Prognosis and longitudinal changes of physical activity in idiopathic pulmonary fibrosis

Liver disease in germline mutations of telomere-related genes: Prevalence, clinical, radiological, pathological features, outcome, and risk factors

BACKGROUND AND AIM

Germline mutations of telomere-related genes (TRG) induce multiorgan dysfunction, and liver-specific manifestations have not been clearly outlined. We aimed to describe TRG mutations-associated liver diseases.

APPROACH AND RESULTS

Retrospective multicenter analysis of liver disease (transaminases > 30 IU/L and/or abnormal liver imaging) in patients with TRG mutations. Main measurements were characteristics, outcomes, and risk factors of liver disease in a TRG mutations cohort. The prevalence of liver disease was compared to a community-based control group (n = 1190) stratified for age and matched 1:3 for known risk factors of liver disease. Among 132 patients with TRG mutations, 95 (72%) had liver disease, with associated lung, blood, skin, rheumatological, and ophthalmological TRG diseases in 82%, 77%, 55%, 39%, and 30% of cases, respectively. Liver biopsy was performed in 52/95 patients, identifying porto-sinusoidal vascular disease in 48% and advanced fibrosis/cirrhosis in 15%. After a follow-up of 21 months (12-54), ascites, hepato-pulmonary syndrome, variceal bleeding, and HCC occurred in 14%, 13%, 13%, and 2% of cases, respectively. Five-year liver transplantation-free survival was 69%. A FIB-4 score ≥ 3·25 and ≥1 risk factor for cirrhosis were associated with poor liver transplantation-free survival. Liver disease was more frequent in patients with TRG mutations than in the paired control group [80/396, (20%)], OR 12.9 (CI 95%: 7.8-21.3, p < 0.001).

CONCLUSIONS

TRG mutations significantly increase the risk of developing liver disease. Although symptoms may be mild, they may be associated with severe disease. Porto-sinusoidal vascular disease and cirrhosis were the most frequent lesions, suggesting that the mechanism of action is multifactorial.

Validity and reliability of the Glittre-ADL test in individuals with idiopathic pulmonary fibrosis

BACKGROUND

Patients with idiopathic pulmonary fibrosis (IPF) often present with dyspnea, fatigue, and desaturation. These symptoms can be highly limiting, as they lead to a decrease in performing activities of daily living (ADL). Therefore, it is essential to evaluate the degree of functional limitation of these individuals.

OBJECTIVE

The present study aimed to evaluate the validity and reliability of the Glittre-ADL test (TGlittre) and its association with self-reported limitation in ADL and health-related quality of life (HRQoL) in patients with IPF.

METHODS

Twenty-seven individuals with IPF (60.5 ± 10.6 years), with forced vital capacity 2.26 ± 1.03 L (51.09 ± 20.62% of predicted) were assessed for the time spent in TGlittre, 6-minute walking distance (6MWD), limitation in ADL and HRQoL.

RESULTS

TGlittre was reliable (intraclass correlation coefficient3,1 = 0.96; P < .001); however, a learning effect of 10.6% was observed between the first and second execution of TGlittre. The time spent in TGlittre correlated with 6MWD, limitation in ADL, and disease-specific HRQoL (P < .05).

CONCLUSION

TGlittre is valid and reliable for assessing functional capacity in patients with IPF. Still, it presents a learning effect and should be performed twice when assessing functional capacity in clinical practice.

The impact of sleep duration on physical activity in daily life in patients with idiopathic pulmonary fibrosis

BACKGROUND

Despite the high prevalence of sleep disturbances in idiopathic pulmonary fibrosis (IPF), the relationship between physical activity in daily life (PADL) and sleep in this population remains unclear.

OBJECTIVES

Investigate the impact of sleep on different domains of PADL in IPF and characterize their PADL profile.

METHODS

Sixty-seven participants (thirty-three with IPF and thirty-four healthy subjects [control group]) were included. The subjects underwent assessments of pulmonary function, exercise capacity, respiratory and peripheral muscle strength, PADL, sleep, dyspnea, and health-related quality of life. PADL and sleep measures were assessed using an activity monitor (Actigraph®, wGT3x-BT). Associations between sleep and PADL were done using correlation and regression models.

RESULTS

In the IPF, sleep duration at night associated significantly with step counts, sedentary, light, and moderate-to-vigorous physical activity (MVPA) (-0.82 ≤ R ≤ 0.43; p < .05 for all). Lung function and sleep partially explained PADL variables (0.19 ≤ R2 ≤ 0.65, p < .05 for all). Compared to controls, the IPF subjects presented lower step counts, less time spent in MVPA, standing position, and more time spent in lying position (p < .05, for all).

CONCLUSIONS

Sleep duration is associated with PADL in IPF. The PADL profile of patients is worse than in control subjects.

Supporting self-management for patients with Interstitial Lung Diseases: Utility and acceptability of digital devices

INTRODUCTION

Patients diagnosed with Interstitial Lung Diseases (ILD) use devices to self-monitor their health and well-being. Little is known about the range of devices, selection, frequency and terms of use and overall utility. We sought to quantify patients' usage and experiences with home digital devices, and further evaluate their perceived utility and barriers to adaptation.

METHODS

A team of expert clinicians and patient partners interested in self-management approaches designed a 48-question cross-sectional electronic survey; specifically targeted at individuals diagnosed with ILD. The survey was critically appraised by the interdisciplinary self-management group at Royal Devon University Hospitals NHS Foundation Trust during a 6-month validation process. The survey was open for participation between September 2021 and December 2022, and responses were collected anonymously. Data were analysed descriptively for quantitative aspects and through thematic analysis for qualitative input.

RESULTS

104 patients accessed the survey and 89/104 (86%) reported a diagnosis of lung fibrosis, including 46/89 (52%) idiopathic pulmonary fibrosis (IPF) with 57/89 (64%) of participants diagnosed >3 years and 59/89 (66%) female. 52/65(80%) were in the UK; 33/65 (51%) reported severe breathlessness medical research council MRC grade 3-4 and 32/65 (49%) disclosed co-morbid arthritis or joint problems. Of these, 18/83 (22%) used a hand- held spirometer, with only 6/17 (35%) advised on how to interpret the readings. Pulse oximetry devices were the most frequently used device by 35/71 (49%) and 20/64 (31%) measured their saturations more than once daily. 29/63 (46%) of respondents reported home-monitoring brought reassurance; of these, for 25/63 (40%) a feeling of control. 10/57 (18%) felt it had a negative effect, citing fluctuating readings as causing stress and 'paranoia'. The most likely help-seeking triggers were worsening breathlessness 53/65 (82%) and low oxygen saturation 43/65 (66%). Nurse specialists were the most frequent source of help 24/63 (38%). Conclusion: Patients can learn appropriate technical skills, yet perceptions of home-monitoring are variable; targeted assessment and tailored support is likely to be beneficial.

Physical activity coaching in patients with interstitial lung diseases: A randomized controlled trial

OBJECTIVES

Physical activity is reduced in patients with interstitial lung disease (ILD) and physical inactivity is related to poor health outcomes. We investigated the effect of a telecoaching intervention to improve physical activity in patients with ILD.

METHODS

Eighty patients with ILD were randomized into the intervention or control group. Patients in the intervention group received a 12-week telecoaching program including a step counter, a patient-tailored smartphone application, and coaching calls. Patients in the control group received usual care. Physical activity (primary outcome), physical fitness and quality of life were measured at baseline and 12 weeks later with an accelerometer, 6-min walking test and quadriceps muscle force and the King's Brief Interstitial Lung Disease questionnaire (K-BILD).

RESULTS

Participation in telecoaching did not improve physical activity: between-group differences for step count: 386 ± 590 steps/day, p = .52; sedentary time: 4 ± 18 min/day, p = .81; movement intensity: 0.04 ± 0.05 m/s2, p = .45). Between-group differences for the 6-min walking test, quadriceps muscle force and K-BILD were 14 ± 10 m, p = .16; 2 ± 3% predicted, p = .61; 0.8 ± 1.7 points, p = .62 respectively.

