OBJECTIVE: To determine the feasibility and efficacy of a six-month, cell phone-based exercise persistence intervention for patients with chronic obstructive pulmonary disease (COPD) following pulmonary rehabilitation. METHODS: Participants who completed a two-week run-in were randomly assigned to either MOBILE-Coached (n = 9) or MOBILE-Self-Monitored (n = 8). All participants met with a nurse to develop an individualized exercise plan, were issued a pedometer and exercise booklet, and instructed to continue to log their daily exercise and symptoms. MOBILE-Coached also received weekly reinforcement text messages on their cell phones; reports of worsening symptoms were automatically flagged for follow-up. Usability and satisfaction were assessed. Participants completed incremental cycle and six minute walk (6MW) tests, wore an activity monitor for 14 days, and reported their health-related quality of life (HRQL) at baseline, three, and six months. RESULTS: The sample had a mean age of 68 +/-11 and forced expiratory volume in one second 18% predicted. Participants reported that logging their exercise and symptoms (FEV(1)) of 40 +/- was easy and that keeping track of their exercise helped them remain active. There were no differences between groups over time in maximal workload, 6MW distance, or HRQL (p > 0.05); however, MOBILE-Self-Monitored increased total steps/day whereas MOBILE-Coached logged fewer steps over six months (p =0.04). CONCLUSIONS: We showed that it is feasible to deliver a cell phone-based exercise persistence intervention to patients with COPD post-rehabilitation and that the addition of coaching appeared to be no better than self-monitoring. The latter finding needs to be interpreted with caution since this was a purely exploratory study. TRIAL REGISTRATION: ClinicalTrials.gov (NCT00373932).

BACKGROUND: People with chronic obstructive pulmonary disease (COPD) continue to experience dyspnea with activities of daily living (ADL) despite optimal medical management. Information and communication technologies may facilitate collaborative symptom management and could potentially increase the reach of such interventions to those who are unable to attend face-to-face pulmonary rehabilitation or self-management programs. OBJECTIVE: The purpose of this randomized study was to test the efficacy of two 6-month dyspnea self-management programs, Internet-based (eDSMP) and face-to-face (fDSMP), on dyspnea with ADL in people living with COPD. METHODS: We randomly assigned 50 participants with moderate to severe COPD who were current Internet users to either the eDSMP (n = 26) or fDSMP (n = 24) group. The content of the two programs was similar, focusing on education, skills training, and ongoing support for dyspnea self-management, including independent exercise. The only difference was the mode (Internet/personal digital assistant [PDA] or face-to-face) in which the education sessions, reinforcement contacts, and peer interactions took place. Participants returned to one of two academic clinical sites for evaluation at 3 and 6 months. The primary outcome of dyspnea with ADL was measured with the Chronic Respiratory Questionnaire. Secondary outcomes of exercise behavior, exercise performance, COPD exacerbations, and mediators, such as self-efficacy and social support, were also measured. A satisfaction survey was administered and a semistructured exit interview was conducted at the final visit. RESULTS: The study was stopped early due to multiple technical challenges with the eDSMP, but follow-up was completed on all enrolled participants. Data were available for 39 participants who completed the study (female: 44%; age: 69.5 +/- 8.5 years; percent predicted forced expiratory volume in 1 s: 49.6 +/- 17.0%). The fDSMP and eDSMP showed similar clinically meaningful changes in dyspnea with ADL from baseline to 3 months (fDSMP:+ 3.3 points; eDSMP:+ 3.5 points) and sustained these improvements at 6 months (fDSMP:+ 4.0 points; eDSMP:+ 2.5 points; time effects P <.001; group by time P =.51). Self-reported endurance exercise time (P =.001), physical functioning (P =.04), and self-efficacy for managing dyspnea (P =.02) also showed positive improvements over time in both groups with no significant differences with respect to program modality. Participants who completed the study reported favorable satisfaction with the programs. CONCLUSIONS: Although there were numerous technical challenges with the eDSMP, both dyspnea self-management programs were effective in reducing dyspnea with ADL in the short term. Our findings will need to be confirmed in a larger randomized trial with more mature Web and personal digital assistant tools, use of a control group, and longer follow-up.

