Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease

Effect of exercise on postoperative recovery of patients with non-small cell lung cancer: a systematic review and meta-analysis

Patients with non-small cell lung cancer (NSCLC) in the postoperative recovery period often experience reduced exercise capacity and impaired lung function, which affects their overall quality of life. This paper investigated the effect of exercise interventions on exercise capacity, lung function, quality of life, and symptoms in these patients.

METHODS

We performed a literature search across Cochrane, Embase, PubMed, Web of Science, and EBSCO databases were comprehensively searched for randomized controlled trials (RCTs) from inception to September 2023, all English RCTs were eligible if they assessed the effects of exercise interventions on postoperative NSCLC patients.

RESULTS

Twelve articles met our inclusion criteria, evidencing that exercise interventions could significantly improve the functional capacity of NSCLC patients in postoperative recovery. Notably, Forced Expiratory Volume in 1 s (FEV1) was improved, indicating enhanced lung function. Furthermore, exercise improved the physical and mental health scores of SF-36, along with increased quadriceps strength and relieved dyspnea. However, fatigue levels were not significantly changed.

CONCLUSIONS

Exercise interventions of NSCLC patients in the postoperative recovery are associated with improved functional capacity, lung function, quality of life, and quadriceps strength, as well as alleviated symptoms of dyspnea. These findings underscore the potential benefits of incorporating exercise into postoperative care for NSCLC patients. Nonetheless, further large-scale RCTs are required to solidify the evidence base on the clinical outcomes of exercise following pneumonectomy.

Development and feasibility of an exercise training program in primary care for patients with COPD experiencing an acute exacerbation

BACKGROUND

Starting rehabilitation soon after an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is crucial to diminish the detrimental effects of this acute event on muscle function. However, uptake in outpatient pulmonary rehabilitation is low.

OBJECTIVES

To design and test a feasible, acceptable and accessible exercise training program (ETP) in primary care for patients experiencing an AECOPD.

DESIGN

(1) A literature review and qualitative study to develop an ETP and (2) A feasibility study of the ETP implemented in primary care.

METHODS

(1) The development of the ETP proceeded in several phases with input from different stakeholders through focus group discussions. (2) Patients experiencing a moderate or severe AECOPD were included and followed the ETP for two weeks with a physiotherapist in primary care. Interviews with the participants took place and patients were given the choice to complete the eight-week program.

RESULTS

(1) Six discussion sessions took place. The ETP contained a flexible set of progressively more difficult exercises applicable in a primary care practice. (2) Eight patients experiencing a moderate (n = 1) or severe (n = 7) AECOPD were included. Patients started the first physiotherapy session 5 (2-6) days after the start of their symptoms or hospital discharge. Seven patients wanted to complete the ETP.

CONCLUSIONS

An ETP in primary care is feasible, acceptable and accessible for patients experiencing a moderate or severe AECOPD, and for physiotherapists. The effectiveness of this ETP on muscle function and physical activity is currently under investigation in a RCT. CONTRIBUTION OF THE PAPER.

Review of the Evidence for Pulmonary Rehabilitation in COPD: Clinical Benefits and Cost-Effectiveness

COPD is a common and lethal chronic condition, recognized as a leading cause of death worldwide. COPD is associated with significant morbidity and disability, particularly among older adults. The disease course is marked by periods of stability and disease exacerbations defined by worsening respiratory status resulting in a high burden of health care utilization and an increased risk of mortality. Treatment is focused on pharmacologic therapies, but these are not completely effective. Pulmonary rehabilitation (PR) represents a key medical intervention for patients with chronic respiratory diseases, including COPD. PR provides individualized and progressive exercise training, education, and self-management strategies through a comprehensive and multidisciplinary program. PR has been associated with improvement in exercise capacity, health-related quality of life, and dyspnea in patients living with COPD. Moreover, PR has been associated with improvements in hospital readmission and 1-y survival. In addition to the clinical benefits, PR is estimated to be a cost-effective medical intervention. Despite these benefits, participation in PR remains low. We will review the evidence for PR in each of these benefit domains among patients with stable COPD and in those recovering from a COPD exacerbation.

Pulmonary Rehabilitation Reimbursement Challenges

Pulmonary rehabilitation (PR) is a highly effective intervention for persons with chronic respiratory diseases, resulting in improvement in exercise capacity, dyspnea, health-related quality of life, mood, reduced hospitalization, and improved survival and cost savings post-COPD hospitalization. Despite demonstrated effectiveness, PR is underutilized in part due to lack of awareness, limited access, and inadequate PR reimbursement. Poor payment is a long-standing barrier to PR's financial stability and access. Addressing PR payment, access, and utilization is a complex challenge and requires strategic, collaborative long-term approaches to meaningful solutions. Strategies to overcome payment disparities begin with legislative approaches to address limitations of Centers for Medicare and Medicaid Services coverage. Additional priorities include permanent approval for remote physician and advanced practice provider (APP) PR supervision, PR referrals by APPs, telerehabilitation using two-way audio/video technology, and elimination of the PR lifetime maximum limit of 72 h or units/patient. Methods are needed to effectively link appropriate PR prescribing and encouragement with primary care providers, hospitalists, case managers, and hospital navigators to optimize PR referrals. There is an important need to address inadequate PR access in rural settings. Potential opportunities to improve PR referrals and access include exploration of PR synergies with value-based care models that emphasize high-quality care and cost savings. Development and use of effective PR provider tools and resources may help address the above challenges as well as financially benefit PR programs.

Barriers to Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is one of the most effective therapies for chronic respiratory diseases, yet it is significantly underutilized. There are several patient-related, geographic, societal, and health system-related barriers to PR. People with chronic respiratory disease face a collectively high burden of treatments including health care provider visits, medications, oxygen and other durable medical equipment, and providers' recommendation to undertake PR may be considered an added burden more than a likely benefit. Transportation difficulties, lack of insurance coverage, competing time priorities, low knowledge of PR, lack of perceived likely benefit, comorbidities, and other factors also pose obstacles to participation in PR for patients. Geographic availability of PR is heterogenous; in the United States, out-patient center-based PR programs are often not available within close proximity to patients' residence, posing barriers to patients' access to it. PR programs are lacking altogether in many areas; rural areas are particularly affected. Existing PR programs are often poorly funded and underresourced. Socioeconomic and racial disparities also influence patients' likelihood of receiving PR. Also, health care professionals (HCPs) often do not refer their patients with chronic respiratory disease to PR, owing to a lack of knowledge and awareness of its content and benefits, patient candidacy, or of the referral process. A limited number of multidisciplinary HCPs trained in PR likely also contributes to limited access to PR for patients. Collectively, these multifaceted barriers to PR create unacceptable health care disparities. Strategies to address barriers to PR are urgently needed in order to enable individuals who need to receive it.

Do pulmonary rehabilitation programmes improve outcomes in patients with COPD posthospital discharge for exacerbation: a systematic review and meta-analysis

INTRODUCTION

Previous systematic reviews have provided heterogeneous and differing estimates for the efficacy of pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease (COPD). The aim of this review was to examine the efficacy of pulmonary rehabilitation programmes initiated within 3 weeks of hospital discharge following an exacerbation of COPD.

METHODS

An update of a previous Cochrane review was undertaken using the Cochrane Airways Review Group Specialised Register. Searches were conducted from October 2015 to August 2023 for studies that initiated pulmonary rehabilitation within 3 weeks of hospital discharge. Studies assessing the impact of solely inpatient pulmonary rehabilitation were excluded. Forest plots were generated using a generic inverse variance random effects method.

RESULTS

Seventeen studies were included. Posthospital discharge pulmonary rehabilitation reduced hospital re-admissions (OR 0.48, 95% CI 0.30 to 0.77, I2=67%), improved exercise capacity (6 min walk test, mean difference (MD) 57 m, 95% CI 29 to 86, I2=89%; incremental shuttle walk test, MD 43 m, 95% CI 6 to 79, I2=81%), health-related quality of life (St. George's Respiratory Questionnaire, MD -8.7 points, 95% CI -12.5 to -4.9, I2=59%; Chronic Respiratory Disease Questionnaire (CRQ)-emotion, MD 1.0 points, 95% CI 0.4 to 1.6, I2=74%; CRQ-fatigue, MD 0.9 points, 95% CI 0.1 to 1.6, I2=91%), and dyspnoea (CRQ-dyspnoea, MD 1.0 points, 95% CI 0.3 to 1.7, I2=87%; modified Medical Research Council Dyspnoea Scale, MD -0.3 points, 95% CI -0.5 to -0.1, I2=60%). Significant effects were not observed for CRQ-mastery, COPD assessment test, EuroQol-5 Dimension-5 Level and mortality. No intervention-related adverse events were reported.

