IntroductionPulmonary rehabilitation (PR) provides substantial benefits, but these are rarely sustained. Walking football (WF), with its slower pace and widespread availability, may offer an exercise-maintenance option. This proof-of-concept study aimed to understand the potential of WF as an exercise-maintenance intervention following PR.MethodsA mixed-methods, prospective observational design was used. Patients completing PR at two NHS trusts were invited to attend weekly 2-hour WF sessions for 6 weeks. Feasibility outcomes included recruitment, adherence, and safety. An ethnographic approach observed participant experiences and engagement. Health outcomes were assessed at baseline and post-intervention, and the intensity of a single WF session was analysed.Results160 individuals were approached; 36 expressed interest and 6 enrolled (5 male; mean age 71 years). Travel difficulties were the most common reason for declining. Five participants attended at least 4 sessions, and all continued WF after the study. One minor, unrelated adverse event occurred. Qualitative analysis of 18-hours of observations and 6 interviews generated 6 themes. The most notable finding highlighted the importance of WF sessions being exclusive to people with breathlessness. At least 3 participants achieved the minimal clinically important difference in functional exercise capacity, strength, health-related quality of life, and symptom burden. During a single session, group mean heart rate reached 66% of estimated HRmax, with a mean distance of 3.23 km covered.ConclusionsWF appears to be a promising, engaging, and potentially sustainable exercise-maintenance option following PR, though travel barriers limited uptake. Future interventions should prioritise accessible locations and consider transport support.

ObjectivesTo determine the prevalence of insomnia in patients with chronic obstructive pulmonary disease (COPD) and evaluate its association with health status, pulmonary function, anxiety/depression, and exacerbations.MethodsA cross-sectional observational study was conducted including consecutive COPD outpatients. Data collected included sociodemographic and clinical variables, daytime sleepiness (Epworth Sleepiness Scale), quality of life (COPD Assessment Test, CAT), anxiety and depression (HADS), insomnia severity (Insomnia Severity Index, ISI), and exacerbations in the previous year. Multivariable logistic regression analysis was performed to identify independent predictors of insomnia.ResultsA total of 103 patients (77 males, 26 females) were included. Insomnia prevalence was 38.8% (32.5% mild, 55.0% moderate, 12.5% severe). No significant differences in pulmonary function were observed between patients with and without insomnia. However, patients with insomnia had poorer health status (CAT 19.13±8.63 vs. 11.32±8.13; p<0.001), greater daytime sleepiness (Epworth 5.23±3.10 vs. 3.84±2.31; p<0.011), higher anxiety prevalence (61.5% vs. 31.2%; OR=3.533), and more exacerbations (50% vs. 28.6%; OR=2.5; p<0.037). In multivariable analysis, the CAT score was the only independent predictor of insomnia (OR 1.083; 95% CI 1.011-1.160; p = 0.023).ConclusionsInsomnia is highly prevalent in COPD and is associated with poorer health status, greater daytime sleepiness, increased anxiety, and more frequent exacerbations. Poorer health status was the only independent predictor of insomnia.

BackgroundEvidence regarding the associations of sarcopenic obesity (SO) with chronic lung disease (CLD) and peak expiratory flow (PEF) remains limited. This study aimed to investigate the relationships between SO and CLD as well as PEF among middle-aged and older adults in China and the United Kingdom.MethodsData were derived from the China Health and Retirement Longitudinal Study (CHARLS, 2011-2020) and the English Longitudinal Study of Ageing (ELSA, waves 2-6). Cox proportional hazards models were used to evaluate the associations of SO with incident CLD and PEF-related outcomes. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics between participants with and without SO. Random forest-based analyses were conducted as supplementary analyses to support the main findings.ResultsA total of 3,572 participants from CHARLS and 2,436 from ELSA without CLD at baseline were included in the CLD analysis. During follow-up, SO was significantly associated with a higher risk of incident CLD. In the CHARLS cohort, SO was positively associated with CLD risk after full adjustment (Model 3: HR = 1.50, P = 0.003). Consistent results were observed in the ELSA cohort after adjustment for ethnicity (Model 1: HR = 2.19, P = 0.006). Associations between SO and PEF were not consistently observed across cohorts.ConclusionsSarcopenic obesity was associated with an increased risk of chronic lung disease among older adults, suggesting that SO may be a potential body composition-related marker of respiratory risk. Findings related to PEF were exploratory and warrant further investigation.

ObjectivePulmonary 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˙O2peak.MethodsPeople with chronic respiratory disease referred to pulmonary rehabilitation completed a cardiopulmonary exercise test to determine peak oxygen consumption (V˙O2peak), 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˙O2peak).ResultsEighteen participants completed the study (mean (SD) age 67 (11) years). Participants spent a mean 72% (21) of the session at ≥60% V˙O2peak, 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.ConclusionA minimal equipment exercise training session can provide an exercise intensity of ≥60% V˙O2peak 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.