The primary purpose of this secondary analysis was to determine whether 103 participants with chronic obstructive pulmonary disease rated the affective dimension of dyspnea (dyspnea-related anxiety and dyspnea-related distress) separately from the sensory dimension (intensity) during baseline exercise testing conducted as part of a randomized clinical trial. A secondary purpose was to determine if dyspnea-related anxiety and distress were rated distinctly different from other measurements of anxiety. At the end of a 6-minute walk and an incremental treadmill test, participant ratings of the magnitude of dyspnea-related anxiety and distress on the Modified Borg Scale were significantly different from their ratings of the intensity of dyspnea. Dyspnea-related anxiety and distress also appeared to be concepts independent from measures of state anxiety, negative affect, and anxiety before a treadmill test.(c) 2009 Wiley Periodicals, Inc.

This is a summary of the presentation on initiating noninvasive management of respiratory insufficiency in neuromuscular disease, presented as part of the program on pulmonary management of pediatric patients with neuromuscular disorders at the 30th annual Carrell-Krusen Neuromuscular Symposium on February 20, 2008.

Abstract Background: There has been limited study of yoga training as a complementary exercise strategy to manage the symptom of dyspnea in patients with chronic obstructive pulmonary disease (COPD). Purpose: The primary purpose of this pilot study was to evaluate a yoga program for its safety, feasibility, and efficacy for decreasing dyspnea intensity (DI) and dyspnea-related distress (DD) in older adults with COPD. Methods: Clinically stable patients with COPD (n = 29; age 69.9 +/- 9.5; forced expiratory volume in 1 second (FEV(1)) 47.7 +/- 15.6% predicted; female = 21) were randomized to a 12-week yoga program specifically designed for people with COPD or usual-care control (UC). The twice-weekly yoga program included asanas (yoga postures) and visama vritti pranayama (timed breathing). Safety measure outcomes included heart rate, oxygen saturation, dyspnea, and pain. Feasibility was measured by patient-reported enjoyment, difficulty, and adherence to yoga sessions. At baseline and at 12 weeks, DI and DD were measured during incremental cycle ergometry and a 6-minute walk (6MW) test. Secondary efficacy outcomes included physical performance, psychologic well-being, and health-related quality of life (HRQoL). Results: Yoga training was safe and feasible for patients with COPD. While yoga training had only small effects on DI after the 6MW test (effect size [ES], 0.20; p = 0.60), there were greater reductions in DD in the yoga group compared to UC (ES, 0.67; p = 0.08). Yoga training also improved 6MW distance (+71.7 +/- 21.8 feet versus -27.6 +/- 36.2 feet; ES = 0.78, p = 0.04) and self-reported functional performance (ES = 0.79, p = 0.04) compared to UC. There were small positive changes in muscle strength and HRQoL. Conclusions: Elderly patients with COPD participated safely in a 12-week yoga program especially designed for patients with this chronic illness. After the program, the subjects tolerated more activity with less DD and improved their functional performance. These findings need to be confirmed in a larger, more sufficiently powered efficacy study.

Noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP) have been used in various unusual settings to assist breathing. NIV is now frequently used to treat exacerbations of chronic obstructive pulmonary disease and chronic respiratory failure in neuromuscular disease. This paper discusses CPAP and NIV for postoperative hypoxemia, preventing intubation in high-risk bronchoscopy, respiratory failure in pandemics, obesity hypoventilation syndrome, and respiratory support during percutaneous endoscopic gastrostomy tube placement.

