The therapeutic role of inspiratory muscle training in the management of asthma: a narrative review.

Asthma is a disorder of the airways characterized by chronic airway inflammation, hyperresponsiveness, and variable recurring airway obstruction. Treatment options for asthma include pharmacological strategies, whereas nonpharmacological strategies are limited. Established pharmacological approaches to treating asthma may cause unwanted side effects and do not always afford adequate protection against asthma, possibly because of an individual's variable response to medications. A potential nonpharmacological intervention that is most available and cost effective is inspiratory muscle training (IMT), which is a technique targeted at increasing the strength and endurance of the diaphragm and accessory muscles of inspiration. Studies examining the impact of IMT on asthma have reported increases in inspiratory muscle strength and a reduction in the perception of dyspnea and medication use. However, because of the limited number of studies and discordant methods between studies more evidence is required to elucidate in individuals with asthma the efficacy of IMT on inspiratory muscle endurance, exercise capacity, asthma control, symptoms, and quality of life as well as in adolescents with differing severities of asthma. Large randomized controlled trials would be a significant step forward in clarifying the effectiveness of IMT in individuals with asthma. Although IMT may have favorable effects on inspiratory muscle strength, dyspnea, and medication use, the current evidence that IMT is an effective treatment for asthma is inconclusive.

The Cardiopulmonary Effects of Medical Masks and Filtering Facepiece Respirators on Healthy Health Care Workers in the Emergency Department: A Prospective Cohort Study.

BACKGROUND: International COVID-19 guidelines recommend that health care workers (HCWs) wear filtering facepiece (FFP) respirators to reduce exposure risk. However, there are concerns about FFP respirators causing hypercapnia via rebreathing carbon dioxide (CO2). Most previous studies measured the physiological effects of FFP respirators on treadmills or while resting, and such measurements may not reflect the physiological changes of HCWs working in the emergency department (ED). OBJECTIVE: Our aim was to evaluate the physiological and clinical impacts of FFP type II (FFP2) respirators on HCWs during 2 h of their day shift in the ED. METHODS: We included emergency HCWs in this prospective cohort study. We measured end-tidal CO2 (ETCO2), mean arterial pressure (MAP), respiratory rate (RR), and heart rate values and dyspnea scores of subjects at two time points. The first measurements were carried out with medical masks while resting. Subjects then began their day shift in the ED with medical mask plus FFP2 respirator. We called subjects after 2 h for the second measurement. RESULTS: The median age of 153 healthy volunteers was 24.0 years (interquartile range 24.0-25.0 years). Subjects' MAP, RR, and ETCO2 values and dyspnea scores were significantly higher after 2 h. Median ETCO2 values increased from 36.4 to 38.8 mm Hg. None of the subjects had hypercapnia symptoms, hypoxia, or other adverse effects. CONCLUSION: We did not observe any clinical reflection of these changes in physiological values. Thus, we evaluated these changes to be clinically insignificant. We found that it is safe for healthy HCWs to wear medical masks plus FFP2 respirators during a 2-h working shift in the ED.

Relieving from Breathlessness in the Wind: A Meta-Analysis and Subjective Report of Effectiveness of Fan Blowing in Patients with Cardiorespiratory Diseases or Cancer.

OBJECTIVES: Breathlessness is common among terminally ill patients with cardiorespiratory disease or cancer. The experience may induce secondary physiological and behavioral responses that limit patient well-being and independence and cause emotional distress. METHODS: We conducted a meta-analysis on randomized controlled trials (RCTs) that examined the effectiveness of fan blowing on breathlessness among patients with cardiorespiratory diseases or cancer. The PubMed, Cochrane Library, Embase, SCOPUS, and CINAHL databases were searched to retrieve potential articles. The primary outcome was breathlessness severity. The secondary outcomes were SpO2, anxiety, depression, and quality of life. Also, we presented the changes of vital signs and subjective feeling of a male patient who used fan blowing for relieving his breathlessness. RESULTS: Eight RCTs were available for analysis. The pooled results demonstrated no significant difference in breathlessness severity between fan-to-face blowing and control methods (standard mean difference: -0.21, 95% confidence interval: -.59 to .17); however, a significant reduction in breathlessness severity was observed in the short-time intervention compared with long-time intervention. A trend occurred toward significance in the reduction of respiratory rate in fan-to-face blowing compared with control methods (MD: -.64, 95% CI: -1.37 to .09). No differences were observed between groups in oxygen saturation, anxiety, depression, or QoL. The male patient who used fan blowing showed an improved vital signs and a satisfied subjective feeling. CONCLUSIONS: Consistent short-time fan-to-face blowing is effective for relieving breathlessness among conscious terminally ill patients with cardiorespiratory diseases or cancer. The use of this convenient method for relieving breathlessness symptoms in terminally ill patients is recommended.

