Improvement In Dyspnea Research Articles

Complete transthoracic resection of giant posterior mediastinal goiter: A case report and review of the surgical approaches

Abstract Intrathoracic goiter (IG) is commonly located in the anterior mediastinum. Here, we report the case of a 54-year-old Chinese woman with successful removal of an intrathoracic goiter and improvement of dyspnea by a right posterolateral thoracotomy approach. Conclusion: Posterior mediastinal thyroid goiter with mediastinal compressive symptoms is an indication for surgery.

Efficacy and safety of intrapleural cisplatin versus silver nitrate in treatment of malignant pleural effusion

IntroductionMalignant pleural effusion is a frequent problem. Pleurodesis is performed to prevent its recurrence. New, effective, and safe sclerosing agents are needed.AimThe aim of this was to compare efficacy and safety of silver nitrate solution 0.5% versus cisplatin in achievement of pleurodesis in malignant pleural effusion.Patients and methodsProspective randomized single-blinded clinical trial performed at Chest, Clinical Oncology and Nuclear Medicine and Pathology Departments, Mansoura University, from February 2016 to March 2017. A total of 60 patients (26 male and 34 female) with malignant pleural effusion were divided into two groups: first group included 30 patients who were managed with silver nitrate pleurodesis, and second group included 30 patients who were managed by intrapleural cisplatin injection. The success rate of pleurodesis was considered if there was no clinical or radiological recurrence of effusion for 1 month after intervention.ResultsThere were significant improvements in cough, chest pain, and dyspnea in the two groups after 1 month versus that before pleurodesis. The success rate of pleurodesis in silver nitrate group was 90 versus 76.7% in cisplatin group, without significant difference (P=0.166). Chest pain was reported in 26.7% in silver nitrate group and 13.3% in cisplatin group, and fever was reported in 33.3% in silver nitrate group and 20.0% in cisplatin group. Recurrence was reported in 10% in silver nitrate group and in 23.3% in cisplatin group.ConclusionSilver nitrate and cisplatin were nearly equally effective, safe, and less expensive agents in achievement of pleurodesis in patients with malignant effusion with high success rate and low complications.

Ventilation strategy and anesthesia management in patients with severe tracheal stenosis undergoing urgent tracheal stenting.

Stenting of airway stenosis is a common procedure in specialized centers. The aim of this study was to summarize our clinical experience in ventilation strategy and anesthesia management of patients undergoing urgent tracheal stenting. Clinical data of 22 patients with severe tracheal stenosis who underwent urgent endoscopic placement of a tracheal stent during a 2-year period were retrospectively reviewed. The efficacy and safety of different ventilation strategies and veno-arterial extracorporeal membrane oxygenation (ECMO), individualized based on the cause and location of tracheal narrowing, were evaluated. Sufficient ventilation was successfully established in all patients; ECMO was used in five patients with stenosis in the mid-trachea who were unable to tolerate conventional intubation; a laryngeal mask airway (LMA) was used in five patients with post-intubation tracheal stenosis; a cuffed tracheal tube was used in eight patients with lower tracheal stenosis; and low-frequency jet ventilation in rigid bronchoscopy was used in four patients with mid- or lower tracheal stenosis. Tracheal stents were successfully placed and there were significant improvements in dyspnea. There were significant increases in the partial pressure of carbon dioxide in patients ventilated with the LMA and cuffed tracheal tube. There was no hypoxia during the operative period. Establishment of effective airway ventilation in patients with severe tracheal stenosis should be based on the cause, location, and severity of tracheal narrowing. Veno- arterial ECMO may be considered in patients with severe stenosis, if they are judged unable to tolerate conventional ventilation or jet ventilation.

