An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation

Beyond pulmonary rehabilitation: can the PICk UP programme fill the gap? A randomised trial in COPD

INTRODUCTION AND OBJECTIVES

Pulmonary rehabilitation (PR) is a fundamental intervention to manage COPD, however, maintaining its benefits is challenging. Engaging in physical activity might help to prolong PR benefits. This study assessed the efficacy and effectiveness of a personalised community-based physical activity programme to sustain physical activity and other health-related PR benefits, in people with COPD.

MATERIALS AND METHODS

This was a multicentre, assessor blinded, randomised controlled trial. Following 12-weeks of PR, people with COPD were assigned to a six-months personalised community-based physical activity programme (experimental group), or to standard care (control group). Physical activity was assessed via: time spent in moderate to vigorous physical activities per day (primary outcome measure), steps/day and the brief physical activity assessment tool. Secondary outcomes included sedentary behaviour, functional status, peripheral muscle strength, balance, symptoms, emotional state, health-related quality of life, exacerbations and healthcare utilization. Assessments were performed immediately post-PR and after three- and six-months. Efficacy and effectiveness were evaluated using intention-to-treat and per-protocol analysis with linear mixed models.

RESULTS

Sixty-one participants (experimental group: n = 32; control group: n = 29), with balanced baseline characteristics between groups (69.6 ± 8.5 years old, 84 % male, FEV1 57.1 ± 16.7 %predicted) were included. Changes in all physical activity outcomes and in one-minute sit-to-stand were significantly different (P < 0.05) between groups at the six-month follow-up. In the remaining outcomes there were no differences between groups.

CONCLUSIONS

The community-based physical activity programme resulted in better physical activity levels and sit-to-stand performance, six-months after completing PR, in COPD. No additional benefits were observed for other secondary outcomes.

Effect of exercise training on modulating the TH17/TREG imbalance in individuals with severe COPD: A randomized controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) induces an imbalance in T helper (Th) 17/regulatory T (Treg) cells that contributes to of the dysregulation of inflammation. Exercise training can modulate the immune response in healthy subjects.

OBJECTIVE

We aimed to evaluate the effects of exercise training on Th17/Treg responses and the differentiation of Treg phenotypes in individuals with COPD.

METHODS

This randomized controlled trial included 50 individuals with severe or very severe COPD who were allocated to the Exercise or Control groups. The Exercise group underwent eight weeks of aerobic and muscle strength training, whereas the Control group received usual care. The primary outcome was the change in the phenotypic characteristics of Tregs and Th17 profile differentiation in systemic inflammation.

RESULTS

Exercise training increased the frequency of total and activated Tregs and decreased the frequency of Th17 cells in between-group comparisons. Additionally, Th17/Treg responses were moderately correlated with improvements in the six-minute walking test, muscle strength of the upper and lower limbs, and daily life physical activity levels.

CONCLUSION

Exercise training improved functional exercise capacity, muscle strength, and physical fitness, which was associated with a decrease in the Th17 inflammatory response and an increase in Treg cell phenotypes immunosuppressive activity.

Estimating endurance training intensity prescription from the 6-minute stepper test in people with chronic obstructive pulmonary disease - a multicenter cross-sectional study with external validation

BACKGROUND

Home-based pulmonary rehabilitation (PR) can enhance accessibility to PR, but no at-home field exercise test has been validated for individualized endurance training prescriptions.

RESEARCH QUESTION

What is the accuracy of the six-minute stepper test (6MST) in estimating endurance training intensity as determined during cardiopulmonary exercise testing (CPET)?

STUDY DESIGN AND METHOD

This multicenter (N = 3) cross-sectional study included individuals with COPD. Participants performed CPET and two 6MSTs to evaluate the 6MST's ability to estimate endurance training intensity based on CPET-derived heart rate at the first ventilatory threshold (HRvt1), the corresponding power output (Pvt1), and peak power output (Ppeak). Predictive equations were tested for external validity using data from two prior studies.

RESULTS

105 patients were included (mean age 61 (SD 9) years; mean FEV1 61 (SD 21) %). Predictive equations moderately predicted HRvt1 (r² = 0.38), strongly predicted Pvt1 (r² = 0.63) and very strongly predicted Ppeak (r² = 0.75). External validity was small to moderate for HRvt1 and Pvt1 but was strong for 60% of Ppeak (mean absolute difference: 10W, 95% CI 5 to 10). Passing and Bablok regression confirmed interchangeability for Pvt1 and 60% of Ppeak.

INTERPRETATION

The 6MST offers a reliable method to set initial training intensity when CPET is unavailable.

CLINICAL TRIAL REGISTRATION

NCT02842463.

Features of COPD That Lead to Stigmatisation and Its Consequences: A Framework Synthesis

COPD is a highly stigmatised condition. To develop effective measures to reduce COPD-related stigma, it is important to understand patients' experiences and identify contributing factors. This systematic review explores qualitative evidence regarding the features of COPD leading to stigmatisation and how it can potentially influence health outcomes. Electronic databases were searched to identify primary qualitative studies focussing on stigma-related experiences of adults with COPD, published between January 1988 to August 2024. Data were synthesised using framework synthesis. Twenty-nine studies with 427 participants were included in this review. Findings fit well into six themes identified from Jones et al.'s framework of stigma dimensions and provide rich description. Smoking habit was not the only factor of stigma but also factors that contributed to disability of individuals. Patients experience COPD-related stigma mainly from themselves and healthcare professionals. Potential consequences of stigma identified are mental distress, isolation, reduced help-seeking behaviour and non-compliance to management. Collective effort by society and healthcare systems will be necessary to alleviate the stigma associated with chronic symptoms and smoking behaviour of COPD and to promote the benefit of pulmonary rehabilitation and available mental health support.

Diagnostic tools in respiratory medicine (Review)

Recent advancements in diagnostic technologies have significantly transformed the landscape of respiratory medicine, aiming for early detection, improved specificity and personalized therapeutic strategies. Innovations in imaging such as multi-slice computed tomography (CT) scanners, high-resolution CT and magnetic resonance imaging (MRI) have revolutionized our ability to visualize and assess the structural and functional aspects of the respiratory system. These techniques are complemented by breakthroughs in molecular biology that have identified specific biomarkers and genetic determinants of respiratory diseases, enabling targeted diagnostic approaches. Additionally, functional tests including spirometry and exercise testing continue to provide valuable insights into pulmonary function and capacity. The integration of artificial intelligence is poised to further refine these diagnostic tools, enhancing their accuracy and efficiency. The present narrative review explores these developments and their impact on the management and outcomes of respiratory conditions, underscoring the ongoing shift towards more precise and less invasive diagnostic modalities in respiratory medicine.

Biomarkers of aging: from molecules and surrogates to physiology and function

Many countries face an unprecedented challenge in aging demographics. This has led to an exponential growth in research on aging, which, coupled to a massive financial influx of funding in the private and public sectors, has resulted in seminal insights into the underpinnings of this biological process. However, critical validation in humans has been hampered by the limited translatability of results obtained in model organisms, additionally confined by the need for extremely time-consuming clinical studies in the ostensible absence of robust biomarkers that would allow monitoring in shorter time frames. In the future, molecular parameters might hold great promise in this regard. In contrast, biomarkers centered on function, resilience, and frailty are available at the present time, with proven predictive value for morbidity and mortality. In this review, the current knowledge of molecular and physiological aspects of human aging, potential antiaging strategies, and the basis, evidence, and potential application of physiological biomarkers in human aging are discussed.

Barriers and enablers to medicine-taking behaviours in chronic obstructive pulmonary disease: a qualitative interview study

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is associated with low health-related quality of life and high costs to healthcare systems, particularly due to hospital admissions and exacerbations. Medicines, inhalers especially, reduce the risk of hospitalisations and exacerbations, but factors influencing medicine-taking behaviours are not fully understood.

AIM

To explore experiences of people with COPD related to medicines, and followingly identify and characterise any barriers and enablers related to medicine-taking behaviours using the Theoretical Domains Framework (TDF).

METHOD

Semi-structured qualitative interviews were conducted and included ten people with COPD who had previously been admitted to hospital. Systematic text condensation was used inductively in the primary analysis of the interviews. In the secondary analysis, meaning units from the primary analysis were mapped to the TDF and summarised as barriers and enablers.

RESULTS

Five major themes were developed in the primary analysis: (1) health literacy and information needs, (2) patient autonomy, (3) lack of access to medicines, (4) lack of effect from medicines, and (5) experiences of medicines-related issues. In the secondary analysis, thirteen barriers and nine enablers were mapped to nine out of the fourteen domains of the TDF.

CONCLUSION

People with COPD experience challenges related to medicines which need to be addressed by researchers and healthcare providers. The identified barriers and enablers mapped to the TDF can guide and inform future design of interventions and health care services.

Development and evaluation of text messages designed for people with COPD on the mobile pulmonary rehabilitation (m-PR™) platform

OBJECTIVE

To develop and evaluate the ease of understanding and helpfulness of text messages designed to educate, support and motivate people with chronic obstructive pulmonary disease (COPD) as part of an eight-week mobile pulmonary rehabilitation program (m-PR™).