CONCLUSIONS

Twelve weeks of telecoaching did not improve physical activity, physical fitness or quality of life in patients with ILD. Future physical or behavioural interventions are needed for these patients to improve physical activity.

Machine learning to detect, stage and classify diseases and their symptoms based on inertial sensor data: a mapping review

This article presents a systematic review aimed at mapping the literature published in the last decade on the use of machine learning (ML) for clinical decision-making through wearable inertial sensors. The review aims to analyze the trends, perspectives, strengths, and limitations of current literature in integrating ML and inertial measurements for clinical applications. The review process involved defining four research questions and applying four relevance assessment indicators to filter the search results, providing insights into the pathologies studied, technologies and setups used, data processing schemes, ML techniques applied, and their clinical impact. When combined with ML techniques, inertial measurement units (IMUs) have primarily been utilized to detect and classify diseases and their associated motor symptoms. They have also been used to monitor changes in movement patterns associated with the presence, severity, and progression of pathology across a diverse range of clinical conditions. ML models trained with IMU data have shown potential in improving patient care by objectively classifying and predicting motor symptoms, often with a minimally encumbering setup. The findings contribute to understanding the current state of ML integration with wearable inertial sensors in clinical practice and identify future research directions. Despite the widespread adoption of these technologies and techniques in clinical applications, there is still a need to translate them into routine clinical practice. This underscores the importance of fostering a closer collaboration between technological experts and professionals in the medical field.

Physical activity measurements in individuals with interstitial lung disease: a systematic review and meta-analysis

BACKGROUND

Physical activity (PA) measurements are becoming common in interstitial lung disease (ILD); however, standardisation has not been achieved. We aimed to systematically review PA measurement methods, present PA levels and provide practical recommendations on PA measurement in ILD.

METHODS

We searched four databases up to November 2022 for studies assessing PA in ILD. We collected information about the studies and participants, the methods used to measure PA, and the PA metrics. Studies were scored using 12 items regarding PA measurements to evaluate the reporting quality of activity monitor use.

RESULTS

In 40 of the included studies, PA was measured using various devices or questionnaires with numerous metrics. Of the 33 studies that utilised activity monitors, a median of five out of 12 items were not reported, with the definition of nonwear time being the most frequently omitted. The meta-analyses showed that the pooled means (95% CI) of steps, time spent in moderate to vigorous PA, total energy expenditure and sedentary time were 5215 (4640-5791) steps·day^-1, 82 (58-106) min·day^-1, 2130 (1847-2412) kcal·day^-1 and 605 (323-887) min·day^-1, respectively, with considerable heterogeneity.

CONCLUSION

The use of activity monitors and questionnaires in ILD lacks consistency. Improvement is required in the reporting quality of PA measurement methods using activity monitors.

Holistic management of patients with progressive pulmonary fibrosis

Progressive pulmonary fibrosis (PF) is a complex interstitial lung disease that impacts substantially on patients' daily lives, requiring personalised and integrated care. We summarise the main needs of patients with PF and their caregivers, and suggest a supportive care approach. Individualised care, education, emotional and psychological support, specialised treatments, and better access to information and resources are necessary. Management should start at diagnosis, be tailored to the patient's needs, and consider end-of-life care. Pharmacological and non-pharmacological interventions should be individualised, including oxygen therapy and pulmonary rehabilitation, with digital healthcare utilised as appropriate. Further research is needed to address technical issues related to oxygen delivery and digital healthcare.

Educational aims

To identify the main needs of patients with PF and their caregivers.To describe the components of a comprehensive approach to a supportive care programme for patients with PF.To identify further areas of research to address technical issues related to the management of patients with PF.

The interplay of physical and cognitive function in rehabilitation of interstitial lung disease patients: a narrative review

Background and Objective

Interstitial lung disease (ILD) encompasses several diverse pulmonary pathologies that result in abnormal diffuse parenchymal changes. When prescribing rehabilitation, several additional factors need to be considered as a result of aging, polypharmacy, and comorbidities manifested in ILD patients. This review aims to discuss issues related to frailty, skeletal muscle and cognitive function that limit physical activities in ILD patients. It will also highlight exercise training and propose complementary strategies for pulmonary rehabilitation.

Methods

A literature search was performed in MEDLINE, CINAHL (inception to October 19th, 2022) using search terms based on concepts of: idiopathic pulmonary fibrosis or interstitial lung disease; frailty; muscular atrophy; skeletal muscle dysfunction; cognitive dysfunction; sleep quality; sleep disorders; anxiety disorders; or depressive disorders. After eligible texts were screened, additional references were included from references cited in the screened articles.

Key Content and Findings

Frailty and skeletal muscle dysfunction are common in ILD. Weight loss, exhaustion, and anti-fibrotic medications can impact frailty, whereas physical inactivity, aging, corticosteroids and hypoxemia can contribute to sarcopenia (loss of muscle mass and function). Frailty is associated with worse clinical status, exercise intolerance, skeletal muscle dysfunction, and decreased quality of life in ILD. Sarcopenia appears to influence wellbeing and can potentially affect overall physical conditioning, cognitive function and the progression of ILD. Optimal assessment tools and effective strategies to prevent and counter frailty and sarcopenia need to be determined in ILD patients. Even though cognitive impairment is evident in ILD, its prevalence and underlying neurobiological model of contributing factors (i.e., inflammation, disease severity, cardiopulmonary status) requires further investigation. How ILD affects cognitive interference, motor control and consequently physical daily activities is not well defined. Strategies such as pulmonary rehabilitation, which primarily focuses on strength and aerobic conditioning have demonstrated improvements in ILD patient outcomes. Future incorporation of interval training and the integration of motor learning could improve transfer of rehabilitation strategies to daily activities.

Conclusions

Numerous underlying etiologies of ILD contribute to frailty, skeletal muscle and cognitive function, but their respective neurobiologic mechanisms require further investigation. Exercise training increases physical measures, but complementary approaches may improve their applicability to improve daily activities.

Influence of home-based pulmonary rehabilitation program among people with interstitial lung disease: A pre-post study

INTRODUCTION

Access to interstitial lung disease programs may not be available in rural settings. Home-based pulmonary rehabilitation (PR) programs have been proposed as an alternative to hospital-based programs.

METHOD

Forty participants with ILD underwent a structured unsupervised home-based pulmonary rehabilitation program from September 2020 to September 2022. Quality of life was assessed using St. George Respiratory Questionnaire (SGRQ) and functional capacity using 6-minute walk test (6MWT). The outcome measures were assessed at baseline and 4 weeks post-unsupervised home-based PR program.

RESULT

We recruited 40 participants with ILD. There was statistically significant improvement in the 6-minute walk distance (353.8 m and 368 m, effect size - 0.5, p ≤ .001) and quality of life using SGRQ total score (38.6 and 42.35, effect size - 2.5, p ≤ .001) between before and after receiving home-based PR among all 40 participants with ILD.

CONCLUSION

Four weeks of home-based PR program, using minimal resources, deliver short-term improvements in functional exercise capacity and quality of life among ILD participants. Our home-based PR program resulted in a quarter percentage improvement in functional capacity, and we believe that if consistency is maintained, it will result in similar changes corresponding to the already established Minimal Clinically Important Difference (MCID) of 35 m.

