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Footnotes: This manuscript has recently been accepted for publication in the ERJ Open Research. It is published here [ERJ Open Research] in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJOR online. This publisher policy does not allow for Open Access for this version in Any Repository. Pulmonary rehabilitation (PR) is a cost-effective intervention with well-known benefits on exercise capacity, symptoms and quality of life in patients with chronic respiratory diseases. Despite the compelling evidence of its benefits, PR implementation is still suboptimal, and maintenance of PR benefits is challenging. To overcome these pitfalls, there has been a growing interest to develop novel models for PR delivery. Digital health is a promising solution, as it has the potential to address some of the most reported barriers to PR uptake and adherence (such as accessibility issues), help maintain the positive results following a PR programme, and/or promote patients’ adherence to a more active lifestyle through physical activity (tele-)coaching. Despite the accelerated use of digital health to deliver PR during the COVID-19 pandemic, there are still several factors that contribute to the resistance in the adoption of digital health, such as the lack of evidence on its effectiveness, low acceptability by patients and healthcare professionals, concerns about implementation and maintenance costs, inequalities in access to the internet and technological devices, and data protection issues. Nevertheless, the trend towards reducing technology costs and the higher availability of digital devices, as well as the greater ease and simplicity of use of devices, enhance the opportunities for future development of digitally enabled PR interventions. This narrative review aimed to examine the current evidence on the role of digital health in the context of PR, including strengths and weaknesses, and to determine possible threats and opportunities, as well as areas for future work. info:eu-repo/semantics/publishedVersion

Background: The INhaler Compliance Assessment (INCATM) device is an electronic monitoring device (EMD) that assesses both patient’s adherence and inhaler technique (IT). This study aimed, first, to assess the value of using the INCATM device as an objective measure during medicine use review (MUR) consultations provided by community pharmacists (CPs) on patients’ adherence and IT. Second, we aimed to explore patients’ perceptions about the INCATM device. Methods: A mixed methods approach was used, involving two phases. Phase one was a service evaluation in independent community pharmacies in London with a before-and-after study design. The service included provision of an MUR consultation to asthma and COPD patients using objective feedback about adherence and IT generated with the INCATM device. Descriptive and inferential statistics were performed using SPSS. Phase two involved semi-structured interviews with respiratory patients. Thematic analysis was performed to generate key findings. Main findings: Eighteen patients participated in the study (12 COPD and 6 asthma). The results showed significant improvement in the INCATM actual adherence from 30% to 68% (p = 0.001) and significant reduction in IT error rate from 51% to 12% (p = 0.002) after conducting the service. Analysis of the interviews revealed patients’ positive attitudes in terms of the perceived benefits of the technology and a desire for future use and recommendation for others. Patients had also positive attitudes towards the consultations provided. Conclusion: Embedding an objective measure about adherence and IT during CPs’ consultations showed a significant improvement in patients’ adherence and IT and was accepted by patients as well.

Chronic obstructive pulmonary disease (COPD) is the end result of a series of dynamic and cumulative gene–environment interactions over a lifetime. The evolving understanding of COPD biology provides novel opportunities for prevention, early diagnosis, and intervention. To advance these concepts, we propose therapeutic trials in two major groups of subjects: “young” individuals with COPD and those with pre-COPD. Given that lungs grow to about 20 years of age and begin to age at approximately 50 years, we consider “young” patients with COPD those patients in the age range of 20–50 years. Pre-COPD relates to individuals of any age who have respiratory symptoms with or without structural and/or functional abnormalities, in the absence of airflow limitation, and who may develop persistent airflow limitation over time. We exclude from the current discussion infants and adolescents because of their unique physiological context and COPD in older adults given their representation in prior randomized controlled trials (RCTs). We highlight the need of RCTs focused on COPD in young patients or pre-COPD to reduce disease progression, providing innovative approaches to identifying and engaging potential study subjects. We detail approaches to RCT design, including potential outcomes such as lung function, patient-reported outcomes, exacerbations, lung imaging, mortality, and composite endpoints. We critically review study design components such as statistical powering and analysis, duration of study treatment, and formats to trial structure, including platform, basket, and umbrella trials. We provide a call to action for treatment RCTs in 1) young adults with COPD and 2) those with pre-COPD at any age.

