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Clinical guidelines have been developed recognizing pulmonary rehabilitation (PR) as a key component in the management of patients with chronic lung disease. The medical director of a PR program is a key player in every program and is a requirement for operation of the program. The medical director must be a licensed physician who has experience in respiratory physiology management. The purpose of this document is to provide an update regarding the clinical, programmatic, legislative, and regulatory issues that impact PR medical directors in North America. It describes the clinical rationale for physician involvement, relevant legislative and regulatory requirements, and resources available that the medical director can utilize to promote evidence-based and cost-effective PR services. All pulmonary rehabilitation (PR) programs must include a medical director. There are many clinical, programmatic, legislative, and regulatory issues that impact the PR medical director. The purpose of this document is to concentrate on the unique roles and responsibilities of the PR medical director.

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.

International audience; Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Background: Observational studies of the long-term effects of COVID-19 infection generally focus on individual symptoms rather than health status. Objective: Longitudinal assessment of general health status following COVID-19 infection. Design: Observational study, with data collected from two telephone surveys at 32 ± 10 and 89 ± 25 days after discharge from the hospital or emergency department (ED) for a COVID-19 infection. Medicaid or no insurance was our marker of low socioeconomic status (SES). Acute disease severity was determined by summing 10 severity markers (yes-no) from the health encounter. Baseline comorbidity was a modified Charlson Index. Participants: 40 patients. Mean age was 54 ± 15 years, 50% were female, and 40% had low socioeconomic status. Main Measures: (1) the 20-item Medical Outcomes Study Short-Form General Health Survey (SF-20); (2) Dyspnea (modified Medical Research Council); (3) Psychological symptoms (Patient Health Questionnaire for Anxiety and Depression); (4) Cognitive function (Cognitive Change Questionnaire); (5) Fatigue (Short Fatigue Questionnaire); (6) A 10-item review of systems (ROS) questionnaire. Key Results: Percentages with abnormal symptoms at the first and second surveys were (respectively): Dyspnea (40, 33), Fatigue (53, 50), Anxiety (33, 18), Depression (20, 10), PHQ-4 Composite (25, 13), and Cognitive (18, 10). Mean scores on the SF-20 subscales, Physical Functioning, Role Functioning, Social Functioning, Health Perception, Mental Health, and Pain were numerically lower than means from a published study of elderly outpatients. With the exception of Pain, all SF-20 subscale scores improved significantly by the second survey. In multivariable analyses, dyspnea was predictive of impairment in all SF-20 subscales at the second survey. Conclusions: COVID-19 infection causes persistent abnormality across multiple patient-reported outcome areas, including health status. The persistence of impairment in each health status component is influenced by baseline dyspnea.

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.

Introduction: Chronic obstructive pulmonary disease (COPD) results in 700,000 hospitalizations annually in the United States and 12-25% of patients are readmitted within 30 days of hospital discharge. A simple scoring system to risk-stratify these patients would be useful in allocating scarce resources. Objective: The objectives of this study were to identify possible predictor variables to develop a clinically-useful instrument that can predict 30-day hospital readmissions in COPD patients. Methods: Fifty patients hospitalized for a COPD exacerbation at two hospitals over a one-month period were studied prospectively. Demographics, disease severity, symptoms, functional status, psychological, and co-morbidity variables were assessed during the hospitalization. Patients were contacted telephonically thirty days post-discharge to determine readmission. Baseline variables were tested as predictors of 30-day readmissions. Results: Mean age was 71 ± 11 years; 77% were female, 60% had Medical Research Council dyspnea 3 or 4; mean FEV1 was 41 ± 13% of predicted. Mean length of stay was 4.3 ± 3.2 days. Sixty percent had ≥ 1 clinical exacerbations in the preceding year, 52% had been hospitalized at least once for a respiratory exacerbation; 61% had been hospitalized at least once; 26% were on chronic prednisone. Thirty-day readmission rate was 24%. Three variables were found to be predictive of hospitalization: Clinical exacerbations in the previous year, chronic prednisone use, and functional limitation from dyspnea predictive of hospitalization. Conclusions: Exacerbations in the previous year, chronic prednisone use, and functional limitation from dyspnea hold promise in a scoring system used to predict 30-day re-hospitalization and could be quickly assessed from a review of hospital record or a brief interview.

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.

