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Background: Pulmonary rehabilitation (PR) is an essential element of chronic obstructive pulmonary disease (COPD) management. However, access to conventional face-to-face PR programmes is limited., Methods: This multicentre, randomised controlled trial recruited patients with COPD from 18 sites in Germany and Switzerland, aiming to evaluate the impact of 12 weeks of a mobile app (intervention group; IVG) on quality of life, measured by COPD Assessment Test (CAT), and exercise capacity, assessed by 1-minute-sit-to-stand-test (1MSTST), compared with a control group (CTG) receiving 'enhanced standard-of-care'., Results: 278 patients were included in the study with a median age of 65 years (IQR 60-70) and forced expiratory volume in 1 s 48% predicted (IQR 37-60). In the intention-to-treat analysis at week 12, CAT improved from baseline by median -4 points versus -3 points in the IVG versus CTG groups, respectively (difference: 0 points (95% CI: -1, 2); p=0.7); 1MSTST improved by 1 vs 2 repetitions, respectively (difference: 1 repetition (95% CI: 0, 2); p=0.12)). In a subset of the IVG, with patients grouped by application adherence (≥3 days/week for≥75% of the weeks), adherent users (40.4%) improved 1MSTST versus non-adherent users by median 2 repetitions (95% CI: 1, 3]; p=0.006. Application use did not raise any safety concerns., Conclusions: Application-based PR improved outcomes in COPD compared with baseline, and adherent users improved exercise capacity more compared with non-adherent users. Although not statistically significant compared with enhanced standard-of-care, this study may support the use of this application for COPD management and addresses the healthcare challenge of access to PR interventions., Trial Registration Number: DRKS 00024390., Competing Interests: Competing interests: RG has received speaker fees from AstraZeneca, Chiesi and GlaxoSmithKline and has attended advisory boards from AstraZeneca and Chiesi. MS has nothing to disclose. AS and AP are employees of Kaia Health Software (Munich, Germany) and hold a Virtual Options Program from Kaia Health Software. DK has nothing to disclose. IJ has received speakers fee from CSL Behring. TS has nothing to disclose. BU received payment from Kaia Health Software for statistical analysis of this manuscript. CFV has received institutional grants from the German Ministry of Education and Science (BMBF), AstraZeneca, Boehringer Ingelheim, Chiesi, CSL Behring, GlaxoSmithKline, Grifols and Novartis. Consulting fees from Aerogen, AstraZeneca, Boehringer Ingelheim, CSL Behring, Chiesi, GlaxoSmithKline, Insmed, Menarini, Novartis, Nuvaira, Sanofi. Speakers fees from Aerogen, AstraZeneca, Boehringer Ingelheim, CSL Behring, Chiesi, GlaxoSmithKline, Insmed, Menarini, Novartis, Nuvaira and Sanofi. ARK has received institutional grants from the Bavarian Ministry of Health. Consulting fees from AstraZeneca, Boehringer Ingelheim, CSL Behring, Chiesi, GlaxoSmithKline, Menarini, Pfizer, PulmonX, and Sanofi. Speakers fees from AstraZeneca, Boehringer Ingelheim, CSL Behring, Chiesi, GlaxoSmithKline, Menarini and Sanofi., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: SARS-CoV-2 is usually diagnosed from naso-/oropharyngeal swabs which are uncomfortable and prone to false results. This study investigated a novel diagnostic approach to Covid-19 measuring volatile organic compounds (VOC) from patients' urine., Methods: Between June 2020 and February 2021, 84 patients with positive RT-PCR for SARS-CoV-2 were recruited as well as 54 symptomatic individuals with negative RT-PCR. Midstream urine samples were obtained for VOC analysis using ion mobility spectrometry (IMS) which detects individual molecular components of a gas sample based on their size, configuration, and charge after ionization., Results: Peak analysis of the 84 Covid and 54 control samples showed good group separation. In total, 37 individual specific peaks were identified, 5 of which (P134, 198, 135, 75, 136) accounted for significant differences between groups, resulting in sensitivities of 89-94% and specificities of 82-94%. A decision tree was generated from the relevant peaks, leading to a combined sensitivity and specificity of 98% each., Discussion: VOC-based diagnosis can establish a reliable separation between urine samples of Covid-19 patients and negative controls. Molecular peaks which apparently are disease-specific were identified. IMS is an additional non-invasive and cheap device for the diagnosis of this ongoing endemic infection. Further studies are needed to validate sensitivity and specificity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: Non-small cell lung cancer (NSCLC) survivors suffer from impaired physical and psychological functioning and reduced health-related quality of life (HRQoL) that persist after active treatment ends. Sustaining rehabilitation benefits, promoting a healthy lifestyle and facilitating self-management at home require a multifaceted aftercare programme. We aim to investigate the effect of a 12-week digital lifestyle intervention on HRQoL and lifestyle-related outcomes in NSCLC survivors after completion of inpatient rehabilitation., Methods and Analysis: QUAlity of life in LUng CAncer Survivors (QUALUCA) is a multicentre randomised controlled trial that follows a hybrid type 1 design. We randomly allocate participants in a 1:1 ratio to the intervention group (digital lifestyle intervention) or the control group (standard care) using block randomisation stratified by tumour stage and study site. Four accredited Swiss inpatient rehabilitation centres recruit participants. Key inclusion criteria are a diagnosis of NSCLC, an estimated life expectancy of ≥6 months and access to a smartphone or tablet. The 12-week intervention comprises physical activity, nutrition and breathing/relaxation, delivered through a mobile application (app). The primary outcome is the change in HRQoL from baseline (1 week after rehabilitation) to follow-up (3 months after baseline), assessed by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Secondary outcomes include body mass index, self-reported physical activity, exercise capacity, risk of low protein intake, appetite, psychological distress, cancer-related fatigue, enablement and self-rated health. Explanatory outcomes in the intervention group include app usability, acceptability, appropriateness, and feasibility of the intervention, experiences and satisfaction with the intervention, and app usage data. We aim to enrol 88 participants. For the main statistical analysis, we will use analysis of covariance, adjusted for baseline measures, stratification variables, age and sex., Ethics and Dissemination: The Ethics Committees of the Canton of Zurich (lead), the Canton of Bern and Northwest and Central Switzerland approved the study (2023-00245). We will disseminate study results to researchers, health professionals, study participants and relevant organisations, and through publications in international peer-reviewed journals., Trial Registration Number: NCT05819346., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

(1) Background: Between the beginning of the coronavirus pandemic and summer 2022, we distinguished four pandemic waves, with different characteristics of the affected patients. This study investigated the impact of patient characteristics on the outcome of inpatient pulmonary rehabilitation (PR). (2) Methods: Using a prospective approach, the characteristics of post-acute COVID-19 patients of the different waves who participated in inpatient PR were compared based on their assessments and results collected as part of PR (Cumulative Illness Rating Scale (CIRS), six-minute walk test (6-MWT), Pulmonary Function Testing (PFT), and Functional Independent Measurement (FIM). (3) Results: A total of 483 patients were included in the analysis (Wave 1 n = 51, Wave 2 n = 202, Wave 3 n = 84, Wave 4 n = 146). Compared to Wave 3 + 4, patients of Wave 1 + 2 were older (69 vs. 63 years; p < 0.001), had a significantly lower CIRS (13.0 vs. 14.7 points; p = 0.004), had significant better PFT (FVC: 73 vs. 68%pred; p = 0.009; DLCO SB : 58 ± 18 vs. 50 ± 17%pred; p = 0.001), and showed significantly more comorbidities (2.0 vs. 1.6 n/pers.; p = 0.009). Wave 3 + 4 showed significantly greater improvements according to the 6-MWT (147 vs. 188 m; p < 0.001) and the FIM (5.6 vs. 21.1 points; p < 0.001). (4) Conclusions: Patients of the COVID-19 infection waves differed significantly according to their anthropometric data, incidence of comorbidities, and impact of the infection. All cohorts achieved clinically relevant and significant functional improvements during PR, with significant higher improvements in Wave 3 + 4.

