Improving dyspnea management in three adults with chronic obstructive pulmonary disease.

This case report describes occupational therapy intervention for three adult outpatients with chronic obstructive pulmonary disease (COPD) at one large urban hospital. The occupational therapy intervention was based on the Management of Dyspnea Guidelines for Practice (Migliore, in press). The learning and practice of controlled breathing were promoted in the context of physical activity exertion in a domiciliary environment. In addition to promoting dyspnea management, the controlled-breathing strategies aimed to facilitate energy conservation and to increase perceived breathing control. Although no causality can be determined in a case study design, the patients' dyspnea with activity exertion decreased and their functional status and quality of life increased following goal-directed, individualized occupational therapy intervention combined with exercise training.     

The relationship between fear of movement,pain and fatigue severity,dyspnea level and comorbidities in patients with chronic obstructive pulmonary disease

Purpose: Dyspnea, sedentary lifestyle, and comorbid diseases may reduce the desire to engage in physical movement in chronic obstructive pulmonary disease (COPD). The aims of this study were to assess levels of kinesiophobia among stable COPD patients and evaluate the relationship between kinesiophobia and pain and fatigue severity, dyspnea level, and comorbidities in this patient group.

Material and Methods: Thirty-one patients with moderate/severe COPD and thirty-one age- and sex-matched healthy controls participated in the study. All participants were assessed using Visual Analog Scale for pain severity, Fatigue Severity Scale, modified Medical Research Council Dyspnea Scale, Charlson Comorbidity Index, and Tampa Scale of Kinesiophobia.

Results: Ninety-three percent of the patients with COPD had a high degree of kinesiophobia (Tampa Scale of Kinesiophobia score >37). The modified Medical Research Council Dyspnea Scale, Charlson Comorbidity Index, and Tampa Scale of Kinesiophobia scores of patients with COPD was significantly higher than those of healthy subjects (p?<?0.001). Tampa Scale of Kinesiophobia score was significantly associated with modified Medical Research Council Dyspnea Scale score (r?=?0.676, p?<?0.001), Charlson Comorbidity Index score (r?=?0.746, p?<?0.001) and fatigue severity level (r?=?0.524, p?=?0.005).

Conclusion: Most moderate/severe COPD patients express fear of movement. Kinesiophobia is strongly associated with dyspnea perception, fatigue severity, multisystemic comorbidities in COPD. Further studies are needed to determine the effects of kinesiophobia on the success of pulmonary rehabilitation.

• Implications for rehabilitation

• Most of moderate-to-severe chronic obstructive pulmonary disease patients have fear of movement.

• Increase fear of movement in moderate–severe chronic obstructive pulmonary disease is associated with increased dyspnea perception and fatigue severity and multisystemic comorbidities.

     

慢性阻塞性肺疾病患者疲劳的研究进展

慢性阻塞性肺疾病(Chronic Obstructive Pulmonary Disease,COPD)是一种常见的慢性疾病,老年人群中34.1%患有COPD[1].COPD是导致老年人死亡、躯体功能不全的主要原因之一[2].据预测,到2020年COPD将成为世界上导致功能残疾的第5位病因[3].疲劳被认为是COPD患者除呼吸困难外的第二大症状[4].本文从COPD患者疲劳问题的发现、疲劳对COPD患者心理和生理的影响、COPD患者疲劳的相关因素等方面展开综述.     

Management of dyspnea in severe chronic obstructive pulmonary disease

Progression of chronic obstructive pulmonary disease (COPD) is frequently associated with increasing dyspnea; indeed, patients with severe COPD constitute the largest group of patients with chronic respiratory insufficiency. The sensation of dyspnea in these patients is mostly related to increased work of breathing, a consequence of an increased resistive load, of hyperinflation, and of the deleterious effect of intrinsic positive end-expiratory pressure (PEEP(i)). Once optimal medical treatment has been provided, pharmacological treatments of dyspnea exist (beta2-agonists, methylxanthines, opiates) but seldom suffice. Nonpharmacological complementary treatments must be envisioned. Patients with severe hyperinflation should be screened as possible candidates for lung reduction surgery. Pulmonary rehabilitation-including chest therapy, patient education, exercise training-has been established as effective on quality of life (QoL) and dyspnea. Noninvasive positive pressure devices may be effective for symptomatic treatment of severe dyspnea: continuous positive airway pressure (CPAP) counteracts the deleterious effect of PEEP(i) in patients with severe hyperinflation; intermittent positive pressure breathing (IPPB) may decrease dyspnea and discomfort during nebulized therapy; finally noninvasive positive pressure ventilation (NIPPV) has been shown to be effective on the sensation of dyspnea and QoL in COPD with severe hypercapnia.     

