Medical Research Council Dyspnea Grade Research Articles

Case Report: Scrub Typhus manifesting as Acute Respiratory Distress Syndrome (ARDS) with corresponding radiological findings

Background Scrub typhus is a life-threatening infectious disease endemic in the Asia-Pacific region. It typically presents with nonspecific symptoms such as fever, headache, and myalgia, making early diagnosis challenging. Acute Respiratory Distress Syndrome (ARDS) is a severe pulmonary condition characterized by acute-onset hypoxemia, bilateral lung infiltrates on radiology, and increased pulmonary capillary permeability. Case Presentation An 18-year-old female student in central India presented with a seven-day history of recurrent fever, chills, dry cough, and severe shortness of breath, escalating to Modified Medical Research Council dyspnea grade III-IV. After unsuccessful local clinic treatment, a chest radiograph revealed bilateral pneumonia. On admission, she displayed tachycardia, tachypnea, hypotension, and hypoxia requiring non-invasive ventilation (NIV). Computed tomography confirmed scrub typhus-associated pneumonia, and serological testing was positive for scrub typhus. She was diagnosed with moderate ARDS and began treatment. Symptomatic improvement was seen in the ICU, and she was discharged on day 10 with radiological and clinical resolution. Management and Outcomes She received intravenous doxycycline and oral azithromycin for scrub typhus and any potential concurrent lung infection. In the ICU, she required continuous NIV and supplemental oxygen, with significant symptomatic improvement, evidenced by reduced tachypnoea and oxygen requirements after 72 hours. She was weaned off NIV and monitored for an additional four days. After satisfactory oxygen saturation on room air, she was discharged on the tenth day. High-resolution CT scan demonstrated resolution of ground glass opacities and consolidation. Sequential chest radiographs exhibited gradual reduction in bilateral alveolar infiltrates over time, in parallel with clinical improvement. Laboratory findings, including reduced CRP and D-dimer values, and a normal hemogram on discharge indicated a resolution of leukopenia. Conclusion This case underscores the importance of early recognition and intervention in scrub typhus-associated ARDS and highlights the utility of timely diagnostic imaging in monitoring the progress of the disease.

Case Report: Scrub Typhus manifesting as Acute Respiratory Distress Syndrome (ARDS) with corresponding radiological findings

Background Scrub typhus is a life-threatening infectious disease endemic in the Asia-Pacific region. It typically presents with nonspecific symptoms such as fever, headache, and myalgia, making early diagnosis challenging. Acute Respiratory Distress Syndrome (ARDS) is a severe pulmonary condition characterized by acute-onset hypoxemia, bilateral lung infiltrates on radiology, and increased pulmonary capillary permeability. Case Presentation An 18-year-old female student in central India presented with a seven-day history of recurrent fever, chills, dry cough, and severe shortness of breath, escalating to Modified Medical Research Council dyspnea grade III-IV. After unsuccessful local clinic treatment, a chest radiograph revealed bilateral pneumonia. On admission, she displayed tachycardia, tachypnea, hypotension, and hypoxia requiring non-invasive ventilation (NIV). Computed tomography confirmed scrub typhus-associated pneumonia, and serological testing was positive for scrub typhus. She was diagnosed with moderate ARDS and began treatment. Symptomatic improvement was seen in the ICU, and she was discharged on day 10 with radiological and clinical resolution. Management and Outcomes She received intravenous doxycycline and oral azithromycin for scrub typhus and any potential concurrent lung infection. In the ICU, she required continuous NIV and supplemental oxygen, with significant symptomatic improvement, evidenced by reduced tachypnoea and oxygen requirements after 72 hours. She was weaned off NIV and monitored for an additional four days. After satisfactory oxygen saturation on room air, she was discharged on the tenth day. High-resolution CT scan demonstrated resolution of ground glass opacities and consolidation. Sequential chest radiographs exhibited gradual reduction in bilateral alveolar infiltrates over time, in parallel with clinical improvement. Laboratory findings, including reduced CRP and D-dimer values, and a normal hemogram on discharge indicated a resolution of leukopenia. Conclusion This case underscores the importance of early recognition and intervention in scrub typhus-associated ARDS and highlights the utility of timely diagnostic imaging in monitoring the progress of the disease.