BACKGROUND: Only limited data exist on the relationship of lung function to patients with extreme obesity. To assess the relationship between lung function tests and clinical characteristics in a cohort of morbidly obese patients undergoing evaluation for bariatric procedures in a university hospital in the United States. METHODS: Consecutive patients undergoing clinical evaluation were reviewed. The variables included demographic, anthropometric, clinical, and pulmonary function data. RESULTS: A total of 229 patients underwent a standardized preoperative evaluation. Of these 229 patients, 136 (59%) had evaluable data and 102 (75%) were women. The mean +/- standard deviation age was 45 +/- 10 years, the mean weight was 164 +/- 42 kg, and the mean body mass index was 57 +/- 13 kg/m(2). Smoking or asthma was reported in 38% and 24% of patients, respectively. The mean forced vital capacity and forced expiratory volume in 1 s was 80%+/- 17% of predicted and 76%+/- 19% of predicted, respectively. Of the 136 patients, 29% had a measured forced expiratory volume in 1 s/forced vital capacity of >/=.08 below the predicted ratio. The mean total lung capacity was 86%+/- 14% of predicted; 26% of subjects had a total lung capacity <80% of predicted. Multivariate logistic regression analysis demonstrated an association of obstructive ventilatory defects with male gender (odds ratio [OR] 2.35, 95% confidence interval [CI] 1.00-5.50) and current or previous smoking (OR 2.41, 95% CI 1.10-5.30), but not body mass index. Restrictive defects were associated with body mass index (OR 1.06, 95% CI 1.01-1.10), in particular, obesity hypoventilation syndrome (OR 3.7, 95% CI 1.2-11.1). CONCLUSION: The mean preoperative spirometry, lung volumes, and gas exchange values were within the established reference ranges. Restrictive ventilatory defects were less common than obstructive ventilatory patterns and were most prominently associated with obesity hypoventilation syndrome.

BACKGROUND Continuous oxygen therapy is not recommended for emphysema patients who are non-hypoxemic at rest, although it is often prescribed(1). Little is known regarding the clinical characteristics and survival of non-hypoxemic emphysema patients using continuous oxygen. Analysis of data from the National Emphysema Treatment Trial (NETT) offers insight into this population. METHODS We analyzed demographic and clinical characteristics of 1215 participants of NETT, stratifying by resting Pa(O2) and reported oxygen use. Eight year survival was evaluated in individuals randomized to medical therapy. RESULTS At enrollment, 33.8%(n=260) of participants non-hypoxemic at rest reported continuous oxygen use. When compared to non-hypoxemic individuals not using oxygen (n=226), those using continuous oxygen had worse dyspnea, lower quality of life, more frequent exercise desaturation and higher case fatality rate. After adjusting for age, BMI, and FEV(1)% predicted, the presence of exercise desaturation accounted for the differential mortality seen between these groups. CONCLUSIONS In NETT, the use of continuous oxygen in resting non-hypoxemic emphysema patients was associated with worse disease severity and survival. The differential survival observed could nearly all be accounted for by the higher prevalence of exercise desaturation in those using continuous oxygen, suggesting that it is not a harmful effect of oxygen therapy contributing to mortality. It remains unclear whether continuous oxygen therapy improves survival in normoxic patients with exercise desaturation.

There is strong evidence for the protective effects of physical activity on chronic health problems. Activity monitors can objectively measure free living occupational and leisure time physical activity. Utility is an important consideration when determining the most appropriate monitor for specific populations and environments. Hours of activity data collected, the reasons for activity hours not being recorded, and how these two factors might change over time when using an activity monitor in free living are rarely reported. This study investigated user perceptions, adherence to minimal wear time and loss of data when using the RT3 activity monitor in 21 healthy adults, in a variety of occupations, over three (7 day) repeated weeks of measurement in free living. An activity diary verified each day of monitoring and a utility questionnaire explored participant perceptions on the usability of the RT3. The RT3 was worn for an average of 14h daily with 90% of participants having complete data sets. In total 6535.8 and 6092.5h of activity data were collected from the activity diary and the RT3 respectively. An estimated 443.3h (6.7%) of activity data were not recorded by the RT3. Data loss was primarily due to battery malfunction (45.2%). Non-adherence to wear time accounted for 169.5h (38.2%) of data loss, of which 14h were due to occupational factors. The RT3 demonstrates good utility for free living activity measurement, however, technical issues and strategies to manage participant adherence require consideration with longitudinal and repeated measures studies.

This study examined sources of variability in physical activity (PA) of youth with developmental disabilities (DD), and determined the optimal number of days required for monitoring PA. Sixteen youth with DD wore two pedometers and two accelerometers for 9 days, including 5 weekdays (W) and 2 weekends (WK). A two-facet in fully crossed two-way ANOVAs were employed to estimate sources of variability across W, WK, and W and WK combined (WWK) for each device. Primary sources of variability were the person and the person by day interaction for both devices. Using a pedometer, four, six, and eight days of measurements were required to determine typical PA levels of the participants during W, WK, and WWK, respectively, Using one accelerometer, four days of measurements were estimated across all days.

