pulmonar en pacientes con EPOC
1: Am Fam Physician 2000 Apr 15;61(8):2419-28, 2333-4 [Texto completo]
Developing and communicating a long-term treatment plan for asthma.
Mellins RB, Evans D, Clark N, Zimmerman B, Wiesemann S
Pediatric Pulmonary Division, Columbia University College of Physicians and
Surgeons, New York, New York 10032, USA.
The treatment of asthma, according to current guidelines, requires complex
treatment regimens that change as clinical conditions improve or deteriorate. We
have developed a practical way to communicate long-term treatment plans in chart
form in the primary care setting that is easy for patients to follow and use.
The chart has been an important element in two interventions that have resulted
in positive changes in health behavior and health outcomes in children with
asthma. The plan provides recommendations for patients and families to make
adjustments in medication based on changes in symptoms or peak expiratory air
flow, or both, that are consistent with the Asthma Guidelines Expert Panel
Report 2, 1997. The plan also indicates when the number and dosage of drugs
should be increased or decreased and when emergency care should be sought,
consistent with the Asthma Guidelines. By placing considerable control in the
family's hands and by clearly delineating the conditions under which medicines
can be reduced or discontinued, the physician provides incentives for families
to adhere to the long-term treatment plan for asthma.
Comment in: Am Fam Physician 2000 Apr 15;61(8):2328, 2330, 2337
2: Chest 2000 Apr;117(4):976-83
Long-term effects of outpatient rehabilitation of COPD: A randomized trial.
Guell R, Casan P, Belda J, Sangenis M, Morante F, Guyatt GH, Sanchis J
Departament de Pneumologia, Hospital de la Santa Creu i de Sant Pau, Universitat
Autonoma de Barcelona, Barcelona, Spain.
OBJECTIVE: To examine the short- and long-term effects of an outpatient pulmonary rehabilitation program for COPD patients on dyspnea, exercise,
health-related quality of life, and hospitalization rate. SETTING: Secondary-care respiratory clinic in Barcelona. METHODS: We conducted a
randomized controlled trial with blinding of outcome assessment and follow-up at
3, 6, 9, 12, 18, and 24 months. Sixty patients with moderate to severe COPD (age
65 +/- 7 years; FEV(1) 35 +/- 14%) were recruited. Thirty patients randomized to
rehabilitation received 3 months of outpatient breathing retraining and chest
physiotherapy, 3 months of daily supervised exercise, and 6 months of weekly
supervised breathing exercises. Thirty patients randomized to the control group
received standard care. RESULTS: We found significant differences between groups
in perception of dyspnea (p < 0.0001), in 6-min walking test distance (p <
0.0001), and in day-to-day dyspnea, fatigue, and emotional function measured by
the Chronic Respiratory Questionnaire (p < 0. 01). The improvements were evident
at the third month and continued with somewhat diminished magnitude in the
second year of follow-up. The PR group experienced a significant (p < 0.0001)
reduction in exacerbations, but not the number of hospitalizations. The number
of patients needed to treat to achieve significant benefit in health-related
quality of life for a 2-year period was approximately three. CONCLUSION: Outpatient rehabilitation programs can achieve worthwhile benefits that persist
for a period of 2 years.
Randomized controlled trial
3: Chest 2000 Feb;117(2 Suppl):23S-8S
Recommendations for the management of COPD.
Botsford Pulmonary Associates, Farmington Hills, and Wayne State University,
Detroit, MI 48336, USA.
Three sets of guidelines for the management of COPD that are widely recognized
(from the European Respiratory Society [ERS], American Thoracic Society [ATS],
and British Thoracic Society [BTS]) are reviewed and compared. None of the
documents uses classic evidence-based documentation, and, in many instances, the
recommendations are empiric because of a lack of scientific evidence. Overall,
there is strong agreement between the documents. All three guidelines recommend
inhaled bronchodilators as first-line therapy. Anticholinergics are noted to be
well tolerated, although potential problems with beta(2)-agonists are mentioned.
