Health-related quality of life in patients with idiopathic pulmonary fibrosis. What is the main contributing factor?

Circular RNAs and their roles in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease with limited treatment options. Circular RNAs (circRNAs) have emerged as a novel class of non-coding RNAs with diverse functions in cellular processes. This review paper aims to explore the potential involvement of circRNAs in the pathogenesis of IPF and their diagnostic and therapeutic implications. We begin by providing an overview of the epidemiology and risk factors associated with IPF, followed by a discussion of the pathophysiology underlying this complex disease. Subsequently, we delve into the history, types, biogenesis, and functions of circRNAs and then emphasize their regulatory roles in the pathogenesis of IPF. Furthermore, we examine the current methodologies for detecting circRNAs and explore their diagnostic applications in IPF. Finally, we discuss the potential utility of circRNAs in the treatment of IPF. In conclusion, circRNAs hold great promise as novel biomarkers and therapeutic targets in the management of IPF.

Dyspnoea relief as an inherent benefit of high flow nasal cannula therapy: A laboratory randomized trial in healthy humans

BACKGROUND AND OBJECTIVE

Persistent dyspnoea is a public health issue for which the therapeutic arsenal is limited. This study tested high-flow nasal cannula therapy (HFNT) as a means to alleviate experimental dyspnoea.

METHODS

Thirty-two healthy subjects underwent an experimental dyspnoea induced by thoracoabdominal elastic loading. HFNT was administered with alternately FiO2 of 100% (HFNT100) or 21% (HFNT21). The sensory (S-VAS) and affective (A-VAS) components of dyspnoea, transcutaneous CO2 pressure (PtcCO2 ), pulse-oximetry oxygen saturation (SpO2 ), heart rate, respiratory rate and skin galvanometry were monitored continuously. Three experimental sessions of 8 min were conducted: the first session consisted in familiarization with the experimental dyspnoea and the next two sessions tested the effects of HFNT100 and HFNT21 alternatively in a randomized order.

RESULTS

HFNT21 and HFNT100 significantly reduced dyspnoea, respectively of ∆A-VAS = 0.80 cm [-0.02-1.5]; p = 0.007 and ∆A-VAS = 1.00 cm [0.08-1.75]; p < 0.0001; ∆S-VAS = 0.70 cm [-0.15-1.98]), p < 0.0001 and ∆S-VAS = 0.70 cm [0.08-1.95]), p = 0.0002) with no significant difference between HFNT21 and HFNT100. HFNT did not significantly alter the respiratory rate or the heart rate, reduced PtcCO2 only on room air and GSR under both experimental conditions.

CONCLUSION

HFNT was associated with a statistically significant reduction in the intensity of the sensory and affective components of dyspnoea, independent of oxygen addition. This relief of laboratory dyspnoea could result from a reduction of afferent-reafferent mismatch.

Supplemental Oxygen Therapy in Interstitial Lung Disease: A Narrative Review

Patients with interstitial lung diseases (ILD) often have hypoxemia at rest and/or with exertion, for which supplemental oxygen is commonly prescribed. The number of patients with ILD who require supplemental oxygen is unknown, although estimates suggest it could be as much as 40%; many of these patients may require high-flow support (>4 L/min). Despite its frequent use, there is limited evidence for the impact of supplemental oxygen on clinical outcomes in ILD, with recommendations for its use primarily based on older studies in patients with chronic obstructive pulmonary disease. Oxygen use in ILD is rarely included as an outcome in clinical trials. Available evidence suggests that supplemental oxygen in ILD may improve quality of life and some exercise parameters in patients whose hypoxemia is a limiting factor; however, oxygen therapy also places new burdens and barriers on some patients that may counter its beneficial effects. The cost of supplemental oxygen in ILD is also unknown but likely represents a significant portion of overall healthcare costs in these patients. Current Centers for Medicare and Medicaid reimbursement policies provide only a modest increase in payment for high oxygen flows, which may negatively impact access to oxygen services and equipment for some patients with ILD. Future studies should examine clinical and quality-of-life outcomes for oxygen use in ILD. In the meantime, given the current limited evidence for supplemental oxygen and considering cost factors and other barriers, providers should take a patient-focused approach when considering supplemental oxygen prescriptions in patients with ILD.

Ultrasound evaluation of diaphragmatic function in patients with idiopathic pulmonary fibrosis: a retrospective observational study

INTRODUCTION

The diaphragm function assessed by ultrasound has been well-studied in COPD, asthma, and intensive care. However, there are only a few studies on diffuse interstitial lung disease, while dyspnea and quality of life are major issues in the management that may depend on the diaphragm.

METHODS

We retrospectively included idiopathic pulmonary fibrosis (IPF) patients followed in our center (Marseille, France) between January 2020 and February 2023 who underwent diaphragmatic ultrasound. Our objectives were to describe the diaphragmatic function of IPFs compared to healthy controls and to correlate with clinical, functional, and lung density on CT-scan.

RESULTS

24 IPF patients and 157 controls were included. The diaphragmatic amplitude in IPF was increased at rest (median of 2.20 cm vs 1.88 cm on the right, p < 0.007, and 2.30 cm vs 1.91 cm on the left, p < 0.03, in IPF and controls respectively) and decreased in deep breathing (median of 4.85 cm vs 5.45 cm on the right, p < 0.009, and 5.10 cm vs 5.65 cm on the left, p < 0.046, in IPF and controls respectively). Diaphragmatic thickness was significantly reduced at rest on the right side (median of 1.75 mm vs 2.00 mm, p < 0.02, in IPF and controls respectively) and in deep breathing on both sides compared to controls (mean of 3.82 mm vs 4.15 mm on the right, p < 0.02, and 3.53 mm vs 3.94 mm, on the left, p < 0.009, in IPF and controls respectively). Diaphragmatic amplitude in deep breathing was moderate to strongly correlated with FVC, DLCO, and 6MWT and negatively correlated with the dyspnea and lung density on CT scan.

CONCLUSION

The diaphragmatic amplitude and thickness were impaired in IPF compared to controls. Diaphragmatic amplitude is the parameter best correlated with clinical, functional, and lung density criteria. Further studies are needed to determine if diaphragmatic amplitude can be a prognostic factor in IPF.

Long-term effect of pulmonary rehabilitation in idiopathic pulmonary fibrosis: a randomised controlled trial

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is characterised by worsening dyspnoea and exercise intolerance.

RESEARCH QUESTION

Does a long-term pulmonary rehabilitation improve exercise tolerance in patients with IPF treated with standard antifibrotic drugs, which are expected to reduce disease progression?

METHODS

This open-label randomised controlled trial was performed at 19 institutions. Stable patients receiving nintedanib were randomised into pulmonary rehabilitation and control groups (1:1). The pulmonary rehabilitation group underwent initial rehabilitation which included twice-weekly sessions of monitored exercise training for 12 weeks, followed by an at-home rehabilitation programme for 40 weeks. The control group received usual care only, without pulmonary rehabilitation. Both groups continued to receive nintedanib. The primary and main secondary outcomes were change in 6 min walking distance (6MWD) and change in endurance time (using cycle ergometry) at week 52.

RESULTS

Eighty-eight patients were randomised into pulmonary rehabilitation (n=45) and control (n=43) groups. Changes in 6MWD were -33 m (95% CI -65 to -1) and -53 m (95% CI -86 to -21) in the pulmonary rehabilitation and control groups, respectively, with no statistically significant difference (mean difference, 21 m (95% CI -25 to 66), p=0.38). Changes in endurance time were significantly better in the pulmonary rehabilitation (64 s, 95% CI -42.3 to 171)) than in the control (-123 s (95% CI -232 to -13)) group (mean difference, 187 s (95% CI 34 to 153), p=0.019).

