if that UPPP adversely influences the future use of continuous positive airway pressure (CPAP).
Thefirst worry (a) we agree concerning the difficulties when evaluating a two- stage treatment. However, the aim of SKUP3was to evaluate the effect of UPPP, which includes tonsillectomy per defin- ition and has been a well-known surgical treatment for obstructive sleep apnoea syndrome (OSAS) since it was first intro- duced in 1981.2 Stradling and Kohler refer to a study of nine OSAS patients with large tonsils who underwent tonsil- lectomy with an 80% success rate, similar to that in children. Adult OSAS patients with large tonsils are few in number, only 6% according to one study.3The majority have a soft palate and uvula that has been traumatised and deranged after several years of snoring and vibrations, leading to bulky tissue, which obstructs the airway during sleep. The results from our previ- ous study of 158 OSAS patients undergo- ing UPPP showed that tonsil size was not a success factor.4 In our experience, ton- sillectomy is important as a part of UPPP in OSAS also in patients with small tonsils, as it enables the lateralisation and suturing of the posterior tonsillar pillar, thus widening the airway space, and our studies support this view.
Furthermore, a meta-analysis of UPP showed an apnoea–hypopnoea index reduction of 32%, comparable with 33%
in UPPP,5indicating that the palatal oper- ation also improves nocturnal respiration.
However, randomised controlled trials comparing tonsillectomy, UPP and UPPP are recommended to further clarify this question.
The second worry of Stradling and Kohler concerns (b) whether UPPP influ- ences future use of CPAP, referring to a study from 1996. The surgical method used at the start in the 1980s and 90s was more radical than it is today. We are performing only minor resections of the soft palate and uvula, that is, a modified UPPP. There is a scarcity of reports on this issue. However, a small Chinese study compared the classical UPPP with a modified UPPP and noted that all the problems with CPAP titrations occurred in the group of classical UPPP patients.6 Further prospective studies are also needed in this matter.
Nanna Browaldh, Danielle Friberg ORL Department, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
Correspondence toDr Nanna Browaldh, ENT-dept B 53, Karolinska University Hospital Huddinge Stockholm, SE-141 86, Sweden; nanna.browaldh@karolinska.se
Competing interests None.
Provenance and peer reviewNot commissioned;
internally peer reviewed.
To cite Browaldh N, Friberg D.Thorax 2014;69:386–387.
Received 10 October 2013 Accepted 10 October 2013
Published Online First 30 October 2013
▸http://dx.doi.org/10.1136/thoraxjnl-2013-204476 Thorax2014;69:386–387.
doi:10.1136/thoraxjnl-2013-204622
REFERENCES
1 Stradling J, Kohler M. SKUP3 trial: comment.Thorax 2014;69:386.
2 Fujita S, Conway W, Zorick F,et al. Surgical correction of anatomic azbnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty.Otolaryngol Head Neck Surg1981;89:923–34.
3 Dahlqvist J, Dahlqvist A, Marklund M,et al. Physical findings in the upper airways related to obstructive sleep apnea in men and women.Acta Otolaryngol 2007;127:623–30.
4 Lundkvist K, Januszkiewicz A, Friberg D.
Uvulopalatopharyngoplasty in 158 OSAS patients failing non-surgical treatment.Acta Otolaryngol 2009;129:1280–6.
5 Caples SM, Rowley JA, Prinsell JR,et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and
meta-analysis.Sleep2010;33:1396–407.
6 Han F, Song W, Li J,et al. Influence of UPPP surgery on tolerance to subsequent continuous positive airway pressure in patients with OSAHS.Sleep Breath 2006;10:37–42.
British Thoracic Society guideline on pulmonary rehabilitation in adults: does objectivity have a sliding scale?
We congratulate the Guideline Develop- ment Group (GDG) on the publication of their new pulmonary rehabilitation guide- line.1However, we are concerned by the contrasting recommendations for limb resistance training (LRT), which is recom- mended, and for inspiratory muscle training (IMT), which is not. Both interventions have identical levels of evidence (1+) and similar evidence statements.
