Community-based respiratory health measures in children and young people with cerebral palsy: A scoping review.

AIM: To identify, map, and describe outcome measurement domains and instruments used within a community setting to assess respiratory health in children and young people aged 1 to 18 years, diagnosed with cerebral palsy (CP). METHOD: A scoping review methodology informed structured searches in nine databases, grey literature, and registries, conducted in August 2021 (updated in February 2023). Articles were screened for eligibility by two independent researchers. Any outcome measurement instruments used to assess respiratory health or associated impact were extracted, categorized, and mapped to health and health-related domains of the International Classification of Functioning, Disability, and Health. RESULTS: Seventy-six outcome measurement instruments were identified across 78 articles worldwide between 1970 and 2023. These were categorized into 'Body functions and structures' (n = 20), 'Activity and performance' (n = 22), and 'Participation and quality of life' (n = 19), with a further 15 mapped to 'Health care resources use'. INTERPRETATION: No consensus of 'what' to measure and 'how' to measure respiratory health in children and young people with CP was found. Moreover, many measures were not replicable in individuals with more severe forms of CP, excluding those at increased risk of respiratory-related morbidity and mortality. Further research is required to agree important outcome domains and associated measures in research and clinical practice. WHAT THIS PAPER ADDS: A limited number and size of experimental designs were found. Seventy-six measures were identified to assess respiratory health in cerebral palsy. No consensus was found in 'what' or 'how' to measure respiratory health. Many measures were not replicable in children and young people at risk of poorer respiratory health outcomes. Children and young people with comorbidities and learning disability were frequently excluded from studies.

Real-world effectiveness of airway clearance techniques in children with cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is commonly characterised by thick respiratory mucus. From diagnosis, people with CF are prescribed daily physiotherapy, including airway clearance techniques (ACTs). ACTs consume a large proportion of treatment time, yet the efficacy and effectiveness of ACTs are poorly understood. This study aimed to evaluate associations between the quality and quantity of ACTs and lung function in children and young people with CF. METHODS: Project Fizzyo, a longitudinal observational cohort study in the UK, used remote monitoring with electronic pressure sensors attached to four different commercial ACT devices to record real-time, breath-by-breath pressure data during usual ACTs undertaken at home over 16 months in 145 children. ACTs were categorised either as conformant or not with current ACT recommendations based on breath pressure and length measurements, or as missed treatments if not recorded. Daily, weekly and monthly associations between ACT category and lung function were investigated using linear mixed effects regression models adjusting for clinical confounders. RESULTS: After exclusions, 45 224 ACT treatments (135 individuals) and 21 069 days without treatments (141 individuals) were analysed. The mean±sd age of participants was 10.2±2.9 years. Conformant ACTs (21%) had significantly higher forced expiratory volume in 1 s (FEV1) (mean effect size 0.23 (95% CI 0.19-0.27) FEV1 % pred per treatment) than non-conformant (79%) or missed treatments. There was no benefit from non-conformant or missed treatments and no significant difference in FEV1 between them (mean effect size 0.02 (95% CI -0.01-0.05) FEV1 % pred per treatment). CONCLUSIONS: ACTs are beneficial when performed as recommended, but most people use techniques that do not improve lung function. Work is needed to monitor and improve ACT quality and to increase the proportion of people doing effective airway clearance at home.

The 'heROIC' trial: Does the use of a robotic rehabilitation trainer change quality of life, range of movement and function in children with cerebral palsy?

