Health-related quality of life in patients under long-term oxygen therapy: a home-based descriptive study

Long-term home oxygen therapy (LTOT) improves survival of hypoxic patients with chronic respiratory insufficiency. However, the health-related quality of life (HRQL) of these patients, when LTOT is initiated, is severely impaired. The present study aims to describe the health-related quality of life (HRQL) of patients under LTOT, assessed at home, to identify parameters relevant to HRQL, and to describe changes over a 1-yr period.Seventy-nine patients (aged 68 ± 11 years, under LTOT for 34 ± 24 months) underwent pulmonary function testing, measurement of average daily distance walked, SaO₂, dyspnoea scores (Borg scale and oxygen-cost diagram), and Hospital Anxiety and Depression scores. After 1 yr, measurements were repeated, and HRQL was measured with the St George Respiratory Questionnaire (SGRQ).Forced expiratory volume in 1 s (FEV₁ % of predicted) was 36 ± 19; SaO₂ (room air) was 87 ± 5%; daily distance walked was 1202 ± 1140 m; 21% suffered from anxiety and 27% from depression. After 1 yr, pulmonary function tests, dyspnoea or prevalence of anxiety or depression were unchanged. Mortality was high (31% 1-yr mortality). Daily distance walked (rho = −0.55, P=0.01 vs. SGRQ) and number of days spent in hospital (rho=0.5, P=0.01 vs. SGRQ) were the parameters with the highest correlation with HRQL scores.Quality of life was poor in these patients, with high rates of emotional disorders. Restoring and maintaining sufficient exercise capacity for everyday life activities through outpatient rehabilitation programmes and support for emotional disturbances should be major goals in the care of these patients.     

The Relation of Fat-free Mass to Maximum Exercise Performance in Patients with Chronic Obstructive Pulmonary Disease

To assess the factors determining maximum exercise performance in patients with chronic obstructive pulmonary disease (COPD), we examined nutritional status with special reference to body composition and pulmonary function in 50 stable COPD patients. Nutritional status was evaluated by body weight and body composition, including fat mass (FM) and fat-free mass (FFM) assessed by bioelectrical impedance analysis (BIA). Exercise performance was evaluated by maximum oxygen uptake (Vo _2max) on a cycle ergometer. A total of 50 patients (FEV₁= 0.98 L) was divided randomly into either a study group (group A, n= 25) or validation group (group B, n= 25). Stepwise regression analysis was performed in group A to determine the best predictors of Vo _2max from measurements of pulmonary function and nutritional status. Stepwise regression analysis revealed that Vo _2max was predicted best by the following equation in group A: Vo _2max (mL/min) = 10.223 × FFM (kg) + 4.188 × MVV (L/min) + 9.952 × DL_co (mL/min/mmHg) − 127.9 (r= 0.84, p < 0.001). This equation was then cross-validated in group B: Measured Vo _2max (mL/min) = 1.554 × Predicted Vo _2max (mL/min) − 324.0 (r= 0.87, p < 0.001). We conclude that FFM is an important factor in determining maximum exercise performance, along with pulmonary function parameters, in patients with COPD. Accepted for publication 15 February 2000     

Health-Related Quality of Life in Patients with Alpha-1 Antitrypsin Deficiency: The French Experience

Abstract

The French registry of patients with alpha-1 antitrypsin deficiency (AATD)-associated emphysema was launched in 2006. Here, we aimed to report on the baseline characteristics of these patients, their health-related quality of life (HRQoL) and factors associated with HRQoL. Another goal was to survey the practices of French physicians regarding augmentation therapy. We included 273 patients with AATD, emphysema, obstructive-pattern [forced expiratory volume in 1 sec/forced volume capacity (FEV₁/FVC) < 0.7], FEV₁ ≤ 80% predicted. Mean (SD) age was 51.8 (11.1) years, 240 (87.9%) of patients were smokers or ex-smokers, mean (SD) FEV₁ was 40.5% (15.7) predicted. Mean (SD) SGRQ score was 49.0 (20.0) and was higher for females than males (52.7 [20.7] vs 46.8 [18.2]; p = 0.01). Dyspnea showed the strongest association with SGRQ score (r = 0.65; p < 0.0001), followed by chronic bronchitis (r = 0.33; p < 0.0001) and wheezing (r = 0.32; p < 0.0001). Number of exacerbations in the year before inclusion was also significantly associated with SGRQ score (r = 0.36; p < 0.0001). The SGRQ score was associated with the 6-min walking distance (r = –0.53, p < 0.0001), FEV₁ (% predicted, r = –0.53, p < 0.0001) and DLCO (% predicted, r = –0.52, p < 0.0001). It was also associated with the GOLD 2006 (r = 0.53; p < 0.0001) and GOLD 2011 (r = 0.63; p < 0.0001) classifications and with the BODE index (r = 0.37; p < 0.0001). Age, history of tobacco smoking or current smoking did not show any association with SGRQ total scores. On multivariate analysis, a model including age, chronic bronchitis, dyspnea (MRC scale), diffusing lung capacity and 6-min walking distance explained 57% of the variation in the score. The French registry provides important insights into the clinical characteristics of French patients with AATD-related emphysema.     

