Publications by authors named "Daniel Langer"

92 Publications

COVID-19 recovery: benefits of multidisciplinary respiratory rehabilitation.

BMJ Open Respir Res 2021 09;8(1)

Department of Respiratory Diseases, KU Leuven University Hospitals Leuven, Leuven, Belgium.

Many patients struggle with ongoing symptoms in different domains (physical, mental, cognitive) after hospitalisation for COVID-19, calling out for a multidisciplinary approach. An outpatient multidisciplinary rehabilitation programme, according to a respiratory rehabilitation strategy, was set up for adult patients who were able to attend group sessions during 12 weeks. Results of 22 adult patients with COVID-19, of which 15 had required intensive care, were analysed and some general impressions and challenges of rehabilitation in COVID-19 were reported. Impressive results on physical recovery were determined after 6 weeks and 3 months, with significant improvement of lung function, muscle force and exercise capacity variables. A positive evolution of mental and cognitive burden was present, although less pronounced than the physical recovery. These mental and cognitive consequences seem, next to musculoskeletal and medical complications, the most challenging aspect of rehabilitating patients with COVID-19. These real-world data show feasibility and efficiency of a multidisciplinary respiratory rehabilitation programme after moderate to severe COVID-19 disease.
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http://dx.doi.org/10.1136/bmjresp-2020-000837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8423511PMC
September 2021

Measurement validity of an electronic training device to assess breathing characteristics during inspiratory muscle training in patients with weaning difficulties.

PLoS One 2021 26;16(8):e0255431. Epub 2021 Aug 26.

Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium.

Inspiratory muscle training (IMT) improves respiratory muscle function and might enhance weaning outcomes in patients with weaning difficulties. An electronic inspiratory loading device provides valid, automatically processed information on breathing characteristics during IMT sessions. Adherence to and quality of IMT, as reflected by work of breathing and power generated by inspiratory muscles, are related to improvements in inspiratory muscle function in patients with chronic obstructive pulmonary disease. The aim of this study was to investigate the validity of an electronic training device to assess and provide real-time feedback on breathing characteristics during inspiratory muscle training (IMT) in patient with weaning difficulties. Patients with weaning difficulties performed daily IMT sessions against a tapered flow-resistive load of approximately 30 to 50% of the patient's maximal inspiratory pressure. Airflow and airway pressure measurements were simultaneously collected with the training device (POWERbreatheKH2, POWERbreathe International Ltd, UK) and a portable spirometer (reference device, Pocket-Spiro USB/BT100, M.E.C, Belgium). Breath by breath analysis of 1002 breaths of 27 training sessions (n = 13) against a mean load of 46±16% of the patient's maximal inspiratory pressure were performed. Good to excellent agreement (Intraclass correlation coefficients: 0.73-0.97) was observed for all breathing characteristics. When individual differences were plotted against mean values of breaths recorded by both devices, small average biases were observed for all breathing characteristics. To conclude, the training device provides valid assessments of breathing characteristics to quantify inspiratory muscle effort (e.g. work of breathing and peak power) during IMT in patients with weaning difficulties. Availability of valid real-time data of breathing responses provided to both the physical therapist and the patient, can be clinically usefull to optimize the training stimulus. By adapting the external load based on the visual feedback of the training device, respiratory muscle work and power generation during IMT can be maximized during the training.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255431PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389486PMC
August 2021

Extradiaphragmatic respiratory muscle perfusion during exercise in patients with COPD: impact on dyspnea.

J Bras Pneumol 2021 Aug 11;47(4):e20210212. Epub 2021 Aug 11.

. Faculty of Health and Life Sciences, Department of Sport, Exercise, and Rehabilitation, Northumbria University Newcastle, Newcastle, United Kingdom.

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http://dx.doi.org/10.36416/1806-3756/e20210212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8352762PMC
August 2021

Influence of an Acute Exacerbation During Pulmonary Rehabilitation in Patients With Chronic Obstructive Pulmonary Disease Awaiting Lung Transplantation.

J Cardiopulm Rehabil Prev 2021 Jul;41(4):267-270

Department of Pulmonary Rehabilitation (Drs Gloeckl, Jarosch, Koczulla, and Kenn and Mss Leitl and Schneeberger), and Division of Pulmonary Diseases, Department of Internal Medicine (Dr Nell), German Center for Lung Research (DZL), Philipps University of Marburg, Marburg, Germany; Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany (Drs Gloeckl, Jarosch, Koczulla, and Kenn and Mss Leitl and Schneeberger); Research Group for Cardiovascular and Respiratory Rehabilitation, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven-University of Leuven, Leuven, Belgium (Dr Langer); Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium (Dr Langer); and Teaching Hospital, Paracelsus Medical University, Salzburg, Austria (Dr Koczulla).

Purpose: Pulmonary rehabilitation (PR) has been shown to be an effective intervention in patients with very severe chronic obstructive pulmonary disease (COPD) awaiting lung transplantation (LTx). The objective of this study was to characterize the prevalence of acute exacerbations (AEs) during PR and their impact on the outcomes of pre-LTx PR.

