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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.

As of 10 March 2021, coronavirus disease 2019 (COVID-19) has resulted in more than 0.1 billion laboratory-confirmed cases and more than 2.5 million deaths globally [1]. Both the economic impact and disease burden of COVID-19 far exceeded those of severe acute respiratory syndrome and Middle East Respiratory Syndrome. The number of patients who have recovered from COVID-19 is increasing [2] despite an escalation of total number of cases worldwide., This editorial reviews the evidence supporting benefits of pulmonary rehabilitation in #COVID19 patients, as well as some unanswered research questions https://bit.ly/39JY3SU

Background Supplemental oxygen is a recommended therapy option in stable hypoxemic COPD patients. Often, supplemental oxygen is provided by continuous flow (CF). However, demand oxygen delivery systems (DODS) that provide an oxygen bolus only during inspiration have gained increasing use as they prolong oxygen cylinder life (beside battery life). However, there is a lack of evidence if different DODS and CF devices are equivalent. Methods Seventy hypoxemic COPD patients (FEV1 32 ± 9% predicted, PaO2 56±7 mmHg) on long-term oxygen therapy were included in this prospective single-blinded, randomized cross-over trial. Following an initial incremental shuttle walk test, patients performed 3 endurance shuttle walk tests (ESWT) at 85% of their maximum walking speed in random order with: (A) CF (ESWT-CF), (B) a DODS based on liquid oxygen (ESWT-DL) and (C) an DODS oxygen concentrator (ESWT-DC). The primary outcome was oxygen saturation (SpO2) at ESWT isotime. Secondary outcomes were total ESWT duration, heart rate (HR) and breathing frequency (BF) at isotime and dyspnea at end-exercise. Results SpO2 at ESWT isotime was not clinically different between devices: 90 ± 4% (CF), 89 ± 5% (DL) and 90 ± 5% (DC). However, 20% of the patients showed a ≥4% lower oxygen desaturation while using a DODS device. Secondary outcomes were similar under the three conditions. Conclusion Oxygen supplementation via DODS (based on liquid oxygen or as a concentrator) yielded comparable physiological effects during standardized walking in stable hypoxemic COPD patients like CF. However, 20% of patients showed a clinically relevant lower oxygen saturation while using a DODS device. Therefore, we suggest individual testing of oxygen saturation of DODS suitability.

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.

ERJ Open Research 7(3), 00454 (2021). doi:10.1183/23120541.00454-2021, Published by European Respiratory Society, [S.l.]

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.

Background: Whole-body vibration training (WBVT) performed on a vibration platform can significantly improve physical performance in COPD patients. It has been suggested that an important mechanism of this improvement is based on an improvement in balance. Aim of this study was to investigate the effects of WBVT versus conventional balance training on exercise performance. Methods: 48 patients with severe COPD (FEV1: 37±7 %pred.) and low exercise performance (6-minute walk distance (6MWD): 55±10 %pred.) were included in a randomized controlled trial during a 3-week inpatient pulmonary rehabilitation. All patients completed a standardized endurance and strength training program. Additionally, patients performed 4 different balance exercises 3x/week for 2x1 minute each either on a vibration platform (Galileo) at varying frequencies (5 - 26 Hz) (WBVT) or on a conventional therapy tool inducing an instable surface (CON). Results: 6MWD improved significantly in both groups (WBVT: 48±46m, p Conclusion: WBVT can improve balance and muscular performance significantly more compared to conventional balance training.

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.

