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BACKGROUND: Oropharyngeal myofunctional therapy is a multi-component therapy effective to reduce the severity of obstructive sleep apnoea (OSA). However, existing protocols are difficult to replicate in the clinical setting. There is a need to isolate the specific effectiveness of each component of the therapy. OBJECTIVE: To assess the effects of a 6 weeks tongue elevation training programme in patients with OSA. METHODS: We conducted a multicentre randomised controlled trial. Eligible participants were adults diagnosed with moderate OSA who presented low adherence to continuous positive airway pressure therapy (mean use

Background: Adherence to treatment is critical when dealing with chronic diseases. One of the difficulties in maintain long-term adherence is the distance from home to rehabilitation center. Objective: To determine the influence of the distance from subjects’ residence to rehabilitation center on adherence of a 12-week pulmonary rehabilitation program in chronic respiratory disease. Methods: This retrospective study analyzed patients’ medical records with chronic respiratory diseases from a pulmonary rehabilitation center. Driving distance between patients’ home and rehabilitation center was calculated with Google maps. The home-rehabilitation center distances were classified in three levels: up to 10, 10-30 and more than 30 km. Results: 280 medical records from patients with chronic pulmonary diseases with medical indication to follow the pulmonary rehabilitation program were found and 148 medical records were included in our study. Out of them, the majority (n = 93) had chronic obstructive pulmonary disease (COPD). Seventy percent of patients lived up to 10 km, 24% lived between 10 and 30 km and 6% lived more than 30 km. No difference in adherence was found comparing the three groups based on the distance from home to rehabilitation center. Conclusion: In this study, distance between home and rehabilitation center did not influence adherence to pulmonary rehabilitation program.

Introduction: The intermittent intrapulmonary deflation (IID) technique is a recent airway clearance technique that intends to delay the onset of expiratory flow limitation (EFL) during exhalation. We showed in a previous study that IID increased the expiratory volume of COPD patients compared to quiet breathing and positive expiratory pressure (PEP) therapy. We hypothesized that it was due to the attenuation of the EFL. Objectives: To verify the physiologic effects of IID and PEP techniques on EFL with a mechanical lung model. Methods: A mechanical lung model was created to assess the effects of IID and PEP techniques. The thorax was simulated by a plexiglas box in which an adult test lung was connected. A calibration syringe simulated the inspiratory phase. Later, with activation of the IID, the expiratory phase was driven by the deflation generated by the device. With PEP, the expiration occurred maintaining an expiratory pressure between 5-10 cmH2O. A pneumotachograph and a pressure transducer were placed in series for flow, volumes and pressure measurements. Results: The model reproduced physiological characteristics of EFL. However, the deflation of the model was slowed by IID and PEP, and flow remained almost constant, so flow limitation was reduced. Conclusion: The IID and PEP attenuate EFL and increase exhaled volume in the in vitro model.

BACKGROUND: The purposes of this study were to verify the correlation between chest expansion and lung function within a larger sample of subjects composed of both healthy subjects and subjects affected by pulmonary disease, and to verify the influence of age, body mass index, and gender on chest expansion. METHODS: Adults were recruited prospectively when they visited the lung function lab. Chest expansion was measured with a measuring tape at 2 different levels of the rib cage by 1 blinded examiner. Spirometry was performed for each subject. RESULTS: Data from 251 subjects between 18 and 88 y old were collected and analyzed. Among the analyzed subjects, mean upper and lower chest expansion were 4.82 ± 1.84 cm and 3.99 ± 2.15 cm, respectively. A significant but poor correlation was found between both chest expansion and all lung function parameters (total lung capacity, FVC, and FEV1) (P = .01). Negative significant correlations were found between chest expansion and age as well as body mass index. The difference in upper chest expansion between obese and nonobese subjects was not statistically significant, but the difference in lower chest expansion was significant for these 2 groups. Finally, upper and lower chest expansion were not different between males and females. CONCLUSIONS: Based on these results, one cannot validate the use of chest expansion measurement to define lung function. In centers that have easy access to more precise and complete methods to measure lung function, the measurement of chest expansion for diagnostic purposes seems to be archaic. Additionally, age and body mass index are 2 parameters that can influence chest expansion.

The Haldane M constant represents the ratio of oxygen/carbon monoxide affinity to hemoglobin. Findings on M values appear to be quite variable among studies. A systematic review and a meta-analysis were conducted to set a reference of human M values according to experimental conditions. The searched included all the relevant articles published from 1985 to January 2016 and extracted from the major electronic libraries database (PubMed/Embase/JSTOR). For each article, the following items were collected: age, temperature, pH, atmospheric pressure, 2,3-diphosphoglycerate (2,3-DPG) or methemoglobin levels, and hemoglobin type. Statistical analyses were performed using JMP®Pro12 software. Among the 1.683 articles analyzed, 15 were selected, which included 111 individual data, 21 mean values related to human adult hemoglobin (HbA) and 57 mean values for fetal hemoglobin (HbF) at known temperature and pH. The median M value at physiological conditions was 218 [191–257] (n = 19) for HbA and 175 [158–192] for HbF. There was a negative correlation between temperature and M value (p < 0.001), but no correlation between M and pH for HbA (p = 0.33), conversely to HbF (p = 0.044). Data were insufficient to perform a meta-analysis on the dependence between M and 2,3-DPG concentration, atmospheric pressure, pregnancy, methemoglobin, and sickle Hb. Our analysis confirmed that the M value in humans at physiological conditions is 218 for HbA and 175 for HbF. Temperature influences M, but further studies are required to clarify pH influence.

BACKGROUND: Treating hypoxemia while meeting the soaring demands of oxygen can be a challenge during the COVID-19 pandemic. OBJECTIVE: To determine the efficacy of the surgical facemask and the double-trunk mask on top of the low-flow oxygen nasal cannula on arterial partial pressure of oxygen (PaO2) in hypoxemic COVID-19 patients. DESIGN: Randomized controlled trial. PARTICIPANTS: Hospitalized adults with COVID-19 and hypoxemia treated with the low-flow nasal cannula were enrolled between November 13, 2020, and March 05, 2021. INTERVENTIONS: Patients were randomized in a 1:1:1 ratio to receive either the nasal cannula alone (control) or the nasal cannula covered by the surgical facemask or the double-trunk mask. Arterial blood gases were collected at baseline and 30 min after the use of each system. The oxygen output was adapted afterwards to retrieve the baseline pulse oxygen saturation. The final oxygen output value was recorded after another 30-min period. MAIN MEASURES: The primary outcome was the absolute change in PaO2. Secondary outcomes included changes in oxygen output, arterial partial pressure of carbon dioxide (PaCO2), vital parameters, and breathlessness. KEY RESULTS: Arterial blood samples were successfully collected in 24/27 (8 per group) randomized patients. Compared to the nasal cannula alone, PaO2 increased with the surgical facemask (mean change: 20 mmHg, 95% CI: 0.7-38.8; P = .04) and with the double-trunk mask (mean change: 40 mmHg; 95% CI: 21-59; P < .001). Oxygen output was reduced when adding the surgical facemask (median reduction: 1.5 L/min [95% CI: 0.5-4.5], P < .001) or the double-trunk mask (median reduction: 3.3 L/min [95% CI: 2-5], P < .001). The double-trunk mask was associated with a PaCO2 increase of 2.4 mmHg ([95% CI: 0-4.7], P = .049). Neither mask influenced vital parameters or breathlessness. CONCLUSIONS: The addition of the surgical facemask or the double-trunk mask above the nasal cannula improves arterial oxygenation and reduces oxygen consumption.