Efficacy of systemic glucocorticoids combined with inhaled steroid on children with acute laryngitis

Objective: To evaluate the efficacy of systemic glucocorticoid (steroid) combined with high dose inhaled steroid in the treatment of children with acute laryngitis. Methods: A total of 78 children with acute laryngitis were randomly divided into study group(n=40) and control group(n=38) between November 2016 and April 2017. In addition to routine treatment of anti infection and symptomatic treatment, Dexamethasone injection(0.3-0.5 mg/kg, 1-3 d, according to the patient's condition) was provided to each group. In addition to the treatment mentioned above, the study group were assigned to receive 1.0 mg Budesonide suspension for inhalation, oxygen-driven atomizing inhalation, every/30 minutes, 2 times in a row, after that every 12 hours. The improvement of inspiratory dyspnea, hoarseness, barking cough and wheezing of both groups was evaluated at 30 min, 1 h, 2 h, 6 h, 12 h, 24 h and 72 h after treatment.Sigmaplot 11.5 software was used to analyze the data. Results: No significant difference was detected in terms of inspiratory dyspnea, hoarseness, barking cough or stridor score before treatment between the two groups(P>0.05). Compared with those before treatment, symptoms of inspiratory dyspnea, hoarseness, barking cough and stridor score of both groups improved markedly at 12 h and 24 h after treatment(P<0.05). While there was no significant difference regarding inspiratory dyspnea, hoarseness, barking cough or stridor score at each time point after treatment between the two groups(P>0.05). The effective rate was 92.50% and 92.11% in study group and control group, respectively, and no significant difference was noted (P>0.05). Conclusion: Compared with single systemic glucocorticoid, systemic glucocorticoids combined with inhaled steroid possessed similar efficacy in treating acute laryngitis and relieving laryngeal obstruction of children.

Cyclophosphamide for connective tissue disease-associated interstitial lung disease.

Cyclophosphamide for connective tissue disease-associated interstitial lung disease.

Neurophysiological mechanisms of exertional dyspnoea in fibrotic interstitial lung disease.

Our understanding of the mechanisms of dyspnoea in fibrotic interstitial lung disease (ILD) is incomplete. The aims of this study were two-fold: 1) to determine whether dyspnoea intensity is better predicted by neural respiratory drive (NRD) or neuromechanical uncoupling (NMU) of the respiratory system in fibrotic ILD, and 2) to examine the effect of breathing 60% oxygen on NRD, NMU and dyspnoea ratings.Fourteen patients with fibrotic ILD were included. Visit 1 comprised a familiarisation incremental cycle exercise test, Visit 2 comprised a normoxic incremental cycling test to address Aim 1, and Visits 3 and 4 consisted of constant-load cycling while breathing room air or 60% oxygen to address Aim 2. Diaphragmatic electromyography (EMGdi) was used as a surrogate of NRD. NMU was calculated as the ratio between EMGdi (%max) and tidal volume (%vital capacity).On adjusted analysis, NMU and its constituents were all significantly associated with dyspnoea ratings during incremental cycling, with EMGdi having the strongest correlation. The between-treatment change in dyspnoea ratings during constant load cycling was only correlated with change in exercise endurance time and NMU.Dyspnoea more strongly reflected the level of EMGdi than NMU in fibrotic ILD. However, the improvement in dyspnoea with 60% oxygen was better predicted by improvements in NMU.

Effects of inspiratory muscle training on dyspnoea in severe COPD patients during pulmonary rehabilitation: controlled randomised trial.

The benefit of inspiratory muscle training (IMT) combined with a pulmonary rehabilitation programme (PRP) is uncertain. We aimed to demonstrate that, in severe and very severe chronic obstructive pulmonary disease (COPD) patients, IMT performed during a PRP is associated with an improvement of dyspnoea.In a single-blind randomised controlled trial, 150 severe or very severe COPD patients were allocated to follow PRP+IMT versus PRP alone. The evaluations were performed at inclusion and after 4 weeks. The primary outcome was the change in dyspnoea using the Multidimensional Dyspnoea Profile questionnaire at the end of a 6-min walk test (6MWT) at 4 weeks. Secondary outcomes were changes in dyspnoea using the Borg (end of the 6MWT) and modified Medical Research Council scales and in functional parameters (maximal inspiratory pressure (PImax), inspiratory capacity, 6MWT and quality of life). All analyses were performed on an intention-to-treat basis.Dyspnoea decreased significantly in both groups; however, the improvement of dyspnoea was not statistically different between the two groups. We only found a statistically significant greater increase of PImax after IMT+PRP than after PRP alone.In this trial including severe or very severe COPD patients, we did not find a significant benefit of IMT during PRP+IMT as compared to PRP alone on dyspnoea, despite a significantly higher improvement of PImax in the IMT group.

