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Introduction: Pulmonary Rehabilitation (PR) reduces hospital admissions following an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) but adherence is known to be poor. Patients' illness perceptions may affect adherence to disease-management strategies but to date have not been explored following an exacerbation. The study aim is two-fold; firstly to prospectively explore acceptance and uptake of post-exacerbation PR and secondly to identify possible clusters of patients' illness perceptions following hospitalisation for an exacerbation of COPD. Methods: Patients admitted to hospital with an exacerbation of COPD were recruited to a prospective observational study. Self-reported illness perceptions, mood, health status and self-efficacy were assessed. Acceptance and uptake of PR were recorded at six months. Cluster analysis of Illness Perceptions Questionnaire-Revised data was used to establish groups of patients holding distinct beliefs. Results: 128 patients were recruited. Acceptance and uptake of PR following an acute exacerbation was poor with only 9% (n = 11) completing the programme. Cluster analysis revealed three distinct groups: Cluster 1 'in control' (n = 52), Cluster 2 'disengaged' (n = 36) and Cluster 3 'distressed' (n = 40). Significant between-cluster differences were observed in mood, health status and self-efficacy (p < 0.01). Acceptance and uptake of PR did not differ between clusters. Conclusions: Acceptance/uptake of post-exacerbation PR was found to be poor. Three distinct illness schema exist in patients following an acute exacerbation. This information may be useful in developing novel psychologically-informed interventions designed to reduce feelings of distress and perhaps facilitate a PR intervention for this vulnerable population. [ABSTRACT FROM AUTHOR]

Background: Patients with COPD have a high prevalence of anxiety and depression. The efficacy of pulmonary rehabilitation (PR) in treating more severe anxiety and depression is unknown. The study aimed to explore the effectiveness of PR in reducing symptoms of anxiety and depression across a spectrum of severities., Methods: The study used principles of comparative effectiveness research. Data was analysed from 518 patients with COPD [57.5% male, mean (SD) age 69.2 years (± 8.8 years)]. Patients were categorised into 3 groups based on their hospital anxiety and depression scale (HADS) scores pre PR ('none' 0-7, 'probable' 8-10 and 'presence' 11-21). A responder was defined as achieving a change of ≥ 48 m on the incremental shuttle walk test (ISWT). Patients were categorised as 'completers' if they attended their discharge assessment for PR., Results: Anxiety and depression did not reduce following PR in patients with no symptoms (p > 0.05). Patients with a 'probable' or 'presence' of symptoms had significant reductions (both p < 0.001). There was a difference between sub-groups in change for anxiety and depression with patients scoring highest on the HADS having the greatest reductions (p < 0.001). There was no correlation between anxiety or depression and completion of PR (p > 0.05). Responders and non-responders did not differ in their anxiety or depression levels (p > 0.05)., Conclusion: PR is effective in reducing symptoms of anxiety and depression. Previous studies may have underestimated the effectiveness of the PR programme in improving mood., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Patients with Chronic Heart Failure (CHF) develop similar symptoms of exertional breathlessness and fatigue as patients with COPD. Although pulmonary (exercise based) rehabilitation (PR) is an integral part of the management of COPD, the potential for exercise rehabilitation (ER) to assist patients with CHF may not be as readily appreciated. We investigated whether combined ER for patients with CHF and COPD was feasible and effective using the model of PR., Methods: 57 patients with CHF were randomized 2:1 to 7 weeks ER (CHF-ER) or 7 weeks of usual care (CHF-UC). As a comparator 55 patients with COPD were simultaneously recruited to the same ER program (COPD-ER). The primary outcome measure was the Incremental Shuttle Walk Test (ISWT) and the secondary outcome measures were the Endurance Shuttle Walk Test (ESWT), isometric quadriceps strength and health status., Results: 27 CHF and 44 COPD patients completed ER and 17 patients with CHF completed UC. The CHF-ER group made significant improvements, compared to CHF-UC, in the mean (95%CI) ISWT distance; 62(35-89)m vs -6(-11 to 33)m p < 0.001. The CHF-ER group also made statistically significant improvements in health status. The improvements in exercise performance and health status were similar between patients with CHF and COPD, treated with ER., Conclusion: Patients with CHF who undergo ER improve similarly in their exercise performance and health status to COPD. Combined training programs for COPD and CHF are effective and feasible, such that service provision could be targeted around common disability rather than the primary organ disease.