The Haldane M-value is the ratio of half-saturation pressures for O2 and CO (PO2/PCO) and is a key value of physiological and pathological models exploring CO metabolism or exposure to CO. Nevertheless, the M-values obtained from different studies and different species appear to be inconsistent. A better estimation of M-values and a consideration of interspecies variation will ensure the accuracy of CO study results and allow reliable models to be constructed. We performed a systematic review and meta-analysis in order to determine and compare M-values according to species and experimental conditions. We used electronic libraries (PubMed/Embase/JSTORE) from 1895 to January 2016. For each article, we collected the following parameters: species, age, temperature, pH, atmospheric pressure, concentration of 2,3-diphosphoglycerate (2,3-DPG) or methemoglobin, and type of hemoglobin. The systematic review found 25 articles addressing the M constant, including 135 with individual data and 51 with mean values concerning mammals, laboratory animals, fish, fetal hemoglobin and invertebrates. M-values at a physiological temperature and pH were assessed only for adult (137 [119–153]) and fetal (135 [112–168]) sheep, dogs (215 [193–218]), mice (194 [118–278]) and rats (191 [177–200]). A correlation between M-values and temperature was confirmed for sheep and horses. A correlation between M-values and pH could not be inferred because there was a lack of data. M-values varied according to species. Only the influence of temperature was confirmed. A formal measurement of the M constant in the given experimental conditions should be performed for each animal model study of CO. Further homogeneous studies are necessary to compare the M-values of different animals.

Introduction: Tele-rehabilitation is increasingly used to deliver pulmonary rehabilitation. The aim of this systematic review was to compare the effect between tele-pulmonary rehabilitation and classical supervised pulmonary rehabilitation. Method: Three databases were analysed (PubMed, PEDro, Scopus). The selection and evaluation of studies followed the PRISMA guidelines. The risk of bias was evaluated using the PEDro Scale. Results: From the initial selection (n = 245), ten studies were retrieved, including from 10 to 67 patients. All but two (IPF) included patients with COPD. Based on the FEV1, patients with COPD were mainly categorised as moderate and severe. The teleactivities were heterogenous in terms of proposed exercises and way of settings and often not in agreement with the guidelines about pulmonary rehabilitation. Despite this, the effects of the interventions were globally positive on functional exercise capacity, quality of life, anxiety and depression, and impact of COPD on personal life but not on dyspnoea. The PEDro scores varied from 4 to 8. The adherence was higher than 80% when supervision during the exercise was included. Conclusion: This review demonstrated that the telerehabilitation is safe and well accepted by the patients, and could be considered as one option of classical pulmonary rehabilitation to improve the functional exercise capacity, quality of life, anxiety and depression, and the impact of COPD on personal’s life. This conclusion cannot be extrapolated to the other chronic lung diseases due to the lack of data.

Dysphagia is common in patients with neuromuscular diseases (NMDs). Its management differs by country and clinical setting. The purpose of this study was to describe current practices in the management of dysphagia in NMDs across Europe. An online survey of sixteen questions was developed, including basic information on facilities, existence of a management protocol, availability of dedicated therapists, tools used during screening, assessment, treatment stages, and treatment strategies. The survey was rolled out to European healthcare facilities providing care for NMDs. A total of 140 facilities across 25 European countries completed the survey. Substantial discrepancies in dysphagia management were identified among respondents. Seventy-two percent of the facilities reported having a protocol for at least one of the three management stages whereas only 39% had one for all. Speech and language therapists were reported as involved throughout the entire management stage while participation of other members from multidisciplinary teams varied depending on the stage. Clinical swallowing assessment was the most frequently reported tool in the assessment and treatment stages. For screening, questionnaires were the most frequently used while instrumental examinations were mainly reported in the assessment stage. For the treatment stage, adaptation strategies (diet, food, and posture) were the most reported approaches. In conclusion, the survey highlighted the absence of a defined protocol concerning the management of dysphagia in most of the surveyed healthcare facilities. Standardized training strategies and guidelines are necessary in the future to familiarize clinicians with each stage of the management of dysphagia.

BACKGROUND: The impact of the COVID-19 pandemic on functional exercise capacity seemed quickly clinically evident. The objective of this study was to assess the functional exercise capacity of patients with severe COVID-19 and to evaluate the effect of a telerehabilitation program in the specific context of the COVID-19 pandemic. METHOD: Patients hospitalized for severe or critical COVID-19 were recruited. The functional exercise capacity (1-min sit-to-stand test (STST)) was prospectively quantified at discharge. A telerehabilitation program was then proposed. A control group was composed with the patients refusing the program. RESULTS: At discharge, none of the 48 recruited patients had a STST higher than the 50th percentile and 77% of them were below the 2.5th percentile. SpO2 was 92.6 ± 3.0% after STST and 15 patients had oxygen desaturation. After 3-months of follow-up, the number of repetitions during STST significantly increased either in telerehabilitation (n = 14) (p < 0.001) or in control groups (n = 13) (p = 0.002) but only one patient had a result higher than the 50th percentile (in Telerehabilitation group) and 37% of them were still under the 2.5th percentile for this result. The improvement was significantly and clinically greater after the telerehabilitation program (p = 0.005). No adverse events were reported by the patients during the program. CONCLUSIONS: Patients hospitalized for COVID-19 have a low functional exercise capacity at discharge and the recovery after three months is poor. The feasibility and the effect of a simple telerehabilitation program were verified, this program being able to substantially improve the functional recovery after three months.

