Nov 262011

Many people with chronic respiratory failure literally waste away -- as evidenced by the contribution of "B" (for body mass index) in the BODE index's prediction of survival in severe COPD. Although long-term oxygen therapy improves survival and quality of life, and pulmonary rehabilitation improves exercise capacity and QOL, efforts to halt or reverse the catabolic wasting process with nutrition and/or weight exercise haven't been shown to be particularly helpful.

Pison et al randomized 122 patients with chronic respiratory failure (age ~66, mostly severe COPD) to receive either a multi-faceted intervention or usual care with health education. These were sick and sickly people, all hypoxemic and/or requiring noninvasive ventilation at baseline, with a BMI of ~21 and an FEV1 of ~13% predicted.

The intervention included 90 days of:

  • Health education
  • Oral nutritional supplements
  • Exercise (endurance training on an ergo-bicycle, as well as resistance training with elastic bands)
  • Oral testosterone for 90 days

There was no difference between groups in their primary endpoint -- six-minute walk distance at 90 days.

However, the intervention group had:

  • a 0.56 increase in BMI,
  • a 0.9 g/dL increase in hemoglobin,
  • and increased strength and endurance on muscle function tests.

There was no difference in exacerbation rates.

6 of the intervention patients and 12 of the controls died over 450 days, although this wasn't stat.significant. However, three of the six intervention patients were non-adherent with the rehabilitation program. If one excluded them, authors point out, there was a survival benefit to the multi-faceted intervention. But of course, one shouldn't exclude them, by the intention-to-treat principle. Still, very interesting.

Of course, testosterone is the most likely secret ingredient in this mix. The risks of testosterone therapy are largely unknown, but to me it seems like for people like these wasting away, its benefits here may well outweigh any risks, as a chaser to the protein shakes. (Of course, we said that about estrogen therapy for postmenopausal women too. But they were otherwise healthy women who didn't need our "help" -- very different situation.)

Pison CM et al. Multimodal nutritional rehabilitation improves clinical outcomes of malnourished patients with chronic respiratory failure: a randomised controlled trial. Thorax 2011;66:953-960.

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Nutrition + weights + testosterone improved function in chronic respiratory failure (RCT)