Completion Of Pulmonary Rehabilitation Research Articles

The IMPROVE trial: study protocol for a pragmatic cluster randomised controlled trial to assess the effectiveness of using lay health workers to improve uptake and completion of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

BackgroundPulmonary rehabilitation (PR) is a programme of exercise and education and the most effective treatment for the symptoms and disability associated with chronic obstructive pulmonary disease. However, the benefits of PR are limited by poor uptake and completion. This trial will determine whether using trained volunteer lay health workers, called “PR buddies,” improves uptake and completion of PR and is cost-effective. This trial protocol outlines the methods for evaluating effectiveness, cost-effectiveness, and acceptability.MethodsThe IMPROVE trial is a pragmatic, open, cluster randomised controlled trial planned in 38 PR services across England and Wales. PR services will be randomised to either intervention arm—offering support from PR buddies to patients with chronic obstructive pulmonary disease—or to usual care as the control arm. PR staff in trial sites randomised to the intervention arm will receive training in recruiting and training PR buddies. They will deliver training to volunteers, recruited from among people who have recently completed PR in their service. The 3-day PR-buddy training programme covers communication skills, confidentiality, boundaries of the PR-buddy role and behaviour change techniques to help patients overcome obstacles to attending PR. An internal pilot will test the implementation of the trial in eight sites (four intervention sites and four in control arm). The primary outcome of the trial is the uptake and completion of PR. A process evaluation will investigate the acceptability of the intervention to patients, PR staff and the volunteer PR buddies, and intervention fidelity. We will also conduct a cost-effectiveness analysis.DiscussionImproving outcomes for chronic obstructive pulmonary disease and access to PR are priorities for the UK National Health Service (NHS) in its long-term plan. The trial hypothesis is that volunteer PR buddies, who are recruited and trained by local PR teams, are an effective and cost-effective way to improve the uptake and completion rates of PR. The trial is pragmatic, since it will test whether the intervention can be incorporated into NHS PR services. Information obtained in this trial may be used to influence policy on the use of PR buddies in PR and other similar services in the NHS.Trial registrationISRCTN12658458. Registered on 23/01/2023.

Pulmonary rehabilitation in patients with prior COVID-19 infections

Abstract
 Background: Patients with prior COVID-19 infections can develop persistent dyspnea and physical limitation. This may reflect chronic lung disease, chronic heart disease, or neuromuscular disease. Treatment approaches include pulmonary rehabilitation. This study analyzed the benefits of conventional pulmonary rehabilitation in patients with chronic symptoms following COVID-19 infections.
 Methods: Twenty-eight patients completed pulmonary rehabilitation at University Medical Center in Lubbock, Texas. The primary outcome was the time spent on four different types of exercise equipment during aerobic exercise sessions.
 Results: This study included 15 women and 13 men, with a mean age of 54.4 years. The racial distribution included 12 White patients, 10 Hispanic patients, and 6 Black patients. Ten patients had a smoking history, 19 patients used supplemental oxygen, 14 patients had hypertension, and 11 patients had diabetes. The median COPD Assessment Test (CAT) score was 21.5 (Q1, Q3: 17.5,29), the median Patient Health Questionnaire-9 (PHQ-9) score was 8 (Q1, Q3: 4.5,15.5), and the median Medical Research Council (MRC) score was 2. Twenty-six patients had the abnormal chest x-rays within 3 months of starting the rehabilitation program; these included 5 patients with focal interstitial infiltrates, 9 patients with diffuse interstitial infiltrates, 6 patients with focal opacities, and 6 patients with bilateral opacities. These patients completed 22.9 (Q1, Q3: 6.8,36) exercise sessions. There were statistically significant increases in all machine times on all 4 machines.
 Conclusion: This study indicates pulmonary rehabilitation can significantly increase aerobic activity levels in patients with prior COVID-19 infections. This improvement occurred in patients with important comorbidity, abnormal chest x-rays, and chronic oxygen supplementation requirements. Patients with prior COVID-19 infections and persistent respiratory symptoms should be referred to pulmonary rehabilitation.
 
