Global mortality and readmission rates following COPD exacerbation-related hospitalisation: a meta-analysis of 65 945 individual patients.

Background: Exacerbations of COPD (ECOPD) have a major impact on patients and healthcare systems across the world. Precise estimates of the global burden of ECOPD on mortality and hospital readmission are needed to inform policy makers and aid preventive strategies to mitigate this burden. The aims of the present study were to explore global in-hospital mortality, post-discharge mortality and hospital readmission rates after ECOPD-related hospitalisation using an individual patient data meta-analysis (IPDMA) design. Methods: A systematic review was performed identifying studies that reported in-hospital mortality, post-discharge mortality and hospital readmission rates following ECOPD-related hospitalisation. Data analyses were conducted using a one-stage random-effects meta-analysis model. This study was conducted and reported in accordance with the PRISMA-IPD statement. Results: Data of 65 945 individual patients with COPD were analysed. The pooled in-hospital mortality rate was 6.2%, pooled 30-, 90- and 365-day post-discharge mortality rates were 1.8%, 5.5% and 10.9%, respectively, and pooled 30-, 90- and 365-day hospital readmission rates were 7.1%, 12.6% and 32.1%, respectively, with noticeable variability between studies and countries. Strongest predictors of mortality and hospital readmission included noninvasive mechanical ventilation and a history of two or more ECOPD-related hospitalisations <12 months prior to the index event. Conclusions: This IPDMA stresses the poor outcomes and high heterogeneity of ECOPD-related hospitalisation across the world. Whilst global standardisation of the management and follow-up of ECOPD-related hospitalisation should be at the heart of future implementation research, policy makers should focus on reimbursing evidence-based therapies that decrease (recurrent) ECOPD.

Physical Activity Profiles among Patients Admitted with Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

People with hospitalised acute exacerbations of chronic obstructive pulmonary disease (AECOPD) exhibit low levels of physical activity (PA) and increased risks of future exacerbations. While methods to objectively measure and express PA are established for people with stable COPD, less clarity exists for people during AECOPD. Further, the relationship between PA during AECOPD and clinically relevant outcomes remains uncertain. The purpose of the study was to evaluate how much PA (step count and intensity) people accumulate during hospitalised AECOPDs, and the effect of accumulated inpatient PA (expressed via differing metrics) on length of stay (LOS), PA recovery, and readmission risk. This study was a secondary analysis of prospective observational cohort data collected with Actigraph wActiSleep-BT devices from patients with AECOPD in a Melbourne hospital from 2016 to 2018. Step counts and PA intensity throughout the hospital admission and at one-month follow-up were collected and analysed. Sixty-eight participants were recruited for inpatient measurement, and 51 were retained for follow-up. There were no significant changes in step count or intensity across the inpatient days, but 33/51 (65%) of participants demonstrated a clinically meaningful improvement in steps per day from 3817.0 to 6173.7 at follow-up. Participants spent most time sedentary and in light PA, with both PA metrics demonstrating significant influences on LOS and follow-up PA intensity, but with generally low explanatory power (R2 value range 7-22%). Those who had LOS < 5 days spent significantly less time sedentary and more time in light PA than those with LOS ≥ 5 days (p < 0.001 for both). Time spent sedentary or in light PA appears to be the most promising metric to associate with clinically relevant outcomes related to recovery following AECOPD. These findings can inform future clinical practice for the evaluation of inpatient PA to better establish its role in the clinical management of patients with AECOPD.

Frailty in the chronic respiratory patient: association with mortality and clinical features in obstructive, restrictive, and mixed spirometric patterns.

