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Dowman LM, Holland AE. Pulmonary rehabilitation in idiopathic pulmonary fibrosis. Curr Opin Pulm Med 2024; 30:516-522. [PMID: 38958566 DOI: 10.1097/mcp.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW This review synthesizes the expanding evidence for pulmonary rehabilitation that has led to its recommended inclusion in the holistic care of people with idiopathic pulmonary fibrosis (IPF), as well as discussing strategies that may maximize and sustain benefits. RECENT FINDINGS Pulmonary rehabilitation is an effective intervention leading to significant improvements in exercise tolerance, symptoms, and quality of life for people with IPF. Improvements in symptoms and quality of life can persist longer term, whereas functional capacity does not; therefore, strategies to preserve functional capacity are an important area of research. Referral early in the disease course is encouraged to promote longer lasting effects. Evidence that high-intensity interval training may optimize benefits of exercise training is emerging. Supplemental oxygen is frequently used to manage exercise-induced desaturation, although its use as an adjunct therapy requires more evidence. SUMMARY Current evidence strongly supports the inclusion of pulmonary rehabilitation in the standard holistic care of IPF, with early participation encouraged. Further research is needed to establish the optimal exercise strategies, modalities and adjunct therapies that enhance outcomes of pulmonary rehabilitation and promote longer lasting effects.
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Affiliation(s)
- Leona M Dowman
- School of Translational Medicine, Monash University
- Departments of Physiotherapy and Respiratory and Sleep Medicine, Austin Health
- Institute for Breathing and Sleep
| | - Anne E Holland
- School of Translational Medicine, Monash University
- Institute for Breathing and Sleep
- Departments of Physiotherapy and Respiratory Medicine, Alfred Health, Melbourne, Australia
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Yanagita Y, Arizono S, Yokomura K, Ito K, Machiguchi H, Tawara Y, Katagiri N, Iida Y, Nakatani E, Tanaka T, Kozu R. Enhancing exercise tolerance in interstitial lung disease with high-flow nasal cannula oxygen therapy: A randomized crossover trial. Respirology 2024; 29:497-504. [PMID: 38387607 DOI: 10.1111/resp.14684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/01/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND OBJECTIVE Interstitial lung disease (ILD) is characterized by dyspnoea on exertion and exercise-induced hypoxaemia. High-flow nasal cannula (HFNC) therapy reduces the respiratory workload through higher gas flow and oxygen supplementation, which may affect exercise tolerance. This study aimed to examine the effects of oxygen and gas flow rates through HFNC therapy on exercise tolerance in ILD patients. METHODS We conducted three-treatment crossover study. All ILD patients performed the exercises on room air (ROOM AIR setting: flow, 0 L/min; fraction of inspired oxygen [FiO2], 0.21), HFNC (FLOW setting: flow 40 L/min, FiO2 0.21), and HFNC with oxygen supplementation (FLOW + OXYGEN setting: flow 40 L/min, FiO2 0.6). The primary endpoint was the endurance time, measured using constant-load cycle ergometry exercise testing at a peak work rate of 80%. RESULTS Twenty-five participants (10 men, 71.2 ± 6.7 years) were enrolled. The increase in exercise duration between the ROOM AIR and FLOW was 46.3 s (95% CI, -6.1 to 98.7; p = 0.083), and the FLOW and FLOW + OXYGEN was 91.5 s (39.1-143.9; p < 0.001). The percutaneous oxygen saturation (SpO2) at rest was significantly higher with the FLOW + OXYGEN setting than with the ROOM AIR and FLOW settings, and the difference persisted during exercise. At equivalent time points during exercise, the SpO2 with the FLOW setting was significantly higher than that with the ROOM AIR setting. CONCLUSION Oxygen supplementation in HFNC therapy improved exercise tolerance and SpO2. We found that gas flow alone did not improve exercise tolerance, but improved SpO2 during exercise.
