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The effect of meditative movement, which includes yoga, tai chi and qi gong, on breathlessness in advanced disease is unknown. This systematic review aims to comprehensively assess the evidence on the effect of meditative movement on breathlessness (primary outcome), health-related quality of life, exercise capacity, functional performance and psychological symptoms (secondary outcomes) in advanced disease. 11 English and Chinese language databases were searched for relevant trials. Risk of bias was assessed using the Cochrane tool. Standardised mean differences (SMDs) with 95% confidence intervals were computed. 17 trials with 1125 participants (n=815 COPD, n=310 cancer), all with unclear or high risk of bias, were included. Pooled estimates (14 studies, n=671) showed no statistically significant difference in breathlessness between meditative movement and control interventions (SMD (95% CI) 0.10 (-0.15-0.34); Chi2 =30.11; I2 =57%; p=0.45), irrespective of comparator, intervention or disease category. Similar results were observed for health-related quality of life and exercise capacity. It was not possible to perform a meta-analysis for functional performance and psychological symptoms. In conclusion, in people with advanced COPD or cancer, meditative movement does not improve breathlessness, health-related quality of life or exercise capacity. Methodological limitations lead to low levels of certainty in the results. [ABSTRACT FROM AUTHOR]

Introduction: Many people with COPD experience frailty. Frailty increases risk of poor health outcomes, including non-completion of pulmonary rehabilitation. Integrated approaches to support people with COPD and frailty throughout and following rehabilitation are indicated. The aim of the present study was to determine the feasibility of conducting a randomised controlled trial of integrating comprehensive geriatric assessment (CGA) for people with COPD and frailty starting pulmonary rehabilitation., Methods: A multicentre mixed-methods randomised controlled feasibility trial ("Breathe Plus"; ISRCTN13051922) was carried out. People with COPD, aged ≥50 years, Clinical Frailty Scale ≥5 and referred for pulmonary rehabilitation were randomised 1:1 to usual pulmonary rehabilitation, or pulmonary rehabilitation plus CGA. Remote intervention delivery was used during COVID-19 restrictions. Outcomes (physical, psychosocial, service use) were measured at baseline, 90 and 180 days, alongside process data and qualitative interviews., Results: Recruitment stopped at 31 participants (mean±sd age 72.4±10.1 years, 68% Medical Research Council Dyspnoea Scale 4-5), due to COVID-19-related disruptions. Recruitment (46% eligible recruited) and retention (87% at 90- and 180-day follow-up) were acceptable. CGAs occurred on average 60.5 days post-randomisation (range 8-129) and prompted 46 individual care recommendations (median 3 per participant, range 0-12), 65% of which were implemented during follow-up. The most common domains addressed during CGA were nutrition and cardiovascular health. Participants valued the holistic approach of CGA but questioned the optimal time to introduce it., Conclusion: Integrating CGA alongside pulmonary rehabilitation is feasible and identifies unmet multidimensional need in people with COPD and frailty. Given challenges around timing and inclusivity, the integration of geriatric and respiratory care should not be limited to rehabilitation services., Competing Interests: Conflict of interest: C. Nolan reports funding from the National Institute for Health Research for Patient Benefit and Brunel University London BRIEF award. Conflict of interest: W.D-C. Man reports funding from the National Institute for Health Research for Patient Benefit and Artificial Intelligence awards, and is an associate editor of this journal. Conflict of interest: L.J. Brighton, C.J. Evans, M. Farquhar, K. Bristowe, A. Kata, J. Higman, M. Ogden, D. Yi, W. Gao, M. Koulopoulou, S. Hasan, K. Ingram, S. Clarke, K. Parmar, E. Baldwin, C.J. Steves and M. Maddocks have no conflicts to declare., (Copyright ©The authors 2024.)