BACKGROUND: Frailty associates with increased vulnerability to adverse health outcomes and reduced tolerance to medical interventions. Its impact on patients with chronic respiratory diseases, particularly beyond chronic obstructive pulmonary disease (COPD), remains poorly understood. AIMS: To evaluate the association between frailty index and 5-year mortality across different "spirometric" patterns and the variation in their occurring frailty determinants. METHODS: This study analyzed data from the SARA study, which enrolled 1968 older adults, to evaluate the association between frailty and 5-year mortality across different spirometric patterns. Frailty was assessed using the frailty index (FI), and spirometry was performed to determine lung function patterns. Hazard ratios (HRs) were calculated using Cox regression models, adjusting for age and sex. RESULTS: Among the study participants, 16% were classified as frail. Frailty was associated with a significantly increased risk of mortality across all spirometric patterns. The 5-year mortality rates were 34.3% in subjects with normal spirometry, 45.1% in those with obstructive defects, 55% in those with restrictive defects, and 42.6% in those with mixed airflow defects. The unadjusted HRs for mortality were 2.64 (95% CI 2.10-3.32) for the overall cohort, 2.24 (95% CI 1.48-3.40) for obstructive defects, 2.45 (95% CI 1.12-5.36) for restrictive defects, and 2.79 (95% CI 1.41-3.17) for mixed airflow defects. After adjusting for age and sex, the HRs remained statistically significant: 2.25 (95% CI 1.37-2.84) for the overall cohort, 2.08 (95% CI 1.37-3.18) for obstructive defects, 2.27 (95% CI 1.04-1.17) for restrictive defects, and 2.21 (95% CI 1.20-3.08) for mixed airflow defects. CONCLUSION: Frailty is a common syndrome and is associated with a significantly increased risk of mortality. The FI provides valuable information for risk profiling and personalized interventions beyond age and lung function parameters. Including frailty assessment in clinical evaluations can aid in resource allocation and improve patient care in respiratory diseases.

European Respiratory Society statement on frailty in adults with chronic lung disease.

Frailty is a complex, multidimensional syndrome characterised by a loss of physiological reserves that increases a person's susceptibility to adverse health outcomes. Most knowledge regarding frailty originates from geriatric medicine; however, awareness of its importance as a treatable trait for people with chronic respiratory disease (including asthma, COPD and interstitial lung disease) is emerging. A clearer understanding of frailty and its impact in chronic respiratory disease is a prerequisite to optimise clinical management in the future. This unmet need underpins the rationale for undertaking the present work. This European Respiratory Society statement synthesises current evidence and clinical insights from international experts and people affected by chronic respiratory conditions regarding frailty in adults with chronic respiratory disease. The scope includes coverage of frailty within international respiratory guidelines, prevalence and risk factors, review of clinical management options (including comprehensive geriatric care, rehabilitation, nutrition, pharmacological and psychological therapies) and identification of evidence gaps to inform future priority areas of research. Frailty is underrepresented in international respiratory guidelines, despite being common and related to increased hospitalisation and mortality. Validated screening instruments can detect frailty to prompt comprehensive assessment and personalised clinical management. Clinical trials targeting people with chronic respiratory disease and frailty are needed.

Elevated blood lactate in COPD exacerbations associates with adverse clinical outcomes and signals excessive treatment with ß2 -agonists.

BACKGROUND AND OBJECTIVE: Raised blood lactate secondary to high dose ß2 -agonist treatment has been reported in asthma exacerbations but has not been investigated during acute exacerbations of COPD (AECOPD). We explored associations of blood lactate measurements with disease outcomes and ß2 -agonist treatments during AECOPD. METHODS: Retrospective (n = 199) and prospective studies (n = 142) of patients hospitalized with AECOPD were conducted. The retrospective cohort was identified via medical records and the prospective cohort was recruited during hospitalization for AECOPD. Baseline demographics, comorbidities, ß2 -agonist treatment, biochemical measurements and clinical outcomes were compared between patients with normal (≤2.0 mmol/L) versus elevated lactate (>2.0 mmol/L). Regression analyses examined associations of lactate measurements with ß2 -agonist dosages. RESULTS: Demographic data and comorbidities were similar between high versus normal lactate groups in both cohorts. The populations were elderly (mean >70 years), predominantly male (>60%) with reduced FEV1 (%) 48.2 ± 19 (prospective cohort). Lactate was elevated in approximately 50% of patients during AECOPD and not related to evidence of sepsis. In the prospective cohort, patients with high lactate had more tachypnoea, tachycardia, acidosis and hyperglycaemia (p < 0.05) and received more non-invasive ventilation (37% vs. 9.7%, p < 0.001, prospective cohort). There was a trend to longer hospitalization (6 vs. 5 days, p = 0.06, prospective cohort). Higher cumulative ß2 -agonist dosages were linked to elevated lactate levels (OR 1.04, p = 0.01). CONCLUSION: Elevated lactate during AECOPD was common, unrelated to sepsis and correlated with high cumulative doses of ß2 -agonists. Raised lactate may indicate excessive ß2 -agonist treatment and should now be investigated as a possible biomarker.