The evidence statement in relation to LRT is as follows:
In patients with COPD, resistance training in combination with aerobic training does not lead to additional benefits to health-related quality of life, dyspnoea or
exercise tolerance compared with aerobic training alone. (Evidence level 1+)
The GDG puts forward a number of arguments to justify recommending LRT, despite the evidence level being 1+:
▸ Lower limb weakness is common in COPD and is a poor prognostic indicator.
▸ LRT has other benefits, such as redu- cing falls in older people in general.
▸ LRT in combination with aerobic train- ing results in greater improvements in peripheral muscle strength than aerobic training alone.
The claim that LRT reduces falls in older people is not supported by a cit- ation, and our understanding is that this link remains equivocal. The other mitigat- ing claims are not unique to LRT (see below).
The evidence statement relating to IMT is very similar to the statement for LRT, but the resulting recommendation is entirely different:
IMT using threshold loading devices or normocapnoeic hyperpnoea does not appear to augment the beneficial effects of general exercise training in patients with COPD. (Evidence level 1+) IMT is not recommended as a routine adjunct to pulmonary rehabilitation.
To our eyes, based upon the evidence statements, the differing recommendations are inconsistent, particularly as the miti- gating factors used by the GDG to justify its recommendation of LRT also hold true for IMT:
▸ Inspiratory muscle weakness is also common in COPD and is an independ- ent determinant of survival.2
▸ IMT in combination with exercise training yields larger improvements in inspiratory muscles strength and endur- ance than aerobic training alone.3 Perhaps most importantly, unlike LRT, standalone IMT is an evidence-based intervention in its own right, and is sup- ported by systematic reviews and meta-analyses.3 4 Established benefits include, “inspiratory muscle strength and endurance, functional exercise capacity, dyspnoea and quality of life”.3
Given the highly influential nature of these guidelines, and their likely adoption as the ‘de facto’ standard of care, dispar- ities in the interpretation of the evidence base must be justified carefully; failure to do so creates an impression of bias.
Alison K McConnell,1Rik Gosselink2,3
1Centre for Sports Medicine & Human Performance, Brunel University, London, UK
ThoraxApril 2014 Vol 69 No 4 387
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2KU Leuven Faculty of Kinesiology and Rehabilitation Sciences, Leuven, Belgium
3Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium Correspondence toProfessor Alison McConnell, Centre for Sports Medicine & Human Performance, Heinz Wolff Building, Brunel University, Uxbridge UB8 3PH, UK; alison.mcconnell@brunel.ac.uk
Competing interests AKM acknowledges a beneficial interest in an inspiratory muscle training product in the form of a share of license income to the University of Birmingham and Brunel University. She also acts as a consultant to companies manufacturing inspiratory muscle training products, as well as being the author of two books on respiratory muscle training.
Provenance and peer reviewNot commissioned;
internally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non- commercial. See: http://creativecommons.org/licenses/
by-nc/3.0/
To cite McConnell AK, Gosselink R.Thorax 2014;69:387–388.
Received 14 October 2013 Accepted 12 December 2013 Published Online First 9 January 2014
▸ http://dx.doi.org/10.1136/thoraxjnl-2013-204754 Thorax2014;69:387–388.
doi:10.1136/thoraxjnl-2013-204684
REFERENCES
1 Bolton CE, Bevan-Smith EF, Blakey JD,et al. British Thoracic Society guideline on pulmonary rehabilitation in adults:
accredited by NICE.Thorax2013;68(Suppl 2):ii1–30.
2 Gray-Donald K, Gibbons L, Shapiro SH,et al.
Nutritional status and mortality in chronic obstructive pulmonary disease.Am J Respir Crit Care Med 1996;153:961–6.
3 Gosselink R, De Vos J, van den Heuvel SP,et al.
Impact of inspiratory muscle training in patients with COPD: what is the evidence?Eur Respir J 2011;37:416–25.
