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Many patients struggle with ongoing symptoms in different domains (physical, mental, cognitive) after hospitalisation for COVID-19, calling out for a multidisciplinary approach. An outpatient multidisciplinary rehabilitation programme, according to a respiratory rehabilitation strategy, was set up for adult patients who were able to attend group sessions during 12 weeks. Results of 22 adult patients with COVID-19, of which 15 had required intensive care, were analysed and some general impressions and challenges of rehabilitation in COVID-19 were reported. Impressive results on physical recovery were determined after 6 weeks and 3 months, with significant improvement of lung function, muscle force and exercise capacity variables. A positive evolution of mental and cognitive burden was present, although less pronounced than the physical recovery. These mental and cognitive consequences seem, next to musculoskeletal and medical complications, the most challenging aspect of rehabilitating patients with COVID-19. These real-world data show feasibility and efficiency of a multidisciplinary respiratory rehabilitation programme after moderate to severe COVID-19 disease. ispartof: BMJ OPEN RESPIRATORY RESEARCH vol:8 issue:1 ispartof: location:England status: published

Background An individualised action plan (AP) is a potentially effective method of helping patients with chronic obstructive pulmonary disease (COPD) to recognise and anticipate early exacerbation symptoms. This multicentre randomised controlled trial evaluates the hypothesis that individualised APs reduce exacerbation recovery time. Methods Two hundred and thirty-three patients with COPD (age 65610 years, forced expiratory volume in 1 s 56621% predicted) were randomised to receive either an individualised AP (n¼111) or care as usual (n¼122). The AP provides individualised treatment prescriptions (pharmaceutical and non-pharmaceutical) related to a colour-coded symptom status to enhance an adequate response to periods of symptom deterioration (reinforced at 1 and 4 months). Exacerbation onset was defined using the Anthonisen symptom diary card algorithm. Every 3 days the Clinical COPD Questionnaire (CCQ) was assessed to evaluate the longitudinal course of health status. The primary outcome was health status recovery in the event of an exacerbation. Results During the 6-month follow-up period there was no difference in exacerbation rates and healthcare utilisation between the two groups. Cox-adjusted survival analysis including frailty showed enhanced health status recovery (HR 1.58; 95% CI 0.96 to 2.60) and reduced length of the exacerbation (HR 1.30; 95% CI 0.92 to 1.84). The mean difference in symptom recovery time was � 3.68 days (95% CI � 7.32 to � 0.04). Mixed model repeated measure analysis showed that an AP decreased the impact of exacerbations on health status both in the prodromal and early post-onset periods. Between-group differences in CCQ scores were above the minimal clinically relevant difference of 0.4 points (3.060.7 vs 3.460.9; p#0.01). Conclusion This study shows that an individualised AP, including ongoing support by a case manager, decreases the impact of exacerbations on health status and tends to accelerate recovery. APs can be considered a key component of self-management programmes in patients with COPD.

Rationale Physical deconditioning is common in patients with chronic obstructive pulmonary disease (COPD), limiting exercise tolerance. PHYSACTO ® (NCT02085161) tested the effects of long-acting bronchodilators alone or combined with exercise training (ExT) on exercise endurance time (EET) in patients with COPD. All patients took part in a standardised physical activity self-management behaviour-modification (BM) programme. Methods A 12-week, randomised, partially double-blind, placebo-controlled, parallel-group trial at 34 sites in Australia, New Zealand, USA, Canada and Europe. Interventions (all with 12-week BM) were: BM + placebo; BM + tiotropium (T) 5 µg; BM + T + olodaterol (T/O) 5/5 µg; BM + T/O 5/5 µg with 8 weeks’ ExT (T/O 5/5 µg + ExT). EET (log transformed) during an endurance shuttle-walk test (ESWT) to symptom limitation was assessed after 8 weeks (primary end point) and 12 weeks. Results 303 patients (200 men) were randomised and treated (full analysis set n=274). Mean post-bronchodilator forced expiratory volume in 1 second was 1.59 L (57% predicted). EET was significantly increased in patients receiving BM + T/O 5/5 µg compared to placebo and was increased to a greater extent in patients receiving BM + T/O 5/5 µg + ExT compared to placebo at 8 weeks. EET was not significantly increased in patients receiving BM + T 5 µg compared to placebo (Table). Similar increases in EET were demonstrated at 12 weeks (Table). 13 patients reached test termination criteria (20 minutes) without symptom limitation (placebo, n=0; T, n=3; T/O, n=2; T/O + ExT, n=8) at 8 weeks. No safety concerns were identified. Conclusions When added to BM, the bronchodilator combination T/O 5/5 µg, used alone and combined with ExT, improved EET during ESWT compared to placebo in moderate to severe COPD. Funding Boehringer Ingelheim. Please refer to page A270 for declarations of interest in relation to abstract S34.