INTERPRETATION

Although pulmonary rehabilitation in patients taking nintedanib did not improve 6MWD in the long term, it led to prolonged improvement in endurance time.

TRIAL REGISTRATION NUMBER

UMIN000026376.

Oxygen in interstitial lung diseases

Domiciliary oxygen is essential in the care of hypoxaemic interstitial lung disease (ILD) patients. Guidelines concur in advising prescription of long-term oxygen therapy (LTOT) for ILD patients with severe hypoxaemia at rest, in view of its beneficial impact on breathlessness/disability and extrapolating potential survival benefits seen in COPD patients. A less severe hypoxaemia threshold for initiation of LTOT is recommended for patients with pulmonary hypertension (PH)/right heart failure, requiring careful evaluation in all ILD patients. In light of evidence suggesting a link between nocturnal hypoxaemia, development of PH and poor survival, studies assessing the impact of nocturnal oxygen are urgently needed. Severe exertional hypoxaemia is frequent in ILD patients, with impact on exercise tolerance, quality of life and mortality. Ambulatory oxygen therapy (AOT) has been associated with improvement in breathlessness and quality of life in ILD patients with exertional hypoxaemia. However, given the paucity of evidence, not all current AOT guidelines are in agreement. Ongoing clinical trials will provide further useful data. Despite its beneficial effects, supplemental oxygen imposes burdens and challenges to patients. A key unmet area of need is the development of less cumbersome and more efficient oxygen delivery systems to reduce the negative impact of AOT on patients' lives.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Retrospective, Descriptive Study of Dyspnea Management in a Multidisciplinary Interstitial Lung Disease Clinic

Background: Fibrotic interstitial lung diseases (F-ILDs) have a high symptom burden with progressive dyspnea as a primary feature. Breathlessness is underrecognized and undertreated primarily due to lack of consensus on how to best measure and manage it. Several nonpharmacologic and pharmacologic strategies are published in the literature, however there is a paucity of real-world data describing their systematic implementation. Objectives: We describe the types of breathlessness interventions and timing of implementation in our multidisciplinary collaborative care (MDC) ILD clinic and the impact of our approach on dyspnea trajectory and acute care use in ILD. Methods: A retrospective, observational study of deceased ILD patients seen in our clinic (2012-2018) was conducted. Patients were grouped by baseline medical research council (MRC) grade and dyspnea interventions from clinic enrolment until death were examined. Healthcare usage in the last 6 months of life was collected through Alberta's administrative database. Results: Eighty-one deceased ILD patients were identified. Self management advice was provided to 100% of patients. Pulmonary rehabilitation (PR) and home care (HC) referrals were made in 40% and 57% of patients, respectively. Eighty percent were treated with oxygen and 53% with opioids during the study. MDC-initiated referral to PR and HC, oxygen and opioid prescriptions were provided a median of 13, 9, 11, and 4 months prior to death, respectively. Stepwise implementation of interventions was observed more commonly in MRC 1-2 and concurrent implementation in MRC 4-5. Conclusions: Our clinic's approach allows early and systematic dyspnea management.

The 1-minute sit-to-stand test to detect desaturation during 6-minute walk test in interstitial lung disease

Although the 6 min walk test (6MWT) is well-established for assessing desaturation in patients with interstitial lung disease (ILD), it cannot be easily performed in primary healthcare settings. This retrospective observational study aimed to evaluate the usefulness of the 1 min sit-to-stand test (1STST) for assessing desaturation during 6MWT in ILD patients with normal resting blood oxygen levels. We included 116 patients, and the pulse oxygen saturation (SpO2) for both methods was analyzed. The SpO2 nadir during the 1STST and 6MWT correlated strongly (ρ = 0.82). The frequency of patients with nadir SpO2 < 90% was consistent for both tests (κ = 0.82). 1STST was superior to diffusing capacity for carbon monoxide in detecting desaturation during the 6MWT. These findings were similarly stratified according to performance status or dyspnea scale. The 1STST can easily measure exertional desaturation in ILD patients with normal resting blood oxygen levels and is an alternative to the 6MWT.

A New Tool to Assess Quality of Life in Patients with Idiopathic Pulmonary Fibrosis or Non-specific Interstitial Pneumonia

Background  Quality of life (QoL) is significantly impaired in patients with pulmonary fibrosis, however reliable tools to assess QoL issues specific for this group of patients are still missing. We thus aimed to develop a new questionnaire called “Quality of life in patients with idiopathic pulmonary fibrosis” (QPF) to measure QoL in patients with fibrotic idiopathic interstitial pneumonias (IIP).

Methods  An item pool was created on the basis of a German expert group with support of patients suffering from pulmonary fibrosis. In a 1st step, this version of the questionnaire was completed by 52 patients with idiopathic pulmonary fibrosis (IPF) or non-specific interstitial pneumonia (NSIP). Following this, an item- and an exploratory factor analysis was carried out and a 2nd version created. In a multicenter validation study in a one-group pre-post design, the questionnaire was filled in by 200 patients with IIP (IPF = 190, iNSIP = 10) at 2 time points with an interval of 6 months. Cross-validation was carried out with the St. Georges Respiratory Questionnaire (SGRQ).

Results  The mean age of the patients was 71.0 years (50–90 years), 82.5 % were male. Item analysis revealed that most of Cronbach alpha and selectivity values of QPF-scales could be considered as sufficient (e. g. QPF-scale “condition” [alpha = 0.827], “impairment” [alpha = 0.882]). At scale level, there were significant differences in terms of a deterioration or improvement in the QPF-condition and QPF-breathlessness scales and also in the SGRQ-activity scale. Analysis of construct validation of QPF and SGRQ showed moderate correlations between both questionnaires. A deterioration in health status from the patient’s and doctorʼs perspective was seen in the scales “impairment”, “shortness of breath” and “health status” of the QPF. The QPF was able to detect a change in the patientʼs mood (“condition” scale) in the course of treatment.

Conclusion  This newly developed questionnaire maps the special needs of the patients well. The QPF is suitable for screening of quality of life as well as for supplementing the medical history and for monitoring the course of disease in fibrotic IIPs.

Protocol for long-term effect of pulmonary rehabilitation under nintedanib in idiopathic pulmonary fibrosis

Background

Pulmonary rehabilitation causes short-term improvement in exercise capacity, dyspnoea and health-related quality of life in idiopathic pulmonary fibrosis (IPF); however, long-term maintenance of the improvement is difficult. Nintedanib, an antifibrotic drug, has been shown to delay the worsening of pulmonary function in IPF. Therefore, the concomitant use of nintedanib with pulmonary rehabilitation is anticipated to contribute to the long-term maintenance of the pulmonary rehabilitation effects. The long-term effect of pulmonary rehabilitation under nintedanib treatment in IPF (FITNESS) study is a multicenter, randomised, prospective, parallel-group, open-label trial.

Methods

The study will enrol 84 patients with IPF who have been treated with nintedanib. Patients in the pulmonary rehabilitation group will receive a programmed short-term induction pulmonary rehabilitation programme, followed by a maintenance home-based pulmonary rehabilitation programme, while patients in the control group will receive usual outpatient care. Patients in both groups will continue to receive nintedanib treatment throughout the study period. The primary end-point of the study is to compare the change in the 6-min walk distance from the baseline to 12 months between the pulmonary rehabilitation and control groups. The main secondary end-point is endurance exercise time, measured using a bicycle ergometer.

