Participation In Pulmonary Rehabilitation Research Articles

Pulmonary rehabilitation in lung transplant candidates

While awaiting lung transplantation, candidates may participate in pulmonary rehabilitation to improve their fitness for surgery. However, pulmonary rehabilitation outcomes have not been systematically evaluated in lung transplant candidates. This investigation was a retrospective cohort study of 345 pre-transplant pulmonary rehabilitation participants who received a lung transplant between January 2004 and June 2009 and had available pre-transplant exercise data. Data extracted included: 6-minute walk tests at standard intervals; exercise training details; health-related quality-of-life (HRQL) measures; and early post-transplant outcomes. Paired t-tests were used to examine changes in the 6MW distance (6MWD), exercise training volume and HRQL during the pre-transplant period. We evaluated the association between pre-transplant 6MWD and transplant hospitalization outcomes. The final 6MWD prior to transplantation was only 15 m less than the listing 6MWD (n = 200; p = 0.002). Exercise training volumes increased slightly from the start of the pulmonary rehabilitation program until transplant: treadmill, increase 0.69 ml/kg/min (n = 238; p < 0.0001); biceps resistance training, 18 lbs. × reps (n = 286; p < 0.0001); and quadriceps resistance training, 15 lbs. × reps (n = 278; p < 0.0001). HRQL measures declined. A greater final 6MWD prior to transplant correlated with a shorter length of stay in the hospital (n = 207; p = 0.003). Exercise capacity and training volumes are well preserved among lung transplant candidates participating in pulmonary rehabilitation, even in the setting of severe, progressive lung disease. Participants with greater exercise capacity prior to transplantation have more favorable early post-transplant outcomes.

Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease: Predictors of Program Completion and Success

Although participation in pulmonary rehabilitation (PR) improves the health outcomes in patients with Chronic Obstructive Pulmonary Disease (COPD), there are insufficient resources to provide PR to all patients with COPD. Thus, predicting which patients are at risk for drop-out and non-response to rehabilitation is necessary in order to optimize limited resources. This study examined which patient characteristics are predictive of PR drop-out and non-response. 814 patients with COPD took part in standard out-patient PR for 8 weeks. Demographic and standard clinical data were collected before the rehabilitation program had started. Data was analyzed retrospectively to determine if baseline patient characteristics could predict drop-out and non-response to rehabilitation. Drop-out was defined as participation in less than 50% of the rehabilitation sessions. Non-response was defined as improvement less than 4% on the St. George's Respiratory Questionnaire (SGRQ). A discriminant function analysis identified age, smoking history, and health status as predictors of patient drop-out, p < .0001, with younger, current smokers and patients with lower health status being at risk for drop-out. No variables measured significantly predicted who those at risk would be for non-response to rehabilitation, p > .05. Pulmonary function data did not predict drop-out or non-response to PR. These findings indicate that perceived impairment (i.e., health status) is more likely to influence completion of rehabilitation than actual pulmonary impairment and that demographic and standard clinical data do not adequately predict patient drop-out and non-response to rehabilitation.

The challenge of increasing uptake of pulmonary rehabilitation: What can we do to maximise the chances of success?