Methods: In this retrospective analysis, 559 patients with COPD awaiting LTx who were referred to a 4-wk inpatient PR program were evaluated. A total of 114 patients (20%) acquired an AE during PR and continued in an adapted fashion. Pulmonary function testing, 6-min walk test (6MWT), and a health-related quality-of-life questionnaire (SF-36) were administered on admission and on discharge of PR.

Results: Following PR, both groups, patients with and without AE, increased their 6MWT significantly (P < .001) to a clinically relevant amount (58 ± 72 and 52 ± 64 m, respectively). The sum scores of the SF-36 also improved significantly without any between-group differences. No observed changes were different between the two groups. No relevant predictors for PR outcomes could be detected by logistic regression.

Conclusions: Our data show that patients with end-stage COPD listed for LTx can achieve clinically relevant improvements in functional exercise capacity and quality of life even if they develop an AE during PR.
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http://dx.doi.org/10.1097/HCR.0000000000000613DOI Listing
July 2021

Elastic Resistance Exercises: Making Pulmonary Rehabilitation More Accessible?

Authors:
Daniel Langer

Chest 2021 May;159(5):1696-1698

Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, Faculty of Kinesiology and Rehabilitation Sciences, and the Clinical Department of Respiratory Diseases, UZ Leuven, BREATHE department CHROMETA, Leuven, Belgium. Electronic address:

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http://dx.doi.org/10.1016/j.chest.2021.01.046DOI Listing
May 2021

Addressing the changing rehabilitation needs of patients undergoing thoracic surgery.

Authors:
Daniel Langer

Chron Respir Dis 2021 Jan-Dec;18:1479973121994783

Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium.

The rehabilitation needs of individuals undergoing thoracic surgery are changing, especially as surgical management is increasingly being offered to patients who are at risk of developing functional limitations during and after hospital discharge. In the past rehabilitative management of these patients was frequently limited to specific respiratory physiotherapy interventions in the immediate postoperative setting with the aim to prevent postoperative pulmonary complications. In the past two decades, this focus has shifted toward pulmonary rehabilitation interventions that aim to improve functional status of individuals, both in the pre- and (longer-term) postoperative period. While there is increased interest in (p)rehabilitation interventions the majority of thoracic surgery patients are however currently on their own with respect to progression of their exercise and physical activity regimens after they have been discharged from hospital. There are also no formal guidelines supporting the referral of these patients to outpatient rehabilitation programs. The current evidence regarding rehabilitation interventions initiated before, during, and after the hospitalization period will be briefly reviewed with special focus on patients undergoing surgery for lung cancer treatment and patients undergoing lung transplantation. More research will be necessary in the coming years to modify or change clinical rehabilitation practice beyond the acute admission phase in patients undergoing thoracic surgery. Tele rehabilitation or web-based activity counseling programs might also be interesting emerging alternatives in the (long-term) postoperative rehabilitative treatment of these patients.
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http://dx.doi.org/10.1177/1479973121994783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8056619PMC
April 2021

Detailing the mechanisms of chronic dyspnea in patients during cardiopulmonary exercise testing.

J Bras Pneumol 2021 02 24;47(1):e20210014. Epub 2021 Feb 24.

. Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Belgium.

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http://dx.doi.org/10.36416/1806-3756/e20210014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8332666PMC
February 2021

Tackling nasal symptoms in athletes: Moving towards personalized medicine.

Allergy 2021 09 26;76(9):2716-2729. Epub 2021 Mar 26.

Allergy and Clinical Immunology Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium.

Adequate nasal breathing is indispensable for athletes, and nasal symptoms have been shown to interfere with their subjective feeling of comfortable breathing and quality of life. Nasal symptoms are caused by either structural abnormalities or mucosal pathology. Structural pathologies are managed differently from mucosal disease, and therefore, adequate diagnosis is of utmost importance in athletes in order to choose the correct treatment option for the individual. Literature suggests that nasal symptoms are more prevalent in athletes compared to the general population and certain sports environments might even trigger the development of symptoms. Given the high demands of respiratory function in athletes, insight into triggering factors is of high importance for disease prevention. Also, it has been suggested that athletes are more neglectful to their symptoms and hence remain undertreated, meaning that special attention should be paid to education of athletes and their caregivers. This review aims at giving an overview of nasal physiology in exercise as well as the possible types of nasal pathology. Additionally, diagnostic and treatment options are discussed and we focus on unmet needs for the management and prevention of these symptoms in athletes within the concept of precision medicine.
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http://dx.doi.org/10.1111/all.14786DOI Listing
September 2021

Moving towards a better identification and management of frailty in ICU survivors.

Thorax 2021 04 11;76(4):322-323. Epub 2021 Feb 11.

Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, Leuven, Belgium.

