Prevalence, impact and specialised treatment of urinary incontinence in women with chronic lung disease.

OBJECTIVES: To determine in women with clinically stable chronic lung disease (CLD) and healthy women; (1) prevalence of urinary incontinence; (2) risk factors for urinary incontinence; (3) effects of a standard course of specialised physiotherapy treatment (PT) in women with CLD. DESIGN: Prospective prevalence study; PT study in CLD subgroup. SETTING: Tertiary metropolitan public hospital. PARTICIPANTS: Women with cystic fibrosis (CF, n=38), chronic obstructive pulmonary disease (COPD, n=27) and 69 healthy women without CLD. PT study - 10 women with CLD. INTERVENTIONS: Five continence PT sessions over 3 months. MAIN OUTCOME MEASURES: Prevalence and impact of incontinence (questionnaire), number of leakage episodes (7-day accident diary), pelvic floor muscle function (ultrasound imaging) and quality of life (King's Health Questionnaire). RESULTS: The majority of women in all three groups reported episodes of incontinence (CF 71%; COPD 70%; healthy women 55%). Compared to age-matched healthy controls, women with CF reported more episodes of incontinence (P=0.006) and more commonly reported stress incontinence (P=0.001). A logistic regression model revealed that women with CLD were twice as likely to develop incontinence than healthy women (P=0.05). Women with COPD reported significantly more 'bother' with incontinence than age-matched women with incontinence. There was a significant reduction in incontinence episodes following treatment, which was maintained after three months. CONCLUSIONS: The presence of CLD is an independent predictor of incontinence in women. In older women this is associated with more distress than in age-matched peers without CLD. Larger treatment studies are indicated for women with CLD and incontinence.

Prevalence and impact of urinary incontinence in men with chronic obstructive pulmonary disease: a questionnaire survey.

OBJECTIVES: To identify urinary incontinence and its impact on men with stable chronic obstructive pulmonary disease (COPD) and men without lung disease. DESIGN: Prospective questionnaire study. SETTING: Outpatients attending a public metropolitan hospital. PARTICIPANTS: Men with COPD (n=49) and age-matched men without lung disease (n=36). INTERVENTIONS: Validated questionnaires to identify the prevalence and impact of urinary incontinence. MAIN OUTCOME MEASURES: Prevalence of urinary incontinence and relationship with disease-specific factors, and relationship of urinary incontinence with anxiety and depression. RESULTS: The prevalence of urinary incontinence was higher in men with COPD (n=19/49) compared with men without lung disease (n=6/36; P=0.027). In men with COPD, symptoms of urgency were more prevalent in men with urinary incontinence (P=0.005), but this was not evident in men without lung disease (P=0.101). Only men with COPD reported symptoms of urgency associated with dyspnoea, and this did not vary between men with and without urinary incontinence (P=0.138). In men with COPD, forced expiratory volume in 1 second (FEV1) was lower in those with urinary incontinence compared with those without urinary incontinence {mean 38 [standard deviation (SD) 14] % predicted vs 61 (SD 24) % predicted; P=0.002}. The impact of urinary incontinence did not differ between the two groups (P=0.333). CONCLUSIONS: Incontinence is more prevalent in men with COPD than in men without lung disease. The prevalence of urinary incontinence increases with greater disease severity, as reflected by lower FEV1. Screening for urinary incontinence should be considered in men with COPD and compromised lung function.

Pulmonary rehabilitation following lung transplantation.

Pulmonary rehabilitation (PR) following lung transplantation (LT) is regarded as part of best practice management; however, the optimal duration and composition of PR programs for LT patients is unknown. This study aimed to describe changes in functional outcomes of LT patients who participated in our standard outpatient post-LT PR program. A prospective, repeated measures design was used. Functional exercise capacity (6-minute walk distance [6MWD]), lung function (forced expiratory volume in 1 second [FEV(1)], forced vital capacity [FVC]) and quality of life (Short Form 34 [SF-36]) were assessed at 1, 2, and 3 months following LT. All subjects attended a 1-hour outpatient group exercise training class 3 days per week until 12 weeks post-LT and education sessions facilitated by the multidisciplinary team. Patients with postoperative complications (mechanical ventilation, major myopathy) were excluded. Data were analyzed using descriptive statistics and analysis of variance with repeated measures. Thirty-six subjects (50% men), 81% bilateral LT, mean age 46 +/- 14 years were included. Significant improvements were demonstrated in 6MWD (451 +/- 126 m to 543 +/- 107 m, P < .001), FEV(1) (71% +/- 18% to 81% +/- 4%, P < .0001), FVC (69% +/- 14% to 81% +/- 18%, P < .0001), and all SF36 domains (P < .05). Large improvements were seen in the first month of rehabilitation, with smaller but clinically significant improvements continuing in the second month. Further prospective, longitudinal studies are required to determine whether a longer period of pulmonary rehabilitation would result in additional improvements.

Clinical determinants of the 6-Minute Walk Test in bronchiectasis.

