The functional impact of an individualized, graded, outpatient pulmonary rehabilitation in end-stage chronic obstructive pulmonary disease

OBJECTIVE: To evaluate the functional impact of an individualized outpatient pulmonary rehabilitation program in end-stage chronic obstructive pulmonary disease (COPD). METHODS: Patients with end-stage COPD were admitted into a 6-week comprehensive outpatient pulmonary rehabilitation program that was "packaged" for each patient. We compared spirometric parameters, exercise tolerance, level of breathlessness, and intensity of work before and after rehabilitation. RESULTS: Of 45 eligible patients, only 14 consented to participate in the study. All 14 patients had forced expiratory volume in 1 second <35% of predicted, and 10 patients (72%) had a 6-minute walk test <180 m. The level of breathlessness was between 7 (moderate to severely breathless) and 10 (maximally breathless) on the Visual Analogue Scale in all patients. After the program, there was significant improvement in the FEV 1 P = 0.04), forced vital capacity P = 0.0045), 6-minute walk test P = 0.00047), and shuttle-walk test (9 of 14 patients). All patients had some improvement in level of dyspnea. CONCLUSIONS: Individualized outpatient pulmonary rehabilitation in end-stage COPD can produce a measurable improvement in spirometry and exercise tolerance with a favorable impact on the level of physical activity.     

Risk factors for hospital readmission in patients with chronic obstructive pulmonary disease

BACKGROUND: Hospital readmissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) are one of the leading causes of health care expenditures worldwide. OBJECTIVES: To identify risk factors for hospital readmission in COPD patients. METHODS:We prospectively evaluated 129 consecutive patients hospitalized for acute exacerbation of COPD. Clinical, spirometric and arterial blood gas variables were measured during hospitalization. Socioeconomic characteristics, comorbidity, dyspnea, functional dependence, depression, social support and quality of life were also analyzed. Readmission was defined as one or more hospitalizations in the following year. RESULTS:During the follow-up period, 75 (58.5%) patients were readmitted. In bivariate analysis, readmission was associated with previous hospitalization for COPD in the past year, dyspnea scale, PaCO(2) at discharge, depression, cor pulmonale, chronic domiciliary oxygen and quality of life measured by the St. George's Respiratory Questionnaire. In multivariate analysis, the best predictor of readmission was the combination of hospitalization for COPD in the previous year (odds ratio, OR: 4.27; 95% confidence interval, CI: 1.5-12), the total score of the St. George's Respiratory Questionnaire >or=50 points (OR: 2.36; 95% CI: 1.03-5.04) and PaCO(2) at discharge >or=45 mm Hg (OR: 2.18; 95% CI: 0.84-5.06). With this model, the probability of readmission for patients without any of these variables was 7%, while it was 70% for the patients with all three variables present. CONCLUSION: The combination of quality of life, hospitalization for COPD in the previous year and hypercapnia at discharge are useful predictors of readmission at 1 year.     

Depressive symptoms and chronic obstructive pulmonary disease: effect on mortality, hospital readmission, symptom burden, functional status, and quality of life

BACKGROUND: Depressive symptoms are common among patients with chronic obstructive pulmonary disease (COPD), but depression's impact on COPD outcomes has not been fully investigated. We evaluated the impact of comorbid depression on mortality, hospital readmission, smoking behavior, respiratory symptom burden, and physical and social functioning in patients with COPD. METHODS: In this prospective cohort study, 376 consecutive patients with COPD hospitalized for acute exacerbation were followed up for 1 year. The independent associations of baseline comorbid depression (designated as a Hospital Anxiety and Depression Scale score of > or =8) with mortality, hospital readmission, length of stay, persistent smoking, and quality of life (determined by responses to the St George Respiratory Questionnaire) were evaluated after adjusting for potential confounders. RESULTS: The prevalence of depression at admission was 44.4%. The median follow-up duration was 369 days, during which 57 patients (15.2%) died, and 202 (53.7%) were readmitted at least once. Multivariate analyses showed that depression was significantly associated with mortality (hazard ratio, 1.93; 95% confidence interval, 1.04-3.58), longer index stay (mean, 1.1 more days; P = .02) and total stay (mean, 3.0 more days; P = .047), persistent smoking at 6 months (odds ratio, 2.30; 95% confidence interval, 1.17-4.52), and 12% to 37% worse symptoms, activities, and impact subscale scores and total score on the St George Respiratory Questionnaire at the index hospitalization and 1 year later, even after controlling for chronicity and severity of COPD, comorbidities, and behavioral, psychosocial, and socioeconomic variables. CONCLUSIONS: Comorbid depressive symptoms in patients with COPD are associated with poorer survival, longer hospitalization stay, persistent smoking, increased symptom burden, and poorer physical and social functioning. Interventions that reduce depressive symptoms may potentially affect COPD outcomes.     

