Evaluation of the effectiveness of a home-based inspiratory muscle training programme in patients with chronic obstructive pulmonary disease using multiple inspiratory muscle tests.

PURPOSE: To evaluate the effectiveness of a home-based inspiratory muscle training (IMT) programme using multiple inspiratory muscle tests. METHOD: Sixty-eight patients (37 M) with moderate to severe chronic obstructive pulmonary disease (COPD) (Mean [SD], FEV1 36.1 [13.6]% pred.; FEV1/FVC 35.7 [11.2]%) were randomised into an experimental or control group and trained with a threshold loading device at intensity >30% maximum inspiratory pressure (PImax) or <15% PImax, respectively, for 7 weeks. Thirty-nine patients (23 M) completed the study. The following measures were assessed pre- and post-IMT: PImax, sniff inspiratory nasal pressure (SNIP), diaphragm contractility (Pdi,tw), incremental shuttle walk test (ISWT), respiratory muscle endurance (RME), chronic respiratory disease questionnaire (CRDQ), the hospital anxiety and depression scale (HADS) and the SF-36. Between-group changes were assessed using one-way analysis of variance (ANOVA). RESULTS: PImax and perception of well-being improved significantly post-IMT [p = 0.04 and <0.05 in four domains, respectively]. This was not reflected in SNIP [p = 0.7], Pdi,tw [p = 0.8], RME [p = 0.9] or ISWT [p = 0.5]. CONCLUSIONS: A seven-week, community-based IMT programme, with realistic use of health-care resources, improves PImax and perception of well-being but a different design may be required for improvement in other measures. Multiple tests provide a more comprehensive evaluation of changes in muscle function post-IMT. IMPLICATIONS FOR REHABILITATION: A seven-week, home-based inspiratory muscle training programme improves maximal inspiratory pressure and perception of well-being in patients with moderate to severe COPD but not sniff nasal inspiratory pressure or diaphragm contractility, respiratory muscle endurance and exercise capacity. Multiple tests are recommended for a more comprehensive assessment of changes in muscle function following inspiratory muscle training programmes. Therapists need to explore different community-based inspiratory muscle training regimes for COPD patients and identify the optimal exercise protocol that is likely to lead to improvements in diaphragm contractility and exercise capacity.

Sniff nasal inspiratory pressure in patients with moderate-to-severe chronic obstructive pulmonary disease: learning effect and short-term between-session repeatability.

BACKGROUND: Sniff nasal inspiratory pressure (SNIP) is a non-invasive measure of inspiratory muscle function often used as an outcome measure in clinical studies. An initial period of familiarisation with the test is recommended to minimise the learning effect. The repeatability of SNIP in patients with chronic obstructive pulmonary disease (COPD) is currently unknown. OBJECTIVES: The aim of this study was to assess the between-session repeatability of SNIP over a 3-week period in moderate-to-severe COPD patients and compare it with that of maximal inspiratory (PI max) and expiratory pressure (PE max). METHODS: Twenty-one patients (13 males) with a mean forced expiratory volume in 1 s (FEV1) of 38% of predicted (SD: 15) and FEV1/forced vital capacity of 34.3% (SD: 10.4) performed SNIP and PI max and PE max manoeuvres on 3 different sessions (S1, S2 and S3) 3-7 days apart. SNIP was performed at functional residual capacity (FRC), and PI max was performed at FRC and at residual volume (RV) to explore volume-dependent differences in the learning effect between sessions and PE max from total lung capacity. RESULTS: The intra-class correlation coefficient (ICC) for SNIP was the highest of the three measures: S1-S3 ICC (95% CI) SNIP: 0.96 (0.88-0.94); PI max at FRC 0.82 (0.63-0.92); PI max at RV: 0.89 (0.78-0.95), and PE max: 0.96 (0.92-0.98), and had the lowest mean change between sessions [mean S2 - S1: 2.1(p = 0.4) and S3 - S2: -0.3 (p = 0.9)]. CONCLUSIONS: SNIP is repeatable over a period of 3 weeks in medically stable, moderate-to-severe COPD patients. In our study, 2 sessions were adequate to learn how to perform the test.

Impact--improving patient access time: arterial cannulation.