The challenge of how to increase participation in pulmonary rehabilitation (PR) is a dilemma that everyone who runs a PR programme faces. We know that PR can be very effective in reducing breathlessness, improving fitness and muscle strength and enhancing a patient’s quality of life. The benefits of PR also extend to the improved management of exacerbations and decreased health care utilization. PR may even improve the survival. However, despite these many well-documented benefits, uptake of PR has remained modest at best. Many programmes report non-completion rates as high as 30–50% and the numbers of people offered PR but failing to attend for assessment is largely unknown. In these times of financial uncertainty and stringent examination of health care budgets, the question of how to maximise the uptake of rehabilitation and the utilisation of precious resources, has never been more pertinent. To this end, the article by Keating et al. in this edition of CRD is very timely. The authors have set out to establish the factors that influence whether people with COPD choose to attend PR at all and also those factors that prevent people from completing a programme. The article is a systematic review of both qualitative and quantitative studies which identified barriers to attendance and completion of rehabilitation. Of the 11 studies which fulfilled the necessary quality criteria for inclusion, 5 were qualitative and 6 were quantitative in design. The major findings of the review are that travel and transport difficulties were identified as a predominant barrier to attendance of PR. Lack of perceived benefit and the influence of the participant’s doctor were also identified as reasons for non-attendance. This is a notoriously difficult area to study as by definition these patients have chosen not to attend, probably do not recognise the value of rehabilitation and therefore are also less likely to participate in rehabilitation-related research. Once patients have started rehabilitation, the main barrier to completion is illness and co-morbidities, which were identified in all eight of the articles that documented the reasons for non-completion. Again, travel was also a major factor, with people living over 36 miles from the place of rehabilitation or travelling more than 30 minutes, being significantly less likely to complete than those with shorter travelling times. This finding would lend support to the growth of community-based rehabilitation programmes where travelling time is potentially reduced considerably. The review also aimed to identify certain patient groups who were more likely to drop out. Interestingly disease severity was not a consistent factor in non-completion whereas presence of depression, living alone or poor social support was. Current smokers were also found to have a higher drop out rate. These findings should prompt clinicians to highlight the importance and support of smoking cessation programmes to those still smoking and of screening for depression with a designated treatment pathway for those patients identified with depression to maximise the chances of success. Although PR has been

Participation in pulmonary rehabilitation in routine clinical practice

Denmark offers COPD rehabilitation to enable patients to tackle the consequences of COPD, but only a minority of the patients complete these programs. To increase the completion rate, an follow-up study was performed, to characterize COPD patients and to identify potential differences between those who complete and those who do not complete rehabilitation or do not even get a rehabilitation offer in daily clinical routine. In- and out COPD-patients who participated in baseline tests were compared in terms of completion of rehabilitation, drop-out, and no rehabilitation offer. We obtained data on basic characteristics, co-morbidity, lung-function (FEV1), dyspnea (MRC), six-minute walkg-distance (6MWD), and quality of life (SF36). The source population counted 521 COPD patients of whom 256 were excluded (diagnosis withdrawn, death, moved away, long-term oxygen, severe illness). Patients who completed rehabilitation had a 15% longer 6MWD than patients not offered rehabilitation and a 10% longer 6MWD than drop-outs despite a significant lower subjective perception of physical function among completers than in the two other groups. Patients not offered rehabilitation had a slightly better lung function than the other two groups. This suggests that lower physical performance with the same (drop-outs) or even higher (not offered) lung function indicates a lower chance of completion. COPD patients who could potentially benefit most from completing rehabilitation seem to be deselected. A mere 9% completed rehabilitation within the study period and 23% ever completed. This demonstrates that the political target that 60% of COPD patients should be offered rehabilitation is still far away.

Improved Neurobehavioral Functioning in Emphysema Patients Following Medical Therapy

To evaluate the neuropsychological and psychological functioning of emphysema patients following 10 weeks of multidisciplinary medical therapy (MT). Patients with moderate to severe emphysema (n = 56) enrolled in the National Emphysema Treatment Trial at 2 sites (National Jewish Health and Ohio State University) completed cognitive, psychological, and quality-of-life (QOL) tests at baseline and 6 to 10 weeks following participation in pulmonary rehabilitation. Healthy control subjects (matched on age, sex, race, and education, n = 54) completed the same tests at baseline and 6 to 10 weeks later. Controlling for practice effects and educational level, emphysema patients in the MT group demonstrated significant improvement compared with controls on a global index of cognition, and in measures of visuomotor sequential skills and visual memory. The MT group showed significant reductions in several measures of depression and anxiety, and the control group showed a significant reduction in total depression, but acute anxiety scores were worse 6 to 10 weeks later. The MT group showed significant improvement on 6 of 9 QOL variables and no change was detected in the control group. Improvement on the cognitive index score in the mt group was related to decline in depression and increased workload. emphysema patients who received MT demonstrated improvement in specific neuropsychological functions, depression, anxiety, and QOL scores compared with control subjects during the same interval (with no treatment). Mechanisms for these neurobehavioral changes include greater exercise endurance and decreased depression.

