Short- and long-term effects of pulmonary rehabilitation for idiopathic pulmonary fibrosis: a systematic review and meta-analysis

Pulmonary rehabilitation and family/friend caregivers: the hidden reciprocal relationship improving outcomes in chronic respiratory diseases

INTRODUCTION

The experiences and needs of living with chronic respiratory diseases (CRD) can be overwhelming. Individuals often rely on informal care for daily assistance and having a family/friend caregiver has been associated with better health outcomes. Nevertheless, family/friend caregivers frequently feel alone and unsupported. Pulmonary rehabilitation (PR) leads to multidimensional benefits across CRD and individuals have suggested improvements for PR. Family/friend caregivers highly support PR in practical and psychosocial ways and have identified this intervention as an opportunity to be supported. This reciprocal relationship between PR and the family/friend caregivers has been scarcely explored and its importance for the management of CRD is poorly understood.

AREAS COVERED

This perspective synthesizes the experiences and needs of living with CRD from the perspective of people with CRD and their family/friend caregivers; and proposes a vision of a reciprocal/symbiotic relationship, through PR, for optimizing care for people with CRD and their caregivers.

EXPERT OPINION

A deeper understanding/recognition of the extensiveness and somewhat overlap of the experiences and unmet needs of individuals with CRD and their family/friend caregivers; and of the reciprocal/symbiotic relationship between PR and the family/friend caregivers might be important to optimizing management and, ultimately, individuals and caregivers' outcomes in CRD.

Manual Therapy as an Alternative Treatment Option for Idiopathic Pulmonary Fibrosis: A Case Report

Idiopathic pulmonary fibrosis (IPF) is a type of interstitial lung disease that results in fibrotic lung tissue leading to symptoms of dyspnea, nonproductive cough, decreased mobility, and fatigue. This case report presents a well-documented case of a 73-year-old female presenting to a chiropractic and rehabilitation center seeking care after failing medication therapy. The patient presented hypoxic on room air with decreased mobility throughout her cervical, thoracic, and lumbar spine. Three manual therapy techniques were performed at the rehabilitation clinic aimed at improving the range of motion of the impacted joints and surrounding tissue. The patient was also given manual therapy exercises to perform at home. Pre- and post-intervention assessments showed an improvement in oxygenation saturation on room air, increased mobility, and stabilization of the patient's pulmonary function test (PFT) values. This case demonstrates the importance of considering manual therapy in patients who have failed the standard of care or are unable to tolerate the medications used to treat IPF.

Understanding the lived experience of idiopathic pulmonary fibrosis and how this shapes views on home-based pulmonary rehabilitation in Delhi, India

OBJECTIVES

Pulmonary Rehabilitation (PR) is a high-impact intervention for individuals with idiopathic pulmonary fibrosis (IPF) but access is limited in India. PR barriers include distance to travel, lack of service provision and lack of healthcare professionals to deliver PR, thus it is disproportionate to the immense burden of IPF in India. We explored the lived experiences of people living with IPF, family caregivers (CGs) and healthcare workers (HCWs) as well as their views towards home-based PR (HBPR) in Delhi, India.

METHODS

A qualitative study using semi-structured interviews with individuals with IPF (n = 20), CGs (n = 10) and HCWs (n = 10) was conducted. Data were analysed using codebook thematic analysis.

RESULTS

Three major themes were generated: (i) Health impact, which included pathophysiological changes, range of symptoms experienced, disease consequences and impact of comorbidities; (ii) Disease management, which described strategies to control the progression and overall management of IPF, such as medications and exercises; (iii) Mode of Pulmonary Rehabilitation, which described perceptions regarding HBPR, comparisons with centre-based programmes, and how HBPR may fit as part of a menu of PR delivery options.

CONCLUSION

People living with IPF, family caregivers and healthcare workers were positive about the potential implementation of HBPR and suggested the development of a paper-based manual to facilitate HBPR over digital/online approaches. The content of HBPR should be sensitive to the additional impact of non-IPF health issues and challenges of reduced interactions with healthcare professionals.

The role of pulmonary rehabilitation in idiopathic pulmonary fibrosis: An overview of systematic reviews

BACKGROUND

The role of pulmonary rehabilitation (PR) in idiopathic pulmonary fibrosis (IPF) has been studied in several systematic reviews (SRs), but no definitive conclusions have been drawn due to the wide variation in the quality and outcomes of the studies. And there are no studies to assess the quality of relevant published SRs. This overview aims to determine the effectiveness of PR in patients with IPF and to summarize and critically evaluate the risk of bias, methodological, and evidence quality of SRs on this related topic.