Background: Evidence suggests that patients with COPD struggle to maintain improved physical activity (PA) after completing pulmonary rehabilitation (PR). Smartphone applications (apps) providing a comprehensive training programme have conferred healthy benefits. This study was conducted to determine whether regular usage of an app maintains PA following PR., Methods: Patients with stage II-IV COPD were enrolled in a 6-month trial following PR. After the screening period, participants were randomised into the Kaia COPD app group (intervention group (IG)) or the control group (CG). The primary outcome was PA (daily steps), measured using an activity tracker. Secondary outcomes included the COPD Assessment Test (CAT), the Chronic Respiratory Disease Questionnaire (CRQ) and the 1 min Sit-to-Stand Test (STST)., Results: Sixty participants completed the study. The median steps from baseline to 6 months were significantly different between the groups, in favour of the IG (-105.3, IQR -1970.1 to 2105.8, vs CG -1173.0, IQR -3813.1 to -93.8; p=0.007). CAT was significantly decreased in the IG (15.1±8.6 vs 19.7±6.4, p=0.02), whereas the CRQ subdomains for dyspnoea (4.5±1.7 vs 3.7±1.3, p=0.033) and fatigue (4.5±1.4 vs 3.5±1.3, p=0.028) improved significantly in the IG. The STST at 6 months was not significant. Sleep duration and sleep efficiency showed no significant differences between the two groups at any time., Conclusions: A comprehensive program by using the Kaia app following PR maintained PA and improved symptoms in patients with COPD at 6 months. The app might be an important accessory tool for enhanced COPD care., Trial Registration Number: DRKS00017275., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pulmonary rehabilitation (PR) improves physical and mental performance as well as quality of life in patients with chronic obstructive pulmonary disease (COPD). However, data on outcomes in very old patients are insufficient. We analyzed whether the elderly with COPD benefit in a similar way to younger patients from participation in an inpatient PR according to the assessments usually collected., Methods: Data from 3173 patients with COPD were retrospectively analyzed. Patients were referred to PR at the Zurich RehaZentren, Switzerland, between January 2013 and December 2019. PR was performed 6 days per week with an average duration of 18.85 days. Functional Independence Measurement (FIM), Feeling Thermometer (FT), and 6-Minute Walk Test (6MWT) were recorded on admission and discharge., Results: In all age groups, the 6MWT and FT improved significantly. FIM results also showed a significant increase. The results of the different age groups showed no significant differences in percentage improvements according to the assessments that were considered., Conclusions: All patient groups with COPD, even the oldest (>85 years), benefited from PR regardless of their age and according to the assessments. Prospective studies are needed to support this hypothesis.

Background: Most patients with COPD do not maintain exercise training after pulmonary rehabilitation (PR)., Research Question: Does a 12-month home-based, minimal-equipment strength training program after PR have an effect on dyspnea, exercise capacity, and patient-reported outcomes in patients with COPD?, Study Design and Methods: In a parallel-arm multicenter study across four Swiss PR clinics, patients with COPD were allocated randomly (1:1 ratio) into an intervention group (IG; home-based strength training program) or control group (CG; usual care). The primary outcome was change in Chronic Respiratory Questionnaire (CRQ) dyspnea scale score from baseline to 12 months. Secondary outcomes were change in exercise capacity (1-min sit-to-stand-test [1MSTST], 6-min walk test [6MWT]), health-related quality of life, exacerbations, and symptoms. We assessed the IG's experience by interviews at study end. Main analyses were based on the intention-to-treat approach, and adjusted linear regression models were used., Results: One hundred twenty-three patients with COPD (IG, n = 61; CG, n = 62) were randomized, 61 of whom were women and whose mean ± SD age was 66.8 ± 8.1 years and mean ± SD FEV 1 was 39.3 ± 15.3% predicted. One hundred four participants completed 12 months of follow-up (IG, n= 53; CG, n= 51). Of the 53 IG participants, 37 participants (70%) conducted the training until study end. We found no difference in change in CRQ dyspnea scale score over 12 months (adjusted mean difference, 0.28; 95% CI, -0.23 to 0.80; P = .27). We found moderate evidence for a difference in 1MSTST repetitions favoring the IG (adjusted mean difference, 2.6; 95% CI, 0.22-5.03; P = .033), but no evidence for an effect in other outcomes. Seventy-nine percent of the IG reported positive effects that they attributed to the training., Interpretation: The home exercise program had no effect on dyspnea, but improved 1MSTST performance and patient-perceived fitness. The supported program was well accepted by patients with COPD and may facilitate continued exercise training at home., Trial Registry: ClinicalTrials.gov; No.: NCT03461887; URL: www., Clinicaltrials: gov., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Dysphagia and aspiration risk are common sequelae of stroke, leading to increased risk of stroke-associated pneumonia. This is often aggravated by stroke-related impairment of cough, the most immediate mechanical defense mechanism against aspiration. In humans, reflex cough can be repeatedly and safely elicited by inhalation of nebulized capsaicin, a compound contained in chili peppers. Could this cough-eliciting property of capsaicin support the recovery of stroke survivors who present with dysphagia and aspiration risk? We present a clinical case report of a 73-year-old man, admitted to inpatient stroke rehabilitation following a right middle cerebral artery infarct with subsequent dysphagia and hospital-acquired pneumonia. A course of daily inhalation therapy with nebulized capsaicin was initiated, triggering reflex coughs to support secretion clearance and prevent recurrence of pneumonia. Clinical observations in each inhalation therapy session demonstrate good patient response, safety and tolerability of nebulized capsaicin in this mode of application. Repeated Fiberoptic Endoscopic Evaluation of Swallowing (FEES) assessments show concurrent improvement in the patient's swallowing status. Inhalation therapy with nebulized capsaicin may offer a viable treatment to facilitate coughing and clearing of secretions, and to minimize aspiration and risk of aspiration-related pneumonia post stroke. Further investigation in a randomized controlled trial design is warranted.

Health-related quality of life (HRQoL) in patients with moderate to severe chronic obstructive pulmonary disease (COPD) is often reduced by high symptom burden and frequent exacerbations. So far, data on therapeutic success in Swiss COPD patients receiving dual bronchodilation therapy as COPD maintenance treatment are limited. Data from a recently published, non-interventional study on clinical benefit after the start of combined tiotropium-olodaterol treatment were analyzed focusing on Swiss patients compared to the overall cohort including patients from various European countries. Demographic data on the changes in Clinical COPD Questionnaire (CCQ) for the assessment of HRQoL in correlation to symptoms and the number of exacerbations, as well as physician's global assessment (PGE), were evaluated 6 weeks after treatment start. In Switzerland ( n = 61), significantly more patients had comorbidities and exacerbations but showed less symptoms compared to the overall cohort ( n = 4639). HRQoL improved in both cohorts, with a negative correlation to symptom burden and number of exacerbations in the overall cohort. PGE scores improved after 6 weeks with a better general condition at baseline in Swiss patients (PGE score 4/5: 68.9% [Swiss cohort] vs. 49.0% [overall cohort]. Despite significant differences regarding the presence of symptoms and exacerbations, therapeutic success was similar in both patient groups. Highly symptomatic patients benefited mostly from tiotropium-olodaterol treatment.

Background: Pulmonary rehabilitation (PR) following severe and very severe COVID-19 infection is known to be effective, according to typical assessments. However, not all patients benefit from PR to the same extent. This analysis aimed to identify the impact of different factors on PR outcomes in post-COVID-19 patients., Methods: This prospective observational study included 184 post-COVID-19 patients. The achievement of the predicted reference walking distance (6 min walking distance (6-MWD)) served as a parameter with which to identify responders and non-responders to PR. Several parameters (e.g., Functional Independent Measurement (FIM); pulmonary function testing (Forced Vital Capacity, FVC); 6MWD) were assessed in order to estimate their impact on PR success. Logistic regression models and classification and regression trees were used for multivariate analysis., Results: A total of 94 patients (51%) reached their reference 6MWD by the end of PR. FVC (0.95 (0.93-0.97)), 6MWD at admission (0.99 (0.99-1.00)), and FIM motoric (0.96 (0.93-0.99)) correlated with the risk not reaching the reference distance. The most important variable was the 6MWD at admission. Classification and regression tree identified 6MWD ≥ 130 m at admission and FVC predicted of >83% as the strongest predictor for reaching predicted 6-MWD., Conclusion: Post-COVID-19 patients with lower 6MWD, lower motoric FIM scores and lower FVC at admission have a high risk of not reaching their target values of physical performance despite intensive rehabilitation. As well as identifying them, it is of utmost importance to develop optimal PR concepts for these patients.

Background: We aimed to longitudinally monitor the recovery in breathlessness, symptom burden, health-related quality-of-life, and mental health status in individuals hospitalised due to SARS-CoV-2 associated respiratory failure. Methods: Individuals hospitalised due to SARS-CoV-2 associated respiratory failure were recruited at hospital discharge in three participating centres. During the 90 day follow-up, European Quality of Life-5 Dimensions-5 Levels Instrument (EQ-5D-5L), modified Medical Research Council (mMRC) Dyspnoea Scale, COPD Assessment Test (CAT), and weekly Hospital Anxiety and Depression Scale (HADS) questionnaires were assessed using a smartphone application. The results were presented using descriptive statistics and graphics. Linear mixed models with random intercept were fitted to analyse differences of intensive-care unit status on the recovery course in each outcome. Results: We included 58 participants, 40 completed the study. From hospital discharge until 90 days post-discharge, EQ-5D-5L index changed from 0.83 (0.66, 0.92) to 0.96 (0.82, 1.0), VAS rating on general health status changed from 62 (50, 75) % to 80 (74, 94) %, CAT changed from 13 (10, 21) to 7 (3, 11) points, mMRC changed from 1 (0, 2) to 0 (0, 1) points, HADS depression subscale changed from 6 (4, 9) to 5 (1, 6) points, HADS anxiety subscale changed from 7 (3, 9) to 2 (1, 8) points. Differences in the recovery courses were observed between intensive-care and ward participants. Participants that were admitted to an intensive-care unit during their hospitalisation ( n = 16) showed increases in CAT, mMRC, HADS scores, and decreases in EQ-5D-5L 30 days after hospital discharge. Conclusion: Being admitted to an ICU led to statistically significant reductions in recovery in the EQ-5D-5L and the CAT. Furthermore, the flare-up in symptom burden and depression scores, accompanied by an attenuated recovery in HrQoL and general health status in the ICU-group suggests that a clinical follow-up 1 month after hospital discharge can be recommended, evaluating further treatments. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [NCT04365595]., Competing Interests: YN is cofounder and Chief Medical Officer of docdok.health with a financial interest in commercialisation of the docdok.health platform. MS received fees for lectures/talks, participation in advisory boards, and travel/accommodation/meeting reimbursements from Boehringer, GSK, OM Pharma, and KAIA Breathe within the last 36 months. All outside the submitted work. CC received fees for lectures/talks, development of educational materials, participation in advisory boards, and travel/accommodation/meeting reimbursements from Roche, Novartis, Boehringer, GSK, Astra Zeneca, Sanofi, Vifor, OM Pharma, and Mundipharma within the last 36 months. All outside the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kohlbrenner, Kuhn, Stüssi-Helbling, Nordmann, Spielmanns and Clarenbach.)

