MRC chronic Dyspnea Scale: Relationships with cardiopulmonary exercise testing and 6-minute walk test in idiopathic pulmonary fibrosis patients: a prospective study

Evaluation of the relationship between intercostal muscle oxygenation measured by near-infrared spectroscopy and exercise capacity in group E COPD patients

Near-infrared spectroscopy (NIRS) can be used to demonstrate muscle metabolism and oxygenation. NIRS-based oximeters enable the noninvasive measurement of static and dynamic muscle oxygenation. This study aimed to evaluate the relationship between NIRS readings and exercise capacity in group E COPD patients. The prospective study included 40 patients with group E COPD who presented to our outpatient clinic between May 2021 and June 2022. The patients were evaluated with pulmonary function testing, 6-Minute Walk Test (6MWT), echocardiography, and dyspnea and quality of life assessments. NIRS muscle oxygen saturation (SmO2) levels at the start and end of the 6MWT were obtained. 6MWT distance was positively correlated with intercostal SmO2 and fingertip SO2 at the start (R = 0.679, p ≤ 0.001 and R = 0.321, p = 0.04, respectively) and end of the 6MWT (R = 0.693, p ≤ 0.001 and R = 0.635, p ≤ 0.001, respectively) and negatively correlated with the number of hospitalizations due to exacerbations in the last year and mean pulmonary arterial pressure (R =  - 0.648, p ≤ 0.001 and R =  - 0.676, p ≤ 0.001, respectively). SF-36 score was positively correlated with intercostal SmO2 at the beginning of the 6MWT (R = 0.336, p = 0.03). Intercostal SmO2 levels at the start of the 6MWT positively correlated with diffusing capacity of the lung for carbon dioxide (DLCO) (R = 0.388, p = 0.01) and ratio of DLCO to alveolar volume (DLCO/VA) levels (R = 0.379, p = 0.02), and these correlations persisted more strongly after the 6MWT (R = 0.524, p = 0.01; R = 0.500, p = 0.01, respectively). NIRS is a practical and noninvasive method for measuring muscle oxygenation and can be used as an alternative to 6MWT in the evaluation of exercise capacity in patients with group E COPD.

Respiratory dysfunction in persistent somatic symptoms: A systematic review of observational studies

OBJECTIVE

This systematic review aims to analyze the existing literature investigating respiratory functioning in people with Persistent Somatic Symptoms (PSS) compared to healthy controls, to identify patterns of respiratory disturbances by symptom or syndrome, and describe any respiratory outcomes consistent across diagnoses.

METHODS

A systematic review following PRISMA guidelines was conducted. A comprehensive search was carried out across five databases (PubMed (NCBI), PsycArticles (Ovid), Web of Science (Core Collection), Embase, and Scopus) using two customised search strings for persistent somatic symptoms and objective respiratory parameters. Title/abstract screening and data extraction were carried out independently by two reviewers. The modified Newcastle-Ottawa Scale was used for quality assessment of the studies. Studies investigating baseline respiratory functioning in adult patients with PSS compared to healthy controls, using at least one objective respiratory were included.

RESULTS

18 studies met the inclusion criteria for the review, with a pooled sample size of n = 3245. Chronic pain conditions were found to be the most prevalent subset of diagnoses of interest, comprising six of the studies. 10 studies included measures of lung capacity, flow and/or volume, nine studies reported measures of ventilation, and four studies investigated respiratory muscle functioning. 13 of the included studies reported significant differences in at least one objective respiratory measure between groups (at rest). Scores on self-reported measures of dysnpea and breathlessness were higher in patients compared to healthy controls, while objective respiratory outcomes were varied.

CONCLUSION

The current systematic review is consistent with previous literature suggesting more pronounced experiences of breathlessness in patients with PSS, and significant disparities between reported dyspnea and objective respiratory outcomes. Research investigating the uncoupling between subjective and objective respiratory outcomes is needed to understand the mechanisms behind breathing disturbances in PSS.

The Beneficial Impact of Pulmonary Rehabilitation in Idiopathic Pulmonary Fibrosis: A Review of the Current Literature

Idiopathic pulmonary fibrosis (IPF) is a chronic and irreversible fibrotic disease whose natural history is characterised by a progressive worsening of the pulmonary function, exertional dyspnoea, exercise intolerance, reduced physical activity, and health-related quality of life (HRQOL) impairment. Pulmonary rehabilitation (PR) is a comprehensive, multi-disciplinary programme that uses a combination of strength training, teaching, counselling, and behaviour modification techniques to reduce symptoms and optimise functional capacity in patients with chronic lung disease. Based on the well-documented effectiveness of PR in chronic obstructive pulmonary disease (COPD), over the years supportive evidence of its benefits for other respiratory diseases has been emerging. Although the latest rehabilitation guidelines recognised PR's efficacy for interstitial lung disease (ILD) and IPF in particular, this comprehensive approach remains underused and under-resourced. In this review, we will discuss the advantages and beneficial effects of PR on IPF, analysing its impact on exercise capacity, disease-related symptoms, cardiovascular outcomes, body composition, and HRQOL.

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.

Comparison of high-intensity interval training versus moderate-intensity continuous training in pulmonary rehabilitation for interstitial lung disease: a randomised controlled pilot feasibility trial

OBJECTIVES

This study aimed to investigate the feasibility and efficacy of high-intensity interval training (HIIT) compared with moderate-intensity continuous training (MICT) in pulmonary rehabilitation (PR) for people with interstitial lung disease (ILD).

DESIGN

Single-centre, randomised controlled feasibility, pilot trial.

SETTING

Patients were recruited from the chest clinic of a tertiary ILD centre and attended circuit-based PR in the hospital's gym, followed by a personalised 6-month community programme.

PARTICIPANTS

58 patients, stratified per ILD type, were randomised into two groups: 33 to HIIT (18 males:15 females) (mean age (SD): 70.2 (11.4) years) and 25 to the MICT exercise mode (14 males:11 females) (mean age (SD): 69.8 (10.8) years).

INTERVENTIONS

8-week, twice weekly, circuit-based PR programme of exercise and education, followed by a personalised 6-month community exercise programme.

OUTCOME MEASURES

Feasibility outcomes included staff-to-patient ratio and dropout rates per group. Primary outcome was the 6 min walk distance (6MWD). Secondary outcomes included the sniff nasal pressure, mouth inspiratory and expiratory pressures, handgrip and quadriceps strength and health status. Random-effects models were used to evaluate average variation in outcomes through time across the two groups.

RESULTS

The 6MWD peaked earlier with HIIT compared with MICT (at 4 months vs 5 months) but values were lower at peak (mean (95% CI): 26.3 m (3.5 to 49.1) vs 51.6 m (29.2 to 73.9)) and declined faster at 6 months post-PR. Secondary outcomes showed similar faster but smaller improvements with HIIT over MICT and more consistent maintenance 6 months post-PR with MICT than HIIT.

CONCLUSIONS

HIIT is feasible in circuit-based ILD PR programmes and provides quick improvements but requires closer supervision of training and resources than MICT and benefits may be less well sustained. This would make it a less attractive option for clinical PR programmes. A definitive, multicentre randomised controlled trial is required to address the role of HIIT in ILD.

TRIAL REGISTRATION NUMBER

ISRCTN55846300.

