Does dynamic hyperinflation contribute to dyspnoea during exercise in patients with COPD?

Dynamic hyperinflation (DH) during exercise occurs in most but not all patients with advanced chronic obstructive pulmonary disease (COPD). It is not known whether the presence or absence of DH has implications for dyspnoea and exercise tolerance. Therefore, we compared detailed ventilatory and sensory responses to exercise in hyperinflators and nonhyperinflators with moderate-to-severe COPD. Nonhyperinflators (n=65) were retrospectively identified from a sample of 427 patients and case-matched to a group of hyperinflators (n=65) based on sex, age, body mass index and % predicted forced expiratory volume in 1 s. Resting pulmonary function and constant work rate cycle exercise responses were compared. Hyperinflators decreased inspiratory capacity (IC) from rest to peak exercise by 0.46±0.24 L whereas the nonhyperinflators increased IC by 0.10±0.15 L (p<0.0001). There were no significant group differences in endurance time (9.11±5.98 versus 8.87±5.24 min) or dyspnoea intensity for any given time or ventilation. An inflection in tidal volume versus ventilation occurred in the majority of nonhyperinflators (n=61) and hyperinflators (n=62) at a similar time and ventilation. Mechanical constraints on tidal volume expansion and the attendant rise in dyspnoea intensity were similar in both groups. Dyspnoea intensity during exercise was associated with progressive mechanical constraints on tidal volume expansion regardless of the presence of DH.     

How do patients with asthma and COPD behave during fasting?

Background-objectiveSeveral factors might affect the adherence to treatment in patients with asthma and COPD. Among these factors, the effect of religious beliefs and behaviours has been less studied so far. In this study, the effect of fasting on drug use behaviours of patients with asthma and COPD were comparatively analysed.MethodsA total of 150 adult patients with asthma and 150 adult patients with COPD were consecutively enrolled into this cross-sectional study. The patients were asked whether they fast during Ramadan and if the answer was yes, they were kindly asked to respond to further questions related to use of inhaled medications during that particular time.ResultsThe majority of the cases from both groups [98 (65.3%) of asthma patients and 139 (92.6%) of COPD] were fasting during Ramadan. The majority of the patients with COPD (n = 126; 90.6%) reported that they quitted their regular therapy basis during Ramadan. On the other hand, the majority of asthma patients used their controller inhaled medications during Ramadan and preferred to use them on iftar and sahur times (n = 81, 82.6%).ConclusionOur results showed that in a Muslim population, the patients with asthma and COPD do not feel their diseases to be an inhibitory factor for fasting during Ramadan. However, fasting seems to be an important determining factor in medication compliance by modifying the drug use behaviours in each group in a different way. Therefore, the patients should be informed about the effects of fasting on their disease and the allowed drugs during fasting.     

Does thoracic bioimpedance accurately determine cardiac output in COPD patients during maximal or intermittent exercise?

STUDY OBJECTIVES: The monitoring of cardiac output (CO) during exercise rehabilitation in patients with COPD, often including strenuous exercise, is advisable. Invasive methods (thermodilution, Fick method) are accurate, but for clinical routine use noninvasive CO estimation is required. We have shown that impedance cardiography (Physio Flow; Manatec Biomedical; Macheren, France) is reliable in COPD patients at rest and during a recumbent, light-intensity exercise. The aim of our study was to evaluate the validity of this noninvasive device in COPD patients during a maximal incremental exercise test (IET) and also during a strenuous intermittent work exercise test (IWET). DESIGN: Prospective comparative study of the impedance cardiograph vs the direct Fick method applied to oxygen. PATIENTS: Eight patients with moderate-to-severe COPD (59 +/- 6 years old; FEV(1), 38 +/- 15% predicted; residual volume, 194 +/- 64% predicted) [mean +/- SD].Measurements and main results: Forty-nine simultaneous measurements of CO by means of the direct Fick method (COfick) and CO measured by the impedance cardiograph (COpf) were obtained during the IET, and 108 measurements were made during the IWET. The correlation coefficients between the two measurements were r = 0.85 and r = 0.71 for the IET and the IWET, respectively. COpf was higher than COfick. The difference between the two methods was 3.2 +/- 2.9 L/min during the IET and 2.5 +/- 2.1 L/min during the IWET. Expressed as a percentage of the mean of the two measurements, this corresponded to 31 +/- 21% and 25 +/- 20%, respectively. CONCLUSIONS: The relatively high number of values differing by > 20% precludes the use of impedance cardiography in clinical routine in such a difficult setting (hyperinflated patients and intense exercise).     

