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Survival after inpatient or outpatient pulmonary rehabilitation in patients with fibrotic interstitial lung disease: a multicentre retrospective cohort study
  1. Sabina Anna Guler1,
  2. Seo Am Hur2,
  3. Michael K Stickland3,
  4. Patrick Brun4,
  5. Luc Bovet4,
  6. Anne E Holland5,
  7. Janet Bondarenko5,
  8. Nathan Hambly6,
  9. Joshua Wald6,
  10. Nima Makhdami7,
  11. Michael Kreuter8,
  12. Rainer Gloeckl9,
  13. Inga Jarosch9,
  14. Benjamin Tan2,
  15. Kerri A Johannson10,
  16. S Ainslie McBride10,
  17. Kaissa De Boer11,
  18. Jacqueline S Sandoz12,
  19. Kelly Sun12,
  20. Deborah Assayag13,
  21. Surya P Bhatt14,
  22. Julie Morisset15,
  23. Vincent Ferraro15,
  24. Chris Garvey16,
  25. Pat G Camp17,18,
  26. Christopher J Ryerson2,18
  1. 1 Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
  2. 2 Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  3. 3 Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
  4. 4 Bern Rehabilitation Center, Heiligenschwendi, Bern, Switzerland
  5. 5 Department of Physiotherapy, Monash University and Alfred Health, Melbourne, Victoria, Australia
  6. 6 Department of Medicine, McMaster University, Firestone Institute for Respiratory Health, Hamilton, Ontario, Canada
  7. 7 Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  8. 8 Center for interstitial and rare lung diseases, Thoraxklinik, University of Heidelberg and German Center for Lung Research, Heidelberg, Germany
  9. 9 Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany
  10. 10 Department of Medicine, University of Calgary, Calgary, Alberta, Canada
  11. 11 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California, USA
  12. 12 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  13. 13 Department of Medicine, McGill University, Montreal, Québec, Canada
  14. 14 Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama At Birmingham, Birmingham, Alabama, USA
  15. 15 Département de Médecine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
  16. 16 Pulmonary Rehabilitation and Sleep Disorders Center, University of California San Francisco, San Francisco, California, USA
  17. 17 Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
  18. 18 Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Sabina Anna Guler, Department of Pulmonary Medicine, Inselspital University Hospital Bern, 3010 Bern, Switzerland; sabina.a.guler{at}


Background The impact of pulmonary rehabilitation (PR) on survival in patients with fibrotic interstitial lung disease (ILD) is unknown. Given the challenges conducting a large randomised controlled trial, we aimed to determine whether improvement in 6-minute walk distance (6MWD) was associated with better survival.

Methods This retrospective, international cohort study included patients with fibrotic ILD participating in either inpatient or outpatient PR at 12 sites in 5 countries. Multivariable models were used to estimate the association between change in 6MWD and time to death or lung transplantation accounting for clustering by centre and other confounders.

Results 701 participants (445 men and 256 women) with fibrotic ILD were included. The mean±SD ages of the 196 inpatients and 505 outpatients were 70±11 and 69±12 years, respectively. Baseline/changes in 6MWD were 262±128/55±83 m for inpatients and 358±125/34±65 m for outpatients. Improvement in 6MWD during PR was associated with lower hazard rates for death or lung transplant on adjusted analysis for both inpatient (HR per 10 m 0.94, 95% CI 0.91 to 0.97, p<0.001) and outpatient PR (HR 0.97, 95% CI 0.95 to 1.00, p=0.042). Participation in ≥80% of planned outpatient PR sessions was associated with a 33% lower risk of death (95% CI 0.49% to 0.92%).

Conclusions Patients with fibrotic ILD who improved physical performance during PR had better survival compared with those who did not improve performance. Confirmation of these hypothesis-generating findings in a randomised controlled trial would be required to definitely change clinical practice, and would further support efforts to improve availability of PR for patients with fibrotic ILD.

  • exercise
  • idiopathic pulmonary fibrosis
  • interstitial fibrosis
  • pulmonary rehabilitation

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.

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Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.

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  • Contributors SAG, SAH and CJR designed the study. SAG, SAH, MKS, PB, LB, AEH, JB, NH, JW, NM, MK, RG, IJ, BT, KAJ, SAM, KDB, JSS, KS, DA, SPB, JM, VF, CG, PGC and CJR contributed to data acquisition. SAG and CJR contributed to analysis of the data and drafting of the manuscript. All authors critically revised and finally approved the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.