Self-management interventions for people with pulmonary fibrosis: a scoping review

BACKGROUND

The most effective method for encouraging self-management in individuals with pulmonary fibrosis (PF) is unclear. This review aimed to identify common self-management components, the outcome measures used and the impact of these components in PF.

METHODS

A scoping review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis using Medline, Embase, PsychInfo, CINAHL and the Cochrane Central Register of Controlled Trials. Eligible studies included those with educational, behavioural or support components aimed at facilitating self-management among adults with PF and employed quantitative and/or qualitative methods.

RESULTS

87 studies were included. Common self-management components included education (78%), managing physical symptoms (66%) and enhancing psychosocial wellbeing (54%). Components were predominantly delivered in a pulmonary rehabilitation setting (71%). No studies tested a PF-specific self-management package. Common outcome measures were 6-min walk distance (60%), St George's Respiratory Questionnaire (37%) and the Medical Research Council Dyspnoea scale (34%). Clinically significant improvements in these outcomes were seen in ≥50% of randomised controlled trials. Qualitative data highlighted the importance of healthcare professional and peer support and increased confidence in managing PF.

CONCLUSION

Self-management components are commonly incorporated into pulmonary rehabilitation programmes rather than being offered as standalone packages. Future research should focus on testing PF-specific self-management packages and employ standardised outcome assessments that include self-efficacy and health-related behaviours.

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.

Idiopathic Pulmonary Fibrosis and Progressive Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF), a common interstitial lung disease (ILD), is a chronic, progressive fibrosing interstitial pneumonia, with an unknown cause. IPF has been linked to several genetic and environmental risk factors. Disease progression is common and associated with worse outcomes. Management often encompasses pharmacotherapy, supportive interventions, addressing comorbidities when present, and treating hypoxia with ambulatory O2. Consideration for antifibrotic therapy and lung transplantation evaluation should occur early. Patients with ILD other than IPF, and who have radiological evidence of pulmonary fibrosis, may have progressive pulmonary fibrosis.

Effects of traditional mind-body movement therapy on chronic cardiopulmonary dyspnoea: a systematic review and meta-analysis

PURPOSE

To evaluate whether traditional mind-body movement therapy (TMBM) can be used as a complementary or alternative therapy for exercise-based cardiopulmonary rehabilitation (EBCR) on chronic cardiopulmonary dyspnoea.

METHODS

PubMed, Embase, Scopus, Web of Science and China National Knowledge Infrastructure were searched from their inception to 2 July 2021. Randomised clinical trials evaluating the effectiveness of TMBM versus EBCR, and TMBM +EBCR versus TMBM in the treatment of chronic cardiopulmonary dyspnoea were selected. The outcomes were exercise capacity (6 min walk distance, 6MWD) and quality of life (QoL).

RESULTS

Thirty-four randomised clinical trials with 2456 patients were included. For TMBM vs EBCR alone, statistically significant improvements in the 6MWD favoured the TMBM for chronic obstructive pulmonary disease (COPD) (mean difference(MD)=12.22 m; 95% CI 5.94 to 18.50; I²=56%) and heart failure (HF) patients (MD=43.65 m; 95% CI 7.91 to 79.38; I²=0%). Statistically significant improvements in QoL also favoured TMBM over EBCR for patients with HF(MD=-9.19; 95% CI -11.05 to -7.32; I²=0%) but non-significant trend for COPD (standardised mean difference (SMD)=-0.31; 95% CI -0.62 to 0.01; I²=78%). Comparisons of TMBM +EBCR versus EBCR alone revealed significant improvements in the QoL for COPD (SMD=-0.52; 95% CI -0.94 to -0.10; I²=86%) and patients with HF (MD=-2.82; 95% CI -4.99 to -0.64; I²=0%). The 6MWD results favoured the TMBM +EBCR for patients with COPD (MD=16.76 m; 95% CI 10.24 to 23.29; I²=0%), but only showed a slight trend towards additional benefits of TMBM +EBCR in the HF studies (MD=13.77 m; 95% CI -1.01 to 28.54; I2=65%) .

CONCLUSIONS

TMBM has positive effects on patients' 6MWD and QoL, with similar or even better effects than EBCR. It may be beneficial to use TMBM as a supplementary or alternative strategy for EBCR in treatment plans.

PROSPERO REGISTRATION NUMBER

CRD42021241181.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]

BACKGROUND

Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated.

METHODS

Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale.

RESULTS

After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

French practical guidelines for the diagnosis and management of idiopathic pulmonary fibrosis - 2021 update. Full-length version

BACKGROUND

Since the latest 2017 French guidelines, knowledge about idiopathic pulmonary fibrosis has evolved considerably.

METHODS

Practical guidelines were drafted on the initiative of the Coordinating Reference Center for Rare Pulmonary Diseases, led by the French Language Pulmonology Society (SPLF), by a coordinating group, a writing group, and a review group, with the involvement of the entire OrphaLung network, pulmonologists practicing in various settings, radiologists, pathologists, a general practitioner, a health manager, and a patient association. The method followed the "Clinical Practice Guidelines" process of the French National Authority for Health (HAS), including an online vote using a Likert scale.