Bilevel Noninvasive Ventilation During Exercise Reduces Dynamic Hyperinflation and Improves Cycle Endurance Time in Severe to Very Severe COPD.

BACKGROUND: During exercise, dynamic hyperinflation (DH), measured by a reduction in inspiratory capacity (IC), increases exertional dyspnea and reduces functional capacity in many patients with severe COPD. Although noninvasive ventilation (NIV) during exercise can improve exercise duration, the effect on DH is unclear. RESEARCH QUESTIONS: In people with COPD, resting hyperinflation, and evidence of DH during exercise, does bilevel NIV during exercise reduce DH and increase endurance time compared with exercise with no NIV, and does NIV with an individually titrated expiratory positive airway pressure (T-EPAP) reduce DH and increase exercise endurance time more than NIV with standardized EPAP (S-EPAP) of 5 cm H2O? STUDY DESIGN AND METHODS: A randomized crossover trial in which investigators and participants were blinded between NIV interventions was performed. Participants (N = 19; FEV1 of 1.02 ± 0.24 L (39% ± 6% predicted) completed three constant work rate endurance cycle tests in random order-no NIV, NIV with S-EPAP, and NIV with T-EPAP-during exercise. Primary outcomes were isotime IC and exercise endurance time. Outcome measures from each intervention were compared at isotime and at end exercise by using a linear mixed-model analysis. RESULTS: Compared with no NIV, isotime IC and endurance time were greater with both NIV with S-EPAP (mean difference: 95% CI, 0.19 L [0.10-0.28]; 95% CI, 153 s [24-280], respectively) and T-EPAP (95% CI, 0.22 L [0.13-0.32]; 95% CI, 145 s [28-259], respectively). There was no difference between NIV with S-EPAP and NIV with T-EPAP. INTERPRETATION: In people with COPD and DH during exercise, NIV during exercise reduced DH and increased cycle endurance time. An S-EPAP of 5 cm H2O was adequate to obtain these benefits. TRIAL REGISTRY: Australian New Zealand Clinical Trials Registry; No.: ACTRN12613000804785; URL: http://www.anzctr.org.au.

Clusters of comorbidities in idiopathic pulmonary fibrosis.

INTRODUCTION: Comorbidities are common in patients with idiopathic pulmonary fibrosis (IPF) and negatively impact health-related quality of life, health-care costs and mortality. Retrospective studies have focused on individual comorbidities, but clusters of multiple comorbidities have rarely been analysed. This study aimed to comprehensively and prospectively assess comorbidities in a multicentre, real-world cohort of patients with IPF, including prespecified conditions of special interest and to analyse clusters of comorbidities and examine characteristics, disease course and mortality of the clusters. METHODS: Several measurements, questionnaires, medications and medical history were combined to assess comorbidities. Using self-organizing maps, clusters of comorbidities were identified and phenotypes characterized. Disease course was assessed using mixed effects models and mortality using Cox regression. RESULTS: One-hundred and fifty IPF patients were included prospectively. All except one patient suffered from at least one comorbidity and multimorbidity was common. Arterial hypertension, gastro-oesophageal reflux disease, hypercholesterolemia, emphysema and obstructive sleep apnea were most prevalent. Four comorbidity clusters were identified. Each cluster had distinct comorbidity profiles, patient characteristics, symptom burden and disease severity. Patients with fewer comorbidities had better exercise capacity and less dyspnea at baseline, but a trend towards faster deterioration was observed. Mortality analyses showed no significant differences between clusters. CONCLUSIONS: Multimorbidity is prevalent in patients with IPF. Four specific clusters of comorbidities may represent phenotypes in IPF. A trend towards faster decline in exercise capacity and dyspnea was observed in patients with fewer comorbidities. Increased knowledge of comorbidities facilitates prevention and treatment of comorbidities in patients with IPF.