Change in individual chronic obstructive pulmonary disease assessment test item scores after short-term bronchodilator therapy and its impact on exacerbation in treatment-naïve patients with chronic obstructive pulmonary disease.

Background:The chronic obstructive pulmonary disease (COPD) assessment test (CAT) measures the health status of patients with COPD. We aimed to investigate the change in individual CAT scores after short-term bronchodilator therapy among treatment-naïve patients with COPD.Methods:Data from 148 patients newly diagnosed with COPD between January 2016 and April 2020 were retrospectively analyzed. We compared the CAT score, modified Medical Research Council (mMRC) dyspnea grade, and forced expiratory volume in 1 s (FEV1) before and after short-term (6 ± 2 months) bronchodilator therapy. We analyzed the change trends using generalized estimating equations.Results:The mean patient age was 70.9 years, and 92.6% were male. The total CAT score did not significantly improve. However, among the CAT items, phlegm [adjusted difference: –0.22 (–0.48, –0.002)], chest tightness [–0.30 (–0.56, –0.05)], and breathlessness [–0.45 (–0.66, –0.23)] scores significantly improved after bronchodilator therapy. The patients were divided into two groups: CAT score improved (n = 69) and not improved group (n = 79). The development of moderate-to-severe exacerbations during follow-up was significantly lower (2.9% versus 17.7%, p = 0.004) in the CAT score improved group.Conclusion:The improvement in CAT items indicating respiratory symptoms was more evident than the CAT total score after short-term bronchodilator therapy. Despite the significant increase in FEV1 after bronchodilator therapy, fewer than half of the patients achieved meaningful improvement in CAT, and this group showed significantly lower development of exacerbation during follow-up.

A mixed-methods pilot study of handheld fan for breathlessness in interstitial lung disease

Dyspnoea is a cardinal symptom of fibrotic interstitial lung disease (ILD), with a lack of proven effective therapies. With emerging evidence of the role of facial and nasal airflow for relieving breathlessness, this pilot study was conducted to examine the feasibility of conducting a clinical trial of a handheld fan (HHF) for dyspnoea management in patients with fibrotic ILD. In this mixed-methods, randomised, assessor-blinded, controlled trial, 30 participants with fibrotic ILD who were dyspnoeic with a modified Medical Research Council Dyspnoea grade ≥ 2 were randomised to a HHF for symptom control or no intervention for 2 weeks. Primary outcomes were trial feasibility, change in Dyspnoea-12 scores at Week 2, and participants’ perspectives on using a HHF for dyspnoea management. Study recruitment was completed within nine months at a single site. Successful assessor blinding was achieved in the fan group [Bang’s Blinding Index − 0.08 (95% CI − 0.45, 0.30)] but not the control group [0.47 (0.12, 0.81)]. There were no significant between-group differences for the change in Dyspnoea-12 or secondary efficacy outcomes. During qualitative interviews, participants reported that using the HHF relieved breathlessness and provided relaxation, despite initial scepticism about its therapeutic benefit. Oxygen-experienced participants described the HHF being easier to use, but not as effective for symptomatic relief, compared to oxygen therapy. Our results confirmed the feasibility of a clinical trial of a HHF in fibrotic ILD. There was a high level of patient acceptance of a HHF for managing dyspnoea, with patients reporting both symptomatic benefits and ease of use.

Can the nutritional condition of chronic obstructive pulmonary disease patients influence the dyspnea severity and quality of life?

Background and objective Nutritional impairment is a frequent issue in patients with chronic obstructive pulmonary disease (COPD) and has a negative effect on both morbidity and mortality. Therefore, this study was designed to explore the nutritional condition of stable COPD patients and to investigate their influence on dyspnea severity and quality of life (QoL). Patients and methods This case–control study was done on 100 stable COPD patients greater than or equal to 65 years old and 80 healthy controls who visited the outpatient clinic of El Demerdash Hospital between January 2019 and December 2019. All patients underwent spirometry and finished the Arabic version short form of the ‘mininutritional assessment’ test. Their dyspnea severity and QoL were also assessed. Results The patients were divided into three groups according to short form of the ‘mininutritional assessment’ test results: well-nourished (n=24, 24%), at risk of malnutrition (n=31, 31%), and malnourished (n=45, 45%). About 90.6% of malnourished patients had dyspnea grade 4; their mean score of COPD assessment test was 36 and they also had the lowest values of spirometric parameters. Conclusion About 45% of stable COPD patients were malnourished; they had a high sensation of dyspnea (higher modified Medical Research Council dyspnea grade) and poorer QoL (high COPD assessment test score).