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

The recommendation for pulmonary rehabilitation (PR) in idiopathic pulmonary fibrosis (IPF) is weak with low-quality evidence. Therefore, the aim of this study is to investigate short-term PR effects and their maintenance after a 3-month follow-up. Fifty-four IPF patients were randomized into a group receiving a 3-week comprehensive, inpatient PR (n = 34, FVC: 74 &plusmn, 19% pred.) or usual care (UC) (n = 17, FVC: 72 &plusmn, 20%pred.). Outcomes were measured at baseline (T1), after intervention (T2), and 3 months after T2 (T3). A 6-min walk distance (6MWD) was used as the primary outcome and chronic respiratory disease questionnaire (CRQ) scores as the secondary outcome. Change in 6MWD from T1 to T2 (&Delta, = 61 m, 95% CI (18.5&ndash, 102.4), p = 0.006) but not from T1 to T3 (∆ = 26 m, 95% CI (8.0&ndash, 61.5), p = 0.16) differed significantly between groups. Higher baseline FVC and higher anxiety symptoms were significant predictors of better short-term 6MWD improvements. For the change in CRQ total score, a significant between-group difference from T1 to T2 (∆ = 3.0 pts, 95% CI (0.7&ndash, 5.3), p = 0.01) and from T1 to T3 (∆ = 3.5 pts, 95% CI (1.5&ndash, 5.4), p = 0.001) was found in favour of the PR group. To conclude, in addition to the short-term benefits, inpatient PR is effective at inducing medium-term quality of life improvements in IPF. PR in the early stages of the disease seems to provoke the best benefits.

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 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 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.

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: Admission to the intensive care unit is associated with sustained loss of muscle mass, reduced quality of life and increased mortality. Early rehabilitation measures may counteract this process. New approaches to rehabilitation while the patient remains in bed are whole-body vibration alone and whole-body vibration with a dumbbell. The aims of this study are to determine the safety of whole-body vibration for patients admitted to the intensive care unit, and to compare the effects of these techniques in intensive care unit patients and healthy subjects. Methods: Twelve intensive care unit patients and 12 healthy subjects using whole-body vibration for the first time were examined while lying in bed. First both groups performed whole body vibration over 3 min. In a second step whole body vibration with dumbbell was performed. In order to determine the safety of the training intensity, heart rate, oxygen saturation and blood pressure were measured. The study was approved by the Marburg ethics committee. Results: There were minor reversible and transient increases in diastolic blood pressure (p = 0.005) and heart rate (p = 0.001) in the control group with whole-body vibration with a dumbbell. In intensive care patients receiving wholebody vibration alone, there were increases in diastolic blood pressure (p = 0.011) and heart rate (p < 0.001). Conclusion: This study demonstrates the feasibility of using whole-body vibration and whole-body vibration with a dumbbell for intensive care unit in-bed patients. No clinically significant safety problems were found. Whole-body vibration and whole-body vibration with a dumbbell might therefore be alternative methods for use in early in-bed rehabilitation, not only for hospitalized patients.

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.

Background: Pulmonary rehabilitation (PR) has a positive impact on functional status and quality of life in patients with interstitial lung disease (ILD). Objectives: This study investigated the effects of PR in hypercapnic ILD patients receiving nighttime noninvasive positive pressure ventilation (NPPV). Methods: Consecutive ILD patients referred to a specialized inpatient PR center were included. All participated in a PR program. Those with hypercapnia received NPPV (NPPV group; n = 29); the remaining patients served as comparison group (n = 319). Results: PR improved the 6-min walk distance by 64.4 ± 67.1 m versus baseline (p < 0.0001) in NPPV patients and by 43.2 ± 55.1 m (p < 0.0001) in the comparison group (difference 21.1 m, 95% confidence interval 0.5-41.8; p = 0.045). There was no change in total lung capacity during PR in NPPV recipients or the comparison group. Forced vital capacity significantly increased from baseline in the comparison, but not the NPPV group. NPPV recipients were significantly more likely than the comparison group to have improved dyspnea during PR (p = 0.049). There was no improvement in the 36-item Short Form (SF-36) physical component score in the NPPV group after PR, but there was in the comparison group. PR improved the SF-36 mental component score versus baseline in both groups. Conclusion: An individually tailored PR plus nighttime NPPV appears feasible in hypercapnic ILD patients and significantly improves exercise capacity and quality of life.