Objective: It is well documented that plasma ammonia accumulates during exercise under conditions of metabolic stress. Metabolic stress (when skeletal muscle ATP supply fails to meet demand) occurs at low work rates during cycling in patients with COPD, but not been described during walking. Walking is an important activity for many patients with COPD and is commonly prescribed in pragmatic outpatient pulmonary rehabilitation programmes. In this study we explored whether metabolic stress occurs during incremental walking at the low work rates these patients achieve., Methods: Twenty-nine subjects with stable COPD [mean(SD) age 68(7)years, FEV(1) 50(19)% predicted] performed maximal cardiopulmonary exercise tests on a cycle ergometer and treadmill. Plasma ammonia concentration was measured at rest, 1 and 2min of exercise, peak exercise and 2min recovery., Results: Subjects achieved mean(SD) cycle work rate of 57(20)W with VO(2max) 15.5(4.6)ml/min per kg, and treadmill distance 284(175)m with VO(2peak) 16.8(4.2)ml/min per kg. Plasma ammonia concentration rose significantly (p<0.001) with walking [mean(SEM) change 24.7(3.8)micromol/l] and cycling [mean(SEM) change 35.2(4.3)micromol/l], but peak exercise ammonia was lower in walking (p<0.01). In a subgroup of subjects (n=7) plasma ammonia did not rise during either cycling or walking despite similar lactate rise and peak exercise indices., Conclusion: Our data indicate that failure of muscle ATP re-synthesis to meet demand and development of metabolic stress can occur during walking in COPD patients at the low work rates these patients achieve. This may therefore be a factor contributing to exercise limitation independent of ventilatory limitation.

Background: It is not clear whether the benefits of pulmonary rehabilitation (PR) apply equally to patients with Chronic Obstructive Pulmonary Disease (COPD) with different levels of starting disability. We have therefore investigated the effect of pulmonary rehabilitation stratified by the MRC dyspnoea scale in patients with COPD., Methods: This is a retrospective, observational study of data collected from 450 consecutive patients with COPD attending outpatient PR: 247 male, mean (SD) age 69.5 (8.9) yrs and FEV(1) 44.6 (19.7)% predicted. The Incremental Shuttle Walk Test (ISWT) was performed before and after the seven-week course, Results: 395 patients (88%) completed the programme. The mean (SD) baseline ISWT performance was 167 (113)m. The distribution of baseline MRC grades was 2 - 15.4%, 3 - 24.9%, 4 - 27.3% and 5 - 32.4%. The mean (95% CI) improvement in ISWT after PR for each MRC scale grade was highly significant (p<0.0005); 2 - 66 (50-83)m, 3 - 63 (50-75)m, 4 - 59 (49-70)m, and 5 - 54 (43-64)m., Conclusions: Patients with COPD, of all MRC dyspnoea grades, benefit comparably from pulmonary rehabilitation achieving both statistically and clinically meaningful improvements in exercise performance. MRC grade should therefore not be used to exclude patients from pulmonary rehabilitation.