Background: Skeletal muscle dysfunction is common in COPD. Ultrasound-derived rectus femoris cross-sectional area (RFCSA) is a radiation free, non-invasive measure of muscle bulk that relates to quadriceps strength in people with COPD. However, there are limited longitudinal data for RFCSA, and it is not known whether longitudinal change in RFCSA reflects change in quadricep strength, exercise capacity, lower limb function or muscle mass. We aimed to quantify longitudinal change in ultrasound-derived RFCSA and assess its relationship with change in quadriceps maximal voluntary contraction (QMVC), incremental shuttle walk test (ISWT), five-repetition sit-to-stand (5STS) and fat-free mass (FFM) over 12 months in people with COPD., Methods: We measured ultrasound-derived RFCSA, QMVC, ISWT, 5STS and FFM (measured by bioelectric impedance analysis) at baseline and 12 months in 169 people with stable COPD. Change was correlated using Pearson's or Spearman's coefficients., Results: Baseline characteristics: mean±sd age 70.4±9.4 years; FEV 1 53.3±18.9% predicted. Over the course of 12 months mean RFCSA change was -33.7 mm 2 (99% CI -62.6- -4.9 mm 2 ; p=0.003) representing a mean±sd percentage change of -1.8±33.5%. There was a weak correlation between change in RFCSA and FFM (r=0.205, p=0.009), but not with change in QMVC, ISWT or 5STS., Conclusion: There is a statistically significant decrease in ultrasound-derived RFCSA over 12 months in people with stable COPD, but this decrease does not correlate with change in quadriceps strength, exercise capacity, FFM or lower limb function., Competing Interests: Conflict of interest: T.O. Jenkins reports grants from the Royal Brompton and Harefield Hospital Charity, outside of the submitted work. T.O. Jenkins received funding from the National Institute for Health Research to undertake the submitted work. C.M. Nolan reports grants from the National Institute for Health and Care Research, Royal Brompton and Harefield Hospital Charities, and Brunel University London, outside of the submitted work. M. Maddocks reports grants from the National Institute for Health Research, the European Commission and UKRI Innovate UK, outside of the submitted work. M. Maddocks received funding from the National Institute for Health Research to undertake the submitted work. W.D-C. Man reports grants from the National Institute for Health Research, outside of the submitted work. W.D-C. Man received funding from the Medical Research Council to undertake the submitted work. W-D.C. Man is an Associate Editor of this journal. The remaining authors report no grants outside of the submitted work, or to undertake the submitted work., (Copyright ©The authors 2024.)

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available., Competing Interests: Conflict of interest: D.J.A. Janssen reports lecture fees from Boehringer Ingelheim (personal), Chiesi (non-personal), AstraZeneca (non-personal) and Abbott (non-personal) within the previous three years outside the submitted work. Conflict of interest: C. Coleman is an employee of the European Lung Foundation. Conflict of interest: D.C. Currow has received intellectual property payments and consultancy fees from Mayne Pharma International Pty Ltd, manufacturers of Kapanol and is a paid adviser to Helsinn Pharmaceuticals. Conflict of interest: G.P. Kurita has received grants from Novo Nordisk Foundation, the Danish Cancer Society and European Commission outside the submitted work. Conflict of interest: M. Maddocks is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust; the views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Conflict of interest: H. Pinnock has received speaker fees from Boehringer Ingelheim, Teva, and Sandoz for non-promotional talks on digital respiratory health and asthma supported selfmanagement. Conflict of interest: T. Tonia is a methodologist for the European Respiratory Society. Conflict of interest: K. Marsaa reports lecture fees from Astellas Pharma, GlaxoSmithKline, AstraZeneca, Novartis, Boehringer Ingelheim, Kyowa Kirin, Norgine, Roche, Bristol-Myers Squibb, Chiesi Pharma outside the submitted work. Conflict of interest: All other panellists have no conflicts of interest to report., (Copyright ©The authors 2023. For reproduction rights and permissions contact permissions@ersnet.org.)

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 pre-requisite 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 under-represented 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., (Copyright ©The authors 2023. For reproduction rights and permissions contact permissions@ersnet.org.)

