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Patients on extracorporeal membrane oxygenation (ECMO) often require prolonged periods of bed rest owing to their severity of illness along with the care required to maintain the position and integrity of the ECMO cannula. Many patients on ECMO receive passive exercises, and rehabilitation is often delayed owing to medical instability, with a high proportion of patients demonstrating severe muscle weakness. The physiological effects of an intensive rehabilitation program started early after ECMO commencement remain unknown.The primary objective of this study was to describe the respiratory and haemodynamic effects of early intensive rehabilitation compared with standard care physiotherapy over a 7-d period in patients requiring ECMO.This was a physiological substudy of a multicentre randomised controlled trial conducted in one tertiary referral hospital. Consecutive adult patients undergoing ECMO were recruited. Respiratory and haemodynamic parameters, along with ECMO settings, were recorded 30 min before and after each session and continuously during the session. In addition, the minimum and maximum values for these parameters were recorded outside of the rehabilitation or standard care sessions for each 24-h period over the 7 d. The number of minutes of exercise per session was recorded.Fifteen patients (mean age = 51.5 ± standard deviation of 14.3 y, 80% men) received ECMO. There was no difference between the groups for any of the respiratory, haemodynamic, or ECMO parameters. The minimum and maximum values for each parameter were recorded outside of the rehabilitation or standard care sessions. The intensive rehabilitation group (n = 7) spent more time exercising per session than the standard care group (n = 8) (mean = 28.7 versus 4.2 min, p 0.0001). Three patients (43%) in the intensive rehabilitation group versus none in the standard care group mobilised out of bed during ECMO.In summary, early intensive rehabilitation of patients on ECMO had minimal effect on physiological parameters.

The coronavirus disease 2019 (COVID-19) pandemic has necessitated adoption of telerehabilitation in services where face-to-face consultations were previously standard. We aimed to understand barriers to implementing a telerehabilitation clinical service and design a behavior support strategy for clinicians to implement telerehabilitation. A hybrid implementation study design included pre- and post-intervention questionnaires, identification of key barriers to implementation using the theoretical domains framework, and development of a targeted intervention. Thirty-one clinicians completed baseline questionnaires identifying key barriers to the implementation of telerehabilitation. Barriers were associated with behavior domains of knowledge, environment, social influences, and beliefs. A 6-week brief intervention focused on remote clinician support, and education was well received but achieved little change in perceived barriers to implementation. The brief intervention to support implementation of telerehabilitation during COVID-19 achieved clinical practice change, but barriers remain. Longer follow-up may determine the sustainability of a brief implementation strategy, but needs to consider pandemic-related stressors.

Background Despite a lack of evidence, ambulatory oxygen therapy is frequently prescribed for patients with interstitial lung disease (ILD) and exertional desaturation. Patients often prefer portable oxygen concentrators to oxygen cylinders. This study aimed to examine the feasibility of conducting a clinical trial of ambulatory oxygen delivered via portable concentrators in patients with ILD. Research Question Is it feasible to conduct a clinical trial of ambulatory oxygen delivered via portable concentrators in patients with ILD? Study Design and Methods In this randomized, triple-blinded, sham-controlled trial, 30 participants with ILD and isolated exertional desaturation to Results Study recruitment was completed within 18 months, with six withdrawals. Participant blinding was successful, with the Bang’s Blinding Index being 0 (95% CI, −0.40 to 0.40) for the oxygen group and 0 (95% CI, −0.42 to 0.42) for the sham group. No significant difference in 6MWD was seen between groups at week 12 (mean difference of −34 m [95% CI, −105 to 36], P = .34). For secondary outcomes, compared with the sham group, the oxygen group had a significantly higher Leicester Cough Questionnaire psychological domain score, indicating better cough-related quality of life (mean difference of 0.9 [95% CI, 0.2 to 1.6], P = .01), but a shorter duration of moderate-to-vigorous activities (mean difference of −135 [95% CI, −267 to −3], P = .04) at week 12. Interpretation Based on the results of this pilot study, a definitive randomized controlled trial with a longer intervention duration is warranted to clarify therapeutic impacts of ambulatory oxygen in patients with ILD. Trial Registry Australian New Zealand Clinical Trials Registry; No.: ACTRN12617000054314; URL: www.anzctr.org.au/

