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BackgroundHome-based noninvasive ventilation has proven cost-effective. But, adherence to therapy still constitutes a common clinical problem. We hypothesized that a behavioral intervention supported by a mobile health (mHealth) app could enhance patient self-efficacy. It is widely accepted that mHealth-supported services can enhance productive interactions among the stakeholders involved in home-based respiratory therapies. ObjectiveThis study aimed to measure changes in self-efficacy in patients with chronic respiratory failure due to diverse etiologies during a 3-month follow-up period after the intervention. Ancillary objectives were assessment of usability and acceptability of the mobile app as well as its potential contribution to collaborative work among stakeholders. MethodsA single-blind, single-center, randomized controlled trial was conducted between February 2019 and June 2019 with 67 adult patients with chronic respiratory failure undergoing home-based noninvasive ventilation. In the intervention group, a psychologist delivered a face-to-face motivational intervention. Follow-up was supported by a mobile app that allowed patients to report the number of hours of daily noninvasive ventilation use and problems with the therapy. Advice was automatically delivered by the mobile app in case of a reported problem. The control group received usual care. The primary outcome was the change in the Self Efficacy in Sleep Apnea questionnaire score. Secondary outcomes included app usability, app acceptability, continuity of care, person-centered care, and ventilatory parameters. ResultsSelf-efficacy was not significantly different in the intervention group after the intervention (before: mean 3.4, SD 0.6; after: mean 3.4, SD 0.5, P=.51). No changes were observed in adherence to therapy nor quality of life. Overall, the mHealth tool had a good usability score (mean 78 points) and high acceptance rate (mean score of 7.5/10 on a Likert scale). It was considered user-friendly (mean score of 8.2/10 on a Likert scale) and easy to use without assistance (mean score of 8.5/10 on a Likert scale). Patients also scored the perception of continuity of care and person-centered care as high. ConclusionsThe integrated care intervention supported by the mobile app did not improve patient self-management. However, the high acceptance of the mobile app might indicate potential for enhanced communication among stakeholders. The study identified key elements required for mHealth tools to provide effective support to collaborative work and personalized care. Trial RegistrationClinicalTrials.gov NCT03932175; https://clinicaltrials.gov/ct2/show/NCT03932175

Introduction Abnormalities of autonomic function have been reported in patients with chronic obstructive pulmonary disease (COPD). Our objectives were to identify determinants of abnormal heart rate recovery at 1 min (HRR.sub.1) following completion of the 6-min walk test (6MWT) in COPD and to establish whether abnormal HRR.sub.1 predicts acute exacerbations (AECOPD). Methods Hundred one COPD patients (FEV.sub.1 (SD) 53 (19) % predicted) were prospectively recruited in a multi-center study. HRR.sub.1 after the 6MWT was evaluated as the difference between heart rate at the end of the test and 1 min into the recovery (HRR.sub.1). Linear and logistic regression was used to identify predictors of HRR.sub.1 and AECOPD, respectively. The best HRR.sub.1 cut-off point to predict AECOPD was selected using the receiver operating characteristics (ROC) curves. The follow-up period was 12 months. Results Distance covered during the 6MWT (m) and DLco (% predicted) were independently associated with HRR.sub.1 (r.sup.2 = 0.51, p = 0.001). Among several potential covariates, HRR.sub.1 emerged as the most significant predictor of AECOPD (Odds ratio [OR], 0.91 per beat of recovery; 95% confidence interval [CI], 0.85-0.97; p = 0.02). The ROC analysis indicated that subjects with HRR.sub.1 less than 14 beats (AUC, 0.71 [CI] 0.60-0.80; p = 0.0001) were more likely to suffer an exacerbation during the follow-up period (for HRR.sub.1, p = 0.004 [log-rank test]). Conclusions HRR.sub.1 after the 6MWT is an independent predictor factor for AECOPD. Further studies are warranted to examine the physiological mechanisms associating a delayed HRR and acute exacerbations in COPD patients., Author(s): Diego A. Rodríguez [sup.1] , Eleni A. Kortianou [sup.2] , Jennifer A. Alison [sup.3] , Alejandro Casas [sup.4] , Santiago Giavedoni [sup.5] , Anael Barberan-Garcia [sup.6] , Ane Arbillaga [...]