Dyspnea Among Patients With Chronic Total Occlusions Undergoing Percutaneous Coronary Intervention: Prevalence and Predictors of Improvement.

Dyspnea is a common angina equivalent that adversely affects quality of life, but its prevalence in patients with chronic total occlusions (CTOs) and predictors of its improvement after CTO percutaneous coronary intervention (PCI) are unknown. We examined the prevalence of dyspnea and predictors of its improvement among patients selected for CTO PCI. In the OPEN CTO registry (Outcomes, Patient health status, and Efficiency iN Chronic Total Occlusion) of 12 US experienced centers, 987 patients undergoing CTO PCI (procedure success 82%) were assessed for dyspnea with the Rose Dyspnea Scale at baseline and 1 month after CTO PCI. Rose Dyspnea Scale scores range from 0 to 4 with higher scores indicating more dyspnea with common activities. A total of 800 (81%) reported some dyspnea at baseline with a mean (±SD) Rose Dyspnea Scale of 2.8±1.2. Dyspnea improvement was defined as a ≥1 point decrease in Rose Dyspnea Scale from baseline to 1 month. Predictors of dyspnea improvement were examined with a modified Poisson regression model. Patients with dyspnea were more likely to be female, obese, smokers, and to have more comorbidities and angina. Among patients with baseline dyspnea, 70% reported less dyspnea at 1 month after CTO PCI. Successful CTO PCI was associated with more frequent dyspnea improvement than failure, even after adjustment for other clinical variables. Anemia, depression, and lung disease were associated with less dyspnea improvement after PCI. Dyspnea is a common symptom among patients undergoing CTO PCI and improves significantly with successful PCI. Patients with other potentially noncardiac causes of dyspnea reported less dyspnea improvement after CTO PCI.

Efficacy and safety of tiotropium and olodaterol in COPD: a systematic review and meta-analysis

BackgroundLong-acting bronchodilators are the cornerstone of pharmacologic treatment of COPD. The new combination of long-acting muscarinic antagonist (LAMA) tiotropium (TIO) and long acting beta-agonists (LABA) olodaterol (OLO) has been introduced as fist line therapy for COPD. This article analyses the evidence of efficacy and safety of the TIO/OLO combination.MethodsA systematic review and metaanalysis of randomized controlled trials (RCT) with a period of treatment of at least 6 weeks, in patients with COPD confirmed by spirometry, comparing combined treatment with TIO/OLO (approved doses only), with any of the mono-components or any other active comparator administered as an inhalator.ResultsA total of 10 Randomized controlled trials (RCT) were identified (N = 10,918). TIO/OLO significantly improved trough FEV1 from baseline to week 12 versus TIO, OLO and LABA/ICS (0.06 L, 0.09 L and between 0.04 and 0.05 L, respectively). TIO/OLO improved transitional dyspnea index (TDI) and St. George’s Respiratory Questionnaire (SGRQ) compared with mono-components, with patients more likely to achieve clinically important improvements in TDI (risk ratio [RR]: 1.17, 95% confidence interval [CI]: [1.07, 1.28] versus TIO and RR: 1.14, 95%CI: [1.01, 1.28] versus OLO) and in SGRQ (RR: 1.21, 95%CI: [1.12, 1.30] versus TIO and RR: 1.28, 95%CI: [1.18, 1.40] versus OLO). Patients treated with TIO/OLO showed a significant reduction in the use of rescue medication and no significant differences in frequency of general and serious adverse events were observed between TIO/OLO and mono-components.ConclusionsTreatment with TIO/OLO provided significant improvements in lung function versus mono-components and LABA/ICS with more patients achieving significant improvements in dyspnea and health status. No differences in adverse events were observed compared with other active treatments.Clinical trial registrationPROSPERO register of systematic reviews (CRD42016040162).

