Pulmonary rehabilitation improves survival in patients with idiopathic pulmonary fibrosis undergoing lung transplantation

Virtual pulmonary rehabilitation approaches in patients with post COVID syndrome: a pilot study

BACKGROUND

The characteristics of optimal virtual pulmonary rehabilitation (PR) for individuals with post-COVID syndrome (PCS) have not been identified. This study aimed to assess the feasibility, safety, and satisfaction associated with a virtual PR program with the exercise component delivered through group or self-directed sessions.

METHODS

Adults with PCS-respiratory symptoms were randomly assigned to the video conference (PRVC) or self-directed (PRSD) group and completed an exercise program (aerobic, strengthening, and breathing exercises) three times/week for eight weeks. PRVC sessions were led by a physiotherapist via Zoom, whereas the PRSD group exercised individually following a pre-recorded video. Both groups received personalized exercise recommendations, education related to the condition, and a weekly follow up call. Satisfaction was assessed through a patient survey. Lung function, dyspnea, fatigue, sit-to-stand capacity, health-related quality of life, and participation were assessed pre- and post-PR.

RESULTS

Fourteen PCS individuals (49 ± 9 years, 86% females) completed 83% of the sessions. All participants were satisfied with information provided by the therapist and frequency of data submission, whereas most were satisfied with the frequency and duration of exercise sessions (88% in PRVC and 83% in PRSD). A higher proportion of participants in the PRVC (88%) were satisfied with the level of difficulty of exercises compared with the PRSD (67%), and 84% of the sample reported a positive impact of the program on their health. No adverse events were reported. Significant changes in sit-to-stand capacity (p = 0.012, Cohen's r = 0.67) and questions related to fatigue (p = 0.027, Cohen's r = 0.58), neurocognitive (p = 0.045, Cohen's r = 0.53), and autonomic (p = 0.024, Cohen's r = 0.60) domains of the DePaul Symptom Questionnaire short-form were also found between groups.

CONCLUSION

Virtual PR with exercises delivered via video conference or pre-recorded video were feasible, safe, and well-received by individuals with PCS.

TRIAL REGISTRATION

NCT05003271 (first posted: 12/08/2021).

Using Remote Technology to Engage Patients with Interstitial Lung Diseases in a Home Exercise Program: A Pilot Study

INTRODUCTION

The access and compliance of patients with interstitial lung diseases (ILDs) to exercise programs (EPs) remain challenges.

OBJECTIVES

We assessed the dropout rate, intervention completion, compliance with data acquisition and submission, safety, and satisfaction of a home EP delivered via video conference (EPVC group) or self-directed (EPSD group) to patients with ILD. Pre- and post-intervention changes in patient outcomes (dyspnea, fatigue, exercise capacity, lung function, and quality of life) were secondarily explored.

MATERIAL AND METHODS

Groups performed an eight-week virtual EP three times/week. Video conferences were led by a registered respiratory therapist, whereas self-directed exercises were completed following a pre-recorded video. Participants submitted spirometry, heart rate, and SpO2 results weekly to the research team.

RESULTS

Fourteen patients with ILD were equally assigned to the EPVC and EPSD groups, but three from the EPSD group dropped out after the initial assessment (dropout rate of 42.8% in the EPSD group). Eleven patients (mean age of 67 ± 12 years) completed 96.5% of sessions. Compliance with data acquisition and submission was optimal (≥97.6% in both groups), and no adverse events were reported. Changes in overall fatigue severity were significantly different between groups (p = 0.014, Cohen's r = 0.64).

CONCLUSIONS

The results suggest that a structured virtual EP delivered via video conference or pre-recorded video can be feasible, safe, and acceptable for patients with ILD.

The efficacy of pulmonary rehabilitation training program for patients after lung transplantation

Background

Pulmonary rehabilitation is recognized widely as one of the most effective measures to promote postoperative recovery of lung transplant recipients (LTRs), and it has positive effects on both short- and long-term quality of life (QoL) and survival outcomes. However, no standardized pulmonary rehabilitation training programs exist specifically for LTRs. The pulmonary rehabilitation programs widely used in clinical practice focus mainly on exercise or respiratory training, to some extent neglecting other therapeutic methods that could promote patient health, such as nutrition support, pain control, spiritual comfort, and so on. This study aimed to develop a postoperative pulmonary rehabilitation training program for LTRs and evaluate its effectiveness.