DISCUSSION

Pulmonary rehabilitation delivered posthospital discharge for exacerbation of COPD results in a reduction in hospital re-admissions and improvements in exercise capacity, health-related quality of life and dyspnoea in the absence of any intervention-related adverse events.

TRIAL REGISTRATION NUMBER

CRD42023406397.

The pulmonary rehabilitation effect on long covid-19 syndrome: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aims to evaluate the efficacy of pulmonary rehabilitation (PR) in improving dyspnea, fatigue, physical activity, quality of life, anxiety and depression in patients with Long COVID-19 (LC). The impact of PR on LC and a comparison of face-to-face and telerehabilitation approaches was explored.

METHODS

This systematic review and meta-analysis followed PRISMA guidelines and was registered in PROSPERO. A literature search included PubMed, Web of Science, and Cochrane Library until January 2023. No language filters were applied. Randomized controlled trials, non-randomized controlled trials, and observational studies were included. The risk of bias was assessed using appropriate tools. Descriptive analysis and meta-analysis were performed. Forest plots presented results. Statistical analyses were conducted using the Metafor Package in R v.3.4.2.

RESULTS/FINDINGS

This systematic review and meta-analysis included 16 studies on PR in LC patients. A total of 1027 adults were included. The studies varied in design, with seven observational studies, three quasi-experimental studies, and six randomized controlled trials. Dyspnea, physical function, quality of life, psychological state, and fatigue were assessed as outcomes. The review found that pulmonary rehabilitation had a significant positive effect on dyspnea, physical function, quality of life (both global and physical domain), anxiety, and depression. However, the effect on fatigue was not significant. Heterogeneity was observed in some analyses, and publication bias was found in certain outcomes. Age and study design were identified as potential moderators. Both face-to-face and telerehabilitation interventions improved the studied outcomes, with only differences in the physical domain of quality of life favoring the face-to-face group.

IMPLICATIONS ON PHYSIOTHERAPY PRACTICE

PR improved dyspnea, physical function, quality of life, and psychological state in LC patients, but not fatigue. Face-to-face and telerehabilitation have similar effects, except for physical quality of life.

High-flow nasal cannula during pulmonary rehabilitation for people with chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an increasingly concerning global public health issue due to its high burden of morbidity and mortality. Pulmonary rehabilitation (PR) is a comprehensive intervention to improve patients' physical and psychological conditions, commonly involving oxygen supplementation. The potential benefits of high-flow nasal cannula (HFNC) have recently sparked interest as oxygen therapy. In this context, this study aims to assess the effects of HFNC during the exercise training component of a PR program in people with COPD.

METHODS

Systematic review (CRD42022330929). We included randomised controlled trials (RCTs), including crossover RCTs with adults with stable COPD. We included trials using oxygen therapy with HFNC during the exercise training component of a PR programme.

PRIMARY OUTCOMES

disease-specific health-related quality of life (HRQoL), exercise capacity (EC) and adverse events.

SECONDARY OUTCOMES

treatment adherence, breathlessness and future exacerbations.

RESULTS

We included five studies with 300 participants with moderate to severe COPD. The certainty of the evidence was primarily low or very low for all outcomes of interest due to risk of bias, inconsistency or imprecision. HFNC has little to no difference in HRQoL (4 studies, 129 participants, MD 0.17, 95% CI -1.20 to 1.54; I2 50%). HFNC may result in little to no difference in EC (3 studies, 212 participants, mean difference 18.73, 95% CI -20.49 to 28.94; I2 56%), and we are uncertain about the effect of HFNC on breathlessness (4 studies; 244 participants, MD of -0.07, 95% CI -0.4 to 0.26; I2 63%). Only one study with 44 participants reported a participant's withdrawal because of progressive dyspnoea during lower limb exercise.

CONCLUSIONS

We are uncertain about the effect of HFNC during the exercise component of a PR programme in HRQoL, EC or dyspnoea compared to usual care or conventional supplementary oxygen. Non-domiciliary oxygen patients showed improvements in HRQoL, EC and dyspnoea.

Effectiveness of neuromuscular electrical stimulation in patients with acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

This study aimed to investigate the effectiveness and acceptability of neuromuscular electrical stimulation (NMES) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

We conducted a systematic review and meta-analysis to investigate the effectiveness and accessibility of NMES and compared them with usual care in patients with acute exacerbation of COPD by searching databases such as MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials published up to April 2022. Randomized controlled trials (RCTs) involving patients with COPD who were treated within 3 weeks of acute exacerbation onset were included. The risk of bias was assessed using the RoB 2 tools. We pooled limb muscle strength and adverse events and performed a comparison between NMES and usual care. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Five RCTs, including 168 patients, met the eligibility criteria. The meta-analysis showed that limb muscle strength was significantly higher in the NMES group (four studies with 148 patients; standardized mean difference, 0.95; 95% confidence interval, 0.60-1.30; p < 0.001). The quality of evidence was very low due to the risk of bias within the studies, imprecision of the estimates, and small number of studies. Any adverse events served as outcomes in three studies (86 patients), although no adverse events occurred.

CONCLUSION

NMES is safe for patients with acute exacerbation of COPD and may maintain and improve limb muscle strength; however, the quality of evidence was very low.

Advanced 3D In Vitro Lung Fibrosis Models: Contemporary Status, Clinical Uptake, and Prospective Outlooks

Fibrosis has been characterized as a global health problem and ranks as one of the primary causes of organ dysfunction. Currently, there is no cure for pulmonary fibrosis, and limited therapeutic options are available due to an inadequate understanding of the disease pathogenesis. The absence of advanced in vitro models replicating dynamic temporal changes observed in the tissue with the progression of the disease is a significant impediment in the development of novel antifibrotic treatments, which has motivated research on tissue-mimetic three-dimensional (3D) models. In this review, we summarize emerging trends in preparing advanced lung models to recapitulate biochemical and biomechanical processes associated with lung fibrogenesis. We begin by describing the importance of in vivo studies and highlighting the often poor correlation between preclinical research and clinical outcomes and the limitations of conventional cell culture in accurately simulating the 3D tissue microenvironment. Rapid advancement in biomaterials, biofabrication, biomicrofluidics, and related bioengineering techniques are enabling the preparation of in vitro models to reproduce the epithelium structure and operate as reliable drug screening strategies for precise prediction. Improving and understanding these model systems is necessary to find the cross-talks between growing cells and the stage at which myofibroblasts differentiate. These advanced models allow us to utilize the knowledge and identify, characterize, and hand pick medicines beneficial to the human community. The challenges of the current approaches, along with the opportunities for further research with potential for translation in this field, are presented toward developing novel treatments for pulmonary fibrosis.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Association of blood cadmium concentration with chronic obstructive pulmonary disease progression: a prospective cohort study

BACKGROUND

Prior studies in patients with chronic obstructive pulmonary disease (COPD) had indicated a potential correlation between cadmium (Cd) exposure and reduction in lung function. Nevertheless, the influence of Cd exposure on the progression of COPD remained unknown. Exploring the relationship between Cd exposure and the progression of COPD was the aim of this investigation.

METHODS

Stable COPD patients were enrolled. Blood samples were collected and lung function was evaluated. Regular professional follow-ups were conducted through telephone communications, outpatient services, and patients' hospitalization records.

RESULTS

Each additional unit of blood Cd was associated with upward trend in acute exacerbation, hospitalization, longer hospital stay, and death within 2 years. Even after adjusting for potential confounding factors, each 1 unit rise in blood Cd still correlated with a rise in the frequencies of acute exacerbation, longer hospital stay, and death. Moreover, COPD patients with less smoking amount, lower lung function and without comorbidities were more vulnerable to Cd-induced disease deterioration.

CONCLUSION

Patients with COPD who have higher blood Cd concentration are susceptible to worse disease progression.

Diversity in pulmonary rehabilitation clinical trials: a systematic review of the literature

BACKGROUND

Underrepresentation of minority groups in clinical trials may hinder the potential benefits of pulmonary rehabilitation (PR) programs for individuals with chronic obstructive pulmonary disease (COPD). The aim of this work was to determine whether participants in PR randomized control trials (RCTs) conducted in the U.S.A., Canada, the UK, and Australia are representative of ethnicity, sex, gender, and sociodemographic characteristics.