中度稳定期慢性阻塞性肺疾病疲劳与多维度指标的关系

目的 探讨中度稳定期慢性阻塞性肺疾病(慢阻肺)患者疲劳与营养指标、生活质量指标、炎症指标、精神情绪指标的关系。方法 采用前瞻性研究,根据一般疲劳定义,从慢阻肺患者中随机选取中度稳定期慢阻肺疲劳患者30例(疲劳组)与中度稳定期慢阻肺非疲劳患者26例(非疲劳组)。收集两组一般资料、营养指标、生活质量指标、炎症指标、精神情绪指标,并进行比较。结果 两组性别、年龄、吸烟指数等方面差异无统计学意义(均P>0.05);与非疲劳组相比,疲劳组白蛋白、血红蛋白、体重指数、第1秒用力呼气容积占预计值的百分比(percent predicted forced expiratory volume in one-second, FEV1%)、6 min步行距离(6-minute walk distance, 6MWD)均显著降低(P<0.05),慢性阻塞性肺疾病评估测试(chronic obstructive pulmonary disease assessment test, CAT)评分、C反应蛋白(C-reactive protein, CRP)、降钙素原(procalcitonin, PC...     

慢性阻塞性肺疾病病人体力活动与运动自我效能的相关性研究

目的:探讨慢性阻塞性肺疾病(COPD)病人体力活动和运动自我效能的相关性.方法:采用方便抽样法抽取在苏州市某三级甲等医院120名住院COPD病人作为研究对象进行调查.结果:120例COPD病人体力活动总分中位数(四分位间距)为11.65(4.76,31.13)分;运动自我效能总分中位数(四分位数间距)为68.00(49.00,89.75)分;除职业性体力活动维度外,体力活动总分、休闲性及家务性体力活动得分与运动自我效能各条目得分呈显著正相关(P＜0.05);单独运动、没有他人支持、气短时运动自我效能是影响体力活动的独立因素.结论:COPD病人体力活动处于低水平,在制定以提高体力活动为目标的干预策略时,可通过呼吸症状控制、调整支持系统,以提高运动自我效能,进而促进体力活动行为.     

Factor analysis of laboratory and clinical measurements of dyspnea in patients with chronic obstructive pulmonary disease

The primary purpose of this study was to determine if there are three distinct factors representing ratings of dyspnea during laboratory exercise, clinical ratings of dyspnea, and pulmonary function in patients with moderate to severe chronic obstructive pulmonary disease (COPD) (n = 92) using factor analysis. Subjects (mean age 66 +/- 7 yrs; FEV1% predicted 44.7 +/- 14.0) were randomly assigned to one of three treatment groups to test the effects of three education and exercise training programs. Outcomes were evaluated at baseline and at 2 months after the intervention. Dyspnea ratings with laboratory exercise (SOB) were measured during incremental (ITT) and endurance (ETT) treadmill tests, and a six-minute walk (6MW) using the modified Borg scale. Clinical measures of dyspnea were measured with the Baseline and Transitional Dyspnea Index (BDI/TDI), UCSD Shortness of Breath Questionnaire (SOBQ), Medical Research Council Dyspnea Scale (MRC), Dyspnea subscale of the Chronic Respiratory Questionnaire (CRQ-D), and a global dyspnea question. Pulmonary function parameters included FEV1% predicted, FEV1/FVC, and RV/TLC. The factor analysis yielded three factors that accounted for 58.7% of the total variance in the data: Factor 1, "Dyspnea with Laboratory Exercise" comprised ETT SOB end, ETT SOB isotime, ITTSOB end, ITT SOB isotime, ITT SOB/Time and ETT SOB/Time. Factor 2, "Clinical Dyspnea," comprised 6MW SOB, 6MW SOB/Feet, BDI, SOBQ, MRC, Global SOB, CRQ-D. Measures of airway resistance (FEV1% predicted, FEV1/FVC) and hyperinflation (RV/TLC) loaded on a third factor, "Pulmonary Function." An additional post hoc factor analysis with post-intervention data provided similar results. The Global SOB question and ITT SOB isostage variables were relatively more sensitive to change compared to the other outcome variables. We conclude that pulmonary function, clinical ratings of dyspnea, and laboratory ratings of dyspnea are three separate and independent factors and should be included in the routine clinical evaluation of patients with COPD.     