 Key words: COVID-19, long COVID, rehabilitation

Bronchoscopic Lung Volume Reduction: Highlighting the Patient Selection Process

Patients with advanced emphysema frequently experience severe dyspnea that is inadequately treated with medical therapy alone. Over the past 4 years, we have seen increased usage of bronchoscopic lung volume reduction (BLVR) with endobronchial valves. Success of the procedure is dependent on patient selection because it is not necessarily appropriate for all patients with severe emphysema. (Table 1) The purpose of this review is to highlight the selection process at a single institution. We also discuss the influence of this process on outcomes. Between March 1, 2019, and October 12, 2021, 2402 patients were referred to a dedicated chronic obstructive pulmonary disease clinic at Mayo Clinic – Rochester, whereas 161 patients were subsequently referred for multidisciplinary BLVR review. Of those patients, 53 (32.9%) were selected to receive valves and 35 (21.7%) ultimately underwent the procedure. The main reasons for exclusion included an incompatible quantitative computed tomography analysis (n=37, 34.3%), presence of pulmonary nodule or active malignancy (n=14, 13.0%), or need for completion of pulmonary rehabilitation (n=9, 8.3%). Full or partial (>70%) target lobe collapse was observed in 58.6% of patients who received valves. Those with collapse experienced statistically significant improvements in spirometric measures. Twelve patients experienced a pneumothorax (34.3%), with 10 patients requiring thoracostomy tube placement and prolonged hospitalization (median, 11 days; range, 4-39 days). Nineteen patients required a secondary procedure within the first year. The study highlights how a multidisciplinary approach to the BLVR selection process enables individualization of a complex procedure and enhances the exclusion of inappropriate candidates.

The effect of d-cycloserine on brain processing of breathlessness over pulmonary rehabilitation: an experimental medicine study.

Pulmonary rehabilitation is the best treatment for chronic breathlessness in COPD but there remains an unmet need to improve efficacy. Pulmonary rehabilitation has strong parallels with exposure-based cognitive behavioural therapies (CBT), both clinically and in terms of brain activity patterns. The partial N-methyl-d-aspartate (NMDA)-receptor agonist d-cycloserine has shown promising results in enhancing efficacy of CBT, thus we hypothesised that it would similarly augment the effects of pulmonary rehabilitation in the brain. Positive findings would support further development in phase 3 clinical trials. 72 participants with mild-to-moderate COPD were recruited to a double-blind pre-registered (ClinicalTrials.gov identifier: NCT01985750) experimental medicine study running parallel to a pulmonary rehabilitation course. Participants were randomised to 250 mg d-cycloserine or placebo, administered immediately prior to the first four sessions of pulmonary rehabilitation. Primary outcome measures were differences between d-cycloserine and placebo in brain activity in the anterior insula, posterior insula, anterior cingulate cortices, amygdala and hippocampus following completion of pulmonary rehabilitation. Secondary outcomes included the same measures at an intermediate time point and voxel-wise difference across wider brain regions. An exploratory analysis determined the interaction with breathlessness anxiety. No difference between d-cycloserine and placebo groups was observed across the primary or secondary outcome measures. d-cycloserine was shown instead to interact with changes in breathlessness anxiety to dampen reactivity to breathlessness cues. Questionnaire and measures of respiratory function showed no group difference. This is the first study testing brain-active drugs in pulmonary rehabilitation. Rigorous trial methodology and validated surrogate end-points maximised statistical power. Although increasing evidence supports therapeutic modulation of NMDA pathways to treat symptoms, we conclude that a phase 3 clinical trial of d-cycloserine would not be worthwhile.

Development and implementation of the lung volume reduction pulmonary rehabilitation tool to identify eligibility for lung volume reduction in people with chronic obstructive pulmonary disease during pulmonary rehabilitation.