Methods

Using convenience sampling, all patients who underwent lung transplantation (LTx) at Shanghai Pulmonary Hospital from January 2021 to December 2022 were screened for inclusion and exclusion criteria, and a total of 68 patients were finally included in this study. A non-synchronous quasi-experimental design was used, with patients who underwent LTx in 2021 as the control group and patients who underwent LTx in 2022 as the experimental group. The control group received routine treatment, health education, and rehabilitation guidance when patients determined the date of surgery. In addition to this, the experimental group received pulmonary rehabilitation training. The incidence of postoperative pulmonary complications (pulmonary infections), duration of chest tube drainage, intensive care unit (ICU) length of stay, postoperative pain scores, postoperative QoL, pulmonary function, oxygenation index, and the distance in the 6-minute walking test (6MWD) were compared between the two groups.

Results

The length of ICU stay and duration of chest tube drainage in the experimental group were lower than those in the control group, and the results of oxygenation index, 6MWD, and St. George's Respiratory Questionnaire (reflecting the QoL) were better than those of the control group (P<0.05). There was no significant difference in the pain of the two groups 1 week after surgery and 3 months after surgery, and the pain score of the experimental group was lower than that of the control group at 1 month after surgery (P<0.05). There was no significant difference in the incidence of complications between the two groups (P>0.05).

Conclusions

The postoperative pulmonary rehabilitation training program for LTRs is safe and effective. It can shorten both the duration of chest tube drainage and ICU stay, it can also improve patients' exercise capacity and pulmonary function while also promote safety outcomes of LTRs, and improve QoL scores.

Perioperative changes in radiographic density in erector spinae muscle and mortality after lung transplantation

RATIONALE

The radiographic density of the erector spinae muscle (ESM) is often decreased early after lung transplantation (LTx). The prognostic impact of this change has not been elucidated.

OBJECTIVE

To investigate whether the decrease in the radiographic density of ESMs early after LTx is associated with a poor prognosis.

METHODS

This study is a single center retrospective cohort study. Routine follow-up chest computed tomography scan data just before and 12 weeks after LTx were retrospectively retrieved for adult patients who underwent primary LTx at Kyoto University Hospital. The radiographic density of ESM was quantitatively evaluated as the mean attenuation of the ESM (ESMct), and the impact of the decreased ESMct during the 12 weeks after LTx on overall survival (OS) was examined by Cox proportional hazard regression.

RESULTS

A total of 151 recipients (94 cadaveric LTx, 57 living-donor lobar LTx) were included in this study. The median duration of postoperative observation was 4.4 years, during which time 39 recipients (26%) died. Decreased postoperative ESMct was significantly associated with poor OS (HR, 1.64; 95% CI, 1.14-2.35, P = 0.008 per 1 Z score decrease) in the multivariate model adjusted for age, sex, episodes of acute rejection, and preoperative ESMct. Similar results were obtained when the subjects were limited to those with cadaveric LTx.

CONCLUSION

A decreased perioperative ESMct was strongly associated with a poor prognosis after LTx in addition to low preoperative ESMct. Maintaining postoperative muscle radiographic density, which reflects muscle quality, may be important for a better prognosis after LTx.

European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates

There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.

Movement therapy in lung transplantation candidates assisted by a lightweight wearable robot

The aim of this pilot-study was to investigate the safety, feasibility and tolerability of an assisted mobilization of patients with advanced pulmonary diseases, using a lightweight, exoskeleton-type robot (Myosuit, MyoSwiss AG, Zurich, Switzerland). Ten patients performed activities of daily life (ADL) both with and without the device. The mean age was 53.6 (±5.6) years; 70% were male. The assessment of outcome included the evaluation of vital signs, adverse events, rates of perceived exertion and dyspnea (PRE, PRD), the ability to perform ADL and the individual acceptability. Robotic-assisted mobilization was feasible in all patients. No adverse events occurred. RPE and RPD showed no significant difference with or without the Myosuit (mean difference in RPE -1.7, 95%-confidence interval (CI) -1.16, 4.49; p = 0.211; mean difference in RPD 0.00, 95%-CI -1.88, 1.88; p = 0.475). 80% of patients were interested to participate in a robotic-assisted training on a regular basis. A robotic exoskeleton-assisted mobilization is safe, feasible, well-tolerated and well-accepted. The results are highly encouraging to further pursue this highly innovative approach.