The ERS and BTS suggest that inhaled corticosteroids may be of value in patients
documented to be steroid responders, whereas the ATS does not recommend their
use at all. All three guidelines support the use of oxygen and pulmonary rehabilitation. There are varying levels of disagreement between the guidelines
related to the role of spirometry, stratification of disease severity, and the
use of theophylline and systemic corticosteroids. Other differences include the
role for nebulizers and metered-dose inhalers, secretion clearance methodologies, and the treatment of acute COPD exacerbations and acute
respiratory failure. All three guidelines agree that more research is needed to
improve our understanding and management of COPD.
4: Lancet 2000 Jan 29;355(9201):362-8
Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a
randomised controlled trial.
Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, Turner-Lawlor PJ, Payne N, Newcombe RG, Lonescu AA, Thomas J, Tunbridge J
Department of Medicine, University of Wales, College of Medicine, Llandough
Hospital, Penarth, UK. firstname.lastname@example.org
BACKGROUND: Pulmonary rehabilitation seems to be an effective intervention in
patients with chronic obstructive pulmonary disease. We undertook a randomised
controlled trial to assess the effect of outpatient pulmonary rehabilitation on
use of health care and patients' wellbeing over 1 year. METHODS: 200 patients
with disabling chronic lung disease (the majority with chronic obstructive
pulmonary disease) were randomly assigned a 6-week multidisciplinary rehabilitation programme (18 visits) or standard medical management. Use of
health services was assessed from hospital and general-practice records. Analysis was by intention to treat. FINDINGS: There was no difference between
the rehabilitation (n=99) and control (n=101) groups in the number of patients
admitted to hospital (40 vs 41) but the number of days these patients spent in
hospital differed significantly (mean 10.4 [SD 9.7] vs 21.0 [20.7], p=0.022).
The rehabilitation group had more primary-care consultations at the general-practitioner's premises than did the control group (8.6 [6.8] vs 7.3
[8.3], p=0.033) but fewer primary-care home visits (1.5 [2.8] vs 2.8 [4.6],
p=0.037). Compared with control, the rehabilitation group also showed greater
improvements in walking ability and in general and disease-specific health
status. INTERPRETATION: For patients chronically disabled by obstructive pulmonary disease, an intensive, multidisciplinary, outpatient programme of
rehabilitation is an effective intervention, in the short term and the long
term, that decreases use of health services.
Randomized controlled trial
5: Arch Phys Med Rehabil 2000 Jan;81(1):102-9
Endurance training in patients with chronic obstructive pulmonary disease: a
comparison of high versus moderate intensity.
Gimenez M, Servera E, Vergara P, Bach JR, Polu JM
Laboratoire de Physiologie de L'Exercice Musculaire, Unite 14 of the Institut
Nationale de la Sante et de la Recherche Medicale, Nancy, France.
PURPOSE: To create a maximum tolerated 45-minute aerobic training program for
patients with chronic obstructive pulmonary disease (COPD) and to compare its
outcomes with those of commonly prescribed moderate exercise. DESIGN: Prospective, randomized trial. SETTING: A work physiology laboratory. PATIENTS
AND METHODS: The maximum exercise intensities that 7 COPD patients could sustain
for 45 minutes were determined on a bilevel exercise ergometer. The patients
then exercised 45 minutes daily, 5 days a week for 6 weeks, working 2.03+/-0.4
kJ/kg per session. They were matched with 6 COPD patients who pushed an O2 cart
for 45 minutes daily, 5 days a week for 6 weeks, working 1.44+/-.35 kJ/kg per
session. RESULTS: A 45 minute maximal regimen was established by alternating
1-minute peak exercise at peak VO2-levels with 4 minutes at the ventilatory
anaerobic threshold or at 40% of peak VO2. Maximal bilevel training significantly decreased dyspnea at rest (p< or =.01) and the blood lactate level
during submaximal exercise (p<.001), and increased peak VO2 and total physical
work (p<.01), maximum inspiratory and expiratory pressures (p<.01), and grip and
forearm strength and endurance (p<.01). The training also increased maximum
voluntary ventilation while decreasing the ventilatory equivalent during exercise (p<.001). The O2 cart pushers significantly improved only on the
12-minute walk (p<.05). CONCLUSIONS: A maximally intense anaerobic exercise
program can be created for most COPD patients that can significantly improve
both skeletal and respiratory muscle strength and endurance as well as dyspnea
and physiologic parameters.
