Francois Fadell MD MBA ATSF 1,2 Linzy Houchen-Wolloff PhD MCSP 3,4
1-Veterans Affairs Western New York Health Care, Buffalo, New York, USA
2-Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
3- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
4- Department of Respiratory Sciences, University of Leicester, Leicester, UK
The American Thoracic Society (ATS) International Conference 2024 was held in San Diego in May 2024. The Pulmonary Rehabilitation (PR) assembly were allocated one meet the expert sessions, two scientific symposia, one postgraduate course and six abstracts sessions that included 59 abstracts presented across two thematic poster sessions, one poster discussion session, one Rapid poster discussion session, and two mini-symposia. The themes for this year were more diversified compared to prior years, where COVID-19 and Telerehabilitation were dominating the topics.
Content of Sessions
The Postgraduate course PG11 entitled: “State of The Art in Cardiopulmonary Exercise Testing: Principles and Best Practices”, was held on Saturday, May 18, 2024 from 8:00 AM to 4:00 PM (PDT). This course focused on cardiopulmonary exercise testing (CPET), combing education on CPET guidelines and quality control with introduction to state of the art methods for assessing the upper airway and central hemodynamics during exercise. Interpretive strategies were covered in didactic sessions and by practice-based learning in an interactive small group setting, led by content experts from around the world. The session also included a live CPET demonstration to reinforce the practical and multidisciplinary aspects of high-quality CPET performance. Its main objectives were:
- To better understand the physiologic principles underlying pulmonary and cardiac function during exercise in cardiopulmonary diseases
- To better understand the utility of CPET to assess safety and prescription for exercise training or pulmonary rehabilitation; stratify disease severity or prognosis; or diagnose mechanisms of exercise limitation
- To develop confidence in application, practice and interpretation of CPET in clinical practice
Meet the Expert Session MTE 14 was entitled: “Non-Pharmacological Management of Patients after Hospitalization with an Exacerbation of COPD”. The faculty expert was Neil James. Greening, MBBS, PhD, FRCP, BMedSci of the University of Leicester. The main objectives of the session were to describe the various non-pharmacological interventions and their evidence in the post-hospital setting for exacerbations of COPD, to apply the evidence outlined in objective 1 and how to implement it in a clinical setting; and to describe new findings in the field of non-pharmacological treatments in the peri-exacerbation period and what future treatments may look like. This session focused on the evidence of several non-pharmacological interventions and how to combine them and maximize impact.
The first scientific symposium session A8 was entitled: “Changes in Cognition and Mood; A New Frontier for Pulmonary Rehabilitation”. The session objectives were the following: To appreciate the prevalence of cognitive impairment and mood disorders in patients with chronic lung disease, to understand the clinical implications of cognition and mood on symptoms, daily activities and respiratory exacerbations, and to better counsel patients in their practice on available management strategies such as coaching, mindfulness, and psychosocial interventions.
The second scientific symposium session C86 entitled: Pulmonary Rehabilitation- Keeping the Wheel Rolling Forward”. The session objectives were the following: To identify the barriers, both physical and psychological, for people in engaging with pulmonary rehabilitation, to critically review current practice in pulmonary rehabilitation for addressing barriers to participation, and to creatively consider new potential directions for pulmonary rehabilitation. View patient participation rates in Pulmonary Rehabilitation remain sub-optimal and there are inabilities to engage patients in positive behavior changes, a re-conceptualization of pulmonary rehabilitation was suggested as the next step in addressing this issue. This symposium explored the evidence for new strategies and futuristic models for pulmonary rehabilitation.