BACKGROUND: The 6-Minute Walk Test (6MWT) is a widely used measurement of functional exercise capacity in chronic lung disease. While exercise intolerance has been identified in patients with bronchiectasis, the clinical determinants of the 6MWT in this population have not been examined. The aim of this study was to 1) establish the relationship between the 6-Minute Walk Distance (6MWD), disease severity and Health-Related Quality of Life (HRQOL) and 2) identify predictors of exercise tolerance in adults with bronchiectasis. METHODS: The 6MWT was performed in 27 patients with bronchiectasis (mean [SD] FEV(1) 73.9% predicted [23.4]). Disease severity was assessed using spirometry and HRCT scoring while HRQOL was evaluated using the St George's Respiratory Questionnaire (SGRQ) and the Short-Form 36 (SF-36). The relationships were evaluated using correlation and multiple regression. RESULTS: The 6MWD correlated positively with FVC (r=0.52, p<0.01), generations of bronchopulmonary divisions (r(s)=0.38, p<0.05) and SF-36 physical summary (r=0.71, p<0.001) while a negative correlation was observed between all domains of the SGRQ (all correlations r>0.5, p<0.001). Multiple regression analysis indicated that the SGRQ activity, symptom scores and generations of bronchial divisions involved were identified as independent predictors of the 6MWD, explaining 76% of the variance. CONCLUSIONS: Measures of HRQOL demonstrated a stronger association with the 6MWD compared to physiological measures of disease severity in patients with predominantly mild to moderate bronchiectasis.

Chest physiotherapy, gastro-oesophageal reflux, and arousal in infants with cystic fibrosis.

BACKGROUND: Postural drainage chest physiotherapy in infants with cystic fibrosis (CF) exacerbates gastro-oesophageal reflux (GOR) and may contribute to a more rapid deterioration in lung function. AIMS: To compare standard postural drainage chest physiotherapy (SPT) and a modified physiotherapy regimen (MPT) without head-down tilt, with regard to GOR, arousal state, and cardiorespiratory function. METHODS: Twenty infants with CF underwent 30 hour oesophageal pH monitoring, during which four chest physiotherapy sessions were administered (day 1: MPT-SPT; day 2: SPT-MPT). Arousal state, heart rate, and oxygen saturation were documented for each of the physiotherapy positions (supine, prone, right lateral, and left lateral with (SPT) or without (MPT) 30 degrees head-down tilt). RESULTS: Significantly more reflux episodes occurred during SPT than during MPT, but there were no significant differences in median episode duration or fractional reflux time. During SPT, left lateral positioning was associated with fewer reflux episodes compared to other positions. During supine and prone positioning, more reflux episodes occurred during SPT than during MPT. Infants were significantly more likely to be awake or cry during SPT. There was a significant association between crying and reflux episodes for SPT. Non-nutritive sucking was associated with a significant reduction in reflux episodes during SPT. Oxygen saturation during SPT was significantly lower during crying and other waking, and non-nutritive sucking during SPT was associated with a significant increase in oxygen saturation. CONCLUSIONS: SPT is associated with GOR, distressed behaviour, and lower oxygen saturation.

Benefits of music therapy as an adjunct to chest physiotherapy in infants and toddlers with cystic fibrosis.

Routine chest physiotherapy (CPT) is an important component of prophylactic therapy in children with cystic fibrosis (CF) and requires a significant commitment of time and energy. It is important, therefore, to establish CPT as a positive experience. In this study, we evaluated the effect of recorded music as an adjunct to CPT. Specifically, we compared the use of newly composed music, familiar music, and the family's usual routine on children's and parents' enjoyment of CPT and the parents' perception of time taken to complete CPT. Enjoyment and perception of time were evaluated via questionnaires designed specifically for this study. Participants were caregivers of one or more children with CF who were aged between 4(1/2) months and 24 months at the commencement of the clinical trial and required CPT on a daily basis. Participants were randomly allocated into control and treatment groups. Control group participants experienced two conditions consecutively: no audiotape (NT; control) and familiar music tape (FT; placebo control). Treatment group participants were given the treatment music tape (TT), which was composed and compiled by a music therapist. After baseline assessment, evaluation occurred at two 6-weekly intervals. Children's enjoyment increased significantly after use of the TT (+1. 25 units) compared to NT (-0.5 units; P = 0.03), as did parents' enjoyment (+1.0 vs. 0.0 units, P = 0.02). Children's enjoyment did not change significantly after use of the FT (+0.75 units) compared to NT (n.s.). Likewise, parents' enjoyment did not change significantly after use of the FT (+1.0 units, n.s.). There was no change in perception of time after use of the TT (-4.5 vs. +0.2 min, n.s.) or the FT (+3.3 min, n.s.). These results indicate that children's and parents' enjoyment of CPT significantly increased after the use of specifically composed and recorded music as an adjunct. We therefore recommend that recorded music, such as that provided in this study, be given to parents to use as an adjunct to CPT when their young children are diagnosed with CF, in order to assist the establishment of a positive routine.

Postural drainage in cystic fibrosis: is there a link with gastro-oesophageal reflux?

