male. No intergroup differences in effort tolerance were found [Intervention 77.6 (75.4)m vs Control 49.5 (73.3)m (p = 0.109)]. Participants with 6MWT distance results < lower limit of normality values showed best improvements in mean (SD) effort tolerance: Intervention, 120.1 (75.8)m vs Control, 59.1 (75.6)m (p = 0.035). After 2 months, mean (SD) 6MWT distances in the 2 groups were similar: Intervention, 475.9 (82.4)m vs Control, 469.2 (118.9)m (p = 0.807). CONCLUSIONS: In individuals with residual disability post-COVID-19 and after inpatient rehabilitation, a home-based exercise program with teleconsultation significantly improves effort tolerance but only for people who had severe effort intolerance at baseline. DATABASE REGISTRATION: ClinicalTrials.gov number, NCT04821934.

Predicting Response to In-Hospital Pulmonary Rehabilitation in Individuals Recovering From Exacerbations of Chronic Obstructive Pulmonary Disease / Predicción de la respuesta a la rehabilitación pulmonar hospitalaria en personas que se recuperan de exacerbaciones de la enfermedad pulmonar obstructiva crónica

Background: Predicting the response to pulmonary rehabilitation (PR) could be valuable in defining admission priorities. We aimed to investigate whether the response of individuals recovering from a COPD exacerbation (ECOPD) could be forecasted using machine learning approaches. Method: This multicenter, retrospective study recorded data on anthropometrics, demographics, physiological characteristics, post-PR changes in six-minute walking distance test (6MWT), Medical Research Council scale for dyspnea (MRC), Barthel Index dyspnea (BId), COPD assessment test (CAT) and proportion of participants reaching the minimal clinically important difference (MCID). The ability of multivariate approaches (linear regression, quantile regression, regression trees, and conditional inference trees) in predicting changes in each outcome measure has been assessed. Results: Individuals with lower baseline 6MWT, as well as those with less severe airway obstruction or admitted from acute care hospitals, exhibited greater improvements in 6MWT, whereas older as well as more dyspnoeic individuals had a lower forecasted improvement. Individuals with more severe CAT and dyspnea, and lower 6MWT had a greater potential improvement in CAT. More dyspnoeic individuals were also more likely to show improvement in BId and MRC. The Mean Absolute Error estimates of change prediction were 44.70m, 3.22 points, 5.35 points, and 0.32 points for 6MWT, CAT, BId, and MRC respectively. Sensitivity and specificity in discriminating individuals reaching the MCID of outcomes ranged from 61.78% to 98.99% and from 14.00% to 71.20%, respectively. Conclusion: While the assessed models were not entirely satisfactory, predictive equations derived from clinical practice data might help in forecasting the response to PR in individuals recovering from an ECOPD. Future larger studies will be essential to confirm the methodology, variables, and utility.(AU)

Upper-limb interval versus constant-load exercise in patients with COPD: a physiological crossover study.

Objective: Upper-limb exercise is recommended for patients with COPD, albeit there are limited data concerning the optimal modality to implement. We compared interval (INT-EX) to continuous (CONT-EX) upper-limb exercise in terms of exercise tolerance, ventilatory and metabolic responses when both conditions were sustained at an equivalent work rate. Methods: 26 stable COPD patients undertook three upper-limb exercise sessions to initially establish peak work rate (PWR) via an incremental exercise test and subsequently two equivalent work rate tests to the limit tolerance in balanced order: 1) INT-EX consisting of 30-s work at 100% PWR interspersed with 30-s work at 40% of PWR; and 2) CONT-EX at 70% PWR. Results: 20 patients (76.9%) had longer tolerance during INT-EX, while six out of 26 (23.1%) exhibited longer tolerance during CONT-EX. The average endurance time was 434.1±184.7 and 315.7±128.7 s for INT-EX and CONT-EX, respectively. During INT-EX at isotime (i.e. when work completed was the same between INT-EX and CONT-EX), the majority of patients manifested lower oxygen uptake, minute ventilation, pulmonary hyperinflation, heart rate, symptoms and higher CO2 blood concentration. Patients with longer INT-EX had a lower comorbidity score (Cumulative Illness Rating Scale: 1.58±0.30 versus 1.88±0.29, p=0.0395) and better-preserved lung function (forced vital capacity 84.7±15.31% versus 67.67±20.56%, p=0.0367; forced expiratory volume in 1 s 57.15±14.59 versus 44.67±12.99% predicted, p=0.0725) compared to patients with longer CONT-EX. Conclusion: INT-EX is more sustainable than CONT-EX for the majority of COPD patients with moderate obstruction, leading to lower dynamic hyperinflation and symptoms at isotime. Further studies need to define the benefits of its application during pulmonary rehabilitation.