Dear Editor, Hypoxaemia is a typical feature of the coronavirus disease 2019 (COVID-19). The rapid rise in the number of patients requiring oxygen therapy during the pandemic may cause a sharp increase in oxygen demands and potential threats of supply disruption, particularly in developing countries1 or nursing homes. Moreover, the use of elevated oxygen flows via nasal cannula raises concerns about exhaled air dispersion distance and the potential risk of generating aerosols [...]

Introduction/aims Oropharyngeal dysphagia is common in patients with neuromuscular diseases (NMDs). Its early recognition is vital for proper management. We tested a large cohort of adult NMD patients for oropharyngeal dysphagia using the Sydney Swallow Questionnaire (SSQ). We also looked for possible differences in characteristics of oropharyngeal dysphagia in various NMD groups and diseases. Finally, we compared results of this screening with those from their corresponding medical records for eventual "clinical history" of dysphagia. Methods We asked patients to fill in the SSQ during follow-up outpatient visits at our neuromuscular reference center. A total score above the cutoff score of 118.5 out of 1700 was indicative of oropharyngeal dysphagia. Results Of the 304 adult patients assessed for eligibility, 201 NMD patients (96 women and 105 men, aged 49.0 ± 16.2 years) were included and tested in this study. Oropharyngeal dysphagia was detected in 45% of all the NMD patients when using the SSQ, whereas only 12% had a positive medical record for dysphagia. The median SSQ scores for patients with myotonic syndromes (including myotonic dystrophy type 1), with amyotrophic lateral sclerosis, and with facioscapulohumeral dystrophy were above the cutoff score. The SSQ scores obtained revealed distinct oropharyngeal dysphagia characteristics in the different NMD groups and diseases. Discussion The SSQ tests positively for oropharyngeal dysphagia in a higher proportion of NMD patients compared with their medical records. The distinct oropharyngeal dysphagia characteristics we revealed in different NMD groups and diseases may help to elaborate adapted clinical approaches in the management of oropharyngeal dysphagia.

Background: Patients with coronavirus disease (COVID-19) can develop severe hypoxemia. Meeting the soaring demands of oxygen may be a challenge. Objective: To test the efficacy of an easily handmade system, the double-trunk mask (DTM), in reducing oxygen consumption while maintaining patient’s oxygenation level. Methods: Hospitalized adults with COVID-19 and hypoxemia treated with low-flow oxygen therapy we recruited. The standard oxygen delivery system was replaced by the DTM with nasal cannula for 30 minutes with an oxygen output adapted to maintain an identical oxygen saturation by pulse oximetry. The standard oxygen delivery system was then reinstated for 30 minutes. Primary outcome was the absolute change in oxygen flow between the standard delivery systems and the DTM. Secondary outcomes were changes in blood gases, vital parameters and patient comfort. Results: Eleven patients were analyzed (mean age 61 years; 27% male). Compared with standard delivery systems, the oxygen output was significantly reduced with the DTM (median, 5 vs 1.5 L/min (95% CI -4 to -1.5, p=0.003)) when oxygen saturation and arterial oxygen tension remained stable. The DTM was also associated with a significant but slight increase in arterial carbon dioxide tension (median, 36 mmHg vs 37 mmHg, p=0.006), and respiratory rate (median, 26 vs 30 breaths/min, p=0.05). Other parameters were unaltered. The DTM was generally judged less comfortable than the baseline oxygen delivery system, especially in patients requiring low oxygen flow at baseline. Conclusions: The DTM is a simple and efficient system to reduce oxygen consumption. This may have clinical implications in places where oxygen supplies are limited.

Coronavirus disease 2019 (COVID-19) is commonly associated with kidney damage, and the angiotensin converting enzyme 2 (ACE2) receptor for SARS-CoV-2 is highly expressed in the proximal tubule cells. Whether patients with COVID-19 present specific manifestations of proximal tubule dysfunction remains unknown. To test this, we examined a cohort of 49 patients requiring hospitalization in a large academic hospital in Brussels, Belgium. There was evidence of proximal tubule dysfunction in a subset of patients with COVID-19, as attested by low-molecular-weight proteinuria (70-80%), neutral aminoaciduria (46%), and defective handling of uric acid (46%) or phosphate (19%). None of the patients had normoglycemic glucosuria. Proximal tubule dysfunction was independent of pre-existing comorbidities, glomerular proteinuria, nephrotoxic medications or viral load. At the structural level, kidneys from patients with COVID-19 showed prominent tubular injury, including in the initial part of the proximal tubule, with brush border loss, acute tubular necrosis, intraluminal debris, and a marked decrease in the expression of megalin in the brush border. Transmission electron microscopy identified particles resembling coronaviruses in vacuoles or cisternae of the endoplasmic reticulum in proximal tubule cells. Among features of proximal tubule dysfunction, hypouricemia with inappropriate uricosuria was independently associated with disease severity and with a significant increase in the risk of respiratory failure requiring invasive mechanical ventilation using Cox (adjusted hazard ratio 6.2, 95% CI 1.9-20.1) or competing risks (adjusted sub-distribution hazard ratio 12.1, 95% CI 2.7-55.4) survival models. Thus, our data establish that SARS-CoV-2 causes specific manifestations of proximal tubule dysfunction and provide novel insights into COVID-19 severity and outcome., Graphical abstract

BACKGROUND: Air-flow oscillations generated by exhaling through oscillatory positive expiratory pressure (OPEP) devices favor airway clearance. Variations in mechanical properties between different devices may influence therapeutic efficacy. The objective of this study was to assess mechanical properties in vitro and to compare the performance of 6 OPEP devices at different resistance levels under active expiratory flow patterns. METHODS: 4 gravity-dependent OPEP devices (ie, Flutter, Gelomuc, Pari O-PEP, Shaker Medic Plus) and 2 gravity-independent OPEP devices (ie, Acapella Choice and Aerobika) were each tested at low, medium, and high resistance settings. All devices were independently connected to a pulmonary waveform generator that reproduced active exhalation flows. Expiratory flow-volume curves were retrieved from 4 subjects with different stages of obstruction severity and were scaled according to either peak expiratory flow (4, 6, and 8 L/s) or volumes (2, 3 and 4 L), thus amounting to 24 active exhalations. Resulting waveforms were divided into 4 parts and the 2 middle parts were used to extract the following mechanical data: positive expiratory pressure (PEP), maximum expiratory pressure (Ppeak), oscillation frequency, and flow oscillation amplitude. The percentage of tests achieving oscillation frequencies ≥ 12 Hz and PEP ≥ 10 cm H2O was calculated for each device. RESULTS: Mechanistic effects of the Acapella, Aerobika, and Shaker devices were not comparable. The Flutter, Gelomuc, and Pari devices behaved similarly and achieved more tests with optimum oscillation frequency and PEP values than the other devices. These 3 devices also produced the highest oscillation amplitudes at the low-resistance level, whereas the Aerobika elicited higher and consistent oscillation amplitudes at medium and high resistance settings. CONCLUSIONS: Operational parameters differed between and within devices, yet the Flutter, Gelomuc, and Pari devices were similar in many aspects. Therapeutic efficacy may depend on the selected OPEP device and set resistance.

