Current status of noninvasive ventilation in stable COPD patients

Noninvasive ventilation (NIV) has been one of the major advances in respiratory medicine in the last decade. NIV improves quality of life, prolongs survival, and improves gas exchange and sleep quality in restrictive patients, but evidence available now does not allow us to establish clear criteria for prescribing NIV in patients with chronic respiratory failure due to COPD. On the basis of the available studies, NIV should not be used as a treatment of choice for all patients with COPD, even when disease is severe. However, there is more evidence that NIV has an important effect in these patients. In fact, a selected group of patients may well benefit from domiciliary mechanical ventilation, and we need to be able to identify who they are. Moreover, NIV can be a new strategy to improve exercise tolerance in COPD patients.     

Home noninvasive ventilation use in patients hospitalized with COPD

Introduction

The study objective was to estimate the prevalence of chronic hypercapnic respiratory failure (CHRF) and home noninvasive ventilation (NIV) use in a high-risk population, individuals with a history of at least one COPD-related hospitalizations.

Methods

We retrospectively analyzed electronic medical record data of patients with at least one COPD-related hospitalization between October 1, 2011, and September 30, 2017, to the Iowa City VA Medical Center. We excluded individuals with no obstructive ventilatory defect.

Results

Of 186 patients, the overall prevalence of compensated hypercapnic respiratory failure (CompHRF), defined as PaCO₂ > 45 mmHg with a pH = 7.35–7.45, was 52.7%, while the overall prevalence of home NIV was 4.3%. The prevalence of CompHRF was 43.6% and home NIV was 1.8% in those with one COPD-related hospitalization. Among those with ≥4 COPD-related hospitalizations, the prevalence of CompHRF was 77.8% (14 of 18), and home NIV was 11.1% (2 of 18).

Conclusion

Approximately half of individuals with at least one COPD-related hospitalization have CompHRF, but only 8.2% of those use home NIV. Future studies should estimate CHRF rates and the degree of underutilization of home NIV in larger multicenter samples.     

Effects of high-intensity exercise training in a pulmonary rehabilitation programme for patients with chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVES: The benefits of pulmonary rehabilitation for patients with COPD depend on the intensity of training. Traditional pulmonary rehabilitation programmes (PRPs) do not consistently achieve high-intensity training and have variable training effects. This study examined the effects of high-intensity exercise training on cardiac and pulmonary function in COPD patients. METHODS: Patients with COPD participated in a 6-week, cardiopulmonary exercise test-based PRP. Spirometry, 6-min walking distance and cardiopulmonary exercise test were used to evaluate cardiopulmonary function, respiratory muscle strength and endurance at rest, during exercise and before and after the programme. Patients were encouraged to complete high-intensity exercise with a targeted training intensity of at least 75% maximum oxygen uptake (VO(2)). RESULTS: Thirty-four COPD patients were enrolled into the study; 16 completed the high-intensity training, 18 did not. At the end of the 12-session PRP, submaximal exercise capacity (6-min walking distance, 461.8 +/- 77.2-502.7 +/- 66.9 m, P < 0.001) improved in both the patients who completed high-intensity training and those who did not. Only the patients who completed high-intensity training had significant improvements in FVC (2.47 +/- 0.70-2.70 +/- 0.62 L, P = 0.024) at rest, maximal exercise capacity (peak VO(2), 1001.6 +/- 286.4-1116.1 +/- 320.4 mL/min, P = 0.020) and work efficiency (7.3 +/- 1.4-8.4 +/- 1.8 mL/min/watt, P = 0.026). There was no statistically significant difference between the two groups in the change in the physiological parameters before and after exercise. CONCLUSIONS: Exercise training in a PRP improved submaximal exercise capacity. Only patients who completed high-intensity exercise training showed improvements in maximal exercise capacity, FVC and work efficiency.     

康复训练对稳定期COPD患者肺功能的影响

目的探讨心肺康复训练与稳定期COPD患者肺功能的相关性。方法以我院收治的稳定期COPD患者57例作为研究对象,分为两组:实验组(n=31),对照组(n=26)。对照组给予氧疗、祛痰以及吸入沙丁胺醇气雾剂等常规治疗,实验组在对照组治疗的基础上行心肺康复训练。观察并比较两组治疗前、后各项指标的变化。结果实验组第12周肺功能指标FEV1、FEV1/FVC及生活质量指数均较前明显改善,差异均有显著性(P0.05)。结论心肺康复训练可以改善COPD稳定期患者的肺功能及生活质量。     

