Dynamic and volumetric variables reliably predict fluid responsiveness in a porcine model with pleural effusion

Background: The ability of stroke volume variation (SVV), pulse pressure variation (PPV) and global end-diastolic volume (GEDV) for prediction of fluid responsiveness in presence of pleural effusion is unknown. The aim of the present study was to challenge the ability of SVV, PPV and GEDV to predict fluid responsiveness in a porcine model with pleural effusions. Methods: Pigs were studied at baseline and after fluid loading with 8 ml kg−1 6% hydroxyethyl starch. After withdrawal of 8 ml kg−1 blood and induction of pleural effusion up to 50 ml kg−1 on either side, measurements at baseline and after fluid loading were repeated. Cardiac output, stroke volume, central venous pressure (CVP) and pulmonary occlusion pressure (PAOP) were obtained by pulmonary thermodilution, whereas GEDV was determined by transpulmonary thermodilution. SVV and PPV were monitored continuously by pulse contour analysis. Results: Pleural effusion was associated with significant changes in lung compliance, peak airway pressure and stroke volume in both responders and non-responders. At baseline, SVV, PPV and GEDV reliably predicted fluid responsiveness (area under the curve 0.85 (p<0.001), 0.88 (p<0.001), 0.77 (p = 0.007). After induction of pleural effusion the ability of SVV, PPV and GEDV to predict fluid responsiveness was well preserved and also PAOP was predictive. Threshold values for SVV and PPV increased in presence of pleural effusion. Conclusions: In this porcine model, bilateral pleural effusion did not affect the ability of SVV, PPV and GEDV to predict fluid responsiveness

Intergenerational transmission of self-esteem : parental determinants and consequences for relationships with children

In the present study, the effect of relationships with parents on adult self-esteem was examined as was the effect of self-esteem on individual well-being. In turn, wellbeing was examined for its effect on relationship with one's child. Two conditions, relationship with spouse and child temperament, were investigated as potential moderators of these relationships. The sample was composed of 1,986 males and 1,859 females. Eighty percent were caucasian, 10.2% African-American, 7.9% Hispanic, and 1.3% divided among Asian-American and American Indian. Mean age of the subjects was 42.3 years; mean education level was completion of high school. Income ranged from $0 to$400,000 with a mean of $40,100. Path analyses suggested that for males, a poor relationship with one's mother predicted low self-esteem. Low self-esteem predicted low well-being which, in turn, predicted a low quality relationship with one's child. For females, a poor relationship with one's father predicted low self-esteem which, in turn, predicted low well-being and a poor relationship with one's child

Physiology of breathlessness associated with pleural effusions

Purpose of review: Pleural effusions have a major impact on the cardiorespiratory system. This article reviews the pathophysiological effects of pleural effusions and pleural drainage, their relationship with breathlessness, and highlights key knowledge gaps. Recent findings: The basis for breathlessness in pleural effusions and relief following thoracentesis is not well understood. Many existing studies on the pathophysiology of breathlessness in pleural effusions are limited by small sample sizes, heterogeneous design and a lack of direct measurements of respiratory muscle function. Gas exchange worsens with pleural effusions and improves after thoracentesis. Improvements in ventilatory capacity and lung volumes following pleural drainage are small, and correlate poorly with the volume of fluid drained and the severity of breathlessness. Rather than lung compression, expansion of the chest wall, including displacement of the diaphragm, appears to be the principle mechanism by which the effusion is accommodated. Deflation of the thoracic cage and restoration of diaphragmatic function after thoracentesis may improve diaphragm effectiveness and efficiency, and this may be an important mechanism by which breathlessness improves. Effusions do not usually lead to major hemodynamic changes, but large effusions may cause cardiac tamponade and ventricular diastolic collapse. Patients with effusions can have impaired exercise capacity and poor sleep quality and efficiency. Summary: Pleural effusions are associated with abnormalities in gas exchange, respiratory mechanics, respiratory muscle function and hemodynamics, but the association between these abnormalities and breathlessness remains unclear. Prospective studies should aim to identify the key mechanisms of effusion-related breathlessness and predictors of improvement following pleural drainage

Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. https://bmjopenrespres.bmj.com/content/bmjresp/5/1/e000265.full.pdfAlberta Innovates Health Solutions Partnership for Research and Innovation in the Health System Program (AIHS PRIHS 201400390), Alberta Health ServicesPeer ReviewedIntroduction: Hospital and emergency department discharge for patients with chronic obstructive pulmonary disease (COPD) is often poorly organised. We developed a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbations of COPD. Methods: A purposeful sample of clinicians and patients were invited to participate in a two-round Delphi study (July–November 2015). In round 1, participants rated on a seven-point Likert scale (1=not at all important; 7=extremely important) the importance of 29 unique COPD care actions. Round 2 comprised items selected from round 1 based on consensus (>80%endorsement for Likert values 5–7). A list of 18 care items from round 2 was discussed in a face-to-face nominal group meeting. Results: Seven care items were included in the COPD discharge bundle based on clinician and patient input: (1) ensure adequate inhaler technique is demonstrated; (2) send discharge summary to family physician and arrange follow-up; (3) optimise and reconcile prescription of respiratory medications; (4) provide a written discharge management plan and assess patient’s and caregiver’s comprehension of discharge instructions; (5) refer to pulmonary rehabilitation; (6) screen for frailty and comorbidities; and (7) assess smoking status, provide counselling and refer to smoking cessation programme. Conclusion: We present a seven-item, patient-centred, evidence-based and consensus-based discharge bundle for patients with acute exacerbations of COPD. Alignment with clinical practice guidelines and feasibility of local adaptations of the bundle should be explored to facilitate wide applicability and evaluation of the effectiveness of the COPD discharge bundle

Pulmonary Rehabilitation With Balance Training for Fall Reduction in Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Controlled Trial

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. A growing body of evidence shows that individuals with COPD have important deficits in balance control that may be associated with an increased risk of falls. Pulmonary rehabilitation (PR) is a key therapeutic intervention for individuals with COPD; however, current international guidelines do not include balance training and fall prevention strategies. OBJECTIVE: The primary aim of this trial is to determine the effects of PR with balance training compared to PR with no balance training on the 12-month rate of falls in individuals with COPD. Secondary aims are to determine the effects of the intervention on balance, balance confidence, and functional lower body strength, and to estimate the cost-effectiveness of the program. METHODS: A total of 400 individuals from nine PR centers across Canada, Europe, and Australia will be recruited to participate in a randomized controlled trial. Individuals with COPD who have a self-reported decline in balance, a fall in the last 2 years, or recent near fall will be randomly assigned to an intervention or control group. The intervention group will undergo tailored balance training in addition to PR and will receive a personalized home-based balance program. The control group will receive usual PR and a home program that does not include balance training. All participants will receive monthly phone calls to provide support and collect health care utilization and loss of productivity data. Both groups will receive home visits at 3, 6, and 9 months to ensure proper technique and progression of home exercise programs. The primary outcome will be incidence of falls at 12-month follow-up. Falls will be measured using a standardized definition and recorded using monthly self-report fall diary calendars. Participants will be asked to record falls and time spent performing their home exercise program on the fall diary calendars. Completed calendars will be returned to the research centers in prepaid envelopes each month. Secondary measures collected by a blinded assessor at baseline (pre-PR), post-PR, and 12-month follow-up will include clinical measures of balance, balance confidence, functional lower body strength, and health status. The cost-effectiveness of the intervention group compared with the control group will be evaluated using the incremental cost per number of falls averted and the incremental cost per quality-adjusted life years gained. RESULTS: Recruitment for the study began in January 2017 and is anticipated to be complete by December 2019. Results are expected to be available in 2020. CONCLUSIONS: Findings from this study will improve our understanding of the effectiveness and resource uses of tailored balance training for reducing falls in individuals with COPD. If effective, the intervention represents an opportunity to inform international guidelines and health policy for PR in individuals with COPD who are at risk of falling