Performance of semi-quantitative lung ultrasound in the assessment of disease severity in interstitial lung disease.

BACKGROUND:Accurate staging of disease severity and its serial monitoring thus is central to the effective management protocols of interstitial lung disease (ILD).PURPOSE:The aim is to evaluate the effectiveness of semi-quantitative parameters of lung ultrasound (LUS) in patients of ILD as a means of staging disease severity.MATERIALS AND METHODS:LUS of 47 patients of ILD and 20 age-matched controls was performed, and findings such as B-line distance, pleural thickening, subpleural changes, decreased lung sliding, and fragmented pleural lining were charted, and an LUS score was done using these parameters. Findings were compared with the Modified Medical Research Council (MMRC) dyspnea grade and spirometry parameters.RESULTS:The presence of B-lines and fragmented pleural lining were the most common findings observed in patients of ILD. Predicted forced vital capacity (FVC) and predicted forced expiratory volume in 1 s (FEV1) showed a good correlation with all the LUS parameters. B-line distance was the most significant LUS parameter to predict the variability in predicted FEVI, FVC, and MMRC dyspnea score. LUS severity score also showed good negative correlation with predicted FEV1 (r = −0.674, P < 0.001) and predicted FVC (r = −0.65, P < 0.001). LUS severity score of 4 or more predicted MMRC dyspnea score of > 3 with 82% sensitivity and 70% specificity.CONCLUSION:Semi-quantitative LUS score and B-line distance can provide a simple but effective estimate of disease severity in ILD.

Predictors of pulmonary rehabilitation completion in the UK

IntroductionPulmonary rehabilitation has been shown to improve dyspnoea, fatigue, quality of life and exercise capacity in individuals with chronic obstructive pulmonary disease (COPD). Our aim was to determine the characteristics of people with COPD associated with completion of pulmonary rehabilitation.MethodsThis was a cross-sectional analysis of 7060 people with COPD enrolled in pulmonary rehabilitation between January 1, 2017 and March 31, 2017. Data were from a UK national audit of COPD care. Factors associated with pulmonary rehabilitation completion were determined using mixed effects logistic regression with a random intercept for pulmonary rehabilitation service. Factors chosen for assessment based on clinical judgement and data availability were age, sex, country, socioeconomic status, body mass index, referral location, programme type, start within 90 days, smoking status, oxygen therapy, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) dyspnoea grade, any exercise test and any health status questionnaire.Results4635 (66%) people with COPD completed a pulmonary rehabilitation programme. People that were aged ≥60 years, resident in Wales, referred within 90 days, an ex- or never-smoker, received an exercise test, or received a health status questionnaire had significantly greater odds of completing pulmonary rehabilitation. People that were in the most deprived quintile, underweight or very severely obese, enrolled in a rolling rather than a cohort programme, had a higher GOLD stage and had a higher MRC grade had significantly lower odds of completing pulmonary rehabilitation.ConclusionsPeople with COPD were more likely to complete pulmonary rehabilitation when best practice guidelines were followed. People with more severe COPD symptoms and those enrolled in rolling rather than cohort programmes were less likely to complete pulmonary rehabilitation. Referring people with COPD in the earlier stages of disease, ensuring programmes follow best practice guidelines and favouring cohort over rolling programmes could improve rates of pulmonary rehabilitation completion.