BACKGROUND: Children with severe cerebral palsy (CP) (GMFCS IV/V) can find it difficult to access equipment that allows them to exercise effectively, potentially impacting their quality of life. Physiotherapists working within special schools are well placed to facilitate increased physical activity as part of the school day. This study explored whether the Innowalk Pro, a robotic rehabilitation trainer, could influence quality of life (measured by the CPCHILD questionnaire), in children with CP, alongside, joint range of movement, spasticity and functional goals of the lower limbs, measured by goniometry, modified Tardieu scale and goal attainment scoring, GAS, respectively. METHODS: A prospective single-arm, pre-post trial was undertaken. The Innowalk Pro was used four times a week for 30 min alongside usual physiotherapy care in a school setting over a 6-week period. Outcomes were evaluated immediately pre/post intervention and at 6 weeks and 3 months post intervention. Analysis also explored differences between primary and secondary age participants. RESULTS: Twenty-seven participants aged 5-18 years with a diagnosis of CP GMFCS IV/V (10 female, 17 male, mean age 12 years) were included from a convenience sample in a special school. Quality of life improved in 36% of participants, the majority of these being secondary aged. Knee extension reduced significantly 3 months post intervention. There were no meaningful changes in spasticity. GAS goals improved in 88% of participants after using the Innowalk Pro. GAS goals tended to decline after a break from using the equipment, with 21% declining by two or more units at 3 months post intervention. CONCLUSION: A 6-week course of the Innowalk Pro can improve quality of life and functional goals for children with CP aged 5-18 years. After a break of 6-12 weeks, functional goals tend to return to baseline. Further research is needed to explore different prescriptions of the Innowalk Pro, to see if increasing the time used/increasing the frequency or number of weeks it is used for can provide longer lasting benefits.

Supervised pulmonary rehabilitation using minimal or specialist exercise equipment in COPD: a propensity-matched analysis.

BACKGROUND: Many trials supporting the benefits of pulmonary rehabilitation (PR) have used specialist exercise equipment, such as treadmills and cycle ergometers. However, access to specialist equipment may not be feasible in some settings. There is growing interest in delivering PR programmes with minimal, low-cost equipment, but uncertainty remains regarding their efficacy compared with programmes using specialist equipment. METHODS: Using propensity score matching, 318 consecutive patients with COPD undergoing supervised PR using minimal equipment (PR-min) were compared 1:1 with a control group of 318 patients with COPD who underwent supervised PR using specialist equipment (PR-gym). A non-inferiority analysis was performed for the primary outcome (incremental shuttle walk (ISW)) and secondary outcomes (Chronic Respiratory Disease Questionnaire (CRQ)-domain and total scores). RESULTS: Similar improvements in ISW and CRQ-domains were observed in PR-min and PR-gym groups (mean difference ISW: 3 m (95% CI -16 to 9); CRQ-total: 0.9 (95% CI -2.7 to 4.5)). The 95% CI between group differences for ISW and CRQ-total did not cross the predefined non-inferiority margins. However, completion rates were lower in PR-min compared with PR-gym (64% vs 73%; p=0.014). CONCLUSIONS: In patients with COPD, PR delivered using minimal equipment produces clinically significant benefits in exercise capacity and health-related quality of life that are non-inferior to rehabilitation delivered using specialist equipment. This study provides support for the provision of PR using minimal exercise equipment, particularly in areas where access to specialist exercise equipment is limited.

Chest Physiotherapy for Mechanically Ventilated Children: A Systematic Review.

The aim of this study was to appraise and summarize the effects of chest physiotherapy in mechanically ventilated children. A systematic review was completed by searching Medline, Embase, Cinahl Plus, PEDro, and Web of Science from inception to February 9, 2021. Studies investigating chest physiotherapy for mechanically ventilated children (0-18 years), in a pediatric intensive care unit were included. Chest physiotherapy was defined as any intervention performed by a qualified physiotherapist. Measurements of effectiveness and safety were included. Exclusion criteria included preterm infants, children requiring noninvasive ventilation, and those in a nonacute setting. Thirteen studies met the inclusion criteria: two randomized controlled trials, three randomized crossover trials, and eight observational studies. The Cochrane risk of bias and the Critical Appraisal Skills Program tools were used for quality assessment. Oxygen saturations decreased after physiotherapy involving manual hyperinflations (MHI) and chest wall vibrations (CWV). Although statistically significant, these results were not of clinical importance. In contrast, oxygen saturations improved after the expiratory flow increase technique; however, this was not clinically significant. An increase in expiratory tidal volume was demonstrated 30 minutes after MHI and CWV. There was no sustained change in tidal volume following a physiotherapy-led recruitment maneuver. Respiratory compliance and dead-space increased immediately after MHI and CWV. Atelectasis scores improved following intrapulmonary percussive ventilation, and MHI and CWV. Evidence to support chest physiotherapy in ventilated children remains inconclusive. There are few high-quality studies, with heterogeneity in interventions and populations. Future studies are required to investigate multiple physiotherapy interventions and the impact on long-term outcomes.