The primary care experience of adults with chronic obstructive pulmonary disease (COPD). An interpretative phenomenological inquiry.

BACKGROUND: Studies of the lived experience of chronic obstructive pulmonary disease (COPD) reveal a number of challenges patients face when interacting with healthcare providers that may be exacerbated by unwillingness or inability to quit smoking. However, none have explored, in-depth, primary care experiences among patients with COPD in community healthcare settings. AIMS/ OBJECTIVE: The study investigated healthcare experiences of patients living independently in the community with COPD who smoked or had recently quit (at most within the last 5 years), seeking care in primary care settings. METHOD: An Interpretative Phenomenological Analysis (IPA) involving thirteen participants purposively recruited from social media posts in COPD and carer support groups, general community groups, community noticeboards and paid adverts on social media. In-depth interviews were held between February and April 2022 by phone or Zoom™ and explored patient experience of primary care, focusing on how smoking patterns, addiction and stigma impact upon and shape these experiences. RESULTS: Participants were aged between 45 to 75 years. Nine were female and two thirds were current smokers. Problematic experiences including time-constrained consultations, having to self-advocate for care "…go digging myself and then go and see him and say, can we do this, can we do that type of thing?" and guilt about smoking were common. Positive care experiences described non-judgemental interpersonal interactions with doctors, timely referral, proactive care and trust "I have an actual great trust for my GP… they're awesome, they'll look after you". Participants described how their care experience shifted as primary care adapted care delivery during COVID-19. CONCLUSIONS: Pro-active, empathetic care from general practitioners is desired from patients living with COPD. Stigma and fear of judgement was an important underlying driver of negative care experiences contributing to delayed help seeking from general practitioners.

Rehabilitation for People with Respiratory Disease and Frailty: An Official American Thoracic Society Workshop Report.

People with respiratory disease have increased risk of developing frailty, which is associated with worse health outcomes. There is growing evidence of the role of rehabilitation in managing frailty in people with respiratory disease. However, several challenges remain regarding optimal methods of identifying frailty and delivering rehabilitation for this population. The aims of this American Thoracic Society workshop were to outline key definitions and concepts around rehabilitation for people with respiratory disease and frailty, synthesize available evidence, and explore how programs may be adapted to align to the needs and experiences of this population. Across two half-day virtual workshops, 20 professionals from diverse disciplines, professions, and countries discussed key developments and identified opportunities for future research, with additional input via online correspondence. Participants highlighted a "frailty rehabilitation paradox" whereby pulmonary rehabilitation can effectively reduce frailty, but programs are challenging for some individuals with frailty to complete. Frailty should not limit access to rehabilitation; instead, the identification of frailty should prompt comprehensive assessment and tailored support, including onward referral for additional specialist input. Exercise prescriptions that explicitly consider symptom burden and comorbidities, integration of additional geriatric or palliative care expertise, and/or preemptive planning for disruptions to participation may support engagement and outcomes. To identify and measure frailty in people with respiratory disease, tools should be selected on the basis of sensitivity, specificity, responsiveness, and feasibility for their intended purpose. Research is required to expand understanding beyond the physical dimensions of frailty and to explore the merits and limitations of telerehabilitation or home-based pulmonary rehabilitation for people with chronic respiratory disease and frailty.