4 O’Brien K, Geddes EL, Reid WD,et al. Inspiratory muscle training compared with other rehabilitation interventions in chronic obstructive pulmonary disease:
a systematic review update.J Cardiopulm Rehabil Prev 2008;28:128–41.
The British Thoracic Society guideline on pulmonary rehabilitation in adults:
your opinion is noted
We thank Professors McConnell and Gosselink for their interest in the British Thoracic Society (BTS) pulmonary rehabili- tation guideline.1 2We welcome the oppor- tunity to highlight the robust, unbiased approach that the guideline development group (GDG) has followed in making their recommendations which have been accre- dited by National Institute of Health and Care Excellence. This process, according to the BTS production manual, is described in the guideline methodology.2 It included initial training, each article being considered by at least two GDG members, independent peer review at multiple stages and consult- ation periods for the public and stake- holders. Continuously updated declaration of interest forms were submitted.
The correspondents question why inspiratory muscle training (IMT) is not recommended as a routine adjunct to pul- monary rehabilitation. The guideline dis- cusses the background to IMT and the nature of the trials undertaken, including a considered judgement of the risk of bias therein. The randomised controlled trials (RCTs) at lowest risk of bias found IMT was of no benefit as an adjunct to the primary aims of rehabilitation, and hence it was not routinely recommended. A similar statement has been adopted in the recent American Thoracic Society/
European Respiratory Society statement on pulmonary rehabilitation.3 The label of ‘1+’ is a standard assessment of the evidence level informing the recommen- dation, not of the strength of support for using the named intervention. As the trials included exercise rather than multidiscip- linary pulmonary rehabilitation, the rec- ommendation was at Grade B. A high-quality RCT of high-intensity IMT in parallel to pulmonary rehabilitation focus- ing on functional exercise capacity and health status is required. As we state, con- sideration of individual interventions such as role of oxygen or IMT in isolation was beyond the remit of the guideline.2
In relation to limb resistance training, the correspondents have omitted the first evidence statement documented in the guideline against this adjunct:
Resistance training in combination with aerobic training leads to greater improvements in peripheral muscle
strength than aerobic training alone.
(Evidence level 1+)
The recommendation that limb resist- ance training is used in addition to aerobic training to improve muscle strength follows from this and has been contextualised in this manner and approved by subsequent reviewers. The recommendation is extrapolated from exercise-based RCTs with a low risk of bias (ie, Grade B).2
In the relevant sections, reference to the importance of peripheral muscle strength regarding mortality and health- care utilisation is made, including one publication by Professor Gosselink. The guideline correctly states that other bene- fits are beyond the scope of the document.
We hope that high-quality, unbiased research in pulmonary rehabilitation con- tinues to accrue and thus guide future iterations of the BTS pulmonary rehabili- tation guideline.
Charlotte E Bolton,1John D Blakey,2 Mike D Morgan,3on behalf of the BTS Pulmonary Rehabilitation Guideline
Development Group for the Standards of Care Committee for the BTS
1Nottingham Respiratory Research Unit, School of Medicine, University of Nottingham, Nottingham, UK
2Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
3Respiratory Medicine, Glenfield Hospital, Leicester, UK Correspondence toDr Charlotte Bolton, Nottingham Respiratory Research Unit, The University of
Nottingham, Clinical Sciences Building, City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK;
charlotte.bolton@nottingham.ac.uk
Contributors CEB, JDB and MDM contributed to the writing of the letter and approved thefinal version.
Competing interests None.
Provenance and peer review Not commissioned;
internally peer reviewed.
To cite Bolton CE, Blakey JD, Morgan MD,et al.
Thorax2014;69:388–389.
Received 25 October 2013 Accepted 26 October 2013
Published Online First 15 January 2014
▸ http://dx.doi.org/10.1136/thoraxjnl-2013-204684 Thorax2014;69:388–389.
doi:10.1136/thoraxjnl-2013-204754
REFERENCES
1 McConnell AK, Gosselink R. British Thoracic Society guideline on pulmonary rehabilitation in adults: does objectivity have a sliding scale?Thorax2014;69:387–8.
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