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

Rationale: Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacer...

Rationale: Individuals recovering from COVID-19 may have prolonged symptoms and functional limitations well after the acute illness has subsided. Pulmonary rehabilitation, with its interdisciplinary, holistic approach to individuals with complex and systematic manifestations from chronic respiratory disease may be a platform to provide comprehensive healthcare to these patients. Methods: We did a structured telephone interview and review of medical records from a random sample of patients discharged home from our hospital approximately five months after a COVID-19 hospitalization this spring. This was a hypothesis-generating study. Data categories included: 1) Demographics;2) Acute disease severity markers;3) Dyspnea (Modified MRC);4) A structured review of systems (ROS);and 5) Generic heath status (Medical Outcomes Study Short Form -12, Version 1). The SF-12 has 8 domains and physical and mental composite scores (PCS and MCS, respectively). Results: In our sample of 26 patients, 65% were male, age (mean ± SD) was 60 ± 16 years, hospital length of stay was 5.6 ± 3.5 days, interval from discharge to telephone contact was 154 ± 34 days, 85% had pneumonia, and 42% required > 4 L/min supplemental oxygen. The most common positive ROS categories were: (% for each) dyspnea (50), cognitive impairment (38), fatigue (27), and sleepiness (24). The MRC (range, 0-4 with higher scores indicating more dyspnea) was 0.87 ± 1.00, corresponding to breathlessness hurrying or walking up a slight hill;27% were MRC2 or higher. SF-12 Composite and its 8 domain scores for the sample are given in Table 1. Comparative reference values for these variables from a large sample are provided. Conclusions: Patients discharged from the hospital following COVID-19 infection approximately five months earlier had, on average, mild-to-moderate MRC dyspnea and mild-to-moderate impairments in general health status. It is uncertain whether these abnormalities are residual effects of the remote COVID -19 infection or represent unrelated medical or mental problems. Limitations of our study include its small size and potential selection bias from evaluating those discharged directly to home from the hospital. Based on these observations, pulmonary rehabilitation would not be uniformly indicated months after hospital discharge for COVID-19. However, in view of the considerable variability in dyspnea and health status, the intervention would be reasonable in selected patients with more substantial limitations.

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

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

The European Respiratory Society (ERS) and American Thoracic Society (ATS) guideline on management of chronic obstructive pulmonary disease (COPD) exacerbations was published in the March 2017 issue of the European Respiratory Journal [1]. Based on evidence syntheses, including meta-analyses, relevant evidence up to September 2015 was summarised and clinical recommendations for treatment of COPD exacerbations were formulated. These guidelines were endorsed by the ERS Executive Committee and approved by the ATS Board of Directors in December 2016.

The treatment of asthma largely depends on guideline-based pharmacologic therapies. However, nonpharmacologic therapies for asthma such as pulmonary rehabilitation, focused breathing techniques, and bronchial thermoplasty have an important, yet underappreciated, role. Structured pulmonary rehabilitation programs can reduce dyspnea and increase cardiopulmonary fitness. The educational component of these programs can ensure that therapies are being used appropriately, increase compliance, and decrease health care utilization. Studies have demonstrated a reduction in inflammatory mediators in patients with asthma who are engaged in an exercise program. Focused breathing techniques are commonly used by patients with asthma, yet benefit has not been clearly shown in randomized controlled trials. For the patients with severe asthma who are unresponsive to maximum medical therapy and have evidence of airway remodeling, bronchial thermoplasty has demonstrated long-term improvement in quality of life and reduction in severe exacerbations and health care utilization. Recent airway biopsy studies have demonstrated bronchial thermoplasty's disease-modifying effect on smooth muscle, inflammatory mediators, and bronchial nerve endings. These nonpharmacologic therapies are complementary to current guideline-based treatment, including the use of biologic modifiers, for severe asthma.

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

Background: Hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are associated with increased mortality and decreased quality of life. Replicate hospital discharge studies were initiated to examine efficacy and safety of once-daily tiotropium HandiHaler® versus placebo, in addition to usual care, in patients discharged from the hospital after an AECOPD. Methods: Both studies were randomized, placebo-controlled, double-blind, parallel-group, multicenter, with inclusion/exclusion criteria providing a diverse COPD patient cohort hospitalized for ≤14 days with AECOPD. Patients received tiotropium or placebo, initiated within 10 days post-discharge. Target recruitment was 604 patients/study and planned duration was event-driven, ending after 631 clinical outcome events across both studies. Inability to reach targeted site numbers and patient recruitment/retention difficulties led to early study termination. Recruitment/retention challenges and protocol amendment impacts were assessed qualitatively to understand the major issues. Results: Over 18 months, 219 patients were enrolled; 158 were randomized and 61 failed screening. Premature treatment discontinuation occurred in 49(31%) patients, of whom 20(41%) completed health status follow-up. All-cause, 30-day hospital readmission was low (8[5%] patients). A total of 154(98%) patients had a concomitant diagnosis and most took pulmonary medication pre-randomization (143[91%]) and during study treatment (144[92%]). Inclusion/exclusion criteria changes failed to improve recruitment. Recruitment/retention barriers were identified, relating to patient and clinician factors, health care infrastructure, and clinical practices. Conclusions: Although AECOPD hospitalization is clinically important and incurs high costs, significant challenges exist in studying this population in clinical trials after hospitalization. Studies are needed to evaluate effective management of AECOPD patients at high risk of adverse clinical outcomes.

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

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

Physical activity (PA) and exercise are interrelated but separate concepts. PA refers to bodily movement produced by skeletal muscles that results in energy expenditure. Exercise is a subset of PA, in which generally higher levels of muscular activity are performed for a purpose, such as achieving physical fitness or winning a sporting contest. Higher exercise capacity is considered to be permissive of greater PA in the home and community settings. Individuals with chronic obstructive pulmonary disease (COPD) are physically inactive when compared with healthy age-matched control subjects. Furthermore, physical inactivity is independently associated with adverse outcome in patients with COPD, including more rapid disease progression, impaired health status, and increased health care utilization and mortality risk. While there are several methods to objectively measure PA, recent scientific studies have commonly utilized questionnaires and activity monitors. The latter include simple pedometers and complex accelerometers, which can measure and record movement in up to 3 planes. In COPD, multiple patient characteristics and disease severity markers are related to activity level, including pulmonary physiological abnormalities such as airway obstruction and hyperinflation; exercise capacity such as the 6-minute walking distance; exacerbations of respiratory disease; and comorbid conditions. Clinical trials of bronchodilators, supplemental oxygen therapy, exercise training or pulmonary rehabilitation, or PA counseling have provided inconsistent results in demonstrating increased PA from the interaction. This is probably because the phenomenon of physical inactivity is complex, resulting not only from physiological impairments, but symptoms, cultural, motivational, and environmental factors.