A pulmonary rehabilitation program for patients with asthma and mild chronic obstructive pulmonary diseases (COPD)

The effects of a pulmonary rehabilitation program on 44 patients with chronic obstructive pulmonary disease (COPD) were compared to a control group. The treated group was admitted to the program for a period of three months. The program consisted of several parts, such as physical training, health education, and psychological and social matters. Before participation, the patients were thoroughly examined and provided with optimal medical treatment. Both groups were assessed by means of biometrical tests and questionnaires for a period of 2 years. The rehabilitation group improved significantly in endurance, psychological parameters, and consumption of medical care. Working days increased and their way of life became more active. Smoking habits and body fat percentage decreased. Bronchial hyperreactivity, need for pulmonary drugs, and coughing and sputum production did not improve in the rehabilitation group compared to the control group. Airway obstruction, expressed as forced expiratory volume in one second, and complaints of dyspnea, allergy and hyperreactivity scores on questionnaires improved only in the short term (<1 year), but did not improve significantly in the long term. This study shows that pulmonary rehabilitation can result in improvements in patients with asthma or COPD who have many complaints despite the fact that their pulmonary function is not severely disturbed.     

无创机械通气治疗慢性阻塞性肺疾病急性加重期呼吸衰竭合并肺大泡的疗效观察

目的观察无创正压通气（NIPPV）辅助治疗慢性阻塞性肺疾病急性加重期呼吸衰竭合并多发性肺大泡患者的临床疗效。方法选择呼吸监护病房住院的57例患者为研究对象,随机分为2组,治疗组30例,对照组27例,2组均进行一般治疗,同时治疗组给予无创通气治疗,吸气压（IPAP）自8~12 cmH2O开始,压力逐渐上升至16~20 cmH2O。呼气压（EPAP）自2~4 cmH2O开始,氧流量2~5 L/min维持氧饱和度（SaO2）〉90%,治疗后2h、24 h、2 d、5 d复查动脉血气,并观察治疗前后临床表现及动脉血气结果。结果治疗组治疗48 h后,pH从治疗前（7.31±0.12）改善至治疗后（7.36±0.17）,差异无统计学意义;动脉血二氧化碳分压（PaCO2）从治疗前（69.17±11.09）mmHg下降至治疗后（38.11±11.12）mmHg（P〈0.05）,动脉血氧分压（PaO2）从治疗前（50.08±12.12）mmHg上升到（70.11±14.15）mmHg,差异有统计学意义;对照组PaO2、PaCO2也较治疗前好转,差异有统计学意义（P〈0.05）。治疗组有28例患者治疗后临床症状改善,气促减轻,有效率为93.3%,对照组有效率为66.6%,差异有统计学意义（P〈0.05）。治疗组的气管插管率和平均住院天数均低于对照组,差异有统计学意义（P〈0.05）。结论无创机械通气对于慢性阻塞性肺疾病急性加重期呼吸衰竭合并肺大泡疗效肯定,只要采取合理的通气策略,不会出现气胸等并发症,值得临床应用。     

Target-flow inspiratory muscle training at home and during pulmonary rehabilitation in COPD patients with a ventilatory limitation during exercise

The effects of a 10-week inspiratory muscle training (IMT) program at home were compared to IMT during a 10-week pulmonary rehabilitation program (PR) in 40 COPD patients with a ventilatory limitation of the exercise capacity. IMT was performed with a target-flow resistive device; the generated mouth pressure as well as the duty cycle were imposed. The mean age of the patients was 59, the mean FEV₁ was 48% of predicted. In the training period the inspiratory muscle strength improved in both groups to the same degree. EMG fatigability of the diaphragm improved in the PR + IMT group, but not in the IMT group. In theIMT group, the 12-min walking distance increased after the training period, but maximal workload (W_max), , and ADL scores did not change. In thePR + IMT group, however, W_max, , walking distance, and ADL scores improved significantly after the training period. Walking distance and ADL scores showed a significantly greater improvement in the PR + IMT group than in the IMT group. It is concluded that both isolated IMT and PR + IMT in COPD patients with a ventilatory limitation have a beneficial effect on inspiratory muscle strength, but PR + IMT improves the physical exercise capacity significantly more than IMT alone.     