Introduction: SELF-BREATHE is a complex, transdiagnostic, supportive, digital breathlessness intervention co-developed with patients. SELF-BREATHE seeks to build capacity and resilience within health services by improving the lives of people with chronic breathlessness using nonpharmacological, self-management approaches. This study aimed to determine whether SELF-BREATHE is feasible to deliver and acceptable to patients living with chronic breathlessness., Methods: A parallel, two-arm, single-blind, single-centre, randomised controlled, mixed-methods feasibility trial with participants allocated to 1) intervention group (SELF-BREATHE) or 2) control group (usual National Health Service (NHS) care). The setting was a large multisite NHS foundation trust in south-east London, UK. The participants were patients living with chronic breathlessness due to advanced malignant or nonmalignant disease(s). Participants were randomly allocated (1:1) to an online, self-guided, breathlessness supportive intervention (SELF-BREATHE) and usual care or usual care alone, over 6 weeks. The a priori progression criteria were ≥30% of eligible patients given an information sheet consented to participate; ≥60% of participants logged on and accessed SELF-BREATHE within 2 weeks; and ≥70% of patients reported the methodology and intervention as acceptable., Results: Between January 2021 and January 2022, 52 (47%) out of 110 eligible patients consented and were randomised. Of those randomised to SELF-BREATHE, 19 (73%) out of 26 logged on and used SELF-BREATHE for a mean±sd (range) 9±8 (1-33) times over 6 weeks. 36 (70%) of the 52 randomised participants completed and returned the end-of-study postal questionnaires. SELF-BREATHE users reported it to be acceptable. Post-intervention qualitative interviews demonstrated that SELF-BREATHE was acceptable and valued by users, improving breathlessness during daily life and at points of breathlessness crisis., Conclusion: These data support the feasibility of moving to a fully powered, randomised controlled efficacy trial with minor modifications to minimise missing data ( i.e. multiple methods of data collection: face-to-face, telephone, video assessment and by post)., Competing Interests: Conflict of interest: C.C. Reilly received support for the present manuscript from the NIHR; and declares funding received from King's Together and Royal Brompton Hospital – King's Health Partnership Transformation, outside the submitted work. Conflict of interest: M. Maddocks has received grants or contracts from National Institute for Health Research (NIHR) Career Development Fellowship (CDF-2017–10-009) and NIHR Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust, outside the submitted work. Conflict of interest: T. Chalder receives salary support from the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London. The views expressed in this article are those of the authors and not necessarily those of the NIHR or the NHS. Conflict of interest: K. Bristowe has received grants or contracts from the National Institute for Health Research, Medical Research Council, Health Education England, European Commission, and Marie Curie, outside the submitted work. Conflict of interest: I.J. Higginson has received grants or contracts from the NIHR, UKRI, Cicely Saunders International and Marie Curie, outside the submitted work., (Copyright ©The authors 2023.)

Introduction: The burden of chronic breathlessness on individuals, family, society and health systems is significant and set to increase exponentially with an ageing population with complex multimorbidity, yet there is a lack of services. This has been further amplified by the coronavirus disease 2019 pandemic. Online breathlessness interventions have been proposed to fill this gap, but need development and evaluation based on patient preferences and choices. This study aimed to explore the preferences and choices of patients regarding the content of an online self-guided chronic breathlessness supportive intervention (SELF-BREATHE)., Methods: Semi-structured telephone interviews were conducted with adults living with advanced malignant and nonmalignant disease and chronic breathlessness (July to November 2020). Interviews were analysed using conventional and summative content analysis., Results: 25 patients with advanced disease and chronic breathlessness (COPD n=13, lung cancer n=8, interstitial lung disease n=3, bronchiectasis n=1; 17 male; median (range) age 70 (47-86) years; median (range) Medical Research Council dyspnoea score 3 (2-5)) were interviewed. Individuals highlighted strong preferences for focused education, methods to increase self-motivation and engagement, interventions targeting breathing and physical function, software capability to personalise the content of SELF-BREATHE to make it more meaningful to the user, and aesthetically designed content using various communication methods including written, video and audio content. Furthermore, they identified the need to address motivation as a key potential determinant of the success of SELF-BREATHE., Conclusion: Our findings provide an essential foundation for future digital intervention development (SELF-BREATHE) and scaled research., Competing Interests: Conflict of interest: C.C. Reilly reports receiving support for the present manuscript from NIHR Clinical Lectureship ICA-CL-2018-04-ST2-001, which funds all aspects of this research; grants or contracts from King's Together: Multi and Interdisciplinary research scheme and Royal Brompton Hospital – King's Health Partnership Transformation funding, outside the submitted work. Conflict of interest: K. Bristowe reports receiving grants or contracts from National Institute for Health Research, Medical Research Council, Health Education England, European Commission and Marie Curie, outside the submitted work. Conflict of interest: A. Roach has nothing to disclose. Conflict of interest: T. Chalder reports receiving support for the present manuscript via salary support from the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London (KCL). The views expressed in this article are those of the authors and not necessarily those of the NIHR or the NHS. Conflict of interest: M. Maddocks reports receiving grants or contracts from National Institute for Health Research (NIHR) Career Development Fellowship (CDF-2017–10-009), and NIHR Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust, outside the submitted work. Conflict of interest: I.J. Higginson reports receiving grants or contracts from NIHR, UKRI, Cicely Saunders International and Marie Curie, outside the submitted work., (Copyright ©The authors 2022.)