A 86-yr-old man was referred for transfemoral aortic valve implantation. Transthoracic echocardiography revealed a severe stenosis (mean gradient: 58 mmHg, aortic valve area: 0.4 cm2), and after multidisciplinary discussion, the risk of surgery was judged too high (logistic Euroscore: 51%), and the patient was proposed for a transfemoral aortic valve implantation (TAVI). On arrival in the operating room, the patient, fully conscious, was noted to have Cheyne–Stokes breathing (CSB), which persisted after 40% oxygen administration. TAVI procedure was successful, and the CSB pattern was interrupted within 8 s. To the best of our knowledge, this report is the first to show an acute disappearance of CSB, occurring only seconds after TAVI and restoration of a normal hemodynamic situation. To explain such rapid changes in breathing pattern, we hypothesize a role played by the acute release of pulmonary hypertension and pulmonary volume overload. NEW & NOTEWORTHY Acute disappearance of Cheyne–Stokes breathing after transfemoral aortic valve implantation suggests a reflex pathway originating from the fall in pulmonary vessels congestion.

As exertional inspiratory dyspnea is a common disabling complaint in hypermobile Ehlers-Danlos syndrome (hEDS) often also known as joint hypermobility syndrome (JHS), we investigated inspiratory muscle (IM) strength in patients with hEDS, and we assessed the effects of IM training (IMT) on IM strength, lung function, and exercise capacity. A prospective evaluation of IM strength followed by a randomized controlled trial of IMT was performed in women with hEDS. Sniff nasal inspiratory pressure (SNIP) was used to routinely measure IM strength and IMT was carried out using a pressure threshold device. IM strength (main outcome), cardiopulmonary function, exercise capacity, and emotional distress of both the treated and control groups were evaluated at the start and at the end of the 6-week training period. IM strength was reduced (

A breath-synchronized nebulization option that could potentially improve drug delivery during noninvasive positive pressure ventilation (NIPPV) is currently not available on single-limb circuit bilevel ventilators. The aim of this study was to compare urinary excretion of amikacin following aerosol delivery with a vibrating mesh nebulizer coupled to a single-limb circuit bilevel ventilator, using conventional continuous (Conti-Neb) and experimental inspiratory synchronized (Inspi-Neb) nebulization modes.A crossover clinical trial involving 6 noninvasive ventilated healthy volunteers (mean age of 32.3 ± 9.5 y) randomly assigned to both vibrating mesh nebulization modes was conducted: Inspi-Neb delivered aerosol during only the whole inspiratory phase, whereas Conti-Neb delivered aerosol continuously. All subjects inhaled amikacin solution (500 mg/4 mL) during NIPPV using a single-limb bilevel ventilator (inspiratory positive airway pressure: 12 cm HThe total daily amount of amikacin excreted in the urine was significantly higher with Inspi-Neb (median: 44.72 mg; interquartile range [IQR]: 40.50-65.13) than with Conti-Neb (median: 40.07 mg; IQR: 31.00-43.73), (p = 0.02). The elimination rate constant of amikacin (indirect measure of the depth of drug penetration into the lungs) was significantly higher with Inspi-Neb (median: 0.137; IQR: 0.113-0.146) than with Conti-Neb (median: 0.116; IQR: 0.105-0.130), (p = 0.02). However, the mean pulmonary drug delivery rate, expressed as the ratio between total daily urinary amount of amikacin and nebulization time, was significantly higher with Conti-Neb (2.03 mg/min) than with Inspi-Neb (1.09 mg/min) (p 0.01).During NIPPV with a single-limb circuit bilevel ventilator, the use of inspiratory synchronized vibrating mesh nebulization may improve pulmonary drug delivery compared with conventional continuous vibrating mesh nebulization.

Purpose The aim of this study was to evaluate the effect of different kinds of music on submaximal performance and exercise tolerance in healthy children by means of the 6-minute walking test (6MWT) and to explore the influence of gender. Design Cross-over study. Method Ninety-seven children performed 6MWT in four conditions (without music, with their preferred music, with slow and with fast music). Distance, cardio-respiratory parameters, perceived exertion rate, and amount of dyspnea were measured. Findings Walked distance depended on the kind of music (p = .022). To listen to fast music promoted a longer distance when compared with slow music. Walked distance was not influenced by gender (p = .721) and there was no interaction between music and gender for walked distances (p = .069). The other parameters were not modified by music and gender. Conclusion Music influences submaximal performances without modifying exercise tolerance in healthy children. Clinical Relevance Music does modify submaximal performance in children.

Introduction: Thoracic or abdominal tumours present a breathing-related motion that can reduce accuracy of radiation treatments. Therefore, motion mitigation strategies have been developed to ensure adequate target dose coverage during successive radiotherapy fractions. In this trial, we investigated a technique that intends to prolong breath-hold while coupling it with Intrapulmonary Percussive Ventilation (IPV), performed with a non-invasive IPV device (Pegaso A-Cough Perc). Our aim was to determine a standardized training protocol allowing a prolonged breath-hold combined to IPV (BHPV), with a maximal reduction of thoracic movement. Methods: Ten volunteers underwent a training protocol divided in three training sessions in order to get used to IPV and to attempt to achieve a BHPV of 10 min. Afterwards, the volunteers performed a final BHPV for a least 10 min (max. 20 min) in the radiotherapy simulation room. During this final BHPV, residual thoracic motion was measured from a tracked point, using an optical tracking system. Stabilization time and stable phase duration were also recorded. Results: All the 10 subjects achieved BHPV of 10 min. During the final BHPV, all the subjects even reached the maximal duration allowed of 20 min. Seven out of ten subjects presented a motion deviation of only 1mm around the mean position for more than 95% of the duration of the stable phase. The mean stabilization time was 2.1 ± 3.3 min and the mean stable phase duration was 16.6 ± 5.5 min. Conclusion: This training protocol allowed a 20min-BHPV. It is based on the combination of breath-hold with IPV while using a commercially available device.