DESIGN, PARTICIPANTS, SETTING AND OUTCOME MEASURES

Text messages were developed in an iterative three stage process: i. development of 85 evidence-based text messages by multidisciplinary health professionals. ii. A survey, including random samples of text messages, was completed by people with COPD who attended a pulmonary rehabilitation assessment at one of five programs in Australia. For each message, participants rated the ease of understanding and helpfulness using a Likert scale and answered an open-ended question seeking feedback. iii. Review of all scores and free text comments informed retention, modification or removal of a text message with the final text messages evaluated for readability.

RESULTS

Eighty-six participants with COPD completed the survey (86/100, 86%; mean (standard deviation) age 72 (9) years; 58% female). Each text message was reviewed by a minimum of five participants. The median score for ease of understanding and helpfulness of text message content was 5 ('strongly agree') and 4 ('agree') respectively. Following review of all text messages, the final bank of 80 text messages had a Flesch-Kincaid Grade level of 6.5 indicating that the messages were fairly easy to read.

CONCLUSION

Most participants with COPD agreed that text messages developed for m-PR™ were easy to understand and helpful. For people with COPD, text messages may educate, support and improve motivation during a pulmonary rehabilitation program. CONTRIBUTION OF PAPER.

Mechanism-Based Neuromodulation in Augmenting Respiratory Motor Function in Individuals with Spinal Cord Injury

Spinal cord injury (SCI) is one of the most debilitating conditions that has profound effects on every physiological system, including respiratory dysfunction, which is listed among the most common causes of mortality and morbidity in this population. Previous research has demonstrated that respiratory training could facilitate respiratory motor- and autonomic activity-based plasticity. However, due to the reduced excitability of spinal networks below the level of injury, the effectiveness of such interventions is often limited to the residual functional capacity preserved after injury. In recent decades, several novel neuromodulatory techniques have been explored to enhance neuronal connectivity and integrate into respiratory rehabilitation strategies. In this review, we examine the mechanisms underlying respiratory deficits following SCI and discuss the neuromodulatory approaches designed to promote neural plasticity for respiratory recovery. Current evidence suggests that integrating multimodal neuromodulation with activity-based respiratory training holds promise; it may significantly enhance respiratory functional recovery and could become a standard component of respiratory rehabilitation protocols in individuals with SCI.

Modifying exercise and physical therapy in medical rehabilitation to promote a physically active lifestyle: Protocol for a multicenter controlled hybrid type 2 effectiveness-implementation study in three German rehabilitation centers

INTRODUCTION

Since rehabilitation programs often do not enhance long-term physical activity in persons with a health condition, there is a great need to arrange rehabilitation concepts towards a stronger emphasis on sustainable physical activity promotion. In this regard, the model of physical activity-related health competence (PAHCO) offers the potential for optimizing physical activity promotion. In the context of medical rehabilitation, the STABEKO study uses a co-creation approach to modify existing exercise and physical therapy according to PAHCO and long-term physical activity promotion in three rehabilitation centers in Bavaria, Germany. The objectives of the STABEKO study are A) to evaluate the implementation of modified exercise and physical therapy and to identify influencing factors for development and implementation, and B) to determine the short- and long-term effectiveness of the modified therapy on PAHCO and physical activity of the persons undergoing rehabilitation.

METHODS

As part of the STABEKO study, we will use cooperative planning as a co-creation approach for planning, developing, and implementing actions to modify exercise and physical therapy by engaging relevant actors from practice, policy, and research in an equal decision-making process. Within a multicenter controlled hybrid type 2 effectiveness-implementation study, we will simultaneously evaluate the effectiveness and implementation of modified exercise and physical therapy by collecting, analyzing, and triangulating qualitative and quantitative data at several measurement time points.

DISCUSSION

The STABEKO study will provide comprehensive insights into the implementation and effectiveness of exercise and physical therapy in medical rehabilitation, modified using a co-creation approach to promote long-term physical activity of persons undergoing rehabilitation. While the implementation study will indicate which modifications could be achieved and which factors have influenced their development and implementation, the effectiveness study will investigate whether modified exercise and physical therapy lead to changes in PAHCO and physical activity in persons undergoing rehabilitation. The results of this study will determine the dissemination of long-term physical activity promotion in the German rehabilitation sector and will provide important information for modifying existing therapeutic concepts to improve their effectiveness and implementation at an international level.

TRIAL REGISTRATION

The study was registered on the Open Science Framework on July 8 2024: https://doi.org/10.17605/OSF.IO/2N8UM and https://doi.org/10.17605/OSF.IO/J3KR2 .

Lesson from COVID-19-Adapting Respiratory Rehabilitation Through Early Multidisciplinary Care: An Opinion Paper from Retrospective Data

The COVID-19 pandemic significantly challenged healthcare systems worldwide, highlighting the critical role of early and multidisciplinary rehabilitation interventions. There remains uncertainty about whether these rehabilitation principles developed in response to COVID-19 can be effectively generalized to chronic respiratory diseases. This opinion paper evaluates retrospective data from early stages of the COVID-19 pandemic to propose a comprehensive early multidisciplinary rehabilitation model, potentially applicable across various chronic respiratory conditions. We retrospectively analyzed data from 62 COVID-19 patients hospitalized at the University Hospital of Messina, Italy, between March and June 2020. The patients underwent structured multidisciplinary rehabilitation sessions initiated upon achieving clinical stability. Functional improvements were assessed weekly using the Barthel Index (BI). Significant correlations were observed between initial BI scores and functional improvements at discharge (p < 0.001) and between functional gains and the number of rehabilitation sessions administered (p = 0.025). Early physiatric evaluation significantly enhanced functional recovery (p = 0.036). Early structured multidisciplinary rehabilitation during acute hospitalization demonstrated clear benefits in COVID-19 patients, indicating potential for broad applicability in chronic respiratory disease management. Systematic implementation could improve clinical outcomes, reduce healthcare resource utilization, and enhance patients' quality of life.

Effects of a 10-week pulmonary rehabilitation program based on the 5A nursing model in patients with interstitial lung disease: a quasi-experimental study

BACKGROUND

Pulmonary rehabilitation (PR) is essential for treating interstitial lung disease (ILD). The 5A nursing model enhances patients' health-promoting behaviors by improving their self-management skills. The aim of this study is to examine and analyze the effectiveness of the PR program based on the 5A nursing model concerning lung function, dyspnea, anxiety, depression, self-efficacy, quality of life, and PR compliance in patients with ILD.

METHODS

64 hospitalized ILD patients were enrolled in this quasi-experimental study. Patients were randomly assigned to an intervention group (PR program based on the 5A nursing model) and a control group (conventional PR) on a ward-by-ward basis. The allocation was not concealed from the patients. A pre- and post-test design was used. An exercise training diary was utilized to evaluate PR compliance, data was gathered using the mMRC, HADS, PRAISE, and SGRQ, and lung function was assessed by a professional PR-trained nurse. SPSS 26.0 was used to analyze the data. For within/between-groups comparisons, the Wilcoxon signed-rank test, Fisher's exact test, t-test, χ²-test, and Mann-Whitney U-test were employed.

RESULTS

Baseline demographics were generally similar between the two groups (P > 0.05). After 10 weeks of intervention, the PR program based on the 5A nursing model group had more significant improvements in self-efficacy (P = 0.001), anxiety (P = 0.005), and depression (P = 0.018) compared to the control group, but there were no significant differences in dyspnea, lung function, or quality of life (P > 0.05). PR compliance was significantly higher in the intervention group than in the control group (P = 0.028). Further within-group comparisons showed significant improvements in DLCO%pred (P = 0.003), dyspnea (P = 0.001), anxiety (P = 0.006), self-efficacy (P < 0.001), and quality of life (P < 0.001) at post-test in patients in the intervention group compared to pre-test.

CONCLUSION

The PR program based on the 5A nursing model is an effective way to reduce anxiety, depression, and improve self-efficacy and PR compliance in patients with ILD.

TRIAL REGISTRATION

Retroactive registration is underway on the Chinese Clinical Trial Registry (ChiCTR).

Acceptability of pulmonary rehabilitation in Malawi: a qualitative study

BACKGROUND

Pulmonary rehabilitation (PR) is an effective non-pharmacological intervention for people with chronic respiratory diseases (CRDs), but its acceptability in Malawi was unknown.

OBJECTIVES

To explore patients' acceptability of PR at Queen Elizabeth Central Hospital, Blantyre, Malawi.

METHODS

This was a pre-post cohort study where participants were offered a two times per week hospital-based PR programme for 6 weeks, consisting of endurance and strengthening exercises. Following programme completion, face-to-face semistructured in-depth interviews with the participants were conducted. Interview transcripts were thematically analysed using a deductive approach.

RESULTS

10 adults (five females and five males) out of 14 invited (~70% uptake) participated in the PR programme and subsequent in-depth interviews. Five key themes emerged: (1) debilitating symptom experience of CRD prior to PR; (2) positive impact of PR on living with CRD; (3) contextual programme design improved participants' experience with PR; (4) one size does not fit all and (5) challenges and opportunities for home-based PR. Participants reported experiencing improvements in physical, psychological and social health associated with PR programme participation. The provision of transport was considered a key facilitator for PR programme completion. Realising the gained PR benefits, participants were willing to continue exercising at their homes.

CONCLUSION

The PR programme improved the participants' perceived health status and was well-accepted. Addressing barriers related to transport facilitated immediate implementation while providing a challenge for the scaling and sustainability of PR beyond the project duration. These findings support the drive for shifting chronic care, including rehabilitation, towards primary care and community.

