LA CONSULTA SEMANAL

MAYO 2000

CONSULTA:

1: Am Fam Physician 2000 Apr 15;61(8):2419-28, 2333-4 [Texto completo] 
Developing and communicating a long-term treatment plan for asthma. 
Mellins RB, Evans D, Clark N, Zimmerman B, Wiesemann S 
Pediatric Pulmonary Division, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA. 
The treatment of asthma, according to current guidelines, requires complex treatment regimens that change as clinical conditions improve or deteriorate. We have developed a practical way to communicate long-term treatment plans in chart form in the primary care setting that is easy for patients to follow and use. The chart has been an important element in two interventions that have resulted in positive changes in health behavior and health outcomes in children with asthma. The plan provides recommendations for patients and families to make adjustments in medication based on changes in symptoms or peak expiratory air flow, or both, that are consistent with the Asthma Guidelines Expert Panel Report 2, 1997. The plan also indicates when the number and dosage of drugs should be increased or decreased and when emergency care should be sought, consistent with the Asthma Guidelines. By placing considerable control in the family's hands and by clearly delineating the conditions under which medicines can be reduced or discontinued, the physician provides incentives for families to adhere to the long-term treatment plan for asthma. 
Publication Types: 
Review 
Review, tutorial 
Comments: 
Comment in: Am Fam Physician 2000 Apr 15;61(8):2328, 2330, 2337 

2: Chest 2000 Apr;117(4):976-83 
Long-term effects of outpatient rehabilitation of COPD: A randomized trial. 
Guell R, Casan P, Belda J, Sangenis M, Morante F, Guyatt GH, Sanchis J 
Departament de Pneumologia, Hospital de la Santa Creu i de Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain. 
OBJECTIVE: To examine the short- and long-term effects of an outpatient pulmonary rehabilitation program for COPD patients on dyspnea, exercise, health-related quality of life, and hospitalization rate. SETTING: Secondary-care respiratory clinic in Barcelona. METHODS: We conducted a randomized controlled trial with blinding of outcome assessment and follow-up at 3, 6, 9, 12, 18, and 24 months. Sixty patients with moderate to severe COPD (age 65 +/- 7 years; FEV(1) 35 +/- 14%) were recruited. Thirty patients randomized to rehabilitation received 3 months of outpatient breathing retraining and chest 
physiotherapy, 3 months of daily supervised exercise, and 6 months of weekly supervised breathing exercises. Thirty patients randomized to the control group received standard care. RESULTS: We found significant differences between groups in perception of dyspnea (p < 0.0001), in 6-min walking test distance (p < 0.0001), and in day-to-day dyspnea, fatigue, and emotional function measured by the Chronic Respiratory Questionnaire (p < 0. 01). The improvements were evident at the third month and continued with somewhat diminished magnitude in the second year of follow-up. The PR group experienced a significant (p < 0.0001) reduction in exacerbations, but not the number of hospitalizations. The number of patients needed to treat to achieve significant benefit in health-related quality of life for a 2-year period was approximately three. CONCLUSION: Outpatient rehabilitation programs can achieve worthwhile benefits that persist for a period of 2 years. 
Publication Types: 
Clinical trial 
Randomized controlled trial 

3: Chest 2000 Feb;117(2 Suppl):23S-8S 
Recommendations for the management of COPD. 
Ferguson GT 
Botsford Pulmonary Associates, Farmington Hills, and Wayne State University, Detroit, MI 48336, USA. 
Three sets of guidelines for the management of COPD that are widely recognized (from the European Respiratory Society [ERS], American Thoracic Society [ATS], and British Thoracic Society [BTS]) are reviewed and compared. None of the documents uses classic evidence-based documentation, and, in many instances, the recommendations are empiric because of a lack of scientific evidence. Overall, there is strong agreement between the documents. All three guidelines recommend inhaled bronchodilators as first-line therapy. Anticholinergics are noted to be well tolerated, although potential problems with beta(2)-agonists are mentioned. The ERS and BTS suggest that inhaled corticosteroids may be of value in patients documented to be steroid responders, whereas the ATS does not recommend their use at all. All three guidelines support the use of oxygen and pulmonary rehabilitation. There are varying levels of disagreement between the guidelines related to the role of spirometry, stratification of disease severity, and the use of theophylline and systemic corticosteroids. Other differences include the role for nebulizers and metered-dose inhalers, secretion clearance methodologies, and the treatment of acute COPD exacerbations and acute respiratory failure. All three guidelines agree that more research is needed to 
improve our understanding and management of COPD. 
Publication Types: 
Review 
Review, tutorial 