The Impact of Chronic Obstructive Pulmonary Disease Exacerbation on Pulmonary Rehabilitation Participation and Functional Outcomes

The purpose of this study was to determine the impact of chronic obstructive pulmonary disease exacerbation (COPDE) on pulmonary rehabilitation (PR) participation and completion and on PR outcomes of daily activity, self-reported daily exercise, and functional capacity. Participants in an 8-week outpatient PR program were studied pre- and post-PR. Variables included COPDE occurrence (computerized patient record system), self-reported exercise (daily activity diary), daily activity (accelerometer), exercise capacity (6-minute walk distance), dyspnea today and over the past 30 days (Lareau's Functional Status and Dyspnea Questionnaire), health status (The Medical Outcomes Study 36-Item Short-Form Health Survey adapted for Veterans), and quality of life (Seattle Obstructive Lung Disease Questionnaire). Outpatients with COPD (N = 146, 140 men) started PR; 112 completed the program and were studied. Of the 30 participants who had at least 1 COPDE during the program, 10 quit the program. Subjects who exacerbated had a lower body mass index than did patients without COPDE (28.4 compared with 30.8, respectively, P < .05), more severe COPD (percent-predicted forced expiratory volume in the first second of expiration, FEV1% predicted, 32%, compared with 40%, respectively, P< .05), and required supplemental oxygen (70% compared with 36%, respectively, P< .05). Exacerbators who completed PR were more likely to be nonsmokers, on oxygen, and have a higher FEV1% predicted than were exacerbators who quit. It was found that postprogram exercise capacity improved overall, with exacerbators performing better than nonexacerbators on the 6-minute walk test (P = .044). There were no significant differences in other outcomes. Findings suggest that COPD exacerbators who completed PR had similar outcomes as did nonexacerbators and should be encouraged to return to PR after COPDE.

Fatigue in patients with COPD participating in a pulmonary rehabilitation program

BackgroundFatigue is a distressing, complex, multidimensional sensation common in individuals with chronic obstructive pulmonary disease (COPD). While fatigue negatively impacts functional performance and quality of life, there has been little study of the fatigue that affects participants in pulmonary rehabilitation programs. The purpose of this study was to examine the emotional, behavioral, cognitive, and physical dimensions of fatigue and their relationships to dyspnea, mental health, sleep, and physiologic factors.Patients and methodsA convenience sample of 42 pulmonary rehabilitation participants with COPD completed self-report questionnaires which measured dimensions of fatigue using the Multidimensional Fatigue Inventory, anxiety and depression using the Hospital Anxiety and Depression Scale, and sleep quality using the Pittsburgh Sleep Quality Index. Data on other clinical variables were abstracted from pulmonary rehabilitation program health records.ResultsAlmost all (95.3%) participants experienced high levels of physical fatigue. High levels of fatigue were also reported for the dimensions of reduced activity (88.1%), reduced motivation (83.3%), mental fatigue (69.9%), and general fatigue (54.5%). Close to half (42.9%) of participants reported symptoms of anxiety, while almost one quarter (21.4%) reported depressive symptoms. Age was related to the fatigue dimensions of reduced activity (ρ = 0.43, P < 0.01) and reduced motivation (ρ = 0.31, P < 0.05). Anxiety was related to reduced motivation (ρ = −0.47, P < 0.01). Fatigue was not associated with symptoms of depression, sleep quality, gender, supplemental oxygen use, smoking status, or Medical Research Council dyspnea scores.ConclusionsFatigue (particularly the physical and reduced motivation dimensions of fatigue) was experienced by almost all participants with COPD attending this pulmonary rehabilitation program. Fatigue affected greater proportions of participants than either anxiety or depression. The high prevalence of fatigue may impact on enrolment, participation, and attrition in pulmonary rehabilitation programs. Further investigation of the nature, correlates, and impact of fatigue in this population is required.