The Impact of High-Frequency Chest-Wall Compression on Mechanical Ventilation Delivery and Flow Bias.

BACKGROUND: It is unclear if high-frequency chest-wall compression (HFCWC) has a role to assist with secretion clearance in patients on mechanical ventilation. The effect of HFCWC on the delivery of mechanical ventilation is unknown. This study describes the effect of HFCWC on mechanical ventilation delivery and flow bias in an orally intubated and mechanically ventilated bench model. METHODS: An orally intubated mannequin was mechanically ventilated in 5 commonly used modes of ventilation at settings that reflect current practice. HFCWC was applied via a randomized combination of oscillation frequencies and pressure settings. Mechanical ventilator flow, flow bias, and breathing frequency were measured before and during the application of HFCWC. RESULTS: HFCWC led to 3- to 7-fold increases in ventilator-delivered breathing frequency during synchronized intermittent mandatory ventilation, bi-level (with pressure support), bi-level-assist, and pressure-regulated volume control modes of ventilation. Only in the bi-level mode without pressure support was the ventilator breathing frequency unaffected by HFCWC. During HFCWC, peak inspiratory flow to peak expiratory flow ratios toward an expiratory flow bias, particularly at higher HFCWC pressures, only in pressure-regulated volume control and synchronized intermittent mandatory ventilation modes were peak inspiratory flow to peak expiratory flow ratios of <0.9 generated that would facilitate secretion clearance. CONCLUSIONS: HFCWC led to 3- to 7-fold increases in ventilator breathing frequency delivered by mechanical ventilation except in the bi-level mode. The bi-level mode may be the optimal mode to use HFCWC to minimize disruption to the delivered ventilator breathing frequency. The peak inspiratory flow to peak expiratory flow ratios < 0.9, the optimal flow bias for secretion clearance, was only achieved in the pressure-regulated volume control and synchronized intermittent mandatory ventilation modes. However, the findings in this bench model with a fixed low compliance may not be generalizable to the patient in the ICU, and we recommend further investigation into the effects of HFCWC in the patient in the ICU.

Physiotherapy assessment of breathing pattern disorder: a qualitative evaluation.

OBJECTIVES: To explore physiotherapists' opinions of physiotherapy assessment of Breathing Pattern Disorder (BPD). METHODS: Qualitative study using focus groups (FGs) with reflexive thematic analysis and survey methods. The survey was distributed via social media and email to UK specialist physiotherapy interest groups. Two FGs, conducted in different settings, included physiotherapists based in hospital outpatients/community, private practice and higher education. RESULTS: One-hundred-and-three physiotherapists completed the survey. Respondents identified a lack of consensus in how to define BPD, but some agreement in the components to include in assessment. Fifteen physiotherapists participated in the FGs. Three themes emerged from FG discussions: (1) nomenclature and language of breathing, (2) BPD and breathlessness and (3) The value of assessment of breathlessness. CONCLUSION: The inconsistent nomenclature of dysfunctional breathing pattern impacts assessment, management and understanding of the diagnosis. Clarity in diagnosis, informing consistency in assessment, is fundamental to improving recognition and treatment of BPD. The findings are useful in the planning of education, training, future research and guideline development in BPD assessment.

Chest physiotherapy for mechanically ventilated children: a survey of current UK practice.