Background: There has been no direct comparison between an incremental and endurance walking test to detect the relative oxygen desaturation in patients with chronic obstructive pulmonary disease (COPD). This is of some importance as current guidelines have suggested that ambulatory oxygen should only be prescribed after a standard assessment and desaturation documented. No clear advice about the nature of the required exercise task is given. This study therefore compared the relative desaturation between the incremental shuttle walking test (ISWT) and the constant speed walking test (ESWT) and response to ambulatory oxygen., Methods: Forty-one patients (29 male), mean (SD), age 71.18 (7.48) yrs, FEV(1) 0.85 (0.29) l with stable COPD were recruited after completion of a 7-week pulmonary rehabilitation programme. Patients completed a baseline (without carrying a cylinder) ISWT and ESWT and then, in random order in double blind fashion, completed the walk tests with a cylinder of air or a cylinder of oxygen. Measurements included distance walked, oxygen saturation, heart rate, perceived breathlessness and exertion (Borg scale)., Results: All patients desaturated (<4% below 90%). There was no significant difference in desaturation between the ISWT and the ESWT. There was a significant improvement in performance with supplementary oxygen compared to cylinder air (p<0.05) for both tests. However, compared to the baseline walk, supplementary oxygen did not enhance the distance walked for either test. There was a significant decrease in walking performance on both the ISWT and the ESWT when carrying an air cylinder compared with the control walk. When comparing the percentage difference between oxygen and air for responders (i.e. those that achieve a 10% or more increase), the ESWT showed a greater percentage change 42.1% compared to 26.1% for the ISWT., Conclusions: This study identifies that incremental and endurance walking provokes significant desaturation and that there is a short-term benefit of oxygen versus air in enhancing exercise performance. There was no significant difference in the level of desaturation between tests. Therefore the ISWT is a suitable exercise test that can be used to evaluate desaturation and is practically more realistic.

Randomised trials have demonstrated that pulmonary rehabilitation (PR) can improve dyspnoea, exercise tolerance and health related quality of life. Rehabilitation has traditionally been provided in secondary care to patients with moderate to severe disease. Current concepts are however recommending that it should be delivered in a primary and community care setting for patients with milder disease. There are several opportunities for spreading the word for PR in primary care. One of these is to improve access to PR for all those disabled by their disease by the increase of community schemes and one such scheme being utilised in Canada is reviewed. The essential components of PR include behavior change, patient self-management and prescriptive exercise. In the last decade new strategies have been developed to enhance the effects of exercise training. An overview of these new approaches being an adjunct to exercise training is reviewed. Although the role of exercise training is well established, we are only just beginning to appreciate the importance of behavior change and patient self-management in contributing to improved health and diminished healthcare resource utilisation.

The forced expiratory volume in 1 sec (FEV1) is the most established outcome measure in chronic obstructive pulmonary disease (COPD). However, changes in FEV1 in response to treatment are small in relation to the repeatability of the measurement and there is increasing interest in other measures including markers of lower airway inflammation in induced sputum, assessment of symptoms and health status using visual analogue scores, and questionnaires. Little is known about the repeatability of these measures or the safety of sputum induction in COPD. We have assessed the safety of sputum induction in 61 subjects with moderate and severe COPD who participated in a placebo-controlled cross-over study The within-subject repeatability of sputum markers of airway inflammation, health status using the chronic respiratory disease questionnaire (CRQ) and symptom visual analogue scores (VAS) were estimated from the data obtained from before and after 2 weeks of treatment with placebo. Sputum induction was performed on 122 occasions and was successful resulting in a cytospin adequate to assess a differential cell count in 95% of inductions. The group mean (SEM) FEV1 was 1.09 (0.05)[41.6 (2.9)% predicted] and the mean (SEM) fall in FEV1 after sputum induction was 120 ml (6) and % fall 10.9% (0.55%). Seven inductions were stopped due to a fall in FEV1 >20% and at a further 13 visits the full sputum induction protocol was not completed due to development of symptoms. The reproducibility of measurements, calculated by the intra-class correlation coefficient, was relatively high for all indices measured (0.4-0.95) with the exception ofthe proportion of lymphocytes (0.15) and epithelial cells (0.3). The ICC for symptom scores and the CRQ domains ranged between 0.87 and 0.96. In conclusion, sputum induction is safe and the cell and fluid phase mediators repeatable in the investigation of airway inflammation in patients with COPD. VAS symptom scores and the CRQ are reproducible outcome measures in COPD.

