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Introduction: This study objectively evaluates the effectiveness of a 6-week Preparatory Training Phase (PTP) programme prior to Basic Military Training (BMT) for less physically conditioned conscripts in the Singapore Armed Forces., Materials and Methods: We compared exercise test results of a group of less fi t recruits who underwent a 16-week modified-BMT (mBMT) programme (consisting of a 6-week PTP and 10-week BMT phase) with their 'fitter' counterparts enlisted in the traditional 10-week direct-intake BMT (dBMT) programme in this prospective cohort study consisting of 36 subjects. The main outcome measures included cardiopulmonary responses parameters (VO(2)max and V(O2AT)) with clinical exercise testing and distance run timings., Results: Although starting off at a lower baseline in terms of physical fitness [VO(2)max 1.73 +/- 0.27 L/min (mBMT group) vs 1.97 +/- 0.43 L/min (dBMT), P = 0.032; V(O2AT) 1.02 +/- 0.19 vs 1.14 +/- 0.32 L/min respectively, P = 0.147], the mBMT group had greater improvement in cardiopulmonary indices and physical performance profiles than the dBMT cohort as determined by cardiopulmonary exercise testing [VO(2)max 2.34 +/- 0.24 (mBMT) vs 2.36 +/- 0.36 L/min (dBMT), P = 0.085; V(O2AT) 1.22 +/- 0.17 vs 1.21 +/- 0.24 L/min respectively, P = 0.303] and 2.4 kilometres timed-run [mBMT group 816.1 sec (pre-BMT) vs 611.1 sec (post-BMT), dBMT group 703.8 sec vs 577.7 sec, respectively; overall P value 0.613] at the end of the training period. Initial mean difference in fitness between mBMT and dBMT groups on enlistment was negated upon graduation from BMT., Conclusion: Pre-enlistment fitness stratification with training modification in a progressive albeit longer BMT programme for less-conditioned conscripts appears efficacious when measured by resultant physical fitness.

Introduction: The purpose of this prospective study is to determine the effects of a pulmonary rehabilitation programme (PRP) conducted at our centre for patients with chronic lung disease., Materials and Methods: Thirty-four patients (27 men and 7 women, mean age 67.7 years) with predominantly moderate-to-severe chronic obstructive pulmonary disease (31 patients), bronchiectasis (2 patients) and interstitial lung disease (1 patient) completed a 6-week outpatient PRP that included education, physical and respiratory care instruction and supervised exercise training. Outcome assessment was performed at baseline, on completion of PRP and 3 months after PRP. Physiologic measures included pulmonary function, incremental exercise and 6-minute walk tests (6MWTs). Disease-specific quality of life was assessed using the Chronic Respiratory Disease Questionnaire (CRDQ)., Results: There was no significant change in resting spirometry or lung volumes after PRP. Maximal oxygen uptake and work-rate improved significantly after PRP by 132.4 mL kg-1 min-1 and 10.7 W, respectively. 6MWT distance improved significantly by a mean of 67.3 m (P < 0.0001). Maximum Borg dyspnoea scores decreased significantly by 1.2 +/- 0.5 (P < 0.038). All domains of the CRDQ completed by a sub-group of patients improved significantly and the total scores increased by a mean of 21.7 points at the end of the PRP. The improvements gained in maximal exercise capacity immediately following PRP were maintained in 17 patients who returned for repeat assessment 3 months after PRP., Conclusion: Patients who completed a comprehensive PRP at our centre showed significant increase in functional capacity, reduction of exertional dyspnoea and improvement in health status.

Introduction: Accurate assessment of the exercise capacity of patients with chronic obstructive pulmonary disease (COPD) is important for the dual purpose of exercise prescription and determining response to therapy. Currently, the clinical utility of cardiopulmonary exercise testing (CPET) of patients with COPD as part of their evaluation for pulmonary rehabilitation is not established. The aims of this study were to evaluate the role of CPET in determining maximal exercise capacity and the causes of exercise limitation in patients with COPD., Materials and Methods: The results of resting pulmonary function tests and CPET performed on 33 subjects with stable COPD as part of their evaluation for pulmonary rehabilitation were reviewed. Thirty-two of these patients had moderate or severe COPD., Results: Twenty-nine of the 33 patients were able to perform maximal exercise tests during CPET. Of these 29 maximal tests, the causes of exercise limitation were ventilatory limitation in 17 patients, significant oxygen desaturation in 1 patient and both ventilatory limitation and oxygen desaturation in 11 patients. Limb muscle dysfunction is a possible limiting factor in the 4 patients with sub-maximal tests. Physical deconditioning may be a contributory factor of exercise intolerance in 2 patients. Although there was significant correlation (r = 0.597, P = 0.01) between peak VO2 percent predicted and FEV1 percent predicted, there was marked variability of peak VO2 for a given degree of airflow obstruction., Conclusions: CPET is useful for determining the causes of exercise limitation and for assessing the maximal exercise capacity of patients with COPD.