Completion of pulmonary rehabilitation is recognised in chronic obstructive pulmonary disease (COPD) guidelines as a key opportunity to consider systematically whether a respiratory review to assess potential suitability for a lung volume reduction (LVR) procedure might be appropriate. We describe the development of a simple decision-support tool (the LVR-PR tool) to aid clinicians working in pulmonary rehabilitation, to operationalise this process. We took an iterative mixed methods approach, which was partnership-based and involved an initial consensus survey, focus groups and an observational study cohort at multiple pulmonary rehabilitation centres. Diagnosis (97%), exercise capacity (84%), breathlessness (78%) and co-morbidities (76%) were acknowledged to be essential items for assessing basic LVR eligibility. Collating prior investigations and assessing patient understanding were considered useful but not essential. Clinician concerns included; streamlining the tool; access to clinical information and investigations; and care needed around introducing LVR therapies to patients in a PR setting. Access to clearer information about LVR procedures, the clinician's role in considering eligibility and how educational resources should be delivered were identified as important themes from patient group discussions. The LVR-PR tool was considered to be feasible and valid for implementation in a variety of PR services across the UK subject to the provision of appropriate health professional training. Clinicians working in specialist LVR centres across the UK who were not otherwise involved in the development process confirmed the tool's validity using the content validity index (CVI). The LVR-PR tool appears to be an acceptable tool that can be feasibly implemented in PR services subject to good quality educational resources for both patients and healthcare professionals.

Pulmonary rehabilitation: A novel adjunct in management of obstructive sleep apnea.

Pulmonary rehabilitation (PR) is being used in the routine management of patients of obstructive sleep apnea (OSA) at some centers. However, the studies documenting benefits of PR in OSA lack standardization in terms of outcome measures. A study was hence planned to determine the efficacy of PR on exercise capacity, health related quality of life (HRQOL), day time sleepiness and sleep-quality of life (QOL) in patients of OSA. As a part of comprehensive therapy, patients diagnosed with OSA are managed with continuous positive airway pressure (CPAP), 8 weeks thrice weekly outpatient hospital-based PR and medical treatment at the Pulmonary Medicine Department, Government Medical College and Hospital, Chandigarh. However, some patients refuse for PR because of time constraints and travel issues. Patients with newly diagnosed OSA without co-existing respiratory disease, who agreed for the CPAP, PR and medical management were enrolled in group A. The patients who refused for PR but were ready for CPAP and medical management were enrolled in Group B; 30 patients were taken in each group. Exercise capacity, HRQOL, day time sleepiness and sleep-QOL were determined at baseline and at 8-weeks follow-up by 6-minute walk distance (6MWD), St. George's Respiratory Questionnaire (SGRQ), Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) and compared amongst the two groups. Four patients from group A were excluded as they did not complete PR; 26 patients from group A and 30 patients from group B were finally analyzed. At baseline, both groups were matched with respect to age, gender, apnea-hypopnea index (AHI), body mass index (BMI), FEV1%predicted, 6MWD, SGRQ, ESS and FOSQ. At follow up at 8 weeks, BMI, 6MWD, SGRQ, ESS and FOSQ improved significantly from baseline in group A (p<0.001). FEV1%predicted also improved but non significantly. In group B, FEV1%predicted, BMI, 6MWD, SGRQ, ESS and FOSQ score did not improve significantly from baseline. Mean improvement from baseline in BMI, 6MWD, SGRQ, ESS and FOSQ was significantly more in group A than group B (p<0.001, p<0.001, p=0.041, p<0.001 and p<0.001, respectively). PR, being beneficial, should be incorporated in standard management of OSA.

Exploring the prevalence and impact of hip and knee pain in pulmonary rehabilitation: a propensity-matched cohort study

BackgroundMusculoskeletal pain is more common in individuals with chronic respiratory diseases than the aged-matched general population. This investigation aimed to understand the prevalence and impact of hip and knee pain on pulmonary rehabilitation outcomes and completion rates.MethodsParticipants who experienced hip/knee pain in the 4 weeks prior to pulmonary rehabilitation completed an Oxford Hip and/or Knee Score alongside a routine pulmonary rehabilitation assessment. Participants engaged in a twice-weekly, 6-week outpatient pulmonary rehabilitation programme. A 1:1 propensity score match for age, sex, BMI, sessions attended and MRC score was completed prior to group comparison for a pulmonary rehabilitation cohort without hip/knee pain.Results6.5% (n = 97) of pulmonary rehabilitation participants reported pain: hip (n = 27), knee (n = 40) or hip and knee pain (n = 30). 75 participants with hip/knee pain provided sufficient data for pre pulmonary rehabilitation matching and were propensity matched with a pulmonary rehabilitation group without hip/knee pain. The average Oxford Score across all reported joints was 28.7 (8.5) indicating moderate/severe pain at baseline. Statistically significant improvements were made in Oxford Scores for the left hip, left knee and right knee (P < 0.01) but not the right hip following pulmonary rehabilitation. There was no statistically significant difference between groups for improvements in quadriceps strength, walking tests or depression scores, both groups achieved within group significance. There were no significant differences in pulmonary rehabilitation completion rates between groups.ConclusionsPrevalence of hip/knee pain in individuals presenting to pulmonary rehabilitation is 6.5%. Pain improved in the majority of joints following pulmonary rehabilitation and pain did not impact the effectiveness or completion of the programme.Trial Registration: This trial was an evaluation of a clinical service and has not been registered in a public domain.