Introduction:  Acute COPD exacerbations (AECOPD) in the context of pulmonary rehabilitation (PR) are frequent and dangerous complications and, in addition to impairing quality of life, lead to an interruption of PR and jeopardize PR success. In this study, a correlation between the health status and an increased risk of AECOPD is described. The question arises whether the Charlson Comorbidity Index (CCI) or the Cumulative Illness Rating Scale (CIRS) are suitable for the preventive detection of COPD patients at risk for exacerbation in PR., Patients and Methods:  In a retrospective study, data of COPD patients who underwent PR in 2018 were analyzed with the CCI as the primary endpoint. All data were taken from the Phoenix Clinical Information System, and COPD exacerbations were recorded. The 44 patients (22 with and 22 without exacerbation during PR) required according to the sample size planning were randomly recruited from this pool of patients (using a random list for each group). CCI and CIRS were determined for all the cases included in the two groups. The primary endpoint (CCI) was evaluated by group comparison of the arithmetic means and Welch test. This was supported by further statistical measures of position and dispersion (median, quartile, standard deviation).In addition, the optimal cut-off point for discrimination in AECOPD and non-AECOPD patients was obtained via Receiver Operating Characteristic (ROC) analysis for both the CCI and the CIRS., Results:  Out of 244 COPD patients who underwent PR for an average of 21 days, 59 (24 %) suffered AECOPD that required treatment during PR. The 22 patients with AECOPD had a mean CCI of 6.77 (SD: 1.97) and the 22 patients without AECOPD had a mean CCI of 4.32 (SD: 1.17). This difference of -2.45 was statistically significant at a level of significance of 5 % (p < 0.001; 95 % CI: [-3.45; -1.46]). The ROC analysis led to 6 as the optimal cut-off point for the CCI, with 81.8 % sensitivity for determining an AECOPD and 86.4 % specificity with an area under the curve (AUC) value of 0.87. The optimal cut-off point for CIRS was 19 with a sensitivity of 50 %, a specificity of 77.2 % and an AUC of 0.65., Conclusion:  COPD patients with acute exacerbation during PR have a higher CCI. The CCI allows the risk of AECOPD to be assessed with high sensitivity and specificity in participants with COPD in an inpatient PR program., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Medical therapy in chronic obstructive pulmonary disease (COPD) usually includes inhaled dual bronchodilation leading not only to an improvement in symptoms but also to an increase in physical performance. However, it remains unknown whether responder rates to dual bronchodilation differ between the Swiss subgroup in comparison to participants of other European countries., Methods: The non-interventional OTIVACTO trial investigated changes in self-reported physical functioning in COPD patients treated with tiotropium/olodaterol 5/5 µg fixed dose combination for 6 weeks. The cut-off between responder and non-responder was defined as a minimum increase of 10 points using the 10-question physical functioning questionnaire (PF-10) score. We searched for patterns of the responder patient group and compared the results of the whole dataset with the subgroup of Swiss participants., Results: Compared to the total cohort (n = 7,608), the Swiss participants (n = 94) were predominantly > 65 years of age and had significantly more comorbidities. There were no significant differences according to COPD stage, smoking status, exacerbation rate in the last 12 months and modified Medical Research Council questionnaire (mMRC) score between the total cohort and the Swiss collective. There were no significant differences between the Swiss subgroup and the total cohort with regard to response to the medication in the PF-10 score. In the intragroup comparison, patients with high mMRC score showed significantly higher values in the PF-10 in both groups. The number of exacerbations had no influence on the PF-10 score in the Swiss subgroup but in the total cohort., Conclusion: In terms of age and number of comorbidities, significant differences were found between the overall patient population and the Swiss participants, having no influence on the success of the medication. The patients suffering from increased dyspnea benefited most from tiotropium/olodaterol treatment (Clinical Trials Registry NCT02720757)., Competing Interests: None to declare., (Copyright 2021, Spielmanns et al.)

Background: Post-stroke dysphagia leads to increased risk of aspiration and subsequent higher risk of pneumonia. It is important to not only diagnose post-stroke dysphagia early but also to evaluate the protective mechanism that counteracts aspiration, i.e., primarily cough. The aim of this study was to investigate the predictive value of cough frequency in addition to aspiration risk for pneumonia outcome., Methods: This was a single-center prospective observational study. Patients with first-ever strokes underwent clinical swallowing evaluation, fibreoptic endoscopic evaluation of swallowing (FEES), and overnight cough recording using LEOSound ® (Löwenstein Medical GmbH & Co. KG, Bad Ems, Germany ). Penetration-Aspiration Scale (PAS) ratings and cough frequency measurements were correlated with incidence of pneumonia at discharge., Results: 11 women (37%) and 19 men (63%), mean age 70.3 years (SD ± 10.6), with ischemic stroke and dysphagia were enrolled. Correlation analysis showed statistically significant relationships between pneumonia and PAS (r = 0.521; p < 0.05), hourly cough frequency (r = 0,441; p < 0.05), and categories of cough severity (r = 0.428 p < 0.05), respectively. Logistic regression showed significant predictive effects of PAS (b = 0.687; p = 0.014) and cough frequency (b = 0.239; p = 0.041) for pneumonia outcome., Conclusion: Cough frequency in addition to aspiration risk was an independent predictor of pneumonia in dysphagic stroke survivors.

Background: Dysphagia assessment in postacute stroke patients can decrease the incidence of complications like malnutrition, dehydration, and aspiration pneumonia. It also helps to avoid unnecessary diet restrictions. The aim of this study is to verify if regular reassessment of dysphagia would change the diet management of postacute stroke patients in rehabilitation settings., Methods: This single-center retrospective study included 63 patients referred to an inpatient neurological rehabilitation center between 2018-2019. A standardized clinical swallowing evaluation and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) were performed. Diet level according to Functional Oral Intake Scale (FOIS) was evaluated. As the primary endpoint, the FOIS values based on diagnostic procedures were assessed at hospital discharge, rehabilitation admission, and after FEES., Results: 19 women (30%) and 44 men (70%), with a mean age of 75 y (SD ± 10.08), were enrolled. The intergroup ANOVA revealed significant differences ( p < 0.001) between dietary prescriptions in an acute care setting and following clinical and endoscopic reassessment in the rehabilitation center. Diet recommendations changed in 41 of 63 (65%) enrolled patients ( p < 0.001)., Conclusion: Instrumental diagnostic by FEES during the early convalescence period of stroke patients leads to clinically relevant changes to diet restrictions and lower rates of pneumonia. Our findings underline the need for regular and qualitative dysphagia diagnostics in stroke patients participating in neurological rehabilitation.