The MRC Dyspnoea Scale and mortality risk prediction in pulmonary arterial hypertension: A retrospective longitudinal cohort study

Risk stratification models in pulmonary arterial hypertension (PAH) rely on World Health Organisation Functional Class (WHO FC). A high proportion of patients are classified as WHO FC III, a heterogenous group which limits the stratification abilities of risk models. The Medical Research Council (MRC) Dyspnoea Scale may allow a more precise assessment of functional status and improve current risk models. We investigated the ability of the MRC Dyspnoea Scale to assess survival in PAH and compared performance to WHO FC and the COMPERA 2.0 models. Patients with Idiopathic, Hereditary or Drug-induced PAH who were diagnosed between 2010 and 2021 were included. The MRC Dyspnoea Scale was retrospectively applied as derived from a combination of patient notes, 6MWD tests results and WHO functional status using a purpose-designed algorithm. Survival was assessed using Kaplan-Meier analyses, log rank testing and Cox proportional hazard ratios. Model performance was compared with Harrell's C Statistic. Data from 216 patients were retrospectively analyzed. At baseline, of 120 patients classified as WHO FC III, 8% were MRC Dyspnoea Scale 2, 12% Scale 3, 71% Scale 4 and 10% Scale 5. The MRC Dyspnoea Scale performed well compared to the WHO FC and COMPERA models at follow up (respectively, C-statistic 0.74 vs. 0.69 vs. 0.75). It was possible to use the MRC Dyspnoea Scale to subdivide patients in WHO FC III into groups which had distinct survival estimates. We conclude that at follow-up, the MRC Dyspnoea Scale may be a valid tool for the assessment of risk stratification in pulmonary arterial hypertension.

Relation of impulse oscillometry and spirometry with quantitative thorax computed tomography after COVID-19 pneumonia

OBJECTIVE

This study aimed to investigate if there is any correlation between the quantitative computed tomography and the impulse oscillometry or spirometry results of post-COVID-19 patients.

METHODS

The study comprised 47 post-COVID-19 patients who had spirometry, impulse oscillometry, and high-resolution computed tomography examinations at the same time. The study group consisted of 33 patients with quantitative computed tomography involvement, while the control group included 14 patients who did not have CT findings. The quantitative computed tomography technology was used to calculate percentages of density range volumes. The relationship between percentages of density range volumes for different quantitative computed tomography density ranges and impulse oscillometry-spirometry findings was statistically analyzed.

RESULTS

In quantitative computed tomography, the percentage of relatively high-density lung parenchyma, including fibrotic areas, was 1.76±0.43 and 5.65±3.73 in the control and study groups, respectively. The percentages of primarily ground-glass parenchyma areas were found to be 7.60±2.86 and 29.25±16.50 in the control and study groups, respectively. In the correlation analysis, the forced vital capacity% predicted in the study group was correlated with DRV%[(-750)-(-500)] (volume of the lung parenchyma that has density between (-750)-(-500) Hounsfield units), but no correlation with DRV%[(-500)-0] was detected. Also, reactance area and resonant frequency were correlated with DRV%[(-750)-(-500)], while X5 was correlated with both DRV%[(-500)-0] and DRV%[(-750)-(-500)] density. Modified Medical Research Council score was correlated with predicted percentages of forced vital capacity and X5.

CONCLUSION

After COVID-19, forced vital capacity, reactance area, resonant frequency, and X5 correlated with the percentages of density range volumes of ground-glass opacity areas in the quantitative computed tomography. X5 was the only parameter correlated with density ranges consistent with both ground-glass opacity and fibrosis. Furthermore, the percentages of forced vital capacity and X5 were shown to be associated with the perception of dyspnea.

Prescribing walking training in interstitial lung disease from the 6-minute walk test

INTRODUCTION AND OBJECTIVE

Endurance training during PR requires exercise prescription at sufficient intensity to achieve physiological benefits. This analysis sought to investigate whether walking training prescribed from 6-minute walk test (6MWT) average speed provides an appropriate training intensity for people with ILD during PR.

METHODS

Individuals with ILD completed cardiopulmonary exercise test (CPET) and 6MWT in random order. A 10-minute constant speed treadmill walk test (10MTW) was undertaken at 80% of the average 6MWT speed. Oxygen uptake (VO₂) was measured during all tests. Percentage VO₂peak during 10MTW was main outcome measure.

RESULTS

Eleven people with ILD (age 71 (8) years; forced vital capacity 73 (18) %predicted, 6-minute walk distance 481 (99) meters, and VO₂peak during CPET 1.3 (0.2) L.min^-1) undertook testing. Average VO₂peak during 10MTW was 91 (18) % of CPET VO₂peak [range 67-116%]. Participants who achieved a greater VO₂peak during CPET walked at a smaller %VO₂peak during 10MTW (r = -0.6; p = .04).

CONCLUSIONS

For people with ILD, walking training prescribed at 80% of 6MWT average speed can provide adequate exercise training intensity for PR.

Assessing dyspnea-related kinesiophobia in patients with systemic sclerosis (SSc): validity and reliability of Turkish Breathlessness Beliefs Questionnaire for SSc

INTRODUCTION/OBJECTIVE

The respiratory system is often affected by systemic sclerosis (SSc), a connective tissue disease characterized by fibrosis, vasculopathy, and inflammation. As a result, especially exertional dyspnea may occur in SSc patients. Evaluation of attitudes towards dyspnea is important in terms of preventing negative consequences such as kinesiophobia. However, no validated tool is available for assessing dyspnea-related kinesiophobia for patients with SSc. The aim of the present study was to perform the Turkish validation of the Breathlessness Beliefs Questionnaire for SSc (BBQ-SSc), which was adapted from the Tampa Kinesiophobia Scale, and to investigate its relationships with physical and clinical characteristics.

METHOD

Fifty patients with SSc (47 females) were included in the study. The patients were evaluated regarding pulmonary function tests, respiratory muscle strength, patient-reported dyspnea, quality of life related to respiratory problems, mood, and fatigue. The patients were re-evaluated 1 week later for the test-retest reliability of the BBQ-SSc.

RESULTS

Internal consistency (Cronbach's alpha: 0.862) and test-retest validity (ICC: 0.831; 95% CI: 0.702-0.907) of the 12-item Turkish BBQ-SSc were found to be good. Principal component analysis confirmed the two-dimensional structure of the questionnaire. The scores of the questionnaire were associated with duration of illness, patient-reported dyspnea, quality of life related to respiratory problems, mood, and fatigue (p < 0.05).

CONCLUSIONS

According to our results, the 12-item Turkish BBQ-SSc is a reliable and valid tool to assess dyspnea-related kinesiophobia in SSc patients. Key Points • There are no structured tools available for assessing dyspnea-related kinesiophobia in patients with systemic sclerosis (SSc) • The 12-item Turkish Breathlessness Beliefs Questionnaire for SSc (BBQ-SSc) is a reliable and valid tool to assess dyspnea-related kinesiophobia in SSc patients.

Patient-reported outcomes to assess dyspnoea in interstitial lung disease and pulmonary hypertension: a systematic literature review of measurement properties

OBJECTIVE

This COnsensus-based Standards for the selection of health measurement INstruments (COSMIN)-based systematic review aims to identify and summarise the quality of measurement properties of dyspnoea-specific patient-reported outcome measures (PROMs) for patients with interstitial lung disease (ILD), pulmonary hypertension (PH) or connective tissue diseases (CTDs).