4: Lancet 2000 Jan 29;355(9201):362-8 
Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. 
Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, Turner-Lawlor PJ, Payne N, Newcombe RG, Lonescu AA, Thomas J, Tunbridge J 
Department of Medicine, University of Wales, College of Medicine, Llandough Hospital, Penarth, UK. griffithstl@cf.ac.uk 
BACKGROUND: Pulmonary rehabilitation seems to be an effective intervention in patients with chronic obstructive pulmonary disease. We undertook a randomised controlled trial to assess the effect of outpatient pulmonary rehabilitation on use of health care and patients' wellbeing over 1 year. METHODS: 200 patients with disabling chronic lung disease (the majority with chronic obstructive pulmonary disease) were randomly assigned a 6-week multidisciplinary rehabilitation programme (18 visits) or standard medical management. Use of health services was assessed from hospital and general-practice records. Analysis was by intention to treat. FINDINGS: There was no difference between the rehabilitation (n=99) and control (n=101) groups in the number of patients admitted to hospital (40 vs 41) but the number of days these patients spent in hospital differed significantly (mean 10.4 [SD 9.7] vs 21.0 [20.7], p=0.022). The rehabilitation group had more primary-care consultations at the general-practitioner's premises than did the control group (8.6 [6.8] vs 7.3 [8.3], p=0.033) but fewer primary-care home visits (1.5 [2.8] vs 2.8 [4.6], p=0.037). Compared with control, the rehabilitation group also showed greater improvements in walking ability and in general and disease-specific health status. INTERPRETATION: For patients chronically disabled by obstructive pulmonary disease, an intensive, multidisciplinary, outpatient programme of rehabilitation is an effective intervention, in the short term and the long term, that decreases use of health services. 
Publication Types: 
Clinical trial 
Randomized controlled trial 

5: Arch Phys Med Rehabil 2000 Jan;81(1):102-9 
Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity. 
Gimenez M, Servera E, Vergara P, Bach JR, Polu JM 
Laboratoire de Physiologie de L'Exercice Musculaire, Unite 14 of the Institut Nationale de la Sante et de la Recherche Medicale, Nancy, France. 
PURPOSE: To create a maximum tolerated 45-minute aerobic training program for patients with chronic obstructive pulmonary disease (COPD) and to compare its outcomes with those of commonly prescribed moderate exercise. DESIGN: Prospective, randomized trial. SETTING: A work physiology laboratory. PATIENTS AND METHODS: The maximum exercise intensities that 7 COPD patients could sustain for 45 minutes were determined on a bilevel exercise ergometer. The patients then exercised 45 minutes daily, 5 days a week for 6 weeks, working 2.03+/-0.4 kJ/kg per session. They were matched with 6 COPD patients who pushed an O2 cart for 45 minutes daily, 5 days a week for 6 weeks, working 1.44+/-.35 kJ/kg per session. RESULTS: A 45 minute maximal regimen was established by alternating 1-minute peak exercise at peak VO2-levels with 4 minutes at the ventilatory anaerobic threshold or at 40% of peak VO2. Maximal bilevel training significantly decreased dyspnea at rest (p< or =.01) and the blood lactate level during submaximal exercise (p<.001), and increased peak VO2 and total physical work (p<.01), maximum inspiratory and expiratory pressures (p<.01), and grip and forearm strength and endurance (p<.01). The training also increased maximum voluntary ventilation while decreasing the ventilatory equivalent during exercise (p<.001). The O2 cart pushers significantly improved only on the 12-minute walk (p<.05). CONCLUSIONS: A maximally intense anaerobic exercise program can be created for most COPD patients that can significantly improve both skeletal and respiratory muscle strength and endurance as well as dyspnea and physiologic parameters. 
Publication Types: 
Clinical trial 
Randomized controlled trial 