Background: The Clinical COPD Questionnaire (CCQ) is a simple patient-reported tool to measure clinical control of chronic obstructive pulmonary disease (COPD)., Objective: This open-label, single-arm, non-interventional study (NCT03663569) investigated changes in CCQ score during treatment with tiotropium/olodaterol in clinical practice., Methods: Data were included from consenting COPD patients, enrolled in Bulgaria, Czech Republic, Hungary, Israel, Lithuania, Poland, Romania, Russia, Slovenia, Switzerland and Ukraine, who were receiving a new prescription for tiotropium/olodaterol according to the treating physician in a real-world environment. The primary endpoint was the occurrence of therapeutic success, defined as a 0.4-point decrease in CCQ score after treatment with tiotropium/olodaterol for approximately 6 weeks., Results: Overall, 4819 patients were treated; baseline and Week 6 CCQ scores were available for 4700 patients, mostly classified as Global Initiative for Chronic Obstructive Lung Disease (GOLD) B (51.6%) or D (42.7%). After 6 weeks' treatment, 81.4% (95% confidence interval [95% CI] 80.24-82.49) of patients achieved therapeutic success; mean improvement in overall CCQ score was 1.02 points (95% CI 1.00-1.05). Improved CCQ score was seen in 92.2% of patients (95% CI 91.43-92.98), 2.5% had no change and 5.3% showed a worsening. When stratified by prior treatment, the greatest benefit was seen in treatment-naïve patients, with 85.7% achieving therapeutic success, compared with 79.5% of those pretreated with long-acting β 2 -agonist (LABA)/inhaled corticosteroid (ICS) and 74.2% of those pretreated with LABA or long-acting muscarinic antagonist (LAMA) monotherapy. Overall, rescue medication decreased by 1.25 puffs/day (95% CI 1.19-1.31) versus baseline. In total, 29 patients (0.6%) reported drug-related adverse events and 7 patients reported serious adverse events (0.15%)., Conclusion: In 4700 COPD patients, 6 weeks' treatment with tiotropium/olodaterol, as initial treatment or follow-up to LAMA or LABA monotherapy or LABA/ICS, improved CCQ and decreased rescue medication use. The adverse event profile was consistent with the known safety profile of tiotropium/olodaterol., Competing Interests: Arschang Valipour has received speaker/consultancy fees from Boehringer Ingelheim during the conduct of the study; and speaker/consultancy fees from Boehringer Ingelheim, Chiesi, Novartis, Menarini and AstraZeneca outside the submitted work. Sergey Avdeev has nothing to disclose. Adam Barczyk has received personal fees from Boehringer Ingelheim. Valentina Bayer was an employee of Boehringer Ingelheim during the conduct of the study. Zvi Fridlender received institutional support for conducting the study from Boehringer Ingelheim. Dr Fridlender received personal fees for lectures/conference travel/advice from GlaxoSmithKline, Novartis, AstraZeneca, Boehringer Ingelheim, Teva and Rafa outside the submitted work. In addition, Dr. Fridlender has a patent for a neutrophil-specific drug delivery pending. Mariela Georgieva received trial sponsorship fees from Chiesi and AstraZeneca, grants for travel and lectures from Boehringer Ingelheim, grants for lectures from Mundipharma, and participated in lectures for Novartis outside the submitted work. Ondřej Kudela reports personal fees from the Charles University in Prague and Boehringer Ingelheim outside the submitted work. Alexey Medvedchikov was an employee of Boehringer Ingelheim during the conduct of the study. Ramona Miron has nothing to disclose. Maria Sanzharovskaya was an employee of Boehringer Ingelheim during the conduct of the study. Virginija Šileikienė has received advisory fees from AstraZeneca and GlaxoSmithKline, speaker fees from AstraZeneca, Berlin-Chemie, Boehringer Ingelheim, GlaxoSmithKline and Novartis, and has been involved with clinical trials for Boehringer Ingelheim, MSD and Novartis outside the submitted work. Jurij Šorli has nothing to disclose. Marc Spielmanns reports personal fees from Boehringer Ingelheim during the conduct of the study. Zsuzsanna Szalai has nothing to disclose. The authors report no other conflicts of interest in this work., (© 2021 Valipour et al.)

Background: Severe COVID-19 infection often leads to impairments requiring pulmonary rehabilitation (PR) following the acute phase. Little is known about the efficacy of PR in these patients. We therefore compared post-COVID-19 patients (PG) referred to PR patients with other lung diseases (LG)., Methods: 99 PG were admitted to PR. In a prospective design, the results of PG were collected and compared to the results of LG of 2019 ( n = 419) according to Functional Independence Measurement (FIM), Cumulative Illness Rating Scale (CIRS), 6-min walk test (6-MWT), duration of PR, and Feeling Thermometer (FT)., Results: According to age, sex, and CIRS, both groups showed no significant differences. The improvements in the 6-MWT in the pre to post comparison were on average 180 (±101) meters for PG and 102 (±89) meters for LG ( p < 0.001). FT showed a significant enhancement for PG of 21 (±14) points and for LG of 17 (±16) points ( p < 0.039), while FIM significantly increased by 11 (±10) points in PG and 7 (±8) points in LG ( p < 0.001)., Conclusions: Comprehensive PR in PG is very effective according to the results in FIM, 6-MWT and FT. Therefore, we recommend PR following severe post-COVID-19 infections.

Objective: The COVID-19 pandemic affects a large number of patients. The impact on feasibility and outcome of rehabilitation during COVID-19 actually remains unclear. Nosocomial infection of healthcare workers or hospitalized patients is common, and prevention of nosocomial infections during rehabilitation is challenging. Therefore, we analyzed a cohort of nosocomial infected COVID-19 patients in a single-center inpatient rehabilitation clinic and described performance and outcome., Design: The cohort (N = 27) describes patients with nosocomial SARS-CoV-2 infection while participating in neuromusculoskeletal rehabilitation. Infection was caused by an initially unidentified so-called superspreader. We compared this cohort with all neuromusculoskeletal rehabilitation inpatients of 2019 (comparison group). Normally distributed continuous variables were presented as mean with standard deviation and the t test was used for comparison between groups. Linear regression was used to assess the impact of COVID-19 on Functional Independence Measure at discharge., Results: COVID-19 patients were mostly male (66.7%) with an age of 71.5 ± 12.3 yrs. Age, sex, and cumulated comorbidities of the comparison group (n = 786) were not different from the COVID-19 group. A total of 92.6% of COVID-19 patients had a mild or moderate course, two patients had to be referred to acute hospital because of respiratory failure, and one of these patients died in the acute hospital. After implementation of a strict hygiene concept, no further nosocomial COVID-19 infections were detected. The rehabilitation duration was significantly longer in the COVID-19 group (54.2 ± 23.6 days vs. 32.1 ± 17.7 days, P < 0.001). Daily therapy duration was 132.3 ± 44 mins before SARS-CoV-2 infection and reduced to 81.9 ± 27.3 mins during COVID-19 (P < 0.001). After discontinuation of isolation measures, therapy duration increased significantly (99.3 ± 70.2 mins, P < 0.05).The baseline Functional Independence Measure score was higher in the COVID-19 group (91.93 ± 25.64 points vs. 82.98 ± 22.73 points) and Functional Independence Measure improvements were lower in COVID-19 patients than in the 2019 comparison group (6.96 ± 8.96 points vs. 20.3 ± 15.98 points, P < 0.001). COVID-19 infection itself had a strong negative impact on Functional Independence Measure change as identified by regression analysis. Linear regression analysis showed that COVID-19 reduced the Functional Independence Measure at discharge by 8.9 points (95% CI = -14.725 to -3.097, P = 0.003) after correction for Functional Independence Measure at admission, age, sex, and morbidity index at admission., Conclusions: COVID-19 had a strong negative impact on rehabilitation benefits as assessed by Functional Independence Measure. Neuromusculoskeletal rehabilitation could be continued, but all patients received less therapy minutes during isolation. After implementation of a strict COVID-19-specific hygiene concept, no further infections were detected., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Obstructive Sleep Apnea (OSA) is common in patients with cardiovascular diseases (CVD) and can negatively impact the course of CVD. However, scarce data are available for patients before or after cardiac surgery (CS) in the context of OSA., Aim: This study investigated the impact of an undetected OSA on the results of cardiac rehabilitation (CR) in patients after CS., Design: Observational study over a period of 3 months following CS., Setting: The setting of this study was inpatient CR after CS or cardiac interventions., Population: CS cohort referred to a CR program to an inpatient rehabilitation clinic in Switzerland., Methods: In this prospective observational study 256 patients were screened for OSA at the entry of CR via a level III screening device (ApneaLink Air TM , Resmed, San Diego, CA, USA). They were stratified into two groups: apnea hypopnea index (AHI) >15 or <15/h. A comprehensive assessment was performed at entry and end of CR including six-minute walk test (6-MWT), Functional Independence Measure (FIM), Hospital Anxiety and Depression Scale, MacNewHeart (MNH), STOP-Bang Questionnaire (SBQ) and Epworth Sleepiness Scale (ESS).All patients participated in a comprehensive CR program with a mean duration of approximately 3 weeks. Another OSA screening was performed at the end of the PR program and after 3 months in order to observe the clinical course of OSA., Results: An AHI>15/h was found in 133 patients (59%) at baseline, 54% after 3 weeks and 43% after 3 months. The AHI>15/h-group was older, had a higher BMI, more frequent hypertension and coronary artery disease, and higher ESS and SBQ scores compared to the AHI<15/h-group. The results of the STOP-Bang and ESS questionnaires showed a statistically significant but weak positive correlation with AHI. However, in both groups ESS did not improve from baseline to the end of CR. A multivariable logistic regression model confirmed age and ESS as independent positive predictors of OSA. No differences were found between both groups according to the results of the 6-MWT, HADS and MNH., Conclusions: OSA had a high prevalence in a large CS cohort referred to CR. However, moderate-severe OSA, though symptomatic, had no significant influence on the outcome during CR and on the parameters representing success., Clinical Rehabilitation Impact: In our study the improvements during CR after CS were not influenced by the presence of significant OSA which is remarkable since the presence of OSA is thought to be associated with increased rates of cardiovascular adverse events after cardiovascular intervention or CS. This is true at least for the success of CR after CS. The long-term consequences of untreated OSA in CVD remain unclear and are still the subject of current research.