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Affiliation(s)
- Yorihide Yanagita
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shinichi Arizono
- Department of Physical Therapy, School of Rehabilitation Sciences, Seirei Christopher University, Hamamatsu, Japan
| | - Koshi Yokomura
- Division of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kumiko Ito
- Department of Rehabilitation, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Hikaru Machiguchi
- Department of Rehabilitation, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Yuichi Tawara
- Department of Physical Therapy, School of Rehabilitation Sciences, Seirei Christopher University, Hamamatsu, Japan
| | - Norimasa Katagiri
- Department of Rehabilitation Medicine, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yuki Iida
- Department of Physical Therapy, School of Health Science, Toyohashi Sozo University, Toyohashi, Japan
| | - Eiji Nakatani
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Takako Tanaka
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryo Kozu
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Tomii K. An additional mechanism enhancing exercise tolerance in interstitial lung disease with high-flow nasal cannula. Respirology 2024; 29:445-446. [PMID: 38527948 DOI: 10.1111/resp.14713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
See related article
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Affiliation(s)
- Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
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Lin LY, Wu YC, Wu JS, Tai HY, Huang TW, Cheng WH. Oxygen therapy for exercise capacity in fibrotic interstitial lung disease: A systematic review and meta-analysis of randomised controlled trials. Respir Med 2024; 227:107657. [PMID: 38718907 DOI: 10.1016/j.rmed.2024.107657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Fibrotic interstitial lung disease (fILD) is characterised primarily by impaired lung function and quality of life. The present study investigated whether oxygen therapy could improve exercise capacity among patients with fILD. METHODS Previously published randomised controlled trials (RCTs) were surveyed. A systematic review and meta-analysis was conducted to evaluate the effectiveness of oxygen therapy in improving the exertional capacity of patients with fILD. The primary outcome was peripheral oxygen saturation (SpO2) during exercise. The effects of oxygen therapy on fatigue, dyspnoea, heart rate, and exercise duration or distance were also analysed. RESULTS Fourteen RCTs involving 370 patients were included. Oxygen therapy improved SpO2 during exercise (mean difference, MD = 6.26 %), exercise duration (MD = 122.15 s), fatigue (standard mean difference, SMD = -0.30), and dyspnoea (MD = -0.75 Borg score units). High-flow oxygen systems tended to be more effective than low-flow systems in improving exercising SpO2, duration, fatigue, dyspnoea, and heart rate. High-flow nasal cannulas (HFNCs) yielded better outcomes regarding SpO2 and fatigue than did high-flow Venturi masks (MD = 1.60 % and MD = -1.19 Borg score units, respectively). No major adverse events were reported. CONCLUSION The evidence from RCTs supports the short-term use of oxygen supplementation to improve SpO2, exercise capacity, fatigue, and dyspnoea among patients with fILD. Further analyses demonstrates that HFNCs yield more favourable outcomes, yet not reaching statistical significance except for improving SpO2 and fatigue. However, the long-term effects of oxygen therapy on quality of life and mortality remain unclear.
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Affiliation(s)
- Lee-Yuan Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chih Wu
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jie-Syuan Wu
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Yu Tai
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tsai-Wei Huang
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Research Center in Nursing Clinical Practice, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.
| | - Wun-Hao Cheng
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan; Respiratory Therapy, Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Pagliaro R, Aronne L, Fomez R, Ferri V, Montella A, Sanduzzi Zamparelli S, Bianco A, Perrotta F. High-Flow Nasal Cannula System in Respiratory Failure Associated with Interstitial Lung Diseases: A Systematic Review and Narrative Synthesis. J Clin Med 2024; 13:2956. [PMID: 38792497 PMCID: PMC11122032 DOI: 10.3390/jcm13102956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Background: High-flow nasal cannula (HFNC) therapy has emerged as a promising treatment modality for interstitial lung disease (ILD)-related respiratory failure. This systematic review aims to evaluate the efficacy and safety of HFNC therapy in patients with ILDs. Methods: A comprehensive literature search was conducted using major electronic databases to identify relevant studies investigating the use of HFNC therapy in ILD patients with respiratory failure. Outcome measures of interest included improvements in oxygenation, dyspnea relief, respiratory rate control, hospital length of stay, and mortality. Results: Twelve studies were analyzed with an overall population of 715 patients included. Idiopathic Pulmonary Fibrosis (IPF) was the most prevalent type of ILD. Evaluated clinical settings were acute (7 studies), chronic (2 studies), and end-stage (3 studies) ILDs. The HFNC as a support for acute respiratory failure seems not inferior to non-invasive ventilation while offering better comfort and patient's perception. Poor data are available about use in chronic/long-term or rehabilitative settings. In end of life/palliative care, an HFNC might improve quality of life. Despite the promising results, further research is warranted to establish optimal HFNC protocols, identify patient subgroups most likely to benefit, and explore long-term outcomes. Conclusions: Overall, the HFNC appears to be a valuable therapeutic option for managing respiratory failure in ILD patients, offering potential improvements in oxygenation and symptom relief.