Pulmonary rehabilitation improves exercise capacity and quality of life in underweight patients with chronic obstructive pulmonary disease

Background and objective: An estimated 20–40% of COPD patients are underweight. We sought to confirm the physiological and psychosocial benefits of pulmonary rehabilitation programmes (PRP) in underweight compared with non‐underweight patients with COPD. Methods: Twenty‐two underweight COPD patients with BMI <20 kg/m², and 22 non‐underweight COPD patients, who were matched for FEV₁ and age, were studied. All patients had moderate‐to‐very severe COPD. All patients participated in 12‐week, hospital‐based outpatient PRP consisting of two sessions per week. Baseline and post‐PRP status were evaluated by spirometry, cardiopulmonary exercise testing, ventilatory muscle strength and the St. George's Respiratory Questionnaire (SGRQ). Results: At baseline, the age distribution and airflow obstruction were similar in underweight and non‐underweight patients with COPD. Baseline exercise capacity, inspiratory muscle strength and SGRQ total and symptoms scores were significantly lower in the underweight patients (all P < 0.05). After the PRP, there was significant weight gain in the underweight COPD patients (mean increase 0.8 kg, P = 0.01). There were also significant improvements in peak oxygen uptake, peak workload and the SGRQ total, symptoms, activity and impact scores in both underweight and non‐underweight patients with COPD (all P < 0.05). Conclusions: Underweight patients with COPD have impaired exercise capacity and health‐related quality of life (HRQL). Exercise training with supplemental oxygen may result in significant weight gains and improvements in exercise capacity and HRQL. Exercise training is indicated for underweight patients with COPD.     

Long‐term oxygen treatment need is less frequent in eosinophilic COPD patients

IntroductionEosinophilic airway inflammation is a recognized inflammatory pattern in subgroups of patients with chronic obstructive pulmonary disease (COPD). However, there are still conflicting results between various studies concerning the effect of eosinophils in COPD patients. Our aim with this study was to evaluate eosinophilic inflammation and its relation to the clinical characteristics in a group of COPD patients.MethodsStable COPD patients with FEV₁% predicted < 50 or with ≥ 1 exacerbation leading to hospital admission or ≥2 moderate or severe exacerbation history were consecutively enrolled from outpatient clinics.ResultsWe included 90 male COPD patients, with a mean age of 63.3 ± 9.2. Mean FEV₁% predicted was 35.9 ± 11.3. Eosinophilic inflammation (eosinophil percentage ≥2%) was evident in 54 (60%) of the patients. Participants with eosinophilic inflammation were significantly older and had better FEV₁ predicted % values. Eosinophilic COPD patients were characterized with better quality of life and fewer symptoms. COPD patients with noneosinophilic inflammation used supplemental long‐term oxygen therapy (LTOT) more frequently compared to patients with eosinophilic inflammation (36.1% vs. 14.8%, p = 0.01). Eosinophilic inflammation is associated with less dyspnea severity measured by mMRC (OR: 0.542 95% CI: 0.342–0.859, p = 0.009) and less LTOT use (OR: 0.334 95% CI: 0.115–0.968, p = 0.04) regardless of age, severity of airflow limitation, and having frequent exacerbation phenotype.ConclusionOur study supports the growing evidence for a potential role of eosinophilic inflammation phenotype in COPD with distinctive clinical characteristics. Eosinophilic inflammation is inversely associated with dyspnea severity measured by mMRC and LTOT use independently from age, total number of exacerbations, St. George Respiratory Questionnaire (SGRQ) total score and FEV₁% predicted.     