Randomized controlled trial
6: J Cardiopulm Rehabil 1999 Nov-Dec;19(6):366-72
Cardiopulmonary responses, muscle soreness, and injury during the one repetition
maximum assessment in pulmonary rehabilitation patients.
Kaelin ME, Swank AM, Adams KJ, Barnard KL, Berning JM, Green A
Southern Indiana Rehabilitation Hospital, New Albany, Indiana, USA.
PURPOSE: The safety of one repetition maximum (1RM) testing for patients with
chronic obstructive pulmonary disease (COPD) has not been determined. Therefore,
this study was conducted to determine the prevalence of abnormal cardiopulmonary
responses, muscle soreness, and muscle injury of patients with moderate to
severe COPD in response to 1RM testing. METHODS: Twenty pulmonary rehabilitation
patients (11 women and 9 men) with moderate or severe COPD participated in this
investigation. The 1RM testing was performed using the parallel squat and incline press. Blood pressure, heart rate dyspnea ratings, and oxygen saturation
responses were measured immediately following the 1RM procedure. Ratings of
muscle soreness and injury were measured immediately after 1RM testing and on
days 2 and 7. RESULTS: No injury, significant muscle soreness, or abnormal
cardiopulmonary responses occurred as a result of 1RM testing. No gender differences were found for any variable measured in response to 1RM testing.
CONCLUSIONS: A properly supervised and screened pulmonary rehabilitation population can be 1RM tested without significant muscle soreness, injury, or
abnormal cardiopulmonary responses.
7: J Cardiopulm Rehabil 1999 Nov-Dec;19(6):362-5
Anxiety and depression in severe chronic obstructive pulmonary disease: the
effects of pulmonary rehabilitation.
Withers NJ, Rudkin ST, White RJ
Department of Medicine, Frenchay Hospital, Bristol, UK.
BACKGROUND: Previous studies have demonstrated high levels of anxiety and depression among patients with chronic obstructive pulmonary disease (COPD). The
effects of an outpatient pulmonary rehabilitation (PR) program on psychological
morbidity were examined in patients with severe COPD. METHODS: Levels of anxiety
and depression in 95 patients with severe COPD (FEV1 < 40% predicted) were
measured on entry to an outpatient PR program using the Hospital Anxiety and
Depression (HAD) scale. HAD scores were remeasured at the completion of PR (3
months) and at 6 month follow-up. The effects of PR on mean HAD scores and on
the number of patients with significant anxiety or depression were determined.
Improvements in exercise capacity after PR were compared in patients with high
and low HAD scores. RESULTS: Of patients, 35 (29.2%) had significant anxiety at
screening and 18 (15%) significant depression. PR produced statistically significant falls in mean HAD scores for anxiety and depression, both of which
remained significantly lowered at 6-month follow-up. PR also reduced the number
of patients with significant anxiety or depression. Patients with high anxiety
levels showed significantly greater improvements in shuttle walk distance than
those with low HAD scores. CONCLUSIONS: Levels of anxiety and depression were
high in a significant minority of this group of patients with severe COPD and
were significantly improved by PR. Patients with higher HAD scores had lower
baseline shuttle walk distances than those with low HAD scores. Anxious patients
showed statistically greater improvements in exercise capacity following PR.
8: Scand J Rehabil Med 1999 Dec;31(4):207-13
Long-term effects of a pulmonary rehabilitation programme in outpatients with
chronic obstructive pulmonary disease: a randomized controlled study.