Discussion

FITNESS is the first randomised controlled study to evaluate the long-term effects of pulmonary rehabilitation in IPF treated with nintedanib. This study will address the hypothesis that concomitant use of nintedanib contributes to the maintenance of long-term effects of pulmonary rehabilitation, thus leading to a comprehensive therapeutic approach of "nintedanib and pulmonary rehabilitation" in the antifibrotic era.

Study protocol for a randomised, placebo-controlled, single-blind phase II study of the efficacy of morphine for dyspnoea in patients with interstitial lung disease (JORTC-PAL 15)

INTRODUCTION

Dyspnoea is common in patients with interstitial lung disease (ILD) and often refractory to conventional treatment. Little is known about the efficacy of systemic morphine for dyspnoea in patients with ILD. The aim of this study is to estimate the efficacy of a single subcutaneous morphine injection for dyspnoea in patients with ILD.

METHODS AND ANALYSIS

We will conduct a multicentre, prospective, randomised, placebo-controlled, single-blinded phase II study of a single subcutaneous morphine injection for dyspnoea in patients with ILD. In patients with ILD who have dyspnoea at rest refractory to conventional treatment will be eligible for participation in this study. The morphine dose will be 2 mg. The primary endpoint is changes in dyspnoea intensity from baseline to 60 min after treatment as measured using an 11-point Numerical Rating Scale and compared between the morphine and placebo groups.

ETHICS AND DISSEMINATION

Ethical approval has been obtained by the Osaka City University Certified Review Board. The results of this study will be submitted for publication in an international peer-reviewed journal and the findings will be presented at international scientific conferences.

TRIAL REGISTRATION NUMBER

jRCTs051190030; pre-results.

Ambulatory oxygen for treatment of exertional hypoxaemia in pulmonary fibrosis (PFOX trial): a randomised controlled trial

INTRODUCTION

Interstitial lung diseases are characterised by scarring of lung tissue that leads to reduced transfer of oxygen into the blood, decreased exercise capacity and premature death. Ambulatory oxygen therapy may be used to treat exertional oxyhaemoglobin desaturation, but there is little evidence to support its efficacy and there is wide variation in clinical practice. This study aims to compare the clinical efficacy and cost-effectiveness of ambulatory oxygen versus ambulatory air in people with fibrotic interstitial lung disease and exertional desaturation.

METHODS AND ANALYSIS

A randomised, controlled trial with blinding of participants, clinicians and researchers will be conducted at trial sites in Australia and Sweden. Eligible participants will be randomised 1:1 into two groups. Intervention participants will receive ambulatory oxygen therapy using a portable oxygen concentrator (POC) during daily activities and control participants will use an identical POC modified to deliver air. Outcomes will be assessed at baseline, 3 months and 6 months. The primary outcome is change in physical activity measured by number of steps per day using a physical activity monitor (StepWatch). Secondary outcomes are functional capacity (6-minute walk distance), health-related quality of life (St George Respiratory Questionnaire, EQ-5D-5L and King's Brief Interstitial Lung Disease Questionnaire), breathlessness (Dyspnoea-12), fatigue (Fatigue Severity Scale), anxiety and depression (Hospital Anxiety and Depression Scale), physical activity level (GENEActive), oxygen saturation in daily life, POC usage, and plasma markers of skeletal muscle metabolism, systematic inflammation and oxidative stress. A cost-effectiveness evaluation will also be undertaken.

ETHICS AND DISSEMINATION

Ethical approval has been granted in Australia by Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/42) with governance approval at all Australian sites, and in Sweden (Lund Dnr: 2019-02963). The results will be published in peer-reviewed scientific journals, presented at conferences and disseminated to consumers in publications for lay audiences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03737409).

Health-related quality of life of patients with idiopathic pulmonary fibrosis: a systematic review and meta-analysis

Idiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease presenting in persons 50 years and older. Through a comprehensive review of available studies, we aimed to assess health-related quality of life (HRQoL) of people living with IPF and the instruments used in this assessment.Searches were conducted up to May, 2020. Quality appraisal and data extraction were performed using pre-designed forms. Narrative synthesis approach was used to report results of the systematic review and a random effects model was used for the meta-analysis. A leave-one-out sensitivity analysis was performed, and a trim and fill method was used to assess publication bias.The review included 134 studies. The most used instruments to measure HRQoL were St George's Respiratory Questionnaire (SGRQ), Short Form 36 (SF36) and EuroQoL (EQ5D). Standardised mean scores (95% confidence interval) for these instruments were as follows: SGRQ total score: 44.72 (42.21-47.22); SF36 physical component score (PCS): 37.00 (34.74-39.26) SF36 mental component score (MCS): 50.18 (48.41-51.95); King's Brief Interstitial Lung Disease questionnaire total score: 58.38 (55.26-61.51); and EQ5D utility: 0.73 (0.68-0.79). Analysis of standardised means for both SGRQ and SF36 demonstrated worse scores in physical health domains as compared to mental health domains.This systematic review confirms that IPF negatively affected HRQoL, mostly impacting the physical health domains. This study also demonstrated that a diverse number of instruments are used to evaluate HRQoL. In view of this diversity, a standardised approach to measurement of HRQoL for IPF is important to ensure that comparisons made are reliable.

Supplemental oxygen for the management of dyspnea in interstitial lung disease

PURPOSE OF REVIEW

This article presents a summary of the evidence relating to supplemental oxygen use for the management of dyspnea in patients with interstitial lung disease (ILD).

RECENT FINDINGS

In contrast to the majority of the available literature, recent findings suggest that supplemental oxygen can significantly reduce exertional dyspnea in ILD. ILD patients' need for supplemental oxygen often surpasses the levels that the most commonly used oxygen delivery systems provide. More effective delivery of supplemental oxygen has the potential for greater relief of dyspnea. There is also evidence suggesting that indications for supplemental oxygen may differ in ILD compared with other chronic lung diseases.

SUMMARY

Large clinical trials are needed to determine if the reductions in dyspnea with supplemental oxygen observed in the laboratory setting can translate into meaningful benefits in everyday life for patients with ILD. More effective and practical oxygen delivery systems are needed. Future guidelines should consider including recommendations addressing the potential role of supplemental oxygen for mildly hypoxemic patients with ILD as well as recommendations specific to supplemental oxygen use for exercise training in ILD.

Evaluation of health-related quality of life and the related factors in a group of Chinese patients with interstitial lung diseases

Introduction

Interstitial lung diseases (ILDs) include a wide variety of chronic progressive pulmonary diseases characterized by lung inflammation, fibrosis and hypoxemia and can progress to respiratory failure and even death. ILDs are associated with varying degrees of quality of life impairments in affected people. Studies on the quality of life in patients with ILDs are still limited, and there are few studies with long-term follow-up periods in these patients.

Methods

Data from patients who were clinically diagnosed with ILDs in the Respiratory Department, Beijing Chaoyang Hospital, Capital Medical University from January 2017 to February 2018 were collected. Clinical status and HRQoL were assessed at baseline and subsequently at 6- and 12-month intervals with the LCQ, mMRC, HADS, SF-36, and SGRQ. Multivariate linear regression was used to evaluate the determinants of the decline in HRQoL.

Results

A total of 139 patients with idiopathic interstitial pneumonia (IIP) and 30 with connective tissue disease-associated ILD (CTD-ILD) were enrolled, 140 of whom completed the follow-up. The mean age was 63.7 years, and 92 patients were men. At baseline, the decline in HRQoL assessed by the SF-36 and SGRQ was significantly associated with the mMRC, LCQ and HADS depression score. In the follow-up, changes in FVC%, DLco%, mMRC and LCQ were significantly associated with changes in HRQoL.

Conclusions

HRQoL in both IIP and CTD-ILD patients deteriorates to varying degrees, and the trend suggests that poor HRQoL in these patients is associated with many determinants, primarily dyspnea, cough and depression. Improving HRQoL is the main aim when treating patients living with ILDs.

