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Profiling of patients with COPD for adequate referral to exercise‑based care

A loss of physical functioning (i.e., a low physical capacity and/or a low physical activity) is a common feature in patients with chronic obstructive pulmonary disease (COPD). To date, the primary care physiotherapy and specialized pulmonary rehabilitation are clearly underused, and limited to patients with a moderate to very severe degree of airflow limitation (GOLD stage 2 or higher). However, improved referral rates are a necessity to lower the burden for patients with COPD and for society. Therefore, a multidisciplinary group of healthcare professionals and scientists proposes a new model for referral of patients with COPD to the right type of exercise-based care, irrespective of the degree of airflow limitation. Indeed, disease instability (recent hospitalization, yes/no), the burden of disease (no/low, mild/moderate or high), physical capacity (low or preserved) and physical activity (low or preserved) need to be used to allocate patients to one of the six distinct patient profiles. Patients with profile 1 or 2 will not be referred for physiotherapy; patients with profiles 3–5 will be referred for primary care physiotherapy; and patients with profile 6 will be referred for screening for specialized pulmonary rehabilitation. The proposed Dutch model has the intention to get the right patient with COPD allocated to the right type of exercise-based care and at the right moment.

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Profiling of patients with COPD for adequate referral to exercise‑based care

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Bronchial mucus transport

Effective clearance of inhaled particles requires mucus production and continuous mucus transport from the lower airways to the oropharynx. Mucus production takes place mainly in the peripheral airways. Mucus transport is achieved by the action of the ciliated cells that cover the inner surface of the airways (mucociliary transport) and by expiratory airflow. The capacity for mucociliary transport is highest in the peripheral airways, whereas the capacity for airflow transport is highest in the central airways. In patients with airways disease, mucociliary transport may be impaired and airflow transport may become the most important mucus transport mechanism.

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Broadening the Berlin definition of ARDS to patients receiving high-flow nasal oxygen

BackgroundHigh-flow nasal oxygen (HFNO) is increasingly used in patients with acute hypoxemic respiratory failure. It is uncertain whether a broadened Berlin definition of acute respiratory distress syndrome (ARDS), in which ARDS can be diagnosed in patients who are not receiving ventilation, results in similar groups of patients receiving HFNO as in patients receiving ventilation.MethodsWe applied a broadened definition of ARDS in a multicenter, observational study in adult critically ill patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19), wherein the requirement for a minimal level of 5 cm H2O PEEP with ventilation is replaced by a minimal level of airflow rate with HFNO, and compared baseline characteristics and outcomes between patients receiving HFNO and patients receiving ventilation. The primary endpoint was ICU mortality. We also compared outcomes in risk for death groups using the PaO2/FiO2 cutoffs as used successfully in the original definition of ARDS. Secondary endpoints were hospital mortality; mortality on days 28 and 90; need for ventilation within 7 days in patients that started with HFNO; the number of days free from HFNO or ventilation; and ICU and hospital length of stay.ResultsOf 728 included patients, 229 patients started with HFNO and 499 patients with ventilation. All patients fulfilled the broadened Berlin definition of ARDS. Patients receiving HFNO had lower disease severity scores and lower PaO2/FiO2 than patients receiving ventilation. ICU mortality was lower in receiving HFNO (22.7 vs 35.6%; p = 0.001). Using PaO2/FiO2 cutoffs for mild, moderate and severe arterial hypoxemia created groups with an ICU mortality of 16.7%, 22.0%, and 23.5% (p = 0.906) versus 19.1%, 37.9% and 41.4% (p = 0.002), in patients receiving HFNO versus patients receiving ventilation, respectively.ConclusionsUsing a broadened definition of ARDS may facilitate an earlier diagnosis of ARDS in patients receiving HFNO; however, ARDS patients receiving HFNO and ARDS patients receiving ventilation have distinct baseline characteristics and mortality rates.Trial registration: The study is registered at ClinicalTrials.gov (identifier NCT04719182).