Engstrom CP, Persson LO, Larsson S, Sullivan M
Department of Pulmonary Medicine, Sahlgrenska University Hospital, Goteborg,
Fifty patients with severe chronic obstructive pulmonary disease (FEV1 < 50%
pred.) were randomized to a rehabilitation group and a control group. The rehabilitation group took part in an individualized multidisciplinary,
outpatient 12-month rehabilitation programme. Exercise training was intensive
during the first 6 weeks and was then gradually replaced by an individual home-training programme and booster sessions. Controls received the usual
outpatient care. Positive effects were found in terms of maximum symptom-limited
exercise tolerance and walking distance (13.5 and 12.1% increase, respectively)
in the rehabilitation group compared with the controls. Quality of life measurements showed minor beneficial effects on the Sickness Impact Profile,
indicating a higher level of activity. No effect was seen on the St George's
Respiratory Questionnaire or the Mood Adjective Check List. Patients expressed
their enthusiasm for the rehabilitation programme in a study-specific questionnaire.
Randomized controlled trial
9: Am J Respir Crit Care Med 1999 Dec;160(6):2018-27
Prospective randomized trial comparing bilateral lung volume reduction surgery
to pulmonary rehabilitation in severe chronic obstructive pulmonary disease.
Criner GJ, Cordova FC, Furukawa S, Kuzma AM, Travaline JM, Leyenson V, O'Brien GM
Divisions of Pulmonary and Critical Care Medicine, Department of Medicine and
Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia,
Pennsylvania 19140, USA. email@example.com
Several uncontrolled studies report improvement in lung function, gas exchange,
and exercise capacity after bilateral lung volume reduction surgery (LVRS). We
recruited 200 patients with severe chronic obstructive pulmonary disease (COPD)
for a prospective randomized trial of pulmonary rehabilitation versus bilateral
LVRS with stapling resection of 20 to 40% of each lung. Pulmonary function
tests, gas exchange, 6-min walk distance, and symptom-limited maximal exercise
testing were done in all patients at baseline and after 8 wk of rehabilitation.
Patients were then randomized to either 3 additional months of rehabilitation or
LVRS. Thirty-seven patients met study criteria and were enrolled into the trial.
Eighteen patients were in the medical arm; 15 of 18 patients completed 3 mo of
additional pulmonary rehabilitation. Thirty-two patients underwent LVRS (19 in
the surgical arm, 13 crossover from the medical arm). After 8 wk of pulmonary
rehabilitation, pulmonary function tests remained unchanged compared with baseline data. However, there was a trend toward a higher 6-min walk distance
(285 +/- 96 versus 269 +/- 91 m, p = 0.14) and total exercise time on maximal
exercise test was significantly longer compared with baseline values (7.4 +/-
2.1 versus 5.8 +/- 1.7 min, p < 0.001). In 15 patients who completed 3 mo of
additional rehabilitation, there was a trend to a higher maximal oxygen consumption (V O(2)max) (13.3 +/- 3.0 versus 12.6 +/- 3.3, p < 0.08). In
contrast, at 3 mo post-LVRS, FVC (2.79 +/- 0.59 versus 2.36 +/- 0.55 L, p <
0.001) and FEV(1) (0.85 +/- 0.3 versus 0.65 +/- 0.16 L, p < 0.005) increased
whereas TLC (6.53 +/- 1.3 versus 7.65 +/- 2.1 L, p < 0.001) and residual volume
(RV) (3.7 +/- 1.2 versus 4.9 +/- 1.1 L, p < 0.001) decreased when compared with
8 wk postrehabilitation data. In addition, Pa(CO(2)) decreased significantly 3
mo post-LVRS compared with 8 wk postrehabilitation. Six-minute walk distance
(6MWD), total exercise time, and V O(2)max were higher after LVRS but did not
reach statistical significance. However, when 13 patients who crossed over from
the medical to the surgical arm were included in the analysis, the increases in
6MWD (337 +/- 99 versus 282 +/- 100 m, p < 0.001) and V O(2)max (13.8 +/- 4
versus 12.0 +/- 3 ml/kg/min, p < 0.01) 3 mo post-LVRS were highly significant
when compared with postrehabilitation data. The Sickness Impact Profile (SIP), a
generalized measure of quality of life (QOL), was significantly improved after 8
wk of rehabilitation and was maintained after 3 mo of additional rehabilitation.