TRIAL REGISTRATION NUMBER

Prospective; 27 August 2021; ISRCTN13836793.

Effects of pulmonary rehabilitation program in a community based hospital in California

INTRODUCTION

The purpose of this study was to evaluate the effectiveness of a community based pulmonary rehabilitation program in central California.

METHOD

This was a retrospective study approved by the institutional review board at Community Regional Medical Centers Fresno. Data were extracted from a pulmonary rehabilitation clinic at a Community Based Hospital in Fresno, CA, USA from 2016 to 2023. The program was designed as follows: patients completed a six-week program, two hours, twice/week. The program included the following: stretching, breathing, and personalized training/exercise. Main outcomes were the following data: six-minute walk tests (6MWT), shortness of breath questionnaire (SOB-Q), Patient Health Questionnaire (PHQ-9), quality of life (QoL), and satisfaction level.

RESULTS

The study included 381 participants, comprising 186 males and 195 females. Our findings demonstrated significant improvements post-program, including increased six-minute walk test (6MWT) distances (633 ± 316 to 925 ± 311 m, p < 0.001), reduced shortness of breath scores (52.28 ± 22.36 to 41.87 ± 20.9, p < 0.001), improved PHQ-9 depression scores (7.83 ± 5.46 to 4.70 ± 4.42, p < 0.001), and higher quality of life scores (16.0 ± 5.88 to 19.00 ± 6.15, p < 0.001). Patient satisfaction was high, with consistent positive feedback on program design and delivery.

CONCLUSION

Our results showed that the program was effective in improving patients' quality of life, shortness of breath, and 6MWT. In addition, patients were satisfied with the program upon completion. Further longitudinal studies in different regions are strongly recommended to confirm and validate our findings.

The effectiveness and feasibility of virtual pulmonary rehabilitation in patients with chronic respiratory diseases: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness and feasibility of virtual pulmonary rehabilitation (PR) in patients with chronic respiratory diseases (CRDs).

METHODS

PubMed, Embase, Web of Science, Cochrane Library, CINAHL, CNKI, Wanfang, VIP and APA PsycInfo database were searched since the establishment of the database to July 26, 2024. Data extraction and quality assessment were independently conducted by two reviewers. The methodological quality was assessed using the Cochrane Risk of Bias Tool 2. RevMan v5.4 was performed to meta-analysis.

RESULTS

This meta-analysis and systematic review included 19 studies (1222 CRDs patients). Meta-analysis showed that compared with the control group, virtual PR increased exercise capacity (MD: 22.88, 95 % CI: 15.54 to 30.23), quality of life (QOL) [COPD Assessment Test (CAT): -3.23, -3.62 to 2.85] and dyspnea (Modified Medical Research Council: -0.38, -0.62 to -0.14). Virtual PR demonstrated statistical significance in improving lung function (forced expiratory volume in 1 s in predicted: 6.30, 3.39 to 9.21; the ratio of forced expiratory volume to forced vital capacity in the first second: 9.18, 8.02 to 10.33) and compliance (4.05, 2.26 to 7.27). Mean changes in CAT, anxiety, depression, and cognitive function reached Minimal clinically important difference (MCID) thresholds. However, Borg score, St George' s respiratory questionnaire (SGRQ) did not show any change. In narrative analysis, virtual PR reported fewer adverse reactions, but the economic benefits should be considered.

CONCLUSIONS

This systematic review thoroughly investigates the effectiveness and feasibility of virtual PR for patients with CRDs, and preliminarily verifies the potential promotion value of virtual PR.

PROSPERO REGISTRATION NUMBER

CRD42024581851.

Bidirectional longitudinal associations between estimated muscle mass and self-reported chronic lung disease in middle-aged and older adults: findings from the China health and retirement longitudinal study

BACKGROUND

The bidirectional relationship between muscle mass and chronic lung diseases (CLD) in middle-aged and older adults remains inadequately explored. This study aims to investigate the bidirectional association between estimated muscle mass and self-reported chronic lung diseases while elucidating the mediating mechanisms underlying this relationship.

METHODS

This study utilized data from the nationally representative China Health and Retirement Longitudinal Study (2011-2018), focusing on individuals aged 45 years or older. Cox regression was used to investigate the bidirectional relationship between estimated muscle mass and self-reported CLD. Causal mediation analysis was employed to evaluate the role of 16 blood biomarkers as potential mediators. Sensitivity analysis using cross-lagged models was conducted to verify the robustness of the bidirectional association between estimated muscle mass and self-reported CLD.

RESULTS

Among 10,591 participants, 1,742 (16%) self-reported CLD during a median follow-up of 4.4 years. Participants with low estimated muscle mass had a 27% higher risk of developing self-reported CLD compared to those with normal muscle mass (HR = 1.27, 95% CI: 1.12-1.44). In a separate analysis of 6,067 participants, 708 (12%) experienced new-onset estimated low muscle mass, with those reporting CLD showing a 26% increased risk of muscle loss during a median follow-up of 2.5 years (HR = 1.26, 95% CI: 1.06-1.49). Notably, individuals with insufficient physical activity exhibited a significantly higher risk of self-reported CLD compared to those who engaged in regular exercise (HR = 1.91; 95% CI: 1.37-2.66). Additionally, the negative impact of low estimated muscle mass was more pronounced in male participants than in females (HR = 1.65; 95% CI: 1.33-2.03) over the same follow-up period. Causal mediation analysis suggested that cystatin C may mediate 0.61% of the association between estimated muscle mass and self-reported CLD.

CONCLUSION

There is a bidirectional relationship between self-reported CLD and low estimated muscle mass. Self-reported CLD may cause varying degrees of estimated muscle mass reduction across different population subgroups. Understanding this dynamic and its variations can enhance prevention and treatment strategies for both conditions.

Optimal Exercise Modalities and Doses for Alleviating Dyspnea Symptoms and Enhancing Exercise Capacity in Patients With Chronic Obstructive Pulmonary Disease: A Network and Dose-Response Meta-analysis

OBJECTIVE

To investigate the optimal exercise modalities and doses for alleviating dyspnea and enhancing exercise capacity in patients with chronic obstructive pulmonary disease (COPD).

DATA SOURCES

PubMed, Cochrane, Embase, and Web of Science were searched until June 2024.

STUDY SELECTION

Randomized controlled trials on dyspnea and exercise capacity in patients with COPD were included.

DATA EXTRACTION

Exercises were compared using a network and dose-response meta-analysis. Two authors independently extracted the data and assessed bias risk.

DATA SYNTHESIS

The study included 46 randomized controlled trials (2363 participants). Continuous aerobic training (mean difference [MD]=55.2; 95% credible interval [CrI], 28.1-84.5; Grading of Recommendations Assessment, Development and Evaluation [GRADE]: Low), interval training (MD=84.5; 95% CrI, 24.6-145; GRADE: Low), Qigong (MD=33.3; 95% CrI, 10.4-58.1; GRADE: Low), and resistance training (MD=41.5; 95% CrI, 7.27-77.7; GRADE: Low) improved 6-minute walk distance (6MWD). Qigong (MD=-8.20; 95% CrI, -15.6 to -1.50; GRADE: Low) and yoga (MD=-28.3; 95% CrI, -48.1 to -8.61; GRADE: Low) showed significant improvements in St. George's Respiratory Questionnaire (SGRQ). Resistance training (MD=12.1; 95% CrI, 4.62-18.7; GRADE: Low) correlated positively with forced expiratory volume in 1 second (FEV1), while Qigong correlated positively with forced vital capacity (FVC) (MD=0.378; 95% confidence interval, 0.087-0.620; GRADE: Low). Interval training, yoga, resistance training, and Qigong ranked the highest in 6MWD, SGRQ, FEV1, and FVC. The dose-response curve revealed an increasing trend in the effect of exercise intensity on enhancing 6MWD with intensified exercise levels. Regarding SGRQ scores, the optimal effect was observed at an exercise intensity of 620 metabolic equivalent of task (MET)-min/wk (MD=-7.07, 95% CrI, -12.23 to -1.87). The optimal exercise intensity was 350 MET-min/wk for FEV1 (MD=0.44, 95% CrI, 0.09-0.80) and FVC (MD=0.44, 95% CrI, 0.09-0.80).

CONCLUSIONS

Low quality evidence shows that interval training, yoga, resistance training, and Qigong effectively improved dyspnea and exercise capacity in patients with COPD. Optimal exercise doses vary across outcomes, necessitating personalized adjustments based on health status.

Increasing Quality and Quantity of Life in Individuals with Chronic Obstructive Pulmonary Disease: A Narrative Review with an Emphasis on Pulmonary Rehabilitation

Goals of medical management of individuals with chronic obstructive pulmonary disease (COPD) should be to live better and live longer-in other words, improve health-related quality of life (HRQL) and survival. This narrative review summarizes the literature in these areas, with an emphasis on pulmonary rehabilitation (PR). Treatments that increase HRQL include pharmacologic agents, exercise training, physical activity promotion, lung volume reduction, PR, self-management training, and supplemental oxygen. Additionally, anything that reduces the frequency or impact of exacerbations substantially increases HRQL. With respect to survival in COPD, the list of beneficial interventions for this outcome is considerably more limited. Supplemental oxygen therapy for hypoxemic patients, smoking cessation interventions, influenza vaccination, and lung volume reduction procedures have the strongest evidence in survival benefit. PR, especially when provided following discharge for exacerbations, may improve survival. A nihilistic view of COPD treatment is unwarranted, as multiple interventions are available that improve HRQL, and likely increase survival for selected patients.