The first mini-symposium session A98 entitled: “Best Intervention Abstracts in Pulmonary Rehabilitation”, included ten abstracts. Machado et al. in their abstracts entitled: “Effects of Home-based Pulmonary Rehabilitation on the Symptoms of People with Exacerbations of COPD: A Mixed-methods Randomized Controlled Trial” found that a 3-weeks home-based PR program is safe, meaningful and 2-4 times more effective than only standard medication in improving the symptoms of people with COPD exacerbations managed in an outpatient basis. Benzo et al. in their abstract entitled: “Increasing Adherence to Early Pulmonary Rehabilitation after COPD-related Hospitalization” concluded that adding the home-based option not only increases adherence to PR but is also the patients' preference. Also, a Home-based PR with Health coaching showed significant improvement in all domains of quality of life and daily physical activity, indicating that it is a feasible and effective intervention for post-hospitalization. Rozenberg et al. in their abstract entitled: “Feasibility of a Home-based Cognitive-physical Exercise Program in Patients with Chronic Obstructive Pulmonary Disease: Feasibility and Pilot Randomized Controlled Trial” concluded that an ongoing supervised home-based cognitive-physical training study may provide a novel strategy to improve activities of daily living (ADL) and health-related quality of life (HRQL) in patients with moderate-severe COPD. Rozenberg et al in their abstract entitled: “Inspiratory Muscle Training for the Management of Dyspnea in Patients with Hypermobile Ehlers Danlos Syndrome (hEDS) and Generalized Hypermobility Spectrum Disorder (G-HSD): Pilot and Feasibility Randomized Controlled Trial”, concluded from their pilot study that the addition of Inspiratory Muscle Training to exercise training may provide a novel therapeutic approach to offset the disability experienced from dyspnea in hEDS and G-HSD patients. Janaudis-Ferreira et al. in their abstract entitled: “Virtual Rehabilitation for Individuals with Long COVID: A Randomized Controlled Trial”, concluded that an 8-week virtual rehabilitation program improved dyspnea, quality of life and anxiety in individuals with long COVID. Also noted that progression of exercise training is challenging in this population; however, among those who were able to advance the exercise program, improvements were also seen in mobility, fatigue, depression, and post-exertional malaise. Brown et al. in their abstract entitled: “Outcomes for a Randomized Controlled Trial of Mobile Health (mHealth) Exercise in Idiopathic Pulmonary Fibrosis Are Related to Extent of Hypoxemia During Training Sessions”, concluded that an mHealth exercise intervention with asynchronous remote monitoring is feasible and effectively increases moderate-to-vigorous physical activity (MVPA) and Health-related quality of life (QoL) for patients with idiopathic pulmonary fibrosis (IPF) stable on antifibrotics. Blanco et al. in their abstract entitled: “Effects of Physical Training on Mitochondrial Function in Pulmonary Arterial Hypertension”, concluded that exercise may partially inhibit the electron transport chain (ETC) in the lungs and the heart but not in the skeletal muscle, potentially benefiting Pulmonary arterial hypertension (PAH) by reducing lipid accumulation and aligning energy production. Naci et al. in their abstract entitled: “Effects of Osteopathic Manipulative Treatment (OMT) Alone or in Combination With Respiratory Training on Chest Wall Expansion, Functional Mobility, and Dyspnea Level in Patients With Pulmonary Arterial Hypertension”, concluded that the addition of respiratory training to OMT revealed further benefit to chest wall expansion and functional mobility compared to OMT alone and that the OMT might be an effective therapeutic method for dyspneic patients having difficulties in participating cardiopulmonary rehabilitation programs. Chen et al. in their abstract entitled: “The Effect of Helmet Ventilation During Eccentric Cycling Training (ECE) on Functional Capacity in Chronic Respiratory Disease (CRD) Patients”, concluded that patients with CRD showed significant improvement in 6MWD and Time Up and Go (TUG) after ECE, with or without helmet ventilation. In patients with CRD, the application of helmet ventilation during exercise achieved similar improvements in functional capacity as those in non-ventilation group but was associated with a more stable hemodynamic status. Houchen-Wolloff et al. in their abstract entitled: “Clinical and Cost-effectiveness of Space for COPD© Delivered as a Maintenance Programme on Pulmonary Rehabilitation Discharge: A Randomised Controlled Trial”, concluded that that a structured PR maintenance programme focused on self-management is cost-effective, driving down General Practitioners (GP).