METHODS

With no language restrictions, eight databases were searched from inception to March 10, 2023. The literature search, screening, and data extraction were carried out separately by two reviewers. We assessed the risk of bias using the ROBIS tool, the reporting quality using PRISMA statements, the methodological quality using AMSTAR-2, and the evidence quality using Grades of Recommendations, Assessment, Development, and Evaluation (GRADE).

RESULTS

Seven SRs from 2018-2023 (including 1836 participants) on PR for the treatment of IPF were selected, all of which included patients with a definitive diagnosis of IPF. After strict evaluation by the ROBIS tool and AMSTAR-2 tool, 42.86% of the SRs had a high risk of bias and 85.71% of the SRs had critically low methodological quality in this overview. PR might be effective for patients with IPF on exercise capacity, quality of life, and pulmonary function-related outcomes, but we did not find high quality evidence to confirm the effectiveness.

CONCLUSION

PR may appear to be an effective and safe treatment for patients with IPF, but the results of this overview should be interpreted dialectically and with caution. Further high-quality, rigorous studies are urgently needed to draw definitive conclusions and provide scientific evidence.

Effect of Chest Physiotherapy on Quality of Life, Exercise Capacity and Pulmonary Function in Patients with Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is one of the most deleterious diseases of the pulmonary fibrosis spectrum. Its clinical presentation includes irreversible loss of lung function, and increasing cough, dyspnea and impaired quality of life. Chest physiotherapy can improve ventilation capacity, gas exchange, dyspnea, exercise capacity and quality of life. The aim of this study was to review the evidence about chest physiotherapy in IPF, specifically meta-analyzing quality of life, exercise capacity and pulmonary function.

METHODS

A wide search was conducted in PubMed, Embase, Cochrane and Web of Science for articles included until October 2023. PROSPERO Identifier: CRD42022333496. The Downs and Black scale and the Cochrane tool were employed to evaluate quality assessments and to assess the risk of bias. Data were pooled, and a meta-analysis was conducted.

RESULTS

We selected 10 studies in which a chest physiotherapy program was performed with a total of 340 patients; of these, three articles were meta-analyzed. Significant effects in favor of chest physiotherapy were found for quality of life (MD = -8.60, 95% CI = -11.30, -5.90; p < 0.00001; I2 = 24%), exercise capacity (MD = 37.62, 95% CI = 15.10, 60.13; p = 0.001; I2 = 65%) and pulmonary function (MD = 7.86, 95% CI = 2.54, 13.17; p = 0.004; I2 = 80%).

CONCLUSIONS

The systematic review showed significant results for the application of chest physiotherapy regarding pulmonary capacity, diffusion of gases and quality of life in IPF patients. The meta-analysis showed a significant improvement associated with applying chest physiotherapy in pulmonary function, exercise capacity and quality of life.

A 1-year follow-up study in patients with idiopathic pulmonary fibrosis regarding adverse outcomes to unintended weight loss

OBJECTIVES

Malnutrition in pulmonary fibrosis may influence clinical outcomes negatively. This project aimed to investigate if weight, unintended weight loss (UWL) at baseline and weight development, and signs of sarcopenia measured by the strength, assistance with the walking, rising from a chair, climbing stairs, and falls questionnaire (SARC-F) are associated with hospital admissions and mortality for idiopathic pulmonary fibrosis outpatients in ≤1 y as well as referral to pulmonary rehabilitation.

METHODS

At baseline, prevalence of weight and UWL were sought in a cross-sectional questionnaire study, consecutively, including 100 patients in an outpatient clinic. Medical records were sought for time from diagnosis and comorbidities. One year after inclusion weight, UWL and SARC-F were collected by phone interviews, and medical records were revisited for clinical outcomes.

RESULTS

Of the 100 patients, two patients died and seven were lost to follow-up. The prevalence of UWL increased within the year (10-13%), and the amount of UWL increased (9.1-11.8 kg). Patients with a UWL at baseline had a significantly higher risk of mortality (odds ratio = 29.8; P = 0.037). UWL at baseline was associated with risk of hospital admissions (odds ratio = 14.7; P = 0.009). Based on the results from SARC-F, 20.9% have signs of sarcopenia. UWL at follow-up was associated with the risk of sarcopenia by SARC-F. Patients with risk of sarcopenia and those with body mass index ≥30 kg/m² were to a higher degree offered pulmonary rehabilitation; however, participation was low.

