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• Potential benefits of long-term pulmonary rehabilitation to preserve exercise capacity in patients with idiopathic pulmonary fibrosis treated with antifibrotic drugs.
  Kazuki Okura, Masahiro Iwakura
  Published on: 13 July 2023

• Published on: 13 July 2023

  Potential benefits of long-term pulmonary rehabilitation to preserve exercise capacity in patients with idiopathic pulmonary fibrosis treated with antifibrotic drugs.

  • Kazuki Okura, Physiotherapist Division of Rehabilitation, Akita University Hospital
  • Other Contributors:
    • Masahiro Iwakura, Physiotherapist

  We were interested in the article "Long-term effect of pulmonary rehabilitation in idiopathic pulmonary fibrosis: a randomised controlled trial" by Kataoka K. et al. [1] The effect of pulmonary rehabilitation in patients with idiopathic pulmonary fibrosis (IPF) is a topical theme in this field. We believe that this multicenter randomised controlled trial conducted in Japan will have an enormous impact on the knowledge of pulmonary rehabilitation in patients with IPF.
  The authors conducted a 12-week supervised and home-based unsupervised exercise therapy-based pulmonary rehabilitation for 45 outpatients with IPF treated with antifibrotic drugs. In addition, the patients were followed by a 40-week home-based unsupervised exercise therapy-based maintenance program. The pulmonary rehabilitation resulted in a more significant change (week 52 - Baseline) in endurance time measured by a constant workload test using a bicycle ergometer compared to 43 control patients who received only usual care (mean difference: 187 s [95% CI: 34 to 153]). Although endurance time is a secondary outcome in the authors' study design, this result suggests that IPF patients treated with antifibrotic drugs may benefit from pulmonary rehabilitation as a combination therapy to maintain exercise tolerance.
  In contrast, the authors found no statistically significant between-group differences in the change in 6-minute walking distance (6MWD) (52 weeks - Baseline), the prima...

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  We were interested in the article "Long-term effect of pulmonary rehabilitation in idiopathic pulmonary fibrosis: a randomised controlled trial" by Kataoka K. et al. [1] The effect of pulmonary rehabilitation in patients with idiopathic pulmonary fibrosis (IPF) is a topical theme in this field. We believe that this multicenter randomised controlled trial conducted in Japan will have an enormous impact on the knowledge of pulmonary rehabilitation in patients with IPF.
  The authors conducted a 12-week supervised and home-based unsupervised exercise therapy-based pulmonary rehabilitation for 45 outpatients with IPF treated with antifibrotic drugs. In addition, the patients were followed by a 40-week home-based unsupervised exercise therapy-based maintenance program. The pulmonary rehabilitation resulted in a more significant change (week 52 - Baseline) in endurance time measured by a constant workload test using a bicycle ergometer compared to 43 control patients who received only usual care (mean difference: 187 s [95% CI: 34 to 153]). Although endurance time is a secondary outcome in the authors' study design, this result suggests that IPF patients treated with antifibrotic drugs may benefit from pulmonary rehabilitation as a combination therapy to maintain exercise tolerance.
  In contrast, the authors found no statistically significant between-group differences in the change in 6-minute walking distance (6MWD) (52 weeks - Baseline), the primary outcome of the study (mean difference: 21 m [95 %CI: -25 to 66]). The authors attributed this result to differences in compliance with pulmonary rehabilitation. Indeed, the supplemental results showed that, among the intervention group, 6MWD changed by -8m (95%CI: -47 to 31) in patients with good adherence, while 6MWD changed by -106 m (95%CI: -172 to -40) in those with poor adherence. These results are significant in pulmonary rehabilitation because active patient engagement is critical to benefit from pulmonary rehabilitation. Thus, future studies are warranted to establish effective interventions to enhance active engagement in pulmonary rehabilitation for patients with poor adherence. Moreover, the present results can also be interpreted from the minimal clinical important difference (MCID). Nathan S. et al. reported that MCIDs of the 6MWD were 29.2 m using a distribution-based approach and 21.7 m using a composite outcome (health events of hospitalisation or death) as an anchor in patients with interstitial lung disease (ILD) [2]. The present trial reported a mean change from baseline to week 52 of -53 m (95% CI: -86 to -21) in the control group. The result means that 6MWD decreased by more than the MCID in almost patients. In contrast, the mean change in the pulmonary rehabilitation group was -33 m (95% CI: -65 to -1), implying that approximately 30 to 40% of patients had a decrease in 6MWD smaller than the MCID. This result suggests that pulmonary rehabilitation may effectively maintain 6MWD after about one year in patients with IPF who received long-term pulmonary rehabilitation compared to patients who did not. We believe that these results can be used to facilitate shared decision-making in introducing pulmonary rehabilitation.
  In summary, long-term pulmonary rehabilitation improved endurance time measured by a constant workload test using a bicycle ergometer compared to usual care. Moreover, the current study showed that patients with IPF treated with antifibrotic drugs and long-term pulmonary rehabilitation were less likely to have clinically significant reductions in 6MWD after 52 weeks, whereas most patients treated with antifibrotic drugs alone experienced clinically significant reductions in 6MWD. This result is a novel point of the study. We fully agree with the authors that improving adherence through closer maintenance programs, such as remote programs, is necessary. Previous studies have also reported that participation in pulmonary rehabilitation is associated with lower mortality [3].
  We look forward to new efforts by the FITNESS study collaborators.

  1 Kataoka K, Nishiyama O, Ogura T, et al. Long-term effect of pulmonary rehabilitation in idiopathic pulmonary fibrosis: a randomised controlled trial. Thorax Published Online First: 3 April 2023. doi:10.1136/thorax-2022-219792
  2 Nathan SD, du Bois RM, Albera C, et al. Validation of test performance characteristics and minimal clinically important difference of the 6-minute walk test in patients with idiopathic pulmonary fibrosis. Respir Med 2015;109:914–22.
  3 Guler SA, Hur SA, Stickland MK, et al. Survival after inpatient or outpatient pulmonary rehabilitation in patients with fibrotic interstitial lung disease: a multicentre retrospective cohort study. Thorax 2021;:thoraxjnl-2021-217361.

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  Conflict of Interest:
  None declared.

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