Balancing the value and risk of exercise-based therapy post-COVID-19: a narrative review

Coronavirus disease 2019 (COVID-19) can lead to ongoing symptoms such as breathlessness, fatigue and muscle pain, which can have a substantial impact on an individual. Exercise-based rehabilitation programmes have proven beneficial in many long-term conditions that share similar symptoms. These programmes have favourably influenced breathlessness, fatigue and pain, while also increasing functional capacity. Exercise-based rehabilitation may benefit those with ongoing symptoms following COVID-19. However, some precautions may be necessary prior to embarking on an exercise programme. Areas of concern include ongoing complex lung pathologies, such as fibrosis, cardiovascular abnormalities and fatigue, and concerns regarding post-exertional symptom exacerbation. This article addresses these concerns and proposes that an individually prescribed, symptom-titrated exercise-based intervention may be of value to individuals following infection with severe acute respiratory syndrome coronavirus 2

Respiratory sequelae of COVID-19: pulmonary and extrapulmonary origins, and approaches to clinical care and rehabilitation

Although the exact prevalence of post-COVID-19 condition (also known as long COVID) is unknown, more than a third of patients with COVID-19 develop symptoms that persist for more than 3 months after SARS-CoV-2 infection. These sequelae are highly heterogeneous in nature and adversely affect multiple biological systems, although breathlessness is a frequently cited symptom. Specific pulmonary sequelae, including pulmonary fibrosis and thromboembolic disease, need careful assessment and might require particular investigations and treatments. COVID-19 outcomes in people with pre-existing respiratory conditions vary according to the nature and severity of the respiratory disease and how well it is controlled. Extrapulmonary complications such as reduced exercise tolerance and frailty might contribute to breathlessness in post-COVID-19 condition. Non-pharmacological therapeutic options, including adapted pulmonary rehabilitation programmes and physiotherapy techniques for breathing management, might help to attenuate breathlessness in people with post-COVID-19 condition. Further research is needed to understand the origins and course of respiratory symptoms and to develop effective therapeutic and rehabilitative strategies

The effect of COVID rehabilitation for ongoing symptoms Post HOSPitalisation with COVID-19 (PHOSP-R):protocol for a randomised parallel group controlled trial on behalf of the PHOSP consortium

Introduction Many adults hospitalised with COVID-19 have persistent symptoms such as fatigue, breathlessness and brain fog that limit day-to-day activities. These symptoms can last over 2 years. Whilst there is limited controlled studies on interventions that can support those with ongoing symptoms, there has been some promise in rehabilitation interventions in improving function and symptoms either using face-to-face or digital methods, but evidence remains limited and these studies often lack a control group. Methods and analysis This is a nested single-blind, parallel group, randomised control trial with embedded qualitative evaluation comparing rehabilitation (face-to-face or digital) to usual care and conducted within the PHOSP-COVID study. The aim of this study is to determine the effectiveness of rehabilitation interventions on exercise capacity, quality of life and symptoms such as breathlessness and fatigue. The primary outcome is the Incremental Shuttle Walking Test following the eight week intervention phase. Secondary outcomes include measures of function, strength and subjective assessment of symptoms. Blood inflammatory markers and muscle biopsies are an exploratory outcome. The interventions last eight weeks and combine symptom-titrated exercise therapy, symptom management and education delivered either in a face-to-face setting or through a digital platform (www.yourcovidrecovery.nhs.uk). The proposed sample size is 159 participants, and data will be intention-to-treat analyses comparing rehabilitation (face-to-face or digital) to usual care. Ethics and dissemination Ethical approval was gained as part of the PHOSP-COVID study by Yorkshire and the Humber Leeds West Research NHS Ethics Committee, and the study was prospectively registered on the ISRCTN trial registry (ISRCTN13293865). Results will be disseminated to stakeholders, including patients and members of the public, and published in appropriate journals. Article summary Strengths and limitations of this study • This protocol utilises two interventions to support those with ongoing symptoms of COVID-19 • This is a two-centre parallel-group randomised controlled trial • The protocol has been supported by patient and public involvement groups who identified treatments of symptoms and activity limitation as a top priorit

Symptom Management of Chronic Obstructive Pulmonary Disease Using High Frequency Airway Oscillations.