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care.

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care.

Effect of pulmonary rehabilitation on dyspnea and exercise tolerance in patients with interstitial lung disease: a systematic review

Purpose Pulmonary rehabilitation (PR) and exercise training have proven effective for dyspnea and exercise tolerance for individuals with chronic obstructive pulmonary disease (COPD) but little is known of its effect on interstitial lung disease (ILD). There is a need in the literature to systematically review the effect of these interventions on individuals with ILD concerning exercise tolerance and/or dyspnea. Methods This systematic review utilized PRISMA guidelines to conduct the reporting of the findings and was registered with PROSPERO (CRD42020186513). Databases searched included: PubMed, CINAHL, ProQuest, Scopus, and Web of Science. Independent screening was performed by two authors with a third acting as a tiebreaker when consensus was not reached. Randomized control trials (RCTs) were included with subjects over 18 years old with a diagnosis of ILD who complete either pulmonary rehabilitation (PR) or exercise training interventions and included the six minutes walk test (6MWT) to measure exercise tolerance and/or outcomes to measure dyspnea. Studies were also included if they were published between 2008 through the date of study collection. A quality assessment was then performed on each RCT using the PEDro score with those with a rating of six or greater being included. Results Eight studies meeting inclusion criteria were included in this review with statistical significance reported in seven of the studies for short-term improvements and in two of the studies for long-term improvements in exercise tolerance. Six reported statistical significance for short-term improvements in dyspnea and two studies reported statistical significance for long-term improvements of dyspnea. Conclusion Individuals with ILD demonstrate improvements in exercise tolerance and symptoms of dyspnea after participating in PR or exercise training interventions.

Predictors of Outpatient Pulmonary Rehabilitation Uptake, Adherence, Completion, and Treatment Response Among Male U.S. Veterans With Chronic Obstructive Pulmonary Disease

ObjectiveTo examine predictors of uptake (never start), adherence (drop out), and completion of pulmonary rehabilitation (PR), as well as PR treatment response based on minimal clinically important difference (MCID) on the 6-minute walk test (6MWT) distance and Chronic Respiratory Questionnaire–Self-Report (CRQ-SR). DesignRetrospective, cohort study. SettingVeterans Health Administration. ParticipantsU.S. veterans with chronic obstructive pulmonary disease (COPD) (N=253) referred to PR between 2010 and 2018. InterventionsOutpatient PR program. Main Outcome MeasuresParticipants completed baseline (time 1) measures of depression (Beck Depression Inventory-II), health-related quality of life (CRQ-SR), self-efficacy (Exercise Self-Regulatory Efficacy Scale [Ex-SRES]), and COPD knowledge. Exercise capacity was assessed with the 6MWT. Participants who completed all 18 sessions of PR repeated assessments (time 2). Logistic regression models examined predictors of uptake, adherence, and completion of PR as well as treatment response based on MCID. ResultsParticipants were referred to PR with 24.90% never starting, 28.90% dropping out, and 46.20% completing. No differences emerged between never starters and dropouts. Having a history of any cancer increased the likelihood of completing PR (vs never starting; odds ratio [OR], 3.18; P=.003). Greater CRQ-SR dyspnea score, indicating less dyspnea, was associated with increased likelihood of completing PR (OR, 1.12; P=.006). Past smoking compared with current smoking was associated with increased likelihood of completion (OR, 3.89; P≤.002). Those without a history of alcohol use disorder had increased likelihood of completing PR (OR, 2.23; P=.048). Greater baseline 6MWT distance was associated with lower likelihood of achieving MCID in 6MWT (OR, 0.99; P<.001). Greater Ex-SRES was associated with decreased likelihood of achieving 6MWT MCID (OR, 0.98; P=.023). ConclusionsFindings suggest that early psychoeducation on dyspnea management and smoking and alcohol cessation may increase completion of PR.