Validity and clinical applicability of the 60-second sit-to-stand test in people with acute exacerbations of COPD.

BACKGROUND: The 60-s sit-to-stand test (60STS) is a simple and increasingly popular test of physical function, however evidence to support its appropriateness for assessing people with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is lacking. AIMS: To evaluate the concurrent, convergent, predictive and discriminant validity, and responsiveness of the 60STS against the 6-min walk test (6MWT) in people hospitalised due to AECOPD. METHODS: Prospective cohort study involving 54 inpatients with AECOPD (53% males, mean age 69.0 years, FEV1 46.5% predicted). 60STS was performed 30 min after a 6-min walk test (6MWT) upon discharge, with follow-up testing repeated one-month later (n = 39). Outcome measures included 60STS repetitions (60STSr), 6-min walk distance (6MWD), heart rate, oxyhaemoglobin saturation (SpO2), perceived dyspnoea (Borg scale), and rate of perceived exertion (RPE). Concurrent validity was assessed via correlation, convergent validity via Bland-Altman plots, predictive validity via multivariate linear regression (adjusted for confounders), discriminant validity via unpaired t tests and responsiveness via χ2 tests. RESULTS: Discharge 60STSr and 6MWD were strongly correlated (r = 0.61). Bland-Altman plots for nadir SpO2, peak HR, Borg and RPE scores showed acceptable agreement in terms of mean differences, but wide limits of agreement. Poor 60STSr performers were older, had weaker quadriceps, and had lower 6MWD than high performers (p < 0.05 for all). 60STSr was not retained as a significant predictor of 6MWD in multivariate regression analyses. 80% of 60STSr improvers also improved >30 m on 6MWT at follow-up. CONCLUSION: The 60STS demonstrates satisfactory validity and responsiveness as a measure of exercise performance in people with AECOPD.

Planning exercise interventions as an adjunct treatment in managing venous leg ulcers: A qualitative study of nurses' perspectives.

OBJECTIVE: To explore clinicians' perspectives regarding strategies to support exercise interventions for people with venous leg ulcers. DESIGN: 1:1 interview was guided by the Behaviour Change Wheel (BCW) to collect thoughts from clinicians with experiences in managing venous leg ulcers. SETTINGS: Clinical nurses in metropolitan/regional Victoria, Australia. PARTICIPANTS: A convenience sample of 21 nurses (mean clinical experience 14 years) was recruited. METHODS: We conducted semi-structured remote interviews. Transcripts were coded and analysed using a theory-driven thematic analysis, and interventions to support the implementation of exercise interventions were mapped across the BCW. RESULTS: Strategies related to capability, opportunity and motivation components from the BCW were identified. The strategies reported to be important included: i) education of patients and family members; ii) the provision of consistent and clear exercise advice; iii) setting realistic and meaningful goals in light of challenges encountered by patients; iv) flexibility in how exercise programmes were organised/structured, particularly to facilitate rapid adoption; and v) clinician education. CONCLUSIONS: In-depth qualitative interviews of nurses working with people with venous leg ulcers in Australia revealed multifactorial issues that potentially affect prescription of care regarding physical exercise. In order to improve and standardise future clinical practice, a clear focus of future research should address such issues.

General practice care following acute exacerbations of COPD: A survey of Australian general practitioners.

Acute exacerbations of COPD (AECOPDs) are one of the leading causes of preventable hospital admissions in Australia. Exacerbations are the strongest predictor for future exacerbations. The period immediately following an exacerbation is a high-risk period for recurrence and critical time to intervene. The aim of this study was to identify current general practice care for patients following an AECOPD in Australia and gain insights into knowledge of evidence-based care. A cross-sectional survey was created and disseminated electronically to Australian general practitioners (GPs). Data were analysed descriptively. Comparisons between groups were made using Chi squared tests. From 64 responses, 47% were familiar with the COPD-X Plan. Only 50% described reviewing patients within seven days of discharge mostly related to a lack of awareness of the hospital admission. 50% of surveyed GPs reported hospital discharge summaries did not provide the information they required. Smoking, immunisation and medications were regularly assessed by >90% respondents at follow-up visits, while referrals to pulmonary rehabilitation, and evaluation of spirometry and oxygen therapy were not prioritised. GPs appear to require support to increase their familiarity with COPD guidelines and inform evidence-based clinical practice. The handover/communication process from hospital to primary care appears an important area for future improvement.