Background: Accelerometers measure intensity, frequency, and duration of physical activity. However, the scarcity of reports on data reduction makes comparing accelerometer results across studies difficult. Methods: Participants were asked to wear a triaxial accelerometer (RT3) for ?10 hours for at least 4 days, including one weekend day. We summarize our data-cleaning procedures and assess the impact of defining a usable day of measurements as at least 6, 8, or 10 hours of wear time, and of standardizing data to a 12-hour day. Results: Eighty-two percent of participants met wear time requirements; 93% met requirements when we defined a day as 8-or-more hours of wear time. Normalization of data to a 12-hour day had little impact on estimates of daily moderate-to-vigorous physical activity (MVPA; 16.9 vs. 17.1 minutes); restricting MVPA to activities occurring in bouts of 10 minutes or longer had greater impact (16.9 vs. 6.3 minutes per day). Conclusion: Our account of accelerometry quality-control and data-cleaning procedures documents the small impact of variations in daily wear time requirements on MVPA estimates, and the larger impact of evaluating total MVPA vs. MVPA occurring in extended bouts. This paper should allow other researchers to duplicate or revise our methods as needed.

To assess physical activity and disability in chronic obstructive pulmonary disease (COPD), we evaluated the use of an accelerometer and checklist to measure free-living physical activity. Seventeen males with stable COPD completed a daily activity checklist for 14 days. Ten subjects concurrently wore an Actiped accelerometer (FitSense, Southborough, Massachussetts) that records steps per day. Regression models assessed relationships between steps per day, number of daily checklist activities performed, and clinical measures of COPD status. The average steps per day ranged from 406 to 4,856. The median intrasubject coefficient of variation for steps per day was 0.52 (interquartile range [IQR] 0.41-0.58) and for number of daily checklist activities performed was 0.28 (IQR 0.22-0.32). A higher number of steps per day was associated with a greater distance walked on the 6-minute walk test and better health-related quality of life. A higher number of daily checklist activities performed was associated with a higher force expiratory volume in 1 s percent predicted and lowerbody mass index, airflow obstruction, dyspnea, exercise capacity (BODE) index. Prospectively measuring free-living physical activity in COPD using an unobtrusive accelerometer and simple activity checklist is feasible. Low intrasubject variation was found in free-living physical activity, which is significantly associated with clinical measures of COPD status.

We sought to develop procedures for computerized analysis of long-term, high-resolution activity monitoring data that allow accurate assessment of the time course of activity levels suitable for use in chronic obstructive pulmonary disease (COPD) patients. Twenty-two COPD patients utilizing long-term oxygen recruited from 5 sites of the COPD Clinical Research Network wore a triaxial accelerometer (RT3, Stayhealthy, Monrovia, CA) during waking hours over a 14-day period. Computerized algorithms were composed allowing minute-by-minute activity data to be analyzed to determine, for each minute, whether the monitor was being worn. Temporal alignment allowed determination of average time course of activity level, expressed as average vector magnitude units (VMU, the vectorial sum of activity counts in three orthogonal directions) per minute, for each hour of the day. Mid-day activity was quantified as average VMU/minute between 10AM and 4PM for minutes the monitor was worn. Over the 14 day monitoring period, subjects wore the monitor an average of 11.4 +/- 3.0 hours x day(-1). During mid-day hours, subjects wore the monitor 76.3% of the time and generated an average activity level of 112 +/- 55 VMU x min(-1). Increase in precision of activity estimates with longer monitoring periods was demonstrated. This analysis scheme allows a detailed temporal pattern of activity to be defined from triaxial accelerometer recordings and has the potential to facilitate comparisons among subjects and between subject groups. This trial is registered at ClinicalTrials.gov (NCT00325754).