CONCLUSIONS

UWL at baseline was significantly associated with risk of hospital admissions and mortality in ≤1 y in idiopathic pulmonary fibrosis outpatients. Patients with signs of sarcopenia and body mass index ≥30 kg/m² were most often referred to pulmonary rehabilitation.

Advances in the management of idiopathic pulmonary fibrosis and progressive pulmonary fibrosis

Similarly to idiopathic pulmonary fibrosis (IPF), other interstitial lung diseases can develop progressive pulmonary fibrosis (PPF) characterized by declining lung function, a poor response to immunomodulatory therapies, and early mortality. The pathophysiology of disordered lung repair involves common downstream pathways that lead to pulmonary fibrosis in both IPF and PPF. The antifibrotic drugs, such as nintedanib, are indicated for the treatment of IPF and PPF, and new therapies are being evaluated in clinical trials. Clinical, radiographic, and molecular biomarkers are needed to identify patients with PPF and subgroups of patients likely to respond to specific therapies. This article reviews the evidence supporting the use of specific therapies in patients with IPF and PPF, discusses agents being considered in clinical trials, and considers potential biomarkers based on disease pathogenesis that might be used to provide a personalized approach to care.

Forced Oscillation Measurements in Patients with Idiopathic Interstitial Pneumonia Subjected to Pulmonary Rehabilitation

(1) Background: Pulmonary rehabilitation (PR) plays a significant therapeutic role for patients with idiopathic interstitial pneumonia (IIP). The study assessed the impact of physical activity on lung function measured by forced oscillation technique (FOT). (2) Methods: The study involved 48 patients with IIP subjected to a 3-week inpatient PR. The control group included IIP patients (n = 44) on a 3-week interval without PR. All patients were assessed at baseline and after 3 weeks of PR by FOT, spirometry, plethysmography, grip strength measurement and the 6-minute walk test. (3) Results: There were no significant changes in FOT measurements in the PR group, except for reduced reactance at 11 Hz, observed in both groups (p < 0.05). Patients who completed PR significantly improved their 6-min walk distance (6MWD) and forced vital capacity (FVC). The change in 6MWD was better in patients with higher baseline reactance (p = 0.045). (4) Conclusions: Patients with IIP benefit from PR by an increased FVC and 6MWD; however, no improvement in FOT values was noticed. Slow disease progression was observed in the study and control groups, as measured by reduced reactance at 11 Hz. Patients with lower baseline reactance limitations achieve better 6MWD improvement.

Clinical evidence for improving exercise tolerance and quality of life with pulmonary rehabilitation in patients with idiopathic pulmonary fibrosis: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of pulmonary rehabilitation for exercise tolerance and quality of life improvement in idiopathic pulmonary fibrosis.

METHODS

We searched PubMed, Cochrane Library, Embase, Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wanfang Database, and Chongqing VIP for randomized controlled trials that compared pulmonary rehabilitation with usual care for idiopathic pulmonary fibrosis. The risk of bias and certainty of evidence were assessed using Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations, Assessment, Development and Evaluation criteria.

RESULTS

Eleven trials in total with 549 participants. Compared with usual care, pulmonary rehabilitation significantly increased 6-minute walking distance (mean difference: 35.2m, 95% confidence intervals: 25.4m-44.9m; ten trials; 447 participants; moderate), decreased the St George's Respiratory Questionnaire total scores (mean difference: -9.11, 95% confidence intervals: -10.78 to -7.43; six trials; 303 participants; moderate), and reduced the modified Medical Research Council scores were lower (mean difference: -0.76, 95% confidence intervals: -1.25 to -0.27; three trials; 196 participants; low). Improvements were noted in forced vital capacity percent-predicted (mean difference: 4.88, 95% confidence intervals: 2.67 to 7.10; four trials; 214 participants; moderate) and diffusing capacity for carbon monoxide (mean difference: 4.71, 95% confidence intervals: 0.96 to 8.46; six trials; 358 participants; low).

CONCLUSIONS

Pulmonary rehabilitation may significantly improve exercise tolerance and quality of life in idiopathic pulmonary fibrosis patients, but the quality of evidence was low to moderate. Large sample, multicenter, randomized controlled trials are needed to verify the efficacy and safety of pulmonary rehabilitation.