Clinical Impact of Physical Activity and Cough on Disease Progression in Fibrotic Interstitial Lung Disease

Physical activity limitations and cough are common in patients with interstitial lung disease (ILD), potentially leading to reduced health-related quality of life. We aimed to compare physical activity and cough between patients with subjective, progressive idiopathic pulmonary fibrosis (IPF) and fibrotic non-IPF ILD. In this prospective observational study, wrist accelerometers were worn for seven consecutive days to track steps per day (SPD). Cough was evaluated using a visual analog scale (VAS_cough) at baseline and weekly for six months. We included 35 patients (IPF: n = 13; non-IPF: n = 22; mean ± SD age 61.8 ± 10.8 years; FVC 65.3 ± 21.7% predicted). Baseline mean ± SD SPD was 5008 ± 4234, with no differences between IPF and non-IPF ILD. At baseline, cough was reported by 94.3% patients (mean ± SD VAS_cough 3.3 ± 2.6). Compared to non-IPF ILD, patients with IPF had significantly higher burden of cough (p = 0.020), and experienced a greater increase in cough over six months (p = 0.009). Patients who died or underwent lung transplantation (n = 5), had significantly lower SPD (p = 0.007) and higher VAS_cough (p = 0.047). Long-term follow up identified VAS_cough (HR: 1.387; 95%-CI 1.081-1.781; p = 0.010) and SPD (per 1000 SPD: HR 0.606; 95%-CI: 0.412-0.892; p = 0.011) as significant predictors for transplant-free survival. In conclusion, although activity didn't differ between IPF and non-IPF ILD, cough burden was significantly greater in IPF. SPD and VAS_cough differed significantly in patients who subsequently experienced disease progression and were associated with long-term transplant-free survival, calling for better acknowledgement of both parameters in disease management.

Clinical impact of weight loss on mortality in patients with idiopathic pulmonary fibrosis: a retrospective cohort study

Patients with idiopathic pulmonary fibrosis (IPF) often experience weight loss during the follow-up period. However, the prevalence and clinical impact of weight loss in these patients still need to be elucidated. This retrospective single-center study reviewed 134 consecutive patients diagnosed with IPF. Weight loss of 5% or more over 1 year was defined as significant weight loss. Clinical data of patients were compared according to the significant weight loss. We analyzed whether the clinical impact of significant weight loss differed regarding the pirfenidone dose. The median follow-up period was 22.1 months. The mean age of patients was 67.3 years, and 92.5% were men. Of the 134 patients, 42 (31.3%) showed significant weight loss. Multivariate cox regression analysis revealed that significant weight loss was independently associated with mortality (hazard ratio [HR]; 2.670; 95% confidence interval [CI] 1.099-6.484; p = 0.030) after adjusting for lung function and other significant risk factors (6-min walk test distance: HR, 0.993; 95% CI 0.987-0.998; p = 0.005). The median survival of patients with significant weight loss (n = 22) was relevantly shorter than that of those without significant weight loss (n = 43) in the reduced dose pirfenidone group (28.2 ± 3.3 vs. 43.3 ± 3.2 months, p = 0.013). Compared with patients without significant weight loss (n = 38), patients with significant weight loss (n = 15) also showed a marginally-significant shorter survival in the full-dose pirfenidone group (28.9 ± 3.1 vs. 39.8 ± 2.6 months, p = 0.085). Significant weight loss is a prognostic factor in patients with IPF regardless of pirfenidone dose. Vigilant monitoring might be necessary to detect weight loss during the clinical course in these patients.

Home monitoring in interstitial lung diseases

The widespread use of smartphones and the internet has enabled self-monitoring and more hybrid-care models. The COVID-19 pandemic has further accelerated remote monitoring, including in the heterogenous and often vulnerable group of patients with interstitial lung diseases (ILDs). Home monitoring in ILD has the potential to improve access to specialist care, reduce the burden on health-care systems, improve quality of life for patients, identify acute and chronic disease worsening, guide treatment decisions, and simplify clinical trials. Home spirometry has been used in ILD for several years and studies with other devices (such as pulse oximeters, activity trackers, and cough monitors) have emerged. At the same time, challenges have surfaced, including technical, analytical, and implementational issues. In this Series paper, we provide an overview of experiences with home monitoring in ILD, address the challenges and limitations for both care and research, and provide future perspectives. VIDEO ABSTRACT.

Physical activity in idiopathic pulmonary fibrosis: Longitudinal change and minimal clinically important difference

BACKGROUND AND OBJECTIVE

Reference values of physical activity to interpret longitudinal changes are not available in patients with idiopathic pulmonary fibrosis (IPF). This study aimed to define the minimal clinical important difference (MCID) of longitudinal changes in physical activity in patients with IPF.

METHODS

Using accelerometry, physical activity (steps per day) was measured and compared at baseline and 6-months follow-up in patients with IPF. We calculated MCID of daily step count using multiple anchor-based and distribution-based methods. Forced vital capacity and 6-minute walk distance were applied as anchors in anchor-based methods. Effect size and standard error of measurement were used to calculate MCID in distribution-based methods.

RESULTS

One-hundred and five patients were enrolled in the study (mean age: 68.5 ± 7.5 years). Step count significantly decreased from baseline to 6-months follow-up (-461 ± 2402, p = .031). MCID calculated by anchor-based and distribution-based methods ranged from 570-1358 steps.

CONCLUSION

Daily step count significantly declined over 6-months in patients with IPF. MCID calculated by multiple anchor-based and distribution-based methods was 570 to 1358 steps/day. These findings contribute to interpretation of the longitudinal changes of physical activity that will assist its use as a clinical and research outcome in patients with IPF.

Efficacy and safety of traditional Chinese medicine treatment for idiopathic pulmonary fibrosis: An exploratory, randomized, double-blinded and placebo controlled trial

Background and objective: Idiopathic pulmonary fibrosis (IPF) is a critical disease, with limited treatments available. Clinical practices show that traditional Chinese medicine (TCM) has certain efficacy. This study was preliminarily to evaluate the efficacy and safety of TCM treatment based on syndrome differentiation in IPF. Methods: A study design of exploratory, multi-centers, randomized, double-blinded, placebo controlled trial has been adopted. A total of 80 IPF patients from four sub-centers were enrolled. All the patients were randomly assigned into TCM group (TCMG) or control group (CG) in 1:1. Patients in TCMG were given CM granules, as patients in CG given with the placebo of CM granule. All the patients received a 26-week treatment. The efficacy was assessed by acute exacerbations (AEs) of IPF, pulmonary function, clinical symptoms, dyspnea scores (mMRC), health-related quality of life (HRQoL), 6-min walk test (6MWT) and all-cause mortality. Safety has also been assessed. Results: A total of 67 patients completed the trial with 35 in TCM group and 32 in control group. Meaningful differences have been observed in mean changes in AEs (-1.56 times; 95% CI, -2.69 to -0.43, p = 0.01), DLco% (5.29; 95% CI, 0.76 to 9.81, p = 0.02), cough scores (-0.38 points; 95% CI, -0.73 to -0.04, p = 0.03), and 6MWT (30.43 m; 95% CI, 2.85 to 58.00, p = 0.03), with no statistical differences in FEV1, FVC, expectoration, chest tightness, Shortness of breath, Fatigue, Cyanosis, mMRC, CAT, SF-36, and SGRQ total scores in 26 weeks after treatment than before treatment. At of the end of follow-up, a total of 10 patients died, including three and seven in the TCM and control group respectively. And the HR (Hazard ratio) for CM granules in all-cause mortality was 0.39 (95% CI, 0.10-1.52). The drug-related adverse events were not observed. Conclusion: CM granules, as compared with placebo, could reduce frequencies of AEs, improve pulmonary function, HRQoL, exercise capacity and symptoms and signs for IPF to some extent with acceptable side-effect.

Predictors and changes of physical activity in idiopathic pulmonary fibrosis

Background

Different clinical predictors of physical activity (PA) have been described in idiopathic pulmonary fibrosis (IPF), but studies are lacking evaluating the potential role of muscle strength and anxiety and depression symptoms in PA limitation. Moreover, little is known about the impact of changes in PA in the course of the disease. The aim of the present study was to investigate the relationship between baseline PA and a wide range of variables in IPF, to assess its longitudinal changes at 12 months and its impact on progression free-survival.

Methods

PA was assessed by accelerometer and physiological, clinical, psychological factors and health-related quality of life were evaluated in subjects with IPF at baseline and at 12 month follow-up. Predictors of PA were determined at baseline, evolution of PA parameters was described and the prognostic role of PA evolution was also established.