To explore the prevalence and impact of hip and/or knee pain in patients presenting for pulmonary rehabilitation

Purpose: Pulmonary rehabilitation (PR) is a key treatment in the management of respiratory conditions and is highly effective in improving respiratory symptoms, quality of life and improving exercise capacity. However, as patients progress through a programme, other (non-respiratory) factors can impact on the patients’ ability to engage in and complete PR. Musculoskeletal problems such as osteoarthritic pain have been found to be more common in patients with COPD and are associated with poor self-related health. The purpose of this investigation was to understand the prevalence and impact of hip and knee pain on PR outcomes and completion rates.

The Need for Expanding Pulmonary Rehabilitation Services.

Pulmonary rehabilitation is a strongly recommended and effective treatment for people with chronic lung disease. However, access to pulmonary rehabilitation is poor. Globally, pulmonary rehabilitation is accessed by less than 3% of people with chronic lung disease. Barriers to referral, uptake and completion of pulmonary rehabilitation are well documented and linked with organizational, practitioner and patient-related factors. Enhancing the knowledge of health care professionals, family carers, and people with chronic lung disease about the program and its benefits produces modest increases in referral and uptake rates, but evidence of the sustainability of such approaches is limited. Additionally, initiatives focusing on addressing organizational barriers to access, such as expanding services and implementing alternative models to the conventional center-based setting, are not yet widely used in clinical practice. The COVID-19 pandemic has highlighted the urgent need for health care systems to deliver pulmonary rehabilitation programs remotely, safely, and efficiently. This paper will discuss the pressing need to address the issue of the low accessibility of pulmonary rehabilitation. It will also highlight the distinctive challenges to pulmonary rehabilitation delivery in rural and remote regions, as well as low-income countries.

Pulmonary Rehabilitation in Idiopathic Pulmonary Fibrosis and COPD: A Propensity-Matched Real-World Study

BackgroundThe adherence to and clinical efficacy of pulmonary rehabilitation in idiopathic pulmonary fibrosis (IPF), particularly in comparison with COPD, remains uncertain. The objectives of this real-world study were to compare the responses of patients with IPF with a matched group of patients with COPD undergoing the same supervised, outpatient pulmonary rehabilitation program and to determine whether pulmonary rehabilitation is associated with survival in IPF.Research QuestionDo people with IPF improve to the same extent with pulmonary rehabilitation as a matched group of individuals with COPD, and are noncompletion of or nonresponse to pulmonary rehabilitation, or both, associated with 1-year all-cause mortality in IPF?Study Design and MethodsUsing propensity score matching, 163 patients with IPF were matched 1:1 with a control group of 163 patients with COPD referred for pulmonary rehabilitation. We compared between-group pulmonary rehabilitation completion rates and response. Survival status in the IPF cohort was recorded over 1 year after pulmonary rehabilitation discharge. Cox proportional hazards regression explored the association between pulmonary rehabilitation status and all-cause mortality.ResultsSimilar pulmonary rehabilitation completion rates (IPF, 69%; COPD, 63%; P = .24) and improvements in exercise response were observed in both groups with no significant mean between-group differences in incremental shuttle walk test (ISWT) change (mean, 2 m [95% CI, –18 to 22 m]). Pulmonary rehabilitation noncompletion (hazard ratio [HR], 5.62 [95% CI, 2.24-14.08]) and nonresponse (HR, 3.91 [95% CI, 1.54-9.93]) were associated independently with increased 1-year all-cause mortality in IPF.InterpretationThis real-word study demonstrated that patients with IPF have similar completion rates and magnitude of response to pulmonary rehabilitation compared with a matched group of patients with COPD. In IPF, noncompletion of and nonresponse to pulmonary rehabilitation were associated with increased all-cause mortality. These data reinforce the benefits of pulmonary rehabilitation in patients with IPF.