Physical activity and cardiac autonomic dysfunction in patients with chronic obstructive pulmonary disease: A cross-sectional analysis

BackgroundThe cardiac autonomic function in patients with chronic obstructive pulmonary disease (COPD) has been poorly studied.ObjectivesWe aimed to 1) describe the cardiac autonomic function assessed by heart rate recovery (HRR) and chronotropic response (CR) during a 6-min walk test (6MWT) and afterward and 2) estimate the association of physical activity with HRR and CR in COPD patients.MethodsThis cross-sectional analysis included 320 patients with mild to very severe COPD. Physical activity (steps, time in any/moderate-to-vigorous/vigorous physical activity, intensity and sedentary time) was measured during 1 week by accelerometer. CR and HRR were measured during a 6MWT and 5 min after, respectively, and their association with physical activity parameters was estimated by multivariable linear regression models.ResultsPatients were 82% male and had a mean (SD) age 68 (8) years, post-bronchodilator FEV₁ 57 (18) % predicted, and walked a mean of 7716 (4139) steps/day. HRR was slow until 5 min after the 6MWT; the mean (SD) HRR was 15 (10), 22 (11), 25 (12), 25 (12) and 27 (12) bpm after 1, 2, 3, 4 and 5 min, respectively. The mean (SD) CR was 35% (16). After adjusting for relevant confounders, time in vigorous physical activity was significantly associated with a fast decrease in HRR (p = 0.044) and an increase in CR (p = 0.021). We found no independent association for other physical activity parameters.ConclusionA cardiac autonomic dysfunction is present in patients with mild to very severe COPD and is inversely related to the practice of vigorous physical activity.Trial registration ClinicalTrials.gov NCT01897298.     

Spirometric correlates of dyspnea improvement among emergency department patients with chronic obstructive pulmonary disease exacerbation

OBJECTIVE: To examine whether change in slow vital capacity (SVC) correlates to dyspnea improvement during emergency department (ED) treatment of chronic obstructive pulmonary disease (COPD) exacerbation. METHODS: We performed a prospective cohort study and enrolled consecutive patients during a 3-week period. ED patients > or = 55 years old with COPD exacerbation were asked to perform bedside spirometry shortly after ED arrival and again at discharge. SVC was measured first, then forced expiratory volume in the first second (FEV1), peak expiratory flow (PEF), and forced vital capacity (FVC). Concurrent with spirometry, patients rated their dyspnea on a 10-cm visual analogue scale. RESULTS: Thirty-six patients were enrolled. The median ED stay was 271 min (interquartile range 219-370 min). Seventy-one percent of the patients reported dyspnea improvement during their ED stay. Change in SVC was significantly higher among the patients whose dyspnea improved than among those whose did not (median increase of 0.15 L vs median decrease of 0.25 L, respectively, p < 0.01). By contrast, the change in spirometry values were similar for FEV1, PEF, and FVC (all p > 0.30). Spearman correlation supported these findings: SVC r = 0.45 (p = 0.02) versus nonsignificant correlation with FEV(1) (r = 0.33), PEF (r = -0.22), and FVC (r = 0.35). CONCLUSIONS: Increase in SVC significantly correlated with dyspnea improvement among ED patients with moderate-to-severe COPD exacerbation. Change in SVC merits consideration when evaluating therapeutic response during COPD exacerbation.     

