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Background During exercise, dynamic hyperinflation (DH), measured by a reduction in inspiratory capacity (IC), increases exertional dyspnea and reduces functional capacity in many patients with severe COPD. Although noninvasive ventilation (NIV) during exercise can improve exercise duration, the effect on DH is unclear. Research Questions In people with COPD, resting hyperinflation, and evidence of DH during exercise, does bilevel NIV during exercise reduce DH and increase endurance time compared with exercise with no NIV, and does NIV with an individually titrated expiratory positive airway pressure (T-EPAP) reduce DH and increase exercise endurance time more than does NIV with standardized EPAP (S-EPAP) of 5 cm H2O? Study Design and Methods A randomized crossover trial in which investigators and participants were blinded between NIV interventions was performed. Participants (N = 19; FEV1 of 1.02 ± 0.24 L (39% ± 6% predicted) completed three constant work rate endurance cycle tests in random order—no NIV, NIV with S-EPAP, and NIV with T-EPAP—during exercise. Primary outcomes were isotime IC and exercise endurance time. Outcome measures from each intervention were compared at isotime and at end exercise by using a linear mixed-model analysis. Results Compared with those with no NIV, isotime IC and endurance time were greater with both NIV with S-EPAP (mean difference: 95% CI, 0.19 L [0.10-0.28]; 95% CI, 153 s [24-280], respectively) and T-EPAP (95% CI, 0.22 L [0.13-0.32]; 95% CI, 145 s [28-259], respectively). There was no difference between NIV with S-EPAP and NIV with T-EPAP. Interpretation In people with COPD and DH during exercise, NIV during exercise reduced DH and increased cycle endurance time. An S-EPAP of 5 cm H2O was adequate to obtain these benefits. Trial Registry Australian New Zealand Clinical Trials Registry; No.: ACTRN12613000804785; URL: http://www.anzctr.org.au

PURPOSE Pulmonary rehabilitation (PR) has been shown to be an effective intervention in patients with very severe chronic obstructive pulmonary disease (COPD) awaiting lung transplantation (LTx). The objective of this study was to characterize the prevalence of acute exacerbations (AEs) during PR and their impact on the outcomes of pre-LTx PR. METHODS In this retrospective analysis, 559 patients with COPD awaiting LTx who were referred to a 4-wk inpatient PR program were evaluated. A total of 114 patients (20%) acquired an AE during PR and continued in an adapted fashion. Pulmonary function testing, 6-min walk test (6MWT), and a health-related quality-of-life questionnaire (SF-36) were administered on admission and on discharge of PR. RESULTS Following PR, both groups, patients with and without AE, increased their 6MWT significantly (P < .001) to a clinically relevant amount (58 ± 72 and 52 ± 64 m, respectively). The sum scores of the SF-36 also improved significantly without any between-group differences. No observed changes were different between the two groups. No relevant predictors for PR outcomes could be detected by logistic regression. CONCLUSIONS Our data show that patients with end-stage COPD listed for LTx can achieve clinically relevant improvements in functional exercise capacity and quality of life even if they develop an AE during PR.

Background:\ud Cognitive impairment might interfere with the efficacy of Pulmonary Rehabilitation (PR) in Chronic Obstructive Pulmonary Disease (COPD). We aimed to identify differential responses to PR between cognitively impaired (CI) and cognitively normal (CN) COPD patients by assessing health status and exercise capacity.\ud \ud Methods:\ud Sixty patients (FEV1: 47 ± 15%) were classified as CI or CN according to the Montreal Cognitive Assessment (MoCA ≤25points) and completed a 3-week inpatient PR program. Cognitive function (neuropsychological battery), health-status (36-Item Short Form Survey [SF-36]), and exercise capacity (6-min walk test [6MWT], cycle-endurance test [CET]) were assessed before and after PR. Responsiveness to PR was estimated by mean change (delta-value [Δ]) and the d-Effect Size (ES).\ud \ud Results:\ud Twenty-five COPD patients (42%) presented evidence of mild CI prior to PR. Both, CI and CN patients significantly improved global cognitive function, health status (the majority of SF-36 components), and exercise capacity (6MWT and cycle endurance) in response to PR. Compared to CN, CI patients did not improve SF-36 subdomains of “role emotional” and “bodily pain”, and demonstrated a lower magnitude of improvement in 6MWT ([Δ]: 25 m; ES: 0.21) compared to CN ([Δ]: 46 m; ES: 0.54).\ud \ud Conclusions:\ud PR has favorable effects on global cognitive function, health status, and exercise capacity in both CI and CN COPD patients. There was no concrete evidence to indicate interference of cognitive impairment to PR effectiveness.

RationaleIn patients with COPD, oxygen (O2)-supplementation via a constant flow oxygen system (CFOS) can result in insufficient oxygen saturation (SpO22-system (ATOS) has been shown to be beneficial compared with an untitrated CFOS, however, it is unknown if ATOS is superior to CFOS, titrated during exercise as stipulated by guidelines. The aim was to investigate the effects of ATOS compared with titrated CFOS on walking capacity in people with hypoxaemic COPD.MethodsFifty participants completed this prospective randomised controlled, double-blind, crossover trial. Participants performed two endurance shuttle walk tests (ESWTs) with: (1) exercise titrated CFOS (ESWTCFOS) and (2) ATOS targeting an SpO2of 92% (ESWTATOS). Primary outcome measure was walking time. Secondary measures were SpO2, transcutaneous-PCO2(TcPCO2), respiratory rate (RR), heart rate (HR) at isotime (end of shortest ESWT) with blood gases and dyspnoea at rest and end exercise.ResultsParticipants (median (IQR): age 66 (59, 70) years, FEV128.8 (24.8, 35.1) % predicted, PO254.7 (51.0, 57.7) mm Hg, PCO244.2 (38.2, 47.8) mm Hg) walked significantly longer with ESWTATOSin comparison to ESWTCFOS(median effect (95% CI) +144.5 (54 to 241.5) s, p2was significantly higher (+3 (95% CI 1 to 4) %, p2, RR and HR were comparable. End exercise, PO2(+8.85 (95% CI 6.35 to 11.9) mm Hg) and dyspnoea (−0.5 (95% CI −1.0 to −0.5) points) differed significantly in favour of ATOS (each p2was comparable.ConclusionIn patients with hypoxaemia with severe COPD the use of ATOS leads to significant, clinically relevant improvements in walking endurance time, SpO2, PO2and dyspnoea with no impact on PCO2.Trial registration numberNCT03803384.

Background: Frailty is prevalent in patients awaiting lung transplant (LTx) and is associated with delisting, death while on the waiting list and death after LTx. Decreasing frailty of LTx-candidates could therefore be important to improve pre- and post-LTx-status. Objective: Primary aim was to investigate the effects of a comprehensive PR-program on physical frailty in LTx-candidates. Methods: 32 participants from an inpatient PR-program with a confirmed diagnosis of COPD or interstitial lung disease who were listed or were in the process to be listed for a LTx were consecutively included in this trial. Primary outcome was the change in physical frailty measured by short physical performance battery test (SPPB; score 0-12) performed at PR-admission and discharge. SPPB results can be categorized into frail (SPPB≤7), pre-frail (SPPB=8-9) and not-frail (SPPB≥10). Participants with an SPPB score≤11 were considered for final analyses. Results: 28 participants (60±5years; FEV1 49±26%pred., SPPB-baseline: frail: n=5 [17.9%], pre-frail: n=10 [35.7%]; not-frail: n=13 [46.4%]) were analysed. Baseline SPPB-score (8.8±2.2) significantly (p Conclusion: Our findings show that a comprehensive PR-program can significantly and to a clinically meaningful extent, reduce frailty in LTx-candidates.

Abstract Lymphangioleiomyomatosis (LAM) is a rare and progressive cystic lung disease with limited therapeutic options. We retrospectively analyzed the effects of a comprehensive 4-week inpatient pulmonary rehabilitation (PR) program in 58 patients with advanced LAM (FEV1: 45 ± 34%predicted, 6-min walk distance (6MWD): 338 ± 167 m). Exercise performance (6MWD: + 49 ± 50 m; p p = 0.049 and mental component: + 5.2 ± 12.1 points; p Trial registration Clinical-Trials registration number: NCT04184193; date of registration: December 3, 2019.