Hospital-Provider Company Network for Home Non-Invasive Ventilation: A Feasibility Pilot Study.

This study assessed the feasibility of implementing a hybrid hospital-provider company (PC) clinical pathway for patients with chronic respiratory failure (CRF) through the adaptation and follow-up of non-invasive ventilation (NIV). Over a 3-month period, a PC physiotherapist case manager oversaw the adaptation process, making adjustments as necessary, using remote monitoring and home visits. Outcome measures, including the number of patients enrolled, serious adverse events, hospitalizations, survival rates, professional time allocation, NIV adherence, nocturnal apnea-hypopnea, and oxygen saturation, Δ arterial carbon dioxide pressure (PaCO2), dyspnea, Short Physical Performance Battery (SPPB), exercise tolerance, quality of life, physical activity, and patient satisfaction, were collected. The recruitment rate was 74% (nineteen patients). Commonly reported adverse events included leakage, discomfort and sleep disturbance. Predominant interventions were four home visits (3; 4) and two NIV adjustments (1; 5). The overall program time commitment averaged 43.97 h per patient (being hospital 40 ± 11% and PC 60 ± 11%). Improvements in PaCO2, dyspnea, SPPB and exercise tolerance were observed by the third month. Adherence to NIV was high, with good or very good satisfaction with its use. This study demonstrates that a hybrid hospital-PC service for NIV adaptation and follow-up is not only feasible but also shows validity, reliability, and acceptability.

Predicting Response to In-Hospital Pulmonary Rehabilitation in Individuals Recovering From Exacerbations of Chronic Obstructive Pulmonary Disease.

BACKGROUND: Predicting the response to pulmonary rehabilitation (PR) could be valuable in defining admission priorities. We aimed to investigate whether the response of individuals recovering from a COPD exacerbation (ECOPD) could be forecasted using machine learning approaches. METHOD: This multicenter, retrospective study recorded data on anthropometrics, demographics, physiological characteristics, post-PR changes in six-minute walking distance test (6MWT), Medical Research Council scale for dyspnea (MRC), Barthel Index dyspnea (BId), COPD assessment test (CAT) and proportion of participants reaching the minimal clinically important difference (MCID). The ability of multivariate approaches (linear regression, quantile regression, regression trees, and conditional inference trees) in predicting changes in each outcome measure has been assessed. RESULTS: Individuals with lower baseline 6MWT, as well as those with less severe airway obstruction or admitted from acute care hospitals, exhibited greater improvements in 6MWT, whereas older as well as more dyspnoeic individuals had a lower forecasted improvement. Individuals with more severe CAT and dyspnea, and lower 6MWT had a greater potential improvement in CAT. More dyspnoeic individuals were also more likely to show improvement in BId and MRC. The Mean Absolute Error estimates of change prediction were 44.70m, 3.22 points, 5.35 points, and 0.32 points for 6MWT, CAT, BId, and MRC respectively. Sensitivity and specificity in discriminating individuals reaching the MCID of outcomes ranged from 61.78% to 98.99% and from 14.00% to 71.20%, respectively. CONCLUSION: While the assessed models were not entirely satisfactory, predictive equations derived from clinical practice data might help in forecasting the response to PR in individuals recovering from an ECOPD. Future larger studies will be essential to confirm the methodology, variables, and utility.

Rehabilitation complexity scale and reimbursement of in-hospital pulmonary rehabilitation.

