Background: Bronchiectasis is a chronic suppurative lung disease often characterised by airflow obstruction and hyperinflation, and leading to decreased exercise tolerance and reduced health status. The role of pulmonary rehabilitation (PR) and inspiratory muscle training (IMT) has not been investigated in this group of patients. Methods: Thirty two patients with idiopathic bronchiectasis were randomly allocated to one of three groups: PR plus sham IMT (PR-SHAM), PR plus targeted IMT (PR-IMT), or control. All patients (except the control group) underwent an 8 week training programme of either PR or PR plus targeted IMT. Exercise training during PR was performed three times weekly at 80% of the peak heart rate. IMT was performed at home for 15 minutes twice daily over the 8 week period. Results: PR-SHAM and PR-IMT resulted in significant increases in the incremental shuttle walking test of 96.7 metres (95% confidence interval (CI) 59.6 to 133.7) and 124.5 metres (95% CI 63.2 to 185.9), respectively, and in endurance exercise capacity of 174.9% (95% CI 34.7 to 426.1) and 205.7% (95% CI 31.6 to 310.6). There were no statistically significant differences in the improvements in exercise between the two groups. Significant improvements in inspiratory muscle strength were also observed both in the PR-IMT group (21.4 cm H 2 O increase, 95% CI 9.3 to 33.4; p = 0.008) and the PR-SHAM group (12.0 cm H 2 O increase, 95% CI 1.1 to 22.9; p = 0.04), the magnitude of which were also similar (p = 0.220). Improvements in exercise capacity were maintained in the PR-IMT group 3 months after training, but not in the PR-SHAM group. Conclusion: PR is effective in improving exercise tolerance in bronchiectasis but there is no additional advantage of simultaneous IMT. IMT may, however, be important in the longevity of the training effects.
Resting lung function is only weakly related to health status in chronic obstructive pulmonary disease, reflecting the multifactorial causes of impairment and the heterogeneous nature of the condition. The current study examined whether density mask analysis of high-resolution computed tomography (HRCT) or exercise capacity were better surrogates for health status in a well-defined, homogeneous group of patients with alpha(1)-antitrypsin deficiency (PiZ). Twenty-nine patients with predominantly lower zone emphysema on HRCT were studied. Exercise was assessed by incremental treadmill (V O(2) peak) and shuttle walking tests (ISWT) and health status by the St. George's Respiratory Questionnaire (SGRQ) and SF-36. Although lower zone expiratory HRCT was related to exercise capacity (rho = -0.64 and -0.63 for V O(2) peak and ISWT, respectively, p < 0.001), multiple regression analysis suggested that FEV(1) was a marginally better predictor (rho = -0.64 and -0.65, p < 0.001). HRCT also related significantly to health status (rho = -0.37 for SGRQ activity, p < 0.05), although again FEV(1) showed a stronger relationship (rho = -0.43, p = 0.01). However, exercise capacity was the best predictor of health status with the ISWT accounting for up to 55% of the variability seen in SGRQ total and up to 53% of the SF-36 domain scores (physical functioning). Although both HRCT and lung function relate to health status, exercise capacity is the best predictor of patients disability in these patients with predominantly lower zone emphysema.