6: J Cardiopulm Rehabil 1999 Nov-Dec;19(6):366-72 
Cardiopulmonary responses, muscle soreness, and injury during the one repetition maximum assessment in pulmonary rehabilitation patients. 
Kaelin ME, Swank AM, Adams KJ, Barnard KL, Berning JM, Green A 
Southern Indiana Rehabilitation Hospital, New Albany, Indiana, USA. 
PURPOSE: The safety of one repetition maximum (1RM) testing for patients with chronic obstructive pulmonary disease (COPD) has not been determined. Therefore, this study was conducted to determine the prevalence of abnormal cardiopulmonary responses, muscle soreness, and muscle injury of patients with moderate to severe COPD in response to 1RM testing. METHODS: Twenty pulmonary rehabilitation patients (11 women and 9 men) with moderate or severe COPD participated in this investigation. The 1RM testing was performed using the parallel squat and incline press. Blood pressure, heart rate dyspnea ratings, and oxygen saturation responses were measured immediately following the 1RM procedure. Ratings of muscle soreness and injury were measured immediately after 1RM testing and on days 2 and 7. RESULTS: No injury, significant muscle soreness, or abnormal cardiopulmonary responses occurred as a result of 1RM testing. No gender differences were found for any variable measured in response to 1RM testing. CONCLUSIONS: A properly supervised and screened pulmonary rehabilitation population can be 1RM tested without significant muscle soreness, injury, or abnormal cardiopulmonary responses. 

7: J Cardiopulm Rehabil 1999 Nov-Dec;19(6):362-5 
Anxiety and depression in severe chronic obstructive pulmonary disease: the effects of pulmonary rehabilitation. 
Withers NJ, Rudkin ST, White RJ 
Department of Medicine, Frenchay Hospital, Bristol, UK. 
BACKGROUND: Previous studies have demonstrated high levels of anxiety and depression among patients with chronic obstructive pulmonary disease (COPD). The effects of an outpatient pulmonary rehabilitation (PR) program on psychological morbidity were examined in patients with severe COPD. METHODS: Levels of anxiety and depression in 95 patients with severe COPD (FEV1 < 40% predicted) were measured on entry to an outpatient PR program using the Hospital Anxiety and Depression (HAD) scale. HAD scores were remeasured at the completion of PR (3 months) and at 6 month follow-up. The effects of PR on mean HAD scores and on the number of patients with significant anxiety or depression were determined. Improvements in exercise capacity after PR were compared in patients with high and low HAD scores. RESULTS: Of patients, 35 (29.2%) had significant anxiety at screening and 18 (15%) significant depression. PR produced statistically significant falls in mean HAD scores for anxiety and depression, both of which remained significantly lowered at 6-month follow-up. PR also reduced the number of patients with significant anxiety or depression. Patients with high anxiety levels showed significantly greater improvements in shuttle walk distance than those with low HAD scores. CONCLUSIONS: Levels of anxiety and depression were high in a significant minority of this group of patients with severe COPD and were significantly improved by PR. Patients with higher HAD scores had lower baseline shuttle walk distances than those with low HAD scores. Anxious patients showed statistically greater improvements in exercise capacity following PR. 