METHODS AND RESULTS

Relevant articles in PubMed and Embase were screened. Based on COSMIN analysis and the Grading of Recommendations, Assessment, Development and Evaluation approach, overall rating and level of evidence were assessed to formulate recommendations. We identified 26 publications on 10 PROMs. For patients with ILD, including CTD-associated ILD, nine PROMs were evaluated, of which the Dyspnea-12 (D12), EXACT-Respiratory Symptoms Idiopathic Pulmonary Fibrosis Breathlessness subscale (ERS-IPF-B), King's Brief Interstitial Lung Disease Health Status Questionnaire breathlessness and activities subscale (KBILD-B) and the University of California San Diego Shortness of Breath Questionnaire (UCSD-SOBQ) had high-quality evidence for sufficient internal consistency, without high-quality evidence of insufficient measurement properties. We reached this same conclusion regarding the D12 for use in patients with PH, including CTD-associated PH. Most PROMs in this systematic review have moderate- or low-quality evidence on construct validity and responsiveness.

CONCLUSION

Four dyspnoea-specific PROMs, D12, ERS-IPF-B, KBILD-B and UCSD-SOBQ, can be recommended for use in patients with ILD, including CTD-associated ILD. Of these four, the D12, despite the limited evidence and the lack of evidence on several important domains, is also suitable for use in patients with PH, including CTD-associated PH.

Features and predictive value of 6-min walk test outcomes in interstitial lung disease: an observation study using wearable monitors

OBJECTIVES

To describe 6-min walk test (6MWT) outcomes, and to investigate their correlations with cardiopulmonary and lung function among patients with interstitial lung disease (ILD) which was not limited to idiopathic pulmonary fibrosis.

METHODS

We collected patients' demographic data and obtained minute-by-minute 6MWT outcomes. Modified Borg scale was employed to assess patients' dyspnoea, whereas New York Heart Association (NYHA) classification and pulmonary function test were used to evaluate patients' cardiopulmonary functions.

RESULTS

Heart rate (HR) exhibited a continuous upward trend, while SpO₂ exhibited an overall downward with a slight increase at the fifth minute. The SpO₂ nadir for 70 patients (9.3%) was lower than 80%. Further, the SpO₂ nadir for 78.27% of the participants appeared at the end of the fourth minute. The 6-min walk distance (6MWD) had the strongest correlation with NYHA classification (r=0.82, p<0.01). The ratio of 6MWD to predicted 6MWD was most correlated to forced expiratory volume in the first second (r=0.30, p<0.01) and forced vital capacity (r=0.30, p<0.01). SpO₂ at 3 min had the strongest correlation to patients' diffusing capacity of the lungs for carbon monoxide (r=0.41, p<0.01). We found significant differences in 6MWD (F=2.44, p=0.033), SpO₂ change (F=2.58, p=0.025), HR at 0 min (F=2.87, p=0.014), HR at end of 6 min (F=2.58, p=0.025) and HR zenith (F=2.64, p=0.022) between the subtypes of ILD.

CONCLUSION

This observation provided an important evidence regarding oxygen titration. It is better to maintain SpO₂ above 88% for 4 min instead of 3 min. SpO₂ at the third minute was the most valuable predictor of patients' lung function. 6MWD and SpO₂ changes were more discriminative in subtypes.

Association of Vaccination with the Persistence of Post-COVID Symptoms

BACKGROUND

Patients who have had COVID-19 often report persistent symptoms after resolution of their acute illness. Recent reports suggest that vaccination may be associated with improvement in post-acute symptoms. We used data from a prospective cohort to assess differences in post-acute sequelae of COVID (PASC) among vaccinated vs. unvaccinated patients.

METHODS

We used data from a cohort of COVID-19 patients enrolled into a prospective registry established at a tertiary care health system in New York City. Participants underwent a baseline evaluation before COVID-19 vaccines were available and were followed 6 months later. We compared unadjusted and propensity score-adjusted baseline to 6-month change for several PASC-related symptoms and measures: anosmia, respiratory (cough, dyspnea, phlegm, wheezing), depression, anxiety, post-traumatic stress disorder (PTSD; COVID-19-related and other trauma), and quality-of-life domains among participants who received vs. those who did not receive COVID-19 vaccination.

RESULTS

The study included 453 COVID-19 patients with PASC, of which 324 (72%) were vaccinated between the baseline and 6-month visit. Unadjusted analyses did not show significant differences in the baseline to 6-month change in anosmia, respiratory symptoms, depression, anxiety, PTSD, or quality of life (p > 0.05 for all comparisons) among vaccinated vs. unvaccinated patients. Similar results were found in propensity-adjusted comparisons and in secondary analyses based on the number of vaccine doses received.

CONCLUSIONS

Our findings suggest that COVID vaccination is not associated with improvement in PASC. Additional studies are needed to better understand the mechanisms underlying PASC and to develop effective treatments.

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.

Cardiopulmonary exercise testing in interstitial lung diseases and the value of ventilatory efficiency

Interstitial lung diseases (ILDs) are diverse parenchymal pulmonary disorders, primarily characterised by alveolar and interstitial inflammation and/or fibrosis, and sharing pathophysiological similarities. Thus, patients generally harbour common respiratory symptoms, lung function abnormalities and modified exercise adaptation. The most usual and disabling complaint is exertional dyspnoea, frequently responsible for premature exercise interruption. Cardiopulmonary exercise testing (CPET) is increasingly used for the clinical assessment of patients with ILD. This is because exercise performance or dyspnoea on exertion cannot reliably be predicted by resting pulmonary function tests. CPET, therefore, provides an accurate evaluation of functional capacity on an individual basis. CPET can unmask anomalies in the integrated functions of the respiratory, cardiovascular, metabolic, peripheral muscle and neurosensory systems in ILDs. CPET uniquely provides an evaluation of all above aspects and can help clinicians shape ILD patient management. Preliminary evidence suggests that CPET may also generate valuable prognostic information in ILDs and can be used to shed light on the presence of associated pulmonary hypertension. This review aims to provide comprehensive and updated evidence concerning the clinical utility of CPET in ILD patients, with particular focus on the physiological and clinical value of ventilatory efficiency (V˙_E/V˙_CO2 ).

Diagnostic accuracy of subjective dyspnoea in detecting hypoxaemia among outpatients with COVID-19: a retrospective cohort study

OBJECTIVES

The majority of patients with mild-to-moderate COVID-19 can be managed using virtual care. Dyspnoea is challenging to assess remotely, and the accuracy of subjective dyspnoea measures in capturing hypoxaemia have not been formally evaluated for COVID-19. We explored the accuracy of subjective dyspnoea in diagnosing hypoxaemia in COVID-19 patients.

METHODS

This is a retrospective cohort study of consecutive outpatients with COVID-19 who met criteria for home oxygen saturation monitoring at a university-affiliated acute care hospital in Toronto, Canada from 3 April 2020 to 13 September 2020. Dyspnoea measures were treated as diagnostic tests, and we determined their sensitivity (SN), specificity (SP), negative/positive predictive value (NPV/PPV) and positive/negative likelihood ratios (+LR/-LR) for detecting hypoxaemia. In the primary analysis, hypoxaemia was defined by oxygen saturation <95%; the diagnostic accuracy of subjective dyspnoea was also assessed across a range of oxygen saturation cutoffs from 92% to 97%.

RESULTS

During the study period, 89/501 (17.8%) of patients met criteria for home oxygen saturation monitoring, and of these 17/89 (19.1%) were diagnosed with hypoxaemia. The presence/absence of dyspnoea had limited accuracy for diagnosing hypoxaemia, with SN 47% (95% CI 24% to 72%), SP 80% (95% CI 68% to 88%), NPV 86% (95% CI 75% to 93%), PPV 36% (95% CI 18% to 59%), +LR 2.4 (95% CI 1.2 to 4.7) and -LR 0.7 (95% CI 0.4 to 1.1). The SN of dyspnoea was 50% (95% CI 19% to 81%) when a cut-off of <92% was used to define hypoxaemia. A modified Medical Research Council dyspnoea score >1 (SP 98%, 95% CI 88% to 100%), Roth maximal count <12 (SP 100%, 95% CI 75% to 100%) and Roth counting time <8 s (SP 93%, 95% CI 66% to 100%) had high SP that could be used to rule in hypoxaemia, but displayed low SN (≤50%).

