Pulmonary rehabilitation at a time of social distancing: prime time for tele-rehabilitation?

A survey exploring the needs, preferences, and challenges of the key stakeholders for participating in and developing pulmonary rehabilitation in Pune, India

Considering a huge burden of chronic respiratory diseases (CRDs) in India, there is a need for locally relevant Pulmonary rehabilitation (PR) services. This cross-sectional survey was aimed to explore the interest, needs and challenges among various stakeholders for PR in Pune city, India. At the outpatient respiratory medicine department of a multi-speciality hospital in Pune, India, 403 eligible people with CRDs were invited to participate in the survey, of which 370 (92%) responded and agreed to participate. (220 males, mean ± SD age 56 ± 15 years). Out of the 370, 323 (87%) people with CRDs were keen to attend PR. In a multiple selection question, there was inclination towards paper-based manuals home-based (70%) and web-based (84%) programs. 207 healthcare providers (HCPs), including physicians, pulmonologists and physiotherapists involved in the care of people living with CRDs across Pune city were invited to participate in the survey. Out of the 207, (80%) of the HCPs believed that PR was an effective management strategy and highlighted the lack of information on PR and need for better understanding of PR (48%) and its referral process. The surveyed stakeholders are ready to take up PR, identifying specific needs around further knowledge of PR, modes of delivery, and referral processes, that could potentially feed the development of relevant PR programs in the Indian healthcare settings.

Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

Background: Despite the known benefits of pulmonary rehabilitation (PR) for patients with chronic respiratory disease, this treatment is underused. Evidence-based guidelines should lead to greater knowledge of the proven benefits of PR, highlight the role of PR in evidence-based health care, and in turn foster referrals to and more effective delivery of PR for people with chronic respiratory disease. Methods: The multidisciplinary panel formulated six research questions addressing PR for specific patient groups (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) and models for PR delivery (telerehabilitation, maintenance PR). Treatment effects were quantified using systematic reviews. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel made the following judgments: strong recommendations for PR for adults with stable COPD (moderate-quality evidence) and after hospitalization for COPD exacerbation (moderate-quality evidence), strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence), conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence), strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence), and conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence). Conclusions: These guidelines provide the basis for evidence-based delivery of PR for people with chronic respiratory disease.

A Systematic Review of Telemedicine-Driven Pulmonary Rehabilitation after the Acute Phase of COVID-19

The acute phase of COVID-19 often leaves patients with persistent pulmonary deficits. Pulmonary Rehabilitation (PR) has been recommended as an essential part of post-acute COVID-19 management. In light of the global pandemic, telerehabilitation has been increasingly employed to deliver PR. This systematic review aimed to evaluate the effectiveness of telemedicine-driven PR in patients recovering from the acute phase of COVID-19, assessing variations in telerehabilitation practices and identifying the degree of change in mental health, physical health, quality of life, and lung function. A systematic search was conducted across PubMed, Web of Science, Cochrane, and Scopus up until April 2023. Studies focusing on telerehabilitation in PR for post-acute COVID-19 patients with outcomes including pulmonary function, exercise capacity, and quality of life were included after careful assessment of this study's protocol. The selection process involved careful scrutiny of abstracts and full texts, and the quality assessment was performed using the National Heart, Lung, and Blood Institute (NHLBI) tool. Seven studies, published between 2021 and 2022, involving a total of 412 patients, were included. The evaluated telerehabilitation programs stretched between 4 and 10 weeks, involving a mobile app or video connection with the patient, integrating a mix of aerobic and resistance training, breathing exercises, functional activities, and muscle strengthening. Findings revealed that telemedicine-driven PR significantly improved physical health, measured by the step test score (73 vs. 71), 6MWD (30.2 vs. 17.1) and BPAQ, mental health evaluated by SF-12 (6.15 vs. 4.17) and PHQ-4, quality of life measured by the SF-12 (7.81 vs. 3.84), SGRQ (31.5 vs. 16.9), and CAT scores, and some parameters of pulmonary function in post-acute COVID-19 patients (mMRC, STST, and MVV). This review substantiates the potential of telemedicine-driven PR to improve various health outcomes in post-acute COVID-19 patients. The findings underscore the importance of integrating telerehabilitation into the management of post-acute COVID-19 and call for further exploration of its long-term effects, cost-effectiveness, and best practices.