8: Scand J Rehabil Med 1999 Dec;31(4):207-13 
Long-term effects of a pulmonary rehabilitation programme in outpatients with chronic obstructive pulmonary disease: a randomized controlled study. 
Engstrom CP, Persson LO, Larsson S, Sullivan M 
Department of Pulmonary Medicine, Sahlgrenska University Hospital, Goteborg, Sweden. 
Fifty patients with severe chronic obstructive pulmonary disease (FEV1 < 50% pred.) were randomized to a rehabilitation group and a control group. The rehabilitation group took part in an individualized multidisciplinary, outpatient 12-month rehabilitation programme. Exercise training was intensive during the first 6 weeks and was then gradually replaced by an individual home-training programme and booster sessions. Controls received the usual outpatient care. Positive effects were found in terms of maximum symptom-limited exercise tolerance and walking distance (13.5 and 12.1% increase, respectively) in the rehabilitation group compared with the controls. Quality of life measurements showed minor beneficial effects on the Sickness Impact Profile, indicating a higher level of activity. No effect was seen on the St George's Respiratory Questionnaire or the Mood Adjective Check List. Patients expressed their enthusiasm for the rehabilitation programme in a study-specific questionnaire. 
Publication Types: 
Clinical trial 
Randomized controlled trial 

9: Am J Respir Crit Care Med 1999 Dec;160(6):2018-27 
Prospective randomized trial comparing bilateral lung volume reduction surgery to pulmonary rehabilitation in severe chronic obstructive pulmonary disease. 
Criner GJ, Cordova FC, Furukawa S, Kuzma AM, Travaline JM, Leyenson V, O'Brien GM 
Divisions of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA. criner@astro.ocis.temple.edu 
Several uncontrolled studies report improvement in lung function, gas exchange, and exercise capacity after bilateral lung volume reduction surgery (LVRS). We recruited 200 patients with severe chronic obstructive pulmonary disease (COPD) for a prospective randomized trial of pulmonary rehabilitation versus bilateral LVRS with stapling resection of 20 to 40% of each lung. Pulmonary function tests, gas exchange, 6-min walk distance, and symptom-limited maximal exercise testing were done in all patients at baseline and after 8 wk of rehabilitation. Patients were then randomized to either 3 additional months of rehabilitation or LVRS. Thirty-seven patients met study criteria and were enrolled into the trial. Eighteen patients were in the medical arm; 15 of 18 patients completed 3 mo of additional pulmonary rehabilitation. Thirty-two patients underwent LVRS (19 in the surgical arm, 13 crossover from the medical arm). After 8 wk of pulmonary rehabilitation, pulmonary function tests remained unchanged compared with baseline data. However, there was a trend toward a higher 6-min walk distance (285 +/- 96 versus 269 +/- 91 m, p = 0.14) and total exercise time on maximal exercise test was significantly longer compared with baseline values (7.4 +/- 2.1 versus 5.8 +/- 1.7 min, p < 0.001). In 15 patients who completed 3 mo of additional rehabilitation, there was a trend to a higher maximal oxygen consumption (V O(2)max) (13.3 +/- 3.0 versus 12.6 +/- 3.3, p < 0.08). In contrast, at 3 mo post-LVRS, FVC (2.79 +/- 0.59 versus 2.36 +/- 0.55 L, p < 0.001) and FEV(1) (0.85 +/- 0.3 versus 0.65 +/- 0.16 L, p < 0.005) increased whereas TLC (6.53 +/- 1.3 versus 7.65 +/- 2.1 L, p < 0.001) and residual volume (RV) (3.7 +/- 1.2 versus 4.9 +/- 1.1 L, p < 0.001) decreased when compared with 
8 wk postrehabilitation data. In addition, Pa(CO(2)) decreased significantly 3 mo post-LVRS compared with 8 wk postrehabilitation. Six-minute walk distance (6MWD), total exercise time, and V O(2)max were higher after LVRS but did not reach statistical significance. However, when 13 patients who crossed over from the medical to the surgical arm were included in the analysis, the increases in 6MWD (337 +/- 99 versus 282 +/- 100 m, p < 0.001) and V O(2)max (13.8 +/- 4 versus 12.0 +/- 3 ml/kg/min, p < 0.01) 3 mo post-LVRS were highly significant when compared with postrehabilitation data. The Sickness Impact Profile (SIP), a generalized measure of quality of life (QOL), was significantly improved after 8 wk of rehabilitation and was maintained after 3 mo of additional rehabilitation. A further improvement in QOL was observed 3 mo after LVRS compared with the initial improvement gained after 8 wk of rehabilitation. There were 3 (9.4%) postoperative deaths, and one patient died before surgery (2.7%). We conclude that bilateral LVRS, in addition to pulmonary rehabilitation, improves static 
lung function, gas exchange, and QOL compared with pulmonary rehabilitation alone. Further studies need to evaluate the risks, benefits, and durability of LVRS over time. 
Publication Types: 
Clinical trial 
Randomized controlled trial 