Exacerbations and time spent outdoors in chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease have a progressive reduction in activity, although its time scale and the contribution of exacerbations are unknown. A rolling cohort of 147 patients (101 male; mean age, 88.5 years; and forced expiratory volume in 1 second as percent predicted, 38.4%) were monitored for a median of 1,044 days (interquartile range, 685 to 1,779) over an 8-year period starting in March 1996. Patients recorded any increase in daily respiratory symptoms and time spent outside their home. They completed the St. George's Respiratory Questionnaire yearly. They experienced 1,465 exacerbations and time outdoors decreased by -0.16 hours/day per year (p < 0.001). This decline was faster in frequent exacerbators (p = 0.011). Before exacerbation, the patients stayed indoors all day for 2.1 days/week (on any day 34.1% were at home), but for 5 weeks postexacerbation they spent 2.5 days/week at home (p < 0.001) (44.4% remaining at home at onset; p = 0.021). St. George's total, activity, and impact scores were independently associated with time outdoors (p < 0.005), but not with symptom score. In conclusion, time spent outside the home declines over time and acutely at exacerbation. Patients with frequent exacerbations are more likely to become housebound and need targeting in rehabilitation programs.     

慢性阻塞性肺疾病患者3年健康相关生活质量的变化及危险因素的分析

目的 探讨生活中COPD患者3年健康相关生活质量(health-related quality of life,HRQoL)的变化规律及影响生活质量变化的可能危险因素.方法 基于慢性呼吸病管理中心数据库3年的COPD患者临床资料,采用回顾性研究,利用圣乔治呼吸问卷(Saint George's Respiratory Questionnaire,SGRQ)评估HRQoL,分析SGRQ随时间变化规律;根据SGRQ 3年变化值进行分组,利用Logistic回归探寻影响HRQoL变化的危险因素.结果 60例COPD患者中63.3％～83.3％的患者经吸入激素联合长效支气管舒剂治疗后,SGRQ总分及各部分评分与基线值比较无明显上升(t值分别为:0.147、-0.014、0.335、0.227,P值均＞0.05),FEV1、FEV1％pred、6分钟步行距离较基线值下降(t值分别为:3.943、6.974、3.977,P值均＜0.05),BODE指数较基线值上升(t=-9.916,P＜0.05);其中生活质量相对稳定者36例(60％),多因素Logistic回归提示BODE指数升高是HRQoL下降的独立危险因素(OR =1.686,P=0.017),重度急性加重次数对其下降亦有影响(OR=3.316,P=0.052).结论 生活中大部分COPD患者经吸入激素联合长效支气管舒张剂治疗后生活质量相对稳定,除药物影响外,BODE指数升高是生活质量下降的独立危险因素,重度急性加重次数可能也对健康相关生活质量的变化具有预测价值.     

Effects of pulmonary rehabilitation in patients with idiopathic pulmonary fibrosis

Background and objective:   Although pulmonary rehabilitation is effective for patients with COPD, its efficacy in patients with IPF is unknown. The purpose of this study was to evaluate the effects of pulmonary rehabilitation in IPF.
Methods:   Thirty patients diagnosed with IPF, according to the consensus statement, were randomly assigned to the rehabilitation group or the control group. The pulmonary rehabilitation mainly consisted of a 10-week programme of exercise training. Pulmonary function, blood gas analysis, 6MWD, dyspnoea rating with the baseline dyspnoea index and health-related quality of life score on the St George's Respiratory Questionnaire were evaluated at baseline and after the programme.
Results:   Assessment of efficacy was carried out on 13 patients who completed the programme and 15 patients in the control group. There were no significant effects of the programme on measures of pulmonary function, values of arterial blood gas analysis or dyspnoea rating. Although there were some differences in the baseline 6MWD and total health-related quality of life score which were not statistically significant, marked improvements were observed in the 6MWD (mean difference 46.3 m (95% CI: 8.3–84.4), P  < 0.05) and the total health-related quality of life score (−6.1 (95% CI: −11.7 to −0.5), P  < 0.05).
Conclusions:   Pulmonary rehabilitation improves both exercise capacity and health-related quality of life in patients with IPF.     