A further improvement in QOL was observed 3 mo after LVRS compared with the
initial improvement gained after 8 wk of rehabilitation. There were 3 (9.4%)
postoperative deaths, and one patient died before surgery (2.7%). We conclude
that bilateral LVRS, in addition to pulmonary rehabilitation, improves static
lung function, gas exchange, and QOL compared with pulmonary rehabilitation
alone. Further studies need to evaluate the risks, benefits, and durability of
LVRS over time.
Randomized controlled trial
10: Am J Respir Crit Care Med 1999 Oct;160(4):1248-53
Exercise rehabilitation and chronic obstructive pulmonary disease stage.
Berry MJ, Rejeski WJ, Adair NE, Zaccaro D
Department of Health, Wake Forest University, Winston-Salem, North Carolina,
To determine the extent to which patients with Stage I COPD experience improvements in physical performance and quality of life as a result of exercise
training, and to compare these improvements with those seen in Stage I and II
patients, 151 patients with COPD underwent a 12-wk exercise program. Outcomes
were measured at baseline and follow-up. Physical performance was evaluated by
means of a 6-min walk, treadmill time, an overhead task, and a stair climb.
General health-related quality of life was assessed in terms of the domains of
Social Function, Health Perceptions, and Life Satisfaction. Disease-specific
health-related quality of life was assessed with the Chronic Respiratory Disease
Questionnaire (CRQ). Six-minute walk distance increased significantly in Stage I
(200.5 ft [95% CI: 165.4, 235.7]), Stage II (238.3 ft [143.3, 333.3]), and Stage
III (112.1 ft [34.6, 189.6]) participants. Treadmill time increased significantly in Stage I (0.42 min [0.20, 0.64]) and Stage II (0.64 min [0.14,
1.4]) participants. Time to complete the overhead task decreased significantly
in Stage I (0.91 s [1.72, 0. 11]) and Stage II (1.39 s [2.66, 0.13]) participants. None of the measures of general health-related quality of life
improved in any of the three groups. Participants in Stages I, II, and III all
experienced improvements in the CRQ domains of dyspnea (0.72 [0.53, 0.91], 0.47
[0.02, 0.91], and 0.46 [0.05, 0.87], respectively) and fatigue (0.49 [0.33,
0.66], 0.54 [0.20, 0.87], and 0.55 [0.05, 1.05], respectively). These results
suggest that all patients with COPD will benefit from exercise rehabilitation.
Berry MJ, Rejeski WJ, Adair NE, Zaccaro D. Exercise rehabilitation and chronic
obstructive pulmonary disease stage.
11: Chest 1999 Aug;116(2):306-13
Trends in the epidemiology of COPD in Canada, 1980 to 1995. COPD and Rehabilitation Committee of the Canadian Thoracic Society.
Lacasse Y, Brooks D, Goldstein RS
Centre de Pneumologie, Hopital Laval, Ste-Foy, Quebec, Canada. firstname.lastname@example.org
PURPOSE: To describe trends in the epidemiology of COPD in Canada from 1980 to
1995, in terms of perceived prevalence, mortality, and hospital morbidity. DATA
SOURCES: We limited the analysis to data related to chronic bronchitis, emphysema, or chronic airway obstruction not classified elsewhere, and excluded
asthma (Ninth International Classification of Diseases, codes 490 to 492 and
496). The perceived prevalence rate of COPD was derived from the 1994-1995
National Health Survey. Mortality and hospital morbidity data (from 1980 to
1995) were obtained from the Health Statistics Division of Statistics Canada.