According to the 2013 American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation (PR), education to promote effective self-management is a cornerstone of this intervention. Despite education's stature within PR, there is currently limited evidence supporting its overall efficacy, and minimal evidence guiding its optimal design and delivery. This workshop was convened to focus on the current state of education in PR for patients with chronic obstructive pulmonary disease, who are the most common people referred to PR. The workshop explored the learning needs and limitations of patients participating in PR, promising design features (from work done outside of PR) that may inform our approach to education, and professional development of PR healthcare educators. Areas identified as needing development include: 1) outcome assessment for the educational component; 2) screening patients for conditions that will impede the learning process (anxiety, depression, cognitive deficits and health literacy issues); 3) tailoring content and optimizing delivery of the educational component; and 4) training PR professionals in their roles as educators. By necessity, the workshop conclusions are painted in broad strokes. However, with ongoing interest in improving quality through individualized patient assessment, educational design innovations, and scientific scrutiny comparable to that given to exercise training, the educational component of PR may achieve effective self-management, leading to successful behavior change and enhancement in health.

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.

Higher levels of exercise capacity and physical activity are each independently related to health in individuals in general and COPD patients in particular [1]. Exercise and physical activity, however, while sharing some features, are separate concepts: exercise is considered a subset of physical activity. Physical activity refers to any bodily movement produced by skeletal muscles that results in energy expenditure. In contrast, exercise is planned, structured, typically repetitive, and done with a particular goal in mind [2]. Increases in both exercise capacity and physical activity are important goals of pulmonary rehabilitation, although the methods (and success) of achieving these goals are different.

Traditional, outpatient pulmonary rehabilitation provided to stable COPD patients leads to significant improvements in dyspnea, exercise capacity and health related quality of life. Also, when started during or shortly after a hospitalization for a COPD exacerbation, pulmonary rehabilitation improves these patient-centered outcomes and arguably reduces subsequent health care utilization and mortality. Despite these benefits, the uptake of traditional pulmonary rehabilitation remains disappointingly poor. Home-based pulmonary rehabilitation, a safe and effective alternative to traditional, center-based programs, can broaden access. While proven improvements in dyspnea, exercise capacity and health status justify implementation of home-based pulmonary rehabilitation, it would be helpful to know whether it can also decrease health care utilization and be cost-effective.

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

There is an urgent need for consensus on what defines a chronic obstructive pulmonary disease (COPD) self-management intervention. We aimed to obtain consensus regarding the conceptual definition of a COPD self-management intervention by engaging an international panel of COPD self-management experts using Delphi technique features and an additional group meeting.In each consensus round the experts were asked to provide feedback on the proposed definition and to score their level of agreement (1=totally disagree; 5=totally agree). The information provided was used to modify the definition for the next consensus round. Thematic analysis was used for free text responses and descriptive statistics were used for agreement scores.In total, 28 experts participated. The consensus round response rate varied randomly over the five rounds (ranging from 48% (n=13) to 85% (n=23)), and mean definition agreement scores increased from 3.8 (round 1) to 4.8 (round 5) with an increasing percentage of experts allocating the highest score of 5 (round 1: 14% (n=3); round 5: 83% (n=19)).In this study we reached consensus regarding a conceptual definition of what should be a COPD self-management intervention, clarifying the requisites for such an intervention. Operationalisation of this conceptual definition in the near future will be an essential next step.

Nonadherence--not taking pharmacologic or nonpharmacologic treatments according to agreed recommendations from a health care provider--is common in patients with chronic obstructive pulmonary disease. Nonadherence in taking maintenance medications, smoking cessation, maintaining regular physical activity and exercise, starting and staying in pulmonary rehabilitation and continuing on with the postrehabilitation exercise/activity prescription, and successfully following self-management directions results in adverse outcomes across multiple areas. These include a faster decline in airway function, higher symptom burden, impaired health status, and increased health care use and mortality risk. Although nonadherence can also occur in health care providers (not following established treatment guidelines), this perspective focuses on patient nonadherence. Factors such as social/economic, health system, therapy-related, patient-related, and condition-related factors all impact this problem. To improve patient adherence, we need to consider these factors in the context of people with chronic obstructive pulmonary disease and implement strategies directly targeting underlying issues. Strategies may include customizing and simplifying learning and intervention regimes, identifying barriers to adherence and addressing them, ensuring patient support structures are in place, and improving self-efficacy. Future directions should focus on research and development in educational design; use of technology to assist education; psychological intervention strategies to support learning, motivation, self-efficacy and behavior change; and ways to improve healthcare providers' engagement with patients.

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.