Healthcare experience of adults with COPD during the COVID-19 pandemic: a rapid review of international literature.

BACKGROUND: People living with chronic obstructive pulmonary disease (COPD) are a group who may be particularly vulnerable to COVID-19. This vulnerability has been associated with increased anxiety or fear about exposure to the virus, which may also impact upon experience in healthcare settings. AIM/OBJECTIVES: The aim of this narrative mixed-methods review was to systematically scope, identify and synthesise findings from peer-reviewed qualitative, quantitative and mixed-methods studies published in academic journals describing the healthcare experiences of adults living with COPD independently in the community, following the emergence of COVID-19 in December 2019-June 2022. METHODS: Databases including Ovid MEDLINE, PsychINFO, Ovid Emcare and CINAHL Plus were searched. Studies were uploaded to Covidence to support selection and appraisal of studies. Studies were appraised for quality using the Mixed Methods Appraisal Tool. A narrative synthesis of these themes was provided, and qualitative and quantitative findings are interpreted together in the discussion. FINDINGS: The quality and experience of care for patients with COPD was impacted through the COVID-19 pandemic. Innovations and adoption of technologies such as telehealth and telerehabilitation were well received and mitigated the potential implications of severe disruption to care access to some extent. Patients feared feeling forgotten and experienced isolation and anxiety; however, telerehabilitation and exercise through modalities such as Zoom classes help support social connection and physical activity. IMPLICATIONS: These innovations are likely to be useful to be offered to patients on an ongoing basis, and education and standardised protocols around their use will benefit healthcare providers and patients alike. PROSPERO REGISTRATION NUMBER: CRD42022341168.

General practice management of COPD patients following acute exacerbations: a qualitative study.

BACKGROUND: Exacerbations are the strongest risk factor for future exacerbations for patients living with chronic obstructive pulmonary disease (COPD). The period immediately following exacerbation is a high-risk period for recurrence and hospital admission, and is a critical time to intervene. GPs are ideally positioned to deliver this care. AIM: To explore perceptions of GPs regarding the care of patients following exacerbations of COPD and to identify factors affecting the provision of evidence-based care. DESIGN AND SETTING: A descriptive qualitative study was undertaken involving semi-structured, in-depth interviews with Australian GPs who volunteered to participate following a national survey of general practice care for COPD patients following exacerbations. METHOD: Interviews were conducted via the Zoom video conference platform, which were audio-recorded and transcribed verbatim. QSR NVivo was used to support data management, coding, and inductive thematic analysis. RESULTS: Eighteen GPs completed interviews. Six key themes were identified: 1) GPs' perceptions and knowledge in the management of COPD patients following exacerbation and admission to hospital; 2) pharmacological management; 3) consultation time; 4) communication between healthcare professionals; 5) access to other health services; and 6) patient compliance. CONCLUSION: Delivery of post-exacerbation care to COPD patients is affected by GPs, patients, and health service-related factors. The care of COPD patients may be further improved by supporting GPs to overcome identified barriers.

Healthcare experiences of adults with COPD across community care settings: a meta-ethnography.