To improve acceptance and use of physical training by patients with chronic lung diseases, recommendations for performing lung exercises on an outpatient basis in a group setting are given by experts in physical training, sports therapists and pulmonologists. The evidence-based positive effects of physical training were analyzed for asthma , COPD, interstitial lung diseases, cystic fibrosis, lung carcinoma, and pulmonary hypertension. The requirements for lung exercises in outpatient groups as well as compensation by care providers were given on the basis of legal regulations. Furthermore, the main items of the training units as well as supervision by specially trained group leaders in relation to the severity of the underlying lung disease are described. Finally, aspects of safety of the participating patients are discussed, including the prevention of infection with corona-2-virus., Competing Interests: H. Worth sieht keine Interessenkonflikte zum Inhalt der Empfehlung. Er erhielt Honorare für Beratungen und Vorträge von: AstraZeneca, Berlin Chemie, Chiesi, GSK, Klosterfrau, MSD, Novartis und Omron., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

The COVID-19 pandemic affects a large number of patients with a rapid progression of respiratory failure often requiring hospitalization or intensive care unit treatment in some patients. Survivors of severe COVID-19 experience persistent weakness and cardiorespiratory failure. Feasibility and potential benefit of cardiopulmonary rehabilitation after COVID-19 remains unclear. Therefore, we retrospectively analyzed a cohort of COVID-19 patients in a single-center inpatient rehabilitation clinic and describe performance and outcome during cardiopulmonary rehabilitation.Patients were referred from acute care hospitals for rehabilitation after severe COVID-19. The cohort (N = 28) was divided in ventilated or not ventilated patients for further analysis. Fifty percent were female, the mean age was 66 yrs, and patients stayed in the acute hospital for 19.3 ± 10.7 days before referral for cardiopulmonary rehabilitation. Seventeen patients (61%) needed previous intensive care unit treatment in the acute care hospital. Risk factors, assessments, and questionnaires on admission were comparable in both groups. Significant enhancements were observed in 6-min walking test and feeling thermometer, which were independent of previous ventilation status.In conclusion, comprehensive cardiopulmonary rehabilitation after COVID-19 is safe, feasible, and effective. Improvements in physical performance and subjective health status were independent of previous ventilation.

Are There Recommended Alternatives to Positive Airway Pressure Therapy in the Treatment of Sleep Apnea? Abstract. For decades, positive airway pressure (PAP) ventilation has been considered the gold standard in the therapy of obstructive sleep apnea (OSA). Although this is a very successful procedure with regard to the elimination of apnea, the long-term adherence of patients to PAP is only 60-80 % for various reasons. In the meantime, there are numerous options such as intraoral devices, spine sleep position avoidance or newer surgical procedures which are advertised as an alternative to PAP in the therapy of OSA. This raises questions about the significance and effectiveness. This article is intended to provide an up-to-date overview of the significance and possibilities of the therapy alternatives.

The German Respiratory Society (DGP) has commissioned Assembly 12 "Rehabilitation, Prevention and Tobacco Control" to develop recommendations for the implementation of pulmonary rehabilitation in COVID-19 patients. This position paper is based on the current state of knowledge, which develops daily. This position paper describes the health consequences in COVID-19 as well as the indications for pulmonary rehabilitation. Rehabilitative therapies in COVID-19 are already indicated on the ward or intensive care unit, continue as early pulmonary rehabilitation in the acute hospital and as pulmonary rehabilitation in pulmonary rehabilitation centers. The main focus of this position paper is to propose recommendations for the content-related implementation of a multimodal, interdisciplinary pulmonary rehabilitation in COVID-19 patients., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Increasing physical activity (PA) is considered to be an important factor for the efficient management of chronic obstructive pulmonary disease (COPD). Successful methods required to achieve improvements in PA following pulmonary rehabilitation (PR), however, are rarely reported. Therefore, we will conduct this trial to evaluate the effectiveness of using a COPD management program delivered to the patient via the KAIA COPD app, a mobile medical application, after the completion of PR., Methods: This is the protocol for a randomized, controlled, open-label, multicentered trial that will be carried out at inpatient PR hospital centers in Germany and Switzerland. The interventions will involve the use of the KAIA COPD app program (Arm 1) or an active comparator, i.e., usual care (Arm 2). Patients completing an in-hospital PR program and consenting to participate in the study will be screened with the inclusion and exclusion criteria and enrolled in the study. After fulfilling the screening requirements, the patients will be randomized into one of the two arms with parallel group assignment in a 1:1 ratio. The training program will be delivered to the participants grouped in Arm 1 via the KAIA COPD app and to participants grouped in Arm 2 via the regular recommendations or standard of care by the PI. In total, 104 participants will be included in the trial. The treatment period will last for 24 weeks. Electronic versions of questionnaires will be used to collect patient-reported assessments remotely. The primary outcome measure is the change in physical activity of the intervention group in comparison to the control group, measured over 1 week as the mean steps per day with a Polar A 370 activity tracker, from baseline (end of PR) to the 6-month follow-up. The secondary outcome measures are functional exercise capacity, health status, sleep quality, exacerbation rate, and depression and anxiety symptoms assessed at several intervals., Discussion: This study seeks to prove the effects of the KAIA COPD mobile application in COPD patients after PR. The app offers educational, exercise training plus activity monitoring and motivational programs that can be easily implemented in the patient's home setting, enabling patients to maintain the effects that are typically elicited in the short term after pulmonary rehabilitation for the long term., Trial Registration: German Clinical Trials Register ( DRKS00017275 ). Protocol version 2.0 dated 3 June 2019.

Aim: This study aimed to address the need for adaptation of the current model of chronic obstructive pulmonary disease (COPD) care in Switzerland, particularly in regard to acute exacerbations, and how far an integrated approach involving advanced nursing practice can meet those needs., Methods: A state analysis guided by the PEPPA framework was initiated by the Pulmonology Clinic of University Hospital Zürich. Literature describing the current provision of COPD care regarding exacerbations in Switzerland and international qualitative studies describing the patient perspective were systematically searched and summarised. The health providers' perspective was investigated in three focus-group interviews., Results: A lack of systematic and state-of-the-art support for patient self-management in Switzerland was described in literature and confirmed by the health providers interviewed. While care was assessed as being comprehensive and of good quality in each individual sector, such as inpatient, outpatient, rehabilitation and home settings, it was identified as being highly fragmented across sectors. The interview participants described day-to-day examples in which a lack of support in COPD self-management and fragmentation of care negatively affected the patients' disease management., Conclusion: The necessity of coordinating the transition between healthcare sectors and self-management support and that these organisational boundaries should be addressed by a multi-professional team were identified. Initial evaluation indicates that advanced practice nurses potentially have the skill set to coordinate the team and address patients' self-management needs in complex patient situations. However, the legal foundation and a reimbursement system to ensure long-term implementation is not yet available., Competing Interests: Conflict of interest: G. Schmid-Mohler reports nonpersonal fees, paid to the University Hospital, for counselling from GSK, outside the submitted work; and a research grant from the Lunge Zürich for the investigator-initiated project NICCO (nurse-led integrated care COPD). Conflict of interest: C. Clarenbach reports personal fees from Roche, Novartis, Boehringer, GSK, AstraZeneca, Sanofi, Vifor and Mundipharma, outside the submitted work. Conflict of interest: G. Brenner has nothing to disclose. Conflict of interest: M. Kohler reports personal fees from Boehringer Ingelheim, Novartis, AstraZeneca, GSK, Roche, Bayer and Mundipharma, outside the submitted work; and a research grant from Lunge Zürich for the investigator-initiated project NICCO. Conflict of interest: E. Horvath has nothing to disclose. Conflict of interest: M. Spielmanns has nothing to disclose. Conflict of interest: H. Petry has nothing to disclose., (Copyright ©ERS 2020.)

Background and Objective: Enterobacteriaceae (EB) spp. family is known to include potentially multidrug-resistant (MDR) microorganisms, and remains as an important cause of community-acquired pneumonia (CAP) associated with high mortality. The aim of this study was to determine the prevalence and specific risk factors associated with EB and MDR-EB in a cohort of hospitalized adults with CAP., Methods: We performed a multinational, point-prevalence study of adult patients hospitalized with CAP. MDR-EB was defined when ≥3 antimicrobial classes were identified as non-susceptible. Risk factors assessment was also performed for patients with EB and MDR-EB infection., Results: Of the 3193 patients enrolled with CAP, 197 (6%) had a positive culture with EB. Fifty-one percent (n = 100) of EB were resistant to at least one antibiotic and 19% (n = 38) had MDR-EB. The most commonly EB identified were Klebsiella pneumoniae (n = 111, 56%) and Escherichia coli (n = 56, 28%). The risk factors that were independently associated with EB CAP were male gender, severe CAP, underweight (body mass index (BMI) < 18.5) and prior extended-spectrum beta-lactamase (ESBL) infection. Additionally, prior ESBL infection, being underweight, cardiovascular diseases and hospitalization in the last 12 months were independently associated with MDR-EB CAP., Conclusion: This study of adults hospitalized with CAP found a prevalence of EB of 6% and MDR-EB of 1.2%, respectively. The presence of specific risk factors, such as prior ESBL infection and being underweight, should raise the clinical suspicion for EB and MDR-EB in patients hospitalized with CAP., (Published 2019. This article is a U.S. Government work and is in the public domain in the USA.)