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http://dx.doi.org/10.1136/thoraxjnl-2020-216530DOI Listing
April 2021

Unilateral diaphragmatic paralysis: inspiratory muscles, breathlessness and exercise capacity.

ERJ Open Res 2021 Jan 1;7(1). Epub 2021 Feb 1.

Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.

Background: Patients with unilateral diaphragmatic paralysis (UDP) may present with dyspnoea without specific cause and limited ability to exercise. We aimed to investigate the diaphragm contraction mechanisms and nondiaphragmatic inspiratory muscle activation during exercise in patients with UDP, compared with healthy individuals.

Methods: Pulmonary function, as well as volitional and nonvolitional inspiratory muscle strength were evaluated in 35 patients and in 20 healthy subjects. Respiratory pressures and electromyography of scalene and sternocleidomastoid muscles were continuously recorded during incremental maximal cardiopulmonary exercise testing until symptom limitation. Dyspnoea was assessed at rest, every 2 min during exercise and at the end of exercise with a modified Borg scale.

Main Results: Inspiratory muscle strength measurements were significantly lower for patients in comparison to controls (all p<0.05). Patients achieved lower peak of exercise (lower oxygen consumption) compared to controls, with both gastric (-9.8±4.6 cmHO 8.9±6.0 cmHO) and transdiaphragmatic (6.5±5.5 cmHO 26.9±10.9 cmHO) pressures significantly lower, along with larger activation of both scalene (40±22% EMGmax 18±14% EMGmax) and sternocleidomastoid (34±22% EMGmax 14±8% EMGmax). In addition, the paralysis group presented significant differences in breathing pattern during exercise (lower tidal volume and higher respiratory rate) with more dyspnoea symptoms compared to the control group.

Conclusion: The paralysis group presented with exercise limitation accompanied by impairment in transdiaphragmatic pressure generation and larger accessory inspiratory muscles activation compared to controls, thereby contributing to a neuromechanical dissociation and increased dyspnoea perception.
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http://dx.doi.org/10.1183/23120541.00357-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7861029PMC
January 2021

Training Specificity of Inspiratory Muscle Training Methods: A Randomized Trial.

Front Physiol 2020 3;11:576595. Epub 2020 Dec 3.

KU Leuven, Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, Leuven, Belgium.

Introduction: Inspiratory muscle training (IMT) protocols are typically performed using pressure threshold loading with inspirations initiated from residual volume (RV). We aimed to compare effects of three different IMT protocols on maximal inspiratory pressures (PImax) and maximal inspiratory flow (V̇Imax) at three different lung volumes. We hypothesized that threshold loading performed from functional residual capacity (FRC) or tapered flow resistive loading (initiated from RV) would improve inspiratory muscle function over a larger range of lung volumes in comparison with the standard protocol.

Methods: 48 healthy volunteers (42% male, age: 48 ± 9 years, PImax: 110 ± 28%pred, [mean ± SD]) were randomly assigned to perform three daily IMT sessions of pressure threshold loading (either initiated from RV or from FRC) or tapered flow resistive loading (initiated from RV) for 4 weeks. Sessions consisted of 30 breaths against the highest tolerable load. Before and after the training period, PImax was measured at RV, FRC, and midway between FRC and total lung capacity (1/2 IC). V̇Imax was measured at the same lung volumes against a range of external threshold loads.

Results: While PImax increased significantly at RV and at FRC in the group performing the standard training protocol (pressure threshold loading from RV), it increased significantly at all lung volumes in the two other training groups (all < 0.05). No significant changes in V̇Imax were observed in the group performing the standard protocol. Increases of V̇Imax were significantly larger at all lung volumes after tapered flow resistive loading, and at higher lung volumes (i.e., FRC and 1/2 IC) after pressure threshold loading from FRC in comparison with the standard protocol (all < 0.05).

Conclusion: Only training with tapered flow resistive loading and pressure threshold loading from functional residual capacity resulted in consistent improvements in respiratory muscle function at higher lung volumes, whereas improvements after the standard protocol (pressure threshold loading from residual volume) were restricted to gains in PImax at lower lung volumes. Further research is warranted to investigate whether these results can be confirmed in larger samples of both healthy subjects and patients.
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http://dx.doi.org/10.3389/fphys.2020.576595DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744620PMC
December 2020

Current developments and future directions in respiratory physiotherapy.

Eur Respir Rev 2020 Dec 15;29(158). Epub 2020 Dec 15.

Reval Rehabilitation Research, Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium

Respiratory physiotherapists have a key role within the integrated care continuum of patients with respiratory diseases. The current narrative review highlights the profession's diversity, summarises the current evidence and practice, and addresses future research directions in respiratory physiotherapy. Herein, we describe an overview of the areas that respiratory physiotherapists can act in the integrated care of patients with respiratory diseases based on the Harmonised Education in Respiratory Medicine for European Specialists syllabus. In addition, we highlight areas in which further evidence needs to be gathered to confirm the effectiveness of respiratory therapy techniques. Where appropriate, we made recommendations for clinical practice based on current international guidelines.
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http://dx.doi.org/10.1183/16000617.0264-2020DOI Listing
December 2020

Early neuromuscular electrical stimulation reduces the loss of muscle mass in critically ill patients - A within subject randomized controlled trial.