The impact of an Education-Based Intervention Program (EBIP) on dyspnea and chronic self-care management among chronic obstructive pulmonary disease patients. A randomized controlled study.

OBJECTIVES: To evaluate the impact of dyspnea and chronic self-care management outcomes of an Education-Based Intervention Program (EBIP) compared to routine care. Methods: The population of the study consisted of self-care management scale of 61 patients diagnosed with chronic obstructive pulmonary disease (COPD) stage 2 and within one month after discharge. A total of 51 conforming patients were divided into experimental and control groups for a single-blind randomized trial. Data were collected using an introductory information form, the baseline dyspnea index (BDI), pulmonary function test (PFT), the self-care management process in chronic illness (SCMP-G) scale and body mass index (BMI). There were no addition interventions to the control group. The intervention group underwent a 3-month EBIP intervention that included education, house visits and follow-ups through phone calls between March 2019 and June 2019. The data were analyzed using Kolmogorov-Smirnov and Shapiro-Wilk tests, χ2, Mann Whitney U and Wilcoxon signed-rank tests. p less than 0.05 was statistically significant. Results: The study was completed with a total of 40 COPD patients. The effect of the EBIP training program on BDI, PFT, and SCMP-G scores in the intervention group was statistically proven (p less than 0.05). However, the differences between the groups in the BDI sub-dimension of functional impairment and PFT were not statistically significant (p greater than 0.05).  Conclusion: Providing patients with illness-related education through EBIP provided a partial improvement in dyspnea and a significant improvement in chronic care management among COPD patients.

Misconceptions of pathophysiology of happy hypoxemia and implications for management of COVID-19.

In the article "The pathophysiology of 'happy' hypoxemia in COVID-19," Dhont et al. (Respir Res 21:198, 2020) discuss pathophysiological mechanisms that may be responsible for the absence of dyspnea in patients with COVID-19 who exhibit severe hypoxemia. The authors review well-known mechanisms that contribute to development of hypoxemia in patients with pneumonia, but are less clear as to why patients should be free of respiratory discomfort despite arterial oxygen levels commonly regarded as life threatening. The authors propose a number of therapeutic measures for patients with COVID-19 and happy hypoxemia; we believe readers should be alerted to problems with the authors' interpretations and recommendations.

Dual Airway and Esophageal Stenting in Advanced Esophageal Cancer With Lesions Near Carina.

BACKGROUND: Tracheobronchial stenting either alone or with esophageal stenting is often required for symptom palliation in obstructive or fistulous lesions of the airway due to esophageal cancer. There is limited evidence regarding dual stenting for lesions near the carina due to esophageal cancer. Hence, this study aims to evaluate the technical feasibility, outcomes, and complications of preplanned dual stenting in these patients. METHODS: This is a prospective observational study carried out over a period of 4 years (January 2015 to July 2019). All patients undergoing dual stenting in the airway and esophagus with obstructive or fistulous lesions near the carina were included. The esophageal stent was placed within 24 hours. Prestenting and poststenting symptoms were compared using a symptom-based visual analog scale, Hugh Jones dyspnea scale and dysphagia scale. RESULTS: Twenty-nine patients (20 males; mean±SD age, 55.3±12.2 y) underwent dual stenting. Twenty-four patients had central airway obstruction due to: infiltration in 20 (69%) and external compression in 4 (13.7%), respectively. Five (17.3%) patients had tracheoesophageal fistula with no airway obstruction. In 80% of the patients (n=23), silicone stents were placed. There was significant improvement in both dyspnea and dysphagia after dual stenting (P<0.001). Mucus plugging, lower respiratory infection, and granulation tissue were the main complications. Median survival after dual stent was 97 days (range, 17 to 297 d). CONCLUSION: Dual stenting within the airway and the esophagus is a safe and viable option for palliative relief of symptoms in patients with advanced esophageal cancer.