Insufficient cerebral blood flow regulation to meet increasing metabolic demand during physical exertion could be associated with cognitive impairment. We compared cerebral oxygen availability during exercise in cognitively impaired (CI) to cognitively normal (CN) COPD patients. Fifty-two patients (FEV1: 51 ± 16%) were classified as CN or CI according to the Montreal Cognitive Assessment. Patients performed cycle-ergometry at 75% peak capacity with continuous measurement of Near-Infrared Spectroscopy frontal-cortex Tissue oxygen Saturation Index (TSI), cerebral haemoglobin indices (oxy/deoxy/total- Hb), transcutaneous carbon-dioxide partial pressure (TcPCO2), and arterial oxygen saturation (SpO2). Twenty-one patients (40%) presented evidences of CI. During exercise, CN and CI patients exhibited mild to moderate SpO2decline (nadir[Δ]≥ −3 ± 2% and −5 ± 3%, respectively) but preserved baseline frontal-cortex TSI levels, whilst presenting small TcPCO2 perturbations and increased cerebral total-Hb (post [Δ]≥ 2.0 ± 3 μM sec−1). CI patients preserve the capacity to adequately maintain cerebral oxygen availability during submaximal exercise. Therefore, rehabilitative exercise training in CI patients with COPD exhibiting mild to moderate exercise-induced SpO2 decline does not appear to lead to reduced cerebral oxygen availability.

Background: Emphysematous destruction of lung parenchyma visible in computed tomography (CT) can be attributed to chronic obstructive pulmonary disease (COPD) or to α1-antitrypsin deficiency (AATD). Objectives: We evaluated if visual semiquantitative phenotyping of CT data helps identifying individuals with AATD in a group of smokers with severe emphysema and airflow limitation. Method: n = 14 patients with AATD and n = 15 with COPD and a minimum of 10 pack years underwent CT, clinical assessment, and full-body plethysmography. The extent and type of emphysema as well as large and small airway changes were rated semiquantitatively for each lobe using a standardized previously published scoring system. Lastly, a final diagnosis for each patient was proposed. Results: AATD had a significantly lower mean emphysema score than COPD, with 8.9 ± 3.4 versus 11.9 ± 3.2 (p < 0.001), respectively. Within both groups, there was significantly more emphysema in the lower lobes (p < 0.05–0.001). The COPD group showed an upper- and middle-lobe predominance of emphysema distribution when compared to the AATD group (p < 0.001). Centrilobular (CLE) and panlobular (PLE) emphysema patterns showed a uniform distribution within both groups, with a CLE predominance in the upper lung and a PLE predominance in the lower lung regions. AATD and COPD both showed significantly more airway changes in lower lobes compared to upper lobes (p = 0.05–0.001), without significant differences between both groups. Conclusion: The typical emphysema distribution patterns seen on CT traditionally assigned to AATD and COPD were of little use in discriminating both entities. Also, airway changes could not contribute to a more precise differentiation. We conclude that a concise standardized phenotyping-driven approach to chest CT in emphysema is not sufficient to identify patients with AATD in a cohort of smokers with advanced emphysema.

The European Respiratory Society (ERS) and American Thoracic Society (ATS) guideline on management of chronic obstructive pulmonary disease (COPD) exacerbations was published in the March 2017 issue of the European Respiratory Journal [1]. Based on evidence syntheses, including meta-analyses, relevant evidence up to September 2015 was summarised and clinical recommendations for treatment of COPD exacerbations were formulated. These guidelines were endorsed by the ERS Executive Committee and approved by the ATS Board of Directors in December 2016.

Background The acute effect of supplemental oxygen during exercise has been shown to differ largely among patients with COPD. It is unknown what factors influence oxygen response. Methods In a randomized, single-blind fashion, 124 patients with COPD underwent one 6-min walk test on supplemental oxygen (6MWTO2) and one 6-min walk test on room air after a practice 6-min walk test. Both gases were delivered via standard nasal prongs (2 L/min). For analyses, patients were stratified on the basis of PaO2 values and compared: (1) 34 patients with resting hypoxemia (HYX); (2) 43 patients with exercise-induced hypoxemia (EIH); and (3) 31 patients with normoxemia (NOX). Results Oxygen supplementation resulted in an increase in the 6-min walk distance in the total cohort (27 ± 42 meters; P Conclusions In contrast to patients with NOX, patients with HYX and EIH generally benefit from supplemental oxygen by increasing exercise capacity. However, less than one-half of patients reached the threshold of clinically relevant improvements. These oxygen responders were characterized by significantly lower exercise capacity levels. Trial Registry ClinicalTrials.gov; No.: NCT00886639; URL: www.clinicaltrials.gov.

Background: Dynamic hyperinflation (DH) can occur during exercise in people with stable COPD and is associated with increased dyspnoea and reduced exercise capacity. While NIV during exercise can improve endurance time, the effect of NIV on IC (a DH marker) is unclear. Objective: To determine the effect of NIV on IC and Tlim in patients with COPD during constant load cycle exercise. Method: 20 patients with severe COPD (FEV1:32±4%pred, RV/TLC:163±29%) and who showed DH during a peak cycle test, in one day, performed three cycle endurance tests at 75% peak work rate to exhaustion, in random order: no NIV, standard NIV (expiratory positive airway pressure (EPAP) 5cmH2O), titrated NIV (individualised EPAP to maximise IC at rest). Metabolic variables, breathing pattern, oxygen saturation (SpO2), transcutaneous carbon dioxide (TcCO2), heart rate and muscular oxygenation (SmO2) (via NIRS) were measured continuously. IC and dyspnoea were measured each minute. Results: Tlim and isotime change in IC (∆IC) were significantly increased (Table 1) with standard and titrated NIV during exercise vs no NIV. In both NIV tests, TcCO2, SpO2 and SmO2 were significantly improved. There were no differences between NIV tests. Conclusion: When using NIV compared to no NIV, stable patients with severe COPD had clinically improved exercise endurance time and significantly reduced DH at isotime

Background: Pulmonary rehabilitation (PR) has been shown to improve cognitive performance in COPD patients even after adjusting for sociodemographic factors. This favourable effect of PR, however, has not been evaluated in COPD lung-transplant (LTx) recipients where immunosuppressant toxicity and/or central nervous system events may be associated with cognitive decline. We investigated the effects of PR on cognitive function in LTx-recipients for COPD. Methods: Twenty-four COPD LTx-recipients (FEV1: 75±22%pred.) were assigned to a 3-week inpatient PR program. A comprehensive neuropsychological battery was used to assess memory, learning skills, attention/ flexibility, visuospatial abilities, psychomotor speed and behavioural activation before and after PR. The magnitude of changes was interpreted by d-Effect Size (ES). Results: In response to PR, LTx-recipients presented small to large improvements (ES range: 0.23 to 1.00, all p ≤0.34) in 50% of the administered cognitive tests. Learning skills and memory ability presented the greatest benefits (Composite scores ES: 0.31 and 0.62; Figure1) that remained similar after stratification by single or bilateral LTx, and sex. Conclusions: PR has a beneficial effect on cognitive function improving memory, learning skills and psychomotor speed in post-transplant phase. Improvements in cognitive function may facilitate recovery in COPD LTx-recipients.

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.