Diagnostic pathways for earlier diagnosis and treatment towards better outcomes for adults living with chronic breathlessness

Chronic breathlessness is a common and distressing symptom, negatively impacting physical function and quality of life. Many individuals presenting with chronic breathlessness wait years for an explanatory diagnosis, leading to delays in accessing effective treatments and worse individual outcomes including premature mortality. In addition, delays to diagnosis are associated with increased healthcare utilisation and therefore potentially avoidable burden on healthcare systems. Diagnosing the underlying causes of chronic breathlessness is complex and can be challenging for clinicians. The current clinical diagnostic approach, related guidelines, and healthcare service structure are typically aligned with a disease-based focus. For this article, we are using a working definition of 'Chronic Breathlessness' to infer breathlessness that has persisted for at least eight weeks. In this narrative review, using the latest available evidence, we aimed to describe a symptom-based approach to diagnosis for adults presenting with chronic breathlessness alongside describing the potential for this approach to improve both clinical outcomes and efficiency for healthcare systems. Therefore, our objectives were to: 1) summarise what is currently known about the time to diagnosis for adults presenting with breathlessness, 2) describe the impact and possible explanations for the current delays to diagnosis, 3) describe potential solutions towards an effective symptom-based diagnosis, 4) review the potential for Artificial Intelligence (AI) to support several areas along the diagnostic pathway for breathlessness, 5) describe how a symptom-based approach to diagnosis can be directly utilised to enable a 'matched' personalised holistic approach to treatment.

Metabolic Changes After Bronchoscopic Lung Volume Reduction With Endobronchial Valves in COPD Patients

OBJECTIVES

Little is known about the effect of bronchoscopic lung volume reduction using endobronchial valves (BLVR-EBV) on extrapulmonary manifestations like body composition, muscle function or metabolism. Pulmonary rehabilitation (PR) clearly addresses extrapulmonary manifestations of COPD, including physical inactivity and low muscle mass. However, the added impact of BLVR-EBV+PR remains unknown. Therefore, this study aimed to assess the effect of BLVR-EBV on body composition, muscle function and metabolic markers and whether PR has an additional impact on these outcomes.

METHODS

Subjects with severe COPD eligible for both PR and BLVR-EBV were randomized into three groups: PR+BLVR-EBV, BLVR-EBV+PR, or only BLVR-EBV (n=97). Assessments included Dual Energy X-ray Absorptiometry, thigh muscle Computed Tomography, muscle strength measurements, accelerometry, and plasma (leptin, adiponectin, insulin, and triglycerides) at baseline and six months after the last intervention.

RESULTS

A total of 74 participants completed the study. At follow-up, there were significant increases in the groups combined and both groups separated in total weight, lean mass, fat mass, muscle strength, daily physical activity, and triglyceride levels while leptin/fat mass ratio levels were significantly reduced. No differences were found between groups who underwent BLVR-EVR alone or BLVR-EBV with PR.

CONCLUSIONS

BLVR-EBV results in significant increases in body weight, lean and fat mass, muscle strength and daily physical activity level, and impacts on adipokine profile, irrespective of PR. This underscores the systemic benefits of addressing lung hyperinflation in patients with severe COPD.

Effect of high fraction of inspired oxygen and high flow on exercise tolerance in patients with COPD and IPF: A randomized crossover trial

BACKGROUND

The effect of combining high fraction of inspired oxygen (FIO2) and high flow through a high-flow nasal cannula (HFNC) on exercise tolerance in chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF) remains unclear.

METHODS

This prospective, single-blind, randomized, crossover study included patients with COPD (n = 25) and IPF (n = 25). The patients performed a 6-min walking test (6 MWT) while attached to a battery-supplied portable HFNC device under the following four conditions: FIO2 set to a minimum percutaneous oxygen saturation (SpO2) of 86-88 % during 6 MWT with a flow rate of 10 L/min (LOLF) or 50 L/min (LOHF); and FIO2 set to a minimum SpO2 of 92-94 % with a flow rate of 10 L/min (HOLF) or 50 L/min (HOHF).

RESULTS

In both groups, the 6-min walking distance (6 MWD) was significantly greater for HOHF than for LOLF (COPD: 323.2 ± 77.6 m vs. 268.6 ± 87.3 m, respectively, p < 0.0001 and IPF: 406 ± 50.7 m vs. 372.3 ± 50.9 m, respectively, p < 0.0001). In the analysis of the interaction effects for the 6 MWD, the combination of high FIO2 and high flow resulted in an additional 15.9-m extension of the 6 MWD (95 % confidence interval: 0.34-31.5; p = 0.050). The interaction between IPF and high-flow was -14.0 m, suggesting a less pronounced extension effect compared with COPD (95 % confidence interval: -29.5-1.6; p = 0.085).

CONCLUSION

The combination of high FIO2 and high flow through an HFNC may improve exercise tolerance in patients with COPD and IPF.

Effects of Inspiratory Muscle Training in Patients With Chronic Obstructive Pulmonary Disease Exacerbations: A Randomized Controlled Trial

OBJECTIVE

Pulmonary rehabilitation (PR) is considered for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, the impact of adding inspiratory muscle training (IMT) to PR on inspiratory muscle function is underexplored. This study aimed to evaluate the effects of IMT in addition to PR on inspiratory muscle function, functional exercise capacity (FEC), and quality of life (QoL) in patients with AECOPD.

DESIGN

Sixteen patients with AECOPD and a maximal inspiratory pressure < 80 cmH 2 O were randomized into the experimental (PR + IMT) or the control (PR + sham IMT) group for an 8-wk intervention. Inspiratory muscle activation was measured using surface electromyography, FEC was examined by 6-min walk distance (6MWD), and QoL was assessed with COPD Assessment Test.

RESULTS

The experimental group showed sustained and significant improvements in inspiratory muscle function, 6MWD, and QoL after intervention (all P < 0.05). The experimental group had higher maximal inspiratory pressure with less diaphragm activation (both P < 0.001) and more improvements in 6MWD and QoL after intervention (both P < 0.05).

CONCLUSIONS

Adding IMT to PR resulted in more improvements in inspiratory muscle function, FEC, and QoL for patients with AECOPD, suggesting IMT as a beneficial addition to PR.

Proposing and refining a physical activity intervention for individuals living with COPD

Preliminary test a two stage, self-determination theory (SDT) and participation-based physical activity and peer support intervention for individuals with Chronic Obstructive Pulmonary Disease (COPD). In Stage 1, four focus groups were conducted to provide insights about individuals' needs and experiences with physical activity. In Stage 2, four individuals with COPD aged 76-90 years (50% female) participated in an eight-week online physical activity and peer support intervention. Pre-post assessments evaluated acceptability, feasibility, and functioning. Participants (n = 14; 36% female) identified that a physical activity-based program using functional task-based exercises and peer support is acceptable for adults with COPD in Stage 1. Three of the four participants improved their satisfaction with and self-reported participation in physical activity in Stage 2. Participants reported the intervention supported their psychological needs, associated with SDT. The online, peer support, participation-based physical activity intervention is feasible in its virtual delivery for physical activity promotion for individuals with COPD.

Combined Physical Exercise in Pulmonary Rehabilitation Does Not Alter Endothelial Function and Vascular Structure in Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial

PURPOSE

The aim of this study was to analyze the effect of exercise on endothelial function and other cardiovascular risk factors in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Forty patients were randomized to an 8-week pulmonary rehabilitation (PR) program or usual care. Symptoms, exercise capacity, and quality of life were measured at baseline and after intervention or observation. Flow-mediated brachial artery dilation (FMD), ankle-brachial index, intermittent claudication questionnaire, cardiovascular risk score, blood pressure, daily steps count, glucose, lipids, and C-reactive protein were evaluated before and after intervention.

RESULTS

Participants had a mean age of 64.2 ± 6.7 years in the PR group and 62.2 ± 8.0 years in the usual care group. The forced expiratory volume in the first second was 45.5 ± 15.4% predicted in the PR group and 48.1 ± 24.3% predicted in the usual care group. Attending PR was associated with reduced symptoms, improved exercise capacity and quality of life in patients with COPD ( P < .005 for all). Endothelial function did not improve after PR (FMD% at baseline 9.38 ± 4.40 vs 9.67 ± 6.56 post PR; P = .87), and there was no difference between the 2 groups ( P = .61). However, exercise reduced C-reactive protein, triglycerides, and glucose and improved cardiovascular risk score, systemic blood pressure, and ankle-brachial index ( P < .005 for all).

CONCLUSIONS

Pulmonary rehabilitation elicited improvement in symptoms, exercise capacity, quality of life, and parameters related to cardiorespiratory fitness. The endothelial function measured by FMD did not change with exercise. However, other cardiovascular risk factors such as blood markers, systemic blood pressure, and lower limb blood flow improved after PR.

Palliative care education as an integrated component of pulmonary rehabilitation: A real-world mixed-methods feasibility study

AIM

To explore the feasibility of integrating palliative care education in pulmonary rehabilitation (PR).