Reference Values and Prediction Equations for FVC and FEV1 in the Greek Elderly

Spirometry prediction equations obtained from middle-age adults, when extrapolated for the elderly, may lead to inaccurate interpretations. The purpose of this study was to determine prediction equations for forced vital capacity (FVC) and forced expiratory volume (FEV₁) in the Greek elderly population. Spirometry prediction equations for normal FVC and FEV₁ have been derived from tests on 71 healthy persons (38 men, 33 women) aged older than 60 years (range, 65–85 years), nonsmokers, white race, urban population using techniques and equipment that meet American Thoracic Society recommendations. Regression analysis using age, height, and weight as independent variables was used to provide prediction equations and values for both sexes. The FVC age coefficient in this healthy group was about 47.19 mL/y for elderly men and 34.27 mL/y for elderly women, and the FEV₁ age coefficient was about 52.8 mL/y for elderly men and 46.4 mL/y for elderly women . Values from this study predicted equations were compared with those from some of the most commonly used sources of spirometry predicted equations. The FVC and FEV₁ predicted values were found to be of less mean square error than that of other compared studies. Higher correlation is between FVC and FEV₁ predicted values by the present model and FVC and FEV₁ observed values in both sexes. The higher correlation between FVC and FEV₁ predicted and observed from this study allows the use of our model for predicting in a rather reliable way the FVC and FEV₁ for elderly Greek individuals. Accepted for publication: 25 April 2000     

Changes in Pulmonary Mechanics after Lung Volume Reduction Surgery

Lung volume reduction surgery (LVRS) is a promising new treatment for emphysema and leads to increased flow rates. We investigated the mechanisms by which flow rates could increase and the correlates of lessened dyspnea in patients undergoing LVRS before and 3 months after LVRS in patients with severe emphysema. The following were done: routine pulmonary function testing, measurements of elastic recoil (Pel), tidal breathing patterns, inspiratory work of breathing (W_insp), construction of static recoil-maximum flow curves, and measurement of baseline and transitional dyspnea index (TDI). There were increases in forced vital capacity (FVC: 2.24 ± 0.71 to 2.92 ± 0.63 liters; p < 0.05), forced expired volume in 1 (FEV₁: 0.64 ± .16 to 1.03 ± 0.28 liters; p < 0.01), and decreases in all divisions of lung volume, e.g. total lung capacity (TLC: 6.86 ± 1.41 to 5.96 ± 1.49 liters; p < 0.01). Maximum Pel increased (11.7 ± 3.7 to 19.8 ± 7.8 cmH₂O; p < 0.02) as did the coefficient of retraction (C_R= Pel/TLC: 1.8 ± 0.7 to 3.6 ± 3.6 ± 2.2 cmH₂O/liter). However, the individual responses in other parameters were markedly different among patients. There was no consistent trend in changes in the slope or position of the static recoil-maximum flow curve or W_insp. The only positive correlate of improved dyspnea (TDI = 3.22 ± 2.22; p < 0.01) was improvement in C_R, FEV₁ being a weak negative correlate and change in lung volume not being a correlate at all. We conclude that there is a heterogeneous response of the airways to LVRS. Increased elastic recoil was the primary determinant of improved flow rates after LVRS and is the only positive correlate for improvement in dyspnea. Accepted for publication: 14 July 1997     

The Change in Body Composition After Bilateral Lung Volume Reduction Surgery for Underweight Patients with Severe Emphysema

The aim of this study was to examine the short-term effect of lung volume reduction surgery (LVRS) on body composition and other nutritional indicators in 28 patients with emphysema underwent thoracoscopic LVRS. Functional tests, body weight (BW), and body composition were measured before and 6 months after surgery. Mean daily caloric intake (CI) was estimated by 3-day dietary record as well. Fat-free mass (FFM) and fat mass (FM) were assessed by bioelectrical impedance analysis (BIA). FEV_1.0 and Vo _2max have improved after LVRS by 35.2% and 23.8%, respectively. Preoperatively, 75% of patients were underweight (% ideal body weight (%IBW) <90) with the mean %IBW at 84.5%. BW, CI, and FFM increased significantly after LVRS, whereas FM was unchanged. The change in BW correlated significantly with the change in FEV_1.0, MVV, and Vo _2max (p < 0.01) but not with CI. Bilateral LVRS results in an increase in FFM and functional improvement for underweight patients with severe emphysema, and it may contribute to the improvement in maximal exercise capacity. Accepted for publication: 12 December 2000     

