OPTIMIZING ASSESSMENT AND OUTCOME FOLLOWING AECOPD

PhD candidate: Fatim Tahirah

Supervisors: A/Prof Sue Jenkins Dr. Kylie Hill

Chronic Obstructive Pulmonary Disease (COPD) preventable and treatable disease with some significant extra pulmonary effects (airflow limitation and abnormal inflammatory response to noxious particles or gases) that may contribute to the severity in individual patients. Chronic bronchitis the presence of a chronic productive cough for 3 months during each of 2 consecutive years. Emphysema abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of walls.

Acute Exacerbation: worsening of the patient s condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication Admission rate 2005-2009 60529 hospital stays for COPD and 7832 (12.9%) are AECOPD 822500 hospital stays for COPD and 514000 (62.5%) are AECOPD 8 9 (range 5-15) 14.89.5 mean Strict protocol Cost per exacerbation mean median 4.7 10 US$ 718364 $7500 $7100 (ranging from $410016000) SEK 940 (SEK 224-SEK 13708) = $142.2 ($34-$2074) Mortality rate Died in the hospital 2.3% 1.8% Ozkaya et al. (2011) : Turkey

2008 Length of hospital stay (days) Median

Wier et al. (2011): USA Roberts et al. (2002): UK Connors et al. (1996): USA Ozkaya et al. (2011) : Turkey Wier et al. (2011): USA Troosters et al. (2010): Belgium Ozkaya et al. (2011) : Turkey Wier et al. (2011): USA Rodriguez-Roisin et al. (2000): USA + Europe Andersson et al. (2002): Sweden Ozkaya et al. (2011) : Turkey Wier et al. (2011): USA

Statement of Problem

1. Gosker et al. (2007), 2. Spruit et al. (2003), 3. Pitta et al.(2006), 4. Decramer et al. (1996), 5. Donalson et al. (2004), 6. Hurst et al. (2008), 7. Roberts et al. (2002), 8. Rodriguez-roisin et al. (2000)

 In clinical practice physiotherapy role at exacerbation is limited only to chest and there are very limited studies looking at exercise training and functional outcome during exacerbation. Recently, Troosters et al. (2010) found that strength training are feasible (85% complete the rehabilitation course)and safe to begin as early as day 2 hospitalization. (Limitation: biased between group intervention & inappropriate OM) Thus, this study aim to optimize the recovery and proposed a specific outcome measure during AECOPD.

AIMS
To proposed 2MWT as the main outcome measure during hospitalized Acute Exacerbation of COPD by; i.comparing the cardiorespiratory and symptom responses during 2MWT with 6MWT in patients with stable COPD ii.exploring the measurement properties of 2MWT; concerning on test-retest repeatability and test learning effects. iii.developing a reference value for 2MWD among healthy sample of Malaysian population To proposed a combined treatment of resistance and endurance training as the best practice during a hospital admission for an acute exacerbation of COPD by; i.undertaking a randomised controlled trial (RCT) to compare the effects of a comprehensive exercise training program (resistance + walking training) on quadriceps muscle force, functional exercise capacity, functional activities and daily physical activity.

Proposed study
Partition 1 assessment b a Comparison of the Cardiorespiratory and Symptom Responses of 2MWT and 6MWT in Patients with COPD Two-minute walk distance (2MWD) in healthy Malaysian participants Optimizing Assessment and Outcome Following Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) SCGH, WA

Healthy Malaysian IPR, HS (Malaysia)

intervention

OPTIMIZING ASSESSMENT AND OUTCOME FOLLOWING AECOPD :Part 1a Comparison of the Cardiorespiratory and Symptom Responses of 2MWT and 6MWT in Patients with COPD

Introduction
Studies of self-paced walking tests as a measure for exercise tolerance in people with CLD first reported in 1976 (12 MWT, McGavin et al 1976)
- Primary outcome measure for self-paced walk test is distance

Tests of shorter duration (6MWT, 2MWT) first proposed by Butland et al (1982) - Properties of the 6MWT most extensively studied 2MWT as an alternative to 6MWT during AECOPD : Severe dyspnea and fatigue AECOPD: Shorter test more acceptable to patients Greater uptake of test by clinicians

2MWT: an alternative to 6MWT during AECOPD

1.Cardiorespiratory responses to 6MWT Clear VE plateau after the 3rd minute of 6MWT indicating that a high intensity constant-load exercise was performed in the first 3 min

VE during 6MWT
Troosters et al. (2002)