Telerehabilitation in pulmonary diseases

PURPOSE OF REVIEW

Telerehabilitation is an alternative delivery model for pulmonary rehabilitation, an evidence-based nonpharmacological intervention, in people with chronic pulmonary disease. This review synthesizes current evidence regarding the telerehabilitation model for pulmonary rehabilitation with an emphasis on its potential and implementation challenges, as well as the clinical experiences from the COVID-19 pandemic.

RECENT FINDINGS

Different models of telerehabilitation for delivering pulmonary rehabilitation exist. Current studies comparing telerehabilitation to centre-based pulmonary rehabilitation primarily focus on the evaluation in people with stable chronic obstructive pulmonary disease, which demonstrated equivalent improvements in exercise capacity, health-related quality of life and symptoms with improved programme completion rates. Although telerehabilitation may improve access to pulmonary rehabilitation by addressing travel burden, improving schedule flexibility and geographic disparity, there are challenges of ensuring satisfaction of healthcare interactions and delivering core components of initial patient assessment and exercise prescription remotely.

SUMMARY

Further evidence is needed on the role of telerehabilitation in various chronic pulmonary diseases, as well as the effectiveness of different modalities in delivering telerehabilitation programmes. Economic and implementation evaluation of currently available and emerging models of telerehabilitation in delivering pulmonary rehabilitation are needed to ensure sustainable adoption into clinical management for people with chronic pulmonary disease.

Implementation of offering choice of pulmonary rehabilitation location to people with COPD: a protocol for the process evaluation of a cluster randomised controlled trial

BACKGROUND

Pulmonary rehabilitation (PR) is a core component of management people with chronic obstructive pulmonary disease (COPD); yet, people with COPD face significant barriers to attending centre-based PR programs. The emergence of new models of PR, remotely delivered directly into people's homes, has the potential to improve rehabilitation access and completion by providing patients with a choice of rehabilitation location (centre or home). However, offering patients a choice of rehabilitation model is not usual practice. We are undertaking a 14-site cluster randomised controlled trial to determine whether offering choice of PR location improves rehabilitation completion rates resulting in reduced all-cause unplanned hospitalisation over 12 months. The aim of this paper is to describe the protocol for the process evaluation of the HomeBase2 trial.

METHODS

A mixed methods process evaluation, to be undertaken in real time, has been developed in accordance with UK Medical Research Council (MRC) recommendations on process evaluation of complex interventions. This protocol describes the intended use of two theoretical frameworks (RE-AIM framework (Reach; Effectiveness; Adoption; Implementation; Maintenance) and Theoretical Domains Framework (TDF)) to synthesise findings and interpret data from a combination of qualitative (semi-structured interviews) and quantitative (questionnaires, clinical outcome data, intervention fidelity) methodologies. Data will be collected at an intervention, patient and clinician level. Qualitative and quantitative data will be used to derive context-specific potential and actual barriers and facilitators to offering patients choice of rehabilitation location. Acceptability and sustainability of the intervention will be evaluated for future scale-up.

DISCUSSION

The process evaluation described here will appraise the clinical implementation of offering a choice of rehabilitation program location for people with COPD. It will identify and evaluate key factors for future scale-up and sustainability and scale-up of offering choice of pulmonary rehabilitation program model for people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04217330 Registration date: January 3 2020.

Perceived Autonomy Support in Telerehabilitation by People With Chronic Respiratory Disease: A Mixed Methods Study

BACKGROUND

Autonomy-supportive health environments can assist patients in achieving behavior change and can influence adherence positively. Telerehabilitation may increase access to rehabilitation services, but creating an autonomy-supportive environment may be challenging.

RESEARCH QUESTION

To what degree does telerehabilitation provide an autonomy-supportive environment? What is the patient experience of an 8-week telerehabilitation program?

STUDY DESIGN AND METHODS

Individuals undertaking telerehabilitation or center-based pulmonary rehabilitation within a larger randomized controlled equivalence trial completed the Health Care Climate Questionnaire (HCCQ; short form) to assess perceived autonomy support. Telerehabilitation participants were invited 1:1 to undertake semistructured interviews. Interviews were transcribed verbatim and coded thematically to identify major themes and subthemes.