Results

Forty participants with IPF were included and 22 completed the follow-up. At baseline, subjects performed 5765 (3442) daily steps and spent 64 (44) minutes/day in moderate to vigorous PA. Multivariate regression models showed that at baseline, a lower six-minute walked distance, lower quadriceps strength (QMVC), and a higher depression score in the Hospital Anxiety and Depression scale were associated to lower daily step number. In addition, being in (Gender-Age-Physiology) GAP III stage, having a BMI ≥ 25 kg/m² and lower QMVC or maximum inspiratory pressure were factors associated with sedentary behaviour. Adjusted for age, gender and forced vital capacity (FVC) (%pred.) a lower progression-free survival was evidenced in those subjects that decreased PA compared to those that maintained, or even increased it, at 12 months [HR 12.1 (95% CI, 1.9–78.8); p = 0.009].

Conclusion

Among a wide range of variables, muscle strength and depression symptoms have a predominant role in PA in IPF patients. Daily PA behaviour and its evolution should be considered in IPF clinical assessment and as a potential complementary indicator of disease prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02134-4.

Dyspnea and outcome expectations are associated with physical activity in persons with pneumoconiosis: a cross-sectional study

Background

There are various reports on factors associated with physical activity in patients with chronic respiratory diseases. However, there are no studies on the relationship between physical activity and psychological or environmental factors. In this study, we investigated the relationship between physical activity and psychological and environmental factors using questionnaires for patients with pneumoconiosis.

Methods

This cross-sectional study included patients with pneumoconiosis who underwent a pneumoconiosis health examination in 2019. A self-administered questionnaire was used to conduct the study. Physical activity was evaluated using the International Physical Activity Questionnaire, and subjective symptoms [dyspnea and quality of life (QOL)], environmental factors (environment around home and life space), psychological factors (depression, stage of change, self-efficacy, decisional balance, and outcome expectations), and others (e.g., experience with pulmonary rehabilitation) were investigated.

Results

The number of respondents in the study was 185 (men: 171, women: 14). Age, dyspnea, stage of change, self-efficacy, outcome expectations, QOL, depression, decisional balance, and life space were significantly correlated with physical activity. In the multivariate analysis, outcome expectations and dyspnea were extracted as independent factors. In the path analysis, outcome expectations and dyspnea had a direct influence on physical activity. Dyspnea directly impacted not only physical activity but also outcome expectations, stage of change, QOL, life space, and depression.

Conclusions

Dyspnea and outcome expectations were associated with physical activity in patients with pneumoconiosis. To improve physical activity in pneumoconiosis patients, it was suggested that it may be necessary to improve dyspnea and promote an understanding of physical activity.

Home monitoring of physiology and symptoms to detect interstitial lung disease exacerbations and progression: a systematic review

Background

Acute exacerbations (AEs) and disease progression in interstitial lung disease (ILD) pose important challenges to clinicians and patients. AEs of ILD are variable in presentation but may result in rapid progression of ILD, respiratory failure and death. However, in many cases AEs of ILD may go unrecognised so that their true impact and response to therapy is unknown. The potential for home monitoring to facilitate early, and accurate, identification of AE and/or ILD progression has gained interest. With increasing evidence available, there is a need for a systematic review on home monitoring of patients with ILD to summarise the existing data. The aim of this review was to systematically evaluate the evidence for use of home monitoring for early detection of exacerbations and/or progression of ILD.

Method

We searched Ovid-EMBASE, MEDLINE and CINAHL using Medical Subject Headings (MeSH) terms in accordance with the PRISMA guidelines (PROSPERO registration number CRD42020215166).

Results

13 studies involving 968 patients have demonstrated that home monitoring is feasible and of potential benefit in patients with ILD. Nine studies reported that mean adherence to home monitoring was >75%, and where spirometry was performed there was a significant correlation (r=0.72–0.98, p<0.001) between home and hospital-based readings. Two studies suggested that home monitoring of forced vital capacity might facilitate detection of progression in idiopathic pulmonary fibrosis.

Conclusion

Despite the fact that individual studies in this systematic review provide supportive evidence suggesting the feasibility and utility of home monitoring in ILD, further studies are necessary to quantify the potential of home monitoring to detect disease progression and/or AEs.

First systematic review that provides supportive evidence for the feasibility and utility of home monitoring in ILD; further studies are necessary to evaluate approaches to detect exacerbation and/or progressionhttps://bit.ly/2Y8OCJL

A Phase-2 Exploratory Randomized Controlled Trial of INOpulse in Patients with Fibrotic Interstitial Lung Disease Requiring Oxygen

RATIONALE

Patients with fibrotic interstitial lung disease often progress to the point of requiring supplemental oxygen. This is invariably accompanied by an impaired quality of life and limitations on activities of daily living.

OBJECTIVE

This study aimed to assess the improvement in physical activity in patients with interstitial lung disease requiring supplemental oxygen treated with pulsed inhaled nitric oxide (iNO) via INOpulse. Additionally, it sought to explore the safety and clinical benefits of INOpulse on multiple patient reported outcomes.

METHODS

Ambulatory fibrotic lung disease patients on supplemental oxygen were randomized in a 2:1 ratio to iNO at 45 µg/kg ideal body weight (IBW)/hr (iNO45) or placebo for four months (3 months post-baseline) of blinded treatment. The study assessed multiple exploratory efficacy endpoints including moderate-to vigorous physical activity (MVPA) as measured by actigraphy and patient reported outcomes using the UCSD Shortness of Breath Questionnaire (UCSD SOBQ) and the St. George's Respiratory Questionnaire (SGRQ).

RESULTS

44 patients (30 iNO45, 14 placebo) were enrolled. A placebo-corrected clinical benefit of 12.3-minutes per day increase in MVPA was observed in the iNO45 group. Clinically meaningful beneficial trends were observed for the UCSD SOBQ (6.05 points) and the SGRQ Total (3.75) scores, as well as the SGRQ activity (5.84), and SGRQ Impact (6.30) domains.

CONCLUSIONS

INOpulse was well tolerated and associated with maintenance of physical activity and improved symptomatology in patients with interstitial lung disease who require supplemental oxygen. Further validation of this beneficial effect warrants further study in a phase 3 trial that is currently underway. Clinical Trial Registration with ClinicalTrials.gov: NCT03267108 Primary Source of Funding: Bellerophon Therapeutics.

Relationship between body composition, exercise capacity and health-related quality of life in idiopathic pulmonary fibrosis

INTRODUCTION

Bioelectrical impedance analysis (BIA) can be used to estimate Fat-Free Mass Index (FFMI). However, the use of directly measured BIA variables, such as phase angle (PhA), has gained attention. The frequency of low FFMI and PhA and its associations with exercise capacity and health-related quality of life (HRQL) in patients with idiopathic pulmonary fibrosis (IPF) have been scarcely studied.

OBJECTIVES

To investigate the frequency of low FFMI and PhA and their associations with exercise capacity and HRQL in patients with IPF.

METHODS

Patients underwent assessment of lung function, body composition, exercise capacity by the 6 min walk distance (6MWD), and HRQL by the Medical Outcomes Study Short-Form 36-item Questionnaire (SF-36). Patients were classified as presenting normal or low PhA or FFMI, accordingly to the 10th percentiles of age-sex-body mass index (BMI)-specific reference values.

RESULTS

98 patients (84 males, age: 68±8 years, forced vital capacity: 64%±18%predicted) were included. 24 patients presented low PhA. They were characterised by worse lung function, exercise capacity and HRQL compared with patients with normal PhA. 10 patients presented low FFMI, but despite differences in body composition, no differences were found between these patients and patients with normal FFMI. In a single regression analysis, age, lung function and body composition variables (except FFMI) were related to 6MWD and SF-36 Physical Summary Score (R²=0.06-0.36, p<0.05). None of the variables were related to SF-36 Mental Summary Score.

CONCLUSION

One-fourth of the patients with IPF with normal to obese BMI present abnormally low PhA. Patients classified as low PhA presented worse lung function, exercise capacity and HRQL.

