Search results

Exercise-based cardiac rehabilitation in patients with coronary heart disease: a practice guideline

Background To improve the quality of exercise-based cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) the CR guideline from the Dutch Royal Society for Physiotherapists (KNGF) has been updated. This guideline can be considered an addition to the 2011 Dutch Multidisciplinary CR guideline, as it includes several novel topics. Methods A systematic literature search was performed to formulate conclusions on the efficacy of exercise-based interventions during all CR phases in patients with CHD. Evidence was graded (1–4) according the Dutch evidence-based guideline development (EBRO) criteria. In case of insufficient scientific evidence, recommendations were based on expert opinion. This guideline comprised a structured approach including assessment, treatment and evaluation. Results Recommendations for exercise-based CR were formulated covering the following topics: preoperative physiotherapy, mobilisation during the clinical phase, aerobic exercise, strength training, and relaxation therapy during the outpatient rehabilitation phase, and adoption and monitoring of a physically active lifestyle after outpatient rehabilitation. Conclusions There is strong evidence for the effectiveness of exercise-based CR during all phases of CR. The implementation of this guideline in clinical practice needs further evaluation as well as the maintenance of an active lifestyle after supervised rehabilitation. LinkedIn: https://www.linkedin.com/in/tinusjongert/

Mechanical insufflation-exsufflation for invasively ventilated critically ill patients

INTRODUCTION: Mechanical Insufflation-Exsufflation (MI-E) is used as an airway clearance intervention in primary care (home ventilation), long-term care (prolonged rehabilitation after intensive care, neuromuscular diseases, and spinal cord injury), and increasingly in acute care in intensive care units (ICU).AIM: We sought to develop in-depth understanding of factors influencing decision-making processes of health care professionals regarding initiation, escalation, de-escalation, and discontinuation of MI-E for invasively ventilated patients including perceived barriers and facilitators to use.METHODS: We conducted focus groups (3 in the Netherlands; 1 with participants from four European countries) with clinicians representing the ICU interprofessional team and with variable experience of MI-E. The semi-structured interview guide was informed by the Theoretical Domains Framework (TDF). Two researchers independently coded data for directed content analysis using codes developed from the TDF.RESULTS: A purposive sample of 35 health care professionals participated. Experience varied from infrequent to several years of frequent MI-E use in different patient populations. We identified four main themes: (1) knowledge; (2) beliefs; (3) clinical decision-making; and (4) future adoption.CONCLUSION: Interprofessional knowledge and expertise of MI-E in invasively ventilated patients is limited due to minimal available evidence and adoption. Participants believed MI-E a potentially useful intervention for airway clearance and inclusion in weaning protocols when more evidence is available.RELEVANCE TO CLINICAL PRACTICE: This focus group study provides an overview of current practice, knowledge and expertise, and barriers and facilitators to using MI-E in mechanically ventilated patients. From these data, it is evident there is a need to develop further clinical expertise and evidence of efficacy to further understand the role of MI-E as an airway clearance technique for ventilated patients.