PURPOSE To determine whether an as-needed repeated pulmonary rehabilitation (PR) intervention produces a clinically important improvement in exercise capacity. METHODS The study included a retrospective analysis of characteristics and 6-minute walk distance (6MWD) of patients with chronic obstructive pulmonary disease (COPD) who completed PR at 2 centers. Data were abstracted from all patients with COPD completing 2 courses of rehabilitation and those of randomly sampled patients completing only 1 course of PR. RESULTS We identified 37 repeaters and selected 69 nonrepeaters for analysis. No significant differences between the 2 groups with regard to age, FEV1 percent predicted, gender, initial 6MWD, improvement in 6MWD, and the percentage of patients achieving the minimal important difference (MID) of ≥ 35 m were observed with the completion of the first rehabilitation. The time between the first and second PR interventions was a mean of 45 ± 24 months. Repeating patients had a decrease of 90 ± 76 m in 6MWD at the beginning of the second rehabilitation course compared with the end of the first intervention (P = .001). Twenty-four (65%) of repeating patients achieved the MID in 6MWD at the end of the second course of PR. Those who achieved the MID in 6MWD during the second course of rehabilitation also tended to have attained greater improvement in this outcome during the first course (P = .07). CONCLUSION Two-thirds of patients with COPD undergoing repeat PR experienced significant improvement in exercise capacity. Offering PR to patients with COPD on an as-needed basis appears to be beneficial even after a prolonged period of time between the interventions.

Although sleep disturbance is common in chronic obstructive pulmonary disease (COPD), relatively little is known on the effect of the exacerbation on sleep quality. Accordingly, we longitudinally assessed sleep variables during exacerbations and clinical stability. This is a sub-study of a larger observational analysis. Inclusion criteria were clinically stable COPD and two or more clinical exacerbations in the preceding 12 months. Patients were followed for approximately 6 months and during this time the following were recorded daily: (1) COPD exacerbations, which were determined in two ways, clinically and symptom defined using the exacerbations of chronic pulmonary disease tool (EXACT); (2) daytime sleepiness, which was measured using the Stanford Sleepiness Scale; (3) subjective awakenings, which was measured from a sleep diary; and (4) sleep duration, efficiency, and objective awakenings, which was measured from actigraphy. These variables for exacerbation and non-exacerbation days were compared. Seventeen patients (9 male, age 63 ± 12 years, forced expiratory volume in 1 second 52 ± 20%) entered data over 135 ± 18 days. During this time, 15 patients had 27 symptom-defined exacerbations and 8 had 9 clinically reported exacerbations. Symptom-defined exacerbation days were 26% of the total study days. More daytime sleepiness, decreased total sleep time (TST), and decreased sleep efficiency (SE) were present during exacerbations compared with clinical stability ( p < 0.001). These disturbances tended to be greater during clinically reported exacerbations than during unreported events ( p < 0.05). Increased daytime sleepiness, less TST, and poorer SE are present during COPD exacerbations.

Proceedings of the European Seminars in Respiratory Medicine course, Long-Term Integrated Care of COPD Patients held in Stresa, Italy, on 16-17 June, 2016

Because physical inactivity in chronic obstructive pulmonary disease (COPD) predicts health care use and mortality, we prospectively evaluated the relationship of this variable to the frequency of 30-day readmissions after a hospitalization for an exacerbation.Consented patients discharged after an exacerbation of COPD were asked to wear a GT3X+ accelerometer (ActiGraph, Pensacola, FL) continuously on the wrist for 30 days after hospital discharge. Vector magnitude units (VMU), the sum of movements in three planes over each minute of use, were recorded. Higher physical activity for each minute was defined by a VMU threshold of at least 3,000 counts. Those patients with fewer than 60 minutes/day over the first week were considered inactive.Fifty-four study patients were discharged from the hospital and 38 underwent activity testing. In the latter subgroup, all-cause hospital readmissions within 30 days occurred in 12 patients (32%). Minutes of higher physical activity per day over the first week after discharge were considerably lower in those eventually readmitted than in those who remained as outpatients: 42 ± 14 (SE) versus 114 ± 19 minutes, respectively (P = 0.02). In addition, physical activity decreased over time in those who were eventually readmitted, but increased in those who were not readmitted. Those with lower physical activity over Week 1 after discharge were more likely to have 30-day all-cause readmissions than those with higher activity: odds ratio, 6.7, P = 0.02. In multivariate testing, both physical inactivity and a history of two or more hospitalizations for exacerbations in the preceding year predicted 30-day readmission.These findings underscore the importance of physical activity as a predictor of this type of health care use outcome.

Richard ZuWallack,1 Lisa Allen,2 Gemzel Hernandez,2 Naitee Ting,2 Roger Abrahams3 1Saint Francis Hospital and Medical Center, Hartford, CT, USA; 2Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA; 3Morgantown Pulmonary Associates, Morgantown, WV, USABackground: Combining bronchodilators with different mechanisms of action may improve efficacy and reduce risk of side effects compared to increasing the dose of a single agent in chronic obstructive pulmonary disease (COPD). We investigated this by combining two long-acting bronchodilators: once-daily muscarinic antagonist tiotropium and once-daily β2-agonist olodaterol.Methods: Two replicate, double-blind, randomized, 12-week studies (ANHELTO 1 [NCT01694771] and ANHELTO 2 [NCT01696058]) evaluated the efficacy and safety of olodaterol 5 µg once daily (via Respimat®) combined with tiotropium 18 µg once daily (via HandiHaler®) versus tiotropium 18 µg once daily (via HandiHaler®) combined with placebo (via Respimat®) in patients with moderate to severe COPD. Primary efficacy end points were area under the curve from 0–3 hours of forced expiratory volume in 1 second (FEV1 AUC0–3) and trough FEV1 after 12 weeks (for the individual trials). A key secondary end point was health status by St George's Respiratory Questionnaire (SGRQ) total score (combined data set).Results: Olodaterol + tiotropium resulted in significant improvements over tiotropium + placebo in FEV1 AUC0–3 (treatment differences: 0.117 L [P