RESEARCH DESIGN

A systematic search was performed for relevant literature from inception to December 2022. Titles and abstracts were screened before undergoing a full article review. Relevant data on reporting of age, sex, gender, ethnicity, and sociodemographic characteristics of participants was extracted.

RESULTS

Thirty-six RCTs met the inclusion criteria. Only 6% of publications reported on ethnicity, with ≥90% of participants reported as 'White.' All 36 papers reported on age, with the mean between 60 and 69 years old. Thirty-five studies reported on sex (97%), with the majority (67%) reporting more male than female participants. There was no mention of different genders in any paper. Other sociodemographic factors were reported in 7 (19%) papers.

CONCLUSIONS

Inclusivity and representation in clinical trials are essential to ensure that research findings are generalizable. Clinical trialists need to consider the demographics of today's society during recruitment.

The effectiveness of an unsupervised home-based pulmonary rehabilitation with self-management program in patients with chronic obstructive pulmonary disease

AIMS

To assess the effectiveness of an unsupervised home-based pulmonary rehabilitation with self-management program in patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

A few recent studies have shown that unsupervised home-based pulmonary rehabilitation can improve the clinical outcome of patients with COPD. More studies are needed to prove its benefits.

DESIGN

This study used a quasi-experimental design.

METHODS

Seventy-two admitted COPD patients were assigned to experimental group or control group through purposeful sampling. Data were collected from March 2016 to November 2017 in the Thoracic Intensive Care Unit of a Medical Center in Taiwan. The Medical Research Council dyspnea scale, the COPD Self-Efficacy Scale and the Clinical COPD Questionnaire were measured before education and at the first, second and third months after discharge.

RESULTS

The Medical Research Council dyspnea scale and COPD Self-Efficacy Scale results in the experimental group were significantly improved compared with the control group in the third month after discharge. The Clinical COPD Questionnaire score continued to improve in both groups in the third month after discharge, and there was no difference between the two groups.

CONCLUSION

A short-term unsupervised home-based pulmonary rehabilitation with self- management program had significant benefits for patients with COPD. The long-term effects need to be confirmed.

Global research publications on cardiovascular and pulmonary rehabilitation and their alignment with population rehabilitation needs: An ecological study

PURPOSE

Towards informing health research policy and planning, this article evaluates the relationship of the research publications in cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) with the rehabilitation needs arising from cardiovascular diseases (except stroke) and chronic respiratory diseases, over time (1990-2017).

METHODS

Ecological study using a secondary analysis and linear regressions of public domain data to associate two datasets of population-level data: (1) research publications for CR and PR (data from the PubMed database); and (2) global need for CR and PR (data from the Global Burden of Disease study).

RESULTS

The percentage of both CR and PR publications (among total rehabilitation research) significantly decreased from 1990 to 2017 (both: p < 0.01). PR needs and research publications were aligned: around 5% of total rehabilitation needs and rehabilitation research. For CR needs (around 2%, but significantly increasing since 1990), we found a greater portion of CR research publications (6.5% or over). Finally, we found an inverse association among the percentage of CR research publications and CR needs (b = -6.08; r2  = 0.37, p = 0.001).

CONCLUSION

The portion of CR and PR research (among total rehabilitation research) is declining over time. Yearly percentage of CR publications were greater than those of PR but for lower level of rehabilitation need, but the disparate trend was significantly decreasing over time. Population rehabilitation needs and their alignment with research volume must be one factor in the design of population-centred, equitable health research priorities.

Exercise-based rehabilitation in and with nature: a scoping review mapping available interventions

INTRODUCTION

Exercise is an effective component in rehabilitation of a range of chronic conditions. There is a growing interest in the use of exercise-based nature interacted rehabilitation (EBNIR), but an overview of current evidence is missing. The objective of this scoping review was to map existing exercise-based rehabilitation interventions conducted with incidental or intentional nature interaction focusing on its populations, types of outcomes, and theoretical rationale for people with physical and mental disabilities.

METHODS

This scoping review identified peer-reviewed publications, registered upcoming trials and grey literature. To map all available knowledge, a comprehensive search of selected databases (MEDLINE; EMBASE; CINAHL; Cochrane; Web of Science; Pedro) from inception to October 2022. Data were synthesized in a thematic presentation guided by TIDieR, supplemented by a checklist developed for this study accounting nature incidental or intentional interaction.

RESULTS

Twelve studies including 856 participants met the inclusion criteria. Eleven were completed trials and one was registered in clinicaltrials.gov to be run in 2023. A total of 856 patients were enrolled in the 12 studies (range 18-262, median 50). The included studies had great variation. The incidental or intentional interacted exercise-based interventions consisted of outdoor walks, neck exercises and surfing interventions in patients with physical or mental health conditions.

CONCLUSIONS

This scoping review presents an overview of limited and diverse evidence within the field of EBNIR, in patients with physical or mental health conditions. Our review provides an overview that will be helpful in the design of future EBNIR trials.

A pulmonary rehabilitation program reduces hospitalizations in chronic obstructive pulmonary disease patients: A cost-effectiveness study

BACKGROUND

Although pulmonary rehabilitation (PR) is recommended in patients with chronic obstructive pulmonary disease (COPD), there is a scarcity of data demonstrating the cost-effectiveness and effectiveness of PR in reducing exacerbations.

METHODS

A quasi-experimental study in 200 patients with COPD was conducted to determine the number of exacerbations 1 year before and after their participation in a PR program. Quality of life was measured using the COPD assessment test and EuroQol-5D. The costs of the program and exacerbations were assessed the year before and after participation in the PR program. The incremental cost-effectiveness ratio (ICER) was estimated in terms of quality-adjusted life years (QALYs).

RESULTS

The number of admissions, length of hospital stay, and admissions to the emergency department decreased after participation in the PR program by 48.2%, 46.6%, and 42.5%, respectively (P < 0.001 for all). Results on quality of life tests improved significantly (P < 0.001 for the two tests). The cost of PR per patient and the cost of pre-PR and post-PR exacerbations were €1867.7 and €7895.2 and €4201.9, respectively. The PR resulted in a cost saving of €1826 (total, €365,200) per patient/year, and the gain in QALYs was+0.107. ICER was -€17,056. The total cost was <€20,000/QALY in 78% of patients.

CONCLUSIONS

PR contributes to reducing the number of exacerbations in patients with COPD, thereby slowing clinical deterioration. In addition, it is cost-effective in terms of QALYs.

The effect of pulmonary rehabilitation on childhood asthma: a systematic review and meta-analysis

INTRODUCTION

Pulmonary rehabilitation (PR) is a comprehensive nursing intervention for lung function improvement in patients with respiratory diseases. This systematic review focused on further exploration of the unclear impacts of PR on childhood asthma.

EVIDENCE ACQUISITION

Web of Science, Cochrane Library, Embase, PubMed, and other databases were searched until May 2021. Randomized controlled trials (RCTs) comparing the effects of PR (including exercise training and education) and routine care on childhood asthma were included. Study selection, data extraction, and bias risk assessment were performed independently by two investigators.

EVIDENCE SYNTHESIS

Fourteen RCTs involving 1401 patients were included. Relative to the control group, the total scores of the asthma quality of life questionnaire were evidently improved in the experimental group, including motor domain scores (MD=0.88, 95% CI: 0.67-1.09), symptom domain scores (MD=1.23, 95% CI: 0.61-1.85), and affective domain scores (MD=1.38, 95% CI: 0.63-2.14). Besides, 6-min walk distance (MD=2.01, 95% CI: 0.86-3.15) and asthma control test (MD=0.31, 95% CI: 0.02-0.60) were prominently improved. However, the maximum oxygen uptake (MD=0.81, 95% CI: -0.2 to 1.82) was not markedly improved. The forced expiratory volume in 1 s (MD=0.42, 95% CI: -0.29 to 1.13), and forced vital capacity (MD=0.07, 95% CI: -0.14 to 0.28) were not remarkably improved. There was an evident improvement in the peak expiratory flow (MD=1.22, 95% CI: 0.15-2.30).

CONCLUSIONS

PR improves some lung functions, exercise tolerance and the quality of life of children with asthma, and it might work as a supplementary therapy for the treatment of childhood asthma. Moreover, more RCTs of high quality and in large sample size are needed for further confirmation.

Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions

Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.