METHODS

A mixed-methods feasibility study was conducted in people with chronic respiratory diseases enrolled in 12-weeks outpatient hospital-based PR. A session about palliative care was integrated in the education content. Feasibility was assessed by attendance to the palliative care session, feasibility and acceptability of outcome assessment, acceptability of the intervention and undesirable effects. After PR, two focus groups were carried out. Descriptive and inductive thematic analyses were performed.

RESULTS

Out of 44 individuals referred to PR, 14 were excluded, six declined to participate and two were referred to another rehabilitation programme. Twenty-two people with chronic respiratory diseases started PR, however, six had discontinued the programme at the time of the palliative care session. Attendance to this session was 81 % (n = 13/16; 11 chronic obstructive pulmonary disease, 1 severe asthma and 1 interstitial lung disease; 77 % men, 65 ± 9 years-old, FEV1 41 ± 21 % of predicted). Outcome assessment was completed in 77 % (n = 10/13) of participants and lasted approximately 90 minutes. Three themes were identified from the focus groups: daily living with a chronic respiratory disease, meaningful care and demystifying misconceptions. Participants found the intervention and outcome assessment acceptable. An improvement in knowledge and change of attitude towards palliative care was considered a major effect of the palliative care session. No undesirable effects were reported.

DISCUSSION

Integrating an education session about palliative care in PR is feasible, meaningful for people with chronic respiratory diseases, and has no undesirable effects. A randomised controlled study is being prepared to strengthen these results.

Short- and long-term outcomes of pulmonary emphysema patients on mechanical ventilation admitted to the intensive care unit for acute respiratory failure: A retrospective observational study

INTRODUCTION

Acute respiratory failure is a leading cause of admission to the intensive care unit (ICU), with mortality rates remaining stagnant despite advances in resuscitation techniques. Comorbidities, notably chronic obstructive pulmonary disease, significantly impact ICU patient outcomes. Pulmonary emphysema, commonly associated with chronic obstructive pulmonary disease, poses a significant risk, yet its influence on ICU mortality remains understudied.

OBJECTIVES

The aim of this study was to assess the short- and long-term outcomes of ICU patients with pulmonary emphysema requiring mechanical ventilation for acute respiratory failure, evaluating the impact of emphysema severity.

METHODS

A single-centre retrospective cohort study was conducted from 2015 to 2021. Patients with pulmonary emphysema requiring invasive ventilation were included. Emphysema severity was assessed using chest computed tomography scans. Data on mortality, length of stay, and ventilator-free days were collected. Statistical analyses were performed to identify factors associated with outcomes.

RESULTS

Of the 89 included patients, 31.5% died during their ICU stay, with a 39.3% mortality within 12 months postdischarge. Emphysema severity did not significantly correlate with mortality or ventilator-free days. Chronic heart failure emerged as a significant predictor of ICU and in-hospital mortality.

CONCLUSIONS

Emphysema severity does not appear to independently affect mortality in intubated ICU patients with acute respiratory failure. However, mortality rates remain high, warranting further investigation into contributing factors. Our findings underline the complexity of managing critically ill patients with pulmonary emphysema and emphasise the need for comprehensive patient assessment and personalised treatment approaches.

Barriers and facilitators to implementing pulmonary rehabilitation guidelines in China: a qualitative study using implementation science frameworks

OBJECTIVE

To understand barriers and facilitators to the implementation of pulmonary rehabilitation guidelines in pulmonary and critical care medicine (PCCM) from an interdisciplinary perspective and to determine potential contextual implementation strategies.

DESIGN

A qualitative study guided by the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF).

SETTING

Four departments of pulmonary and critical care medicine in China.

PARTICIPANTS

Forty-two healthcare professionals (12 physicians, 22 nurses, 4 rehabilitation therapists, 2 respiratory therapists, and 2 physiotherapists).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

We conducted semi-structured interviews with healthcare professionals. Transcripts of the semi-structured interviews were analysed using content analysis. Data were coded using a deductive approach. Identified factors influencing non-adherence and utilization of guidelines were then mapped to corresponding intervention strategies from the CFIR-Expert Recommendations for Implementing Change compilation (ERIC) database.

RESULTS

Our analysis revealed barriers and facilitators across three themes: opportunity and support, staff characteristics and motivating factors. Key barriers to guideline implementation encompassed environmental hindrances, guideline complexity and time restriction, poor interdisciplinary communication, lack of awareness, knowledge or skills, capability concerns, and vague professional roles. Potential facilitators included social support and peer influence, MOH policies, robust evidence base and contextual adaptability, planning, monitoring, feedback, autonomous motivation, sense of optimism, and positive outcome expectations of guideline adoption. Environmental restructuring, educational meeting and ongoing training, clinician implementation team meetings and electronic order sets/digital proforma may be needed to facilitate guideline implementation.

CONCLUSIONS

CFIR and TDF provided valuable frameworks for evaluating both contextual-level and individual-level facilitators and barriers to implementing pulmonary rehabilitation guidelines and understanding what adaptations may be needed to improve compliance. These would be essential to inform future interventions in the PCCM and contribute to optimize pulmonary rehabilitation management.

Occupational Therapy Embedded Within Pulmonary Rehabilitation: A Process Evaluation

Exploration of the impact and contributions of occupational therapy within multidisciplinary pulmonary rehabilitation (PR) is necessary to strengthen the clinical evidence-base. The objective of this study was to describe occupational therapy embedded within a community-based PR program and explore mechanisms of impact. A process evaluation of occupational therapy practice embedded within an 8-week multidisciplinary PR was conducted. Data sources included administrative and medical record data, intervention checklists, and semi-structured interviews incorporating the Canadian Occupational Performance Measure and Modified Borg Dyspnea Scale. Nine participants completed the PR program. The home visit and personalized, one-to-one, occupation-centered interventions were identified as key mechanisms of impact. Goal-directed training occurred within the home but not in community clinic environments. The repetitive, occupation-based training was important for learning and everyday application and promoted application of multidisciplinary learning. This evaluation highlighted that individualized occupational therapy assisted PR patients to apply knowledge, from occupational therapy and other disciplines, to real-life challenges.

The Effect of 6 Weeks of Dynamic Neuromuscular Stabilization Exercises on Motor Control, Cardiovascular Fitness, and Respiratory Performance in Overweight and Obese Women

Background: Obesity is linked to impairments in motor control, cardiovascular fitness, and respiratory function. Dynamic Neuromuscular Stabilization (DNS) aims to enhance core stability, diaphragmatic breathing, and neuromuscular coordination. This study investigated the effects of a 6-week DNS program on these functional outcomes in overweight and obese women. Methods: Thirty-six participants (aged 35-50 years, BMI: 25-34 kg/m2) were randomly assigned to either an experimental group (n = 18), which underwent DNS training, or a control group (n = 18), which received no intervention. The DNS program consisted of six weekly sessions (three supervised, three home-based), emphasizing core stabilization, diaphragmatic breathing, and neuromuscular coordination. Motor control (lumbar movement control tests), cardiovascular fitness (two-minute step test), and respiratory performance (breath-hold time, respiratory rate, and respiratory muscle strength) were assessed before and after the intervention. Results: The DNS group demonstrated significant improvements compared to the control group, with notable increases in motor control scores (p < .001) and cardiovascular fitness (p < .001). Additionally, inspiratory and expiratory breath-hold times (p < .001 for both), respiratory rate (p < .001), and maximum inspiratory and expiratory pressures (p < .001) showed substantial enhancements. No significant changes were observed in the control group. Conclusion: A 6-week DNS exercise program significantly improved motor control, cardiovascular fitness, and respiratory performance in overweight and obese women. These findings support DNS training as an effective intervention for enhancing core stability, breathing efficiency, and neuromuscular coordination, with potential applications in rehabilitation and health promotion.

Percentage of Discharged COPD Patients with Exclusion Criteria for Participation in Outpatient Pulmonary Rehabilitation

Background/Objectives: Despite documented benefits across multiple outcome areas, referral and uptake into pulmonary rehabilitation (PR) following discharge after an exacerbation of chronic obstructive pulmonary disease (COPD) is low in many health care systems. Surveys documenting this underutilization may ignore the fact of disease severity or comorbidity severe enough to make many patients ineligible based on accepted selection criteria for the intervention. The aim of this study was to evaluate the magnitude of non-eligibility for PR following discharge after a COPD exacerbation. Methods: Medical records of COPD patients discharged over a one-year period in two hospitals were reviewed. Records from 353 patients discharged home were reviewed by six clinicians with experience in respiratory medicine and/or PR, three at each hospital. Results: The mean age of the total sample was 71 ± 12 years; 53% were female. Full concordance (all three reviewers agreed on the eligibility or non-eligibility of each patient) was 73%. Our eligibility criterion (two of three reviewers agreed) for PR was 39%. Categories (%) of non-eligibility criteria included the severity of medical condition(s) (44%), cognitive problems, psychiatric disease or substance abuse (24%), incorrect diagnosis (18%), institutionalized post-discharge (9%), and language barriers (4%) (patients may have been placed into more than one criteria category). Conclusions: Our study indicates that a majority of patients with clinical diagnoses of COPD discharged following exacerbations may not be appropriate referrals to PR based on accepted inclusion and/or exclusion criteria for the intervention. However, even after taking this into account, PR uptake is still critically underutilized.