A study of modified DECAF score in predicting hospital outcomes in patients of acute exacerbation of chronic obstructive pulmonary disease at SMS Medical College, Jaipur

Background: The value of Modified DECAF Score as a clinical prediction tool that can accurately risk stratify all patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) is needed to be assessed. Aim: The aim of this study is to evaluate the prognostic effect of the Modified DECAF score in predicting outcomes in AECOPD. Materials and Methods: A hospital-based descriptive type of observational study done on 160 patients admitted with AECOPD at the Institute of Respiratory Diseases, SMS Medical College, Jaipur. Modified DECAF score was calculated for each patient, and the individual parameters used in calculating the score were recorded. Modified DECAF score has five variables (baseline dyspnoea extended Medical Research Council Dyspnea Grade 5a or 5b, Eosinopenia (

Correlation between Physical Activity and Lung Function in Dusty Areas: Results from the Chronic Obstructive Pulmonary Disease in Dusty Areas (CODA) Cohort.

BackgroundAlthough physical activity is known to be beneficial to lung function, few studies have been conducted to investigate the correlation between physical activity and lung function in dusty areas. Therefore, the purpose of this study is to investigate the correlation between physical activity and lung function in a Korean cohort including normal and COPD-diagnosed participants.MethodsData obtained from the COPD in dusty areas (CODA) cohort was analyzed for the following factors: lung function, symptoms, and information about physical activity. Information on physical activity was valuated using questionnaires, and participants were categorized into two groups: active and inactive. The evaluation of the mean lung function, modified Medical Research Council dyspnea grade scores, and COPD assessment test scores was done based on the participant physical activity using a general linear model after adjusting for age, sex, smoking status, pack-years, height, and weight. In addition, a stratification analysis was performed based on the smoking status and COPD.ResultsPhysical activity had a correlation with high forced expiratory volume in 1 second (FEV1) among CODA cohort (p=0.03). While the active group exhibited significantly higher FEV1 compared to one exhibited by the inactive group among past smokers (p=0.02), no such correlation existed among current smokers. There was no significant difference observed in lung function after it was stratified by COPD.ConclusionThis study established a positive correlation between regular physical activity in dusty areas and lung function in participants.

GOLD assessment of COPD severity in the Clinical Practice Research Datalink (CPRD).

To evaluate availability of spirometry and symptom data in the Clinical Practice Research Datalink (United Kingdom) to assess COPD severity using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016 definition and comparing it with an algorithm used in other studies. This was a descriptive, noninterventional, secondary database cohort study of patients with COPD aged 40years or older, who initiated treatment with specific COPD medications. Patients were classified according to COPD severity (1) in GOLD 2016 "ABCD" categories based on symptoms (Medical Research Council dyspnea grade, COPD Assessment Test, breathlessness), percent predicted FEV1, and exacerbation history and (2) as mild, moderate, severe, or very severe based on treatment and exacerbation history. The study included 63900 patients with COPD aged 40years or older that were new users of 1 or more COPD medication of interest. Percent predicted FEV1 was available for 80.9% of patients; symptoms for 75.6% of patients. Classification into GOLD 2016 ABCD categories was possible for 75.6% of the patients. The GOLD 2016 ABCD definition classified more patients under the high-risk categories (22.1%, A; 18.8%, B; 21.3%, C; 37.9%, D) than did the adapted algorithm (7.9%, mild; 48.6%, moderate; 42.1%, severe; 1.4%, very severe). Using our adaptation of the GOLD 2016 COPD severity classification, the information in the Clinical Practice Research Datalink allowed us to ascertain COPD severity in approximately 75% of patients with COPD. Algorithms that include medication use tend to misclassify patients with the extreme COPD severity categories.

Validation of 4-meter-gait-speed test and 5-repetitions-sit-to-stand test in patients with pulmonary fibrosis: a clinimetric validation study.