Background As our population ages, older adults are increasingly exposed to trauma. Frailty could be a useful measure to identify patients at risk of a poor outcome. This study aimed to determine the impact of frailty in an Australian trauma intensive care unit (ICU) population. Methods A prospective observational study of critically ill trauma patients ≥50 years of age. Frailty was determined on admission to the ICU using the frailty phenotype. Demographic and hospital data were collected, and patients were followed up at 6 and 12 months. The primary outcome was 12-month mortality, and multiple regression was used to determine associated factors. Results One hundred thirty-eight patients were included, whose mean age was 68 years; 78.2% (108/138) were classified as major trauma (Injury Severity Score >12). Twenty-two percent (30/138) of patients were identified as frail. Patients with frailty were significantly older: however, they were less severely injured and required lower rates of surgical interventions and mechanical ventilation. Frailty was independently associated with mortality at 6 and 12 months (odds ratio: 5.9, 95% confidence interval: 1.9–18.1 and odds ratio: 7.3, 95% confidence interval: 2.5–21.9, respectively). Patients with frailty had lower measures of global functioning (Glasgow Outcome Scale-Extended frail 3 [1–5] vs nonfrail 6 [(5–7], p = 0.002) and health status (Euro Qol 5Q-5D-5L utility score 0.6 [0.5–0.7] vs 0.7 [0.6–0.9], p = 0.02) at 12 months than patients without frailty. Conclusion Frailty is a useful predictor of poor outcomes in critically ill trauma patients. Registration of protocol number ACTRN12615000039583.

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

Objective The aim of this study was to determine the duration of physical activity (PA) monitoring required for reliable measurements following stroke. Design Single-center, prospective, observational study. Setting PA was measured in a community setting. Participants Adults (N=70) poststroke. Main Outcome Measures The SenseWear armband was used to monitor PA for 5 days (≥10 hours wear per day). Data Analysis Variance among 2, 3, 4, and 5 days of consecutive measurements for PA variables was examined using intraclass correlation coefficients (ICCs). The minimum number of days to achieve acceptable reliability (ICC ≥0.8) was calculated. Differences between weekdays and weekend days were investigated using paired t tests and Wilcoxon signed rank tests. Results Two days of measurement was sufficient to achieve an ICC ≥0.8 for daily averages of total energy expenditure, step count, and time spent sedentary (≤1.5 metabolic equivalent tasks [METs]) and in light (1.5-3 METs) and moderate- to vigorous-intensity (>3 METs) PA. At least 3 days were required to achieve an ICC ≥0.8 when investigating the number of and time spent in bouts (≥10 minutes) of moderate to vigorous PA and sedentary behavior. Participants took significantly more steps (P=.03) and spent more time in light PA (P=.03) on weekdays than weekends. Conclusion Following stroke, 2 days of measurement appears sufficient to represent habitual PA for many simple variables. Three or more days may be necessary for reliable estimates of bouts of PA and sedentary behavior. Consistent inclusion or exclusion of a weekend day is recommended for measuring step count and light PA. Short periods of monitoring provide reliable PA information and may make PA measurement more feasible in the clinical setting.

Objectives To determine in women with clinically stable chronic lung disease (CLD) and healthy women; (1) prevalence of urinary incontinence; (2) risk factors for urinary incontinence; (3) effects of a standard course of specialised physiotherapy treatment (PT) in women with CLD. Design Prospective prevalence study; PT study in CLD subgroup. Setting Tertiary metropolitan public hospital. Participants Women with cystic fibrosis (CF, n = 38), chronic obstructive pulmonary disease (COPD, n = 27) and 69 healthy women without CLD. PT study — 10 women with CLD. Interventions Five continence PT sessions over 3 months. Main outcome measures Prevalence and impact of incontinence (questionnaire), number of leakage episodes (7-day accident diary), pelvic floor muscle function (ultrasound imaging) and quality of life (King’s Health Questionnaire). Results The majority of women in all three groups reported episodes of incontinence (CF 71%; COPD 70%; healthy women 55%). Compared to age-matched healthy controls, women with CF reported more episodes of incontinence (P = 0.006) and more commonly reported stress incontinence (P = 0.001). A logistic regression model revealed that women with CLD were twice as likely to develop incontinence than healthy women (P = 0.05). Women with COPD reported significantly more ‘bother’ with incontinence than age-matched women with incontinence. There was a significant reduction in incontinence episodes following treatment, which was maintained after three months. Conclusions The presence of CLD is an independent predictor of incontinence in women. In older women this is associated with more distress than in age-matched peers without CLD. Larger treatment studies are indicated for women with CLD and incontinence.