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: Pulmonary rehabilitation (PR) in patients awaiting lung transplantation is crucial to ensure a transplant benefit. However, PR in patients with end-stage lung disease treated with noninvasive ventilation (NIV) remains an area of uncertainty. Objectives: The aim of the study was to assess the potential benefit of PR in patients awaiting lung transplantation treated with NIV. Methods: Patients awaiting lung transplantation who underwent comprehensive inpatient PR from 1998 to 2015 were retrospectively analyzed. Success of PR was assessed by comparing admission and discharge. Multivariate regression models were applied to assess the impact of long-term nocturnal NIV on PR success. Results: In total, 1,044 patients were included in the analysis. Thereof, 296 patients (28%) were treated with NIV. PR in patients treated with NIV resulted in a significant increase in 6-min walk distance (6MWD; from 250 ± 117 to 309 ± 116 m; p < 0.0001) and in various items of the Short Form Health Survey (SF)-36 questionnaire. The increase in 6MWD was higher in patients treated with NIV than in patients without NIV (59 ± 63 vs. 48 ± 55 m; p = 0.003). Furthermore, improvements of various lung function variables were higher in patients with NIV. Finally, multivariate generalized regression analysis revealed that NIV therapy was associated with improvement of 6MWD (p = 0.023) while controlling for various baseline characteristics. Conclusions: PR in patients with end-stage lung disease awaiting lung transplantation on nocturnal NIV is feasible and is associated with improvements of exercise capacity and quality of life. Furthermore, despite more advanced lung disease, patients treated with NIV have an increased benefit of PR compared to patients without NIV while awaiting lung transplantation.

Background: Whole-body vibration training (WBVT) has been shown to be a feasible and effective exercise modality in patients directly following lung transplantation (LTx). Aim of this study was to investigate WBVT effects in long-term LTx patients (LTx>1year). Methods: 70 long-term LTx patients (mean duration since LTx: 5.7±4.5 years) participated in this randomized controlled trial. All patients performed a comprehensive pulmonary rehabilitation program of 3-weeks duration including a standardized endurance and strength training program on 5 days per week. On top, patients were randomized into squat training groups 3x/wk performing dynamic squat exercises for 4x2 min either on a side-alternating WBVT platform at high frequencies of 24-26 Hz (WBVT group) or for the same amount on the floor (control group, CON). Results: Patients in both groups reached a significant increase in 6-minute walk distance (WBVT: 44±44m versus CON: 22±34m) which was significantly superior in favor of the WBVT-group (delta: 22m, p=0.027). Also peak cycling work rate increased significantly more in the WBVT group (15±9W versus 10±9W, between-group difference: 5W, p=0.044). Furthermore, LTx patients who performed WBVT showed a significant increase in insulin-like growth factor (+18±49ng/ml) compared to control (-14±51ng/ml, between-group difference: 32ng/ml, p=0.035). Conclusion: Squat training on a vibration platform induced significantly higher improvements in exercise capacity compared to squat training on the floor. Therefore, WBVT seems to be an effective add-on exercise modality also in long-term LTx patients.

Aim: To investigate any relationship between, i)quality of training sessions, ii)improvements in inspiratory muscle function, iii)changes in exercise capacity following well-controlled, high-intensity inspiratory muscle training (IMT), in combination with 3-months of pulmonary rehabilitation. Methods: 169 patients (FEV1 41±16%pred.) with low maximal inspiratory pressure (PImax 51±15%pred) were recruited and randomized into an intervention group (IMT ≥50%PImax) or a control group (IMT ≤10%PImax). Patients participated in daily IMT using a tapered flow resistive loading device. Subgroup analyses were performed by pooling the data of both groups and subsequently dividing it into tertiles based on improvements in PImax after the intervention. Results: Training characteristics (total inspiratory work performed/session, average peak power/session, and IMT intensity) were significantly related to improvements in PImax (Figure 1A-1C). Average training compliance (84±19%) was not associated with change in PImax (p-for-trend=0.129). Larger improvements in PImax were related to larger increases in endurance cycling time (Figure 1D). Conclusion: The quality rather than the number of performed training sessions is strongly associated with improvement in inspiratory muscle strength which in turn relates to improvements in endurance cycling time.

