The Medical Research Council dyspnea scale in the estimation of disease severity in idiopathic pulmonary fibrosis

Association of patient-reported outcome measures with lung function and mortality in fibrotic interstitial lung disease: a prospective cohort study

Background

Patient-reported outcome measures (PROMs) may provide clinicians and researchers with direct insights into disease impact and patient well-being. We assessed whether selected PROMs and their domains are associated with baseline and longitudinal changes in lung function and can predict mortality in patients with fibrotic interstitial lung disease (f-ILD).

Methods

A single-centre prospective study of adult patients with f-ILD enrolled over 3 years was conducted assessing baseline and short-term changes in PROMs. Three questionnaires, the modified Medical Research Council dyspnoea scale (mMRC), Chronic Respiratory Questionnaire (CRQ) and Self-Management Ability Scale (SMAS-30) were administered at planned intervals and assessed for their association with baseline clinical findings, change in lung function (% predicted forced vital capacity (FVC%) and diffusion capacity of the lung for carbon monoxide (DLCO%)) and all-cause mortality.

Results

199 patients were enrolled with a mean PROM follow-up of 9.6 months. When stratified by FVC% quartiles at presentation, lower mMRC (less dyspnoea), higher CRQ Physical and Emotional domain (better health-related quality of life) and higher total SMAS-30 scores (better self-management ability) were associated with higher FVC%. Short-term changes in all three PROMs appeared to be associated with changes in FVC% and DLCO%. Adjusted and unadjusted baseline and serial PROM changes were also predictive of mortality.

Conclusions

Baseline and serial assessments of PROMs were associated with changes in lung function and predicted death in patients with f-ILD. PROMs may strengthen comprehensive assessments of disease impact in clinical practice as well as support patient-centred outcomes in research.

Therapeutic Approaches for the Treatment of Interstitial Lung Disease: An Exploratory Review on Molecular Mechanisms

BACKGROUND

Interstitial Lung Diseases (ILDs) are characterized by shortness of breath caused by alveolar wall inflammation and/or fibrosis.

OBJECTIVE

Our review aims to study the depth of various variants of ILD, diagnostic procedures, pathophysiology, molecular dysfunction and regulation, subject and objective assessment techniques, pharmacological intervention, exercise training and various modes of delivery for rehabilitation.

METHOD

Articles are reviewed from PubMed and Scopus and search engines.

RESULTS

ILD is a rapidly progressing disease with a high mortality rate. Each variant has its own set of causal agents and expression patterns. Patients often find it challenging to self-manage due to persistent symptoms and a rapid rate of worsening. The present review elaborated on the pathophysiology, risk factors, molecular mechanisms, diagnostics, and therapeutic approaches for ILD will guide future requirements in the quest for innovative and tailored ILD therapies at the molecular and cellular levels.

CONCLUSION

The review highlights the rationale for conventional and novel therapeutic approaches for better management of ILD.

Measure of lung dielectric proprieties in patients with Idiopathic Pulmonary Fibrosis: correlation with clinical, radiological and pulmonary functional parameters

BACKGROUND

Dielectric properties of biological tissues are biophysical parameters; in lung they change with amount of air, blood and parenchyma. Remote Dielectric Sensing (ReDS™) technology measures dielectric properties of lung tissues quantifying the content of fluids inside the scan volume. We aimed to evaluate the reliability of ReDS™ measure in Idiopathic Pulmonary Fibrosis (IPF) patients and in healthy volunteers, and to investigate the correlation of ReDS™ score with clinical, radiological and functional parameters.

METHODS

We conducted a prospective observational study, including 52 patients with diagnosis of IPF and 17 healthy volunteers; for each patient we recorded: complete functional evaluation, dyspnoea score (mMRC scale), Usual Interstitial Pneumonia (UIP) Computed Tomography (CT) pattern (UIP definite or probable) and ReDS™ measure (expressed in %).

RESULTS

ReDS™ measure was reported as correct both in patients and controls, the firsts with higher scores (33.8% vs 29.1%, p = 0.003). In IPF patients we observed a significant inverse correlation with ReDS™ score and Forced Vital Capacity (FVC), Vital Capacity (VC) and Total Lung Capacity (TLC) measures and, when we considered only patients with UIP definite CT pattern, the correlation was inverse with FVC, VC, TLC, DLCO. In IPF patients the higher was mMRC dyspnoea index, the higher was ReDS™ score. No significant correlations were observed between ReDS™ score and functional parameters in healthy controls.

DISCUSSION

We demonstrated a correlation of ReDS™ scores with some functional (mainly indicative or diagnostic for restriction) and clinical parameters in IPF patients; the score was correlated with density of tissues possibly quantifying tissue fibrosis in IPF patients.

Influence of home-based pulmonary rehabilitation program among people with interstitial lung disease: A pre-post study

INTRODUCTION

Access to interstitial lung disease programs may not be available in rural settings. Home-based pulmonary rehabilitation (PR) programs have been proposed as an alternative to hospital-based programs.

METHOD

Forty participants with ILD underwent a structured unsupervised home-based pulmonary rehabilitation program from September 2020 to September 2022. Quality of life was assessed using St. George Respiratory Questionnaire (SGRQ) and functional capacity using 6-minute walk test (6MWT). The outcome measures were assessed at baseline and 4 weeks post-unsupervised home-based PR program.

RESULT

We recruited 40 participants with ILD. There was statistically significant improvement in the 6-minute walk distance (353.8 m and 368 m, effect size - 0.5, p ≤ .001) and quality of life using SGRQ total score (38.6 and 42.35, effect size - 2.5, p ≤ .001) between before and after receiving home-based PR among all 40 participants with ILD.

CONCLUSION

Four weeks of home-based PR program, using minimal resources, deliver short-term improvements in functional exercise capacity and quality of life among ILD participants. Our home-based PR program resulted in a quarter percentage improvement in functional capacity, and we believe that if consistency is maintained, it will result in similar changes corresponding to the already established Minimal Clinically Important Difference (MCID) of 35 m.

Expectations, symptoms, and quality of life before and after 1 year of Pirfenidone treatment in patients with idiopathic pulmonary fibrosis: A single-arm, open-label nonrandomized study

Background and Aims

Antifibrotic therapies reduce lung function decline in patients with idiopathic pulmonary fibrosis (IPF). This single-arm, open-label, nonrandomized study aimed to determine the influence of antifibrotic treatment on patients' reported symptoms and expectations of the therapy.

Methods

Fifty-two patients with confirmed IPF at a mean age of 65 ± 8.63 years (73% male) completed the following surveys at baseline and after 12 months of Pirfenidone treatment: Short Form Healthy Survey (SF-36), St. George's Respiratory Questionnaire (SGRQ), Baseline Dyspnea Index (BDI), Fatigue Assessment Scale (FAS), Leicester Cough Questionnaire (LCQ), and Patient's Needs and Expectations Authors' Survey.

Results

The most important patients' needs were access to novel therapy, fast and easy access to health centers specializing in IPF treatment, and the improvement of the general condition or the maintenance of its level. These needs did not change with time, except for the significantly more important right of deciding on disease management after 12 months of treatment (p = 0.014). The quality of life per SF-36, after 1 year of Pirfenidone treatment, significantly improved in the physical cumulative score (p = 0.004) and mental cumulative score (p = 0.003). Significant deteriorations were observed in bodily pain and vitality. For the remaining questionnaires (SGRQ, BDI, FAS, and LCQ), no significant changes in the course of the study were noticed. Around one in 10 patients subjected to Pirfenidone therapy had achieved general symptom improvement in all areas; that is, quality of life improvement as well as cough and dyspnea reduction.

