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Lisa Jane Brighton,1 Claire M Nolan,2,3 Ruth E Barker,2,4,5 Suhani Patel,2,4 Jessica A Walsh,2 Oliver Polgar,2 Samantha SC Kon,2,4,6 Wei Gao,1 Catherine J Evans,1,7 Matthew Maddocks,1 William DC Man2,4,8,9 1Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK; 2Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas NHS Foundation Trust, London, UK; 3Division of Physiotherapy, College of Health, Medicine and Life Sciences, Brunel University London, London, UK; 4National Heart and Lung Institute, Imperial College, London, UK; 5Insight Innovation, Wessex Academic Health Science Network, Southampton, UK; 6Department of Respiratory Medicine, The Hillingdon Hospital NHS Trust, London, UK; 7Brighton General Hospital, Sussex Community NHS Foundation Trust, Brighton, UK; 8Harefield Pulmonary Rehabilitation Unit, Guy’s and St Thomas NHS Foundation Trust, London, UK; 9Faculty of Life Sciences & Medicine, King’s College London, London, UKCorrespondence: Lisa Jane Brighton, Cicely Saunders Institute, Bessemer Road, Denmark Hill, London, SE5 9PJ, UK, Tel +44 020 7848 5041, Email lisa.brighton@kcl.ac.ukBackground: Identifying frailty in people with chronic obstructive pulmonary disease (COPD) is deemed important, yet comparative characteristics of the most commonly used frailty measures in COPD are unknown. This study aimed to compare how the Fried Frailty Phenotype (FFP) and Short Physical Performance Battery (SPPB) characterise frailty in people with stable COPD, including prevalence of and overlap in identification of frailty, disease and health characteristics of those identified as living with frailty, and predictive value in relation to survival time.Methods: Cohort study of people with stable COPD attending outpatient clinics. Agreement between frailty classifications was described using Cohen’s Kappa. Disease and health characteristics of frail versus not frail participants were compared using t-, Mann–Whitney U and Chi-Square tests. Predictive value for mortality was examined with multivariable Cox regression.Results: Of 714 participants, 421 (59%) were male, mean age 69.9 years (SD 9.7), mean survival time 2270 days (95% CI 2185– 2355). Similar proportions were identified as frail using the FFP (26.2%) and SPPB (23.7%) measures; classifications as frail or not frail matched in 572 (80.1%) cases, showing moderate agreement (Kappa = 0.469, SE = 0.038, p < 0.001). Discrepancies seemed driven by FFP exhaustion and weight loss criteria and the SPPB balance component. People with frailty by either measure had worse exercise capacity, health-related quality of life, breathlessness, depression and dependence in activities of daily living. In multivariable analysis controlling for the Age Dyspnoea Obstruction index, sex, BMI, comorbidities and exercise capacity, both the FFP and SPPB had predictive value in relation to mortality (FFP aHR = 1.31 [95% CI 1.03– 1.66]; SPPB aHR = 1.29 [95% CI 0.99– 1.68]).Conclusion: In stable COPD, both the FFP and SPPB identify similar proportions of people living with/without frailty, the majority with matching classifications. Both measures can identify individuals with multidimensional health challenges and increased mortality risk and provide additional information alongside established prognostic variables.Keywords: respiratory disease, chronic obstructive pulmonary disease, frailty, survival

Ruth E Barker,1,2 Lisa J Brighton,3 Matthew Maddocks,3 Claire M Nolan,1,2 Suhani Patel,1 Jessica A Walsh,1 Oliver Polgar,1 Jenni Wenneberg,4 Samantha SC Kon,4 Jadwiga A Wedzicha,2 William DC Man,1,2 Morag Farquhar5 1Harefield Respiratory Research Group, Harefield Hospital, Middlesex, UK; 2National Heart and Lung Institute, Imperial College, London, UK; 3Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK; 4The Hillingdon Hospitals NHS Foundation Trust, London, UK; 5School of Health Sciences, University of East Anglia, Norwich, UKCorrespondence: Ruth E BarkerHarefield Respiratory Research Group, Harefield Hospital, Hill End Road, Middlesex, UB9 6JH, United KingdomTel +44 01895 828851Email r.barker2@rbht.nhs.ukBackground: Hospital at home (HaH) schemes allow early discharge of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Traditional outpatient pulmonary rehabilitation (PR) following an AECOPD has an established evidence-base, but there are issues with low referral, uptake and completion. One commonly cited barrier to PR post-hospitalisation relates to poor accessibility. To address this, the aim of this project was to enrol service users (patients with COPD and informal carers) and healthcare professionals to co-design a model of care that integrates home-based exercise training within a HaH scheme for patients discharged from hospital following AECOPD.Methods: This accelerated experience-based co-design project included three audio-recorded stakeholder feedback events, using key “touchpoints” from previous qualitative interviews and a recent systematic review. Audio-recordings were inductively analysed using directed content analysis. An integrated model of care was then developed and finalised through two co-design groups, with the decision-making process facilitated by the tables of changes approach.Results: Seven patients with COPD, two informal carers and nine healthcare professionals (from an existing outpatient PR service and HaH scheme) participated in the stakeholder feedback events. Four key themes were identified: 1) individualisation, 2) progression and transition, 3) continuity between services, and 4) communication between stakeholders. Two patients with COPD, one informal carer and three healthcare professionals participated in the first joint co-design group, with five healthcare professionals attending a second co-design group. These achieved a consensus on the integrated model of care. The agreed model comprised face-to-face supervised, individually tailored home-based exercise training one to three times a week, delivered during HaH scheme visits where possible by a healthcare professional competent to provide both home-based exercise training and usual HaH care.Conclusion: An integrated model of care has been co-designed by patients with COPD, informal carers and healthcare professionals to address low uptake and completion of PR following AECOPD. The co-designed model of care has now been integrated within a well-established HaH scheme.Keywords: COPD, exacerbations, rehabilitation, exercise training, integrated care, co-design