A Systematic Review of the Effectiveness of Interventions to Promote Referral; Adherence; and Uptake of Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Background

Pulmonary rehabilitation (PR) is an effective treatment for patients with chronic obstructive pulmonary disease (COPD). However, referral, uptake, and adherence remain low.

Objective

To determine effectiveness of interventions to increase patient referral, uptake, and adherence to PR programs for patients with COPD.

Methods

Randomized controlled trials (RCTs), non-randomized controlled trials, pre-post studies, and uncontrolled studies were sought from 7 databases and 3 clinical trial registries, to end August 2021. Full articles/conference abstracts were included if a coordinated set of activities was targeted to healthcare professionals (HCPs) caring for COPD patients, adults with COPD or their carers, to increase referral, uptake or adherence to any type of PR program. Two review authors independently screened titles, abstracts and full texts, extracted data and critically appraised studies using standard risk of bias tools.

Results

From 11,272 records, 30 studies (23 full-text; 7 abstracts) met inclusion criteria: study interventions and designs were varied and generally low quality, targeting patients (n=13), HCPs (n=14) or both (n=3 studies). A CCT of patient held evidence score cards increased referral by 7.3% compared to 1.3% for usual care (p-0.03). A cluster RCT involving COPD nurse home visits with individualized care plans increased uptake to 31% compared to 10% in usual care (p=0.002). For people with anxiety or depression, one RCT of cognitive behavioral therapy alongside PR increased adherence (mean sessions 14.0 (sd 1.7) compared to 12.4 (sd 2.6)).

Conclusion

Although a small number of studies, the weight of evidence suggested that interventions incorporating partnership working between patients and HCPs appeared to increase referral, uptake, and adherence with greater effectiveness than those targeting single populations. Increasing knowledge and empowering HCPs and patients may be important strategies. Concerns about study design and risk of bias suggest clear need for well-designed trials of interventions to report full pathway outcomes.

The effects of an innovative GP-physiotherapist partnership in improving COPD management in primary care

BACKGROUND

Evidence suggests that management of people with Chronic Obstructive Pulmonary Disease (COPD) in primary care has been suboptimal, in particular, with low referral rates to pulmonary rehabilitation (PR). The aim of this study was to evaluate the effectiveness of a GP-physiotherapist partnership in optimising management of COPD in primary care.

METHODS

A pragmatic, pilot, before and after study was conducted in four general practices in Australia. A senior cardiorespiratory physiotherapist was partnered with each general practice. Adults with a history of smoking and/or COPD, aged ≥ 40 years with ≥ 2 practice visits in the previous year were recruited following spirometric confirmation of COPD. Intervention was provided by the physiotherapist at the general practice and included PR referral, physical activity and smoking cessation advice, provision of a pedometer and review of inhaler technique. Intervention occurred at baseline, one month and three months. Main outcomes included PR referral and attendance. Secondary clinical outcomes included changes in COPD Assessment Test (CAT) score, dyspnoea, health activation and pedometer step count. Process outcomes included count of initiation of smoking cessation interventions and review of inhaler technique.

RESULTS

A total of 148 participants attended a baseline appointment where pre/post bronchodilator spirometry was performed. 31 participants with airflow obstruction on post-bronchodilator spirometry (mean age 75yrs (SD 9.3), mean FEV₁% pred = 75% (SD 18.6), 61% female) received the intervention. At three months, 78% (21/27) were referred to PR and 38% (8/21) had attended PR. No significant improvements were seen in CAT scores, dyspnoea or health activation. There was no significant change in average daily step count at three months compared to baseline (mean difference (95% CI) -266 steps (-956 to 423), p = 0.43). Where indicated, all participants had smoking cessation interventions initiated and inhaler technique reviewed.

CONCLUSION

The results of this study suggest that this model was able to increase referrals to PR from primary care and was successful in implementing some aspects of COPD management, however, was insufficient to improve symptom scores and physical activity levels in people with COPD.

TRIAL REGISTRATION

ANZCTR, ACTRN12619001127190. Registered 12 August 2019 - Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx .

Needs assessment for introducing pulmonary rehabilitation for chronic obstructive pulmonary disease management in a rural Indian setting: a qualitative study

BACKGROUND

Pulmonary rehabilitation (PR) is an effective strategy to improve breathlessness, health status and exercise tolerance and to reduce readmissions and mortality. In India, there is no government health programme for chronic obstructive pulmonary disease (COPD) management while in the private sector availability of PR is limited. Most PR centres are in urban areas, with few services accessible to rural populations. We aimed to assess the need for PR from the perspective of patients with COPD and healthcare professionals (HCPs: registered medical practitioners and medical officers) in rural Maharashtra.

METHODOLOGY

Between June and October 2020, we conducted semi-structured interviews with 14 patients with COPD and 9 HCPs to explore their perceptions of, and need for, PR in rural Maharashtra. Interviews were transcribed and analysed thematically.

RESULTS

We approached 14 patients with COPD and 9 HCPs practising in rural areas. Five HCPs stated that they did not advise PR for patients with COPD citing poor compliance to PR referral and follow-up of the patients. Patients with COPD had symptoms and needs that could be helped by PR but commented how transportation would be a problem for them to visit a PR centre. In contrast, they could understand the benefits of PR and expressed their willingness to join such programmes. A PR service was established that addressed these needs.

CONCLUSION

Patients with COPD have unmet needs that could benefit from attending a PR programme, but there are barriers at both healthcare and patient levels that we addressed in a new PR service for people with chronic respiratory disease in rural Maharashtra.

Pulmonary Rehabilitation in Persons With COPD

Pulmonary rehabilitation (PR) is a high-value intervention for persons with COPD and other chronic lung diseases. It is associated with improvement in exercise capacity, dyspnea, health-related quality of life, and depression as well as a reduction in hospitalization and improved survival when PR follows COPD-related hospitalizations. PR is underused in the United States and other countries despite strong evidence of both clinical effectiveness and cost-effectiveness. Additional challenges include a lack of equitable reimbursement and poor access, particularly in rural settings. Models, for example, virtual PR, may be an option for improving access but coverage in the United States by Medicare is tenuous. In addition, virtual PR models have considerable heterogeneity, which challenges uniform efficacy and selection of optimal candidates.

An overview of Cochrane systematic reviews for pulmonary rehabilitation interventions in people with chronic obstructive pulmonary disease: a mapping synthesis

INTRODUCTION

There is a global unmet need for rehabilitation to meet which the World Health Organization, in collaboration with Cochrane Rehabilitation, is developing the Package of Interventions for Rehabilitation with the aim of identifying rehabilitation interventions relevant to a range of key health conditions, including chronic obstructive pulmonary disease (COPD). The purpose of this paper is to describe the best available evidence on pulmonary rehabilitation interventions for people with COPD.

EVIDENCE ACQUISITION

An Overview of Cochrane Systematic Reviews (CSRs). Through the search strategy, COPD-related systematic reviews published from January 2009 to November 2021 were identified. Data were extracted on each reported outcome related to an intervention and judgements about the quality of evidence were made, using the GRADE approach.

EVIDENCE SYNTHESIS

Seventeen reviews were analyzed, for a total of 314 primary studies that included 22,206 participants. CSRs provided information on the effectiveness of rehabilitation on functioning, activity, quality of life, anxiety, depression, mortality, and health care resource utilization.

CONCLUSIONS

Our findings report that comprehensive pulmonary rehabilitation programs and water exercises improve the exercise capacity and quality of life (QoL) in people with COPD. Different exercise modalities, intensities, and settings for different muscle groups, breathing exercises, and counseling can improve exercise capacity, QoL, dyspnea, hospitalizations, and physical activity. It is uncertain whether breathing exercise, low-intensity exercise, neuromuscular electrical stimulation, and psychological intervention have an effect on exercise capacity, dyspnea, QoL, and physical activity. The protocol was registered on OSF (registration DOI: 10.17605/OSF.IO/8A26Q).

Year in Review: Long COVID and Pulmonary Rehabilitation

There have been an estimated 100 million people diagnosed with COVID-19 in the United States, with a majority of patients reporting persistent symptoms expressed as long COVID. The 2 most frequently reported long COVID symptoms are shortness of breath and fatigue. Exercise training during pulmonary rehabilitation (PR) is a successful strategy for improving the lives of people with persistent respiratory symptoms caused by a variety of lung diseases. This narrative review assessed the impact of exercise interventions on functional exercise capacity measures and related symptoms (dyspnea, fatigue) in people with long COVID over the last year. Articles were accessed through electronic databases including PubMed, Embase, CINAHL Plus with full text (EBSCO), and LitCovid. Findings for this Year in Review revealed that exercise interventions and PR show promise for improving functional exercise capacity, dyspnea, and fatigue in people with long COVID. This review supports the need for more rigorous scientific studies on the benefits of structured PR in people with long COVID who have respiratory-related symptoms.