LONG-TERM IMPACT OF PULMONARY REHABILITATION ON SLEEP IN COPD PATIENTS AS MEASURED BY ACTIGRAPHY

TOPIC: Pulmonary Rehabilitation TYPE: Original Investigations PURPOSE: Chronic obstructive pulmonary disease (COPD) is associated with poor sleep quality. Compared to the general population, COPD patients have delayed sleep initiation, impaired sleep maintenance, increased nightmares, and excessive daytime sleepiness. Poor sleep negatively affects functional capacity, peripheral muscle strength, and health-related quality of life (HRQL), and is associated with increased COPD exacerbations and mortality. Pulmonary rehabilitation (PR) has been shown to improve daytime function, HRQL, and subjective sleep quality in COPD. It has also been shown to improve sleep subjectively but not objectively, as measured by actigraphy in short duration (8-12 weeks). Long-term effects of PR on sleep have not been studied well. We hypothesized that actigraphy would demonstrate subjective and objective improvement in sleep with long-term exercise following completion of PR. METHODS: This was a retrospective study of COPD patients who completed PR at Veteran’s Affairs Loma Linda from 2013 to 2020. Participants underwent 8 weeks of structured PR and 12 months of unstructured exercise program (home and in-center). Actigraphic watch recordings before PR, after 8 weeks of PR, and 12 months after completion of PR were taken. Data were collected on sleep variables, including total time in bed (TBT), total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), wakefulness after sleep onset (WASO), and total nocturnal awakenings. Data on spirometry, six-minute walk distance (6MWD), Pittsburgh Sleep Quality Index (PSQI), St. George's Respiratory Questionnaire (SGRQ), and modified Medical Research Council Dyspnea (mMRC) score were also collected. Paired comparisons (t-tests) were performed to assess the impact of PR on sleep variables. RESULTS: Out of 98 participants enrolled for PR during the study period, 16 completed 12-month post-PR assessments including actigraphy and were included in the final analysis. All participants were male with an average age of 72 ± 8 yrs and more than two-thirds (69%) had severe COPD (GOLD stage 3 or 4). Details of subjective and objective sleep outcomes are in the table. There was sustained improvement in 6MWD (mean difference, 68.8m, 95% CI -1.3 to 139, p=0.05) and SGRQ (mean difference, - 8.1 points, 95% CI-16.3 to 0.1, p=0.05), as well as stable mMRC score (mean difference, -0.4 points, -1.2 to 0.5, p=0.37). However, objective sleep variables from actigraphy worsened (TBT, TST) or did not improve (SOL, SE, WASO, Awakenings). PSQI did not improve significantly after 12 months post-PR (mean change, -1.3, 95% CI -3.1 to 0.5, p=0.14). CONCLUSIONS: Pulmonary rehabilitation with an unstructured exercise program after completion of 8 weeks of structured program was not associated with qualitative or quantitative improvements in sleep. Further studies are needed to evaluate whether long-term structured exercise programs following PR could improve sleep in COPD patients. CLINICAL IMPLICATIONS: Sleep is significantly impaired in patients with COPD. Poor sleep can lead to increased cognitive impairment, cardiovascular disease, COPD exacerbations, and mortality. Sleep quality in COPD patients has not been shown to improve after completion of pulmonary rehabilitation. However, long-term structured exercise programs following completion of pulmonary rehabilitation may improve sleep quality in this population. DISCLOSURES: No relevant relationships by Shawn Band Mani Benedict, source=Web Response No relevant relationships by Kathleen Ellstrom, source=Web Response No relevant relationships by Joseph Mak, source=Admin input No relevant relationships by Suman Thapamagar, source=Web Response

Feasibility of an online platform delivery of pulmonary rehabilitation for individuals with chronic respiratory disease

IntroductionSARS-CoV-2 has restricted access to face-to-face delivery of pulmonary rehabilitation (PR). Evidence suggests that telehealth-PR is non-inferior to outpatient PR. However, it is unknown whether patients who have been referred...

Barriers to pulmonary rehabilitation - A narrative review and perspectives from a few stakeholders.