Introduction: The burden of chronic breathlessness on individuals, family, society and health systems is significant, and set to increase exponentially with population ageing, complex multimorbidity and coronavirus disease 2019 (COVID-19)-related disability. Breathlessness support services are effective; however, reach and access are limited. Delivering online breathlessness interventions may build capacity and resilience within health systems to tackle chronic breathlessness through supported self-management. The aim of this study was to explore accessibility and willingness of patients with chronic breathlessness to use an internet-based breathlessness self-management intervention (SELF-BREATHE)., Methods: Semi-structured telephone interviews were conducted with adults living with advanced malignant and non-malignant disease and chronic breathlessness (July to November 2020). Interviews were analysed using conventional and summative content analysis., Results: 25 patients (COPD: n=13; lung cancer: n=8; interstitial lung disease (ILD): n=3; bronchiectasis: n=1) were interviewed: 17 male, median (range) age 70 (47-86) years and Medical Research Council dyspnoea score 3 (2-5). 21 patients had internet access. Participants described greater use, acceptance and normalisation of the internet since the advent of the COVID-19 pandemic. They described multifaceted internet use: functional, self-investment (improving health and wellbeing) and social. The concept of SELF-BREATHE was highly valued, and most participants with internet access were willing to use it. In addition to technical limitations, personal choice and perceived value of the internet were important factors that underpinned readiness to use online resources., Conclusion: These findings suggest that patients living with chronic breathlessness that have access to the internet would have the potential to benefit from the online SELF-BREATHE intervention, if given the opportunity., Competing Interests: Provenance: Submitted article, peer reviewed. Conflict of interest: An NIHR Clinical Lectureship (ICA-CL-2018-04-ST2-001) supports C.C. Reilly, which funds all aspects of this research. In addition, and unrelated to the present research, they declare funding to their institution from “King's Together: Multi and Interdisciplinary research scheme” (GBP 19 000) and from Royal Brompton Hospital–King's Health Partnership Transformation (GBP 75 000). K. Bristowe declares research grants to their institution from the National Institute for Health Research, Medical Research Council, Health Education England, European Commission and Marie Curie, in the 36 months prior to manuscript submission. A. Roach declares no competing interests. M. Maddocks declares a National Institute for Health Research (NIHR) Career Development Fellowship (CDF-2017–10-009), and an infrastructure grant from the NIHR Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust, in the 36 months prior to manuscript submission. I.J. Higginson declares research grants from the National Institute for Health Research, UK Research & Innovation, Cicely Saunders International and Marie Curie, in the 36 months prior to manuscript submission., (Copyright ©The authors 2022.)