Long-Term Maintenance Strategies after Pulmonary Rehabilitation: Perspectives of People with Chronic Respiratory Diseases, Informal Carers, and Healthcare Professionals

Pulmonary rehabilitation (PR) is an effective intervention for people with chronic respiratory diseases (CRD); however, its effects fade after 6–12 months. Community-based strategies might be valuable to sustain PR benefits, but this has been little explored. People with CRD, informal carers, and healthcare professionals (HCPs) were recruited from pulmonology appointments of two local hospitals, two primary care centres, and one community institutional practice and through snowballing technique. Focus groups were conducted using a semi-structured guide. Data were thematically analysed. Twenty-nine people with CRD (24% female, median 69 years), 5 informal carers (100% female, median 69 years), and 16 HCPs (75% female, median 36 years) were included. Three themes were identified: “Maintaining an independent and active lifestyle” which revealed common strategies adopted by people with “intrinsic motivation and professional and peer support” as key elements to maintain benefits, and that “access to information and partnerships with city councils’ physical activities” were necessary future steps to sustain active lifestyles. This study suggests that motivation, and professional and peer support are key elements to maintaining the benefits of PR in people with CRD, and that different physical activity options (independent or group activities) considering peoples’ preferences, should be available through partnerships with the community, namely city councils.

Effectiveness of Pulmonary Rehabilitation in Interstitial Lung Disease, Including Coronavirus Diseases: A Systematic Review and Meta-analysis

OBJECTIVE

A meta-analysis of randomized controlled trials (RCTs) was conducted to determine the effect of pulmonary rehabilitation on functional capacity and quality of life in interstitial lung diseases, including those caused by coronaviruses.

DATA SOURCES

MEDLINE, EMBASE, SPORTDiscus, Cochrane Library, Web of Science, and MedRxiv from inception to November 2020 were searched to identify documents.

STUDY SELECTION

Publications investigating the effect of pulmonary rehabilitation on lung function (forced vital capacity [FVC]), exercise capacity (6-minute walk distance [6MWD]), health related quality of life (HRQOL), and dyspnea were searched.

DATA EXTRACTION

The data were extracted into predesigned data extraction tables. Risk of bias was evaluated with the Cochrane Risk of Bias tool (RoB 2.0).

DATA SYNTHESIS

A total of 11 RCTs with 637 interstitial lung disease patients were eligible for analyses. The pooled effect sizes of the association for pulmonary rehabilitation were 0.37 (95% confidence interval [CI], 0.02-0.71) for FVC, 44.55 (95% CI, 32.46-56.64) for 6MWD, 0.52 (95% CI, 0.22-0.82) for HRQOL, and 0.39 (95% CI, -0.08 to 0.87) for dyspnea. After translating these findings considering clinical improvements, pulmonary rehabilitation intervention increased predicted FVC by 5.5%, the 6MWD test improved by 44.55 m, and HRQOL improved by 3.9 points compared with baseline values. Results remained similar in sensitivity analyses.

CONCLUSIONS

Although specific evidence for pulmonary rehabilitation of coronavirus disease 2019 patients has emerged, our data support that interstitial lung disease rehabilitation could be considered as an effective therapeutic strategy to improve the functional capacity and quality of life in this group of patients.

Early Intervention of Pulmonary Rehabilitation for Fibrotic Interstitial Lung Disease Is a Favorable Factor for Short-Term Improvement in Health-Related Quality of Life

Patients with fibrosing interstitial lung disease (FILD) have poor health-related quality of life (HRQOL). We analyzed predictors of short-term improvement of HRQOL after starting pulmonary rehabilitation (PR) in moderate to severe FILD patients. This study involved 28 consecutive patients with FILD (20 males, median age of 77.5 years), who participated in PR program of our hospital for >6 weeks. The St. George’s Respiratory Questionnaire (SGRQ) score and the 6-min walk distance (6MWD) were evaluated before and after PR, and the predictors of efficacy of PR were analyzed. The duration from diagnosis of FILD to start of PR showed a positive correlation with the increase in the SGRQ score, and the baseline SGRQ score showed a negative correlation with increase in the 6MWD. The FILD subtype, modified Medical Research Council score, and treatment history were not associated with the endpoints. According to the receiver operating characteristic curve (ROC) analyses, starting PR within 514 days after diagnosis of FILD was a significant favorable predictor of improvement in the SGRQ total score more than a minimal clinically important difference of 4. In this study, early intervention of PR and lower SGRQ score were associated with the favorable response to PR. PR for FILD should be initiated early before the disease becomes severe.