J Crit Care 2021 04 28;62:65-71. Epub 2020 Nov 28.

Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium; Department of Intensive Care, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. Electronic address:

Purpose: To investigate the effect of Neuromuscular Electrical Stimulation (NMES) on muscle thickness, strength and morphological and molecular markers of the quadriceps.

Materials And Methods: Adult critically ill patients with an expected prolonged stay received unilateral quadriceps NMES sessions for 7 consecutive days. Before and after the intervention period, quadriceps thickness was measured with ultrasound. After the intervention period, strength was assessed in cooperative patients and muscle biopsies were taken. Multivariable regression was performed to identify factors affecting muscle thickness loss.

Results: Muscle thickness decreased less in the stimulated leg (-6 ± 16% versus -12 ± 15%, p = 0.014, n = 47). Strength was comparable. Opioid administration, minimal muscle contraction and more muscle thickness loss in the non-stimulated muscle were independently associated with better muscle thickness preservation. Stimulated muscles showed a shift towards larger myofibers and higher MyHC-I gene expression. NMES did not affect gene expression of other myofibrillary proteins, MuRF-1 or atrogin-1. Signs of myofiber necrosis and inflammation were comparable for both muscles.

Conclusions: NMES attenuated the loss of muscle mass, but not of strength, in critically ill patients. Preservation of muscle mass was more likely in patients receiving opioids, patients with a minimal muscle contraction during NMES and patients more prone to lose muscle mass.

Trial Registration: clinicaltrials.govNCT02133300.
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http://dx.doi.org/10.1016/j.jcrc.2020.11.018DOI Listing
April 2021

Toward a Global Frame of Reference for Cardiopulmonary Exercise Testing Parameters in Adults.

Chest 2020 12;158(6):2258-2259

Faculty of Kinesiology and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, Leuven, Belgium; Clinical Department of Respiratory Diseases, UZ Leuven, BREATHE Department CHROMETA, Leuven, Belgium.

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http://dx.doi.org/10.1016/j.chest.2020.07.070DOI Listing
December 2020

High-intensity exercise impairs extradiaphragmatic respiratory muscle perfusion in patients with COPD.

J Appl Physiol (1985) 2021 02 29;130(2):325-341. Epub 2020 Oct 29.

Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium.

The study investigated whether high-intensity exercise impairs inspiratory and expiratory muscle perfusion in patients with chronic obstructive pulmonary disease (COPD). We compared respiratory local muscle perfusion between constant-load cycling[sustained at 80% peak work rate (WRpeak)] and voluntary normocapnic hyperpnea reproducing similar work of breathing (WoB) in 18 patients [forced expiratory volume in the first second (FEV): 58 ± 24% predicted]. Local muscle blood flow index (BFI), using indocyanine green dye, and fractional oxygen saturation (%StiO) were simultaneously assessed by near-infrared spectroscopy (NIRS) over the intercostal, scalene, rectus abdominis, and vastus lateralis muscles. Cardiac output (impedance cardiography), WoB (esophageal/gastric balloon catheter), and diaphragmatic and extradiaphragmatic respiratory muscle electromyographic activity (EMG) were also assessed throughout cycling and hyperpnea. Minute ventilation, breathing pattern, WoB, and respiratory muscle EMG were comparable between cycling and hyperpnea. During cycling, cardiac output and vastus lateralis BFI were significantly greater compared with hyperpnea [by +4.2 (2.6-5.9) L/min and +4.9 (2.2-7.8) nmol/s, respectively] ( < 0.01). Muscle BFI and %StiO were, respectively, lower during cycling compared with hyperpnea in scalene [by -3.8 (-6.4 to -1.2) nmol/s and -6.6 (-8.2 to -5.1)%], intercostal [by -1.4 (-2.4 to -0.4) nmol/s and -6.0 (-8.6 to -3.3)%], and abdominal muscles [by -1.9 (-2.9 to -0.8) nmol/s and -6.3 (-9.1 to -3.4)%] ( < 0.001). The difference in respiratory (scalene and intercostal) muscle BFI between cycling and hyperpnea was associated with greater dyspnea (Borg CR10) scores ( = -0.54 and = -0.49, respectively, < 0.05). These results suggest that in patients with COPD, ) locomotor muscle work during high-intensity exercise impairs extradiaphragmatic respiratory muscle perfusion and ) insufficient adjustment in extradiaphragmatic respiratory muscle perfusion during high-intensity exercise may partly explain the increased sensations of dyspnea. We simultaneously assessed the blood flow index (BFI) in three respiratory muscles during hyperpnea and high-intensity constant-load cycling sustained at comparable levels of work of breathing and respiratory neural drive in patients with COPD. We demonstrated that high-intensity exercise impairs respiratory muscle perfusion, as intercostal, scalene, and abdominal BFI increased during hyperpnea but not during cycling. Insufficient adjustment in respiratory muscle perfusion during exercise was associated with greater dyspnea sensations in patients with COPD.
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http://dx.doi.org/10.1152/japplphysiol.00659.2020DOI Listing
February 2021

Clinical Utility of Measuring Inspiratory Neural Drive During Cardiopulmonary Exercise Testing (CPET).