Effects of 3-week Outpatient Pulmonary Rehabilitation on Exercise Capacity, Dyspnea, and Quality of Life in COPD

The effects of intensive 3-week outpatient pulmonary rehabilitation (PR) on exercise capacity, dyspnea, and health-related quality of life (HRQL) were investigated in patients with COPD. Two hundred ten patients with COPD (mean FEV₁ = 54%pred) underwent PR consisting of exercise training, patient and psychosocial education, breathing and relaxation therapy, nutrition counseling, and smoking cessation support. Before and after PR, exercise capacity was assessed with 6-min walking tests (6MWT) and constant cycle ergometer exercise (CEE). Dyspnea was measured after 6MWTs with a Borg scale and after PR with the Transition Dyspnoea Index (TDI). HRQL was examined with the Medical Outcomes Study Short Form 36 (SF-36). Results showed improvements in the 6MWT (+39 m, p < 0.001) and CEE (+241 W × min, p < 0.001) after PR, paralleled by decreased dyspnea during the 6MWT (−0.5, p < 0.001) and during activities (TDI score = 3.6). Increases in all SF-36 subscales reflected improved HRQL after PR (p < 0.001). No gender differences were found. Patients with milder versus more severe COPD improved similarly in most outcomes. Regression analyses revealed that TDI scores were the most important predictor of improvements in HRQL. The results suggest that intensive 3-week outpatient PR is associated with improvements in exercise capacity, dyspnea, and HRQL in male and female patients with COPD irrespective of COPD severity. Reduced dyspnea during activities contributed the most to improvements in HRQL.     

Outpatient pulmonary rehabilitation for severe asthma with fixed airway obstruction: Comparison with COPD

Background: The benefit of exercise has been demonstrated in asthma, but the role of pulmonary rehabilitation (PR) in people with severe asthma, especially with airway obstruction, has been less investigated. The activity limitation mechanisms differ in asthma and COPD, so the effect of a PR program not specific to asthma is unclear. Methods: We retrospectively compared the effect of an ambulatory PR program in nonsmoking patients with severe asthma and airway obstruction (FEV1/FVC ratio <70% and FEV1?<?80% measured twice, not under an exacerbation) and sex-, age-, FEV1-, and BMI-matched COPD controls. Results: We included 29 patients, each with asthma and COPD. Airway obstruction was moderate (median FEV1 57% [44–64]). VO₂ at peak was higher for asthma than COPD patients (19.0 [15.7–22.2] vs 16.1 [15.3–19.6] ml.min^?1.kg^?1, p?=?0.05). After PR, asthma and COPD groups showed a significant and similar increase in constant work cycling test of 378 [114–831] s and 377 [246–702] s. Changes in Hospital Anxiety and Depression Scale (HAD) total score were similar (–2.5 [–7.0 to 0.0] vs –2.0 [–5.0 to 2.0], p?>?0.05). Quality of life on the St. George’s Respiratory Questionnaire (SGRQ) was significantly improved in both groups (–14.0 [–17.7 to –2.0], p?<?0.005 and –8.3 [–13.0 to –3.6], p?<?0.0001). Conclusion: Outpatient PR is feasible and well tolerated in patients with severe asthma with fixed airway obstruction. A nondedicated program strongly improves HAD and SGRQ scores and constant work-rate sub-maximal cycling, with similar amplitude as with COPD.     