The second mini-symposium B97 entitled: “Advanced Insights into Pulmonary Rehabilitation”, included eight abstracts. Adami et al. in their abstract entitled: “Association of Duration and Intensity of Physical Activity on Muscle Oxidative Capacity in Older Adults with or Without COPD”, concluded that for older patients with COPD or dyspnea, who have difficulty accumulating long durations of moderate-to-vigorous physical activity (MVPA), brief vigorous bursts of vigorous physical activity (VPA) may provide a strategy to accrue muscular and health benefits. Indeed, although >150 min/week MVPA was not associated with, however longer duration (>300 min/week) of MPVA or higher intensity (>75 min/week VPA) was associated with greater muscle oxidative capacity. Benzo et al. in their abstract entitled:” Application of a Theoretical Model to Support Home-based Pulmonary Rehabilitation with Health Coaching and Chronic Obstructive Pulmonary Disease Outcomes”, concluded that a home-based PR with Health Coaching (HC) as part of the Self-Determination Theory (SDT) is associated with improved outcomes and improved autonomy through competence, relatedness, self-management, emotional and physical QoL. Ghamloush et al. in their abstract entitled: “Exercise Physiology and Biomarkers of Inflammation and Vascular Remodeling in Individuals With Persistent Dyspnea, Fatigue and Exercise Intolerance After COVID-19”, concluded through exercise physiologic testing that exercise limitations are predominantly related to circulatory impairment, mixed physiologic impairments, or isolated dysfunctional breathing/hyperventilation. Assessment of levels of several biomarkers of cardiovascular injury, remodeling, and immune dysregulation/inflammation suggests that some of the difference in the levels of these biomarkers may be related to prior COVID-19 as opposed to Post-Acute Sequelae of SARS-CoV-2 and/or persistent fatigue, dyspnea and/or exercise intolerance (PASC-DFE). Jbeli et al. in their abstract entitled: “One-minute Sit-To-Stand Test (1STST) in Fibrotic Interstitial Lung Disease: Correlation With Six-minute Walk Test (6MWT) and PFT”, concluded that there is a moderate positive correlation between the 1STST and the 6MWT in individuals with fibrosing ILD. Significantly, the 1STST demonstrates a moderate positive correlation with FVC and the DLCO. Roberts et al. in their abstract entitled: “What Do Pulmonary Rehabilitation Participants Want Their Educational Sessions to Comprise Of? Exploring a Participant-centered Approach to Designing Pulmonary Rehabilitation Education”, concluded that programs should evaluate their current delivery and determine if the format, delivery and length of the educational session meets the needs of the patients. Tailoring PR education in this way may positively impact on completion rates and enhance condition self-management. Nursat et al. in their abstract entitled: “Improving Use of Medication Inhalers: Factors Linked to Suboptimal Inhaler Use”, recommended that to address the COPD readmission rate, adequate patient training in medication inhaler use is needed as reported by others, that Pulmonary rehabilitation programs are a candidate location for developing and testing inhaler teaching programs because patients have repeat visits and followed for up to eight weeks, that a single teaching activity is not adequate for medication inhaler training in a meaningful number of patients, and that a repeat education and follow-up has the potential to reduce acute care needs, improve quality of life, and reduced costs. Appendini et al. in their abstract entitled: “Peepi-induced Inspiratory Threshold Workload Is Reduced Both by High Flow Nasal Cannula (HF) Device and Non-invasive Positive Pressure Ventilation (NIV) in Severe Stable Chronic Obstructive Pulmonary Disease Patients”, concluded that HF is as effective as NIV in reducing the inspiratory effort in severe stable COPD patients with significant baseline PEEPi and close to hypercapnia. Beauchamp et al. in their abstract entitled: “Unveiling 2-year Functional Outcomes in COVID-19 Survivors: Breaking Results From a Multi-center Prospective Cohort Study”, concluded that the functional and cognitive deficits after moderate to severe COVID-19 do not meaningfully resolve over 2 years post-infection for over 40% of patients. This highlights the importance of early interventions and rehabilitation for preventing long-term functional challenges in hospitalized COVID-19 patients.