Improvements in exercise capacity during a 4-weeks pulmonary rehabilitation program for COPD patients do not correspond with improvements in self-reported health status or quality of life

Ninety-two patients with moderate or severe chronic obstructive pulmonary disease (COPD) were assessed for walking tolerance, lung function, perceived health status (HS), perceived quality of life (QoL) and anxiety before and after a four weeks inpatient pulmonary rehabilitation (PR) program. There were significant improvements on all outcomes except anxiety, although the effect sizes were small or moderate. The largest improvement was observed on the walking test, but patients also improved on perceived health status (HS) and perceived quality of life (QoL). Relations between outcome indicators were analyzed cross-sectionally and longitudinally. Cross-sectional correlations were in line with earlier studies. However, improvements on the walking test were generally unrelated to changes in lung function, HS and QoL. Different patients improve on different outcome measures following PR, and this could have implications for the planning and designs of PR programs.     

Noninvasive ventilation in pulmonary rehabilitation of COPD patients

Noninvasive positive pressure ventilation (NIPPV) has been shown to improve exercise tolerance and health-related quality of life in patients with advanced COPD. This study tested the feasibility of nocturnal NIPPV as an additional tool in a hospital-based pulmonary rehabilitation program. This prospective observational trial included forty COPD patients in GOLD stage IV. NIPPV was successfully introduced and accepted during sleep by all patients. All patients received pressure support ventilation for 7.9 ± 0.5 h per day with an inspiratory support of 17.5 ± 4.4 cmH₂O, and an expiratory pressure of 4.5 ± 0.9 cmH₂O. The outcome of pulmonary rehabilitation in patients receiving nocturnal NIPPV was compared with the results of forty matched control patients who underwent the same program. Rehabilitation with nocturnal NIPPV resulted in the 6-minute walk test and in the longest non-stop walk distance in improvements of 82 and 89 m, respectively, while patients without nocturnal ventilatory support improved by 50 and 51 m (p < 0.04 and p < 0.03 between groups, respectively). Further significant improvements were found for FEV₁, lung hyperinflation, and blood gases in the NIPPV treated, but not in the control subjects. Health-related quality of life, assessed by the SF-36 questionnaire, improved moderately or largely in patients receiving NIPPV in the categories role-physical, vitality, social function, and mental health. Control subjects improved moderately in vitality only. In conclusion, nocturnal NIPPV is feasible and enhances the effects of pulmonary rehabilitation in advanced stage COPD.     

Effects of transdermal tulobuterol on dyspnea and respiratory function during exercise in patients with chronic obstructive pulmonary disease

Background

Poor exercise tolerability is a major barrier to improving the quality of life of patients with chronic obstructive pulmonary disease (COPD). Although COPD is often treated with long-acting β₂ adrenergic agonists, few studies have examined their effects on exercise tolerability.

Methods

In this study, Japanese COPD patients were treated with 2 mg transdermal tulobuterol, a long-acting β₂ agonist, once daily for 4 weeks. Spirometry and exercise tests were conducted at baseline and at the end of treatment. The patients conducted constant load (30 W for 5 min) and incremental load (starting at 10 W and increasing by 10 W every 1 min for 5 min to a maximum load of 50 W) exercise tests on a cycle ergometer.

Results

Thirteen patients with stable COPD participated in this study (mean age ± standard deviation (SD), 69.5±9.7 years; smoking history 55.9±27.8 pack-years). Resting spirometric parameters were unchanged at the end of treatment. The maximum Borg scale for dyspnea and the Borg scale slope (BSS) decreased significantly from baseline to the end of treatment. The threshold load of dyspnea (TLD) increased slightly, although not significantly, in the constant load test but not in the incremental load test. There were no changes in respiratory parameters during exercise after treatment.

Conclusions

In conclusion, we found that treatment with transdermal tulobuterol for 4 weeks improved self-assessed dyspnea in Japanese COPD patients during constant and incremental exercise tests. This improvement in dyspnea may encourage patients to perform daily life activities or regular physical activity.     

肺康复对稳定期慢性阻塞性肺疾病的疗效分析

目的探讨肺康复锻炼对稳定期慢性阻塞性肺疾病患者的临床疗效及意义。方法 300例稳定期慢阻肺患者,采用前瞻性随机对照法分为两组:康复组(n=149)给予门诊慢阻肺健康宣教,包括饮食干预,戒烟教育,用药指导;肺康复锻炼(呼吸运动训练联合步行运动训练)。对照组(n=151)仅给予门诊慢阻肺健康宣教。比较6个月后两组患者的血气分析、肺功能、6MWD(6分钟步行距离)及慢阻肺急性加重期住院的次数等。结果 6个月后共234例完成试验,康复组(n=121)较对照组(n=113)的6MWD,血气分析等指标有明显改善,具有统计学意义(P0.05),而两组间肺功能FEV_1/FVC、FEV_1%和慢阻肺急性加重期住院的次数无统计差异(P0.05)。结论肺康复锻炼(呼吸运动训练联合步行运动训练)能有效提高PaO_2及降低PaCO_2,提高6MWD,适度改善运动耐力,是一种简便易行的康复锻炼方法,值得临床应用及推广。     