Background: The use of case-based reimbursement for medical rehabilitation is greatly discussed. The investigators explored the relationship between disability and reimbursement opportunities in individuals with respiratory diseases undergoing in-hospital pulmonary rehabilitation (PR), considering the correlation (if any) between the Rehabilitation Complexity Scale (RCS-E v13) scores used at admission and the actual reimbursement. Methods: This study is part of a larger prospective multicenter study conducted by eight Pulmonary Rehabilitation Units in Italy. Here, investigators considered only data from the Lombardy Region. On January 30th or February 28th, 2023, participants were allocated according to the main DRG into 4 groups [tracheostomized/ventilated (TX/V), chronic respiratory failure (CRF), COPD, and miscellaneous group]. We recorded anthropometrics, diagnosis, international outcome measures, and calculated admission and discharge RCS-E v13 scores and hospital stay reimbursement according to the healthcare system (HS). Results: Three hundred and sixteen participants were evaluated. Patients were elderly, in the majority of cases with CRF, presenting comorbidities, disability, dyspnea, and reduced effort tolerance. At admission, RCS-E v13 showed an average moderate value of complexity. The median (IQR) HS reimbursement/stay was different among groups. RCSE v13 evaluated at admission was weakly (r=0.3471), but significantly related to the HS reimbursement/stay (p<0.0001) mainly due to TX/V and miscellaneous subgroups, while no relationship was found for COPD and CRF patients. After PR, all outcome measures improved significantly in all groups (p<0.001 for all). Higher RCS-E v13 scores at admission did not correspond to a proper amount of reimbursement, being this latter under- or over-estimated if compared to needs assessed by RCS-E v13. RCS-E v13 at discharge decreased for all subgroups (range from -6 to -11) reaching a low value of complexity. Conclusions: The RCS-E v13 disability score does not fully mirror the HS reimbursement for patients undergoing inhospital PR.

Comparison among three different follow-up models for obstructive sleep apnea syndrome patients: focus on the physiotherapist's role.

In obstructive sleep apnea syndrome (OSAS) subjects different follow-up modalities have been proposed to improve adherence to the continuous positive airway pressure (CPAP) device. This retrospective study compares three different health professional approaches dedicated to caring OSAS patients in three consecutive follow-up periods of 15 months each. The three different follow-up models are: i) physician-oriented follow-up (P-F); ii) physiotherapist-oriented follow-up (PT-F); and iii) tele-titration plus PT-oriented follow-up (TT-PT-F). Health personal visits and actions delivered, patients' adherence, CPAP efficacy, and problems under CPAP use were considered for comparison. Data from 122 OSAS patients with a new prescription of CPAP were analyzed: 39 (32.0%) in the P-F, 38 (31.1%) in the PT-F, and 45 (36.9%) in the TT-PT-F period. We found a reduction over time (from 40.9% in P-F to 8.2% in TT-PT-F, p<0.001) in patients missing the 1-year follow-up visit. The PT-F and TT-PT-F lead to a reduction in physician visits in comparison to P-F (5.2% and 8.9% vs 100%, p<0.001) with no differences in time to the first follow-up visit, CPAP efficacy, and patients' adherence among the three periods. More device-related problems were found in the PT-F (57.8%), compared with the PF (25.6%) period (p<0.001); the most common troubles were mask problems evaluated in 26.2% of cases. In conclusion, different follow-up models offer similar efficacy and short-term adherence for CPAP leading to a significant reduction in physician visits under the PT-F with or without tele-titration, being mask problems as the most commonly treated. Further analysis should be useful to define the best cost-efficacy follow-up intervention.

Effects of pulmonary rehabilitation in survivors of severe acute respiratory syndrome coronavirus 2. Role of vaccination.

Survivors of severe COVID-19 requiring hospital admission may suffer from short- and long-term sequelae, including disability and reduced physical performance. Vaccination and pulmonary rehabilitation (PR) are effective tools against COVID-19 effects. While the beneficial effect of each of these treatments is known, there are no data about their combined effect. In people admitted to PR hospitals after severe COVID-19 disease, we retrospectively analyzed whether PR outcome might be influenced by vaccination status. Ninety-six individuals were studied (46 vaccinated, 50 unvaccinated). Unvaccinated individuals were younger and less comorbid than vaccinated ones and had needed more intensive care support during the previous hospitalization. Measures of disability and physical performance did not differ between groups at the beginning and at the end of the PR program. However, each group showed a statistically significant improvement in all outcome measures (6-minute walking test, short physical performance battery, Barthel Index). We conclude that vaccination status does not influence the outcome of in-patient PR programs for survivors of severe COVID-19.

COVID-19 teleassistance and teleconsultation: a matched case-control study (MIRATO project, Lombardy, Italy).