踏车运动训练对慢性阻塞性肺病患者吸气肌力、呼吸困难和下肢疲劳程度的影响

目的 探讨踏车运动训练后慢性阻塞性肺病(COPD)患者运动耐力的改善与吸气肌力、呼吸困难和下肢疲劳程度的关系.方法 22例中、重度COPD患者分为康复组12例和对照组10例,康复组患者进行12周的下肢踏车运动训练.在运动训练前、后2组患者分别进行常规肺通气功能、弥散功能、肺容积、最大吸气压(MIP)、呼气气流受限(EFL)、症状限制递增功率心肺运动试验和恒定功率心肺运动试验.运动试验过程中同步进行Borg呼吸困难评分和下肢疲劳程度评分(BS).结果 训练后,康复组患者峰运动功率(WRpeak)显著提高(P<0.05);常规肺通气功能、弥散功能、肺容积指标无显著改善;5分法EFL评分无显著改善(P>0.05);最大吸气压显著增加(P<0.01);运动训练后等时间点Borg呼吸困难评分和下肢疲劳程度评分较前显著下降(P<0.01);△MIP(r=0.535,P<0.05)、△Borg(r=0.512,P<0.05)、△Bs(r=0.497,P<0.05)分别与△WRpeak呈显著正相关关系.结论 下肢踏车运动训练可能通过增加吸气肌肉力量,减轻COPD患者在运动过程中呼吸困难和下肢疲劳的主观感觉,改善运动耐力.

Abstract：

Objective To explore the relationship between improved exercise endurance and inspiratory muscle strength,dyspnea and lower limb fatigue in chronic obstructive pulmonary disease(COPD)patients. Methods Twelve moderate-to-severe COPD patients were given lower limb exercise training for 12 weeks.Routine tests of pulmonary ventilation function,diffusion function,lung volume,maximal inspiratory pressure(MIP),expiratory flow limitation(EFL),cycle ergometer exercise capacity and constant work rate capacity were administered before and after the training program.Borg's scale(BS)was used to assess dyspnea and lower limb fatigue was measured during the exercise tests.Results After training,the average peak work rate(W Rpeak)and average MIP both had increased significantly,but no significant change was observed in routine pulmonary ventilation function,diffusion function or lung volume.The 5-point EFL score showed no significant change.hut Borg's scale dyspnea scores and lower limb fatigue decreased significantly.The changes in W Rpeak were positively correlated with the MIP changes,Borg scale scores and changes in Borg scores.All of these relationships were statistically significant. Conclusion The improved exercise endurance of moderate-to-severe COPD patients after lower limb exercise training is due to increased inspiratory muscle strength and decreases in the sensation of dyspnea and lower limb fatigue.     

肺康复疗法改善慢性阻塞性肺疾病运动和呼吸功能的临床研究

目的:观察肺康复疗法改善慢性阻塞性肺疾病(COPD)患者运动能力和呼吸困难的临床效果。方法:选取2014年至2018年收治的COPD患者100例,采用随机数字表法将其随机分为对照组( n＝50)和观察组( n＝50)。对照组患者给予常规药物治疗,观察组患者在此基础上增加包含健康指导、氧疗、呼吸生...     

The relationship between physical activity and health status in patients with chronic obstructive pulmonary disease following pulmonary rehabilitation

Aim: To investigate the relationship between physical activity (PA) and measures of health-related quality of life (HRQoL) and hospital admissions in people with chronic obstructive pulmonary disease (COPD) following pulmonary rehabilitation (PR). Method: CINAHL, Medline, PubMed, AMED, PsycINFO and Cochrane Library (database inception to July 2014) were searched. Relevant outcomes included relationships between PA and HRQoL, lung function (forced expiratory volume in one?second, FEV₁) and/or hospital admission. Six quantitative and 11 qualitative studies were included and Harden’s method of data synthesis in a mixed-methods systematic review was applied. Results: Six months following PR, increase activity levels was associated with improvement of 62m in 6MWD, 2.31 and 15.55 points increase in SGRQ and CRDQ total scores, respectively, 1.3% FEV₁ and reduced dyspnoea. No study reported on hospital admission. Reported relationships were facilitated by healthcare professionals, social supporters, motivation and encouragement, reduced fear and seeing benefits and hindered by changing physical health, environment, lack of motivation, fear and social isolation. Conclusion: The associations between increased levels of PA and quality of life, respiratory function and dyspnoea are largely based on 6MWD and PA questionnaires. Objective measurement of free living activity in exercise maintenance phase is required along with participants’ views.

• Implications for rehabilitation

• Pulmonary rehabilitation (PR) is a non-therapeutic intervention in which a team of multidisciplinary health care professionals use individually tailored supervised exercise training, self-management education, psychological and social support to optimize the physical and social performance and autonomy of patients with chronic respiratory impairment. Initial benefits from PR decline after program completion.

• Clinical guidelines advocate increase exercise and activity in sustaining initial benefits of PR. Following PR, increased levels of physical activity in people with COPD undertaking exercise maintenance programmes are positively related with improvements in exercise capacity, quality of life and dyspnoea.