Access to respiratory rehabilitation in France: Opinions of pulmonologists and people with chronic obstructive pulmonary disease

Despite its well-known benefits, respiratory rehabilitation (RR) remains underutilized among people with chronic obstructive lung disease (COPD) due to both patient- and physician-related barriers. This qualitative study (October 2023-March 2024) used two questionnaires: one for people with COPD to assess disease severity and access challenges, and another for pulmonologists to identify prescription obstacles. Distributed via associations and mailing lists, the survey reached 3,000 people with COPD and 500 pulmonologists, revealing shared concerns about facility shortages, poor information, and transportation issues. Enhancing RR access through better training, patient education, and expanded facilities should be a public health priority.

Clinical effect of pulmonary rehabilitation during radiotherapy in lung cancer: A randomized controlled trial

OBJECTIVES

Radiotherapy for lung cancer can cause lung injury, which may lead to decreased pulmonary function, worsened clinical symptoms, reduced quality of life, and poor prognosis. Given that patients with compromised lung function are more likely to undergo radiotherapy, adjunct treatments to enhance its safety should be explored. We performed this study to determine whether outpatient-based pulmonary rehabilitation (PR) provides positive clinical effects for patients with lung cancer undergoing radiotherapy.

METHODS

A randomized controlled trial was conducted between June 2022 and May 2023. Patients were stratified by radiotherapy objectives and assigned to the PR or control groups. The outpatient-based PR program was implemented 2-3 times per week during radiotherapy.

RESULTS

Improvements in 6-minute walking distance from baseline were significant in the PR group (16.9 ± 69.9 m vs. -26.1 ± 49.8 m at the end of radiotherapy, P = 0.008; 34.9 ± 39.4 m vs. -24.0 ± 48.3 m at 1-month post-radiotherapy, P < 0.001; 40.7 ± 75.7 m vs. -3.1 ± 47.5 m at 7-month post-radiotherapy, P = 0.043). Grip strength and muscle mass-related parameters showed similar trends. The incidence of radiation pneumonitis requiring steroid treatment was significantly lower in the PR group (9.4 % vs. 54.5 %, P < 0.001).

CONCLUSION

PR during radiotherapy for patients with lung cancer improved the 6-minute walking distance and reduced the occurrence of radiation pneumonitis requiring medical intervention. These findings support the integration of PR into radiotherapy for patients with lung cancer.

CLINICAL TRIAL REGISTRATION

NCT05414188 at ClinicalTrials.gov (2022-06-10).

Functional impairment in COPD can be predicted using genomic-derived data

OBJECTIVE

Reduced functional capacity and muscle weakness are two major contributors to functional impairment in chronic obstructive pulmonary disease (COPD). The underlying causes of functional impairment are poorly understood and, therefore, we sought to investigate the contribution of genetic factors.

METHODS

We conducted a cross-sectional analysis of sociodemographic, clinical and genetic information of people with COPD. Hierarchical clustering based on functional capacity (6-minute walk test and 1-minute sit-to-stand test) and muscle strength (quadriceps isometric muscle strength and handgrip muscle strength) was performed. A genome-wide association study (GWAS) was performed using cluster assignment as phenotype. Polygenic risk scores (PRSs) were calculated for each variable. Genomic-derived data was used to construct a model to predict functional impairment.

RESULTS

Two clusters were identified among 245 individuals. Cluster 1 (n=104) was composed of younger, less symptomatic patients, with preserved functional capacity and muscle strength, whereas cluster 2 (n=141) included those older, more symptomatic, with reduced functional capacity and muscle weakness. GWAS identified two polymorphisms suggestively associated with functional impairment, mapped to xanthine dehydrogenase. Cluster 2 was enriched in individuals with risk alleles for rs1991541 and rs10524730, and lower PRSs for functional capacity and muscle strength. A prediction model using genomic-derived data was constructed (n=159) and tested (n=37), yielding an area under the curve of 0.87 (0.76-0.99).

CONCLUSION

Genetic factors are significantly associated with functional impairment in COPD. The incorporation of genetic information, particularly PRSs, into a predictive model offers a promising avenue for timely identifying individuals at greater risk of functional decline, potentially facilitating personalised and preventive interventions. Further studies on independent external cohorts are needed to validate our model.

Effectiveness of Virtual Reality-Complemented Pulmonary Rehabilitation on Lung Function, Exercise Capacity, Dyspnea, and Health Status in Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory condition characterized by persistent airflow obstruction. Pulmonary rehabilitation (PR) is a cornerstone of COPD management but remains underutilized due to barriers such as low motivation and accessibility issues. Virtual reality (VR)-complemented PR offers a novel approach to overcoming these barriers by enhancing patient engagement and rehabilitation outcomes.

OBJECTIVE

This review aims to evaluate the effect of VR-complemented PR compared with comparators on lung function, exercise capacity, dyspnea, health status, and oxygenation in patients with COPD. Additionally, the study aimed to identify which comparator type (active exercise vs nonactive exercise control group) and intervention duration would result in the greatest improvements in rehabilitation outcomes. The study also assessed patient-reported experience measures, including acceptability and engagement.

METHODS

A comprehensive search of 11 international and Chinese databases identified randomized controlled trials (RCTs) published up to November 2024. Data were analyzed using RevMan 5.4, with pooled effect sizes reported as mean differences (MDs) and 95% CIs.

RESULTS

A total of 16 RCTs involving 1052 participants were included. VR-complemented PR significantly improved lung function (forced expiratory volume in 1 second [FEV1] [L], MD 0.25, P<.001; FEV1/forced vital capacity [FVC], MD 6.12, P<.001; FVC, MD 0.28, P<.001) compared with comparators. Exercise capacity, assessed by the 6MWD, significantly improved (MD 23.49, P<.001) compared with comparators; however, it did not reach the minimally clinically important difference of 26 m, indicating limited clinical significance despite statistical significance. VR-complemented PR also significantly reduced dyspnea measured by the modified British Medical Research Council scale (MD -0.28, P<.001), improved health status measured by the COPD Assessment Test (MD -2.95, P<.001), and enhanced oxygenation status measured by SpO2 (MD 1.35, P=.04) compared with comparators. Subgroup analyses revealed that VR-complemented PR had a significantly greater effect on FEV1 (L) (MD 0.32, P=.005) and 6MWD (MD 40.93, P<.001) compared with the nonactive exercise control group. Additionally, VR-complemented PR showed a greater improvement in FEV1/FVC (MD 6.15, P<.001) compared with the active exercise control group. Intervention duration influenced outcomes, with 5-12-week programs showing the greatest improvement in 6MWD (MD 38.96, P<.001). VR-complemented PR was well-accepted, with higher adherence and engagement rates than comparators.

CONCLUSIONS

VR-complemented PR significantly improves lung function, exercise capacity, dyspnea, health status, and oxygenation in patients with COPD compared with comparators, while enhancing adherence and engagement. Subgroup analyses showed greater effects on FEV1 (L) and 6MWD compared with the nonactive exercise control group, and a larger improvement in FEV1/FVC compared with the active exercise control group. Interventions (5-12 weeks) yielded the most significant benefits in exercise capacity. These findings highlight VR as a promising adjunct to traditional PR, with future research focusing on long-term outcomes and standardized protocols.

Optimizing Pulmonary Rehabilitation in Saudi Arabia: Current Practices, Challenges, and Future Directions

Chronic respiratory diseases (CRDs) are a significantly major cause of mortality in Saudi Arabia, with their progression frequently involving comorbidities and exacerbations that extend beyond the lungs. This review considers the current state of pulmonary rehabilitation (PR) in Saudi Arabia, this being a well-known non-pharmacological intervention to help control and reduce the burden of CRDs, highlighting the intervention's availability, multidisciplinary approach, and integration within the healthcare system, as well as examining the diseases' contribution to overall symptom severity, impairing daily activities and significantly worsening the patient's quality of life. Although PR is strongly recommended for managing CRDs, its utilization in Saudi Arabia remains limited or unavailable in many regions. Key barriers to PR access include inadequate awareness among healthcare providers and patients, logistical challenges, and an insufficient number of specialized facilities and trained professionals. Expanding PR programs in Saudi Arabia requires addressing geographical barriers, ensuring adequate space, resources, and trained personnel, and raising awareness among healthcare providers through education and training. Integrating PR principles into medical education and offering incentives for specialization can help overcome personnel shortages. Additionally, promoting telerehabilitation can enhance patient compliance and ensure the long-term success of PR programs. These initiatives aim to optimize PR services and improve patient outcomes across the nation.

The Association of Conventional Therapy Associated with Somatosensory Interactive Game Enhances the Effects of Early Pulmonary Rehabilitation for Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

Objective: This study aimed to evaluate the effect of somatosensory interactive games in combination with pulmonary rehabilitation programs (PRPs) on exercise tolerance, balance function, pulmonary function, inflammatory markers, and healthcare utilization in individuals with acute exacerbation of chronic obstructive pulmonary disease over 12 months. Design: In a randomized controlled trial, 80 patients were divided into two groups. The control group participated in a lasted 30 minutes daily program composed of postural training for 10 minutes, limb movement for 10 minutes, and breathing exercises for 10 minutes based on regular oxygen therapy and medication. The experimental group received a once-daily, 20-minute somatosensory interactive game session based on the control group. Patients began treatment within 48 hours after admission and lasted for 6 weeks. Results: The time × group interactions on 6-minute walk distance (6MWD) and Brief Balance Evaluation Systems Test (Brief-BESTest) between the two groups were significant (P < 0.001). At the postintervention and each time point of follow-up, the 6-minute walk distance (6MWD) and Brief-BESTest of the intervention group were significantly higher than those of the control group (P < 0.05). The effects of time factor on forced expiratory volume in one second and forced vital capacity were statistically significant (P < 0.05). The 6MWD and Brief-BESTest of the intervention group peaked 3 months after the intervention and were higher than the control group within 12 months. C-reactive protein and procalcitonin were similar between the groups before and after intervention (P > 0.05). The readmission rates and mean length of time spent in the hospital were comparable between the groups at 12 months (P > 0.05). Conclusions: The addition of somatosensory interactive games based on a PRP was safe and feasible, and this benefit persisted for 12 months, peaked at 3 months after the intervention, and then gradually decreased.