RESULTS

After a literature review, 54 guidelines were formulated, improved, and then validated by the working groups. These guidelines addressed multiple aspects of the disease: epidemiology, diagnostic procedures, quality criteria and interpretation of chest CT scans, lung biopsy indication and procedures, etiological workup, methods and indications for family screening and genetic testing, assessment of the functional impairment and prognosis, indication and use of antifibrotic agents, lung transplantation, management of symptoms, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are intended to guide the diagnosis and practical management of idiopathic pulmonary fibrosis.

Current trends in candidate selection, contraindications, and indications for lung transplantation

Lung transplantation is an established treatment option that can improve quality of life and prolong survival for select patients diagnosed with end-stage lung disease. Given the gaps in organ donation and failures to make effective use of available organs, careful selection of candidates for lung transplant remains one of the most important considerations of the transplant community. Toward this end, we briefly reviewed recent trends in pretransplant evaluation, candidate selection, organ allocation, and organ preservation techniques. Since the latest consensus statement regarding appropriate selection of lung transplant candidates, many advances in the science and practice of lung transplantation have emerged and influenced our perspective of 'contraindications' to transplant. These advances have made it increasingly possible to pursue lung transplant in patients with risk factors for decreased survival-namely, older recipient age, increased body mass index, previous chest surgery, poorer nutritional status, and presence of chronic infection, cardiovascular disease, or extrapulmonary comorbid conditions. Therefore, we reviewed the updated evidence demonstrating the prognostic impact of these risk factors in lung transplant recipients. Lastly, we reviewed the salient evidence for current trends in disease-specific indications for lung transplantation, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension, among other less common end-stage diseases. Overall, lung transplant remains an exciting field with considerable hope for patients as they experience remarkable improvements in quality of life and survival in the modern era.

Effect of supervised exercise training on exercise capacity, pulmonary function and growth differentiation factor 15 levels in patients with interstitial lung disease: A preliminary study

BACKGROUND: Interstitial lung disease is characterized by exertion dyspnea, exercise limitation and reduced quality of life. The role of exercise training in this diverse patient group is unclear. The growth differentiation factor 15 (GDF15) is a stress-sensitive circulating factor that regulates systemic energy balance and could be a possible biomarker in interstitial lung disease. OBJECTIVE: To evaluate the effect of supervised exercise (endurance and resistance) training (SET) on exercise capacity, pulmonary function parameters and GDF15 levels in patients with interstitial lung disease (PwILD). METHODS: In this non-randomized case-control trial, the experimental group comprised of 10 PwILD (7 women and 3 men) while the control group consisted of of 18 apparently healthy participants s 11 women and 7 men). All subjects completed an 8-week supervised exercise training program, at a rate of twice a week. Dyspnea was evaluated using the Shortness of Breath Respiratory Questionnaire. Exercise capacity was measured using the 6-min walk test while the heart rate (HR) was monitored before and after the exercise training. GDF15 levels were measured by Enzyme-Linked Immunosorbent Assay (ELISA). RESULTS: PwILD had significantly shorter 6-min walk distance than the control subjects at both the 1st and the 15th visit. However, both groups improved significantly in this test. The change (pre to post-exercise) in HR value was smaller in PwILD compared to the controls. Moreover, PwILD had higher Shortness of Breath Respiratory Questionnaire score than controls. While the mean pre-post GDF15 change values in both groups remained statistically unchanged the GDF15 values of the PwILD patients were significantly higher compared to the controls with respect to pre-post exercise training respectively. CONCLUSION: Supervised exercise training did not affect GDF15 levels in both patient and control groups but its values in PwILD were significantly higher compared to those of controls (p⩽0.05). The exercise capacity and dyspnea in these patients improved after exercise training program.

Pulmonary rehabilitation for idiopathic pleuroparenchymal fibroelastosis: A retrospective study on its efficacy, feasibility, and safety

BACKGROUND

The beneficial effects of pulmonary rehabilitation (PR) for patients with idiopathic pleuroparenchymal fibroelastosis (IPPFE) remain unknown. This study aimed to examine the efficacy, feasibility, and safety of PR for IPPFE.

METHODS

We retrospectively investigated 25 patients with IPPFE referred for PR between April 2007 and March 2017. The PR mainly consisted of a 10-week exercise training program. The primary outcome was a change in 6-min walk distance (6MWD). Secondary outcomes included changes in dyspnea (transition dyspnea index [TDI]), anxiety and depression (hospital anxiety and depression scale [HADS]), and health-related quality of life (HRQoL) (St George's respiratory questionnaire [SGRQ]).

RESULTS

Thirteen patients participated in the PR program (PRP). Recurrent pneumothorax was the most common reason for patients not participating in the PRP. Four patients discontinued the PRP due to the recurrence of pneumothorax, new onset of pneumomediastinum, stroke, and another reason, respectively. Nine patients completed the PRP. Significant improvement was observed in 6MWD (median [interquartile range], 90 m [55-116 m]; P = 0.033). Clinically important improvements in the 6MWD, and TDI, HADS-anxiety, HADS-depression, and SGRQ total domain scores were observed in seven (78%), five (56%), four (44%), four (44%), and five (56%) of the nine patients, respectively.

CONCLUSIONS

Patients with IPPFE benefited from PR in terms of exercise capacity, dyspnea, anxiety, depression, and HRQoL. Pneumothorax and pneumomediastinum may impede the implementation of a PRP for patients with IPPFE. While careful patient selection is required, PR may be an efficacious non-pharmacological approach for managing disabilities in patients with IPPFE.

