Evidence-based recommendations on the clinical use of cardiopulmonary exercise testing (CPET) in lung and heart disease are presented, with reference to the assessment of exercise intolerance, ...prognostic assessment and the evaluation of therapeutic interventions (e.g. drugs, supplemental oxygen, exercise training). A commonly used grading system for recommendations in evidence-based guidelines was applied, with the grade of recommendation ranging from A, the highest, to D, the lowest. For symptom-limited incremental exercise, CPET indices, such as peak O(2) uptake (V'O(2)), V'O(2) at lactate threshold, the slope of the ventilation-CO(2) output relationship and the presence of arterial O(2) desaturation, have all been shown to have power in prognostic evaluation. In addition, for assessment of interventions, the tolerable duration of symptom-limited high-intensity constant-load exercise often provides greater sensitivity to discriminate change than the classical incremental test. Field-testing paradigms (e.g. timed and shuttle walking tests) also prove valuable. In turn, these considerations allow the resolution of practical questions that often confront the clinician, such as: 1) "When should an evaluation of exercise intolerance be sought?"; 2) "Which particular form of test should be asked for?"; and 3) "What cluster of variables should be selected when evaluating prognosis for a particular disease or the effect of a particular intervention?"
Several cellular and molecular alterations have been described in skeletal and respiratory muscles of patients with chronic obstructive pulmonary disease (COPD), but information on potential ...abnormalities of mitochondrial function is scarce. The aim of the present study was to investigate mitochondrial function in the vastus lateralis (VL) and external intercostalis (EI) of COPD patients. Biopsies from VL and EI were obtained during surgery for lung cancer in 13 patients with mild to moderate COPD (age 68+/-6 yrs, forced expiratory volume in one second (FEV(1)) 66+/-15% predicted) and 19 control subjects (age 67+/-9 yrs, FEV(1) 95+/-18% pred). State 3 and 4 mitochondrial oxygen consumption (V'(O(2),m)), ATP synthesis, citrate synthase, cytochrome oxidase (COX) and complex I-III activities, as well as reactive oxygen species (ROS) production, were determined. In COPD patients, in both muscles, COX activity (VL: COPD 3.0+/-0.8 versus control 2.0+/-0.8; EI: 3.7+/-1.6 versus 2.4+/-0.9 micromol min(-1) mg(-1)) and ROS production (VL: 1,643+/-290 versus 1,285+/-468; EI: 1,033+/-210 versus 848+/-288 arbitrary units) were increased, whereas state 3 V'(O(2),m) was reduced (VL: 2.9+/-0.3 versus 3.6+/-0.4; EI: 3.6+/-0.3 versus 4.1+/-0.4 mmol min(-1) kg(-1)). Skeletal muscle mitochondria of patients with chronic obstructive pulmonary disease show electron transport chain blockade and excessive production of reactive oxygen species. The concurrent involvement of both vastus lateralis and external intercostalis suggests a systemic (rather than a local) mechanism(s) already occurring in relatively early stages (Global Initiative for Chronic Obstructive Lung Disease stage II) of the disease.
The endurance time during constant high work-rate exercise (t(LIM)) is used to assess exercise capacity in patients with chronic obstructive pulmonary disease and as an outcome measure for pulmonary ...rehabilitation. Our study was designed to establish the minimum clinically important difference for the t(LIM). t(LIM) was measured in 105 patients (86 males) before and after an 8-week outpatient pulmonary rehabilitation programme. Subjects were asked to identify, from a five-point Likert scale, the perceived change in their exercise performance immediately upon completion of the exercise tests. The scale ranged from "better" to "worse". The mean+/-sd age was 64+/-5 yrs, forced expiratory volume in 1 s (FEV(1)) 47+/-10% and FEV(1)/forced vital capacity 54.7+/-16.3%. Baseline t(LIM) at 75% of the peak work rate was 397+/-184 s, which increased by 62+/-63% after rehabilitation. In subjects who felt their exercise tolerance was "slightly better", the mean improvement was 34% in the relative improvement over the baseline value (95% CI 29-39)% or 101 (86-116) s compared with 121 (109-134)% in those who reported that their exercise tolerance was "better" and 8 (2-14)% in those who felt their exercise tolerance was "about the same". Minimum clinically important improvement for t(LIM) averaged approximately 33% of baseline. Patients were able to distinguish at least one further additional level of benefit at 120% of baseline.
Postoperative continuous positive airway pressure (CPAP) can improve lung function. The aim of our study was to assess the efficacy of prophylactic CPAP on the PaO2/FIO2 ratio measured the day after ...surgery in patients undergoing lung resection surgery (LRS).
