抑郁外文文献1.pdf

Six minute walk distance and dyspnoea scores to assess the course of COPD exacerbation in elderly patients Thomas Blankenburg Anne Guettel Christian Busch and Wolfgang Schuette Second Medical Clinic Hospital Martha Maria Halle Doelau Halle Germany Abstract Introduction While the severity of stable chronic obstructive pulmonary disease COPD has been defi ned in a valid and relevant prognostic manner parameters that describe the course of COPD exacerbations are not yet established Physical performance and dyspnoea are of prognostic relevance in stable COPD The issue investigatedwastoassessthecourseof COPDexacerbationstofi ndparametersthat describe this situation better Methods In 82 hospitalised patients with acute exacerbation of COPD who respondedtointensifi edmedicaltreatment age67 3 9 5 years forcedexpiratory volume in 1 s 1 0l 40 predicted we measured the 6 min walk distance and the visual analogue scale dyspnoea scores before the start of treatment prior to dis charge and after a 4 week stable period Additionally the conventional clinical parameters of COPD and quality of life were documented Results The 6 min walk distance was signifi cantly increased from 97 114 m to 290 106 m After 4 weeks of outpatient treatment in clinically stable patients the 6 min walk distance fell non signifi cantly to 270 120 m The increment in walk distance fell signifi cantly with advancing severity of COPD from 112 68 m for grade I and II to 56 88 m for grade IV Resting as well as exertional dyspnoea scores were signifi cantly reduced resting dyspnoea from 4 to 2 and exertional dyspnoea from 8 to 6 Conclusion We were able to demonstrate that 6 min walk test and dyspnoea scores butnotpulmonaryfunctiontest aresuitableparameterstoassessthecourse of COPD exacerbations Please cite this paper as Blankenburg T Guettel A Busch C and Schuette W Six minute walk distance and dyspnoea scores to assess the course of COPD exac erbation in elderly patients Clin Respir J 2012 DOI 10 1111 j 1752 699X 2012 00312 x Key words COPD dyspnoea score exacerbation pulmonary function test 6 min walk test Correspondence Thomas Blankenburg MD Hospital Martha Maria Halle Doelau Second Medical Clinic Roentgenstr 1 D 06120 Halle Saale Germany Tel 49 345 559 1440 Fax 49 345 559 1442 email th blankenburg gmx de Received 17 February 2012 Revision requested 04 June 2012 Accepted 17 July 2012 DOI 10 1111 j 1752 699X 2012 00314 x Author and contributionship Thomas Blankenburg designed this investigation and wrote the manuscript Anne Guettel collected and analysed the data Christian Busch recruited patients reviewed the manuscript Wolfgang Schuette designed this investigation reviewed the manuscript Ethics This clinical trial has been reviewed and approved by the local ethical committee and patients gave informed consent prior to the inclusion of the study It complies with the principles laid down in the Declaration of Helsinki recommendations guiding physicians in biomedical research involving human subjects Confl ict of interest The authors have stated explicitly that there are no confl icts of interest in connection with this article Introduction The severity of chronic obstructive pulmonary disease COPD isdefi nedbythedegreeof airwayobstruction measured by forced expiratory volume in 1 s FEV1 FEV1is of prognostic relevance 1 but airway obstruction is not yet a useful outcome or target parameter of therapeutic interventions 2 4 In patients with stable COPD outcome parameters of therapeutic intervention are the exacerbation rate dyspnoea or quality of life 4 7 To estimate the prog nosis of COPD these clinical parameters are valid and The Clinical Respiratory JournalORIGINAL ARTICLE 1The Clinical Respiratory Journal 2012 ISSN 1752 6981 2012 Blackwell Publishing Ltd commonly used 8 too Comparison with the estima tion of prognosis according to Global Initiative for Obstructive Lung Disease GOLD shows that the earlier mentioned clinical parameters exert an addi tional prognostic effect This permits the conclusion that the individual clinical variables are meaningful outcome parameters in therapeutic intervention too In acute exacerbated COPD AECOPD the appli cation of outcome or target parameters is a special problem This is partly because of the diffi culty in defi ning exacerbation and also because of the previ ously mentioned problem of valid outcome param eters in COPD The severity and course of exacerbations have not been measurable routinely Commonly used