Regular walking and long-term maintenance of outcomes after pulmonary rehabilitation

BACKGROUND: Empirical evidence supports the role of exercise as part of pulmonary rehabilitation in improving symptoms of breathlessness (dyspnea), health-related quality of life, and exercise tolerance among patients with chronic lung disease. However, many studies show that these initial benefits tend to diminish 12 to 18 months after rehabilitation. Given the importance of exercise (ie, walking) during rehabilitation, we examined whether patient adherence to regular walking enhanced the long-term maintenance of functional benefits gained from an 8-week pulmonary rehabilitation program. METHODS: One hundred twenty-three patients with moderate to severe chronic lung disease completed an 8-week pulmonary rehabilitation program and participated in a 12-month maintenance intervention trial. Measures of weekly walking, lung function, self-efficacy for walking, dyspnea during activities of daily living, exercise capacity (6-minute walk test, 6MW), perceived breathlessness after the 6MW, and health-related quality of life were obtained at postrehabilitation, and at 6, 12, and 24 months after completing pulmonary rehabilitation. Regular walkers were defined as those active on most days or every single day of the week on the average throughout the 24-month period, whereas irregular walkers walked on some days, rarely, or not at all. RESULTS: The effects of the maintenance program on average frequency of walking were nonsignificant, with 44% of the maintenance patients and 38% of the standard care patients classified as regular walkers. There were no significant differences between walking groups on gender, healthcare utilization over the 24-month follow-up period, and postrehabilitation measures of lung function, 6MW distance, perceived breathlessness after 6MW, health-related quality of life, dyspnea, or age. Repeated measures analyses of variance using a 2 x 4 mixed model approach were applied to examine group differences and changes in outcomes over time. Overall, participants decreased in 6MW distance (P <.001), reported increases in perceived breathlessness after the 6MW (P <.05), and decreased in overall health-related quality of life (P <.001) from postrehabilitation to 24 months. Regular walkers reported significantly better health-related quality of life (P <.05) as compared to irregular walkers, averaging across time points. Irregular walkers declined significantly more than regular walkers on measures of shortness of breath during activities of daily living (P <.01) and walking self-efficacy (P <.001) from postrehabilitation to 24 months. CONCLUSIONS: Findings suggest that participation in regular exercise such as walking after completing pulmonary rehabilitation is associated with slower declines in overall health-related quality of life and walking self-efficacy as well as less progression of dyspnea during activities of daily living. Regular exercise after rehabilitation may be protective against increases in dyspnea symptoms and perceived limitations in walking which are both characteristic of progressing chronic lung disease.     

An evaluation of the acute impact of pursed lips breathing on walking distance in nonspontaneous pursed lips breathing chronic obstructive pulmonary disease patients

This study was designed to test the effects of pursed lips breathing (PLB) during exercise in patients with chronic obstructive pulmonary disease (COPD) who did not spontaneously perform PLB. Sixty-nine COPD patients, mean FEV1 (SD) 1.09 (0.5), age 68 (51-83) were recruited to the study. They performed three incremental shuttle walk tests (ISWT). The first walk was designed to identify natural PLBs and the next two walks were performed in a random order; ISWT + PLB or ISWT whilst breathing normally. Measures of respiratory rate (RR), breathlessness and oxygen saturation were taken before and after walks. Data was analysed using the t-test. Fifteen patients demonstrated PLB on baseline ISWT and were therefore excluded from further walking tests although baseline data was included in the analysis. There was no significant difference between walks, mean (SD), 298.5 (173.7) PLB and non-PLB; 292.5 (161.9) nor any difference in dyspnoea. There was a significant reduction in end exercise RR and recovery time with PLB, mean difference (95% CI); 6.2 (4.5-7.9) and 24.9 (2.8-47.0) seconds, respectively. Patients who showed a good response with the PLB walk (41%) had significantly higher baseline breathlessness, Borg score, mean (SD), 1.5 (1.0) versus 0.74 (0.96) (P = 0.02). Natural PLB patients demonstrated lower exercise tolerance on the baseline walk (P = 0.01) and a trend towards greater resting breathlessness than those who did not. This study shows PLB during exercise and recovery results in lower post exercise RR and speeds return to pre exercise breathlessness, compared with exercise and non-PLB. Reductions in RR appear to be greatest in those patients with resting breathlessness.     