New technologies have allowed remote real-time electronic recording of symptoms and spirometry. The feasibility of utilising this technology in COPD patients has not been investigated. This is a feasibility study. The primary objective is to determine whether the use of an electronic diary with a portable spirometer can be performed by COPD patients with a moderate to severe disease. Secondary objectives are to investigate the value of this method in early detection of acute exacerbations of COPD (AECOPD). In this 6-month study, 18 patients recorded daily their symptom score and spirometry. Data was sent on real time. AECOPD which was defined according to pre-set criteria were noted. Spirometry values and scores for health-related quality of life were compared between the start and the end of the study. Hospitalisation rate due to AECOPD was compared with a parallel period in the previous year. On average, patients were able to record 77% of their total study days. The system detected 73% of AECOPD. In further 27% of AECOPD patients sought treatment although the change in symptoms did not meet AECOPD definition. The number of COPD-related hospitalisations significantly reduced compared to the previous year. There was a significant increase in FEV(1) and FVC from the start to the end of the study. The remote monitoring device used in this study can be used in COPD patients. AECOPD was detected early in the majority of cases. Hospitalisation rate due to AECOPD was reduced and FEV(1) and FVC values increased during the study.

INTRODUCTION: Regular moderate physical activity in COPD reduces morbidity and improves life expectancy. Many programmes often fail after rehabilitation because regular training at home, possibly caused by a lack of motivation, is not maintained, the performance parameters then decline to the prerehabilitation levels. For cost reasons, a simple procedure is required to measure the training times in the home environment with a daily transmission of telemetric data so that, in the case of decline, advice and assistance can be provided. QUESTIONS: How long is the actual daily training time monitored by telemetry of COPD patients if a target of 20 minutes per day is prescribed by the doctor? Is there a correlation between physical activity at home and the training period? METHOD: We used a device for training the upper extremities with a GSM data transmission module for the transfer of the training times. The physical activity before an exacerbation of COPD and the willingness to modify the training behaviour were determined by questionnaires. 13 patients with COPD (age 69 +/- 9 years, FEV1 48.6 +/- 23.9 %) were investigated prospectively for 6 days under stationary conditions. RESULTS: The mean training period (target 20 min/day) was 16.1 +/- 11.7 min/day. The frequency of physical activity per week correlated with the daily ergometry training period in the clinic (r = 0.59). CONCLUSION: Training supervised by telemonitoring represents a useful way to objectively obtain training times. Ergometric training in combination with online transmission (telemetric monitoring) and regular phone calls could be an inexpensive method to increase physical activity.

OBJECTIVES: This study aims to determine the incidence of reported and unreported exacerbations, to identify predictors of reporting, and to compare the impact of reported and unreported exacerbations on health status. METHODS: The study is based on a multi-center Canadian cohort of COPD patients. MEASUREMENTS: Patients completed a daily diary from which exacerbations were defined as a worsening of at least one key symptom (dyspnea, sputum amount, sputum color) recorded on at least two consecutive days. Patients were asked to contact the study center if there was a sustained worsening of symptom. Reported exacerbations were events that led to contacting study center or health care visit. MAIN RESULTS: The study enrolled 421 patients. The overall incidence of exacerbations was 2.7 per person per year, and 1.9 per person per year were not reported. Predictors of reporting included age (HR 0.90; 95% CI 0.81-0.98 per 5 year increase), FEV1 % predicted (HR 0.84; 95% CI 0.70-0.99 per 10% increase), number of symptoms at onset (HR 1.59; 95% CI 1.37-1.84 per additional symptom) and time of the week (HR 0.35; 95% CI 0.22-0.56 weekend versus weekday) where HR is hazard ratio and CI is confidence interval. There was a clinically important decline in health status for 52% of patients with reported exacerbation and 43% with unreported. CONCLUSIONS: This study has shown that less than one third of the exacerbations were reported. The number of symptoms at onset was the most important predictor of reporting exacerbation, and both reported and unreported xacerbations had an impact on health status.

