Background Pulmonary rehabilitation (PR) is a highly effective intervention for people with chronic respiratory disease; however, it is not known how best to sustain its benefits. Clinical trials are needed to establish if participation in singing for lung health (SLH) groups following PR will improve health-related quality of life, healthcare utilisation and exercise capacity compared with usual care. A feasibility study would help to guide development of these trials.Methods In a multicentre, mixed-methods randomised controlled feasibility trial, PR participants at four sites were prescreened at baseline assessment. An SLH taster session was included routinely as part of the PR programmes. Eligible PR completers were invited to take part in the trial and randomised to usual care or a 12-week SLH course. Feasibility outcomes included recruitment rate, intervention compliance (at least 8/12 sessions) and health economic analysis. Interviews with participants and study personnel were undertaken and thematic analysis of the results was completed.Results Between October 2022 and November 2023, 1311 patients were assessed to start PR, 838 completed. Of those completing, 243 were ineligible to take part (predominantly due to vaccination status and excluded diagnoses for PR referral), and 531 declined. 64 people (33 female, mean (SD) age 69 (12), 41 ethnically white, 33 with chronic obstructive pulmonary disease, 16 with asthma, 9 with interstitial lung disease, 6 with bronchiectasis) were recruited, with 30 (93.8%) SLH and 29 (90.6%) controls completing the study. 20 (62.5%) of the SLH group completed at least 8/12 SLH sessions. There was enthusiasm for a definitive trial from participants, clinicians and singing group leaders’ perspectives, based on positive experiences of trial involvement. Improvements to recruitment strategy, intervention structure, outcome measures and staffing were suggested.Conclusions A definitive randomised controlled trial of SLH post-PR appears feasible, with acceptable uptake and completion rates.Trial registration number ISRCTN11056049.

People with chronic obstructive pulmonary disease (COPD) face increased risk of social isolation and loneliness. However, social dimensions are frequently overlooked in respiratory care. We aimed to explore the role of social connection in living with COPD, including influences on health and function. We conducted a reflexive thematic analysis of semi-structured interviews with 19 people with COPD (median age 78 years [range 58-88]; 14 with severe airflow obstruction). Three themes were identified: social connection supports COPD self-management, the "triple threat" of COPD to social connection, and the inseparable nature of social health. Participants described how worsening symptoms, particularly breathlessness, contribute to disconnection through physical restrictions, psychological reactions, and societal unawareness, with negative impacts on self-management and wider physical and psychological health. We conclude that social connections become increasingly valuable, yet increasingly difficult to maintain, as COPD progresses. Supporting individuals to maintain connections within a biopsychosocial approach may unlock wider health benefits.

Introduction:Following completion of Pulmonary Rehabilitation (PR), the biopsychosocial benefits often decline. PR maintenance is recommended to extend the benefits; however, detail lacks on what this should entail. SPACE for COPD© is a light touch, evidenced-based self-management intervention which we tested as a maintenance strategy during the COVID-19 pandemic. We explored the acceptability of SPACE for COPD© as a maintenance option following PR for both patients and facilitators using qualitative research methods. Methods:We conducted semi-structured interviews and focus groups with patients and intervention facilitators involved in the SPACE for COPD© maintenance study. These were audio recorded, transcribed verbatim and analysed using Framework Analysis. Results:Seventeen patients were interviewed; 13 (76.5%) of which were programme completers: five (29.4%) received a group-based intervention, four (23.5%) received one-to-one, and eight (47.1%) received hybrid. Two focus groups were conducted with eight facilitators; six (75%) were physiotherapists, one (12.5%) was a nurse, and one (12.5%) was a health psychologist. Analysis generated six themes: (1) the changing structure of maintenance SPACE for COPD©; (2) the integral role of the facilitator; (3) engagement with the manual required time and commitment from patients; (4) staying active on maintenance SPACE for COPD© was facilitated by goal setting and exercise; (5) biopsychosocial outcomes of maintenance SPACE for COPD©; and (6) the future of maintenance SPACE for COPD©. Conclusion:Maintenance SPACE for COPD© was acceptable and could be implemented into the PR healthcare pathway during the COVID-19 pandemic. It helped patients to adopt and integrate new exercise habits if they could adapt and personalise these to their home lives. Adaptions made during the COVID-19 pandemic created a menu of options. Building upon this personalisation is required to ensure the intervention is accessible and patient-centred.