Pulmonary Rehabilitation (PR) is an essential and comprehensive intervention recommended in the management of people with chronic respiratory diseases (CRD). Scientific evidence suggests significant health benefits with respect to repeated hospital admissions, exercise tolerance and Health Related Quality of Life (HRQoL). However, the uptake and completion of PR programs are globally low. In order to understand the factors contributing to underutilization of PR, it is important to review and recognize the barriers to PR program. A literature search was conducted on Medline (PubMed) database. After reviewing the title and abstracts, full text articles were scrutinized for their relevance. Twenty-two studies involving factors affecting the uptake, participation and completion of PR program were included in this review. Reported barriers to PR were healthcare system, healthcare professional and patient related factors. Primary factors related to healthcare system and healthcare professionals were fewer PR centers, accessibility inconvenience, lack of awareness of PR program, low knowledge of referral process and lack of interdisciplinary teamwork. Difficulties faced by patients to take up and/or to complete PR programs were lack of transportation, co-morbidities, lack of perceived benefits, socio-economic status and lack of funding facilities. Identified and reported barriers resulted into discontinuity between knowledge of health benefits and utilization of PR service for patients with CRDs. Addressing the barriers would accelerate the healthcare professionals' referral and patients to avail the health benefits of rehabilitation service.

Predictors of pulmonary rehabilitation completion in the UK

IntroductionPulmonary rehabilitation has been shown to improve dyspnoea, fatigue, quality of life and exercise capacity in individuals with chronic obstructive pulmonary disease (COPD). Our aim was to determine the characteristics of people with COPD associated with completion of pulmonary rehabilitation.MethodsThis was a cross-sectional analysis of 7060 people with COPD enrolled in pulmonary rehabilitation between January 1, 2017 and March 31, 2017. Data were from a UK national audit of COPD care. Factors associated with pulmonary rehabilitation completion were determined using mixed effects logistic regression with a random intercept for pulmonary rehabilitation service. Factors chosen for assessment based on clinical judgement and data availability were age, sex, country, socioeconomic status, body mass index, referral location, programme type, start within 90 days, smoking status, oxygen therapy, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) dyspnoea grade, any exercise test and any health status questionnaire.Results4635 (66%) people with COPD completed a pulmonary rehabilitation programme. People that were aged ≥60 years, resident in Wales, referred within 90 days, an ex- or never-smoker, received an exercise test, or received a health status questionnaire had significantly greater odds of completing pulmonary rehabilitation. People that were in the most deprived quintile, underweight or very severely obese, enrolled in a rolling rather than a cohort programme, had a higher GOLD stage and had a higher MRC grade had significantly lower odds of completing pulmonary rehabilitation.ConclusionsPeople with COPD were more likely to complete pulmonary rehabilitation when best practice guidelines were followed. People with more severe COPD symptoms and those enrolled in rolling rather than cohort programmes were less likely to complete pulmonary rehabilitation. Referring people with COPD in the earlier stages of disease, ensuring programmes follow best practice guidelines and favouring cohort over rolling programmes could improve rates of pulmonary rehabilitation completion.

Experiences of Pulmonary Rehabilitation in People Living with Chronic Obstructive Pulmonary Disease and Frailty. A Qualitative Interview Study.

Rationale: People living with both chronic obstructive pulmonary disease (COPD) and frailty have high potential to benefit from pulmonary rehabilitation but face challenges completing programs. However, research to understand ways to optimize participation in this group is lacking.Objectives: To explore the experiences, needs, and preferences of people with COPD and frailty referred for outpatient pulmonary rehabilitation.Methods: Semistructured interviews with people with COPD and physical frailty, purposively sampled by age, living status, level of frailty, and completion of pulmonary rehabilitation. Thematic analysis with a critical realist perspective was used, involving relevant stakeholders with clinical, academic, and lived experience for interpretive rigor.Results: Nineteen people with COPD and frailty were interviewed, with a median age of 78 years (range, 58–88). Nine did not complete their pulmonary rehabilitation program. Four themes were identified: striving to adapt to multidimensional loss, tensions of balancing support with independence, pulmonary rehabilitation as a challenge worth facing, and overcoming unpredictable disruptions to participation. Participants described constantly adapting to their changing health and resulting multidimensional losses (e.g., functional abilities, relationships, confidence). This involved traversing between independence and seeking support, set against a mismatch between their needs and what support is available. People with COPD and frailty can be highly motivated to participate in pulmonary rehabilitation, despite the physical and mental demands it entails, and report a range of benefits. Yet in the context of changeable health, they must often overcome multiple unpredictable disruptions to completing rehabilitation programs. Participant determination and flexibility of services can facilitate ongoing attendance, but for some, these unpredictable disruptions erode their motivation to attend.Conclusions: People with COPD and frailty experience accumulating, multidimensional loss. This group are motivated to complete pulmonary rehabilitation but often require additional support and flexibility owing to fluctuating and unpredictable health. Person-centered approaches should be considered to minimize disruptive health events and support pulmonary rehabilitation participation and completion. Service adaptations could allow more flexibility to meet the changing needs of this group and enable communication around how pulmonary rehabilitation might align with their priorities.