Background Transcutaneous carbon-dioxide partial-pressure (TCPCO2) can be reliably measured and may be of clinical relevance in COPD. Changes in TCPCO2 and exercise-induced hypercapnia (EIH) during six-minute walk test (6MWT) need further investigation. We aimed (1) to define patterns of TCPCO2 trends during 6MWT and (2) to study determinants of CO2-retention and EIH. Methods Sixty-two COPD patients (age: 63 ± 8years, FEV1: 33 ± 10%pred.) were recruited and TCPCO2 was recorded by SenTec digital-monitoring-system during 6MWT. Results Half of patients (50%) exhibited CO2-retention (TCPCO2 [Δ] >4 mmHg); 26% preserved and 24% reduced TCPCO2. Nineteen (31%) patients presented EIH (TCPCO2 >45 mmHg). EIH was associated to higher baseline-PCCO2, worse FEV1, lower inspiratory-pressures, underweight/normal BMI, and pre-walk dyspnea. Stronger determinants of CO2-retention were FEV1 and pre-walk dyspnea, whereas baseline-PCCO2 and pre-walk dyspnea better predict EIH. Conclusions PCO2 response to 6MWT is highly heterogeneous; however, very low FEV1 and elevated baseline-PCCO2 together with pre-walk dyspnea increase the risk for CO2-retention and EIH. Overweight-BMI seems to carry a protective effect against EIH in very severe COPD.

Both loss of muscle mass (ie, sarcopenia) and obesity adversely impact clinically important outcomes in patients with chronic obstructive pulmonary disease (COPD). Currently, there are only a few studies in patients with COPD with sarcopenia and concurrent obesity, termed sarcopenic obesity (SO).To explore the effects of SO on exercise capacity, health status, and systemic inflammation in COPD.Baseline data collected from a total of 2548 participants (2000 patients with COPD, mean age (SD), 63.5 (7.1) years; and 548 controls, 54.8 (9.0) years) from ECLIPSE (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints) study, a multicenter longitudinal observational study, were used.All participants were divided into 4 body composition phenotypes using bioelectrical impedance analysis: (1) normal body composition, (2) obesity, (3) sarcopenia, and (4) SO. In patients with COPD, the 6-minute walking distance, disease-specific health status, and plasma inflammatory markers were compared among the respective body composition groups.Patients with COPD were 3 times more likely to present with SO compared with controls without COPD (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.0-5.4, P.001). In patients with COPD, SO was related to reduced 6-minute walking distance (-28.0 m, 95% CI -45.6 to -10.4), P.01) and to higher systemic inflammatory burden (an elevation of at least 2 inflammatory markers, OR 1.6, 95% CI 1.1-2.5, P = .028) compared with the normal body composition group after adjustments for age, sex, smoking, body mass index, and airflow limitation.Our findings suggest that SO is associated with worse physical performance and higher systemic inflammatory burden compared with other body composition phenotypes in patients with COPD.ClinicalTrials.gov no. NCT00292552.

People with chronic obstructive pulmonary disease (COPD) are affected by somatic as well as psychological symptoms such as anxiety and depression and reduced quality of life. Protective psychological factors exist which enable people to adapt successfully to disease, but research about these factors in COPD is sparse. The aim of this study was to investigate whether sense of coherence (SOC), resilience and social support are potential protective factors and thus associated with reduced levels of symptoms of anxiety and depression and lower perceived disability in people with COPD. An online study was conducted in which n = 531 participants with COPD completed questionnaires assessing protective psychological factors, anxiety and depressive symptoms (Hospital Anxiety and Depression Scale) and disease-specific disability (COPD Disability Index). Regression analyses were conducted. SOC and resilience contributed significantly to reduced levels of symptoms of anxiety and depression and to lower disease-specific disability after controlling for confounding variables and disease severity. Symptoms of anxiety and depression were most strongly predicted by SOC. This study’s results indicated that SOC and resilience could represent helpful individual resources due to their protective potential helping people adjust to COPD. Limitations and implications of this study are discussed.

Background Pulmonary rehabilitation (PR) following lung transplantation (LTx) is considered part of the optimal treatment in chronic obstructive pulmonary disease (COPD) for favourable post-operative outcomes. We investigated the effects of a PR intervention in the post-transplant phase with regard to lung function, exercise responses and cognitive function in COPD LTx recipients. Methods 24 COPD LTx recipients (mean±sd forced expiratory volume in 1 s 75±22% predicted) were assigned to a comprehensive 3-week inpatient PR programme. Changes from PR admission to discharge in lung function variables, 6-min walk test-derived outcomes and cognitive function were assessed and examined for several factors. The magnitude of changes was interpreted by effect size (ES). Results In response to the PR intervention, LTx recipients had improved lung function with regard to diffusing capacity of the lung for carbon monoxide (+4.3%; p=0.012) and static hyperinflation (residual volume/total lung capacity −2.3%; p=0.017), increased exercise capacity (6-min walk test +86 m; p, Pulmonary rehabilitation (PR) demonstrates beneficial effects on functional and cognitive status in COPD LTx recipients. Even a short PR programme of 3 weeks may improve memory ability, learning skills and psychomotor speed in the post-transplant phase. http://bit.ly/2xbRViD

Background More than 60,000 people have health problems due to chemical weapons exposure during the Iran–Iraq war. Respiratory consequences of mustard gas exposure are common and disabling; medical interventions have limited effect. Patients complain of cough, sputum, breathlessness and exercise limitation. We hypothesized that patients with this condition would benefit from pulmonary rehabilitation. Methods We outline the protocol for an assessor-blind, two-armed, parallel-design randomized controlled clinical trial (IRCT2016051127848N1). Sixty patients with respiratory disease due to documented sulfur mustard gas exposure will be randomized to either take part in a 6-week pulmonary rehabilitation programme or receive usual care. Inclusion criteria include forced expiratory volume in 1 second < 80% predicted and Medical Research Council dyspnoea score ≥ 3. The primary endpoint will be the change in cycle endurance time at 70% baseline exercise capacity at 6 weeks. Lung function, physical activity, the strength and endurance of the quadriceps muscle, and quality of life will also be compared. Outcomes will be assessed at 6 weeks and 12 months. Health care utilization will also be assessed. Discussion If the study confirms that rehabilitation is effective for patients with mustard gas lung disease this should prompt provision of the intervention to this patient group. Trial registration Iranian Registry of Clinical Trials, IRCT2016051127848N1. Registered on 24 May 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3180-3) contains supplementary material, which is available to authorized users.

BACKGROUND Long-term oxygen therapy (LTOT) is an established treatment for patients with chronic hypoxemia. Its scientific basis is derived mainly from two trials from the early 1980s that showed a survival advantage for patients with chronic obstructive pulmonary disease (COPD) treated with LTOT. Robust data are not available for other diseases associated with hypoxemia. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed. RESULTS The use of LTOT for 15 to 16 hours per day (or, better, 24 hours per day) is recommended in current guidelines for patients with chronic hypoxemia (PaO2 ≤ 55 mm Hg) because this treatment was found to be associated with a lower mortality rate compared to no LTOT (33% vs. 55%, p

Background: Previous research has calculated the minimal important difference (MID) for the 1-minute sit-to-stand test (1-STST) in patients with COPD to be three repetitions and stated that the 1-STST could be an alternative to the traditional 6-minute walk test (6MWT) to measure exercise performance. Objective: The aim of our study was to prospectively estimate the MID for the 1-STST in response to a 3-week inpatient pulmonary rehabilitation program (PR) in patients with advanced COPD. Methods: 95 patients with COPD (66±8years; FEV1: 37±12%/pred.;1-STST: 19.3±6.9reps) were included in this observational study (NCT02708719). At PR-start and PR-end patients performed a 1-STST on a force platform. Patients also performed two 6MWTs and filled out the chronic respiratory questionnaire (CRQ) for performing an anchor based method. Additionally, difference distribution based methods were used to estimate the MID. Results: An anchor based method could not be used due to the lack of properly associated anchors. Neither the change in 6MWD, nor the changes in the CRQ scores correlated well with the change in 1-STST (all r Conclusion: Results from this study estimated the MID for the 1-STST after PR to be between 2.03 and 3.45 repetitions in this specific population. However, since the change in 1-STST only correlated weakly with the change in 6MWD (r=0.21) it can be assumed that the 1-STST and the 6MWT may measure different qualities of exercise performance.