The Rapid Poster Discussion Session B27 entitled: “Pulmonary Rehabilitation: Online Resources, Complex Patients and Palliative Care.” Included ten abstracts. Matta et al. in their abstract entitled: “Pulmonary Rehabilitation Utilization and Completion by Disease State in the US Population (2014-2019)” concluded that the utilization of PR in the management of chronic respiratory conditions remains low across all chronic respiratory disorders (CRDs) and only half of the patients completed 8 or more sessions. Choudhary et al. in their abstract entitled: “Assessment of Online Videos as a Source of Information and Instruction for Pulmonary Rehabilitation”, concluded that PR videos were of intermediate quality with a moderate-strong relationship between content scores and quality metrics. They reflected that the current findings highlight gaps in online PR content and provide future direction for the development of patient-directed resources for individuals with chronic lung disease. Dhawan et al. in their abstract entitled: “Characterizing the Content, Quality, and Readability of Internet Resources on Exercise Training and Pulmonary Manifestations in Ehlers-danlos Syndromes (EDS) and Generalized Hypermobility Spectrum Disorder (G-HSD)”, concluded that exercise training content was variable across websites with the most common elements focusing on musculoskeletal fitness and exercise safety. Only one-fifth of sites addressed respiratory considerations specifically. The moderate-strong correlation between website quality and content highlights the importance of developing online resources that integrate scientific consensus recommendations, patient-focused outcomes and appropriate reading level for individuals with EDS/G-HSD. Baray M. in the abstract entitled: “Reviewing Clinical Applications of Chatbots Powered by Large Language Models: Learning CPET”, reflected on the emerging world of AI which poses exciting ways to enhance clinical learning. One of those modality is a chatbot which is a software application that emulates human conversation in response to text inputs and which can assist in learning. Vallerand et al. in their abstract entitled: “Barriers to Exercise Rehabilitation in Canadian Patients With Pulmonary Hypertension (PH)”, concluded that very few patients with PH report prior PR participation. The main barrier to PR appears to be a lack of referral to such programs and that efforts to improve access to supervised/in-person and virtual/home PR would be congruent with patient preferences. Bailey et al. in their abstract entitled: “Feasibility of Home-based Pulmonary Rehabilitation with Remote Monitoring in Pulmonary Arterial Hypertension”, concluded that a home based PR program with motivational interviewing is feasible in patients with PAH. Patients reported an overall positive experience. Etruw et al. in their abstract entitled: “Enhancing Rehabilitation Programs for Complex Chronic Obstructive Pulmonary Disease (COPD) Patients: Insights From Patients and Providers”, recommended that for individuals with complex COPD, an improved rehabilitation program should take a multi-morbidity approach, focusing on patient goals, adopting a collaborative healthcare team approach, leveraging digital technology for enhanced communication and self-management, and promoting strong social connections among patients. Rozenberg et al. in their abstract entitled: “Characterizing Respiratory Symptoms, Physical Activity Levels, and Daily Function in Lung Transplant Candidates (LTx) Managed by Palliative Care (PC): A Mixed Methods Study”, highlighted the contribution of PC support in LTx candidates in managing symptoms and daily function. Goyal et al. in their abstract entitled: “A New Lens for Quality of Life Measurements: Novel Application of the FACIT-pal Score” demonstrated a novel application of the Functional Assessment of Chronic Illness Therapy - Palliative Care (FACIT-pal) score to patients with advanced pulmonary disease to capture a comprehensive assessment across the functional domains of quality of life. Patients with ILD, asthma, PH and COPD experience different burdens on QOL. This study further highlights the benefits of PR as nearly half of patients experienced a clinically significant increase in their FACIT-pal score at completion of pulmonary rehabilitation. Garvey et al. in their abstract entitled: “Characteristics of Virtual Pulmonary Rehabilitation Programs (VPRs) in the US: Results From a National Electronic Survey”, concluded that VPRs in the US are heterogeneous, with notable lack of in-person standardized exercise testing by commercial models. Recommendations given to establish quality metrics, inform trial design comparing VPR to center-based PR, and support reimbursement for VPRs.