Diagnosis and Management of Fibrotic Interstitial Lung Diseases

Nonidiopathic pulmonary fibrosis (non-IPF) progressive fibrotic interstitial lung diseases (PF-ILDs) are a heterogeneous group of ILDs, often challenging to diagnose, although an accurate diagnosis has significant implications for both treatment and prognosis. A subgroup of these patients experiences progressive deterioration in lung function, physical performance, and quality of life after conventional therapy. Risk factors for ILD progression include older age, lower baseline pulmonary function, and a usual interstitial pneumonia pattern. Management of non-IPF P-ILD is both pharmacologic and nonpharmacologic. Antifibrotic drugs, originally approved for IPF, have been considered in patients with other fibrotic ILD subtypes, with favorable results in clinical trials.

Management of Connective Tissue Disease-Associated Interstitial Lung Disease

The presence of interstitial lung disease (ILD) negatively affects prognosis among patients with an underlying connective tissue disease (CTD). The initial approach to care should determine whether the CTD-ILD needs pharmacologic treatment or not. There is little direct evidence to guide who and how to treat. At present, any severe, active, and/or progressive ILD should be pharmacologically treated. Immunosuppressants and/or corticosteroids are the mainstay of pharmacologic therapy for all CTD-ILDs, whereas antifibrotics may be beneficial in some scenarios. A comprehensive and multidisciplinary approach to management is also an important aspect of patient care.

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

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

Treatment of Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrosing interstitial pneumonia of unknown cause, occurring in adults and limited to the lungs. In the past, treatment was aimed at minimizing inflammation and slowing the progression of inflammation to fibrosis. However, the underlying lesion in IPF may be more fibrotic than inflammatory, explaining why few patients respond to anti-inflammatory therapies and the prognosis remains poor.

In this review of literature, we will be focusing on main lines of treatment including current medications, supportive care, lung transplantation evaluation, and potential future strategies of treatment.

Pulmonary Rehabilitation in COVID-19: The Contribution of other Chronic Lung Syndromes for the Intervention of a Novel Disease

Abstract::

COVID-19 has spread throughout the world causing a significant number of cases of pneumonia and SARS. Patients with COVID-19 may also have other cardiovascular, respiratory, and neuromuscular disorders. These multisystemic complications present the need for comprehensive interventions focused on improving symptoms, functional capacity, and quality of life. Pulmonary rehabilitation has the potential to offer some of these benefits. However, the evidence related to specific aspects of pulmonary rehabilitation evaluation and intervention in COVID19 is limited. We have learned from experiences with other types of chronic lung diseases that have used pulmonary rehabilitation successfully. While the evidence of rehabilitation emerges in COVID-19, it is necessary to establish some initial recommendations, prepared according to the sequelae found until now.

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

Background and objective

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

Methods

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

Results

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

Conclusion

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

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

SeeCover Image

Inspiratory neural drive and dyspnea in interstitial lung disease: Effect of inhaled fentanyl

BACKGROUND

Exertional dyspnea in interstitial lung disease (ILD) remains difficult to manage despite advances in disease-targeted therapies. Pulmonary opioid receptors present a potential therapeutic target for nebulized fentanyl to provide dyspnea relief.

METHODS

ILD patients were characterized with reference to healthy volunteers. A randomized, double-blind, placebo-controlled crossover comparison of 100 mcg nebulized fentanyl vs placebo on dyspnea intensity and inspiratory neural drive (IND) during constant work rate (CWR) cycle exercise was performed in 21 ILD patients.

RESULTS

Dyspnea intensity in ILD increased in association with an increase in IND (diaphragm activation) from a high resting value of 16.66 ± 6.52 %-60.04 ± 12.52 % of maximum (r = 0.798, p < 0.001). At isotime during CWR exercise, Borg dyspnea intensity ratings with fentanyl vs placebo were 4.1 ± 1.2 vs 3.8 ± 1.2, respectively (p = 0.174), and IND responses were also similar.

CONCLUSION

IND rose sharply during constant work rate exercise in association with dyspnea intensity in mild to moderate ILD but was not different after nebulized fentanyl compared with placebo.

Comprehensive pulmonary rehabilitation in patients with bronchiolitis obliterans syndrome: A case series

Chronic graft-versus-host disease (GVHD) is a significant complication of allogeneic hematopoietic stem cell transplantation, affecting 30%-70% of transplant recipients. One of the most challenging manifestations of chronic pulmonary GVHD is bronchiolitis obliterans syndrome (BOS), a rare and difficult-to-diagnose disease associated with a high mortality rate. BOS results in progressive circumferential fibrosis and, ultimately, cicatrization of the small terminal airways, manifesting as new fixed airflow obstruction. Although BOS patients are typically treated with immunosuppressive agents, there is no strong evidence that any specific therapies are effective in improving long-term outcomes. Thus, the mortality rate remains high. Therefore, there is an increasing need for additional therapies, including pulmonary rehabilitation (PR), in patients with BOS. PR is an evidence-based and comprehensive intervention for patients with chronic obstructive lung disease aimed at alleviating respiratory symptoms and optimizing functional capacity. This present case series demonstrates that comprehensive PR may also improve exercise tolerance and dyspnea in patients with BOS.

Identification and Assessment of Breathlessness in Clinical Practice: A Systematic Review and Narrative Synthesis

CONTEXT

Breathlessness is common in chronic conditions but often goes unidentified by clinicians. It is important to understand how identification and assessment of breathlessness occurs across health care settings, to promote routine outcome assessment and access to treatment.