Background and objective: Patients with pulmonary fibrosis (PF) have a clear exercise intolerance. The 4-meter-gait-speed (4MGS) test and the 5-repetitions-sit-to-stand (5STS) test are easy, inexpensive and reliable measures of functional performance. Both tests have been validated in healthy adults and patients with chronic obstructive pulmonary disease. 4MGS test and 5STS test have not been studied in patients with PF. Methods: In this cross-sectional clinimetric validation study 51 PF patients conducted in random order the 4MGS test, 5STS test and the 6-min walk test (6MWT) on a single day. Additionally, body weight, height, lean body mass, health-related quality of life, disease severity, handgrip strength, dyspnoea and leg fatigue were assessed. The setting was a tertiary referral center for Interstitial Lung Diseases. Results: Patients had a diagnosis of idiopathic pulmonary fibrosis (IPF, 37%), PF other than IPF (47%), or unclassified (16%). Patients walked 453±111m in six minutes. Moreover, it took the patients 2.0±0.5s to walk 4 m, and 12.0±3.8s for the 5STS test. The 4MGS test (r = 0.77; p<0.01) and the 5STS test (r = -0.41; p<0.01) correlated significantly with the distance walked in 6MWT. Indeed, 4MGS combined with handgrip strength and Medical Research Council dyspnoea grade could explain 75% of the variance in 6MWD. Conclusions: 4-meter-gait-speed and 5-repetitions sit-to-stand are significantly and independently correlated with the 6-minute walk distance in patients with pulmonary fibrosis. Indeed, 4-meter-gait-speed test may serve as a simple initial field test to assess exercise performance in patients with pulmonary fibrosis. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 317-326)

Redefining Cut-Points for High Symptom Burden of the Global Initiative for Chronic Obstructive Lung Disease Classification in 18,577 Patients With Chronic Obstructive Pulmonary Disease

BackgroundPatients with chronic obstructive pulmonary disease (COPD) can be classified into groups A/C or B/D based on symptom intensity. Different threshold values for symptom questionnaires can result in misclassification and, in turn, different treatment recommendations. The primary aim was to find the best fitting cut-points for Global initiative for chronic Obstructive Lung Disease (GOLD) symptom measures, with an modified Medical Research Council dyspnea grade of 2 or higher as point of reference. MethodsAfter a computerized search, data from 41 cohorts and whose authors agreed to provide data were pooled. COPD studies were eligible for analyses if they included, at least age, sex, postbronchodilator spirometry, modified Medical Research Council, and COPD Assessment Test (CAT) total scores. Main outcomesReceiver operating characteristic curves and the Youden index were used to determine the best calibration threshold for CAT, COPD Clinical Questionnaire, and St. Georges Respiratory Questionnaire total scores. Following, GOLD A/B/C/D frequencies were calculated based on current cut-points and the newly derived cut-points. FindingsA total of 18,577 patients with COPD [72.0% male; mean age: 66.3 years (standard deviation 9.6)] were analyzed. Most patients had a moderate or severe degree of airflow limitation (GOLD spirometric grade 1, 10.9%; grade 2, 46.6%; grade 3, 32.4%; and grade 4, 10.3%). The best calibration threshold for CAT total score was 18 points, for COPD Clinical Questionnaire total score 1.9 points, and for St. Georges Respiratory Questionnaire total score 46.0 points. ConclusionsThe application of these new cut-points would reclassify about one-third of the patients with COPD and, thus, would impact on individual disease management. Further validation in prospective studies of these new values are needed.

Salivary diurnal cortisol profiles in patients suffering from chronic breathlessness receiving supportive and palliative care services: A cross-sectional study

Chronic breathlessness is a common source of psychological and physical stress in patients with advanced or progressive disease, suggesting that hypothalamic-pituitary-adrenal (HPA) axis dysregulation may be prevalent. The aim of this study was to measure the salivary diurnal cortisol profile in patients receiving supportive and palliative care for a range of malignant and non-malignant conditions and to compare the profile of those experiencing moderate-to-severe disability due to breathlessness against that of patients with mild/no breathlessness and that of healthy controls. Saliva samples were collected over two consecutive weekdays at 3, 6, and 12h after awakening in 49 patients with moderate-to-severe breathlessness [Medical Research Council (MRC) dyspnoea grade ≥3], 11 patients with mild/no breathlessness (MRC dyspnoea grade ≤2), and 50 healthy controls. Measures of breathlessness, stress, anxiety, depression, wellbeing and sleep were examined concomitantly. The diurnal cortisol slope (DCS) was calculated for each participant by regressing log-transformed cortisol values against collection time. Mean DCS was compared across groups using ANCOVA. Individual slopes were categorised into one of four categories: consistent declining, consistent flat, consistent ascending and inconsistent. Controlling for age, gender and socioeconomic status, the mean DCS was significantly flatter in patients with moderate-to-severe breathlessness compared to patients with mild/no breathlessness and healthy controls [F (2, 103)=45.64, p<0.001]. Furthermore, there was a higher prevalence of flat and ascending cortisol profiles in patients with moderate-to-severe breathlessness (23.4%) compared to healthy controls (0%). The only variable which correlated significantly with DCS was MRC dyspnoea grade (rs=0.29, p<0.05). These findings suggest that patients with moderate-to-severe breathlessness have evidence of HPA axis dysregulation and that this dysregulation may be related to the functional disability imposed by breathlessness.