Canadian Consensus Recommendations for a Research Agenda in Pulmonary Rehabilitation Post-Acute Exacerbation of COPD: A Meeting Report

Rationale: A recent Cochrane review concluded that Pulmonary Rehabilitation (PR) post-acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is safe, reduces hospital admissions and improves quality of life and exercise capacity of patients post-AECOPD. Despite these benefits, recent reports have highlighted poor referral, uptake, and completion rates of early post-AECOPD PR. These concerns provided the foundation for the “PR Post-AECOPD Meeting”, which was funded by the Canadian Institutes of Health Research and held in Montreal in November 2017. Objectives: To identify key research priorities in the complex area of care of delivering PR post-AECOPD.Methods: Meeting participants were asked to complete a pre-meeting survey in order to foster thinking prior to the beginning of the discussions. The first day of the meeting involved presentations from experts and a review of the pre-meeting survey results. Facilitated small group discussions occurred using the consensus building technique (Strengths, Weaknesses, Opportunities, and Threats (SWOT) method). The second day focused on large group discussions in order to identify the research themes.Results: The top three research themes identified were: 1) a phased approach to PR post-AECOPD, 2) patient-centered interventions and outcomes, and 3) gaining a greater understanding of the emotional and psychological impacts of AECOPD. Other identified themes were: how to improve referral, uptake and access to PR post-AECOPD, how to reach under-served patient groups and cost-effectiveness of potential individualized interventions.Conclusions: In this meeting the stakeholders identified research priorities that should guide clinicians and researchers in their efforts to produce high-quality evidence. <br/

Pulmonary Rehabilitation with balance training for fall reduction in Chronic Obstructive Pulmonary Disease: a randomized controlled trial

Introduction: Patients with Chronic obstructive pulmonary disease (COPD) have an increased fallrisk in part due to impaired balance and other comorbidities. Traditional pulmonary rehabilitation(PR) primarily focuses on exercise, education and psychosocial support. Long-term effects ofadding balance training to traditional PR on falls is not well understood. Methods: To determine theeffect of a tailored balance exercise program on the 12-month rate of falls in adults with COPD, weconducted a prospective, parallel-group, multi-center randomized controlled trial (RCT) in Canada,the United Kingdom, Portugal, and Australia (NCT02995681). Eligible participants were adults withCOPD at a high risk of falls who were randomly assigned (1:1) to the intervention or control group.Both groups received traditional PR (2-3 times per week for 8-12 weeks). The intervention includedthe addition of tailored balance training. Primary outcome was the incidence of falls at 12-monthfollow-up using monthly fall diary calendars. We employed zero-inflated generalized linear mixedmodels (Poisson regression) to examine the effect of the intervention on the rate of falls and usedmultiple imputation to deal with missing values as the sensitivity analysis. Results: This studyincluded 245 participants (125 in the intervention group and 120 in the control group), with the meanage at study entry being 72±9 years (from 37 to 95 years); 104 (42%) were female; 146 (60%) hada fall history in the last two years. Of the 245 participants, 67 (27%) did not return any fall informationduring the follow-up and therefore were excluded. We included 178 participants (91 assigned tointervention group and 87 assigned to control group) in the main analysis with well-balancedbaseline characteristics between the two groups. Falls occurred in 41 (45%) participants in theintervention group and 33 (38%) in the control group (Chi-Square= 0.93, P=0.34). The meannumber of falls was similar between the two groups (intervention: 1.10 ± 2.43 versus control 1.01 ±1.87). We did not find statistically significant effects of adding balance training to PR on the rate offalls in the mixed models (Relative risk 1.30; 95% CI: 0.59-2.87, p=0.52). The results are robustafter multiple imputations for missing data. Conclusion: Adding tailored balance training totraditional PR was not different from PR only in terms of the rate of falls over 12-months of follow-upin adults with COPD with high fall risk. COVID-19 pandemic impacted study recruitment, participantretention and data collection.publishe