IntroductionDyspnoea and sputum retention are common problems in patients with Chronic Obstructive Pulmonary Disease (COPD). A High Frequency Airway Oscillating (HFAO) device offers respiratory muscle training and oscillatory mechanism with the aim of addressing dyspnoea and sputum retention, both common symptoms in COPD. The assessment of sputum clearance is challenging due to lack of reliable outcome measures. This thesis aims to assess the feasibility and clinical effectiveness of using a HFAO device in patients with COPD and assess the feasibility and responsiveness of the Lung Clearance Index as a surrogate measure for sputum clearance.MethodsThree main study designs were undertaken to assess the above aims.1. Systematic review to assess the effect of airway clearance devices on sputum clearance, exacerbation frequency and health related quality of life.2. Single arm feasibility study to assess the use of HFAO device and LCI.3. A randomised, double blinded, sham controlled trial to determine the clinical effectiveness of the HFAO device and the response of the LCI to an intervention.ResultsThe use of the HFAO device is feasible in stable COPD however in a double-blind randomised controlled trial did not demonstrate statistically significant improvements when compared to the sham. There were favourable improvements in the multidimensional dyspnoea profile however this was not significant over the sham. The LCI offers promise in the assessment of sputum clearance, and whilst this worsened following the intervention, there were improvements in peripheral ventilation (measured by the Sacin).ConclusionThe use of HFAO device does not improve dyspnoea in patients with stable COPD. There was no identified clinical responders’ group however further research should focus on patients with frequent exacerbations. The LCI can be a valuable outcome measure in the assessment of sputum clearance when supplemented by the Sacin.</div

The management of chronic breathlessness

Chronic breathlessness can be hard to make sense of and manage because its severity is often unrelated to the severity of the underlying medical conditions. Treatments for the underlying conditions may help breathlessness but rarely ameliorate it. This chapter will review the latest evidence for the nonpharmacological and pharmacological management of chronic breathlessness using a transdiagnostic approach. These approaches will be discussed using the Breathing, Thinking, Functioning framework, which conceptualises breathlessness in a way that helps understand the symptom and provides a rationale for symptom management. Although developed in a palliative breathlessness setting, the model can be used when a patient first presents with chronic breathlessness. Each element of this model can be addressed through different techniques such as breathing exercises and positioning, anxiety management, exercise rehabilitation and pharmacotherapy. To help clinicians provide holistic breathlessness management, a breathlessness toolbox and an outline of very brief advice for short consultations are provided

Review of the British Thoracic Society Winter Meeting 23 November 2022 23-25 November 2022.

The British Thoracic Society Winter Meeting at the QEII Centre in London provided the first opportunity for the respiratory community to meet and disseminate research findings face to face since the start of the COVID-19 pandemic. World-leading researchers from the UK and abroad presented their latest findings across a range of respiratory diseases. This article aims to represent the range of the conference and as such is written from the perspective of a basic scientist, a physiotherapist and two doctors. The authors reviewed showcase sessions plus a selection of symposia based on their personal highlights. Content ranged from exciting new developments in basic science to new and unpublished results from clinical trials, delivered by leading scientists from their fields including former deputy chief medical officer Professor Sir Jonathan Van-Tam and former WHO chief scientist Dr Soumya Swaminathan

High-Frequency Airway Oscillating Device for Respiratory Muscle Training in Subjects With COPD

BACKGROUND: COPD is characterized by expiratory flow limitation, which results in symptomatic dyspnea and reduced exercise capacity. Changes in breathing mechanics mean the respiratory muscles are unable to respond to the ventilatory demands, increasing the sensation of dyspnea. A high-frequency oscillating device has been developed to improve dyspnea in patients with COPD. We conducted a feasibility trial to gain insight into the potential for recruitment, retention, and study design for a future randomized controlled trial. METHODS: Symptomatic subjects with COPD were included on the basis of a Medical Research Council (MRC) score ≥ 3 and FEV1/FVC < 0.70). Patients were excluded if they received pulmonary rehabilitation within the last 6 months. The intervention employed the device for 8 weeks, 3 times daily. Clinical outcomes included the MRC score, maximal expiratory and inspiratory pressures (PEmax/PImax), the incremental shuttle walk test (ISWT), and the endurance shuttle walk test (ESWT). RESULTS: We successfully recruited 23 subjects with established COPD (65.2% male, mean age 65 ± 5.03 y, mean % predicted FEV1 43.9 ± 16, mean FEV1/FVC ratio 0.46 ± 0.13, and median [interquartile range] MRC 4 [3-5]). There was a significant change in MRC from 4 to 3 pre to post intervention (P = .003). There was a statistically significant difference in PEmaxP < .008 and PImaxP = .044. There were no significant differences observed in the ISWT or ESWT. CONCLUSIONS: This study design appeared feasible to proceed to a clinical effectiveness trial. The use of the device for 8 weeks showed a significant improvement in PEmax, PImax, and reducing symptomatic dyspnea on the MRC dyspnea score. The results of this study should encourage a randomized controlled trial