CONCLUSIONS

Subjective dyspnoea measures have inadequate accuracy for ruling out hypoxaemia in high-risk patients with COVID-19. Safe home management of patients with COVID-19 should incorporate home oxygenation saturation monitoring.

Effect of Co-trimoxazole (Trimethoprim-Sulfamethoxazole) vs Placebo on Death, Lung Transplant, or Hospital Admission in Patients With Moderate and Severe Idiopathic Pulmonary Fibrosis: The EME-TIPAC Randomized Clinical Trial

IMPORTANCE

Idiopathic pulmonary fibrosis (IPF) has a poor prognosis and limited treatment options. Patients with IPF have altered lung microbiota, with bacterial burden within the lungs associated with mortality; previous studies have suggested benefit with co-trimoxazole (trimethoprim-sulfamethoxazole).

OBJECTIVE

To determine the efficacy of co-trimoxazole in patients with moderate and severe IPF.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, placebo-controlled, parallel randomized trial of 342 patients with IPF, breathlessness (Medical Research Council dyspnea scale score >1), and impaired lung function (forced vital capacity ≤75% predicted) conducted in 39 UK specialist interstitial lung disease centers between April 2015 (first patient visit) and April 2019 (last patient follow-up).

INTERVENTIONS

Study participants were randomized to receive 960 mg of oral co-trimoxazole twice daily (n = 170) or matched placebo (n = 172) for between 12 and 42 months. All patients received 5 mg of folic acid orally once daily.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to death (all causes), lung transplant, or first nonelective hospital admission. There were 15 secondary outcomes, including the individual components of the primary end point respiratory-related events, lung function (forced vital capacity and gas transfer), and patient-reported outcomes (Medical Research Council dyspnea scale, 5-level EuroQol 5-dimension questionnaire, cough severity, Leicester Cough Questionnaire, and King's Brief Interstitial Lung Disease questionnaire scores).

RESULTS

Among 342 individuals who were randomized (mean age, 71.3 years; 46 [13%] women), 283 (83%) completed the trial. The median (interquartile range) duration of follow-up was 1.02 (0.35-1.73) years. Events per person-year of follow-up among participants randomized to the co-trimoxazole and placebo groups were 0.45 (84/186) and 0.38 (80/209), respectively, with a hazard ratio of 1.2 ([95% CI, 0.9-1.6]; P = .32). There were no statistically significant differences in other event outcomes, lung function, or patient-reported outcomes. Patients in the co-trimoxazole group had 696 adverse events (nausea [n = 89], diarrhea [n = 52], vomiting [n = 28], and rash [n = 31]) and patients in the placebo group had 640 adverse events (nausea [n = 67], diarrhea [n = 84], vomiting [n = 20], and rash [n = 20]).

CONCLUSIONS AND RELEVANCE

Among patients with moderate or severe IPF, treatment with oral co-trimoxazole did not reduce a composite outcome of time to death, transplant, or nonelective hospitalization compared with placebo.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN17464641.

Standardization of the 6-min walk test in clinical trials of idiopathic pulmonary fibrosis

The 6-min walk test (6MWT) is an important measure of functional capacity in idiopathic pulmonary fibrosis (IPF) and has been an endpoint of several IPF clinical trials. However, current guidance for the 6MWT offers insufficient advice on standardization, particularly oxygen supplementation, for clinical trials. Three physicians experienced with the 6MWT and IPF developed a standardized protocol for the 6MWT based on existing clinical guidelines and published literature. The protocol comprises guidance on test conditions, pre-defined parameters to measure at specified timepoints, and step-by-step instructions on conducting the test. The standardized test will be evaluated in the large-scale phase 3 ISABELA trials (NCT03711162; NCT03733444). The test is conducted indoors, using standardized equipment, along a flat, straight, 30-m unobstructed corridor; tests for each individual are performed by the same administrators at the same time of day; warm-up prior to testing is prohibited; supplemental oxygen tanks are permitted and moved by the patient in the same manner for each test; precise wording is used to instruct and encourage patients. Contraindications and stopping criteria are specified. Key assessments include: 6-min walk distance, distance walked at 1 and 3 min, the Borg CR10 scale, heart rate, blood pressure, and oxygen desaturation levels. A standardized 6MWT for IPF will enable more reliable comparisons between clinical trials and limit variability, optimizing use as an endpoint. Application of the standardized 6MWT in the ISABELA program will allow its correlation with other clinically important endpoints and may lead to novel composite endpoints for use in future trials. Submission category: Study Design, Statistical Design, Study Protocols. Submission classifications: Clinical study methodology; Clinical trial design; Clinical trials; Pulmonary disease; Pulmonary disease clinical trial; Respiratory medicine.

Measuring airway clearance outcomes in bronchiectasis: a review

While airway clearance techniques (ACTs) are recommended for individuals with bronchiectasis, many trials have demonstrated inconsistent benefits or failed to reach their primary outcome. This review determined the most common clinical and patient-reported outcome measures used to evaluate the efficacy of ACTs in bronchiectasis. A literature search of five databases using relevant keywords and filtering for studies published in English, up until the end of August 2019, was completed. Studies included randomised controlled trials, using crossover or any other trial design, and abstracts. Studies were included where the control was placebo, no intervention, standard care, usual care or an active comparator. Adults with bronchiectasis not related to cystic fibrosis were included. Extracted data comprised study authors, design, duration, intervention, outcome measures and results. The search identified 27 published studies and one abstract. The most common clinical outcome measures were sputum volume (n=23), lung function (n=17) and pulse oximetry (n=9). The most common patient-reported outcomes were health-related quality of life (measured with St George's Respiratory Questionnaire, n=4), cough-related quality of life (measured with Leicester Cough Questionnaire, n=4) and dyspnoea (measured with Borg/modified Borg scale, n=8). Sputum volume, lung function, dyspnoea and health- and cough-related quality of life appear to be the most common clinical and patient-reported measures of airway clearance treatment efficacy.

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.

A systematic review of literature to evaluate the burden of physical and psychological symptoms and palliative care in patients diagnosed with idiopathic pulmonary fibrosis

Background

Palliative care improves quality of life in patients with life-threatening illnesses, such as idiopathic pulmonary fibrosis (IPF), in a holistic manner and should be integrated early into the management of these patients.

Objective

To evaluate the degree of physical and psychological symptoms in patients with IPF and the extent to which palliative care is used in patient management.

Methods

Several databases were searched for studies reporting on symptom burden, quality of life or palliative interventions in patients with IPF.

Results

A total of 46 articles were included in this review. Studies showed that many patients experienced dyspnoea, which improved with pulmonary rehabilitation in some cases. Fatigue and poor quality of sleep had a notable negative impact on daily life activities. Instruments evaluating anxiety and depression showed that many patients with IPF experienced mild to moderate depression and anxiety. Quality of life was shown to be negatively affected across all domains. Two studies indicated poor referral to palliative care units and one study reported positively on the use of morphine for managing breathlessness in advanced IPF.

Conclusion

Patients with IPF generally experience poor quality of life. Patients are seldom referred to palliative care, even in developed countries. No data were available on the use of palliative care in developing countries. Furthermore, research on the burden of symptoms and management of these symptoms appears to be limited. Increased awareness of and research on the palliative care needs of patients with IPF are recommended, particularly in resource-limited settings such as South Africa.