Patients with clinically stable chronic obstructive pulmonary disease (COPD) are physically inactive, and this inactivity appears to be an independent predictor of hospitalizations. To explore this relationship further, we compared physical activity of COPD patients assessed in 2008 to subsequent hospitalizations and mortality. Sixty adults with a history of cigarette smoking, a diagnosis of COPD, a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) of 1, body mass index, and supplemental oxygen requirement, were related to subsequent all-cause and respiratory-related hospitalizations that occurred over the ensuing 53 ± 2 months. The mean age was 68 ± 11 years, 50% were male, and the FEV1 was 53 ± 19%. All-cause and respiratory-related hospitalizations occurred in 58 and 35%, respectively. A 6MWD < 350 m and VMU < 170 each significantly predicted subsequent all-cause and respiratory-related hospitalizations in univariate Cox proportional hazards analyses after controlling for previous exacerbations. Both 6MWD < 350 m and VMU < 170 counts remained in a multivariate model predicting respiratory-related hospitalization. These results indicate that both directly measured physical activity and functional exercise capacity are important predictors of hospitalization in COPD.

SummaryBackgroundLimited data are available as to the relationship between computed tomography (CT) derived data on emphysema and airway wall thickness, and quality of life in subjects with chronic obstructive pulmonary disease (COPD). Such data may work to clarify the clinical correlate of the CT findings.MethodsWe included 1778 COPD subjects aged 40–75 years with a smoking history of at least 10 pack-years. They were examined with St George's Respiratory Questionnaire (SGRQ-C) and high-resolution chest CT. Level of emphysema was assessed as percent low-attenuation areas less than −950 Hounsfield units (%LAA). Airway wall thickness was estimated by calculating the square root of wall area of an imaginary airway with an internal perimeter of 10 mm (Pi10).ResultsIn both men and women, the mean total score and most of the subscores of SGRQ-C increased with increasing level of emphysema and increasing level of airway wall thickness, after adjusting for age, smoking status, pack years, body mass index and FEV1. The highest gradient was seen in the relationship between the activity score and the emphysema level. The activity score increased by 35% from the lowest to the highest emphysema tertile. The relationship between level of emphysema and the total SGRQ-C score became weaker with increasing GOLD (Global initiative for Chronic Obstructive Lung Disease) stages (p

BACKGROUND Patients hospitalized with decompensated heart failure are at high risk for readmission within 30 days of discharge. Since physical inactivity is associated with increased health care utilization in other diseases, it may predict rehospitalization in heart failure. METHODS In a single-center, prospective study, physical activity was measured following hospital discharge using an accelerometer on the wrist. We then related this activity to the 30-day all-cause rehospitalization rate in heart failure. Each minute of activity was dichotomized into higher or lower intensity, based on a threshold of 3000 vector magnitude units. Counts above this threshold corresponded to a higher level of physical activity. Logistic regression and Kaplan-Meier survival analyses were used to relate the activity group to 30-day readmissions. RESULTS Ninety-five patients admitted to a heart failure unit were screened; 61 met inclusion criteria and provided consent. Fifty patients were evaluated. Forty-six percent were male, mean age was 71 ± 15 years, and 46% had left ventricular ejection fraction

Summary: Background: Prevention of tuberculosis (TB) in the United States usually involves testing for latent tuberculosis infection (LTBI) with a tuberculin skin test (TST), followed by offering therapy to those who have a positive test result. QuantiFERON-TB Gold assay (QFT-G) is more specific for infection with Mycobacterium tuberculosis than the TST, especially among persons vaccinated with bacillus Calmette-Guérin, thereby reducing the number of false positive tests. Methods: Adults referred to a pulmonary clinic for a positive TST result were tested with QFT-G. We assessed factors for having a positive QFT-G. Results: Among 100 adults who were BCG-vaccinated and had a positive TST result, 30 (30%) had a positive result using QFT-G. Persons from high-incidence countries were 8.2 times more likely to have a positive QFT-G result compared with persons from low-incidence countries (46% versus 9%). Using logistic regression to assess QFT-G positivity, strong predictors included having an abnormal chest radiograph consistent with healed TB, a TST induration of ≥16 mm, and birth in a high-incidence country. Conclusion: Use of QFT-G assay following a positive TST result further identifies persons who would most benefit from treatment for LTBI. Keywords: Tuberculosis, Latent tuberculosis infection, Diagnosis, Treatment, Prevention

Patients with chronic obstructive pulmonary disease (COPD) are physically inactive, and this predicts poor outcome. Factors influencing activity levels in COPD patients are poorly understood. Depression is common in COPD patients and may influence activity. Accordingly, in this pilot study, we evaluated the relationship between depressive symptoms and activity in clinically stable COPD (forced expiratory volume in 1 second [FEV(1)]/forced vital capacity0.70, FEV(1)80%). An additional inclusion criterion was the Hospital Anxiety and Depression Scale depression score, which had to be ≤7 or ≥10, representing low and high levels of depressive symptoms, respectively.Sixteen patients with high depression scores (DEPR) and 20 with low depression scores (non-DEPR), were studied. Physical activity was measured over 7 consecutive days, using the SenseWear armband (BodyMedia Inc, Pittsburgh, PA) worn on the arm.The mean age was 69 ± 9 years and the FEV(1) was 49 ± 16%. The Hospital Anxiety and Depression Scale depression scores in DEPR and non-DEPR patients were 12.0 ± 2.3 and 3.7 ± 2.0, respectively. There were no significant between-group differences in age, gender, body mass index, FEV(1), supplemental oxygen requirement, and walk distance. DEPR and non-DEPR patients did not differ in estimated steps per day (3490 ± 2020 vs 3634 ± 2000; P = .83) or minutes per day, with activity3 metabolic equivalents (11 ± 7 vs 13 ± 9; P = .42). Steps correlated with the FEV(1) (r = 0.49; P = .002) and the 6-minute walk distance (r = 0.69; P = .0001).We were unable to demonstrate a relationship between depressive symptoms and directly measured physical activity level in patients with COPD.

