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Michele Vitacca,1 Alberto Malovini,2 Bruno Balbi,3 Maria Aliani,4 Serena Cirio,5 Antonio Spanevello,6,7 Claudio Fracchia,8 Mauro Maniscalco,9 Giacomo Corica,10 Nicolino Ambrosino,8 Mara Paneroni1 1Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Lumezzane, Brescia, Italy; 2Istituti Clinici Scientifici Maugeri IRCCS, Laboratory of Informatics and Systems Engineering for Clinical Research of the Institute of Pavia, Pavia, Italy; 3Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Veruno, Novara, Italy; 4Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Cassano Delle Murge, Bari, Italy; 5Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Pavia, Pavia, Italy; 6Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Tradate, Varese, Italy; 7University of Insubria, MACRO, Varese, Italy; 8Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Montescano, Pavia, Italy; 9Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Telese, Benevento, Italy; 10Istituti Clinici Scientifici Maugeri IRCCS, Health Directorate of the Institute of Lumezzane, Brescia, ItalyCorrespondence: Michele VitaccaIstituti Clinici Scientifici Maugeri IRCCS, Via Salvatore Maugeri, 4, Pavia 27100, ItalyEmail michele.vitacca@icsmaugeri.itBackground: The Barthel Index dyspnea (BId) is responsive to physiological changes and pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). However, the minimum clinically important difference (MCID) has not been established yet.Aim: To identify the MCID of BId in patients with COPD stratified according to the presence of chronic respiratory failure (CRF) or not.Materials and Methods: Using the Medical Research Council (MRC) score as an anchor, receiver operating characteristic curves and quantile regression were retrospectively evaluated before and after pulmonary rehabilitation in 2327 patients with COPD (1151 of them with CRF).Results: The median post-rehabilitation changes in BId for all patients were − 10 (interquartile range = − 17 to − 3, p< 0.001), correlating significantly with changes in MRC (r = 0.57, 95% CI = 0.53 to 0.59, p< 0.001). Comparing different methods of assessment, the MCID ranged from − 6.5 to − 9 points for patients without and − 7.5 to − 12 points for patients with CRF.Conclusion: The most conservative estimate of the MCID is − 9 points in patients with COPD, without and − 12 in those with CRF. This estimate may be useful in the clinical interpretation of data, particularly in response to intervention studies.Keywords: activities of daily life, breathlessness, dyspnea, chronic respiratory failure, exercise training, health related quality of life, rehabilitation

Mara Paneroni,1 Nicolino Ambrosino,2 Carla Simonelli,1 Laura Bertacchini,1 Massimo Venturelli,3 Michele Vitacca1 1Respiratory Rehabilitation Division, ICS Maugeri SPA SB, Institute of Lumezzane, IRCCS, Brescia, Italy; 2Respiratory Rehabilitation Division, ICS Maugeri SPA SB, Institute of Montescano, IRCCS, Pavia, Italy; 3Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, ItalyCorrespondence: Mara PaneroniRespiratory Rehabilitation Department, Istituti Clinici Scientifici Maugeri IRCCS, Via Salvatore Maugeri, 4, Pavia 27100, ItalyEmail mara.paneroni@icsmaugeri.itBackground and aim: There are few studies evaluating physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT).Aim: To assess PA in hypoxemic COPD patients on LTOT.Methods: In this cross-sectional study, we compared lung function, arterial blood gases, respiratory and peripheral muscle strength, 6-min walking distance (6MWD), daily energy expenditure and steps, and health-related quality of life (HRQL) in COPD patients on LTOT (LTOT group) versus two groups of control patients not needing LTOT: with (HYPOX) and without (COPD) exercise-induced desaturations.Results: Groups did not differ as regards demographics, anthropometrics, peripheral or respiratory muscle strength. Compared to the other groups, LTOT patients had more severe airway obstruction and lung hyperinflation, greater number and severity of comorbidities, shorter 6MWD, as well as lower mean SpO2 during 6MWD and worse quality of life. LTOT patients had a lower daily energy expenditure, shorter time spent > 3.0 METs and longer sedentary time compared to the COPD group, and less daily steps compared to the other groups. No significant difference in any parameter of PA was found between COPD and HYPOX. In LTOT patients, daily steps showed a strong correlation with 6MWD, and a moderate correlation with airway obstruction, level of oxygenation, comorbidities and quality of life but not with peripheral and respiratory muscle strength. In COPD and HYPOX patients, daily steps were strongly correlated with 6MWD and level of oxygenation as assessed by PaO2/FiO2. There was no significant correlation between mean SpO2 and 6MWD in any group.Conclusion: COPD patients on LTOT perform less physical activity than patients not needing LTOT, both with and without exercise-induced desaturations. Patients with exercise-induced desaturations do not perform less physical activity than those without.Keywords: exercise, rehabilitation, activity daily living, COPD

Antonio M Esquinas Rodriguez,1 Rafaelle Scala,2 Nicolino Ambrosino31International Fellow AARC, Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain; 2Respiratory Ward and Respiratory Intensive Care Unit, S, Donato Hospital, Arezzo, Italy; 3Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Department, University Hospital Pisa, Pisa, ItalyIn the last decade, the treatment and prognosis of chronic obstructive pulmonary disease (COPD) patients have been improved by noninvasive ventilation (NIV).1However, the choice between invasive mechanical ventilation (IMV) and NIV, is still influenced by several critical factors.2 We read with interest the original article and related commentary by Scarpazza et al, reporting a very high NIV success rate in patients with acute hypercapnic respiratory failure due to acute exacerbations of COPD (AECOPD) with related reduction in IMV-associated complications.3 Nevertheless, although NIV represents one of the most important progresses in pulmonary medicine in the last decade, we believe that there are still some unresolved questions.View original paper by Scarpazza and colleagues.

BACKGROUND: Increasing evidence suggests that post-TB lung disease (PTLD) causes significant morbidity and mortality. The aim of these clinical standards is to provide guidance on the assessment and management of PTLD and the implementation of pulmonary rehabilitation (PR).METHODS: A panel of global experts in the field of TB care and PR was identified; 62 participated in a Delphi process. A 5-point Likert scale was used to score the initial ideas for standards and after several rounds of revision the document was approved (with 100% agreement).RESULTS: Five clinical standards were defined: Standard 1, to assess patients at the end of TB treatment for PTLD (with adaptation for children and specific settings/situations); Standard 2, to identify patients with PTLD for PR; Standard 3, tailoring the PR programme to patient needs and the local setting; Standard 4, to evaluate the effectiveness of PR; and Standard 5, to conduct education and counselling. Standard 6 addresses public health aspects of PTLD and outcomes due to PR.CONCLUSION: This is the first consensus-based set of Clinical Standards for PTLD. Our aim is to improve patient care and quality of life by guiding clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage PTLD.