Background: During the COVID-19 pandemic, telemedicine has been recognised as a powerful modality to shorten the length of hospital stay and to free up beds for the sicker patients. Lombardy, and in particular the areas of Bergamo, Brescia, and Milan, was one of the regions in Europe most hit by the COVID-19 pandemic. The primary aim of the MIRATO project was to compare the incidence of severe events (hospital readmissions and mortality) in the first three months after discharge between COVID-19 patients followed by a Home-Based Teleassistance and Teleconsultation (HBTT group) program and those discharged home without Telemedicine support (non-HBTT group). Methods: The study was designed as a matched case-control study. The non-HBTT patients were matched with the HBTT patients for sex, age, presence of COVID-19 pneumonia and number of comorbidities. After discharge, the HBTT group underwent a telecare nursing and specialist teleconsultation program at home for three months, including monitoring of vital signs and symptoms. Further, in this group we analysed clinical data, patients' satisfaction with the program, and quality of life. Results: Four hundred twenty-two patients per group were identified for comparison. The median age in both groups was 70 ± 11 years (62% males). One or more comorbidities were present in 86% of the HBTT patients and 89% in the non-HBTT group (p = ns). The total number of severe events was 17 (14 hospitalizations and 3 deaths) in the HBTT group and 40 (26 hospitalizations and 16 deaths) in the non-HBTT group (p = 0.0007). The risk of hospital readmission or death after hospital discharge was significantly lower in HBTT patients (Log-rank Test p = 0.0002). In the HBTT group, during the 3-month follow-up, 5,355 teleassistance contacts (13 ± 4 per patient) were performed. The number of patients with one or more symptoms declined significantly: from 338 (78%) to 183 (45%) (p < 0.00001). Both the physical (ΔPCS12: 5.9 ± 11.4) component and the mental (ΔMCS12: 4.4 ± 12.7) component of SF-12 improved significantly (p < 0.0001). Patient satisfaction with the program was very high in all participants. Conclusions: Compared to usual care, an HBTT program can reduce severe events (hospital admissions/mortality) at 3-months from discharge and improve symptoms and quality of life. Clinical trial registration: www.ClinicalTrials.gov, NCT04898179.

Effect of Pulmonary Rehabilitation on COPD Assessment Test Items in Individuals Classified as GOLD Group E.

BACKGROUND: A new Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification has been proposed, based also on COPD Assessment Test (CAT). OBJECTIVES: The aim of this large, multicenter, retrospective study was to determine the impact of pulmonary rehabilitation (PR) on CAT items in individuals with COPD, GOLD group E, recovering from an exacerbation (ECOPD). As secondary aims, we evaluated whether gender, associated chronic respiratory failure (CRF), and age might influence results. METHODS: Data of 2,213 individuals with available paired pre- and post-PR CAT were analyzed. Other common outcome measures were also assessed. RESULTS: After PR, total CAT improved from 20.8 ± 7.8 to 12.4 ± 6.9 (p = 0.000), and 1,911 individuals (86.4%) reached the minimal clinically important difference (MCID). All CAT items improved significantly without any significant difference among them. However, item "confidence with disease" improved significantly more in males than in females (p = 0.009). Total CAT and six out of eight items improved significantly more in individuals with CRF than in those without (all p < 0.001). Total CAT and three items improved significantly more in younger than in older individuals (p = 0.023). Only presence of CRF was significantly associated with the probability of improving total CAT more than the MCID. CONCLUSION: In individuals with COPD, GOLD group E, recovering from ECOPD, PR improves all CAT items; however, gender, associated CRF and age may influence the effect size, suggesting the need to evaluate all items in addition to total CAT score.

Dysbiosis and leaky gut in hyper-inflated COPD patients: Have smoking and exercise training any role?

