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Tristan Bonnevie,1,2 Clement Medrinal,2,3 Yann Combret,4,5 David Debeaumont,6 Bouchra Lamia,2,3,7 Jean-François Muir,1,2,7 Antoine Cuvelier,2,7 Guillaume Prieur,2,3,5 Francis-Edouard Gravier1,2 1ADIR Association, Rouen University Hospital, Rouen, France; 2Normandy University UNIROUEN, UPRES EA 3830, Haute Normandie Research and Biomedical Innovation, Rouen, France; 3Intensive Care Unit Department, Le Havre Hospital, Le Havre, France; 4Physiotherapy Department, Le Havre Hospital, Le Havre, France; 5Institute of Experimental and Clinical Research (IREC), Pole of Pulmonology, ORL and Dermatology, Catholic University of Louvain, Brussels, Belgium; 6Department of Respiratory and Exercise Physiology and CIC-CRB 1404, Rouen University Hospital, Rouen, France; 7Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, FranceCorrespondence: Tristan BonnevieADIR Association, Rouen University Hospital, Rouen, FranceTel +33 235592970Fax +33 235592971 Email rehabilitation@adir-hautenormandie.comPurpose: Cognitive dysfunction is a common impairment associated with COPD. However, little is known about 1) its prevalence among those subjects referred for pulmonary rehabilitation (PR), 2) how it may affect the benefit of PR, 3) whether PR improves cognitive function and 4) whether cognitive dysfunction affects the usability of telehealth technology usually used to deliver in-home PR.Patients and Methods: Fifty-six subjects with stable COPD (54% females, mean age 62 years (SD 9) and median FEV1 0.9 L (IQR 0.7 to 1.1)) participated in this multicenter observational study and performed 24 sessions of PR. The Montreal Cognitive Assessment tool (MoCA) was used to assess the occurrence of mild cognitive dysfunction (using a screening cutoff < 26) at baseline, completion of PR and 3 months of follow-up.Results: Mild cognitive dysfunction was found in 41 subjects (73% [95% CI: 60 to 83%]). The MoCA score significantly improved following PR for those people with baseline mild cognitive dysfunction (p< 0.01). There was no significant difference in clinical outcomes between those people with or without mild cognitive dysfunction following PR nor in the proportion of subjects who were autonomous in using the telemonitoring system (83% compared with 71%, p=0.60).Conclusion: Mild cognitive dysfunction is highly prevalent among those people with COPD referred for PR but does not affect the benefits of PR nor the usability of a telemonitoring system. PR may improve short- and mid-term cognitive function for those people who experience mild cognitive dysfunction at the time they are referred to PR.Keywords: COPD, pulmonary rehabilitation, exercise, cognitive dysfunction

Tristan Bonnevie,1,2 Mathilde Allingham,3 Guillaume Prieur,1,4 Yann Combret,5,6 David Debeaumont,7 Maxime Patout,1,8 Antoine Cuvelier,1,8 Catherine Viacroze,8 Jean-François Muir,1,2,8 Clement Medrinal,1,4 Francis-Edouard Gravier1,2 1Normandie University, UNIROUEN, UPRES EA 3830, Rouen University Hospital, Haute Normandie Research and Biomedical Innovation, Rouen, France; 2ADIR Association, Rouen University Hospital, Rouen, France; 3Rouen University Hospital, School of Physiotherapy, Rouen, France; 4Intensive Care Unit Department, Le Havre Hospital, Hôpital Jacques Monod, Montivilliers, France; 5Institute of Experimental and Clinical Research (IREC), Pole of Pulmonology, ORL and Dermatology, Catholic University of Louvain, Brussels, Belgium; 6Physiotherapy Department, Le Havre Hospital, Le Havre, France; 7Department of Respiratory and Exercise Physiology and CIC-CRB 1404, Rouen University Hospital, Rouen, France; 8Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, France Purpose: There are many barriers to pulmonary rehabilitation, including a limited access to evaluation centers. To cope with these difficulties, field tests are often used to prescribe endurance training. As field tests are related to muscle strength, they could also be used to prescribe strength training and increase the access to pulmonary rehabilitation in rural area. However, their validity for this purpose has never been studied.Patients and methods: The relationship between the 6-minute stepper test (6MST), 6-minute walk test, maximal workload achieved during cardiopulmonary exercise testing (Wpeak), and one repetition maximum (1RM) was assessed in 35 patients with COPD through a retrospective chart review to derive predictive equation of the 1RM from these tests. The effectiveness of these equations to prescribe strength training at 70% of the 1RM was assessed in an independent cross-validation group of 34 patients with COPD.Results: There was a moderate relationship between the 6MST, Wpeak and the 1RM (r=0.44 and r=0.41, respectively, both P≤0.01). Whatever the test, the prescription of strength training using the estimated 1RM compared with the measured 1RM resulted in a mean absolute difference and a mean bias of about 30 kg.Conclusion: The use of the 6MST and Wpeak for the prescription of strength training would result in a clinically not acceptable error. Therefore, they should not be used as a substitute for the 1RM to prescribe strength training. Keywords: six-minute stepper test, strength training, COPD, pulmonary rehabilitation