Background: SIMEOX produces a non-invasive succession of very short air depressions through a mouthpiece during expiration. Therefore, the SIMEOX technology claims to reduce expiratory flow limitation. Objective: To assess the safety and to measure expiratory volume and flow mobilized with SIMEOX. Methods: Non-smoker adults with no history of cardio-respiratory disease were recruited. Each participant performed 3 slow vital capacity (VC) maneuvers followed by 3 slow maximal exhalations from total lung capacity with SIMEOX. Flow and volume were measured using a pneumotachograph. The highest volume of each attempt was reported while flow was averaged from the 3 repetitions. Participants were further categorized according to the lower limit of normality (LLN) of VC calculated from ERS 1993 equations. Results: Thirty-two subjects (21F, 24 ± 8y) were recruited. Mean (±SD) volume during slow expiration with SIMEOX and slow VC was respectively 4.01 ± 0.93L and 4.05 ± 1.08L (p=0.55). Mean expiratory flow with SIMEOX was significantly lower than during slow VC (0.8 ± 0.1L/s vs 2 ± 0.9L/s, p Conclusions: Our preliminary data suggest that SIMEOX modifies the expiratory pattern and may be able to mobilize an extra volume of air in subjects with abnormal lung function. Collection of data in patients with COPD is ongoing.

We developed a training protocol based on Intrapulmonary Percussive Ventilation in order to prolong breath-hold while nearly suppressing the thorax motion. This protocol allowed ten subjects to achieve a 20-minutes-breath-hold, while reducing the residual surface motion to 1 mm around its mean position for more than 95% of the breath-hold duration.

BACKGROUND AND PURPOSE: When using highly conformal radiotherapy techniques, a stabilized breathing pattern could greatly benefit the treatment of mobile tumours. Therefore, we assessed the feasibility of Mechanically-assisted non-invasive ventilation (MANIV) on unsedated volunteers, and its ability to stabilize and modulate the breathing pattern over time. MATERIALS AND METHODS: Twelve healthy volunteers underwent 2 sessions of dynamic MRI under 4 ventilation modes: spontaneous breathing (SP), volume-controlled mode (VC) that imposes regular breathing in physiologic conditions, shallow-controlled mode (SH) that intends to lower amplitudes while increasing the breathing rate, and slow-controlled mode (SL) that mimics end-inspiratory breath-holds. The last 3 modes were achieved under respirator without sedation. The motion of the diaphragm was tracked along the breathing cycles on MRI images and expressed in position, breathing amplitude, and breathing period for intra- and inter-session analyses. In addition, end-inspiratory breath-hold duration and position stability were analysed during the SL mode. RESULTS: MANIV was well-tolerated by all volunteers, without adverse event. The MRI environment led to more discomfort than MANIV itself. Compared to SP, VC and SH modes improved the inter-session reproducibility of the amplitude (by 43% and 47% respectively) and significantly stabilized the intra- and inter-session breathing rate (p

BACKGROUND: Clinical benefits of inhaled therapies are related to the amount of drug deposited in the targeted area of the lung. Body positions that influence the distribution of lung ventilation should impact lung deposition of the nebulized drug. The aim of this study was to analyze the immediate effect of body position while the subject lies on his side (lateral decubitus) during nebulization on 3-dimensional total and regional lung deposition. METHODS: A randomized crossover trial was performed on healthy male volunteers without cardiovascular or pulmonary disease. A technetium-99m diethylenetriaminepentaacetic acid (99mTc-DTPA) solution (4 mL) was nebulized using an individual-controlled inhalation system in left lateral decubitus and sitting positions with a 96-h washout period (43 inspirations of 4 s [ie, drug delivered until second 3] with a tidal volume of 0.8 L and a low inspiratory flow (200 mL/s). Drug deposition was followed with the use of planar images and single-photon-emission computed tomography combined with low-resolution computed tomography. Total and regional depositions were the main outcomes. Penetration index was also considered. RESULTS: Six participants (26.8 ± 6.9 y old) were included. Total lung deposition tended to be higher in a sitting position than in a lateral decubitus position: 10.2 ± 0.9% of nominal dose (95% CI 9.1–11.3) vs 8.6 ± 1.4% of nominal dose (95% CI 6.8–10.4) (P = .09). The deposition was significantly reduced in the dependent (left) lung in the lateral decubitus position: 3.5 ± 0.7% of nominal dose (95% CI 2.6–4.3) vs 4.7 ± 0.3% of nominal dose (95% CI 4.3–5.0) (P = .03). Penetration index was only influenced by body position for the dependent (left) lung (P = .043). CONCLUSIONS: The total amount of drug delivered to the lungs during nebulization with an individual-controlled inhalation system tended to decrease when performed in the left lateral decubitus position. Moreover, contrary to the initial hypothesis, the deposition of particles in the dependent lung was not improved by the lateral decubitus position in this configuration. (ClinicalTrials.gov registration NCT02451501.)

Background COVID-19 pandemic resulted in an unprecedented number of hospitalizations in general wards and intensive care units (ICU). Severe and critical COVID-19 patients suffer from extensive pneumonia; therefore, long-term respiratory sequelae may be expected. Research question We conducted a cohort study to determine respiratory sequelae in patients with severe and critical COVID-19. We aimed at evaluating the proportion of patients with persisting respiratory symptoms and/or abnormalities in pulmonary function tests (PFT) or in lung imaging. Study design and methods: This is a single center cohort study including COVID-19 survivors who underwent a three-month follow-up with clinical evaluation, PFT and lung high-resolution computed tomography (HRCT). All clinical, functional, and radiological data were centrally reviewed. Multiple linear regression analysis was performed to identify factors associated with residual lesions on HRCT. Results Full clinical evaluation, PFT and lung HRCT were available for central review in 126, 122 and 107 patients, respectively. At follow-up, 25% of patients complained from dyspnea and 35% from fatigue, lung diffusion capacity (DLCO) was decreased in 45%, 17% had HRCT abnormalities affecting more than 5% of their lung parenchyma while signs of fibrosis were found in 21%. In multiple linear regression model, number of days in ICU were related to the extent of persisting lesions on HRCT, while intubation was associated with signs of fibrosis at follow-up (P = 0.0005, Fisher's exact test). In contrast, the severity of lung imaging or PFT changes were not predictive of fatigue and dyspnea. Interpretation Although most hospitalized COVID-19 patients recover, a substantial proportion complains from persisting dyspnea and fatigue. Impairment of DLCO and signs suggestive of fibrosis are common but are not strictly related to long-lasting symptoms.