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Affiliation(s)
- Raffaella Pagliaro
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Luigi Aronne
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Ramona Fomez
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Vincenzo Ferri
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Antonia Montella
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | | | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Fabio Perrotta
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
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Ikrama M, Usama M, Israr S, Humayon M. Pulmonary fibrosis: Is stem cell therapy the way forward? J Taibah Univ Med Sci 2024; 19:82-89. [PMID: 37876594 PMCID: PMC10590845 DOI: 10.1016/j.jtumed.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/15/2023] [Accepted: 09/30/2023] [Indexed: 10/26/2023] Open
Abstract
Pulmonary fibrosis, a chronic and fatal lung disease affecting millions of people worldwide, is characterized by the scarring of lung tissue, thereby impairing oxygen exchange between the lungs and blood. The etiology of pulmonary fibrosis is multifactorial, involving environmental exposures, comorbidities, and genetic mutations. Current pharmacological treatments can only slow the disease progression, and lung transplantation is limited by donor availability and complications. Stem cell therapy has emerged as a potential alternative treatment for pulmonary fibrosis, in which stem cells modulate the inflammatory response, differentiate into lung epithelial cells, secrete growth factors and extracellular matrix components, and enhance vascularization and tissue regeneration. Various sources of stem cells, such as endogenous lung stem cells, embryonic stem cells, induced pluripotent stem cells, and mesenchymal stem cells, have been investigated in animal models and human trials. Various delivery routes, such as intravenous injection, intratracheal instillation, and inhalation, have been tested for safety and efficacy. However, several challenges and limitations remain to be overcome, such as high costs, ethical issues, immunological compatibility, cell survival and homing, and long-term outcomes. Further research is needed to optimize the protocols and parameters in stem cell therapy for pulmonary fibrosis, and to evaluate the clinical benefits and risks for patients.
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Affiliation(s)
- Muhammad Ikrama
- Services Institute of Medical Sciences, Department of Medicine, Lahore, Pakistan
| | - Muhammad Usama
- Services Institute of Medical Sciences, Department of Medicine, Lahore, Pakistan
| | - Shifa Israr
- Services Institute of Medical Sciences, Department of Medicine, Lahore, Pakistan
| | - Maryam Humayon
- Services Institute of Medical Sciences, Department of Medicine, Lahore, Pakistan
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Vézina FA, Bouchard PA, Breton-Gagnon É, Dion G, Viglino D, Roy P, Bilodeau L, Provencher S, Denault MH, Saey D, Lellouche F, Maltais F. Automated O 2 Titration Alone or With High-Flow Nasal Cannula During Walking Exercise in Chronic Lung Diseases. Respir Care 2023; 69:respcare.10810. [PMID: 37491073 PMCID: PMC10753602 DOI: 10.4187/respcare.10810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Exercise-induced O2 desaturation contributes to dyspnea and exercise intolerance in various respiratory diseases. This study assessed whether automated O2 titration was superior to fixed-flow O2 to improve exertional dyspnea and walking exercise endurance. We also aimed at evaluating possible additive effects of high-flow nasal cannula coupled with automated O2 titration on these outcomes. METHODS Subjects with chronic respiratory diseases and exercise-induced desaturation performed a 3-min constant-speed shuttle test (CSST) and an endurance shuttle walking test (ESWT) with either (1) fixed-flow O2, (2) automated O2 titration targeting an SpO2 of 94% (± 2%), and (3) automated O2 titration + high-flow nasal cannula according to a randomized sequence. The main outcome was Borg dyspnea score at the end of the 3-min CSST. Secondary outcomes included endurance time and dyspnea during ESWT and oxygenation status during exercise. RESULTS Ten subjects with COPD, 10 with interstitial lung disease, 5 with pulmonary hypertension, and 3 with cystic fibrosis completed the study. Compared to fixed-flow O2, automated O2 titration did not reduce dyspnea