RESULTS

One hundred thirty-six participants (n = 69 telerehabilitation) completed the HCCQ and 30 telerehabilitation participants (42%) undertook interviews. HCCQ summary scores indicated that participants strongly agreed that the telerehabilitation environment was autonomy supportive, which was similar to center-based participants (HCCQ summary score, P = .6; individual HCCQ items, P ≥ .3). Telerehabilitation interview data supported quantitative findings identifying five major themes, with subthemes, as follows: (1) making it easier to participate in pulmonary rehabilitation, because telerehabilitation was convenient, saved time and money, and offered flexibility; (2) receiving support in a variety of ways, including opportunities for peer support and receiving an individualized program guided by expert staff; (3) internal and external motivation to exercise as a consequence of being in a supervised group, seeing results for effort, and being inspired by others; (4) achieving success through provision of equipment and processes to prepare and support operation of equipment and technology; and (5) after the rehabilitation program, continuing to exercise, but dealing with feelings of loss.

INTERPRETATION

Telerehabilitation was perceived as an autonomy-supportive environment, in part by making it easier to undertake pulmonary rehabilitation. Support for behavior change, understanding, and motivation were derived from clinicians and patient-peers. The extent to which autonomy support translates into ongoing self-management and behavior change is not clear.

TRIAL REGISTRY

ClinicalTrials.gov; No.: ACTRN12616000360415; URL: www.

CLINICALTRIALS

gov.

From Inception to Implementation: Strategies for Setting Up Pulmonary Telerehabilitation

Background

The emergence of innovative technology-enabled models of care is an opportunity to support more efficient ways of organizing and delivering healthcare services and improve the patient experience. Pulmonary telerehabilitation started as a promising area of research and became a strategic pandemic response to patients' decreased accessibility to rehabilitation care. Still, in the pre-COVID-19 era, we conducted a participatory study aiming to develop strategies for setting up pulmonary telerehabilitation as a person-centered digitally-enabled model of care.

Methods

We performed operational participatory research between June 2019 and March 2020 with the engagement of all stakeholders involved in the implementation of pulmonary telerehabilitation, including 14 people with Chronic Obstructive Pulmonary Disease. Patients were assessed subjectively and objectively pre and post a 3-month pulmonary rehabilitation program including exercise and education, which started in a face-to-face hospital setting during the first month and continued as a home-based, remotely supervised exercise training intervention.

Results

Five major groups of requirements targeted operational strategies for setting up pulmonary telerehabilitation: (1) pulmonary rehabilitation core principles, (2) quality and security standards, (3) technological functionality, (4) home environment appropriateness, and (5) telesetting skills. There was a statistical significance in the median change in the CAT score from 15.5 to 10.5 (p = 0.004) and in the PRAISE score from 49.5 to 53.0 (p = 0.006). Patients' mean levels of satisfaction regarding rehabilitation goals achievements were 88.1 ± 8.6% and the mean levels of satisfaction regarding the telerehabilitation experienced as a model of care were 95.4% ± 6.3%.

Conclusions

The success of telerehabilitation implementation was grounded on stakeholder engagement and targeted strategies for specific setup requirements, achieving patients' high satisfaction levels. Such operational experiences should be integrated into the redesigning of upgraded telerehabilitation programs as part of the solution to improve the effectiveness, accessibility, and resilience of health systems worldwide.

Telerehabilitation improves physical function and reduces dyspnoea in people with COVID-19 and post-COVID-19 conditions: a systematic review

QUESTION

How effective and safe is telerehabilitation for people with COVID-19 and post-COVID-19 conditions?

DESIGN

Systematic review of randomised trials.

PARTICIPANTS

People with COVID-19 and post-COVID-19 conditions.

INTERVENTION

Any type of telerehabilitation.

OUTCOME MEASURES

Satisfaction, quality of life, adverse events, adherence to telerehabilitation, dyspnoea, functional performance, readmissions, mortality, pulmonary function and level of independence.