Ambulatory oxygen therapy in lung transplantation candidates with idiopathic pulmonary fibrosis referred for pulmonary rehabilitation

OBJECTIVE

To determine independent factors related to the use of oxygen and the oxygen flow rate in idiopathic pulmonary fibrosis (IPF) patients placed on a lung transplant waitlist and undergoing pulmonary rehabilitation (PR).

METHODS

This was a retrospective quasi-experimental study presenting functional capacity and health-related quality of life (HRQoL) data from lung transplant candidates with IPF referred for PR and receiving ambulatory oxygen therapy. The patients were divided into three groups on the basis of the oxygen flow rate: 0 L/min (the control group), 1-3 L/min, and 4-5 L/min. Data on functional capacity were collected by means of the six-minute walk test, and data on HRQoL were collected by means of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), being collected before and after 36 sessions of PR including aerobic and strength exercises.

RESULTS

The six-minute walk distance improved in all three groups (0 L/min: Δ 61 m, p < 0.001; 1-3 L/min: Δ 58 m, p = 0.014; and 4-5 L/min: Δ 35 m, p = 0.031). Regarding HRQoL, SF-36 physical functioning domain scores improved in all three groups, and the groups of patients receiving ambulatory oxygen therapy had improvements in other SF-36 domains, including role-physical (1-3 L/min: p = 0.016; 4-5 L/min: p = 0.040), general health (4-5 L/min: p = 0.013), social functioning (1-3 L/min: p = 0.044), and mental health (1-3 L/min: p = 0.046).

CONCLUSIONS

The use of ambulatory oxygen therapy during PR in lung transplant candidates with IPF and significant hypoxemia on exertion appears to improve functional capacity and HRQoL.

Lung Transplant Rehabilitation-A Review

BACKGROUND

Both lung transplant recipients and candidates are characterised by reduced training capacity and low average quality of life (QoL). This review investigates the impact of training on exercise ability and QoL in patients before and after lung transplant.

METHODS

Searches were conducted from the beginning to 7 March 2022 using the terms "exercise," "rehabilitation," "lung transplant," "exercise ability," "survival," "quality of life" and "telerehabilitation" in six databases, including Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, CINAHL, Nursing and Allied Health, and Scopus. The inclusion criteria were studies evaluating the effects of an exercise training programme concurrent with lung transplantation as well as patients and candidates (>18 years old) through any lung diseases. The term "lung transplant rehabilitation" was used to refer to all carefully thought-out physical activities with the ultimate or intermediate objective of improving or maintaining physical health.

RESULTS

Out of 1422 articles, 10 clinical- and 3 telerehabilitation studies, candidates (n = 420) and recipients (n = 116) were related to the criteria and included in this review. The main outcome significantly improved in all studies. The 6-min walk distance, maximum exercise capacity, peak oxygen uptake, or endurance for constant load rate cycling improved measuring physical activity [aerobic exercises, breathing training, and aerobic and inspiratory muscle training sessions (IMT)]. Overall scores for dyspnoea improved after exercise training. Furthermore, health-related quality of life (HRQOL) also improved after aerobic exercise training, which was performed unsupervised or accompanied by breathing sessions. Aerobic training alone rather than combined with inspiratory muscle- (IMT) or breathing training enhanced exercise capacity.

CONCLUSION

In conclusion, rehabilitation programmes seem to be beneficial to patients both preceding and following lung transplantation. More studies are required to determine the best training settings in terms of time scale, frequency, and work intensity in terms of improving exercise ability, dyspnoea, and HRQOL.

Antifibrotic therapy in idiopathic pulmonary fibrosis candidates for lung transplantation undergoing pulmonary rehabilitation

OBJECTIVE

To investigate the impact of pulmonary rehabilitation (PR) on functional outcomes and health-related quality of life (HRQoL) in idiopathic pulmonary fibrosis (IPF) patients placed on a lung transplant waitlist and receiving antifibrotic therapy (AFT).