at the end of the 3-min CSST. Endurance time during the ESWT was prolonged with automated O2 titration (mean difference 298 [95% CI 205-391] s, P < .001), and dyspnea at isotime was reduced. No further improvement was noted when high-flow nasal cannula was added to automated O2 titration. Compared to fixed-flow O2, O2 flows were higher with automated O2 titration, resulting in better oxygenation. CONCLUSIONS Automated O2 titration was superior to fixed-flow O2 to alleviate dyspnea and improve exercise endurance during the ESWT in subjects with a variety of chronic respiratory diseases. Adding high-flow nasal cannula to automated O2 titration provided no further benefits.
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Affiliation(s)
- Felix-Antoine Vézina
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada; and Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec City, Québec, Canada
| | - Pierre-Alexandre Bouchard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Émilie Breton-Gagnon
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Geneviève Dion
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Damien Viglino
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada; and Université Grenoble Alpes, Laboratoire Hypoxie-Physiopathologie HP2 INSERM U1300, Grenoble, France
| | - Pascalin Roy
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Lara Bilodeau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Steeve Provencher
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Marie-Hélène Denault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Didier Saey
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - François Lellouche
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - François Maltais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec City, Québec, Canada.
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Janowiak P, Szymanowska-Narloch A, Siemińska A. IPF Respiratory Symptoms Management - Current Evidence. Front Med (Lausanne) 2022; 9:917973. [PMID: 35966835 PMCID: PMC9368785 DOI: 10.3389/fmed.2022.917973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive, chronic disease of the lungs which is characterized by heavy symptom burden, especially in the last year of life. Despite recently established anti-fibrotic treatment IPF prognosis is one of the worst among interstitial lung diseases. In this review available evidence regarding pharmacological and non-pharmacological management of the main IPF symptoms, dyspnea and cough, is presented.
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Affiliation(s)
- Piotr Janowiak
- Department of Pulmonology, Medical University of Gdańsk, Gdańsk, Poland
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Ruggeri P, Esquinas A. Is it time to use HFNC oxygen therapy during exercise in IPF patients? Respirology 2022; 27:316-317. [PMID: 35112423 DOI: 10.1111/resp.14220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/13/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Paolo Ruggeri
- Pulmonology Unit, Department of Biomedical and Dental Sciences, Morphological and Functional Images (BIOMORF), University of Messina, Messina, Italy
| | - Antonio Esquinas
- Department of Intensive Care and Noninvasive Ventilatory Unit, Intensive Care Unit, Hospital Morales Meseguer Murcia, Murcia, Spain
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Harada J, Nagata K, Morimoto T, Iwata K, Matsunashi A, Sato Y, Tachikawa R, Ishikawa A, Tomii K. Reply. Respirology 2022; 27:318-319. [PMID: 35112437 DOI: 10.1111/resp.14221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Jumpei Harada
- Department of Rehabilitation, Kobe City Medical Center General Hospital, Kobe, Japan.,Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Kazuma Nagata
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takeshi Morimoto
- Department of Clinical Research Center, Kobe City Medical Center General Hospital, Kobe, Japan.,Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kentaro Iwata
- Department of Rehabilitation, Kobe City Medical Center General Hospital, Kobe, Japan.,Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Atsushi Matsunashi
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuki Sato
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryo Tachikawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Akira Ishikawa
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
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