Do exercise and self-management interventions benefit patients with osteoarthritis of the knee? A metaanalytic review

OBJECTIVE: Osteoarthritis (OA) is the most prevalent health condition among seniors and it causes significant pain and disability. We assessed the influence of patient education and exercise regimens on the well-being of patients with knee OA. METHODS: A metaanalysis was conducted on 16 studies reporting exercise and/or self-management interventions for patients with knee OA. The effects on physical and psychological well-being were assessed immediately after the interventions. RESULTS: Compared to control conditions, exercise regimens led to improvement in physical health (by self-report and direct measures) and in overall impact of OA. Perceived psychological health remained unchanged by the exercise programs. Although the effect sizes for the self-management programs were significant for psychological outcomes and for the overall effect of OA, there was a significant difference between self-management and control groups only in psychological outcomes. CONCLUSION: Overall, both patient education and exercise regimens had a modest, yet clinically important, influence on patients' well-being.     

Do inhaled corticosteroids protect against lung cancer in patients with COPD? A systematic review

Inhaled corticosteroids (ICS) are commonly prescribed to COPD patients, particularly those with more advanced stages of the disease. These patients are also at increased risk of lung cancer. A systematic review was undertaken to identify studies that examined the association between lung cancer risk and ICS therapy in COPD patients. The search strategy was created in MEDLINE and extended to EMBASE as well as other relevant databases. Both randomized controlled trials (RCTs) and observational studies were considered for inclusion. Studies were required to have incident lung cancer or deaths from lung cancer as an outcome in order to be included in the review. Six studies met the inclusion criteria. Two observational studies directly addressed the specific research. Four RCTs presented sufficient data to calculate the relative risk of lung cancer in COPD patients. None of the identified RCTs showed a statistically significant association of ICS use with lung cancer risk. Observational studies showed a protective effect from ICS use, particularly at high doses. Given the observational evidence and the low numbers of lung cancer events in the RCTs, these results may be prone to type II error. The observational studies dealt with very specific patient populations and exposure definitions, which might not have adequately captured the complex relationship between ICS exposure and lung cancer risk. Results from RCTs suggest no effect of ICS on the risk of lung cancer. However, results from observational studies suggest the potential that ICS may confer a protective effect, particularly at high doses.     

Is hormonal activation during exercise useful for risk stratification in patients with moderate congestive heart failure?

Background

We previously demonstrated that A-type natriuretic peptide (ANP) at peak exercise was an independent predictor of cardiac survival. No data are available concerning the predictive value of B-type natriuretic peptide (BNP) at peak exercise.

Methods

One hundred and fifty consecutive stable patients with moderate congestive heart failure (CHF) underwent echocardiography and a cardiopulmonary exercise test. Blood samples were drawn at rest and at peak exercise for the determination of plasma levels of ANP, BNP, and norepinephrine.

Results

Exercise significantly increased plasma values of ANP, BNP, and norepinephrine. After a median follow-up period of 1171 days, there were 35 cardiac related deaths. Mortality rates at 1 and 2 years were 4% and 8%, respectively. Independent predictors of cardiac survival were percent of maximal predicted oxygen consumption (RR = 4.8 [2.1-11], P = .002), BNP at rest (RR = 2.5 [1.2-5.6], P = .01), and left atrial diameter (RR = 2.8 [1.2-6.5], P = .02).