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Broadening the Berlin definition of ARDS to patients receiving high-flow nasal oxygen

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Alternative ventilation system for operating theaters: parameter study and full-scale assessment of the performance of a local ventilation system

A local operating theater ventilation device to specifically ventilate the wound area has been developed and investigated. The ventilation device is combined with a blanket which lies over the patient during the operation. Two configurations were studied: Configuration 1 where HEPA-filtered air was supplied around and parallel to the wound area and Configuration 2 where HEPA-filtered air was supplied from the top surface of the blanket, perpendicular to the wound area. A similar approach is investigated in parallel for an instrument table. The objective of the study was to verify the effectiveness of the local device. Prototype solutions developed were studied experimentally (laboratory) and numerically (CFD) in a simplified setup, followed by experimental assessment in a full scale mock-up. Isothermal as well as non-isothermal conditions were analyzed. Particle concentrations obtained in proposed solutions were compared to the concentration without local ventilation. The analysis procedure followed current national guidelines for the assessment of operating theater ventilation systems, which focus on small particles (<10 mm). The results show that the local system can provide better air quality conditions near the wound area compared to a theoretical mixing situation (proof-of-principle). It cannot yet replace the standard unidirectional downflow systems as found for ultraclean operating theater conditions. It does, however, show potential for application in temporary and emergency operating theaters

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Alternative ventilation system for operating theaters: parameter study and full-scale assessment of the performance of a local ventilation system

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Multiple score comparison

BACKGROUND: Prediction models and prognostic scores have been increasingly popular in both clinical practice and clinical research settings, for example to aid in risk-based decision making or control for confounding. In many medical fields, a large number of prognostic scores are available, but practitioners may find it difficult to choose between them due to lack of external validation as well as lack of comparisons between them.METHODS: Borrowing methodology from network meta-analysis, we describe an approach to Multiple Score Comparison meta-analysis (MSC) which permits concurrent external validation and comparisons of prognostic scores using individual patient data (IPD) arising from a large-scale international collaboration. We describe the challenges in adapting network meta-analysis to the MSC setting, for instance the need to explicitly include correlations between the scores on a cohort level, and how to deal with many multi-score studies. We propose first using IPD to make cohort-level aggregate discrimination or calibration scores, comparing all to a common comparator. Then, standard network meta-analysis techniques can be applied, taking care to consider correlation structures in cohorts with multiple scores. Transitivity, consistency and heterogeneity are also examined.RESULTS: We provide a clinical application, comparing prognostic scores for 3-year mortality in patients with chronic obstructive pulmonary disease using data from a large-scale collaborative initiative. We focus on the discriminative properties of the prognostic scores. Our results show clear differences in performance, with ADO and eBODE showing higher discrimination with respect to mortality than other considered scores. The assumptions of transitivity and local and global consistency were not violated. Heterogeneity was small.CONCLUSIONS: We applied a network meta-analytic methodology to externally validate and concurrently compare the prognostic properties of clinical scores. Our large-scale external validation indicates that the scores with the best discriminative properties to predict 3 year mortality in patients with COPD are ADO and eBODE.

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Mortality prediction in chronic obstructive pulmonary disease comparing the gold 2015 and gold 2019 staging

In 2019, The Global Initiative for Chronic Obstructive Lung Disease (GOLD) modified the grading system for patients with COPD, creating 16 subgroups (1A–4D). As part of the COPD Cohorts Collaborative International Assessment (3CIA) initiative, we aim to compare the mortality prediction of the 2015 and 2019 COPD GOLD staging systems. We studied 17 139 COPD patients from the 3CIA study, selecting those with complete data. Patients were classified by the 2015 and 2019 GOLD ABCD systems, and we compared the predictive ability for 5-year mortality of both classifications. In total, 17139 patients with COPD were enrolled in 22 cohorts from 11 countries between 2003 and 2017; 8823 of them had complete data and were analysed. Mean±SD age was 63.9±9.8 years and 62.9% were male. GOLD 2019 classified the patients in milder degrees of COPD. For both classifications, group D had higher mortality. 5-year mortality did not differ between groups B and C in GOLD 2015; in GOLD 2019, mortality was greater for group B than C. Patients classified as group A and B had better sensitivity and positive predictive value with the GOLD 2019 classification than GOLD 2015. GOLD 2015 had better sensitivity for group C and D than GOLD 2019. The area under the curve values for 5-year mortality were only 0.67 (95% CI 0.66–0.68) for GOLD 2015 and 0.65 (95% CI 0.63–0.66) for GOLD 2019. The new GOLD 2019 classification does not predict mortality better than the previous GOLD 2015 system.