METHODS

This was a retrospective observational study of consecutive IPF patients receiving AFT with either pirfenidone or nintedanib (the AFT group) and undergoing PR between January of 2018 and March of 2020. The AFT group and the control group (i.e., IPF patients not receiving AFT) participated in a 12-week PR program consisting of 36 sessions. After having completed the program, the study participants were evaluated for the six-minute walk distance (6MWD) and HRQoL. Pre- and post-PR 6MWD and HRQoL were compared within groups and between groups.

RESULTS

There was no significant difference between the AFT and control groups regarding baseline characteristics, including age, airflow limitation, comorbidities, and oxygen requirement. The AFT group had a significant increase in the 6MWD after 12 weeks of PR (effect size, 0.77; p < 0.05), this increase being significant in the between-group comparison as well (effect size, 0.55; p < 0.05). The AFT group showed a significant improvement in the physical component of HRQoL at 12 weeks (effect size, 0.30; p < 0.05).

CONCLUSIONS

Among IPF patients undergoing PR, those receiving AFT appear to have greater improvements in the 6MWD and the physical component of HRQoL than do those not receiving AFT.

Russian Registry of Idiopathic Pulmonary Fibrosis: Clinical Features, Treatment Management, and Outcomes

A registry of patients with idiopathic pulmonary fibrosis (IPF) was founded in Russia in 2016. The aim of this study was to analyze the demographic, clinical, functional, radiological, and morphological data of the patients included in this registry.

METHODS

This was a prospective multicenter, observational, non-interventional study. Patients' risk factors, demographics, clinical data, results of high-resolution computed tomography (HRCT) of the chest and pulmonary function testing, and lung tissue biopsy findings were analyzed. We also analyzed the exercise tolerance (6-min walking test) of patients, serological markers of systemic connective tissue diseases, treatment, clinical course, and outcomes of the disease. Multidisciplinary discussion (MDD) was used as needed.

RESULTS

One thousand three hundred and fifty-three patients were included in the registry from 2016 to 2020. The mean age was 64.4 ± 10.7 years, most patients were active smokers or ex-smokers. Antifibrotic therapy was administered to 90 of 948 patients (9.5%). Since starting the registry in 2016, the incidences of IPF have increased and the time period from manifestation of the disease to making the diagnosis has shortened, the number of patients on antifibrotic therapy has increased and the number of patients taking systemic steroids decreased.

CONCLUSION

The registry of patients with IPF was helpful to improve IPF diagnosis and to implement antifibrotic agents in clinical practice. Further analysis of the clinical course and prognostic markers of IPF in the Russian population is needed. An analysis of the long-term efficacy of antifibrotic therapy in this population is also important.

A Telerehabilitation Program for Maintaining Functional Capacity in Patients With Chronic Lung Diseases During a Period of COVID-19 Social Isolation: Quasi-Experimental Retrospective Study

BACKGROUND

Pulmonary diseases represent a great cause of disability and mortality in the world, and given the progression of these pathologies, pulmonary rehabilitation programs have proven to be effective for people with chronic respiratory diseases. During the COVID-19 pandemic, telerehabilitation has become an alternative for patients with such diseases.

OBJECTIVE

The aim of this study was to compare the outcomes (ie, functional capacity and quality of life) of telerehabilitation to those of usual care among patients who previously participated in face-to-face pulmonary rehabilitation programs.

METHODS

We conducted a quasi-experimental retrospective study from April 2020 to August 2021. A total of 32 patients with chronic lung diseases were included and divided into the control and intervention groups. The intervention group performed telerehabilitation synchronously twice per week and was supervised by a physical therapist during breathing, strengthening, and aerobic exercises. Changes in the degree of dyspnea and leg discomfort were assessed based on changes in Borg scale scores. The control group did not perform any activities during the period of social isolation. Functional capacity was assessed with the 6-minute walk test, and quality of life was assessed with the Medical Outcomes Study 36-item Short Form Health Survey.

RESULTS

The telerehabilitation group's mean 6-minute walk distance decreased by 39 m, while that of the control group decreased by 120 m. There was a difference of 81 m between the groups' mean 6-minute walk distances (P=.02). In relation to the quality of life, telerehabilitation was shown to improve the following two domains: social functioning and mental health.

CONCLUSIONS

Telerehabilitation programs for patients with chronic lung diseases can ease the deleterious effects of disease progression, be used to maintain functional capacity, and improve aspects of quality of life.