RESULTS: From the National Health Survey, it was estimated that 750,000 Canadians had chronic bronchitis or emphysema diagnosed by a health
professional. Prevalence rates were the following: ages 55 to 64 years, 4.6%;
ages 65 to 74 years, 5.0%; > or =75 years, 6.8%. From 1980 to 1995, the total
number of deaths from COPD increased from 4,438 to 8,583. Although the age-standardized mortality rate remained stable throughout this period in men
(around 45/100,000 population), it doubled in women (8.3/100,000 in 1980 to
17.3/100,000 in 1995). There were 55,782 hospital separations in 1993-1994 with
COPD as the primary discharge diagnosis (compared to 42,102 in 1981-1982). In
people aged > or =65 years, the age-specific hospital separation rate increased
over this period, especially in women > or =75 years (from 504/100,000 to 1,033/100,000). The average in-hospital length of stay was 9.6 days in 1981-1982
and 8.3 days in 1993-1994. CONCLUSION: COPD represents a major health issue in
Canada and will likely remain so for decades. Physician and non-physician health
professionals who provide health care, as well as those who fund it must actively encourage approaches for primary and secondary prevention of this
condition as well as approaches shown to be effective in addressing its associated impairment, disability, and handicap.
12: Am J Phys Med Rehabil 1999 Jul-Aug;78(4):330-5
Quality of life and exercise tolerance in chronic obstructive pulmonary disease:
effects of a short and intensive inpatient rehabilitation program.
Fuchs-Climent D, Le Gallais D, Varray A, Desplan J, Cadopi M, Prefaut C
Laboratoire de Physiologie des Interactions, Service Central de Physiologie,
Hopital Arnaud de Villeneuve, Montpellier, France.
The quality of life and the exercise endurance of patients with chronic obstructive pulmonary disease are impaired. The aim of our study was to
determine the impact of a 3-wk intensive inpatient rehabilitation program on the
quality of life of patients with chronic obstructive pulmonary disease and to
examine the correlation between quality-of-life measures and physiologic measures throughout rehabilitation. Thirty-two patients with chronic obstructive
pulmonary disease (20 men, 12 women) were evaluated by spirometry and maximal
exercise testing for exercise endurance and by the French version of the Nottingham Health Profile for quality of life. Rehabilitation components were
individualized exercise at ventilatory threshold (4 hr/day), health education,
and physical therapy and relaxation for 3 wk. Our results showed an improvement
in the quality of life (especially in physical mobility, energy, and social
isolation) and exercise endurance (increase of 14% of maximal power and symptom-limited oxygen uptake). In contrast, no significant correlations were
found between the quality of life and physiologic parameters (gas exchange,
cardiovascular and lung function parameters) throughout rehabilitation. Changes
in the quality of life seem to be independent of the physiologic results during
the course of a short and intensive inpatient rehabilitation program. Quality of
life should, therefore, be more systematically evaluated to determine the psychosocial benefits, which, although subjective, are important for encouraging
patients' compliance with rehabilitation programs.
13: Eur Respir J 1999 Apr;13(4):855-9
Respiratory rehabilitation in chronic obstructive pulmonary disease: predictors of nonadherence.
Young P, Dewse M, Fergusson W, Kolbe J
Dept of Physiotherapy, Green Lane Hospital, Auckland, New Zealand.
Rehabilitation is now an integral part of chronic obstructive pulmonary disease
(COPD) management. The objective of the study was to determine predictors of
nonadherence to a COPD rehabilitation programme. Patients attending a COPD
clinic were invited to participate in a 4 week, hospital-based, outpatient, COPD
rehabilitation programme conducted predominantly by respiratory physiotherapists. All potential participants undertook an interviewer
administered questionnaire addressing social, economic, psychological and healthcare factors, and underwent baseline physiological measures. Subsequently
they were classified as: 1) "adherent" group who completed the total programme
(n=55) or 2) "nonadherent" group who refused or began but did not complete the
programme (n=36). The nonadherent group compared to the adherent group were more
likely to be divorced (22 versus 2%, p<0.005), live alone (39 versus 14%,
p<0.02), and to live in rented accommodation (31 versus 6%, p<0.005). There were
no differences between the two groups in terms of baseline physiological parameters (forced expiratory volume in one second, forced vital capacity, 6-min
walk distance, oxygen saturation, perceived dyspnoea), quality of life domains
(Chronic Respiratory Disease Questionnaire), or indices of COPD-related morbidity. The nonadherent group were more likely to be current smokers (28
versus 8%, p<0.02) and less likely to use inhaled corticosteroids (16 versus
42%, p<0.005). The nonadherent group was not significantly likely to be
depressed, anxious, prone to hyperventilation or to have had previous emotional
counselling and was more likely to be dissatisfied with disease-specific social
support (51 versus 2%, p<0.001). In conclusion, a substantial proportion of
eligible subjects who did not participate in a chronic obstructive pulmonary
disease rehabilitation programme were not more physiologically impaired, but
were more likely to be: socially isolated, lack chronic obstructive pulmonary
disease-related social support, still be smoking and be less compliant with
other healthcare activities. Identification of one or more of these factors
reliably allows prediction for nonadherence to a rehabilitation programme.