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Mortality prediction in chronic obstructive pulmonary disease comparing the gold 2015 and gold 2019 staging

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Survey on Deep Inspiration Breath holding in the Netherlands

The results have shown that a lot of different techniques are used in radiotherapy departments in the Netherlands. The majority of the departments (70%) uses the same breath-hold method for all patients, while the main reason that patients are treated during free breathing is that they cannot hold their breath long enough (75%).

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Survey on Deep Inspiration Breath holding in the Netherlands

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Building and building systems energy prediction models to enhance energy flexibility control

The built environment requires energy-flexible buildings to reduce energy peak loads and to maximize the use of (decentralized) renewable energy sources. The challenge is to arrive at smart control strategies that respond to the increasing variations in both the energy demand as well as the variable energy supply. This enables grid integration in existing energy networks with limited capacity and maximises use of decentralized sustainable generation. Buildings can play a key role in the optimization of the grid capacity by applying demand-side management control. To adjust the grid energy demand profile of a building without compromising the user requirements, the building should acquire some energy flexibility capacity. The main ambition of the Brains for Buildings Work Package 2 is to develop smart control strategies that use the operational flexibility of non-residential buildings to minimize energy costs, reduce emissions and avoid spikes in power network load, without compromising comfort levels. To realise this ambition the following key components will be developed within the B4B WP2: (A) Development of open-source HVAC and electric services models, (B) development of energy demand prediction models and (C) development of flexibility management control models. This report describes the developed first two key components, (A) and (B). This report presents different prediction models covering various building components. The models are from three different types: white box models, grey-box models, and black-box models. Each model developed is presented in a different chapter. The chapters start with the goal of the prediction model, followed by the description of the model and the results obtained when applied to a case study. The models developed are two approaches based on white box models (1) White box models based on Modelica libraries for energy prediction of a building and its components and (2) Hybrid predictive digital twin based on white box building models to predict the dynamic energy response of the building and its components. (3) Using CO₂ monitoring data to derive either ventilation flow rate or occupancy. (4) Prediction of the heating demand of a building. (5) Feedforward neural network model to predict the building energy usage and its uncertainty. (6) Prediction of PV solar production. The first model aims to predict the energy use and energy production pattern of different building configurations with open-source software, OpenModelica, and open-source libraries, IBPSA libraries. The white-box model simulation results are used to produce design and control advice for increasing the building energy flexibility. The use of the libraries for making a model has first been tested in a simple residential unit, and now is being tested in a non-residential unit, the Haagse Hogeschool building. The lessons learned show that it is possible to model a building by making use of a combination of libraries, however the development of the model is very time consuming. The test also highlighted the need for defining standard scenarios to test the energy flexibility and the need for a practical visualization if the simulation results are to be used to give advice about potential increase of the energy flexibility. The goal of the hybrid model, which is based on a white based model for the building and systems and a data driven model for user behaviour, is to predict the energy demand and energy supply of a building. The model's application focuses on the use case of the TNO building at Stieltjesweg in Delft during a summer period, with a specific emphasis on cooling demand. Preliminary analysis shows that the monitoring results of the building behaviour is in line with the simulation results. Currently, development is in progress to improve the model predictions by including the solar shading from surrounding buildings, models of automatic shading devices, and model calibration including the energy use of the chiller. The goal of the third model is to derive recent and current ventilation flow rate over time based on monitoring data on CO₂ concentration and occupancy, as well as deriving recent and current occupancy over time, based on monitoring data on CO₂ concentration and ventilation flow rate. The grey-box model used is based on the GEKKO python tool. The model was tested with the data of 6 Windesheim University of Applied Sciences office rooms. The model had low precision deriving the ventilation flow rate, especially at low CO2 concentration rates. The model had a good precision deriving occupancy from CO₂ concentration and ventilation flow rate. Further research is needed to determine if these findings apply in different situations, such as meeting spaces and classrooms. The goal of the fourth chapter is to compare the working of a simplified white box model and black-box model to predict the heating energy use of a building. The aim is to integrate these prediction models in the energy management system of SME buildings. The two models have been tested with data from a residential unit since at the time of the analysis the data of a SME building was not available. The prediction models developed have a low accuracy and in their current form cannot be integrated in an energy management system. In general, black-box model prediction obtained a higher accuracy than the white box model. The goal of the fifth model is to predict the energy use in a building using a black-box model and measure the uncertainty in the prediction. The black-box model is based on a feed-forward neural network. The model has been tested with the data of two buildings: educational and commercial buildings. The strength of the model is in the ensemble prediction and the realization that uncertainty is intrinsically present in the data as an absolute deviation. Using a rolling window technique, the model can predict energy use and uncertainty, incorporating possible building-use changes. The testing in two different cases demonstrates the applicability of the model for different types of buildings. The goal of the sixth and last model developed is to predict the energy production of PV panels in a building with the use of a black-box model. The choice for developing the model of the PV panels is based on the analysis of the main contributors of the peak energy demand and peak energy delivery in the case of the DWA office building. On a fault free test set, the model meets the requirements for a calibrated model according to the FEMP and ASHRAE criteria for the error metrics. According to the IPMVP criteria the model should be improved further. The results of the performance metrics agree in range with values as found in literature. For accurate peak prediction a year of training data is recommended in the given approach without lagged variables. This report presents the results and lessons learned from implementing white-box, grey-box and black-box models to predict energy use and energy production of buildings or of variables directly related to them. Each of the models has its advantages and disadvantages. Further research in this line is needed to develop the potential of this approach.