Evaluation of health-related quality of life in low-income patients with COPD receiving long-term oxygen therapy

STUDY OBJECTIVE: To assess health-related quality of life (HRQL) in a low-income population of patients with hypoxemia and COPD receiving long-term oxygen therapy (LTOT). DESIGN: Cross-sectional study. SETTING: Large, tertiary care, university teaching hospital. Patients or participants: Thirty-six patients with COPD requiring LTOT (mean age, 63.5 years; mean FEV(1), 32.1% of predicted; PaO(2), 50.2 mm Hg) and 33 control subjects with COPD but no severe hypoxemia (mean age, 63.1 years; FEV(1), 35.7%; PaO(2), 66.5 mm Hg). INTERVENTIONS: Patients underwent pulmonary function testing to assess physiologic function and the degree of respiratory impairment. A baseline dyspnea index (BDI) was used to determine levels of dyspnea, and a 6-min walk test was performed to evaluate physical performance and exercise capacity. The St. George Respiratory Questionnaire (SGRQ) and the Medical Outcomes Study Short-Form 36-item questionnaire (SF-36) were used to assess health status and HRQL. Measurements and results: The scores on the SGRQ and SF-36 indicated severe impairment. Patients receiving LTOT showed a trend toward worse scores on most dimensions of the SGRQ and SF-36, but differences between groups were only statistically significant for the physical functioning and social functioning dimensions of the SF-36. Dyspnea, as measured by the BDI, significantly correlated with all questionnaire domains except the SF-36 pain index. CONCLUSIONS: The HRQL of these low-income patients with COPD was markedly impaired, with more pronounced impairment in those receiving LTOT. The severity of dyspnea was a significant predictor of various components of quality of life in these patients.     

Validation of the St George’s respiratory questionnaire and risks factors affecting the quality of life of Lebanese COPD and asthma patients

Objective: We aimed to validate the Arabic version of the St George’s Respiratory Questionnaire (SGRQ) for use in Lebanese Chronic obstructive pulmonary disease (COPD) and asthma patients and to identify risk factors that might affect the quality of life in these patients. Methods: COPD (n?=?90) and asthma patients (n?=?124) were recruited from the outpatient clinics of the Pulmonology department of a university hospital and a medical center in Beirut. They filled out a standardized questionnaire. The total SGRQ score and the component scores (symptoms, activity and impacts) were calculated. To confirm the SGRQ validity in the Lebanese population, factor analyses were applied for the whole sample, only asthma and only COPD patients, respectively. The associations between the total SGRQ score and FEV₁% predicted, CCQ score and MRC scale were assessed. Multiple linear regression models were used to evaluate the association between the total SGRQ scores and the socio-demographics and the diseases risk factors. Results: COPD patients had a higher SGRQ total and subscales scores compared to asthma patients. A high Cronbach’s alpha was found for the whole sample (0.802), only COPD patients (0.833) and only asthma patients (0.734). A significant negative correlation was found between FEV₁% predicted and the total SGRQ scores. Occupational exposure, BMI and previous waterpipe smoking were among the factors that significantly and positively influenced a higher SGRQ score. Conclusions: The Lebanese version of the SGRQ emerges as a good health-related quality of life evaluative instrument that is reasonable to be used in COPD and asthma patients in Lebanon.     

Assessing the Effectiveness of the COPD Assessment Test (CAT) to Evaluate COPD Severity and Exacerbation Rates

Aims: The CAT is a short, simple eight-item questionnaire for assessing and monitoring COPD. It is not known how reliable the CAT scores are for COPD patients who are frequently exacerbated. The effectiveness of the CAT for assessing COPD severity and exacerbation rates was evaluated. Methods: This study enrolled 165 stable COPD patients who completed the CAT between April 2011 and February 2012. Results: Patients had a mean forced expiratory volume in one second (FEV₁) equal to 43.7% of the predicted value and a mean CAT score of 21.2 (± 7.56) units. There was a good association between the FEV₁ (percentage of predicted value) and CAT scores (p < 0.0001). Frequent exacerbators had significantly higher CAT scores than infrequent exacerbators (24.8 ± 6.7 versus 17.5 ± 6.5, p < 0.0001). Also, as the frequency of the COPD exacerbations increased, CAT scores (p < 0.0001) significantly increased. There was a significant association between the frequency of hospitalization and the CAT scores (p = 0.001). Conclusions: We observed a good relation between the CAT, FEV 1, and disease severity in patients with COPD. We found that the baseline CAT scores are elevated in frequent exacerbators.     