Effect of 1-year treatment with roflumilast in severe chronic obstructive pulmonary disease

RATIONALE: The oral phosphodiesterase-4 (PDE4) inhibitor, roflumilast, can improve lung function in moderate chronic obstructive pulmonary disease (COPD). Whether treatment is effective in more severe COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages III and IV) over a longer period is unknown. OBJECTIVES: To determine whether roflumilast improves lung function and decreases exacerbation frequency over 1 year in patients with stable COPD. METHODS: We conducted a randomized, placebo-controlled, double-blind, parallel-group trial for 1 year. We recruited 1,513 patients (mean post-bronchodilator FEV1 41% predicted), 760 receiving oral 500 microg roflumilast and 753 receiving placebo once daily. MEASUREMENTS AND MAIN RESULTS: We recorded post-bronchodilator FEV1, exacerbation rate, St. George's Respiratory Questionnaire total score at the study end point, and number and type of reported adverse events during treatment. Post-bronchodilator FEV1 increased by 39 ml with roflumilast compared with placebo by 52 weeks (p=0.001). The mean exacerbation rate was low and comparable in both treatment groups (0.86 vs. 0.92 exacerbations/patient/yr for roflumilast and placebo, respectively). In a retrospective analysis, the exacerbation rate in patients in GOLD stage IV disease was 36% lower in patients treated with roflumilast than in those treated with placebo (1.01 vs. 1.59 exacerbations/patient/year, respectively; p=0.024). The St. George's Respiratory Questionnaire total score did not differ between treatments. The commonest adverse events related to roflumilast treatment were diarrhea, nausea, and headache, which usually subsided during continued treatment. However, roflumilast resulted in more withdrawals within the first 3 to 4 weeks of administration. CONCLUSIONS: In severe, stable COPD, PDE4 inhibition with roflumilast produced a modest but significant improvement in lung function without changing the exacerbation rate or health status. However, patients with very severe disease experienced fewer exacerbations with roflumilast.     

Neurobehavioral improvement after brief rehabilitation in patients with chronic obstructive pulmonary disease

PURPOSE: Depressive symptoms, physiologic function, and cognition were examined in patients with chronic obstructive pulmonary disease (COPD) after 3 weeks of rehabilitation. METHODS: Patients with COPD completed measures of depression, neuropsychological function, exercise, and spirometry before and after a 3-week rehabilitation program. The 30 rehabilitation patients with COPD were compared with 29 untreated patients with COPD and 21 healthy controls similar in age, education, and gender. RESULTS: A significant group by time interaction effect was found on the Beck Depression Inventory (BDI). A significant interaction effect was also found on the 6-minute walk. Patients in the COPD rehabilitation program had decreased depressive symptoms and increased 6-minute walk distance compared with the untreated groups. Across the 3 groups, no significant interaction effects were found on neuropsychological tests. However, clinically significant improvement in sustained visual attention, verbal retention, and visuospatial ability were reported in the most impaired patients with COPD in the rehabilitation group. CONCLUSION: Compared with control groups, decline in depressive symptoms and increased exercise capacity occurred in patients with COPD after brief rehabilitation. Clinical improvement in visual attention, verbal memory, and visuospatial functions occurred in the impaired patients with COPD participating in treatment. Neurobehavioral improvements after such a brief rehabilitation intervention are relevant for clinical care and warrant continued investigation in well-designed clinical trials.     