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.

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.

Background There is growing evidence that patients with idiopathic pulmonary fibrosis (IPF) benefit from pulmonary rehabilitation (PR) in terms of exercise capacity and health related quality of life (HRQL). However, the effects of PR on mental aspects of HRQL are still unknown. Objective The aim of our study was to investigate (a) short-term effects of an inpatient PR and (2) sustainability after 3 months in IPF patients. Methods 33 IPF patients were randomized into a PR group (PRG) receiving 3 weeks of inpatient PR (n=18, 68±9y, FVC: 73±17%pred.) and a control group (CG) with usual care (n=15, 65±10y; FVC: 72±21%pred.). Data were collected at the begin of the study [T1], after 6 weeks of usual care (CG) or following PR (PRG)[T2], and at 3 months follow-up (n=24)[T3]. Results From T1 to T2, PRG but not CG improved significantly in HADS scores (anxiety: -1.5±2.7pts., depression: -1.7±2.3pts.), mental score of SF36 questionnaire (6.1±7.9pts.), and CRQ categories of mastery (0.7±1.2pts.), fatigue (0.9±1.5pts.) and emotion (0.9±1.1pts.). CRQ dyspnea score worsened significantly in CG (-0.5±0.7pts.). At T3, PRG improved clinically relevant in all CRQ domains (>0.5pts.) and HADS scores (each >1.0pts.) compared to CG. 6-minute walking distance (6MWD) increased from T1 to T2 in PRG (+60±94m, p Conclusion PR improves anxiety and depression, HRQL and 6MWD in IPF patients. The benefit of PR was sustained after 3 months to a clinical relevant extent regarding HRQL, symptoms of anxiety and depression but not 6MWD.

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.

Aim: With this large, multi-center, randomized controlled trial we aimed to examine the effects of a well-controlled, high-intensity inspiratory muscle training (IMT) program in a combination with a 3-month pulmonary rehabilitation (PR) on functional exercise capacity in COPD patients with inspiratory muscle weakness. Methods: Patients with reduced maximal inspiratory pressure (PImax 2 O or Results: While most baseline characteristic of patients were comparable between groups, the intervention group was more impaired in some pulmonary function characteristics and limb muscle strength. Conclusion: Inclusions will be completed by September 2016 and preliminary results of between group comparisons will be presented then.

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.

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.

Background: The Oxymizer ® device is a special oxygen nasal cannula that provides a higher luminal diameter in combination with an incorporated oxygen reservoir. In the past we found that Oxymizer® was beneficial in hypoxemic COPD patients by increasing oxygenation during exercise. Objective: Aim of this prospective cross-over study was to investigate the effects of an Oxymizer® in comparison to a conventional nasal cannula (CNC) during exercise in hypoxemic patients with pulmonary fibrosis. Methods: 24 patients with pulmonary fibrosis (m:f=:15:9; VC=54±22%pred.; DLCO=20±12mmol/kg/min; PaO 2 =54,90±7,3mmHg; PaCO 2 =40,5±5,5mmHg, peak work rate [PWR]=74±21Watt) were recruited during pulmonary rehabilitation. After an initial incremental cycle test, patients performed 4 constant cycling work rate tests (CWRT) at 70% of their PWR (twice with Oxymizer ® and twice with CNC in random order). Results: Endurance time (581sec.[351-1142] vs. 498sec.[303-796], p=0.009) and oxygen saturation during exercise (90%[87-93] vs. 88%[85-91], p=0.002) were significantly higher by using Oxymizer® compared to CNC. No significant differences were found between Oxymizer® and CNC regarding PaCO2 (37.8mmHg [33.5-41.0] vs. 37.6mmHg [33.3-41.5], p=n.s.) and perceived dyspnea rated on the modified Borg scale (7.5pts. [7-8] vs. 7.5pts. [6-8], p=n.s.). Discussion: This study showed that oxygen delivery via Oxymizer ® is superior to CNC in patients with pulmonary fibrosis with regard to a longer endurance time and although a better oxygenation during exercise. Oxymizer ® seems to be a simple and useful device in hypoxemic patients with pulmonary fibrosis.