Conclusions

One year of antifibrotic treatment resulted in a general improvement in the quality of life per the SF-36 questionnaire. Patients' expectations of disease management did not change; also, access to novel therapies and easy access to health centers specializing in IPF management remained their top needs.

Home-Based Pulmonary Rehabilitation and Health Coaching in Fibrotic Interstitial Lung Disease: IMPLEMENTATION AND QUALITATIVE ASSESSMENT OF A PILOT TELEHEALTH PROGRAM

PURPOSE

Pulmonary rehabilitation is a behavioral modification intervention shown to improve exercise tolerance and patient-reported quality of life in patients with fibrotic interstitial lung disease. Home-based rehabilitation may provide easier access for those who struggle to complete center-based rehabilitation programs due to increased symptom burden or frailty.

METHODS

We present the quantitative and qualitative findings of a pilot study of 21 patients with fibrotic interstitial lung disease who participated in a 12-wk home-based pulmonary rehabilitation program with activity monitoring and health coaching.

RESULTS

Pre- and post-intervention patient-reported outcome questionnaires suggested improvements in dyspnea and respiratory-related quality of life but were underpowered to meet statistical significance. Half had increases in mean daily step counts while a quarter declined because of disease progression. Qualitative analysis of semistructured participant interviews suggested a significant baseline disease burden with related secondary impacts, including anxiety regarding disease progression and prognosis. Many who participated had no specific program expectations or self-determined goals but still found the program impactful, particularly on their abilities to adapt and cope with the disease.

CONCLUSION

Our study suggests feasibility in a diverse set of patients with varying severity and diagnostic subtypes. We also provide quantitative and qualitative aspects of program impact on patient well-being and highlight the complex interaction between measured physical and self-reported outcomes and disease experience.

Impact of physical functional capacity on quality of life in patients with interstitial lung diseases

This study aimed to investigate the physical functioning predictors for health-related quality of life (HRQL) decline in patients with idiopathic interstitial fibrosis (IPF), sarcoidosis and other interstitial lung disease (ILD). The study enrolled 52 patients with ILD and 16 healthy individuals. Participants' HRQL was assessed using the 36-item Short-Form Health Survey questionnaire. Spirometry, physical performance, and daily physical activity (PA) were monitored. Patients with IPF showed significantly lower PA compared to patients with other ILD (p =0.002)and sarcoidosis (p =0.01). The type of disease aetiology had no significant effect on aerobic capacity, HRQL and fatigue. Patients with ILD showed significant greater fatigue, lower physical functioning and greater physical aspects scores compared to the control group (F=6.0; p=0.018; F=12.64; p=0.001, respectively). A significant positive correlation was observed between 6-minute walking distance (6MWD) and the physical domain of HRQL (r=0.35, p=0.012) and PA and the physical aspects of HRQL (r=0.37, p=0.007). This study revealed that the key predictors for HRQL decline were lower lung function, lower PA and physical performance.

Clinical outcomes of dose modification during pirfenidone treatment for IPF: A nationwide post-marketing surveillance study

Background: Pirfenidone, an antifibrotic medication approved for the treatment of idiopathic pulmonary fibrosis (IPF), often requires dose reduction owing to adverse events. In this study, we evaluated if pirfenidone's reduced dose has any impact on clinical outcomes in patients with IPF. Methods: We used the data of a prospective post-marketing study of pirfenidone conducted at 10 hospitals in South Korea from 2014 to 2017. Dose reduction was defined when the pirfenidone dose was temporarily or permanently reduced to manage adverse events or when the treatment dose failed to reach the standard dose. Study patients were classified based on the most frequently administered dose during 48-week follow-up-1800 mg, 1,200 mg, and <1,200 mg/days. The following clinical outcomes were compared between the groups: death, hospitalization, acute exacerbation, pulmonary function decline, and changes in severity of dyspnea and cough. Results: The median follow-up duration in all 143 patients was 11 months. During the study period, 70.6% experienced at least one dose reduction. Patients treated with standard-dose pirfenidone tended to be young and had the lowest diffusing capacity. Pulmonary function changes did not differ depending on the pirfenidone dose. The three groups were not significantly different in terms of the proportion of death, hospitalization, and acute exacerbation. The symptom changes were also similar between the groups. Conclusion: Reduced doses did not negatively impact clinical outcomes compared with the standard-dose pirfenidone in patients with IPF. Dose reduction may be a useful method to manage adverse events while maintaining therapeutic efficacy.

Baseline characteristics of systemic sclerosis patients with restrictive lung disease in a multi-center US-based longitudinal registry

AIM

Interstitial lung disease (ILD) is the leading cause of disease-related death in systemic sclerosis (SSc). Here, we assess baseline characteristics of SSc subjects with and without restrictive lung disease (RLD) in a multi-center, US-based registry.

METHODS

SSc patients within 5 years of disease onset were enrolled in the Collaborative National Quality and Efficacy Registry (CONQUER), a multi-center US-based registry of SSc study participants (age ≥ 18 years) enrolled at 13 expert centers. All subjects met 2013 American College of Rheumatology / European League Against Rheumatism criteria. Subjects with a pulmonary function test (PFT) at baseline before April 1, 2020 were included. High-resolution computed tomography scan of the chest was not available to characterize ILD for all subjects. RLD was defined as forced vital capacity (FVC) <80% or total lung capacity (TLC) <80% predicted.

RESULTS

There were 160 (45%) SSc subjects characterized as having RLD. There was no significant difference in age, gender or disease duration. RLD subjects had a mean disease duration from date of first non-Raynaud's symptom of 2.6 years and a mean FVC% predicted of 67% at baseline. In multivariable analysis, non-White race, higher physician global health assessment and modified Medical Research Council (mMRC) dyspnea scores, were independently associated with RLD. In the subgroup of RLD subjects with ILD, ILD had a negative correlation with RNA polymerase III antibody.

CONCLUSION

CONQUER is the largest, multi-center, prospective cohort of early SSc patients in the US. Non-White race was independently associated with RLD. In addition, 45% of CONQUER subjects already had RLD, highlighting the importance of screening for SSc-ILD at initial diagnosis.

Environmental hazards and demographic and clinical data of childhood interstitial lung diseases in a tertiary institute in Egypt

Background

The incidence of childhood interstitial lung diseases increased in the last years in Egypt. Changes in environmental and climatic conditions may be contributing factors. Also, raising birds at home increased in the past years due to financial issues. Other environmental factors include increased industries, traffic, and pollution. Our study aimed to assess the environmental hazards and the severity of childhood interstitial lung diseases.

Results

Sixty-five percent of patients with childhood interstitial lung diseases (chILD) were exposed to cigarette smoke; 45% were exposed to birds, 30% to industrial wastes, 20% to grass and pesticides, and 10% to animals.

Conclusions

Exposure to cigarette smoke and birds increases the risk of development of chILD.

High intensity interval training versus moderate intensity continuous training for people with interstitial lung disease: protocol for a randomised controlled trial

Background

Interstitial lung disease is a debilitating condition associated with significant dyspnoea, fatigue, and poor exercise tolerance. Pulmonary rehabilitation is an effective and key intervention in people with interstitial lung disease. However, despite the best efforts of patients and clinicians, many of those who participate are not achieving clinically meaningful benefits. This assessor-blinded, multi-centre, randomised controlled trial aims to compare the clinical benefits of high intensity interval exercise training versus the standard pulmonary rehabilitation method of continuous training at moderate intensity in people with fibrotic interstitial lung disease.