One in five people with COPD also lives with frailty. People living with both COPD and frailty are at increased risk of poorer health and outcomes, and face challenges to completing pulmonary rehabilitation. Integrated approaches that are adapted to the additional context of frailty are required. The aim of the present study is to determine the feasibility of conducting a randomised controlled trial of an integrated Comprehensive Geriatric Assessment for people with COPD and frailty starting pulmonary rehabilitation. This is a multicentre, mixed-methods, assessor-blinded, randomised, parallel group, controlled feasibility trial ("Breathe Plus"; ISRCTN13051922). We aim to recruit 60 people aged ≥50 with both COPD and frailty referred for pulmonary rehabilitation. Participants will be randomised 1:1 to receive usual pulmonary rehabilitation, or pulmonary rehabilitation with an additional Comprehensive Geriatric Assessment. Outcomes (physical, psycho-social and service use) will be measured at baseline, 90 days and 180 days. We will also collect service and trial process data, and conduct qualitative interviews with a sub-group of participants and staff. We will undertake descriptive analysis of quantitative feasibility outcomes (recruitment, retention, missing data, blinding, contamination, fidelity), and framework analysis of qualitative feasibility outcomes (intervention acceptability and theory, outcome acceptability). Recommendations on progression to a full trial will comprise integration of quantitative and qualitative data, with input from relevant stakeholders. This study has been approved by a UK Research Ethics Committee (ref.: 19/LO/1402). This protocol describes the first study testing the feasibility of integrating a Comprehensive Geriatric Assessment alongside pulmonary rehabilitation, and testing this intervention within a mixed-methods randomised controlled trial., Competing Interests: Conflict of interest: L.J. Brighton has nothing to disclose. Conflict of interest: C.J. Evans has nothing to disclose. Conflict of interest: M. Farquhar has nothing to disclose. Conflict of interest: K. Bristowe has nothing to disclose. Conflict of interest: A. Kata has nothing to disclose. Conflict of interest: J. Higman has nothing to disclose. Conflict of interest: M. Ogden has nothing to disclose. Conflict of interest: C. Nolan reports personal fees from Novartis outside the submitted work. Conflict of interest: D. Yi has nothing to disclose. Conflict of interest: W. Gao has nothing to disclose. Conflict of interest: M. Koulopoulou has nothing to disclose. Conflict of interest: S. Hasan has nothing to disclose. Conflict of interest: C. Steves has nothing to disclose. Conflict of interest: W.D-C. Man reports grants from the National Institute for Health Research and the British Lung Foundation, personal fees from Jazz Pharmaceuticals and Mundipharma, grants from Pfizer, personal fees from Novartis, and nonfinancial support from GSK, outside the submitted work. Conflict of interest: M. Maddocks has nothing to disclose., (Copyright ©ERS 2021.)

We assessed efficacy and effectiveness of pharmacological and nonpharmacological interventions in improving symptom control, functional exercise capacity and quality of life (QoL) in people living with fibrotic interstitial lung disease (ILD). We summarised evidence from three previous reviews (to June 2014) and conducted an updated search of nine databases and grey literature (2011-2019) (registration: CRD42017065933) for prospective studies of interventions aimed to alleviate symptoms, improve QoL or functional exercise capacity in fibrotic ILD. Data were synthesised through narrative synthesis or meta-analysed as appropriate. Forty-seven studies with 2527 participants were included. From 22 pharmacological studies of 11 different interventions (n=1683), the most tested interventions were bosentan and sildenafil. From 25 nonpharmacological studies, the most tested intervention was for pulmonary rehabilitation/exercise training (PR) (22 studies, n=748). There was an improvement in 6-min walk distance immediately following PR (six studies; n=200, mean difference (MD) (95% CI) 39.9 m (18.2 to 61.5)), but not longer term (3 or 6 months, four studies; n=147, MD 5.3 m (-12.9 to 23.4). Multiple, varied outcome measures were used ( e.g. 37 studies assessing dyspnoea used 10 different scales with a lack of reporting of rate of deterioration in outcomes). Evidence gap mapping highlighted the most and least researched symptoms, as dyspnoea and cough, respectively. This evidence synthesis highlights overwhelmingly that the most researched symptom is dyspnoea and the strongest evidence base is for short-term PR. The least researched symptom was cough. Research going forward must focus on prioritising and standardising meaningful outcomes and focussing interventions on neglected symptoms., Competing Interests: Conflict of interest: S. Bajwah has nothing to disclose. Conflict of interest: J. Colquitt has nothing to disclose. Conflict of interest: E. Loveman has nothing to disclose. Conflict of interest: C. Bausewein has nothing to disclose. Conflict of interest: H. Almond has nothing to disclose. Conflict of interest: A. Oluyase has nothing to disclose. Conflict of interest: M. Dzingina has nothing to disclose. Conflict of interest: M. Maddocks has nothing to disclose. Conflict of interest: I.J. Higginson has nothing to disclose. Conflict of interest: A. Wells has nothing to disclose., (Copyright ©ERS 2021.)