Objective-To compare the incremental shuttle walk test (ISWT) with treadmill exercise testing (TT) derived measurement of peak oxygen consumption (peak VO 2 ) in patients undergoing assessment for cardiac transplantation. Design-Prospective comparison. All investigations occurred during a single period of admission for transplant assessment. Setting-Single UK cardiothoracic transplantation unit. Patients-25 patients recruited (21 men). Mean age was 53 years. Interventions-Patients underwent two TT of peak VO 2 using the modified Naughton protocol and three (one practice) ISWT. Investigations were performed on consecutive days. Main outcome measures-Main outcome measures were repeatability of TT and ISWT assessments; relation between peak VO 2 and distance walked in the ISWT; and receiver operating characteristic (ROC) analysis to establish a distance walked in the ISWT that predicted which patients would have a peak VO 2 greater than 14 ml/min/kg. Results-Both the ISWT and the TT were highly reproducible. Following the first practice walk, mean (SD) ISWT distances were 400.0 (146) m (ISWT2) and 401.3 (129) m (ISWT3), r = 0.90, p < 0.0001. Mean peak VO 2 by TT was 15.2 (4.4) ml/kg/min (TT1) and 15.0 (4.4) ml/ kg/min (TT2), r = 0.83, p < 0.0001. The results revealed a strong correlation between distance covered in the ISWT and peak VO 2 obtained during TT (r = 0.73, p = 0.0001). ROC analysis showed that a distance walked of 450 m allowed the selection of patients with a peak VO 2 of over 14 ml/min/kg. Conclusions-This work confirms the utility of the ISWT in the assessment of exercise capacity in patients with severe heart failure undergoing assessment for cardiac transplantation. ISWT may provide a widely applicable surrogate measure for peak VO 2 estimation in this population. Shuttle distance walked may therefore allow the convenient, serial assessment of patients with heart failure before referral for transplantation.
Patients with ANCA-associated disease may have significant lung function impairment irrespective of lung involvement at the time of diagnosis. Patients showed reduced respiratory muscle strength, health status and exercise capacity, which correlated with reduced transfer factor.
Use of noseclips during spirometryC Newall et al. 54Chronic Respiratory Disease had normal spirometry, 17 patients had obstructive ventilatory disorders (FEV 1 /FVC Ͻ 70%) and nine patients had a restrictive ventilatory disorder (FEV 1 /FVC Ͼ 80% and standardized residuals for FEV 1 and FVC both ϾϪ1.64).The mean measurements for all parameters are shown in Table 2 for each of the groups. There were no significant differences between the mean measurements obtained in Groups 1 and 2 for all parameters. Similarly, there were no significant differences between the within patient coefficient of variation (CV) obtained for all measurements with and without the use of noseclips (Table 3). Effect of previous experienceOf the 52 patients studied 26 were naive to the testing procedure and the remaining 26 patients had performed the tests before (ranging from one to 30 times, mean 3.29 (7.13) occasions). The absolute differences between the measurements with and without the use of noseclips was similar in naive and non-naive patients (mean difference in FEV 1 0.046 L (0.216) and Ϫ0.016 L (0.100) in naive and non-naive patients respectively; FVC Ϫ0.013 L (0.094) and Ϫ0.028 L (0.129) respectively; VC 0.004 L (0.140) and 0.004 L (0.156) respectively; all P Ͼ 0.05).The mean differences between the measurements with and without the use of noseclips was similar regardless of the order in which the tests were performed (mean differences in FEV 1 0.030 L and Ϫ0.005 L for Groups 1 and 2 respectively; FVC Ϫ0.007 L and Ϫ0.040 L respectively; VC mean differences 0.036 L and Ϫ0.040 L respectively; all P Ͼ 0.05).Overall, there were four patients with differences between measurements with and without the use of noseclips outside the 95% confidence limits for FEV 1 , VC and FVC respectively (Figures 1a, b and c, respectively). In two patients the differences in VC between measurements obtained with and without the use of noseclips were greater than 330 mL and therefore greater than the ARTP/BTS guidelines for significant bronchodilator reversibility. 2 For FEV 1 , there were five patients with differences of greater than 160 mL between measurements obtained with and without noseclips, which is greater than the criteria for bronchodilator reversibility. 2 No significant correlations were obtained between the absolute differences in measurements obtained with and without the use of noseclips and severity of lung disease, age, smoking history or absolute lung volume (all P Ͼ 0.05). DiscussionWe have shown that the use of noseclips during spirometry using a wedge bellows device does not result in any systematic differences in the measurements of VC, FVC and FEV 1 . The differences between the measurements obtained with and without noseclips were not influenced by the order in which the tests were performed, previous experience at performing the tests, demographic (eg, age, BMI) or physiological (eg, disease severity, disease type) characteristics. There was, however, a wide range of individual differences between the measurements obtained wi...
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