Prehabilitation has shown its potential for most intra-cavity surgery patients on enhancing preoperative functional capacity and postoperative outcomes. However, its large-scale implementation is limited by several constrictions, such as: i) unsolved practicalities of the service workflow, ii) challenges associated to change management in collaborative care; iii) insufficient access to prehabilitation; iv) relevant percentage of program drop-outs; v) need for program personalization; and, vi) economical sustainability. Transferability of prehabilitation programs from the hospital setting to the community would potentially provide a new scenario with greater accessibility, as well as offer an opportunity to effectively address the aforementioned issues and, thus, optimize healthcare value generation. A core aspect to take into account for an optimal management of prehabilitation programs is to use proper technological tools enabling: i) customizable and interoperable integrated care pathways facilitating personalization of the service and effective engagement among stakeholders; ii) remote monitoring (i.e. physical activity, physiological signs and patient-reported outcomes and experience measures) to support patient adherence to the program and empowerment for self-management; and, iii) use of health risk assessment supporting decision making for personalized service selection. The current manuscript details a proposal to bring digital innovation to community-based prehabilitation programs. Moreover, this approach has the potential to be adopted by programs supporting long-term management of cancer patients, chronic patients and prevention of multimorbidity in subjects at risk. [ABSTRACT FROM AUTHOR]

Summary: Aim: We hypothesize that training‐induced changes in muscle oxygen saturation (StO2) assessed by near‐infrared spectroscopy (NIRS) during constant work rate cycling exercise (CWRE) may be a useful marker of the effects of training at 'vastus medialis' of the quadriceps in patients with chronic obstructive pulmonary disease (COPD). Methods: Incremental exercise [peak oxygen uptake (VO2)] and CWRE at 70% pretraining peak VO2, before and after 8‐w training, were done in 10 healthy age‐matched subjects (H) [80% men, 65(11) years, FEV1 105(14)%] and 16 COPD patients [94% men, 70(5) years, FEV1 46(11) %] encompassing the entire spectrum of disease severity, recruited in the outpatient clinics. NIRS was used to assess StO2 in the 'vastus medialis' of the left quadriceps. Results: Pretraining CWRE decreased StO2 (P<0·05) and generated marked StO2 rebound (P<0·001) after unloading in the two groups. After training, VO2 peak increased in H [253(204) ml min−1] (P<0·01) and in COPD [180(183) ml·min−1] (P = 0·01) and blood lactate fell [−4·4 (2·7) and −1·6(2·3) mmol·m−1] (P<0·05 each). Training generated a further fall in StO2 during CWRE [−10(12)% and −10(10)%, P<0·05] and increased StO2 rebound after unloading [8(7)% and 5(9)%, P<0·05] in both groups. Conclusion: Endurance training further decreased StO2 during CWRE, similarly in both groups, likely due to training‐induced enhancement of muscle O2 transfer and utilization. Training‐induced StO2 fall during CWRE may be useful individual marker for non‐invasive assessment of enhanced muscle aerobic post‐training function. [ABSTRACT FROM AUTHOR]