Consensus-Statement der Österreichischen Gesellschaften für Pneumologie und Rheumatologie zur Definition, Evaluation und Therapie von progredient fibrosierenden interstitiellen Lungenerkrankungen (pfILD)

Interstitielle Lungenerkrankungen (ILD) sind eine heterogene Gruppe von Pathologien, die zunehmend als relevanter Faktor pulmonaler Morbidität und Mortalität erkannt werden. Verschiedene ILD wie die idiopathische Lungenfibrose (IPF), aber auch durch Autoimmunprozesse oder durch exogene Noxen bedingte ILD können zu progredienter, meist irreversibler Lungenfibrose führen. Die antifibrotischen Substanzen Nintedanib und Pirfenidon können den Krankheitsverlauf bei IPF-Patienten günstig beeinflussen. Dagegen werden ILD, die auf entzündlichen Prozessen wie z. B. rheumatologischen Grunderkrankungen oder exogen-allergischer Alveolitis beruhen, bis dato klassischerweise immunsuppressiv therapiert. Immer wieder kommt es aber trotz einer solchen Behandlung zu progredienter Fibrosierung. Eine positive Wirkung antifibrotischer Medikation auf progredient fibrosierende (pf)ILD abseits der IPF konnte in rezenten Studien demonstriert werden, auch wenn der Stellenwert der Antifibrotika in solchen Situationen noch nicht vollständig geklärt ist. Dieses Consensus-Statement beruht auf einem virtuellen, multidisziplinären Expertenmeeting von Rheumatologen, Pneumologen und Radiologen und wurde durch die jeweiligen ILD-Arbeitskreise der Österreichischen Gesellschaften für Pneumologie sowie Rheumatologie (ÖGP und ÖGR) akkordiert. Ziel war es, den aktuellen Stand von klinischer Praxis und wissenschaftlicher Datenlage zu Definition, Evaluation und Therapie von pfILD darzustellen. Zusammenfassend sollen ILD-Patienten einer standardisierten Abklärung unterzogen, in einem multidisziplinären ILD-Board diskutiert und dementsprechend therapiert werden. Kern dieser Empfehlungen ist, auch Non-IPF-Patienten mit dokumentiert progredient fibrosierendem ILD-Verlauf antifibrotisch zu behandeln, insbesondere wenn Honigwabenzysten oder eine bereits ausgedehnte Erkrankung vorliegen. Patienten mit fibrotischer ILD, die auf Basis der ILD-Board-Empfehlung primär keiner oder ausschließlich einer immunsuppressiven Therapie unterzogen werden, sollten engmaschig hinsichtlich eines progredienten Verlaufes überwacht werden.

Clinical Improvement and Effectiveness of Exercise-Based Pulmonary Rehabilitation in Patients With Idiopathic Pulmonary Fibrosis: A BRIEF ANALYTICAL REVIEW

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive lung disease associated with high mortality rates and poor clinical condition. Exercise-based pulmonary rehabilitation (EBPR) has been demonstrated to be effective in improving 6-min walk distance (6MWD), although the clinical improvement and effectiveness are less characterized. The current review examined the existing evidence of EBPR among patients with IPF and aimed to analyze the effect of EBPR on clinical improvement and effectiveness.

METHODS

A systematic databases search (MEDLINE/PubMed, EMBASE, and the Cochrane Library) was conducted for available publications as of January 2020. Randomized controlled trials (RCTs) and meta-analyses of RCTs examining the effect of EBPR in patients with IPF were reviewed. Mean difference for RCTs and weighted mean difference for meta-analyses between the EBPR arm and the usual-care arm in 6MWD were compared with the established minimal clinically important difference (MCID) of 30 m. Clinical improvement following EBPR was determined when mean difference and weighted mean difference were equal or exceeding the MCID. Effectiveness of EBPR was assessed using the number needed to treat (NNT) analysis.

RESULTS

Five independent RCTs (including 21-61 patients/study) and five meta-analyses (including two to five studies with 62-169 patients/meta-analysis) were included. The mean difference of 6MWD ranged from 16-81 m in RCTs. Three of five RCTs demonstrated an average improvement that meets or exceeds the MCID. Two RCTs showed favorable improvement in 6MWD but did not reach the MCID. The weighted mean difference of 6MWD ranged from 27-49 m in the meta-analyses. Four of five meta-analyses showed an average improvement that meets or exceeds the MCID. One early meta-analysis of only two RCTs showed significant improvement, although did not reach the MCID. The NNT in three RCTs and four meta-analyses that met clinical improvement in 6MWD was one.