Front Med (Lausanne) 2020 18;7:483. Epub 2020 Sep 18.

Research Group for Rehabilitation in Internal Disorders, Respiratory Rehabilitation and Respiratory Division, Department of Rehabilitation Sciences, University Hospital Leuven, KU Leuven, Leuven, Belgium.

Cardiopulmonary exercise testing (CPET) has traditionally included ventilatory and metabolic measurements alongside electrocardiographic characterization; however, research increasingly acknowledges the utility of also measuring inspiratory neural drive (IND) through its surrogate measure of diaphragmatic electromyography (EMGdi). While true IND also encompasses the activation of non-diaphragmatic respiratory muscles, the current review focuses on diaphragmatic measurements, providing information about additional inspiratory muscle groups for context where appropriate. Evaluation of IND provides mechanistic insight into the origins of dyspnea and exercise limitation across pathologies; yields valuable information reflecting the integration of diverse mechanical, chemical, locomotor, and metabolic afferent signals; and can help assess the efficacy of therapeutic interventions. Further, IND measurement during the physiologic stress of exercise is uniquely poised to reveal the underpinnings of physiologic limitations masked during resting and unloaded breathing, with important information provided not only at peak exercise, but throughout exercise protocols. As our understanding of IND presentation across varying conditions continues to grow and methods for its measurement become more accessible, the translation of these principles into clinical settings is a logical next step in facilitating appropriate and nuanced management tailored to each individual's unique physiology. This review provides an overview of the current state of understanding of IND measurement during CPET: its origins, known patterns of behavior and links with dyspnea in health and major respiratory diseases, and the possibility of expanding this approach to applications beyond exercise.
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http://dx.doi.org/10.3389/fmed.2020.00483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530180PMC
September 2020

Early mobilization in clinical practice: the reliability and feasibility of the 'Start To Move' Protocol.

Physiother Theory Pract 2020 Aug 31:1-11. Epub 2020 Aug 31.

Department of Rehabilitation Sciences KU Leuven, Belgium.

Purpose: The properties of a local Intensive Care Unit early mobilization protocol ('Start To Move As Soon As Possible') in critically ill patients, consisting of an objective diagnostic assessment linked to six treatment levels were evaluated. This study aimed to investigate whether the protocol can be reliably applied by different health-care providers (reliability), to examine the associations between prescribed and delivered treatments (feasibility) and to explore safety and patient satisfaction with the protocol.

Methods: Cross-sectional observational study evaluating the reliability of the protocol between physiotherapist was evaluated with Cohen's kappa, percentage of agreement, and intraclass correlation coefficients in 61 patients. Feasibility was analyzed as agreement between prescribed and delivered treatments with Spearman's rank correlation coefficients in 60 patients. A satisfaction survey was used to evaluate patient satisfaction with the protocol.

Results: Excellent agreement was observed between physiotherapists for diagnostic level assignment (Kappa = 0.92), while the majority of the treatment proposals per level showed moderate to substantial agreement between the physiotherapists (Kappa range: 0.40-0.89). Three hundred and thirteen treatments were prescribed. Perfect agreement was observed between prescribed and delivered treatments in level 0 (Spearman's rho 1.00) and excellent associations for levels 1-5 (0.941, 0.995, 0.951, 0.998, and 0.999), respectively. Unwanted safety events rate was 3%. Most patients (92%) were very satisfied with physiotherapy.

Conclusion: Excellent inter-rater agreement for diagnostic level assignment and moderate to substantial agreement for proposed treatments support the reliability of the protocol. Perfect to excellent associations between prescribed and delivered treatments supports its feasibility. Complications were rare, and most patients were very positive regarding the care provided by physiotherapists during their stay in the ICU.
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http://dx.doi.org/10.1080/09593985.2020.1805833DOI Listing
August 2020

Profiling of Patients with COPD for Adequate Referral to Exercise-Based Care: The Dutch Model.

Sports Med 2020 Aug;50(8):1421-1429

Department of Research and Development, CIRO+, Horn, The Netherlands.

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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http://dx.doi.org/10.1007/s40279-020-01286-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375985PMC
August 2020

Brain Activations to Dyspnea in Patients With COPD.

Front Physiol 2020 24;11. Epub 2020 Jan 24.

Health Psychology, KU Leuven, Leuven, Belgium.