Conclusions

In patients with stable, moderate CHF, plasma levels of ANP, BNP, and norepinephrine measured at peak exercise did not improve risk stratification. However, in addition to percent of maximal predicted oxygen consumption and left atrial diameter, plasma level of BNP at rest was an independent predictor of survival in CHF patients with low risk of cardiac events.     

Do all patients require supplemental oxygen during flexible bronchoscopy?

STUDY OBJECTIVES: Some respiratory units routinely administer supplemental oxygen to all patients during flexible bronchoscopy, but other units give oxygen only to those who desaturate (arterial oxygen saturation [SaO(2)], < 90%). We performed a study to examine both the requirement for supplemental oxygen and the effect of IV midazolam therapy on oxygenation during flexible bronchoscopy for patients with a known FEV(1). DESIGN: Data on the SaO(2) of patients during flexible bronchoscopy were collected prospectively for all procedures performed in our respiratory unit for the period 1992 to 1997. RESULTS: There were 1,051 flexible bronchoscopy procedures performed in which the patient had a known FEV(1) and was not receiving supplemental oxygen before the procedure. Supplemental oxygen was commenced during or immediately after the procedure in 151 cases (14.4%), while a further 101 cases (9.6%) had momentary desaturation (ie, < 20 s) not requiring oxygen therapy. The lower the FEV(1), the greater the risk of significant desaturation and the need for supplemental oxygen (p < 0.0001) [supplemental O(2) therapy was administered in 35% of cases if FEV(1) < 1.0 L, in 14% of cases if FEV(1) was 1.0 to 1.5 L, and in 7% of cases if FEV(1) > 1.5 L]. The use of low-to-moderate doses of midazolam as sedation did not affect the probability of the occurrence of significant desaturation (p = 0.204). CONCLUSIONS: This study supports guidelines that suggest that all patients should be monitored by pulse oximetry during flexible bronchoscopy. Desaturation may occur at any FEV(1) level even without sedation. The majority of our patients did not require routine oxygen supplementation, especially the group with an FEV(1) above 1 L.     

Is impairment similar between arm and leg cranking exercise in COPD patients?

Impaired skeletal muscle function has been reported in patients with chronic obstructive disease (COPD), but such impairment is not homogenous and its distribution between the upper and the lower limbs is still unclear. The present study was designed to assess and compare upper and lower limb capacities in patients with moderate to severe COPD during incremental and constant-load exercises. Thirteen COPD patients of similar age with moderate to severe air flow limitation (FEV(1): 35%+/-5% predicted) and 19 healthy subjects were studied. Four sessions were organized: two incremental and two constant-load cycling exercises with arm or leg in randomized order. As observed in a previous study involving incremental and constant tests, power, VO(2), RER, VE, and HR were all significantly lower in the upper and lower limbs of patients with COPD than in healthy controls. In the healthy population, aerobic capacity and mechanical efficiency (ME) were lower in the course of arm exercises than in leg exercises. For the same relative workload, dyspnea and blood lactate production were higher during arm exercise. In contrast, no significant difference was observed between arm and leg capacities for any of these parameters in COPD patients. Conclusion: Although aerobic capacity is impaired in COPD patients, arm aerobic capacity is relatively preserved. Given the lack of significant difference between arm and leg capacities in COPD, we hypothesize that upper limb muscles are less compromised than lower limb muscles in this patient population.     

Do exercise habits during middle age affect locomotive syndrome in old age?

Objectives: Locomotive syndrome (LS) encompasses conditions that may lead to the need for nursing services. We aimed to quantify the association between exercise habits during youth or the middle-age years and both physical function and the presence of LS in Japanese elderly people.