RESULTS

Database searches retrieved 2,962 records, of which six trials with 323 participants were included in the review. Breathing exercises delivered via telerehabilitation improved 6-minute walk distance (MD 101 m, 95% CI 61 to 141; two studies), 30-second sit-to-stand test performance (MD 2.2 repetitions, 95% CI 1.5 to 2.8; two studies), Multidimensional Dyspnoea-12 questionnaire scores (MD -6, 95% CI -7 to -5; two studies) and perceived effort on the 0-to-10 Borg scale (MD -2.8, 95% CI -3.3 to -2.3; two studies), with low certainty of evidence. Exercise delivered via telerehabilitation improved 6-minute walk distance (MD 62 m, 95% CI 42 to 82, four studies), 30-second sit-to-stand test performance (MD 2.0 repetitions, 95% CI 1.3 to 2.7; two studies) and Multidimensional Dyspnoea-12 scores (MD -1.8, 95% CI -2.5 to -1.1; one study), with low certainty of evidence. Adverse events were almost all mild or moderate and occurred with similar frequency in the telerehabilitation group (median 0 per participant, IQR 0 to 2.75) as in the control group (median 0 per participant, IQR 0 to 2); Hodges-Lehmann median difference 0 (95% CI 0 to 0), with low certainty of evidence.

CONCLUSION

Telerehabilitation may improve functional capacity, dyspnoea, performance and physical components of quality of life and does not substantially increase adverse events.

REGISTRATION

PROSPERO CRD42021271049.

Pulmonary rehabilitation in a postcoronavirus disease 2019 world: feasibility, challenges, and solutions

PURPOSE OF REVIEW

Pulmonary rehabilitation improves clinical outcomes in patients with chronic obstructive pulmonary disease (COPD). Traditional centre-based (in-person) pulmonary rehabilitation was largely shut down in response to the COVID-19 pandemic, forcing many centres to rapidly shift to remote home-based programs in the form of telerehabilitation (tele-pulmonary rehabilitation). This review summarizes the recent evidence for the feasibility and effectiveness of remote pulmonary rehabilitation programs, and their implications for the delivery of pulmonary rehabilitation in a postpandemic world.

RECENT FINDINGS

A number of innovative adaptations to pulmonary rehabilitation in response to COVID-19 have been reported, and the evidence supports tele-pulmonary rehabilitation as a viable alternative to traditional centre-based pulmonary rehabilitation. However, these studies also highlight the challenges that must be surmounted in order to see its widespread adoption.

SUMMARY

There are outstanding questions regarding the optimal model for tele-pulmonary rehabilitation. In the post-COVID-19 world, a 'hybrid' model may be more desirable, with some components held in person and others via telehealth technology. This would be determined by the infrastructure and expertise of individual centres, and the needs of their patients. In order to achieve a truly patient-centred pulmonary rehabilitation program, high-quality studies addressing these outstanding questions, as well as multidisciplinary collaboration, are required.

Pulmonary rehabilitation in Lebanon "What do we have"? A national survey among chest physicians

Background

Pulmonary rehabilitation (PR) is not very often used by physicians in Lebanon despite evidence on its positive effects on health-related quality of life.

Aim

This study assesses the knowledge, attitudes and practices of PR among physicians in Lebanon. In addition, the study identifies the main barriers to access to PR according to chest physicians. Insight into these issues will help to increase awareness about the need for PR programs and can contribute to designing such programs in the country.

Methods

A survey was conducted during the regional conference of the Lebanese Pulmonary Society. One week after the initial survey, the survey questionnaire was sent by email to all chest physicians who were registered with the Lebanese Pulmonary Society but did not attend the conference. A 25-item questionnaire was used to collect information on PR.

Results

Responses were analyzed using descriptive statistics. The response rate was 40%. Results show that only one-third of Lebanese chest physicians have good knowledge about the nature and multidisciplinary content of PR. Physicians generally support the current “Pulmonary Rehabilitation Program” in Beirut. Key barriers found are the lack of referral, lack of motivation by patients due to their health, cost of care and lack of qualified health care specialists in Lebanon.

Conclusion

Absence of awareness and education about PR among healthcare providers plays an important role in increasing access to the “Pulmonary Rehabilitation Program”. Awareness campaigns and education for physicians, health care professionals and patients should be considered to increase PR in the country.

The Accessibility, Feasibility, Safety of a Standardized Community-Based Tele-Pulmonary Rehab Program for COPD: A 3-Year Real-World Prospective Study

RATIONALE

Few individuals with COPD are able to access pulmonary rehabilitation (PR) despite its importance. Barriers include increased travel time and lack of resources. Tele-PR has been proposed as a novel solution to overcome such barriers and improve access.

OBJECTIVE

Our study aimed to provide information on implementing a novel province-wide standardized community-based tele-PR program and determine its accessibility, feasibility and safety. Secondary objectives examined the effectiveness of tele-PR compared to standard-PR and if clinical improvements were sustained over time.