Background: Demand oxygen delivery systems (DODS) prolong oxygen cylinder life compared to continuous flow (CONT) use, however evidence regarding their effects during use is lacking. Methods: Four databases were searched from 1980 - Jan 2018. Outcomes were oxyhaemoglobin saturation (SpO2%) at rest and during exercise and exercise performance. Risk of bias was evaluated using the Cochrane tool. Data were analyzed via meta-analysis where possible using the generic inverse variance method in Revman 5.3 and narrative synthesis. Results: 10 randomized crossover trials involving 152 COPD patients (FEV1 range 27-42% pred) were included. There was a large degree of uncertainty regarding potential bias related to allocation concealment and blinding for all studies. Data from 3 studies (n=44) showed no significant differences between DODS and CONT in terms of SpO2% at rest or during exercise (Figure). The pooled mean difference in 6-minute walk distance was 3.7m (95%CI -3.0 to 10.3; 2 studies; n=56). Findings were consistent between the meta-analysis and narrative synthesis. Conclusion: DODS and CONT appear to confer similar effects in terms of SpO2% or exercise performance for people with COPD. SpO2% testing may still be indicated for those considering DODS due to intra-individual differences that may arise from different DODS specifications.

Background The benefits of pulmonary rehabilitation (PR) on fatigue-resistant skeletal muscle fibre type I have been found to be smaller in COPD patients with alpha-1 antitrypsin deficiency (AATD) than in those without AATD. Alpha-1 antitrypsin (AAT) augmentation therapy was suggested as a potential factor of influence. Whether this finding mirrors different improvements in 6-min walk distance (6MWD) between both groups remains unknown. Methods 140 patients with AATD-related COPD (phenotype PiZZ, FEV 1 : 31 ± 8%pred.) and 280 COPD patients without AATD (FEV 1 : 31 ± 8%pred.) were matched for baseline 6MWD and included in a retrospective analysis. AATD patients were divided into those “on” (AATD AUG+ ) or “off” (AATD AUG- ) augmentation therapy. 6MWD was assessed pre and post an inpatient 4-week PR program. Plasma level of creatinine was analysed at baseline. Results In AATD and COPD patients with comparable initial 6MWD (331 ± 106 m and 326 ± 101 m, p = n.s.), improvements in 6MWD following PR were similar (+49 ± 49 m and +53 ± 52 m, intra-group change: p AUG+ : +51 ± 55 m, AATD AUG- : +47 ± 40 m, p = n.s.). Only in AATD group, higher baseline creatinine levels and lower 6MWD were positive predictors for the PR-related increase in 6MWD. Conclusions Independently of the genetic variant of AAT, COPD patients achieved the same training-related benefit in 6MWD. Augmentation therapy showed no effect on 6MWD adaptation during PR.

Introduction: Non-invasive ventilation (NIV) can increase exercise endurance time and reduce respiratory muscle work in patients with COPD. Previous studies measuring oxygen consumption (VO2) in exercise with NIV did not correct for the effect of NIV pressure on the oxygen sensor of the metabolic measuring device. We have previously published a VO2 correction factor for use with NIV. Aims: To determine the effect of NIV on VO2 (using VO2 correction) at rest and during constant work rate cycle tests (CWR) among patients with COPD. Methods: People with COPD were recruited. Two CWR were performed in random order with and without NIV. In the NIV arm, whilst participants were seated on the cycle ergometer, 10 min of resting data was collected, the last 5 min with NIV applied. Participants then cycled at 75% of their previous peak work rate until fatigue. Breath-by-breath measures of VO2 were recorded continuously. VO2 at rest with and without NIV was of the last 30 seconds of the first 5 minutes rest and the 5 minutes of rest with NIV. Exercise VO2 was calculated from a 30-second average at isotime of the trial with the shortest exercise duration. Results: Nine participants with COPD (mean ± SD) FEV1 43 ± 8 %pred, RV/TLC ratio 0.51 ± 0.10, PCO2 37 ± 4 completed the study. NIV (inspiratory pressure 16.4 ±1.9 cmH2O, expiratory 5 cmH2O) reduced VO2 at rest by a mean difference (MD) of 1.05 mL/Kg/min (95% CI: 0.38 to 1.73; p Conclusion: NIV reduced VO2 at rest and during exercise in people with normocapnic COPD compared to exercise without NIV, most likely due to a lower oxygen cost of breathing.

Aim: To compare the effect of Pulmonary Rehabilitation (PR) on cognitive function, health status, and exercise outcomes in cognitive normal (CN) and cognitive impaired (CI) patients with COPD. Methods: 60 COPD patients (FEV1: 47±15%; 42%women) referred to 3-week in-patient PR and classified as “CN” or “CI” according to the Montreal Cognitive Assessment (MoCA) cutoff-score (≤25points). Domain-specific cognitive function (MoCA, SMMSE, ACER, TICS), health status (CAT), health-related quality of life (SF-36), the 6MWT and cerebral oxygen availability during cycle endurance test (CET) at 75%WR, were assessed on admission and discharge. Results: 25 patients (42%) presented evidences of CI and low performance in cognitive tests. Compared to CN, CI patients improved visuospatial skills and fluency (effect size; ES: 0.44; 0.48), whilst similar improvements in memory (ES: 0.75), physical and social function (ES: 0.45; 0.47), vitality (ES: 0.56), general and mental health (ES: 0.47; 0.67) were observed, respectively. CI patients did not improve body pain and limitations from emotional problems as assessed by SF-36 but increased 6MWD (from 378 to 403m, p=0.052), CET (from 10.0 to 12.3min, p Conclusion: CI patients gain significant benefits in cognitive function from PR but are not responsive to improvements in body pain and emotional limitations compared to CN. Persistent body pain may have limited the effectiveness of PR and improvements in the 6MWT in CI patients with COPD.

Demand oxygen delivery systems (DODS) enable prolongation of liquid oxygen cylinder life compared to continuous oxygen flow (CONT) use. Evidence is lacking, however, regarding their efficacy. This study investigated the literature comparing liquid-based CONT to DODS in patients with chronic obstructive pulmonary disease (COPD). Four electronic databases were searched from 1980 until January 2018. Primary outcomes were oxyhaemoglobin saturation (SpO2 %) at rest and during exercise and exercise performance. Risk of bias was evaluated using the Cochrane tool. Data were analysed via meta-analysis where possible using the generic inverse variance method in Revman 5.3 or narrative synthesis. Ten crossover trials involving 152 patients with moderate to severe COPD (forced expiratory volume in 1 s (FEV1 ) range: 27-42% predicted) were included. There was a large degree of uncertainty regarding potential bias related to allocation concealment and blinding for all studies. Data from three studies (n = 44) showed no significant differences between DODS and CONT in terms of SpO2 % at rest -0.2% (95% CI: -0.5% to 0.1%) or during exercise -0.3% (95% CI: -2.1% to 1.5%). The pooled mean difference of two studies (n = 56) in 6-min walk distance was 5.7 m (95% CI: -14.4 to 25.8 m). Findings were consistent between the meta-analysis and narrative synthesis. These findings from a limited number of studies suggest oxygen delivery via DODS or CONT confers similar effects in terms of SpO2 % or exercise performance in patients with COPD. However, as DODS devices use various specifications that may yield large intra-individual differences, individual SpO2 % testing appears advisable for those considering DODS use.

