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Unlabelled: BACKGROUND, OBJECTIVES, AND MEASUREMENTS: Patients with chronic airway obstruction (CAO) frequently experience dyspnea and fatigue during activities performed by accessory muscles of ventilation, which competitively participate in arm elevation. This systematic review of randomized controlled trials (RCTs) concerning patients with CAO addresses the effects of upper-extremity exercise training (UEET), added to lower-extremity training or comprehensive pulmonary rehabilitation, on the following patient-centered outcomes: exercise capacity, symptoms, ability to perform daily activities, and health-related quality of life., Methods: Studies were retrieved using comprehensive database and hand-search strategies. Two independent reviewers determined study eligibility based on inclusion criteria. A detailed description of treatments was mandatory. Reviewers rated study quality and extracted information on study methods, design, intervention, and results., Results: Forty publications were evaluated. Four RCTs met the inclusion criteria but had serious methodological limitations, which introduce possible biases that reduce their internal validity. The outcomes measured were heterogeneous, and the results were inconsistent regarding maximal exercise capacity, dyspnea, and health-related quality of life. No effect of UEET was demonstrated for measures of arm fatigue., Limitations and Conclusions: The limited methodological quality of the studies retrieved prevented us from performing a meta-analysis, the results of which could be misleading. This systematic review shows that there is limited evidence examining UEET and that the evidence available is of poor quality. Therefore, a recommendation for the inclusion or exclusion of UEET in pulmonary rehabilitation programs for individuals with CAO is not possible. Further research is needed to definitively ascertain the effects of this training modality on patient-centered outcomes.

Background: A cost analysis of nocturnal non-invasive ventilation (NNV) in stable chronic obstructive pulmonary disease (COPD) patients would be helpful in decision making, when the balance between the increased demand and the availability of resources should be checked., Objectives: Based on data from the Italian trial in stable hypercapnic COPD patients, this study compares the cost of care associated with the use of NNV when added to the usual long-term oxygen therapy (LTOT) with the cost of care of LTOT regimen alone., Methods: Cost was calculated in 77 of 90 patients included into that trial. Analysis included drug therapy, hospitalisations due to acute exacerbation, oxygen and ventilator equipment. An estimation of charges was made according to the national sources of cost for drugs and hospital admissions and the actualised reimbursement for the home care provided to both oxygen and ventilator users. The cost/day comparison was made between the individual patients in the 2 groups (NNV + LTOT, n = 35; LTOT, n = 42)., Results: The mean cost of drugs and oxygen was similar in both groups, whereas the cost of hospitalisation tended to be lower in NNV + LTOT compared to LTOT alone (8.25 +/-10.29 vs. 12.50 +/- 20.28 EUR/patient/day, p < 0.05). Inclusion of the ventilator equipment increased the total cost to 23.73 EUR/day in the NNV + LTOT compared to 21.42 EUR/day in the LTOT group (not significant)., Conclusions: The present report suggests that long-term management with addition of non-invasive ventilation does not increase costs compared with the usual LTOT regimen: the hospital-related costs were reduced when using the ventilator in these hypercapnic COPD patients., ((c) 2008 S. Karger AG, Basel.)

Disabled patients with chronic respiratory disease and peripheral skeletal muscle disorders have limitations in their exercise capacity, which may be improved after specific training in a pulmonary rehabilitation (PR) program. Individual assessment of exercise capacity by clinically available exercise tests represents an important patient-centered outcome that should be embedded in the rehabilitation process. These measurements include laboratory (treadmill and/or cycle ergometer) and field (walking) tests. The cardiopulmonary exercise test, both performed with incremental (incremental-load test) or predetermined (constant-load or endurance test) loading, is an excellent means to describe the profile of an individual's maximal exercise capacity and to record its change after PR. Among the variety of field-based tests, 6-min walking and shuttle walking are 2 simple tests widely used during PR. These tests are inexpensive and provide information on an individual's functional abilities: the 6-min walking test has been shown to provide level of disability and functional status, whereas the shuttle walking test has been shown to be more suitable to detect change of physical performance following PR. Overall, several available physiologically targeted tests are useful to measure the patient's tolerance to exercise, and many are even sensitive to change once intervention has taken place. In particular, endurance modality tests seem to provide better measurement of changes after PR than incremental exercise tests., (2009 S. Karger AG, Basel.)

Objective: To assess the effectiveness of domiciliary physical fitness programmes in obese individuals., Design: Nine-month randomized controlled trial., Setting: Home-based intervention with outpatient visits., Subjects: Morbidly obese subjects (body mass index (BMI) > or = 30) aged 25-65 years suitable for physical activities at home., Intervention: At the end of a preliminary one-month in-hospital rehabilitation programme (baseline), 52 patients were randomly assigned either to a structured educational programme (intervention group) of daily incremental physical activity at home (walking and skeletal muscle resistance training, with booklets and written instructions) or to a programme of general advice (control group) regarding exercise and long-term fitness., Main Measures: Both groups were evaluated at baseline and every three months for: (1) time, metabolic equivalents (METs), and heart rate reserve (HRR) during a standardized 2-km walking test (2kmWT); (2) anthropometric measures (body weight, BMI, abdominal and neck circumference); (3) the Polar Fitness Test index (PFTI), and (4) time to exhaustion while sustaining consecutive isoload extensions in the dominant leg (isoload LE). Time during 2kmWT was the study primary outcome., Results: Body weight, BMI and abdominal circumference improved significantly (P < 0.05) over time in the intervention group. The cardiopulmonary fitness variables changed significantly (P < 0.05) over time in both study groups. However, all variables improved in the intervention patients, while some worsened or remained stable in the controls. Thus, the mean group difference in changes was significant (P < 0.05) for 2kmWT time (-77.4 seconds), HRR (11.7%), and PFTI (5.4 points)., Conclusion: This structured domiciliary fitness programme is feasible and provides sustained anthropometric and physiological benefits in some morbidly obese individuals.