Methods: We examined 460 participants of the eighth, ninth, and tenth iterations of the Miyagawa study. Participants were divided into an LS group and a no-LS group according to their scores on the 25-question Geriatric Locomotive Function Scale. The following physical function tests were performed: grip strength, 6-m walk at normal and maximum speed, single-leg stance time with eyes open, and chair stand time. The frequency of past physical activity was determined by interview.

Results: Ninety-seven participants (21.1%) were classified as having LS. The LS group had worse physical function than the no-LS group. Exercise habits between the ages of 25 and 50 years were significantly related to later LS.

Conclusions: Participants with LS were less likely to report a regular exercise habit between the ages of 25 and 50 years than participants without LS. Participants who reported regular exercise habits in middle age had better physical function during old age. Regular exercise habits in middle age appear to protect against LS during the older years.     

Do patients with obstructive sleep apnea wake up with headaches?

BACKGROUND: There is a controversy regarding the association of obstructive sleep apnea (OSA) and morning headaches. This study investigates whether this relationship exists. METHODS: This is a retrospective study of 80 consecutive patients with OSA who underwent sleep polysomnography from December 1996 to March 1997. Patients were interviewed about their headache history. Headaches were classified according to International Headache Society criteria and the severity graded by the Chronic Pain Index. Headache characteristics were compared with those of 22 control patients with periodic limb movement disorder. Headache response to continuous positive airway pressure or uvulopalatopharyngoplasty in the patients with OSA was also assessed. RESULTS: Forty-eight (60%) patients had headaches in the year prior to study. Twenty-five of the 48 patients had headaches that did not fit any category. Of these 25 patients, 23 (48% of total group) reported awakening headaches. These awakening headaches were significantly more common in the OSA group compared with the periodic limb movement disorder group, 9 (41%) of whom had headaches, none of which occurred on awakening. The proportion of common types of headaches in both groups was similar. The awakening headaches were brief (shorter than 30 minutes), and their occurrence and severity correlated with OSA severity. Of the 29 patients with OSA who were treated with continuous positive airway pressure or uvulopalatopharyngoplasty, awakening headaches improved by a mean of 80% compared with minimal improvement of migraine, tension, and cervicogenic headaches. CONCLUSIONS: Awakening headaches are associated with OSA. These headaches are of brief duration, and their occurrence and severity increase with increasing OSA severity. Treatment of OSA with continuous positive airway pressure or uvulopalatopharyngoplasty can reduce these headaches.     

Do physicians spend more time with non-english-speaking patients?

OBJECTIVE: To determine whether physicians at a general internal medicine clinic spend more time with non-English-speaking patients. DESIGN: A time-motion study comparing physician time spent with non-English-speaking patients and time spent with English-speaking patients during 5 months of observation. We also tested physicians' perceptions of their time use with a questionnaire. SETTING: Primary care internal medicine clinic at a county hospital. PATIENTS/PARTICIPANTS: One hundred sixty-six established clinic patients, of whom 57 were non-English speaking and 109 were English speaking, and 15 attending physicians and 8 third-year resident physicians. MEASUREMENTS AND MAIN RESULTS: Outcome measures included total patient time in clinic, wait for first nurse or physician contact, time in contact with the nurse or physician, physician time spent on the visit, and physician perceptions of time use with non-English-speaking patients. After adjustment for demographic and comorbidity variables, non-English-speaking and English-speaking patients did not differ on any time-motion variables, including physician time spent on the visit (26.0 vs 25.8 minutes). A significant number of clinic physicians believed that they spent more time during a visit with non-English-speaking patients (85.7%) and needed more time to address important issues during a visit (90. 4%), (both p <.01). Physicians did not perceive differences in the amount they accomplished during a visit with non-English-speaking patients. CONCLUSIONS: There were no differences in the time these physicians spent providing care to non-English-speaking patients and English-speaking patients. An important limitation of this study is that we were unable to measure quality of care provided or patients' satisfaction with their care. Physicians may believe that they are spending more time with non-English-speaking patients because of the challenges of language and cultural barriers.