Methods

Eligible participants will be randomised to either a standard pulmonary rehabilitation group using moderate intensity continuous exercise training or high intensity interval exercise training. Participants in both groups will undertake an 8-week pulmonary rehabilitation program of twice-weekly supervised exercise training including aerobic (cycling) and strengthening exercises. In addition, participants in both groups will be prescribed a home exercise program.

Outcomes will be assessed at baseline, upon completion of the intervention and at six months following the intervention by a blinded assessor. The primary outcome is endurance time on a constant work rate test. Secondary outcomes are functional capacity (6-min walk distance), health-related quality of life (Chronic Respiratory Disease Questionnaire (CRQ), St George’s Respiratory Questionnaire idiopathic pulmonary fibrosis specific version (SGRQ-I), breathlessness (Dyspnoea 12, Modified Medical Research Council Dyspnoea Scale), fatigue (fatigue severity scale), anxiety (Hospital Anxiety and Depression Scale), physical activity level (GeneActiv), skeletal muscle changes (ultrasonography) and completion and adherence to pulmonary rehabilitation.

Discussion

The standard exercise training strategies used in pulmonary rehabilitation may not provide an optimal exercise training stimulus for people with interstitial lung disease. This study will determine whether high intensity interval training can produce equivalent or even superior changes in exercise performance and symptoms. If high intensity interval training proves effective, it will provide an exercise training strategy that can readily be implemented into clinical practice for people with interstitial lung disease.

Trial registration ClinicalTrials.gov Registry (NCT03800914). Registered 11 January 2019, https://clinicaltrials.gov/ct2/show/NCT03800914

Australian New Zealand Clinical Trials Registry ACTRN12619000019101. Registered 9 January 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376050&isReview=true

ACR Appropriateness Criteria® Diffuse Lung Disease

Diffuse lung disease, frequently referred to as interstitial lung disease, encompasses numerous disorders affecting the lung parenchyma. The potential etiologies of diffuse lung disease are broad with several hundred established clinical syndromes and pathologies currently identified. Imaging plays a critical role in diagnosis and follow-up of many of these diseases, although multidisciplinary discussion is the current standard for diagnosis of several DLDs. This document aims to establish guidelines for evaluation of diffuse lung diseases for 1) initial imaging of suspected diffuse lung disease, 2) initial imaging of suspected acute exacerbation or acute deterioration in cases of confirmed diffuse lung disease, and 3) clinically indicated routine follow-up of confirmed diffuse lung disease without acute deterioration. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Psychometric properties of patient reported outcome measures in idiopathic pulmonary fibrosis

BACKGROUND

Various patient reported outcome measures (PROMs) are used in idiopathic pulmonary fibrosis (IPF). We aimed to describe their psychometric properties, assess their relationship with 1-year mortality and determine their minimal clinically important differences (MCIDs).

METHODS

In a prospective multicentre study, participants with IPF completed the King's Brief Interstitial Lung Disease Questionnaire (K-BILD), the modified Medical Research Council (mMRC) dyspnoea scale, St George's Respiratory Questionnaire (SGRQ) and University of California, San Diego shortness of breath questionnaire (UCSD-SOBQ) three-monthly intervals over a 12-month period. Forced vital capacity (FVC) was matched with questionnaires and mortality was captured. Anchor- and distribution-based methods were used to derive MCID.

RESULTS

Data were available from 238 participants. All PROMs had good internal consistency and high degree of correlations with other tools (except UCSD-SOBQ correlated poorly with FVC). There were significant associations with mortality for K-BILD (hazard ratio 16.67; 95% CI 2.38-100) and SGRQ (hazard ratio 4.65; 95% CI 1.32-16.62) but not with the other PROMs or FVC. The median MCID (range) for K-BILD was 6.3 (4.1-7.0), SGRQ was 7.0 (3.8-9.6), mMRC was 0.4 (0.1-0.5) and UCSD-SOBQ was 9.6 (4.1-14.2).

CONCLUSIONS

The K-BILD was related to other severity measures and had the strongest relationship with mortality.

A telerehabilitation programme in post-discharge COVID-19 patients (TERECO): a randomised controlled trial

Objectives

To investigate superiority of a telerehabilitation programme for COVID-19 (TERECO) over no rehabilitation with regard to exercise capacity, lower limb muscle strength (LMS), pulmonary function, health-related quality of life (HRQOL) and dyspnoea.

Design

Parallel-group randomised controlled trial with 1:1 block randomisation.

Setting

Three major hospitals from Jiangsu and Hubei provinces, China.

Participants

120 formerly hospitalised COVID-19 survivors with remaining dyspnoea complaints were randomised with 61 allocated to control and 59 to TERECO.

Intervention

Unsupervised home-based 6-week exercise programme comprising breathing control and thoracic expansion, aerobic exercise and LMS exercise, delivered via smartphone, and remotely monitored with heart rate telemetry.

Outcomes

Primary outcome was 6 min walking distance (6MWD) in metres. Secondary outcomes were squat time in seconds; pulmonary function assessed by spirometry; HRQOL measured with Short Form Health Survey-12 (SF-12) and mMRC-dyspnoea. Outcomes were assessed at 6 weeks (post-treatment) and 28 weeks (follow-up).

Results

Adjusted between-group difference in change in 6MWD was 65.45 m (95% CI 43.8 to 87.1; p<0.001) at post-treatment and 68.62 m (95% CI 46.39 to 90.85; p<0.001) at follow-up. Treatment effects for LMS were 20.12 s (95% CI 12.34 to 27.9; p<0.001) post-treatment and 22.23 s (95% CI 14.24 to 30.21; p<0.001) at follow-up. No group differences were found for lung function except post-treatment maximum voluntary ventilation. Increase in SF-12 physical component was greater in the TERECO group with treatment effects estimated as 3.79 (95% CI 1.24 to 6.35; p=0.004) at post-treatment and 2.69 (95% CI 0.06 to 5.32; p=0.045) at follow-up.

Conclusions

This trial demonstrated superiority of TERECO over no rehabilitation for 6MWD, LMS, and physical HRQOL.

Trial registration number

ChiCTR2000031834.

Providing Patient-Centered Care in Interstitial Lung Disease

There have been growing interest in and emphasis on health systems adopting a patient-centered care (PCC) approach, which focuses on providing care that is respectful and responsive to patient preferences, needs, and values. The features of PCC can fall into 3 domains: structure, process, and outcomes. These domains encompass the necessary infrastructure and culture required to facilitate respectful and compassionate care and patient engagement. This review discusses the features that characterize each of these PCC domains and how they can be applied specifically to clinical care and research within the field of interstitial lung disease.

Right ventricular contractility decreases during exercise in patients with non-advanced idiopathic pulmonary fibrosis

Early right ventricular dysfunction in patients with non-advanced idiopathic pulmonary fibrosis (IPF) has not been fully elucidated. Thus, we aimed to assess right ventricular functions in IPF patients and controls by speckle-tracking strain echocardiography at rest and peak exercise.We screened 116 IPF patients from February to August 2019 to include 20 patients with no history of oxygen therapy, peripheral saturation levels ≥92% at rest, Gender-Age-Physiology Index score ≤5, and modified Medical Research Council score ≤3. Additionally, we enrolled 10 matched controls. Transthoracic echocardiography images were acquired at rest and during a cardiopulmonary exercise test. We analyzed 2-dimensional echocardiographic parameters and right ventricular function using the global longitudinal strain assessed by the 2-dimensional speckle-tracking technique.In the control group, we found normal values of right ventricle longitudinal strain (RVLS) at rest and at peak exercise, the latter being much more negative (-23.6 ± 2.2% and -26.8 ± 3.1%, respectively; P < .001). By contrast, RVLS values in the IPF group increased from -21.1 ± 3.8% at rest to -17.0 ± 4.5% at peak exercise (P < .001). The exercise revealed a difference between the 2 groups as the mean RVLS values moved during peak exercise in opposite directions. Patients with IPF got worse, whereas control patients presented improved right ventricular contractility.Right ventricular dysfunction was unveiled by speckle-tracking echocardiography during exercise in non-advanced IPF patients. We suggest that this reflects an inadequate right ventricular-arterial coupling decreasing the right ventricular longitudinal contraction during exercise in these patients. This parameter may be useful as an early index of suspected pulmonary hypertension.