OBJECTIVES: Chest physiotherapy is a treatment option for mechanically ventilated children. However, there is a lack of consensus regarding its value and informal discussions suggest variation in practice. This study describes chest physiotherapy practices for mechanically ventilated children in the UK and explores clinical decision making related to its delivery. DESIGN: Cross-sectional study, using an anonymous, electronic survey. PARTICIPANTS: Qualified physiotherapists working in UK NHS paediatric intensive care units (PICUs). RESULTS: The response rate was 61% (72/118), this included physiotherapists from 26/27 (96%) PICUs. All participants reported using manual hyperinflations and position changes 'always' or 'often'. Variation in practice was evident for some techniques, including Metaneb® and percussion. DNase (99%, 71/72) and hypertonic saline (90%, 65/72) were the most frequently used mucoactives: 91% (59/65) of physiotherapists reported only nebulising hypertonic saline and 69% (49/71) use both nebulised and instilled DNase. Use and delivery of N-acetylcysteine was inconsistent (nebulised only 55%, 26/47; instilled only 15%, 7/47; both 30%, 14/47). Chest physiotherapy was most commonly delivered with a nurse (67%, 48/72). Clinical decision making processes were comparable between physiotherapists and encompassed three main elements: individual patient assessment, involvement of the multidisciplinary team, and risk versus benefit analysis. CONCLUSIONS: A range of chest physiotherapy treatments and adjuncts were used with ventilated children. Variation was apparent and may be due to individual preferences of those training staff or local policies. Pragmatic, interventional studies are required to determine best practice. Further exploration is necessary to understand the variation in practice and intricacies of decision making.

Quantity and quality of airway clearance in children and young people with cystic fibrosis.

Children and young people with CF (CYPwCF) get advice about using positive expiratory pressure (PEP) or oscillating PEP (OPEP) devices to clear sticky mucus from their lungs. However, little is known about the quantity (number of treatments, breaths, or sets) or quality (breath pressures and lengths) of these daily airway clearance techniques (ACTs) undertaken at home. This study used electronic pressure sensors to record real time breath-by-breath data from 145 CYPwCF (6-16y) during routine ACTs over 2 months. ACT quantity and quality were benchmarked against individual prescriptions and accepted recommendations for device use. In total 742,084 breaths from 9,081 treatments were recorded. Individual CYPwCF maintained consistent patterns of ACT quantity and quality over time. Overall, 60% of CYPwCF did at least half their prescribed treatments, while 27% did fewer than a quarter. About 77% of pre-teens did the right number of daily treatments compared with only 56% of teenagers. CYPwCF usually did the right number of breaths. ACT quality (recommended breath length and pressure) varied between participants and depended on device. Breath pressures, lengths and pressure-length relationships were significantly different between ACT devices. PEP devices encouraged longer breaths with lower pressures, while OPEP devices encouraged shorter breaths with higher pressures. More breaths per treatment were within advised ranges for both pressure and length using PEP (30-31%) than OPEP devices (1-3%). Objective measures of quantity and quality may help to optimise ACT device selection and support CYPwCF to do regular effective ACTs.

The unique contribution of manual chest compression-vibrations to airflow during physiotherapy in sedated, fully ventilated children.

OBJECTIVE: This study aimed to quantify the specific effects of manual lung inflations with chest compression-vibrations, commonly used to assist airway clearance in ventilated patients. The hypothesis was that force applied during the compressions made a significant additional contribution to increases in peak expiratory flow and expiratory to inspiratory flow ratio over and above that resulting from accompanying increases in inflation volume. DESIGN: Prospective observational study. SETTING: Cardiac and general pediatric intensive care. PATIENTS: Sedated, fully ventilated children. INTERVENTIONS: Customized force-sensing mats and a commercial respiratory monitor recorded force and respiration during physiotherapy. MEASUREMENTS: Percentage changes in peak expiratory flow, peak expiratory to inspiratory flow ratios, inflation volume, and peak inflation pressure between baseline and manual inflations with and without compression-vibrations were calculated. Analysis of covariance determined the relative contribution of changes in pressure, volume, and force to influence changes in peak expiratory flow and peak expiratory to inspiratory flow ratio. MEASUREMENTS AND MAIN RESULTS: Data from 105 children were analyzed (median age, 1.3 yrs; range, 1 wk to 15.9 yrs). Force during compressions ranged from 15 to 179 N (median, 46 N). Peak expiratory flow increased on average by 76% during compressions compared with baseline ventilation. Increases in peak expiratory flow were significantly related to increases in inflation volume, peak inflation pressure, and force with peak expiratory flow increasing by, on average, 4% for every 10% increase in inflation volume (p < .001), 5% for every 10% increase in peak inflation pressure (p = .005), and 3% for each 10 N of applied force (p < .001). By contrast, increase in peak expiratory to inspiratory flow ratio was only related to applied force with a 4% increase for each 10 N of force (p < .001). CONCLUSION: These results provide evidence of the unique contribution of compression forces in increasing peak expiratory flow and peak expiratory to inspiratory flow ratio bias over and above that related to accompanying changes from manual hyperinflations. Force generated during compression-vibrations was the single significant factor in multivariable analysis to explain the increases in expiratory flow bias. Such increases in the expiratory bias provide theoretically optimal physiological conditions for cephalad mucus movement in fully ventilated children.