Background and Objective: Obesity hypoventilation syndrome (OHS) can be treated with either continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) therapy; the device choice has important economic and operational implications., Methods: This multicentre interventional trial investigated the safety and short-term efficacy of switching stable OHS patients who were on successful NIV therapy for ≥3 months to CPAP therapy. Patients underwent an autotitrating CPAP night under polysomnography (PSG); if the ensuing parameters were acceptable, they were sent home on a fixed CPAP for a 4-6-week period. It was hypothesized that blood gas analysis, PSG parameters and lung function tests would remain unchanged., Results: A total of 42 OHS patients were recruited, of whom 37 patients were switched to CPAP therapy. All patients had a history of severe obstructive sleep apnoea syndrome; chronic obstructive pulmonary disease (COPD) (Global Initiative for Obstructive Lung Disease (GOLD) I/II) was present in 52%. Regarding the primary outcome, 30 of 42 patients (71%, 95% CI: 55-84%) maintained daytime partial pressure of carbon dioxide (PaCO 2 ) levels ≤45 mm Hg after the home CPAP period. There was no further impairment in quality of life, sleep parameters or lung function. Interestingly, 24 patients (65%) preferred CPAP as their long-term therapy, despite the high pressure levels used (mean: 13.8 ± 1.8 mbar). After the CPAP period, 7 of 37 patients were categorized as CPAP failure, albeit only due to mild hypercapnia (mean: 47.9 ± 2.7 mm Hg)., Conclusion: It is feasible to switch most stable OHS patients from NIV to CPAP therapy, a step that could significantly reduce health-related costs. The auto-adjusted CPAP device, used in combination with the analysis of the PSG and capnometry, is a valid titration method in OHS patients., (© 2019 Asian Pacific Society of Respirology.)

Background: Numerous studies have reported positive effects of exercise training in patients with interstitial lung disease (ILD) on physical capacity and quality of life. However, evidence is rare on the effects of specific forms of training and further pathophysiological mechanisms in these patients., Objectives: In this multicenter study we aimed to explore the clinical effects of whole-body vibration training (WBVT) in patients with ILD on various outcome measures, including proinflammatory cytokines and myostatin., Methods: We randomly assigned 26 patients with different forms of multidisciplinary confirmed fibrotic ILDs either to the WBVT group (n = 11; 55% male, 61 ± 14 years old, forced vital capacity 83.2 ± 29.3% predicted, 6-min walking distance [6MWD] 478 ± 79 m) performing 3 months of a standardized training (3 times per week), or to a control training group (CTG, n = 15; 60% male, 63 ± 9 years old, FVC 74.6 ± 20.5% predicted, 6MWD 455 ± 85 m) performing sham WBV training. Training in the two groups was performed on a GalileoTM vibration plate (6-20 vs. 5 Hz). The functional assessments before and after the intervention period included pulmonary function, 6MWD test, chair rise test, ultrasonographic measurement of quadriceps muscle thickness (cross-sectional area), quality of life questionnaires, and serum samples., Results: We observed a significant increase in 6MWD (∆Training = 30 m [12-67], p = 0.024) and a decrease of myostatin (∆Training = -465 pg/mL [-713 to -166], p = 0.008) in the WBVT group. In contrast, no significant differences were observed in the CTG., Conclusions: The present study demonstrates that WBVT is able to significantly increase 6MWD and decrease myostatin in patients with fibrotic ILDs. Therefore, WBVT seems to be a beneficial and feasible training modality in ILD patients. Clinical Trial Registry: German Clinical Trials Registry (DRKS00012930)., (© 2020 S. Karger AG, Basel.)

Background: Monitoring for physical activity becomes popular and actually many devices are available. Some physical activity monitors (PAMs) provide data about sleep quality for the user, but there are scarce data concerning validity and usability of these measurements. This study compared the data of sleep parameters generated by a PAM with the polysomnography (PSG)., Methods: In 2016, data of 26 patients in two consecutive PSGs as well as in two daytime and nighttime measurements with a PAM according to physical activity and sleep quality were collected. Furthermore, sleep quality, using the Pittsburgh sleep quality index (PSQI), daytime fatigue, using the multidimensional fatigue inventory (MFI-20) and additionally data of a sleep diary were collected., Results: There were positive correlations of both methods with respect to total sleep time (TST) (r = 0.76, P < 0.01) and sleep efficiency (r = 0.71, P < 0.01). Data analysis over two nights showed that over 90% of the TST (95% confidence interval (CI) -1.59 to 0.82) and of the sleep efficiency (95% CI -8.28 to 15.51) were within the limits of agreement. The analysis of the PSQI and the sleep efficiency of the PAM showed no significant correlations. The daytime fatigue correlated negatively with the physical activity (r = -0.72, P < 0.01)., Conclusion: The sleep efficiency and TST measured with the PAM sufficiently reflect the PSG sleep parameters and the subjects' subjective feelings. At the same time, PAM results are also correlated with the subjectively perceived quality of sleep. Further investigations to assess the long-term results are pending., Competing Interests: None to declare., (Copyright 2019, Spielmanns et al.)

Easy come, easy go? Current strategies for maintaining the effects of pulmonary rehabilitation in COPD patients Abstract. Pulmonary rehabilitation (PR) is a comprehensive treatment method in the non-drug management of chronic respiratory diseases. Most evident data exists for COPD patients. However, the effect of PR is no longer detectable after 6 to 12 months, unless the patient participates in a kind of maintenance program following PR. But the contents of such a maintenance program are still unclear in terms of duration, location, methods and intensity. They are still subject of current research. Therefore concrete recommendations are still missing and further studies are necessary. This review aims to give an overview of the existing results in this field.

Fresh air for weakened lungs - pulmonary rehabilitation in Switzerland 2019 Abstract. Pulmonary rehabilitation traditionally plays an important role in the treatment of chronic pulmonary diseases in Switzerland. There is a good availability of pulmonary rehabilitation with 17 centers offering inpatient pulmonary rehabilitation across the country. There is good evidence that pulmonary rehabilitation is not only effective but also cost-effective, especially for the indication of COPD but also for other chronic pulmonary diseases. According to the GOLD guidelines there is an undersupply of COPD patients with pulmonary rehabilitation in Switzerland. Pulmonary rehabilitation is not only limited to the improvement of physical exercise, but also covers all the important aspects for an individual to function in everyday life. Though the daily costs for pulmonary rehabilitation are only a fourth to a thirth of the costs in a hospital. Offering pulmonary rehabilitation to the patients who also have an indication for it lies in the responsibility of the admitting doctors, the insurances and the patients themselves, who need to bring a basic motivation to participate in pulmonary rehabilitation.

Purpose: Purpose of this study was to analyze the impact of a pulmonary rehabilitation (PR) program on the measured inspiratory capacity (IC) in patients with chronic obstructive pulmonary disease (COPD) while performing a 6-min walk test (6MWT)., Methods: Before and after PR, IC was measured by spirometry both at the beginning and at the end of the 6MWT for 15 patients with COPD in the PR group (PRG) and compared with a similar calisthenics training group (CTG; n = 15). In addition, the COPD Assessment Test (CAT), St George's Respiratory Questionnaire (SGRQ), and other lung function tests were recorded and compared., Results: Both groups were not significantly different at baseline. Compared with the CTG, the PRG achieved a significant increase in the delta of IC measured during the 6MWT (0.5 ± 0.2 L [PRG] vs -0.2 + 0.2 L [CTG], P = .001). Significant differences were found for the 6MWT walking distance (PRG: 99 ± 36 m vs CTG: 5 ± 25 m, P = .001). No significant increase in dyspnea while performing the 6MWT was found in either group. The differences in the CAT score and the SGRQ Global score were significant only for the PRG in intragroup comparisons, whereas the intergroup comparison showed no significant differences. Except for residual volume, no significant changes in all parameters of the static lung function tests were observed in either group., Conclusion: Participation in a PR may lead to a significant and clinically relevant increase in IC and the walking distance. Additional research is necessary to define the effects of this increase in IC on exercise capacity.

Background: Prognostic factors for clinical failure of acute exacerbation in patients with COPD (AECOPD) are of special importance in order to choose an adequate therapy and resources during inpatient treatment. Our database was analyzed to identify predictors for a negative outcome., Materials and Methods: In a retrospective analysis medical records of 616 patients (299 women; 317 men) hospitalized for AECOPD between January 2011 and January 2016 were analyzed in order to evaluate demographic and clinical parameters leading to adverse events. Only the first admission was considered. Logistic regression analysis was performed to determine the relative risk (odds ratio (OR) leading to severe adverse events such as intensive care unit (ICU) admission, mechanical ventilation (invasive or noninvasive), early readmission to ICU and hospital and death)., Results: An increased risk of an ICU admission was found for patients with a coronary heart disease (OR = 5.734; p = 0.009) and for patients requiring an antibiotic therapy (OR = 11.721; p = 0.003). An increased risk for rehospitalisation and mortality was found for age (OR = 1.034; p = 0.028) and a longer duration of the hospital stay (OR = 1.063; p = 0.042). A lower C‑reactive protein (CRP) level was associated with a lower risk of readmission to the hospital (OR = 0.991; p = 0.03). An increased risk of ventilator therapy was found for patients with chronic heart failure (OR = 6.166; p = 0.02) and sleep apnea syndrome (OR = 6.698; p = 0.003), diabetes (OR = 3.754; p = 0.041) and a long stay in the ICU (OR = 2.018; p = 0.000)., Conclusions: Comorbidities in patients with AECOPD were found to be a major risk factor for ICU admission and mechanical ventilation. Elderly patients and patients with prolonged hospital stay showed a higher risk for readmission and mortality. Patients with a low CRP blood level seemed to have a lower risk for rehospitalisation.