Oxygen for interstitial lung diseases

PURPOSE OF REVIEW

Supplemental oxygen therapy is prescribed for management of hypoxaemia in patients with interstitial lung disease (ILD). This review summarizes current evidence and implications of the use of supplemental oxygen therapy at home and during exercise training in ILD.

RECENT FINDINGS

Despite the significance of hypoxaemia in patients with ILD, there is a lack of high-quality evidence to guide the use of oxygen therapy in this population. Recent studies suggest that ambulatory oxygen may improve symptoms and health-related quality of life in patients with ILD. Long-term oxygen therapy for resting hypoxaemia in ILD is recommended by international guidelines. Supplemental oxygen during exercise may augment training effects, whereas therapeutic effects of nocturnal oxygen therapy are yet to be evaluated in patients with ILD. Nevertheless, it is important to consider the potential burden imposed by oxygen therapy on patients' daily activities of living.

SUMMARY

Ambulatory oxygen may be considered in ILD patients with exertional hypoxaemia, with long-term oxygen therapy being a standard care for resting hypoxaemia. Trials are currently underway to clarify therapeutic potentials of supplemental oxygen for exertional hypoxaemia and during exercise training in ILD patients, with additional research needed for the evaluation of nocturnal oxygen therapy.

Validation of the King's Brief Interstitial Lung Disease questionnaire in Idiopathic Pulmonary Fibrosis

Background

Health-related quality of life (HRQL) is impaired in patients with idiopathic pulmonary fibrosis (IPF). The King’s Brief Interstitial Lung Disease questionnaire (K-BILD) is a validated measure of HRQL, but no previous studies have focused on the validity of K-BILD in IPF. Moreover, the relationship between K-BILD and dyspnoea or the 6-min walk test (6MWT) has not been assessed. The aim of this study was to validate K-BILD in the largest cohort of patients with IPF to date and assess how K-BILD correlates to dyspnoea and 6MWT.

Methods

Firstly, K-BILD was translated into Danish using validated translation procedures. Consecutive patients with IPF were recruited. At baseline, patients completed K-BILD, the IPF-specific version of St. Georges Respiratory Questionnaire, University of California, San Diego Shortness of Breath Questionnaire (SOBQ) Short Form-36, and pulmonary function tests and 6MWT were performed. After 14 days, K-BILD and Global Rating of Change Scales were completed. Internal consistency, concurrent validity, test-retest reliability and known groups validity were assessed. Analyses were also performed in subgroups of patients with different time since diagnosis.

Results

At baseline, 150 patients with IPF completed the questionnaires, and 139 patients completed the questionnaires after 14 days. K-BILD had a high internal consistency (Cronbach’s α = 0.92). The concurrent validity was strong compared to SOBQ (r = − 0.66) and moderate compared to 6MWT (r = 0.43). Intraclass correlation coefficients (ICC = 0.91) and a Bland Altman plot demonstrated a good reliability. K-BILD was also able to discriminate between patients with different stages of disease (p < 0.002, Δscore > 7.4) and most results were comparable in patients with different time since diagnosis.

Conclusion

K-BILD is a valid and reliable instrument in patients with IPF and in patients with different time since diagnosis. To a major extent, K-BILD scores reflected the impact of dyspnoea on HRQL and the impact of physical functional capacity measured by the 6MWT to a moderate degree. Compared to PFTs alone, K-BILD provides additional information on the burden of living with IPF, and importantly, K-BILD is simple to implement in both research and clinical contexts.

Trial registration

Clinicaltrials.org (NCT02818712) on 30 June 2016.

Diaphragmatic ultrasound findings correlate with dyspnea, exercise tolerance, health-related quality of life and lung function in patients with fibrotic interstitial lung disease

BACKGROUND

Fibrotic interstitial lung disease (FILD) patients are typically dyspneic and exercise-intolerant with consequent impairment of health-related quality of life (HRQoL). Respiratory muscle dysfunction is among the underlying mechanisms of dyspnea and exercise intolerance in FILD but may be difficult to diagnose. Using ultrasound, we compared diaphragmatic mobility and thickening in FILD cases and healthy controls and correlated these findings with dyspnea, exercise tolerance, HRQoL and lung function.

METHODS

We measured diaphragmatic mobility and thickness during quiet (QB) and deep breathing (DB) and calculated thickening fraction (TF) in 30 FILD cases and 30 healthy controls. We correlated FILD cases' diaphragmatic findings with dyspnea, exercise tolerance (six-minute walk test), lung function and HRQoL (St. George's Respiratory Questionnaire).

RESULTS

Diaphragmatic mobility was similar between groups during QB but was lower in FILD cases during DB when compared to healthy controls (3.99 cm vs 7.02 cm; p <  0.01). FILD cases showed higher diaphragm thickness during QB but TF was lower in FILD when compared to healthy controls (70% vs 188%, p <  0.01). During DB, diaphragmatic mobility and thickness correlated with lung function, exercise tolerance and HRQoL, but inversely correlated with dyspnea. Most FILD cases (70%) presented reduced TF, and these patients had higher dyspnea and exercise desaturation, lower HRQoL and lung function.

CONCLUSION

Compared to healthy controls, FILD cases present with lower diaphragmatic mobility and thickening during DB that correlate to increased dyspnea, decreased exercise tolerance, worse HRQoL and worse lung function. FILD cases with reduced diaphragmatic thickening are more dyspneic and exercise-intolerant, have lower HRQoL and lung function.

Effect of pirfenidone on breathlessness in patients with idiopathic pulmonary fibrosis

Dyspnoea is a frequent and debilitating symptom in patients with idiopathic pulmonary fibrosis (IPF) and is reported as the most important factor determining their health-related quality of life (QoL) [1–3]. Previous post hoc analysis of pooled data from IPF clinical trials has shown that a worsening of dyspnoea was particularly likely in patients with more severe versus less severe disease [4]. Interestingly, it has been suggested that patients with more severe disease may experience a greater benefit from pirfenidone on categorical worsening of dyspnoea or death compared with patients with less severe disease [4]. Here, we report the results of a post hoc analysis aiming to further examine the effect of pirfenidone compared with placebo on dyspnoea severity in patients with IPF, including the change from baseline in dyspnoea over 12 months and categorical changes in dyspnoea at 12 months.

New post hoc analysis of IPF clinical trials suggests that treatment with pirfenidone slows the worsening of patient-reported breathlessness over 12 months versus placebo in patients with more advanced disease (GAP stage II/III or FVC <80%)http://bit.ly/2yJyUVT

Clinical validation of the Swedish version of Dyspnoea-12 instrument in outpatients with cardiorespiratory disease

Introduction

Breathlessness is the cardinal symptom in both cardiac and respiratory diseases, and includes multiple dimensions. The multidimensional instrument Dyspnoea-12 has been developed to assess both physical and affective components of breathlessness. This study aimed to perform a clinical validation of the Swedish version of Dyspnoea-12 in outpatients with cardiorespiratory disease.

Methods

Stable outpatients with cardiorespiratory disease and self-reported breathlessness in daily life were recruited from five Swedish centres. Assessments of Dyspnoea-12 were performed at baseline, after 30-90 min and after 2 weeks. Factor structure was tested using confirmatory factor analysis and internal consistency using Cronbach's alpha. Test-retest reliability was analysed using intraclass correlation coefficients (ICCs). Concurrent validity at baseline was evaluated by examining correlations with lung function and several instruments for the assessment of symptoms and health status.