Improvements in outcomes for chronic obstructive pulmonary disease (COPD) attributable to a hospital-based respiratory rehabilitation programme

Aim: To determine whether the benefits of pulmonary rehabilitation, demonstrated in selected subjects in randomised controlled studies, can be achieved by a hospital-based respiratory rehabilitation programme conducted as part of routine clinical management. Methods: Design: A prospective longitudinal study of patients with severe chronic obstructive pulmonary disease (COPD) enrolled in a hospital based, non-medically supervised, outpatient, respiratory rehabilitation programme was undertaken. The rehabilitation programme was of pragmatic design and content, supervised by respiratory physiotherapists and comprised seven two hour sessions over one month for groups of six to eight patients. It included education on disease management, practical instruction in coping skills, as well as a progressive aerobic exercise programme for specific muscle training related to functional activities. Subjects were assessed prior to the programme but after optimisation of pharmacologic therapy, at the completion of the programme and at three months and six months post-programme. Principal outcome parameters were exercise capacity (as assessed by a six minute walk distance [MWD] test), degree of perceived breathlessness and quality of life (QOL) (assessed by the Chronic Respiratory Disease Questionnaire [CRDQ]). Results: Fifty-one subjects with severe COPD (Fev₁=0.9±0.4 1) completed the programme. There was a significant improvement in exercise capacity (a six MWD test improved from 375±126 m at baseline to 440±109 m at three months, p<0.005). There were significant improvements in QOL (in the total CRDQ score as well as in the domains of dyspnoea, fatigue and mastery). There was a reduction in the level of perceived dyspnoea (modified Borg Scale). Most improvements were maintained for three and six months following completion of the programme. Compared with the six months preceding the programme there was a reduction in hospital admissions and reduction in courses of oral steroids. Conclusions: An outpatient, hospital-based respiratory rehabilitation programme pragmatically adapted for clinical utility produces substantial and clinically significant improvements in exercise tolerance and QOL, similar in type and magnitude to those obtained in controlled clinical trials. There was an associated reduction in COPD-related morbidity. Such gains were mostly maintained for six months after completion of the programme. Thus respiratory rehabilitation must be regarded as an essential component of a comprehensive clinical programme for the management of COPD.     

无创正压通气治疗COPD并肺性脑病疗效观察

目的探讨无创正压通气对COPD并肺性脑病的治疗效果。方法60例COPD并肺性脑病患者随机分人观察组及对照组,对照组仅行常规药物治疗,观察组在常规药物治疗的基础上加用无创正压通气治疗。比较治疗开始2h、24h、48h两组同期血气及临床等改变情况。观察轻中重度肺性脑病无创正压通气效果。结果观察组同期血气、神志改善明显高于对照组,而死亡率低于对照组（P均〈0．05）。轻中度肺脑无创通气效果好于重度患者。结论无创通气对COPD并肺性脑病患者尤其是轻中度患者有确切疗效。     

Observational studies of a one year self-management program and a two year pulmonary rehabilitation program in patients with COPD

Objective:

To describe the outcome of a one year self-management program (SMG) and a two year pulmonary rehabilitation program (PRG).

Methods:

Two open prospective observational studies with 30 patients in each study. SMG had 46 hours over 12 months. PRG had in addition three weekly exercise sessions parallel which lasted an additional year.

Results:

In SMG, health-related quality of life (HRQoL, measured by St. George’s Respiratory Questionnaire) had an improvement of −3.6 points (95% CI −6.7 to −0.5) one year after the end of the intervention, but there was no change in the six minutes walking test (6MWT). The PRG had an improvement in HRQoL at the end of the intervention of −11.2 points (95% CI −13.9 to −8.4) and the 6MWT was clinically significant improved with 86 metres (95% CI 63 to 109). None of the groups showed any clinical relevant change in lung function.

Conclusion:

Participants in the SMG had had an improvement in quality of life and no deterioration in exercise tolerance one year after the end of the program compared to the start. Participants in the PRG significantly improved their quality of life and exercise tolerance the first year, but had no further clinical relevant improvement the second year.     