Multivariate models of determinants of health-related quality of life in severe chronic obstructive pulmonary disease

Persons with severe chronic obstructive pulmonary disease (COPD) and similar levels of forced expiratory volume in 1 second (FEV(1)), exercise capacity, and dyspnea have a wide range of health-related quality of life (HRQL). We identified the independent determinants of HRQL in persons with COPD. Comprehensive assessments of physiological, psychosocial, and clinical variables from the National Emphysema Treatment Trial were used. HRQL was assessed by the Medical Outcomes Study 36-Item Short Form Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and the St. George's Respiratory Questionnaire total score (SGRQ-TS). In multivariate linear regression models, exercise capacity, dyspnea, age, single-breath diffusing capacity of the lung for carbon monoxide percent predicted, and self-report of being disabled were significant determinants of PCS score. Dyspnea, depression, antidepressant use, daytime sleepiness, and education were significant determinants of MCS score. Prior participation in pulmonary rehabilitation, supplemental oxygen use, and oral corticosteroid use were significant determinants of SGRQ-TS. Although FEV(1), 6-minute walk test distance, and dyspnea significantly correlated with HRQL, their effects on HRQL were reduced when other variables were considered. Greater exercise capacity, prior participation in pulmonary rehabilitation, and use of supplemental oxygen were significantly associated with better HRQL. Self-perception of being disabled, (Abstract continued) depression, dyspnea, oral corticosteroid use, and daytime sleepiness were associated with worse HRQL. To optimize HRQL, clinicians should pay attention to a number of clinical and physiological factors.

RETROSPECTIVE ANALYSIS OF SUCCESSFUL COMPLETION OF PULMONARY REHABILITATION

PURPOSE: Pulmonary rehabilitation is an accepted part of the treatment algorithm for Chronic Obstructive Pulmonary Disease (COPD). Participation in pulmonary rehabilitation requires a significant mental, physical and time commitment on the part of the participant. We sought to analyze adherence rates at a local pulmonary rehabilitation facility.

Development and Validation of an Improved, COPD-Specific Version of the St. George Respiratory Questionnaire

To produce an improved, COPD-specific version of the St. George respiratory questionnaire (SGRQ-C). Five different steps were required: (1) Rasch analysis of the responses of 893 COPD patients to the St. George respiratory questionnaire (SGRQ) identified weaker items to be removed; (2) a scoring algorithm was produced using data from 1,036 patients; (3) validity of the new and original SGRQ was tested using data from the original validation study; (4) responsiveness was tested using data from a previously published trial; and (5) a reworded version (SGRQ-C) that no longer specified the recall period was administered to 63 pulmonary rehabilitation participants. Items were removed due to lack of response (n = 1), misfit to the Rasch model (n = 8), and disordered responses (n = 1). Another six items had disordered responses; this was corrected. Scores from the two versions differed slightly, so the scoring algorithm was revised to produce scores equivalent to the original. Intraclass correlation coefficient (ICCC) for the scores for original and new versions was 0.99. Correlations with other measures of disease were very similar to those obtained with the original. New and original scores for treatment effects were similar: difference, 0.1 +/- 2.7 U (+/- SD). Baseline SGRQ and SGRQ-C scores were similar (ICCC, 0.95; 95% confidence interval, 0.92 to 0.97; mean difference, 0.9 +/- 5.8 U). Change scores were similar (difference, 1.0 +/- 7.3 U). The SGRQ-C contains the best of the original items, no longer specifies a recall period, and produces scores equivalent to the original.