Relationship of Exercise Capacity, Physical Function, and Frailty Measures With Clinical Outcomes and Healthcare Utilization in Lung Transplantation: A Scoping Review

Measures of exercise capacity, frailty, and physical function are commonly used in lung transplant candidates and recipients to evaluate their physical limitations and the effects of exercise training and to select candidates for transplantation. It is unclear how these measures are related to clinical outcomes and healthcare utilization before and after lung transplantation. The purpose of this scoping review was to describe how measures of exercise capacity, physical function, and frailty are related to pre- and posttransplant outcomes.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part I - Lung Transplantation

This special article focuses on the highlights in cardiothoracic transplantation literature in the year 2020. Part I encompasses the recent literature on lung transplantation, including the advances in preoperative assessment and optimization, donor management, including the use of ex-vivo lung perfusion, recipient management, including those who have been infected with coronavirus disease 2019, updates on the perioperative management, including the use of extracorporeal membrane oxygenation, and long-term outcomes.

Erector spinae muscle radiographic density is associated with survival after lung transplantation

OBJECTIVE

The study objective was to verify whether low preoperative radiographic density of erector spinae muscles is associated with poor prognosis after lung transplantation.

METHODS

Preoperative chest computed tomography scans for patients who underwent deceased-donor lung transplantation between 2013 and 2019 at Kyoto University Hospital were retrospectively retrieved. The radiographic density of erector spinae muscles was quantitatively evaluated as the mean attenuation of erector spinae muscles, and low mean radiographic density of the erector spinae muscles was defined as a mean radiographic density of the erector spinae muscles value below the median value for all patients. Overall survival and chronic lung allograft dysfunction-free survival with high and low mean radiographic density of the erector spinae muscles were estimated using the Kaplan-Meier method and evaluated by the log-rank test, as well as by univariate and multivariate Cox proportional hazard analyses.

RESULTS

Of the 107 adult patients who underwent primary transplantation, 96 underwent at least 1 chest computed tomography scan within 24 hours before lung transplantation. The median mean radiographic density of the erector spinae muscles in these 96 patients was 49.2 Hounsfield units. A low mean radiographic density of the erector spinae muscles value was significantly associated with decreased overall survival (hazard ratio, 4.50; P = .030) and chronic lung allograft dysfunction-free survival (hazard ratio, 3.18; P = .028) in the multivariate analysis. Additionally, patients with preoperative steroid use and a low mean radiographic density of the erector spinae muscles value had a worse overall survival (P < .001) and chronic lung allograft dysfunction-free survival (P < .001) than patients with preoperative steroid use and a high mean radiographic density of the erector spinae muscles value and those without preoperative steroid use.

CONCLUSIONS

Low mean radiographic density of the erector spinae muscles was closely associated with a poor prognosis after lung transplantation. The prognosis was particularly poor in patients with preoperative steroid use and a low mean radiographic density of the erector spinae muscles. These results may be useful when considering the indications for lung transplantation or preoperative interventions. VIDEO ABSTRACT.

Advances in lung transplantation for interstitial lung diseases

PURPOSE OF REVIEW

Lung transplantation (LTx) is increasingly used as ultimate treatment modality in end-stage interstitial lung diseases (ILDs). This review aims to give an overview of the latest evolutions in this field.

RECENT FINDINGS

In the last two years, important new findings regarding LTx outcomes in specific ILD entities have been reported. More data are available on optimization of pre-LTx management of ILD patients especially with regard to pretransplant antifibrotic treatment.

SUMMARY

LTx is the only treatment option with curative intent for ILDs and is increasingly used for this indication. Several studies have now reported adequate outcomes in different ILD entities, although outcome is shown to be affected by underlying telomeropathies. As new studies could not replicate inferior survival with single compared with double LTx, both options remain acceptable. ILD specialists can beneficially impact on post-LTx outcome by optimizing pre-LTx management: corticosteroids should be avoided, antifibrotics should be initiated whenever possible and BMI and nutritional status optimized, rehabilitation and depression-screening strategies should be implemented in all LTx candidates, as these interventions may all improve postlung transplant survival.