Background: Studies investigating lived experiences of patients with COPD raise important concerns about interactions with healthcare professionals. Patients often describe feelings of guilt and shame associated with their COPD and may experience stigma and poor patient experience of care. The aims and objectives of the present study were to systematically scope and synthesise findings from peer-reviewed qualitative studies describing healthcare experiences of patients living with COPD across community care settings. Methods: A meta-ethnography was undertaken. Database searches were performed in Ovid MEDLINE, PsychINFO, Ovid Emcare, CINAHL Plus and Sociological Abstracts. Eligible qualitative studies were included. Study screening and data extraction was performed by two independent reviewers. A "line-of-argument" synthesis and deductive and inductive analysis was used to identify key themes, where the deductive element aligned to Wong and Haggerty's six key dimensions of patient experiences. Results: Data from 23 studies were included. Experiences and their meaning to patients were explored within the context of six domains of patient experience including access, interpersonal communication, continuity and coordination, comprehensiveness and trust. Inductive coding revealed emotion, stigma, identity and vulnerability shaped healthcare experiences of adults with COPD. Implications: Experiences often fell short of what was expected and needed in community settings. Adopting strategies to improve experiences of care in the community can be expected to improve self-management and contribute to improved health outcomes and quality of life. These strategies should take account of vulnerability, stigma and emotions such as guilt and blame that are potent affective drivers of the experience of care for patients with COPD.

Association between physical activity levels and healing in people with venous leg ulcers: secondary analysis of prospective cohort data.

Aim: To explore the relationship between physical activity levels and wound healing and recurrence in people with venous leg ulcers. Methods: Questionnaires and medical records were used to collect data, with responses used to group participants into different physical activity groups. The differences in healing and recurrence outcomes of ulcers among different physical activity groups were compared using Chi-square, Kaplan Meier survival analysis, Cox proportional hazards regression analysis, and Kruskal-Wallis test. To measure the strength of the association between physical activity levels and patient outcomes, Spearman's Rho tests were used. We used descriptive analysis to examine how physical activity levels change over 24 weeks. Results: Participants were classified into four distinct groups based on physical activity levels reported at baseline and week 12. The survival analysis showed higher physical activity level was associated with a shorter time to healing (log-rank test = 14.78, df = 3; p = 0.002). The persistently moderate-to-vigorous group had a 7.3-fold increased likelihood of healing compared to the persistently sedentary group. High levels of physical activity were also associated with a better quality of life score at baseline (ρ = 0.41, p < 0.000), week 12 (ρ = 0.36, p < 0.001), and week 24 (ρ = 0.49, p < 0.000). Most participants (48.5%) reported low levels of physical activity, which remained low for the entire study period. Conclusion: An increased level of physical activity was linked to a shorter healing time and enhanced quality of life. Low levels of physical activity appeared common among people with venous leg ulcers.

Pulmonary function testing during SARS-CoV-2: An ANZSRS/TSANZ position statement.

The Thoracic Society of Australia and New Zealand (TSANZ) and the Australian and New Zealand Society of Respiratory Science (ANZSRS) commissioned a joint position paper on pulmonary function testing during coronavirus disease 2019 (COVID-19) in July 2021. A working group was formed via an expression of interest to members of both organizations and commenced work in September 2021. A rapid review of the literature was undertaken, with a 'best evidence synthesis' approach taken to answer the research questions formed. This allowed the working group to accept findings of prior relevant reviews or societal document where appropriate. The advice provided is for providers of pulmonary function tests across all settings. The advice is intended to supplement local infection prevention and state, territory or national directives. The working group's key messages reflect a precautionary approach to protect the safety of both healthcare workers (HCWs) and patients in a rapidly changing environment. The decision on strategies employed may vary depending on local transmission and practice environment. The advice is likely to require review as evidence grows and the COVID-19 pandemic evolves. While this position statement was contextualized specifically to the COVID-19 pandemic, the working group strongly advocates that any changes to clinical/laboratory practice, made in the interest of optimizing the safety and well-being of HCWs and patients involved in pulmonary function testing, are carefully considered in light of their potential for ongoing use to reduce transmission of other droplet and/or aerosol borne diseases.

Pulmonary rehabilitation versus usual care for adults with asthma.