Background: Pulmonary rehabilitation (PR) improves oxidative capacity of peripheral muscles in patients with chronic obstructive pulmonary disease (COPD). The exercise-induced oxidative skeletal muscle adaptation in COPD patients with inherited alpha-1 antitrypsin deficiency (A1ATD) has not been studied. Objectives: To compare PR effects on skeletal muscle adaptation in COPD patients with and without A1ATD. Methods: Nine COPD patients with A1ATD (genotype PiZZ, 6 receiving A1AT augmentation therapy), and 10 ‘usual' COPD patients (genotype PiMM) performed an incremental cycling test and underwent musculus vastus lateralis biopsies before and after a 3-week PR program including exercise training. Results: PiZZ and PiMM patients improved peak work rate following PR (+9 ± 11 W, p < 0.05, and +18 ± 9 W, p < 0.001, between-group difference p < 0.05). PiMM patients increased fibre type I (+8.1%), reduced fibre type IIA (-2.1%) and hybrid fibre type IIA/IIX proportion (-3.9%). Following PR, PiMM patients also raised mitochondrial signalling proteins PGC-1α (4.5-fold), and TFAM (6.4-fold). PiZZ patients had no change in fibre type I but showed a shift of type IIA/IIX (-8.8%) towards fibre type IIA distribution (+8.9%). The capillary to fibre ratio increased by 28% (p < 0.05) in PiZZ, whereas no change was observed in PiMM patients. Linear regression analysis revealed that diffusion capacity and A1AT therapy are predictor variables for myofibre type I response to PR (r2 = 0.684, p < 0.01). Conclusions: Following a 3-week PR with comparable training modalities, PiMM but not PiZZ patients increased the oxidative myofibre type I proportion. This skeletal muscle adaptation pattern suggests better improvement of exercise capacity in PiMM than in PiZZ patients with COPD.

Background and objective Patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnic respiratory failure (CHRF) characteristically have exercise intolerance and limitations in performing conventional training. Therefore, the aim of this study was to investigate the acute effects of non-invasive ventilation (NIV) as a supportive tool during exercise in CHRF. Methods Two cycle endurance tests (CET) at 60% of the peak work rate were performed. Patients were randomly assigned to cycle in two conditions: (i) high-pressure NIV (mean inspiratory positive airway pressure: 27 ± 3 cm H2 O) along with oxygen supplementation or (ii) control: oxygen-use only. Transcutaneously measured partial pressure of carbon dioxide (TcPCO2 ), oxygen saturation and heart rate were continuously recorded. Muscle oxygen availability of intercostal and vastus lateralis muscle was measured during exercise by near-infrared spectroscopy (NIRS). Results A total of 20 patients with CHRF (forced expiratory volume in 1 s (FEV1 ): 19 ± 4% predicted, partial pressure of oxygen (PaO2 ): 55 ± 9 mm Hg, partial pressure of carbon dioxide (PaCO2 ): 51 ± 7 mm Hg) were recruited in a randomized cross-over trial. On NIV, COPD patients increased cycle endurance time by 39% compared to oxygen-use only (663 ± 360 vs 477 ± 249 s, P = 0.013). On NIV, TcPCO2 was significantly lower at rest (44.9 ± 6.2 vs 50.7 ± 6.6 mm Hg, P Conclusion NIV with high pressures as add-on to oxygen supplementation increases cycle endurance time, mitigates exertional dyspnoea and limits exercise-induced hypercapnia in COPD patients with CHRF.

Chronic obstructive pulmonary disease (COPD) is a common condition that is becoming increasingly prevalent. It affects 13.2% of the population over age 40 in Germany. In 2020, it will be the third most common cause of morbidity and mortality around the world. It markedly impairs the quality of life of those who suffer from it and presents a major economic challenge to the health-care system.This review is based on pertinent publications retrieved by a selective literature search and on the authors' clinical experience.Pulmonary rehabilitation (PR) for patients with COPD is supported by evidence on the highest level. It is associated with statistically significant (p0.001) and clinically relevant improvement in physical performance (6-minute walk distance: + 44 m; 95% confidence interval [33; 55]), shortness of breath (Chronic Respiratory Disease Questionnaire: +0.79 points [0.56; 1.03]), and the quality of life (Saint George´s Respiratory Questionnaire: -6.9 points [-9.3; -4.5]). The benefits of PR are especially evident after an acute exacerbation of COPD: it significantly lowers the rate of readmission to the hospital (odds ratio 0.22 [0.08; 0.58], p = 0.002) and improves physical performance ability (6-minute walk distance: + 62 m [38; 86] and the quality of life (Saint George´s Respiratory Questionnaire: -7.8 points [-12.1; -3.5]; p0.001 for both).PR is an effective and cost-effective therapeutic intervention that improves physical performance ability, shortness of breath, and the quality of life in patients with COPD, but it has not yet been fully implemented as recommended in the relevant guidelines. There is a need for targeted, problem-oriented referral to a range of PR programs with problem-specific content. The necessary outpatient PR structures still need to be established in Germany.

BackgroundThis study aimed to investigate whether adjunctive inspiratory muscle training (IMT) can enhance the well-established benefits of pulmonary rehabilitation (PR) in patients with COPD.Methods219 patients with COPD (FEV1: 42%±16% predicted) with inspiratory muscle weakness (PImax: 51±15 cm H2O) were randomised into an intervention group (IMT+PR; n=110) or a control group (Sham-IMT+PR; n=109) in this double-blind, multicentre randomised controlled trial between February 2012 and October 2016 (ClinicalTrials.govNCT01397396). Improvement in 6 min walking distance (6MWD) was a priori defined as the primary outcome. Prespecified secondary outcomes included respiratory muscle function and endurance cycling time.FindingsNo significant differences between the intervention group (n=89) and the control group (n=85) in improvements in 6MWD were observed (0.3 m, 95% CI −13 to 14, p=0.967). Patients who completed assessments in the intervention group achieved larger gains in inspiratory muscle strength (effect size: 1.07, pInterpretationImprovements in respiratory muscle function after adjunctive IMT did not translate into additional improvements in 6MWD (primary outcome). Additional gains in endurance time and reductions in symptoms of dyspnoea were observed during an endurance cycling test (secondary outcome)Trial registration numberNCT01397396; Results.

The diagnosis of a life-threatening illness can trigger end-of-life fears. Early studies show that end-of-life fears play an important role in chronic obstructive pulmonary disease (COPD). However, predictors of these fears have not yet been identified. This study investigated the relevance of socio-demographic variables, illness severity, psychological distress and disease-specific anxieties as predictors of end-of-life fears in COPD.A total of 131 COPD patients participated at two time points. Regression and mediation analyses, as well as cross-lagged panel analyses were conducted.The participants completed questionnaires assessing end-of-life fears (Multidimensional Orientation toward Dying and Death Inventory), psychological distress (Hospital Anxiety and Depression Scale), and disease-specific anxieties (COPD Anxiety Questionnaire). Pulmonary function and a 6-min walk test served as measures of illness severity.Illness severity was not predictive of end-of-life fears. However, gender and psychological distress explained incremental variance. When disease-specific anxieties were included as additional predictors, psychological distress was no longer significant. Cross-lagged panel analyses mostly supported these results. Moreover, disease-specific anxieties mediated the association between psychological distress and end-of-life fears.Administration and intensity of end-of-life care (especially concerning end-of-life fears) in COPD patients should be based not only on illness severity, but rather on psychological distress and disease-specific anxieties.

Cognitive impairment is highly prevalent in patients with COPD and demonstrates multiple detrimental effects on many aspects of patient state and therapeutic outcomes. It is attributed to several overlapping pathophysiological factors, with the most common being the low level of oxygen saturation due to respiratory insufficiency. Despite the impact of cognitive impairment on clinical outcomes, the screening for coexisting cognitive deficits which may interfere with the successful progress of respiratory treatment is yet neglected. There is a special consideration that cognitive deficits should be taken into account when developing respiratory therapy plans. Cognitively impaired patients are likely to require more support and have need of an individualised respiratory care plan which can also be beneficial for their cognitive deficits. Pulmonary rehabilitation as a multidisciplinary approach could be prioritised for COPD patients with cognitive impairment. Educational aims To illustrate the common signs of cognitive impairment and define potential associations between lung and cognitive dysfunction. To illustrate the potential influence of cognitive deficits on the optimal progress of respiratory therapy. To illustrate the importance of cognitive evaluation as part of a comprehensive clinical assessment for patients suspected of suffering cognitive impairment., Cognitive impairment in COPD may affect respiratory treatment and should be considered in therapeutic strategy http://ow.ly/aK3s309RiS9