Background: Skeletal muscle weakness is assumed to be present in patients with sarcoidosis but has never been reported in a consecutive group of patients. Moreover, its relationship with previously observed exercise intolerance and reduced health status has never been studied in these patients. Methods: Pulmonary function, skeletal and respiratory muscle forces, peak and functional exercise capacity, health status, and the circulating levels of inflammatory and anabolic markers were determined in 25 patients with sarcoidosis who complained of fatigue (15 men) and in 21 healthy subjects (13 men). Results: Patients with sarcoidosis had lower respiratory and skeletal muscle forces, reduced exercise capacity and health status, higher anxiety and depression scores, and higher circulating levels of tumour necrosis factor-α than healthy subjects (all p⩽0.01). Its soluble receptor p75 tended to be higher (p = 0.04). Circulating levels of interleukin (IL)-6, IL-8, insulin-like growth factor I and its binding protein 3 were not significantly different between the two groups. Skeletal muscle weakness was related to exercise intolerance, depression, and reduced health status in patients with sarcoidosis, irrespective of age, sex, body weight and height (p⩽0.05). Quadriceps peak torque was inversely related to fatigue but not to the circulating levels of inflammatory or anabolic markers. The mean daily dose of corticosteroids received in the 6 month period before testing was related to quadriceps peak torque only in patients who received oral corticosteroids. Conclusion: Skeletal muscle weakness occurs in patients with sarcoidosis who complain of fatigue and is associated with reduced health status and exercise intolerance.

Introduction and objectives The format of pulmonary rehabilitation (PR) may not meet the needs of all patients with COPD or lead to improved physical activity (PA) levels. Drop outs from PR can be high. A pedometer driven physical activity intervention (PAI) may offer patients an alternative method for increasing their PA. The aim of this study was to assess the feasibility of a 12 week clinician facilitated PAI versus PR in people with COPD. Methods The design was a multicenter-randomised, parallel-group, feasibility study. Patients with COPD referred for PR were included. Spirometry and demographics were recorded. The following were assessed at baseline, post-intervention and follow up (12 weeks): PA using an ActiGraph GT3X+ accelerometer, sealed Yamax Digiwalker pedometer and the International Physical Activity Questionnaire (IPAQ) (long form); exercise capacity (Incremental Shuttle Walk Test (ISWT)); COPD Assessment Test (CAT). Recruitment, retention and completion/rates were recorded. Descriptive statistics and mean differences were used to analyse the data. Results 50 patients (mean (SD) age 64 (8) years, 24M, FEV1 1.44 (0.63)) were recruited and randomised: PR n = 26, PAI n = 24. Of those screened 50/651, 13% were recruited. One participant randomised to the PAI started PR, a per protocol analysis was conducted; PR n = 27 and PAI n = 23. Completion of the PAI was 74% (17/23) and PR was 48% (13/27). Retention overall was 74% post-intervention (n = 18 PAI; n = 19 PR), and 66% at follow up (n = 15 PAI; n = 18 PR). There was a mean (95% confidence interval (CI)) change of 972 (−1080 to 3024) steps/day and 4 (−441 to 449) in the PAI and PR group respectively; results are found in Table 1. There were 4 minor adverse events (PAI n = 3 PR n = 1). Conclusions This study will inform a future large scale randomised control trial (RCT). The LIVELY PAI intervention appears to be feasible and safe within this preliminary study, and enhanced physical activity in people with COPD. While the results require confirmation in a fully powered RCT, the mean increase in step count is in line with a recently published minimally clinically important difference.1 Reference Demeyer H, et al. The Minimal Important Difference in Physical Activity in Patients with COPD. PLoS One. 2016;11:0154587.

Introduction Chronic obstructive pulmonary disease is generally progressive and associated with reduced physical activity. Both pharmacological therapy and exercise training can improve exercise capacity; however, these are often not sufficient to change the amount of daily physical activity a patient undertakes. Behaviour-change self-management programmes are designed to address this, including setting motivational goals and providing social support. We present and discuss the necessary methodological considerations when integrating behaviour-change interventions into a multicentre study. Methods and analysis PHYSACTO is a 12-week phase IIIb study assessing the effects on exercise capacity and physical activity of once-daily tiotropium+olodaterol 5/5 µg with exercise training, tiotropium+olodaterol 5/5 µg without exercise training, tiotropium 5 µg or placebo, with all pharmacological interventions administered via the Respimat inhaler. Patients in all intervention arms receive a behaviour-change self-management programme to provide an optimal environment for translating improvements in exercise capacity into increases in daily physical activity. To maximise the likelihood of success, special attention is given in the programme to: (1) the Site Case Manager, with careful monitoring of programme delivery; (2) the patient, incorporating patient-evaluation/programme-evaluation measures to guide the Site Case Manager in the self-management intervention; and (3) quality assurance, to help identify and correct any problems or shortcomings in programme delivery and ensure the effectiveness of any corrective steps. This paper documents the comprehensive methods used to optimise and standardise the behaviour-change self-management programme used in the study to facilitate dialogue on the inclusion of this type of programme in multicentre studies. Ethics and dissemination The study has been approved by the relevant Institutional Review Boards, Independent Ethics Committee and Competent Authority according to national and international regulations. The results of this study will be disseminated through relevant, peer-reviewed journals and international conference presentations. Trial registration number NCT02085161.