Utility of the six-minute walk test in patients with idiopathic pulmonary fibrosis

The six-minute walk test (6MWT) is a simple test that is widely used to assess functional exercise capacity in patients with idiopathic pulmonary fibrosis (IPF). Patients with IPF have reduced exercise capacity due to a number of factors, such as impaired respiratory mechanics and circulatory problems. As a self-paced and usually submaximal exercise test, the 6MWT reflects the exercise level of everyday activities. Variables measured during the 6MWT, such as six-minute walk distance (6MWD) and desaturation, are strong predictors of mortality in patients with IPF. However, the results of a 6MWT are affected by numerous factors, including age, body size, comorbidities and the use of supplemental oxygen during the test, and these need to be borne in mind when interpreting the results of individual and serial tests. Clinical studies, including trials of potential therapies for IPF, have differed in the methodology used to implement the 6MWT, hindering the comparison of results across studies. In this review, I describe the utility of the 6MWT in patients with IPF and provide recommendations for standardisation of the test for use both in clinical practice and research. A brief video on how to set up and administer the 6MWT is available at http://www.usscicomms.com/respiratory/lancaster/6mwt/

The 6-Minute Walk Test as a Tool for Determining Exercise Capacity and Prognosis in Patients with Silicosis

OBJECTIVE

To evaluate exercise capacity using the 6-minute walk test (6MWT) in patients with complicated silicosis, and to determine how results shape the prognostic value of 6MWT for hospitalization and mortality.

METHOD

Prospective observational study in 143 patients with complicated silicosis who performed the 6MWT in our outpatient pulmonology clinic between 2009 and the end of 2016. Lung function tests, computed tomography findings and 6MWT parameters (distance walked and oxygen desaturation) were evaluated.

RESULTS

Patients with complicated silicosis walked 387±92m. Results deteriorated as silicosis severity increased; category A: 407±97m, B: 370±88m, and C: 357±68m (P=.022). The 6MWT correlated positively with lung function and inversely with dyspnea determined by mMRC (P<.001). Patients with moderate/severe emphysema and greater CT90 presented a worse result on 6MWT. Patients who walked<350m had more hospitalizations (3.7±4.0) than those who walked>350m (1.1±2.9). There was an impact on survival: non-survivors walked 327.9±73.0m, while survivors walked 404.5±89.7m (P<.001).

CONCLUSIONS

Spirometry values and category of complicated silicosis correlated with 6MWT and distance walked was a prognostic factor for hospitalization and mortality. The 6MWT is a useful tool in occupational health for monitoring patients with silicosis.

Physiology of the lung in idiopathic pulmonary fibrosis

The clinical expression of idiopathic pulmonary fibrosis (IPF) is directly related to multiple alterations in lung function. These alterations derive from a complex disease process affecting all compartments of the lower respiratory system, from the conducting airways to the lung vasculature. In this article we review the profound alterations in lung mechanics (reduced lung compliance and lung volumes), pulmonary gas exchange (reduced diffusing capacity, increased dead space ventilation, chronic arterial hypoxaemia) and airway physiology (increased cough reflex and increased airway volume), as well as pulmonary haemodynamics related to IPF. The relative contribution of these alterations to exertional limitation and dyspnoea in IPF is discussed.

Physiological impairment in IPF is complex and involves all compartments of the respiratory systemhttp://ow.ly/gyao30hdHUb

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.

Daily physical activity affects exercise capacity in patients with idiopathic pulmonary fibrosis

[Purpose] The aim of this study was to determine which factors, including pulmonary, physical, and mental functions; dyspnea; and daily physical activity (PA) affect the 6-minute walk distance (6MWD) in IPF patients. [Subjects and Methods] The pulmonary, physical, and mental functions; dyspnea; PA; and 6MWD were assessed in 38 outpatients with IPF. PA was represented by the mean number of steps per day. [Results] The mean 6MWD was 443.8 m (SD, 98.5), and the mean number of steps per day showing PA was 5148.4 (SD, 3295.7). The 6MWD was correlated with age, base dyspnea index, vital capacity (VC), diffusion capacity of carbon monoxide, quadriceps force (QF), dyspnea during the 6-minute walk test, and PA. Stepwise multiple regression analysis revealed that VC (β=0.382), QF (β=0.272), and PA (β=0.574) were contributing factors of the 6MWD. [Conclusion] In patients with IPF, PA has a greater effect on the 6MWD than VC and QF. The evaluation of daily PA, in addition to physiological and muscle functions, is important in patients with IPF.

Clinical and economic burden of dyspnea and other COPD symptoms in a managed care setting

PURPOSE

The degree to which symptoms such as dyspnea affect patients with COPD is individualized. To address the gap between clinical symptom measures and self-perceived disease burden, we investigated the symptom status of adult patients with COPD and followed with an administrative claims analysis of health care resource utilization and costs.

METHODS

This was a hybrid US observational study consisting of a cross-sectional patient survey followed by a retrospective analysis of administrative claims data. The primary COPD symptom measures were the modified Medical Research Council (mMRC) Dyspnea scale and the COPD Assessment Test (CAT).

RESULTS

A total of 673 patients completed the survey. Of these, 65% reported mMRC grades 0-1 (low symptomatology) and 35% reported mMRC grades 2-4 (high symptomatology); 25% reported CAT score <10 (low symptomatology) and 75% reported CAT score ≥10 (high symptomatology). More patients with high symptomatology (by either measure) had at least one COPD-related inpatient hospitalization, emergency room visit, physician office visit, or other outpatient services, and filled at least one COPD-related prescription medication vs patients with low symptomatology. COPD-related costs were higher for patients with high symptomatology than patients with low symptomatology. In a multivariate analysis, COPD-related costs were also higher in patients reporting severe symptoms.

CONCLUSION

Patients with high COPD symptomatology utilized more health care resources and had higher COPD-related health care costs during the 6-month post-survey period than patients with low symptomatology.

Environmental asbestos disease: pleural plaque volume measurement with Chest Tomography is there a correlation between pulmonary function?

Objectives: Chest X-ray is correlated with pulmonary function of asbestos related disease. These correlations limited by low specific and sensitive. Computed tomography (CT) more sensitive. There was no adopted for the measurement of CT. Our aim in this study was to determine correlation between pleural plaque (PP) volume and lung function for use improving classification with CT. Methods: The study included 75 patients with environmental asbestos exposure. PP areas measured in patients were divided by the patient lung area to determine PP ratio with CT. Diffusing capacity and six minute walking distance (6MWD) measured and evaluated quality of life. Results:PP identified in 66 (88%) of the patients with CT. PP most frequently noted in the front right quadrant and had an average plaque volume of 7729,17 mm3. Plaque ratio taken as the percentage of the ratio to the lung volume, mean plaque percentage was 0,37±0,45% (0,003-2,3). In 12(18,1%) of the patients, asbestosis not seen with chest X-ray was detected with CT. Conclusions: PP volume and ratios were not statistically significantly correlated with respiratory functions, exercise capacity, cumulative amount of exposure. Patient of asbestos disease total lung capacity was lower, 6MWD distance was shorter and quality of life was poorer. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 336-342).

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.