Background: The primary goal of COPD management is to optimize a patient's functional status and quality of life. By encouraging effective patient self-management within primary health care, unplanned and potentially avoidable COPD admissions to the emergency department can be avoided. Aim: The aim of this study is to examine whether distance to hospital influences the rate of ED presentation, hospital admission and hospital length of stay for COPD patients. Methods: The 2016 to 2018 resulted in a total of 5253 patient presentations with a primary medical diagnosis code of J44 (COPD). These were at the main hospitals of three Queensland Hospital and Health Services: Toowoomba, Ipswich and Gold Coast. To examine the variations in patient characteristics based on distance a one-way ANOVA (Analysis of Variance) test was conducted. The Kruskal-Wallis (KW) test indicated that there were group differences. Results: This study identified significant variation in COPD-related hospital length of stay and distance to hospital among COPD patients within three hospitals in South East Queensland, Australia. These results confirm that distance plays an important role in determining duration of hospital stay (in number of days) among COPD patients, with clear evidence of the distance 'decay phenomenon'. It appears from the findings of the current study that distance to the hospital is not associated with the greater likelihood of ED presentation but may influence length of stay. Conclusions: Several distance-specific studies have concluded that lower utilisation of hospital care is associated with distance to hospital. This article is protected by copyright. All rights reserved.

Rationale: High-flow nasal therapy (HFNT) has beneficial effects in patients hospitalized with acute hypoxemic respiratory failure. HFNT has not been extensively studied following hospitalization for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Objective: We explored the feasibility of conducting a multicentered trial to evaluate the use of HFNT to increase the time to next moderate/ severe exacerbation in patients recently hospitalized for a COPD exacerbation. In this pilot study we measured the hours of home daily HFNT use, maximally tolerated flow rates and temperature, and side effects for a period of 90 days. Methods: Patients were enrolled in a 90-day, open-labeled pilot study of HFNT to determine the safety and feasibility of home use for daily outpatient COPD management. Patients ≥ 40 years of age with prior hospitalization within the past 12 weeks for an AECOPD were enrolled. COPD was the primary diagnosis in all patients. Results: Thirty patients presented for HFNT titration. Two dropped out; 1 after receiving a lung transplant and the other was lost to follow-up. The remaining 28 patients completed 90 days of HFNT. None withdrew from HFNT due to intolerance. Use of HFNT averaged 6.8 (2.1) hours daily. Conclusions: Daily home HFNT for up to 3 months is feasible in COPD patients following hospitalization for AECOPD. Improvements observed in disease-specific quality of life, respiratory symptoms, and 6-minute walk distance suggest the need for a prospective multicenter controlled clinical trial.

International audience; In addition to exercise intolerance and a sedentary lifestyle, functional capacity, referring to an individual’s balance, mobility, and transfer abilities, is particularly altered in end-stage disease,1 conferring a high risk for disability, hospitalization, and mortality.2,3 The situation may even be worse in individuals who develop hypoxemic or hypercapnic chronic respiratory failure, that could lead to a stage of vulnerability and physical dependence called frailty.4 Frailty syndrome affects approximatively 1 in 5 patients with chronic obstructive pulmonary disease (COPD),5 with an increasing proportion of frail individuals in the most severe stages of the disease. 6,7 Frail patients with COPD are at higher risk of disability and falls, exercise intolerance, anxiety and depressive symptoms, hospitalizations, and death compared to their non-frail counterparts.6,7Pulmonary rehabilitation (PR) is highly effective at improving dyspnea, exercise tolerance, and health status in patients with moderate to severe COPD.8-10 Although less documented, center-based PR is feasible and has shown similar benefits in COPD patients with chronic respiratory failure.11-13 However, PR attendance and completion are likely compromised in frail individuals with chronic respiratory failure,6,14 to whom a home-based intervention could help in eliminating barriers that affect PR attendance.The design of an effective PR program to prevent or delay functional decline and disability in older persons is a public health priority15 that has been addressed in multiple reviews.16,17 This question has received little attention in patients with COPD, although a few studies reported short-term effectiveness of center-based PR programs for improving balance, gait speed, and frailty syndrome in patients with moderate to severe COPD.18-20 Whether similar benefits of PR could be obtained in COPD patients with chronic respiratory failure who are at risk of altered functional status and physical frailty is uncertain. Home-based PR, using exercise and self-managing interventions tailored to each patient’s individual abilities and needs, is an attractive approach for these individuals that could further increase the program completion.21,22 Furthermore, focusing on functional status and autonomy in daily life activities and individualizing physical exercises in frail COPD patients with chronic respiratory disease could enhance the benefits of PR on functional capacity and frailty syndrome.The main objective of this prospective interventional study was to evaluate the effectiveness of an 8-week, home-based PR program with COPD patients with chronic respiratory failure. A secondary objective was to specifically evaluate the impact of frailty status on the efficacy of PR in improving functional capacity, exercise tolerance, health-related quality of life, and anxiety and depressive symptoms.MethodsParticipants and Study DesignThis was a prospective interventional study conducted in the north of France from December 2018 to October 2020. Participants were referred to the home-based PR program by their pulmonologist who was responsible for providing the clinical assessment and certifying the presence of COPD according to the Global initiative for chronic Obstructive Lung Disease (GOLD) classification system.23 Eligible patients were aged 40 years or above with a diagnosis of COPD as a main disease, and had chronic respiratory failure, defined as the requirement for either long-term oxygen therapy (LTOT) and/or non-invasive ventilation (NIV). Exclusion criteria included recent participation in PR (