OBJECTIVE

The objective of this study was to summarize how breathlessness is identified and assessed in adults with chronic conditions across different health care settings.

METHODS

This is a systematic review and descriptive narrative synthesis (PROSPERO registration: CRD42018089782). Searches were conducted on Medline, PsycINFO, Cochrane Library, Embase, and CINAHL (2000-2018) and reference lists. Screening was conducted by two independent reviewers, with access to a third, against inclusion criteria. Data were extracted using a bespoke proforma.

RESULTS

Ninety-seven studies were included, conducted in primary care (n = 9), secondary care (n = 53), and specialist palliative care (n = 35). Twenty-five measures of identification and 41 measures of assessment of breathlessness were used. Primary and secondary care used a range of measures to assess breathlessness severity, cause, and impact for people with chronic obstructive pulmonary disease. Specialist palliative care used measures assessing broader symptom severity and function with less focus on overall quality of life. Few studies were identified from primary care.

CONCLUSION

Various measures were identified, reflective of the setting's purpose. However, this highlights missed opportunities for breathlessness management across settings; primary care is particularly well placed to diagnose and support breathlessness. The chronic obstructive pulmonary disease approach (where symptoms and quality of life are part of disease management) could apply to other conditions. Better documentation of holistic patient-reported measures may drive service improvement in specialist palliative care.

Ongoing clinical trials and treatment options for patients with systemic sclerosis-associated interstitial lung disease

SSc is a rare CTD that affects multiple organ systems, resulting in substantial morbidity and mortality. Evidence of interstitial lung disease (ILD) is seen in ∼80% of patients with SSc. Currently there is no approved disease-modifying treatment for ILD and few effective treatment options are available. CYC is included in treatment guidelines, but it has limited efficacy and is associated with toxicity. MMF is becoming the most commonly used medication in clinical practice in North America and the UK, but its use is not universal. Newer agents targeting the pathogenic mechanisms underlying SSc-ILD, including fibrotic and inflammatory pathways, lymphocytes, cell-cell and cell-extracellular membrane interactions, hold promise for better treatment outcomes, including improved lung function, patient-related outcomes and quality of life. Here we review ongoing trials of established and novel agents that are currently recruiting patients with SSc-ILD.

Using 6-Min Walk Distance Expressed as a Percentage of Reference to Evaluate the Effect of Pulmonary Rehabilitation in Elderly Patients With Interstitial Lung Disease

PURPOSE

The aim of this study was to investigate the effect of outpatient pulmonary rehabilitation (PR) program and the use of 6-min walk distance (6MWD), expressed as a percentage of the predicted value (%6MWD), to quantify response to PR in elderly patients with interstitial lung disease (ILD).

METHODS

This was a prospective, nonrandomized controlled study. Forty eligible patients with stable ILD (≥65 y old) were advised to attend an outpatient PR program for 3 mo. Thirteen patients completed the PR program and formed the PR group. Ten patients who did not attend the PR program were evaluated after 3 mo and formed the control group. Patients in the PR group underwent a comprehensive 3-mo hospital-based outpatient PR program, consisting of educational support and supervised exercise training, and attended the rehabilitation unit weekly.

RESULTS

Change in the absolute 6MWD (Δ6MWD) in the PR group was not significantly different compared with the control group (P = .062). Change in %6MWD (Δ%6MWD) was greater in the PR group than in the control group. Baseline 6MWD was not correlated with Δ6MWD, but baseline %6MWD was significantly correlated with Δ6MWD and Δ%6MWD.

CONCLUSION

PR had a beneficial effect on elderly patients with ILD in terms of exercise endurance. %6MWD might be more useful than the absolute 6MWD as an outcome measure of PR and as a predictor of response to PR in elderly patients with ILD.

Idiopathic Pulmonary Fibrosis and Lung Transplantation: When it is Feasible

Despite the availability of antifibrotic therapies, many patients with idiopathic pulmonary fibrosis (IPF) will progress to advanced disease and require lung transplantation. International guidelines for transplant referral and listing of patients with interstitial lung disease are not specific to those with IPF and were published before the widespread use of antifibrotic therapy. In this review, we discussed difficulties in decision-making when dealing with patients with IPF due to the wide variability in clinical course and life expectancy, as well as the acute deterioration associated with exacerbations. Indeed, the ideal timing for referral and listing for lung transplant remains challenging, and the acute deterioration might be influenced after transplant outcomes. Of note, patients with IPF are frequently affected by multimorbidity, thus a screening program for occurring conditions, such as coronary artery disease and pulmonary hypertension, before lung transplant listing is crucial to candidate selection, risk stratification, and optimal outcomes. Among several comorbidities, it is of extreme importance to highlight that the prevalence of lung cancer is increased amongst patients affected by IPF; therefore, candidates’ surveillance is critical to avoid organ allocation to unsuitable patients. For all these reasons, early referral and close longitudinal follow-up for potential lung transplant candidates are widely encouraged.