Results

In total, 182 patients were included: with the mean age of 69 years and 53% women. The main causes of breathlessness were chronic obstructive pulmonary disease (COPD; 25%), asthma (21%), heart failure (19%) and idiopathic pulmonary fibrosis (19%). Factor analysis confirmed the expected underlying two-component structure with two subdomains. The Dyspnoea-12 total score, physical subdomain score and affective subdomain scores showed high internal consistency (Cronbach's alpha 0.94, 0.84 and 0.80, respectively) and acceptable reliability after 2 weeks (ICC total scores 0.81, 0.79 and 0.73). Dyspnoea-12 showed concurrent validity with the instruments modified Medical Research Council scale, COPD Assessment Test, European Quality of Life-Five Dimensions-Five levels, the Functional Assessment of Chronic Illness Therapy-Fatigue, the Hospital Anxiety and Depression Scale, and with forced expiratory volume in 1 s in percentage of predicted value. The results were consistent across different cardiorespiratory conditions.

Conclusion

The Dyspnoea-12 is a valid instrument for multidimensional assessment of breathlessness in Swedish patients with cardiorespiratory diseases.

Validation of the COPD Assessment Test (CAT) in patients with idiopathic pulmonary fibrosis

INTRODUCTION

Idiopathic pulmonary fibrosis (IPF) is a chronic disease with high morbidity and mortality. A reliable and manageable questionnaire that assesses patients' quality of life is needed to help to improve the content of clinical consultations. The chronic obstructive pulmonary disease (COPD) Assessment Test (CAT) is used in clinical practice; therefore, the aim of this study was to investigate correlations among the CAT, St. George's Respiratory Questionnaire (SGRQ) and clinical parameters among patients diagnosed with IPF. Methods: A retrospective cohort design was employed in which 87 patients diagnosed with IPF who were receiving treatment at an outpatient clinic were included. Results: The CAT was found to be significantly correlated with SGRQ (p < 0.001). Furthermore, the CAT was significantly correlated with all of the included physiological variables. Conclusions: This add to support the validity of the COPD Assessment test (CAT) as a measure of symptoms in patients with IPF which in clinical practice in combination with dialogue between healthcare professionals and the patient, can help to improve the content of a clinical consultation.

A narrative literature review of palliative care regarding patients with idiopathic pulmonary fibrosis

AIM

The aim of this study was to examine the reported characteristics of extant studies on palliative care for patients with idiopathic pulmonary fibrosis.

DESIGN

Narrative review.

METHODS

A comprehensive search of the following electronic databases in English and Japanese commenced from 2002 - December 2017. Eligibility criteria was determined by the inclusion and exclusion criteria.

RESULTS

Nineteen articles were eligible. The characteristics of palliative care for patients with idiopathic pulmonary fibrosis were symptoms relief, start time of palliative care and palliative care needs of patients and care partners. Also, patients' education of disease management including advanced care planning and developing a palliative care system by the healthcare provider including multidisciplinary professional teams was identified. The care provided was a "care conference" and integrated palliative care was carried out in the patient's home. The majority of the studies were qualitative and retrospective in design. The palliative care system and the development of palliative care were limited.

Impact of novel antifibrotic therapy on patient outcomes in idiopathic pulmonary fibrosis: patient selection and perspectives

Patients with idiopathic pulmonary fibrosis, an incurable, progressive fibrotic interstitial lung disease, suffer an impaired quality of life due to symptoms, resultant functional limitations, and the constraints of supplemental oxygen. Two antifibrotic medications, nintedanib and pirfenidone, are approved for the treatment of idiopathic pulmonary fibrosis. Both medications slow the rate of decline of lung function, but their effect on patient-reported outcomes is not yet fully understood. Nintedanib may slow the decline in health-related quality of life for treated patients. Pirfenidone may slow the progression of dyspnea and improve cough. Patients and providers should participate in shared decision-making when starting antifibrotic therapy, taking into consideration the benefits of treatment in addition to drug-related side effects and dosing schedules. Although antifibrotic therapy may have an impact on health-related quality of life, providers should also focus on comprehensive care of the patient to improve health-related outcomes. This includes a multidisciplinary evaluation, diagnosis and treatment of comorbid medical conditions, and referral to and participation in a pulmonary rehabilitation program.

Morphine for Refractory Dyspnea in Interstitial Lung Disease: A Phase I Study (JORTC-PAL 05)

Background: Dyspnea is common in interstitial lung disease (ILD) patients and often refractory to conventional treatment. Little is known regarding the safety of systemic morphine in ILD patients. Objective: The objective of this study is to evaluate the safety of a single subcutaneous morphine injection and to determine the recommended dose of morphine for alleviating dyspnea in ILD patients. Design: We conducted a dose-escalation Phase I study for investigating the recommended dose of a single subcutaneous morphine injection to alleviate dyspnea in ILD patients. Setting/Subjects: Eligible subjects were ILD inpatients with dyspnea at rest who were refractory to conventional dyspnea treatment. The morphine doses used were 1 mg and 2 mg in cohort 1 and cohort 2, respectively. The primary endpoint was dose-limiting toxicity, which was defined as (1) respiratory depression, that is, 30% reduction of respiratory rate and 10 Torr increase of PaCO₂ compared with baseline; (2) hypotension, that is, 20% reduction of systemic blood pressure compared with baseline and presentation of hypotension-related symptoms; or (3) grade 3, 4, or 5 treatment-emergent adverse events graded by Common Terminology Criteria for Adverse Events (version 4). Results: A total of six patients were enrolled, with three patients each in cohorts 1 and 2. No dose-limiting toxicities were observed; three patients experienced worsened somnolence, but no patients experienced sedation. Conclusion: We conclude that 2 mg of morphine has a tolerable safety profile in ILD patients with dyspnea, and can be tested in further clinical trials.

Pathophysiological mechanisms of exertional breathlessness in chronic obstructive pulmonary disease and interstitial lung disease

PURPOSE OF REVIEW

Breathlessness is a common and distressing symptom in patients with chronic obstructive pulmonary disease (COPD) and fibrotic interstitial lung disease (ILD), particularly during exercise. Effective medical management of exertional breathlessness in people living with COPD and fibrotic ILD is challenging for healthcare providers and requires an understanding of its mechanisms. Thus, in this brief review we summarize recent advances in our understanding of the pathophysiological mechanisms of exertional breathlessness in COPD and fibrotic ILD.

RECENT FINDINGS

The collective results of recent physiological and clinical trials suggest that higher intensity ratings of exertional breathlessness in both COPD and fibrotic ILD compared to healthy control individuals is mechanistically linked to the awareness of greater neural respiratory drive (quantified using inspiratory muscle electromyography) needed to compensate for pathophysiological abnormalities in respiratory mechanics and pulmonary gas exchange efficiency.

SUMMARY

Any therapeutic intervention capable of decreasing intrinsic mechanical loading of the respiratory system and/or increasing pulmonary gas exchange efficiency has the potential to decrease the prevalence and severity of activity-related breathlessness and improve related clinical and patient-reported outcomes (e.g., exercise tolerance and health-related quality of life) by decreasing neural respiratory drive in people with COPD and fibrotic ILD.

The Burden of Illness of Idiopathic Pulmonary Fibrosis: A Comprehensive Evidence Review

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a debilitating condition with significant morbidity and poor survival. Since 2010, there has been increased activity in the development of treatments that aim to delay progression of the disease.

OBJECTIVE

Our study involves a comprehensive review of the literature for evidence on health-related quality of life (HRQoL), healthcare resource use (HCRU) and costs, and an assessment of the burden of illness of the condition.

METHODS

We carried out a systematic literature review (SLR) to identify economic evaluations and HRQoL studies. We searched EMBASE, MEDLINE and MEDLINE In Process for relevant studies from database origins to April 2017. Alongside the presentation of the study characteristics and the available evidence, we carried out a qualitative comparison using reference population estimates for HRQoL and national health expenditure for costs.