PURPOSE: To determine the feasibility of using an accelerometer to characterize physical activity patterns (PA) surrounding chronic obstructive pulmonary disease (COPD) exacerbations (AECOPD) in patients with COPD for 16 weeks. METHODS: Patients with COPD (n = 8) wore the RT3, a triaxial accelerometer (Stayhealthy, Monrovia, CA) during waking hours and kept daily symptom diaries. The mean vector magnitude unit (VMU) per minute was calculated by dividing the total VMU for the day by the number of minutes the device was worn. Descriptive statistics were used and plots were made showing PA for each subject with AECOPD markers based on symptom diaries and health resource utilization. RESULTS: Sample characteristics were: age 71 +/- 4; 5 Females; forced expiratory volume in one second (FEV1)% predicted: 40%+/- 16%; FEV1/forced vital capacity: 45 +/- 7; and Medical Research Council dyspnea scale: 2.3 +/- 0.9. Overall adherence to the monitoring protocol was 97.6%(Range 92%-100%) while adherence to wearing the device for at least 10 hours per day was 91.5%(Range 75%-99%). Mean vector magnitude units per minute was 117.8 +/- 47 (Range 61.4-184.1). Seven exacerbations were captured over a total of 896 person-days of monitoring. There were substantial intra-individual fluctuations in daily PA during both the stable state and with outpatient treated exacerbations. CONCLUSIONS: Patients with COPD were able to adhere to a 16-week activity monitoring protocol and reported a willingness to wear such a device for an extended period of time if the data yield important and useful information for themselves and their health provider. Future work will need to focus first, on validating other promising devices that produce higher quality PA data and second, replicate this monitoring protocol with a larger sample of COPD patients over a longer period.

BACKGROUND: There is great interest in chronic obstructive pulmonary disease (COPD) and the associated large burden of disease. COPD is characterised by frequent day by day fluctuations, and repetitive clinical exacerbations are typical. Self-management is a term applied to educational programmes aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. In COPD, the value of self-management education is not yet clear. The first Cochrane review about self-management was published in 2003. It was intended to shed light on the effectiveness of self-management programmes in COPD and the relative efficacy of their constitutive elements. No conclusions about the effectiveness of self-management could be drawn because of the large variation in outcome measures used in the limited number of included studies. This article describes the first update of this review. OBJECTIVES: The objective of this review was to assess the settings, methods and efficacy of COPD self-management education programmes on health outcomes and use of health care services. SEARCH STRATEGY: We searched the Cochrane Airways Group trial register, MEDLINE (January 1985 to January 2006), reference lists, and abstracts of medical conferences. SELECTION CRITERIA: Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on pulmonary rehabilitation and studies without usual care as a control group were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed study quality and extracted data. Investigators were contacted for additional information. MAIN RESULTS: The reviewers included 15 group comparisons drawn from 14 trials. They assessed a broad-spectrum of interventions and health outcomes with different follow-up times. Meta-analyses could often not appropriately be performed because of heterogeneity among studies. The studies showed a significant reduction in the probability of at least one hospital admission among patients receiving self-management education compared to those receiving usual care (OR 0.64; 95% CI (0.47 to 0.89)). This translates into a one year NNT ranging from 10 (6 to 35) for patients with a 51% risk of exacerbation, to an NNT of 24 (16 to 80) for patients with a 13% risk of exacerbation. On the disease specific SGRQ, differences reached statistical significance at the 5% level on the total score (WMD -2.58; 95% CI (-5.14 to -0.02)) and impact domain (WMD -2.83; 95% CI (-5.65 to -0.02)), but these difference did not reach the clinically relevant improvement of 4 points. A small but significant reduction was detected in dyspnoea measured with the BORG-scale (WMD -0.53; 95% CI (-0.96 to -0.10)). No significant effects were found either in number of exacerbations, emergency department visits, lung function, exercise capacity, and days lost from work. Inconclusive results were observed in doctor and nurse visits, on symptoms other than dyspnoea, the use of courses of oral corticosteroids and antibiotics, and the use of rescue medication. AUTHORS' CONCLUSIONS: It is likely that self-management education is associated with a reduction in hospital admissions with no indications for detrimental effects in other outcome parameters. This would in itself already be enough reason for recommending self-management education in COPD. However, because of heterogeneity in interventions, study populations, follow-up time, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and contents of self-management education programmes in COPD. There is an evident need for more large RCTs with a long-term follow-up, before more conclusions can be drawn.