Background: There is only little evidence on the acute effects of non-invasive ventilation (NIV) during exercise in hypercapnic COPD patients. Methods: Fifteen hypercapnic COPD patients (age: 62±7 yrs, FEV1: 18±4 %pred., pCO2: 51±5mmHg) were recruited. Patients underwent a two-day assessment. On the first day an incremental cycling test was performed to determine peak work rate. On the second day patients performed two constant work rate cycling tests (CWRT) at 60% of peak work rate until exhaustion. CWRTs were randomly assigned to 2 conditions; a) with oxygen supplementation (4±2lpm) only, and b) with the same oxygen supplementation plus effective NIV (inspiratory pressure: 25±2 cmH20, expiratory pressure: 6±1 cmH20) including one hour of rest in between. Results: There was a clinically relevant change concerning a longer cycle endurance time with the use of NIV (627±384 sec versus 506±291 sec, p=0.34). Furthermore, NIV limited CO2 retention. At isotime (the shortest test between the two experimental conditions in a given subject) CO2 increased from 50.7±6.8mmHg up to 55.7±6.9mmHg without NIV and from 45.1±5.8mmHg to 49.9±5.8mmHg with NIV (p=0.019). Furthermore, oxygen saturation at isotime tended to be higher with NIV (96.0±4.5% versus 92.5±5.9%, p=0.081). Dyspnea rated on the Borg scale was significantly lower at the end of the CWRT with NIV (3.2±1.9 pts versus 5.3±1.5 pts, p=0.006). Conclusion: NIV during exercise in hypercapnic COPD patients prevented CO2 retention and reduced dyspnea. This might provide the basis for a feasible and safe endurance training program in this specific cohort of patients with very advanced COPD.

Background: Cognitive impairment (CI) is a prevalent extrapulmonary manifestation in COPD. Potential disturbances in cerebral circulation and oxygen delivery due to reduced ventilatory efficiency and ventilatory drive may be associated with higher rates of CI. We assessed cerebral tissue oxygen index (TOI) and cerebral hemodynamics at exertion in COPD patient with and without CI. Method: 52 COPD patients (aged: 68±8yrs; FEV1: 45±14%; 40%women) underwent a comprehensive cognitive assessment. Patients were assigned to “CI” and “non-CI” groups according to Montreal Cognitive Assessment (MoCA) cutoff score ≤25points. Patients performed cycle endurance test (CET) at 75% of peak work rate while transcutaneous carbon-dioxide partial-pressure (TCPCO2), cerebral tissue oxygen index (TOI) and hemoglobin responses were recorded by SenTec and Portalite systems, respectively. Results: 23 patients (44%) presented evidences of CI (MoCA≤25) with also lower scores in other cognitive tests (all p Conclusion: COPD patients have the capacity to autoregulate cerebral cortex blood flow in response to hypercapnia and hypoxemia, at least during exercise, and thus to normalize cerebral tissue oxygenation. These findings suggest that exercise is safe and can be beneficial regarding to cognitive function in COPD.

Background: Cognitive impairment (CI) is a prevalent extrapulmonary manifestation in COPD. We assessed the prevalence and the determinants of CI in COPD. Method: 52 COPD patients (aged: 68±8yrs; FEV 1 : 45±14%; 40%women) underwent a comprehensive cognitive assessment. Patients were assigned to “CI” and “non-CI” groups according to Montreal Cognitive Assessment (MoCA) cutoff score ≤25points. Clinical data including medical history, respiratory function, health/ mood status evaluation by Saint-George respiratory questionnaire (SGRQ) and hospital anxiety-depression scale (HADS) were collected. Patients performed six-minute walk test (6MWT) and cycle endurance test (CET) at 75% of peak work rate. Results: 23 patients (44%) presented evidences of CI (MoCA≤25) with also lower scores in the other cognitive tests (all p 1 %, health and mood status (SGRQ, HADS), and exercise capacity (6MWD: 359 ±85m vs 380 ±116m, p=0.48; CET: 616 ±329sec vs 551 ±370sec, p=0.51) but greater oxygen desaturation during the CET (SpO 2 nadir: 92.3 ±2.9% vs 89.9 ±3.9%, p=0.014). Certain threshold of SpO 2 nadir (≤90%) increased the risk for CI after adjustment for oxygen-use (p=0.026). Conclusion: CI is highly prevalent in patients with COPD and affects several cognitive domains. It is associated with the years of education and the oxygen desaturation during the CET, however, it seems that is not associated with exercise capacity in COPD patients.

Background: Inspiratory muscle dysfunction occurs in patients with chronic obstructive pulmonary disease (COPD) and is associated with dyspnea and decreased exercise capacity. Aim of this study was to investigate additional benefits of adding inspiratory muscle training (IMT) to a general exercise training program during pulmonary rehabilitation (PR) in COPD patients with inspiratory muscle weakness. Methods: 70 COPD patients (FEV1: 39±13%pred., PImax: 51±14 cmH2O) participated in this randomized controlled trial. All patients performed a 3-week comprehensive inpatient PR including standardized endurance and strength training. On top, patients performed supervised IMT on 7 days/wk randomized into an intervention group and a Sham-IMT group (initial IMT pressure: 61±15% of PImax and 13±8% of PImax, respectively) Results: At 3 weeks, PImax improved significantly more in the IMT group (IMT: 18±12cmH2O vs. 6±11cmH2O, p Conclusion: A complementary inspiratory muscle training on top of a general exercise training program in COPD patients with inspiratory muscle weakness significantly improved inspiratory muscle function. However, these benefits did not transfer into further improvements of functional exercise capacity.

Anxiety is frequently observed in persons with chronic obstructive pulmonary disease (COPD). Although anxiety in persons with COPD is multifaceted, it is mostly assessed as a general psychopathological condition. Consequently, the objectives of this study were to revise an existing questionnaire assessing relevant anxieties for use in clinical practice and research, to examine the association between COPD-related fears and disability, and finally to develop norms for COPD-related fears. Disease severity (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, use of long-term oxygen), sociodemographic characteristics, COPD-specific disability (COPD assessment test), and psychopathology (depression, general anxiety, somatoform symptoms, and disease-related fears) were obtained from a sample of 1025 individuals with COPD via the Internet. We used the COPD Anxiety Questionnaire (German: CAF) for the assessment of different fears that have been found to be relevant in COPD: fear of dyspnea, fear of physical activity, fear of progression, fear of social exclusion, and sleep-related worries. Mean COPD-specific disability was high (22.87). After explanatory and confirmatory factor analyses, a revised version of the CAF was constructed. The economical and user-friendly CAF-R showed adequate reliability and expected correlations with convergent and discriminant constructs. Gender-specific norms are provided for use in clinical practice and research. Even after controlling for GOLD stage, sociodemographic variables, and psychopathology, COPD-related fears contributed incrementally to disease-specific disability. The CAF-R is an economical and reliable tool to assess different specific fears in COPD. Results indicate that disease-specific fears have an impact on disability, supporting the assumption that detailed assessment of anxiety in COPD should be included in clinical practice.

Background Several studies have shown that whole-body vibration training (WBVT) improves exercise capacity in patients with severe COPD. The aim of this study was to investigate the determinants of improved exercise capacity following WBVT. Methods Seventy-four COPD patients (FEV1: 34 ± 9%predicted) were recruited during a 3-week inpatient pulmonary rehabilitation (PR) program. Conventional endurance and strength exercises were supplemented with self-paced dynamic squat training sessions (4bouts*2min, 3times/wk). Patients were randomly allocated to either a WBVT-group performing squat training on a side-alternating vibration platform (Galileo) at a high intensity (24–26 Hz) or a control group performing squat training without WBVT. Results Patients in the WBVT group significantly improved postural balance in several domains compared to the control-group (i.e. tandem stance: WBVT +20% (95%CI 14 to 26) vs. control −10% (95%CI 6 to 15), p Conclusions Implementation of WBVT improves postural balance performance and muscle power output. The neuromuscular adaptation related to improved balance performance may be an important mechanism of the improvement in exercise capacity after WBVT especially in COPD patients with impaired balance performance and low exercise capacity.