To establish the feasibility and effectiveness of a 6-week ballistic strength training protocol in people with stroke.Randomized, controlled, assessor-blinded study.Subacute inpatient rehabilitation.Consecutively admitted inpatients with a primary diagnosis of first-ever stroke with lower limb weakness, functional ambulation category score of ≥3, and ability to walk ≥14 m were screened for eligibility to recruit 30 participants for randomization.Participants were randomized to standard therapy or ballistic strength training 3 times per week for 6 weeks.The primary aim was to evaluate feasibility and outcomes included recruitment rate, participant retention and attrition, feasibility of the exercise protocol, therapist burden, and participant safety. Secondary outcomes included measures of mobility, lower limb muscle strength, muscle power, and quality of life.A total of 30 participants (11% of those screened) with mean age of 50 years (SD 18) were randomized. The median number of sessions attended was 15 of 18 and 17 of 18 for the ballistic and control groups, respectively. Earlier than expected discharge to home (n=4) and illness (n=7) were the most common reasons for nonattendance. Participants performed the exercises safely, with no study-related adverse events. There were significant (P.05) between-group changes favoring the ballistic group for comfortable gait velocity (mean difference [MD] 0.31m/s, 95% confidence interval [CI]: 0.08-0.52), muscle power, as measured by peak jump height (MD 8cm, 95% CI: 3-13), and peak propulsive velocity (MD 64cm/s, 95% CI: 17-112).Ballistic training was safe and feasible in select ambulant people with stroke. Similar rates of retention and attrition suggest that ballistic training was acceptable to patients. Secondary outcomes provide promising results that warrant further investigation in a larger trial.

BACKGROUND: The relationship between pre- and post-stroke physical activity levels is underexplored. OBJECTIVE: To determine whether self-reported physical activity changes from pre-stroke to two years post-stroke; and to explore the relationship between self-reported and objectively measured physical activity post-stroke. METHODS: Stroke survivors admitted to rehabilitation were included in this observational study. Participants were assessed at rehabilitation discharge (five months post-stroke) and two years later. Participants were asked about their pre-stroke and current activity levels. The Sensewear Armband was worn for one week to measure physical activity at each timepoint. The relationship between self-reported and objectively measured physical activity was explored with Spearman correlation coefficients and multiple regression models. RESULTS: Sixty-eight stroke survivors (65% male, mean age 64) participated at baseline. Fifty participants reported undertaking physical activity pre-stroke, and 48 of these active participants reported undertaking physical activity two years post-stroke. At two years one third of the active participants reported doing the same type of activity (primarily walking). Approximately one third reported doing the same type of activity and more and approximately one third had to modify the type of activity undertaken. Self-reporting of physical activity time was positively correlated with objective measures of physical activity at two years (r = 0.61, p

Background The intensive care unit mobility scale (IMS) is reliable, valid and responsive. Establishing the minimal important difference (MID) of the IMS is important in order to detect clinically significant changes in mobilization. Objective To calculate the MID of the IMS in intensive care unit patients. Methods Prospective multi center observational study. The IMS was collected from admission and discharge physiotherapy assessments. To calculate the MID we used; anchor based methods (global rating of change) and two distribution-based methods (standard error of the mean and effect size). Results We enrolled 184 adult patients; mean age 62.0 years, surgical, trauma, and medical. Anchor based methods gave a MID of 3 with area under the curve 0.94 (95% CI 0.89-0.97). The two distribution based methods gave a MID between 0.89 and 1.40. Conclusion These data increase our understanding of the clinimetric properties of the IMS, improving its utility for clinical practice and research.