We compared the perception and neural processing of respiratory sensations between 20 COPD patients and 20 healthy controls by means of respiratory-related evoked potentials (RREP) in the electroencephalogram (EEG). RREPs were induced by short inspiratory occlusions while 129-channel EEG was measured. COPD patients rated the occlusions as more intense and unpleasant ('s < 0.001) and showed higher mean amplitudes for the RREP components P1 ( = 0.0004), N1 ( = 0.024), P2 ( = 0.019), and P3 ( = 0.018). Our results indicate that COPD patients demonstrate greater perception and neural processing of respiratory sensations, which presumably reflects the highly aversive and attention-demanding character of these sensations for COPD patients.
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http://dx.doi.org/10.3389/fphys.2020.00007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992658PMC
January 2020

Differences in Respiratory Muscle Responses to Hyperpnea or Loaded Breathing in COPD.

Med Sci Sports Exerc 2020 05;52(5):1126-1134

Laboratory of Research in Respiratory Physiotherapy (LFIP), Department of Physiotherapy, Universidade Estadual de Londrina (UEL), Londrina, BRAZIL.

Introduction: We aimed to compare acute mechanical and metabolic responses of the diaphragm and rib cage inspiratory muscles during two different types of respiratory loading in patients with chronic obstructive pulmonary disease.

Methods: In 16 patients (age, 65 ± 13 yr; 56% male; forced expiratory volume in the first second, 60 ± 6%pred; maximum inspiratory pressure, 82 ± 5%pred), assessments of respiratory muscle EMG, esophageal pressure (Pes) and gastric pressures, breathing pattern, and noninvasive assessments of systemic (V˙O2, cardiac output, oxygen delivery and extraction) and respiratory muscle hemodynamic and oxygenation responses (blood flow index, oxygen delivery index, deoxyhemoglobin concentration, and tissues oxygen saturation [StiO2]), were performed during hyperpnea and loaded breathing.

Results: During hyperpnea, breathing frequency, minute ventilation, esophageal and diaphragm pressure-time product per minute, cardiac output, and V˙O2 were higher than during loaded breathing (P < 0.05). Average inspiratory Pes and transdiaphragmatic pressure per breath, scalene (SCA), sternocleidomastoid, and intercostal muscle activation were higher during loading breathing compared with hyperpnea (P < 0.05). Higher transdiaphragmatic pressure during loaded breathing compared with hyperpnea was mostly due to higher inspiratory Pes (P < 0.05). Diaphragm activation, inspiratory and expiratory gastric pressures, and rectus abdominis muscle activation did not differ between the two conditions (P > 0.05). SCA-blood flow index and oxygen delivery index were lower, and SCA-deoxyhemoglobin concentration was higher during loaded breathing compared with hyperpnea. Furthermore, SCA and intercostal muscle StiO2 were lower during loaded breathing compared with hyperpnea (P < 0.05).

Conclusion: Greater inspiratory muscle effort during loaded breathing evoked larger rib cage and neck muscle activation compared with hyperpnea. In addition, lower SCA and intercostal muscle StiO2 during loaded breathing compared with hyperpnea indicates a mismatch between inspiratory muscle oxygen delivery and utilization induced by the former condition.
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http://dx.doi.org/10.1249/MSS.0000000000002222DOI Listing
May 2020

ERS statement on standardisation of cardiopulmonary exercise testing in chronic lung diseases.

Eur Respir Rev 2019 Dec 18;28(154). Epub 2019 Dec 18.

Paediatric Dept, University Hospital Würzburg, Würzburg, Germany

The objective of this document was to standardise published cardiopulmonary exercise testing (CPET) protocols for improved interpretation in clinical settings and multicentre research projects. This document: 1) summarises the protocols and procedures used in published studies focusing on incremental CPET in chronic lung conditions; 2) presents standard incremental protocols for CPET on a stationary cycle ergometer and a treadmill; and 3) provides patients' perspectives on CPET obtained through an online survey supported by the European Lung Foundation. We systematically reviewed published studies obtained from EMBASE, Medline, Scopus, Web of Science and the Cochrane Library from inception to January 2017. Of 7914 identified studies, 595 studies with 26 523 subjects were included. The literature supports a test protocol with a resting phase lasting at least 3 min, a 3-min unloaded phase, and an 8- to 12-min incremental phase with work rate increased linearly at least every minute, followed by a recovery phase of at least 2-3 min. Patients responding to the survey (n=295) perceived CPET as highly beneficial for their diagnostic assessment and informed the Task Force consensus. Future research should focus on the individualised estimation of optimal work rate increments across different lung diseases, and the collection of robust normative data.
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http://dx.doi.org/10.1183/16000617.0101-2018DOI Listing
December 2019

Novel serum markers HSP60, CHI3L1, and IGFBP-2 in metastatic colorectal cancer.

Oncol Lett 2019 Dec 26;18(6):6284-6292. Epub 2019 Sep 26.

Department of Oncology, First Faculty of Medicine, Charles University, and General University Hospital in Prague, 128 08 Prague 2, Czech Republic.