The COPD Assessment Test as a Prognostic Marker in Interstitial Lung Disease

The chronic obstructive pulmonary disease (COPD) Assessment Test (CAT), which was developed to measure the health status of patients with COPD, was applied to patients with interstitial lung disease, aiming to examine the CAT as a predictor of outcome. Over a follow-up period of more than one year, 101 consecutive patients with interstitial lung disease were evaluated by the CAT. The CAT scores of 40 in total were categorized into four subsets according to the severity. Patients with higher (more severe) scores exhibited lower forced vital capacity and lung diffusion capacity for carbon monoxide. The survival rate was significantly lower in patients with higher scores (log-rank test, P = 0.0002), and the hazard ratios for death of the higher scores and lower lung diffusion capacity for carbon monoxide were independently significant. These findings suggest that CAT can indicate the risk of mortality in patients with interstitial lung disease.

Oxygen desaturation during a 6-minute walk test as a predictor of maximal exercise-induced gas exchange abnormalities in sarcoidosis

BACKGROUND

Common tests for evaluating gas exchange impairment have different strengths and weaknesses. Alveolar-to-arterial oxygen pressure difference (AaDO2) at peak exercise is a sensitive indicator but it cannot be measured repeatedly. Diffusing capacity of the lung for carbon monoxide (DLco) is measured at rest and may be too insensitive to predict the effects of exercise on gas exchange impairment. Oxygen desaturation during a 6-minute walk test (∆SpO2-6MWT) can be measured repeatedly, but its value in sarcoidosis is unknown. Here, we evaluated the ability of ∆SpO2-6MWT and DLco to predict gas exchange impairment during exercise in sarcoidosis.

METHODS

This retrospective study of 130 subjects with sarcoidosis investigated the relationship between DLco, ∆SpO2-6MWT, and peak AaDO2 using correlation tests, inter-test reliability analyses, and predictive values. For the analyses of inter-test reliability and predictive values, DLco, peak AaDO2, and ∆SpO2-6MWT were considered as binary variables (normal/abnormal) according to previously defined thresholds.

RESULTS

Correlation coefficients between DLco, ∆SpO2-6MWT, and peak AaDO2 were intermediate (0.53-0.67, P<0.0003) and Kappa coefficients were low (0.21-0.42, P=0.0003-0.02). DLco predicted (I) increased peak AaDO2 with a positive predictive value (PPV) of 66% and a negative predictive value (NPV) of 78% and (II) increased ∆SpO2-6MWT with a PPV at 36% and an NPV at 88%. Normal DLco was a good predictor of the absence of severe desaturation during the 6MWT (94% NPV) and at peak exercise during cardiopulmonary exercise test (CPET) (100% NPV). ∆SpO2-6MWT predicted peak AaDO2 increase with a PPV of 74% and an NPV of 60%.

CONCLUSIONS

In a large population of sarcoidosis patients, neither ∆SpO2-6MWT nor DLco was a good predictor of increased peak AaDO2. In contrast, normal DLco was a good predictor of the absence of severe desaturation during the 6MWT and at peak exercise during CPET.

Exercise training in idiopathic pulmonary fibrosis: is it of benefit?

Key points

Educational aims

Exercise is a well-documented safe and effective intervention for prevention and rehabilitation of chronic diseases. Idiopathic pulmonary fibrosis (IPF) is a chronic deadly lung disease associated with severe signs and symptoms, exercise intolerance, diminished quality of life and poor prognosis. In the short term, supervised exercise training programmes have demonstrated clinical benefits in improving exercise capacity, dyspnoea and quality of life in patients with IPF. The underlying mechanisms of chronic adaption to a regular exercise regimen in IPF have yet to be well described and require further investigation. The available data underscore the importance of implementing training principles to target the pathophysiological impairments of IPF in order to optimise training adaption and enhance the outcomes. The current exercise training data in IPF provide sufficient evidence of clinical benefit for consideration to be given to recommending exercise-based pulmonary rehabilitation as standard of care for IPF.

An overview of data on exercise for IPF patients, highlighting the importance of exercise training in IPF managementhttp://ow.ly/4mWCCd

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.

Monitoring of Lung Involvement in Rheumatologic Disease

The monitoring of lung involvement in patients with connective tissue diseases is central to optimal long-term management and is directed towards: (a) the detection of supervening lung involvement not present at presentation and (b) the identification of disease progression in established lung disease. For both goals, accurate surveillance requires multi-disciplinary evaluation with the integration of symptomatic change, serial pulmonary function trends and imaging data. Evaluated in isolation, each of these monitoring domains has significant limitations. Symptomatic change may be confounded by a wide variety of systemic factors. Pulmonary function tests provide the most reliable data, but are limited by measurement variability, the heterogeneity of functional patterns and the confounding effects of non-pulmonary factors. Chest radiography is insensitive to change but may provide rapid confirmation of major disease progression or alert the clinician to respiratory co-morbidities. Although high-resolution computed tomography has a central role in assessing disease severity, it should be used very selectively as a monitoring tool due to the associated radiation burden. Ancillary tests include echocardiography and exercise testing to proactively identify cases of pulmonary hypertension and worsening of oxygenation. In summary, a multi-disciplinary approach is essential for the identification of disease progression and prompt treatment of comorbidities that severely impact on the morbidity and mortality of disease.

A meta-analysis of four randomized clinical trials to confirm the reliability and responsiveness of the Shortness of Breath with Daily Activities (SOBDA) questionnaire in chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) is characterized by non-reversible airflow limitation. A common symptom of COPD is dyspnea or shortness of breath. Dyspnea may vary daily, with a large impact on patients’ lives. Previous clinical trials used patient-reported outcome (PRO) measures that quantified dyspnea at discrete intervals and hence did not reflect this variability. Recently the Shortness of Breath with Daily Activities (SOBDA) questionnaire was developed as a PRO measure of dyspnea utilizing a daily diary. This confirmatory post hoc meta-analysis of SOBDA data from a large clinical study program further supports the questionnaire and clarifies the minimum threshold of SOBDA response.

Methods

Data from four clinical trials (DB2113361, NCT01313637; DB2113373, NCT01313650; DB2113360, NCT01316900; DB2113374, NCT01316913) were analyzed. These 24-week trials were randomized, blinded studies investigating the efficacy and safety of several COPD treatments. These post hoc analyses focused on the SOBDA questionnaire properties. This electronic-diary consists of 13 items completed daily, in which patients rate their breathlessness level during common daily activities. Resultant SOBDA scores were compared with related, commonly used assessments: modified Medical Research Council Research Dyspnea Scale (mMRC), Baseline Dyspnea Index (BDI), Transition Dyspnea Index (TDI), St George’s Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT), and trough forced expiratory volume in 1 s (FEV₁). The consistency, reliability, validity (convergent, known groups), and responsiveness of the SOBDA questionnaire was assessed.

Results

In total, 4967 patients with COPD provided data for these analyses. The SOBDA questionnaire had high internal consistency (Cronbach’s alpha = 0.936), high test-retest reliability (Pearson’s correlation coefficient = 0.86) and convergent validity with related measures (SGRQ total score, Pearson’s correlation coefficient = 0.59; CAT, Spearman rank-order correlation coefficient = 0.50). SOBDA scores were statistically significantly lower in responders (as defined by TDI, SGRQ, CAT, and trough FEV₁ levels) versus non-responders (p < 0.001 for all assessments and all time points). Using an anchor-based method, the threshold of a minimum response was calculated as a SOBDA score change of −0.2 (SOBDA score range = 1–4).

Conclusions

The reliability, validity, and responsiveness of the SOBDA questionnaire as a PRO measure to quantify dyspnea was supported in a large clinical trial population of patients with moderate–very severe COPD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-015-0369-3) contains supplementary material, which is available to authorized users.