The use of health status as an outcome measure is becoming more widespread in pulmonary rehabilitation. There are a number of health status measures but the choice remains uncertain. Three disease specific measures and two generic measures of health status were employed to observe their relative sensitivity to a 7-week course of pulmonary rehabilitation. Patients with stable chronic obstructive pulmonary disease (COPD) were recruited into a rehabilitation programme. They completed a shuttle-walking test and three disease-specific questionnaires: the Chronic Respiratory Questionnaire (CRQ), the St. George's Hospital Respiratory Questionnaire (SGRQ) and the Breathing Problems Questionnaire (BPQ). Patients also completed two generic questionnaires: a global quality-of-life scale and an activity checklist. Ninety-seven patients [58 male mean (SD) age 67 (8.7) years] completed the course over a 12-month period. The mean pre-rehabilitation (SD) FEV1 was 1.06 (0.59) l. The shuttle-walking test and the treadmill-endurance test increased significantly after rehabilitation (P<0.001). All three disease-specific questionnaires improved significantly (the CRQ and SGRQ improved beyond minimum clinically important difference). The global score improved significantly whilst the 'things people do' decreased. All three disease-specific measures were responsive to pulmonary rehabilitation. However the operator-led CRQ appears to be the most sensitive short-term outcome measure.

In a prospective, randomized study we examined the effect of (i) ambulatory oxygen and (ii) a portable, inspiratory pressure support (IPS) device on the endurance shuttle walk test (ESWT) in patients with severe chronic obstructive pulmonary disease (COPD). Ten outpatients [median (range) FEV1 0.60 l(0.35, 1.45)] performed the ESWT under five test conditions: baseline walk (no assistance), IPS at 14 cmH2O from a portable ventilator (the HIPPY, Friday Medical, U.K.), sham IPS (< 8 cmH2O), ambulatory oxygen at 2 l min(-1), and sham oxygen (carrying the portable oxygen cylinder and breathing air). There were significant improvements in the ESWT with ambulatory oxygen, but a negative effect with the HIPPY device [mean (SD) time: baseline 172 (48) sec; oxygen 242 (62) sec; HIPPY 84 (35) sec]. The ESWT appeared sensitive to the effect of cylinder weight although differences in endurance capacity were not significant [sham oxygen 151 (45) sec]. The ESWT was sensitive to the acute application of oxygen, demonstrating a beneficial effect on endurance performance in patients with severe COPD. The ESWT could form the basis of a standardized assessment for ambulatory oxygen.

Pulmonary rehabilitation is widely available in North America and parts of Europe for patients with chronic obstructive pulmonary disease (COPD). Here, we describe the feasibility and benefits of providing a comprehensive but cost effective pulmonary rehabilitation programme in a U.K. district general hospital. Two hundred and sixty-seven patients with respiratory disability were referred for pulmonary rehabilitation. Patients were assessed and recruited onto a 7 week outpatient-based pulmonary rehabilitation programme including elements of exercise and education without longer term maintenance. Exercise performance was measured by the shuttle walking test and a treadmill endurance test, and quality of life as measured by two disease specific questionnaires, the Breathing Problems Questionnaire and the Chronic Respiratory Disease Questionnaire. Of 267 patients referred between 1993 and 1996, 132 (110 with COPD) have completed rehabilitation and could be evaluated. For all graduates, shuttle distance increased by 58 m (27%) and treadmill endurance time increased by 15.9 min (294%). The Breathing Problems Questionnaire proved sensitive to changes in quality of life in some domains. The Chronic Respiratory Disease Questionnaire showed significant improvements in all domains in a sub-set of 57 patients who completed it. Longer term follow-up of 49 patients at a mean of 10.3 months following pulmonary rehabilitation revealed that previous gains in exercise performance and quality of life were maintained with improvements in shuttle walking distance of 33 m (14% over baseline) and endurance time of 16 min (280% over baseline). The Breathing Problems Questionnaire showed no overall change but the Chronic Respiratory Disease Questionnaire showed continued improvement in a small number of patients. We therefore concluded that a short outpatient based pulmonary rehabilitation programme without a maintenance element has produced significant gains in exercise performance and quality of life for 132 patients at a district general hospital in the U.K.