10: Am J Respir Crit Care Med 1999 Oct;160(4):1248-53 
Exercise rehabilitation and chronic obstructive pulmonary disease stage. 
Berry MJ, Rejeski WJ, Adair NE, Zaccaro D 
Department of Health, Wake Forest University, Winston-Salem, North Carolina, USA. berry@wfu.edu 
To determine the extent to which patients with Stage I COPD experience improvements in physical performance and quality of life as a result of exercise training, and to compare these improvements with those seen in Stage I and II patients, 151 patients with COPD underwent a 12-wk exercise program. Outcomes were measured at baseline and follow-up. Physical performance was evaluated by means of a 6-min walk, treadmill time, an overhead task, and a stair climb. General health-related quality of life was assessed in terms of the domains of Social Function, Health Perceptions, and Life Satisfaction. Disease-specific health-related quality of life was assessed with the Chronic Respiratory Disease Questionnaire (CRQ). Six-minute walk distance increased significantly in Stage I (200.5 ft [95% CI: 165.4, 235.7]), Stage II (238.3 ft [143.3, 333.3]), and Stage III (112.1 ft [34.6, 189.6]) participants. Treadmill time increased significantly in Stage I (0.42 min [0.20, 0.64]) and Stage II (0.64 min [0.14, 1.4]) participants. Time to complete the overhead task decreased significantly in Stage I (0.91 s [1.72, 0. 11]) and Stage II (1.39 s [2.66, 0.13]) participants. None of the measures of general health-related quality of life improved in any of the three groups. Participants in Stages I, II, and III all experienced improvements in the CRQ domains of dyspnea (0.72 [0.53, 0.91], 0.47 [0.02, 0.91], and 0.46 [0.05, 0.87], respectively) and fatigue (0.49 [0.33, 0.66], 0.54 [0.20, 0.87], and 0.55 [0.05, 1.05], respectively). These results suggest that all patients with COPD will benefit from exercise rehabilitation. Berry MJ, Rejeski WJ, Adair NE, Zaccaro D. Exercise rehabilitation and chronic obstructive pulmonary disease stage. 

11: Chest 1999 Aug;116(2):306-13 
Trends in the epidemiology of COPD in Canada, 1980 to 1995. COPD and Rehabilitation Committee of the Canadian Thoracic Society. 
Lacasse Y, Brooks D, Goldstein RS 
Centre de Pneumologie, Hopital Laval, Ste-Foy, Quebec, Canada. lacassey@videotron.ca 
PURPOSE: To describe trends in the epidemiology of COPD in Canada from 1980 to 1995, in terms of perceived prevalence, mortality, and hospital morbidity. DATA SOURCES: We limited the analysis to data related to chronic bronchitis, emphysema, or chronic airway obstruction not classified elsewhere, and excluded asthma (Ninth International Classification of Diseases, codes 490 to 492 and 496). The perceived prevalence rate of COPD was derived from the 1994-1995 National Health Survey. Mortality and hospital morbidity data (from 1980 to 1995) were obtained from the Health Statistics Division of Statistics Canada. RESULTS: From the National Health Survey, it was estimated that 750,000 Canadians had chronic bronchitis or emphysema diagnosed by a health professional. Prevalence rates were the following: ages 55 to 64 years, 4.6%; ages 65 to 74 years, 5.0%; > or =75 years, 6.8%. From 1980 to 1995, the total number of deaths from COPD increased from 4,438 to 8,583. Although the age-standardized mortality rate remained stable throughout this period in men (around 45/100,000 population), it doubled in women (8.3/100,000 in 1980 to 17.3/100,000 in 1995). There were 55,782 hospital separations in 1993-1994 with COPD as the primary discharge diagnosis (compared to 42,102 in 1981-1982). In people aged > or =65 years, the age-specific hospital separation rate increased over this period, especially in women > or =75 years (from 504/100,000 to 1,033/100,000). The average in-hospital length of stay was 9.6 days in 1981-1982 and 8.3 days in 1993-1994. CONCLUSION: COPD represents a major health issue in Canada and will likely remain so for decades. Physician and non-physician health professionals who provide health care, as well as those who fund it must actively encourage approaches for primary and secondary prevention of this condition as well as approaches shown to be effective in addressing its associated impairment, disability, and handicap. 