P1.12-009 Experience with Fully Covered Metallic Stents in Patients with Malignant Airway Obstruction

Airway stenting provides a solution to restore patency of the airways in patients with malignant conditions that are unsuitable for surgical procedures. Their use has been associated with significant improvement in symptoms and quality of life. There is little experience with recent commercially available fully covered metallic stents. All patients who underwent fully silicon covered nitinol mono-filament Aerstent® (Leufen, Bess, Germany) placement at the Hospital Universitari de Bellvitge from September 2013 and February 2017 were retrospectively reviewed for medical records, bronchoscopy and microbiological results, as well as stent related complications and patient survival. 66 stents were implanted in 54 patients during this 36 months period, with mean age of 59 years (43-81 years). The main indication of stent placement was lung cancer in 41 (76%) patients (22 squamous, 9 adenocarcinoma, 5 undetermined NSCLC, 4 small-cell lung cancer and 1 atypical carcinoid). Stents were deployed with rigid bronchoscopy under fluoroscopic control in main bronchus (n=42), trachea (n=7), and main carina (Y shape n=17). Photocoagulation with YAP laser and/or mechanical debulking was necessary in 44 (66.6%) procedures prior to stenting. Seven stents (10.6%) required repositioning after deployment using rigid grasping forceps. Major bleeding occurred in 12 procedures (18.1%) and was successfully managed with endoscopic methods. No immediate complications occurred after the procedures. In 52 cases (96.3%) immediate and significate clinical improvement in dyspnea was registered. Median survival after first stent deployment was 144 days (6-484). 7 patients died within 30 days after the procedure. 50 patients (92%) had stent related complications during follow up (Table 1). In our case series, Aerstent (Leufen, Bess) has provided immediate dyspnoea relief in 96.3% of patients, without significate complications during deployment or within the first 24 hours. Mucostasis is the most common complication (77%) and is detected during the first month (mean 28.2 days).

MTE 19.01 Laser Therapy for Airway Obstruction

MTE 19.01 Laser Therapy for Airway Obstruction

P3.12-003 Optimized Inhaler Therapy Is Superior to Supportive Care Alone for Dyspnea in Patients with Coexisting COPD and Lung Cancer

Breathlessness is a common, debilitating symptom associated with both COPD and lung cancer. Opiates remain the mainstay of treatment for breathlessness in oncology. Lung cancer patients were prospectively enrolled in this single-center, open-label, randomized controlled trial. Eligible patients met British Thoracic Society diagnostic criteria for COPD, had a visual analogue score (VAS) dyspnea ≥4 and had other reversible causes for breathlessness excluded. Patients were randomly assigned (1:1) between the intervention arm of salbutamol 100 mcg, 2 puffs QDS and tiotropium 18 mcg OD ± salmeterol 50 mcg/fluticasone 500 mcg 1 puff BD (if FEV1 <50% predicted) in combination with best supportive care (BSC) or to BSC alone (control). Control arm patients could continue on any short-acting bronchodilators and BSC included oral morphine and/or benzodiazepines. Patients underwent spirometry, 6 minute walk test (6MWT), VAS dyspnea and quality of life questionnaires (QOLQ) at baseline and after 2 and 4 weeks. The primary endpoint was the proportion of patients with ≥2 point improvement in VAS dyspnea at 4 weeks. Among the intention to treat population (n=63), 53 patients (84%) had NSCLC and 10 (16%) had SCLC. The median baseline VAS was 7.1 and the median baseline FEV1 was 1.5L (63% predicted). The primary endpoint response rate (RR) was higher in the intervention group n= 32 [RR: 53% (95%CI 35% to 71%)] than in the control group n= 31 [RR: 26% (95% CI 12% to 45%) p = 0.02]. There were no statistically significant differences between the groups for change in 6MWT or QOLQ between baseline and the 4 week assessments. For patients with co-existing COPD and lung cancers, VAS dyspnea is significantly improved by the addition of inhaled therapies to best supportive care. This study highlights the importance of diagnosing and treating COPD in all lung cancer patients.