defi ni tions of exacerbation presume a persistent deteriora tion of the patient s condition extending beyond the day to dayrangeof variations Thedeteriorationstarts acutely and necessitates a modifi cation of the patient s regular medication Other defi nitions add clinical infection criteria and defi ne grades of severity 9 11 Correlating severity grades with metric parameters or with a singular fi nding specifi c for exacerbation was not been attempted thus far A patient s physical performance is known to be reduced during an exacerbation of COPD 12 The 6 min walk distance 6MWD is a standardised test 13 14 that refl ects physical performance during stable COPD as well as exacerbations of COPD 8 The test is simple to perform comprehensible for the patient and can be done at home In large studies it was shown that walk distance is an independent prog nostic factor 15 16 Therefore it may well serve as a suitable target parameter in exacerbations of COPD In addition to physical performance and cough dys pnoea and quality of life are essential criteria of COPD exacerbations Increased dyspnoea and or reduced clinical performance may lead to the diagnosis of an exacerbation Dyspnoea is measured using semiquan titative scores 6 8 17 Quality of life measurements are of established value in therapy studies 5 Exacer bations exert a negative impact on quality of life 18 Disease specifi c as well as disease unspecifi c quality of life instruments had been used to describe COPD 19 Themeasurementof disease unspecifi cqualityof life may well refl ect the characteristic of COPD exac erbations as deteriorations that extend beyond the day to day variability of the disease Based on the earlier paragraphs two questions arise with regard to the present study does the 6MWD as a measure of physical performance improve under effective exacerbation therapy Does dyspnoea meas ured by a visual analogue scale VAS improve under effectiveexacerbationtherapy Apartfromtheseissues severity dependent characteristics of the course of COPD exacerbations are discussed Materials and methods General considerations In 82 elderly patients age 67 3 9 5 years FEV11 0l 40 predicted who underwent inpatient treatment for exacerbated COPD successfully we measured physical performance dyspnoea quality of life and conventional clinical parameters over a period of 4 months The time points of measurement were the following during early exacerbation treatment before discharge and during stable disease COPD was confi rmed according to the European Respiratory Society American Thoracic Society ERS ATS guidelines 20 prior to commencement of the study Patients with other accompanying diseases that might affect physical performance and or dyspnoea data e g congestive heart failure severe pain pulmo naryembolism wereexcluded Non evaluablequality of life data were also treated as an exclusion criterion No patient underwent any rehabilitation programme between discharge after exacerbation and readmission An exacerbation was considered to be present when patients fulfi lled the criteria of the German Airway League and the ERS ATS task force 20 for inpatient treatment because of AECOPD These specifi cally con sistedofexternallydiagnosedprogressionofsymptoms with severe breathlessness cyanosis non effective intensifi cationofoutpatienttherapy increasedproduc tion of sputum and deterioration of the patient s general condition The existing long term medication consisted of inhaled bronchodilatators in all patients Exacerbation treatment was conducted according to the guidelines depending on the indication with nebulised beta agonists parasympatholytics and systemic glucocorti costeroids antibiotics and theophylline All patients received four to six times daily 0 5 mg fenoterol and 0 25 mg ipratropiumbromide via nebuliser Seventy eight patients 95 1 were treated with systemic cor ticosteroids in a dose range between 0 8 and 1 2 mg prednisolone per kg weight per day for 3 to 5 days following by a de escalation scheme until 0 mg pred nisoloneatday7to12 Insixpatients twowithGOLD II three in GOLD III and one in GOLD IV intrave nous methylxanthines were given for 48 h and than stopped Twenty seven patients 32 9 received anti biotics over a time period of 7 to 14 days Patients were discharged when the exacerbation criteria could be Walking distance and dyspnoea in exacerbated COPDBlankenburg et al 2The Clinical Respiratory Journal 2012 ISSN 1752 6981 2012 Blackwell Publishing Ltd reduced to