Application of the RE-AIM framework to evaluate the implementation of telehealth pulmonary rehabilitation in a randomized controlled trial among African-American and Hispanic patients with advanced stage Chronic Obstructive Pulmonary Disease

BACKGROUND

Pulmonary rehabilitation (PR) decreases rehospitalization for people with COPD. However, less than 2% receive PR, partly due to lack of referral and sparsity of PR facilities. This disparity is particularly pronounced in African American and Hispanic persons with COPD. Telehealth-provided PR could increase access and improve health outcomes.

METHODS

We applied the RE-AIM framework in a post-hoc analysis of our mixed methods RCT comparing referral to Telehealth-delivered PR (TelePR) versus standard PR (SPR) for African American and Hispanic COPD patients hospitalized for COPD exacerbation. Both arms received a referral to PR for 8 weeks, social worker follow-up, and surveys administered at baseline, 8 weeks, 6, and 12 months. PR sessions were conducted twice a week for 90 min each (16 sessions total). Quantitative data were analyzed using 2-sample t tests or nonparametric Wilcoxon tests for continuous data and χ²/Fisher exact tests for categorical data. Logistic regression-estimated odds ratios (ORs) were used for the intention-to-treat primary outcome. Qualitative interviews were conducted at the end of the study to assess adherence and satisfaction and were analyzed using inductive and deductive methods. The goal was to understand Reach (whether the target population was able to be enrolled), Effectiveness (primary outcome was a composite of 6-month COPD rehospitalization and death), Adoption (proportion of people willing to initiate the program), Implementation (whether the program was able to be executed as intended, and Maintenance (whether the program was continued).

RESULTS

Two hundred nine people enrolled out of a 276-recruitment goal. Only 85 completed at least one PR session 57/111 (51%) TelePR; 28/98 (28%) SPR. Referral to TelePR compared to SPR did not decrease the composite outcome of 6-month COPD-readmission rate/death (OR1.35;95%CI 0.69,2.66). There was significant reduction in fatigue (PROMIS® scale) from baseline to 8-weeks in TelePR compared to SPR (MD-1.34; ± SD4.22; p = 0.02). Participants who received TelePR experienced improvements from baseline in several outcomes (ie, before and after 8 weeks of PR) in the following: COPD symptoms, knowledge about COPD management, fatigue, and functional capacity. Among the patients who had 1 initial visit, adherence rates were similar (TelePR arm, 59% of sessions; SPR arm, 63%). No intervention-related adverse events occurred. Barriers to PR adoption included difficulty or reluctance to complete medical clearances and beliefs about PR efficacy. Notably, only 9 participants sustained exercise after program completion. Maintenance of the program was not possible due to low insurance reimbursement and sparsity of Respiratory Therapists.

CONCLUSIONS

TelePR can reach COPD patients with health disparities and can be successfully implemented. The small sample size and large confidence intervals prevent conclusion about the relative effectiveness of participating in TelePR compared to SPR. However, improved outcomes were seen for those in TelePR as well as in SPR. Increasing adoption of PR and TelePR requires consideration of comorbidity burden, and perception of PR utility, and must facilitate medical clearances. Given the sparsity of SPR locations, TelePR can overcome at least the barrier of access. However, given the challenges to the uptake and completion of PR - many of the additional barriers in PR (both in TelePR and SPR) need to be addressed. Awareness of these real-world challenges will not only inform implementation of TelePR for clinicians seeking to adopt this platform but will also inform study designers and reviewers regarding the feasibility of approaches to patient recruitment and retention.

Effects of Early Pulmonary Rehabilitation on Hospitalized Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Background

Pulmonary rehabilitation (PR) effectively improves symptoms and exercise ability in patients with stable chronic obstructive pulmonary disease (COPD). However, the effectiveness and timing of early PR on hospitalized patients with acute exacerbation of COPD (AECOPD) is still debated.

Methods

This study conducted a meta-analysis to compare the outcome benefits between early PR and usual care for patient hospitalized due to AECOPD. A systematic search was performed for retrieving randomized control trials (RCTs) from the PubMed, Embase, and Cochrane library until November 2021. RCTs reporting early PR for AECOPD with hospitalization, either during admission or within four weeks of discharge, were enrolled for systematic review and meta-analysis.

Results

Twenty RCTs (1274 participants) were included. Early PR showed significantly improved readmission rate (ten trials, risk ratio 0.68, 95% confidence interval (CI) 0.50-0.92), 6-minute walking distance (6MWD, twelve trials, MD 59.73, 95% CI 36.34-83.12), St George's Respiratory Questionnaire score (eight trials, MD -10.65, 95% CI -14.78 to -6.52), Borg score (eight trials, MD -0.79, 95% CI -1.26 to -0.32), and modified Medical Research Council dyspnea scale (eight trials, MD -0.38, 95% CI -0.5 to -0.25). However, the trend of mortality (six trials, risk ratio 0.72, 95% CI 0.39-1.34) benefit was not significant. The subgroup analysis showed non-significant trends of better effect in early PR during admission than those after discharge for outcomes of 6MWD, quality of life, and dyspnea. However, non-significant trends of less benefits on mortality and readmission rate were found in early PR during the admission.

Conclusion

Overall, early PR is beneficial for AECOPD with hospitalization, and there was no significant outcome difference between PR initiated during admission or within 4 weeks of discharge.

Access to Pulmonary Rehabilitation among Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease

Rationale: Pulmonary rehabilitation (PR) remains substantially underused as a treatment modality for chronic obstructive pulmonary disease (COPD). A major barrier to the uptake of PR is the poor availability of and access to PR. Objectives: To quantify patients' access to PR centers in the United States. Methods: Using the 100% Medicare population with coverage for 2018, four geodesic distance-based buffers of 10-, 15-, 25-, and 50-mi radii around the geographic centroid of each ZIP code with at least one beneficiary with COPD were created. Street addresses of PR centers across the continental United States were geocoded. We calculated the distance between the residential ZIP code centroid and the closest PR center. The proportions of individuals with at least one PR center available within the four distance buffers were calculated overall as well as in metropolitan, micropolitan, small-town, and rural areas. Results: Of 62,930,784 Medicare beneficiaries, 10,376,949 (16.5%) had COPD. There were 1,696 PR centers across the United States, with one PR center for every 6,030 individuals with COPD. Mean distance to the nearest PR center was 12.4 (standard deviation, 16.6) mi. Overall, the proportions of individuals with COPD who had PR centers available within 10-, 15-, 25-, and 50-mi radii were 61.5%, 73.2%, 86.6%, and 97.1%, respectively. Proportions for rural areas were 11.3%, 24.3%, 53.4%, and 88.6%, respectively. Compared with those living in metropolitan areas, those living in rural areas were 95% less likely to have PR centers within 10 mi of their residences (odds ratio, 0.048 [95% confidence interval, 0.039-0.057]). Conclusions: In a nationally representative sample of Medicare beneficiaries, we found that two-fifths of adults with COPD overall, and eight in nine of those in rural areas, have poor access to PR.

Promoting Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease, Strategies of Top-performing Systems: A Qualitative Study

Rationale: Pulmonary rehabilitation (PR) after hospitalization for chronic obstructive pulmonary disease (COPD) is recommended by guidelines; however, few patients participate, and rates vary between hospitals. Objectives: To identify contextual factors and strategies that may promote participation in PR after hospitalization for COPD. Methods: Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States, we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th percentile, at least 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of PR rates after discharge, we identified innovative hospitals on the basis of a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes. Results: Interviews were conducted with 38 stakeholders at nine hospitals (seven high-performers and two innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR medical directors, PR managers, respiratory therapists, inpatient and outpatient providers, and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after admission for COPD in response to the Centers for Medicare and Medicaid Services/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance in overcoming barriers. Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of a larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.