Barriers and Enablers to Pulmonary Rehabilitation in Low- and Middle-Income Countries: A Qualitative Study of Healthcare Professionals.

Introduction: Low- and middle-income countries bear a disproportionately high burden of global morbidity and mortality caused by chronic respiratory diseases. Pulmonary rehabilitation is recommended as a core intervention in the management of people with chronic respiratory diseases. However, the intervention remains poorly accessed/utilised globally, especially in low- and middle-income countries. Aim: This qualitative study explored barriers and enablers to pulmonary rehabilitation in low- and middle-income countries from the perspective of healthcare professionals with pulmonary rehabilitation experience in these settings. Methods: Online-based semi-structured in-depth interviews with healthcare professionals were undertaken to data saturation, exploring lived barriers and enablers to pulmonary rehabilitation in their low- or middle-income country. Anonymised interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results: A total of seven healthcare professionals from seven low- and middle-income countries representing Africa, Asia, and South America were interviewed. They included five physiotherapists (four females), one family physician (male), and one pulmonologist (female). Themes for barriers to pulmonary rehabilitation included limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Themes for enablers included local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Conclusion: Barriers to pulmonary rehabilitation in low- and middle-income countries include limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Enablers include local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Successful implementation of these enablers will require engagement with multiple stakeholders. The findings of this study are a necessary step towards developing strategies that can overcome the existing pulmonary rehabilitation evidence-practice gap in low- and middle-income countries and alleviating the burden of chronic respiratory diseases in these countries.

Protocol for a single-centre mixed-method pre-post single-arm feasibility trial of a culturally appropriate 6-week pulmonary rehabilitation programme among adults with functionally limiting chronic respiratory diseases in Malawi.

INTRODUCTION: Malawi has a substantial burden of chronic respiratory diseases (CRDs) which cause significant morbidity and loss of economic productivity, affecting patients, families and health systems. Pulmonary rehabilitation (PR) is a highly recommended non-pharmacological intervention in the clinical management of people with CRDs. However, Malawi lacks published evidence on the implementation of PR for people with CRDs. This trial will test the feasibility and acceptability of implementing a culturally appropriate hospital-based PR programme among adults with functionally limiting CRDs at Queen Elizabeth Central Hospital in Blantyre, Malawi. METHODS AND ANALYSIS: This is a single-centre mixed-methods pre-post single-arm feasibility trial. Ten patients aged ≥18 years, with a spirometry confirmed diagnosis of a CRD and breathlessness of ≥2 on the modified Medical Research Council dyspnoea scale, will be consecutively recruited. Their baseline lung function, exercise tolerance and health status will be assessed; including spirometry, Incremental Shuttle Walk Test and Chronic Obstructive Pulmonary Disease Assessment Test, respectively. Pretrial semistructured in-depth interviews will explore their experiences of living with CRD and potential enablers and barriers to their PR uptake. Along with international PR guidelines, these data will inform culturally appropriate delivery of PR. We initially propose a 6-week, twice-weekly, supervised centre-based PR programme, with an additional weekly home-based non-supervised session. Using combination of researcher observation, interaction with the participants, field notes and informal interviews with the participants, we will assess the feasibility of running the programme in the following areas: participants' recruitment, retention, engagement and protocol adherence. Following programme completion (after 6 weeks), repeat assessments of lung function, exercise tolerance and health status will be conducted. Quantitative changes in clinical outcomes will be described in relation to published minimal clinically important differences. Post-trial semistructured interviews will capture participants' perceived impact of the PR programme on their quality of life, enablers, and barriers to fully engaging with the programme, and allow iteration of its design. ETHICS AND DISSEMINATION: Ethical approval for this trial was obtained from University of Malawi College of Medicine Research and Ethics Committee (COMREC), Blantyre, Malawi (protocol number: P.07/19/2752) and University of Leicester Research Ethics Committee, Leicester, UK (ethics reference: 31574). The results of the trial will be disseminated through oral presentations at local and international scientific conferences or seminars and publication in a peer-reviewed journal. We will also engage the participants who complete the PR trial and the Science Communication Department at Malawi-Liverpool-Wellcome Trust Clinical Research Programme to organise community outreach activities within Blantyre to educate communities about CRDs and PR. We will also broadcast our trial results through national radio station programmes such as the weekly "Thanzi la Onse" (Health of All) programme by Times Radio Malawi. We will formally present our trial results to Blantyre District Health Office and Malawi Ministry of Health. TRIAL REGISTRATION NUMBER: ISRCTN13836793.