Objectives: Physical activity is key to improve the prognosis of chronic obstructive pulmonary disease (COPD). To help to tailor future interventions we aimed to identify the baseline characteristics of COPD patients which predict 12-month completion and response to a behavioral physical activity intervention. Methods: This is a 12-month cohort study of the intervention arm of the Urban Training randomized controlled trial (NCT01897298), an intervention proven to be efficacious to increase physical activity. We considered baseline sociodemographic, interpersonal, environmental, clinical and psychological characteristics as potential determinants of completion and response. We defined completion as attending the 12-month study visit. Among completers, we defined response as increasing physical activity ≥1100 steps/day from baseline to 12 months, measured by accelerometer. We estimated the factors independently for completion and response using multivariable logistic regression models. Results: Of a total of 202 patients (m (SD) 69 (9) years, 84% male), 132 (65%) completed the study. Among those, 37 (28%) qualified as responders. Higher numbers of baseline steps/day (OR [95% CI] 1.11 [1.02–1.21] per increase of 1000 steps, p<0.05) and living with a partner (2.77 [1.41–5.48], p<0.01) were related to a higher probability of completion while more neighborhood vulnerability (0.70 [0.57–0.86] per increase of 0.1 units in urban vulnerability index, p<0.01) was related to a lower probability. Among the completers, working (3.14 [1.05–9.33], p<0.05) and having an endocrino-metabolic disease (4.36 [1.49–12.80], p<0.01) were related to a higher probability of response while unwillingness to follow the intervention (0.21 [0.05–0.98], p<0.05) was related to a lower probability. Conclusions: This study found that 12-month completion of a behavioral physical activity intervention was generally determined by previous physical activity habits as well as interpersonal and environmental physical activity facilitators while response was related to diverse factors thought to modify the individual motivation to change to an active lifestyle. [ABSTRACT FROM AUTHOR]

Purpose: Accessible interventions to train patients with chronic obstructive pulmonary disease (COPD) are needed. We designed urban trails of different intensities (low, moderate and high) in different types of public spaces (boulevard, beach and park). We aimed to validate the trails’ design by assessing the physiological response to unsupervised walking trails of: (1) different intensities in COPD patients, and (2) same intensity from different public spaces in healthy adults. Methods: On different days and under standardized conditions, 10 COPD patients walked the three intensity trails designed in a boulevard space, and 10 healthy subjects walked the three intensity trails in three different spaces. We measured physiological response and energy expenditure using a gas analyzer. We compared outcomes across trails intensity and/or spaces using mixed-effects linear regression. Results: In COPD patients, physiological response and energy expenditure increased significantly according to the trails intensity: mean (SD) peak O2 15.9 (3.5), 17.4 (4.7), and 17.7 (4.4) mL/min/kg (p-trend = 0.02), and MET-min 60 (23), 64 (26), 72 (31) (p-trend<0.01) in low, moderate and high intensity trails, respectively. In healthy subjects there were no differences in physiological response to walking trails of the same intensity across different spaces. Conclusions: We validated the trails design for the training of COPD patients by showing that the physiological response to and energy expenditure on unsupervised walking these trails increased according to the predefined trails’ intensity and did not change across trails of the same intensity in different public space. Walkable public spaces allow the design of trails that could be used for the training of COPD patients in the community. [ABSTRACT FROM AUTHOR]

Background: Abnormalities of autonomic function have been reported in patients with chronic obstructive pulmonary disease. The effect of the exercise training in heart rate recovery (HRR) has not been established in patients with COPD. Objective: To assess the effects of 8-weeks' endurance training program on parasympathetic nervous system response measured as heart rate recovery in a sample of moderate-to-severe COPD patients. Methods: We recruited a consecutive sample of patients with COPD candidates to participate in a pulmonary rehabilitation program from respiratory outpatient clinics of a tertiary hospital. HRR was calculated, before and after training, as the difference in heart rate between end-exercise and one minute thereafter (HRR1) in a constant-work rate protocol. Results: A total of 73 COPD patients were included: mean (SD) age 66 (8) years, median (P25-P75) post-bronchodilator FEV1 39 (29-53)%. The prevalence of slow HRR1 (≤12 beats) at baseline was 63%, and was associated with spirometric severity (mean FEV1 35% in slow HRR1 vs 53 in normal HRR1, p < 0.001). After 8-weeks training, HRR1 improved from mean (SD) 10 (7) to 12 (7) beats ( p = 0.0127). Multivariate linear regression models showed that the only variable related to post-training HRR1 was pre-training HRR1 ( p < 0.001). Conclusions: These results suggest that training enhances HRR in patients with moderate-to-severe COPD. HRR is an easy tool to evaluate ANS such that it may be a useful clinical marker of parasympathetic nervous system response in patients with COPD. [ABSTRACT FROM AUTHOR]

