Narelle S. Cox

Objective: Pulmonary rehabilitation is recommended for people with chronic respiratory disease, yet attendance barriers persist. There is increasing interest in models that may overcome some of these barriers, including minimal equipment exercise training. The capacity of a purely minimal equipment circuit to elicit an acute physiological response sufficient to confer health benefits has not been evaluated. This study assessed whether a minimal equipment circuit session enabled participants to achieve a training intensity of ≥60% V ˙ O ₂ peak. Methods: People with chronic respiratory disease referred to pulmonary rehabilitation completed a cardiopulmonary exercise test to determine peak oxygen consumption ( V ˙ O ₂ peak), followed by a 60-minute minimal equipment exercise circuit training session. The session included 3 circuits each comprising 7 exercise stations including upper- and lower-limb training. Physiological signs and symptoms were monitored throughout. The primary outcome was the percentage of session spent at or above the desired training intensity (≥60% V ˙ O ₂ peak). Results: Eighteen participants completed the study (mean (SD) age 67 (11) years). Participants spent a mean 72% (21) of the session at ≥60% V ˙ O ₂ peak, with a median [IQR] of 40[32-47] minutes above this threshold. Fifteen participants (83%) achieved the target intensity for ≥30 minutes. Participants reported positive immediate ratings of confidence, comfort, and enjoyment (5-point Likert scale median 5, IQR 4-5) at the conclusion of the minimal equipment session. Conclusion: A minimal equipment exercise training session can provide an exercise intensity of ≥60% V ˙ O ₂ peak for >70% of the exercise session in people with chronic respiratory disease. This approach requires further investigation as to whether it may support pulmonary rehabilitation delivery in diverse settings.

Objectives: Genetic testing is increasingly used in the diagnosis and management of respiratory conditions, including pulmonary fibrosis (PF). The perspectives of people with PF and healthcare professionals (HCP) on the use of genetic testing remain largely unexplored. Methods: A qualitative study was undertaken. People living with PF, their caregivers, and HCP were invited to undertake a semi-structured interview. Interviews were conducted via videoconference or telephone, audio-recorded, and transcribed verbatim. Data were analysed by two researchers using inductive thematic analysis. Results: Thirty-eight participants; 15 people living with PF, 1 caregiver, and 22 HCPs were interviewed. Analysis revealed three key themes. Genetic testing in PF was valued by all groups; people with PF wanted testing now, whilst respiratory physicians were cautious, citing their uncertainty regarding clinical value. All groups desired more information and support; people with PF desired a better understanding of terminology, whilst genetic counsellors wanted to better understand PF. No single model for returning genetic results in PF was identified, however resources, multidisciplinary care, and timely return of results was considered important. Conclusion: Genetic testing is valued by people with PF and their HCP, but uncertainties remain regarding whether it should be offered and how results should be best communicated.

Pulmonary rehabilitation (PR) is a multidisciplinary intervention whose cornerstone is aerobic and resistive exercise training coupled with disease education. Advances in the field of PR have focused on remote delivery to address access to this guideline-driven intervention. A scientific symposium on key unresolved issues facing tele-PR was programmed at the 2025 American Thoracic Society International Conference. This narrative review summarizes presentations by PR experts on synchronous versus asynchronous delivery modes; exercise training using aerobic gym equipment versus minimal equipment; and the primary functional outcome being a measure of exercise capacity versus measures of frailty or physical activity. While synchronous tele-PR may enhance safety, allow real-time feedback during exercise, and foster group camaraderie, asynchronous delivery offers flexibility and individualized engagement with clinicians. Gym equipment may facilitate higher exercise intensity training and progression, but the experienced PR clinician can achieve both with minimal equipment and a clear prescription for ground walking speed, walking duration, or weight additions. Finally, improvement in exercise capacity is a well-established outcome of PR, yet evidence is variable as to whether this benefit translates into increased physical activity. It will be important to study the concept of frailty to individualize program content. All PR models must provide the core components and lead to the expected outcomes. New tele-PR models must be rigorously evaluated. The goal is to provide equitable access to effective PR to as many people with chronic lung disease as possible. Tele-PR has the potential to improve access, but should not replace center-based PR.

Pulmonary rehabilitation (PR) is a key component in managing chronic respiratory diseases (CRDs). Primary care, often the first point of contact for people with CRD, is well-positioned to facilitate referral to PR, yet referral rates are low. This systematic review aimed to identify the key components of primary care interventions to support referral to PR and synthesise their effect on referral rate. Five electronic databases were searched to identify studies of any design that reported interventions implemented in primary care to support referral to PR for people with CRD. Interventions could target people with CRD and/or healthcare professionals. Screening, quality appraisal using the Downs and Black checklist, and data extraction were conducted independently by two reviewers. Interventions were mapped to the Expert Recommendations for Implementing Change (ERIC) taxonomy-a framework of 73 strategies seeking to enhance the adoption, implementation, and sustainability of evidence-based interventions. Thirteen studies were included, employing a range of quasi-experimental, observational, and randomised designs. Overall, the studies were of moderate quality (mean total score 14, range 10 to 25 out of 27). Interventions incorporated a mean of 12 ERIC strategies across five domains, most commonly education and training, interactive assistance, clinician support, and audit and feedback. Impact of interventions on referral rates was minimal (n = 3 randomised controlled trials, pooled mean difference 0%, 95% confidence interval -0.24 to 0.25). Multi-component interventions, including numerous implementation strategies, have achieved minimal improvement in PR referral rates from primary care. Understanding how strategies are delivered and applied, rather than simply the number of strategies or the combination they are used in, may be important for operationalisation of referral focussed interventions. Addressing the behavioural processes underpinning referral decisions, together with the use of theory-informed, context-specific approaches may enhance effectiveness of referral focussed interventions.

Background: Barriers to delivery of pulmonary rehabilitation are not evenly distributed across people with chronic lung disease. The aim of this systematic review was to evaluate equity in pulmonary rehabilitation delivery and outcomes, in relation to the social determinants of health. Methods: A systematic search of four online databases was undertaken. Two reviewers independently screened studies and extracted data. Social determinants of health were categorised according to the PROGRESS-Plus framework, and mapped to the Health Equity Implementation Framework. We reported the impact of PROGRESS-Plus factors on pulmonary rehabilitation access, uptake and completion, and outcomes of health-related quality of life and exercise capacity. Results: 32 studies from 13 countries were included. Place of residence (rurality, travel distance) was consistently associated with poor access and uptake. Uptake was lower for Black people than White people (OR 0.87, 95% CI 0.81–0.95; two studies, n=1 128 623) and in those of low socioeconomic status (OR 0.63, 95% CI 0.55–0.73; two studies, n=1 134 811). Men were more likely to complete than women (OR 1.13, 95% CI 1.06–1.20; eight studies, n=20 509). People who were working were less likely to complete (OR 0.70, 95% CI 0.47–1.04; three studies, n=3292). There was no impact of PROGRESS-Plus features on improvements in health-related quality of life or exercise capacity with pulmonary rehabilitation. Conclusions: There are inequities in delivery of pulmonary rehabilitation. Targeted efforts to improve pulmonary rehabilitation delivery in disadvantaged groups are required, to ensure that all people with chronic lung disease are able to realise its benefits.