To compare advanced musculoskeletal physiotherapists with other health professionals by measuring outcomes for patients presenting to the emergency department with lower limb soft tissue injuries or acute low back pain.A prospective study was conducted (Lower limb soft tissue injury cohort, n=88), (Acute low back pain cohort, n=29) at the emergency departments of two urban hospitals. A univariate analysis was completed for a number of outcome measures: Lower Extremity Functional Scale, Roland Morris Disability Questionnaire, imaging requirements, Patient Satisfaction Questionnaire, Numerical Pain Rating Scale and medication use. Data was obtained at discharge, two weeks and six weeks post-discharge.Advanced musculoskeletal physiotherapists ordered less imaging, had less opioids (lower limb soft tissue injury) administered to patients, and patients' described equal or more satisfaction when compared to another health professional (p0.05). No significant differences were found between groups for functional or pain related outcomes in both cohorts (p0.05).Advanced musculoskeletal physiotherapists are less likely to order imaging, obtain similar outcomes regarding pain medications and display equal or more patient satisfaction when compared to other health professionals for patients presenting to the emergency department with lower limb soft tissue injuries or acute low back pain.

Objective To evaluate the inter-rater and intra-rater reliability of the hand held dynamometer in measuring muscle strength in people with interstitial lung disease (ILD). Design Test retest reliability of hand-held dynamometry for elbow flexor and knee extensor strength between two independent raters and two testing sessions. Setting Physiotherapy department within a tertiary hospital. Participants Thirty participants with ILD of varying aetiology were included. Twenty participants completed the inter-rater reliability protocol (10 idiopathic pulmonary fibrosis, mean (SD) age 73 (10) years, 11 male) and 21 participants completed the intra-rater reliability protocol (10 idiopathic pulmonary fibrosis, mean age 71 (10) years, 11 male). Main outcome measures Mean muscle strength (kg). Agreement between the two raters and testing sessions was analyzed using Bland–Altman plots and reliability was estimated using intraclass correlation coefficients (ICC). Results For elbow flexor strength there was a mean difference between raters of −0.6kg (limits of agreement (LOA) −5.6 to 4.4kg) and within raters of −0.3kg (LOA −2.8 to 2.3kg). The ICCs were 0.95 and 0.98, respectively. For knee extensor strength there was a mean difference between raters of −1.5kg (LOA −6.9 to 3.9kg) and within raters of −0.7kg (LOA −3.9 to 2.4kg). The ICCs were 0.95 and 0.97, respectively. Conclusions Hand-held dynamometry is reliable in measuring elbow flexor and knee extensor strength in people with ILD.

Objectives To determine the barriers and facilitators of early mobilisation in the Intensive Care Unit. Background It is well established that mobilising critically ill patients has many benefits, however it is not occurring as frequently as expected. The causes and ways to change this are not clearly understood. Methods A qualitative descriptive study involving focus groups with medical, nursing and physiotherapy clinicians, from an Australian quaternary hospital Intensive Care Unit. Results The major themes related to barriers included the culture of the Intensive Care Unit; communication; and a lack of resources. Major themes associated with facilitating early mobilisation included organisational change; improved communication between medical units; and improved resources. Conclusions Early mobilisation was considered an important aspect of critically ill patient's care by all clinicians. Several major barriers to mobilisation were identified, which included unit culture, lack of resources, prioritisation and leadership. A dedicated mobility team led by physiotherapists in the ICU setting could be a viable option to address the identified barriers related to mobility.

Objectives To determine the prevalence and impact of urinary incontinence (UI) in men with cystic fibrosis (CF). Design Prospective observational study. Setting Adult CF clinics at tertiary referral centres. Participants Men with CF ( n =80) and age-matched men without lung disease ( n =80). Interventions Validated questionnaires to identify the prevalence and impact of UI. Main outcome measures Prevalence of UI and relationship to disease specific factors, relationship of UI with anxiety and depression. Results The prevalence of UI was higher in men with CF (15%) compared to controls (10%) ( p =0.339). Men with CF and UI had higher scores for anxiety than those without UI (mean 9.1 (SD 4.8) vs 4.7 (4.1), p =0.003), with similar findings for depression (6.8 (4.6) vs 2.8 (3.4), p =0.002) using the Hospital Anxiety and Depression Scale. Conclusions Incontinence is more prevalent in adult men with CF than age matched controls, and may have an adverse effect on mental health. The mechanisms involved are still unclear and may differ from those reported in women.