Reliability and validity of the Glittre-ADL test to assess the functional status of patients with interstitial lung disease

The study objective was to investigated the reliability and validity of the ADL-Glittre test (TGlittre) to assess the functional status of patients with interstitial lung disease (ILD). Twenty-one individuals with ILD participated (age: 63 ± 11 years; DLCO: 51.0 ± 12.6%predicted), evaluated with body plethysmography, Saint George Respiratory Questionnaire, modified Medical Research Council dyspnea scale, six-minute walk test (6MWT) and monitoring of physical activity of daily living. Two TGlittre were performed, with an interval of 30 minutes between them. The TGlittre demonstrated high test-retest reliability, with an intraclass correlation coefficient of 0.90 (95%CI: 0.75–0.96; p < 0.001). Nineteen patients (90.5%) performed better on the second test (mean difference between TGlittre 1 and 2: −0.57 ± 0.96 minute; p = 0.001), with a learning effect of 11.6%. The time in TGlittre correlated with 6MWT (r = −0.70; p = 0.002) and with the total energy expenditure in physical activity of daily living (r = −0.52; p = 0.02). In %predicted, TGlittre and 6MWT also correlated (r = −0.50; p = 0.04). Correlations were observed between TGlittre and pulmonary function variables (r = −0.47 to −0.57; p = 0.01 to p = 0.04). There was no difference in the physiological response between TGlittre 1 and 2, and between TGlittre and 6MWT (p > 0.05). In conclusion, the TGlittre is reliable and valid for assessing functional status of patients with ILD.

Brain-heart autonomic axis across different clinical status and severity of chronic obstructive pulmonary disease

PURPOSE

Impairment of cardiac autonomic integrity is common in chronic obstructive pulmonary disease (COPD) patients. The influence of the interaction between clinical and severity status on brain-heart autonomic axis (BHAA) is not well known. We aimed to investigate the BHAA function across different clinical status and severity of COPD.

METHODS

Cross-sectional study involving 77 COPD patients allocated into four groups according to clinical status [acute exacerbation (GAE) or stable (GST)] and severity [less (-) or more (+)]: 1) GAE-, n = 13; 2) GAE+, n = 20; 3) GST-, n = 23; and 4) GST+, n = 21. Heart rate variability (HRV) at rest and heart rate recovery (HRR) after 6-min walk test were markers of BHAA. Mean R-R, STDRR, RMSSD, RRtri, HF, LF, SD1, SD2, ApEn and SampEn were the HRV indexes and, HRR was obtained as: HR at 1st min of recovery minus peak HR.

RESULTS

A main effect of clinical status (p < 0.001) was found to vagal modulation in GAE-vs. GST- (RMSSD: 25.0 ± 14.8 vs. 12.6 ± 5.5 ms; SD1: 18.0 ± 10.6 vs. 8.9 ± 3.9 ms) and to GAE + vs. GST+ (RMSSD: 26.4 ± 15.2 vs. 15.4 ± 6.3 ms; SD1: 18.3 ± 11.2 vs. 10.9 ± 4.5 ms). An effect of clinical status (p = 0.032) and severity (p = 0.030) were found to HF (vagal) in GAE + compared to GAE- and GST+ (264.7 ± 239.0 vs. 134.7 ± 169.7 and 135.8 ± 139.7 ms²). Lower HRR was found in GAE-compared to GST- (8.0 ± 2.4 vs. 19.6 ± 2.4 bpm), p = 0.002.

CONCLUSION

In COPD patients, clinical status (AECOPD or stable) was more dominant than the severity on BHAA function. A more pronounced parasympathetic modulation was found in AECOPD patients with a lower HRR to exercise.

Pulmonary rehabilitation in patients with interstitial lung diseases: Correlates of success

BACKGROUND AND AIM

Benefits of pulmonary rehabilitation in Interstitial Lung Diseases (ILD) have been reported. The aim of this large multicenter study was to identify the success predictors of pulmonary rehabilitation in a real-life setting.

METHODS

Data of 240 in-patients (110 idiopathic pulmonary fibrosis (IPF), 106 ILD other than IPF and 24 undetermined ILD) undergoing pulmonary rehabilitation in a 10-year period were retrospectively evaluated. Six minute walking distance (6MWT), body weight-walking distance product tests, dyspnoea and arterial blood gases were assessed at admission and discharge. Differences in post rehabilitation changes in outcome measures as function of baseline characteristics were evaluated.

RESULTS

After rehabilitation, patients showed improvements in all outcome measures (p < 0.05), regardless of the underlying diagnosis or disease severity. Patients needing oxygen therapy at rest showed reduced benefits. Baseline 6MWD inversely correlated with its changes at discharge. Non-significant greater benefits after rehabilitation were found in IPF patients under antifibrotic therapy. In a subset of 50 patients assessed on average 10.3 ± 3.5 months after discharge, the benefits in 6MWD were not maintained (312.9 ± 139.4, 369.7 ± 122.5 and 310.8 ± 139.6 m at admission, discharge and follow up respectively: p < 0.0001).

CONCLUSION

Pulmonary rehabilitation may improve dyspnoea, exercise capacity and fatigue in patients with ILD of different aethiologies and level of severity. The long-term effects need to be established.

Diaphragmatic thickness and excursion by lung ultrasound in pediatric chronic pulmonary diseases

PURPOSE

Many patients with chronic pulmonary diseases, such as interstitial lung disease, cystic fibrosis, and non-cystic fibrosis bronchiectasis, suffer from dyspnea and exercise intolerance. Reduced lung compliance is the main cause of the patients' dyspnea, but weak respiratory muscles could be an additional factor. The diaphragm is considered the major respiratory muscle. Our study aimed to detect diaphragmatic thickness and excursion by ultrasound in pediatric patients with chronic pulmonary diseases to assess respiratory muscle weakness in these patients.

METHODS

A case-control study was conducted on 130 patients with pediatric chronic pulmonary diseases (childhood interstitial lung diseases, cystic fibrosis, and non-cystic fibrosis bronchiectasis) and 100 control subjects. Ultrasound was used to detect diaphragmatic excursion and thickness, which were correlated with the severity of the disease, both clinically and functionally.

RESULTS

The right and left diaphragmatic excursions were significantly lower in the patients (19.469 ± 9.984 and 18.5 ± 10.131, respectively) than in the control subjects (29.6 ± 14.131 and 25.6 ± 12.827, respectively) (p values of 0.002 and 0.019). In contrast, the difference in the right and left diaphragmatic thicknesses between the patients and the controls was statistically insignificant (p values of 0.884 and 0.344). The left diaphragmatic excursion was positively correlated with the patients' age and weight, while both the right and the left diaphragmatic excursion significantly correlated with the patients' height, FEV1/FVC ratio, and heart rate.