Nonpharmacological management of psychological distress in people with COPD

Psychological distress is prevalent in people with COPD and relates to a worse course of disease. It often remains unrecognised and untreated, intensifying the burden on patients, carers and healthcare systems. Nonpharmacological management strategies have been suggested as important elements to manage psychological distress in COPD. Therefore, this review presents instruments for detecting psychological distress in COPD and provides an overview of available nonpharmacological management strategies together with available scientific evidence for their presumed benefits in COPD. Several instruments are available for detecting psychological distress in COPD, including simple questions, questionnaires and clinical diagnostic interviews, but their implementation in clinical practice is limited and heterogeneous. Moreover, various nonpharmacological management options are available for COPD, ranging from specific cognitive behavioural therapy (CBT) to multi-component pulmonary rehabilitation (PR) programmes. These interventions vary substantially in their specific content, intensity and duration across studies. Similarly, available evidence regarding their efficacy varies significantly, with the strongest evidence currently for CBT or PR. Further randomised controlled trials are needed with larger, culturally diverse samples and long-term follow-ups. Moreover, effective nonpharmacological interventions should be implemented more in the clinical routine. Respective barriers for patients, caregivers, clinicians, healthcare systems and research need to be overcome.

Experiences of Using an Electronic Health Tool Among Health Care Professionals Involved in Chronic Obstructive Pulmonary Disease Management: Qualitative Analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is one of the most common and deadliest chronic diseases of the 21st century. eHealth tools are seen as a promising way of supporting health care professionals in providing evidence-based COPD care, for example, by reinforcing information and interventions provided to the patients and providing easier access and support to the health care professional themselves. Still, knowledge is scarce on the experience of using eHealth tools from the perspective of the health care professional involved in COPD management.

OBJECTIVE

The study explored the experiences of using an eHealth tool among health care professionals that worked with patients with COPD in their daily clinical practice.

METHODS

This exploratory qualitative study is part of a process evaluation in a parallel group, controlled, pragmatic pilot trial. Semistructured interviews were performed with 10 health care professionals 3 and 12 months after getting access to an eHealth tool, the COPD Web. The COPD Web, developed using cocreation, is an interactive web-based platform that aims to help health care professionals provide health-promoting strategies. Data from the interviews were analyzed using qualitative content analysis with an inductive approach.

RESULTS

The main results reflected health care professionals' experiences in 3 categories: receiving competence support and adjusting practice, improving quality of care, and efforts required for implementation. These categories highlighted that using an eHealth tool such as the COPD Web was experienced to provide knowledge support for health care professionals that led to adaptation and facilitation of working procedures and person-centered care. Taken together, these changes were perceived to improve the quality of care through enhanced patient contact and encouragement of interprofessional collaboration. In addition, health care professionals expressed that patients using the COPD Web were better equipped to tackle their disease and adhered better to provided treatment, increasing their self-management ability. However, structural and external barriers bar the successful implementation of an eHealth tool in daily praxis.

CONCLUSIONS

This study is among the first to explore experiences of using an eHealth tool among health care professionals involved in COPD management. Our novel findings highlight that using an eHealth tool such as the COPD Web may improve the quality of care for patients with COPD (eg, by providing knowledge support for health care professionals and adapting and facilitating working procedures). Our results also indicate that an eHealth tool fosters collaborative interactions between patients and health care professionals, which explains why eHealth is a valuable means of encouraging well-informed and autonomous patients. However, structural and external barriers requiring time, support, and education must be addressed to ensure that an eHealth tool can be successfully implemented in daily praxis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02696187; https://clinicaltrials.gov/ct2/show/NCT02696187.

One-minute sit-to-stand test as a quick functional test for people with COPD in general practice

Assessing changes in functional exercise capacity is highly relevant in the treatment of people with Chronic Obstructive Pulmonary Disease (COPD), as lung function is often static. In Denmark, most people with COPD are followed in general practice where traditional functional tests, like six-minute walk test, require too much time and space. Therefore, there is an urgent need for a quick functional exercise capacity test that can be performed in a limited setting, such as general practice. This study aimed to identify a quick test to measure functional exercise capacity in people with COPD and identify which factors could affect the implementation of such a test in general practice. A mixed method feasibility study composed of a literature review and qualitative interviews was used. Quick functional tests for people with COPD were identified and evaluated through the COSMIN methodology. For the interviews, 64 general practices were included, and 50 staff members and 14 general practitioners (GPs) participated in the interviews. Responses were categorized and thematically analyzed. The 1 min sit-to-stand-test (1 M STST) was found suitable for a general practice setting. The COSMIN methodology rated it "sufficient" in reliability (ICC 0.90-0.99), measurement error (MID 2.5-3), construct validity and responsiveness (AUC 0.72), and found a moderate to strong correlation in criterion validity (r = 0.4-0.75). Several GPs wished for a quick functional test and emphasized evidence, information, and limitations as essential when deciding on implementation. Other factors identified included time, other tests, and economy. 1 M STST is a valid test to assess functional exercise capacity in people with COPD. The test is quick and can easily be performed in a standard consultation, and several GPs wished for such a test.

Availability and characteristics of pulmonary rehabilitation programs in family health centers and hospitals from Chile: Descriptive, retrospective and multicentric study

OBJECTIVE

To determine availability and characteristics of pulmonary rehabilitation programs performed in 2019 in family health centers and hospitals from Chile.

METHODOLOGY

A descriptive and retrospective study was designed, considering PR programs operated in 2019. A non-probability and convenience sample was obtained. Availability and characteristics of centers and PR were measured using a questionnaire translated, modified, validated, and sent by email.

RESULTS

Out of 80 responses (22.8%), 60% of centers offered PR program, where the lack of time was the greatest barrier. The programs were mainly outpatient, non-personalized, with 10(IQR 4-11) participants, 12 (IQR 12-16) weeks of length, with 2.4 ± 0.6 session/week, and 1 (IQR 1-2) hours/session. Chronic Obstructive Pulmonary Disease (COPD) was the most frequent diagnostic. The programs were mainly comprised of strength training exercises of lower extremity, upper extremity, walking and education. Team was constituted of physiotherapist and physician, with completed training, and directed by a physiotherapist. Modified Borg, MRC dyspnea scale, six-minute walking test and oximetry were used in the assessments. Between 40-80% of patients completed PR, and the major barrier was patient relocated.

CONCLUSION

Increasing PR availability, homogenization of exercises and education, prioritization of assessments supported by scientific evidence, and inclusion of follow-up could be useful to improve the access, quality and results of the treatment, considering new models of PR that allow greater access and acceptability.

Personalised exercise therapy and self-management support for people with multimorbidity: feasibility of the MOBILIZE intervention

BACKGROUND

Exercise therapy is safe and effective in people with single conditions, but the feasibility in people with two or more conditions is unclear. Therefore, the aim was to evaluate the feasibility of exercise therapy and self-management in people with multimorbidity prior to a randomised, controlled trial (RCT).

METHODS

This was a mixed-methods feasibility study performed in two general hospitals and one psychiatric hospital. 20 adult patients (8 females; mean age (SD) 67 (6.9)) with at least two long-term conditions and a score of ≥ 3 on Disease Burden Impact Scale for at least one condition (at least moderate limitations of daily activities) and of ≥ 2 for at least one other condition. Patients with unstable health conditions, at risk of serious adverse events (SAE) or with terminal conditions were excluded. Participants received 12 weeks of exercise (18 60-min group-based and 6 home-based sessions) and self-management support (6 90-min group-based sessions) supervised by physiotherapists. Pre-defined progression to RCT criteria were the primary outcomes and included recruitment rate (acceptable 20 participants in 3 months), retention through follow-up (75% retention), compliance (75% complete > 9 of exercise and > 3 self-management sessions), outcome burden (80% do not find outcomes too burdensome), improvement in quality of life (EQ-5D-5L) and function (6-min walk test; ≥ 50% experience clinically relevant improvements) and intervention-related SAEs (No SAEs). Furthermore, a purposeful sample including eleven participants and two facilitators were interviewed about their experiences of participating/facilitating. Qualitative data was analysed using thematic analysis.

RESULTS

Recruitment rate (20 in 49 days), retention (85%), outcome burden (95%), and SAEs (0 related to intervention) were acceptable, while compliance (70%) and improvements (35% in quality of life, 46% in function) were not (amendment needed before proceeding to RCT). The intervention was found acceptable by both participants and physiotherapists with some barriers among participants relating to managing multiple chronic conditions while caring for others or maintaining a job. Physiotherapists expressed a need for additional training.

CONCLUSIONS

Exercise therapy and self-management are feasible in people with multimorbidity. The subsequent RCT, amending the intervention according to progression criteria and feedback, will determine whether the intervention is superior to usual care alone.

