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Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk–benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.

BACKGROUND AND OBJECTIVE: People living with pulmonary fibrosis (PF) report unmet needs for information and support. Lung Foundation Australia (LFA) have developed the Peer Connect Service to facilitate telephone support for people with PF across Australia. This project documented the experiences of participants and the resources required to support the service. METHODS: Consenting participants took part in semi-structured interviews by telephone. Primary peers (peers who agreed to initiate contact) and secondary peers (eligible patients who sought a peer match) were interviewed. Thematic analysis was undertaken by two independent researchers. Data were collected on the number of matches and contacts required to establish each match. RESULTS: Interviews were conducted with 32 participants (16 primary peers, 15 secondary peers and 1 who was both), aged from 53 to 89 years with 56% being male. Major themes included the value of shared experiences, providing mutual support and the importance of shared personal characteristics (e.g. gender and hobbies) in allowing information and emotional support needs to be met. Participants saw face-to-face contact with peers as highly desirable whilst acknowledging the practical difficulties. Primary peers were cognizant that their role was not to provide medical advice but to listen and share experiences. In the 12-month period, 60 peer matches were made, each match requiring a minimum of seven staff contacts. CONCLUSION: The Peer Connect Service provides a unique opportunity for people with PF to share experiences and offer mutual support. This telephone matching model may be useful in providing peer support for individuals with rare diseases who are geographically dispersed.

Introduction/Aim Exercise training in pulmonary rehabilitation is an effective intervention for people with interstitial lung disease (ILD). However, a large proportion of those who participate are not attaining its benefit. Alternative training strategies to the current method of continuous exercise at moderate intensity may prove more effective in people with ILD. This study aims to compare the acute physiological effects of high intensity interval training (HIIT), moderate intensity interval training (MIIT) and moderate intensity continuous training (MICT) in people with ILD. Methods Six participants with ILD performed in random order three different cycle training protocols until volitional exhaustion, symptom limitation or desaturation (SpO2 < 80%) after performance of a baseline cardiopulmonary exercise test. Training protocols were thirty second intervals alternating 100% peak work rate with unloaded cycling (HIIT), two minute intervals alternating between 80% and 40% peak work rate (MIIT) and continuous exercise at 60% peak work rate (MICT). The cycle tests were separated by a minimum of one week. Heart rate (HR), blood pressure, SpO2, oxygen uptake (VO2), minute ventilation (VE) and Borg scores for dyspnoea and fatigue were recorded. Results The MIIT protocol resulted in significantly higher VO2, HR and VE (Table 1) when compared to other exercise protocols. During MIIT, participants exercised at a higher percentage of VO2peak (Table 1) and were associated with more dyspnoea, leg fatigue and oxygen desaturation, although this was not statistically significant. There was no significant difference between HIIT and MICT protocols for the VO2, VE, HR, SpO2, leg fatigue or dyspnoea. However, HIIT was associated with a smaller volume of work. Conclusion Using HIIT for people with ILD may allow for a greater training load with similar levels of breathlessness and desaturation to traditional endurance training. Whereas MIIT appears to result in a greater physiological challenge suggesting it is a less effective training strategy.

New treatments for idiopathic pulmonary fibrosis (IPF) have improved survival; however, the complexity of care may be difficult for patients. The aim of this study was to assess the patient experience of modern IPF care.A qualitative study was undertaken for 100 people with IPF with a range of disease severity (forced vital capacity range: 46-106% predicted). Participants were asked about their experience of care using semi-structured interviews. Two investigators independently undertook analysis using the principles of grounded theory.Participants reported dissatisfaction with information received about IPF, particularly at the time of diagnosis. Most were enthusiastic about the benefits of specialist IPF centres including regular monitoring, frequent contact with health professionals and access to clinical trials. However, the burden of travel to specialist centres and costs of treatment were significant. Many reported that side effects of anti-fibrotics caused them to titrate or pause therapy, sometimes without consulting their treating team. Co-morbid medical conditions had a negative impact on well-being and highlighted poor coordination of care. Participants perceived a responsibility for self-management that included exercise, diet, vaccination and treatment of chest infections; many felt this active role should receive more positive emphasis from health professionals.These data show opportunities to improve modern IPF care including accurate and timely provision of information, improving access to specialist care, more support for managing treatment side effects and better coordination of care for patients with co-morbid conditions. Future research should explore the impact of self-management strategies on IPF outcomes.

Idiopathic pulmonary fibrosis (IPF) is a fibrosing interstitial lung disease (ILD) of unknown aetiology with a median survival of only 2–5 years. It is characterized by progressive dyspnoea and worsening lung function, ultimately resulting in death. Until recently, there were no effective therapies for IPF; however, with the publication of two landmark clinical trials in 2014, the anti-fibrotic therapies, nintedanib and pirfenidone, have gained widespread approval. This position paper aims to highlight the current evidence for the treatment of IPF, with particular application to the Australian and New Zealand population. We also consider areas in which evidence is currently lacking, especially with regard to the broader IPF severity spectrum and treatment of co-morbid conditions. The utility of non-pharmacological therapies including pulmonary rehabilitation, oxygen as well as symptom management thought to be important in the holistic care of IPF patients are also discussed.