Pulmonary rehabilitation and palliative care are two important components of the integrated care of the patient with chronic respiratory disease such as chronic obstructive pulmonary disease (COPD). These two interventions are remarkably similar in many respects. Both utilize a multidisciplinary team that focuses on the specific needs of the individual patient. Care in both is goal defined and includes relief of symptoms and improvements in functional status and quality of life. Pulmonary rehabilitation is commonly given in a specific setting, such as a hospital-based outpatient setting, while palliative care is often hospital based, with its services extending into the home setting in the form of hospice. Components of pulmonary rehabilitation and palliative care should be administered as part of good medical care. Both pulmonary rehabilitation and palliative care are currently underutilized in the respiratory patient, and often provided relatively late in the patient’s clinical course. The case provided illustrates the often-overwhelming symptom burden of advanced COPD and demonstrates opportunities for the application of these twin interventions.

The optimal care of the patient with chronic obstructive pulmonary disease (COPD) requires an individualized, patient-centered approach that recognizes and treats all aspects of the disease, addresses the systemic effects and comorbidities, and integrates medical care among healthcare professionals and across healthcare sectors. In many ways the integration of medical care for COPD is still in its infancy, and its implementation will undoubtedly represent a paradigm shift in our thinking. This article summarizes the proceedings of a workshop, The Integrated Care of the COPD Patient, which was funded by the American Thoracic Society. This workshop included participants who were chosen because of their expertise in the area as well as their firsthand experience with disease management models. Our summary describes the concepts of integrated care and chronic disease management, details specific components of disease management as they may apply to the patient with COPD, and provides several innovative examples of COPD disease management programs originating from different healthcare systems. It became clear from the discussions and review of the literature that more high-quality research in this area is vital. It is our hope that the information presented here provides a "call to arms" in this regard.

Although obesity is a common co-morbid condition in COPD, relatively little is known how it may affect functional exercise capacity. Accordingly, we compared physiologic responses during a 6 min walk test in 10 obese and 10 non-obese COPD patients matched by gender, age, and spirometric severity category. Patients first exercised on a treadmill to determine maximal exercise responses, then following a rest period they completed a 6 min walk test. Breath by-breath analyses of expired air via a facemask was obtained using a portable, battery operated device. Oxygen consumption (VO(2)), carbon dioxide production (VCO(2)), tidal volume (VT), respiratory rate (RR), minute ventilation (VE), and inspiratory capacity (IC) were compared. The mean FEV1 in the obese and non-obese groups was 52 ± 13 and 58 ± 18 percent of predicted, respectively, and the BMI of the obese patients was 37 ± 02 kg/m(2). Obese patients had shorter 6 min walk distances than non-obese patients (247 ± 73 vs 348 ± 51 m, respectively, p = 0.003), but walk-work, defined as 6 min walk distance × weight (in kg), was not different. There were no significant between-group differences in any exercise variable measured during the 6 min walk test. In both groups, VO(2) and VE increased linearly over the first 2-3 min, then plateaued at approximately 80% of maximum. Although 6 min walk distance is shorter in obese COPD patients, their physiologic responses are similar to those of non-obese patients.

Despite remarkable advances in medicine and technology, the management of the patient with COPD is often inefficient and fragmented. Optimizing care for these individuals requires that a proactive, patient-centered, de-fragmented and integrated plan of care. Integrated care, which draws heavily from the chronic care model, incorporating holistic, self-management and care coordination principles to meet the needs of the complex COPD patient, is a desirable approach to improving medical management. The relationship of integrated care to other, similar conceptual models, including self-management, disease management, care coordination, and patient centered medical home is discussed.

The optimal care of patients with chronic obstructive pulmonary disease generally requires combining pharmacologic and nonpharmacologic therapies. The latter include smoking cessation, the encouragement of physical activity and exercise, influenza and pneumonia vaccinations, education on adherence to medical therapy, collaborative self-management strategies, such as a plan to manage exacerbations, and advance directives. Although each of these is a component of good medical practice, they can be given together in the form of a comprehensive outpatient pulmonary rehabilitation program. Pulmonary rehabilitation, which includes exercise training, education, psychosocial support, and nutritional intervention, has demonstrated effectiveness over multiple outcome areas, despite the fact that it has virtually no direct effect on the underlying pathophysiology of the lung. This intervention works primarily through its beneficial effects on associated morbidity, such as physical deconditioning. Pulmonary rehabilitation is indicated when respiratory symptoms or functional limitations persist despite otherwise standard medical therapy. Combining optimal bronchodilator therapy and/or supplemental oxygen therapy with exercise training will enhance the effectiveness of the latter.

This paper summarizes the Part 2 of the proceedings of the 8th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations. This paper (Part 2) includes sections regarding: Promoting Physical Activity across the Spectrum of COPD (Physical activity: definitions, measurements, and significance; Increasing Physical Activity through Pharmacotherapy in COPD); Pulmonary Rehabilitation in Critical Illness (Complex COPD with comorbidities and its impact during acute exacerbation; Collaborative Self-Management in COPD: A Double-Edged Sword?; and Pulmonary Rehabilitation in Critical Illness.

Background: Lower physical activity in COPD predicts increased health care utilization. Activity after a CHF exacerbation may be low and may also predict health care utilization. Objective: Compare post-discharge physical activity in CHF and COPD. Methods: We measured activity over 1 month (using tri-axial accelerometers on the wrist) in 37 discharged after a hospitalization for CHF. Minutes per day above 3000 vector magnitude units (sum of movements per minute in 3 planes) from the wrist device were analyzed; this corresponds to light-moderate intensity. Physical activity was compared with that from 38 discharged COPD patients from a similarly-designed earlier study. We then evaluated activity as a predictor of 30-day, all-cause hospital re-admissions in both diseases. Results: Re-admissions in CHF and COPD were 32 and 24%, respectively. Overall, higher-intensity activity in CHF and COPD were similar over 4 weeks, and, in both, physical activity was lower in those eventually re-admitted (Figure 1). Lower activity tended to predict readmission in both diseases: odds ratio (CHF) = 5.0 and (COPD) = 6.7 (p = 0.05 and 0.02, respectively). Conclusions: Physical activity post-discharge is similar in CHF and COPD, and predicts 30-day all-cause hospital re-admissions in both. At present, we do not know how these activity levels compare to those of healthy controls.