Diagnosing complications and co-morbidities of fibrotic interstitial lung disease

Introduction: Interstitial lung diseases (ILDs) represent a heterogeneous group of rare disorders that include more than 200 entities, mostly associated with high mortality. In recent years, the progress regarding the understanding of the pathogenesis of these diseases led to the approval of specific treatments. In ILDs, the presence of comorbidities has a significant impact on the quality of life and the survival of patients and, therefore, their diagnosis and treatment has a pivotal role in management and could improve overall outcome. Areas covered: We discuss key diagnostic issues with regard to the most frequent comorbidities in ILDs. Treatment options are also discussed as the decision to investigate more definitively in order to identify specific comorbidities (including lung cancer, pulmonary hypertension, GE reflux, and obstructive sleep apnoea) is critically dependent upon whether comorbidity-specific treatments are likely to be helpful in individual patients, judged on a case by case basis. Expert opinion: The extent to which clinicians proactively pursue the identification of comorbidities depends on realistic treatment goals in individual patients.

Efficacy of a Structured Exercise Program for Improving Functional Capacity and Quality of Life in Patients With Stage 3 and 4 Sarcoidosis: A RANDOMIZED CONTROLLED TRIAL

PURPOSE

This study investigated the effects of an exercise program on functional capacity and quality of life in patients with stage 3 and stage 4 sarcoidosis.

METHODS

Eighteen patients with stage 3 and 4 sarcoidosis were recruited; 9 received 12 wk of supervised exercise training and 9 received usual care. Patients underwent the following evaluations at baseline and follow-up: 6-min walk test, maximal inspiratory and expiratory pressure tests, back and leg dynamometer test, modified Medical Research Council Dyspnea Scale, Fatigue Severity Scale, St George Respiratory Questionnaire, Short Form-36 Quality of Life Questionnaire, Hospital Anxiety and Depression Questionnaire, body plethysmography, carbon monoxide diffusing capacity test, and blood gas analysis.

RESULTS

The median (interquartile range) increase in 6-min walk distance in the intervention group was 40 (31-62) m. Improvement in functional capacity; perception of dyspnea; fatigue; anxiety; peripheral and inspiratory muscle strength; partial arterial oxygen pressure; arterial oxygen saturation; and the symptom, activity, and total scores of the St George Respiratory Questionnaire were significantly greater in the intervention group than in the usual care group at follow-up (P < .05).

CONCLUSIONS

Exercise training improves functional capacity, muscle strength, dyspnea, quality of life, anxiety, fatigue, and oxygenation in patients with stage 3 and stage 4 sarcoidosis. Standard treatment of patients with late-stage sarcoidosis should integrate exercise training and pulmonary rehabilitation.

Frailty and geriatric conditions in older patients with idiopathic pulmonary fibrosis

BACKGROUND

Functional status, an important predictor of health outcomes in older patients, has not been studied in an IPF population. This study aimed to determine the prevalence of frailty and geriatric conditions in older patients with IPF.

METHODS

IPF patients age ≥65 years were identified prospectively at the University of Michigan. Frailty was assessed using the Fried frailty phenotype. Questionnaires addressing functional status, geriatric conditions and symptoms were administered. Quantitative measurement of pectoralis muscle area was performed. Patient variables were compared among different frailty groups.

RESULTS

Of the 50 participants, 48% were found to be frail and 40% had ≥2 geriatric conditions. Frailty was associated with increased age, lower lung function, shorter 6-min walk distance, higher symptom scores and a greater number of comorbidities, geriatric conditions and functional limitations (p < 0.05). Pectoralis muscle area was nearly significant (p = 0.08). Self-reported fatigue score (odds ratio [OR] = 2.13, confidence interval [CI] 95% 1.23-3.70, p = 0.0068) and diffusion capacity (OR = 0.54 CI 95% 0.35-0.85, p = 0.0071) were independent predictors of frailty.

CONCLUSIONS

Frailty and geriatric conditions are common in older patients with IPF. The presence of frailty was associated with objective (diffusion capacity) and subjective (self-reported fatigue score) data. Longitudinal evaluation is necessary to determine impact of frailty on disease-related outcomes in IPF.

Management of Chronic Respiratory Failure in Interstitial Lung Diseases: Overview and Clinical Insights

Interstitial lung diseases (ILDs) may be complicated by chronic respiratory failure (CRF), especially in the advanced stages. Aim of this narrative review is to evaluate the current evidence in management of CRF in ILDs. Many physiological mechanisms underlie CRF in ILDs, including lung restriction, ventilation/perfusion mismatch, impaired diffusion capacity and pulmonary vascular damage. Intermittent exertional hypoxemia is often the initial sign of CRF, evolving, as ILD progresses, into continuous hypoxemia. In the majority of the cases, the development of CRF is secondary to the worsening of the underlying disease; however, associated comorbidities may also play a role. When managing CRF in ILDs, the need for pulmonary rehabilitation, the referral to lung transplant centers and palliative care should be assessed and, if necessary, promptly offered. Long-term oxygen therapy is commonly prescribed in case of resting or exertional hypoxemia with the purpose to decrease dyspnea and improve exercise tolerance. High-Flow Nasal Cannula oxygen therapy may be used as an alternative to conventional oxygen therapy for ILD patients with severe hypoxemia requiring both high flows and high oxygen concentrations. Non-Invasive Ventilation may be used in the chronic setting for palliation of end-stage ILD patients, although the evidence to support this application is very limited.