CONCLUSION

The diaphragmatic excursion is lower in children and adolescents with chronic pulmonary diseases than in healthy control subjects. The diaphragmatic excursion is positively correlated with patients' age, weight, height, FEV1/FVC ratio, and heart rate.

Performance of semi-quantitative lung ultrasound in the assessment of disease severity in interstitial lung disease

BACKGROUND:

Accurate staging of disease severity and its serial monitoring thus is central to the effective management protocols of interstitial lung disease (ILD).

PURPOSE:

The aim is to evaluate the effectiveness of semi-quantitative parameters of lung ultrasound (LUS) in patients of ILD as a means of staging disease severity.

MATERIALS AND METHODS:

LUS of 47 patients of ILD and 20 age-matched controls was performed, and findings such as B-line distance, pleural thickening, subpleural changes, decreased lung sliding, and fragmented pleural lining were charted, and an LUS score was done using these parameters. Findings were compared with the Modified Medical Research Council (MMRC) dyspnea grade and spirometry parameters.

RESULTS:

The presence of B-lines and fragmented pleural lining were the most common findings observed in patients of ILD. Predicted forced vital capacity (FVC) and predicted forced expiratory volume in 1 s (FEV1) showed a good correlation with all the LUS parameters. B-line distance was the most significant LUS parameter to predict the variability in predicted FEVI, FVC, and MMRC dyspnea score. LUS severity score also showed good negative correlation with predicted FEV1 (r = −0.674, P < 0.001) and predicted FVC (r = −0.65, P < 0.001). LUS severity score of 4 or more predicted MMRC dyspnea score of > 3 with 82% sensitivity and 70% specificity.

CONCLUSION:

Semi-quantitative LUS score and B-line distance can provide a simple but effective estimate of disease severity in ILD.

What parameters can be used to identify early idiopathic pulmonary fibrosis?

Elucidating the disease process of early idiopathic pulmonary fibrosis (IPF) will help clinicians in addressing the contentious issues of when and in which patients, therapeutic intervention should be initiated. Here, we discuss several possible parameters for diagnosing early IPF and their clinical impacts. Physiologically, early IPF can be considered as IPF with normal or mild impairment in pulmonary function. Radiologically, early IPF can be considered as IPF with a small extent and/or early features of fibrosis. Symptomatically, early IPF can be considered as asymptomatic or less symptomatic IPF. IPF at Gender-Age-Physiology index stage I can be considered early IPF. Interstitial lung abnormalities are defined as parenchymal abnormalities in more than 5% of the lung in patients with no prior history of interstitial lung disease, and in some cases, this seems to be equivalent to early IPF. Previous clinical trials showed the effect of antifibrotic therapies in early IPF, but the effects of therapy are uncertain in early IPF outside of clinical trials, such as in cases of IPF with normal pulmonary function, IPF without honeycombing or traction bronchiectasis, and asymptomatic IPF. Moreover, little has been reported on disease progression in such conditions. Because the conceptual framework of early IPF may vary depending on its definition, not only is a diagnosis of early IPF important but prediction of disease progression is also crucial. Further investigations are needed to identify biomarkers that can detect patients who may experience greater degrees of disease progression and require treatment even with those forms of early IPF.

The St. George's Respiratory Questionnaire in Pulmonary Sarcoidosis

RATIONALE

The Saint George's Respiratory Questionnaire (SGRQ) is a frequently used tool to assess health status in pulmonary disease patients. However, its performance characteristics in sarcoidosis patients are not well characterized.

METHODS

Data from a clinical trial of 138 symptomatic adults with sarcoidosis were used to examine the performance characteristics of SGRQ. Data were available at both baseline and week 24. Other assessments included FVC, FEV1, ATS dyspnea score, Borg's CR 10 dyspnea score, 6-min walk distance (6MWD), and Short Form-36 Physical Component Summary (SF-36 PCS) score.

RESULTS

Baseline SGRQ was 46.8, indicating impaired health status. At baseline, SGRQ total score correlated significantly with % predicted FVC, FEV1, ATS dyspnea score, Borg's CR 10 dyspnea score, 6MWD, and SF-36 PCS (r =  - 0.37, - 0.32, 0.57, 0.40, - 0.55, and - 0.80, respectively, p < 0.001). Change from baseline in SGRQ score also statistically significantly correlated with change from baseline in these parameters at week 24: r =  - 0.25, - 0.20, 0.30, 0.22, - 0.20, - 0.45, respectively (p < 0.05).

CONCLUSIONS

The SGRQ correlated with other outcome measures in sarcoidosis initially and with treatment. Improvement in FVC % predicted correlated with improvement in SGRQ. These data suggest the SGRQ may function as a reliable endpoint in clinical sarcoidosis trials.

Home-Based Pulmonary Rehabilitation for Patients With Idiopathic Pulmonary Fibrosis: A PILOT STUDY

PURPOSE

To evaluate the adherence and effectiveness of a home-based exergame program for patients with idiopathic pulmonary fibrosis (IPF).

METHOD

Patients with IPF were randomly assigned to a relatively unsupervised Wii Fit exergame intervention group or Wii video game control group (with no active whole-body movement involved). Participants in both groups were instructed to play their respective games 30 min/d, 3 d/wk for 12 wk. In addition, they were asked to perform their usual exercise/physical activities. Outcome measures were 6-min walk distance (6MWD), exercise-related dyspnea, and St George's Respiratory Questionnaire (SGRQ).

RESULTS

The 20 participants differed significantly between intervention and control groups in baseline characteristics (forced vital capacity = 2.0 ± 0.5 vs 3.1 ± 0.7 L; forced expiratory volume in 1 sec = 1.7 ± 0.4 vs 2.5 ± 0.6 L, respectively). Participant adherence rate to the exergame program was very low (20%). There was no significant improvement in the outcome measures in either group. In fact, both the intervention and control groups had a deterioration in 6MWD (-22 ± 56 m vs -60 ± 111 m), respectively and SGRQ scores (3 ± 9 vs 1 ± 11), respectively.

CONCLUSIONS

The home-based exergame intervention for patients with IPF did not show improvement in functional performance, dyspnea, or health-related quality of life at the completion of the 12-wk program in our 2 heterogeneous groups. In addition to the low adherence rate, insufficient frequencies and durations of exergaming may contribute to the lack of improvement. A lack of effectiveness of home-based pulmonary rehabilitation using exergaming for patients with IPF appears consistent with prior observational studies that used more traditional modes of home-based exercise.

Palliative care in pulmonary medicine

Palliative care was initially developed for patients with advanced cancer. The concept has evolved and now encompasses any life-threatening chronic disease. Studies carried out to compare end-of-life symptoms have shown that although symptoms such as pain and dyspnea are as prevalent in patients with lung disease as in patients with cancer, the former receive less palliative treatment than do the latter. There is a need to refute the idea that palliative care should be adopted only when curative treatment is no longer possible. Palliative care should be provided in conjunction with curative treatment at the time of diagnosis, by means of a joint decision-making process; that is, the patient and the physician should work together to plan the therapy, seeking to improve quality of life while reducing physical, psychological, and spiritual suffering.

