Background: Chronic obstructive pulmonary disease (COPD) is often associated with other chronic diseases. These patients are often admitted to hospital based rehabilitation programmes. Objectives: To determine the prevalence of chronic comorbidities in patients with COPD undergoing pulmonary rehabilitation and to assess their influence on outcome. Design: Observational retrospective cohort study. Setting: A single rehabilitation centre. Patients: 2962 inpatients and outpatients with COPD (73% male, aged 71 (SD 8) years, forced expiratory volume in 1 s (FEV 1 ) 49.3 (SD 14.8)% of predicted), graded 0, 1 or >2 according to the comorbidity categories and included in a pulmonary rehabilitation programme. Measurements: The authors analysed the number of self-reported comorbidities and recorded the Charlson Index. They then calculated the percentage of patients with a predefined positive response to pulmonary rehabilitation (minimum clinically important difference (MCID)), as measured by improvement in exercise tolerance (6 min walking distance test (6MWD)), dyspnoea (Medical Research Council scale) and/or health related quality of life (St George's Respiratory Questionnaire (SGRQ)). Results: 51% of the patients reported at least one chronic comorbidity added to COPD. Metabolic (systemic hypertension, diabetes and/or dyslipidaemia) and heart diseases (chronic heart failure and/or coronary heart disease) were the most frequently reported comorbid combinations (61% and 24%, respectively) among the overall diseases associated with COPD. The prevalence of patients with MCID was different across the comorbidity categories and outcomes. In a multiple categorical logistic regression model, the Charlson Index (OR 0.72 (96% CI 0.54 to 0.98) and 0.51 (96% CI 0.38 to 0.68) vs 6MWD and SGRQ, respectively), metabolic diseases (OR 0.57 (96% CI 0.49 to 0.67) vs 6MWD) and heart diseases (OR 0.67 (96% CI 0.55 to 0.83) vs SGRQ) reduced the probability to improve outcomes of rehabilitation. Conclusions: Most patients with COPD undergoing pulmonary rehabilitation have one or more comorbidities. Despite the fact that the presence of comorbidities does not preclude access to rehabilitation, the improvement in exercise tolerance and quality of life after rehabilitation may be reduced depending on the comorbidity.Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality.

Background-The rate of failure of noninvasive mechanical ventilation (NIMV) in patients with chronic obstructive pulmonary disease (COPD) with acute respiratory insuYciency ranges from 5% to 40%. Most of the studies report an incidence of "late failure" (after >48 hours of NIMV) of about 10-20%. The recognition of this subset of patients is critical because prolonged application of NIMV may unduly delay the time of intubation. Methods-In this multicentre study the primary aims were to assess the rate of "late NIMV failure" and possible associated predictive factors; secondary aims of the study were evaluation of the best ventilatory strategy in this subset of patients and their outcomes in and out of hospital. The study was performed in two respiratory intensive care units (ICUs) on patients with COPD admitted with an episode of hypercapnic respiratory failure (mean (SD) pH 7.23 (0.07), PaCO 2 85.3 (15.8) mm Hg). Results-One hundred and thirty seven patients initially responded to NIMV in terms of objective (arterial blood gas tensions) and subjective improvement. After 8.4 (2.8) days of NIMV 31 patients (23%; 95% confidence interval (CI) 18 to 33) experienced a new episode of acute respiratory failure while still ventilated. The occurrence of "late NIMV failure" was significantly associated with functional limitations (ADL scale) before admission to the respiratory ICU, the presence of medical complications (particularly hyperglycaemia), and a lower pH on admission. Depending on their willingness or not to be intubated, the patients received invasive ventilation (n=19) or "more aggressive" (more hours/day) NIMV (n=12). Eleven (92%) of those in this latter subgroup died while in the respiratory ICU compared with 10 (53%) of the patients receiving invasive ventilation. The overall 90 day mortality was 21% and, after discharge from hospital, was similar in the "late NIMV failure" group and in patients who did not experience a second episode of acute respiratory failure.Conclusions-The chance of COPD patients with acute respiratory failure having a second episode of acute respiratory failure after an initial (first 48 hours) successful response to NIMV is about 20%. This event is more likely to occur in patients with more severe functional and clinical disease who have more complications at the time of admission to the ICU. These patients have a very poor inhospital prognosis, especially if NIMV is continued rather than prompt initiation of invasive ventilation.