TRIAL REGISTRATION

ClinicalTrials.gov registration: NCT04645732 Open Science Framework https://osf.io/qk6yg/.

The Impact of Wearable Devices on Physical Activity for Chronic Disease Patients: Findings from the 2019 Health Information National Trends Survey

BACKGROUND

Wearable devices are shown to be an advanced tool for chronic disease management, but their impacts on physical activity remain uninvestigated. This study aims to examine the effect of wearable devices on physical activity in general people and chronic patients.

METHODS

Our sample was from the third cycle of the fifth iteration of the Health Information National Trends Survey (HINTS), which includes a total of 5438 residents. Genetic matching was used to evaluate the effect of wearable devices on physical activity in different populations.

RESULTS

(1) Both using wearable devices and using them with high frequency will improve physical activity for the whole population. (2) Wearable devices may have greater positive effects on physical activity for chronic patients. (3) Especially in patients with hypertension, high-frequency use of wearable devices can significantly improve the duration and frequency of physical activity.

CONCLUSIONS

Wearable devices lead to more physical activity, and the benefit is more noticeable for chronic patients, particularly those with hypertension.

Recognising the importance of chronic lung disease: a consensus statement from the Global Alliance for Chronic Diseases (Lung Diseases group)

BACKGROUND

Chronic respiratory diseases are disorders of the airways and other structures of the lung, and include chronic obstructive pulmonary disease (COPD), lung cancer, asthma, bronchiectasis, interstitial lung diseases, occupational lung diseases and pulmonary hypertension. Through this article we take a broad view of chronic lung disease while highlighting (1) the complex interactions of lung diseases with environmental factors (e.g. climate change, smoking and vaping) and multimorbidity and (2) proposed areas to strengthen for better global patient outcomes.

CONCLUSION

We suggest new directions for the research agenda in high-priority populations and those experiencing health disparities. We call for lung disease to be made a research priority with greater funding allocation globally.

Taking Charge After Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Randomized Controlled Feasibility Trial of a Psychologically Informed Self-Management Intervention

Purpose

Few interventions improve outcomes for people with Chronic Obstructive Pulmonary Disease (COPD), particularly higher risk groups such as those admitted to hospital with an acute exacerbation of COPD (AECOPD). The aim of the study was to test the feasibility and acceptability of a modified version of the Take Charge program in people after AECOPD and to determine the potential to improve self-reported limitations, health-related quality of life and reduce future hospitalizations.

Patients and Methods

A prospective, parallel group randomized trial with blinded endpoint assessment. Participants had been discharged from hospital with a diagnosis of AECOPD and were randomized to receive either a single 60-90 minute session of "Take Charge for COPD" from a trained facilitator in their own home or usual care. Take Charge is a "talking therapy" that encourages a sense of purpose, autonomy, mastery, and connectedness with others. The primary outcome was the rate of moderate or severe episodes of AECOPD in the subsequent 12 months.

Results

Fifty-six people were randomized (study target 60): predominantly European (71%), female (61%), older (mean [SD] age 70 [11] years), and non-smokers (89%). Charlson Comorbidity Index mean (SD) score was 2.3 (1.6) indicating mild to moderate comorbidity severity. There were 85 moderate or severe AECOPD episodes in the 12 months after the index admission for the Take Charge participants and 84 episodes in the control group (relative rate 0.93; 95% confidence interval (CI) 0.69 to 1.26). COPD Clinical Questionnaire (CCQ) scores were significantly lower (better) in the Take Charge group (mean difference -1.26; 95% CI -2.06 to -0.45).

Conclusion

The Take Charge intervention proved feasible with a population of people recently discharged from hospital with AECOPD. The direction of change in the primary outcome and some secondary outcomes suggest that an adequately powered study is justified.

A systematic review of exercise studies for individuals hospitalized with an acute exacerbation of chronic obstructive pulmonary disease: Focus on the principles of exercise training

BACKGROUND

For exercise interventions to be effectively reproduced or applied in a "real world" clinical setting, clinical trials must thoroughly document all components of the exercise prescription and ensure that participants adhere to each component. However, previous reviews have not critically examined the quality of exercise prescription of inpatient Pulmonary Rehabilitation (PR) programs.

OBJECTIVE

The objectives of this review were to evaluate the (a) application of the principles of exercise training, (b) reporting of the frequency, intensity, time and type (FITT) components of exercise prescription, and (c) reporting of patient's adherence to the FITT components in intervention studies for patients admitted to hospital for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

METHODS

Relevant scientific databases were searched for randomized controlled trials (RCTs) that compared in-hospital PR with usual care for people hospitalized with AECOPD. Title and abstract followed by full-text screening were conducted independently by two reviewers. Data were extracted and synthesized to evaluate the application of the principles of exercise training and the reporting/adherence of the FITT components.

RESULTS

Twenty-seven RCTs were included. Only two applied all principles of exercise training. Specificity was applied by 70%, progression by 48%, overload by 37%, initial values by 89% and diminishing returns and reversibility by 37% of trials. Ten trials adequately reported all FITT components. Frequency and type were the components most reported (85% and 81%, respectively), while intensity was less frequently reported (52%). Only three trials reported on the patient's adherence to all four components.

CONCLUSIONS

Studies have not adequately reported the exercise prescription in accordance with the principles of exercise training nor reported all the FITT components of the exercise prescription and patient's adherence to them. Therefore, interpretation of the current literature is limited and information for developing exercise prescriptions to individuals hospitalized with an AECOPD is lacking.

Personalised exercise therapy and self-management support for people with multimorbidity: Development of the MOBILIZE intervention

BACKGROUND

To our knowledge, there is no intervention which includes personalised exercise therapy and self-management support for people with multimorbidity, although these interventions may be as effective as for people with single chronic conditions. Therefore, we developed a novel intervention, including personalised exercise therapy and self-management support for people with multimorbidity.

METHODS

We followed the Medical Research Council framework and conducted one scoping review, five systematic reviews, two registry-based studies, one qualitative interview study and a mixed-methods feasibility study. Following an iterative approach, together with feedback from people with multimorbidity and relevant stakeholders, we developed the MOBILIZE intervention.

RESULTS

The intervention included 24 (60 minutes) sessions of personalised exercise therapy and 24 (30 minutes) sessions of self-management support twice a week for 12 weeks, delivered in small groups by specifically trained physiotherapists. The intervention targets physiological, psychosocial, behavioural, and contextual factors to improve health-related quality of life and physical function in people living with multimorbidity.

CONCLUSIONS

We developed a personalised exercise therapy and self-management support programme for people with multimorbidity. The intervention will be tested for its safety and effectiveness in a randomised controlled trial.

Pulmonary Rehabilitation in Patients with COVID-19-A Protocol for Systematic Review and Meta-Analysis

INTRODUCTION

Pulmonary rehabilitation (PR) is a well-established treatment for patients with chronic lung disease; however, its role in patients with COVID-19 has not been systematically studied. We provide a protocol outlining the methods and analyses that will be used in the systematic review.

METHODS

The methodology of this systematic review protocol has been filed in PROSPERO under the registration number CRD42022301418. Five electronic databases (PubMed, Web of Science, Cochrane Library, EBSCO, and CNKI databases) will be searched from 2019 to 28 July 2022, using pre-determined search terms. Eligibility criteria will be defined using a PICOS framework. Pulmonary function, exercise capacity, and health-related quality of life will be the primary outcomes. Quantitative findings will be narratively synthesized, whilst argument synthesis combined with refutational analysis will be employed to synthesize qualitative data.

RESULTS

The results will be presented by both meta-analysis and qualitative analysis.

CONCLUSION

This protocol describes what will be the first systematic review to conduct a worldwide assessment of the effect of PR in patients with COVID-19. Because this is a systematic review and meta-analysis, no ethical approval is needed. The systematic review and meta-analysis will be published in a peer-reviewed journal and disseminated both electronically and in print.

Does pulmonary rehabilitation address treatable traits? A systematic review

BACKGROUND

There is growing interest in a "treatable traits" approach to pulmonary rehabilitation in chronic airways disease. The frequency with which pulmonary rehabilitation programmes address treatable traits is unknown.

METHODS

Randomised controlled trials of pulmonary rehabilitation compared to usual care in patients with stable chronic airways disease were included. The components of pulmonary rehabilitation delivered were extracted and mapped to treatable traits in pulmonary, extrapulmonary and behavioural/lifestyle domains. Meta-analysis was used to evaluate the impact of addressing >1 treatable trait on exercise capacity and health-related quality of life (HRQoL).