BACKGROUND:Lung function measurement is central to assessing disease severity and monitoring progression in bronchiectasis. Although home spirometry is convenient for remote monitoring, there is limited evidence for its performance. AIMS:In an a priori defined substudy in the CLEAR trial (a multicentre, randomised, open-label study of hypertonic saline and carbocisteine versus usual care in bronchiectasis), we assessed the performance of home spirometry in adults with bronchiectasis using the PANACEA framework (seven domains: test Performance, disease mANAgement, Cost, patient Experience, clinician Experience, researcher Experience, and Access). METHODS:Participants performed supervised 'clinic' spirometry at five visits and unsupervised 'home' spirometry weekly and during exacerbations over 52 weeks. Analyses evaluated agreement, longitudinal variation, changes in lung function across exacerbations, measurement quality, adherence and patient experience. Agreement was evaluated using Bland-Altman analysis; other outcomes were summarised descriptively. RESULTS:257 participants had home spirometry data. Clinic and home spirometry demonstrated close agreement, with a mean forced expiratory volume in 1 s (FEV1) difference of 20 mL (95% CI -130 to 170). Variability decreased over time (coefficient of variation 12.25% to 8.81%). Among 462 exacerbations, 195 had spirometry data within 7 days of exacerbation start/end dates. A >100 mL decline in FEV1 occurred in 48% of exacerbations; 35% returned to within 100 mL of pre-exacerbation stable values by exacerbation end. Most spirometry sessions met American Thoracic Society/European Respiratory Society quality criteria, adherence declined over time while patient experience was generally positive. CONCLUSION:Home spirometry demonstrates good agreement with clinic spirometry, with variability between measurements decreasing over time. Home spirometry detected changes in lung function across exacerbations, although variability may limit interpretation at the individual patient level. With appropriate patient support to maintain adherence, home spirometry has potential as a tool for remote monitoring and decentralised clinical trials in bronchiectasis. TRIAL REGISTRATION NUMBER:ISRCTN89040295.

The purpose of the document is to provide commissioners, service providers and individuals with a guide to the minimum standards of care that participants attending pulmonary rehabilitation should expect, together with measures of good practice.

Introduction Pulmonary rehabilitation (PR) is an effective intervention for patients with chronic obstructive pulmonary disease (COPD) but impact typically only lasts 6–12 months. This paper presents results of an economic evaluation of a PR maintenance programme (Self-management Programme of Activity, Coping and Education (SPACE)) undertaken within a prospective assessor-blind randomised controlled trial.Methods Adults with COPD who had completed PR within the previous 4 weeks were randomised to SPACE or best usual care. Healthcare use, personal expenditure and societal costs were recorded at baseline, 6 and 12 months. SPACE costs included staff training, materials and delivery of group sessions. Health utility recorded (EQ-5D-5L) with analysis comparing differences in mean values at 6 and 12 months, over baseline utility scores. Observed changes compared with threshold for COPD clinical significance. Incremental cost-effectiveness ratios estimated from National Health Service and societal perspectives. Cost per quality-adjusted life-year (QALY) values compared with willingness-to-pay threshold (≤£30 000). Uncertainties in costs and outcomes incorporated into a sensitivity analysis. Missing values imputed using a Bayesian mixed model with confounders.Results 116 patients recruited between October 2019 and June 2022 (57 intervention and 59 control). No significant differences at baseline in age, body mass index, smoking, forced expiratory volume in 1 s and health utility (EQ-5D-5L). Mean healthcare costs in the SPACE group were £139.72 lower per patient over 12 months compared with usual care. At 12 months, the SPACE group retained higher (p=0.04) utility value 0.7609 (SE=0.0238) versus control patients 0.6738 (SE=0.0348). The recorded 0.1178 advantage in mean QALY values (p<0.05) is above the threshold (0.051) for COPD significance. Cost-effectiveness acceptability curves indicate a 97% chance of achieving £20 000 per QALY. Patient and societal costs increase this percentage.Discussion This study addresses an important gap in current evidence for non-pharmacological COPD interventions. The PR maintenance programme (SPACE) is shown to be highly cost-effective at 12 months. Future research should consider cost-effectiveness of telerehabilitation programmes, as well as tailored digital support beyond 12 months.