Background: Occupational therapy (OT) has been defined as a task of rehabilitation for disabled patients, giving them maximal function and independence to sustain specific activities of daily living. Objectives: To evaluate the effectiveness of OT as an adjunctive measuring during pulmonary rehabilitation (PR) of hospitalized COPD patients. Methods: A prospective clinical trial with parallel groups was undertaken in severely disabled COPD patients (n = 71, age 73 ± 5 years). They were assigned to either OT+PR (n = 47, FEV₁ 46 ± 21%pred.) or PR (n = 24, FEV₁ 44 ± 12%pred.). PR consisted of eighteen 3-hour daily sessions, whilst OT (domestic activities) was added 3 times a week up to nine 1-hour sessions. Six-min walk (6MWD) with evaluation of BORG dyspnea (D) and leg fatigue (F) scores at end of effort, breathlessness sensation (B) by means of the MRC scale as well as the number of functions lost in the Basic Activity of Daily Living (BADL) categories were assessed as outcomes before (T₀) and after (T₁) rehabilitation. Results: 6MWD (from 165 ± 63 to 233 ± 66 and from 187 ± 52 to 234 ± 65 m in the OT+PR and PR groups, respectively), D (from 4.9 ± 2.1 to 3.2 ± 1.6 and from 5.3 ± 2.1 to 3.4 ± 2.1), F (from 6.1 ± 0.5 to 4.5 ± 1.7 and from 5.9 ± 0.8 to 4.3 ± 0.8) and B (from 4.3 ± 0.9 to 3.0 ± 0.9 and from 4.2 ± 1.0 to 3.2 ± 0.8) had similarly improved (p < 0.01) in both groups at T₁. The percentage distribution of patients across the BADL categories significantly changed (p = 0.004) in OT+PR (from 17 to 61%, from 70 to 34% and from 23 to 5% in categories A, B and C, respectively) but not in the PR group. Conclusions: The addition of OT to comprehensive PR is able to specifically improve the outcome of severely disabled COPD inpatients.

This hospital-based CR provides indication for effectiveness in advanced morbidly obese subjects and warrants further controlled trials to confirm the results.

Background: The use of respiratory therapist-directed (RD) protocols in non-ICU hospitalized patients decreases respiratory care charges as compared with physician-directed (PD) protocols. Objectives: To determine whether RD or PD protocol assessments in COPD patients may impact: (1) prescription of respiratory treatments, and (2) outcomes of pulmonary rehabilitation program (PRP). Methods: In a retrospective observational case-control study, 73 cases (RD) were compared with controls (PD) matched for age, sex, FEV₁ and diagnosis of either chronic airflow obstruction (CAO), pulmonary emphysema (PE) or chronic respiratory insufficiency (CRI). PRP programs were specifically tailored and assessed for inpatients with moderate to severe COPD. Type of PRP protocol (P), number of respiratory treatments (RT), number of exercise training prescription (EXP) and failure (EXF), time to start PRP (T) and length of hospital stay (LOS) were recorded. Perceived breathlessness (B) as assessed by MRC scale, 6-min walk meters (6MWD), and BORG-dyspnea at rest (D-rest) and end of effort (D-effort) were also assessed as outcome measures before (T0) and after (T1) the PRP. Results: Frequency distribution of P, EXP and EXF was similar in the two groups. However, prescription of additional RT (1.9 ± 0.8 and 2.5 ± 1.1 days, p < 0.01), T (1.2 ± 0.4 and 1.8 ± 1.2 days, p < 0.001) and LOS (17.2 ± 2.0 and 18.2 ± 1.8 days, p < 0.05) were lower in cases than in controls. Both cases and controls similarly improved (p < 0.0001) B, 6MWD, D-rest and D-effort at T1. Conclusions: RT-directed assessment results in less respiratory treatments prescription than PD-directed protocol and it does not affect the outcomes of in-hospital pulmonary rehabilitation of COPD patients.