INTERVAL VERSUS CONTINUOUS HIGH-INTENSITY EXERCISE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Puhan MA, Busching G, Schunemann HJ, VanOort E, Zaugg C, Frey M Ann Intern Med. 2006;145:816-825. Background Guidelines recommend high-intensity continuous exercise to reduce peripheral muscle dysfunction in patients with chronic obstructive pulmonary disease but acknowledge that interval exercise might be an equally effective alternative that is better tolerated by patients. Objective. To assess whether interval exercise is no less effective than high-intensity continuous exercise and whether it is tolerated better by patients with severe chronic obstructive pulmonary disease. Design. Randomized, noninferiority trial. Setting. Publicly funded rehabilitation hospital in Switzerland. Patients. 98 patients with severe chronic obstructive pulmonary disease, with or without recent exacerbations. Intervention. 12 to 15 supervised interval or high-intensity continuous exercise sessions (over 3 weeks) followed by exercise at home. Measurements. Health-related quality of life determined by using the Chronic Respiratory Questionnaire (CRQ) (scores from 1 [most severe impairment] to 7 [no impairment]) after 5 weeks and number of unintended breaks during supervised exercise. Results. Both groups experienced large improvements in health-related quality of life (increase of CRQ total scores of 1.00 [SD, 0.98] for the interval exercise group and 1.02 [SD, 1.05] for the continuous exercise group). Adjusted between-group differences between the interval exercise group and the continuous exercise group (−0.05 [95% CI, −0.42 to −0.32] for CRQ and 1.1 meters [CI, −25.4 to 27.6 meters] for 6-minute walking distance) were within the a priori defined boundaries of noninferiority (0.5 for CRQ and 45 meters for 6-minute walking distance). Twenty-one (47.9%) patients using interval exercise and 11 (24.0%) patients using continuous exercise were able to adhere to the protocol (difference, 23.9 percentage points [CI, 5.0 to 42.8 percentage points]; P = 0.014). The median number of unintended breaks lasting 1 minute or more was 2 (interquartile range, 0 to 16) for patients in the interval exercise group and 11 (interquartile range, 2 to 26) for patients in the continuous exercise group (P = 0.023). Limitations. The study focused on initiation of exercise and not on outpatient or home-based maintenance of exercise. Conclusions. Clinicians and patients can choose either of the 2 exercise plans to initiate physical exercise. Comment. The use of high-intensity exercise protocols in the initiation of pulmonary rehabilitation is well established. However, the more severely impaired patient often has difficulty with sustained exercise at the requisite workload levels (>70% of maximal exercise capacity), and this may directly affect not only the short-term outcome of exercise training but also the longer-term adherence to recommendations made during participation in pulmonary rehabilitation. This study is a well-designed randomized trial seeking to show that interval exercise (brief high-intensity bursts alternating with low-intensity exercise) is not inferior to high-intensity continuous exercise. Forty-nine and 51 patients were randomized to interval and continuous exercise groups, respectively; all had severe chronic obstructive pulmonary disease (mean FEV1, approximately 35% predicted, GOLD stage 3 and 4). At the end of 5 weeks (12 to 15 sessions), the interval group did not show less benefit in both health-related quality-of-life measures and 6-minute walk distance. Not only did the interval exercise group do at least as well using standard outcome measures, adherence to the assigned protocol was also significantly higher in this group, suggesting a higher level of patient preference. Whether the benefits would carry over into maintenance exercise training is unestablished, but the 2 protocols, interval and continuous exercise, seem to be equivalent in the initiation of pulmonary rehabilitation and can be offered as such, especially to patients with severe chronic obstructive pulmonary disease who may find the interval protocol more acceptable. SK

Improved Neurobehavioral Functioning in Emphysema Patients Following Lung Volume Reduction Surgery Compared With Medical Therapy