BackgroundExercise adherence is central to pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD), yet sustained adherence remains difficult. Fear of exertional symptoms, particularly dyspnoea, may promote exercise avoidance. This study explored perceived facilitators and barriers to exercise adherence using the fear-avoidance model.MethodsFace-to-face semi-structured interviews were conducted with 18 patients with COPD recruited from respiratory inpatient wards. Data were analysed using qualitative content analysis, with the fear-avoidance model used as a sensitising framework.ResultsTwo interrelated themes and five subthemes were developed. Threat appraisal transformed exertional symptoms into cues for fear-related avoidance when exercise was viewed as unsafe, symptoms were interpreted as deterioration, and inactivity was used as self-protection. Manageable experiences and social responses rebuilt safety and control through graded success, practical resources, and family and professional responses. Family influence was bidirectional: reassurance supported engagement, whereas alarmed symptom interpretations reinforced avoidance.ConclusionsExercise adherence appeared to be shaped not only by symptoms, but also by how symptoms were interpreted in relation to previous experiences and social context. Interventions should combine symptom reappraisal, individually graded exercise, and structured family and professional support.

Chronic pulmonary diseases are major contributors to death for males and females, yet the extent to which mortality risk within individual pulmonary diseases differs between the sexes remains understudied. We hypothesized that mortality risk differs between males and females with obstructive and restrictive lung diseases after accounting for demographic factors, comorbidities, smoking history, disease severity, and neighborhood-level resource availability. We conducted a retrospective cohort study of adults aged 18-95 years (median age 67 years) with obstructive lung disease (OLD) or restrictive lung disease (RLD) who had their first pulmonary medicine visit at the Cleveland Clinic Health System between 2013 and 2025. Patients were included if they had ≥2 encounters with an OLD or RLD diagnosis and ≥1 pulmonary function test. Multivariable Cox proportional hazards models were used to estimate sex-specific risk of all-cause mortality and by disease subtype after adjusting for demographic characteristics and other clinical risk factors as covariates. The cohort included 70,218 patients (OLD n=49,254, RLD n=20,964) with a median duration of follow-up of 2.6 years. In OLD, males had a 37% higher unadjusted risk of death (hazard ratio [HR] 1.37, 95% CI 1.32-1.43), which remained elevated after adjustment (HR 1.16, 95% CI 1.11-1.20). In RLD, males had a 69% higher unadjusted mortality risk (HR 1.69, 95% CI 1.59-1.80) with persistent excess risk after adjustment (HR 1.49, 95% CI 1.36-1.63). Survival differences persisted after accounting for comorbidities, Area Deprivation Index, smoking history, or differences in pulmonary function.Males with obstructive and restrictive lung disease experienced consistently higher all-cause mortality compared to females in this cohort. These findings highlight sex-associated differences in survival across subtypes of obstructive and restrictive lung disease and underscore the need for future work to clarify underlying mechanisms and further refine prognostic risk stratification across a wide spectrum of chronic pulmonary diseases.

BackgroundMindfulness-Based Stress Reduction (MBSR) has demonstrated benefits in chronic conditions such as cancer, chronic pain, cardiovascular disease, and type 2 diabetes. However, evidence in chronic obstructive pulmonary disease (COPD) remains limited, particularly regarding the feasibility of implementing a full standardized program within pulmonary rehabilitation.MethodsThis prospective pilot study evaluated the feasibility of delivering a standardized 8-weeks MBSR program to people with COPD enrolled in pulmonary rehabilitation. Feasibility outcomes included recruitment, program completion, attendance at group sessions, home practice, and reasons for withdrawal. Adherence was conceptualized as behavioral engagement, assessed through predefined measures (session attendance and weekly self-reported home practice), and interpreted post hoc using thresholds commonly applied in previous MBSR feasibility studies (attendance ≥6/8 sessions; home practice ≥3 days/week). Reasons for discontinuation were collected by phone or email follow-up. Descriptive statistics were used.ResultsEighteen people with COPD (56% women, mean age 68 (±7.4) years; mean FEV1 48 (±16%) predicted) were enrolled. 14 participants (78%) completed the program, and 86% attended at least eight of nine sessions. Participants reported an average of 4.4 (±2.3) days of home practice per week, indicating regular engagement despite inter-individual variability. Reasons for withdrawal included musculoskeletal pain (n = 2) and limited availability (n = 2).ConclusionsThe standardized, in-person 8-weeks MBSR program was feasible in people with COPD undergoing pulmonary rehabilitation, as reflected by their regular attendance at hospital sessions and reported engagement in home practice. This structured context likely supported adherence and program fidelity, but its generalizability to individuals with reduced mobility or clinical instability remains uncertain. Future research should evaluate the feasibility of extending this approach to broader COPD populations and its potential psychological and clinical benefits.

The option of tracheostomy and prolonged invasive mechanical ventilation (IMV) for chronic respiratory failure in myotonic dystrophy type 1 (DM1) poses challenges in decision-making. The Myotonic Dystrophy Foundation consensus recommendations on respiratory management do not directly address the implications of this intervention given the progressive physical and cognitive manifestations of DM1. Here, we consider IMV in DM1 using the ethical principles of beneficence, non-maleficence, autonomy and justice. We call for further research on post-tracheostomy morbidity, mortality, and quality of life (QOL) to help guide decision-making. Our ethical analysis has yielded programmatic changes we hope will improve patient outcomes.