A Lay Health Worker Intervention to Increase Uptake and Completion of Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease: Assessing Fidelity of Intervention Delivery

The benefits of pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) are restricted by poor uptake and completion. Lay health workers (LHWs) have been effective in improving access to treatment and services for other health conditions. We have successfully shown the feasibility of this approach in a PR setting and its acceptability to the LHWs and COPD patients. We present here the feasibility of assessment, and the fidelity of delivery of LHW support achieved for COPD patients referred for PR. LHWs, volunteer COPD patients experienced in PR, received training in the intervention including communication skills, confidentiality and behaviour change techniques (BCTs). Interactions between LHWs and patients were recorded, transcribed and coded for delivery style and BCTs. Inter-rater agreement on the coding of delivery style and BCTs was high at >84%. LHWs built rapport and communicated attentively in over 80% of interactions. LHWs most consistently delivered BCTs concerning information provision about the consequences of PR often making those consequences salient by referring to their own positive experience of PR. Social support BCTs were also used by the majority of LHWs. The use of BCTs varied between LHWs. The assessment of intervention delivery fidelity by LHWs was feasible. LHW training in the setting of PR should add emphasis to the acquisition of BCT skills relating to goal setting and action planning.

Clinical Outcomes and Inflammatory Responses of the Frequent Exacerbator in Pulmonary Rehabilitation: A Prospective Cohort Study

Frequent exacerbators of Chronic Obstructive Pulmonary Disease (COPD) is a distinct clinical phenotype characterised by systemic inflammation. Study objectives were to determine clinical outcomes of pulmonary rehabilitation in frequent exacerbators and the impact this has on the key surrogate markers of this phenotype. Eighty-five mild-very severe COPD patients (FEV1 pred, 52 ± 18%) were categorised as frequent (≥2 exacerbations per year, n = 50) or infrequent exacerbators (≤1 exacerbation per year, n = 35). The primary outcomes were completion rates of pulmonary rehabilitation (clinical) and plasma fibrinogen (biological). Secondary outcomes were: incremental shuttle (ISWT) & endurance shuttle walk tests (ESWT), chronic respiratory disease questionnaire (CRQ), hospital anxiety and depression scale (HADS), plasma C-reactive protein (CRP), blood leukocyte counts, blood neutrophil activation (CD11b, CD62L, CD66b) and subsets (mature, immature, suppressive, progenitor). Fibrinogen and CRP concentrations were determined via ELISA’s with neutrophil activation markers assessed using flow cytometry. Frequent exacerbators were less likely to complete pulmonary rehabilitation (44% vs 69%; p = 0.025). Both groups experienced improvements in ISWT (p < 0.001), ESWT (p < 0.001), all domains of the CRQ (p < 0.001) and Depression (p = 0.017). Pulmonary rehabilitation reduced resting concentrations of fibrinogen (frequent exacerbators = 12%, infrequent exacerbators = 4%, p = 0.033) and % of progenitor blood neutrophils (p = 0.015) in both groups, with reductions in total blood leukocyte (p = 0.018) and neutrophil counts (p = 0.018) also observed in frequent exacerbators. No significant reductions in CRP concentration (p = 0.937), neutrophil activation (CD11b, p = 0.553; CD62L, p = 0.070; CD66b, p = 0.317), or other neutrophil subsets (mature, p = 0.313; immature, p = 0.756; suppressive, p = 0.259) were observed. Frequent exacerbators of COPD were less likely to complete pulmonary rehabilitation, but those who complete experience similar benefits to infrequent exacerbators. Pulmonary rehabilitation may serve to have immune-modulatory properties for frequent exacerbators.