Identifying Opportunities to Improve Pain Among Patients With Serious Illness

ContextPain is a common and distressing symptom. Pain management is a core competency for palliative care (PC) teams. ObjectiveIdentify characteristics associated with pain and pain improvement among inpatients referred to PC. MethodsThirty-eight inpatient PC teams in the Palliative Care Quality Network entered data about patients seen between December 12, 2012 and March 15, 2016. We examined patient and care characteristics associated with pain and pain improvement. ResultsOf patients who could self-report symptoms, 30.7% (4959 of 16,158) reported moderate-to-severe pain at first assessment. Over 40% of these patients had not been referred to PC for pain. Younger patients (P < 0.0001), women (P < 0.0001), patients with cancer (P < 0.0001), and patients in medical/surgical units (P < 0.0001) were more likely to report pain. Patients with pain had higher rates of anxiety (P < 0.0001), nausea (P < 0.0001), and dyspnea (P < 0.0001). Sixty-eight percent of patients with moderate-to-severe pain improved by the PC team's second assessment within 72 hours; 74.7% improved by final assessment. There was a significant variation in the rate of pain improvement between PC teams (P < 0.0001). Improvement in pain was associated with improvement in anxiety (OR = 2.9, P < 0.0001) and dyspnea (OR = 1.4, P = 0.03). Patients who reported an improvement in pain had shorter hospital length-of-stay by two days (P = 0.003). ConclusionPain is common among inpatients referred to PC. Three-quarters of patients with pain improve and improvement in pain is associated with other symptom improvement. Standardized, multisite data collection can identify PC patients likely to have marked and refractory pain, create benchmarks for the field, and identify best practices to inform quality improvement.

Inhaled nebulised unfractionated heparin improves lung function in moderate to very severe COPD: A pilot study

BackgroundCOPD is an inflammatory airway disease characterised by progressive airflow limitation and air trapping, leading to lung hyperinflation and exercise limitation. Acute worsening of symptoms, including dyspnea, cough and sputum production, occurs during exacerbations which are associated with significantly reduced health related quality of life, and increased morbidity and mortality. Chronic bronchial mucus production and productive cough are risk factors for exacerbations. Medicines targeting bronchoconstriction and airway inflammation are the current mainstays of COPD therapy. However, there is growing concern with an increased risk of pneumonia in patients with COPD receiving regular inhaled corticosteroids and there is therefore a need to find safer alternative treatments.Previous studies have indicated that inhalation of unfractionated heparin (UFH) treats local inflammation, mucus hypersecretion and lung injury, without systemic anticoagulation, and is safe. Therefore, our primary objective was to demonstrate that inhaled UFH significantly improves lung function (FEV1) over 21 days of treatment in patients with COPD receiving pulmonary rehabilitation and that UFH provides a novel, safe and effective way of treating this complex disease. MethodsForty patients with moderate to very severe COPD admitted to the IRCCS San Raffaele Pisana Hospital for 21 days pulmonary rehabilitation were randomised to receive nebulised inhaled UFH (75,000 or 150,000 IU BID) or placebo for 21 days. All patients also received nebulised salbutamol (1 mg) and beclomethasone dipropionate (400 μg) BID over the same period.Lung function was measured at day 0, 7, 14 and 21 of treatment and at a follow-up visit 7 days post-treatment. Exercise capacity (6MWT) and dyspnoea (Borg score) were measured before and after treatment.In pre-clinical studies, the ability of basic proteins found in COPD sputum to neutralise the anticoagulant activity of heparin was determined using the AMAX heparin assay kit. Main resultsAt both doses, UFH significantly increased FVC following 7 days of treatment and 150,000 IU BID significantly increased FEV1 (+249 ± 69 ml compared with placebo) at this time, an effect maintained to the 28 day follow-up. Clinically significant improvement in exercise capacity and dyspnoea were seen after 21 days of treatment with both doses of UFH. There were no serious adverse events or effects on systemic coagulation. Pre-clinical studies demonstrated that the basic proteins lactoferrin, platelet factor-4 (PF-4), IL-8 and polyarginine, as a model of the eosinophil cationic protein (ECP), found in COPD sputum neutralise the anticoagulant activity of heparin. ConclusionInhaled nebulised UFH is safe and provides additional clinical benefit for patients with moderate to very severe COPD through effects that are independent of its anticoagulant activity.