RESULTS

Our search identified a total of 3241 records. After removing duplicates and not relevant articles, we analysed 124 publications referring to 88 studies published between 2000 and 2017. Sixty studies were HRQoL and 28 were studies on costs or HCRU. We observed an exponential growth of publications in the last 3-5 years, with the majority of the studies conducted in Europe and North America. Among the HRQoL studies, and despite regional differences, there was some agreement between estimates on the absolute and relative level of HRQoL for patients with IPF compared with the general population. Regarding costs, after adjustments for the cost years and currency, the suggested annual per capita cost of patients with IPF in North America was estimated around US$20,000, 2.5-3.5 times higher than the national healthcare expenditure. Additionally, studies that analysed patients with IPF alongside a matched control cohort suggested a significant increase in resource use and cost.

CONCLUSION

The reviewed evidence indicates that IPF has considerable impact on HRQoL, relative to the general population levels. Furthermore, in studies of cost and resource use, most estimates of the burden were consistent in suggesting an excess cost for patients with IPF compared with a control cohort or the national health expenditure. This confirms IPF as a growing threat for public health worldwide, with considerable impact to the patients and healthcare providers.

End-of-life trajectory of coping and self-care of patients with idiopathic pulmonary fibrosis: A meta-synthesis using meta-ethnography

AIM

This study aimed to extract patient narratives regarding the end-of-life trajectory of their self-care and coping experiences as patients with idiopathic pulmonary fibrosis and to use meta-ethnography to discover common metaphors of their experience in order to inform the development of nursing interventions.

METHODS

A comprehensive search of qualitative research using electronic databases, in English and Japanese, regarding patients with IPF, identified four articles. The meta-ethnography approach followed seven steps, which provided a synthesis of the phenomena from both comparative and cumulative analyses of the qualitative data.

RESULTS

Seven key concepts and metaphors were synthesized: (i) an extended period before obtaining a diagnosis ("Waiting for the other shoe to drop"); (ii) suffering as the pathway of illness ("Gloom and doom"); (iii) the burden of the symptoms and loss of independence ("Staggering under the load"); (iv) acceptance and living with the restrictions of home oxygen therapy ("A double-edged sword"); (v) changes in the family role ("All in the same boat"); (vi) existential suffering ("Dead-end streets and rays of hope"); and (vii) challenges to maintain independent living ("Making the best of it"). Reciprocal, refutational, and line-of-argument modes of synthesis revealed the relationships of the metaphors. Meta-ethnography provided a mechanism for a cumulative knowledge base for necessary nursing interventions.

CONCLUSIONS

The critical nursing interventions were: the relief of symptoms, particularly dyspnea and cough; coordinating lifestyle changes; providing psychological support for living with an illness beginning from the time of diagnosis; and carefully starting the end-of-life discussions with patients and families.

Clinical significance and usefulness of rehabilitation for systemic sclerosis

Systemic sclerosis is a multisystem connective tissue disorder characterized by excessive fibrosis of the skin and internal organs. Impairments in skin, the musculoskeletal system, and respiratory system require rehabilitation therapy because they may lead to disabilities and reduce the quality of life in daily activities. Rehabilitation for systemic sclerosis mainly comprises two distinct approaches that include local and global rehabilitation. Local rehabilitation is applied to maintain and/or improve hand and face functions, while global rehabilitation includes aerobic and resistance exercises. Although few high-quality randomized clinical trials have been conducted to date, previous studies indicated the effectiveness of rehabilitation therapy for decreasing local and systemic disabilities, resulting in improved quality of life. Rehabilitation for systemic sclerosis needs to be regularly and constantly performed at home as well as in hospitals. Physicians involved in the treatment of systemic sclerosis need to consider rehabilitation, and skilled physiotherapists and occupational therapists also play a crucial role in evaluating and treating systemic sclerosis patients.

Physical activity and activity space in patients with pulmonary fibrosis not prescribed supplemental oxygen

Background

Patients with pulmonary fibrosis (PF) have impaired quality of life, and research suggests that dyspnea and physical activity are primary drivers. As PF progresses, some patients notice the disease “shrinks their worlds”. The objective of this study is to describe movement (both physical activity and activity space) in a cohort of patients with PF of various etiologies who have not been prescribed supplemental oxygen (O₂).

Methods

Subjects with PF not on supplemental O₂ during the day were enrolled from across the U.S. from August 2013 to October 2015. At enrollment, each subject completed questionnaires and, for seven consecutive days, wore an accelerometer and GPS tracker.

Results

One hundred ninety-four subjects had a confirmed diagnosis of PF and complete, analyzable GPS data. The cohort was predominantly male (56%), Caucasian (95%) and had idiopathic pulmonary fibrosis (30%) or connective tissue disease related-PF (31%). Subjects walked a median 7497 (interquartile range [IQR] 5766-9261) steps per day. Steps per day were correlated with symptoms and several quality of life domains. In a model controlling for age, body mass index, wrist- (vs. waist) worn accelerometer and percent predicted diffusing capacity (DLCO%), fatigue (beta coefficient = −51.5 ± 11.7, p < 0.0001) was an independent predictor of steps per day (model R²=0.34).

Conclusions

Patients with PF, who have not been prescribed O₂ for use during the day, have wide variability in their mobility. Day-to-day physical activity is related to several domains that impact quality of life, but GPS-derived activity space is not. Wearable data collection devices may be used to determine whether and how therapeutic interventions impact movement in PF patients.

Trial registration

NCT01961362. Registered 9 October, 2013.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0495-2) contains supplementary material, which is available to authorized users.

Tracking dyspnea up to supplemental oxygen prescription among patients with pulmonary fibrosis

BACKGROUND

Dyspnea is the hallmark symptom of pulmonary fibrosis. Supplemental oxygen (O₂) is prescribed to many patients with pulmonary fibrosis in hopes of alleviating dyspnea and improving physical functioning. We used response data from the University of California San Diego Shortness of Breath Questionnaire (UCSD) which was administered monthly in the context of a longitudinal, observational study to plot a rich trajectory for dyspnea over time in patients with pulmonary fibrosis. We used other data from that study to identify clinical predictors of being prescribed O₂ and to provide additional information for how UCSD scores could be used for clinical purposes.

METHODS

We used linear mixed-effects models and multivariate Cox proportional hazards to model change in dyspnea scores over time and to identify significant predictors of time-to-O₂-prescription among a pool of clinically-meaningful candidate variables. In the longitudinal study, all decisions, including whether or not to prescribe O₂, were made by subjects' treating physicians, not members of the research team.

RESULTS

One-hundred ninety-four subjects with pulmonary fibrosis completed more than one UCSD or were prescribed O₂ at some point during the follow-up period (N = 43). Twenty-eight of the 43 had analyzable, longitudinal data and contribute data to the longitudinal UCSD analyses. All 43 were included in the time-to-O₂-prescription analyses. Subjects prescribed O₂ had more severe dyspnea at enrollment (38.4 ± 19.6 vs. 22.6 ± 18.7, p < 0.0001) and a steeper increase in UCSD scores over time (slope = 1.18 ± 0.53 vs. 0.24 ± 0.09 points per month, p = 0.02) than subjects not prescribed O₂. Controlling for baseline UCSD score and FVC%, subjects with a clinical summary diagnosis of idiopathic pulmonary fibrosis (IPF) were far more likely to be prescribed O₂ than subjects with other forms of pulmonary fibrosis (hazard ratio = 4.85, (2.19, 10.74), p < 0.0001).