Background: The COPD diagnosis rests on demonstration of airflow limitation in an appropriate clinical setting, while the diagnosis of its exacerbation relies on clinical presentation alone. Not requiring spirometry can potentially lead to diagnostic errors. Methods: We evaluated clinical characteristics of patients hospitalized with a clinical diagnosis of COPD exacerbation (discharge diagnosis plus exacerbation-directed therapy) and performed spirometry in all before discharge. We then compared characteristics of those above and below our threshold for airflow limitation, FEV1/FVC ≤ 0.70. Results: Forty-seven patients (age 68 ± 12 years) met criteria for a clinical diagnosis of COPD exacerbation; 37 (79%) had airflow limitation and 10 (21%) did not (mean FEV1/FVC = 0.54 and 0.76, resp.). The groups did not differ in age, gender, smoking history, concurrent asthma or CHF, prednisone-days in the previous year, health status, supplemental O2, or bronchodilator or intravenous diuretic therapy in the hospital. Compared to those with COPD, those without airflow limitation had higher body-mass index (41 vs 29 kg/m 2 , p = 0.002), more sleep impairment in the COPD Assessment Test (CAT) (2.9 vs 1.8, p = 0.02), and greater Medical Research Council (MRC) dyspnea (2.4 vs 1.8, p = 0.04). All-cause readmissions at 30 days and one year were not significantly different. Conclusions: About one out of five admitted with a clinical COPD exacerbation did not have corresponding airflow limitation. Obesity appears to be a confounding condition. Non-COPD patients had more dyspnea and sleep disturbance. Subsequent hospitalizations out to one year were similar in both groups.

Over the past three decades, pulmonary rehabilitation has risen to the stature as a gold standard for the treatment of chronic obstructive pulmonary disease (COPD). This rise is owing to both the development of science explaining mechanisms underlying its effectiveness and the demonstration of its substantial benefits across multiple outcome areas of importance to patients. Arguably, pulmonary rehabilitation provides the greatest improvements of any therapy in the areas of dyspnea-relief, exercise performance, and functional and health status. Emerging science also indicates that it reduces subsequent health care utilization and-when administered in the perihospital period-mortality risk. These beneficial effects are realized despite the fact that pulmonary rehabilitation has virtually no direct effect on lung function in COPD. Instead, this comprehensive, patient-centered intervention reduces the negative effects from systemic morbidity (such as muscle wasting) and comorbidity (such as depression and anxiety) that frequently accompany COPD. Two major components of pulmonary rehabilitation are exercise training and behavioral interventions. An example of the latter is a collaborative action plan for the early recognition and prompt treatment of the COPD exacerbation. Innovation in pulmonary rehabilitation includes (1) expanding its applicability, such as demonstrating effectiveness in the non-COPD respiratory patient, in milder COPD, in the periexacerbation period, and its provision in the home and community settings; (2) improving its process, such as refining the self-management and behavioral interventions, and the promotion of physical activity in the home and community settings; and (3) promoting its accessibility, such as exploring its potential usefulness in nontraditional settings (the home and community) and developing technology to assist in its implementation.

Background Several small studies found night-time awakenings due to COPD symptoms were associated with decreased health status. In this study, night-time awakenings in patients with COPD were examined and effects of tiotropium therapy evaluated. Methods This study was a post hoc, exploratory, pooled analysis of twin, multicenter, double-blind, randomized, placebo-controlled, parallel-group trials. Patients with stable moderate-to-severe COPD were randomized to tiotropium HandiHaler® (n = 550) or placebo (n = 371) and followed for 13 weeks. During a 2-week, pre-treatment baseline period and for 13 weeks on treatment, self-reported night-time awakenings due to COPD symptoms, rescue medication (albuterol) use, and morning and evening peak expiratory flow rate (PEFR) were recorded daily. Nightly, COPD-related awakenings were scored: 0 = no awakenings; 1 = 1 awakening; 2 = 2–3 awakenings; or 3 = awake most of the night. Health-related quality-of-life (HRQoL) and energy–fatigue questionnaires were completed at baseline and during treatment. Results Patients were aged 65.2 ± 8.7 years (mean ± SD), with a mean pre-bronchodilator FEV1 of 36.1 ± 13.5 % predicted normal at baseline. Data for night-time awakenings and albuterol use were available for 543 (99 %) patients on tiotropium and 352 (95 %) on placebo. At baseline, 280 (51.5 %) patients on tiotropium and 179 (50.1 %) on placebo reported ≥1 COPD-related night-time awakening per week. Over the 13-weeks’ treatment, tiotropium was associated with fewer night-time awakenings, with mean ± SE overall awakening scores per week of 0.356 ± 0.006 compared with 0.421 ± 0.007 for placebo (p

Physical inactivity is common in patients with chronic obstructive pulmonary disease (COPD) compared with age-matched healthy individuals or patients with other chronic diseases. Physical inactivity independently predicts poor outcomes across several aspects of this disease, but it is (at least in principle) treatable in patients with COPD. Pulmonary rehabilitation has arguably the greatest positive effect of any current therapy on exercise capacity in COPD; as such, gains in this area should facilitate increases in physical activity. Furthermore, because pulmonary rehabilitation also emphasizes behavior change through collaborative self-management, it may aid in the translation of increased exercise capacity to greater participation in activities involving physical activity. Both increased exercise capacity and adaptive behavior change are necessary to achieve significant and lasting increases in physical activity in patients with COPD. Unfortunately, it is readily assumed that this translation occurs naturally. This concise clinical review will focus on the effects of a comprehensive pulmonary rehabilitation program on physical activity in patients with COPD. Changing physical activity behavior in patients with COPD needs an interdisciplinary approach, bringing together respiratory medicine, rehabilitation sciences, social sciences, and behavioral sciences.

Chronic obstructive pulmonary disease (COPD) is characterized by chronic airflow limitation, gas exchange abnormalities, hyperinflation, and other pathophysiologic events. However, patients are usually unaware of these physical changes and only seek medical attention when distressing symptoms, such as dyspnea and exercise limitation, begin to appear. Therefore, it is reasonable to directly assess these clinical areas of importance to the patient, both as determinants of the impact of the disease process and as outcomes following intervention. Although many of the physiologic abnormalities of COPD are only partially or poorly reversible with treatment, dyspnea, exercise performance, and health status often show impressive gains with therapy. Incorporating clinically relevant outcome assessments complements traditional physiologic measurements and provides the clinician with a yardstick to determine whether a particular intervention is causing a meaningful improvement in the patient. This article discusses these clinical assessments and provides specific examples of their applicability and usefulness in treating patients with COPD.