Improvement of dyspnea after bariatric surgery is associated with increased Expiratory Reserve Volume: A prospective follow-up study of 45 patients

ObjectivesTo assess the effects of bariatric surgery in patients with obesity on dyspnea and to analyze the relationships between improvement of dyspnea after bariatric surgery and changes in pulmonary function, especially Expiratory Reserve Volume (ERV) which is the lung volume abnormality most frequently associated with obesity.MethodsForty-five patients (5 males/40 females, mean Body Mass Index = 46.2 ± 6.8 kg/m2) were evaluated before and 6 to 12 months after bariatric surgery. Dyspnea was assessed by the modified Medical Research Council (mMRC) scale. Pulmonary function tests, arterial blood gases and six-minute walk test were performed. Laboratory parameters including C-Reactive Protein (CRP) were analyzed.ResultsNinety percent of patients were dyspneic before surgery (mMRC scale ≥ 1) versus 59% after surgery (p<0.001). Mean mMRC score improved after bariatric surgery (1.5 ± 0.9 vs 0.7 ± 0.7, p<0.0001). Among patients with dyspnea before surgery (n = 38), a more marked increase in ERV after surgery was observed in patients with improvement of dyspnea compared to patients with no improvement of dyspnea (+0.17 ± 0.32 L vs +0.49 ± 0.35 L, p = 0.01). Multivariate analysis including age, variation of BMI, variation of CRP, variation of Total Lung Capacity and variation of ERV demonstraded that ERV was the only variable associated with improvement of the mMRc score after bariatric surgery (p = 0.04).ConclusionWeight loss associated with bariatric surgery improves dyspnea in daily living. This improvement could be partly related to increased ERV.

Past, present, and future of acute heart failure clinical trials-a high-risk population in search of a strategy.

Past, present, and future of acute heart failure clinical trials-a high-risk population in search of a strategy.

Effects of Expiratory Positive Airway Pressure on Exercise Tolerance, Dynamic Hyperinflation, and Dyspnea in COPD.

The application of expiratory positive airway pressure (EPAP) in patients with COPD during exercise may reduce dynamic hyperinflation, while, on the other hand, it can increase the resistive work of breathing. Therefore, we evaluated the effects of 2 intensities of EPAP during exercise on tolerance, dynamic hyperinflation, and dyspnea in subjects with moderate to very severe COPD. We performed a cross-sectional, experimental, 4-visit study. In visit 1, subjects performed symptom-limited cycling incremental cardiopulmonary exercise test (CPET). In visits 2-4, at least 48 h apart, in a randomized order, subjects performed constant CPET without EPAP, EPAP with 5 cm H2O (EPAP5), or EPAP with 10 cm H2O (EPAP10). The study included 15 non-hypoxemic subjects ranging from moderate to very severe COPD (mean FEV1 = 35 ± 11% predicted). Increasing intensities of EPAP during constant CPET tended to cause progressive reduction in exercise tolerance (P = .11). Of note, 10 of 15 subjects demonstrated significantly shorter average exercise duration with EPAP10 compared to the test without EPAP (-151 ± 105 s, P = .03 or -41 ± 26%). Minute ventilation increment was constrained by EPAP, secondary to a limited increase in tidal volume (P = .01). Finally, dyspnea sensation and serial measurements of inspiratory capacity during exercise were similar when comparing the three interventions at isotime and at end-constant CPETs. The application of EPAP5 or EPAP10 during exercise tended to cause a progressive reduction in exercise tolerance in subjects with COPD without improvement in dyspnea or dynamic hyperinflation at equivalent exercise duration.