OBJECTIVE:Post-COVID syndrome involves prolonged symptoms with multisystem and functional impairment lasting ≥12 weeks after acute coronavirus disease 2019 (COVID-19). We aimed to determine the efficacy of exercise-based rehabilitation interventions, either face-to-face or remote, compared to usual care in individuals experiencing post-COVID syndrome following a hospitalisation with acute COVID-19. DESIGN:This single-blind randomised controlled trial compared two exercise-based rehabilitation interventions (face-to-face or remote) to usual care in participants with post-COVID syndrome following a hospitalisation. The interventions were either a face-to-face or remote 8-week programme of individually prescribed exercise and education. The primary outcome was the change in Incremental Shuttle Walking Test (ISWT) following 8 weeks of intervention (either face-to-face or remote) compared to usual care. Other secondary outcomes were measured including health-related quality of life (HRQoL), and exploratory outcomes included lymphocyte immunotyping. RESULTS:181 participants (55% male, mean±sd age 59±12 years, length of hospital stay 12±19 days) were randomised. There was an improvement in the ISWT distance following face-to-face rehabilitation (mean 52 m, 95% CI 19-85 m; p=0.002) and remote rehabilitation (mean 34 m, 95% CI 1-66 m; p=0.047) compared to usual care alone. There were no differences between groups for HRQoL self-reported symptoms. Analysis of immune markers revealed significant increases in naïve and memory CD8+ T-cells following face-to-face rehabilitation versus usual care alone (p<0.001, n=31). CONCLUSION:Exercise-based rehabilitation improved short-term exercise capacity in post-COVID syndrome following an acute hospitalisation and showed potential for beneficial immunomodulatory effects.

Background:There is interest in digital technology-enabled models of pulmonary rehabilitation (Digital-PR) as a means of increasing capacity, uptake and accessibility. However, there are little data on real-world implementation or how Digital-PR could support other models of pulmonary rehabilitation delivery. Methods:We conducted a mixed-methods, feasibility study to evaluate the acceptability of a hybrid model of pulmonary rehabilitation (Hybrid-PR) blending Digital-PR with traditional, supervised pulmonary rehabilitation (PR). To determine acceptability, we measured engagement and use of the app and conducted patient interviews. We assessed differences in PR completion, number of scheduled sessions and staff time between Hybrid-PR and a propensity-matched control group attending PR without Digital-PR (Control-PR). Results:Of 69 people undergoing Hybrid-PR, 87% opted for in-person, centre-based care and 13% for home-based care (10% supported by video-teleconferencing, 3% supported by telephone). 86% activated Digital-PR at least once, but only 35% activated regularly (at least weekly for 8 weeks). 88% never accessed the exercise components of Digital-PR. There were no significant differences in PR completion rates, number of supervised PR sessions, nor staff time in Hybrid-PR when compared to Control-PR. Both patients and staff identified digital literacy, limited flexibility to adapt/tailor Digital-PR and increased time-commitment as potential barriers. Conclusion:Hybrid-PR was not considered acceptable due to intervention fidelity and limited patient engagement with Digital-PR. Hybrid-PR was not associated with reduction in scheduled supervised sessions. Poor digital literacy is an important barrier to implementation of Digital-PR in the real-world setting.