BACKGROUND: Asthma is a respiratory disease characterised by variable airflow limitation and the presence of respiratory symptoms including wheeze, chest tightness, cough and/or dyspnoea. Exercise training is beneficial for people with asthma; however, the response to conventional models of pulmonary rehabilitation is less clear. OBJECTIVES: To evaluate, in adults with asthma, the effectiveness of pulmonary rehabilitation compared to usual care on exercise performance, asthma control, and quality of life (co-primary outcomes), incidence of severe asthma exacerbations/hospitalisations, mental health, muscle strength, physical activity levels, inflammatory biomarkers, and adverse events. SEARCH METHODS: We identified studies from the Cochrane Airways Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform, from their inception to May 2021, as well as the reference lists of all primary studies and review articles. SELECTION CRITERIA: We included randomised controlled trials in which pulmonary rehabilitation was compared to usual care in adults with asthma. Pulmonary rehabilitation must have included a minimum of four weeks (or eight sessions) aerobic training and education or self-management. Co-interventions were permitted; however, exercise training alone was not.  DATA COLLECTION AND ANALYSIS: Following the use of Cochrane's Screen4Me workflow, two review authors independently screened and selected trials for inclusion, extracted study characteristics and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. We contacted study authors to retrieve missing data. We calculated between-group effects via mean differences (MD) or standardised mean differences (SMD) using a random-effects model. We evaluated the certainty of evidence using GRADE methodology. MAIN RESULTS: We included 10 studies involving 894 participants (range 24 to 412 participants (n = 2 studies involving n > 100, one contributing to meta-analysis), mean age range 27 to 54 years). We identified one ongoing study and three studies awaiting classification. One study was synthesised narratively, and another involved participants specifically with asthma-COPD overlap. Most programmes were outpatient-based, lasting from three to four weeks (inpatient) or eight to 12 weeks (outpatient). Education or self-management components included breathing retraining and relaxation, nutritional advice and psychological counselling. One programme was specifically tailored for people with severe asthma.  Pulmonary rehabilitation compared to usual care may increase maximal oxygen uptake (VO2 max) after programme completion, but the evidence is very uncertain for data derived using mL/kg/min (MD between groups of 3.63 mL/kg/min, 95% confidence interval (CI) 1.48 to 5.77; 3 studies; n = 129) and uncertain for data derived from % predicted VO2 max (MD 14.88%, 95% CI 9.66 to 20.1%; 2 studies; n = 60). The evidence is very uncertain about the effects of pulmonary rehabilitation compared to usual care on incremental shuttle walk test distance (MD between groups 74.0 metres, 95% CI 26.4 to 121.4; 1 study; n = 30). Pulmonary rehabilitation may have little to no effect on VO2 max at longer-term follow up (9 to 12 months), but the evidence is very uncertain (MD -0.69 mL/kg/min, 95% CI -4.79 to 3.42; I2 = 49%; 3 studies; n = 66). Pulmonary rehabilitation likely improves functional exercise capacity as measured by 6-minute walk distance, with MD between groups after programme completion of 79.8 metres (95% CI 66.5 to 93.1; 5 studies; n = 529; moderate certainty evidence). This magnitude of mean change exceeds the minimally clinically important difference (MCID) threshold for people with chronic respiratory disease. The evidence is very uncertain about the longer-term effects one year after pulmonary rehabilitation for this outcome (MD 52.29 metres, 95% CI 0.7 to 103.88; 2 studies; n = 42). Pulmonary rehabilitation may result in a small improvement in asthma control compared to usual care as measured by Asthma Control Questionnaire (ACQ), with an MD between groups of -0.46 (95% CI -0.76 to -0.17; 2 studies; n = 93; low certainty evidence); however, data derived from the Asthma Control Test were very uncertain (MD between groups 3.34, 95% CI -2.32 to 9.01; 2 studies; n = 442). The ACQ finding approximates the MCID of 0.5 points. Pulmonary rehabilitation results in little to no difference in asthma control as measured by ACQ at nine to 12 months follow-up (MD 0.09, 95% CI -0.35 to 0.53; 2 studies; n = 48; low certainty evidence). Pulmonary rehabilitation likely results in a large improvement in quality of life as assessed by the St George's Respiratory Questionnaire (SGRQ) total score (MD -18.51, 95% CI -20.77 to -16.25; 2 studies; n = 440; moderate certainty evidence), with this magnitude of change exceeding the MCID. However, pulmonary rehabilitation may have little to no effect on Asthma Quality of Life Questionnaire (AQLQ) total scores, with the evidence being very uncertain (MD 0.87, 95% CI -0.13 to 1.86; 2 studies; n = 442). Longer-term follow-up data suggested improvements in quality of life may occur as measured by SGRQ (MD -13.4, 95% CI -15.93 to -10.88; 2 studies; n = 430) but not AQLQ (MD 0.58, 95% CI -0.23 to 1.38; 2 studies; n = 435); however, the evidence is very uncertain. One study reported no difference between groups in the proportion of participants who experienced an asthma exacerbation during the intervention period. Data from one study suggest adverse events attributable to the intervention are rare.  Overall risk of bias was most commonly impacted by performance bias attributed to a lack of participant blinding to knowledge of the intervention. This is inherently challenging to overcome in rehabilitation studies.  AUTHORS' CONCLUSIONS: Moderate certainty evidence shows that pulmonary rehabilitation is probably associated with clinically meaningful improvements in functional exercise capacity and quality of life upon programme completion in adults with asthma. The certainty of evidence relating to maximal exercise capacity was very low to low. Pulmonary rehabilitation appears to confer minimal effect on asthma control, although the certainty of evidence is very low to low. Unclear reporting of study methods and small sample sizes limits our certainty in the overall body of evidence, whilst heterogenous study designs and interventions likely contribute to inconsistent findings across clinical outcomes and studies. There remains considerable scope for future research.