Tiotropium bromide is a quaternary ammonium compound structurally related to ipratropium and has recently been approved in the US for the long-term, once-daily, maintenance treatment of bronchospasm associated with chronic-obstructive pulmonary disease (COPD). It is available in a dry powder form, where 18 microg [corrected] of the drug is inhaled once-daily through a device, the HandiHaler). The potency and long duration of effect of this anticholinergic bronchodilator result primarily from a prolonged blockade of the M1 and M3 muscarinic receptors in the airways and a relatively more rapid dissociation from the M2 receptor (which provides inhibitory feedback). Multiple studies of up to a duration of 1 year have demonstrated its effectiveness as a bronchodilator for COPD, with a trough increase (measured approximately 24 h after administration of the drug) in forced expiratory volume in 1 s of approximately 0.12 l and a peak increase of approximately 0.25 l. Tiotropium inhalation also leads to a significant reduction in static lung volumes in hyperinflated patients with COPD; this probably contributes to the reduction in dyspnoea that is associated with long-term use of this maintenance bronchodilator. Regular use of the drug was associated with clinically meaningful increases in the Transitional Dyspnoea Index, which indicate reductions in dyspnoea associated with daily activities. Improvement in the respiratory-specific health status questionnaire, the St George's Respiratory Questionnaire component and total scores was also documented. Finally, pooled data from two 1-year studies and two 6-month studies documented 20 and 28% reductions in the number of exacerbations per patient per year. Side effects have been relatively minimal, with dry mouth the most common symptom, ranging 6 - 16% of patients and rarely leading to discontinuation of the study drug. Limited comparisons of efficacy with other bronchodilators are available. Once-daily tiotropium has been demonstrated to be clearly superior to ipratropium four times daily as a bronchodilator for COPD. Combined results from two studies comparing once-daily tiotropium to twice-daily inhalation of standard doses of salmeterol, indicate a magnitude of the bronchodilator response similar in the two drugs early in the study. However, by 6 months, the bronchodilator effect of tiotropium was somewhat greater than that of the long-acting beta-agonist. Preliminary data suggest that combining tiotropium with long-acting beta-agonists may produce additional bronchodilator action in COPD.

The Standards for the Diagnosis and Treatment of Patients with COPD document 2004 updates the position papers on chronic obstructive pulmonary disease (COPD) published by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) in 1995 1, 2. Both societies felt the need to update the previous documents due to the following. 1) The prevalence and overall importance of COPD as a health problem is increasing. 2) There have been enough advances in the field to require an update, especially adapted to the particular needs of the ATS/ERS constituency. 3) It allows for the creation of a “live” modular document based on the web; it should provide healthcare professionals and patients with a user friendly and reliable authoritative source of information. 4) The care of COPD should be comprehensive, is often multidisciplinary and rapidly changing. 5) Both the ATS and the ERS acknowledge the recent dissemination of the Global Initiative of Obstructive Lung Disease (GOLD) 3 as a major worldwide contribution to the battle against COPD. However, some specific requirements of the members of both societies require adaptation of the broad GOLD initiative. Those requirements include specific recommendations on oxygen therapy, pulmonary rehabilitation, noninvasive ventilation, surgery in and for COPD, sleep, air travel, and end-of-life. In addition, special emphasis has been placed on issues related to the habit of smoking and its control. ### Goals and objectives The main goals of the updated document are to improve the quality of care provided to patients with COPD and to develop the project using a disease-oriented approach. To achieve these goals, both organisations have developed a modular electronic web-based document with two components. 1) A component for health professionals that intends to: raise awareness of COPD; inform on the latest advances in the overall pathogenesis, diagnosis, monitoring and management of COPD; and …

Background: In patients with COPD, changes in inspiratory capacity (IC) have shown a higher correlation to patient-focused outcomes, such as dyspnea with exercise, than other standard spirometric measurements. Changes in IC reflect changes in hyperinflation. Tiotropium is a once-daily inhaled anticholinergic that has its effect through prolonged M3 muscarinic receptor antagonism and has demonstrated sustained improvements in spirometric and health outcomes. We sought to evaluate changes in resting IC and lung volumes after long-term administration of tiotropium. Methods: To evaluate the effect of tiotropium, 18 g/d, on IC, a 4-week, randomized, doubleblind, placebo-controlled study was conducted in 81 patients with stable COPD. At each of the visits (weeks 0, 2, and 4) FEV1, FVC, IC, slow vital capacity (SVC), and thoracic gas volume (TGV) were measured prior to study drug (– 60 and – 15 min) and after study drug (30 min, 60 min, 120 min, and 180 min). Results: Mean age was 64 years; 62% were men. Mean baseline FEV1 was 1.12 L (43% predicted). The mean differences (tiotropium placebo) in FEV1 trough (morning before drug), peak, and area under the curve over 3 h values (adjusted for baseline and center differences) at week 4 were 0.16 L, 0.22 L, and 0.22 L, respectively (p < 0.01 for all); differences in IC for these variables were 0.22 L, 0.35 L, and 0.30 L (p < 0.01 for all). Differences in TGV were – 0.54 L, – 0.60 L, and – 0.70 L, respectively (p < 0.01 for all). The percentage improvement in area under the curve above baseline with tiotropium was similar among FEV1 and lung volumes (FEV1, 18%; FVC, 20%; SVC, 16%; IC, 16%; TGV, 14%). Conclusions: Observed improvements in IC and reductions in TGV with once-daily tiotropium reflect improvements in hyperinflation that are maintained over 24 h. (CHEST 2003; 124:1743–1748)