Idiopathic Pulmonary Fibrosis: A Review of Disease, Pharmacological, and Nonpharmacological Strategies With a Focus on Symptoms, Function, and Health-Related Quality of Life

Despite several advances in treatment, idiopathic pulmonary fibrosis (IPF) remains a progressive, symptomatic, and terminal disease in patients not suitable for lung transplantation. With disease progression, IPF often leads to a constellation of symptoms, including dyspnea, cough, anxiety, and depression. Palliative care is appropriate to support these patients. However, traditional curriculum in palliative care has often focused on supporting patients with malignant disease, and clinicians are not universally trained to manage patients with progressive nonmalignant diseases such as IPF. Current antifibrotic therapies aim to slow disease progression but are not able to reduce symptoms or improve daily function and health-related quality of life (HRQL). Palliative care in this patient group requires an understanding of the clinical characteristics of IPF, comorbidities, common medications used, and nonpharmacological strategies that can be undertaken to improve daily function and HRQL. This review focuses on IPF management strategies and their effects on symptoms, exercise tolerance, HRQL, and survival. Pharmacological interactions and considerations related to commonly used palliative care medications are also reviewed. This review highlights the needs of patients with IPF and caregivers, psychosocial function, patient-reported assessment tools, and topics related to advance care planning.

Patient-reported outcome measures in systemic sclerosis-related interstitial lung disease for clinical practice and clinical trials

Systemic sclerosis (SSc) is a progressive vasculopathic, fibrosing autoimmune condition, portending significant mortality; wherein interstitial lung disease (ILD) is the leading cause of death. Although lacking a definitive cure, therapeutics for (SSc-ILD) that stave progression exist with further promising primary and adjuvant compounds in development, as well as interventions to reduce symptom burden and increase quality of life. To date, there has been a significant but varied history related to systemic sclerosis-related interstitial lung disease trial design and endpoint designation. This is especially true of endpoints measuring patient-reported perceptions of efficacy and tolerability. This article describes the underpinnings and complexity of the science, methodology, and current state of patient-reported outcome measures used in (SSc-ILD) systemic sclerosis-related interstitial lung disease in clinical practice and trials.

Comparing effectiveness of prognostic tests in idiopathic pulmonary fibrosis

Introduction: Idiopathic pulmonary fibrosis (IPF) is a debilitating and progressive fibrotic interstitial lung disease often resulting in death over several years. Prediction of disease course or survival remains of keen interest for clinicians and patients though a commonly used test or tool remain elusive. Areas covered: We undertook a comprehensive review of the published literature highlighting prognostic indicators and predictors of survival in IPF. Baseline and longitudinal clinical, functional, histopathologic, and radiologic findings have been extensively studied as prognostic predictors, both individually and in composite models. Recent approaches include automated quantifiable radiologic scoring, circulating biomarkers, and genetic polymorphisms or abnormalities. This review highlights individual and composite predictors and their relative utility in clinical practice and research studies. Expert opinion: There is a growing body of knowledge highlighting readily available individual and composite predictors of outcome, though none have come to the forefront for common clinical use. Recent advances include quantitative imaging analysis, circulating serologic markers, and genetic testing, which may be more standardized and less prone to lead-time bias or related complications and comorbidities.

ACR Appropriateness Criteria® Chronic Dyspnea-Noncardiovascular Origin

Chronic dyspnea may result from a variety of disorders of cardiovascular, pulmonary, gastrointestinal, neuromuscular, systemic, and psychogenic etiology. This article discusses guidelines for the initial imaging of six variants for chronic dyspnea of noncardiovascular origin: (1) Chronic dyspnea of unclear etiology; (2) Chronic dyspnea with suspected chronic obstructive pulmonary disease; (3) Chronic dyspnea with suspected central airways disease; (4) Chronic dyspnea with suspected interstitial lung disease; (5) Chronic dyspnea with suspected disease of the pleura or chest wall; and (6) Chronic dyspnea with suspected diaphragm dysfunction. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Validation of the COPD Assessment Test (CAT) in patients with idiopathic pulmonary fibrosis

INTRODUCTION

Idiopathic pulmonary fibrosis (IPF) is a chronic disease with high morbidity and mortality. A reliable and manageable questionnaire that assesses patients' quality of life is needed to help to improve the content of clinical consultations. The chronic obstructive pulmonary disease (COPD) Assessment Test (CAT) is used in clinical practice; therefore, the aim of this study was to investigate correlations among the CAT, St. George's Respiratory Questionnaire (SGRQ) and clinical parameters among patients diagnosed with IPF. Methods: A retrospective cohort design was employed in which 87 patients diagnosed with IPF who were receiving treatment at an outpatient clinic were included. Results: The CAT was found to be significantly correlated with SGRQ (p < 0.001). Furthermore, the CAT was significantly correlated with all of the included physiological variables. Conclusions: This add to support the validity of the COPD Assessment test (CAT) as a measure of symptoms in patients with IPF which in clinical practice in combination with dialogue between healthcare professionals and the patient, can help to improve the content of a clinical consultation.

Clinico-radiological features and efficacy of anti-fibrotic agents in atypical idiopathic pulmonary fibrosis

Background

Atypical idiopathic pulmonary fibrosis (IPF) including multiple cysts or markedly atelectatic induration in upper lung predominance occasionally can confirm the diagnosis of IPF through a multidisciplinary discussion (MDD) between clinician, radiologist and, pathologist in clinical practice. The aim of this study was to clarify the differences in clinico-radiological characteristics and the efficacy of anti-fibrotic agents between atypical IPF and typical IPF.

Methods

We retrospectively evaluated the differences in clinico-radiological characteristics between patients with atypical IPF (n=44) and those with typical IPF (n=87) and examined efficacy of anti-fibrotic agents in atypical IPF. Atypical IPF was characterized by the presence of markedly atelectatic induration in upper lung predominance (pleuroparenchymal fibroelastosis; PPFE like lesion) with and without multiple thick-walled large cysts (TWLC), so-called macrocystic honeycombing (TWLC; >2.5 cm in diameter with 1-3 mm thickness) in addition to honeycombing in the bilateral lower lobes predominance.

Results

There was no difference in the baseline disease severity for IPF between both groups. The annual change value of fibrotic score and traction bronchiectasis (TBE) score, and decreased changes in forced vital capacity (FVC) during 6 months were significantly higher in atypical IPF than those in typical IPF. Survival time was significantly lower in patients with atypical IPF (MST: 33.4 vs. 47.9 months, P=0.03). The multivariate Cox regression model demonstrated that the prognostic predictors were presence of atypical IPF and increased Gender-Age-Physiology (GAP) staging. Moreover, the rate of decrease in FVC value 6 months after treatment with anti-fibrotic agents was significantly higher in atypical IPF than those in typical IPF (-11.8%±14.0% vs. -1.0%±12.7%; P=0.01).

Conclusions

This study demonstrated that the prognosis for atypical IPF was significantly worse than that for typical IPF. Future studies are required prospective analyses of efficacy of anti-fibrotic agents for patients with atypical IPF.

Psycho-Physiological Associates of Dyspnea in Hospitalized Patients with Interstitial Lung Diseases: A Cross-Sectional Study

Dyspnea has been found to be an independent predictor of mortality among patients with respiratory diseases and is often regarded as a difficult symptom to control in patients with interstitial lung diseases (ILDs). Previous studies have found an association of psychological and physiological factors with dyspnea among patients with chronic obstructive airway diseases. However, symptom management of hospitalized patients with ILDs has been hampered by difficulty in priority, since they are often admitted with multiple psycho-physiological needs. This study examined the prevalence of dyspnea and the psycho-physiological factors associated with it among hospitalized Chinese patients with ILDs. We studied 165 hospitalized patients with ILDs recruited consecutively over three months in a public hospital in Guangzhou, China. Dyspnea and common psycho-physiological factors, including cough symptoms, activity capacity, lung function, physical and mental health status, and anxiety and depression symptoms, were measured. By ordered logistic regression, level of dyspnea statistically significantly affected performance in a six-minute walk test and physical functioning in work or other regular daily activities in hospitalized patients with ILDs. Respiratory rehabilitation with an appropriate intensity of exercise training or other strategies for enhancing the physical functioning of this population with moderate and severe levels of dyspnea should be prioritized.