RESULTS

116 trials were included (6893 participants). Almost all pulmonary rehabilitation programmes addressed deconditioning (97% of trials). The most commonly addressed extrapulmonary traits were nutritional status (obesity and cachexia, 18% each) and mood disturbance (anxiety and depression, 10% each). Behavioural/lifestyle traits most frequently addressed were nonadherence (46%), poor inhalation technique (24%) and poor family/social support (19%). Exercise capacity and HRQoL outcomes did not differ between studies that addressed deconditioning alone and those that targeted additional traits, but heterogeneity was high.

CONCLUSION

Aside from deconditioning, treatable traits are infrequently addressed in existing trials of pulmonary rehabilitation. The potential of the treatable traits approach to improve pulmonary rehabilitation outcomes remains to be explored.

Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis

INTRODUCTION

Despite proven effectiveness for people with chronic respiratory diseases, practical barriers to attending centre-based pulmonary rehabilitation (centre-PR) limit accessibility. We aimed to review the clinical effectiveness, components and completion rates of home-based pulmonary rehabilitation (home-PR) compared to centre-PR or usual care.

METHODS AND ANALYSIS

Using Cochrane methodology, we searched (January 1990 to August 2021) six electronic databases using a PICOS (population, intervention, comparison, outcome, study type) search strategy, assessed Cochrane risk of bias, performed meta-analysis and narrative synthesis to answer our objectives and used the Grading of Recommendations, Assessment, Development and Evaluations framework to rate certainty of evidence.

RESULTS

We identified 16 studies (1800 COPD patients; 11 countries). The effects of home-PR on exercise capacity and/or health-related quality of life (HRQoL) were compared to either centre-PR (n=7) or usual care (n=8); one study used both comparators. Compared to usual care, home-PR significantly improved exercise capacity (standardised mean difference (SMD) 0.88, 95% CI 0.32-1.44; p=0.002) and HRQoL (SMD -0.62, 95% CI -0.88--0.36; p<0.001). Compared to centre-PR, home-PR showed no significant difference in exercise capacity (SMD -0.10, 95% CI -0.25-0.05; p=0.21) or HRQoL (SMD 0.01, 95% CI -0.15-0.17; p=0.87).

CONCLUSION

Home-PR is as effective as centre-PR in improving functional exercise capacity and quality of life compared to usual care, and is an option to enable access to pulmonary rehabilitation.

Inspiratory Muscle Rehabilitation Training in Pediatrics: What Is the Evidence?

Pulmonary rehabilitation is typically used for reducing respiratory symptoms and improving fitness and quality of life for patients with chronic lung disease. However, it is rarely prescribed and may be underused in pediatric conditions. Pulmonary rehabilitation can include inspiratory muscle training that improves the strength and endurance of the respiratory muscles. The purpose of this narrative review is to summarize the current literature related to inspiratory muscle rehabilitation training (IMRT) in healthy and diseased pediatric populations. This review highlights the different methods of IMRT and their effects on respiratory musculature in children. Available literature demonstrates that IMRT can improve respiratory muscle strength and endurance, perceived dyspnea and exertion, maximum voluntary ventilation, and exercise performance in the pediatric population. These mechanistic changes help explain improvements in symptomology and clinical outcomes with IMRT and highlight our evolving understanding of the role of IMRT in pediatric patients. There remains considerable heterogeneity in the literature related to the type of training utilized, training protocols, duration of the training, use of control versus placebo, and reported outcome measures. There is a need to test and refine different IMRT protocols, conduct larger randomized controlled trials, and include patient-centered clinical outcomes to help improve the evidence base and support the use of IMRT in patient care.

Efficacy of Repeating Pulmonary Rehabilitation in People with COPD: A Systematic Review

Background

Pulmonary rehabilitation is an effective intervention for people with chronic obstructive pulmonary disease (COPD). People with COPD undertake repeat programs, but synthesis of evidence regarding such practice has not been undertaken. The aim of this systematic review was to establish the effects of repeating pulmonary rehabilitation subsequent to an initial program in people with COPD.

Methods

Studies where participants with COPD undertook >1 pulmonary rehabilitation program were included, incorporating RCT (randomized controlled trial) and non-randomized studies. Electronic database searches were undertaken. Two authors independently undertook study identification, data extraction and risk of bias assessment. The primary outcome was health-related quality of life (HRQoL); secondary outcomes were exercise capacity, hospitalizations and exacerbations, adherence, mortality and adverse events. Narrative synthesis was undertaken for clinically heterogeneous trials. Data from RCTs and non-randomized studies were not combined for analysis.

Results

Ten included studies (2 RCTs) involved 907 participants with COPD (n=653 had undertaken >1 program). The majority of studies were at high risk of bias. One RCT (n=33) reported no difference in HRQol after a repeat program vs usual care following exacerbation (Chronic Respiratory Disease Questionnaire dyspnea domain score MD 0.4, 95% CI -0.5 to 3). In stable patients, clinically important and statistically significant improvements in HRQoL and exercise capacity were reported after repeat programs, but of a smaller magnitude than initial programs. There was evidence for reductions in exacerbations and hospitalizations, and shorter hospital length of stay for patients who repeated a program twice in 12 months compared to those who repeated once. No data for mortality or adverse events were available.

Conclusion

This systematic review provides limited evidence for benefits of repeating pulmonary rehabilitation in people with COPD, including improved HRQoL and exercise capacity, and reduced hospitalizations. However, most studies have high risk of bias, which reduces the certainty of these conclusions.

Study Registration

PROSPERO (CRD42020215093).

Scientific Evidence of Traditional Chinese Exercise (Qigong) for Chronic Obstructive Pulmonary Disease: An Overview of Systematic Reviews and Meta-Analyses

Background

As a traditional Chinese exercise, Qigong has potential benefits for the management of chronic obstructive pulmonary disease (COPD). This overview is aimed at assessing the existing evidence for the intervention of Qigong in COPD so as to provide scientific guidance for clinical decision-making.

Methods

The systematic reviews (SRs)/meta-analyses (MAs) of Qigong for the treatment of COPD were obtained from 7 electronic databases with the search date set at April 5, 2022. Two researchers independently assessed the methodological quality, reporting quality, and evidence quality for the included SRs/MAs using the following tools: the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2), the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020), and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Results

A total of 13 SRs/MAs were included in this overview. All SRs/MAs assessed by AMSTAR-2 had more than one critical defect, so all SR/MAs were rated very low. Regarding the assessment of reporting quality, the results of PRISMA 2020 showed that none of the SRs/MAs were fully reported. In addition, the results of the GRADE assessment of the quality of evidence indicated that only 3 outcomes were rated as high quality across all SRs/MAs.

Conclusion

Current evidence suggests that Qigong is effective and safe for the management of patients with COPD. However, the high risk of bias in the original clinical studies and the low quality of the SRs/MAs reduced the reliability of the results.

Giving Voice to People - Experiences During Mild to Moderate Acute Exacerbations of COPD

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) have a negative impact on health status and disease progression, but their clinical presentation is heterogenous. A comprehensive understanding of individuals' experiences during an AECOPD is needed to develop person-centered interventions, such as pulmonary rehabilitation (PR). This study aimed to explore people's experiences during mild to moderate AECOPDs, and their thoughts on PR during this period.

METHODS

Short, semi-structured interviews were conducted with people with mild to moderate AECOPDs treated on an outpatient basis within 48 hours of the diagnosis. Interviews were audio recorded, transcribed, and analyzed by deductive thematic analysis using the Web Qualitative Data Analysis software.

RESULTS

Eleven people with AECOPDs (9 male, 67±10 years, forced expiratory volume in 1 second 41±16%predicted) participated. Four themes and 17 subthemes were identified: impact of an AECOPD (symptoms, physiological changes, limitations in activities of daily living, social constraints, psychological and emotional challenges, family disturbances); dealing with an AECOPD, ([not] depending on others, planning and compensation strategies); main needs during an AECOPD (breathe better, feel less tired, get rid of sputum, be able to walk); and (un)certainty about PR (lack of knowledge, getting better, exercises, design and timing, trust in health professionals).

CONCLUSION

AECOPDs, even when not requiring hospital admission, have a huge negative impact on people's lives. Individuals' thoughts about PR reflect the need to raise awareness for this intervention during AECOPDs. This study provides a foundation for the development of meaningful person-centered interventions during AECOPDs.