The Poster Discussion Session D29 entitled: “Insights Into Mechanisms and Effectiveness of Different Components of Pulmonary Rehabilitation” included 12 abstracts. Kuwahara et al. in their abstract entitled: “Discrepancy Between Exercise Tolerance and Physical Activity in Treatment-naive COPD” concluded that although no significant difference in patient characteristics were shown between a group of patients with high exercise tolerance and high physical activity, compared to a group with high exercise tolerance, however low physical activity. Physicians should pay attention not only to exercise tolerance, but also to reduced physical activity in patients with treatment-naïve COPD. Rolim et al. in their abstract entitled: “How About the Exercise Capacity and Symptoms in Individuals With Preserved Ratio Impaired Spirometry (PRISM): A Cross-sectional Study?” concluded that Compared with adults with normal lung capacity, individuals with PRISm pattern demonstrated worse exercise capacity, higher symptoms and disease impact. The results highlight the need to early detection of PRISm and health-related support. Gonzalez-Diaz et al. in their abstract entitled: “Respiratory Response to Exercise in Primary Ciliary Dyskinesia (PCD)” concluded that that while FEV1 and nNO levels did not show immediate changes post-exercise, the significant SpO2 increase in patients with PCD indicates a potential physiological response to aerobic exercise. Although the sample size is limited, and the study focused on a specific mutation, these preliminary findings suggest that aerobic exercise may be beneficial for patients with PCD without immediate respiratory risks. Muñiz-Hernández et al. in their abstract entitled: “The Impact of Exercise on Respiratory Mechanics as Measured by Forced Oscillation Technique (FOT) in Primary Ciliary Dyskinesia (PCD)”, concluded that a brief six-minute exercise challenge on a stationary bicycle does not appear to induce significant alterations in FOT parameters in individuals with PCD. Accordingly, these results provide valuable insights into the potential resilience of the respiratory system in PCD patients during short-term exercise. Avdeev et al. in their abstract entitled: “Chest Wall Vibroacoustic Therapy (CWVAT) in Patients with Severe COVID-19: A Pilot Feasibility Study” concluded that the use of CWVAT is feasible in patients with severe COVID-19, and its application results in favorable outcomes, such as shortening of hospital stay, improved oxygenation, and reduction of dyspnea. It was also well tolerated. Bridges et al. in their abstract entitled: “Assessment of the Clinical Value of an Oscillating Positive Expiratory Pressure (OPEP) Device and Active Cycle of Breathing Technique (COPD) for Chronic Obstructive Pulmonary Disease (COPD) Post Exacerbation: A 12 Week Prospective, Randomized Study Using the Leicester Cough Questionnaire (LCQ) and COPD Assessment Test (CAT)”, concluded that for COPD patients both interventions were associated with clinically important improvements in cough and quality of life and that such improvements were generally maintained or improved further after 12 weeks. Kumar et al. in their abstract entitled: “Comparison of Virtual and In-person Pulmonary Rehabilitation Completion Rates and Clinical Outcomes in Patients with Chronic Obstructive Pulmonary Disease” concluded of the superior completion amongst patients undergoing virtual PR, with comparable improvements in select clinical outcomes. This underscored the value of virtual PR and is in keeping with the latest ATS guidelines recommending that patients are offered both virtual and in-person options. Benzo et al. et al. in their abstract entitled: “Exploring the Participant's Experience of Home-based Pulmonary Rehabilitation with Health Coaching After a COPD Related Hospitalization”, reflected on participants' feedback highlighting the high acceptability and efficacy of the home PR program tested and sharing the barriers and facilitators for doing home PR after a hospitalization. Sinha et al. in their abstract entitled: “To Determine the Effectiveness of Pulmonary Rehabilitation on Functional Exercise Capacity and Health-related Quality of Life (HRQOL) in Patients with Post Tuberculosis Lung Disease: Pre-and Post- Interventional Cohort Study”, concluded that PR significantly improves clinical features, functional exercise capacity, and HRQOL. Pinheiro et al. in their abstract entitled: “Aerobic Training Versus Behavioral Intervention to Increase Physical Activity in Patients with Asthma: A Preliminary Data From a Randomized Clinical Trial”, concluded that both interventions similarly improve clinical control and health-related quality of life. However, only the aerobic training group improves peak VO2. Rassam et al. in their abstract entitled: “Respiratory Versus Limb Muscle Dual Tasking on Prefrontal Cortex Activity and Cognitive Performance in Healthy Adults”, concluded that the heightened cognitive decrements, perceptual response, and prefrontal cortex (PFC) activity suggests that inspiratory muscle loading and its accompanied dyspnea results in greater cognitive interference than rhythmic pedaling, despite the greater cardiovascular response of the latter. Alexander et al. in their abstract entitled: “Classification of Exercise Intolerance in Formerly Deployed Veterans Varies Substantially with Choice of Reference Equation” concluded that in the sample of symptomatic deployed Veterans with respiratory complaints, classification of exercise tolerance (‘normal’ or ‘reduced') varies considerably as a function of reference equation. As clinical decision making and disability impairment rating often relies upon thresholds or cut-offs (e.g., VȮ2 peak < 80% predicted) for classification, the implications of reference equation selection are considerable and should be carefully evaluated in the Veteran and other populations.