Airway Eosinophilic Inflammation and Bronchial Hyperresponsiveness after Allergen Inhalation Challenge in Asthma

Allergen exposure in atopic asthmatic patients is associated with recruitment and activation of eosinophils in the airways. Once activated, eosinophils release toxic products, including the eosinophil cationic protein (ECP), able to damage bronchial structures and to increase bronchial hyperresponsiveness. With this background, the present study was designed to evaluate whether ECP levels in bronchoalveolar lavage (BAL) fluid could reflect, better than BAL eosinophil counts, the cellular activation that follows allergen exposure in atopic asthmatics. Twenty-two atopic patients attended the laboratory on two separate days. On the 1st day, they underwent methacholine (MCh) inhalation challenge to detect the degree of nonspecific bronchial hyperresponsiveness. On the 2nd day, they underwent fiberoptic bronchoscopy and BAL, at baseline or 4–6 h after allergen inhalation challenge. In this latter patient group, MCh challenge was repeated 3–5 h after allergen challenge, 1 h before fiberoptic bronchoscopy. The analysis of the mean baseline FEV₁ values and the degree of bronchial reactivity to MCh (MCh Pd₂₀) on the 1st study day did not demonstrate differences between the two patient groups (p > 0.1, each comparison). In addition, in the allergen-challenged group, MCh Pd₂₀ was decreased significantly after allergen challenge (151.4 μg/ml and 67.6 μg/ml, respectively, before and after challenge; p < 0.05). Evaluation of the different BAL cell types demonstrated that the proportions of eosinophils and epithelial cells were increased significantly in the allergen-challenged group compared with the group evaluated at baseline (p < 0.01 and p < 0.05, respectively). Moreover, ECP levels, corrected by the correspondent albumin levels (ECP/Alb), were higher in the allergen-challenged group compared with the group evaluated at baseline (p < 0.05). In addition, although a positive correlation was demonstrated between BAL eosinophil percentages and ECP/Alb values (r= 0.72, p < 0.05) in the group evaluated at baseline, no links were found between these parameters in the allergen-challenged group (p > 0.1). However, in this latter group, a weak positive correlation was demonstrated between eosinophil percentages and ΔMch, i.e., the increased nonspecific bronchial reactivity, which is observed after allergen challenge (r= 0.55; p < 0.05). Thus, in stable asthmatic patients an ongoing activation of eosinophils parallels their migration, but this eosinophilic inflammation is not strictly related to bronchial reactivity to Mch. By contrast, after allergen inhalation challenge, eosinophil recruitment and activation seem to follow different temporal kinetics, and eosinophilic inflammation may be partially associated with the degree of airway hyperresponsiveness. Accepted for publication: 15 September 1997     

Dynamic Expiratory Tracheal Collapse in Morbidly Obese COPD Patients

Abstract

Morbid obesity may influence several aspects of airway function. However, the effect of morbid obesity on expiratory tracheal collapse in COPD patients is unknown. We thus prospectively studied 100 COPD patients who underwent full pulmonary function tests (PFTs), 6-minute walk test (6MWT), Saint George's Respiratory Questionnaire (SGRQ), and low-dose CT at total lung capacity and during dynamic exhalation with spirometric monitoring. We examined correlations between percentage dynamic expiratory tracheal collapse and body mass index (BMI). The association between tracheal collapse and BMI was compared to a control group of 53 volunteers without COPD. Patients included 48 women and 52 men with mean age 65 ± 7 years; BMI 30 ± 6; FEV₁ 64 ± 22% predicted and percentage expiratory collapse 59 ± 19%. Expiratory collapse was significantly associated with BMI (69 ± 12% tracheal collapse among 20 morbidly obese patients with BMI ≥35 compared to 57 ±19% in others, p = 0.002, t-test). In contrast, there was no significant difference in collapse between healthy volunteers with BMI ≥ 35 and < 35. COPD patients with BMI ≥ 35 also demonstrated shorter 6MWT distances (340 ± 139 m vs. 430 ± 139 m, p = 0.003) and higher (worse) total SGRQ scores (48 ± 19 vs. 36 ± 20, p = 0.013) compared to those with BMI < 35. In light of these results, clinicians should consider evaluating for excessive expiratory tracheal collapse when confronted with a morbidly obese COPD patient with greater quality of life impairment and worse exercise performance than expected based on functional measures.     