12: Am J Phys Med Rehabil 1999 Jul-Aug;78(4):330-5 
Quality of life and exercise tolerance in chronic obstructive pulmonary disease: effects of a short and intensive inpatient rehabilitation program. 
Fuchs-Climent D, Le Gallais D, Varray A, Desplan J, Cadopi M, Prefaut C 
Laboratoire de Physiologie des Interactions, Service Central de Physiologie, Hopital Arnaud de Villeneuve, Montpellier, France. 
The quality of life and the exercise endurance of patients with chronic obstructive pulmonary disease are impaired. The aim of our study was to determine the impact of a 3-wk intensive inpatient rehabilitation program on the quality of life of patients with chronic obstructive pulmonary disease and to examine the correlation between quality-of-life measures and physiologic measures throughout rehabilitation. Thirty-two patients with chronic obstructive pulmonary disease (20 men, 12 women) were evaluated by spirometry and maximal exercise testing for exercise endurance and by the French version of the Nottingham Health Profile for quality of life. Rehabilitation components were individualized exercise at ventilatory threshold (4 hr/day), health education, and physical therapy and relaxation for 3 wk. Our results showed an improvement in the quality of life (especially in physical mobility, energy, and social isolation) and exercise endurance (increase of 14% of maximal power and symptom-limited oxygen uptake). In contrast, no significant correlations were found between the quality of life and physiologic parameters (gas exchange, cardiovascular and lung function parameters) throughout rehabilitation. Changes in the quality of life seem to be independent of the physiologic results during the course of a short and intensive inpatient rehabilitation program. Quality of life should, therefore, be more systematically evaluated to determine the psychosocial benefits, which, although subjective, are important for encouraging patients' compliance with rehabilitation programs. 
Publication Types: 
Clinical trial 

13: Eur Respir J 1999 Apr;13(4):855-9 
Respiratory rehabilitation in chronic obstructive pulmonary disease: predictors of nonadherence. 
Young P, Dewse M, Fergusson W, Kolbe J 
Dept of Physiotherapy, Green Lane Hospital, Auckland, New Zealand. 
Rehabilitation is now an integral part of chronic obstructive pulmonary disease (COPD) management. The objective of the study was to determine predictors of nonadherence to a COPD rehabilitation programme. Patients attending a COPD clinic were invited to participate in a 4 week, hospital-based, outpatient, COPD rehabilitation programme conducted predominantly by respiratory physiotherapists. All potential participants undertook an interviewer administered questionnaire addressing social, economic, psychological and healthcare factors, and underwent baseline physiological measures. Subsequently they were classified as: 1) "adherent" group who completed the total programme (n=55) or 2) "nonadherent" group who refused or began but did not complete the programme (n=36). The nonadherent group compared to the adherent group were more likely to be divorced (22 versus 2%, p<0.005), live alone (39 versus 14%, p<0.02), and to live in rented accommodation (31 versus 6%, p<0.005). There were no differences between the two groups in terms of baseline physiological parameters (forced expiratory volume in one second, forced vital capacity, 6-min walk distance, oxygen saturation, perceived dyspnoea), quality of life domains (Chronic Respiratory Disease Questionnaire), or indices of COPD-related morbidity. The nonadherent group were more likely to be current smokers (28 
versus 8%, p<0.02) and less likely to use inhaled corticosteroids (16 versus 42%, p<0.005). The nonadherent group was not significantly likely to be depressed, anxious, prone to hyperventilation or to have had previous emotional counselling and was more likely to be dissatisfied with disease-specific social support (51 versus 2%, p<0.001). In conclusion, a substantial proportion of eligible subjects who did not participate in a chronic obstructive pulmonary disease rehabilitation programme were not more physiologically impaired, but were more likely to be: socially isolated, lack chronic obstructive pulmonary 
disease-related social support, still be smoking and be less compliant with other healthcare activities. Identification of one or more of these factors reliably allows prediction for nonadherence to a rehabilitation programme. 