the level prior to exacerbation The pre existing long term medication was continued and unchanged after the exacerbation treatment Datasets were obtained during the fi rst 2 days of the in hospital stay T1 the last 2 days before discharge T2 and the fi rst 2 days of the subsequent in hospital stay T3 Each dataset walk test VAS dyspnoea score pulmonary function tests was collected in 1 day Six minute walk tests and dyspnoea scores were performed between 8 and 10 am after breakfast and taking the morning medication Lung function tests were done the same day the walk test was documented after a resting time period of 2 h minimum Fig 1 patients were asked to fi ll out the quality of life questionnaires in the afternoon They were collected the following morning during ward rounds A minimum period of 4 weeks should have elapsed between discharge and readmission Patients who had renewed exacerbation criteria at the subsequent in hospital stay were excluded from the study Patient characteristics Patient characteristics are shown in Table 1 Given a gender distribution of 2 6 1 the proportion of men was larger than the proportion of woman The patients mean age was 67 years and their weight on average was normal Eighty per cent of the patients presented with more than two exacerbation criteria 6MWD Physical performance was measured by the 6 min walk test basedonthemethodpublishedbyGuyattet al by having the patient walk on a 43 m long corridor in the ward guided by a physiotherapist 21 The fi rst two walk test attempts were not considered The following concessions were applied to patients severely limited in their physical performance bedridden patients 0 m patientsmovinginthewardwhocouldnotstartawalk test 10 m Data were registered during the fi rst 3 days of the in hospital stay during 2 days prior to discharge and the fi rst 2 days of the subsequent hospital stay Additionally allclinicallystablepatientsperformedthe 6 min walk test 4 weeks after discharge under the same conditions they had done before Dyspnoea score Resting and exertional dyspnoea were determined according to a semiquantitative score visual analogue score Zero meant no dyspnoea while 10 meant the worst perceived dyspnoea The patients marked their current perception of dyspnoea in the morning at rest before measurement of the walk distance and after interruption of the walk test Data were registered during the fi rst 3 days of the in hospital stay and during 2 days prior to discharge Quality of life Quality of life was measured using the disease unspecifi c instrument 36 item Short Form Health Survey SF 36 22 From 36 items questions seven subscales and a global quality of life score were gener In hospital stay T3 6MWT x x XXX 74 VAS X X QoL X X PFT X X Time pointT1T2 n6982 n8281 n69 n6976 82 Figure 1 Time line T1 fi rst dataset early in exacerbation T2 second dataset before discharge T3 third dataset after 4 weeks in stable disease 6MWT only n number of successfully performed manoeuvre 6MWT 6 min walk test PFT pulmo nary function test QoL quality of life 36 item Short Form Health Survey VAS dyspnoea visual analogue scores x not considered attempt X valid test Table 1 Patient characteristics Number82 Age in years67 9 5 Gender distribution m f 2 6 1 BMI22 7 3 6 FEV11 01 40 Severity GOLD I FEV1 forced expiratory volume in 1 s GOLD Global Initiative for Obstructive Lung Disease Blankenburg et al Walking distance and dyspnoea in exacerbated COPD 3The Clinical Respiratory Journal 2012 ISSN 1752 6981 2012 Blackwell Publishing Ltd ated and transformed into per centages A high value indicated better quality of life Patients were asked to fi ll the questionnaire on their own Incomplete ques tionnaires or questionnaires fi lled by a person other than the patient were excluded from the evaluation Data were registered during the fi rst 3 days of the in hospital stay and during 2 days prior to discharge Conventional clinical parameters The lung function test was performed by body plethys mography using the Masterlab of VIASYS Company Hoechberg Germany in the late morning The patient performed the test in sitting position after administration of a short acting bronchospasmolytic agent The severity of COPD was given according to GOLD 2003 Pulmonary function tests were registered during the fi rst 2 days of the in hospital stay and during 1 day prior to discharge To determine the body mass index the patient s height was asked and the current bodyweight was measured Age was calculated