Evaluating disease severity in idiopathic pulmonary fibrosis

Accurate assessment of idiopathic pulmonary fibrosis (IPF) disease severity is integral to the care provided to patients with IPF. However, to date, there are no generally accepted or validated staging systems. There is an abundance of data on using information acquired from physiological, radiological and pathological parameters, in isolation or in combination, to assess disease severity in IPF. Recently, there has been interest in using serum biomarkers and computed tomography-derived quantitative lung fibrosis measures to stage disease severity in IPF. This review will focus on the suggested methods for staging IPF, at baseline and on serial assessment, their strengths and limitations, as well as future developments.

A comparison of published multidimensional indices to predict outcome in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) has an unpredictable course and prognostic factors are incompletely understood. We aimed to identify prognostic factors, including multidimensional indices from a significant IPF cohort at the Bristol Interstitial Lung Disease Centre in the UK.

Patients diagnosed with IPF between 2007 and 2014 were identified. Longitudinal pulmonary physiology and exercise testing results were collated, with all-cause mortality used as the primary outcome. Factors influencing overall, 12- and 24-month survival were identified using Cox proportional hazards modelling and receiver operating characteristic curve analysis.

We found in this real-world cohort of 167 patients, diffusing capacity for carbon monoxide (D_LCO) and initiation of long-term oxygen were independent markers of poor prognosis. Exercise testing results predicted 12-month mortality as well as D_LCO, but did not perform as well for overall survival. The Composite Physiological Index was the best performing multidimensional index, but did not outperform D_LCO. Our data confirmed that patients who experienced a fall in forced vital capacity (FVC) >10% had significantly worse survival after that point (p=0.024).

Our data from longitudinal follow-up in IPF show that D_LCO is the best individual prognostic marker, outperforming FVC. Exercise testing is important in predicting early poor outcome. Regular and complete review should be conducted to ensure appropriate care is delivered in a timely fashion.

D_LCOis a powerful prognostic marker in IPFhttp://ow.ly/EaEr307VTRN

A simple dyspnoea scale as part of the assessment to predict outcome across chronic interstitial lung disease

BACKGROUND AND OBJECTIVE

The Medical Research Council dyspnoea score (MRCDS) is a simple, objective scale to assess dyspnoea, the main complaint in patients with chronic interstitial lung disease (ILD). We sought to investigate whether MRCDS is a predictor of outcome in patients with chronic ILD.

METHODS

One hundred and fifteen patients (50 idiopathic pulmonary fibrosis (IPF) and 65 non-IPF ILD) were retrospectively studied. Baseline (time of diagnosis) MRCDS and 3-6-month changes were considered. Endpoints were (i) 18-month clinical progression, defined as either: ≥10% absolute reduction in forced vital capacity (FVC) percent predicted; ≥50-m decline in 6-min walk distance; hospitalization for respiratory causes; lung transplantation (LTx) assessment or death and (ii) 18-month survival.

RESULTS

At the end of the observation period, 54 subjects (47%) experienced clinical progression (including 22 deaths and 3 LTx). In patients with IPF, a longitudinal increase in MRCDS predicted clinical progression significantly (area under the curve (AUC) = 0.76, sensitivity = 62%, specificity = 91%); baseline MRCDS was a strong predictor of mortality (AUC = 0.80, sensitivity = 87%, specificity = 57%). In patients with non-IPF ILD, longitudinal increases in MRCDS, but not baseline values, were predictive of both clinical progression (AUC = 0.81, sensitivity = 85%, specificity = 77%) and mortality (AUC = 0.76, sensitivity = 91%, specificity = 61%). Considering the whole population, MRCDS increase and FVC decline were independent predictors of mortality.

CONCLUSION

Longitudinal increases of MRCDS predict poor outcome in chronic ILD, with good accuracy. Baseline MRCDS remains a strong predictor of mortality in IPF. MRCDS should be included in the global assessment of the clinical course of chronic ILD.

Physical Activity and Exertional Desaturation Are Associated with Mortality in Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease that manifests in hypoxemia, inactivity, and poor prognosis. This study aimed to assess the prognostic role of physical activity (PA) and exertional desaturation (ED) with mortality in IPF. At baseline, 34 IPF patients (68 (50–81) years) were interviewed using the International Physical Activity Questionnaire (IPAQ), and SpO₂ was assessed pre to post 6-min walking test (∆SpO₂). Patients were prospectively followed up for 40 months. Receiver operating characteristics curve analysis determined cut-off points associated with mortality, and Cox proportional hazard ratio (HR) were conducted. Thresholds for increased mortality risk in IPF patients were determined as IPAQ ≤ 417 metabolic equivalent task (METS)-min/week, p = 0.004 (HR; 9.7, CI 95% (1.3–71.9), p = 0.027), and ∆SpO₂ ≥ 10%, p = 0.002, (HR; 23.3, CI 95% (1.5–365), p = 0.025). This study demonstrated a significant association of PA and ED with mortality in IPF patients. The findings emphasize the clinical importance of PA and ED assessments to aid in IPF risk stratification, prognosis prediction, and in providing early appropriate treatments, such as pulmonary rehabilitation, PA consultation, oxygen supplementation, and lung transplantation referral. These results underscore that even low levels of PA corresponding to 100–105 min/week were associated with a reduced mortality risk and better survival in IPF.

Short-Term Improvement in Physical Activity and Body Composition After Supervised Exercise Training Program in Idiopathic Pulmonary Fibrosis

OBJECTIVE

To examine the effect of participating in a 12-week supervised exercise training (ET) program on physical activity and body composition in patients with idiopathic pulmonary fibrosis (IPF).

DESIGN

Randomized controlled trial assessing physical activity and body composition at baseline, after 12-week intervention, and at 11 months follow-up.

SETTING

Outpatient hospital.

PARTICIPANTS

Patients with IPF (N=34; mean age, 68±8y) recruited for this study; 32 patients completed the 12-week intervention (ET group: n=15; control group: n=17) and 28 patients (14 in each group) reassessed at 11-month follow-up from baseline.

INTERVENTIONS

Participation in a 12-week supervised ET program or regular medical treatment.

MAIN OUTCOME MEASURES

Changes in physical activity levels as measured by the International Physical Activity Questionnaire.

RESULTS

After the 12-week intervention, physical activity levels were significantly increased in the ET group whereas the control group showed a trend toward deterioration (median difference between the groups, 2164MET-min/wk [interquartile range, 1576MET-min/wk]; MET = metabolic equivalent; P<.001). Body composition was also significantly improved in the ET group, whereas the control group showed an opposite trend. At 11-month follow-up, no significant differences were observed between the 2 groups in all variables. The ET group lost most of the achieved improvements in the outcomes and returned to near baseline levels, whereas the control group showed a trend toward worsened outcomes.

CONCLUSIONS

Physical activity and body composition in patients with IPF were improved after a 12-week supervised ET program, although the benefits were not sustained at 11-month follow-up. These results may support the efficacy of participation in supervised ET to improve physical activity and body composition in patients with IPF; however, maintenance strategies are warranted to preserve the improved outcomes.