Background: Maximal oxygen consumption (V ˙ O 2max ) is the most frequently used variable to determine postoperative risk in patients with non-small cell lung cancer (NSCLC), however patients frequently cannot provide the necessary maximum effort to ensure the validity of the V ˙ O 2 measurements. The aim of this observational study was to assess exercise-limiting factors and the rate of achievement of the currently recommended maximality criteria in patients with NSCLC who had been routinely referred for cardiopulmonary exercise testing (CPET) to assess their postoperative risk., Methods: Patient data, including peak exercise variables and markers used to designate the exercise test as maximal, were retrospectively analysed from 203 preoperative CPET assessments that were performed at Rouen University Hospital from January 2014 until July 2019., Results: Ventilatory limitation was the most common physiological cause of exercise cessation. A total of 62 patients (or 30.5%) achieved either one, or no, markers of maximality. The mean duration of the incremental phase (after the 3-minute warm-up) was 5.1±2 minutes., Conclusions: About 30% of the patients in this study did not generate maximum effort during CPET. As a result, it is likely that their V ˙ O 2peak was underestimated and that their post-operative risk was overestimated. It is therefore important to incorporate strategies to verify V ˙ O 2peak results for patients with values close to the risk threshold., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-1528). The authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Objective: Cardiopulmonary exercise testing (CPET) for patients awaiting lung resection for non-small cell lung cancer (NSCLC) has developed considerably in recent years. Pulmonary rehabilitation before surgery (prehabilitation) improves postoperative risk factors such as forced expiratory volume in 1 second and peak oxygen consumption (VO 2peak ). Ventilatory inefficiency assessed according to the linear regression of the ratio between the increase in minute ventilation and the expired carbon dioxide flow during CPET (VE/VCO 2 slope) >35, is a high-risk factor for postoperative complications. Our objective was to assess the effect of prehabilitation on VE/VCO2 slope, and its relationship with VO 2peak ., Methods: This retrospective cohort study was performed between January 1, 2014 and December 31, 2017 at Rouen University Hospital. One hundred fifty-two patients with NSCLC awaiting lung surgery who underwent CPET were screened. A total of 50 patients who underwent CPET before and after prehabilitation were included., Results: VE/VCO 2 slope did not change significantly after prehabilitation (median, 37.1 [25th-75th percentile, 33.8-43.4] vs median, 35.4 [25th-75th percentile, 31.1-40.5]; P = .09), whereas VO 2peak increased significantly (from a median of 13.2 [25th-75th percentile, 11.9-14.7] to a median of 14.8 [25th-75th percentile, 13.1-16.4] mL/kg/min). The number of patients with a high risk of postoperative complications (ie, VE/VCO 2 slope >35) did not change significantly after prehabilitation. Cardiorespiratory parameters improved significantly more in patients who underwent at least 15 sessions of ambulatory prehabilitation., Conclusions: VE/VCO 2 slope, a known predictor of favorable surgical outcomes in patients with NSCLC, did not change with the prehabilitation program used in this study, despite clear improvements in VO 2peak and other CPET measures. Larger, prospective studies are needed to confirm the results of this study., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the additional effect of a home-based neuromuscular electrical stimulation (NMES) program as an add-on to pulmonary rehabilitation (PR), on functional capacity in subjects with chronic obstructive pulmonary disease (COPD)., Design: Single-blind, multicenter randomized trial., Setting: Three PR centers., Participants: Subjects with severe to very severe COPD (N=73; median forced expiratory volume in 1 second, 1L (25th-75th percentile, 0.8-1.4L) referred for PR. Twenty-two subjects discontinued the study, but only 1 dropout was related to the intervention (leg discomfort)., Intervention: Subjects were randomly assigned to either PR plus quadricipital home-based NMES (35Hz, 30min, 5 time per week) or PR without NMES for 8 weeks., Main Outcome Measure: The 6-minute walk test (6MWT) was used to assess functional capacity., Results: Eighty-two percent of the scheduled NMES sessions were performed. In the whole sample, there were significant increases in the distance walked during the 6MWT (P<.01), peak oxygen consumption (P=.02), maximal workload (P<.01), modified Medical Research Council dyspnea scale (P<.01), and Saint George's Respiratory Questionnaire total score (P=.01). There was no significant difference in the magnitude of change for any outcome between groups., Conclusions: Home-based NMES as an add-on to PR did not result in further improvements in subjects with severe to very severe COPD; moreover, it may have been a burden for some