Introduction: Pulmonary rehabilitation (PR) services are increasingly using alternative programme delivery modes, for example telerehabilitation strategies including videoconferencing, to improve patient choice and accessibility. Although telerehabilitation results in improvements in core outcomes, the effect on knowledge attainment is not known. Aim: To observe the real-world responses of patients choosing to undergo videoconference PR to a matched control group choosing to undergo in-person PR, in terms of knowledge attainment. Methods: Using propensity score matching, 25 people with COPD who completed videoconference PR were matched 1:1 with a control group of 25 people with COPD who completed in-person PR. Knowledge attainment was measured using the Lung Information Needs Questionnaire (LINQ). Results: There was a statistically and clinically significant improvement in LINQ score in both groups (mean (95%CI): videoconference -3.2 (-4.7 to -1.6); in-person -3.0 (-4.5 to -1.4)), with no significant between-group difference (mean (95%CI): 0.2 (-2.0 to -2.4)). 76% and 80% of participants achieved the minimal important difference of the LINQ in the videoconference and in-person PR groups respectively. Conclusion: In conclusion, this real-world service evaluation indicates that videoconference PR may be associated with similar improvements in knowledge attainment as in-person PR, but this requires corroboration due to the small sample size.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous chronic lung condition often accompanied by comorbidities and systemic manifestations that affect the person’s clinical condition and prognosis and often require specific treatment. Therefore, the management of COPD extends beyond treatment for the lungs per se. Pulmonary rehabilitation (PR) should be considered as part of person-centered management, and supervised exercise training is a core component of this intervention. PR exercise training parameters (e.g., frequency, intensity, time, and type) should be individualized to maximize each individual’s functional gains while targeting systemic manifestations and comorbidities. This manuscript presents evidence-based tailored recommendations for optimizing exercise interventions for people with COPD and comorbidities that significantly affect prognosis (e.g., mortality, hospitalizations) including cardiovascular disease (CVD) (e.g., chronic coronary syndrome, heart failure), CVD risk factors (e.g., type 2 diabetes mellitus [T2DM], hypertension), and sarcopenia. To achieve these goals, existing guidelines and evidence for exercise training in COPD, CVD, CVD risk factors, and sarcopenia have been reviewed to identify synergies between PR and cardiac rehabilitation, as well as the treatment of T2DM and sarcopenia. In addition, we provided clinical cases to illustrate how PR can be adapted to accommodate specific comorbidities. These examples offer practical guidance for tailoring exercise prescriptions within PR programs to address the unique needs of people with COPD and clinically relevant comorbidities, thereby enhancing overall treatment effectiveness and optimizing health outcomes.

IMPORTANCE:The minimum important difference (MID) for field walking tests aims to improve interpretation of outcomes, but the volume and heterogeneity of MIDs for these tests is challenging. We aimed to determine the MID for the 6-min walk distance (6MWD), incremental shuttle walk test (ISWT) and endurance shuttle walk test (ESWT) in adults with long-term conditions. METHODS:This systematic review included studies that generated a MID using an anchor-based approach in patients with long-term conditions for the 6MWD, ISWT or ESWT field walking tests. Studies were screened and data extracted by independent reviewers. Meta-analyses were performed using RevMan. RESULTS:42 studies were included in the analyses, involving n=13 949 participants. Of these, 12 studies involving exercise as an intervention were included in the meta-analyses to produce MIDs, presented as mean (95% confidence interval). The MID for the 6MWD was 25 m (24-26 m) for respiratory conditions, 23 m (8-37 m) for cardiac conditions and 37 m (26-49 m) for neurological/musculoskeletal conditions. The MID for the ISWT was 48 m (39-57 m) for respiratory conditions and 70 m (55-85 m) for cardiac conditions. The MID for ESWT in COPD was 159 s (94-224 s). The pooled MID across conditions within exercise interventions was 26 m (22-40 m) for the 6MWD and 53 m (44-62 m) for the ISWT, with reasonable heterogeneity (I2=48% and I2=47%, respectively). CONCLUSION:We propose new MIDs for exercise interventions using anchor-based methodology in long‑term conditions for the 6MWD, ISWT and ESWT. These can be used internationally for meta‑analyses where studies have used different field walking tests, to optimise trial sample size calculations, and for clinical service benchmarking.