Bi-level Positive Airway Pressure (BiPAP) with Standard Exhalation Valve Does Not Improve Maximum Exercise Capacity in Patients with COPD

Background: Although BiPAP has been used as an adjunct to exercise, little is know about its effect on exercise in COPD. We aimed to evaluate the acute effect of BiPAP delivered with a standard valve (Vision, Respironics), compared to no assist, on exercise capacity in individuals with COPD. Methods: Peak exercise workload (WL_peak), dyspnea (Borg), end-expiratory lung volume (EELV), tidal volume (V_T), minute ventilation (V_E), O₂ uptake (VO₂), and CO₂ production (VCO₂) were assessed in 10 COPD patients (FEV₁ 53 ± 22% pred) during three symptom-limited bicycle exercise tests while breathing i) without a ventilator (noPS), ii) with a pressure support (PS) of 0 cm H₂O (PS0; IPAP & EPAP 4 cm H₂O) and iii) PS of 10 cm H₂O (PS10; IPAP 14 & EPAP 4 cm H₂O) on separate days using a randomized crossover design. Results: WL_peak was significantly lower with PS10 (33 ± 16) and PS0 (30.5 ± 13) than noPS (43 ± 19) (p < 0.001). Dyspnea at peak exercise was similar with noPS, PS0 and PS10; at isoload it was lower with noPS compared to PS10 and PS0 (p < 0.01). V_T and V_E were highest with PS10 and lowest with noPS both at peak exercise and isoload (p < 0.001). EELV was similar at peak exercise with all three conditions. VO₂ and VCO₂ were greater with PS10 and PS0 than noPS (p < 0.001), both at peak exercise and isoload. Conclusion: Use of BiPAP with a standard exhalation valve during exercise increases V_T and V_E at the expense of augmenting VCO₂ and dyspnea, which in turns reduces WL_peak in COPD patients.     

无创正压机械通气对重度慢性阻塞性肺疾病稳定期患者的治疗作用

目的探索无创正压机械通气（NPPV）长期家庭治疗重度慢性阻塞性肺疾病（COPD）稳定期患者的治疗作用。方法将40例经住院治疗处于稳定期的重度COPD患者，分为治疗组（常规治疗＋NPPV）20例和对照组（常规治疗）20例。分别记录治疗前、治疗2年后的肺功能、动脉血气、6min行走距离（6MWO）；病死率及每年住院次数等指标。结果治疗组与对照组的年龄、性别、身高、体重、动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）、用力肺活量（FVC）、第一秒用力呼气容积（FEV1）、6MWD、每年住院次数均具有可比性（t值分别为0．42、3．84、0．29、0．42、0．29、0．32、1．01、1．65、0．38、0．23，P均〉0．05）。2年后治疗组死亡5例，对照组死亡8例，两组比较差异无统计学意义（χ^2=3．84，P〉0．05）。2年后治疗组PaO2、PaCO2、6MWD、每年住院次数与对照组比较差异均有统计学意义（t值分别为0．29、7．25、0．32、6．26、1．01、6．2、1．65、3．44、0．38、3．02、0．23、7．62，P均〈0．05）。结论长期家庭无创正压机械通气对有选择性稳定期重度COPD患者治疗作用较为肯定。     

无创正压通气治疗COPD合并早期肺性脑病临床分析

目的探讨无创正压通气对COPD合并早期肺性脑病患者的治疗效果。方法 36例慢阻肺合并肺性脑病患者给予S/T模式无创正压通气,总结治疗前后血气变化、临床转归。结果 36例中1例改气管插管机械通气,4例放弃治疗,28例好转出院,有效率77.8%。结论 S/T模式无创正压通气对部分合并肺性脑病的患者仍然有效,临床可以谨慎扩大适应症。     

无创通气治疗COPD合并重症呼吸衰竭的作用

目的评价无创通气治疗慢性阻塞性肺疾病(COPD)合并重症呼吸衰竭的价值。方法45例COPD合并重症呼吸衰竭患者随机分为两组:常规治疗+无创通气组(A组)和常规治疗组(B组)。A组30例在常规治疗的同时采用B iPAP呼吸机进行辅助通气。B组15例患者给予常规治疗。结果45例COPD合并急性重症呼吸衰竭的病人中,A组24 h神志明显改善,PaCO2明显下降。治疗组的插管率、死亡率及住院时间均低于对照组,差异有显著性。结论无创通气为COPD合并呼吸衰竭进一步的治疗提供了宝贵的时间,大大提高了生存率。