Do commonly used ventilator settings for mechanically ventilated adults have the potential to embed secretions or promote clearance?

BACKGROUND: Intubation and mechanical ventilation can impair mucociliary clearance and cause secretion retention, airway occlusion, atelectasis, and pneumonia. Animal and laboratory work has demonstrated that mechanical ventilator settings can generate a flow bias (inspiratory or expiratory) that may result in mucus movement either away from the ventilator (deeper into the lungs) or toward the ventilator (toward the mouth), respectively. An absolute difference of 17 L/min, and a relative difference of ≥ 10%, between the expiratory and inspiratory flow have been reported as thresholds for mucus movement. METHODS: We measured baseline peak inspiratory and expiratory flows during quiet mechanical ventilation in a convenience sample of 20 intubated and ventilated adult patients. RESULTS: Nineteen patients had an inspiratory flow bias of ≥ 10%. Eight patients had an absolute mean inspiratory flow bias of ≥ 17 L/min. CONCLUSIONS: Commonly used mechanical ventilator settings generate an inspiratory flow bias that may promote secretion retention.

ECG changes during ISWTs in adult patients commencing CR: a retrospective case note review.

The incremental shuttle walk test (ISWT) is a valid, reliable submaximal exercise test used in the assessment of patients prior to cardiac rehabilitation (CR). Simultaneous electrocardiogram (ECG) measurements would provide important information on the safety of the test, and adequacy of subsequent cardiac risk stratification. Risk stratification is recommended to assess patients' suitability for cardiac rehabilitation. For example, ST-segment depression >2 mm from baseline during testing would place a person in a high-risk category. However, such ECG measurements are rarely undertaken in clinical practice. The aim of the study was to investigate the incidence of ECG changes during an ISWT, and report on the possible impact of these findings on subsequent cardiac risk stratification. A retrospective case note review was undertaken for the year 2017. Baseline clinical characteristics from eligible patients were gathered including those with ischaemic heart disease, heart failure, transplant and valve replacement, along with ECG measurements during the ISWT. The impact of ECG findings on cardiac risk stratification was calculated, based on risk stratification developed by the American Association of Cardiovascular and Pulmonary Rehabilitation. The safety of the ISWT was measured by the absence of major ECG changes. Data were gathered for 295 patients. Minor ECG changes were identified during the ISWT in 189 patients (64.1%), with no major changes. The presence of silent myocardial ischaemia (ST-segment depression) had an impact on cardiac risk stratification in 27 patients. There was a statistically significant positive association between ST-segment depression with cardiac risk stratification (p<0.001). In conclusion, the ISWT is safe in terms of ECG changes. The impact of ECG findings on cardiac risk stratification is significant and worthy of further consideration.

Feasibility of an Outpatient Training Program after COVID-19.

Long-term physical consequences of coronavirus disease 2019 (COVID-19) are currently being reported. As a result, the focus is turning towards interventions that support recovery after hospitalization. To date, the feasibility of an outpatient program for people recovering from COVID-19 has not been investigated. This study presents data for a physiotherapy-led, comprehensive outpatient pulmonary rehabilitation (PR) program. Patients were recruited after hospital discharge. Training consisted of twice weekly, interval-based aerobic cycle endurance (ACE) training, followed by resistance training (RT); 60-90 min per session at intensities of 50% peak work rate; education and physical activity coaching were also provided. Feasibility outcomes included: recruitment and dropout rates, number of training sessions undertaken, and tolerability for dose and training mode. Of the 65 patients discharged home during the study period, 12 were successfully enrolled onto the program. Three dropouts (25%) were reported after 11-19 sessions. Tolerability of interval-based training was 83% and 100% for exercise duration of ACE and RT, respectively; 92% for training intensity, 83% progressive increase of intensity, and 83% mode in ACE. We tentatively suggest from these preliminary findings that the PR protocol used may be both feasible, and confer benefits to a small subgroup of patients recovering from COVID-19.