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。     

The effects of pulmonary rehabilitation in the national emphysema treatment trial

STUDY OBJECTIVES: Pulmonary rehabilitation is an established treatment in patients with chronic lung disease but is not widely utilized. Most trials have been conducted in single centers. The National Emphysema Treatment Trial (NETT) provided an opportunity to evaluate pulmonary rehabilitation in a large cohort of patients who were treated in centers throughout the United States. DESIGN: Prospective observational study of cohort prior to randomization in a multicenter clinical trial. SETTING: University-based clinical centers and community-based satellite pulmonary rehabilitation programs.Patients and intervention: A total of 1,218 patients with severe emphysema underwent pulmonary rehabilitation before and after randomization to lung volume reduction surgery (LVRS) or continued medical management. Rehabilitation was conducted at 17 NETT centers supplemented by 539 satellite centers. MEASUREMENTS AND RESULTS: Lung function, exercise tolerance, dyspnea, and quality of life were evaluated at regular intervals. Significant (p < 0.001) improvements were observed consistently in exercise (cycle ergometry, 3.1 W; 6-min walk test distance, 76 feet), dyspnea (University of California, San Diego Shortness of Breath Questionnaire score, -3.2; Borg breathlessness score: breathing cycle, -0.8; 6-min walk, -0.5) and quality of life (St. George Respiratory Questionnaire score, -3.5; Quality of Well-Being Scale score, +0.035; Medical Outcomes Study 36-item short form score: physical health summary, +1.3; mental health summary, + 2.0). Patients who had not undergone prior rehabilitation improved more than those who had. In multivariate models, only prior rehabilitation status predicted changes after rehabilitation. In 20% of patients, exercise level changed sufficiently after rehabilitation to alter the NETT subgroup predictive of outcome. Overall, changes after rehabilitation did not predict differential mortality or improvement in exercise (primary outcomes) by treatment group. CONCLUSIONS: The NETT experience demonstrates the effectiveness of pulmonary rehabilitation in patients with severe emphysema who were treated in a national cross-section of programs. Pulmonary rehabilitation plays an important role in preparing and selecting patients for surgical interventions such as LVRS.     

Predictors of success and failure in pulmonary rehabilitation.

The purpose of the present study was to identify prognostic features of chronic obstructive pulmonary disease (COPD) associated with success or failure in pulmonary rehabilitation. Patients were stratified according to the Medical Research Council (MRC) dyspnoea score. A total of 74 stable COPD patients (mean+/-sd age 68+/-10 yrs), 21 MRC dyspnoea score grade 1/2, 29 grade 3/4 and 24 grade 5, with a mean forced expiratory volume in one second of 1.1+/-0.6 L, attended for rehabilitation. Assessments consisted of the following: quadriceps torque, 6-minute walking distance (6MWD), Brief Assessment Depression Cards and St George's Respiratory Questionnaire (SGRQ). Predictors of drop-out and of response (a change in SGRQ of four points or 6MWD of 54 m) were tested using binary logistic regression. In total, 51 patients completed the study. Of these, 39 (77%) showed a clinically significant benefit in either 6MWD or SGRQ. Baseline variables were poor predictors of response in each case. Significant differences were seen between MRC dyspnoea score groups for change in 6MWD and SGRQ Score. Only grade 1/2 and 3/4 patients improved. Depression was a risk factor for subject drop-out compared with nondepressed patients. Baseline state is a poor predictor of response to rehabilitation, although Medical Research Council dyspnoea score grade 5 patients showed smaller magnitudes of improvement than patients with less severe Medical Research Council dyspnoea score grades. Risk of drop-out is significantly greater in depressed compared with nondepressed patients.     

噻托溴铵联合沙美特罗/丙酸氟替卡松治疗慢性阻塞性肺疾病稳定期患者的疗效观察

目的 观察沙美特罗/丙酸氟替卡松(舒利迭)联合噻托溴铵粉吸入剂(思力华)对慢性阻塞性肺疾病(COPD)缓解期的治疗效果.方法 采用随机、双肓的方法将85例COPD患者分为观察组和对照组,观察组A组给予噻托溴铵和沙美特罗/丙酸氟替卡松治疗,对照组B组给予沙美特罗/内酸氟替卡松治疗.分别对两组患者治疗前后的呼吸困难的评分、...     