Background: Pulmonary rehabilitation (PR) following lung transplantation (LTx) has been shown to be effective with regard to exercise capacity and health-related quality of life (HRQL). However, outcome data is limited with respect to LTx as a population. Differences concerning the effects of PR in patients with single LTx (SLTx) or double LTx (DLTx) have not been studied yet. Objectives: The aim was to compare possible differences concerning PR outcomes between SLTx and DLTx. Methods: In a retrospective analysis (period: 1997-2016), data from 722 patients with either chronic obstructive pulmonary disease (COPD; SLTx: n = 129, FEV1 51 ± 17% pred.; DLTx: n = 204, FEV1 74 ± 20% pred.) or interstitial lung disease (ILD; SLTx: n = 135, FVC 58 ± 18% pred.; DLTx: n = 254, FVC 63 ± 18% pred.) after LTx were included. All patients underwent a specialized inpatient PR program. The data of the 6-minute walk distance (6MWD) and HRQL (physical [PCS] and mental [MCS] component summary of the SF- 36 questionnaire) were analyzed. Results: Independently from the procedure and pretransplant diagnosis, patients significantly (p < 0.05) improved the 6MWD without any differences between SLTx and DLTx (COPD: SLTx: +109 ± 68 m, DLTx: +117 ± 82 m; ILD: SLTx: +115 ± 80 m, DLTx: +132 ± 77 m). The PCS (COPD: SLTx: +9 ± 9 points, DLTx: +7 ± 9 points; ILD: SLTx: +6 ± 9 points, DLTx: +9 ± 9 points) and MCS (COPD: SLTx: +8 ± 15 points, DLTx: +7 ± 15 points; ILD: SLTx: +10 ± 13 points, DLTx: +8 ± 12 points) also improved significantly without any group differences. Conclusions: LTx patients with a pretransplant diagnosis of COPD or ILD all benefitted significantly and with clinical relevance with regard to exercise capacity and HRQL from an inpatient PR performed within 1 year postoperatively. PR outcomes were similar regardless of SLTx or DLTx.

Several studies in patients with chronic obstructive pulmonary disease (COPD) have shown that whole-body vibration training (WBVT) has beneficial effects on exercise capacity. However, the acute cardiopulmonary demand during WBVT remains unknown and was therefore investigated in this study. Ten patients with severe COPD (forced expiratory volume in 1 s: 38±8% predicted) were examined on two consecutive days. On day one, symptom-limited cardiopulmonary exercise testing was performed on a cycle ergometer. The next day, six bouts of repeated squat exercises were performed in random order for one, two or three minutes either with or without WBVT while metabolic demands were simultaneously measured. Squat exercises with or without WBVT induced comparable ventilatory efficiency (minute ventilation (VE)/carbon dioxide production (V′CO2): 38.0±4.4 with WBVT versus 37.4±4.1 without, p=0.236). Oxygen uptake after 3 min of squat exercises increased from 339±40 mL·min−1 to 1060±160 mL·min−1 with WBVT and 988±124 mL min−1 without WBV (p=0.093). However, there were no significant differences between squat exercises with and without WBVT in oxygen saturation (90±4% versus 90±4%, p=0.068), heart rate (109±13 bpm versus 110±15 bpm, p=0.513) or dyspnoea (Borg scale 5±2 versus 5±2, p=0.279). Combining squat exercises with WBVT induced a similar cardiopulmonary response in patients with severe COPD compared to squat exercises without WBVT. Bearing in mind the small sample size, WBVT might be a feasible and safe exercise modality even in patients with severe COPD., Whole-body vibration training is a feasible and safe exercise modality even in patients with severe COPD http://ow.ly/FNK5307VSPC

Background: Carbon dioxide pressure (pCO2) can be reliably measured transcutaneously and may be of clinical relevance in COPD. Retention of CO2 and exercise-induced hypercapnia (EIH) has been scarcely studied as disease marker in COPD. The aims of this study were (1) to study pCO2 response during the 6MWT and (2) to compare clinical characteristics amongst patients with and without CO2 retention and those with and without EIH during the 6MWT. Methods: Sixty-two COPD patients (age: 63±8years, FEV1: 33±10%pred) participated in study. Transcutaneous carbon dioxide pressure (tcpCO2) was measured continuously during the 6MWT by the use of SenTec device. Measurements where repeated after 1 week and data from the longest 6MWT were analyzed. Results: Half of the patients (50%) had CO2 retention (ΔtcpCO2 >4mmHg from baseline) while the rest preserved or reduced tcpCO2 levels. Nineteen patients (31%) exhibited EIH (tcpCO2 >45mmHg) during the 6MWT. Physiological characteristics of CO2 retainers were similar with non-retainers but patients with EIH were characterized by higher resting tcpCO2 levels within the normal range, lower inspiratory pressures (Pimax), lower BMI, more severe FEV1 and higher dyspnoea at rest compared to non-EIH. The determinants of pCO2 retention were pre-walk dyspnoea and FEV1 while pre-walk dyspnoea and baseline pCO2 levels were crucial for EIH. Conclusions: The pCO2 response to 6MWT is highly heterogeneous in COPD. CO2 retention is related to more pre-walk dyspnoea and worse FEV1 while EIH is associated with more pre-walk dyspnoea and higher baseline PaCO2 levels. Monitoring of pCO2 changes during 6MWT might help to identify patients who need special attention regarding to EIH.

Background: There are several studies that have shown that whole body vibration training (WBVT) is able to improve exercise capacity in patients with COPD. However, the underlying mechanisms remain unknown. Objective: To evaluate the effect of WBVT on balance and muscle power in patients with severe COPD. Methods: Fifty patients (age: 63±7 ys, FEV 1 : 35±10 %pred.) were recruited during a 3-week inpatient pulmonary rehabilitation program (PR). On top of conventional endurance and strength training patients performed dynamic squat training sessions (4x2min, 3x/wk) randomized into a WBVT-group performing squat training on a vibration platform or a control group (CON) exercising on the floor. To assess balance patients were asked to stand still for 10 sec in different static positions (Romberg stand, tandem stand, 1-leg stand with open and closed eyes). Muscle power tests consisted of 2-leg jumps, 5-repetition sit-to-stand test (STST) as well as the 1-min STST. All tests were performed on a force measurement platform pre and post PR. Results: After PR the WBVT-group could improve balance significantly more in 2 out of 4 domains compared to the CON-group (tandem stand: WBVT +10% vs. CON -14%, p=0.008 and 1-leg stand: WBVT +6% vs. CON -9%). Also some measures of muscle power like jump height (WBVT: +26% vs. CON: +1%, p=0.010) and the 5-STST (WBVT: -5.2±5.1sec vs. CON: -2.4±0.9sec) improved significantly more in the WBVT-group. Conclusion: This is the first study that investigated potential mechanisms of the beneficial effect of WBVT. It was found that neuromuscular adaptations like improvements in balance and muscle power may explain some of these positive effects.

The two-minute walk test (2MWT) is less well validated than the well-known six-minute walk test (6MWT) as a field walking test in patients with chronic obstructive pulmonary disease (COPD). The primary objective of this study was to compare the accuracy of the 2MWT to the 6MWT in detecting exercise-induced oxygen desaturation in patients with severe COPD. Twenty-six patients with COPD (age: 61 ± 10 years, forced expired volume in one second: 37 ± 10%) that were normoxemic at rest performed a 2MWT and a 6MWT under normal ambient conditions on two consecutive days in random order. Oxygen saturation, total walking distance, heart rate, breathing frequency, dyspnea, and leg fatigue were evaluated. Average walking distances were 150 m (95% confidence interval (95% CI): 134–165 m) and 397 m (95% CI: 347–447 m) for the 2MWT and 6MWT, respectively ( r = 0.80, p < 0.0001). The difference in minimum oxygen saturation during the 2MWT (83%, 95% CI: 81–86%) and 6MWT (mean 82%, 95% CI: 80–84%) was not statistically different and the data strongly correlated between the groups ( r = 0.81, p < 0.0001). Other measurements from the 6MWT, including heart rate, breathing rate, and levels of perceived exertion were also comparable in 2MWT. The 2MWT showed comparable validity in detecting exercise-induced oxygen desaturation in patients with severe COPD compared to the 6MWT.