Aim: To analyse the diagnosis-related characteristics and the costs of treating patients with difficult/prolonged weaning from mechanical ventilation we have undertaken a retrospective observational study., Methods: The study has considered all the patients admitted to our weaning unit of a regional Rehabilitation department during 3 consecutive periods since the opening date. Characteristics of the admitted patients and the DRG-related cares delivered have been recorded. A cost analysis has been obtained over time., Results: The number of beds allocated to this unit (from 4 in the 1st period to 6 in the 2nd and 3rd periods) and the number of patients cared for (from 32 to 43 and to 65, respectively) increased over time. In particular, the COPD to non-COPD patient ratio (from 2.2 to 1.3 and to 1.0) and the DRG/patient weight (from 3.0 +/- 0.3 to 3.1 +/- 0.2 and to 3.3 +/- 0.2 point) changed significantly (p < 0.05). The daily reimbursement per patient from the public health care system only slightly increased, whereas the operating margin (reimbursement less costs) per patient significantly improved (from -304, to +17 and +55 Euro/pt/day, respectively, p < 0.05) due to a gradual restriction in the variable costs. Length of stay, mortality rate and weaning rate did not change over time., Conclusion: The weaning centre is a hospital area where economic burdens should be carefully evaluated. Given the actual reimbursement received on a national level for these patients, variable costs might be better spread, thus optimising the burdens without losing out on clinical outcomes.

It is known that respiratory muscles undergo adaptation in response to overload stimuli during exercise training in stable COPD patients, thus resulting in significant increase of respiratory muscle function as well as the individual's improvements. The present article reviews the most updated evidence with regard to the use of respiratory muscle training (RMT) methods in COPD patients. Basically, three types of RMT (resistive training, pressure threshold loading, and normocapnic hyperpnea) have been reported. Frequency, duration, and intensity of exercise must be carefully considered for a training effect. In contrast with the plentitude of existing data inherent to inspiratory muscle training (IMT), literature is still lacking in showing clinical and physiological studies related to expiratory muscle training (EMT). In particular, while it seems that IMT is slightly superior to EMT in providing additional benefits other than respiratory muscle function such as a reduction in dyspnea, both the effects and the safety of EMT is still to be definitively elucidated in patients with COPD.

Objective: To investigate whether the addition of intrapulmonary percussive ventilation to the usual chest physiotherapy improves gas exchange and lung mechanics in tracheostomized patients., Design and Setting: Randomized multicenter trial in two weaning centers in northern Italy., Patients and Participants: 46 tracheostomized patients (age 70 +/- 7 years, 28 men, arterial blood pH 7.436 +/- 0.06, PaO(2)/FIO(2) 238 +/- 46) weaned from mechanical ventilation., Interventions: Patients were assigned to two treatment groups performing chest physiotherapy (control), or percussive ventilation (IMP2 Breas, Sweden) 10 min twice/day in addition to chest physiotherapy (intervention)., Measurements and Results: Arterial blood gases, PaO(2)/FIO(2) ratio, and maximal expiratory pressure were assessed every 5th day for 15 day. Treatment complications that showed up in 1 month of follow-up were recorded. At 15 days the intervention group had a significantly better PaO(2)/FIO(2) ratio and higher maximal expiratory pressure; after follow-up this group also had a lower incidence of pneumonia., Conclusions: The addition of percussive ventilation to the usual chest physiotherapy regimen in tracheostomized patients improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia.

Background: The optimal frequency of delivering a pulmonary rehabilitation program (PR) is not yet a well established issue. It is still unclear whether repeated PR at established intervals will result in effective maintenance or further improvement in the patient's health status., Objectives: To investigate whether more frequently repeated PR in patients with COPD (1) leads to similar short and long-term physiological gains, and (2) decreases the burden due to hospitalization., Methods: Thirty-five disabled COPD patients (FEV(1) below 50% predicted, MRC score 3) in a stable state were studied in a randomized controlled trial. After completing an initial inpatient PR program, they were randomly assigned to either group 1 (performing a second and a third PR after 6 and 12 months) or group 2 (performing only a second PR after 12 months)., Results: Lung functions, exercise capacity (by means of a timed walk test - 6MWT), peak-effort dyspnea (D) and leg fatigue (F), and health-related quality of life by means of SGRQ were assessed prior to (T1, T3, T5) and after (T2, T4, T6) each PR program: the same measures were taken on an outpatient basis at T3 in group 2. The number of hospital admissions (HA) and days spent in the hospital (DH) were also recorded over the year. The two groups did not differ in any parameter at baseline. 6MWD, D, F and SGRQ improved to the same level (p = 0.05) after each PR in both groups. However, the baseline level of D, F and SGRQ symptoms and impact scores progressively improved over time in group 1 but not in group 2. After 12 months, a larger amount of patients in Group 1, as compared to Group 2, reported H10 DH/year (p < 0.0001)., Conclusions: In severe and disabled COPD, a more frequently repeated inpatient PR may lead to some additional physiological and clinical benefits over 1 year.