CONCLUSIONS

This review provides novel evidence with respect to clinical improvement and high effectiveness of EBPR among patients with IPF. The results suggest that, on average, the majority of patients would be expected to clinically improve by completing the EBPR program. The findings further support the prescription of EBPR as clinically effective therapy and implementation as standard of care for patients with IPF. Future studies examining clinical improvement and effectiveness utilizing additional outcomes with the MCID are warranted.

Pulmonary Daoyin as a traditional Chinese medicine rehabilitation programme for patients with IPF: A randomized controlled trial

Background and objective

IPF is a chronic progressive lung disease in which PR provides benefit for patients. PD, a TCM PR programme, has known effectiveness in COPD, but its utility in IPF is unknown. We investigated its effectiveness and safety in patients with IPF.

Methods

A 6‐month randomized controlled trial (RCT) was conducted in three Chinese clinics. Ninety‐six participants diagnosed with IPF were randomly assigned to one of the three groups: the PD group received a PD programme two times a day, 5 days/week for 2 months, and the exercise group exercised via a stationary cycle ergometer, 30 min/day, 5 days/week for 2 months. Volunteers in the control group were advised to maintain their usual activities. Primary outcomes were changes from baseline in the 6MWD and HRQoL score on the SGRQ‐I at 1 and 2 months (at the end of the intervention) and at 6 months (4 months after the intervention). Secondary outcomes measures included FVC, DL_CO (% predicted) and the changes in mMRC.

Results

The 6MWD was increased in the PD group compared to exercise and control groups. 6MWD increased by 60.44 m in the PD group, 32.16 m in the exercise group and 12.42 m in controls after the 2 months of rehabilitation programme. The between‐group differences in the change from baseline were 28.78 m (95% CI: 0.54 to 56.01; P = 0.044) and 48.02 m (95% CI: 23.04 to 73.00; P < 0.001) at 2 months, and 25.61 m (95% CI: −0.67 to 51.89; P = 0.058) and 50.93 m (95% CI: 25.47 to 76.40; P < 0.001) at 6 months, respectively, including a difference exceeding the MCID. There was no significant change in the SGRQ‐I score, the mMRC dyspnoea score, FVC and DL_CO (% predicted) in either the PD or exercise groups.

Conclusion

Two months after the intervention, a clinically meaningful difference in 6MWD was observed favouring the PD programme. The PD programme is safe and effective as a rehabilitation intervention designed to increase exercise tolerance and is an appropriate substitute for PR.

This is a randomized clinical trial evaluating the effects of PD, a TCM PR programme, in patients with IPF. PD was associated with a clinically meaningful difference in the 6MWD.

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Effects of Vibration Training in Interstitial Lung Diseases: A Randomized Controlled Trial

BACKGROUND

Numerous studies have reported positive effects of exercise training in patients with interstitial lung disease (ILD) on physical capacity and quality of life. However, evidence is rare on the effects of specific forms of training and further pathophysiological mechanisms in these patients.

OBJECTIVES

In this multicenter study we aimed to explore the clinical effects of whole-body vibration training (WBVT) in patients with ILD on various outcome measures, including proinflammatory cytokines and myostatin.

METHODS

We randomly assigned 26 patients with different forms of multidisciplinary confirmed fibrotic ILDs either to the WBVT group (n = 11; 55% male, 61 ± 14 years old, forced vital capacity 83.2 ± 29.3% predicted, 6-min walking distance [6MWD] 478 ± 79 m) performing 3 months of a standardized training (3 times per week), or to a control training group (CTG, n = 15; 60% male, 63 ± 9 years old, FVC 74.6 ± 20.5% predicted, 6MWD 455 ± 85 m) performing sham WBV training. Training in the two groups was performed on a GalileoTM vibration plate (6-20 vs. 5 Hz). The functional assessments before and after the intervention period included pulmonary function, 6MWD test, chair rise test, ultrasonographic measurement of quadriceps muscle thickness (cross-sectional area), quality of life questionnaires, and serum samples.

RESULTS

We observed a significant increase in 6MWD (∆Training = 30 m [12-67], p = 0.024) and a decrease of myostatin (∆Training = -465 pg/mL [-713 to -166], p = 0.008) in the WBVT group. In contrast, no significant differences were observed in the CTG.