The goal of this study was to evaluate the neuropsychological and psychological functioning of emphysema patients following lung volume reduction surgery (LVRS) compared with patients receiving only medical therapy (MT). Patients with moderate-to-severe emphysema who were enrolled in the National Emphysema Treatment Trial at two sites (National Jewish Medical and Research Center and Ohio State University) were given a neuropsychological battery at baseline, 6 to 10 weeks later (following participation in pulmonary rehabilitation), and at 6 months following randomization to either LVRS or MT treatment. Twenty patients randomized to MT, 19 patients randomized to LVRS, and 39 matched, healthy control subjects completed a battery of tests that measured cognitive functioning, depression, anxiety, and quality of life (QoL). Controlling for practice, patients in the LVRS treatment arm at the 6-month follow-up demonstrated significant improvement compared with MT patients in cognitive tasks involving sequential skills and verbal memory. The LVRS patients also showed significant reductions in depression compared with the MT patients, as well as improved physical and psychosocial QoL. Correlational analysis indicated that improved immediate verbal memory in the LVRS group was related to improved QoL. No associations were found between changes in cognitive function and changes in depression, exercise performance, or pulmonary functioning. Patients who received LVRS demonstrated improvement in specific neuropsychological functions, depression, anxiety, and QoL scores compared with patients with continued MT treatment 6 months following randomization. However, mechanisms for these neurobehavioral changes are unclear. Improved verbal memory and sequential skills following LVRS were not directly associated with depression or exercise capacity. Nonetheless, LVRS led to a strong and likely clinically significant improvement in neuropsychological functioning over and above that explained by practice effects or MT. This finding adds to the growing list of clinical benefits of LVRS over MT, and supports additional research into the underlying mechanisms of this therapeutic effect.

Pulmonary rehabilitation and the BODE index in COPD

The BODE index, which integrates body mass index, airflow limitation (forced expiratory volume in one second), dyspnoea and 6-min walk distance, predicts mortality in chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation (PR) improves some components of BODE. It was hypothesised that changes in BODE may reflect the effects of PR. To test this, participation in PR was offered to 246 patients (BODE quartiles 2-4). The patients were divided as follows: no PR (130 who declined rehabilitation or who dropped out from PR), and PR (116 who completed PR). BODE was determined at entry, after PR, and at 1 and 2 yrs. Other outcomes were: length of stay (LOS) for respiratory-related hospitalisations and mortality. At entry, the two groups had similar age and comorbidity but different BODE. After PR, the BODE improved by 19% and returned to baseline after 2 yrs. The BODE worsened in the no PR group by 4% at 12 months and 18% at 2 yrs. Respiratory mortality at 2 yrs for PR was 7%, compared with 39% for no PR. LOS at 1 yr for COPD decreased 20% in PR, while it increased 25% in no PR. In conclusion, pulmonary rehabilitation participation improves BODE and is associated with better outcomes. The BODE index change after pulmonary rehabilitation provides valuable prognostic information.

Seattle Obstructive Lung Disease Questionnaire

To evaluate the ability of the Seattle Obstructive Lung Disease Questionnaire (SOLDQ) to detect change in health-related quality of life (HRQOL) following a pulmonary rehabilitation program (PRP) and to determine associations with other functional indicators. A prospective pre- and post-test design. A PRP was offered for 60 minutes, 2 times per week for 8 weeks. Measured at entry and exit to the PRP: the SOLDQ (physical, emotional, and coping skills), 6-minute walk, Medical Outcomes Study Short Form Health Survey-36 Veterans (SF-36V) (physical and mental), Lareau Functional Status and Dyspnea Questionnaire, and the Multidimensional Assessment of Fatigue (MAF) scale. Setting was an outpatient PRP in a VA Medical Center. Participants included 58 adults who completed the PRP (age mean = 66, SD +/- 9.8; FEV1% predicted mean = 39, SD +/- 15.9). At baseline, significant correlations were found between SOLDQ physical functioning and SF-36V physical, dyspnea, fatigue, 6-minute walk distance, SF-36V mental, and spirometry. SOLDQ emotional functioning significantly correlated with fatigue, dyspnea, and SF-36V mental and physical. SOLDQ coping skills significantly correlated with fatigue, dyspnea, and SF-36V mental and physical. Paired, 2-tailed, t tests comparing the SOLDQ subscales pre- and post-program were significant, with the biggest treatment effect seen with emotional functioning. Other measures showing significant improvement included 6-minute walk, SF-36V physical, dyspnea, and fatigue. After participation in a PRP, all 3 SOLDQ subscales improved significantly and were associated with other indicators of function. These findings validate the SOLDQ as a measure sensitive to functional changes associated with participation in pulmonary rehabilitation.