Background: Levalbuterol, the R-isomer of albuterol, has advantages over racemic albuterol in asthma; however, the effectiveness of this β-agonist in COPD has received little attention. Objectives: To evaluate the effectiveness of a single dose of nebulized levalbuterol in COPD. Design: A randomized, double-blind, placebo-controlled trial comparing nebulized levalbuterol to racemic albuterol, combined racemic albuterol and ipratropium, and placebo. Patients: Thirty patients with stable COPD (FEV 1 between 45% and 70% of predicted) were studied. Methods: After withholding usual bronchodilator medications for appropriate washout periods, patients were randomized on separate visits to receive single doses of each the following nebulized bronchodilator medications: (1) levalbuterol, 1.25 mg; (2) racemic albuterol, 2.5 mg; (3) combined racemic albuterol, 2.5 mg, and ipratropium, 0.5 mg; or (4) placebo. FEV 1 , FVC, pulse rate, and oxygen saturation were measured at baseline, 0.5 h following nebulization, and hourly for 6 h. Hand tremor, using a 7-point scale, was measured at baseline, 0.5 h, 1 h, and 2 h. Treatment-placebo differences were analyzed using repeated-measures analysis of variance and least-squares means. Results: The mean age (± SD) of patients was 69 ± 15 years. Mean FEV 1 was 1.15 ± 0.49 L. By 0.5 h following study drug administration, all three nebulized bronchodilator treatments led to similar, significant improvements in FEV 1 compared to placebo. These effects persisted at 1 h and 2 h for all three treatments; however, by 3 h, only the combined albuterol/ipratropium group had a mean change in FEV 1 significantly greater than placebo. There were no significant differences between bronchodilator groups at any time period. A mild increase in pulse rate was observed in all treatment groups. There were no significant treatment-placebo differences in oxygen saturation or hand tremor. Conclusion: For single-dose, as-needed use in COPD, there appears to be no advantage in using levalbuterol over conventional nebulized bronchodilators.

Study objectives To compare the effectiveness of two forms of exercise training in pulmonary rehabilitation. Design A prospective, randomized, unblinded, 8-week trial. Setting A hospital-based outpatient pulmonary rehabilitation program. Patients Forty patients (20 patients in each group) with COPD who were referred for pulmonary rehabilitation. Interventions We compared the short-term effectiveness of a high-intensity, lower-extremity endurance program with a low-intensity, multicomponent calisthenics program for the rehabilitation of patients with COPD. The high-intensity group trained predominately on the stationary bicycle and treadmill, with a goal of exercising at ≥ 80% of maximal level determined from incremental testing for 30 min per session. The low-intensity group performed predominately classroom exercises for approximately 30 min per session. For both groups, twice-weekly sessions were held for 8 weeks. The primary outcome measure was health status, measured using the Chronic Respiratory Disease Questionnaire. Other outcomes included peak oxygen consumption on incremental treadmill exercise testing, exertional dyspnea, treadmill endurance time, the number of sit-to-stand repetitions and arm lifts in 1 min, overall dyspnea, and questionnaire-rated functional status. Measurements and results Both groups showed significant postrehabilitation improvement in exercise variables, exertional and overall dyspnea, functional performance, and health status. Patients in the high-intensity group showed greater increases in treadmill endurance and greater reductions in exertional dyspnea, whereas those in the low-intensity group showed greater increases in arm-endurance testing. Both groups had similar improvements in overall dyspnea, functional performance, and health status. Conclusions Despite differences in exercise performance, both high-intensity, lower-extremity endurance training and low-intensity calisthenics led to similar short-term improvements in questionnaire-rated dyspnea, functional performance, and health status.

Arguably, three outcome categories are of greatest importance to chronic obstructive pulmonary disease (COPD) patients, their families and their caregivers: health-related quality of life (including symptom burden); hospitalisations and other forms of healthcare utilisation; and, of course, mortality. Lower levels of baseline physical activity are not only prevalent in patients with COPD [1, 2], they are associated a negative impact in each of these three outcome categories [3–5]. Of considerable importance to healthcare professionals, increases in physical activity appear to predict enhanced health-related quality of life and reduced hospitalisations. For example, in an analysis of 391 patients with COPD who had physical activity and health-related quality of life assessments at baseline and 5 years later [6], those who increased or maintained their high levels of physical activity had clinically meaningful improvements in quality of life. In contrast, those who stayed at a low level or decreased their physical activity had a worsening in this outcome. From one perspective, this comes close to a tautology, as physical function impairment and distressing symptoms associated with physical activity are prominent components of health-related quality of life questionnaires. With respect to healthcare utilisation, a longitudinal analysis of COPD patients over 5 years demonstrated that the change in physical activity over the first 2 years significantly predicted hospitalisations 3 years later: those without regular physical activity, those who maintained a low level of physical activity or those who decreased their physical activity were at significantly greater risk of being hospitalised than …

Bronchodilator therapy represents a potentially valuable therapeutic option to increase exercise tolerance and enhance lung function in mild to moderate chronic obstructive pulmonary disease (COPD).To determine effects of tiotropium on pulmonary hyperinflation and exercise tolerance in patients with symptomatic Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1 and 2 COPD who experienced inspiratory capacity decrease greater than or equal to 100 ml during incremental and constant work rate treadmill exercise.This 22-week, randomized, double-blind, two-period crossover study evaluated the efficacy of once-daily tiotropium bromide (18 μg) versus placebo in patients with GOLD 1 and 2 COPD. Primary endpoint was between-group (tiotropium vs. placebo) difference in inspiratory capacity at isotime (i.e., at the time the shortest test ended) during constant work rate treadmill exercise from baseline to the end of a 6-week treatment period. Key secondary endpoints included differences in exercise duration and exertional dyspnea. Safety was assessed by recording adverse events.Study population comprised 48 patients with GOLD 1 COPD and 78 patients with GOLD 2 COPD. Resting inspiratory capacity significantly improved with tiotropium versus placebo in the overall (P0.0001), GOLD 1 (P = 0.0183), and GOLD 2 (P0.0001) groups. Isotime inspiratory capacity was significantly enhanced during exercise in the overall (P = 0.0087) and GOLD 2 (P = 0.0494) groups after tiotropium versus placebo. Tiotropium versus placebo significantly enhanced exercise duration in the GOLD 2 group (P = 0.0070) but not in the GOLD 1 or overall patient groups. In the overall group, increase in exercise duration seen with tiotropium was well correlated with the increase in isotime inspiratory capacity (r = 0.463, P0.0001).Resting and exercise hyperinflation were ameliorated by bronchodilator therapy with tiotropium in the overall GOLD 1 plus 2 COPD group. Exercise tolerance was enhanced in GOLD 2, but not GOLD 1, COPD. Clinical trial registered with www.clinicaltrials.gov (NCT01072396).