Colorectal cancer (CRC) is the second leading tumor diagnosis in women and men in the Czech Republic. Patient outcome depends on tumor stage at the time of diagnosis and, in metastatic disease, on the localization and extent of distant metastases. The early detection of metastatic liver disease is an important indication for liver surgery. Therefore, novel biomarkers are urgently required. Serum samples were collected from 97 patients with histologically confirmed metastatic CRC at the time of diagnosis or at the time of progression during palliative treatment, and 79 samples from healthy controls. All patients exhibited adequate liver and renal function and signed informed consent was obtained from all patients included in the current study. The serum levels of Heat shock protein 60 (HSP60), Chitinase-3-like protein 1 (CHI3L1) and Insulin-like growth factor binding protein 2 (IGFBP-2) were measured using immunochemistry. The serum levels of HSP60, CHI3L1 and IGFBP-2 were significantly higher in patients with CRC compared with healthy controls. When compared with carcinoembryonic antigen (CEA), HSP60 exhibited the same sensitivity and specificity, while CHI3L1 and IGFBP-2 exhibited decreased sensitivity. Additionally, the serum levels of HSP60 and IGFBP-2 were indicated to be correlated with the presence of liver metastases, which is in contrast to CEA and Cancer antigen 19-9 (CA19-9). Patients with higher HSP60 and IGFBP-2 levels exhibited a significantly worse survival (P<0.001 and 0.007, respectively). The results of the current study indicate HSP60 to be an effective biomarker in patients with metastatic CRC, with it exhibiting an equal sensitivity to CEA. Additionally, HSP60 and IGFBP-2 levels also strongly correlated with extension of liver metastases and exhibited a prognostic value that contrasted that of CEA.
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http://dx.doi.org/10.3892/ol.2019.10925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6864964PMC
December 2019

Assessing the effects of inspiratory muscle training in a patient with unilateral diaphragm dysfunction.

Breathe (Sheff) 2019 Jun;15(2):e90-e96

Faculty of Movement and Rehabilitation Sciences, Dept of Rehabilitation Sciences, Research Group for Cardiovascular and Respiratory Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium.

http://bit.ly/2QdxNFP.
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http://dx.doi.org/10.1183/20734735.0129-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876147PMC
June 2019

Why does oxygen supplementation during exercise training in COPD patients with exercise-induced desaturation not consistently improve exercise capacity?

Eur Respir J 2019 11 14;54(5). Epub 2019 Nov 14.

Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium.

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http://dx.doi.org/10.1183/13993003.01586-2019DOI Listing
November 2019

Cerebral cortex and respiratory muscles perfusion during spontaneous breathing attempts in ventilated patients and its relation to weaning outcomes: a protocol for a prospective observational study.

BMJ Open 2019 10 31;9(10):e031072. Epub 2019 Oct 31.

Department of General Internal Medicine, University Hospitals Leuven, Medical Intensive Care Unit, Leuven, Belgium.

Introduction: In addition to the well-documented factors that contribute to weaning failure, increased energy demands of the respiratory muscles during spontaneous breathing trials (SBTs) might not be met by sufficient increases in energy supplies. This discrepancy may deprive blood and oxygen of other tissues. In this context, restrictions in perfusion of splanchnic organs and non-working muscles during SBT have been associated with weaning failure. However, alterations in perfusion of the brain during the weaning process are less well understood.

Objective And Hypothesis: To investigate whether cerebral cortex perfusion evolves differentially during the transition from mechanical ventilation (MV) to spontaneous breathing between patients failing or succeeding the SBT. We hypothesise that patients failing the SBT will exhibit reduced cerebral cortex perfusion during the transition from MV to spontaneous breathing as compared with patients succeeding the SBT.

Methods And Analysis: This single-centre, prospective, observational study will be conducted in a medical Intensive Care unit of University Hospital Leuven, Belgium in ready to wean patients. Blood flow index in the cerebral cortex (prefrontal area), inspiratory (scalene) and expiratory muscle (upper rectus abdominis) and a non-working muscle (thenar eminence) will be simultaneously assessed by near-infrared spectroscopy (NIRS) using the tracer indocyanine green dye. Measurements will be performed on the same day during MV and during SBT. NIRS-derived tissue oxygenation index and cardiac output (by pulse contour analyses) will be recorded continuously. Twenty patients failing an SBT are estimated to be sufficient for detecting a significant difference in the change of cerebral cortex perfusion from MV to SBT (primary outcome) between SBT failure and success patients.

Ethics And Dissemination: Ethics approval was obtained from the local ethical committee (Ethische Commissie Onderzoek UZ/KU Leuven protocol ID: S60516). Results from this study will be presented at scientific meetings and congresses and published in peer-reviewed journals.

Trial Registration Number: NCT03240263; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2019-031072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830828PMC
October 2019

Serum levels of TIMP-1 and MMP-7 as potential biomarkers in patients with metastatic colorectal cancer.

Int J Biol Markers 2019 Sep 4;34(3):292-301. Epub 2019 Sep 4.

Department of Oncology, First Faculty of Medicine, Charles University, and General University Hospital in Prague, Czech Republic.