The 6-min walk distance (6MWD), a widely used test of functional capacity, has limited evidence of construct validity among patients surviving acute respiratory failure (ARF) and ARDS. The objective of this study was to examine construct validity and responsiveness and estimate minimal important difference (MID) for the 6MWD in patients surviving ARF/ARDS.For this secondary data analysis of four international studies of adult patients surviving ARF/ARDS (N = 641), convergent and discriminant validity, known group validity, predictive validity, and responsiveness were assessed. MID was examined using anchor- and distribution-based approaches. Analyses were performed within studies and at various time points after hospital discharge to examine generalizability of findings.The 6MWD demonstrated good convergent and discriminant validity, with moderate to strong correlations with physical health measures (|r| = 0.36-0.76) and weaker correlations with mental health measures (|r| = 0.03-0.45). Known-groups validity was demonstrated by differences in 6MWD between groups with differing muscle strength and pulmonary function (all P.01). Patients reporting improved function walked farther, supporting responsiveness. 6MWD also predicted multiple outcomes, including future mortality, hospitalization, and health-related quality of life. The 6MWD MID, a small but consistent patient-perceivable effect, was 20 to 30 m. Findings were similar for 6MWD % predicted, with an MID of 3% to 5%.In patients surviving ARF/ARDS, the 6MWD is a valid and responsive measure of functional capacity. The MID will facilitate planning and interpretation of future group comparison studies in this population.

Background A paucity of studies has examined the effect of exercise training after left ventricular assist device (LVAD) implantation. Previous research has demonstrated that insertion of the LVAD alone improves exercise capacity and quality of life (QOL). This study investigated whether supervised exercise training results in a further improvement. Methods This prospective, randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis investigated the effect of exercise training on exercise capacity and QOL in 14 patients who underwent LVAD insertion as a bridge to heart transplantation. Exercise training consisted of 8 weeks of gym-based aerobic and strengthening exercises 3 times a week, with a progressive mobilization program, compared with the control group that completed mobilization alone. Exercise capacity was measured before and after the intervention using maximal cardiopulmonary exercise testing and 6-minute walk distance (6MWD). QOL was measured using the Short Form 36-item assessment. Results No adverse events were reported. There was a trend toward greater improvement in peak oxygen consumption (V o 2 ), 6MWD, and QOL in the exercise group ( n = 7) compared with the control group ( n = 7); however, no significant between-group difference was detected for improvements in peak V o 2 [mean difference (exercise – control)] of 2.96 ml/kg/min (95% confidence interval, −1.04 to 6.97), 6MWD at 54 meters (−51 to 159 meters), and QOL scores over time ( p > 0.05). Conclusion Exercise training is feasible and safe in patients with a LVAD. Trends toward greater improvement in exercise capacity and QOL after exercise training warrant further investigation in a larger trial.

Summary Background and aims Inhalation of hypertonic saline (HTS) has short term positive effects on airways clearance in non-cystic fibrosis (CF) bronchiectasis, however its long term effects are unknown. The aim of this study was to determine the effect of HTS 6% on exacerbations, quality of life (QOL) and respiratory function over 12 months in non-CF bronchiectasis. Methods Forty patients were randomised to inhale isotonic saline (IS) 0.9% or HTS 6% daily for 12 months. Participants recorded their symptoms in a daily diary. Quality of life and respiratory function were measured after three, six and 12 months. Number of exacerbations and changes in sputum colonisation were recorded at 12 months. Participants, assessors and clinicians were blinded to group allocation. Results The exacerbation rate at 12 months was similar in the two groups and similar clinically significant improvements in QOL were seen in both groups. The FEV 1 increased in both groups after six months (mean 90 ml, 95% confidence interval 11–169 ml) with no difference between groups ( p = 0.394). The FEF 25–75% significantly improved at all time points (mean increase at 12 months 187 ml, 69–304 ml) with no difference between groups ( p = 0.705). There was a reduction in sputum colonisation in both groups ( p = 0.046). Conclusions Inhalation of HTS or IS has similar effects on exacerbations, QOL, sputum colonisation and respiratory function over 12 months in non-CF bronchiectasis. The trial was registered with both Clinical Trials.gov – NCT00484263 and Australian New Zealand Clinical Trials Registry – ACTRN12607000367448.