COPD Assessment Test for measurement of health status in patients with idiopathic pulmonary fibrosis: A cross-sectional study.

The COPD Assessment Test (CAT) has been reported to have potential utility for measuring health status of idiopathic pulmonary fibrosis (IPF). Although the CAT has been developed for the assessment of COPD patients, it has not been fully evaluated exclusively in IPF. This study was designed to evaluate the validity of the CAT in IPF. The clinical data for 106 consecutive subjects with newly diagnosed IPF who completed pulmonary function tests, partial pressure of oxygen in arterial blood (PaO2 ) at rest, 6-min walk test (6MWT), CAT, St George's Respiratory Questionnaire (SGRQ), modified Medical Research Council (mMRC) dyspnoea grade and Hospital Anxiety and Depression Scale (HADS), were analysed. We assessed the validity of the CAT in comparison with the SGRQ. The present subjects showed mild to moderate restrictive impairment on spirometry. Mean CAT score and total SGRQ were 12.8 ± 8.0 and 30.8 ± 17.7, respectively. The concurrent validity of the CAT score in comparison with the SGRQ total score was significant (r = 0.72, P < 0.001). Internal consistency (Cronbach's α = 0.869) and repeatability over 3 months (intraclass correlation coefficient = 0.742) of the CAT were also significant. Single regression analysis showed that the CAT had significant construct validity. In multiple regression analysis, mMRC, PaO2 at rest, minimum SpO2 during 6MWT and anxiety of HADS were independent predictors for the CAT. The CAT is a valid health status measurement in IPF patients. Multiple regression analysis showed that the CAT was significantly correlated with dyspnoea severity, oxygenation impairment and anxiety.

Breathlessness and inflammation: potential relationships and implications.

Breathlessness and chronic inflammation both span a wide range of disease contexts and hold prognostic significance. The possibility of a causal relationship between the two has been hypothesized. The aims of this article are to review the intersections between breathlessness and inflammation in the literature, describe potential mechanisms connecting the two phenomena, and discuss the potential clinical implications of a causal relationship. There is a very limited literature exploring the relationship between systemic inflammation and breathlessness in chronic obstructive pulmonary disease, heart failure, and cancer. One large study in cancer patients is suggestive of a weak association between self-reported breathlessness and inflammation. Studies exploring the relationship between inflammation and Medical Research Council Dyspnoea grade in chronic obstructive pulmonary disease patients have produced inconsistent findings. Although a causal relationship has not yet been proven, there is evidence to support the existence of potential mechanisms mediating a relationship. This evidence points to a role for the skeletal muscle and stress hormone systems. There is much progress to be made in this area. Interventional studies, evaluating the impact of anti-inflammatory interventions on breathlessness, are needed to help determine whether a causal relationship exists. If proven, this relationship might have important implications for both the treatment and impact of breathlessness.

Simplified Graded Baseline Symptom Assessment in Patients With Lung Cancer Undergoing First-Line Chemotherapy: Correlations and Prognostic Role in a Resource-Constrained Setting.