BACKGROUND: To characterize the leaky gut syndrome in a cohort of COPD patients with lung hyperinflation according to their clinical history (i.e. hyperinflation severity, chronic respiratory failure [CRF] presence, GOLD stage, prescribed therapy, smoking history) and with or without recent exercise training activity. METHODS: At the ambulatory visit, we evaluated selected COPD patients with lung hyperinflation [residual volume (RV)≥110% pred, TLC≤120% pred)] in clinical stability, identifying them as those who have attended a recent program of exercise training and those who were waiting for it. Clinical and respiratory characteristics (forced expiratory volume at the first second, forced vital capacity, and arterial blood gasses) were collected. Microbiota composition (CFU/ml), and intestinal permeability (i.e., Zonulin ng/ml) were measured in the stool and normalized to the normality cutoff value. RESULTS: All patients [n = 32, median age: 67 years, median RV: 185.0% pred (IQR: 162.0-206.0) and TLC 125.0% pred (IQR: 113.0-138.0)] showed depletion of Lactobacilli, Bacteroides and a great increase in E. Coli, KES (2 and 6.4 times) and Saccharomyces concentrations (2.5 times) other than normality. All evaluations on gut microbiota composition in the whole population were independent of BMI, CRF, GOLD stage or hyperinflation severity, and inhaled steroid therapy. Smoking habits (smokers vs ex-smokers) influenced only Bacteroides species (p<0.05) and no systemic inflammation was present in these patients. On the contrary, Zonulin concentration, a marker of intestinal permeability, was significantly higher than normal (2.8 times) and was correlated with Saccharomyces (p = 0.013). Zonulin (p = 0.001) and Saccharomyces (p<0.0001) were also significantly different in patients undergoing exercise training with respect to those on the waiting list for training. These findings were not influenced by smoking habits. CONCLUSIONS: A marked dysbiosis and leaky gut alteration characterize all COPD hyper-inflated patients, being worse in patients waiting for exercise training. A pre-to-post study is necessary to confirm these preliminary findings.

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.

Perceptual and qualitative voice alterations detected by GIRBAS in patients with Parkinson's disease: is there a relation with lung function and oxygenation?

BACKGROUND: Impairments in respiration, voice and speech are common in people with Parkinson's disease (PD). AIMS: To evaluate the prevalence of dysphonia, assessed by a specific acoustic evaluation and description of the voice by the speech therapist (GIRBAS), and its relation with lung function and oxygenation, in particular cough ability and during the night or exercise desaturation. METHODS: This is a posthoc analysis of a prospective cross-sectional observational study on PD patients collecting anthropometric and clinical data, comorbidities, PD severity, motor function and balance, respiratory function at rest, during exercise and at night, voice function with acoustic analysis and presence of speech disorders, in addition to the GIRBAS scale. Based on GIRBAS Global dysphonia ('G') score, we divided patients into dysphonic (moderate-to-severe deviance from the euphonic condition) vs. no/mild dysphonic and analyzed the relations with respiratory impairments. RESULTS: We analyzed 55 patients and found significant impairments in both respiratory and voice/speech functions. Most patients (85.5%) presented mild-to-severe deviance from the euphonic condition in at least one GIRBAS perceptual element (80% of cases for Global dysphonia) and only 14.5% did not show deviance in all elements simultaneously. At Odds Ratio analysis, the risk of presenting nocturnal desaturation and reduced peak cough expiratory flow was approximately 24 and 8 times higher, respectively, in dysphonic patients vs. those with no/mild dysphonia. CONCLUSION: Perceptual and qualitative evaluation of the voice with GIRBAS showed that mild-to-severe dysphonia was highly prevalent in PD patients, and associated with nocturnal oxygen desaturation and poor cough ability.

Airflow grades, outcome measures and response to pulmonary rehabilitation in individuals after an exacerbation of severe chronic obstructive pulmonary disease.

BACKGROUND: Individuals with COPD may be staged according to symptoms and exacerbation history (GOLD groups: A-D) and on airflow obstruction (GOLD grades: 1-4). Guidelines recommend pulmonary rehabilitation (PR) for these individuals, including those recovering from an exacerbation (ECOPD) OBJECTIVE: To evaluate whether in individuals with clinically severe COPD, recovering from an ECOPD, the effect size of an in-hospital PR program would be affected by airflow severity grades and assessed outcome measures. METHODS: Retrospective, multicentre study. Participants were compared according to different GOLD airflow grades. In addition to the MRC dyspnoea scale, six-minute walking distance test and COPD assessment test (CAT), Barthel dyspnoea index (Bid), and Short Physical Performance Battery (SPPB) were assessed, evaluating the proportion of individuals reaching the minimum clinically important difference (MCID) (responders). RESULTS: Data of 479 individuals, completing the program were evaluated. Most of the participants were allocated in GOLD grades 4, (57.6%) and 3 (22.1%). All outcome measures significantly improved after PR (p < 0.05), without any significant difference in the proportion of responders in any measure. CONCLUSIONS: in individuals with severe COPD, recovering from ECOPD the success rate of PR does not depend on airflow severity, or outcome measure assessed. In addition to the most used outcome measures, also Bid and SPPB are sensitive to PR.