Summary Background Pulmonary rehabilitation improves functional capacity and symptoms in the interstitial lung diseases (ILDs), however there is marked variation in outcomes between individuals. The aim of this study was to establish the impact of the aetiology and severity of ILD on response to pulmonary rehabilitation. Methods Forty-four subjects with ILD, including 25 with idiopathic pulmonary fibrosis (IPF), underwent eight weeks of pulmonary rehabilitation. Relationships between disease aetiology, markers of disease severity and response to pulmonary rehabilitation were assessed after eight weeks and six months, regardless of program completion. Results In IPF, greater improvements in 6-minute walk distance (6MWD) immediately following pulmonary rehabilitation were associated with larger forced vital capacity ( r = 0.49, p = 0.01), less exercise-induced oxyhaemoglobin desaturation ( r S = 0.43, p = 0.04) and lower right ventricular systolic pressure ( r = −0.47, p = 0.1). In participants with other ILDs there was no relationship between change in 6MWD and baseline variables. Less exercise-induced oxyhaemoglobin desaturation at baseline independently predicted a larger improvement in 6MWD at six month follow-up. Fewer participants with IPF had clinically important reductions in dyspnoea at six months compared to those with other ILDs (25% vs 56%, p = 0.04). More severe dyspnoea at baseline and diagnosis other than IPF predicted greater improvement in dyspnoea at six months. Conclusions Patients with IPF attain greater and more sustained benefits from pulmonary rehabilitation when disease is mild, whereas those with other ILDs achieve benefits regardless of disease severity. Early referral to pulmonary rehabilitation should be considered in IPF.

Summary Background: A short stay elective centre was opened in 2007 at The Alfred in Melbourne, Australia. The objective was to safely discharge patients home on the third post-operative day. This prospective observational study reports the outcomes for hip and knee replacement patients during the first year of operation. Methods: Forty-seven patients (28 women and 19 men; mean age 65years) were eligible for the study. Data was collected at preadmission, discharge and 6months. Results: Thirty-four of 47 patients (72.3%) achieved discharge home within 3days. Mean length of stay for the whole group was 4.55days (95% CI3.78–5.33days). Patients who had medical complications were significantly more likely to stay longer than 3days ( p p =0.09). Six month re-admission rates were 6% for those with a 3day discharge and 15% for others. Conclusions: Preliminary findings suggest that a 3-day length of stay is possible for a defined group of patients, and can be achieved without increase in complication or re-admission rates. Failure to achieve Day 3 discharge is primarily related to medical complications.

Question What prevents people with chronic obstructive pulmonary disease (COPD) from attending and completing pulmonary rehabilitation programs? Design Qualitative design using semi-structured interviews. Participants 19 adults with COPD who had declined to participate and 18 adults with COPD who had not completed a pulmonary rehabilitation program at a metropolitan teaching hospital. Results A lack of perceived benefit from pulmonary rehabilitation was a significant theme for those who chose not to participate in pulmonary rehabilitation. Participants expressed perceptions that exercise was not a worthwhile treatment, or that they were already doing enough exercise at home. Difficulty getting to the program related to poor mobility, lack of transport, and cost of travel was a significant theme, expressed both by those who chose not to participate and those who did not complete. Another major theme associated with both uptake and completion involved being unwell, with participants indicating that the burden of COPD and other comorbidities impacted on attendance. Minor themes involved competing demands on time, older age, fatigue, program timing, and lack of social support. Conclusion Many people with COPD who elect not to take up a referral to pulmonary rehabilitation perceive that they would not experience any health benefits from attendance. Difficulties with travel to the program and being unwell are barriers to both uptake and completion. Improving attendance at pulmonary rehabilitation requires consideration of how information regarding the proven benefits of pulmonary rehabilitation can be conveyed to eligible patients, along with flexible program models that facilitate access and accommodate co-morbid disease.

Objective To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx). Design Randomized controlled trial. Setting Physiotherapy gym. Participants Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx. Interventions All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment. Main Outcome Measures Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors. Results After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P P =.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P =.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported. Conclusions UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.