Frailty and aging-associated syndromes in lung transplant candidates and recipients

Many lung transplant candidates and recipients are older and frailer compared to previous eras. Older patients are at increased risk for pre- and posttransplant mortality, but this risk is not explained by numerical age alone. This manuscript represents the product of the American Society of Transplantation (AST) conference on frailty. Experts in the field reviewed the latest published research on assessment of elderly and frail lung transplant candidates. Physical frailty, often defined as slowness, weakness, low physical activity, shrinking, and exhaustion, and frailty evaluation is an important tool for evaluation of age-associated dysfunction. Another approach is assessment by cumulative deficits, and both types of frailty are common in lung transplant candidates. Frailty is associated with death or delisting before transplant, and may be associated with posttransplant mortality. Sarcopenia, cognitive dysfunction, depression, and nutrition are other important components for patient evaluation. Aging-associated inflammation, telomere dysfunction, and adaptive immune system senescence may also contribute to frailty. Developing tools for frailty assessment and interventions holds promise for improving patient outcomes before and after lung transplantation.

Effects of exercise-based pulmonary rehabilitation on adults with asthma: a systematic review and meta-analysis

BACKGROUND

Pulmonary rehabilitation (PR) has been proposed as an effective method for many respiratory diseases. However, the effects of exercise-based PR on asthma are currently inconclusive. This review aimed to investigate the effects of exercise-based PR on adults with asthma.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science, International Clinical Trials Registry Platform and ClinicalTrials.gov databases were searched from inception to 31 July 2019 without language restriction. Randomized controlled trials (RCTs) investigating the effects of exercise-based PR on adults with asthma were included. Study selection, data extraction and risk of bias assessment were performed by two investigators independently. Meta-analysis was conducted by RevMan software (version 5.3). Evidence quality was rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

Ten literatures from nine studies (n = 418 patients) were identified. Asthma quality of life questionnaire total scores (MD = 0.39, 95% CI: 0.02 to 0.76) improved significantly in the experimental group compared to control group, including activity domain scores (MD = 0.58, 95% CI: 0.21 to 0.94), symptom domain scores (MD = 0.52, 95% CI: 0.19 to 0.85), emotion domain scores (MD = 0.53, 95% CI: - 0.03 to 1.09) and environment domain scores (MD = 0.56, 95% CI: 0.00 to 1.11). Both the 6-min walk distance (MD = 34.09, 95% CI: 2.51 to 65.66) and maximum oxygen uptake (MD = 4.45, 95% CI: 3.32 to 5.58) significantly improved. However, improvements in asthma control questionnaire scores (MD = - 0.25, 95% CI: - 0.51 to 0.02) and asthma symptom-free days (MD = 3.35, 95% CI: - 0.21 to 6.90) were not significant. Moreover, there was no significant improvement (MD = 0.10, 95% CI: - 0.08 to 0.29) in forced expiratory volume in 1 s. Nonetheless, improvements in forced vital capacity (MD = 0.23, 95% CI: 0.08 to 0.38) and peak expiratory flow (MD = 0.39, 95% CI: 0.21 to 0.57) were significant.

CONCLUSIONS

Exercise-based PR may improve quality of life, exercise tolerance and some aspects of pulmonary function in adults with asthma and can be considered a supplementary therapy. RCTs of high quality and large sample sizes are required.

CLINICAL TRIAL REGISTRATION

The review was registered with PROSPERO (The website is https://www.crd.york.ac.uk/prospero/ , and the ID is CRD42019147107).

Rho-Kinase 1/2 Inhibition Prevents Transforming Growth Factor-β-Induced Effects on Pulmonary Remodeling and Repair

Transforming growth factor (TGF)-β-induced myofibroblast transformation and alterations in mesenchymal-epithelial interactions contribute to chronic lung diseases such as chronic obstructive pulmonary disease (COPD), asthma and pulmonary fibrosis. Rho-associated coiled-coil-forming protein kinase (ROCK) consists as two isoforms, ROCK1 and ROCK2, and both are playing critical roles in many cellular responses to injury. In this study, we aimed to elucidate the differential role of ROCK isoforms on TGF-β signaling in lung fibrosis and repair. For this purpose, we tested the effect of a non-selective ROCK 1 and 2 inhibitor (compound 31) and a selective ROCK2 inhibitor (compound A11) in inhibiting TGF-β-induced remodeling in lung fibroblasts and slices; and dysfunctional epithelial-progenitor interactions in lung organoids. Here, we demonstrated that the inhibition of ROCK1/2 with compound 31 represses TGF-β-driven actin remodeling as well as extracellular matrix deposition in lung fibroblasts and PCLS, whereas selective ROCK2 inhibition with compound A11 did not. Furthermore, the TGF-β induced inhibition of organoid formation was functionally restored in a concentration-dependent manner by both dual ROCK 1 and 2 inhibition and selective ROCK2 inhibition. We conclude that dual pharmacological inhibition of ROCK 1 and 2 counteracts TGF-β induced effects on remodeling and alveolar epithelial progenitor function, suggesting this to be a promising therapeutic approach for respiratory diseases associated with fibrosis and defective lung repair.