CONCLUSIONS

Baseline dyspnea and rise in dyspnea over time predict timing of O₂ prescription. Accounting for disease severity, patients with IPF are more likely than patients with other forms of pulmonary fibrosis to be prescribed O₂. UCSD scores provide clinically useful information; frequent administration could yield timely data on changes in disease status in patients with pulmonary fibrosis.

TRIAL REGISTRATION

The longitudinal study is registered on ClinicalTrials.gov ( NCT01961362 ). Registered October 9, 2013.

Evaluation of Skeletal Muscle Function in Lung Transplant Candidates

BACKGROUND

Lung transplantation (LTx) is offered to older and more complex patients who may be at higher risk of skeletal muscle dysfunction, but the clinical implications of this remain uncertain. The study aims were to characterize deficits in skeletal muscle mass, strength and physical performance, and examine the associations of these deficits with clinical outcomes.

METHODS

Fifty LTx candidates (58% men; age, 59 ± 9 years) were prospectively evaluated for skeletal muscle deficits: muscle mass using bioelectrical impedance, quadriceps, respiratory muscle and handgrip strength, and physical performance with the Short Physical Performance Battery. Comparisons between number of muscle deficits (low muscle mass, quadriceps strength and physical performance) and 6-minute walk distance (6MWD), London Chest Activity of Daily Living Questionnaire, and quality of life were assessed using one-way analysis of variance. Associations with pretransplant and posttransplant delisting/mortality, hospital duration, and 3-month posttransplant 6MWD were evaluated using Fisher exact test and Spearman correlation.

RESULTS

Deficits in quadriceps strength (n = 27) and physical performance (n = 24) were more common than muscle mass (n = 8). LTx candidates with 2 or 3 muscle deficits (42%) compared with those without any deficits (26%) had worse 6MWD = -109 m (95% confidence interval [CI], -175 to -43), London Chest Activity of Daily Living Questionnaire = 18 (95% CI, 7-30), and St. George's Activity Domain = 12 (95% CI, 2-21). Number of muscle deficits was associated with posttransplant hospital stay (r = 0.34, P = 0.04), but not with delisting/mortality or posttransplant 6MWD.

CONCLUSIONS

Deficits in quadriceps muscle strength and physical performance are common in LTx candidates and further research is needed to assess whether modifying muscle function pretransplant can lead to improved clinical outcomes.

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.

Factors affecting dyspnea after the 6-minute walk test in idiopathic pulmonary fibrosis patients presenting with exercise-induced hypoxemia

[Purpose] The current study aimed to investigate factors affecting dyspnea after the 6-minute walk test (6MWT) in idiopathic pulmonary fibrosis (IPF) patients presenting with hypoxemia. [Subjects and Methods] The subjects were IPF out-patients with stable symptoms whose percutaneous arterial oxygen saturation fell to 88% during the 6MWT test. Quadriceps force, 6-minute walk distance (6MWD), dyspnea after the 6MWT, and leg fatigue (LF) were evaluated as exercise-related variables. [Results] The subjects were 14 patients (mean age 73.6 ± 6.3 years) classed based on the modified Medical Research Council dyspnea scale as 0 for 2 patients, 1 for 6 patients, and 2 for 6 patients, indicating that the patients were comparatively mild cases. Mean 6MWD was 408.9 ± 102.4 m, and dyspnea after the 6MWT and LF were 3.0 ± 1.4 and 1.5 ± 1.5, respectively. Dyspnea after the 6MWT was correlated with vital capacity (VC), forced vital capacity, and LF. Stepwise multiple regression analysis identified VC and LF as factors significantly affecting dyspnea after the 6MWT. [Conclusion] The results of this study demonstrated that it is necessary to evaluate both pulmonary function and LF in IPF patients presenting with exercise-induced hypoxemia and exertional dyspnea.

Health related quality of life in patients with idiopathic pulmonary fibrosis in clinical practice: insights-IPF registry

Background

The INSIGHTS-IPF registry provides one of the largest data sets of clinical data and self-reported patient related outcomes including health related quality of life (QoL) on patients with idiopathic pulmonary fibrosis (IPF). We aimed to describe associations of various QoL instruments between each other and with patient characteristics at baseline.

Methods

Six hundred twenty-three IPF patients with available QoL data (St George’s Respiratory Questionnaire SGRQ, UCSD Shortness-of-Breath Questionnaire SoB, EuroQol visual analogue scale and index EQ-5D, Well-being Index WHO-5) were analysed. Mean age was 69.6 ± 8.7 years, 77% were males, mean disease duration 2.0 ± 3.3 years, FVC pred was 67.5 ± 17.8%, DL_CO pred 35.6 ± 17%.

Results

Mean points were SGRQ total 48.3, UCSD SoB 47.8, EQ-5D VAS 66.8, and WHO-5 13.9. These instruments had a high or very high correlation (exception WHO-5 to EQ-5D VAS with moderate correlation). On bivariate analysis, QoL by SGRQ total was statistically significantly associated with clinical symptoms (NYHA; p < 0.001), number of comorbidities (p < 0.05), hospitalisation rate (p < 0.01) and disease severity (as measured by GAP score, CPI, FVC and 6-min walk test; p < 0.05 each). Multivariate analyses showed a significant association between QoL (by SGRQ total) and IPF duration, FVC, age, NYHA class and indication for long-term oxygen treatment.

Conclusions

Overall, IPF patients under real-life conditions have lower QoL compared to those in clinical studies. There is a meaningful relationship between QoL and various patient characteristics.

Trial registration

The INSIGHTS-IPF registry is registered at Clinicaltrials.gov (NCT01695408).

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-017-0621-y) contains supplementary material, which is available to authorized users.

Dyspnoea-12: a translation and linguistic validation study in a Swedish setting

BACKGROUND

Dyspnoea consists of multiple dimensions including the intensity, unpleasantness, sensory qualities and emotional responses which may differ between patient groups, settings and in relation to treatment. The Dyspnoea-12 is a validated and convenient instrument for multidimensional measurement in English. We aimed to take forward a Swedish version of the Dyspnoea-12.

METHODS

The linguistic validation of the Dyspnoea-12 was performed (Mapi Language Services, Lyon, France). The standardised procedure involved forward and backward translations by three independent certified translators and revisions after feedback from an in-country linguistic consultant, the developerand three native physicians. The understanding and convenience of the translated version was evaluated using qualitative in-depth interviews with five patients with dyspnoea.

RESULTS

A Swedish version of the Dyspnoea-12 was elaborated and evaluated carefully according to international guidelines. The Swedish version, 'Dyspné-12', has the same layout as the original version, including 12 items distributed on seven physical and five affective items. The Dyspnoea-12 is copyrighted by the developer but can be used free of charge after permission for not industry-funded research.

CONCLUSION

A Swedish version of the Dyspnoea-12 is now available for clinical validation and multidimensional measurement across diseases and settings with the aim of improved evaluation and management of dyspnoea.

Ambulatory oxygen in fibrotic lung disease (AmbOx): study protocol for a randomised controlled trial

BACKGROUND

Fibrotic interstitial lung diseases (ILDs) are chronic and often progressive conditions resulting in substantial morbidity and mortality. Shortness of breath, a symptom often linked to oxygen desaturation on exertion, is tightly linked to worsening quality of life in these patients. Although ambulatory oxygen is used empirically in their treatment, there are no ILD-specific guidelines on its use. To our knowledge, no studies are available on the effects of ambulatory oxygen on day-to-day life in patients with ILD.