The Contribution of Peripheral Muscle Function to Shuttle Walking Performance in Patients With Chronic Obstructive Pulmonary Disease

The contribution of muscle strength and mass to incremental and endurance walking performance in chronic obstructive pulmonary disease (COPD) is unknown. This study analyzes the relationship between field incremental and endurance walking performance and indices of peripheral muscle mass and strength. Eighty-five stable COPD patients (53 males; mean [SD] age = 67 [9] years; mean [SD] forced expiratory volume in 1 second [FEV1] = 35 [14] [% predicted]) were studied prior to participation in pulmonary rehabilitation. Isometric quadriceps and handgrip strength were measured. Total body and lower limb lean muscle mass were estimated using dual energy x-ray absorptiometry. Exercise performance was measured using the incremental shuttle walk test (ISWT) and the endurance (ESWT) shuttle walk test. ISWT was related to muscle strength (r = 0.467, P </= .001) but not to whole body or lower limb lean mass. There was no association between muscle strength or mass and ESWT. In a multivariate linear regression analysis, the only variables significantly contributing to ISWT were age (P < .001), FEV1 (% predicted) (P < .001) and quadriceps strength (P < .001). Variables contributing to ESWT were FEV1 (% predicted) (P < .001) and ISWT performance (P < .001). We conclude that muscle strength is related to incremental but not endurance shuttle walking performance. Muscle mass and strength are not synonymous in their effects on exercise performance in patients with COPD.

Acute Exacerbation of COPD

Nurses in acute care settings play a vital role in caring for individuals during an acute exacerbation of chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States. In addressing this health concern, the Global Initiative for Chronic Obstructive Lung Disease Report summarized the goals for COPD management and recommended treatment supported by current data and research. It is imperative that our clinical nursing practice is based upon research-supported interventions: use of appropriate medications, monitoring acid-base status, administering controlled oxygen therapy, assessing the need for mechanical ventilation, and close monitoring of comorbid illnesses. Health promotion includes patient and family education on early recognition of symptoms, smoking cessation strategies, and participation in pulmonary rehabilitation that can reduce long-term morbidity from this chronic disease.

Lack of Relationship Between Functional and Perceived Quality of Life Outcomes Following Pulmonary Rehabilitation

Individuals with chronic obstructive pulmonary disease (COPD) have been shown to benefit from participation in pulmonary rehabilitation (PR) programs that include exercise training and education. To examine the relationship between improvements in 6 minute walk distance and perceived quality of life in individuals with COPD following completion of a PR program. The records of 139 individuals completing a PR program (3 times a week for 8 weeks) were retrospectively examined. Prior to entry and upon completion of the program each individual completed a 6 minute walk test (6MWT), the SF-36 Health survey, and the UCSD Shortness of Breath Questionnaire (SOB). SF-36 results were analyzed according to 8 subscales [Physical Functioning (PF), Role Physical (RF), Bodily Pain (BP), General Health (GH), Vitality (V), Social Functioning (SF), Role Emotional (RE), and Mental Health (MH)]. PR resulted in significant improvements in 6MWTdistance (Pre = 845 +/- 37 ft, Post = 1127 +/- 32 ft, p < 0.001), PF (p < 0.001), RF (p = 0.001), Vitality (p = 0.002), SF (p < 0.001), RE (p = 0.037), MH (p < 0.001) and SOB (Pre = 53 +/- 2, Post = 47 +/- 2, p < 0.001). The change in 6MWT distance was not related to changes in PF (r = 0.17), RF (r = 0.03), GH (r = 0.03), Vitality (r = -0.001), SF (r = 0.01), RE (r = 0.06), MH (r = -0.04) or SOB (r = 0.12). The magnitude of improvement in 6MWT distance (68%) was much greater than that observed in PF (15%), RF (16%), GH (6%), VT (18%), SF (20%), RE (14%), MH (14%), or SOB (8%). PR has a positive impact on 6 minute walk distance and perceived quality of life in individuals with COPD; however, changes in 6 minute walk distance appear to have no relationship to changes in perceived quality of life.