OBJECTIVES: The overall aim of the project was for an advanced critical care practitioner (ACCP)to develop the clinical competency of arterial catheterisation. The study examined the impact of the intervention being performed by a different staff group member. DESIGN: The project took the form of service development, employing a service redesign route-map. The general strategy was a pre/post implementation audit providing a baseline,to evaluate the change. SETTING: The setting was an Adult General High Dependency Unit (HDU) in a large Teaching Hospital. OUTCOME MEASURES: To reduce delay in arterial line insertion, whilst maintaining patient safety pre/post procedure, to a standard comparable to medical colleagues and to reduce the number of arterial punctures. RESULTS: Insertion complications reduced by 9% (1), with no increase in infection. Post procedure complications increased by 18% (2); however this occurred during medical team insertions, with no increase in infection during ACCP line insertions.Observing the whole service, both medical and ACCP insertions, mean length of wait, reduced from 4.3 hours to 1.2 hours: compared to less than 45 minutes during ACCP insertions. The total number of arterial punctures for each patient, prior to receiving an arterial line, decreased to less than three stabs. CONCLUSION: All outcomes were achieved within ACCP practice, showing safe arterial line insertion by an ACCP in critically ill patients on HDU. Regular practice of the skill led to an improved technique and a reduction in delays.

Interprofessional working in acute care.

BACKGROUND: This paper describes the development and implementation of an interprofessional (IP) module for pre-qualification medical, nursing and physiotherapy students. The module focuses on clinical care in the acute care setting, and is called Interprofessional Working in Acute Care (IWAC). CONTEXT: The authors are acute-care practitioners and educators familiar with an environment where good interprofessional collaboration and communication are prerequisite for, and linked to, good patient outcomes. We believe that explicit opportunities to learn the skills of collaborative IP working are required. INNOVATION: We developed a blended-learning 15-credit module that was vertically integrated into the existing curricula of the three programmes. It used several different types of learning: self-directed learning; in-practice teaching; clinical observation; simulation-based teaching (SBT); and collaborative peer-group working and student presentations. The contact teaching time had to be limited because of the constraints of three divergent timetables, and was dominated by SBT that featured four acute care scenarios. The scenarios were formulated so that they could not be managed without interprofessional collaboration. Each student was assigned to an IP group (comprising at least one student from each discipline) for the whole module. A common assessment included a collaborative presentation by each IP group where members were expected to discuss and reflect upon the role of a different professional within their group. IMPLICATIONS: This narrative account exhibits our development of teaching praxis in the story of teaching innovation, and highlights some of the challenges and opportunities within IP learning in undergraduate education.

Effect of a home exercise video programme in patients with chronic obstructive pulmonary disease.

OBJECTIVE: This pilot study investigated whether a home exercise video programme could improve exercise tolerance and breathlessness in patients with moderate to severe chronic obstructive pulmonary disease. METHODS: Twenty subjects completed the study after being randomized to intervention or control. The intervention group (n=10), watched a 19-min video on the benefits of exercise for patients with chronic obstructive pulmonary disease and were given a 30-min exercise video, an illustrated exercise diary and an educational booklet about chronic obstructive pulmonary disease, for use at home. They were advised to follow the exercise video programme 4 times a week for 6 weeks. The control group (n=10) received the chronic obstructive pulmonary disease educational booklet only. Exercise tolerance was measured using the Incremental Shuttle Walk Test and breathlessness by the self-reported Chronic Respiratory Questionnaire. RESULTS: The median change in the Incremental Shuttle Walk Test and breathlessness score significantly improved in the intervention group compared with the control (+45 m vs -15 m, p=0.013 and +0.5 vs -0.1 Chronic Respiratory Questionnaire units, p=0.042). The other findings for the self-reported Chronic Respiratory Questionnaire showed significant improvements in the intervention group for emotion (p<0.001) and fatigue (p=0.012), but not mastery (p=0.253). CONCLUSION: This pilot study suggests that participation in a home exercise video programme may benefit people with chronic obstructive pulmonary disease.

Factors in the rejection and survival of captive cotton top tamarins (Saguinus oedipus).

Captive colonies of cotton top tamarins experience a high rate of rejection of infants within the 1st week of life. The rates of rejection and survival to maturity (2 or more years) among 659 live colony-born infants were correlated with rearing, birth group, litter size, season of birth, gender, origin of parents, experience of parents raising siblings, parity and age of parents, and experience of parent pairs. The most important factors associated with low rejection rates were family life and parental experience raising infants. Infants born into family groups or reared in families were rejected at a significantly lower rate. Rejection of infants whose sires were raised with siblings was significantly lower. Paternal experience was more important than maternal experience. Litter size had no effect on rejection of infants born to family groups, whereas, rejection of triplets was significantly higher than twins or singles among those born to parents alone. Rejection was significantly higher among primiparous births than multiparous birth. The combined experience of colony-born parents was not related to rejection if there were no sibling helpers in the cage at the time of birth. Rejection was significantly lower if sibling helpers were present. High survival of infants who were not rejected was correlated with rearing by or being born into family groups and higher parity and older age of the sires.