Functional status in pulmonary rehabilitation participants

PURPOSE: This study examined functional status abnormalities in pulmonary rehabilitation patients, its responsiveness to pulmonary rehabilitation intervention, and its relationship to patient characteristics and traditional measures of disease severity. METHODS: One hundred sixty-four men and women age 69 years (SD +/- 8), who participated in 1 of 10 pulmonary rehabilitation programs in Connecticut, were studied pre- and postrehabilitation with the following outcome measures: (1) the 6-minute walk distance, (2) the Pulmonary Functional Status Scale (PFSS), and (3) in a subset of 60 subjects, health-related quality of life was measured using the Chronic Respiratory Disease Questionnaire (CRDQ). Patient characteristics were compared to baseline values of these measures using Spearman correlations and Wilcoxon Rank Sum tests, whereas pre- to post-changes in outcome measures were evaluated using Wilcoxon signed-ranks tests. Effect size, representing a standardized measure of change, was calculated for the PFSS. RESULTS: The mean FEV1 was 0.95 +/- 0.50 liters (38 +/- 18% predicted). Rehabilitation resulted in significant increases in the 6-minute walk distance (24%, P < 0.001, the total PFSS scores [13%, P < 0.001, effect size 1.0]) and the total CRDQ (18% P < 0.001). The prerehabilitation function subscore and total PFSS score correlated strongly with the 6-minute walk distance (r = 0.76, 0.73; P < 0.001) and to a lesser degree with the FEV1 (r = 0.31, 0.33; P < 0.001). Males scored higher baseline scores in several PFSS subscales, the total PFSS score, and the 6-minute walk distance; females showed more improvement in some of the PFSS scores. CONCLUSION: The 6-minute walk distance, the PFSS, and CRDQ all improved significantly with rehabilitation. Functional status, as measured by the PFSS is very strongly correlated with the 6-minute walk. Gender differences in the timed walk distance and functional status highlight the need to study this variable more thoroughly.     

The effects of pulmonary rehabilitation with chronic obstructive pulmonary disease (COPD)]

It is controversial whether pulmonary rehabilitation is effective in patients with chronic obstructive pulmonary disease (COPD). To test the effect of pulmonary rehabilitation, 7 patients with COPD (aged 76.0 +/- 2.6 years) were enrolled in pulmonary rehabilitation program for 6 weeks. The program consisted of relaxation, pursed lip breathing, diaphragmatic breathing, panic control, muscle stretch gymnastics, and exercise training. The distance of the 6-minute walking test increased significantly from 246.4 +/- 38.0 (m) to 304.3 +/- 28.4 (m) (p < 0.05). The minimum SpO2 during the 6-minute walking test increased from 86.0 +/- 2.8 (%) to 90.1 +/- 1.3 (%) and dyspnea as measured with Borg scale decreased from 5.6 +/- 1.1 to 4.6 +/- 0.5, although they were not significantly different. These results suggest that pulmonary rehabilitation might improve exercise tolerance in elderly patients with COPD.     

Rehabilitation in COPD: the long-term effect of a supervised 7-week program succeeded by a self-monitored walking program

Pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) improves exercise tolerance and health status, however, these effects have been shown to decline after termination of the rehabilitation program. This study has examined the long-term effect of a 7-week supervised rehabilitation program combined with daily self-monitored training at home on exercise tolerance and health status. Two hundred and nine consecutive COPD patients who had completed a 7-week pulmonary rehabilitation program were assessed with endurance shuttle walk test (ESWT) and the St George's Respiratory Questionnaire (SGRQ) at baseline, 0, 3, and 12 months after the program. Sixty-eight (32.5%) patients did not attend the 1-year follow-up. Among the 141 patients who competed the 1-year evaluation, the initial improvement after the 7-week program in the ESWT time was 180 s or 101% (p = 0.001) and in SGRQ 3.4 units (p = 0.001). These effects were maintained at the 1-year evaluation (ESWT 59% above baseline; p < 0.001 and improved SGRQ 3.0 units compared with baseline; p = 0.011). The 31 patients who attended the 6-month, but not the 12-month evaluation, improved ESWT time by 96 s (p = 0.02) without any change in SGRQ +2.0 (p = 0.40). A relative simple and inexpensive 7-week supervised rehabilitation program combined with daily self-monitored training at home was able to maintain significant improvement in exercise tolerance and health status throughout 1 year. Death and hospital admissions due to acute exacerbations were the main reasons for non-attendance in the follow-up period.     

