Description and Reliability of Internet Resources on Pulmonary Rehabilitation for Individuals with Chronic Lung Disease

RATIONALE Pulmonary rehabilitation (PR) is an important management modality in individuals with chronic lung disease. The internet is commonly used as a source of health information by individuals with lung disease. Given the ongoing COVID-19 pandemic and closure of in-person PR programs, many patients with lung disease rely on online resources for exercise training;however, the quality and reliability of online information on PR has not been evaluated. Thus, the objective of this study is to characterize internet resources on PR, and to assess the readability, content and quality of patient-directed PR resources. METHODS The first 200 websites for the search term 'pulmonary rehabilitation resources and exercise' were analyzed in Google, Yahoo and Bing. Website content was evaluated based on a predefined scoring system of the key components of PR, as described in the most recent international consensus guidelines. Website quality and reliability were determined using the validated DISCERN instrument and the Global Quality Scale (GQS). RESULTS A total of 70 unique websites were identified with the two most common categories being academic resources (63%) and foundation/advocacy organizations (33%). The average reading grade level of PR websites was equivalent to grade 11. There was significant heterogeneity in content (Table 1) across websites related to exercise training, education, and behaviour change (17.7 ± 5.1 out of 30). Most websites focused on traditional modalities of aerobic (96%) and resistance training (87%), in contrast to balance exercises (16%) and inspiratory muscle training (19%). A small majority of websites provided education focused on smoking cessation (59%), breathing strategies (59%), and nutrition (54%), with fewer websites addressing self-efficacy (37%) and motivation (13%). Website quality was good across PR websites (DISCERN median score 4.0 IQR (3.0-4.0) and GQS 4.0 IQR (2.0-4.0) out of 5 for both measures). CONCLUSIONS PR content varied significantly across websites and only partially captured items outlined in the PR international consensus guidelines. Website quality was good, suggesting that most PR websites were overall useful for patients;however, the higher-than-recommended reading level of patient education materials may compromise utilization and comprehension of PR resources. Efforts need to be made to better tailor online PR resources to the general lung population. (Figure Presented).

Natural history of COVID-19 recovery: Changes in physiologic, radiologic and patient-reported outcomes 12 months after symptom onset

RATIONALE: The long-term trajectory of people recovering from COVID-19 and the cause of COVID-19;imaging;patient persistent symptoms remains poorly understood. OBJECTIVE: We sought to determine how pulmonary function tests (PFTs), patient-reported outcome pulmonary function measures (PROMs) and radiologic features change over 12months in people hospitalized with COVID-19. METHODS: A prospective, consecutive cohort of patients hospitalized with PCR-confirmed SARS-CoV-2 were recruited. Longitudinal clinical data, PROMs, PFTs and computed tomography (CT) chests were collected at 3, 6 and/or 12months after symptom onset. Repeated analysis of variance (ANOVA) and Friedman tests were used to compare changes in outcomes over time. MEASUREMENT AND MAIN RESULTS: Eighty-one patients were enrolled with 70 completing the 12-month visit. At 3months, the mean diffusing capacity of the lung for carbon monoxide was reduced at 76 +/- 16%-predicted and improved to 80 +/- 16%-predicted at 6months (p<0.001). The median values for dyspnea, cough, sleep and quality of life (QoL) were abnormal at 3months, with QoL being the only PROM that significantly improved at 6 months. There was no further statistically significant change in PFT parameters or PROMs between 6 and 12 months. The percentages of lung affected by ground glass and reticulation at 3months were 11.3% (IQR 5.6-19.6) and 4.4% (IQR 1.6-7.9), respectively. These improved at 12months with ground glass being 0% (IQR 0-3.3) and reticulation 1.7% (IQR 0-3.3). CONCLUSIONS: PFTs improve between 3 and 6 months, with no change over the subsequent 6months in patients hospitalized with COVID-19. Despite improved and nearly normal physiologic and radiologic results in most patients, 60% report abnormal PROMs at 12months.

Pulmonary Function and Functional Capacity in COVID19 Survivors with and Without Persistent Dyspnea in a Mexican Population