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Building and building systems energy prediction models to enhance energy flexibility control

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Oxygen Consumption with High-Flow Nasal Oxygen versus Mechanical Ventilation—An International Multicenter Observational Study in COVID–19 Patients (PROXY–COVID)

The COVID–19 pandemic led to local oxygen shortages worldwide. To gain a better understanding of oxygen consumption with different respiratory supportive therapies, we conducted an international multicenter observational study to determine the precise amount of oxygen consumption with high-flow nasal oxygen (HFNO) and with mechanical ventilation. A retrospective observational study was conducted in three intensive care units (ICUs) in the Netherlands and Spain. Patients were classified as HFNO patients or ventilated patients, according to the mode of oxygen supplementation with which a patient started. The primary endpoint was actual oxygen consumption; secondary endpoints were hourly and total oxygen consumption during the first two full calendar days. Of 275 patients, 147 started with HFNO and 128 with mechanical ventilation. Actual oxygen use was 4.9-fold higher in patients who started with HFNO than in patients who started with ventilation (median 14.2 [8.4–18.4] versus 2.9 [1.8–4.1] L/minute; mean difference 5 11.3 [95% CI 11.0–11.6] L/minute; P, 0.01). Hourly and total oxygen consumption were 4.8-fold (P, 0.01) and 4.8-fold (P, 0.01) higher. Actual oxygen consumption, hourly oxygen consumption, and total oxygen consumption are substantially higher in patients that start with HFNO compared with patients that start with mechanical ventilation. This information may help hospitals and ICUs predicting oxygen needs during high-demand periods and could guide decisions regarding the source of distribution of medical oxygen.

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Profiling of patients with COPD for adequate referral to exercise‑based care

Bronchial mucus transport

Broadening the Berlin definition of ARDS to patients receiving high-flow nasal oxygen

Alternative ventilation system for operating theaters: parameter study and full-scale assessment of the performance of a local ventilation system

Multiple score comparison

Mortality prediction in chronic obstructive pulmonary disease comparing the gold 2015 and gold 2019 staging

Survey on Deep Inspiration Breath holding in the Netherlands

Building and building systems energy prediction models to enhance energy flexibility control

Oxygen Consumption with High-Flow Nasal Oxygen versus Mechanical Ventilation—An International Multicenter Observational Study in COVID–19 Patients (PROXY–COVID)

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Profiling of patients with COPD for adequate referral to exercise‑based care

Bronchial mucus transport

Broadening the Berlin definition of ARDS to patients receiving high-flow nasal oxygen

Alternative ventilation system for operating theaters: parameter study and full-scale assessment of the performance of a local ventilation system

Multiple score comparison

Mortality prediction in chronic obstructive pulmonary disease comparing the gold 2015 and gold 2019 staging

Survey on Deep Inspiration Breath holding in the Netherlands

Building and building systems energy prediction models to enhance energy flexibility control

Oxygen Consumption with High-Flow Nasal Oxygen versus Mechanical Ventilation—An International Multicenter Observational Study in COVID–19 Patients (PROXY–COVID)