METHODS

We conducted a concurrent prospective study of people with COPD enrolled in either standard-PR or community-based tele-PR at satellite centers between January 2017 and January 2020. To determine accessibility and feasibility, we recorded the number of participating centers meeting eligibility criteria, centers remaining in the program over 3 years, number of delivered programs and major adverse events. Participants had a 6MWT and CAT at baseline, immediately post-PR and at 1,3,6 and 12 months. Descriptive analysis was carried out for accessibility, feasibility and safety. Mixed-effects random models were used to estimate change in 6MWT and CAT.

RESULTS

Seven tele-sites were recruited into the tele-PR program with 6 continuing to participate at 3 years, delivering a total of 58 programs for 177 individuals with COPD. During that same period, the standard-PR site delivered 15 programs for 89 individuals with COPD. Over 70% of participants completed each program and no major adverse events were reported. There were significant improvements in the 6MWT and CAT scores in both groups immediately post-PR with no between-group differences. Participants in both programs had persistent 6MWT improvement at 1,3,6 and 12 months post-PR. Participants in tele-PR had persistent improvement of CAT scores but not in standard-PR beyond 1 month post-PR.

CONCLUSION

This study provides real-world evidence demonstrating successful implementation of tele-PR. The Canadian standardized tele-PR program is an accessible, feasible, safe and effective model for delivering PR.

Web-Based Self-management Program (SPACE for COPD) for Individuals Hospitalized With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Nonrandomized Feasibility Trial of Acceptability

BACKGROUND

Hospital admissions due to the acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are costly for individuals and health services. Pulmonary rehabilitation (PR) is known to reduce hospital readmissions when delivered after hospitalization, but the uptake and completion of PR following hospitalization remains poor (<10% of those eligible in the UK audit data). A web-based platform of the SPACE (Self-management Program of Activity Coping and Education) for COPD (chronic obstructive pulmonary disease) has previously shown promising results in patients with stable COPD but has not been tested following an AECOPD.

OBJECTIVE

This study aims to assess the feasibility and acceptability of a web-based self-management program.

METHODS

A nonrandomized feasibility study for patients with confirmed AECOPD who were deemed web literate was conducted. All patients consented during their hospitalization and received access to the website following discharge in addition to usual care. The program aims to facilitate patients to better understand and manage their condition through education and home-based exercises. Participants were asked to complete the Bristol COPD Knowledge Questionnaire at baseline and after 6 months. A total of 14 participants were also interviewed (n=8 completers; n=6 noncompleters) regarding their experiences with the web-based program and trial. The interviews were analyzed using thematic analysis.

RESULTS

In total, 2080 patients were screened for eligibility, of which 100 patients (age: mean 71.2 years, SD 9.3 years; male: 55/100, 55%; forced expiratory volume in 1 second/forced vital capacity ratio: mean 0.46, SD 0.14; pack-years: mean 50.2, SD 31.0; current smokers: 35/100, 35%) were recruited (4.8% of those screened). The main reason for ineligibility was a lack of web literacy (1366/1980, 68.98%). In total, 18% (18/100) of patients had completed the web program by 6 months, with others still registered in the program (27/100, 27%), and more than half did not register (55/100, 55%). There was a mean change in Bristol COPD Knowledge Questionnaire scores at 6 months of 7.8 (SD 10.2) points. Qualitative interviews identified three main themes: preparing for, engagement with, and benefits of the study and program. A total of 57% (57/100) accepted a referral to PR on discharge and 19% (19/100) had completed the program after 6 months.

CONCLUSIONS

On the basis of the challenges of recruiting, retaining, and engaging participants in a web-based self-management program, it is not a feasible approach to roll out widely. This study acknowledges that this is a challenging time for patients with an AECOPD to engage in exercise and self-management education. However, for patients who were able to engage in such an intervention, the completion rate of PR was double the previous audit estimates from the United Kingdom, disease knowledge improved, and the intervention was of value to patients.

TRIAL REGISTRATION

ISRCTN Registry 13081008; https://www.isrctn.com/ISRCTN13081008.