Exercise training for lung transplant candidates and recipients: a systematic review

Exercise intolerance and impaired quality of life (QoL) are characteristic of lung transplant candidates and recipients. This review investigated the effects of exercise training on exercise capacity, QoL and clinical outcomes in pre- and post-operative lung transplant patients.A systematic literature search of PubMed, Nursing and Allied Health, Cochrane (CENTRAL), Scopus and CINAHL databases was conducted from inception until February, 2020. The inclusion criteria were assessment of the impact of exercise training before or after lung transplantation on exercise capacity, QoL or clinical outcomes.21 studies met the inclusion criteria, comprising 1488 lung transplant candidates and 1108 recipients. Studies consisted of five RCTs, two quasi-experimental and 14 single-arm cohort or pilot studies. Exercise training improved or at least maintained exercise capacity and QoL before and after lung transplantation. The impact on clinical outcomes was less clear but suggested a survival benefit. The quality of evidence ranged from fair to excellent.Exercise training appears to be beneficial for patients before and after lung transplantation; however, the evidence for direct causation is limited by the lack of controlled trials. Well-designed RCTs are needed, as well as further research into the effect of exercise training on important post-transplant clinical outcomes, such as time to discharge, rejection, infection, survival and re-hospitalisation.

Idiopathic pulmonary fibrosis: Molecular mechanisms and potential treatment approaches

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive disease with high mortality that commonly occurs in middle-aged and older adults. IPF, characterized by a decline in lung function, often manifests as exertional dyspnea and cough. Symptoms result from a fibrotic process driven by alveolar epithelial cells that leads to increased migration, proliferation, and differentiation of lung fibroblasts. Ultimately, the differentiation of fibroblasts into myofibroblasts, which synthesize excessive amounts of extracellular matrix proteins, destroys the lung architecture. However, the factors that induce the fibrotic process are unclear. Diagnosis can be a difficult process; the gold standard for diagnosis is the multidisciplinary conference. Practical biomarkers are needed to improve diagnostic and prognostic accuracy. High-resolution computed tomography typically shows interstitial pneumonia with basal and peripheral honeycombing. Gas exchange and diffusion capacity are impaired. Treatments are limited, although the anti-fibrotic drugs pirfenidone and nintedanib can slow the progression of the disease. Lung transplantation is often contraindicated because of age and comorbidities, but it improves survival when successful. The incidence and prevalence of IPF has been increasing and there is an urgent need for improved therapies. This review covers the detailed cellular and molecular mechanisms underlying IPF progression as well as current treatments and cutting-edge research into new therapeutic targets.

Long-Term Combined Training in Idiopathic Pulmonary Fibrosis: A Case Study

A supervised combined training program was applied to a sedentary 56-year-old man with idiopathic pulmonary fibrosis (IPF) along three years, until lung transplantation. It included: (a) aerobic continuous (CT) and interval training (IT), (b) high load resistance training (RT) and (c) inspiratory muscle training (IMT). IT and IMT were applied for two years, while CT and RT could be maintained until transplantation using supplemental oxygen. Maximal inspiratory pressure (MIP) kept above 180 cm H₂O and forced vital capacity (FVC) remained stable until lung transplantation. Peak oxygen uptake VO₂ increased during 1.5 years before its decline, staying above the poor prognosis level two years. Finally, the patient maintained his walking capacity and independence for 2 years, before the decline due to the disease. After receiving a two-lung transplant, the patient remained intubated for 12 h, left the intensive care unit after 3.5 days and was discharged after 18 days (average values: 48 h, 7–10 days and 25–35 days, respectively). These results show that systematic and supervised combined training can be safety applied in an IPF patient to maintain functionality and quality of life. In addition, we show that RT can be maintained for as long as necessary without complications.