Lisa Jane Brighton,1 Catherine J Evans,1,2 William DC Man,3,4 Matthew Maddocks1 1Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK; 2Brighton General Hospital, Sussex Community NHS Foundation Trust, Brighton, UK; 3National Heart and Lung Institute, Imperial College, London, UK; 4Harefield Respiratory Research Group, Royal Brompton and Harefield NHS Foundation Trust, London, UKCorrespondence: Lisa Jane BrightonKing’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UKTel +44 20 7848 5041Email lisa.brighton@kcl.ac.ukBackground: People living with both chronic obstructive pulmonary disease (COPD) and frailty have high potential to benefit from exercise-based interventions, including pulmonary rehabilitation, but face challenges completing them. Research to understand ways to optimise exercise-based interventions in this group is lacking. We aimed to understand how exercise-based interventions might improve outcomes for people living with both COPD and frailty.Methods: This realist review used database searches and handsearching until October 2019 to identify articles of relevance to exercise-based interventions for people living with COPD and frailty. A scoping search explored what is important about the context of living with COPD and frailty, and what mechanisms might be important in how exercise-based interventions result in their intended outcomes. Through discussion with stakeholders, the review scope was refined to areas deemed pertinent to improving care. We retained articles within this refined scope and identified additional articles through targeted handsearching. Data were extracted and synthesised in a narrative, prioritised by relevance and rigour.Results: Of 344 records identified, 35 were included in the review and 20 informed the final synthesis. Important contextual factors to consider included: negative beliefs about themselves and exercise-based interventions; heterogenous presentation and comorbidities; decreased reserves and multidimensional loss; and experiencing unpredictable health and disruptions. In these circumstances, mechanisms that may help maximise outcomes from exercise-based interventions included: trusting relationships; creating a shared understanding of needs; having the capacity to address multidimensional concerns; being able to individualise approaches to needs and priorities; and flexible approaches to intervention delivery. Mixed-methods research and explicit theorising were often absent.Conclusion: Building trusting relationships, understanding priorities, using individualised and multidisciplinary approaches, and flexible service delivery can improve the value of exercise-based interventions for people living with both COPD and frailty. Development and evaluation of new and adapted interventions should consider these principles.Keywords: chronic obstructive pulmonary disease, frailty, rehabilitation, exercise, review

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.)

Rationale: People living with both chronic obstructive pulmonary disease (COPD) and frailty have high potential to benefit from pulmonary rehabilitation but face challenges completing programs. However, research to understand ways to optimize participation in this group is lacking. Objectives: To explore the experiences, needs, and preferences of people with COPD and frailty referred for outpatient pulmonary rehabilitation. Methods: Semistructured interviews with people with COPD and physical frailty, purposively sampled by age, living status, level of frailty, and completion of pulmonary rehabilitation. Thematic analysis with a critical realist perspective was used, involving relevant stakeholders with clinical, academic, and lived experience for interpretive rigor. Results: Nineteen people with COPD and frailty were interviewed, with a median age of 78 years (range, 58-88). Nine did not complete their pulmonary rehabilitation program. Four themes were identified: striving to adapt to multidimensional loss, tensions of balancing support with independence, pulmonary rehabilitation as a challenge worth facing, and overcoming unpredictable disruptions to participation. Participants described constantly adapting to their changing health and resulting multidimensional losses (e.g., functional abilities, relationships, confidence). This involved traversing between independence and seeking support, set against a mismatch between their needs and what support is available. People with COPD and frailty can be highly motivated to participate in pulmonary rehabilitation, despite the physical and mental demands it entails, and report a range of benefits. Yet in the context of changeable health, they must often overcome multiple unpredictable disruptions to completing rehabilitation programs. Participant determination and flexibility of services can facilitate ongoing attendance, but for some, these unpredictable disruptions erode their motivation to attend. Conclusions: People with COPD and frailty experience accumulating, multidimensional loss. This group are motivated to complete pulmonary rehabilitation but often require additional support and flexibility owing to fluctuating and unpredictable health. Person-centered approaches should be considered to minimize disruptive health events and support pulmonary rehabilitation participation and completion. Service adaptations could allow more flexibility to meet the changing needs of this group and enable communication around how pulmonary rehabilitation might align with their priorities.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are one of the most common causes of emergency hospital admission and place great burden upon healthcare systems. Furthermore, AECOPD represent an important life event for patients, and are associated with significant reductions in physical activity, skeletal muscle function, exercise tolerance and health-related quality of life. Pulmonary rehabilitation, an intervention comprising supervised exercise-training and education, may counteract these negative consequences and target modifiable risk factors for hospital readmission. A recent Cochrane systematic review included 20 randomized controlled trials comparing pulmonary rehabilitation after exacerbation of COPD versus conventional care. Overall, the evidence supports moderate to large effects on health-related quality of life and exercise capacity. However, there is substantial heterogeneity across studies, and more recent studies have been more equivocal, including around hospital readmissions, particularly when rehabilitation is started in the inpatient setting. In this narrative review, we examine the rationale for pulmonary rehabilitation following AECOPD with a particular focus on skeletal muscle function, review the current evidence for pulmonary rehabilitation in the AECOPD setting, and identify areas that require future research, including the structure and nature of the intervention, improving uptake and adherence, and the role of alternative rehabilitation strategies for patients with AECOPD., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.