• Barriers to activity participation in exercise maintenance programmes, which need to be overcome, are fear, lack of motivation, environmental factors, such as social isolation and changes in physical health. Rehabilitation professionals and social supporters can make rehabilitation more long-lasting and facilitate people with COPD to participate in activity by motivating and encouraging them, reducing their fears and reinforcing the benefits of activity participation.

     

Soluble P-selectin as a marker of platelet hyperactivity in patients with chronic obstructive pulmonary disease.

A comparative analysis between soluble (s) P-selectin and von Willebrand Factor (vWF) was performed in 40 patients with chronic obstructive pulmonary disease (COPD) and 20 healthy subjects, with the aim of investigating whether the occurrence of elevated levels of sP-selectin may reflect activation of platelets, endothelial cells, or both. Plasma sP-selectin levels were significantly higher in patients compared to controls (P < 0.01). Similarly vWF levels were elevated in patients compared to healthy subjects, although the difference did not reach statistical significance. Lipoprotein (a) [Lp(a)] levels were lower in COPD patients than controls (P < 0.0001). The analysis of the correlation among all the variables demonstrated that plasma sP-selectin did not correlate with vWE. Conversely, plasma sP-selectin levels significantly correlated with either oxygen (rho = -0.41, P < 0.05) or carbon dioxide (rho = 0.47, P < 0.05) tension. An inverse correlation between serum Lp(a) and plasma sP-selectin levels (rho = -0.35, P < 0.05) was also observed. Moreover, increasing levels of sP-selectin in COPD patients significantly correlated with the impairment of blood gas tensions. In conclusion, the results obtained indicate the prominent platelet origin of circulating sP-selectin, suggesting that sP-selectin might be considered a marker of in vivo platelet activation in patients with COPD.     

Depression in patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in adults in the United States and worldwide. Depression is a common comorbidity in this population, but often goes undiagnosed in persons with COPD. Because the presence of depression has the potential to negatively impact COPD-related outcomes, it is essential for health care practitioners involved in the care of patients with COPD to diagnose and treat COPD and the associated comorbidities, including depression. Although there is a lack of comprehensive guidelines for treating depression in those with COPD, an algorithm has been proposed to screen and manage depression in these patients. Several questionnaires are available that can be used to assess and assist in diagnosing depression in these patients. Following diagnosis, antidepressant therapy should be considered along with nonpharmacological strategies, such as pulmonary rehabilitation and cognitive behavioral therapy.     

Fatigue in patients with chronic obstructive pulmonary disease

BACKGROUND: Fatigue is a frequently occurring symptom in patients with chronic obstructive pulmonary disease (COPD). Despite this, relatively few studies have objectively assessed patients' perceptions of fatigue and the impact of perceived fatigue on their everyday lives. OBJECTIVE: The purpose of this study was to describe the prevalence, duration and severity of fatigue among patients with COPD and the impact of perceived fatigue on cognitive, physical and psychosocial functioning in comparison with controls. METHOD: The Fatigue Impact Scale, including physical, psychosocial and cognitive dimension and structured questions about the frequency, duration, and severity of fatigue was mailed to 44 outpatients with COPD and 88 randomly selected age- and sex-matched controls. In total 36 patients and 37 controls completed the questionnaire. RESULTS: Almost half of the patients (47.2%), reported fatigue every day during the preceding month compared with 13.5% of the control group (P < 0.001). The duration of fatigue was more than 6 hours in 52.7% of the patients and 44.4% reported that fatigue was either the worst or one of the worst symptoms they had, compared with 18.9% (P < 0.001) and 10.8% (P < 0.01) in the control group. The patients reported a significantly greater impact of fatigue on cognitive, physical and psychosocial functioning compared with the control group (P < 0.001). CONCLUSION: These findings indicate that fatigue is a highly prevalent symptom, which impacts on patients' functional condition and needs to be professionally assessed and managed.     

Arrhythmias in patients with chronic obstructive pulmonary disease

Cardiac arrhythmias are commonly associated with chronic obstructive lung disease and these arrhythmias can impair arterial blood oxygenation. The etiology of the arrhythmias is multifactorial. The treatment of the arrhythmias is largely the treatment of the deranged physiology and the underlying pulmonary disease. The association of arrhythmias with chronic obstructive lung disease portends a poor prognosis.