Summary: Background & Aims: Low physical activity (PA) levels and a poor-quality diet are common in chronic obstructive pulmonary disease (COPD) patients eligible for pulmonary rehabilitation (PR). PR may improve short-term nutritional status and exercise capacity but generally not long-term lifestyle outcomes. We hypothesized that healthy lifestyle motivation is related to PA levels and dietary quality before PR and the responsiveness thereof after PR. Methods: Before and after standardized outpatient PR, 81 COPD patients with low muscle mass completed validated motivational regulation self-reports. Physical (in)activity was assessed before and after PR through 7-day accelerometry (GT3X Actigraph). Dietary quality was assessed using a validated cross-check dietary history before and after PR and quantified as the Mean Adequacy Ratio (MAR). Results: Patients' baseline motivational profile was unrelated to dietary quality or PA. Baseline integrated motivation and its change during PR significantly predicted MAR change during PR and its levels after PR. Baseline introjected motivation and its change during PR significantly predicted PA change during PR and its levels after PR. Conclusions: Specific motivational regulations predict dietary quality and PA improvements of patients with COPD admitted to PR. Therefore, targeting integrated and introjected motivation may be key to achieving lasting behavior change after PR. Registry site: Maastricht University Medical Centre+. Clinical trial identifier number: NCT01344135.

Yanxiong Mao,1,&ast; Yuanyuan Qian,2,&ast; Xiaoyan Sun,3 Na Li,1 Huaqiong Huang1 1Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China; 2Department of Respiratory and Critical Care Medicine, Haining People’s Hospital, Haining Branch, The First Affiliated Hospital, Zhejiang University, Haining, Zhejiang, People’s Republic of China; 3Department of Gynecology, Women’s Hospital School of Medicine Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Huaqiong HuangKey Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of ChinaTel/Fax +86-571-87783552Email zr_hhq@zju.edu.cnBackground: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) could be triggered by community-acquired pneumonia (CAP). Peripheral blood eosinopenia are strongly associated with increased mortality. In hospitalized AECOPD patients with CAP, eosinopenia may be used to identify patients with high risk of death on admission.Methods: We conducted a retrospective cohort study in 82 hospitalized AECOPD patients with CAP. Patients who had received systemic corticosteroids preadmission were excluded. The patients were identified by individual case file review. According to blood eosinophil count, patients were grouped as eosinopenia (< 50/μL) and non-eosinopenia (≥ 50/μL). Association of eosinopenia with infection and 18-month survival were analyzed using appropriate statistical methods.Results: Baseline demographic, comorbidity, CURB65 and Pneumonia Severity Index scores were similar between two groups. The eosinopenia group had significantly higher pro-brain natriuretic peptide, D-dimer, neutrophil percentage, and lower lymphocyte count and lymphocyte percentage. The eosinopenia group had significantly higher C-reactive protein (median 77.30 vs 16.55, p=0.008) and procalcitonin (median 0.32 vs 0.12, p=0.001). Survival at 18 months after hospital discharge was significantly lower in the eosinopenia group vs non-eosinopenia group (log rank, p=0.002).Conclusion: Eosinopenia (< 50/μL) was a strong predictor of 18-month mortality and associated with more severe infection in hospitalized AECOPD patients with CAP. Eosinophil count at admission can be used as a prognosis marker of mortality in those population.Keywords: eosinopenia, chronic obstructive pulmonary disease, community-acquired pneumonia, mortality