The first Thematic Poster Session A67 entitled: “Cough, Ventilatory Constraints, and Neural Ventilatory Control: Implications to Pulmonary Rehabilitation”, included eight abstracts. Alghamdi et al. in their abstract entitled: “Preference and Clinical Practice of Family and Pulmonary Physicians to Prescribe Cough and Sputum Devices for Chronic Obstructive Pulmonary Disease: An Observational Study”, concluded that family and pulmonary doctors prefer Flutter and Acapella devices, but significant portion of doctors is unaware of any such devices. Their data showed no record of prescribed cough and sputum devices for COPD management. Accordingly, further initiatives needed to increase awareness in clinical practice. Suggett et al. in their abstract entitled: “The Impact of an Oscillating Positive Expiratory Pressure (OPEP) Device on Mucus Plugs: A Case Study Using Functional Respiratory Imaging (FRI) and a COPD Patient”, concluded of the utility of the mucus detection technology within the FRI assessment, and highlighted the potential value of OPEP therapy in clearing the airways of excess secretions / plugs. Torres-Castro et al. in their abstract entitled: “Inspiratory Muscle Training (IMT) in Patients with a Chronic Respiratory Disease: An Overview of Systematic Reviews”, concluded that the IMT improves maximal inspiratory pressure (MIP) in Asthma and OSA. Additionally, IMT may improve MIP in COPD, Pulmonary Hypertension (PH), Lung Resection (LR) and bronchiectasis, exercise tolerance in COPD, PH and lung resection, lung function in asthma and sleep apnoea, dyspnea in COPD, and asthma, and quality of life in COPD. Bentley et al. in their abstract entitled: “Inspiratory and Expiratory Lag Times for a Novel Phrenic Nerve Stimulation Device”, concluded that the novel phrenic nerve stimulation device demonstrated its ability to detect ventilator inspiration and expiration and activate or deactivate electrical stimulation in a similar or less than time than commercially available ventilators. Adding that for both the 1:1 and 1:4 stimulation breath scenarios, the system was found to have reliably delivered stimulation on the intended breath. Bentley et al. also in their abstract entitled: “Discordance Simulation Testing of a Novel Phrenic Nerve Neurostimulation Device”, concluded that during simulated patient-ventilator discordance testing, the novel phrenic nerve stimulation device functioned as intended, delivering stimulation during inspiration and not expiration, for both the 1:1 and 1:4 breath stimulation rate scenarios. Adding that the device has demonstrated its ability to detect inspiration and expiration and synchronize stimulation with breath start and stop in simulated discordant patient-ventilator interactions. Silva et al. reported in their abstract: “Paresis of the Right Hemidiaphragm and Anhidrosis of the Right Hemithorax: A Case Report” reported a rare case of anhidrosis of the right hemithorax combined to a right hemidiaphragmatic paresis without dyspnea, orthopnea or nocturnal dyspnea. Jain et al. in their abstract entitled: “The Effect of Body Mass Index on Ventilatory Parameters During Cardiopulmonary Exercise Testing” concluded that BMI has a significant correlation with exercise capacity (VO2max) but does not affect ventilatory parameters. Hence, BMI does not affect ventilatory parameters during exercise. Cifci et al. in their abstract entitled: “Ventilatory Constraints in Patients With HFpEF During Exercise: Impact of Lung Size and Upper Body Adiposity”, concluded that patients with HFpEF have limited ventilatory reserve during exercise and that upper body adiposity is an important contributing factor to this limited ventilatory reserve.