Introduction: The efficacy of prehabilitation (PreHab) to reduce surgical complications, and facilitate postoperative recovery, has been demonstrated (Ann Surg. 2018; 267(1):50-56). Deployment of PreHab as mainstream service at Hospital Clínic de Barcelona (HCB) has been undertaken. However, there is a need for consolidation of modular digital health tools to address two main aspects of service scalability: to empower patients for self-management at community level and to support collaborative work among professionals. Practice change implemented: PreHab has a trimodal approach including: supervised endurance training & promotion of physical activity, nutritional balance and psychological support (mindfulness). Supporting technologies include an adaptive case management platform to enhance collaborative work among health professionals and patients themselves using a mobile application for self-management at community level. Aim and theory of change: A recent design thinking process involving all stakeholders identified that transferability of the PreHab service can improve with modularity of both service workflow and digital health tools. Moreover, service accessibility and sustainability should be enhanced by shared care agreements with community-based services. Targeted population: Effectiveness and sustainability of PreHab is currently being assessed in a real world setting (HCB, 300 patients/yr.). Timeline: The technological support with full integration between community (patient) and health information systems at HCB (professionals) was implemented and is currently being evaluated. Next steps, during 2019, are: i) regional deployment of PreHab; ii) integration of the selfmanagement platform into the regional personal health folder (La Meva Salut© - lamevasalut.gencat.cat), iii) evolution of the service toward a perioperative care program with a population-health approach; iv) refinement of the adaptive case management functionalities using the Camunda© (camunda.org) open source workflow and decision automation platform; and, v) transferability of selected traits of PreHab to rehabilitation of chronic stable patients. Highlights: The supervised endurance training sessions are managed and tracked with the proprietary Technogym® equipment (i.e. Mywellness). Patient self-management is based on MyPathway® (mypathway.healthcare). Integration with hospital information systems is performed using an open source HL7 FHIR API (i.e. HAPI). System usability is planned to be assessed by means of a Net Promoter Score survey in case of patients and the User Experience Questionnaire (UEQ) in case of healthcare professionals. Comments on sustainability: PreHab has shown potential for health value generation, both at provider and at health system levels, indicating that the operational costs can be fully covered by savings generated through adoption of the service. Comments on transferability: Regional transferability of PreHab is planned during 2019 and transferability at International level will be undertaken thereafter. Conclusions: PreHab digital health tools for patient self-management with off-line remote monitoring and access to a case manager are ready to be integrated with provider-specific and regional health information systems for a large scale development. Discussions: Individualized work plans should combine face to face supervised sessions and community-based remotely supervised activities, including access to partnering health/wellness centers. Lessons learned: Personalization and modularization of the service, as well as the supporting digital health tools, were identified as core traits to ensure adoption. [ABSTRACT FROM AUTHOR]