Background: This is a preliminary study to measure DLCO-SB in COPD patients in Persahabatan Hospital to know the magnitude of disturbance in diffusing capacity of the lung in COPD patients. Methods: This was a cross sectional study in which COPD patients attending COPD-Asthma clinic in Persahabatan Hospital Jakarta were performed spirometry and DLCO-SB consecutively between May 2015–July 2015. Comorbidities conditions were also recorded. Results: Spirometry and DLCO-SB measurement were conducted on 65 COPD subjects of which 10.8% subjects were COPD Group A, 29.2% were Group B, 32.3% were COPD group C and 27.7% were COPD group D. The mean age was 64.15; mean FEV1% was 46.05%, mean DLCO measured was 19.42 ml/min/mmHg and the mean DLCO% was 72.00%. The proportion of decreasing in diffusing capacity of the lung in COPD patients was 56.92%. There was significant correlation between grup COPD, GOLD COPD gade, VEP1, BMI and comorbidities with magnitude of decresing DLCOvalue. There were no correlation between DLCO value with sex, smoking history, brinkmann index, age, obstruction-mix criteria, comorbidities and length of COPD period. Conclusion: The proportion of decreasing in DLCO in COPD patients was 56.92%. There was significant correlation between grup COPD, GOLD COPD gade, VEP1, BMI and previous TB history with magnitude of decresing DLCOvalue.

The aim of the work is to find out the effectiveness and duration of the breathing exercises with PEEP action on the cardiovascular system state in older patients with COPD. Materials and methods. A total of 35 patients with COPD aged 60–74 years were examined. All the patients were divided into two groups: the main group (18 people) who received breathing exercises with PEEP, and the control group (17 people) who received simulated exercises. The cardiovascular system state was assessed. The examinations were performed in the initial state (before training), immediately after, one month later, and three months after the training course. Results. The cardiovascular system state improved as a result of breathing exercises with PEEP in older patients with COPD. At the same time, the duration of the breathing exercises with PEEP action was short; the effect of their use was not preserved in a month. Relationships between shifts in SpO2 and cardiac output, as well as between shifts in SpO2 and peripheral vascular resistance immediately after the use of breathing exercises with PEEP in older patients with COPD have been established. A more significant and prolonged effect of breathing exercises with PEEP on the cardiovascular system functional state was observed in older COPD patients with more severe symptoms of the disease. Conclusions. The increase in cardiovascular performance was influenced by breathing exercises with PEEP in older COPD patients due to the improved lung oxygenation capacity. The effect of breathing exercises with PEEP remained within a month after the training course and was more stable and longer in patients with severe clinical symptoms. Older COPD patients are advised to repeat the courses of breathing exercises with PEEP every month.

For two decades, the GOLD Initiative has consistently identified the use of bronchodilators as a priority in the pharmacotherapeutic strategy for COPD. The authors of international and national clinical guidelines consider fixed combinations of long-acting beta2-agonists (LABAs) and long-acting muscarinic receptor antagonists (LAMAs) as “first-line” drugs in most patients with COPD. Numerous clinical studies have shown that fixed LABAs/LAMAs combinations provide optimal bronchodilation and play a paramount role in preventing exacerbations of COPD. Outperforming placebo and active controls, LABAs, LAMAs, inhaled glucocorticosteroids (ICS)/LABAs combination bronchodilators may differ in their therapeutic potential. The available evidence base currently does not allow to make an unambiguous choice in favor of one or another fixed LABAs/ LAMAs combination. With the appearance of “triple” combinations (ICS/LABAs/LAMAs) on the pharmaceutical market, the issue of their comparison with “dual” bronchodilators has become particularly acute. Currently available data suggest that the use of “triple” therapy is not considered as a starting treatment option for COPD and is appropriate only in a subgroup of patients with a higher baseline risk of exacerbations: in the presence of a history of exacerbations ≥ 1, which required prescription of systemic antibiotics and/or glucocorticosteroids, or necessitated hospitalization during the previous year. Thus, ICS-containing therapy is justified only in cases of recurrent exacerbations of moderate COPD or single episodes of severe exacerbations, despite the continued administration of LABAs/LAMAs, as well as in certain categories of patients whose inflammatory profile suggests a “response” to ICS.