One year follow-up of physical performance and quality of life in patients surviving COVID-19: a prospective cohort study.

INTRODUCTION: The coronavirus disease (COVID-19) continues to affect many countries globally, with the long-term impact of the disease now being recognized. According to the latest research, some of the affected individuals continue to experience functional limitations, reduced physical performance and impaired health-related quality of life (HRQoL) even after eight months. This prospective cohort study aimed to describe the longer-term recovery of physical performance and HRQoL in COVID-19 survivors over one year. METHOD: A cohort (n = 43; 32-84 years old) hospitalized with COVID-19 between March and June 2020 was followed over one year and assessed at three time points: hospital discharge, 3 months and 12 months post-admission. Participants experienced mild (10/43) to critical (6/43) pneumonia and stayed in the hospital for a median of 10 days (IQR 9). Participants were assessed for physical performance (six-minute walk test), HRQoL (EQ-5D-5L), COVID-19 related limitations in functionality (PCFS), hospital-related anxiety and depression (HADS-A/-D), lung function (FEV1, FVC) and dyspnea during activity (mMRC). All assessments were conducted by physiotherapists trained in cardio-respiratory rehabilitation. RESULTS: After discharge, 8/34 showed reduced physical performance, 9/42 had lower HRQoL and 14/32 had COVID-19 induced limitations in functionality on the PCFS scale. Physical performance did not change significantly between discharge and 12-month follow-up, but 15/34 participants showed clinically relevant improvements in walking distance (>30 m). However, 16/34 had a decreased walking distance >30 m when comparing 3-month to 12-month follow-up. At 12 months, 12/41 of participants still perceived COVID-19 related limitations in daily life on the PCFS scale. For HRQoL, 12/41 participants still perceived moderate-to-severe symptoms of pain and discomfort and 13/41 slight-to-severe symptoms of anxiety and depression. CONCLUSION: This cohort of adult patients hospitalized for mild to severe COVID-19 in Switzerland was generally mildly affected but still reported some limitations after one year. These results offer preliminary indications for ongoing support after hospitalization and point towards the need for specific, individualized follow-up to support their recovery.

Protocol for Project Fizzyo, an analytic longitudinal observational cohort study of physiotherapy for children and young people with cystic fibrosis, with interrupted time-series design.

INTRODUCTION: Daily physiotherapy is believed to mitigate the progression of cystic fibrosis (CF) lung disease. However, physiotherapy airway clearance techniques (ACTs) are burdensome and the evidence guiding practice remains weak. This paper describes the protocol for Project Fizzyo, which uses innovative technology and analysis methods to remotely capture longitudinal daily data from physiotherapy treatments to measure adherence and prospectively evaluate associations with clinical outcomes. METHODS AND ANALYSIS: A cohort of 145 children and young people with CF aged 6-16 years were recruited. Each participant will record their usual physiotherapy sessions daily for 16 months, using remote monitoring sensors: (1) a bespoke ACT sensor, inserted into their usual ACT device and (2) a Fitbit Alta HR activity tracker. Real-time breath pressure during ACTs, and heart rate and daily step counts (Fitbit) are synced using specific software applications. An interrupted time-series design will facilitate evaluation of ACT interventions (feedback and ACT-driven gaming). Baseline, mid and endpoint assessments of spirometry, exercise capacity and quality of life and longitudinal clinical record data will also be collected.This large dataset will be analysed in R using big data analytics approaches. Distinct ACT and physical activity adherence profiles will be identified, using cluster analysis to define groups of individuals based on measured characteristics and any relationships to clinical profiles assessed. Changes in adherence to physiotherapy over time or in relation to ACT interventions will be quantified and evaluated in relation to clinical outcomes. ETHICS AND DISSEMINATION: Ethical approval for this study (IRAS: 228625) was granted by the London-Brighton and Sussex NREC (18/LO/1038). Findings will be disseminated via peer-reviewed publications, at conferences and via CF clinical networks. The statistical code will be published in the Fizzyo GitHub repository and the dataset stored in the Great Ormond Street Hospital Digital Research Environment. TRIAL REGISTRATION NUMBER: ISRCTN51624752; Pre-results.