[Linguistic Validation of the "German Lung Fibrosis Health Related Quality of Life Questionnaire"]

Health status and quality of life are impaired in patients with idiopathic pulmonary fibrosis (IPF) and idiopathic non-specific interstitial fibrosis (iNSIP). In Germany exists only the K-BILD questionnaire for patients with ILD 1 in a professional translation by Kreuter et al. 2 This questionnaire focuses on the main problems in patients with progressive lung fibrosis in a limited manner. Therefore a new quality of life questionnaire for patients with idiopathic pulmonary fibrosis was developed and linguistically validated.

METHODS

 The linguistic validation of our questionnaire was carried out in a multistage process in collaboration with the developer of the questionnaire and bilingual, professional translators. Review by the developers and back translations as well as clinical assessment by IPF- and iNSIP-patients ensured that the translated questionnaire reflected the intention of the original English version of our questionnaire.Cross-validation was carried out with the St. Georges Respiratory Questionnaire (SGRQ).

RESULTS

 The new questionnaire concerning the health status was composed in English and German language. The questions cover five scales (sensitivity, selectivity and symptoms like breathlessness and cough and a visual analog scale on general health status) with 23 items.

CONCLUSIONS

 The results show that the FFB maps the special needs of the patients with IPF and iNSIP well and can support clinical and scientific questions and can be helpful in monitoring the clinical course.

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

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

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

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

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

Physical activity decline is disproportionate to decline in pulmonary physiology in IPF

BACKGROUND AND OBJECTIVE

Patients with idiopathic pulmonary fibrosis (IPF) have reduced levels of daily physical activity (DPA); however, little is known about how DPA changes as disease progresses. We aimed to (i) describe change in DPA over 12 months, (ii) analyse its association with conventional markers of disease severity and quality of life and (iii) assess DPA as a prognostic tool.

METHODS

A total of 54 patients with IPF had DPA monitored at baseline and at 6 and 12 months with a SenseWear armband for 7 consecutive days. Participants completed the Hospital Anxiety and Depression scale, St George's Respiratory Questionnaire and Leicester Cough Questionnaire at each time point and provided clinical data including forced vital capacity (FVC), diffusion capacity of carbon monoxide and 6-min walk distance (6MWD).

RESULTS

Baseline and 12-month daily step count (DSC) were 3887 (395) and 3326 (419), respectively. A significant reduction in DSC (mean = 645 [260], p = 0.02) and total energy expenditure (mean = 486 kJ [188], p = 0.01) was demonstrated at 12 months. The decline in DSC over 12 months was proportionally larger than decline in lung function. Annual change in DPA had weak to moderate correlation with annual change in FVC % predicted and 6MWD (range r = 0.34-0.45). Change in physical activity was not associated with long-term survival.

CONCLUSION

In IPF, decline in DPA over 12 months is significant and disproportionate to decline in pulmonary physiology and may be a useful tool for assessment of disease progression.

Patient-centered Outcomes Research in Interstitial Lung Disease: An Official American Thoracic Society Research Statement

Background: In the past two decades, many advances have been made to our understanding of interstitial lung disease (ILD) and the way we approach its treatment. Despite this, many questions remain unanswered, particularly those related to how the disease and its therapies impact outcomes that are most important to patients. There is currently a lack of guidance on how to best define and incorporate these patient-centered outcomes in ILD research. Objectives: To summarize the current state of patient-centered outcomes research in ILD, identify gaps in knowledge and research, and highlight opportunities and methods for future patient-centered research agendas in ILD. Methods: An international interdisciplinary group of experts was assembled. The group identified top patient-centered outcomes in ILD, reviewed available literature for each outcome, highlighted important discoveries and knowledge gaps, and formulated research recommendations. Results: The committee identified seven themes around patient-centered outcomes as the focus of the statement. After a review of the literature and expert committee discussion, we developed 28 research recommendations. Conclusions: Patient-centered outcomes are key to ascertaining whether and how ILD and interventions used to treat it affect the way patients feel and function in their daily lives. Ample opportunities exist to conduct additional work dedicated to elevating and incorporating patient-centered outcomes in ILD research.

Cutoff Points for Step Count to Predict 1-year All-Cause Mortality in Patients with Idiopathic Pulmonary Fibrosis

BACKGROUND

Although physical activity is associated with mortality in patients with idiopathic pulmonary fibrosis (IPF), reference values to interpret levels of physical activity are lacking.

OBJECTIVES

This study aimed to investigate the prognostic significance of physical activity assessed by step count and its cutoff points for all-cause mortality.

METHODS

We measured physical activity (steps per day) using an accelerometer in patients with IPF at the time of diagnosis. Relationships among physical activity and mortality, as well as cutoff points of daily step count to predict all-cause mortality were examined.

RESULTS

Eighty-seven patients (73 males) were enrolled. Forty-four patients (50.1%) died during the follow-up (median 54 months). In analysis adjusting for Gender-Age-Physiology stage and 6-min walk distance, daily step count was an independent predictor of all-cause mortality (hazard ratio (HR) = 0.820, 95% confidence interval (CI) = 0.694-0.968, p = 0.019). The optimal cutoff point (receiving operating characteristic analysis) for 1-year mortality was 3,473 steps per day (sensitivity = 0.818 and specificity = 0.724). Mortality was significantly lower in patients with a daily step count exceeding 3,473 steps than in those whose count was 3,473 or less (HR = 0.395, 95% CI = 0.218-0.715, p = 0.002).

CONCLUSIONS

Step count, an easily interpretable measurement, was a significant predictor of all-cause mortality in patients with IPF. At the time of diagnosis, a count that exceeded the cutoff point of 3,473 steps/day more than halved mortality. These findings highlight the importance of assessing physical activity in this patient population.

Idiopathic pulmonary fibrosis beyond the lung: understanding disease mechanisms to improve diagnosis and management

Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive disorder with an estimated median survival time of 3–5 years after diagnosis. This condition occurs primarily in elderly subjects, and epidemiological studies suggest that the main risk factors, ageing and exposure to cigarette smoke, are associated with both pulmonary and extrapulmonary comorbidities (defined as the occurrence of two or more disorders in a single individual). Ageing and senescence, through interactions with environmental factors, may contribute to the pathogenesis of IPF by various mechanisms, causing lung epithelium damage and increasing the resistance of myofibroblasts to apoptosis, eventually resulting in extracellular matrix accumulation and pulmonary fibrosis. As a paradigm, syndromes featuring short telomeres represent archetypal premature ageing syndromes and are often associated with pulmonary fibrosis. The pathophysiological features induced by ageing and senescence in patients with IPF may translate to pulmonary and extrapulmonary features, including emphysema, pulmonary hypertension, lung cancer, coronary artery disease, gastro-oesophageal reflux, diabetes mellitus and many other chronic diseases, which may lead to substantial negative consequences in terms of various outcome parameters in IPF. Therefore, the careful diagnosis and treatment of comorbidities may represent an outstanding chance to improve quality of life and survival, and it is necessary to contemplate all possible management options for IPF, including early identification and treatment of comorbidities.

Associations between Patient-reported Outcomes and Death or Lung Transplant in Idiopathic Pulmonary Fibrosis. Data from the Idiopathic Pulmonary Fibrosis Prospective Outcomes Registry

Rationale: Progression of idiopathic pulmonary fibrosis (IPF) is accompanied by worsening of symptoms, exercise capacity, and health-related quality of life. However, the utility of patient-reported outcomes as predictors of mortality remains uncertain.Objectives: To assess whether patient-reported outcomes are independently associated with mortality beyond clinical risk factors in patients with IPF.Methods: Data from the observational IPF Prospective Outcomes Registry were used to examine associations between patient-reported outcomes at enrollment and the composite outcome of death or lung transplant in the following year. Associations were examined using univariable models and models adjusted for age and clinical variables that have been associated with death or lung transplant in patients with IPF in this cohort (oxygen use, forced vital capacity % predicted, and diffusing capacity of the lungs for carbon monoxide % predicted at enrollment).Results: Among 662 patients, 45 died and 12 underwent lung transplant over 1 year. In the model adjusted for age and clinical variables that were associated with death or lung transplant, worse scores on the St. George's Respiratory Questionnaire (SGRQ) total score (hazard ratio [HR], 1.22 [95% confidence interval (CI), 1.01-1.48] per 10-point increase), SGRQ activity score (HR, 1.25 [95% CI, 1.02-1.54] per 10-point increase) and SGRQ symptoms score (HR, 1.17 [95% CI, 1.01-1.36] per 10-point increase) were associated with death or lung transplant over 1 year.Conclusions: Patient-reported outcomes that assess symptoms and physical activity are independently associated with mortality in patients with IPF.