ZusammenfassungPatienten mit COPD haben ein erhöhtes Risiko für schwerwiegende Verläufe einer COVID-19-Erkrankung. Der Ausbruch von COVID-19 auf einer Station für nicht invasive Beatmung (NIV) zeigte darüber hinaus eine hohe Mortalität (32 %) unter COPD-Patienten mit NIV sowie Hinweise für eine verstärkte Infektionsübertragung durch die eingesetzten Therapiegeräte. Maßnahmen zur Prophylaxe und Eindämmung von COVID-19-Infektionen im stationären Setting werden hier aufgeführt.

Background: Chronic Obstructive Pulmonary Disease (COPD) is a narrowing of the air flow caused by inflammation in the airways resulting in the shortness of breath and reduced oxygen levels in the blood thereby affecting patients’ quality of life.Purpose: The purpose of this study was to determine the effect of exercise on the PLB to Scale of Breathlessness and oxygen saturation (SaO2) in COPD patients.Methods: The research method utilized quasi experimental design with randomized pretest-posttest control group. Sample of 68 respondents (60 respondents PLB group, and 8 respondents control group) was recruited through total sampling technique.Result: Independent t-test showed difference of decreasing Scale of Breathlessness (p=0.018) & increasing of SaO2 (p=0.023) between PLB & control group. The results of Multiple linear regression test showed an effect of PLB on a Scale of Breathlessness (p=0.030) and SaO2 (p=0.002).Conclusion: It can be concluded that the PLB exercises influenced changes in the value Scale of Breathlessness and SaO2.

Arto Yuwono Soeroto,1 Dadan Setiawan,2 Nabila Nauli Asriputri,3 Guntur Darmawan,4 Geraldo Laurus,3 Prayudi Santoso1 1Division of Respiratory and Critical Illness, Department of Internal Medicine, Faculty of Medicine Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, Indonesia; 2Department of Internal Medicine, Occupational Health General Hospital, Bandung, West Java, Indonesia; 3Department of Internal Medicine, Faculty of Medicine Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, Indonesia; 4Department of Internal Medicine, Faculty of Medicine, Krida Wacana Christian University, Jakarta, IndonesiaCorrespondence: Arto Yuwono Soeroto Tel +62 811 246 930Email aysoeroto@yahoo.co.idPurpose: This study aimed to assess the association between vitamin D levels and forced expiratory volume in one second (FEV1), number of exacerbations, and symptoms based on COPD assessment test (CAT) scores in stable COPD patients in Indonesia.Patients and Methods: An observational cross-sectional study was conducted. Subjects were stable COPD patients who were treated at a pulmonary clinic in a tertiary referral hospital in West Java from March to June 2018.Results: Thirty subjects were recruited this study with an average age 62± 8 years. The mean vitamin D level was 20.17± 8.91 ng/mL. Half of the patients had low vitamin D level (< 20ng/mL) (50%). The mean FEV1 (%) predicted value was 37.2± 14. The median exacerbation per year was 1 (0– 5) and symptoms based on CAT score was 14 (3– 34). No correlation was found between vitamin D levels and FEV1 (%) predicted value (r=0.126, p=0.253). Vitamin D level was inversely correlated with number of exacerbations (r=− 0.639, p< 0.001) and CAT (r= − 0.802, p< 0.001).Conclusion: Low level of vitamin D was associated with more frequent exacerbation and higher CAT scores but was not associated with FEV1 (%) predicted.Keywords: COPD, vitamin D, FEV1, CAT score

Background: Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable chronic respiratory diseases. The BODE, ADO, DOSE are the composite indices taking into consideration for prognostication. In addition, COPD assessment test (CAT) score is associated with quality of life, taken for assessing symptoms severity and for personalizing treatments. Objective: To investigate the CAT score in Thai COPD patients according to their BODE, ADO, and DOSE in the influence of clinical parameters and outcomes. Methods: Medical records were reviewed between January 2016 and December 2016. BODE, ADO and DOSE was calculated based on their individual components. Results: Total 125 consecutive COPD patients were recruited. There was difference between CAT score among the GOLD stages classified (P = .02). There was significant difference of CAT between 4 BODE quartiles in cohort (P = .001).Thai COPD patients had the higher ADO index exhibit the higher CAT score than those with the lower ADO index (P = .001). There was no difference in CAT score between COPD with the higher and the lower DOSE index (P = .05). Conclusions: The higher CAT score found in Thai COPD patients with the higher composite indices of BODE and ADO. However, there was no difference in the DOSE index.