Use of short-acting opioids in the management of breathlessness: an evidence-based review.

PURPOSE OF REVIEW: To provide an evidence-based review on the use of short-acting opioids for management of breathlessness in patients with advanced diseases. RECENT FINDINGS: We identified 28 randomized controlled trials that examined the effect of short-acting opioids on breathlessness under three study settings: as a prophylactic dose given prior to exertion; as a rescue dose for treatment of breathlessness at rest or episodic breathlessness; or as a scheduled medication for overall reduction of breathlessness. These trials varied widely in regard to patient population (opioid naive or tolerant), opioid (formulation, dose, timing of administration, and scheduling) and control intervention. Taken together, there is good evidence to support that short-acting opioids can reduce breathlessness and improve activity level when given before exertion. There is some evidence that parenteral opioids are efficacious for the as needed treatment of episodic breathlessness or breathlessness at rest. However, there is only limited evidence to support scheduled short-acting opioids for overall relief of breathlessness. SUMMARY: There is evidence to support that short-acting opioids have a pharmacologic effect on breathlessness. More research is needed to clarify how opioids can be prescribed to optimize breathlessness relief, function, and quality of life.

Critical appraisal of the impact of surgical repair of type II-IV paraoesophageal hernia (POH) on pulmonary improvement: A systematic review and meta-analysis.

BACKGROUND: Paraoesophageal hernia (POH) comprising type II-IV hiatal hernia often presents with pulmonary symptoms such as shortness of breath. However, impact of surgical repair on improvement in pulmonary symptoms is unclear. OBJECTIVE: This systematic review and meta-analysis aimed at characterising impact of POH repair on patient reported improvement in pulmonary symptoms. METHODS: This systematic review identified studies reported pulmonary symptoms in patients with undergoing surgical repair for Type II-IV POH from 1st January 2001 to 1st December 2018. Primary outcome was improvement in pulmonary symptoms. Secondary outcomes were improvement in other patient-reported outcomes such as heartburn, regurgitation, chest pain, and dysphagia and intraoperative and postoperative outcomes. RESULTS: This systematic review identified 27 studies (n = 4428 patients) reporting assessment of pulmonary symptoms. However, only 21 studies (n = 2902 patients) reported preoperative and postoperative pulmonary symptoms and hence these were included in the final meta-analysis. There was significant improvement in pulmonary symptoms following POH repair (OR: 8.40, CI95%: 4.91-14.35, p < 0.001), with improvement in all types of POH. Rates of overall and major complications were 16% and 5%, respectively. Rates of conversion, 30-day mortality, reoperation and recurrence were 2%, 1% 4% and 12% respectively. CONCLUSION: This review demonstrates that POH repair is associated with improvement in pulmonary symptoms with acceptable low laparoscopic conversion rates, morbidity, mortality and recurrence rates.

Therapeutic effects of nebulized verapamil on chronic obstructive pulmonary disease: A randomized and double-blind clinical trial.

OBJECTIVES: In this study, we assessed the clinical effect of inhaled verapamil on hospitalized COPD patients in a randomized and double-blind study. METHOD: COPD patients randomly received 10 mg of inhaled verapamil or 4 cc nebulized distilled water (DW) as placebo. RESULTS: Twenty patients enrolled in each group with no difference in baseline characteristics. Mean age was 64.95 ± 8.9 and 66.9 ± 10.74 years in verapamil and control group; respectively, (P > 0.05). The mean dyspnea score was 6.4 ± 1.2 and 6.2 ± 1.8 in the verapamil and control group, respectively and decreased to 4.9 ± 1.3 and 5.7 ± 1.8 after the intervention. The mean change in the verapamil group was significantly higher, (22.43% ± 10.6% vs 8.7% ± 12.1%), P = 0.00. Unlike the control group, the FEV1 value in the verapamil group significantly increased and reached to 1.17 ± 0.4 L from 1.03 ± 0.4. There was a significant decrease in airway resistance in both groups after intervention. However, neither total lung capacity and residual volume nor forced vital capacity changed significantly. Moreover, oxygen saturation in the verapamil group changed 4.8% ± 2.5% and this improvement in the control group was 1.8 ± 1 (P = 0.00). Smoker subjects, ones with PAP more than 35 mm Hg and obese patients benefit from verapamil. CONCLUSION: The beneficial impact of inhaled verapamil on the diminishing of dyspnea score along with its bronchodilatory effect would make this selective calcium blocker agent a therapeutic option in COPD.