Introduction: We evaluated the results of patients with congestive heart failure (CHF) who underwent cardiopulmonary exercise testing (CPET) as part of their assessment for heart transplantation in order to examine the relationship between exercise capacity and resting indices of left ventricular function in these patients., Materials and Methods: Twenty-seven ambulatory heart transplant candidates underwent CPET using a cycle ergometer and an incremental work-rate protocol till symptom-limitation. These patients included 24 men and 3 women with a mean age of 42.3 years. The aetiology of CHF was coronary artery disease in 14 patients, dilated cardiomyopathy in 11 patients, and congenital heart disease in 2 patients. Mean resting left ventricular ejection fraction (LVEF) was 19% (range 7% to 36%)., Results: Thirteen of the 27 tests performed were maximal studies and all except 2 subjects attained a measurable anaerobic threshold during CPET. Of the 13 maximal tests, the causes of exercise limitation were cardiomyopathy in 3 patients, ischaemic heart disease in 2 patients, significant oxygen desaturation in 2 patients, ventilatory limitation due to obstructive lung disease in 1 patient, ventilatory limitation secondary to a restrictive lung disease in 3 patients, and combined obstructive ventilatory and cardiovascular limitation in 2 patients. There was no significant correlation between resting LVEF and peak VO2 percent predicted (r = 0.14, P = 0.49)., Conclusions: Exercise intolerance in patients with CHF may not be related to limited cardiac reserve and non-cardiac causes of exertional symptoms should also be considered. CPET is useful for the evaluation of functional capacity and mechanisms of exercise intolerance in patients with CHF.

Introduction: Patients with the upper airway resistance syndrome are frequently overlooked, and even if clinically suspected, often escape identification by polysomnographic monitoring., Clinical Picture: Three cases (2 women and a man) with excessive daytime sleepiness and fatigue were confirmed to have the upper airway resistance syndrome after undergoing polysomnography with oesophageal pressure monitoring., Treatment: Nasal CPAP during sleep was prescribed for 2 cases but 1 case refused all available treatment options., Outcome: After one month of CPAP therapy, the 2 cases reported improved symptoms and Epworth sleepiness scores. Lower daytime blood pressures were also recorded., Conclusions: Oesophageal pressure monitoring and EEG arousal analysis can greatly enhance the diagnostic accuracy in the upper airway resistance syndrome. Accurate diagnosis and effective treatment of this condition is important because of its sequelae of hypersomnolence and association with other disorders like systemic hypertension.

Introduction: Lung volume reduction surgery (LVRS) and pulmonary rehabilitation are newer options available in the treatment of advanced emphysema. We describe the progress of our first local patient to have undergone these 2 new treatment modalities., Clinical Picture: A 65-year-old man with advanced emphysema, limited by crippling dyspnoea despite maximal medical therapy with inhaled bronchodilator therapy, methylxanthines and supplementary oxygen., Treatment: Physical reconditioning with a 4-week inpatient pulmonary rehabilitation programme, followed by LVRS and a further 6-week outpatient pulmonary rehabilitation., Outcome: Dramatic improvements in spirometric indices, arterial blood gases, exercise capacity and overall functional status. Improvements maintained at one-year follow up period., Conclusions: LVRS with pulmonary rehabilitation is an exciting new treatment option in a select group of patients with advanced emphysema. Their role in improving overall performance status and quality of life should be considered in patients otherwise considered to have reached the limits of medical therapy.

The main advantage of noninvasive ventilation over conventional mechanical ventilation is in the avoidance of endotracheal intubation and its related complications. Currently, the role of noninvasive ventilation in the management of patients with acute respiratory failure is still not firmly established. We conducted a prospective study to evaluate the efficacy of nasal positive pressure ventilation in patients with acute respiratory failure. Thirty-three consecutive patients with acute failure in whom intubation and mechanical ventilation were strongly considered were included in the study. They received ventilatory support by means of BiPAP ventilatory support system and nasal mask. Physical findings and laboratory measurements were documented before and at specific intervals after initiation of support. Eighty per cent (24/30) of patients were successfully supported. Successfully supported patients tolerated the device with improved gas exchange, hence avoiding endotracheal intubation. The mean duration of support was 19.2 hours. There were major associated complications, e.g. gastric distention or aspiration.

The ideal position of the endotracheal tube (ETT) within the trachea is 5 +/- 2 cm from the carina with the head and neck in neutral position (Goodman's criteria). We assessed the possibility of achieving ideal placement of ETTs in our population by positioning them at reference marks of 23 cm in men and 21 cm in women. From January 1995 to April 1995, 105 intubated patients in the Medical Intensive Care Unit, Singapore General Hospital were studied. The mean distance of the ETT tip from the carina was 4.02 cm +/- 3.90. The ETT tip was < 3 cm from the carina in 30 cases (28.6%) with one case resulting in endobronchial intubation. These 30 patients were significantly shorter in height when compared to the rest of the study population (P = 0.01). Five cases (4.8%) had ETT tip > 7 cm from the carina. Adopting the above-mentioned reference marks did not result in ideal positioning of ETTs in a significant proportion of cases (33.4%). We postulate that this is because our Asian population is generally shorter than those in previous studies which had achieved ideal ETT positioning using similar reference marks.