Interval (IT) and continuous training (CT) represent well-established exercise modalities in patients with moderate to severe chronic obstructive pulmonary disease (COPD). However, their effects and feasibility in patients with end-stage COPD remain unclear.Sixty patients (53 ± 6 years, 53% women) being evaluated for lung transplantation where randomly assigned either to IT (n = 30, cycling at 100% peak work rate for 30 seconds alternating with 30 seconds of rest) or CT (n = 30, cycling at 60% of peak work rate) during a 3-week inpatient rehabilitation program. Both exercise protocols yielded an equivalent amount of total work. Patients had a mean forced expiratory volume at 1 second (FEV(1)) of 25% ± 8% of predicted value.Patients in both groups achieved similar clinically relevant improvements in 6-minute walking distance of 35 ± 29 meters for IT and 36 ± 43 meters for CT, with a between-group difference of 0.3 meters (95% confidence interval, -18.2 to 18.8). Changes in lung function parameters were not significant. Perceived intensity of dyspnea was significantly (p0.05) lower in IT (Borg 6.2 ± 1.8) compared with CT (Borg 7.1 ± 1.7). Patients required a median of 5 unintended breaks (interquartile range, 2-28) during IT exercise and 29 (interquartile range, 6-68) during CT (p0.001).IT is associated with a lower intensity of dyspnea during exercise and fewer unintended breaks but achieves similar improvements in exercise capacity compared with CT in pre-lung transplant COPD patients.

Ziel der vorliegenden Studie ist die Analyse von krankheitsbezogenen Angsten im Zusammenhang mit Depressivitat bei COPD-Patienten. Sowohl Angst als auch Depressivitat sind ein haufiges komorbides Phanomen bei COPD. Beides kann einen erheblichen Einfluss auf den Verlauf und das Erleben der Erkrankung haben. Bislang wurden in Studien lediglich allgemeine – nicht aber COPD-assoziierte – Angste erfasst. An der Studie nahmen insgesamt 96 COPD-Patienten (GOLD III/IV) teil. Die MANOVA ergab, dass COPD-Patienten mit auffalligen Depressivitatswerten starkere krankheitsbezogene Angste berichten als Patienten mit unauffalligen Depressivitatswerten. Sie leiden unter groserer Angst vor sozialer Ausgrenzung, Angst vor Dyspnoe, Angst vor korperlicher Aktivitat und Progredienzangst. Es ergaben sich keine Unterschiede zwischen den beiden Vergleichsgruppen in den medizinisch-objektiven Parametern (FEV 1 % des Solls; 6-Minuten-Gehtest). Insgesamt belegt unsere Studie die hohe Relevanz der Erfassung krankheitsspezifischer Angste bei COPD-Patienten im Zusammenhang mit Depressivitat. Die rechtzeitige Identifikation und angemessene Behandlung von COPD-bezogenen Angsten und Depressivitat hat eine grose Bedeutung fur den Krankheitsverlauf.

Zahlreiche Studien zeigen eine hohe Komorbiditat der COPD mit psychischen Beschwerden. Angesichts der realen Bedrohung durch die Erkrankung treten bei den Betroffenen auch krankheitsbezogene Angste (Progredienz, End-of-Life) auf. Diese konnen die Lebensqualitat beeintrachtigen und den Krankheitsverlauf verschlechtern. Es existieren wenige Studien, die krankheitsbezogene Angste bei COPD untersuchen. Ziel der Studie war es, Zusammenhange zwischen krankheitsbezogenen Angsten, psychischer Symptomatik und Lebensqualitat zu erfassen sowie deskriptive Erkenntnisse zu krankheitsbezogenen Angsten und End-of-Life-Care zu berichten. An der Untersuchung nahmen 132 COPD-Patienten teil. Es zeigten sich keine Unterschiede im Ausmas der krankheitsbezogenen Angste zwischen verschiedenen COPD-Stadien. Es ergaben sich signifikante Korrelationen der End-of-Life-Angste zu Progredienzangst, Depressivitat und psychischer Lebensqualitat. Deskriptive Analysen zeigten, dass bezuglich der Kommunikation von End-of-Life-Aspekten erheblicher Verbesserungsbedarf besteht. Unsere Ergebnisse unterstreichen die grose Bedeutung krankheitsbezogener und End-of-Life-Angste bei COPD.

The study aimed to construct a questionnaire for COPD specific anxiety. Anxiety is a prevalent comorbid complication in COPD; however, assessment has focused on anxiety questionnaires in general and not on COPD related fears. Ninety-six patients with COPD (GOLD III/IV) participated in the study. Results of a principal component analysis with Varimax-rotation suggested 5 factors, jointly explaining 64.7% of variance. These factors depict: fear of social isolation, dyspnea related fear, fear of movement, fear of progression of disease, anxiety in relationships, and fear of LTOT. Satisfying internal consistencies (a=0.77-0.89) resulted for all factors. Validity analyses confirmed discriminant and convergent associations, as well as correlations with functional tests. Overall, the COPD-Anxiety-Questionnaire constitutes a reliable and valid measure to assess COPD-related fears. Moreover, it enables the early identification of COPD patients suffering from disease related anxiety.

Noninvasive positive pressure ventilation (NIPPV) has been shown to improve exercise tolerance and health-related quality of life in patients with advanced COPD. This study tested the feasibility of nocturnal NIPPV as an additional tool in a hospital-based pulmonary rehabilitation program. This prospective observational trial included forty COPD patients in GOLD stage IV. NIPPV was successfully introduced and accepted during sleep by all patients. All patients received pressure support ventilation for 7.9+/-0.5h per day with an inspiratory support of 17.5+/-4.4 cmH(2)O, and an expiratory pressure of 4.5+/-0.9 cmH(2)O. The outcome of pulmonary rehabilitation in patients receiving nocturnal NIPPV was compared with the results of forty matched control patients who underwent the same program. Rehabilitation with nocturnal NIPPV resulted in the 6-minute walk test and in the longest non-stop walk distance in improvements of 82 and 89 m, respectively, while patients without nocturnal ventilatory support improved by 50 and 51 m (p0.04 and p0.03 between groups, respectively). Further significant improvements were found for FEV(1), lung hyperinflation, and blood gases in the NIPPV treated, but not in the control subjects. Health-related quality of life, assessed by the SF-36 questionnaire, improved moderately or largely in patients receiving NIPPV in the categories role-physical, vitality, social function, and mental health. Control subjects improved moderately in vitality only. In conclusion, nocturnal NIPPV is feasible and enhances the effects of pulmonary rehabilitation in advanced stage COPD.

The use of non-invasive ventilation (NIV) to improve physical activity in COPD patients has been addressed in several clinical investigations in the past. In general, NIV can be applied directly during exercise, but also intermittently when used for long-term treatment thereby aiming at improving physical activity during spontaneous breathing. There is increasing evidence that NIV enhances exercise capacity in COPD patients with a reduction of exercise-induced dyspnea when applied during exertion. Furthermore, physical training has been shown to produce positive results when training was performed under NIV-aided conditions. However, the results regarding tolerance of NIV, exercise ability and dyspnea are individually different. In most studies where NIV was applied during exercise, patients had no indication for long-term NIV, and patients were ventilated with low inspiratory pressures, which produced varying results. In contrast, the use of higher inspiratory pressures in hypercapnic COPD patients was more effective in enhancing exercise capacity. The intermittent application of NIV also positively affects exercise capacity in COPD patients, although different results were achieved with different ventilator strategies, mainly with a variety of inspiratory pressure levels. Different ventilation modes were used for NIV to aid exercise and for the intermittent approach in addition to different settings: CPAP, pressure support ventilation, proportional assist ventilation and controlled NIV. Therefore, it is still unclear how to define the best technique for NIV to be used in order to enhance exercise capability in COPD patients. Future studies are needed to define which subgroup of patients benefit from NIV in view of its effects on exercise. Further studies should also be aimed at clarifying which mode and which ventilator settings are most beneficial in improving exercise capability in COPD patients.