Efficacy and Safety of Umeclidinium Added to Fluticasone Propionate/Salmeterol in Patients with COPD: Results of Two Randomized, Double-Blind Studies

Combinations of drugs with distinct and complementary mechanisms of action may offer improved efficacy in the treatment of chronic obstructive pulmonary disease (COPD). In two 12-week, double-blind, parallel-group studies, patients with COPD were randomized 1:1:1 to once-daily umeclidinium (UMEC; 62.5 μg and 125 μg) or placebo (PBO), added to twice-daily fluticasone propionate/salmeterol (FP/SAL; 250/50 μg). In both studies, the primary efficacy measure was trough forced expiratory volume in 1 second (FEV1) at Day 85. Secondary endpoints were weighted-mean (WM) FEV1 over 0-6 hours post-dose (Day 84) and rescue albuterol use. Health-related quality of life outcomes (St. George's Respiratory Questionnaire [SGRQ] and COPD assessment test [CAT]) were also examined. Safety was assessed throughout. Both UMEC+FP/SAL doses provided statistically significant improvements in trough FEV1 (Day 85: 0.127-0.148 L) versus PBO+FP/SAL. Similarly, both UMEC+FP/SAL doses provided statistically-significant improvements in 0-6 hours post-dose WM FEV1 versus PBO+FP/SAL (Day 84: 0.144-0.165 L). Rescue use over Weeks 1-12 decreased with UMEC+FP/SAL in both studies versus PBO+FP/SAL (Study 1, 0.3 puffs/day [both doses]; Study 2, 0.5 puffs/day [UMEC 125+FP/SAL]). Decreases from baseline in CAT score were generally larger for both doses of UMEC+FP/SAL versus PBO+FP/SAL (except for Day 84 Study 2). In Study 1, no differences in SGRQ score were observed between UMEC+FP/SAL and PBO+FP/SAL; however, in Study 2, statistically significant improvements were observed with UMEC 62.5+FP/SAL (Day 28) and UMEC 125+FP/SAL (Days 28 and 84) versus PBO+FP/SAL. The incidence of on-treatment adverse events across all treatment groups was 37-41% in Study 1 and 36-38% in Study 2. Overall, these data indicate that the combination of UMEC+FP/SAL can provide additional benefits over FP/SAL alone in patients with COPD.

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.

Efficacy and safety of umeclidinium plus vilanterol versus tiotropium, vilanterol, or umeclidinium monotherapies over 24 weeks in patients with chronic obstructive pulmonary disease: results from two multicentre, blinded, randomised controlled trials

BACKGROUND

Combination long-acting bronchodilator treatment might be more effective than long-acting bronchodilator monotherapy for the treatment of chronic obstructive pulmonary disease (COPD). We aimed to compare the efficacy and safety of umeclidinium (UMEC) plus vilanterol (VI) with tiotropium (TIO) monotherapy, UMEC monotherapy, or VI monotherapy in patients with moderate to very severe COPD.

METHODS

In two multicentre, randomised, blinded, double-dummy, parallel-group, active-controlled trials, eligible patients (current or former smokers aged 40 years or older with an established clinical history of COPD) were randomly assigned in 1:1:1:1 ratio to UMEC 125 μg plus VI 25 μg, UMEC 62·5 μg plus VI 25 μg, TIO 18 μg, and either VI 25 μg (study 1) or UMEC 125 μg (study 2). All study drugs were used once daily for 24 weeks. TIO was delivered via the HandiHaler inhaler and all other active treatments were delivered via the ELLIPTA dry powder inhaler. Random assignment (by a validated computer-based system) was done by centre and was not stratified. All patients and physicians were masked to assigned treatment during the studies. The primary efficacy endpoint of both studies was trough forced expiratory volume in 1 s (FEV1) on day 169, which was analysed in the intention-to-treat population. Both studies are registered with ClinicalTrials.gov, numbers NCT01316900 (study 1) and NCT01316913 (study 2).

FINDINGS

1141 participants were recruited in study 1, and 1191 in study 2. For study 1, after exclusions, 208, 209, 214, and 212 patients were included in the intention-to-treat analyses for TIO monotherapy, VI monotherapy, UMEC 125 μg plus VI 25 μg, and UMEC 62·5 μg plus VI 25 μg, respectively. For study 2, 215, 222, 215, and 217 patients were included in the intention-to-treat analyses for TIO monotherapy, UMEC monotherapy, UMEC 125 μg plus VI 25 μg, and UMEC 62·5 μg plus VI 25 μg, respectively. In both studies, we noted improvements in trough FEV1 on day 169 for both doses of UMEC plus VI compared with TIO monotherapy (study 1, UMEC 125 μg plus VI 25 μg: 0·088 L [95% CI 0·036 to 0·140; p=0·0010]; study 1, UMEC 62·5 μg plus VI 25 μg: 0·090 L [0·039 to 0·141; p=0·0006]; study 2, UMEC 125 μg plus VI 25 μg: 0·074 L [0·025 to 0·123; p=0·0031]; study 2, UMEC 62·5 μg plus VI 25 μg: 0·060 L [0·010 to 0·109; nominal p=0·0182]). Both doses of UMEC plus VI also improved trough FEV1 compared with VI monotherapy (UMEC 125 μg plus VI 25 μg: 0·088 L [0·036 to 0·140; p=0·0010]; UMEC 62·5 μg plus VI 25 μg: 0·090 L [0·039 to 0·142; p=0·0006], but not compared with UMEC 125 μg monotherapy (UMEC 125 μg plus VI 25 μg: 0·037 L [-0·012 to 0·087; p=0·14]; UMEC 62·5 μg plus VI 25 μg: 0·022 L [-0·027 to 0·072; p=0·38]). All treatments produced improvements in dyspnoea and health-related quality of life; we noted no significant differences in symptoms, health status, or risk of exacerbation between UMEC plus VI and TIO. The most common on-treatment, severe-intensity adverse event in both studies was acute exacerbation of COPD (1-4 [<1-2%] patients across treatment groups in study 1 and 1-6 [<1-3%] patients in study 2). We recorded five to 15 (2-7%) on-treatment serious adverse events across treatment groups in study 1, and nine to 22 (4-10%) in study 2. We noted no substantial changes from baseline in vital signs, clinical laboratory findings, or electrocardiography findings in any of the treatment groups.

INTERPRETATION

Combination treatment with once-daily UMEC plus VI improved lung function compared with VI monotherapy and TIO monotherapy in patients with COPD. Overall our results suggest that the combination of UMEC plus VI could be beneficial for the treatment of moderate to very severe COPD.

FUNDING

GlaxoSmithKline.

Heart rate recovery post 6-minute walking test in obstructive sleep apnea: cycle ergometry versus 6-minute walking test in OSA patients

PURPOSE

To examine the clinical usefulness of heart rate recovery (HRR) post 6-minute walking test (6MWT) as a simple marker of cardiovascular risk in obstructive sleep apnea (OSA) patients in comparison to HRR post cycle ergometry, the validated and more sophisticated protocol.

METHODS

Seventy-four participants underwent full overnight polysomnography, cycle ergometry and 6MWT. The HRR at 1, 2 and 3 min (HRR-1, HRR-2 and HRR-3) 6MWT was compared to HRR at 1, 2, and 3 min post cycle ergometry in normal subjects and in moderate and severe OSA patients before and after 6-month CPAP treatment.