14: Medicina (B Aires) 1998;58(6):717-27
[Exercise training in chronic obstructive pulmonary disease. Comparative study of aerobic training of lower limbs vs. combination with upper limbs].
Sivori M, Rhodius E, Kaplan P, Talarico M, Gorojod G, Carreras B, Lopez C,
Servicio de Neumonologia, Policlinico Bancario, Buenos Aires, Argentina. email@example.com
A prospective, randomized and controlled study has been performed in 28 patients
with severe COPD. A group of 14 has been trained with their lower limbs (LL),
while another similar group of 14 patients was also trained with their upper
limbs (UL). Results showed improvement in both groups in the endurance test for
LL, dyspnea scale, efficiency and muscular working capacity. A considerable
improvement was observed in the oxygen uptake at the anerobic threshold (VO2AT)
which suggests a training effect, expressed through an improvement in exercise
tolerance. Only the group who trained UL showed a remarkable improvement in the
dyspnea scale, endurance test and maximal static mouth pressure, showing a
better intrinsic working capacity and participation of the UL muscles producing
those manoeuvres. At the end of training, quality of life was significantly
increased and the hospitalization rate was lower in both groups. According to
these findings, it is suggested that patients with severe COPD included in
training programmes add UL exercises to the LL usually carried out.
Randomized controlled trial
15: Can Respir J 1999 Jan-Feb;6(1):55-63
Pulmonary rehabilitation programs in Canada: national survey.
Brooks D, Lacasse Y, Goldstein RS
Department of Physical Therapy, University of Toronto, Toronto, Canada. firstname.lastname@example.org
OBJECTIVE: To characterize pulmonary rehabilitation (PR) programs in terms of
their type, size, duration, patient population, content and staffing. DESIGN:
Surveys were sent to members of the Rehabilitation Committee of the Canadian
Thoracic Society, as well as any program identified by members of the Canadian
Physiotherapy Cardio-Respiratory Society, by provincial lung associations or by
the respondents. PARTICIPANTS: Of 51 surveys sent, responses were received from
44 facilities (86% response rate). In-patient or out-patient pulmonary rehabilitation programs were offered by 36 facilities. RESULTS: Most programs
(97%) admitted out-patients, and 22% had an in-patient capability. Out-patient
programs enrolled 13 patients (median 11; range five to 48) at a given time for
a duration of 8.3 weeks (range two to 26). In-patient programs enrolled nine
patients at a given time (range two to 26) for 4.6 weeks (range one to eight).
Programs included patients with chronic obstructive pulmonary disorder (100%),
restrictive disease (93%), asthma (82%), adults with cystic fibrosis (46%),
patients pre- or postlung transplantation (45%) and patients receiving mechanical ventilatory support (18%). Breathing retraining, education and upper
extremity training were incorporated in more than 90% of all programs. Only
one-third of programs offered smoking cessation as part of the rehabilitation.
Education sessions on medications and inhaler usage were included in most programs, but sexuality was addressed in only half the programs. CONCLUSIONS:
This first comprehensive national survey of PR programs in Canada shows that
there are similarities in the format, content and staffing of PR programs.