Outcome of Hospitalization for COVID-19 in Patients with Interstitial Lung Disease. An International Multicenter Study

Rationale: The impact of coronavirus disease (COVID-19) on patients with interstitial lung disease (ILD) has not been established.Objectives: To assess outcomes in patients with ILD hospitalized for COVID-19 versus those without ILD in a contemporaneous age-, sex-, and comorbidity-matched population.Methods: An international multicenter audit of patients with a prior diagnosis of ILD admitted to the hospital with COVID-19 between March 1 and May 1, 2020, was undertaken and compared with patients without ILD, obtained from the ISARIC4C (International Severe Acute Respiratory and Emerging Infection Consortium Coronavirus Clinical Characterisation Consortium) cohort, admitted with COVID-19 over the same period. The primary outcome was survival. Secondary analysis distinguished idiopathic pulmonary fibrosis from non-idiopathic pulmonary fibrosis ILD and used lung function to determine the greatest risks of death.Measurements and Main Results: Data from 349 patients with ILD across Europe were included, of whom 161 were admitted to the hospital with laboratory or clinical evidence of COVID-19 and eligible for propensity score matching. Overall mortality was 49% (79/161) in patients with ILD with COVID-19. After matching, patients with ILD with COVID-19 had significantly poorer survival (hazard ratio [HR], 1.60; confidence interval, 1.17-2.18; P = 0.003) than age-, sex-, and comorbidity-matched controls without ILD. Patients with an FVC of <80% had an increased risk of death versus patients with FVC ≥80% (HR, 1.72; 1.05-2.83). Furthermore, obese patients with ILD had an elevated risk of death (HR, 2.27; 1.39-3.71).Conclusions: Patients with ILD are at increased risk of death from COVID-19, particularly those with poor lung function and obesity. Stringent precautions should be taken to avoid COVID-19 in patients with ILD.

Analysis of body mass index, weight loss and progression of idiopathic pulmonary fibrosis

BACKGROUND

Nintedanib is an approved therapy for idiopathic pulmonary fibrosis (IPF). Some patients treated with nintedanib experience weight loss. Exploratory data suggest that low body mass index or weight loss are associated with worse outcomes in patients with IPF. We investigated whether BMI at baseline or weight loss over 52 weeks was associated with FVC decline, or influenced the effect of nintedanib, in patients with IPF.

METHODS

Using pooled data from the two INPULSIS trials, we analysed the rate of decline in FVC (mL/yr) over 52 weeks in patients treated with nintedanib and placebo in subgroups by baseline BMI (< 25; ≥25 to < 30; ≥30 kg/m²) and by weight loss over 52 weeks (≤5; > 5%) using random coefficient regression.

RESULTS

In the placebo group, the mean rate of FVC decline over 52 weeks was numerically greater in patients with lower baseline BMI (- 283.3 [SE 22.4], - 207.9 [20.9] and - 104.5 [21.4] in patients with BMI < 25 kg/m², ≥25 to < 30 kg/m² and ≥ 30 kg/m², respectively). Nintedanib reduced the rate of FVC decline versus placebo in all subgroups by BMI, with a consistent treatment effect across subgroups (interaction p = 0.31). In the placebo group, the mean rate of FVC decline was numerically greater in patients with > 5% than ≤5% weight loss over 52 weeks (- 312.7 [SE 32.2] versus - 199.5 [SE 14.4] mL/year). Nintedanib reduced the rate of FVC decline versus placebo in both subgroups by weight loss, with a greater treatment effect in patients with > 5% weight loss (interaction p = 0.0008). The adverse event profile of nintedanib was similar across subgroups.

CONCLUSIONS

In patients with IPF, lower BMI and weight loss may be associated with faster decline in FVC. Nintedanib reduces the rate of FVC decline both in patients who lose weight on treatment and those who do not.

TRIAL REGISTRATION

ClinicalTrials.gov ; Nos. NCT01335464 and NCT01335477 ; URL: www.clinicaltrials.gov .

Variability of forced vital capacity in progressive interstitial lung disease: a prospective observational study

Background

Fibrotic interstitial lung disease (ILD) is often associated with poor outcomes, but has few predictors of progression. Daily home spirometry has been proposed to provide important information about the clinical course of idiopathic pulmonary disease (IPF). However, experience is limited, and home spirometry is not a routine component of patient care in ILD. Using home spirometry, we aimed to investigate the predictive potential of daily measurements of forced vital capacity (FVC) in fibrotic ILD.

Methods

In this prospective observational study, patients with fibrotic ILD and clinical progression were provided with home spirometers for daily measurements over 6 months. Hospital based spirometry was performed after three and 6 months. Disease progression, defined as death, lung transplantation, acute exacerbation or FVC decline > 10% relative was assessed in the cohort.

Results

From May 2017 until August 2018, we included 47 patients (IPF n = 20; non-IPF n = 27). Sufficient daily measurements were performed by 85.1% of the study cohort. Among these 40 patients (IPF n = 17; non-IPF n = 23), who had a mean ± SD age of 60.7 ± 11.3 years and FVC 64.7 ± 21.7% predicted (2.4 ± 0.8 L), 12 patients experienced disease progression (death: n = 2; lung transplantation: n = 3; acute exacerbation: n = 1; FVC decline > 10%: n = 6). Within the first 28 days, a group of patients had high daily variability in FVC, with 60.0% having a variation ≥5%. Patients with disease progression had significantly higher FVC variability than those in the stable group (median variability 8.6% vs. 4.8%; p = 0.002). Cox regression identified FVC variability as independently associated with disease progression when controlling for multiple confounding variables (hazard ratio: 1.203; 95% CI:1.050–1.378; p = 0.0076).

Conclusions

Daily home spirometry is feasible in IPF and non-IPF ILD and facilitates the identification of FVC variability, which was associated with disease progression.

Novel Input for Designing Patient-Tailored Pulmonary Rehabilitation: Telemonitoring Physical Activity as a Vital Sign-SMARTREAB Study

Physical inactivity may be a consequence of chronic diseases but also a potential modifiable risk factor. Therefore, it should be clinically assessed as a vital sign of patients’ general physical condition prior to any exercise-based intervention. This cross-sectional study describes physical activity in the daily life of 100 chronic respiratory patients before pulmonary rehabilitation, comparing subjective and objective measures. The assessment combined the International Physical Activity Questionnaire (IPAQ) and 4-day accelerometer and oximeter telemonitoring with SMARTREAB technology, assessing heart rate, transcutaneous oxygen saturation and activity-related energy expenditure by metabolic equivalent of task (MET). According to IPAQ, 49% of patients had a moderate level of physical activity in daily life (PADL), a weekly mean level of 2844 ± 2925 MET.min/week, and a mean sedentary time of 5.8 ± 2.7 h/day. Alongside this, SMARTREAB telemonitoring assessed maximum activity ranging from 1.51 to 4.64 METs, with 99.6% daytime spent on PADL below 3 METs and 93% of patients with daily desaturation episodes. Regardless of the self-reported IPAQ, patients spend at least 70% of daytime on PADL below 2 METs. SMARTREAB was demonstrated to be an innovative methodology to measure PADL as a vital sign, combining oximetry with accelerometry, crossmatched with qualitative patient data, providing important input for designing patient-tailored pulmonary rehabilitation.