Pulmonary Rehabilitation in patients with Interstitial Lung Disease: The effects of a 12-week programme

BACKGROUND

The inclusion of Pulmonary Rehabilitation as part of the management of Interstitial Lung Disease, although being highly recommended in most recent guidelines, still has limited studies exploring the outcomes from such an intervention. The present study aims to contribute to the available literature by investigating the effects of a high intensity, 12 week PR programme on functional and quality of life measures in patients with a diagnosis of Interstitial Lung Disease.

METHOD

ology: This paper reports outcomes of an observational, prospective, quasi experimental type of study. A total of 120 participants were recruited: 60 patients formed part of the active group, and another 60 patients were enrolled in an inactive group. Each participant was classified according to the modified Medical Research Council dyspnoea scale and placed in one of 5 categories (0-4) according to self-perceived breathlessness during daily activities. The following outcomes were measured: Lung function tests including plethysmography and diffusion capacity of carbon monoxide (D_LCO), functional tests (6-min walking distance test, Dyspnoea Borg Scale) and health status measures (St George's Respiratory Questionnaire and Hospital Anxiety and Depression Score).

RESULTS

A 12-week PR programme for patients with Interstitial Lung Disease, led to significant improvements in the active group of patients in the 6 min walking distance test, the modified Borg Scale, mMRC scores and in the health status measures. Lung function measures did not show any significant improvement following this intervention.

CONCLUSION

This 12week Pulmonary Rehabilitation programme resulted in improvements in functional aspects for patients with Interstitial Lung Disease. Further studies are recommended as Pulmonary Rehabilitation for Interstitial Lung Disease may have an impact at both an individual level and at global organisational/financial levels.

Short and long-term effects of pulmonary rehabilitation in interstitial lung diseases: a randomised controlled trial

BACKGROUND

Few data are available on the long-term effect of pulmonary rehabilitation (PR) and on long PR programs in interstitial lung diseases (ILD). We aimed to evaluate the effects of PR on exercise capacity (6-Minute Walking Distance, 6MWD; Peak Work Rate, W_max), quality of life (St George's Respiratory Questionnaire, SGRQ), quadriceps force (QF) and objectively measured physical activity in ILD after the 6-month PR-program and after 1 year.

METHODS

60 patients (64 ± 11 years; 62% males; 23% with IPF) were randomly assigned to receive a 6 month-PR program or usual medical care.

RESULTS

Exercise capacity, quality of life and muscle force increased significantly after the program as compared to control (mean,95%CI[ll to ul]; 6MWD + 72,[36 to 108] m; W_max 19, [8 to 29]%pred; SGRQ - 12,[- 19 to - 6] points; QF 10, [1 to 18] %pred). The gain was sustained after 1 year (6MWD 73,[28 to 118] m; Wmax 23, [10 to 35]%pred; SGRQ - 11,[- 18 to - 4] points; QF 9.5, [1 to 18] %pred). Physical activity did not change.

CONCLUSIONS

PR improves exercise tolerance, health status and muscle force in ILD. The benefits are maintained at 1-year follow-up. The intervention did not change physical activity.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00882817 .

Función pulmonar, capacidad funcional y calidad de vida en pacientes con fibrosis pulmonar idiopática. Revisión de la literatura

Introducción. La fibrosis pulmonar idiopática (FPI) es un tipo de enfermedad intersticial, crónica y progresiva que suele manifestarse con disnea y deterioro progresivo de la tolerancia al ejercicio y a las actividades de la vida diaria, llegando a comprometer el nivel psicológico y la interacción social.Objetivos. Seleccionar y sintetizar información acerca de la respuesta de la capacidad funcional, la función pulmonar y la calidad de vida relacionada con la salud en pacientes con FPI luego de ser sometidos a un programa de rehabilitación pulmonar.Materiales y métodos. Revisión de la literatura desde 2000 a 2016, utilizando las bases de datos PubMed y ScienceDirect.Resultados. Se seleccionaron 10 ensayos clínicos randomizados. Se observó tendencia al aumento significativo en la distancia recorrida en test de marcha de 6 minutos. Respecto a la función pulmonar, los resultados variaron entre las poblaciones estudiadas. En la calidad de vida relacionada con la salud se observó mejora en los pacientes sometidos a rehabilitación, pero los niveles de disnea mostraron resultados discordantes.Conclusión. Se evidenciaron beneficios en términos de capacidad funcional y calidad de vida relacionada con la salud, pero los estudios siguen siendo escasos y con poblaciones pequeñas; los efectos de los programas de rehabilitación no se mantienen a los 6 meses de evaluación post-entrenamiento.

Japanese guideline for the treatment of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a disease of unknown etiology which accounts for a large proportion of cases of idiopathic interstitial pneumonia. It has a very poor prognosis with a 5-year survival rate of 30% or below, and so far there has been no guideline in Japan offering an established effective therapy based on evidence. In addition to the establishment of basic therapies, there is also an urgent need to establish therapies to deal with complications, as death occurs in many cases due to acute exacerbation or comorbid lung cancer. It was therefore decided to formulate a guideline in order to promote evidence-based clinical practice, to further improve the quality of medical treatment in the clinical setting, and to allow the benefits to be enjoyed by the public.

Cardiorespiratory adaptation during 6-Minute Walk Test in fibrotic idiopathic interstitial pneumonia patients who did or did not respond to pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation (PR) improves performance in the 6-min walk test (6MWT) in a subset of patients with fibrotic idiopathic interstitial pneumonia (f-IIP); however, a large proportion of patients does not respond to PR.