RESULTS

The HRR-1, HRR-2 and HRR-3 in 6MWT were significantly different between normal, moderate and severe OSA patients with higher rates achieved in normal. The higher the severity of OSA the lower the HRR was. There were also no differences found between work rate and distance walked during cycle ergometry or 6MWT, respectively, concerning normal, moderate and severe OSA patients. Heart rate recovery was further associated with minimum saturation of oxygen during sleep independently of the duration of apnea episodes of BMI and ESS. The treatment with CPAP had a beneficial effect on HRR both post-6MWT and post cycle ergometry.

CONCLUSIONS

Autonomic nervous system dysfunction in OSA can be found even with submaximal exertion. Heart rate recovery post-6MWT, such as HRR post cycle ergometry, was significantly impaired in OSA patients in comparison to normals and was favorably influenced from CPAP treatment. Furthermore, it was found to be more sensitive compared with distance walked in 6MWT in discriminating severity of OSA. The HRR post-6MWT was found to be an easily measured and reliable marker of OSA severity both before and after CPAP treatment.

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.

Connective tissue disease related interstitial lung diseases and idiopathic pulmonary fibrosis: provisional core sets of domains and instruments for use in clinical trials

RATIONALE

Clinical trial design in interstitial lung diseases (ILDs) has been hampered by lack of consensus on appropriate outcome measures for reliably assessing treatment response. In the setting of connective tissue diseases (CTDs), some measures of ILD disease activity and severity may be confounded by non-pulmonary comorbidities.

METHODS

The Connective Tissue Disease associated Interstitial Lung Disease (CTD-ILD) working group of Outcome Measures in Rheumatology-a non-profit international organisation dedicated to consensus methodology in identification of outcome measures-conducted a series of investigations which included a Delphi process including >248 ILD medical experts as well as patient focus groups culminating in a nominal group panel of ILD experts and patients. The goal was to define and develop a consensus on the status of outcome measure candidates for use in randomised controlled trials in CTD-ILD and idiopathic pulmonary fibrosis (IPF).

RESULTS

A core set comprising specific measures in the domains of lung physiology, lung imaging, survival, dyspnoea, cough and health-related quality of life is proposed as appropriate for consideration for use in a hypothetical 1-year multicentre clinical trial for either CTD-ILD or IPF. As many widely used instruments were found to lack full validation, an agenda for future research is proposed.

CONCLUSION

Identification of consensus preliminary domains and instruments to measure them was attained and is a major advance anticipated to facilitate multicentre RCTs in the field.

The Role of Cardiopulmonary Exercise Test in IPF Prognosis

Background. In IPF, defects in lung mechanics and gas exchange manifest with exercise limitation due to dyspnea, the most prominent and disabling symptom. Aim. To evaluate the role of exercise testing through the 6MWT (6-minute walk test) and CPET (cardiopulmonary exercise testing) in the survival of patients with IPF. Methods. This is a prospective, observational study evaluating in 25 patients the relationship between exercise variables through both the 6MWT and CPET and survival. Results. By the end of the observational period 17 patients were alive (33% mortality). Observation ranged from 9 to 64 months. VE/VCO₂ slope (slope of relation between minute ventilation and CO₂ production), VO₂ peak/kg (peak oxygen consumption/kg), VE/VCO₂ ratio at anaerobic threshold, 6MWT distance, desaturation, and DLCO% were significant predictors of survival while VE/VCO₂ slope and VO₂ peak/kg had the strongest correlation with outcome. The optimal model for mortality risk estimation was VO₂ peak/kg + DLCO% combined. Furthermore, VE/VCO₂ slope and VO₂ peak/kg were correlated with distance and desaturation during the 6MWT. Conclusion. The integration of oxygen consumption and diffusing capacity proved to be a reliable predictor of survival because both variables reflect major underlying physiologic determinants of exercise limitation.

Efficacy and safety of once-daily umeclidinium/vilanterol 62.5/25 mcg in COPD

STUDY OBJECTIVE

To examine the efficacy and safety of the once-daily, inhaled, long-acting muscarinic antagonist/β2-agonist combination umeclidinium/vilanterol (UMEC/VI) compared with UMEC and VI monotherapies in patients with chronic obstructive pulmonary disease (COPD).

METHODS

In this 24-week, double-blind, placebo-controlled, parallel-group study (ClinicalTrials.gov: NCT01313650) eligible patients were randomised 3:3:3:2 to treatment with UMEC/VI 62.5/25 mcg, UMEC 62.5 mcg, VI 25 mcg or placebo administered once daily via dry powder inhaler (N = 1532; intent-to-treat population). Primary endpoint was trough forced expiratory volume in one second (FEV1) on Day 169 (23-24 h post-dose). Additional lung-function, symptomatic, and health-related quality-of-life endpoints were assessed, including 0-6 h weighted-mean FEV1, rescue salbutamol use, Transition Dyspnoea Index (TDI), Shortness Of Breath With Daily Activity (SOBDA) and St. George's Respiratory Questionnaire (SGRQ) scores. Safety evaluations included adverse events (AEs), vital signs, 12-lead/24-h Holter electrocardiography parameters and clinical laboratory/haematology measurements.

RESULTS

All active treatments produced statistically significant improvements in trough FEV1 compared with placebo on Day 169 (0.072-0.167 L, all p < 0.001); increases with UMEC/VI 62.5/25 mcg were significantly greater than monotherapies (0.052-0.095 L, p ≤ 0.004). Improvements were observed for UMEC/VI 62.5/25 mcg vs placebo for weighted-mean FEV1 on Day 168 (0.242 L, p < 0.001), rescue salbutamol use during Weeks 1-24 (-0.8 puffs/day, p = 0.001), TDI (1.2 units, p < 0.001), SOBDA (-0.17 units, p < 0.001) and SGRQ (-5.51 units, p < 0.001) scores. No clinically-significant changes in vital signs, electrocardiography, or laboratory parameters were observed.

CONCLUSION

Once-daily UMEC/VI 62.5/25 mcg was well tolerated and provided clinically-significant improvements in lung function and symptoms in patients with COPD.

Sleep oxygen desaturation predicts survival in idiopathic pulmonary fibrosis

BACKGROUND

Recent studies suggest poor sleep quality in patients with idiopathic pulmonary fibrosis (IPF). However, so far, the impact of IPF-related sleep breathing disorders (SBDs) on survival has not been extensively studied.

METHODS

In a cohort of 31 (24 males) treatment-naïve, newly diagnosed consecutive IPF patients, we prospectively investigated the relationship of SBD parameters such as apnea-hypopnea index (AHI), maximal difference in oxygen saturation between wakefulness and sleep (maxdiff SpO2), and lowest sleep oxygen saturation (lowest SpO2) with clinical (survival, dyspnea, daytime sleepiness), pulmonary function, submaximal (6-min walk test [6MWT]) and maximal exercise variables (cardiopulmonary exercise test [CPET]), and right ventricular systolic pressure (RVSP).

RESULTS

Sleep oxygen desaturation exceeded significantly that of maximal exercise (p < 0.001). Maxdiff SpO2 was inversely related to survival, DLCO%, and SpO2 after 6MWT, and directly with dyspnea, AHI, and RVSP. The lowest SpO2 was directly related to survival and to functional (TLC%, DLCO%) as well as submaximal and maximal exercise variables (6MWT distance, SpO2 after 6MWT, peak oxygen consumption/kg, SpO2 at peak exercise), while an inverse association with dyspnea score, AHI, and RVSP was observed.

CONCLUSIONS

Our findings provide evidence that intermittent sleep oxygen desaturation significantly exceeds that of maximal exercise and is associated with survival in IPF patients. Furthermore, they imply the existence of a link between lung damage and apnea events resulting to the induction and severity of intermittent sleep oxygen desaturation that aggravate pulmonary arterial hypertension and influence IPF survival.