Oxygen for interstitial lung diseases

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Short-Term Effects of Comprehensive Pulmonary Rehabilitation and its Maintenance in Patients with Idiopathic Pulmonary Fibrosis: A Randomized Controlled Trial

The recommendation for pulmonary rehabilitation (PR) in idiopathic pulmonary fibrosis (IPF) is weak with low-quality evidence. Therefore, the aim of this study is to investigate short-term PR effects and their maintenance after a 3-month follow-up. Fifty-four IPF patients were randomized into a group receiving a 3-week comprehensive, inpatient PR (n = 34, FVC: 74 ± 19% pred.) or usual care (UC) (n = 17, FVC: 72 ± 20%pred.). Outcomes were measured at baseline (T1), after intervention (T2), and 3 months after T2 (T3). A 6-min walk distance (6MWD) was used as the primary outcome and chronic respiratory disease questionnaire (CRQ) scores as the secondary outcome. Change in 6MWD from T1 to T2 (Δ = 61 m, 95% CI (18.5–102.4), p = 0.006) but not from T1 to T3 (∆ = 26 m, 95% CI (8.0–61.5), p = 0.16) differed significantly between groups. Higher baseline FVC and higher anxiety symptoms were significant predictors of better short-term 6MWD improvements. For the change in CRQ total score, a significant between-group difference from T1 to T2 (∆ = 3.0 pts, 95% CI (0.7–5.3), p = 0.01) and from T1 to T3 (∆ = 3.5 pts, 95% CI (1.5–5.4), p = 0.001) was found in favour of the PR group. To conclude, in addition to the short-term benefits, inpatient PR is effective at inducing medium-term quality of life improvements in IPF. PR in the early stages of the disease seems to provoke the best benefits.

Comparing effectiveness of prognostic tests in idiopathic pulmonary fibrosis

Introduction: Idiopathic pulmonary fibrosis (IPF) is a debilitating and progressive fibrotic interstitial lung disease often resulting in death over several years. Prediction of disease course or survival remains of keen interest for clinicians and patients though a commonly used test or tool remain elusive. Areas covered: We undertook a comprehensive review of the published literature highlighting prognostic indicators and predictors of survival in IPF. Baseline and longitudinal clinical, functional, histopathologic, and radiologic findings have been extensively studied as prognostic predictors, both individually and in composite models. Recent approaches include automated quantifiable radiologic scoring, circulating biomarkers, and genetic polymorphisms or abnormalities. This review highlights individual and composite predictors and their relative utility in clinical practice and research studies. Expert opinion: There is a growing body of knowledge highlighting readily available individual and composite predictors of outcome, though none have come to the forefront for common clinical use. Recent advances include quantitative imaging analysis, circulating serologic markers, and genetic testing, which may be more standardized and less prone to lead-time bias or related complications and comorbidities.

Differences Between Patients With Idiopathic Pleuroparenchymal Fibroelastosis and Those With Other Types of Idiopathic Interstitial Pneumonia in Candidates for Lung Transplants

INTRODUCTION

The prognostic implications of having patients with idiopathic pleuroparenchymal fibroelastosis (IPPFE) on lung transplantation waiting lists have been unclear. In Japan, where a severe shortage of brain-dead donors remains a major limitation for organ transplantation, it is particularly important to predict the prognoses of patients when they are listed for transplantation. The purpose of this study was to investigate the characteristics of lung transplantation candidates with IPPFE and the influence of those characteristics on prognosis.

METHODS

This was a retrospective review of 29 consecutive adult lung transplant candidates with idiopathic interstitial pneumonia between January 2014 and April 2018.

RESULTS

Eight patients with IPPFE and 21 with other types of idiopathic interstitial pneumonia were included. Body mass index (median 17.1 kg/m² vs 23.5 kg/m², P < .01) and ratio of anteroposterior to transverse diameter of the thoracic cage were significantly lower (0.530 vs 0.583, P = .02) in the IPPFE group. Patients with a body mass index <20.0 kg/m² (P = .02), 6-minute walk distance <250.0 m (P < .01), ratio of PaO₂ to fraction of inspiratory oxygen <300.0 mm Hg (P < .01), and an inability to perform the diffusing capacity of carbon monoxide test (P < .01) had significantly shorter survival times in the other idiopathic interstitial pneumonia, but not in the IPPFE, group. Some patients with IPPFE survived for long enough to undergo transplantation.

CONCLUSIONS

Patients with IPPFE waiting for transplantation have some distinctive characteristics and should be retained on waiting lists to receive transplants.

Impact of Psychological Deficits and Pain on Physical Activity of Patients with Interstitial Lung Disease

PURPOSE

The impact of psychological deficits and pain on physical activity has not been adequately studied in patients with fibrotic interstitial lung disease (ILD). We aimed to determine the association of depression, anxiety, sleep quality, and pain with physical activity in fibrotic ILD.

METHODS

Waist ActiGraph activity monitors were worn for seven consecutive days to track step counts and moderate-to-vigorous physical activity (MVPA) minutes at baseline and 6-month follow-up. Psychological deficits and pain were assessed using the Hospital Anxiety and Depression Scale, the Pittsburgh Sleep Quality Index, and the Brief Pain Inventory. Multivariable linear regression was used to determine if each deficit independently predicted physical activity when adjusted for potential confounders.

RESULTS

A total of 111 patients were recruited, with 91 of these patients completing the 6-month follow-up. Median step count and MVPA minutes were 3853 steps/day (interquartile range 2236-6805) and 87 (17-225) min/week at baseline, respectively, with no significant changes at follow-up. Borderline or abnormal depression and anxiety scores were present in 19% and 22% of patients, respectively. Poor sleep quality and moderate-to-severe pain were present in 61% and 9% of patients. Higher depression scores were associated with fewer baseline and follow-up step counts and lower MVPA minutes at follow-up on unadjusted analysis; higher pain severity scores were associated with fewer baseline step count. Pain severity remained an independent predictor of reduced step count after adjusting for patient's age, smoking status, ILD severity, and weather variables.

CONCLUSIONS

Pain severity may be a potentially modifiable determinant of physical activity in patients with fibrotic ILD.

The clinical course of idiopathic pulmonary fibrosis and its association to quality of life over time: longitudinal data from the INSIGHTS-IPF registry

Background

Quality of life (QoL) is profoundly impaired in patients with idiopathic pulmonary fibrosis (IPF). However, data is limited regarding the course of QoL. We therefore analysed longitudinal data from the German INSIGHTS-IPF registry.

Methods

Clinical status and QoL were assessed at enrollment and subsequently at 6- to 12-months intervals. A range of different QoL questionnaires including the St. George’s Respiratory Questionnaire (SGRQ) were used.

Results

Data from 424 patients were included; 76.9% male; mean age 68.7 ± 9.1 years, mean FVC% predicted 75.9 ± 19.4, mean DL_CO% predicted 36.1 ± 15.9. QoL worsened significantly during follow-up with higher total SGRQ scores (increased by 1.47 per year; 95% CI: 1.17 to 1.76; p < 0.001) and higher UCSD-SOBQ scores and lower EQ-5D VAS and WHO-5 scores. An absolute decline in FVC% predicted of > 10% was associated with a significant deterioration in SGRQ (increasing by 9.08 units; 95% CI: 2.48 to 15.67; p = 0.007), while patients with stable or improved FVC had no significantly change in SGRQ. Patients with a > 10% decrease of DL_{CO %} predicted also had a significant increase in SGRQ (+ 7.79 units; 95% CI: 0.85 to 14.73; p = 0.028), while SQRQ was almost stable in patients with stable or improved DL_CO. Patients who died had a significant greater increase in SGRQ total scores (mean 11.8 ± 18.6) at their last follow-up visit prior to death compared to survivors (mean 4.2 ± 18.9; HR = 1.03; 95% CI: 1.01 to 1.04; p < 0.001). All QoL scores across the follow-up period were significantly worse in hospitalised patients compared to non-hospitalised patients, with the worst scores reported in those hospitalised for acute exacerbations.