Voice Alterations, Dysarthria, and Respiratory Derangements in Patients With Parkinson's Disease.

PURPOSE: Almost 90% of people with Parkinson's disease (PD) develop voice and speech disorders during the course of the disease. Ventilatory dysfunction is one of the main causes. We aimed to evaluate relationships between respiratory impairments and speech/voice changes in PD. METHOD: At Day 15 from admission, in consecutive clinically stable PD patients in a neurorehabilitation unit, we collected clinical data as follows: comorbidities, PD severity, motor function and balance, respiratory function at rest (including muscle strength and cough ability), during exercise-induced desaturation and at night, voice function (Voice Handicap Index [VHI] and acoustic analysis [Praat]), speech disorders (Robertson Dysarthria Profile [RDP]), and postural abnormalities. Based on an arbitrary RDP cutoff, two groups with different dysarthria degree were identified-moderate-severe versus no-mild dysarthria-and compared. RESULTS: Of 55 patients analyzed (median value Unified Parkinson's Disease Rating Scale Part II 9 and Part III 17), we found significant impairments in inspiratory and expiratory muscle pressure (> 90%, both), exercise tolerance at 6-min walking distance (96%), nocturnal (12.7%) and exercise-induced (21.8%) desaturation, VHI (34%), and Praat Shimmer% (89%). Patients with moderate-severe dysarthria (16% of total sample) had more comorbidities/disabilities and worse respiratory pattern and postural abnormalities (camptocormia) than those with no-mild dysarthria. Moreover, the risk of presenting nocturnal desaturation, reduced peak expiratory flow, and cough ability was about 11, 13, and 8 times higher in the moderate-severe group. CONCLUSIONS: Dysarthria and respiratory dysfunction are closely associated in PD patients, particularly nocturnal desaturation and reduced cough ability. In addition, postural condition could be at the base of both respiratory and voice impairments. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21210944.

Effectiveness of pulmonary rehabilitation in individuals with Chronic Obstructive Pulmonary Disease according to inhaled therapy: The Maugeri study.

BACKGROUND AND AIM: Real-life studies report discordant prescribing of inhaled triple therapy (TT) among individuals with COPD. Guidelines recommend pulmonary rehabilitation (PR) for persistent breathlessness and/or exercise limitation. This real-life study aimed to assess the effects of in-patient PR in individuals under TT as compared to other inhaled therapies (no TT). METHODS: Multicentric, retrospective analysis of data from individuals admitted to in-hospital PR. Baseline characteristics were recorded and lung function was assessed. Outcome measures were: 6-min walking test (6MWT: primary outcome), Medical Research Council (MRC) scale for dyspnoea, and COPD assessment test (CAT). RESULTS: Data of pre and post program 6MWT of 1139 individuals were available. Pulmonary rehabilitation resulted in significant improvement in 6MWT in both groups, however, the effect size (by 54.3 ± 69.7 vs 42.5 ± 64.2 m, p = 0.004) and proportion of individuals reaching the minimal clinically important difference (MCID) of 6MWT (64.2%, vs 54.3%, p = 0.001) were higher in TT group. Both groups significantly improved also the other outcome measures. The significant independent predictors of reaching the MCID of 6MWT were hospital provenience, TT use, and high eosinophils count. CONCLUSION: Pulmonary rehabilitation results in significant benefits in individuals with COPD irrespective of the use of TT. However, individuals under TT report larger benefits in exercise tolerance than those under no TT.

Hidden biases in clinical decision-making: potential solutions, challenges, and perspectives.

Every day, we must make decisions that range from simple and risk-free to difficult and risky. Our cognitive sources' limitations, as well as the need for speed, can frequently impair the quality and accuracy of our reasoning processes. Indeed, cognitive shortcuts lead us to solutions that are sufficiently satisfying to allow us to make quick decisions. Unfortunately, heuristics frequently misguide us, and we fall victim to biases and systematic distortions of our perceptions and judgments. Because suboptimal diagnostic reasoning processes can have dramatic consequences, the clinical setting is an ideal setting for developing targeted interventions to reduce the rates and magnitude of biases. There are several approaches to bias mitigation, some of which may be impractical. Furthermore, advances in information technology have given us powerful tools for addressing and preventing errors in health care. Recognizing and accepting the role of biases is only the first and unavoidable step toward any effective intervention proposal. As a result, our narrative review aims to present some insights on this contentious topic based on both medical and psychological literature.