Effects of 100 % oxygen during exercise in patients with interstitial lung disease.

PURPOSE: Hypoxemia limits exercise in some patients with interstitial lung disease (ILD). High levels of supplemental oxygen during exercise might allow physical training at a higher level and more effective pulmonary rehabilitation (PR). Our goals were to use graded cardiopulmonary exercise testing (CPET) to determine whether hyperoxia (FIO2≈1.0) increased exercise tolerance in patients with mild to moderate ILD. METHODS: We studied 6 patients with ILD, including idiopathic pulmonary fibrosis (IPF) and nonspecific interstitial pneumonia (NSIP). The study population included 3 females and 3 males (age 69 ± 5 [SD] years; FVC 61 ± 14 %; absolute DLCO 53 ± 19 %). Subjects underwent 2 ramped (15 W/min) CPET protocols on a cycle ergometer (Jaeger Oxycon Pro™, CareFusion Respiratory Care) breathing either air or oxygen (FIO2≈1.0) from a Douglas bag in random order. RESULTS: Minute ventilation (VE) increased significantly during CPET breathing air (pre CPET, 18 ± 2 [SEM] L/min; post CPET, 47 ± 6; P = 0.01), but it did not increase significantly breathing oxygen (pre CPET, 15 ± 3 [SEM]; post CPET, 29 ± 9; P = 0.06). Likewise, carbon dioxide production (VCO2) increased significantly during CPET breathing air (pre CPET, 450 ± 93 [SEM] mL/min; post CPET, 1311 ± 200; P = 0.01), but it did not increase significantly breathing oxygen (pre CPET, 369 ± 129; post CPET, 847 ± 832; P = 0.09). Exercise time during CPET did not differ significantly (P = 0.34) in air (5.6 ± 0.9 [SEM] min) or oxygen (7.0 ± 1.8). Increases in heart rate (HR) and Borg dyspnea index (BDI) after CPET were not affected by breathing oxygen. CONCLUSION: Exercise-induced increases in VE and VCO2 were prevented by breathing pure oxygen during CPET, demonstrating both decreased ventilatory drive and more efficient exercise at achieved workloads. Hyperoxia could enhance the ability of patients with ILD to train at higher workloads, resulting in more effective rehabilitation.

New technique to reduce systemic side effects of timolol eye drops: The tissue press method-Cross-over clinical trial.

IMPORTANCE: Nasolacrimal occlusion (NLO) is effective in reducing systemic absorption of eye drop medication but it is difficult and often performed poorly. We propose an alternative easier and equally effective technique. BACKGROUND: To test the effectiveness of systemic absorption, we evaluated plasma concentration and ocular effects after topically administered timolol and compared to NLO. DESIGN: Cross-over trial carried out in Capital Eye Specialist, Wellington. PARTICIPANTS: A total of 21 subjects over 18 years without contraindications for topical beta-blocker medication and not using systemic beta-blockers. METHODS: During three clinic visits separated by at least one week, alternative approaches to reduce systemic eye drop absorption were tested. These were: (a) nasolacrimal (punctal) occlusion for 5 min, (b) tissue press method or (c) no intervention. Timolol plasma levels were measured 1 h after drop application. At each visit, baseline measurement of blood pressure, heart rate and intraocular pressure (IOP) were performed, and repeated 1 h after timolol 0.5% eye drop application. MAIN OUTCOME MEASURES: Comparison of timolol plasma concentration after each intervention. Secondary outcome measurements included effects on blood pressure, heart rate and IOP. RESULTS: Plasma timolol concentrations after tissue press method and NLO were significantly lower than those without intervention. Comparing tissue press method to NLO, there were no significant differences in plasma levels of timolol, blood pressure, heart rate or IOP. CONCLUSION AND RELEVANCE: The tissue press method is equally effective as NLO in reducing systemic absorption of timolol. It is also easier and faster to administer.