The study population comprised 110 patients undergoing LRS. On arrival in the postanaesthesia care unit (PACU), patients were randomized to receive CPAP at 5–7 cm H2O during the first 6 h after surgery (CPAP group) or supplemental oxygen through a Venturi mask (Venturi group). The PaO2/FIO2 ratio was measured on arrival in the PACU, 7 h after admission, and the day after surgery. The PaO2/FIO2 ratio is the primary endpoint of our study. We also analysed the chest radiograph and assessed the postoperative course. We then analysed the impact of ventilatory management in the PACU depending on the respiratory risk of the patient.
Baseline characteristics were similar in both groups. Patients who received CPAP had significantly higher PaO2/FIO2 at 24 h after surgery compared with patients managed conventionally (Venturi group) (48.6±14 vs 42.3±12, P=0.031), but there were no differences at 7 h. On subgroup analysis, we found that the benefits of CPAP were greater in higher risk patients. The incidence of postoperative pulmonary complications and stay in the PACU and hospital were similar in both groups.
In patients undergoing LRS, prophylactic CPAP during the first 6 h after surgery with a pressure of 5–7 cm H2O improved the PaO2/FIO2 ratio at 24 h. This effect was more evident in patients with increased risk of postoperative pulmonary complications.
Background: Chronic obstructive pulmonary disease (COPD) usually occurs alongside other conditions. Few studies on comorbidities have taken into account the phenotypes of COPD patients. The objective ...of this study is to evaluate the prevalence of comorbidities included in the Charlson index and their influence on the survival of patients with COPD, taking phenotypes into account. Methods: An observational study was conducted on a group of 273 patients who had COPD and underwent spirometry in the first half of 2011, with a median prospective follow-up period of 68.15 months. The survival of these patients was analyzed according to the presence of various comorbidities. Results: Of the 273 patients, 93 (34.1%) died within the follow-up period. An increased presence of chronic ischemic heart disease (CIHD), chronic heart failure (CHF), chronic kidney disease (CKD), and malignancy was found in deceased patients. All of these conditions shorten the survival of COPD patients globally; however, when considering phenotypes, only CHF influences the exacerbator with chronic bronchitis phenotype, CKD influences the non-exacerbator phenotype, and malignancy influences the positive bronchodilator test (BDT) and exacerbator with chronic bronchitis phenotypes. In the multivariate model, advanced age (hazard ratio, HR: 1.05; p=0.001), CHF (HR: 1.74; p=0.030), and the presence of malignancy (HR: 1.78; p=0.010) were observed as independent mortality risk factors. Conclusion: The survival is shorter in the presence of CIHD in overall COPD patients and also CHF, CKD, and malignancy for certain phenotypes. It is important to pay attention to these comorbidities in the comprehensive care of COPD patients.
Chronic obstructive pulmonary disease (COPD) is a major cause of disability and death worldwide. Consequently, COPD patients are frequent users of health and social resources. Therefore, they are ...highly vulnerable to decreases in investment in healthcare services. We aimed to describe the utilization of health and home care services among Spanish COPD patients during the economic crisis to identify factors independently associated with changes in the utilization of these services and to study the time trends from 2009 to 2014.
We used data from the European Health Interview Surveys for Spain (EHSS) conducted between 2009/2010 (n=22,188) and 2014 (n=22,842). We included responses from adults with COPD aged 40 years or over. Dependent variables included self-reported hospitalizations during the previous year, general practitioner (GP) visits during the last 4 weeks, other health care services used during the previous year (nursing, rehabilitation, and psychological services), and home care services use during the previous year. Independent variables included demographic and socioeconomic characteristics, health status variables, and lifestyles.
We identified 1,328 and 1,008 COPD patients from EHSS 2009 and EHSS 2014, respectively. We observed a significant increase in non-GP services use (30.6% in 2009 vs 39.11% in 2014;
<0.001). No changes were found for hospitalizations, GP visits, and home care services use over time. Multivariable models showed that associated factors with a higher use included any chronic comorbidity and worse self-rated health. Physical activity was a strong predictor of fewer hospitalizations and less home care service use. Female sex was associated with significantly fewer hospitalizations (OR 0.72; 95% CI 0.58-0.89).
We found an increase in the use of non-GP services (nursing, rehabilitation, and psychological) but not in other health and home care services. The only differences in hospitalizations were observed according to sex. Therefore, the effect of the economic crisis, if any, seems to have been of small magnitude.
In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore ...improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.
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