Rationale: Dyspnea is one of the most common symptoms associated with coronavirus disease 2019 (COVID-19). Over 40% of COVID-19 survivors experience persistent dyspnea approximately 60 days following hospital discharge (Carfi et al., JAMA, 2020). Understanding differences in pulmonary function and functional capacity between those that do and do not experience persistent dyspnea may provide insight into the underlying mechanisms of this symptom in survivors of COVID-19. Accordingly, the purpose of this study was to compare spirometry, diffusing capacity of the lungs for carbon monoxide (DLCO), and 6-minute walk test (6MWT) outcomes in COVID-19 patients with and without persistent dyspnea. We hypothesized that COVID-19 patients with persistent dyspnea would have lower forced vital capacity (FVC), DLCO, and 6-minute walk distance (6MWD) compared to patients without persistent dyspnea. Methods: Non-critical patients (n=186) with varying degrees of COVID-19 severity reported all persistent symptoms using a standardized questionnaire and underwent pulmonary function testing and a 6MWT between 30 and 90 days following the onset of acute COVID-19 symptoms. Patients were divided into those with (n=70) and those without (n=116) persistent dyspnea. Independent t-tests and Fisher's Exact test were used where appropriate to compare anthropometric, pulmonary function, symptoms, and 6MWT variables. Results: There was no difference in the time of experimental testing relative to the onset of acute COVID-19 symptoms between those with vs. those without dyspnea (59±13 vs. 60±14 days, respectively). Groups had similar age, height, mass, body mass index, sex, and frequency of comorbidities. Patients with persistent dyspnea had significantly lower FVC (p=0.03), forced expiratory volume in 1 second (p=0.04), and DLCO (p=0.01) compared to non-dyspnea patients. 47% of patients with persistent dyspnea had a restrictive pattern on spirometry compared to 33% in the non-dyspnea group. Patients with persistent dyspnea also had lower 6MWD (% predicted, p=0.03) and nadir oxygen saturation (p<0.001), and higher Borg 0-10 ratings of dyspnea and fatigue (both p<0.001) during the 6MWT compared to patients without persistent dyspnea. Conclusions: We have shown that dyspnea is a common persistent symptom across varying degrees of initial COVID-19 severity. Patients with persistent dyspnea had a number of abnormalities compared to well-matched patients without persistent dyspnea, including greater restriction on spirometry, lower DLCO, reduced functional capacity, and increased desaturation and exertional symptoms during a 6MWT. This suggests that there is a true physiological mechanism that may explain persistent dyspnea after COVID-19.

Predictors of functional outcome after COVID-19 illness: A prospective study in mexico

Rationale: Clinical outcomes after coronavirus-2019 disease (COVID-19) have been well described, including persistent symptoms and abnormalities on pulmonary function tests and imaging. However, the presence and underlying mechanism of functional impairments after COVID-19 remain unclear. Methods: Patients with SARS-CoV-2 confirmed by real-time polymerase chain reaction were recruited from a hospital in Yucatan, Mexico. Patients who were able to complete surveys, pulmonary function tests, and 6-minute walk tests within 30-90 days after symptom onset were included. COVID-19 severity based on the location of treatment and need for supplemental oxygen was categorized as follows: mild (ambulatory, no hypoxemia), moderate (ambulatory, supplemental oxygen (O2) ≤ 5 l/min), or severe (hospitalised, O2 > 5 l/min without invasive mechanical ventilation). The association between COVID-19 severity and 6-minute walk distance (6MWD) was determined using multivariable linear regression, and underlying mechanisms for reduced 6MWD were then explored. Unadjusted and adjusted linear regression models were used to determine the association between potential predictor variables (Borg dyspnea, Borg fatigue, and end-exercise SpO2) and 6MWD. A final model with Borg dyspnea and end-exercise SpO2 as co-primary endpoints was performed to explore the independent relationship of these two predictors with 6MWD. All models were adjusted for age, sex, smoking, and body mass index (BMI). Results: There were 148 eligible patients with a mean age of 47±14 years and BMI of 32±7kg/m2, with 66% males and 19% current or past-smokers. There were 26% patients with mild, 10% with moderate, and 64% with severe COVID-19 illness. The mean follow-up time was 59 days. The mean 6MWD was 450±104m (83±19% predicted). Patients with severe COVID-19 had a lower 6MWD compared to patients with mild COVID-19 (- 52m [95%CI -88,-15], p=0.006). There was no difference in 6MWD between mild and moderate COVID-19. For every unit increase, Borg dyspnea (coefficient -21m [95%CI -31,-10]) and end-exercise SpO2 (coefficient 13m [95%CI 8,18]) were associated with 6MWD (both p<0.001);however, Borg fatigue was not. When Borg dyspnea and end-exercise SpO2 were included as co-primary predictors, both variables remained independently associated with reduced 6MWD with coefficients of -13m (95%CI -23,-2) and 10m (95%CI 5,16), respectively, after adjusting for covariates (Table 1). Conclusions: Patients with severe COVID-19 had significantly lower 6MWD compared to those with mild disease. Exertional dyspnea and hypoxemia were independent predictors of lower 6MWD, suggesting that dyspnea related to hypoxemia is not the sole driver of reduced functional capacity in COVID- 19 survivors.