2MWT: an alternative to 6MWT during AECOPD

2. Pacing in 2MWT

Patients walked further during the 2MW than during any 2M segment of the 6MW Distance decreased during the latter two intervals of the longer test

Guyatt et al. (1984)

2MWT: an alternative to 6MWT during AECOPD

3. Uptake of timed walking tests by clinicians during AECOPD A prospective cross-sectional postal survey across Canada between Jan and June 2007 (n=109)

completed by the PT predominantly involved in managing patients hospitalized with an AECOPD Measures of functional exercise capacity were used always or frequently by 16% for 6MWT

Harth et al. (2009)

Methodology
Comparison of the Cardiorespiratory and Symptom Responses of 2MWT and 6MWT in Patients with COPD Study design Single group observational study : Patients will attend two testing sessions of 2hours duration each Setting Stable COPD attending Pulmonary Rehabilitation Programs conducted in metropolitan Perth that are under the jurisdiction of the Human Research Ethics Committee (HREC) of Sir Charles Gairdner Hospital (SCGH).

Procedures

Measures

Heart rate will be continuously monitored using a Polar Heart Rate monitor (Polar a1, Polar Electro Oy, Kempele, Finland). A finger sensor attached to a pulse oximeter will be used to measure SpO2 (Masimo Rad-5v, Masimo Corporation, California, USA). Both dyspnoea and leg fatigue will be measured using the modified Borg category ratio scale4. Approval will be sought from the Human Research Ethics Committees (HRECs) at Sir Charles Gairdner Hospital and Curtin University. All subjects will be required to give written, informed consent prior to data collection Statistical analyses will be performed using SPSS software (Version 19, SPSS Inc., Chicago, IL, USA). P-values 0.05 will be regarded as statistically significant. The distribution of data will be explored using frequency histograms and Shapiro-Wilks test. Data that are not normally distributed will be either transformed or analysed using non-parametric statistics. Data will be expressed as mean standard deviation (SD) or median and interquartile range. cardiorespiratory and symptoms response will be expressed as mean SD or median and interquartile range. Where possible, the 95% confidence intervals will be report. cardiorespiratory and symptom responses measured both within tests and between tests will be compared using either paired t-tests (for normally distributed data) or Wilcoxon tests (for data that is not normally distributed). measures of 2MWD over the three tests will be compared using a repeated measures analysis of variance. the bias and coefficient of repeatability will be determined using the best 2MWD measured during the first testing session and the 2MWD measured during the second testing session. Specifically, the bias will be defined as the average difference between the 2MWDs measured across the two days and the coefficient of repeatability will be defined as twice the standard deviation of the difference in 2MWDs measured across the two days.

Ethical issues Data analysis

References
1 Butland RJ, Pang J, Gross ER, et al. Two-, six-, and 12-minute walking tests in respiratory disease. Br Med J (Clin Res Ed) 1982; 284:1607-1608 2 Guyatt GH, Pugsley SO, Sullivan MJ, et al. Effect of encouragement on walking test performance. Thorax, 1984; 818822 3 Bernstein ML, Despars JA, Singh NP, et al. Reanalysis of the 12-minute walk in patients with chronic obstructive pulmonary disease. Chest 1994; 105:163-167 4 Eiser N, Willsher D, Dore CJ. Reliability, repeatability and sensitivity to change of externally and self-paced walking tests in COPD patients. Respir Med 2003; 97:407-414 5 Leung AS, Chan KK, Sykes K, et al. Reliability, validity, and responsiveness of a 2-min walk test to assess exercise capacity of COPD patients. Chest 2006; 130:119-125 6 Jenkins S, Cecins NM. Six-minute walk test in pulmonary rehabilitation: do all patients need a practice test? Respirology 2010; 15:1192-1196 7 Troosters T, Vilaro J, Rabinovich R, et al. Physiological responses to the 6-min walk test in patients with chronic obstructive pulmonary disease. Eur Respir J 2002; 20:564-569 8 Casas A, Vilaro J, Rabinovich R, et al. Encouraged 6-min walking test indicates maximum sustainable exercise in COPD patients. Chest 2005; 128:55-61 9 Harth L, Stuart J, Montgomery C, et al. Physical therapy practice patterns in acute exacerbations of chronic obstructive pulmonary disease. Can Respir J 2009; 16:86-92 10 Demers C, McKelvie RS, Negassa A, et al. Reliability, validity, and responsiveness of the six-minute walk test in patients with heart failure. Am Heart J 2001; 142:698-703

Appendices
BORG Scale Patient particulars form

6MWT Test Protocol

2MWT Test Protocol

Ethics approval

Thank you

To be continue