Background Careful patient selection is the prerequisite to raise transplant benefit. In lung transplant (LT) candidates, the effect of body mass index (BMI) on postoperative outcome remains controversial, possibly due to the inaccuracy of BMI in discriminating between fat and muscle mass. We therefore hypothesized that assessment of body composition by muscle mass measures is more accurate than by BMI regarding postoperative outcome. Methods All LT recipients from 2011 to 2014 were included and retrospectively analyzed. Lean psoas area (LPA) was assessed from pretransplant computed tomography scans, and associations with postoperative outcomes were investigated. Results Included were 103 consecutive LT recipients with a mean pre-LT BMI of 22.0 ± 4.0 kg/m 2 and a mean LPA of 22.3 ± 8.3 cm 2 . LPA was inversely associated with length of mechanical ventilation ( p = 0.03), requirement of tracheostomy ( p = 0.035), and length of stay in the intensive care unit ( p = 0.02), while controlling for underlying disease, BMI, sex, age, and procedure; in contrast, BMI was not ( p = 0.25, p = 0.54, and p = 0.42, respectively.). Multiple regression analysis revealed that the 6-minute walk distance at the end of pulmonary rehabilitation was significantly associated with LPA ( p = 0.02). Conclusions LPA can easily be assessed in LT candidates as part of pretransplant evaluation and was significantly associated with short-term outcome, whereas BMI was not. Assessment of LPA may provide additional information on body composition beyond BMI. However, the clinical utility has to be further evaluated.

Background In recent years, some studies have shown that whole-body vibration training (WBVT) may be a beneficial training mode in patients with chronic obstructive pulmonary disease (COPD). However, the effects of WBVT in patients after lung transplantation (LTx) have not yet been investigated. Methods Eighty-three LTx patients (56 ± 7 years of age, 51% male, 10 ± 12 weeks post-LTx, forced expiratory volume in 1 second [FEV 1 ] 68 ± 20 percent predicted [% pred], baseline 6-minute walk distance [6MWD] 350 ± 120 meters) admitted to a 4-week inpatient multidisciplinary program of pulmonary rehabilitation (PR) performed supervised endurance and strength training on 5 days per week. In addition, patients were randomly assigned to 1 of 2 supervised intervention groups on 3 days/week: (1) 4 × 2 minutes of bilateral dynamic squat exercises on a side-alternating vibration platform at 24 to 26 Hz (WBVT); and (2) a control group (CON) with the same amount of exercise time on the floor. Results Seventy patients completed the study (WBVT: n = 34; CON: n = 36). Improvement in 6MWD was significantly ( p = 0.029) higher in the WBVT group (83.5 meters [95% CI 65.4 to 101.7]) compared with the CON group (55.2 m [95% CI 37.5 to 72.8]). Also, peak work rate increased significantly ( p = 0.042) more in the WBVT group (16.8 W [95% CI 13.5 to 20.5]) than in the CON group (12.6 W [95% CI 9.0 to 16.1]). No adverse events related to the intervention occurred during the study. Conclusions A complementary WBVT on top of conventional endurance and strength training seems to be a feasible and safe exercise modality in patients after LTx. Furthermore, it may even enhance the benefits of a comprehensive PR on exercise capacity.