OBJECTIVES: To determine the clinical effects of a change from postural drainage (PD) to positive expiratory pressure chest physiotherapy (PEP) in children with cystic fibrosis (CF) and symptoms of gastro-oesophageal reflux (GOR). To measure the effects of PD on GOR in children with CF. METHODS: Study 1: Six adolescents with CF and symptoms of GOR during PD were changed to upright PEP physiotherapy. The effects on lung function, reflux symptom scores and annual hospital days were measured. Study 2: Twenty-four children with CF (mean age 11 years) and symptoms suggestive of GOR underwent 24-h pH monitoring, including periods of chest physiotherapy. RESULTS: Study 1: All six patients reported a reduction in reflux symptoms during PEP therapy (P < 0.001). Lung function parameters improved during the first 6 months of PEP (P < 0.001). This improvement was sustained for a further 18 months. Annual hospital days decreased significantly (P < 0.0005). Study 2: Nine of 24 patients (37.5%) had pathological GOR. Reflux episodes were significantly increased during PD (P < 0.0001), as was fractional reflux time (P < 0.01). CONCLUSIONS: Upright PEP physiotherapy may be more appropriate than PD in selected patients with CF and symptomatic GOR. The role of GOR as a cofactor in the progression of pulmonary disease in CF needs further evaluation.

Gastro-oesophageal reflux in infants under 6 months with cystic fibrosis.

AIM: To establish the incidence of pathological gastro-oesophageal reflux (GOR) in newly diagnosed infants with cystic fibrosis and to identify clinical predictors of increased reflux. METHODS: 26 infants with cystic fibrosis less than 6 months of age (14 male, 12 female; mean (SEM) age 2.1 (0.21) months, range 0.8 to 5.6 months) underwent prolonged oesophageal pH monitoring (mean duration 27.1 (0.49) hours; range 21.3 to 30.2 hours). Reflux symptoms, anthropometric variables, pancreatic status, meconium ileus, genotype, and chest x ray findings were correlated with pH monitoring data. RESULTS: Five infants (19.2%) had an abnormal fractional reflux time of greater than 10%, seven (26.9%) of 5-10%, and 14 (53.8%) of below 5%. Infants who presented with frequent vomiting had a significantly higher fractional reflux time than infants who had infrequent or no vomiting. There was no significant association between abnormal chest x rays and pathological GOR. Sex, genotype, nutritional status, meconium ileus, and pancreatic enzyme supplementation were not significantly associated with pathological GOR. CONCLUSIONS: About one in five newly diagnosed infants with cystic fibrosis had pathological GOR. Pathologically increased reflux was present before radiological lung disease was established. Apart from frequent vomiting, no useful clinical predictors of pathological reflux were found.

The role of interstitial starling forces in the pathogenesis of burn edema.

The formation and sustainability of burn edema require substantial change in net microvascular forces. We directly measured interstitial hydrostatic pressure (Pi) and total interstitial absorptive pressure (Pi + IIi), in dermis of anesthetized sheep, before and after a 70% to 85% total body surface area scald and during fluid resuscitation. The most rapid change occurred in Pi in the burn wound, which rapidly decreased from its baseline value of approximately -2 mm Hg to -11 mm Hg in the first 5 minutes, and thereafter increased but remained approximately -4 mm Hg through 4 hours of resuscitation. Pi in nonburned skin slowly increased from its preburn level -2 mm Hg, to become positive +1 mm Hg after 4 hours of resuscitation. The total interstitial absorptive pressure, Pi + IIi, slowly declined similarly from 15 to 16 mm Hg to approximately 10 to 11 mm Hg over 6 hours of resuscitation in both burned and nonburned dermis. Taken together, these data suggest that the rapid formation of burn edema is the result of development of a negative Pi in the burn wound, and its sustainability is the result of a large increase in interstitial compliance. Edema in nonburned skin did not start until after fluid resuscitation was initiated, and then developed as the plasma oncotic pressure declined from 21 to 10 mm Hg.

Postural drainage and gastro-oesophageal reflux in infants with cystic fibrosis.

UNLABELLED: Gastro-oesophageal reflux is increased in cystic fibrosis and it is possible that postural drainage techniques may exacerbate reflux, potentially resulting in aspiration and further impairment of pulmonary function. AIM: To evaluate the effects of physiotherapy with head down tilt (standard physiotherapy, SPT) on gastroesophageal reflux and to compare this with physiotherapy without head down tilt (modified physiotherapy, MPT). METHOD: Twenty (mean age 2.1 months) infants with cystic fibrosis underwent 30 hour oesophageal pH monitoring during which SPT and MPT were carried out for two sessions each on consecutive days. RESULTS: The number of reflux episodes per hour, but not their duration, was significantly increased during SPT compared with MPT (SPT 2.5 (0.4) v MPT 1.6 (0.3), p = 0.007) and to background (1.1 (0.)1, p = 0.0005). Fractional reflux time was also increased during SPT (11.7 (2.6)%) compared with background (6.9 (1.3)%) p = 0.03) but not compared with MPT (10.7 (2.7)%). There was no significant difference between MPT and background for number of reflux episodes, their duration, or fractional reflux time. CONCLUSIONS: SPT, but not MPT, was associated with a significant increase in gastro-oesophageal reflux in infants with cystic fibrosis.