ObjectivesThe relationship between physical or cognitive frailty and chronic obstructive pulmonary disease (COPD) has been established. This study aimed to evaluate the association between social frailty and disease severity as well as prognosis in people with COPD.MethodsEligible people with stable COPD were prospectively enrolled. Baseline data were collected via medical records and face-to-face interviews, and social frailty was assessed using the Makizako Index (grouping criteria). During a 1-year follow-up, changes in participants' disease status and prognostic outcomes were recorded. Multivariate logistic regression was applied to analyze the associations.ResultsOf 725 participants, 281 had social frailty and 444 were non-frail. Baseline social frailty was associated with a greater number of previous acute exacerbations (p<0.001); with a higher risk of frequent acute exacerbations during follow-up (p<0.001); and with higher risks of hospitalization >7 days and ICU stay >3 days at the first acute exacerbation during follow-up (p<0.001, p=0.006). It also predicted greater dyspnea, abnormal blood gas, worse pulmonary function, elevated inflammatory markers, triple therapy escalation, and escalated steroids during this acute exacerbation (all p<0.01).ConclusionSocial frailty may, to a certain extent, serve as a potential predictor for assessing the prognosis of people with COPD.

BackgroundSelf-management ability for patients with chronic obstructive pulmonary disease (COPD) in China urgently needs to be strengthened. The Health Action Process Approach (HAPA) promotes health-oriented behaviour change by tailoring interventions to each stage of the individual's disease. This approach has been applied across a wide range of fields. However, its application among patients with COPD remains relatively limited.ObjectiveTo construct a patient health management journey map based on the HAPA theory.MethodsUsing the HAPA theory as a framework, a patient health management patient journey map was developed through literature review, reference to standardised guidelines, phenomenological research and expert consultation.ResultsFrom the literature review, 12 relevant articles were included to form the preliminary framework. Semi-structured interviews with 5 respiratory medical staff identified the core stages of the patient journey. In a separate subsequent process, the 8 experts selected for consultation had an average work experience of 19.13 ± 3.27 years. Education levels included 2 with a bachelor's degree and 6 with a master's degree or above; professional titles included 3 associate senior doctors, 3 senior doctors and 2 intermediate doctors; and research specialties included 5 in respiratory medicine and 3 in internal medicine nursing. As for the consultation involvement, 3 experts participated once and 5 experts participated twice or more. The familiarity coefficient with consultation content was 0.851, the judgment basis coefficient was 0.916 and the authority coefficient of the experts was 0.889. The coordination of expert opinions was measured by Kendall's W and was 0.429 (χ[2] = 42.452, P < 0.001). Finally, a proof-of-concept test with 5 patients refined the patient journey map's usability by simplifying terminology and adjusting adherence strategies.DiscussionThe patient health management journey map constructed in this study, based on the HAPA theory, is scientific, comprehensive and usable, covering key stages such as disease diagnosis, acute exacerbation management, stable period maintenance and rehabilitation support. It provides patients with comprehensive scientific guidance and promotes the establishment of healthy behaviours.

BackgroundAccurate assessment of asthma symptom control is central to effective management. Spirometry is the gold standard for evaluating lung function and monitoring physiological impairment, and the Global Lung Function Initiative (GLI) has developed widely used spirometric reference equations applicable across populations. However, population-specific equations may better reflect regional characteristics. This study examined the impact of using different spirometric reference equations on asthma assessment.MethodsIn this cross-sectional study, pre-bronchodilator forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC were assessed in 384 adults with asthma, and symptom control status was assessed using the Asthma Control Test (ACT). Reference values, z-scores, and lower limits of normal (LLN) were derived using the GLI Global (GLI-2022 race-neutral) equation (GLIgl), GLI-2012 Caucasian equation (GLI2012_cauc), GLI-2012 Other/mixed equation (GLI2012_other), and Al-Qerem local equation (LOCAL). Agreement between equations was evaluated using Cohen's kappa, and their sensitivity and specificity for identifying ACT-defined uncontrolled symptoms were assessed.ResultsSpirometric values differed significantly across equations. Associations between spirometric impairment and ACT-defined uncontrolled symptoms were modest, with low-to-moderate discrimination. Higher FEV1 and FVC z-scores were consistently associated with higher ACT scores across all equations, although explained variance was limited and model-fit differences were minimal. Pairwise agreement between equation sets was substantial to near-perfect for FEV1 < LLN (kappa = 0.692-0.907) and FEV1/FVC < LLN (kappa = 0.757-0.945), while LLN-defined impairment rates differed across equations.ConclusionsThe choice of spirometric reference equation substantially influences impairment classification and its concordance with ACT-defined symptom control, but overall predictive performance remains modest. Spirometry should be interpreted as a complementary, rather than standalone, tool in asthma assessment, with careful consideration of population-appropriate reference standards.