Many clinical and psychological factors are known to influence the health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD). However, research on whether environmental factors, such as air pollution, noise, temperature, and blue/green spaces also influence HRQL in COPD has not been systematically investigated. To assess the relationship between air pollution, road traffic noise, temperature, and distance to blue/green spaces and respiratory-specific HRQL in COPD. We used cross-sectional data from a multicenter study in 407 stable mild-to-very severe COPD patients from Barcelona (Catalonia). Patients answered the COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Individual residential exposure to air pollutants (nitrogen dioxide [NO 2 ] and particulate matters of varying aerodynamic diameters [PM 2.5 , PM 10 , and PM 2.5absorbance ]), road traffic noise (L den), and land surface temperature were estimated using long-term averages from land-use regression models, 24-h noise maps, and land surface temperature maps, respectively. We measured residential distances to blue/green spaces from the Urban Atlas. We used mixed-effect negative binomial (for CAT) and linear (for CCQ) regression models, adjusted for potential confounders, with a random effect by center. Of those patients, 85 % were male and had a mean (SD) age of 69 (9) years, CAT score of 12 (7), CCQ-total score of 1.4 (1.0), and post-bronchodilator forced expiratory volume in 1 s (FEV 1) of 57 (18) %predicted. We found that NO 2 and PM 2.5absorbance were associated with worsened CAT and CCQ-mental scores, e.g., 0.15-unit change in CAT score [regression coefficient (β) = 0.15; 95 % confidence interval (CI) = 0.03, 0.26] per interquartile range in NO 2 [13.7 μg/m3]. Greater distances to blue/green spaces were associated with worsened CCQ-mental scores [0.08; 0.002, 0.15]. Our study showed that increased air pollution, particularly NO 2 and PM 2.5absorbance and greater distances to blue/green spaces negatively influence HRQL in COPD patients. These findings have important implications for the WHO promotion to develop healthy cities for our future. • We measured health-related quality of life (HRQL) in COPD patients in association with physical environment. • A significant association was found between air pollution, and greater distances to blue/green spaces, and worse HRQL in COPD patients. • Environmental factors also significantly influence HRQL, particularly in patients with a chronic respiratory disease. [ABSTRACT FROM AUTHOR]

Introduction: Although mean physical activity in COPD patients declines by 400-500steps/day annually, it is unknown whether the natural progression is the same for all patients. We aimed to identify distinct physical activity progression patterns using a hypothesis-free approach and to assess their determinants., Methods: We pooled data from two cohorts (usual care arm of Urban Training [NCT01897298] and PROactive initial validation [NCT01388218] studies) measuring physical activity at baseline and 12 months (Dynaport MoveMonitor). We identified clusters (patterns) of physical activity progression (based on levels and changes of steps/day) using k-means, and compared baseline sociodemographic, interpersonal, environmental, clinical and psychological characteristics across patterns., Results: In 291 COPD patients (mean±SD 68±8 years, 81% male, FEV 1 59±19% pred ) we identified three distinct physical activity progression patterns: Inactive (n=173 [59%], baseline: 4621±1757 steps/day, 12-month change (Δ): -487±1201 steps/day), ActiveImprovers (n=49 [17%], baseline: 7727±3275 steps/day, Δ:+3378±2203 steps/day) and ActiveDecliners (n=69 [24%], baseline: 11 267±3009 steps/day, Δ: -2217±2085 steps/day). After adjustment in a mixed multinomial logistic regression model using Active Decliners as reference pattern, a lower 6-min walking distance (RRR [95% CI] 0.94 [0.90-0.98] per 10m, P=.001) and a higher mMRC dyspnea score (1.71 [1.12-2.60] per 1 point, P=.012) were independently related with being Inactive. No baseline variable was independently associated with being an Active Improver., Conclusions: The natural progression in physical activity over time in COPD patients is heterogeneous. While Inactive patients relate to worse scores for clinical COPD characteristics, Active Improvers and Decliners cannot be predicted at baseline., (Copyright © 2020 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.)