PurposeThere are limited data from developing countries on graded baseline symptom (BS) assessment in lung cancer. This prospective study aimed to assess the prognostic role of BS and correlation of BS with comorbidity, demographic, and investigation profiles in a cohort of 238 patients with lung cancer undergoing first-line chemotherapy over a 15-month period.MethodsThe Medical Research Council (MRC) scale was used to assess dyspnea, whereas the visual analog scale (VAS; score of 1 to 10) was used to assess anorexia, fatigue, chest pain, and cough. Weight loss (WL) was noted as percentage of pre-illness baseline. All patients received histology-guided platinum doublet chemotherapy. Outcomes assessed were overall survival (OS) and radiologic responses by RECIST.ResultsSignificant correlations (Spearman ρ) were noted for fatigue and anorexia with all other BSs. Dyspnea differed significantly among groups on the basis of either the simplified comorbidity score or Charlson comorbidity index. Median OS was 287 days (95% CI, 232 to 342 days). OS was significantly higher for anorexia VAS score less than 4 (388 v 229 days for VAS score ≥ 4), fatigue VAS score less than 3 (388 v 213 days for VAS score ≥ 3), WL less than 5% (410 v 259 days for WL ≥ 5%), and MRC dyspnea grade less than 3 (377 v 187 days for MRC grade ≥ 3). On univariable Cox proportional hazards analysis, worse OS was noted for all BSs, stage, and performance status, but on multivariable analysis, only fatigue (hazard ratio [HR], 1.21), Eastern Cooperative Oncology Group performance status ≥ 2 (HR, 1.57), and stage IV disease (HR, 1.61) were significant. Nonresponders (stable disease and progressive disease [PD]) had a higher percentage of WL and higher mean VAS scores for cough, chest pain, anorexia, and fatigue. On multivariable logistic regression analysis, PD was associated with fatigue and percentage of WL.ConclusionBSs are prognostic for patients with lung cancer on first-line chemotherapy. Fatigue is prognostic for worse OS and PD. Comorbidity and investigation profiles do not correlate with either OS or response rates.

Combined pulmonary fibrosis and emphysema: effect of pulmonary rehabilitation in comparison with chronic obstructive pulmonary disease

ObjectiveTo evaluate the effectiveness of short-term comprehensive inpatient pulmonary rehabilitation for patients with combined pulmonary fibrosis and emphysema (CPFE), and to compare responses with those of patients with chronic obstructive...

Bedside assessment of quadriceps muscle by ultrasound after admission for acute exacerbations of chronic respiratory disease.

Hospitalization represents a major event for the patient with chronic respiratory disease. There is a high risk of readmission, which over the longer term may be related more closely to the underlying condition of the patient, such as skeletal muscle dysfunction. We assessed the risk of hospital readmission at 1 year, including measures of lower limb muscle as part of a larger clinical trial. Patients hospitalized with an exacerbation of chronic respiratory disease underwent measures of muscle function including quadriceps ultrasound. Independent factors influencing time to hospital readmission or death were identified. Patients were classified into four quartiles based on quadriceps size and compared. One hundred and ninety-one patients (mean age, 71.6 [SD, 9.1] yr) were recruited. One hundred and thirty (68%) were either readmitted or died. Factors associated with readmission or death were age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.08; P = 0.015), Medical Research Council (MRC) dyspnea grade (OR, 4.57; 95% CI, 2.62-7.95; P < 0.001), home oxygen use (OR, 12.4; 95% CI, 4.53-33.77; P < 0.001), quadriceps (rectus femoris) cross-sectional area (Qcsa) (OR, 0.34; 95% CI, 0.17-0.65; P = 0.001), and hospitalization in the previous year (OR, 4.82; 95% CI, 2.42-9.58; P < 0.001). In the multivariate analyses, home oxygen use (OR, 4.80; 95% CI, 1.68-13.69; P = 0.003), MRC dyspnea grade (OR, 2.57; 95% CI, 1.44-4.59; P = 0.001), Qcsa (OR, 0.46; 95% CI, 0.22-0.95; P = 0.035), and previous hospitalization (OR, 3.04; 95% CI, 1.47-6.29; P = 0.003) were independently associated with readmission or death. Patients with the smallest muscle spent more days in hospital than those with largest muscle (28.1 [SD, 33.9] vs. 12.2 [SD, 23.5] d; P = 0.007). Smaller quadriceps muscle size, as measured by ultrasound in the acute care setting, is an independent risk factor for unscheduled readmission or death, which may have value both in clinical practice and for risk stratification.

Is a Practice Incremental Shuttle Walk Test Needed for Patients with Chronic Obstructive Pulmonary Disease Admitted to Hospital for an Acute Exacerbation?