Barriers and enablers to physical activity in people with venous leg ulcers: A systematic review of qualitative studies.

BACKGROUND: Venous leg ulceration is caused by chronic venous insufficiency and affects millions of adults worldwide who suffer prolonged healing episodes and due to underlying pathophysiology ulcer recurrence is common after healing. Compression therapy is the current best practice for managing venous leg ulcer since it provides constant pressure, which promotes circulation in the lower limbs. Nevertheless, the healing outcomes of venous leg ulcer vary considerably. Physical activity may be an effective adjunct treatment to improve ulcer healing outcomes. However, a low level of physical activity level is observed in this cohort. OBJECTIVE: To identify the barriers and enablers that affect physical activity participation in people with venous leg ulcers. DESIGN: A systematic review of qualitative studies using the mega-aggregation approach. METHODS: We followed the Joanna Briggs Institute methodology for systematic reviews of qualitative evidence. We searched MEDLINE, CINAHL PLUS, PsycINFO and Emcare to identify relevant articles published in English from 1806 to January 2021. Two reviewers independently screened and selected articles against inclusion criteria. Eligible studies were appraised for methodological quality using Joanna Briggs Institute Critical Appraisal tool. Qualitative data were extracted manually. Theoretical Domain Framework was used to map barriers and enablers to physical activity participation. RESULTS: Eighteen studies were included in this review. The main barriers and enablers identified in this review that influence physical activity engagement in people with venous leg ulcers are as follows: understanding the chronic nature of venous leg ulcers and the reasons for undertaking physical activities; specific beliefs that people hold about their own capabilities; pain related to wound and compression therapy; information and supports received from treating clinicians; feeling of fear and embarrassment. The confidence level for most of the synthesis findings was moderate to low. CONCLUSIONS: Our review identified people with venous leg ulcers experience significant challenges preventing them from engaging in physical activity. Factors such as knowledge of physical activity, availability of information, and self-belief may be particularly important for promoting physical activity in this cohort. Future interventions are recommended to provide educational information and clear instructions to improve participation. Further research is needed to explore potential interventions that may change physical activity behaviour in this population group. REGISTRATION: PROSPERO CRD42021238579.