Numerous studies have shown the effectiveness of comprehensive pulmonary rehabilitation (PR) programs in chronic obstructive pulmonary disease (COPD). At present, it is uncertain whether PR is also effective in the management of patients with various diseases awaiting lung transplantation (LTx).In a retrospective clinical preanalysis and postanalysis, we investigated the effects of a 5-week inpatient PR in LTx candidates. We compared data of patients with COPD, α-1-antitrypsin deficiency, interstitial lung disease, or cystic fibrosis before and after PR with regard to exercise capacity (6-min walking distance [6MWD]) and health-related quality of life (HRQL; SF36). Multivariate stepwise regression analysis was performed to detect predictors of PR outcome.Eight hundred eleven data sets from consecutive patients referred to our PR center before LTx could be analysed (COPD, 360; α-1-antitrypsin deficiency, 127; interstitial lung disease, 195; cystic fibrosis, 69; other, 60). After PR 6MWD increased by 56 ± 58 m (P0.001), the physical summary component of SF36 (0-100) improved by 1.9 ± 8.5 points (P0.001), the mental summary component of SF36 by 8.7 ± 13.5 points (P0.001). Stepwise regression analysis yielded no relevant predictors of success or nonsuccess of PR with regard to age, sex, disease, body mass index, 6MWD, and HRQL on admission.Short-term comprehensive PR can significantly improve exercise capacity and HRQL in LTx candidates to a clinically relevant extent independent of the underlying lung disease. No relevant predictor influencing PR outcome could be detected. Further research is needed to evaluate the relevance of PR before LTx and its impact on clinical outcome after transplantation.

Background: The Oxymizer® is a special nasal cannula that provides a higher luminal diameter in combination with an incorporated oxygen (O2) reservoir. It is assumed that a higher O2 concentration can be delivered breath by breath in order to increase oxygenation. Objective: We aimed to investigate the effects of the Oxymizer on endurance time in comparison to a conventional nasal cannula (CNC). Methods: Forty-three patients with severe chronic obstructive pulmonary disease (COPD, age 60 ± 9 years, FEV1 37 ± 16% pred.) and indications for LTOT were recruited during pulmonary rehabilitation for this cross-over study. After an initial maximal incremental cycle test, all patients performed 4 cycling endurance time tests at 70% of their peak work rate (twice with the Oxymizer and twice with a CNC, in reverse order). Results: The endurance time was significantly higher when patients cycled while using the Oxymizer in comparison to while using the CNC [858 ± 754 vs. 766 ± 652 s; between-group difference 92 s (95% confidence interval 32-152), p < 0.001]. In addition to a longer cycling duration, O2 saturation at isotime was significantly higher with the Oxymizer (93.5 ± 5.4 vs. 90.4 ± 5.3%; p = 0.027). Furthermore, there was a positive correlation (r = 0.427, p = 0.002) between the O2 flow rate and improvements in the constant work rate test, showing greater improvements in favor of the Oxymizer in patients with a higher demand for O2 (≥4 liters/min). Conclusion: We show that O2 delivery via the Oxymizer is superior to a CNC with regard to endurance capacity and oxygenation during exercise in patients with severe COPD. It seems that patients with a higher demand for O2 (≥4 liters/min), in particular, may benefit more from the use of the Oxymizer.

Background Patients with stable COPD show improvements in exercise capacity and muscular function after the application of whole body vibration. We aimed to evaluate whether this modality added to conventional physiotherapy in exacerbated hospitalised COPD patients would be safe and would improve exercise capacity and quality of life. Methods 49 hospitalised exacerbated COPD patients were randomized (1:1) to undergo physiotherapy alone or physiotherapy with the addition of whole body vibration. The primary endpoint was the between-group difference of the 6-minute walking test (day of discharge – day of admission). Secondary assessments included chair rising test, quality of life, and serum marker analysis. Results Whole body vibration did not cause procedure-related adverse events. Compared to physiotherapy alone, it led to significantly stronger improvements in 6-minute walking test (95.55 ± 76.29 m vs. 6.13 ± 81.65 m; p = 0.007) and St. Georges Respiratory Questionnaire (-6.43 ± 14.25 vs. 5.59 ± 19.15, p = 0.049). Whole body vibration increased the expression of the transcription factor peroxisome proliferator receptor gamma coactivator-1-α and serum levels of irisin, while it decreased serum interleukin-8. Conclusion Whole body vibration during hospitalised exacerbations did not cause procedure-related adverse events and induced clinically significant benefits regarding exercise capacity and health-related quality of life that were associated with increased serum levels of irisin, a marker of muscle activity. Trial registration German Clinical Trials Register DRKS00005979. Registered 17 March 2014.