Background: The incremental shuttle walk test (ISWT) assesses exercise capacity in chronic obstructive pulmonary disease (COPD) patients. Guidelines suggest that 2 ISWTs should be performed. However, in inpatients with an acute exacerbation, it is unknown if 2 ISWTs are required. Objective: To investigate if a practice ISWT is needed for inpatients with an acute COPD exacerbation. Methods: Patients admitted to hospital with an acute exacerbation completed 2 ISWTs prior to discharge. Patients provided informed consent and were included if they used the same oxygen and mobility aid (if any) between tests. Results: Thirty-nine inpatients with COPD were included with a mean (SD) forced expiratory volume in 1 s (FEV₁) of 1.1 litres (0.5) [42.5% predicted (13.2)] and a median (interquartile range) Medical Research Council dyspnoea grade of 4 (3-5). Participants achieved 88.2 m (96.7) on ISWT1, and there was a statistically significant increase of 14.1 m (28.4) for ISWT2 (p < 0.05). Multiple regression explained 98.8% of the variance (F_(8-22) p < 0.001, R² = 0.988) between ISWTs using age, FEV₁/forced vital capacity (FVC)%, FVC, resting oxygen saturation, resting heart rate (HR), ISWT1 distance, ISWT1 post-HR and post-Rated Perceived Exertion (p < 0.05). Using this equation to calculate predicted ISWT2, there was good agreement and no significant difference between this and actual ISWT2 (0.01 m, p > 0.05). Conclusions: There was a small but statistically significant increase between ISWTs, which was below the minimal clinically important difference but would have had consequences for exercise prescription. This exploratory work has shown that we may be able to predict the difference between ISWTs using a multiple regression equation which could substitute the need for a second ISWT; this needs to be confirmed prospectively.

P124 Do We Need A Practice Incremental Shuttle Walk Test For Patients With Interstitial Lung Disease Referred For Pulmonary Rehabilitation?

Background Patients with Interstitial Lung Disease (ILD) are more frequently being referred to Pulmonary Rehabilitation (PR) where exercise capacity is measured, often by an Incremental Shuttle Walk Test (ISWT). These patients are frequently limited by severe dyspnoea and exertional desaturation. Available guidelines 1 suggest two ISWTs are needed, however this can be time consuming. Objective To investigate if a practice ISWT is needed for patients with ILD referred to PR. Methods Patients with ILD recorded on our PR database, who attended a PR assessment and performed 2 ISWTs, 1 were selected. Patients were included if they had 2 recorded ISWTs using the same oxygen prescription and mobility aid (if any) between tests and provided written consent. Hospital notes were retrieved, diagnosis confirmed and relevant data extracted and validated. Results 43 patients (24 male) were included, 18 with Idiopathic Pulmonary Fibrosis. Participants were mean (SD) 72.17(10.54) years, Forced Vital Capacity was 2.28(0.87)l [77.24(25.46)% predicted], Transfer factor for the Lung for Carbon Monoxide 3.60(1.07)ml/mmHg [44.79(12.80)% predicted], median (inter-quartile range) Medical Research Council dyspnoea grade 3.5(3–4) and 29 used oxygen therapy. Participants achieved 165.12(123.89)m on ISWT1 with post-SaO 2 87.86(5.86)%, heart rate 97.03(14.71), Borg breathlessness 4(3–5) and Rated Perceived Exertion (RPE) 13(11.25–15). There was a change of 28.84(31.71)m between the two ISWTs (p 2 . 426). For those who did not improve, ISWT1 was ≤210 m. Bland-Altman plot showed good agreement between the ISWTs, however the limits of agreement were wide. There was a significant difference in Endurance Shuttle Walk Test levels when calculated at 85% of VO 2 peak as estimated from ISWT1 and ISWT2 (p Conclusions For patients with ILD, we have shown that there are significant differences between the first and second ISWT and therefore a practice ISWT is needed in order to accurately assess exercise capacity, prescribe an exercise programme and ensure services and interventions are correctly evaluated. We were unable to predict those who did not need to complete 2 ISWTs. Reference Singh et al . Development of a shuttle walking test of disability in patients with chronic airways obstruction. Thorax .1992; 47 :1019–1024