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognizes that interdisciplinary health care professionals providing pulmonary rehabilitation services need to have certain core competencies. This statement updates the previous clinical competency guidelines for pulmonary rehabilitation professionals, and it complements the AACVPR's Guidelines for Pulmonary Rehabilitation Programs. These competencies provide a common core of 13 professional and clinical competencies inclusive of multiple academic and clinical disciplines. The core competencies include patient assessment and management; dyspnea assessment and management; oxygen assessment, management, and titration; collaborative self-management; adherence; medication and therapeutics; non-chronic obstructive pulmonary diseases; exercise testing; exercise training; psychosocial management; tobacco cessation; emergency responses for patient and program personnel; and universal standard precautions.

Background Patients with COPD often require multiple therapies to improve lung function and decrease symptoms and exacerbations. Salmeterol and theophylline are indicated for the treatment of COPD, but the use of these agents in combination has not been extensively studied. Objectives To compare the efficacy and safety of salmeterol plus theophylline vs either agent alone in COPD. Methods Randomized, double-blind, double-dummy, parallel-group trial in 943 patients with COPD. After an open-label theophylline titration period (serum levels, 10 to 20μ g/mL), patients were randomly assigned to receive salmeterol (42μ g bid) plus theophylline, salmeterol (42 μg bid), or theophylline for 12 weeks. Serial pulmonary function tests were completed on day 1 and treatment week 12. Patients kept diary cards and noted their peak flow rates, symptom scores, and albuterol use, and periodically completed quality-of-life and dyspnea questionnaires. Results All three groups significantly improved compared with baseline. Combination treatment with salmeterol plus theophylline provided significantly (p ≤ 0.045) greater improvements in pulmonary function; significantly (p ≤ 0.048) greater decreases in symptoms, dyspnea, and albuterol use; and significantly fewer COPD exacerbations (p = 0.023 vs theophylline). In general, treatment with salmeterol provided greater improvement in lung function and satisfaction with treatment compared with theophylline. Salmeterol treatment was also associated with significantly fewer drug-related adverse events (p ≤ 0.042) than either treatment that included theophylline. The safety profile (adverse events, vital signs, and ECG findings) of the two treatments that included theophylline were similar. Conclusion Patients with COPD may benefit from combination treatment with salmeterol plus theophylline, without a resulting increase in adverse events or other adverse sequelae.

Chronic obstructive pulmonary disease (COPD) is a condition in which continuous bronchodilation may have clinical advantages. This study evaluated salmeterol, a beta-agonist bronchodilator with a duration of action substantially longer than that of short-acting beta-agonists, compared with ipratropium, an anticholinergic bronchodilator, and placebo in patients with COPD. Four hundred and five patients with COPD received either salmeterol 42 microg twice daily, ipratropium bromide 36 microg four times daily, or placebo for 12 wk in this randomized, double-blind, parallel-group study. Patients were stratified on the basis of bronchodilator response to albuterol (12% and200-ml improvement) and were randomized within each stratum. Bronchodilator response was measured over 12 h four times during the treatment period. Salmeterol provided similar maximal bronchodilatation to ipratropium but had a longer duration of action and a more constant bronchodilatory effect with no evidence of bronchodilator tolerance. Both active treatments were well tolerated. Salmeterol was an effective bronchodilator with a consistent effect over this 12-wk study in patients with COPD, including those "unresponsive" to albuterol. The long duration of action of salmeterol offers the advantage of twice daily dosing compared with the required four times a day dosing with ipratropium.

Objective To evaluate the efficacy and safety of fluticasone propionate administered as a once-daily or twice-daily regimen over a period of 1 year to patients with moderate asthma. Design Double-blind, randomized, parallel group, and placebo-controlled phase (12 weeks) and an open-label phase (54 weeks). Setting Multicenter study in an outpatient setting. Participants Patients (n = 253; age,≥ 12 years) with a mean FEV 1 of 67% predicted normal were stratified according to baseline therapy of maintenance inhaled corticosteroids vs β 2 -agonists alone. Measurements and interventions Fluticasone propionate (250μ g bid or 500 μg qd) or placebo (bid) was administered via the Diskus multidose powder inhaler (Glaxo Wellcome; Research Triangle Park, NC) for 12 weeks. During open-label treatment, patients were re-randomized to once-daily or twice-daily fluticasone propionate. Results Compared to placebo, fluticasone propionate administered qd or bid significantly improved FEV 1 (p 1 , albuterol use, and withdrawal due to lack of efficacy. During 54 weeks of open-label treatment, FEV 1 and PEF continued to improve with both regimens, and improvements seen in the first 12 weeks were maintained in patients who switched from twice-daily to once-daily dosing. Fluticasone propionate treatment over a 54-week period was well tolerated, with few drug-related adverse events, which were primarily topical effects of inhaled corticosteroids. Conclusions Fluticasone propionate powder improved lung function when administered either qd or bid over a 1-year period to patients with moderate asthma, with twice-daily dosing demonstrating significantly greater improvement in some efficacy parameters than once-daily dosing over the first 12 weeks of treatment. Fluticasone propionate treatment was not associated with significant systemic effects.

OBJECTIVE This study examined the within-person relations between transitory changes in mood, asthma symptoms, and peak expiratory flow rate (PEFR). METHODS Thrice-daily for 21 consecutive days, 48 adults with moderate to severe asthma entered information in palm-top computers about their mood and asthma symptoms. A multidimensional model of mood, ie, the mood circumplex, informed the assessment of mood arousal and mood pleasantness. At each observation, participants also recorded their PEFR with peak flow meters that stored blinded data. Albuterol doses were also monitored electronically. Before and after the 21-day study, spirometric measures of airways obstruction were taken under controlled conditions. RESULTS Random effects regression models revealed a significant, but weak, within-person relation between symptoms and PEFR. Changes in mood vectors with an arousal component were significantly related to PEFR changes, whereas changes in mood vectors with a pleasantness component tracked changes in asthma symptom reports, even after adjustment for contemporaneous PEFR and after controlling for time of day and albuterol dosing. Comparison of spirometric assessments with unsupervised PEFR suggested that part of the relation between mood arousal and PEFR may be attributable to the "effort-dependence" of peak flow self-monitoring. CONCLUSIONS Different dimensions of mood were associated with transitory changes in asthma symptoms and PEFR. This may be one reason why individuals with asthma misperceive the severity of their symptoms in relation to underlying airways obstruction.