SummaryThe aim of this study was to determine the minimal important difference for the six-minute walk distance in people with diffuse parenchymal lung disease.MethodsForty-eight subjects (24 idiopathic pulmonary fibrosis) undertook the six-minute walk test before and after an 8-week exercise program. The minimal important difference was calculated using a distribution-based and an anchor-based method. A global rating of change scale was used as the external criterion to judge patients as clinically unchanged or changed.ResultsThe mean change in six-minute walk distance in improved subjects was 50.0m, compared to 4.0m in unchanged subjects and a reduction of 64.3m in those classified as worse (p

and study objectives: Patients with end-stage cystic fibrosis (CF) develop respiratory failure and hypercapnia. In contrast to COPD patients, altered electrolyte transport and malnutrition in CF patients may predispose them to metabolic alkalosis and, therefore, may contribute to hypercapnia. The aim of this study was to determine the prevalence of metabolic alkalosis in adults with hypercapnic respiratory failure in the setting of acute exacerbations of CF compared with COPD.Levels of arterial blood gases, plasma electrolytes, and serum albumin from 14 consecutive hypercapnic CF patients who had been admitted to the hospital with a respiratory exacerbation were compared with 49 consecutive hypercapnic patients with exacerbations of COPD. Hypercapnia was defined as a PaCO(2) ofor = 45 mm Hg.Despite similar PaCO(2) values, patients in the CF group were significantly more alkalotic than were those in the COPD group (mean [+/- SD] pH, 7.43 +/- 0.03 vs 7.37 +/- 0.05, respectively; p0.01). A mixed respiratory acidosis and metabolic alkalosis was evident in 71% of CF patients and 22% of COPD patients (p0.01). The mean concentrations of plasma chloride (95.1 +/- 4.9 vs 99.8 +/- 5.2 mmol/L, respectively; p0.01) and sodium (136.5 +/- 2.8 vs 140.4 +/- 4.5 mmol/L, respectively; p0.01) were significantly lower in the CF group, and the levels of serum albumin were significantly reduced (27.4 +/- 5.8 vs 33.7 +/- 4.8 mmol/L, respectively; p0.01).Metabolic alkalosis contributes to hypercapnic respiratory failure in adults with acute exacerbations of CF. This acid-base disturbance occurs in conjunction with reduced total body salt levels and hypoalbuminemia.

Objective To examine the effect of pulmonary rehabilitation (PR) (exercise and education) or exercise training (ET) on exercise capacity, health-related quality of life (HRQOL), symptoms, frequency of exacerbations, and mortality compared with no treatment in adults with bronchiectasis. Data Sources Computer-based databases were searched from their inception to February 2016. Study Selection Randomized controlled trials of PR or ET versus no treatment in adults with bronchiectasis were included. Data Extraction Two reviewers independently extracted data and assessed methodologic quality using the Cochrane risk-of-bias tool. Data Synthesis Four trials with 164 participants were included, with variable study quality. Supervised outpatient PR or ET of 8 weeks improved incremental shuttle walk distance (weighted mean difference [WMD]=67m; 95% confidence interval [CI], 52–82m) and disease-specific HRQOL (WMD=−4.65; 95% CI, −6.7 to −2.6 units) immediately after intervention, but these benefits were not sustained at 6 months. There was no effect on cough-related quality of life (WMD=1.3; 95% CI, −0.9 to 3.4 units) or psychological symptoms. PR commenced during an acute exacerbation and continued beyond discharge had no effect on exercise capacity or HRQOL. The frequency of exacerbations over 12 months was reduced with outpatient ET (median, 2 vs 1; P =.013), but PR initiated during an exacerbation had no impact on exacerbation frequency or mortality. Conclusions Short-term improvements in exercise capacity and HRQOL were achieved with supervised PR and ET programs, but sustaining these benefits is challenging in people with bronchiectasis. The frequency of exacerbations over 12 months was reduced with ET only.