Treatment for exercise induced asthma (EIA) in sporting competition is controlled to prevent the use of agents which might enhance physical performance. There is little information concerning the effects of the long-acting inhaled, and oral, sustained release type bronchodilators on the cardiorespiratory effects of submaximal exercise. The aim of this study was to compare the cardiorespiratory effects of submaximal exercise in patients with EIA before and after pretreatment with high-dose inhaled salmeterol xinafoate (SX) and controlled release oral salbutamol (CR). Patients were treated with SX (100 micrograms b.d.) and CR (8 mg b.d.) for > or = 3 days in a double-blind randomized cross-over design, with a 5-14 day washout period between treatments. A submaximal exercise test (total exercise time 6 min, final 3 min at 60% of VEpeak) was performed prior to each treatment period, and repeated at 1, 6, and 12 h postdose at the end of the treatment period. Two subjects were withdrawn from the study. Three subjects required relief medication after 1 h (CR) and one subject after 6 h (SX) and they did not perform further exercise tests. Both treatments increased baseline FEV1, with SX producing significantly greater pre-exercise bronchodilation than CR (P = 0.04). Following CR, there were no significant differences from the pretreatment values for VO2, VE, respiratory exchange ratio, heart rate, ventilatory equivalents for VO2, and oxygen pulse during the submaximal exercise challenge. Following SX, there were no significant differences for any of the exercise variables except for VE at 6 and 12 h (mean increase 4.27 l min-1 at 6 h, P < 0.01 and 4.69 l min-1 at 12 h, P = 0.05). The changes in ventilation following SX did not have an effect on oxygen consumption, and the ventilatory efficiency (VE/VO2) remained unchanged. The findings from this study demonstrate that, despite exercising from a higher baseline FEV1, short pretreatment periods with controlled release oral salbutamol and with inhaled salmeterol do not confer any cardiorespiratory advantage during submaximal exercise in subjects with EIA.

Patients using domiciliary nasal ventilation, or long-term oxygen, require regular assessment which could be carried out in the home. Blood gas analysis may be regarded as an essential part of the assessment. The present study investigated the effect of a 1-h time delay on the measurement of capillary blood gases. Four samples of arterialized earlobe blood were collected from 15 outpatients. One sample was analysed immediately, the other three were stored on crushed ice and analysed at intervals of 30, 45, and 60 min post-collection. In order to examine any range effect, a wide range of PaO2 values were examined. The delay, at all levels, resulted in minor changes in the measurement of PaO2, which would be unlikely to alter clinical management. The technique might be used for the reliable assessment of patients in the home.

We have compared the maximal and endurance exercise capacities in 22 (15 male) adult cystic fibrosis (CF) patients with a resting oxygen saturation (SaO2) > or = 90%, with age and sex matched controls (CON). The maximum oxygen uptake (VO2max) and heart-rate were lower for the CF group whereas the maximum ventilation reached a higher percentage of predicted. Furthermore, for the CF group there was a relationship between the % predicted VO2max and measures of lung function, confirming a ventilatory limit to maximum exercise in patients with more severe disease and a near normal maximum exercise capacity in those with mild disease. Endurance capacity, defined as the duration of exercise at 80% of each individuals VO2max, was however similar for the two groups [CF: 22.21 (15.82) vs. CON: 24.94 (13.05) min]; despite the CF group exercising under less efficient ventilatory conditions. Endurance capacity was not related to the measurements of lung function. Of the seven CF patients desaturating at maximal exercise (SaO2 < 90%), five desaturated at a work load of 80% VO2max, whereas only one desaturated at 50% VO2max. This study confirms that with increasing severity of disease, maximal exercise capacity may be limited in adult CF patients, whereas endurance capacity (at the same relative work load) is unimpaired. Furthermore, CF patients who desaturate during a progressive maximal exercise test are likely to desaturate during constant work load exercise if the intensity is high but unlikely to do so if the intensity is low. The information from these exercise tests would be of value for prescribing individual training programmes and for evaluating the effects.

We have examined the role of the Chronic Respiratory Questionnaire in practice. The questionnaire covers aspects of disability in patients with chronic lung disease in terms of dyspnoea, fatigue, emotional function and mastery. It therefore provides a measure of physical disability and quality of life in patients with lung disease. The questionnaire was validated in older patients with chronic obstructive lung disease and is particularly responsive to changes within an individual. Its major disadvantages include the lack of sensitivity in patients with minor symptoms or possibly those in a younger age group and that it is also not possible to make comparisons between populations with the CRQ. It is, however, particularly good at demonstrating changes in disability in older patients with chronic airways disease.