Introduction: Frailty affects about 20% of people living with COPD (Marengoni Chest 2018) with reduced functional performance a common and distressing state for these individuals (Brighton Annals ATS 2020). Individuals living with COPD and frailty who complete pulmonary rehabilitation (PR) experience numerous improvements, including exercise capacity (Maddocks Thorax 2016). Whether PR improves functional performance in this population, as in the general COPD population (Stoffels Arch Phys Med Rehab 2021), is not known. Therefore, this research aimed to investigate the responsiveness of functional performance, measured using the Short Physical Performance Battery (SPPB), to PR in this population. Methods: This was a secondary analysis of a previously published single-centre cohort study (Maddocks Thorax 2016). Participants were people with COPD who completed PR and were categorised as frail using the Fried Frailty Phenotype (Fried J Gertonolgy Series A 2001) at the pre-PR assessment. The SPPB, includes three sub-tests: static standing balance, usual gait speed over four metres (4MGS) and five-repetition sit-to-stand (5STS) test (Guralnik J Gerontology 1994). Each subtest is scored 0-4, summed for a total score of 0-12, with higher scores indicating better function. PR was an in-person, outpatient, eight-week, twice weekly programme of exercise and education. Pre- and post-PR SPPB scores were reported using descriptive statistics and within-group differences were analysed using paired t-test, Wilcoxon signed-rank test, or chi-square test. Results: Data from 67 individuals were analysed. Baseline characteristics: male sex n=43 (64%); mean (standard deviation) age 73 years (8); FEV1 %predicted 49.1% (22.7); FEV1/FVC ratio 0.53 (0.17); MRC 4 (1); BMI 28.3 kg/m2(7.5); SPPB total 7.0 (2.6); balance score 3.1 (1.2); 4MGS score 2.7 (1.0); 4MGS speed 0.69 m/s (0.21); 5STS score 1.3 (1.2); median (25th, 75th centile) 5STS time 16.9 sec (13.6, 22.4). Immediately following PR there were significant improvements in SPPB total, 4MGS and 5STS (scores and speed/time) that exceeded the minimal important differences for SPPB, 4MGS speed and 5STS time. No significant change was observed in the balance score (table 1). The number (percent) of participants unable to perform 5STS reduced from 21 (31%) to 14 (21%) following PR (p<0.01). Conclusion: PR is associated with improvements in functional performance in people living with COPD and frailty, with improvements driven by faster usual walking speed and sit-to-stand time. Future research should investigate balance training and assessment as part of PR in this population. Funding source: None

Rationale: Quality and accuracy of interpretation of spirometry performed in primary care is variable. Artificial Intelligence (AI) support software has been shown to be of benefit to pulmonologists interpreting lung function tests and has recently been validated in primary care datasets with potential to support primary care clinicians with spirometry interpretation. We aimed to understand patient perspectives on AI decision support software in aiding clinicians to perform and interpret spirometry. Methods: Participants enrolled in a real-world evaluation of an AI support software (ArtiQ.Spiro) in Primary Care spirometry pathways were invited to take part in a focus group to explore the acceptability of the intervention and patient perspectives on AI in this setting. The focus group was conducted on-line via a video conference call, recorded and transcribed verbatim. Two qualitative researchers facilitated the focus group and a topic guide was used to direct the discussion to capture key information. A structured framework approach was used for analysis based on previous qualitative themes relating to this programme of work1 and specifically to understand the patient view on their clinician receiving an AI report and the perceived values or challenges of using AI reports for spirometry. Results: Nine participants undergoing spirometry in primary care and enrolled in the real-world study completed the focus group: 5 female, 4 male, age range: 44 – 81 years. Themes developed from the data were 1) AI can help clinicians make better decisions, and 2) the human element should not be lost from clinical care (Figure 1). Participants described potential benefits in speeding up the process for their spirometry results, whilst expressing some concerns that a clinician ought to retain oversight of the spirometry report and diagnostic outcomes. Conclusion: Overall participants expressed views that AI was a positive addition to healthcare but that human interaction was still important and they valued clinician ability to query the AI outcome. 1. Doe, G. et al. Spirometry services in England post-pandemic and the potential role of AI support software: a qualitative study of challenges and opportunities. British Journal of General Practice73, e915-e923, doi:10.3399/bjgp.2022.0608 (2023).