Nebulized drugs are frequently administrated through tracheostomy in clinical routine. So far, the amount of drug deposited into the lung in these patients remains unknown. The aim of our pharmacokinetic study was to compare lung delivery of amikacin in the same subjects in two settings: spontaneously breathing through a tracheostomy and through the mouth.Lung delivery was measured by amikacin urinary drug concentration in nine patients who were transitory tracheostomized for the need of a head and neck oncologic surgery. Patients performed two nebulization sessions: with a mouthpiece (MB) and through tracheostomy (TB) using a adapted jet nebulizer (SidestreamLung delivery was similar with the two conditions of nebulization (6.5 ± 2.5% vs. 6.3 ± 2.0% of the nominal mass of amikacin, respectively, for MB and TB; p = 0.95). Duration of nebulization was also comparable (19.7 ± 1.6 vs. 20.1 ± 1.8 min, respectively, for mouth and tracheostomy breathing; p = 0.307). The half-life and elimination rate constant were not different between the two settings. We conclude that nebulized therapy can be administered in spontaneously breathing tracheostomized adults patients, with a similar amount of drug delivered to the lung compared with spontaneously mouth breathing patients.

Background Recently, gait speed reached an increasing importance in the management of respiratory patients. The aim of this retrospective study was to compare walking speed and physiological adaptations during the 6MWT in COPD and CF patients. Methods 6MWT performed by COPD and CF patients were retrospectively reviewed. Global and sequential walking speeds were measured on six minutes and every sequence of two minutes respectively. Heart rate, oxygen saturation and dyspnea were analyzed. Results 78 and 246 tests from CF and COPD patients were reviewed respectively. FEV1 (52.3 vs 56.2% pred) and FVC (72.5 vs 73.8% pred) were similar between both diseases. However, 6MWT in patients with CF were characterized by significantly higher heart rate, global walking speed and walking distance (+68%) while dyspnea evolutions and the proportions of patients presenting walking speed decline over the 6 min were significantly lower. Conclusion Walking speed and cardio-respiratory parameters evolution during 6MWT differ between COPD and CF patients.

Objective : The purposes of this study were to (1) evaluate the reliability and reproducibility of chest expansion (CE) measurement on 2 different levels and (2) observe relationships between upper and lower CE measurements and lung function. // Methods : Fifty-three healthy subjects aged between 18 and 39 years were recruited. Chest expansion measurements were taken with a cloth tape measure at 2 levels of the rib cage (upper and lower). Reproducibility of the measurement was measured for 2 physiotherapists and on 2 different days. Lung function (ie, forced expiratory volume in 1 second [FEV1], forced vital capacity (FVC), vital capacity and, inspiratory capacity) was measured for all subjects by a spirometer (MEC Pocket-spiro USB100, Medical Electronic Construction, Brussels, Belgium). // Results : Upper CE was less than lower CE (5.4 cm and 6.4 cm, respectively; P < .001). Intrarater and interrater reliability were good for upper and lower CE. Reproducibility between physiotherapists was verified for both CE measurements. Reproducibility between days was only verified for upper CE. Sex influenced lower CE. Upper and lower CE values were correlated (r = 0.747; P < .01). Lower and upper CE were significantly and positively correlated with all lung function parameters and inspiratory muscle strength (moderately and weakly, respectively) except to inspiratory capacity for upper CE (P = .051) and for FEV1/FVC for both CE measurements. // Conclusion : Upper and lower CE measurements showed good intra- and interrater reliability and reproducibility in healthy subjects. Although both measurements were correlated with lung functions (ie, FEV1, FVC, and vital capacity), the findings of this study showed that upper CE measurements may be more useful in clinical practice to evaluate chest mobility and to give indirect information on lung volume function and inspiratory muscle strength.

Resume Introduction L’incidence des infections a mycobacteries atypiques est estimee en Europe a un cas pour 100 000 personnes/annee. Malgre la rarete des infections mycobacteriennes non tuberculeuses, le Mycobacterium avium peut realiser une lesion nodulaire donnant le change avec un cancer pulmonaire. Nous rapportons un cas de mycobacteriose atypique pulmonaire, ayant conduit a la lobectomie. Observation Il s’agit d’un nodule pulmonaire droit decouvert chez un patient de 63 ans, BPCO, partiellement nephrectomise pour carcinome renal, hebdomadairement sous methotrexate pour polyarthrite rhumatoide. A la tomographie par emission de positron (TEP scan), la lesion etait faiblement hypermetabolique, avec des micronodules non hypermetaboliques de la petite scissure. La bronchoscopie ne retrouvait pas de lesions endoluminales. L’examen cytobacteriologique etait non contributif. L’examen histopathologique du nodule pulmonaire apical, obtenu par biopsie transthoracique revelait un adenocarcinome bronchique au stade T1(a)N0M0. Le patient beneficia alors d’une lobectomie superieure avec curage ganglionnaire. L’analyse anatomopathologique a retrouve des nodules granulomateux necrosant entoures de cellules geantes evoquant un tuberculome. La culture mycobacterienne des echantillons de lavage bronchique s’est revelee positive a Mycobacterium avium apres 7 semaines. Conclusion Dans les formes pseudoneoplasiques des mycobacterioses atypiques, la presence d’anomalies cytonucleaires alveolaires inflammatoires peut mimer un adenocarcinome. Faire la difference entre les anomalies cytonucleaires d’origine reactionnelles ou d’origine neoplasique reste donc une difficulte journaliere en histopathologie.

BACKGROUND: Sputum production and purulence were proposed as criteria for justifying the use of antimicrobial agents. The Sputum Color Chart was developed and validated to standardize purulence of sputum evaluation. The aim of this study was to observe the reproducibility of the Sputum Color Chart from different categories of health caregivers. METHODS: The color of 10 sputum samples was evaluated using photographs for intra- and inter-reliability. The observation was repeated 3 times. Eighteen volunteers from 6 categories of health caregivers (student in physiotherapy, senior chest physiotherapist, junior resident in pulmonology, medical microbiologist, pulmonologist, and general practitioner) were investigated. // RESULTS: Poor inter-rater reliability was observed for all categories with the exception of senior chest physiotherapists. The best intra-rater reliability was observed for microbiologists and senior chest physiotherapists. We found a great proportion (>40%) of important discrepancies in 2 categories (junior pulmonologist and general practitioner). The proportion of non-discrepancy between evaluators varied between 10 and 40%, depending on the category. // CONCLUSIONS: Even if the Sputum Color Chart is a useful tool for the clinician in the context of clinical deterioration, it presents non-uniform reliability regarding the caregivers and their category.