14: Medicina (B Aires) 1998;58(6):717-27 
[Exercise training in chronic obstructive pulmonary disease. Comparative study of aerobic training of lower limbs vs. combination with upper limbs]. 
Sivori M, Rhodius E, Kaplan P, Talarico M, Gorojod G, Carreras B, Lopez C, Shimojo C 
Servicio de Neumonologia, Policlinico Bancario, Buenos Aires, Argentina. neumo@hosrm.sld.ar 
A prospective, randomized and controlled study has been performed in 28 patients with severe COPD. A group of 14 has been trained with their lower limbs (LL), while another similar group of 14 patients was also trained with their upper limbs (UL). Results showed improvement in both groups in the endurance test for LL, dyspnea scale, efficiency and muscular working capacity. A considerable improvement was observed in the oxygen uptake at the anerobic threshold (VO2AT) which suggests a training effect, expressed through an improvement in exercise tolerance. Only the group who trained UL showed a remarkable improvement in the dyspnea scale, endurance test and maximal static mouth pressure, showing a better intrinsic working capacity and participation of the UL muscles producing those manoeuvres. At the end of training, quality of life was significantly increased and the hospitalization rate was lower in both groups. According to these findings, it is suggested that patients with severe COPD included in training programmes add UL exercises to the LL usually carried out. 
Publication Types: 
Clinical trial 
Randomized controlled trial 

15: Can Respir J 1999 Jan-Feb;6(1):55-63 
Pulmonary rehabilitation programs in Canada: national survey. 
Brooks D, Lacasse Y, Goldstein RS 
Department of Physical Therapy, University of Toronto, Toronto, Canada. dina.brooks@utoronto.ca 
OBJECTIVE: To characterize pulmonary rehabilitation (PR) programs in terms of their type, size, duration, patient population, content and staffing. DESIGN: Surveys were sent to members of the Rehabilitation Committee of the Canadian Thoracic Society, as well as any program identified by members of the Canadian Physiotherapy Cardio-Respiratory Society, by provincial lung associations or by the respondents. PARTICIPANTS: Of 51 surveys sent, responses were received from 44 facilities (86% response rate). In-patient or out-patient pulmonary rehabilitation programs were offered by 36 facilities. RESULTS: Most programs (97%) admitted out-patients, and 22% had an in-patient capability. Out-patient programs enrolled 13 patients (median 11; range five to 48) at a given time for a duration of 8.3 weeks (range two to 26). In-patient programs enrolled nine patients at a given time (range two to 26) for 4.6 weeks (range one to eight). Programs included patients with chronic obstructive pulmonary disorder (100%), restrictive disease (93%), asthma (82%), adults with cystic fibrosis (46%), patients pre- or postlung transplantation (45%) and patients receiving mechanical ventilatory support (18%). Breathing retraining, education and upper extremity training were incorporated in more than 90% of all programs. Only one-third of programs offered smoking cessation as part of the rehabilitation. Education sessions on medications and inhaler usage were included in most programs, but sexuality was addressed in only half the programs. CONCLUSIONS: This first comprehensive national survey of PR programs in Canada shows that there are similarities in the format, content and staffing of PR programs. Programs are only able to service a small percentage of patients with chronic respiratory conditions. 