LUNG VOLUME REDUCTION IS OF QUESTIONABLE BENEFIT IN A TRANSPLANT POPULATION

985 PURPOSE: To determine the benefit of lung volume reduction surgery (LVRS) in those patients awaiting lung transplant (LTx). METHODS: The records of 13 patients who were listed for LTx and had undergone LVRS were reviewed and compared to 10 non listed patients (NLP) who had undergone LVRS with respect to pulmonary mechanics, exercise capacity, and functional status. As well, the pulmonary architecture was evaluated with CT scanning and grading. RESULTS: Bilateral procedures were done in 12/13 patients. A gradient was present in 7/13 patients but was less pronounced than the NSP group where a significant gradient was observed. The table below shows functional data of the LTx group compared to the NLP. Results for pulmonary mechanics are reported as a percentage ± SD based on indexed BSA.Table*Currently 2 listed patients feel "too well" for transplant, 3 patients have been transplanted, and 8 patients are awaiting transplant. CONCLUSIONS: LVRS for LTx patients does not appear to offer significant improvement or durable relief from emphysema when compared to a cohort of carefully selected patients with a significant gradient on CT scanning. Although participation in pulmonary rehabilitation did improve exercise capability significantly in both groups, this did not appear to be due to a significant improvement in pulmonary mechanics in the LTx group. The use of LVRS as a bridge to transplant may be of benefit in only carefully selected patients.

Functional status in pulmonary rehabilitation participants.

This study examined functional status abnormalities in pulmonary rehabilitation patients, its responsiveness to pulmonary rehabilitation intervention, and its relationship to patient characteristics and traditional measures of disease severity. One hundred sixty-four men and women age 69 years (SD +/- 8), who participated in 1 of 10 pulmonary rehabilitation programs in Connecticut, were studied pre- and postrehabilitation with the following outcome measures: (1) the 6-minute walk distance, (2) the Pulmonary Functional Status Scale (PFSS), and (3) in a subset of 60 subjects, health-related quality of life was measured using the Chronic Respiratory Disease Questionnaire (CRDQ). Patient characteristics were compared to baseline values of these measures using Spearman correlations and Wilcoxon Rank Sum tests, whereas pre- to post-changes in outcome measures were evaluated using Wilcoxon signed-ranks tests. Effect size, representing a standardized measure of change, was calculated for the PFSS. The mean FEV1 was 0.95 +/- 0.50 liters (38 +/- 18% predicted). Rehabilitation resulted in significant increases in the 6-minute walk distance (24%, P < 0.001, the total PFSS scores [13%, P < 0.001, effect size 1.0]) and the total CRDQ (18% P < 0.001). The prerehabilitation function subscore and total PFSS score correlated strongly with the 6-minute walk distance (r = 0.76, 0.73; P < 0.001) and to a lesser degree with the FEV1 (r = 0.31, 0.33; P < 0.001). Males scored higher baseline scores in several PFSS subscales, the total PFSS score, and the 6-minute walk distance; females showed more improvement in some of the PFSS scores. The 6-minute walk distance, the PFSS, and CRDQ all improved significantly with rehabilitation. Functional status, as measured by the PFSS is very strongly correlated with the 6-minute walk. Gender differences in the timed walk distance and functional status highlight the need to study this variable more thoroughly.