Erectile dysfunction in COPD patients

Sexual dysfunction is a common problem in chronic obstructive pulmonary disease (COPD). We aimed to assess the presence of erectile dysfunction (ED) in COPD patients. Ninety-three outpatients who had been diagnosed as COPD and followed in Bolvadin State Hospital, Afyon, Turkey, were included in the study. All patients underwent pulmonary function tests and arterial blood gas analysis. They completed International Physical Activity Questionnaire (IPAQ), Medical Research Council (MRC) Dyspnea Scale, Short Form 36-item Scale (SF-36), and International Index of Erectile Function (IIEF) Questionnaire. The mean age of 10 (10.8%) mild, 46 (49.5%) moderate, 28 (30.1%) severe, and 9 (9.7%) very severe COPD patients was 61.4 ± 9.8 years. Varying degrees of ED were detected in 67.7% of COPD patients. All patients with hypoxemia had ED. IPAQ score and all SF-36 parameters were low in patients with ED, while MRC score was high. Forced expiratory volume in one second, forced vital capacity, partial pressure of oxygen in blood, oxygen (O2) saturation, IPAQ score, and role-physical parameters were statistically low in ED patients (p = 0.04, 0.02, <0.01, <0.01, 0.02, and 0.04, respectively); MRC score was statistically higher in patients with ED (p = 0.02). Patients with moderate and severe ED had statistically lower score of mental health (p < 0.01 and p = 0.02, respectively). There was a positive correlation between IIEF score and IPAQ scores (p < 0.01), MRC scores (p = 0.01), general health (p < 0.01), role-physical (p < 0.01), role-emotional (p < 0.01), physical functioning (p < 0.01), and mental health (p < 0.01) parameters in SF-36. ED is frequently seen in COPD patients. Hypoxemia, smoking, and limitation of physical activity are thought to be associated with ED in COPD as mechanisms. Quality of life and the functional capacity are negatively affected with the presence of ED. It is important for a physician to question the sexual functions in patients with COPD. The presence of ED may be routinely considered in the daily practice of pulmonologists in COPD patients.

Outcome Measures for Clinical Trials in Interstitial Lung Diseases

The chronic fibrosing idiopathic interstitial pneumonias (IIPs) are a group of heterogeneous pulmonary parenchymal disorders described by radiologic and histological patterns termed usual interstitial pneumonia (UIP) and non-specific interstitial pneumonia (NSIP). These include idiopathic pulmonary fibrosis (IPF) and those related to connective tissue disease (CTD) and are associated with substantial morbidity and mortality. Beyond the importance of establishing an appropriate diagnosis, designing optimal clinical trials for IIPs has been fraught with difficulties in consistency of clinical endpoints making power analyses, and the establishment of efficacy and interpretation of results across trials challenging. Preliminary recommendations, developed by rigorous consensus methods, proposed a minimum set of outcome measures, a 'core set', to be incorporated into future clinical trials (Saketkoo et al, THORAX. 2014.). This paper sets out to examine the candidate instruments for each domain (Dyspnea, Cough, Health Related Quality of Life, Imaging, Lung Physiology and Function, Mortality). Candidate measures that were not selected as well as measures that were not available for examination at the time of the consensus process will also be discussed.

Evaluation of activity limitation in patients with idiopathic pulmonary fibrosis grouped according to Medical Research Council dyspnea grade

OBJECTIVE

To investigate the relations between Medical Research Council (MRC) dyspnea grade and peripheral muscle force, activities of daily living (ADL) performance, health status, lung function, and exercise capacity in subjects with idiopathic pulmonary fibrosis (IPF).

DESIGN

Prospective cross-sectional observational study.

SETTING

University hospital.

PARTICIPANTS

Subjects with IPF (N=65, 46 men) in a stable clinical state with a mean age of 68±7 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Right ventricular systolic pressure (RVSP) via transthoracic echocardiography, pulmonary function, isometric quadriceps force (QF) and handgrip force (HF), 6-minute walk distance (6MWD), ADL score, and health status (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]) were assessed and compared between subjects grouped according to MRC grade.

RESULTS

Of the participants, 16 were in MRC grade 2, 17 were in MRC grade 3, 17 were in MRC grade 4, and 15 were in MRC grade 5. RVSP, pulmonary function, QF, HF, 6MWD, ADL, and SF-36 scores decreased with increasing MRC grade (all P<.001). All measures were lower (P<.05) in subjects with grades 4 and 5 than subjects with grades 2 and 3. Strong associations were found between MRC grade and 6MWD (ρ=-.89, P=.001) and ADL score (ρ=-.82, P=.001). MRC grade was also associated with RVSP, pulmonary function, QF, and HF (all ρ≥.56, P=.001).

CONCLUSIONS

The MRC dyspnea scale provides a simple and useful method of categorizing individuals with IPF with respect to their activity limitation and may assist in understanding the impact of IPF on an individual.

Vocal and ventricular fold lateralization using crossing sutures with the thyroplasty window technique for bilateral vocal fold immobility: long-term results

CONCLUSIONS

Vocal and ventricular fold lateralization using crossing sutures with the thyroplasty window technique is an effective and durable procedure for the management of patients with bilateral vocal fold immobility.

OBJECTIVES

To review the long-term results of bilateral vocal fold immobility in 26 patients treated with vocal and ventricular fold lateralization using crossing sutures with the thyroplasty window technique over a 6-year period.

METHODS

This retrospective study examined patients with a minimum follow-up of 1 year. The main outcome measures used were the modified Medical Research Council (MRC) dyspnoea scale and the assessment of voice quality pre- and postoperatively using the Likert method.

RESULTS

The mean follow-up period was 23.77 ± 12.01 months. All patients reported marked symptomatic improvement in dyspnoea (p = 0.0001). The voice quality worsened as expected; however, this difference did not reach a significant level (p = 0.642). Transient microaspiration was noted in seven of the patients and resolved in 1 or 2 days. The procedure was performed for the contralateral vocal fold in one case, due to the loss of suture tension. No patient showed aspiration postoperatively or during follow-up. All patients were regularly followed up for the beginning of movement of the lateralized or contralateral vocal folds in our outpatient clinic.

The benefits of exercise training in interstitial lung disease: protocol for a multicentre randomised controlled trial

Background

Interstitial lung disease encompasses a diverse group of chronic lung conditions characterised by distressing dyspnoea, fatigue, reduced exercise tolerance and poor health-related quality of life. Exercise training is one of the few treatments to induce positive changes in exercise tolerance and symptoms, however there is marked variability in response. The aetiology and severity of interstitial lung disease may influence the response to treatment. The aims of this project are to establish the impact of exercise training across the range of disease severity and to identify whether there is an optimal time for patients with interstitial lung disease to receive exercise training.

Methods/Design

One hundred and sixteen participants with interstitial lung disease recruited from three tertiary institutions will be randomised to either an exercise training group (supervised exercise training twice weekly for eight weeks) or a usual care group (weekly telephone support). The 6-minute walk distance, peripheral muscle strength, health-related quality of life, dyspnoea, anxiety and depression will be measured by a blinded assessor at baseline, immediately following the intervention and at six months following the intervention. The primary outcome will be change in 6-minute walk distance following the intervention, with planned subgroup analyses for participants with idiopathic pulmonary fibrosis, dust-related interstitial lung disease and connective-tissue related interstitial lung disease. The effects of disease severity on outcomes will be evaluated using important markers of disease severity and survival, such as forced vital capacity, carbon monoxide transfer factor and pulmonary hypertension.

Discussion

This trial will provide certainty regarding the role of exercise training in interstitial lung disease and will identify at what time point within the disease process this treatment is most effective. The results from this study will inform and optimise the clinical management of people with interstitial lung disease.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12611000416998