16: Am J Respir Crit Care Med 1999 Mar;159(3):896-901 
Aerobic and strength training in patients with chronic obstructive pulmonary disease. 
Bernard S, Whittom F, Leblanc P, Jobin J, Belleau R, Berube C, Carrier G, Maltais F 
Unite de Recherche, Institut de Cardiologie et de Pneumologie de Quebec, Universite Laval, Ste-Foy, Quebec, Canada. 
The purpose of this study was to evaluate whether strength training is a useful addition to aerobic training in patients with chronic obstructive pulmonary disease (COPD). Forty-five patients with moderate to severe COPD were randomized to 12 wk of aerobic training alone (AERO) or combined with strength training (AERO + ST). The AERO regimen consisted of three weekly 30-min exercise sessions on a calibrated ergocycle, and the ST regimen included three series of eight to 10 repetitions of four weight lifting exercises. Measurements of peripheral muscle strength, thigh muscle cross-sectional area (MCSA) by computed tomographic scanning, maximal exercise capacity, 6-min walking distance (6MWD), and quality of life with the chronic respiratory questionnaire were obtained at baseline and after training. Thirty-six patients completed the program and constituted the study group. The strength of the quadriceps femoris increased significantly in both groups (p < 0.05), but the improvement was greater in the AERO + ST group (20 +/- 12% versus 8 +/- 10% [mean +/- SD] in the AERO group, p < 0.005). The thigh MCSA and strength of the pectoralis major muscle increased in the AERO + ST group by 8 +/- 13% and 15 +/- 9%, respectively (p < 0.001), but not in the AERO group (3 +/- 6% and 2 +/- 10%, respectively, p > 0.05). These changes were significantly different in the two study groups (p < 0.01). The increase in strength of the latissimus dorsi muscle after training was modest and of similar magnitude for both groups. The changes in peak exercise work rate, 6MWD, and quality of life were comparable in the two groups. In conclusion, the addition of strength training to aerobic training in patients with COPD is associated with significantly greater increases in muscle strength and mass, but does not provide additional improvement in exercise capacity or quality of life. 
Publication Types: 
Clinical trial 
Randomized controlled trial 

17: Chest 1999 Feb;115(2):383-9 
Health-related quality of life improves following pulmonary rehabilitation and lung volume reduction surgery. 
Moy ML, Ingenito EP, Mentzer SJ, Evans RB, Reilly JJ Jr 
Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA. 
STUDY OBJECTIVES: To evaluate changes in health-related quality of life (HRQL) as assessed by the Medical Outcomes Study Short Form 36-item questionnaire (SF-36) after pulmonary rehabilitation and lung volume reduction surgery (LVRS). DESIGN: Prospective cohort study. PATIENTS: Nineteen patients with severe emphysema who underwent pulmonary rehabilitation in preparation for LVRS. INTERVENTIONS: Pulmonary rehabilitation followed by bilateral sequential LVRS. MEASUREMENTS AND RESULTS: HRQL assessed by the SF-36 was measured at baseline, after pulmonary rehabilitation, and 6 months after LVRS. One-way analysis of variance with repeated measures demonstrated no significant change from baseline in any of the eight domains after pulmonary rehabilitation. Scores for only one domain, vitality, improved significantly after LVRS compared with scores after pulmonary rehabilitation. However, significant improvements over baseline scores were demonstrated after combined preoperative pulmonary rehabilitation and LVRS in the domains of physical functioning, role limitations due to physical problems, social functioning, and vitality. Pulmonary rehabilitation contributed most to the overall improvements in role limitations due to physical problems, whereas LVRS contributed mainly to the overall improvements in physical functioning, social functioning, and vitality. CONCLUSIONS: Patients with severe emphysema experience significant improvements in both physical and social health status as assessed by the SF-36 after combined pulmonary rehabilitation and LVRS. Each intervention makes unique and complementary contributions to the overall improvements in HRQL.