The impact of home-based pulmonary rehabilitation on people with mild chronic obstructive pulmonary disease: A randomised controlled trial.

INTRODUCTION: People with mild chronic obstructive pulmonary disease (COPD) experience exercise intolerance, dyspnoea and poor quality of life. However, the role of pulmonary rehabilitation (PR) in this group is unclear. OBJECTIVES: This randomised controlled trial aimed to explore the effects of home-based PR in people with mild COPD. METHODS: People with mild COPD (FEV1 /FVC < 70%; FEV1  > 80%predicted) with a smoking history of ≥10 packet years were randomised to either 8 weeks of home-based PR (one home visit and seven once-weekly telephone calls) or standard care (weekly social telephone calls). Six minute walk distance (6MWD), and Modified Medical Research Council Dyspnoea Scale (mMRC) and Chronic Respiratory Disease Questionnaire (CRQ) scores were compared. RESULTS: A total of 58 participants (34 males, mean age 68 (SD 9) years, FEV1 %predicted 90 (7), 6MWD 496 (105) m) were included with 31 participants randomised to home-based PR. Participants attended an average of 6.8 of the 8 scheduled sessions, ranging from 3 to 8 sessions. Both groups showed improvements in exercise capacity, symptoms and health-related quality of life (HRQoL) over time, however there was no difference in 6MWD at end-intervention (mean difference -3 m, 95% confidence interval (CI) -64 to 58) or 6 months (7 m, 95% CI -59 to 72). At 6 months home-based PR participants were more likely to have clinically important improvements in CRQ emotional function (50% of home PR vs 0% control, P < 0.001) and CRQ total score (45% vs 17%, P = 0.05). CONCLUSION: For people with mild COPD, home-based PR did not improve exercise capacity more than standard care. The trial was registered at the Australia New Zealand clinical trial registry (https://www.anzctr.org.au, Trial ID: ACTRN12616000965404).

Development of an app for lung cancer survivors (iEXHALE) to increase exercise activity and improve symptoms of fatigue, breathlessness and depression.

OBJECTIVE: Exercise-based self-management interventions are recommended for lung cancer survivors and can provide physical, psychosocial and emotional relief. Mobile health technologies can encourage self-management; however, currently, no cancer-related app addresses exercise-specific needs of lung cancer survivors. This paper details the design, development and testing of an exercise app for lung cancer survivors (iEXHALE), which aims to increase exercise activity and improve symptoms. METHODS: The research had two stages: (1) focus groups with healthcare professionals, patients and family members (n=21) and (2) app development and usability study with lung cancer survivors (n=6). The Capability, Opportunity, Motivation-Behaviour model was used as a theoretical framework; data were thematically analysed. RESULTS: Focus group findings identified many helpful exercises for managing lung cancer survivors' symptoms. These findings, alongside relevant literature, informed iEXHALE's content and design. The usability study found that lung cancer survivors valued iEXHALE's self-management capabilities but identified potential modifications including improved self-monitoring diaries and navigation. CONCLUSIONS: iEXHALE's development has been theoretically and empirically informed, showing value as a self-management tool. Next, we will test its effectiveness, acceptability and cost-effectiveness.

[Pulmonary Rehabilitation]. / Pulmonale Rehabilitation.

Pulmonary Rehabilitation Abstract. Pulmonary rehabilitation is a comprehensive therapeutic approach for patients with advanced chronic lung diseases which leads to a decline of dyspnea, an increase of exercise capacity and an increase of quality of life. Further effects are a reduction of frequency of hospitalisations and an increase of physical activity, if a self management education program is integrated. Pulmonary rehabilitation incorporates an individualised training program with focus on endurance, strength and mobility, further a disease specific education with the goal to improve self efficacy and self management of the patients, specially with the goal to improve their daily physical activity. Due to the good evidence of pulmonary rehabilitation, the accredited programs are accepted and paid by the swiss insurances.