There is a need to increase and maintain physical activity in patients with chronic obstructive pulmonary disease (COPD). We assessed 12-month efficacy and effectiveness of the Urban Training intervention on physical activity in COPD patients.This randomised controlled trial (NCT01897298) allocated 407 COPD patients from primary and hospital settings 1:1 to usual care (n=205) or Urban Training (n=202). Urban Training consisted of a baseline motivational interview, advice to walk on urban trails designed for COPD patients in outdoor public spaces and other optional components for feedback, motivation, information and support (pedometer, calendar, physical activity brochure, website, phone text messages, walking groups and a phone number). The primary outcome was 12-month change in steps·day -1 measured by accelerometer.Efficacy analysis (with per-protocol analysis set, n=233 classified as adherent to the assigned intervention) showed adjusted (95% CI) 12-month difference +957 (184-1731) steps·day -1 between Urban Training and usual care. Effectiveness analysis (with intention-to-treat analysis set, n=280 patients completing the study at 12 months including unwilling and self-reported non-adherent patients) showed no differences between groups. Leg muscle pain during walks was more frequently reported in Urban Training than usual care, without differences in any of the other adverse events.Urban Training, combining behavioural strategies with unsupervised outdoor walking, was efficacious in increasing physical activity after 12 months in COPD patients, with few safety concerns. However, it was ineffective in the full population including unwilling and self-reported non-adherent patients., Competing Interests: Conflict of interest: A. Arbillaga-Etxarri has nothing to disclose. Conflict of interest: E. Gimeno-Santos has nothing to disclose. Conflict of interest: A. Barberan-Garcia has nothing to disclose. Conflict of interest: E. Balcells has nothing to disclose. Conflict of interest: M. Benet has nothing to disclose. Conflict of interest: E. Borrell has nothing to disclose. Conflict of interest: N. Celorrio has nothing to disclose. Conflict of interest: A. Delgado has nothing to disclose. Conflict of interest: C. Jané has nothing to disclose. Conflict of interest: A. Marin has nothing to disclose. Conflict of interest: C. Martín-Cantera has nothing to disclose. Conflict of interest: M. Monteagudo has nothing to disclose. Conflict of interest: N. Montellà has nothing to disclose. Conflict of interest: L. Muñoz has nothing to disclose. Conflict of interest: P. Ortega has nothing to disclose. Conflict of interest: D.A. Rodríguez has nothing to disclose. Conflict of interest: R. Rodríguez-Roisin reports grants from Almirall and Menarini, personal fees for advisory board work from Boehringer Ingelheim, Pearl Therapeutics and TEVA, personal fees for lecturinf from Novartis and Takeda, during the conduct of the study, all related to COPD. Conflict of interest: P. Simonet reports personal fees for speaking from Menarini, Gebro, Teva, Boehringer, Rovi, AstraZeneca and GSK, outside the submitted work. Conflict of interest: P. Torán-Monserrat has nothing to disclose. Conflict of interest: J. Torrent-Pallicer has nothing to disclose. Conflict of interest: P. Vall-Casas has nothing to disclose. Conflict of interest: J. Vilaró has nothing to disclose. Conflict of interest: J. Garcia-Aymerich reports personal fees for consulting and lecture fees paid to institution from AstraZeneca, personal fees for lecturing from Esteve and Chiesi, outside the submitted work., (Copyright ©ERS 2018.)

Purpose: Accessible interventions to train patients with chronic obstructive pulmonary disease (COPD) are needed. We designed urban trails of different intensities (low, moderate and high) in different types of public spaces (boulevard, beach and park). We aimed to validate the trails' design by assessing the physiological response to unsupervised walking trails of: (1) different intensities in COPD patients, and (2) same intensity from different public spaces in healthy adults., Methods: On different days and under standardized conditions, 10 COPD patients walked the three intensity trails designed in a boulevard space, and 10 healthy subjects walked the three intensity trails in three different spaces. We measured physiological response and energy expenditure using a gas analyzer. We compared outcomes across trails intensity and/or spaces using mixed-effects linear regression., Results: In COPD patients, physiological response and energy expenditure increased significantly according to the trails intensity: mean (SD) peak V̇O2 15.9 (3.5), 17.4 (4.7), and 17.7 (4.4) mL/min/kg (p-trend = 0.02), and MET-min 60 (23), 64 (26), 72 (31) (p-trend<0.01) in low, moderate and high intensity trails, respectively. In healthy subjects there were no differences in physiological response to walking trails of the same intensity across different spaces., Conclusions: We validated the trails design for the training of COPD patients by showing that the physiological response to and energy expenditure on unsupervised walking these trails increased according to the predefined trails' intensity and did not change across trails of the same intensity in different public space. Walkable public spaces allow the design of trails that could be used for the training of COPD patients in the community.