AIM

To investigate the effects of a PR program on cardiorespiratory responses during a 6MWT and to identify the characteristics of patients who do not show improved performance after PR.

DESIGN

An observational study.

SETTING

Patients were recruited from the Competence Centre for Rare Pulmonary Diseases at Lille University Hospital, France and completed an 8-week home-based PR program.

POPULATION

A total of 19 patients with f-IIP; 12 with idiopathic pulmonary fibrosis (IPF) and 7 with fibrotic non-specific interstitial pneumonia.

METHODS

Patients underwent spirometry and completed a 6MWT before and after an 8-week PR program. Gas exchange, heart rate, and pulse O2 saturation were measured continuously during the 6MWT. Quality of life, dyspnea, and anxiety/depression were assessed using the Short-Form 36 (SF-36), the baseline/transition dyspnea index (BDI/TDI), and the Hospital Anxiety and Depression Scale (HADS) questionnaires.

RESULTS

Patients who did and did not improve the distance walked in the 6MWT by at least 30 m after PR were classified as responders (N.=9) and non-responders (N.=10), respectively. O2 uptake, ventilation rate, and distance covered during the 6MWT were significantly improved only in the responder group (P<0.05). Changes in SF-36, BDI/TDI, and HADS scores did not differ significantly between responders and non-responders. The non-responder group contained significantly more patients with IPF (P<0.05) and experienced greater arterial oxygen desaturation during the 6MWT compared with the responder group.

CONCLUSIONS

Failure to improve performance in the 6MWT after PR was associated with a diagnosis of IPF, non-improvement in gas exchange, and greater arterial oxygen desaturation.

CLINICAL REHABILITATION IMPACT

Most f-IIP patients who did not respond to PR were diagnosed with IPF and displayed greater hypoxemia during exercise. Clinical practitioners should seek to determine why patients fail to improve exercise performance after PR and propose an alternative exercise regimen to these patients.

Differential Pulmonary Rehabilitation Outcomes in Patients With and Without COPD: ROLE OF GENDER

PURPOSE

Individuals with all forms of pulmonary disease are referred for pulmonary rehabilitation. This study examines pulmonary rehabilitation outcomes between individuals with chronic obstructive lung disease (COPD) and non-COPD disease and the impact of gender.

METHODS

This is a retrospective study at a tertiary center. The primary endpoint was the difference in 6-min walk test distance. Secondary measurements included treadmill and NuStep minutes; biceps curls and front arm raises load; quality of life measured by the St George's Respiratory Questionnaire; and University of California San Diego-Shortness of Breath Questionnaire (UCSD-SOBQ) scores.

RESULTS

Eighty patients were included: 38 men (23 COPD, 15 non-COPD) and 42 women (31 COPD, 11 non-COPD). There was a statistically significant improvement in 6-min walk test distances pre- to post-pulmonary rehabilitation for all participants, P = .0003. Although both the COPD and non-COPD groups demonstrated overall improvement (P < .0004 and P = .02, respectively), subgroup analysis showed no statistically significant change in the non-COPD group when divided by gender. There was a significant statistical improvement in lower and upper extremity strength in all participants. Only women with COPD showed a statistically significant improvement with respect to overall quality of life as measured by St. George's Respiratory Questionnaire (P = .01). Women showed significant improvement in their depression score, as well as a trend toward improvement in the University of California San Diego-Shortness of Breath Questionnaire, while only men with COPD showed any improvement in their sleep quality measured by the Pittsburgh Sleep Quality Index.

CONCLUSIONS

Pulmonary rehabilitation results in different but improved outcomes regardless of gender or disease state.

The Unmet Educational Needs of Patients with Interstitial Lung Disease. Setting the Stage for Tailored Pulmonary Rehabilitation

RATIONALE

There is no standardized education program for patients with interstitial lung disease (ILD). Pulmonary rehabilitation is a resource for structured disease education that is still geared primarily toward patients with chronic obstructive pulmonary disease.

OBJECTIVES

The goals of this qualitative study were to identify the educational needs of patients with ILD and explore how pulmonary rehabilitation can become an appropriate setting for ILD education.

METHODS

Four focus groups including 24 patients with ILD and 10 semistructured interviews with healthcare professionals with expertise in ILD and/or pulmonary rehabilitation were conducted in two academic centers (University of California San Francisco and Centre Hospitalier de l'Université de Montréal). We conducted a qualitative thematic analysis of the transcripts using an iteratively developed codebook.

MEASUREMENTS AND MAIN RESULTS

The transcript analysis highlighted four major themes: patient dissatisfaction with the current educational model, lack of attention to emotional well-being, specific recommendations for educational content, and operationalizing education in the context of pulmonary rehabilitation. Seven key topics to be included an ILD-specific, pulmonary rehabilitation-based education program were identified: disease education, symptom management, clinical tests, autonomy, oxygen use, medications, and end-of-life counseling.

CONCLUSIONS

This study provides a better understanding of the needs of patients and healthcare providers regarding education of patients with ILD. It lays the foundation for the development of a structured education intervention that could be delivered in the context of pulmonary rehabilitation.