patients., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Non-invasive ventilation (NIV) is a common treatment for bronchiolitis. However, consensus concerning its efficacy is lacking. The aim of this systematic review was to assess NIV effectiveness to reduce respiratory distress. Secondary objectives were to summarize the effects of NIV, identify predictive factors for failure and describe settings and applications., Evidence Acquisition: Literature searches were conducted in MEDLINE/PubMed, PEDro, Cochrane, EMBASE, CINAHL, Web of Science, UpToDate, and SuDoc from 1990 to April 2015. Randomized controlled trials, controlled non-randomized trials and prospective studies of NIV (continuous positive airway pressure [CPAP], bi-level CPAP, or neurally-adjusted ventilator assist) for bronchiolitis in infants younger than 2 years were included., Evidence Synthesis: Fourteen studies were included, for a total of 379 children. Of these, 357 were treated with NIV as first intention. Respiratory distress, heart rate, respiratory rate and respiratory effort improved (P<0.05). Results were inconclusive regarding prevention of endotracheal intubation. Few adverse events were reported. NIV reduced carbon dioxide pressure (pCO2) in 10 studies. Two randomized controlled studies reported a decrease of 7 mmHg in pCO2 (P<0.05). Predictive factors of NIV failure were apneas, high pCO2, young age, low weight, elevated heart rate and high pediatric risk of mortality score. NIV is mostly administered through a nasal mask, nasal cannula or helmet, with an initial expiratory positive airway pressure of 7 cmH2O., Conclusions: NIV shows promising results for the reduction of respiratory distress in acute viral bronchiolitis, as shown in several recent studies. However, there is a lack of robust studies to confirm this.

Pulmonary rehabilitation (PR) improves outcomes in patients with chronic obstructive pulmonary disease (COPD). Optimal assessment includes cardiopulmonary exercise testing (CPET), but consultations are limited. Field tests could be used to individualize PR instead of CPET. The six-minute stepper test (6MST) is easy to set up and its sensitivity and reproducibility have previously been reported in patients with COPD. The aim of this study was to develop a prediction equation to set intensity in patients attending PR, based on the 6MST. The following relationships were analyzed: mean heart rate (HR) during the first (HR 1-3 ) and last (HR 4-6 ) 3 minutes of the 6MST and HR at the ventilatory threshold (HRvt) from CPET; step count at the end of the 6MST and workload at the Ventilatory threshold (VT) (Wvt); and forced expiratory volume in 1 second and step count during the 6MST. This retrospective study included patients with COPD referred for PR who underwent CPET, pulmonary function evaluations and the 6MST. Twenty-four patients were included. Prediction equations were HRvt = 0.7887 × HR 1-3 + 20.83 and HRvt = 0.6180 × HR 4-6 + 30.77. There was a strong correlation between HR 1-3 and HR 4-6 and HRvt (r = 0.69, p < 0.001 and r = 0.57, p < 0.01 respectively). A significant correlation was also found between step count and LogWvt (r = 0.63, p < 0.01). The prediction equation was LogWvt = 0.001722 × step count + 1.248. The 6MST could be used to individualize aerobic training in patients with COPD. Further prospective studies are needed to confirm these results.

Questions: How common is inspiratory muscle training by physiotherapists in the intensive care unit (ICU)? Which patients receive the training? What methods are used to administer the training? Is maximal inspiratory pressure used to evaluate the need for the training and the patient's outcome after training?, Design: Cross-sectional survey of all ICUs in France., Participants: Two hundred and sixty-five senior physiotherapists., Results: The response rate was 99% among eligible units. Therapist experience in ICU was significantly associated with the use of inspiratory muscle training (p=0.02). Therapists mainly used inspiratory muscle training either systematically or specifically in patients who failed to wean from mechanical ventilation. The training was used significantly more in non-sedated patients (p<0.0001). The most commonly nominated technique that respondents claimed to use to apply the training was controlled diaphragmatic breathing (83% of respondents), whereas 13% used evidence-based methods. Among those who applied some form of inspiratory muscle training, 16% assessed maximal inspiratory pressure. Six respondents (2%, 95% CI 1 to 5) used both an evidence-based method to administer inspiratory muscle training and the recommended technique for assessment of inspiratory muscle strength., Conclusion: Most physiotherapists in French ICUs who apply inspiratory muscle training use methods of uncertain efficacy without assessment of maximal inspiratory pressure. Further efforts need to be made in France to disseminate information regarding evidence-based assessment and techniques for inspiratory muscle training in the ICU. The alignment of inspiratory muscle training practice with evidence could be investigated in other regions., (Copyright © 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)