Introduction: The use of pulmonary function tests (PFT) is built on an expert opinion. PFT interpretation relies on the recognition of patterns but scarcely leads to a specific respiratory disease diagnosis. We aimed to explore the accuracy and inter-rater variability of pulmonologists when: 1/ interpreting PFT’s, 2/ suggesting a respiratory disease diagnosis based on clinical info and PFT’s. We compared it with artificial intelligence (AI)-based software developed on 1430 historical patient cases. Methods: 6000 interpretations of complete PFT (spirometry, body box and diffusion) and clinical info were made by 120 pulmonologists from 16 European hospitals on 50 patient cases. ATS/ERS guidelines were used as the gold standard for test interpretation. The gold standard diagnosis was derived from clinical history, PFT and all additional tests, and finally confirmed by an expert panel. AI software examined the same cases. Results: The interpretations of pulmonologists (senior 73%, junior 27%) matched the guidelines in 74.4% (±5.9) of the cases (range: 56-88%). Inter-rater variability of 0.67 pointed to a common agreement. Readers were able to correctly appoint the primary disease diagnosis in only 44.6% (±8.7) of the cases (range: 24-62%). Inter-rater variability of 0.35 indicates a common disagreement between readers. AI-based software perfectly (100%) matched the interpretation of ATS/ERS guidelines while it assigned a correct diagnosis in 82% of cases. Conclusions: Interpreting PFTs and suggesting primary respiratory disease diagnosis by expert clinicians contains discrepancy and incorrectness. The AI-based software provides a powerful decision support tool to improve current clinical practice.

Background: Many oscillatory positive expiratory pressure (OPEP) devices exist and some of them use unique mechanism to produce air-flow oscillations. However their operational parameters and elicited therapeutic effects may vary. Objectives: To assess the mechanical performance of 6 OPEP devices at different resistance levels. Methods: Four gravity-dependent (Flutter, Gelomuc, Shaker, PARI-OPEP) and 2 gravity-independent OPEP devices (Acapella Choice and Aerobika) were tested at 3 resistance levels (low, medium, high). Each device was independently attached to an artificial lung driven by a ventilator in order to simulate an active exhalation. Ventilator settings were adjusted to produce peak expiratory flow rate between 40-45 L.min-1 at 10 breaths.min-1. The middle-third of the exhalation phase was used to compare positive expiratory pressure (PEP), oscillatory frequency (OF) and pressure amplitude (PA). Optimal operational parameters were defined as OFs of 12 Hz or above and PEP ranging between 10-20 cmH2O. Corresponding PAs at these settings were analysed. Results: Only gravity-dependent devices at medium and high resistance levels produced the desired OFs and PEP settings, ranging from 16 to 22 Hz and 12 to 18 cmH2O, respectively. Corresponding PAs ranged from 0.6 to 1.8 cmH2O. Compared to these devices, Acapella and Aerobika elicited higher PAs (from 1.7 to 4.2 cmH2O) although they did not achieve optimal PEP or OF parameters. Conclusions: The gravity-dependent devices displayed close mechanical performances and produced optimal operational parameters at the simulated exhalation settings. Acapella and Aerobika probably require higher expiratory pressure to reach theoretical therapeutic effectiveness.

To compare the effects of He/O(2) and external PEEP (PEEPe) on intrinsic PEEP (PEEPi), respiratory mechanics, gas exchange, and ventilation/perfusion (V(A)/Q) in mechanically ventilated COPD patients.Prospective, interventional study in the intensive care unit of a university hospital.Ten intubated, sedated, paralyzed, mechanically ventilated COPD patients studied in the following conditions: (a) baseline settings made by clinician in charge, air/O(2), ZEEP; (b) He/O(2), ZEEP; (c) air/O(2), ZEEP; (d) air/O(2), PEEPe 80% of PEEPi. Measurements at each condition included V(A)/Q by the multiple inert gas elimination technique (MIGET).PEEPi and trapped gas volume were comparably reduced by He/O(2) (4.2+/-4 vs. 7.7+/-4 cmH(2)O and 98+/-82 vs. 217+/-124 ml, respectively) and PEEPe (4.4+/-1.3 vs. 7.8+/-3.6 cmH(2)O and 120+/-107 vs. 216+/-115 ml, respectively). He/O(2) reduced inspiratory and expiratory respiratory system resistance (15.5+/-4.4 vs. 20.7+/-6.9 and 19+/-9 vs. 28.8+/-15 cmH(2)O l(-1)s(-1), respectively) and plateau pressure (13+/-4 vs. 17+/-6 cmH(2)O). PEEPe increased airway pressures, including total PEEP, and elastance. PaO(2)/FIO(2) was slightly reduced by He/O(2) (225+/-83 vs. 245+/-82) without significant V(A)/Q change.He/O(2) and PEEPe comparably reduced PEEPi and trapped gas volume. However, He/O(2) decreased airway resistance and intrathoracic pressures, at a small cost in arterial oxygenation. He/O(2) could offer an attractive option in COPD patients with PEEPi/dynamic hyperinflation.

A model consisting of a motivated working group that identified the different stakeholders to convince them, through education, over the Global Lung Function Initiative reference values has appeared to be successful in implementing these in Belgiumhttp://ow.ly/Q21630kuE1N

Background The new predicted values for the carbon monoxide transfer factor (TL,CO) for Caucasians by the Global Lung Function Initiative are available since September 2017. Several authors have previously shown that the predicted values of Cotes et al. (ERS′93), overestimated TL,CO. However, the GLI′17 authors omitted to compare their predicted values with the ERS′93 equations, still in use throughout Europe. We present the differences between the two sets of predicted values, and in an attempt to improve the readability, used the contour plots instead of the classical 2-dimensional representations. Methods Predicted values were computed for males and females for ages between 18 and 70 years and heights between 155 and 180 cm using Matlab software with increments of one unit (1 yr, 1 cm). Results We demonstrate that GLI-‘17 predicted values of TL,CO are systematically lower than those of ERS-‘93, but also that the magnitude of the differences varies according to age, height and sex. More specifically, differences increase in both males and females by decreasing age and height, reaching up to 16% in males and 24% in females. Conclusion The predicted values of TL,CO by Cotes at al. are systematically larger than the new GLI’17 values. Plotting all the possible differences between predicted variables using contour graphs allows to identify the groups of subjects in whom significant changes in their predicted values will occur. Our findings should prompt physicians to investigate how switching to GLI-17 equations affects the clinical interpretation of TL,CO measurements in a real-live setting.