Introduction:Up to 11% of patients are left with residual lung abnormalities following COVID-19 infection. It is unclear whether these changes resolve over time or progress to fibrosis. The airway microbiome is altered in interstitial lung disease, potentially contributing to pathogenesis and disease progression. We hypothesised that the airway microbiome in patients with post-COVID-19 residual lung abnormalities may be altered. Methods:The POST COVID-19 interstitial lung DiseasE (POSTCODE) study recruited subjects with post-COVID-19 residual lung abnormalities for bronchoscopy. 16S ribosomal RNA gene amplicon sequencing was performed on DNA extracted from bronchoalveolar lavage fluid and compared with that from patients with idiopathic pulmonary fibrosis, fibrotic hypersensitivity pneumonitis and control subjects. Results:28 subjects with post-COVID-19 residual lung abnormalities were recruited an average of 11 months after infection. No significant associations were found between the lower airway microbiome or bacterial burden and disease severity or trajectory. There was no difference in bacterial burden between post-COVID-19 patients and interstitial lung disease or control subjects. Furthermore, no differences in microbial composition were observed between these patients and those with fibrotic hypersensitivity pneumonitis or controls. However, compared with idiopathic pulmonary fibrosis, there was an increased abundance of Streptococcus and higher α-diversity in subjects with post-COVID-19 residual lung abnormalities. Conclusions:The microbiome and bacterial burden in the lower airways of subjects with post-COVID-19 residual lung abnormalities do not differ from those of controls. The microbiome differs from idiopathic pulmonary fibrosis. This, and the absence of associations between microbial features and disease severity or clinical outcomes, suggests that the microbiome is unlikely to contribute to residual lung abnormalities in patients recovering from COVID-19 infection.

BackgroundCentre-PR may not be accessible for people living distant from PR centres. Remote digital PR may have equivalent benefits to centre-PR; however, previous trials were potentially biased towards digitally literate patients, and largely excluded participants with a preference for centre-PR. There is limited data on the real-world implementation of, and acceptability for, Digital-PR alone or as an adjunct to other models of PR.ObjectivesTo gather patients' views about the acceptability of Active+me REMOTE, a digital pulmonary rehabilitation app (Digital-PR).MethodsA qualitative exploratory study using semi-structured interviews with a subset (n = 15) of patients in a mixed method, feasibility study of a hybrid pulmonary rehabilitation, blending Digital-PR with other models of PR. Transcribed data were coded descriptively using Braun and Clarkes' methodology, data interpretation was facilitated through a Miro virtual whiteboard.ResultsThere was appreciation for the concept of Digital-PR, indicated by positive responses in the domains of "friends and family recommendation," "intention to continue using the app," and "privacy concerns." Benefits were reported by two participants who had declined centre-based PR. The app was rated low regarding user-friendliness. Challenges in understanding/using the app and a perception of challenges for others were reported and were associated with poor digital literacy and tech savviness. High digital skills did not predict a favourable assessment of the app as user-friendly.DiscussionWhilst there was a general appreciation for the concept of digital PR as an adjunct or alternative to traditional centre-based PR, the app did not appear to be user-friendly, nor acceptable to people with low digital literacy. The findings have implications for the wider routine implementation of Digital-PR.