Physiotherapist prediction of extubation outcome in the adult intensive care unit.

OBJECTIVE: Most patients requiring intubation and mechanical ventilation are extubated successfully at the first attempt; however, a minority experience extubation failure, which is associated with increased risk of ventilator-associated pneumonia, prolonged intensive care unit (ICU) length of stay and mortality. Physiotherapists have expertise to assess cough strength, work of breathing, respiratory muscle strength, and respiratory secretion load, which are important factors in the outcome of extubation. Accurate prediction of extubation outcome could help to inform management plans pre-extubation and postextubation. The primary objective of this service evaluation was to report the accuracy of physiotherapists' prediction of extubation outcome in the adult ICU. METHODS: A single-centre case note review was undertaken. All subjects who received a physiotherapy assessment of extubation suitability prior to extubation between January and March 2016 in the adult ICU of a large teaching hospital in the United Kingdom were included. Assessment, by both specialist and nonspecialist physiotherapists-which included risk stratification of extubation failure as "high," "moderate," or "low"-was undertaken prior to extubation. Logistic regression analysis was performed to determine which pre-extubation factors were predictive of extubation outcome. RESULTS: During the evaluation period, 68 subjects were extubated following a physiotherapy assessment. Physiotherapy risk stratification as "high risk" (OR 4; 95% confidence interval, CI, [1.312]; p=0.009) and "inappropriate" neurological status (OR 3.3; 95% CI [1.0410]; p=0.037) were the only pre-extubation factors significantly associated with extubation failure. Assessment by specialist physiotherapists demonstrated greater sensitivity (100% vs. 22%) but lower specificity (68% vs. 95%) to detect extubation failure compared with the assessment performed by nonspecialist physiotherapists. CONCLUSION: Patients classified as "high risk" of extubation failure by a physiotherapist are significantly more likely to fail extubation. Specialist physiotherapists should be involved in the decision to extubate patients in the adult ICU.

Differences in delivery of respiratory treatments by on-call physiotherapists in mechanically ventilated children: a randomised crossover trial.

OBJECTIVES: To investigate differences, if any, in the delivery of respiratory treatments to mechanically ventilated children between non-respiratory on-call physiotherapists and specialist respiratory physiotherapists. SETTING: Paediatric, tertiary care hospital in the United Kingdom. PARTICIPANTS: 93 children (aged between 3 days and 16 years), and 22 physiotherapists (10 specialist respiratory physiotherapists) were recruited to the study. INTERVENTIONS: Recruited children received two physiotherapy treatments during a single day, one delivered by a non-respiratory physiotherapist, the other by a specialist respiratory physiotherapist in a randomised order. Selection, delivery and effects of techniques were recorded for each treatment. OUTCOME MEASURES: Primary outcomes were selection and application of treatment components. Secondary outcomes included respiratory effects (in terms of changes in flow, volume and pressure) of selected treatment components. RESULTS: Both non-respiratory on-call physiotherapists and specialist respiratory physiotherapists used combinations of saline instillation, manual lung inflations, chest wall vibrations and endotracheal suction during treatments. However specialist respiratory physiotherapists used combinations of chest wall vibrations with suction, and recruitment manoeuvres, significantly more frequently than non-respiratory on-call physiotherapists (92% vs 52%, and 87% vs 46% of treatments respectively, P<0.001). Chest wall vibrations delivered by non-respiratory on-call physiotherapists were 15% less effective at increasing peak expiratory flow. CONCLUSION: Clinically important differences between non-respiratory and specialist respiratory physiotherapists' treatment outcomes may be related to differences in the selection and application of techniques. This suggests an important training need for non-respiratory on-call physiotherapists, particularly in the effective delivery of physiotherapy techniques. TRIAL REGISTRATION: Clinicaltrials.gov NCT01999426.