Objective: Tissue inhibitor of metalloproteinases 1 (TIMP-1) and matrix metalloproteinase 7 (MMP-7) were reported to have potent growth promoting activity. Lack of balance between MMPs and TIMPs is an important factor in the development of gastrointestinal malignancies.

Methods: We collected serum samples from 97 patients with metastatic colorectal cancer and 79 samples from healthy controls. Serum levels of TIMP-1 and MMP-7 were measured immunochemically and compared with standard tumor markers carcinoembryonic antigen and CA19-9.

Results: Serum levels of TIMP-1 and MMP-7 were significantly higher in patients with colorectal cancer compared to healthy controls (both, P < 0.001). TIMP-1 and MMP-7 correlate with the presence of colon involvement (P = 0.001; P = 0.012) and the presence of liver metastases (P = 0.002; P = 0.037), and negatively correlate with pulmonary metastases (P = 0.014; P = 0.005). MMP-7 had similar sensitivity and the same specificity as carcinoembryonic antigen. TIMP-1 and MMP-7 had better sensitivity than CA19-9. TIMP-1 and MMP-7 level correlate with worse outcome (P = 0.002).

Conclusion: The results indicate that TIMP-1 and MMP-7 are effective biomarkers in patients with metastatic colorectal cancer with good sensitivity. TIMP-1 and MMP-7 levels strongly correlate with the extent of liver disease and have prognostic value.
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http://dx.doi.org/10.1177/1724600819866202DOI Listing
September 2019

Comparison Between Manual and (Semi-)Automated Analyses of Esophageal Diaphragm Electromyography During Endurance Cycling in Patients With COPD.

Front Physiol 2019 10;10:885. Epub 2019 Jul 10.

Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium.

Electrocardiogram (ECG) contamination is present in diaphragm electromyography (EMGdi) recordings. Obtaining EMGdi without ECG contamination is crucial for EMG amplitude analysis. Manually selecting EMGdi in between QRS complexes has been most commonly applied in recent years (manual method). We developed a semi-automated analysis method based on Least Mean Square Adaptive Filtering combined with a synchronously recorded separate ECG channel to remove ECG artifacts from the EMGdi signals. We hypothesized that this approach would shorten analysis duration and might minimize the potential for inter-rater disagreement. We aimed to evaluate agreement between the semi-automated method and the manual method and inter-rater reliability of the manual method. Electromyography signals of seven patients with COPD were recorded using an esophageal catheter during an exercise test on a cycle ergometer. Four patients subsequently participated in an inspiratory muscle training (IMT) program for 8 weeks. After IMT, the tests were repeated. EMGdi/EMGdiMax as obtained either manually by the two assessors or retrieved from the semi-automated method were compared. Semi-automated EMGdi/EMGdiMax agreed well with values obtained by one of the two manual assessors (assessor 1) both at pre-intervention measurements (mean difference -0.5%, 95% CI: -19.6 to 18.6%) and for the pre/post IMT differences (mean difference 1.2%, 95% CI: -16.8 to 19.2%). Intra-class correlation coefficients between methods were 0.96 (95% CI: 0.94-0.97) at pre-intervention measurements and 0.78 (95% CI: 0.58-0.89) for pre/post IMT differences (both < 0.001). EMGdi/EMGdiMax from assessor 2 was systematically lower than from assessor 1 and agreed less well with the semi-automated method both at pre-intervention measurements (mean difference: 9.3%, 95% CI: -11.4 to 29.9%) and for pre/post IMT differences (mean difference 7.0%, 95% CI: -20.4 to 34.4%). Analysis duration of the semi-automated method was significantly shorter (29 ± 9 min) than the manual method (82 ± 20 min, < 0.001). The developed semi-automated method is more time efficient and will be less prone to inter-rater variability that was observed when applying the manual analysis method. It is, therefore, proposed as a new standard for objective EMGdi amplitude analyses in future studies.
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http://dx.doi.org/10.3389/fphys.2019.00885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637315PMC
July 2019

Introduction of the harmonised respiratory physiotherapy curriculum.

Breathe (Sheff) 2019 Jun;15(2):110-115

Dept of Physiotherapy, Laboratory of Research in Respiratory Physiotherapy (LFIP), State University of Londrina (UEL), Londrina, Brazil.

Building on the core syllabus for postgraduate training in respiratory physiotherapy, published in 2014, the European Respiratory Society (ERS) respiratory physiotherapy task force has developed a harmonised and structured postgraduate curriculum for respiratory physiotherapy training. The curriculum outlines the knowledge, skills and attitudes which must be mastered by a respiratory physiotherapist working with adult or paediatric patients, together with guidance for minimal clinical exposures, and forms of learning and assessment. This article presents the rationale, methodology and content of the ERS respiratory physiotherapy curriculum. The full curriculum can be found in the supplementary material.
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http://dx.doi.org/10.1183/20734735.0124-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544793PMC
June 2019
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