Conclusions

QoL assessments in the INSIGHTS-IPF registry demonstrate a close relationship between QoL and clinically meaningful changes in lung function, comorbidities, disease duration and clinical course of IPF, including hospitalisation and mortality.

Electronic supplementary material

The online version of this article (10.1186/s12931-019-1020-3) contains supplementary material, which is available to authorized users.

Daily life physical activity in patients with chronic stage IV sarcoidosis: A multicenter cohort study

BACKGROUND AND OBJECTIVES

Little is known about the consequences of chronic sarcoidosis on daily life physical activity (DLPA). The aim of this prospective study was to measure DLPA in patients with chronic sarcoidosis and to determine its relationship to clinical and functional parameters.

METHODS

Fifty-three patients with chronic sarcoidosis and 28 healthy control subjects were enrolled in this multicenter prospective study. Two markers of DLPA (number of steps walked per day [SPD]) and total daily energy expenditure (TEE) were assessed for five consecutive days with a physical activity monitor. Pulmonary function, aerobic capacity (maximal oxygen uptake [VO2max]), exercise capacity (6-min walk test [6MWT]), and quality of life (self-reported questionnaires) were also evaluated. Comparisons of DLPA parameters between the two groups were performed using an analysis of covariance adjusted for age, sex, and body mass index (BMI). Relationships between DLPA parameters and patient characteristics were assessed in multivariable linear regression models.

RESULTS

Patients with sarcoidosis walked significantly fewer SPD than did the control subjects (6395 ± 4119 and 11 817 ± 3600, respectively; P < 0.001 after adjustment for age, BMI, and sex). TEE was not significantly different between patients with sarcoidosis and healthy controls (median [interquartile range]: 2369 [2004-2827] and 2387 [2319-2876] kcal/day, respectively, P = 0.054 adjusted for age, BMI, and sex). SPD showed significant positive correlations with 6MWT distance (Pearson's correlation, r = 0.32, 95% confidence intervals [95%CI] = 0.06, 0.55; P = 0.019), VO2max (r = 0.44, 95%CI = 0.17, 0.65; P = 0.002), and Visual Simplified Respiratory Questionnaire score (r = 0.44, 95%CI = 0.19, 0.64; P = 0.001), and a significant negative correlation with modified Medical Research Council questionnaire score (r = -0.38, 95%CI = -0.60, -0.10; P = 0.009). TEE was significantly correlated with BMI (r = 0.38, 95%CI = 0.13, 0.59; P = 0.004), forced expiratory volume in 1 second (r = 0.55, 95%CI = 0.33, 0.71; P < 0.001), total lung capacity (r = 0.44, 95%CI = 0.18, 0.64; P = 0.001), and forced vital capacity (r = 0.56, 95%CI = 0.34, 0.72; P < 0.001). In multivariable analysis, SPD remained associated only with VO2max.

CONCLUSION

Patients with chronic sarcoidosis appear to have reduced DLPA mainly because of compromised VO2max.

Design of a Study Assessing Disease Behaviour During the Peri-Diagnostic Period in Patients with Interstitial Lung Disease: The STARLINER Study

Background/Objectives

This study will aim to characterise disease behaviour during the peri-diagnostic period in patients with suspected interstitial lung disease (ILD), including idiopathic pulmonary fibrosis (IPF), using daily home spirometry and accelerometry. Additionally, this study will aim to increase collaboration between secondary and tertiary centres using a digital collaboration platform.

Methods

The STARLINER study (NCT03261037) will enrol approximately 180 symptomatic patients aged 50 years or more with radiological evidence of ILD/IPF from community and tertiary centres in Canada and Europe. Approximately two-thirds of sites will be community centres. Patients will be followed during pre-diagnosis (inclusion to diagnosis; up to a maximum of 12 months) and post-diagnosis (diagnosis to treatment initiation; up to a maximum of 6 months). The study will be facilitated by a digital ecosystem consisting of the devices used for home-based assessments and a digital collaboration platform enabling communication between community and tertiary centres, and between clinicians and patients.

Planned Outcomes

The primary endpoint will be time-adjusted semi-annual change in forced vital capacity (FVC; in millilitres) during the peri-diagnostic period. Physical functional capacity and patient-reported outcomes (PROs) will also be assessed. FVC and physical functional capacity will be measured using daily home spirometry and accelerometry, and at site visits using spirometry and the 6-min walk test. PROs will be assessed prior to, or during, site visits and will always be completed in the same order.

Conclusions

Findings from this study may help to facilitate the early and accurate diagnosis of ILDs by increasing knowledge about disease progression, enabling collaboration between community and tertiary centres and improving communication between clinicians and patients.

Trial Registration Number

NCT03261037.

Funding

F. Hoffmann-La Roche, Ltd., Basel, Switzerland.

Plain Language Summary

Plain language summary available for this article.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0845-3) contains supplementary material, which is available to authorized users.

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

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

Effects of pulmonary rehabilitation on daily life physical activity of fibrotic idiopathic interstitial pneumonia patients

According to the international consensus statement of 2011, idiopathic pulmonary fibrosis (IPF) and idiopathic nonspecific interstitial pneumonia (NSIP) are classified as fibrotic idiopathic interstitial pneumonia (f-IIP) of unknown aetiology [1]. f-IIP patients display persistent and significant dyspnoea, exercise intolerance and poor health-related quality of life [2]. f-IIP is also associated with a marked reduction in daily life physical activity (DL_PA) [3], which is related to morbidity and mortality in many chronic diseases, including f-IIP [4–6].

Fibrotic idiopathic interstitial pneumonia patients derived benefit from a pulmonary rehabilitation programme in terms of exercise tolerance, anxiety, depression and quality of life without increasing their daily life physical activityhttp://ow.ly/WV7U30kgNkU

Nutritional status and muscle dysfunction in chronic respiratory diseases: stable phase versus acute exacerbations

Nutritional abnormalities are frequent in different chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic fibrosis (CF), interstitial fibrosis and lung cancer, having important clinical consequences. However, nutritional abnormalities often remained underdiagnosed due to the relative lack of awareness of health professionals. Therefore, systematic anthropometry or even better, assessment of body composition, should be performed in all patients with chronic respiratory conditions, especially following exacerbation periods when malnutrition becomes more accentuated. Nutritional abnormalities very often include the loss of muscle mass, which is an important factor for the occurrence of muscle dysfunction. The latter can be easily detected with the specific assessment of muscle strength and endurance, and also negatively influences patients' quality of life and prognosis. Both nutritional abnormalities and muscle dysfunction result from the interaction of several factors, including tobacco smoking, low physical activity-sedentarism, systemic inflammation and the imbalance between energy supply and requirements, which essentially lead to a negative balance between protein breakdown and synthesis. Therapeutic approaches include improvements in lifestyle, nutritional supplementation and training. Anabolic drugs may be administered in some cases.

Integrating Patient Perspectives into Personalized Medicine in Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive and ultimately fatal disease which has a major impact on patients’ quality of life (QOL). Except for lung transplantation, there is no curative treatment option. Fortunately, two disease-modifying drugs that slow down disease decline were recently approved. Though this is a major step forward, these drugs do not halt or reverse the disease, nor convincingly improve health-related QOL. In daily practice, disease behavior and response to therapy greatly vary among patients. It is assumed that this is related to the multiple biological pathways and complex interactions between genetic, molecular, and environmental factors that are involved in the pathogenesis of IPF. Recently, research in IPF has therefore started to focus on developing targeted therapy through identifying genetic risk factors and biomarkers. In this rapidly evolving field of personalized medicine, patient factors such as lifestyle, comorbidities, preferences, and experiences with medication should not be overlooked. This review describes recent insights and methods on how to integrate patient perspectives into personalized medicine. Furthermore, it provides an overview of the most used patient-reported outcome measures in IPF, to facilitate choices for both researchers and clinicians when incorporating the patient voice in their research and care. To enhance truly personalized treatment in IPF, biology should be combined with patient perspectives.