Clinical Significance of Radiologic Characterizations in COPD

ABSTRACT

COPD is a heterogeneous disorder with clinical assessment becoming increasingly multidimensional. We hypothesized HRCT phenotype would strongly influence clinical outcomes including health status, exacerbation frequency, and BODE. COPD subjects were characterized via the SF-12, SGRQ, MMRC, physiologic testing, and standardized volumetric chest HRCT. Visual semi-quantitative estimation of bronchial wall thickness (VBT) and automated quantification of emphysema percent and bronchial wall thickness were generated. Multivariate modeling compared emphysema severity and airway abnormality with clinical outcome measures. Poisson models were used to analyze exacerbation frequency. SGRQ and SF-12 physical component scores were influenced by FEV₁% predicted, emphysema percent, and VBT. VBT scores > 2 (scale 0–48) were associated with increased exacerbation frequency (p = 0.009) in the preceding year adjusting for age, gender, emphysema percent, smoking history and FEV₁% predicted, although this effect was attenuated by age. Emphysema percent correlated with total BODE score in unadjusted (r = 0.73; p < 0.0001) and adjusted (p < 0.0001) analyses and with BODE individual components. HRCT provides unique COPD phenotyping information. Radiographic quantification of emphysema and bronchial thickness are independently associated with SGRQ and physical component score of the SF-12. Bronchial thickness but not emphysema is associated with exacerbation frequency, whereas emphysema is a stronger predictor of BODE and its systemic components MMRC, 6MWT, and BMI. Future research should clarify whether CT parameters complement BODE score in influencing survival.     

St. George's Respiratory Questionnaire Has Longitudinal Construct Validity in Lymphangioleiomyomatosis

BackgroundLymphangioleiomyomatosis (LAM) is an uncommon, progressive, cystic lung disease that causes shortness of breath, hypoxemia, and impaired health-related quality of life (HRQL). Whether St. George's Respiratory Questionnaire (SGRQ), a respiratory-specific HRQL instrument, captures longitudinal changes in HRQL in patients with LAM is unknown.MethodsUsing data from the Multicenter International Lymphangioleiomyomatosis Efficacy and Safety of Sirolimus trial, we performed analyses to examine associations between SGRQ scores and values for four external measures (anchors). Anchors included (1) FEV₁, (2) diffusing capacity of the lung for carbon monoxide, (3) distance walked during the 6-min walk test, and (4) serum vascular endothelial growth factor-D.ResultsSGRQ scores correlated with the majority of anchor values at baseline, 6 months, and 12 months. Results from longitudinal analyses demonstrated that SGRQ change scores tracked changes over time in values for each of the four anchors. At 12 months, subjects with the greatest improvement from baseline in FEV₁ experienced the greatest improvement in SGRQ scores (Symptoms domain, ?13.4 ± 14.6 points; Activity domain, ?6.46 ± 8.20 points; Impacts domain, ?6.25 ± 12.8 points; SGRQ total, ?7.53 ± 10.0 points). Plots of cumulative distribution functions further supported the longitudinal validity of the SGRQ in LAM.ConclusionsIn LAM, SGRQ scores are associated with variables used to assess LAM severity. The SGRQ is sensitive to change in LAM severity, particularly when change is defined by FEV₁, perhaps the most clinically relevant and prognostically important variable in LAM. The constellation of results here supports the validity of the SGRQ as capable of assessing longitudinal change in HRQL in LAM.     

Spirometric Thresholds for Diagnosing COPD: 0.70 or LLN,Pre- or Post-dilator Values?

Abstract

In absence of a gold standard for chronic obstructive pulmonary disease (COPD) it remains difficult to compare the true diagnostic characteristics of the forced expiratory volume in 1 second to the forced vital capacity (FEV₁/FVC) <0.70 and < lower limit of normal (LLN). COPD is a clinical diagnosis, based on symptoms signs and lung function results combined, and an expert panel assessment would be an adequate reference standard. We compared the diagnostic properties of FEV₁/FVC <LLN and <0.70 against this panel diagnosis: 342 participants, aged >50, consulting for persistent cough, but without physician-diagnosed COPD, were prospectively enrolled. All underwent extensive history taking, physical examination, spirometry and diffusion testing. An expert panel, including a board certified respiratory physician, assessed all diagnostic information to determine the presence or absence of COPD and served as reference standard. Then, 104 participants were diagnosed with COPD by the panel. The reproducibility of the panel diagnosis was high (kappa of 0.94). Sensitivity estimates of <0.70 were significantly higher than that of <LLN (0.73 and 0.47, respectively, p < 0.001). The fixed approach was less specific than the LLN (0.95 and 0.99, respectively, p < 0.001). There was no significant difference in diagnostic property when using pre- or post-bronchodilator FEV₁/FVC (p = 0.615). In a symptomatic primary care population, the FEV₁/FVC <0.70 was more accurate to detect COPD.     