Renewed vision on pulmonary rehabilitation service delivery for chronic obstructive pulmonary disease management beyond COVID-19

Pulmonary rehabilitation (PR) is a cornerstone management for chronic obstructive pulmonary disease (COPD). International respiratory societies defined PR is more than "just an exercise program"; it is a comprehensive care delivered by a team of dedicated healthcare professionals with a strong emphasis on long-term health-enhancing Behaviors. However, "Uncertainty" exists with varied reasons for the political and geographical barriers of referral, uptake, attendance, and completion of PR in both primary and secondary care. Besides, COVID-19 pandemic has sparked many global controversies and challenges on pulmonary rehabilitation service delivery. Post-COVID-19 guidelines emphasize on integrated care rehabilitation for patients with COPD. Thus, this concise review intends to understand the gaps in United Kingdom healthcare policies, practices, and PR services resources. To date, there is no clear consensus on PR integrated care model pathway to address the unmet needs, measure the health and social care disparities; adds to the disease burden of COPD. Based on the culmination of evidence, this perspective offers a theoretical framework of PR integrated service model, a pathway to deliver high-value personalized care to patients with COPD.

Impact of COVID-19 lockdown on the incidence and mortality of acute exacerbations of chronic obstructive pulmonary disease: national interrupted time series analyses for Scotland and Wales

BACKGROUND

The COVID-19 pandemic and ensuing national lockdowns have dramatically changed the healthcare landscape. The pandemic's impact on people with chronic obstructive pulmonary disease (COPD) remains poorly understood. We hypothesised that the UK-wide lockdown restrictions were associated with reductions in severe COPD exacerbations. We provide the first national level analyses of the impact of the COVID-19 pandemic and first lockdown on severe COPD exacerbations resulting in emergency hospital admissions and/or leading to death as well as those recorded in primary care or emergency departments.

METHODS

Using data from Public Health Scotland and the Secure Anonymised Information Linkage Databank in Wales, we accessed weekly counts of emergency hospital admissions and deaths due to COPD over the first 30 weeks of 2020 and compared these to the national averages over the preceding 5 years. For both Scotland and Wales, we undertook interrupted time-series analyses to model the impact of instigating lockdown on these outcomes. Using fixed-effect meta-analysis, we derived pooled estimates of the overall changes in trends across the two nations.

RESULTS

Lockdown was associated with 48% pooled reduction in emergency admissions for COPD in both countries (incidence rate ratio, IRR 0.52, 95% CI 0.46 to 0.58), relative to the 5-year averages. There was no statistically significant change in deaths due to COPD (pooled IRR 1.08, 95% CI 0.87 to 1.33). In Wales, lockdown was associated with 39% reduction in primary care consultations for acute exacerbation of COPD (IRR 0.61, 95% CI 0.52 to 0.71) and 46% reduction in COPD-related emergency department attendances (IRR 0.54, 95% CI 0.36 to 0.81).

CONCLUSIONS

The UK-wide lockdown was associated with the most substantial reductions in COPD exacerbations ever seen across Scotland and Wales, with no corresponding increase in COPD deaths. This may have resulted from reduced transmission of respiratory infections, reduced exposure to outdoor air pollution and/or improved COPD self-management.

Telemedicine in the management of patients with chronic respiratory failure

Patients with chronic respiratory failure are often required to attend multiple hospital appointments, which may be difficult due to their physical disabilities and the amount of equipment they are required to bring. Their caregivers often struggle with the lack of immediate care available when the patient suffers difficulties at home. Telemedicine is an opportunity to bridge the gap between home and healthcare professionals by allowing the healthcare team to reach into patients' homes to provide more frequent support. The evidence for the use of telemedicine in patients with chronic respiratory failure remains equivocal. Although the uptake of telemedicine has been slow, the SARS-CoV-2 pandemic has resulted in the rapid dissemination of telemedicine to allow the delivery of care to vulnerable patients while reducing the need for their attendance in hospital. Logistical and legal challenges to the delivery of telemedicine remain, but the pandemic may serve as a driver to ameliorate these challenges and facilitate wider use of this technology to improve the experience of patients with chronic respiratory failure.

Educational aims

To provide an overview of the rationale for delivering care via telemedicine for patients with chronic respiratory failure.To provide the evidence base for establishing a telemedicine service.To highlight the potential opportunities and challenges in delivering a telemedicine service for patients with chronic respiratory failure.

