Predictors of premature discontinuation and prevalence of dropouts from a pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease.

INTRODUCTION: To date, very little is known about the risk factors that contribute to premature discontinuation (dropout) from pulmonary rehabilitation (PR) in patients with chronic obstructive pulmonary disease (COPD). We examined prevalence and predictors of premature discontinuation in patients who participated in an eight week PR program. METHODS: We analyzed a prospectively maintained data-base of patients with COPD who attended a PR program from 2013 to 2019. We included patients 40 years or older with forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio less than 0.7. Subjects were assigned completers or non-completers based on whether they completed the 8-week PR program. Quality of life was measured using the St-George's Respiratory Questionnaire (SGRQ), anxiety using the Anxiety Inventory for Respiratory disease (AIR), dyspnea using the modified Medical Research Council (mMRC) scale, and exercise capacity using the Incremental Shuttle Walk Test (ISWT). RESULTS: Nine hundred nighty three COPD patients (mean age = 70.82 years, FEV1 = 59.21% predicted, 51% male) entered the PR program. Of these, 259 (26%) discontinued PR prematurely and 139 (53%) were male. Compared with completers, non-completers had elevated symptoms of dyspnea and anxiety, had reduced exercise tolerance, were younger, and had poorer quality of life at entry (all p < 0.05). On multivariate analysis, the following variables were independently associated with discontinuation from PR: younger age (p < 0.001), elevated symptoms of anxiety (p < 0.001), elevated symptoms of dyspnea (p < 0.01) and reduced exercise tolerance (p < 0.002). CONCLUSION: Over a quarter of COPD patients discontinued the PR program prematurely. Discontinuation of PR was associated with younger age, elevated symptoms of dyspnea and anxiety, and reduced exercise capacity, but not with severity of airflow obstruction.

The responsiveness of the Manchester Chronic Obstructive Pulmonary Disease Fatigue Scale to pulmonary rehabilitation.

BACKGROUND: We examined the responsiveness of the Manchester Chronic Obstructive Pulmonary Disease (COPD) Fatigue Scale (MCFS) in patients with COPD following 8 weeks of pulmonary rehabilitation (PR). METHODS: Patients (n = 273) with clinically stable COPD completed 8 weeks of outpatient multidisciplinary PR, comprising 2 h (1 h exercise and 1 h education) weekly. Anxiety, exercise capacity, quality of life, dyspnea, fatigue were measured pre- and post-PR, utilizing the Anxiety Inventory for Respiratory Disease (AIR), Incremental Shuttle Walk Test (ISWT), St. George's Respiratory Questionnaire (SGRQ), and modified Medical Research Council (mMRC) scale and MCFS, respectively. RESULTS: The mean (SD) age of participants was 72 (8) years, and 50% were women. Total MCFS score fell after PR mean (95% confidence interval) -4.89 (-7.90 to -3.79) as did domain scores: physical -1.89 (-2.33 to -1.46), cognition -1.37 (-1.65 to -1.09), and psychosocial -1.62 (-2.00 to -1.62). Total MCFS effect size (ES) was 0.55; and for domains, physical was 0.52, cognition was 0.59, and psychosocial was 0.51. The ES for AIR was 0.30, mMRC was 0.38, SGRQ was 0.66, and ISWT was 1.19. MCFS changes correlated with changes in both SGRQ (p < 0.002) and AIR (p < 0.004), but not ISWT (p = 0.30) or mMRC (p = 0.18). The AIR, SGRQ, mMRC, and ISWT all improved after PR (all, p < 0.001). CONCLUSION: The MCFS scale is a valid and responsive scale to measure fatigue in patients with COPD after pulmonary rehabilitation.

Management of asthma COPD overlap.

OBJECTIVE: To review the latest literature on management approaches to patients with asthma chronic obstructive pulmonary disease (COPD) overlap (ACO). DATA SOURCES: Studies and reports were identified from the databases of PubMed/Medline and ClinicalTrials.gov from the US National Institutes of Health and the Cochrane Register of Controlled Trials. STUDY SELECTIONS: Studies on the management of asthma, COPD, and ACO were included in this review. RESULTS: Patients with asthma COPD overlap tend to have greater morbidity than those with asthma or COPD alone, but the information on the best therapeutic approach to this group of patients is still limited. Current treatment recommendations rely on expert opinions, roundtable discussions, and strategy documents, because most clinical studies in asthma and COPD have excluded patients with ACO. Because of the potential risk described in patients with asthma with the use of long-acting 2 agonist monotherapy, initial therapy for patients with ACO is recommended to include a long-acting bronchodilator in conjunction with inhaled corticosteroids. Long-acting muscarinic antagonists are effective in both asthma and COPD and should be considered in ACO as an add-on treatment. If inhaler therapy is not effective, advanced therapies based on phenotyping and identification of treatable traits may be considered. CONCLUSION: Few studies have evaluated prospectively therapies in the ACO population, and future studies need to determine best strategies for the treatment of these patients, focusing on targeting its different phenotypes and its treatable traits.

Asthma COPD overlap: Impact of associated comorbidities.

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic pulmonary conditions worldwide which often coexist. Patients with asthma COPD overlap (ACO) may have worse outcomes than those with either disease alone, for example, more respiratory symptoms and frequent exacerbations, and worse lung function. Additionally, there is a growing interest in factors that affect the disease including comorbid conditions. Indeed, recent studies have demonstrated higher rates of comorbid conditions in the ACO population, but the mechanisms behind these observations remain unclear. The objective of this review is to describe current knowledge and clinical implications of the overlapping features of asthma and COPD, and discuss the prevalence and impact of comorbidities, such as osteoporosis, cardiovascular disease, gastroesophageal reflux disease, and depression, in this subgroup of patients.

A review of the most common patient-reported outcomes in COPD--revisiting current knowledge and estimating future challenges.

Patient-reported outcome (PRO) measures that quantify disease impact have become important measures of outcome in COPD research and treatment. The objective of this literature review was to comprehensively evaluate psychometric properties of available PRO instruments and the ability of each of them to characterize pharmaceutical treatment effects from published clinical trial evidence. Identified in this study were several PRO measures, both those that have been used extensively in COPD clinical trials (St George's Respiratory Questionnaire and Chronic Respiratory Questionnaire) and new instruments whose full value is still to be determined. This suggests a great need for more information about the patient experience of treatment benefit, but this also may pose challenges to researchers, clinicians, and other important stakeholders (eg, regulatory agencies, pharmaceutical companies) who develop new treatment entities and payers (including but not limited to health technology assessment agencies such as the National Institute for Health and Care Excellence and the Canadian Agency for Drugs and Technologies in Health). The purpose of this review is to enable researchers and clinicians to gain a broad overview of PRO measures in COPD by summarizing the value and purpose of these measures and by providing sufficient detail for interested audiences to determine which instrument may be the most suitable for evaluating a particular research purpose.