Objective Exercise training provides a cornerstone of pulmonary rehabilitation (PR) in COPD-patients. However, the components of the training are not yet fully investigated. We conducted a randomized controlled trial to investigate the effectiveness of a sensory-motoric training (SMT) in comparison to a conventional strength training (KT) according to the physical performance. Patients and Methods: 43 COPD patients were randomized and participated either in the intervention group (SMT = 30 minutes SMT per day) or in the control group (KT = 30 minutes KT per day). The SMT was performed as circuit training with five stations. The primary endpoint was the difference between T1 (start of the PR) and T2 (end of the PR) in 5-Times Sit-to-stand test (5-STST) in the intergroup comparison. Secondary endpoints were the intra- and intergroup comparisons of T1 and T2 in the 6-Minute Walk Test (6-MWT), COPD Assessment Test (CAT), St. George Respiratory Questionnaire (SGRQ), Hospital Anxiety- and Depression Scale (HADS) and in lung function. Results No significant differences were seen in the results of the 5-STST between the groups. Likewise, in the 6-MWT, SGRQ, CAT, HADS and lung function. The intragroup comparison between T1 and T2 showed significant differences in 5-STST, 6-MWT, SGRQ, CAT and HADS in both groups. The differences in lung function were not significantly, neither in the inter- nor in the intragroup comparison. Conclusion Similarly to a conventional strength training improvements in exercise capacity could be achieved with a SMT during PR in COPD patients. Further studies are necessary to define the role of the SMT in regards to postural control., Competing Interests: Interessenkonflikt: Alle Autoren kennen diesen Artikel und sind mit der Veröffentlichung in der vorliegenden Version einverstanden. Alle Autoren versichern, dass keine Interessenkonflikte aufgrund wirtschaftlicher oder persönlicher Verbindungen bestehen. Die Ergebnisse dieser Studie und der Artikel sind bei keinem anderen Journal zur Publikation eingereicht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The aim of the study was to investigate whether whole-body vibration training (WBVT) can be applied beneficially within an outpatient low frequency exercise program., Methods: In a prospective, controlled, randomized study, WBVT effectiveness and safety were investigated in COPD stage II-IV patients undergoing a 3-month training program. Participants took part in a 90-min circuit training once a week. On top patients were randomized to either perform squats with WBVT, or without (conventional training group (CTG)). Before and after the intervention, a sit-to-stand test (STST), a 6-min walk test (6-MWT), the COPD assessment test (CAT), and the chronic respiratory disease questionnaire (CRQ) were evaluated., Results: Twenty-eight out of 55 patients completed the study (n = 12 WBTV, n = 16 CTG). The STST time remained nearly constant for the CTG (Δ -0.8 ± 3.1 s) and the WBVT (Δ 1.4 ± 3.2 s; P = 0.227), respectively. Similarly, for both WBVT and CTG, the 6-min walk distance remained unchanged (Δ 7 ± 55 m vs. 9 ± 45 m, P = 0.961). In three out of four categories, the CRQ scores showed a significant improvement within WBVT, and in one category when comparing across groups. The CAT score dropped by -0.8 ± 2.9 points within CTG and by 2.4 ± 2.7 points within WBVT (P = 0.105). There were no adverse events related to WBVT., Conclusion: The implementation of WBVT in the context of an outpatient low frequency exercise program did not significantly improve the patients' exercise capacity. An improvement in CAT and partially in CRQ was shown within WBVT. However, regarding the high dropout rate (49%), these results must be interpreted with caution.

Background: The objective of this study was to investigate the benefits of a low-volume out-patient whole-body vibration training (WBVT) program on exercise capacity in comparison with a calisthenics training program in subjects with COPD., Methods: In this single-center randomized controlled trial, 29 subjects with mild to severe COPD were randomized to WBVT or to calisthenics training, including relaxation and breathing retraining in combination with calisthenics exercises. Both groups equally exercised for a duration of 3 months with 2 sessions of 30 min/week. Outcome parameters were 6-min walk distance (6MWD, primary outcome), 5-repetition sit-to-stand test, leg press peak force, Berg balance scale, St George Respiratory Questionnaire, and COPD assessment test., Results: Twenty-seven subjects completed the study (WBVT, n = 14; calisthenics training program, n = 13). Baseline characteristics between groups were comparable. Subjects in the WBVT group significantly improved median (interquartile range) 6MWD (+105 [45.5-133.5] m, P = .001), sit-to-stand test (-2.3 [-3.1 to -1.3] s, P = .001), peak force (28.7 [16.7-33.3] kg, P = .001), and Berg balance scale (1.5 [0.0-4.0] points, P = .055). Changes in 6MWD, sit-to-stand test, and leg press peak force were also found to be significantly different between groups in favor of the WBVT group. Only the between-group difference of the COPD assessment test score was in favor of the calisthenics training group ( P = .02)., Conclusions: A low-volume WBVT program resulted in significantly and clinically relevant larger improvements in exercise capacity compared with calisthenics exercises in subjects with mild to severe COPD. (ClinicalTrials.gov registration DRKS9706.)., (Copyright © 2017 by Daedalus Enterprises.)

Background: Pseudomonas aeruginosa infection impairs respiratory muscle function in adolescents with cystic fibrosis, but its impact on adult patients has not been characterised., Objectives: To investigate respiratory muscle function in adult cystic fibrosis patients according to P. aeruginosa status (repetitive samples over 12 months)., Methods: The pressure-time index of the respiratory muscles (PTImus), a measure of their efficiency, served as the primary outcome. In addition, respiratory load and maximal respiratory muscle strength were assessed., Results: In 51 patients examined (65% female; median age 32 years, IQR 24-40), a median of 3.0 (IQR 2-4) different pathogens was found in each patient. The PTImus was 0.113 and 0.126 in Pseudomonas-positive (n = 33) and -negative (n = 18) patients, respectively (p = 0.53). Univariate analysis showed a lower PTImus in male than in female patients (p = 0.006). Respiratory muscle load and strength were otherwise comparable, with the exception of higher nasal sniff pressures in Pseudomonas-positive patients who were chronically infected (>50% of positive samples). Quality of Life (according to the Cystic Fibrosis Questionnaire-Revised) was higher if both respiratory load and the PTImus were low (high respiratory muscle efficiency)., Conclusions: Chronic P. aeruginosa infection does not influence respiratory muscle efficiency in adult cystic fibrosis patients with otherwise multiple co-infections. In addition, patients with reduced respiratory muscle efficiency had worse Quality of Life., (© 2016 S. Karger AG, Basel.)

Background: Various exercise training programs are used for patients with chronic obstructive pulmonary disease (COPD) of different severity., Objectives: To investigate the impact of individualized high-intensity training on exercise capacity with COPD., Methods: A total of 49 patients agreed to participate. Of these, 31 were assigned to the training group and 18 served as controls. The training group exercised twice a week for 90 min with consecutively increasing loads. At the time of enrollment (T0), as well as after 3 (T1) and 6 (T2) months, a 6-min walk test (6-MWT) was performed and data on health-related quality of life, femoral muscle thickness, and various serum markers were obtained., Results: The training group improved in their 6-MWT results (T0 = 407 ± 152 m vs. T1 = 459 ± 127 m, p = 0.002, vs. T2 = 483.2 ± 130.1 m, p = 0.004), in their cross-sectional area of the musculus rectus femoris (T0 = 6.2 ± 1.2 cm2 vs. T1 = 6.9 ± 1.2 cm2, p = 0.003, vs. 7.5 ± 1.6 cm2, p = 0.002), and in their St. George's Respiratory Questionnaire (SGRQ) score (T0 = 43.3 ± 18.0 vs. T1 = 36.0 ± 18.4, p = 0.001, vs. T2 = 34.7 ± 18. 0, p = 0.004). Serum levels of myostatin, irisin, resistin, and α-Klotho did not change significantly within the training period. Of note, the exercise group showed an inverse relationship between serum levels of resistin and those of α-Klotho after 6 months (r = -0.608, p = 0.021)., Conclusions: COPD patients undergoing an individualized, structured, high-intensity training program improved their exercise capacity, gained muscle mass, and improved their quality of life., (© 2017 S. Karger AG, Basel.)