Objective To investigate the effects of a supervised longer- (14wk) versus shorter-duration (7wk) rehabilitation program after lung transplantation (LTX). Design Randomized controlled trial. Setting Outpatient rehabilitation gym setting. Participants Post-LTX patients aged ≥18 years (N=66; 33 women; mean age, 51±13y) who had undergone either single LTX or bilateral LTX. Intervention Outpatient rehabilitation program consisting of thrice-weekly sessions with cardiovascular training on bike ergometer and treadmill plus upper and lower limb strength training. Main Outcome Measures Measures were taken at baseline, 7 weeks, 14 weeks, and 6 months by assessors who were blinded to group allocation. Functional exercise capacity was measured by the 6-minute walk test (6MWT). Strength of quadriceps and hamstrings was measured on an isokinetic dynamometer and recorded as average peak torque of 6 repetitions for both muscles. Quality of life (QOL) was assessed with the Medical Outcomes Study 36-Item Short-Form Health Survey. Results Of the participants, 86% had bilateral LTX and 41% had primary diagnosis of chronic obstructive pulmonary disease. The 6MWT increased in both groups with no significant difference between groups at any time point (mean 6mo 6MWD: short, 590±85m vs long, 568±127m; P =0.5). Similarly, at 6 months, there was no difference between groups in quadriceps average peak torque (mean, 115±38Nm vs 114±40Nm, respectively; P =.59), hamstring average peak torque (57±18Nm vs 52±19Nm, respectively; P =.36), or mental or physical health domains of quality of life. Conclusions Shorter duration (7wk) of rehabilitation achieves comparable outcomes with 14 weeks of supervised rehabilitation for functional exercise capacity, lower limb strength, and quality of life at 6 months after LTX.

s S73 self-care characteristics were significant. Identified optimal cut-off values may inform discharge planning and care coordination with extended care facilities. Funded by NIH R01NR010711 (DeVito Dabbs).

s S237 Therapy (BTT) may include either medical or social criteria. We sought to find the rate at which patients who were originally implanted as DT candidates changed their classification to BTT. Methods: We reviewed charts of patients who received LVADS at our center as Destination Therapy between February, 2012 and September, 2014. There was a cohort of 56 patients during this timeframe. Patients who were implanted at other centers were not included in this review. Results: Of the fifty-six DT LVAD patients, six of twenty-two with elevated Body Mass Index eventually were listed for heart transplant (conversion rate 27%); five of thirteen patients who had active/recent smoking or other tobacco use were eventually listed (38%); two out of four patients with uncontrolled diabetes mellitus (50%) eventually met transplant criteria and were listed; two of three patients initially not candidates due to active or recent malignancy were cleared for listing; one of four patients with active or recent drug use (25%) later were listed; one of two patients within insufficient support established support after LVAD and were listed for transplant (50%); one patient who did not originally have sufficient insurance coverage did acquire it and was listed for transplant. Those DT patients who were implanted due to age, pulmonary hypertension or other end-organ dysfunction have not been listed for transplant. One patient transferred care after LVAD placement and was lost to followup. The average time from LVAD implant to listing was 150 days. Two of the patients who were listed after LVAD implant are currently inactive due to elevated BMI. Conclusion: For those with controllable factors such as elevated BMI, smoking, or diabetes control, there is an assumption that the patients can quickly modify these factors to enable transplant listing. This review showed that a large percentage of these patients do not. It also showed that some patients temporarily modify behaviors in order to be listed for transplant, but then later again become ineligible.

s S73 self-care characteristics were significant. Identified optimal cut-off values may inform discharge planning and care coordination with extended care facilities. Funded by NIH R01NR010711 (DeVito Dabbs).

Background: Postural changes have been reported in patients with CF as they age. Aims: To measure musculoskeletal and postural function in adults with CF; to identify problems related to disease progression and to further develop a clinically appropriate musculoskeletal assessment screening tool. Method: A physiotherapy screening tool was developed to assess musculoskeletal function in the inpatient and outpatient settings when patients were at baseline function. Spinal curves, head, shoulder and scapulae positions, thoracic extension & shoulder flexion, thoracic lateral flexion and rotation, hamstring, calf and quads muscle length were assessed. Results: 94 patients were screened aged 18 to 50 years with 11% with normal lung function; 31% with mild; 32% with moderate and 26% with severe lung disease. The following postural changes were found in this sample: cervical changes 33%; thoracic kyphosis 42%; increased lumbar lordosis 35%; anterior shoulder protraction 51%; elevated shoulders 34%; abducted or winged scapulae 49%; decreased thoracic lateral flexion 31%; restricted thoracic rotation 31%; tight hamstrings 52%; tight calf muscles 26%. Quadriceps length was normal in all subjects. Thoracic kyphosis, scapulae abduction/winging and anterior shoulder protraction appeared to be related to disease severity. Conclusions: The results of this sample of postural screening highlights the importance of regular review of musculoskeletal function in adults with CF in order to prevent problems developing and to manage problems as they are diagnosed. The screening tool has been further developed. Musculoskeletal screening should be considered as part of the annual review in CF.