Impact of Tele-Pulmonary Rehabilitation in Patients with Chronic Obstructive Disease: A Systematic Review and Network Meta-Analysis

Introduction: Pulmonary rehabilitation (PR) is essential for long-term management of chronic obstructive pulmonary disease (COPD). However, evidence regarding the effectiveness of various PR delivered via telemedicine (tele-pulmonary rehabilitation [tele-PR]) is lacking. This study aims to assess the comparative effects of different tele-PR types on clinical outcomes in patients with COPD. Methods: The following databases were searched: PubMed, EMBASE, CENTRAL, CINAHL, and EBSCO Open Dissertations from inception to May 2023. We included randomized controlled trials, quasi-experimental, and cohort studies investigating the effects of tele-PR on exercise capacity. The Cochrane Effective Practice and Organization of Care Group risk of bias was used to assess the quality of included studies. Data were analyzed using STATA 17.0 with a random-effects model. Tele-PR comparisons were ranked using surface under the cumulative ranking (SUCRA). Results: Seven studies (n = 815) encompassing five tele-PR types were included in the network meta-analysis. Two studies were justified as having a high risk of bias. There were no significant differences among different types of tele-PR and face-to-face PR, in terms of improving the 6-minute walk test. However, the hierarchy estimation suggested that tele-coaching by virtual agents more often than three sessions per week is more likely to be better than other tele-PRs (SUCRA 95.4%). Discussion: While uncertainty persists regarding the optimal tele-PR delivery model, our study suggests that tele-PR was not different from face-to-face PR. However, limited studies and evidence of low-quality underscore the need for well-designed clinical trials to yield more robust comparative evidence.

Associations between postoperative pulmonary interventions based on enhanced recovery programs and outcomes in patients with lung cancer: A retrospective propensity score matching study

PURPOSE

The purpose of the study was to assess the impact of postoperative pulmonary interventions based on enhanced recovery programs (PPIE) on patients undergoing lung cancer surgery using a retrospective propensity score matching (PSM).

METHODS

The non-PPIE group only received the enhanced recovery programs, while the PPIE group received additional postoperative pulmonary interventions, including the active cycle of breathing techniques, oscillatory positive expiratory pressure therapy, incentive spirometry training, and early mobilization, conducted by nurses.

RESULTS

656 patients with lung cancer were identified from January 2020 to December 2022. PSM resulted in 253 patients in each group. The PPIE group showed significant improvements in the presence of postoperative pulmonary complications within the first 30-day (4.7% vs. 11.9%, OR 0.37, 95% CI 0.19-0.74, p = 0.004) and in-hospital postoperative pulmonary complications (3.2% vs. 11.1%, OR 0.26, 95% CI 0.12-0.59, p = 0.001). PPIE was associated with an estimated median reduction in the postoperative hospital length of stay by 1 day (P < 0.001). Moreover, the duration of chest tube indwelling didn't significantly differ between groups (p = 0.394).

CONCLUSION

PPIE is beneficial to the outcomes of patients after lung cancer surgery, except for the duration of postoperative chest tube indwelling. Postoperative pulmonary interventions could be integrated into the ERPs to enhance rehabilitation. Moreover, nurses play a role in facilitating the recovery of patients who have undergone lung cancer surgery.

Effect of traditional Chinese exercise on pulmonary function in middle-aged and older patients with stable chronic obstructive pulmonary disease: A randomized controlled trial

BACKGROUND

Traditional Chinese exercise (TCE) has been shown effective for chronic obstructive pulmonary disease (COPD). However, there are no studies investigating the effect of traditional Chinese exercise (TCE) programme on COPD. The aim of this study was to evaluate the effectiveness of specific TCE programme on the pulmonary function in patients with COPD.

METHODS

76 patients with COPD was randomly assigned to receive either TCE group or control group in a 1:1 ratio. The primary outcome was changes in forced vital capacity (FVC) from baseline to 12 weeks. Secondary outcomes included forced expiratory volume in the first second (FEV1), tidal volume (VT), inspiratory capacity (IC), expiratory reserve volume (ERV), FEV1/FVC, peak expiratory flow (PEF), the 6-min walking test (6MWT), the COPD Assessment Test (CAT), the Short Form 36-item Health Survey (SF-36), modified medical research council scale (mMRC).

RESULTS

After 12 weeks, the TCE group demonstrated a significantly greater improvement of FVC (-12.67; 95 % CI, -18.21 to -7.15; P < 0.001) and FEV1 (-9.70; 95 % CI, -13.73 to -5.68; P < 0.001). But there was no statistically significant difference between groups in FEV1/FVC, PEF, VT, IC or ERV. Besides, patients in the TCE group also reported a statistically significant within-group difference at week 12 in CAT, mMRC and 6MWT. As for eight dimensions of SF-36, patients in TCE group had higher scores in SF-36 (P < 0.05 for 8 dimensions).

CONCLUSION

Our results demonstrate that the traditional Chinese exercise can serve as an effective therapeutic tool for middle-aged and older patients with COPD.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry, ChiCTR2300069283, https://www.chictr.org.cn/showproj.html?proj=192116.

Effects of Physical Exercise on Walking Distance and Functional Limitations in Patients with Chronic Dyspnea

Background and Objectives: Chronic dyspnea is a common clinical manifestation in patients suffering from cardiovascular and respiratory diseases globally, representing an independent predictor of mortality for these patients. In addition, it may be a symptom associated with other conditions such as anemia, physical deconditioning, or anxiety. Methods: A prospective study was conducted, between 1 January 2021 and 30 June 2022, at the Medical Recovery Section from "Dr. Pop Mircea Municipal Hospital Pop Mircea" in Marghita. A total of 163 consecutive patients with chronic dyspnea of various etiologies were evaluated for inclusion in the study. Patients who met the inclusion criteria followed a personalized physical training program of variable duration (between 20 and 40 min) up to the limit of exercise tolerance (grade 3-4 modified Borg scale or up to 70% of maximum heart rate, calculated with the formula 220 age in years); the first 10 days, the training was supervised by a physiotherapist, then patients followed a program of 30 min of exercise 5 days/week at home for 3 months. Assessments, performed at inclusion and after 3 months of training, consisted of the 6 min walk test (6MWT) and the London Chest Activity of Daily Living (LCADL) scale. Results: Pulmonary etiology is the most common cause of dyspnea in the cohort (61.65%). The number of patients without ventilatory defects is 56, or 38.35%. The mean value of initial functional limitation (LCADL1) improved significantly after 3 months (LACDL2) of rehabilitation treatment (38% versus 26.5%); at the same time, the mean walking distance (6MWT) increased by 76 m. Conclusions: An adequate rehabilitation program and sedentary lifestyle change significantly reduce the functional limitation of the patient with chronic dyspnea and increase walking distance. Predictors for 6MWT gait test are age, LCADL score, dyspnea level, and cardiac etiology of chronic dyspnea.

Efficacy of digital therapeutics for perioperative management in patients with lung cancer: a randomized controlled trial

BACKGROUND

Perioperative management and lung function recovery are vital for lung cancer patients. We conducted an open-label, single-center, noninferiority, randomized controlled trial in China to evaluate the efficacy of digital therapeutic (DTx)-assisted management vs. multidisciplinary management (MM) in the perioperative management of patients with lung cancer.

METHODS

From July 2022 to June 2023, 186 minimally invasive lung surgery patients were randomized, and 147 completed the study. The participants were randomly assigned a 1:1 ratio to receive DTx-assisted management (n = 72) or traditional MM (n = 75). The primary endpoint was the pulmonary function recovery rate measured by forced expiratory volume in the first second (FEV1%) 3 weeks after surgery, and the noninferiority margin was set to 4.8%. The secondary endpoints included hospital stay duration, 90-day unplanned readmission rate, symptom scores, patient management time, and patient satisfaction rate. Exploratory endpoints include factors influencing postoperative lung function recovery.

RESULTS

The lung function FEV1% recovery rate of the DTx group was not inferior to that of the MM group (87.18% ± 11.01% vs. 84.21% ± 11.75%). There were no significant differences between the two groups in terms of postoperative hospitalization duration or 90-day unplanned readmission rates. The patient management time in the DTx group was significantly shorter than that in the MM group (1.48 ± 3.22 min vs. 16.67 ± 6.41 min, P < 0.001). Patient symptom scores tended to decrease over time after discharge, and the 5 target symptoms included pain, coughing, shortness of breath, disturbed sleep, and fatigue. On the 7th day after discharge, the DTx group had a lower occurrence rate of the 5 target symptoms triggering the alert threshold compared to the MM group (P = 0.002). Patients with higher education levels achieved a better FEV1% recovery rate with DTx-assisted management (P = 0.021).