Airway care interventions and prone positioning in critically ill patients

Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis

BACKGROUND: Chest physiotherapy is widely used in people with cystic fibrosis in order to clear mucus from the airways.OBJECTIVES: To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis.SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 04 February 2013.SELECTION CRITERIA: Randomised or quasi-randomised clinical studies in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in people with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone.DATA COLLECTION AND ANALYSIS: Both authors independently assessed study eligibility, extracted data and assessed study quality. There was heterogeneity in the published outcomes, with variable reporting which meant pooling of the data for meta-analysis was not possible.MAIN RESULTS: The searches identified 144 studies, of which eight cross-over studies (data from 96 participants) met the inclusion criteria. There were differences between studies in the way that interventions were delivered, with several of the intervention groups combining more than one treatment modality. One included study looked at autogenic drainage, six considered conventional chest physiotherapy, three considered oscillating positive expiratory pressure, seven considered positive expiratory pressure and one considered high pressure positive expiratory pressure. Of the eight studies, six were single-treatment studies and in two, the treatment intervention was performed over two consecutive days (once daily in one, twice daily in the other). This enormous heterogeneity in the treatment interventions prevented any meta-analyses from being performed.Four studies, involving 28 participants, reported a higher amount of expectorated secretions during chest physiotherapy as compared to a control. One study, involving 18 participants, reported no significant differences in sputum weight. In five studies radioactive tracer clearance was used as an outcome variable. In three of these (28 participants) it was reported that chest physiotherapy, including coughing, increased radioactive tracer clearance as compared to the control period. One study (12 participants) reported increased radioactive tracer clearance associated with all interventions compared to control, although this was only reported to have reached significance for postural drainage with percussion and vibrations; and the remaining study (eight participants) reported no significant difference in radioactive tracer clearance between chest physiotherapy, without coughing, compared to the control period. Three studies, involving 42 participants reported no significant effect on pulmonary function variables following intervention; but one further study did report significant improvement in pulmonary function following the intervention in some of the treatment groups.AUTHORS' CONCLUSIONS: The results of this review show that airway clearance techniques have short-term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long-term effects.

Sputum Proteome Signatures of Mechanically Ventilated Intensive Care Unit Patients Distinguish Samples with or without Anti-pneumococcal Activity

Respiratory pathogens like Streptococcus pneumoniae can cause severe pneumonia. Nonetheless, mechanically ventilated intensive care patients, who have a high risk of contracting pneumonia, rarely develop pneumococcal pneumonia. Mechanically ventilated patients are at risk of contracting pneumonia. Therefore, these patients often receive prophylactic systemic antimicrobial therapy. Intriguingly however, a previous study showed that antimicrobial activity in bronchoalveolar aspirates (here referred to as “sputa”) from ventilated patients was only partially explained by antibiotic therapy. Here we report that sputa from these patients presented distinct proteome signatures depending on the presence or absence of antimicrobial activity. Moreover, we show that the same distinction applied to antibodies against Streptococcus pneumoniae , which is a major causative agent of pneumonia. Specifically, the investigated sputa that inhibited growth of S. pneumoniae , while containing subinhibitory levels of the antibiotic cefotaxime, presented elevated levels of proteins implicated in innate immune defenses, including complement and apolipoprotein-associated proteins. In contrast, S. pneumoniae -inhibiting sputa with relatively high cefotaxime concentrations or noninhibiting sputa contained higher levels of proteins involved in inflammatory responses, such as neutrophil elastase-associated proteins. In an immunoproteomics analysis, 18 out of 55 S. pneumoniae antigens tested showed significantly increased levels of IgGs in inhibiting sputa. Hence, proteomics and immunoproteomics revealed elevated levels of antimicrobial host proteins or S. pneumoniae antigen-specific IgGs in pneumococcal growth-inhibiting sputa, thus explaining their anti-pneumococcal activity. IMPORTANCE Respiratory pathogens like Streptococcus pneumoniae can cause severe pneumonia. Nonetheless, mechanically ventilated intensive care patients, who have a high risk of contracting pneumonia, rarely develop pneumococcal pneumonia. This suggests the presence of potentially protective antimicrobial agents in their lung environment. Our present study shows for the first time that bronchoalveolar aspirates, “sputa,” of ventilated patients in a Dutch intensive care unit were characterized by three distinct groups of proteome abundance signatures that can explain their anti-pneumococcal activity. Importantly, this anti-pneumococcal sputum activity was related either to elevated levels of antimicrobial host proteins or to antibiotics and S. pneumoniae -specific antibodies. Further, the sputum composition of some patients changed over time. Therefore, we conclude that our study may provide a novel tool to measure changes that are indicative of infection-related conditions in the lungs of mechanically ventilated patients.

Doxycycline for exacerbations of chronic obstructive pulmonary disease in outpatients

No clinical characteristics, particularly not sputum characteristics, can guide antibiotic prescription in patients with mild to severe COPD exacerbations