CONCLUSIONS

The present study demonstrates that WBVT is able to significantly increase 6MWD and decrease myostatin in patients with fibrotic ILDs. Therefore, WBVT seems to be a beneficial and feasible training modality in ILD patients. Clinical Trial Registry: German Clinical Trials Registry (DRKS00012930).

The effect of the walk-bike on quality of life and exercise capacity in patients with idiopathic pulmonary fibrosis: a feasibility study

Idiopathic pulmonary fibrosis (IPF) is characterized by progressive loss of pulmonary function and exercise capacity, leading to loss of quality of life and often social isolation. A new walking aid, the walk-bike, showed an improvement in exercise performance in COPD patients. Aims of this pilot study were to evaluate feasibility of a homebased walk-bike intervention study in IPF patients and to explore the effect of the walk-bike on quality of life (QoL) and exercise capacity. Twenty-three patients with IPF were included in a randomized multicenter crossover study with 8 weeks of standard care and 8 weeks of walk-bike use at home. Ten patients completed both study phases. Study barriers included reluctance to participate and external factors (e.g. weather and road conditions) that hampered adherence. Patients’ satisfaction and experience with the walk-bike varied greatly. After training with the walk-bike, health-related QoL (St. George’s Respiratory and King’s Brief Interstitial Lung Disease questionnaires) demonstrated a tendency towards improvement, exercise capacity did not. A clinically important difference was found between 6-minute walk test with the walk-bike and the standard test; median (range) respectively 602 m (358-684) and 486 m (382-510). Conclusions: Due to practical barriers a larger study with the walk-bike in patients with IPF seems not feasible. Individual patients may benefit from the use of a walk-bike as it improved action radius and showed a tendency towards improvement in QoL. No effect on exercise capacity was observed. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 192-202)

The therapy of idiopathic pulmonary fibrosis: what is next?

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrosing interstitial lung disease, characterised by progressive scarring of the lung and associated with a high burden of disease and early death. The pathophysiological understanding, clinical diagnostics and therapy of IPF have significantly evolved in recent years. While the recent introduction of the two antifibrotic drugs pirfenidone and nintedanib led to a significant reduction in lung function decline, there is still no cure for IPF; thus, new therapeutic approaches are needed. Currently, several clinical phase I-III trials are focusing on novel therapeutic targets. Furthermore, new approaches in nonpharmacological treatments in palliative care, pulmonary rehabilitation, lung transplantation, management of comorbidities and acute exacerbations aim to improve symptom control and quality of life. Here we summarise new therapeutic attempts and potential future approaches to treat this devastating disease.

A comprehensive and practical approach to the management of idiopathic pulmonary fibrosis

Introduction: Idiopathic pulmonary fibrosis (IPF) is a debilitating, progressive, and fatal fibrotic pulmonary disease with a prognosis comparable to that of lung cancer. IPF management is a complex process that involves pharmacological and nonpharmacological interventions, extensive patient education, and addressing patient needs that change through the course of the illness. Areas covered: This review summarizes the key aspects of a multifaceted, multidisciplinary, individualized approach to IPF care that incorporates available treatment options, strategies to improve compliance with antifibrotic therapies, pulmonary rehabilitation, and the integration of palliative care for symptom management. Aspects of care discussed include the use of antifibrotic therapy and nonpharmacological treatments, targeted education and psychosocial support, evaluation and management of comorbidities, and early integration of palliative care. Expert opinion: By incorporating this comprehensive approach to disease management, physicians can address most aspects of care for a patient with IPF to optimize survival and quality of life.

Long-term evaluation of home-based pulmonary rehabilitation in patients with fibrotic idiopathic interstitial pneumonias

Background

Few studies have examined the benefits of pulmonary rehabilitation in patients with fibrotic idiopathic pulmonary pneumonia (f-IIP). Here, we report the results of an observational study in routine clinical practice of home-based pulmonary rehabilitation for f-IIP patients.

Methods

A total of 112 consecutive patients (61 with idiopathic pulmonary fibrosis and 51 with fibrotic nonspecific interstitial pneumonitis) were enrolled, of whom 65 had mild-to-moderate disease (forced vital capacity (FVC) ≥50% predicted and diffusing capacity of the lung for carbon monoxide (D_LCO) ≥30% predicted) and 47 had severe disease (FVC <50% predicted and/or D_LCO <30% predicted). The 2-month pulmonary rehabilitation programme consisted of a once-weekly visit with retraining, therapeutic education and psychosocial support. Patients were provided with an individualised action plan and were followed-up bimonthly for 12 months. Exercise tolerance (6-min stepper test (6MST)), mood (Hospital Anxiety and Depression Scale (HADS)) and quality of life (QoL) (Visual Simplified Respiratory Questionnaire (VSRQ)) were assessed before (T₀), immediately after (T₂), 6 months after (T₈) and 12 months after (T₁₄) the end of the pulmonary rehabilitation programme.