CONCLUSIONS

Compared with the MM group, the DTx group achieved noninferior results in all evaluated clinically meaningful endpoints but was significantly more efficient in perioperative management, providing an alternative digitalized management mode for patients with lung cancer surgery.

TRIAL REGISTRATION

ChiCTR2200064723.

Reducing stroke-associated pneumonia through pulmonary rehabilitation in moderate-to-severe acute ischemic stroke

OBJECTIVES

This study investigated the effect of a comprehensive pulmonary rehabilitation (CPR) program on stroke-associated pneumonia (SAP) in patients with moderate-to-severe acute ischemic stroke (AIS) after thrombolysis.

METHODS

This study was a prospective randomized controlled intervention study. Eighty patients with moderate-to-severe AIS were divided into the conventional rehabilitation (CR) and CPR groups. Demographic and general clinical data were collected. Patients were evaluated by the Fatigue Severity Scale (FSS), Fugl-Meyer Assessment (FMA), and Fugl-Meyer balance (FMB). The incidence of pneumonia in the acute phase and the treatment efficacy were compared.

RESULTS

FSS scores at T1 and T2 (2 weeks and 4 weeks after treatment), FMA scores, and FMB scores were higher than those at T0 (first day of admission). FSS scores in the CPR group were lower, while FMA and FMB scores were higher than those in the CR group at T1 and T2. The incidence of pneumonia was 10.00% in the CPR group and 25.00% in the CR group. The rehabilitation effective rate was 92.50% in the CPR group and 80.00% in the CR group, but the proportion of rehabilitation effect in the CPR group was higher than that in the CR group.

CONCLUSIONS

CPR program improves fatigue and motor function and reduces the occurrence of SAP in AIS patients.

Effect of pulmonary rehabilitation on lung cancer surgery outcomes: a matched-case analysis

Pulmonary rehabilitation programs for COPD patients are extensively accessible throughout the UK and have demonstrated efficacy in enhancing outcomes, including recovery from exacerbations. Numerous lung cancer surgery patients possess COPD, and the surgery may be regarded as a definitive aggravation of COPD. It is ambiguous in practical application whether referral to pulmonary rehabilitation programs enhances surgical and patient-reported results. We want to address this topic by conducting a propensity-score analysis (PSA) of participants in an enriched cohort trial. Methods An enriched cohort research was conducted, providing rehabilitation both pre- and post-surgery pragmatically through local pulmonary rehabilitation providers for patients undergoing lung cancer resection, and compared to a contemporaneous control group receiving standard treatment. The study enrolled 873 participants (pulmonary rehabilitation (PR) n = 135, non-intervention or control (NG) n = 738). Regression analyses for exposed and unexposed matching, effect estimation, and standard error estimations were conducted.Results A total of 114 participants were matched PR (n = 57) and NG (n = 57). The multivariate-linear regression indicated a reduction in length of stay (LOS) of 0.2 days of LOS compared to the usual care group (EE = - 0.20), and that reduction could potentially go up to 1.8 days (95% CI = - 1.8-1.6). The multivariate log-binomial regression revealed that PR had a reduction of 60% postoperative pulmonary complications (PPC) rate (EE = - 0.60, 95% CI = - 1.8-0.5). Lastly, the multivariate-linear regression showed an improvement in quality of life 6 weeks and 6 months after surgery (QoL) in patients in PR, especially in the physical functioning score in which an improvement of 6.6% was noted for the PR group compared to the NG group following surgery (EE = 6.6). Conclusion Participation in "real world" pulmonary rehabilitation prior to and following surgery seems to yield improved patient and clinical results post-lung cancer surgery. Nonetheless, prompt access to pulmonary rehabilitation may be a significant challenge following COVID.

Smartphone application-based pulmonary rehabilitation in COPD: a multicentre randomised controlled trial

BACKGROUND

Pulmonary rehabilitation (PR) is an essential element of chronic obstructive pulmonary disease (COPD) management. However, access to conventional face-to-face PR programmes is limited.

METHODS

This multicentre, randomised controlled trial recruited patients with COPD from 18 sites in Germany and Switzerland, aiming to evaluate the impact of 12 weeks of a mobile app (intervention group; IVG) on quality of life, measured by COPD Assessment Test (CAT), and exercise capacity, assessed by 1-minute-sit-to-stand-test (1MSTST), compared with a control group (CTG) receiving 'enhanced standard-of-care'.

RESULTS

278 patients were included in the study with a median age of 65 years (IQR 60-70) and forced expiratory volume in 1 s 48% predicted (IQR 37-60). In the intention-to-treat analysis at week 12, CAT improved from baseline by median -4 points versus -3 points in the IVG versus CTG groups, respectively (difference: 0 points (95% CI: -1, 2); p=0.7); 1MSTST improved by 1 vs 2 repetitions, respectively (difference: 1 repetition (95% CI: 0, 2); p=0.12)). In a subset of the IVG, with patients grouped by application adherence (≥3 days/week for≥75% of the weeks), adherent users (40.4%) improved 1MSTST versus non-adherent users by median 2 repetitions (95% CI: 1, 3]; p=0.006. Application use did not raise any safety concerns.

CONCLUSIONS

Application-based PR improved outcomes in COPD compared with baseline, and adherent users improved exercise capacity more compared with non-adherent users. Although not statistically significant compared with enhanced standard-of-care, this study may support the use of this application for COPD management and addresses the healthcare challenge of access to PR interventions.

TRIAL REGISTRATION NUMBER

DRKS 00024390.

Application of Discrete Event Simulation Models for COPD Management: A Systematic Review

Background

This systematic review aims to comprehensively assess the current application of discrete event simulation (DES) models in managing chronic obstructive pulmonary disease (COPD). By synthesizing and analyzing multiple studies, we incorporate the latest evidence, evaluate research quality, identify gaps, and provide recommendations for the future application of DES in COPD management.

Methods

We systematically searched six electronic databases including PubMed, Web of Science, Embase, Cochrane, Econlit, and China National Knowledge Infrastructure (CNKI) for articles published up to August 22, 2024. Reference lists of the included articles were also manually checked. Depending on the study type, we assessed quality using either the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist or the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Practice Guidelines.

Results

Out of the 273 records identified, nine studies met the inclusion criteria. All of these studies focused on health economic evaluations using DES in COPD management, and were conducted in high-income countries. The studies were divided into three groups based on the modeling systems they used: cost-effectiveness analyses of different pharmacological treatments (n=3), economic evaluations of case detection strategies (n=3), and assessments of various interventions on COPD healthcare services (n=3). All studies reported model validation methods (n=9); however, only two studies performed subgroup analysis.

Conclusion

This review highlights the current use of DES in COPD management and suggests avenues for future research and resource allocation to enhance the effectiveness of COPD interventions.

Tuberculosis

Tuberculosis is a leading cause of death globally. Given the airborne transmission of tuberculosis, anybody can be infected, but people in high-incidence settings are more exposed. Risk of progression to disease is higher in the first years after infection, and in people with undernourishment, immunosuppression, or who smoke, drink alcohol, or have diabetes. Although cough, fever, and weight loss are hallmark symptoms, people with tuberculosis can be asymptomatic, so a high index of suspicion is required. Prompt diagnosis can be made by sputum examination (ideally with rapid molecular tests), but chest radiography can be helpful. Most people with disease can be treated with regimens of 6 months or less; longer regimens may be necessary for those with drug resistance. Central to successful treatment is comprehensive, person-centred care including addressing key determinants, such as undernourishment, smoking, and alcohol use, and optimising management of comorbidities, such as diabetes and HIV. Care should continue after treatment ends, as long-term sequelae are common. Prevention relies mostly on treatment with rifamycin-based regimens; current vaccines have limited efficacy. Ongoing research on shorter and safer regimens for infection and disease treatment, and simpler and more accurate diagnostic methods will be key for tuberculosis elimination.

Improvements of depression, anxiety, stress, and social support through a telerehabilitation system in discharged COVID-19 patients: a randomized controlled pilot study

INTRODUCTION

Post-acute COVID-19 patients who were discharged from hospitals during the epidemic faced significant challenges, not only physical sequelae, but also psychological distress, anxiety, and depression. It is already known that continued exercise improves psychosocial components, but few studies have explored the impact of multimodal rehabilitation programs, including therapeutic education, in this type of patient. There are no studies that explore the application of these programs through asynchronous telerehabilitation, which would open up new therapeutic windows.

METHODS

This pilot single-blinded randomized controlled trial included 35 post-discharge COVID-19 patients allocated to two intervention arms: an asynchronous telerehabilitation group (ATG) and a booklet-based rehabilitation group (BRG). The aim was to analyze the preliminary changes in depression, anxiety, stress, and social support comparing both groups.

RESULTS

The ATG exhibited statistically significant reductions in depression (p = 0.048) and stress (p = 0.033) compared to the BRG after intervention. While both groups showed improvements in psychosocial variables, the ATG demonstrated consistent lower depression levels at 3- and 6-month follow-ups (p = 0.010, p = 0.036 respectively) and notably higher social support at 3- and 6-month follow-ups (p = 0.038, p = 0.028 respectively).

DISCUSSION

This pilot study suggests that a multimodal rehabilitation program using asynchronous telerehabilitation provides substantial benefits in terms of alleviating psychological distress and improving social support in discharged COVID-19 patients. These data will enable for larger studies to confirm these results.