A comparison trial of eight weeks versus twelve weeks of exercise program in interstitial lung diseases

Background: Exercise training have been shown to be the effective approach for functional outcomes in interstitial lung diseases (ILD). In many studies, the duration of exercise programs (EPs) varies between 8-12 weeks. However, the optimal duration of EPs is still unknown. Objective: In our prospective non-controlled study, we aimed to compare the results of the 8^th week with the results of the 12^th week of the PR programs applied to the patients with ILD. Methods: A total of 14 patients [Age; 63(53,70) years, body mass index: 28(25,32) kg/m², disease duration; 1.5 (1,4) years] with ILD [11 idiopathic pulmonary fibrosis, 2 sarcoidosis (stage 3 and 4) and 1 nonspecific interstitial pneumonia] were included in the study. 6-minute walk test, pulmonary function test, arterial blood gas analysis, mMRC dyspnea scale, quality of life questionnaires and hospital anxiety depression scale were performed at before and 8 and 12 weeks after the program. Results: 6-minute walk distance, dyspnea, anxiety, depression and quality of life improved both at 8^th and 12^th week after EP when compared the with the initial assessment(P<0.05). When compared with 8^th week; mMRC dyspnea score, 6-minute walk distance and quality of life scores significantly improved at 12^th weeks (P=0.046, P=0.016, P<0.05, respectively). Conclusions: Prolonging duration of the EPs results in more improvement in functional outcomes in patients with ILD. However, it has no effect on pulmonary functions and arterial blood gas results. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 299-307)

Effectiveness of pulmonary rehabilitation in patients with interstitial lung disease of different etiology: a multicenter prospective study

BACKGROUND

Recent evidences show that Pulmonary Rehabilitation (PR) is effective in patients with Interstitial Lung Disease (ILD). It is still unclear whether disease severity and/or etiology might impact on the reported benefits. We designed this prospective study 1) to confirm the efficacy of rehabilitation in a population of patients with ILDs and 2) to investigate whether baseline exercise capacity, disease severity or ILD etiology might affect outcomes.

METHODS

Forty-one patients (IPF 63%, age 66.9 ± 11 ys) were enrolled in a standard PR course in two centers. Lung function, incremental and endurance cyclo-ergometry, Six Minutes Walking Distance (6MWD), chronic dyspnea (Medical Research Council scale-MRC) and quality of life (St. George Respiratory Questionnaire-SGRQ) were recorded before and at the end of PR to measure any pre-to-post change. Correlation coefficients between the baseline level of Diffuse Lung Capacity for Carbon monoxide (DLCO), Forced Vital Capacity (FVC), 6MWD, power developed during incremental endurance test, GAP index (in IPF patients only) and etiology (IPF or non-IPF) with the functional improvement at the 6MWDT (meters), at the incremental and endurance cyclo-ergometry (endurance time) and the HRQoL were assessed.

RESULTS

Out of the 41 patients, 97% (n = 40) completed the PR course. Exercise performance (both at peak load and submaximal effort), symptoms (iso-time dyspnea and leg fatigue), SGRQ and MRC significantly improved after PR (p < .001). Patients with lower baseline 6MWD showed greater improvement in 6MWD (Spearman r score = - .359, p = .034) and symptoms relief at SGRQ (r = -.315, p = .025) regardless of underlying disease.

CONCLUSION

Present study confirms that comprehensive rehabilitation is feasible and effective in patients with ILD of different severity and etiology. The baseline submaximal exercise capacity inversely correlates with both functional and symptom gains in this heterogeneous population.

Advances in the Evaluation of Respiratory Pathophysiology during Exercise in Chronic Lung Diseases

Dyspnea and exercise limitation are among the most common symptoms experienced by patients with various chronic lung diseases and are linked to poor quality of life. Our understanding of the source and nature of perceived respiratory discomfort and exercise intolerance in chronic lung diseases has increased substantially in recent years. These new mechanistic insights are the primary focus of the current review. Cardiopulmonary exercise testing (CPET) provides a unique opportunity to objectively evaluate the ability of the respiratory system to respond to imposed incremental physiological stress. In addition to measuring aerobic capacity and quantifying an individual's cardiac and ventilatory reserves, we have expanded the role of CPET to include evaluation of symptom intensity, together with a simple "non-invasive" assessment of relevant ventilatory control parameters and dynamic respiratory mechanics during standardized incremental tests to tolerance. This review explores the application of the new advances in the clinical evaluation of the pathophysiology of exercise intolerance in chronic obstructive pulmonary disease (COPD), chronic asthma, interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). We hope to demonstrate how this novel approach to CPET interpretation, which includes a quantification of activity-related dyspnea and evaluation of its underlying mechanisms, enhances our ability to meaningfully intervene to improve quality of life in these pathologically-distinct conditions.

Treatment of idiopathic pulmonary fibrosis: a position paper from a Nordic expert group

Idiopathic pulmonary fibrosis (IPF) is a fatal progressive lung disease occurring in adults. In the last decade, the results of a number of clinical trials based on the updated disease classification have been published. The registration of pirfenidone and nintedanib, the first two pharmacological treatment options approved for IPF, marks a new chapter in the management of patients with this disease. Other nonpharmacological treatments such as lung transplantation, rehabilitation and palliation have also been shown to be beneficial for these patients. In this review, past and present management is discussed based on a comprehensive literature search. A treatment algorithm is presented based on available evidence and our overall clinical experience. In addition, unmet needs with regard to treatment are highlighted and discussed. We describe the development of various treatment options for IPF from the first consensus to recent guidelines based on evidence from large-scale, multinational, randomized clinical trials, which have led to registration of the first drugs for IPF.