according to the date of admis sion and the patient s date of birth Statistics Means and simple standard deviations are given for metric equally distributed parameters 6MWD pul monary function tests In these cases the graphic illustration is shown as an error bar and a t test was usedforstatisticalcalculation Mediansandpercentiles are given for categorical variables or unequally distrib uteddata thegraphicillustrationisshowninboxplots quality of life dyspnoea scores In these cases the Mann Whitney U test was used for calculation Statisticalsignifi cancewasassignedatanerrorprob ability below 5 P 0 05 Results Physical performance The 6MWD was signifi cantly increased under exacer bation treatment from 97 114 m to 290 106 m during inpatient treatment and fell non signifi cantly to 270 120 m after 4 weeks of outpatient treatment in clinically stable patients Fig 2 Before exacerbation treatment the 6MWD was identical in the groups with COPD grade I II grade III and grade IV The increment in walk distance was dependent on the severity of the disease in grade I II disease there was a signifi cant increment of 112 68 m in walk distance In grade III the incre mentinwalkdistancewasalittleless 109 75 m but signifi cant compared with the values prior to therapy In grade IV disease the increment in walk distance according to GOLD was not signifi cant at 56 88 m Fig 3 Thirteen patients 15 8 of all evaluated on T1 were not able to perform the walking test because of impaired physical activity Four patients were com pletely bed bound Nine patients were able to walk from bed to table but too weak to perform the 6 min walk Of the 13 patients who were not able to perform the walk test three patients were in GOLD II six patients in GOLD III and four patients in GOLD IV Dyspnoea Under exacerbation treatment there was a signifi cant reduction in resting and exertional dyspnoea from 4 to 2 resting and 8 to 6 exertional The severity of COPD had no impact on resting and exertional dysp noea data over time Table 2 Quality of life Under exacerbation treatment the patient s data con cerning global quality of life improved signifi cantly from 30 to 45 points Physical performance over time time stableexacerbated distance m 350 300 250 200 150 100 Figure 2 Six minute walk distance during exacerbation treat ment and after 4 weeks P 0 05 First bar beginning of in hospital stay second bar before discharge third bar after 4 weeks clinical stability Walking distance and dyspnoea in exacerbated COPDBlankenburg et al 4The Clinical Respiratory Journal 2012 ISSN 1752 6981 2012 Blackwell Publishing Ltd was improved from 17 5 to 30 points Table 3 The quality of life data did not correlate with the severity of COPD Pulmonary function tests Comparisonof lungfunctiondatadeterminedbybody plethysmography yielded no differences The discrep ancy between identical absolute values and different relative values e g FEV1 inspiratory vital capacity was because of different weight data The reductions of airway resistance and intrathoracic gas volume were not signifi cant Table 4 Discussion Our results show that under effective treatment of acute exacerbations of COPD physical performance determined by the 6MWD improves in a signifi cant and clinically relevant manner Furthermore a signifi cant reduction in resting as well as exertional dysp noea measured on a VAS was observed during the investigation period The improvement in physical performance and dyspnoea occurred despite lack of GOLD IVIIII and II distance m 450 400 350 300 250 200 150 100 6MWD admission 6MWD discharge Figure 3 Six minute walk distance 6 MWD under exacerba tion treatment depending on the severity of chronic obstructive pulmonary disease P 0 05 GOLD Global Initiative for Obstructive Lung Disease Table 2 Dyspnoea under exacerbation treatment for chronic obstructive pulmonary disease Before treatmentAt discharge DS totalMedian percentilesMedian percentiles Resting DS4 3 6 2 1 4 Exertional DS8 7 10 6 4 8 Severity dependent Resting DS I and II4 5 4 5 8 3 1 5 III5 3 2 7 8 2 1 4 IV3 2 4 2 1 4 Exertional DS I and II8 5 8 8 6 4 7 III8 6 2 10 6 4 8 IV9 7 10 6 3 2 7 8 P 0 05 DS dyspnoea score I II III IV Global Initiative for Obstructive Lung Disease degree Table 3 Quality of life under exacerbation treatment for chronic obstructive pulmonary disease Before treatmentAt discharge median percentiles median percentiles General perception of health 35 20 41 45 25 60 8 Physical function17 5 5 35 30 15 51 2 Vitality