Mobile Pulmonary Rehabilitation: Feasibility of Delivery by a Mobile Phone-Based Program

Background: Pulmonary rehabilitation (PR) has been proven effective but is not well accessed due to transport, time, cost, and physical limitations of patients. We have developed a mobile phone-based PR program (mPR) that could be offered as an alternative for those unable to attend in-person. This was developed following formative research with patients, their families and clinicians. mPR has a core text message program plus an app that includes an action plan, exercise videos, lung visualization, symptom score questionnaire and 1-min sit-to-stand test.

Aims: To determine the feasibility of delivering pulmonary rehabilitation by mobile phone.

Methods: A 9-week non-randomized (1-arm) pilot study was conducted. Participants were 26 adults with chronic obstructive pulmonary disease plus four family members, who were offered participation at first assessment or during group PR sessions. Outcomes included satisfaction, engagement with the program, and perceived impacts.

Results: Eight people (31%) opted for text messages only, and 18 (69%) chose text messages plus the app. Three people stopped the program early, 20 said they would recommend it to others, 19 said it helped them to feel more supported, 17 said it helped them to change their behavior.

Conclusion: It is feasible to deliver PR support via mobile phone, including exercise prescription and support. Our mPR program was appreciated by a small number of people with chronic respiratory disorders and family members. Suggestions for improvements are being used to inform the further development of the program, which will then be tested for effectiveness. Registered with the Australia New Zealand Clinical Trials Registry ACTRN12619000884101 (www.anzctr.org.au).

Telerehabilitation for chronic respiratory disease

BACKGROUND

Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in-person on an outpatient basis at a hospital or other healthcare facility (referred to as centre-based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home-based models and the use of telehealth. Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease.

OBJECTIVES

To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting abstracts.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS-I tool to assess bias in non-randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in-person (centre-based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation.

MAIN RESULTS

We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) -10.82 m to 10.94 m; 556 participants; four studies; moderate-certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD -1.26, 95% CI -3.97 to 1.45; 274 participants; two studies; low-certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40; 426 participants; three studies; low-certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in-person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI -38.89 m to 83.23 m; 94 participants; two studies; low-certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low-certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in-person rehabilitation or no rehabilitation.

AUTHORS' CONCLUSIONS

This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre-based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.

COPD in the time of COVID-19: an analysis of acute exacerbations and reported behavioural changes in patients with COPD

INTRODUCTION

The impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and associated "lockdown" measures on acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is unknown. We aimed to evaluate the change in AECOPD treatment frequency during the first 6 weeks of lockdown in the UK compared with 2019 and assess changes in self-reported behaviour and wellbeing.

METHODS

In this observational study in Leicestershire, UK, patients with COPD under a secondary care clinic were recruited. Exacerbation frequency in the first 6 weeks of COVID-19 lockdown was compared with the same period in 2019 using electronic health records. A telephone survey was used to assess changes in anxiety, inhaler adherence, physical activity and behaviour during the pre-lockdown and lockdown periods compared with normal.

RESULTS

160 participants were recruited (mean±sd age 67.3±8.1 years, 88 (55%) males, mean±sd forced expiratory volume in 1 s 34±13% pred). 140 (88%) reported at least one AECOPD in the previous year. Significantly more community managed exacerbations were observed in 2020 compared with 2019 (126 versus 99; p=0.026). The increase was a result of multiple courses of treatment, with a similar proportion of patients receiving at least one course (34.4% versus 33.8%).

DISCUSSION

During lockdown participants reported significantly increased anxiety, adherence to their preventative inhalers and good adherence to shielding advice (all p<0.001). A significant reduction in self-reported physical activity and visitors was reported (both p<0.001).

CONCLUSIONS

Treatment for AECOPD events increased during the first 6 weeks of the SARS-CoV-2 pandemic in the UK compared with 2019. This was associated with increased symptoms of anxiety and significant behavioural change.

COVID-19 rehabilitation delivered via a telehealth pulmonary rehabilitation model: a case series

International statements have suggested the pulmonary rehabilitation (PR) model as an appropriate rehabilitation option for people recovering from coronavirus disease 2019 (COVID-19). In this case series, we present our COVID-19 telehealth rehabilitation programme, delivered within a PR setting, and discuss the management of our first three cases. All patients were male, with a median age of 73 years. Following hospital discharge, the patients presented with persistent limitations and/or symptoms (e.g. breathlessness, fatigue, and reduced exercise capacity) which warranted community-based rehabilitation. Patients were assessed and provided with an initial six-week rehabilitation programme supported via telehealth using a treatable traits approach. Patients demonstrated improvements in exercise capacity and breathlessness; however, fatigue levels worsened in two cases and this was attributed to the difficulties of managing returning to work and/or carer responsibilities whilst trying to recover from a severe illness. We found that PR clinicians were well prepared and able to provide an individualized rehabilitation programme for people recovering from COVID-19.