Use of a small bore pleural catheter in the managemen of patients with malignant pleural effusion

BackgroundMalignant pleural effusions (MPEs) can produce significant respiratory symptoms and decreased quality of life in patients with terminal malignancies; palliation of respiratory symptoms can be performed by several different approaches, but a minimally invasive procedure to provide relief of respiratory symptoms would be optimal.ObjectiveThis study aimed to evaluate the usage of a small bore catheter in outpatients as an alternative, effective, and safe method to the traditionally large bore chest tube in the management of MPE.Patients and methodsFifty patients with MPE were grouped randomly into two groups according to the method of drainage.ResultsThe results showed that there were significant statistical differences in the results of both groups as the duration of catheter was 4 (3–5) days to 11 (10–10.25) days in the chest tube group; the cost of hospital and medication was 780±1400 LE in the pleural catheter group, whereas in the chest tube group, it was 11 520±1895.61 LE and the total cost was 5520±17 600 in the pleural catheter group and 14 020.00 ±1895.61 LE in the chest tube group. The modified Borg scale for dyspnea after insertion showed a 43% improvement in dyspnea in the small bore pleural catheter group compared with 41% in the chest tube group.ConclusionOn the basis of the results of this study and other studies, we conclude that a small bore catheter is as effective and safe as a large bore chest tube in the treatment of MPEs and use in the outpatient clinic led to few complications.

There's no place like home: Integrating pulmonary rehabilitation into the home setting.

Traditional, outpatient pulmonary rehabilitation provided to stable COPD patients leads to significant improvements in dyspnea, exercise capacity and health related quality of life. Also, when started during or shortly after a hospitalization for a COPD exacerbation, pulmonary rehabilitation improves these patient-centered outcomes and arguably reduces subsequent health care utilization and mortality. Despite these benefits, the uptake of traditional pulmonary rehabilitation remains disappointingly poor. Home-based pulmonary rehabilitation, a safe and effective alternative to traditional, center-based programs, can broaden access. While proven improvements in dyspnea, exercise capacity and health status justify implementation of home-based pulmonary rehabilitation, it would be helpful to know whether it can also decrease health care utilization and be cost-effective.

Efficacy and safety of direct switch to indacaterol/glycopyrronium in patients with moderate COPD: the CRYSTAL open-label randomised trial

BackgroundDual bronchodilation combining a long-acting β2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) is the preferred choice of treatment recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 guidelines for the management of patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). The once-daily (q.d.) fixed-dose combination (FDC) of LABA, indacaterol 110 μg and LAMA, glycopyrronium 50 μg (IND/GLY 110/50 μg q.d.) demonstrated superior improvements in lung function, dyspnoea and overall health status and better tolerability against LABA or LAMA monotherapies and combination of LABA and inhaled corticosteroid (ICS) in more than 11,000 patients with moderate-to-severe COPD in several randomised controlled clinical trials.MethodsThe CRYSTAL study was the first, 12-week, randomised, open-label trial that evaluated the efficacy and safety of a direct switch from previous treatments to IND/GLY 110/50 μg q.d. on lung function and dyspnoea in patients with moderate COPD and a history of up to one exacerbation in the previous year. Patients were divided into 2 groups according to their background therapy and symptom scores and were randomised (3:1) to IND/GLY or to continue with their previous treatments.ResultsThe study included 4389 randomised patients, of whom 2160 were in groups switched to IND/GLY (intention-to-treat population). The effect of IND/GLY was superior to LABA + ICS on trough forced expiratory volume in 1 s (FEV1; treatment difference, Δ = +71 mL) and transition dyspnoea index (TDI; [Δ = 1.09 units]), and to LABA or LAMA on trough FEV1 (Δ = +101 mL) and a TDI (Δ = 1.26 units). Improvements in health status and lower rescue medication use were also observed with IND/GLY. The safety profile of the study medication was similar to that observed in previous studies.ConclusionsIND/GLY demonstrated superior improvements in lung function and dyspnoea after direct switch from previous treatments.Trial registrationClinicalTrials.gov number: NCT01985334.