Programs are only able to service a small percentage of patients with chronic
16: Am J Respir Crit Care Med 1999 Mar;159(3):896-901
Aerobic and strength training in patients with chronic obstructive pulmonary
Bernard S, Whittom F, Leblanc P, Jobin J, Belleau R, Berube C, Carrier G, Maltais F
Unite de Recherche, Institut de Cardiologie et de Pneumologie de Quebec, Universite Laval, Ste-Foy, Quebec, Canada.
The purpose of this study was to evaluate whether strength training is a useful
addition to aerobic training in patients with chronic obstructive pulmonary
disease (COPD). Forty-five patients with moderate to severe COPD were randomized
to 12 wk of aerobic training alone (AERO) or combined with strength training
(AERO + ST). The AERO regimen consisted of three weekly 30-min exercise sessions
on a calibrated ergocycle, and the ST regimen included three series of eight to
10 repetitions of four weight lifting exercises. Measurements of peripheral
muscle strength, thigh muscle cross-sectional area (MCSA) by computed tomographic scanning, maximal exercise capacity, 6-min walking distance (6MWD),
and quality of life with the chronic respiratory questionnaire were obtained at
baseline and after training. Thirty-six patients completed the program and
constituted the study group. The strength of the quadriceps femoris increased
significantly in both groups (p < 0.05), but the improvement was greater in the
AERO + ST group (20 +/- 12% versus 8 +/- 10% [mean +/- SD] in the AERO group, p
< 0.005). The thigh MCSA and strength of the pectoralis major muscle increased
in the AERO + ST group by 8 +/- 13% and 15 +/- 9%, respectively (p < 0.001), but
not in the AERO group (3 +/- 6% and 2 +/- 10%, respectively, p > 0.05). These
changes were significantly different in the two study groups (p < 0.01). The
increase in strength of the latissimus dorsi muscle after training was modest
and of similar magnitude for both groups. The changes in peak exercise work
rate, 6MWD, and quality of life were comparable in the two groups. In conclusion, the addition of strength training to aerobic training in patients
with COPD is associated with significantly greater increases in muscle strength
and mass, but does not provide additional improvement in exercise capacity or
quality of life.
Randomized controlled trial
17: Chest 1999 Feb;115(2):383-9
Health-related quality of life improves following pulmonary rehabilitation and
lung volume reduction surgery.
Moy ML, Ingenito EP, Mentzer SJ, Evans RB, Reilly JJ Jr
Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital,
Boston, MA 02115, USA.
STUDY OBJECTIVES: To evaluate changes in health-related quality of life (HRQL)
as assessed by the Medical Outcomes Study Short Form 36-item questionnaire
(SF-36) after pulmonary rehabilitation and lung volume reduction surgery (LVRS).
DESIGN: Prospective cohort study. PATIENTS: Nineteen patients with severe emphysema who underwent pulmonary rehabilitation in preparation for LVRS.
INTERVENTIONS: Pulmonary rehabilitation followed by bilateral sequential LVRS.
MEASUREMENTS AND RESULTS: HRQL assessed by the SF-36 was measured at baseline,
after pulmonary rehabilitation, and 6 months after LVRS. One-way analysis of
variance with repeated measures demonstrated no significant change from baseline
in any of the eight domains after pulmonary rehabilitation. Scores for only one
domain, vitality, improved significantly after LVRS compared with scores after
pulmonary rehabilitation. However, significant improvements over baseline scores
were demonstrated after combined preoperative pulmonary rehabilitation and LVRS
in the domains of physical functioning, role limitations due to physical problems, social functioning, and vitality. Pulmonary rehabilitation contributed
most to the overall improvements in role limitations due to physical problems,
whereas LVRS contributed mainly to the overall improvements in physical functioning, social functioning, and vitality. CONCLUSIONS: Patients with severe
emphysema experience significant improvements in both physical and social health
status as assessed by the SF-36 after combined pulmonary rehabilitation and
LVRS. Each intervention makes unique and complementary contributions to the
overall improvements in HRQL.