Moving singing for lung health online in response to COVID-19: experience from a randomised controlled trial

INTRODUCTION

Singing for lung health (SLH) is a popular arts-in-health activity for people with long-term respiratory conditions. Participants report biopsychosocial benefits, however, research on impact is limited. The 'SLH: Improving Experiences of Lung Disease trial', a randomised controlled, single (assessor) blind, trial of 12 weeks SLH versus usual care for people with chronic obstructive pulmonary disease (COPD) (n=120) was setup to help to address this. The first group (n=18, nine singing and nine controls) started face-to-face (five sessions) before changing to online delivery (seven sessions) due to COVID-19-related physical distancing measures. As such, the experience of this group is here reported as a pilot study to inform further research in this area.

METHODS

We conducted semistructured interviews and thematic analysis regarding barriers, facilitators and key considerations for transitioning from face-to-face to online delivery. Pilot quantitative outcomes include attendance, premeasures and postmeasures of quality of life and disease impact (Short Form 36 Health Survey, COPD Assessment Test score), breathlessness (Medical Research Council breathlessness scale, Dyspnoea-12), depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalised Anxiety Disorder-7), balance confidence (Activity specific Balance Confidence, ABC scale) and physical activity (clinical visit PROactive physical activity in COPD tool, combining subjective rating and actigraphy).

RESULTS

Attendance was 69% overall, (90% of the face-to-face sessions, 53% online sessions). Analysis of semistructured interviews identified three themes regarding participation in SLH delivered face to face and online, these where (1) perceived benefits; (2) digital barriers (online) and (3) digital facilitators (online). Findings were summarised into key considerations for optimising transitioning singing groups from face-to-face to online delivery. Pilot quantitative data suggested possible improvements in depression (treatment effect -4.78 PHQ-9 points, p<0.05, MCID 5) and balance confidence (treatment effect +17.21 ABC scale points, p=0.04, MCID 14.2).

DISCUSSION

This study identifies key considerations regarding the adaptation of SLH from face-to-face to online delivery. Pilot data suggest online group singing for people with COPD may deliver benefits related to reducing depression and improved balance confidence.

Which functional outcome measures can we use as a surrogate for exercise capacity during remote cardiopulmonary rehabilitation assessments? A rapid narrative review

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has seen many cardiopulmonary rehabilitation services delivering programmes remotely. One area of concern is how to assess exercise capacity when a supervised exercise test is not possible. The aim of this review was to examine the relationship between functional exercise tests and recommended exercise tests for cardiopulmonary rehabilitation.

METHODS

A rapid narrative review was carried out. Searches were conducted by two of the study authors. The study had the following features. Participants: adults, all with long-term conditions; intervention: any/none; outcome: Duke activity status index (DASI), sit to stand (STS, 30 s, 1 min and 5 repetitions), short physical performance battery (SPPB), 4-metre gait speed (4MGS) or step test (Chester/others) AND directly compared to one of the recommended exercise tests for cardiopulmonary rehabilitation: 6-min walk test (6MWT), incremental shuttle walk test (ISWT) or cardiopulmonary exercise test (CPET) in terms of reporting agreement/correlation; Study design: primary research only, controlled trials or observational studies.

RESULTS

Sixteen articles out of 249 screened were included (n=2271 patients). Overall, there were weak-strong correlations for the included tests with a recommended exercise test (r=0.38-0.85). There were few reported issues with feasibility or safety of the tests. However, all tests were supervised in a clinical setting. The test that had the highest correlation with the field walking test was the 4MGS with the ISWT (r=0.78) and with the 6MWT (r=0.85).

DISCUSSION

The 4MGS has the highest correlation with routine measures of exercise tolerance. However, it may be difficult to standardise in a remote assessment or to prescribe exercise from. Clinicians should strive for face-to-face standardised exercise tests where possible to be able to guide exercise prescription.