Background Background Patients undergoing tumour necrosis factor (TNF)-alpha antagonist therapy are at increased risk of latent tuberculosis infection (LTBI) reactivation. The aim of this study was to determine the optimum available screening strategy for identifying patients for tuberculosis (TB) chemoprophylaxis. Methods Methods We conducted a prospective observational study of consecutive adults with chronic rheumatological disease referred for LTBI screening prior to commencement of TNF-alpha antagonist therapy. All patients included had calculation of TB risk according to age, ethnicity and year of UK entry, as described in the 2005 British Thoracic Society (BTS) guidelines and measurement of tuberculin skin test (TST) and T.Spot.TB. Results Results There were 187 patients included in the study, with 157 patients (84%) taking immunosuppressants. 137 patients would require further risk stratification according to the BTS algorithm, with 110 (80.3%) classified as being at low risk of having LTBI. There were 39 patients (35.5%) who were categorised as low risk but were either TST and/or T.Spot positive and would not have received chemoprophylaxis according to the BTS algorithm. Combination of all three methods (risk stratification and/or positive T.Spot and/or positive TST) identified 66 patients out of 137 who would potentially be offered chemoprophylaxis, which was greater than any single test or two-test combination. Conclusion Conclusion Performing both a TST and T.Spot in patients on immunosuppressants prior to commencement of TNF-alpha antagonist therapy gives an additional yield of potential LTBI compared with use of risk stratification tables alone. Our results suggest that use of all three screening modalities gives the highest yield of patients potentially requiring chemoprophylaxis.

[Singh, Sally J.] Univ Hosp Leicester NHS Trust, Ctr Exercise & Rehabil Sci, Leicester LE3 9QP, Leics, England. [Singh, Sally J.] Univ Loughborough, Sch Sport Exercise & Hlth Sci, Loughborough, Leics, England. [Spruit, Martijn A.] Ctr Expertise Chron Organ Failure, CIRO, Dept Res & Educ, Horn, Netherlands. [Spruit, Martijn A.] Hasselt Univ, BIOMED Biomed Res Inst, REVAL Rehabil Res Ctr, Fac Med & Life Sci, Diepenbeek, Belgium. [Troosters, Thierry] Univ Hosp Leuven, Resp Rehabil & Resp Div, Leuven, Belgium. [Troosters, Thierry] Katholieke Univ Leuven, Dept Rehabil Sci, Fac Kinesiol & Rehabil Sci, Leuven, Belgium. [Holland, Anne E.] Austin Hlth, Inst Breathing & Sleep, Melbourne, Vic, Australia. [Holland, Anne E.] La Trobe Univ, Dept Physiotherapy, Melbourne, Vic, Australia. [Holland, Anne E.] Alfred Hlth, Dept Physiotherapy, Melbourne, Vic, Australia.

The use of oxygen therapy in COPD needs more careful study Long term oxygen therapy (LTOT) is one of the few treatments which has significant survival benefits in patients with severe hypoxaemia. It may modify disease progression, as indicated by a slower progression of hypoxia induced pulmonary hypertension,1–4 and the acute reduction in pulmonary hypertension to oxygen administration has been suggested as predictive for the survival benefit in individual patients. Reduced pulmonary vascular resistance and hence the reduced load on the right heart is probably the most important working mechanism of LTOT. In less severe hypoxaemic patients the benefits of LTOT on survival are less clear.5 Other benefits of oxygen administration are generally accepted. Reduced ventilation, especially during exercise, helps to avoid dynamic hyperinflation and hence reduces symptoms and increases exercise tolerance in the majority of patients with chronic obstructive pulmonary disease (COPD), even in patients with mild hypoxaemia.6 There is also some evidence to support the suggestion that LTOT may improve cognitive function in hypoxaemic COPD patients7 and may improve health related quality of life.8 LTOT is therefore a recognised treatment in hypoxaemic patients …