Fatigue in COPD: prevalence and effect on outcomes in pulmonary rehabilitation

Patients with chronic obstructive pulmonary disease (COPD) complain of dyspnea and fatigue. We sought to estimate the prevalence of high fatigue in this population and to determine whether individuals with high fatigue had a different response to pulmonary rehabilitation. This observational study was embedded within a randomized trial. Participants underwent 3 months of pulmonary rehabilitation including education and exercise training. We divided 251 individuals into low and high fatigue groups using population normal scores of the SF-36 vitality domain. Baseline data included spirometry, 6-minute walk distance (6MWD), peak exercise capacity, constant workrate cycling endurance time, and questionnaires including the St. George's and Chronic Respiratory questionnaires (SGRQ, CRQ). The response to pulmonary rehabilitation was evaluated using changes in these measures at 3 months and 1 year after entry. High fatigue was present in 97/251 (39%) of patients. High fatigue patients were younger, had more depressive symptoms, greater dyspnea and poorer SGRQ scores (p < 0.01). They also had lower 6MWD, endurance times, and peak volume of oxygen consumption (VO(2); p < 0.05). Patients in both groups improved similarly in their dyspnea, the 6MWD and endurance time. High-fatigue patients had greater improvements in both the CRQ fatigue (by 0.74 more points) and the SGRQ scores (by 6.0 points; p < 0.01), with clinically significant gains maintained at 1 year. This study suggests that high levels of fatigue is a common feature in patients with COPD. They have a lower exercise capacity and a lower health status. However, they benefit from pulmonary rehabilitation.     

集束化肺康复对重度及极重度COPD的疗效观察

目的 探讨集束化肺康复对重度及极重度COPD的疗效.方法 前瞻性选取2014年1月至2015年6月诊断为重度及极重度COPD急性加重期的住院患者共130例,随机分为肺康复组65例,对照组65例.肺康复组在常规治疗基础上,给予集束化肺康复治疗.对照组仅给予常规治疗.观察治疗前、治疗后3个月、6个月及12个月2组间肺功能、6分钟步行距离(6MWD)以及圣·乔治呼吸问卷(SGRQ)的差异以及12个月内再住院次数.结果 治疗3个月后,肺康复组FVC、FVC％ pred、FEV1、FEV1％pred较治疗前及对照组明显改善;6MWD在治疗后较治疗前[(206.50±34.01)m vs(183.73±31.65)m,P＜0.05]及对照组[(206.50±34.01)m vs (183.80±20.58)m,P＜0.05]明显改善;SGRQ评分在治疗3个月后较治疗前明显改善[(60.83±5.78)分Vs(64.87士5.03)分,P＜0.05],治疗6个月后较对照组明显改善[(57.53±6.04)分vs (63.55±6.84)分,P＜0.05];肺康复组12个月内再住院次数较对照组减少[(0.97±0.72)次/年vs (1.56±0.89)次/年,P＜0.05].结论 重度及极重度COPD急性加重期患者早期院内实施集束化肺康复治疗,能显著改善肺功能、运动能力及生活质量,值得临床推广.     

The effectiveness of outpatient pulmonary rehabilitation in chronic lung disease: a randomized controlled trial

BACKGROUND: Patients with chronic pulmonary disease have been shown to benefit from pulmonary rehabilitation programs. Published work has often been from specialized teaching centers and has involved inpatient stay. We assessed an entirely outpatient-based program of pulmonary rehabilitation in patients with chronic lung disease, using the St. George's Respiratory Questionnaire (SGRQ) (which measures health-related quality of life) as the primary outcome measure. METHODS: We undertook a randomized, prospective, parallel-group controlled study of an outpatient rehabilitation program in 65 patients with COPD (44 men and 21 women; mean age, 69.5 years [SD, 9.2 years]; FEV(1), 41% predicted [SD, 18.5%]). The active group (n = 36) took part in a 6-week program of education (2 h weekly) and exercise (1 h weekly). The control group (n = 29) were reviewed routinely as medical outpatients. The SGRQ was administered under supervision by a blinded observer at study entry, 12 weeks, and 24 weeks. RESULTS: The SGRQ in the active group was 59.9 (SE, 2.0) at study entry (n = 36), 47.4 (SE, 2.3) at 12 weeks (n = 32), and 50.6 (SE, 2.5) at 24 weeks (n = 24). The SGRQ in the control group was 59.3 (SE, 2.5) at study entry and did not change significantly over 24 weeks. There was a difference of 10.4 points (confidence interval [CI], 3.6 to 17.3) between the two groups at 12 weeks (p < 0.001) and of 8.1 points (CI, 1.4 to 14.9) at 24 weeks (p = 0.02) in favor of the active group. CONCLUSIONS: A 6-week outpatient-based program significantly improved quality of life in patients with moderate-to-severe COPD. Benefit was still evident after 24 weeks.