Oropharyngeal dysphagia is frequently under-reported and early detection may lead to adapt strategies of rehabilitation and management decisions. The Sydney Swallow Questionnaire (SSQ), a self-reported questionnaire for the detection and quantification of oropharyngeal dysphagia, was previously adapted and validated in other languages but not in French. The purposes of this study were to develop and validate a French version of SSQ (SSQ-f) and to assess its psychometric properties. This SSQ-f, obtained by back-translation and cross-cultural adaptation, was validated in 27 patients with impaired swallowing and 27 healthy controls. After inclusion, patients filled in the SSQ-f and performed a videofluoroscopic swallow study. The penetration aspiration scale (PAS) and Dysphagia outcome and severity scale (DOSS) were assigned to assess construct validity. Sensitivity and specificity of cut-off scores for the SSQ-f were assessed by the receiver operating characteristic (ROC) curves. Moreover, the SSQ-f was repeated after 2 weeks to evaluate its test-retest reliability. The results supported that SSQ-f was considered understandable. Its total score was strongly correlated to the DOSS (r = - 0.873) and to the PAS (r = 0.738). It demonstrated acceptable internal consistency, with Cronbach's alpha values ranging from 0.744 to 0.956. The test-retest reliability was excellent. According to the ROC curve, cut-off scores of 118.5 or 218.5 were proposed for determining oropharyngeal dysphagia using DOSS as a reference and 755.0, using PAS as reference. No ceiling or floor effects were observed. In conclusion, the SSQ-f is a valid and reliable instrument to measure and detect oropharyngeal dysphagia in French-speaking subjects and can be used in a clinical setting.

INTRODUCTION: In an experimental study on carbon monoxide (CO) exposure in swine, we aimed to compare the influence of oxygen therapy using a non-rebreathing mask (NRM) to continuous positive airway pressure (CPAP) and two pressure support ventilation (PSV) devices on the decrease of the terminal elimination half-life of carboxyhemoglobin (COHb t(1/2)). This was the primary outcome. METHODS: Eight spontaneously breathing pigs were sedated by propofol and exposed to 940 ppm CO several times (n = 25) to obtain COHb levels of 30%. CPAPb (high flow open system, CPAP Boussignac® [7.5 cmH(2)O]), PSV-Vy (open system, Vylife Boussignac®), and PSV-Leg (closed system, Legendair® [inspiratory/expiratory airway pressure 12/4 cmH(2)O]) devices were used in a randomized order and compared to NRM (O(2) at 15 l min(−1)) and atmospheric air (AA). The primary outcome was COHb t(1/2). Multiple comparisons were performed using Dunn’s tests. RESULTS: Median FiO(2) and minute ventilation were significantly higher in the PSV-Leg group than the NRM group (p

Evidence and guidelines are becoming increasingly clear about imbalance between the risks and benefits of inhaled corticosteroids (ICSs) in patients with COPD. While selected patients may benefit from ICS-containing regimens, ICSs are often inappropriately prescribed with – according to Belgian market research data – up to 70% of patients in current practice receiving ICSs, usually as a fixed combination with a long-acting β2-adrenoreceptor agonist. Studies and recommendations support withdrawal of ICSs in a large group of patients with COPD. However, historical habits appear difficult to change even in the light of recent scientific evidence. We have built a collaborative educational platform with chest physicians and primary care physicians to increase awareness and provide guidance and support in this matter., SCOPUS: re.j, info:eu-repo/semantics/published

BACKGROUND: Positive expiratory pressure (PEP) is regularly used as a self-administered airway clearance technique. OBJECTIVE: The aim of this study was to evaluate the need to teach the correct use of the PEP device and to measure the progress of the success rate of the maneuver after training. METHOD: A PEP system (PariPEP-S Sytem) was used to generate PEP in 30 healthy volunteers. They were instructed by a qualified physical therapist to breathe correctly through the PEP device. Then they were evaluated during a set of ten expirations. Two other evaluations were performed at day 2 and day 8 (before and after feedback). The mean PEP and the success rate were calculated for each set of expirations. The number of maneuvers needed to obtain a correct use was calculated on the first session. RESULTS: An optimal PEP was reached after 7.5 SD 2.7 attempts by all subjects. Success rates and mean pressures were similar between the different sets of expirations (p=0.720 and p=0.326, respectively). Pressure variability was around 10%. After one week, 30% of subjects generated more than two non-optimal pressures in the set of ten expirations. No difference in success rate was observed depending on the evaluations. CONCLUSION: This study demonstrates that good initial training on the use of the PEP device and regular follow-up are required for the subject to reach optimal expiratory pressure.

Background Pharmaceutical companies offer an increasing number of inhaler devices, whether or not together with new substances, for maintenance treatment of patients with COPD or asthma. However, well-designed studies to support these developments are scarce. Objectives The aim of this research was to evaluate how far new developments of inhaler devices are scientifically supported and translate into improvements of patient preferences and/or clinical outcomes. Methods A systematic literature review was performed to retrieve randomised controlled trials in patients with COPD or asthma that studied the in-company evolution of inhaler devices. Results were tabulated and discussed. Results A total of 30 studies were found comparing Respimat ® vs. HandiHaler ® , Diskus ® (Accuhaler ® ) vs. Diskhaler ® (Rotadisk ® ) or pMDI, Ellipta ® vs. Diskus ® (Accuhaler ® ), Nexthaler ® vs. pMDI, or Breezhaler ® vs. Aerolizer ® . These studies show that developments of inhaler devices may improve patient satisfaction but do not lead to demonstrable improvements in clinical efficacy. Current changes of devices are most commonly parallelled by changes in administration frequency towards once daily treatment. The only well-documented effect was found for the Respimat ® Soft Mist™ Inhaler, which realises a more than 3-fold lowering of the once-daily tiotropium dose through increased performance of the inhaler device. There are however, no data on clinical efficacy or safety comparing the two devices at the same dosage. Conclusions Future developments of inhaler devices should all require well-designed studies to demonstrate patient benefit.

Pulmonary rehabilitation is a key element in the treatment of COPD. Music has been shown to have a positive effect on parameters related to a decrease in exercise tolerance. The aim of this study was to evaluate the effect of listening to ambient music on perceived exertion during a pulmonary rehabilitation session for COPD subjects.COPD subjects randomly performed a session of pulmonary rehabilitation with or without ambient music. Perceived exertion (Borg scales), anxiety (Hospital Anxiety and Depression Scale-Anxiety Subscale), dyspnea (visual analog scale), and cardiorespiratory parameters were compared at the end of both sessions.Forty-one subjects were analyzed. The characteristics of the COPD subjects were as follows: age, 70.5 ± 8.4 y; body mass index, 22.7 ± 3.9 kg/m(2); and FEV1, 38.6 ± 12.5 % predicted. Perceived exertion was not modified by ambient music, but anxiety was improved (P = .02). Dyspnea, fatigue and cardiorespiratory parameters were not influenced by music during a typical session of the pulmonary rehabilitation program.This study demonstrates that perceived exertion during one pulmonary rehabilitation session was not influenced by ambient music. However, a positive effect on anxiety was observed. (ClinicalTrials.gov registration NCT01833260.).