Results

6MST strokes, HADS Anxiety score and VSRQ score were each significantly improved at T₂ (n=101), T₈ (n=76) and T₁₄ (n=62) compared with T₀ values. The improvements in outcomes were not influenced by disease severity or subtype. Patients who completed the study had significantly better baseline FVC and D_LCO values than those who did not.

Conclusions

Home-based pulmonary rehabilitation provides long-term benefits in exercise tolerance, anxiety and QoL for patients with f-IIP. Pulmonary rehabilitation should be prescribed systematically as part of the therapeutic arsenal for these patients.

This 12-month follow-up study shows that home-based pulmonary rehabilitation (PR) provides long-term benefits for patients with fibrotic idiopathic interstitial pneumonias. Home-based PR offers an alternative to in-hospital or outpatient PR programmes.http://ow.ly/JVdw30nSOYz

Pulmonary Rehabilitation for Exercise Tolerance and Quality of Life in IPF Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this study is to evaluate the efficacy and safety of pulmonary rehabilitation (PR) in patients with idiopathic pulmonary fibrosis (IPF). Methods. Embase, PubMed, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chongqing VIP (CQVIP), Wanfang Data, and Chinese Biomedical Literature Database (SinoMed) were comprehensively searched. Randomized controlled trials (RCTs) that investigated the effects of PR for IPF patients were included. Literature selection and data extraction were conducted by two review authors independently. The Cochrane Collaboration's Risk of Bias tool and RevMan software (version 5.3) were used to evaluate the quality of studies and conduct statistical analysis, respectively. Results. Seven studies (190 participants) were included. PR had a significant effect on six-minute walk distance (6MWD) (MD:48.60; 95%CI: 29.03 to 68.18; Z=4.87, P<0.00001), and 6MWD was improved more in subgroup analysis including studies conducted in Asia (MD: 53.62; 95%CI: 30.48 to 76.66; Z=4.54, P<0.00001) and Europe (MD:54.10; 95% CI: 26.65 to 101.56; Z=2.23, P=0.03). Forced vital capacity (FVC%) was higher (MD: 3.69; 95%CI: 0.16 to 7.23; Z=2.05, P=0.04). St. George's Respiratory Questionnaire (SGRQ)/IPF-specific SGRQ (SGRQ-I) total score was lower (MD: -7.87; 95% CI: -11.44 to -4.30; Z=4.32, P<0.0001). No significant effects were found for lung diffusing capacity determined by the single-breath technique (DLCO%) (MD: 3.02; 95%CI: -0.38 to 6.42; Z=1.74, P=0.08).

CONCLUSIONS

This study suggests that PR may enhance exercise capacity and improve quality of life in IPF patients. Besides, PR may also delay the decline of lung function of patients with IPF. However, further research should more fully assess the efficacy and safety of PR for IPF.

The past, present and future of pulmonary rehabilitation

Abundant evidence supports the use of pulmonary rehabilitation as a treatment for stable and exacerbated chronic obstructive pulmonary disease. Several questions around the science base of rehabilitation in other patient groups as well as the role of rehabilitation as a component in other comprehensive care trajectories remain to be addressed. The impact of a rehabilitation programme could also perhaps be enhanced if clear guidance would be available on how to individualize the components of a rehabilitation programme in individual patients. The rehabilitation community, in an attempt to increase access to programmes, has developed less rigorous interventions. These may serve specific patients (e.g. less severe patients or may be used as a maintenance programme), but in order to have conceptual clarity they should not be called substitutes for rehabilitation if they do not meet the definition of rehabilitation. Reaching clarity on the best format for maintenance programmes in order to achieve long-lasting health benefits for patients is another challenge. Furthermore, as many patients as possible should be referred to adequate rehabilitation programmes within their reach with fair reimbursement. Programmes should take into account the burden of the disease of a patient, the required components to tackle the problems, adequate assessment to document the outcome and the patient's preference. In summary, pulmonary rehabilitation is one of the most potent evidence-based therapies for patients with respiratory diseases. Researchers should continue to fine tune the interventions, get clarity on terminology as well as the ultimate outcomes for rehabilitation to ensure sustainable health effects.