Objective  Acute exacerbation of COPD (AECOPD) provides for patients a significant hazard and is crucial for the prognosis. Data on the effects of pulmonary rehabilitation (PR) on the frequency of reexacerbations after AECOPD are inconsistent. A prospective, case-control study was conducted with the aim of measuring the impact of PR on the frequency of reexacerbations after AECOPD. Patients and Methods  A PR was performed in 57 patients with COPD after AECOPD. 30 participants were followed-up after one year and compared to 32 Control-Group (KG = hospitalized for AECOPD without PR). The rate of reexacerbations was both retrospectively in the year preceding the AECOPD, and prospectively in the year after AECOPD analyzed within groups and between groups. Results  In the intra group comparison the exacerbation rate was significantly lower in the PR-group in the year after rehabilitation (0.97 ± 2.67 vs. 1.52 ± 1.12; p < 0.001). The intergroup comparison also showed a significantly lower number of exacerbations for the PR-group (0.97 ± 1.52 vs 2.16 ± 1.25; p < 0.001). Conclusion  It was shown that the exacerbation rate after an AECOPD could be significantly reduced in the PR-group in comparison to the KG-group during the investigation period of one year by PR. More prospective studies are required to define the value of PR in the context of AECOPD., (© Georg Thieme Verlag KG Stuttgart · New York.)

Exercise training is one of the most important components in disease management for patients with chronic respiratory diseases. The clinically relevant benefits of endurance and strength training on dyspnea, exercise capacity and quality of life have been evaluated very well. However, there are some legal limitations by the German Working Group for Rehabilitation (BAR) concerning outpatient exercise training programs (beyond pulmonary rehabilitation): only group-based callisthenic training programs receive funding from health care insurances while professional equipment-based training programs are excluded despite their outstanding effectiveness.This review provides an overview on the methodology and the benefits of outpatient exercise training programs for patients with chronic respiratory diseases, and it critically discusses the organizational structures of these programs in Germany., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: A large proportion of COPD patients do not achieve the recommended level of physical activity. It is suggested that feedback on the level of activity by using an activity monitoring device (PAM) increases awareness and may stimulate patients to increase their physical activity in daily life. Our objective was to assess the validity and usability of a simple and low-cost physical activity monitor (Polar A300™) when compared with the validated and established Bodymedia-SenseWear™ (SWA) device., Methods: To assess the diagnostic equivalent, two different PAM devices were used in parallel in 20 COPD patients GOLD I to IV during 3 consecutive days of daily life. Both systems were compared in terms of steps, calories burned, daily activity time and metabolic equivalents using linear regression analysis and Bland-Altman plots. Practical usability was examined by a 16-item-questionnaire., Results: High correlations of both devices were observed with regard to the sensed step count (r = 0.96; p < 0.01) and calories burned (r = 0.74; p < 0.01), and a lower correlation of daily activity (r = 0.25; p < 0.01) was found. Data analysis over 3 days showed that 90% of the steps (95% CI -4223 to 1887), 100% of the calories (95% CI -2798 to 1887), 90% of the daily activity data (95% CI -12.32, 4065) and 95% of the MET (95% CI -3.11 to 2.75) were within the limits of agreement. A favorable usability (system-, information- and interface quality) of the A300™ device was shown (p < 0.01)., Conclusion: The A300™ device with easy practical usability was shown not to be inferior for assessment of physical activity time, step count and calorie consumption in COPD patients when compared with the SWA. It is suggested to consider widespread available devices as commonly used for monitoring recreational sporting activities also in patients for assessment of physical activity in daily life.

Background: The response of patients in a pulmonary rehabilitation (PR) is essentially good. However, not all patients benefit from PR to the same extent. In this analysis we wanted to identify the impact of gender and other factors on PR outcomes in patients with chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD)., Methods: Patients suffering from COPD (n = 1492) or ILD (n = 599), treated during an inpatient PR between 1997 and 2015, were analysed according to the effects of PR on exercise capacity and quality of life with regard to the impact of gender or other predictors by univariate and multivariate analyzes., Results: In the group of COPD patients, 30% did not achieve the expected physical performance during the 6-min walk test (28% of female and 32% of male patients). However, the non-responders initially have had a higher 6-min walking distance (6-MWD) (p < 0.001) and both male and female showed a significant lower BODE index (p = 0.025) in the multivariate analysis. In the ILD-group, 37% females and 43% males were classified as non-responders with regard to the 6-MWD. Also in this group, the non-responders initially have had a higher 6-MWD (p < 0.001). All other variables (age, BMI, lung function, blood gases, C-reactive Protein, Haemoglobin or rehabilitation duration) had no influence on the outcome., Conclusion: Our study supports the positive effects of PR in COPD and ILD patients. In both groups, patients with the biggest limitations benefit most from PR. However, relevant gender differences or other predictors could not be found., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: Positive effects of pulmonary rehabilitation on chronic obstructive pulmonary disease (COPD) are well known, and inpatient rehabilitation programs are the preferred modality in Germany. In this paper, we report on the recent results of a daily outpatient rehabilitation program offered at an acute hospital, the first of this kind in Germany. It is not known whether this kind of rehabilitation is an effective approach., Methods: 32 consecutive COPD patients GOLD-stage II-IV, phenotype B-D (mean 64.5±21.9 years; 18 male, 14 female) completed a rehabilitation program of 19 (15-21) days conducted according to the recommendations of the National Accociation for Rehabilitation. In this prospective observational study, data (walking distance in the 6-MWD, BODE-Index, HADS-, BDI/TDI-, CAT-questionnaire) were collected at the beginning (T1) and at the end (T2) of the program and the results are presented in a pre- vs. post-analysis., Results: We found significant positive effects for most of the measured parameters, except for body plethysmography, diffusion capacity and blood gas. Especially the increase in the 6 min walking distance (6-MWD) was remarkable (T1: 485.78±158.24, T2: 527.97±146.75 m, p=0.0212). There were no adverse events or complications. All participants were able to complete the program properly., Conclusion: Most of the measured parameters in COPD patients with stage II or worse disease improved significantly during the comprehensive outpatient rehabilitation program. A limitation of this study is the small number of cases, and further conclusions can only be made after examining a larger sample. The setting of this rehabilitation program in an acute hospital seems to be meaningful in an organisational and structural sense., (© Georg Thieme Verlag KG Stuttgart · New York.)

The positive influence of regular physical training on the course of many chronic diseases in different fields is well documented. Especially for obstructive respiratory diseases the benefit of lung exercise is convincing. An overview will be given in this work how lung exercise can be an effective form of therapy for pulmonary diseases. Actually the evidence of the efficacy of physical activity is particularly overwhelming in obstructive pulmonary diseases. Several clinical trials showed an enhancement in endurance and exercise capacity, quality of life and a decrease of dyspnea and disease-related symptoms. However in comparison to other disease groups, the benefits and awareness and therefore a widespread dissemination is still insufficient. Regular physical activity is an important, effective and also cost-effective component of the therapy of respiratory diseases and is sometimes even superior to a drug therapy. Enough reason to share this kind of therapy with our patients with pulmonary diseases., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: It is well established that physical training enhances functionality and quality of life in patients with COPD. However, little data exist concerning the effects of the usefulness of oxygen supply during exercise training for > 3 months in patients with COPD who are normoxemic at rest and during exercise. We hypothesized that oxygen supply during training sessions enables higher training intensity and thus optimizes training results in patients with COPD., Methods: In this blinded randomized controlled study, we carried out a 24-week training program with progressively increasing loads involving large muscle groups. In addition, we compared the influences of oxygen supplementation. Thirty-six subjects with moderate-to-severe COPD who were not dependent on long-term oxygen therapy trained under supervision for 24 weeks (3 times/week at 30 min/session). Subjects were randomized into 2 groups: oxygen supply via nasal cannula at a flow of 4 L/min and compressed air at the same flow throughout the training program. Lung function tests at rest (inspiratory vital capacity, FEV1, Tiffeneau index), cycle spiroergometry (peak ventilation, peak oxygen uptake, peak respiratory exchange rate, submaximal and peak lactic acid concentrations), 6-min walk tests, and quality-of-life assessments (Medical Outcomes Study 36-Item Short Form questionnaire) were conducted before and after 12 and 24 weeks., Results: Independent of oxygen supplementation, statistically significant improvements occurred in quality of life, maximal tolerated load during cycling, peak oxygen uptake, and 6-min walk test after 12 weeks of training. Notably, there were no further improvements from 12 to 24 weeks despite progressively increased training loads., Conclusions: Endurance training 3 times/week resulted in significant improvements in quality of life and exercise capacity in subjects with moderate-to-severe COPD within the initial 12 weeks, followed by a stable period over the following 12 weeks with no further benefits of supplemental oxygen., (Copyright © 2015 by Daedalus Enterprises.)

The acute venous thromboembolism (VTE) is a life threatening event which might cause difficulties in diagnostic and therapeutic considerations because of the nonspecific symptomatic. In addition to the probability of a VTE, the risk stratification is of decisive importance to the further diagnostic and therapeutic management. The introduction of the new oral direct anticoagulation substances offer important variation to the previous therapy options and are mentioned in this article. The duration of the secondary prophylaxis therapy of VTE will be much more influenced by the reduced bleeding risk profile of the new agents., (© Georg Thieme Verlag KG Stuttgart · New York.)