METHODS/DESIGN

Ambulatory oxygen in fibrotic lung disease (AmbOx) is a multicentre, randomised controlled crossover trial (RCT) funded by the Research for Patient Benefit Programme of the National Institute for Health Research. The trial will compare ambulatory oxygen used during daily activities with no ambulatory oxygen in patients with fibrotic lung disease whose oxygen saturation (SaO₂) is ≥94% at rest, but drops to ≤88% on a 6-min Walk Test. The randomised controlled trial (RCT) will evaluate the effects on health status (measured by the King's Brief ILD Questionnaire: K-BILD) of ambulatory oxygen used at home, at an optimal flow rate determined by titration at screening visit, and administered for a 2-week period, compared to 2 weeks off oxygen. Key secondary outcomes will include breathlessness on activity scores, as measured by the University of California San Diego Shortness of Breath Questionnaire, global patient assessment of change scores, as well as quality of life scores (St George's Respiratory Questionnaire), anxiety and depression scores (Hospital Anxiety and Depression Scale), activity markers measured by SenseWear Armbands, pulse oximetry measurements, patient-reported daily activities, patient- and oxygen company-reported oxygen cylinder use. The study also includes a qualitative component and will explore in interviews patients' experiences of the use of a portable oxygen supply and trial participation in a subgroup of 20 patients and carers.

DISCUSSION

This is the first RCT of the effects of ambulatory oxygen during daily life on health status and breathlessness in fibrotic lung disease. The results generated should provide the basis for setting up ILD-specific guidelines for the use of ambulatory oxygen.

TRIAL REGISTRATION

National Clinical Trials Registry, identifier: NCT02286063 . Registered on 8 October 2014 (retrospectively registered).

Low-Dose Morphine for Dyspnea in Terminally Ill Patients with Idiopathic Interstitial Pneumonias

BACKGROUND

Dyspnea is highly prevalent in patients with idiopathic interstitial pneumonias (IIPs).

OBJECTIVE

The objective of this study is to examine the effectiveness and safety of continuous subcutaneous morphine for dyspnea in terminally ill IIP patients.

SETTING/SUBJECTS

We retrospectively reviewed cases of terminally ill IIP patients who received continuous subcutaneous morphine for dyspnea.

MEASUREMENTS

We reviewed dyspnea severity measured using numerical rating scale (NRS) and respiratory rate (RR) before and two and four hours after morphine initiation. We conducted subgroup analyses of patients with and without noninvasive positive pressure ventilation (NPPV).

RESULTS

Twenty-five patients were included in this study. Median morphine dose at morphine initiation and two and four hours after treatment was 0.25, 0.25, and 0.5 mg/hour, respectively. Dyspnea NRS decreased significantly four hours after (mean ± standard deviation: 5.32 ± 2.58, p = 0.04) but not two hours (5.52 ± 2.43, p = 0.11) after morphine initiation compared with baseline (7.08 ± 2.33). RR did not change significantly either two or four hours after treatment compared with baseline. The median survival after morphine initiation was 47 hours. Patients who were not using NPPV showed significantly improved dyspnea both two and four hours after treatment compared with baseline, although patients who used NPPV showed no significant improvement with morphine. RR did not significantly change in either subgroup.

CONCLUSIONS

Morphine might improve dyspnea in terminally ill IIP patients without decrease in RR.

The association between health-related quality of life and disease progression in idiopathic pulmonary fibrosis: a prospective cohort study

Background and objective: Generally, a disease-specific health-related quality of life (HRQOL) measurement is more useful than generic measures in assessing perceived physical and mental health characteristic of a particular disease. The idiopathic pulmonary fibrosis (IPF)-specific version of St. George’s Respiratory Questionnaire (SGRQ-I) has been recently developed for patients with IPF. We proposed to evaluate associations between the SGRQ-I and other clinical indices, as well as its prognostic value in patients with IPF. Methods: Fifty-two patients with IPF were recruited in this prospective cohort study. HRQOL was assessed using the SGRQ-I and the Medical Outcomes Study 36-item Short Form, dyspnea using the modified Medical Research Council (mMRC) dyspnea scale, and psychological status using the Hospital Anxiety and Depression Scale (HADS). We then evaluated the relationship between the SGRQ-I and other clinical measures, as well as one-year clinical deterioration defined as a hospital admission due to respiratory exacerbation or all-cause death. Results: Stepwise multiple-regression analyses revealed that the mMRC dyspnea scale, the HADS anxiety or depression, and minimum oxygen saturation during a six-minute walk test significantly contributed to the Total and three components of the SGRQ-I. In multivariate Cox proportional-hazards analyses, the Total score of SGRQ-I predicted clinical deterioration independent of forced vital capacity, the six-minute walk distance, or partial pressure of arterial oxygen on room air. Conclusions: The SGRQ-I is a multidisciplinary instrument representing physical, functional and psychological impairments in patients with IPF. The SGRQ-I is a significant predictor of short-term disease progression independent of physiological measurements. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 226-235)

Depression Is Significantly Associated with the Health Status in Patients with Idiopathic Pulmonary Fibrosis

Objective Depression is reported to be relatively common in idiopathic pulmonary fibrosis (IPF) patients. Thus far, however, whether or not depression independently determines the health-related quality of life (HRQOL) has not been evaluated exclusively in IPF patients. We designed this study to identify independent determinants of the St. George' s Respiratory Questionnaire (SGRQ) score among various factors, including a depression scale, in IPF patients. Methods We retrospectively analyzed consecutive subjects with IPF who completed a systematic evaluation including pulmonary function tests, PaO₂ at rest, 6-minute walk test (6MWT), SGRQ, Baseline Dyspnea Index (BDI), and Hospital Anxiety and Depression Scale (HADS). All eligible patients in the present study had newly diagnosed IPF and had not received any prior treatments, such as antidepressants, pirfenidone, corticosteroids, immunosuppressants, or long-term oxygen therapy. Results The 121 patients with IPF included 99 men. On the SGRQ, mild to moderate disturbance was observed in the total and each component score. According to the HADS, 27 patients (22.3%) had borderline or definite depression. In a univariate regression analysis, the forced vital capacity (FVC), diffusion capacity of carbon monoxide (DLco), PaO₂ at rest, BDI, HADS for Anxiety (HADS-A) and Depression (HADS-D), 6-minute walk distance (6MWD), and lowest SpO₂ during the 6MWT were significantly correlated with the SGRQ total score. In a stepwise multiple regression model, BDI, 6MWD, and HADS-D were selected as independent determinants of the total SGRQ score. The total variance in this model was 59% (p<0.001). Conclusion We concluded that depression was a significant determinant of the HRQOL or health status in patients with IPF.

Psychometric properties of the St George's Respiratory Questionnaire in patients with idiopathic pulmonary fibrosis

The St George's Respiratory Questionnaire (SGRQ) has been used to measure health-related quality of life (HRQoL) in patients with idiopathic pulmonary fibrosis (IPF).

This analysis evaluated the psychometric properties of the SGRQ using data from 428 patients with IPF who participated in a 12-month, randomised, placebo-controlled phase II trial of nintedanib.

Internal consistency (Cronbach's α) was 0.91 for SGRQ total and >0.70 for domain scores. Test–retest reliability (intraclass correlation coefficients) was 0.77, 0.77, 0.69 and 0.66 for SGRQ total, activity, impact and symptoms scores, respectively. Construct validity of SGRQ total and domain scores was supported by weak to moderate cross-sectional correlations with the Medical Research Council dyspnoea scale (0.32–0.55), 6-min walk test distance (−0.25– −0.34), percentage predicted forced vital capacity (−0.11– −0.15) and measures of gas exchange (−0.26–0.03). There was some evidence that the SGRQ total score was sensitive to detecting change.

The reliability, construct validity and responsiveness of the SGRQ in patients with IPF suggest that this is an acceptable measure of HRQoL in patients with IPF.