Short Term Effects of Bracing on Exercise Performance in Mild Idiopathic Thoracic Scoliosis

In adolescent idiopathic thoracic scoliosis (ITS) working capacity may be reduced during exercise. Despite concern about its usefulness, bracing is still being used in ITS. Thus the effects of bracing on exercise performance need to be examined. We studied six females, ages 12–15 years who had mild ITS (Cobb angle range 20–35°). Pulmonary volumes, maximal voluntary ventilation (MVV), breathing pattern, the lowest (most negative in sign) pleural pressure during sniff maneuver (Ppl_sn), and pleural pressure swings (Ppl_sw) were measured first. Then, Ppl_sw, O₂ uptake (Vo ₂), CO₂ output (Vco ₂), heart rate (HR) at rest and during progressive incremental exercise on a cycling ergometer (10 watts/min) were recorded. The exercise test was performed under control conditions without bracing (C) and after 7 days of bracing with the brace on (B). Dyspnea was measured by a modified Borg scale. At rest, bracing mildly affected total lung capacity and forced vital capacity (p <0.03 for both) but not breathing pattern, Ppl_sn, or Ppl_sw(%Ppl_sn), a measure of respiratory effort. Furthermore, bracing did not consistently affect maximum work rate (WR_max). In both B and C VO₂ was below (<70%) the predicted value, Ve was below (<45%) MVV, and HR reserve was <15 beats/min, indicating some cardiovascular deconditioning. On the other hand, respiratory frequency (Rf) increased more in B than in C (p < 0.03). In addition, Ppl_sw, Ppl_sw(%Ppl_sn), and Ppl_sw(%Pplsn)/Vt, an index of neuroventilatory dissociation (NVD) of the respiratory pump, were greater in B (p < 0.03 for all). At a similar work rate, the Borg rating score was greater with bracing on than off, and the difference (ΔBorg) tended to relate to concurrent changes in Ppl_sw(%Ppl_sn)/Vt (r ²= 0.71; p < 0.07). We conclude that bracing affects respiratory effort, NVD, and dyspnea score during progressive exercise. These effects are consistent with increased lung elastance. Diminished exercise tolerance in patients with mild ITS probably reflects impaired physical fitness but is not affected by bracing. Training programs proposed for this subset of patients to increase peripheral muscle performance might also consider NVD of the respiratory pump. Accepted for publication: 27 January 1997     

A Comparison of the Assessment of Quality of Life with CAT,CCQ, and SGRQ in COPD Patients Participating in Pulmonary Rehabilitation

Abstract

Background: The aim of this study was to compare the COPD specific health-related quality of life (HR-QoL) instruments, the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT), and COPD Clinical Questionnaire (CCQ), in terms of feasibility and correlations in COPD patients participating in pulmonary rehabilitation (PR). Methods/materials: Ninety consecutive patients with mainly severe COPD who participated in a 7-week PR programme were assessed with CAT, CCQ, SGRQ. In addition to evaluating the scores obtained by the questionnaires we also assessed the need of help and the time needed to complete the questionnaires. Results: Patients had mean FEV₁ = 38.7% of predicted value and poor quality of life (mean SGRQ total score 51.1, CAT 1.81, and CCQ 26.5 units). There were good correlations between the overall scores for the three HR-QoL instruments: CAT versus CCQ, r = 0.77; CAT versus SGRQ, r = 0.73; and CCQ versus SGRQ, r = 0.75 (p < 0.001 for all correlations).

The average time to complete the questionnaires was 578 seconds for SGRQ, 107 seconds for CAT, and 134 seconds for CCQ. The need for assistance while answering the questionnaire was 86.5% for SGRQ, 53.9% for CAT, and 36.0% for CCQ. Conclusions : we observed a good correlation between the SGRQ, CCQ and CAT in this group of patients with severe COPD undergoing pulmonary rehabilitation. We found that CAT and CCQ have the advantage of being easier and faster to complete than the SGRQ. The need for help with the completion of the questionnaires was especially seen in patients with low education level.