Background and objective Ambulatory oxygen therapy is often provided to patients with interstitial lung disease (ILD). Lightweight portable oxygen concentrators (POCs) provide an alternative to traditional portable systems such as compressed oxygen cylinders; however, their efficacy in patients with ILD has not been assessed. This study aimed to evaluate the clinical performance of three ambulatory oxygen systems (two different POCs and a compressed oxygen cylinder) during 6-min walk tests (6MWTs) in patients with ILD and exertional desaturation. Methods A total of 20 participants with ILD of varying aetiologies who demonstrated exertional desaturation to

Inhaled mucoactive agents are used in respiratory disease to improve mucus properties and enhance secretion clearance. The effect of mannitol, recombinant human deoxyribonuclease/dornase alfa (rhDNase) and hypertonic saline (HS) or normal saline (NS) are not well described in chronic lung conditions other than cystic fibrosis (CF). The aim of this review was to determine the benefit and safety of inhaled mucoactive agents outside of CF. We searched Medline, Embase, CINAHL and CENTRAL for randomized controlled trials investigating the effects of mucoactive agents on lung function, adverse events (AEs), health-related quality of life (HRQOL), hospitalization, length of stay, exacerbations, sputum clearance and inflammation. There were detrimental effects of rhDNase in bronchiectasis, with average declines of 1.9–4.3% in forced expiratory volume in 1 s (FEV1 ) and 3.7–5.4% in forced vital capacity (FVC) (n = 410, two studies), and increased exacerbation risk (relative risk = 1.35, 95% CI = 1.01–1.79 n = 349, one study). Some participants exhibited a reduction in FEV1 (≥10–15%) with mucoactive agents on screening (mannitol = 158 of 1051 participants, rhDNase = 2 of 30, HS = 3 of 80). Most AEs were mild and transient, including bronchospasm, cough and breathlessness. NS eased symptomatic burden in COPD, while NS and HS improved spirometry, HRQOL and sputum burden in non-CF bronchiectasis. Mannitol improved mucociliary clearance in asthma and bronchiectasis, while the effects of N-acetylcysteine were unclear. In chronic lung diseases outside CF, there are small benefits of mannitol, NS and HS. Adverse effects of rhDNase suggest this should not be administered in non-CF bronchiectasis.

Background and objective The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts. Methods The Guideline methodology adhered to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. Nine key questions were constructed in accordance with the PICO (Population, Intervention, Comparator, Outcome) format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE (Gradings of Recommendations, Assessment, Development and Evaluation) criteria. The Guidelines were externally reviewed by a panel of experts. Results The Guideline panel recommended that patients with mild-to-severe COPD should undergo PR to improve quality of life and exercise capacity and to reduce hospital admissions; that PR could be offered in hospital gyms, community centres or at home and could be provided irrespective of the availability of a structured education programme; that PR should be offered to patients with bronchiectasis, interstitial lung disease and pulmonary hypertension, with the latter in specialized centres. The Guideline panel was unable to make recommendations relating to PR programme length beyond 8 weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented in the summary. Conclusion The Australian and New Zealand Pulmonary Rehabilitation Guidelines present an evaluation of the evidence for nine PICO questions, with recommendations to provide guidance for clinicians and policymakers.

Background and objective: Supplemental oxygen is commonly prescribed in patients with idiopathic pulmonary fibrosis (IPF), although its benefits have not been proven. The aims of this study were to investigate the effect of oxygen on oxidative stress, cytokine production, skeletal muscle metabolism and physiological response to exercise in IPF. Methods: Eleven participants with IPF received either oxygen, at an FiO2 of 0.50, or compressed air for 1h at rest and during a cycle endurance test at 85% of peak work rate. Blood samples collected at rest and during exercise were analysed for markers of oxidative stress, skeletal muscle metabolism and cytokines. The protocol was repeated a week later with the alternate intervention. Results: Compared with air, oxygen did not adversely affect biomarker concentrations at rest and significantly improved endurance time (mean difference=99±81s, P=0.002), dyspnoea (-1±1U, P=0.02), systolic blood pressure (BP; -11±11mm Hg, P=0.006), nadir oxyhaemoglobin saturation (SpO2 ; 8±6%, P=0.001), SpO2 at 2-min (7±6%, P=0.003) and 5-min isotimes (5±3, P< 0.001) and peak exercise xanthine concentrations (-42±73μmol/L, P=0.03). Air significantly increased IL-10 (5±5pg/mL, P=0.04) at 2-min isotime. Thiobarbituric acid-reactive substances (TBARs), IL-6, TNF-α, creatine kinase, lactate, heart rate and fatigue did not differ between the two interventions at any time point. Conclusion: In patients with IPF, breathing oxygen at FiO2 of 0.50 at rest seems safe. During exercise, oxygen improves exercise tolerance, alleviates exercise-induced hypoxaemia and reduces dyspnoea. A potential relationship between oxygen administration and improved skeletal muscle metabolism should be explored in future studies.

Studies in children with cystic fibrosis (CF) suggest greater physical activity (PA) is associated with a slower rate of decline in respiratory function. In adults with CF, objectively measured PA time and its relationship to long-term clinical outcomes of respiratory function and need for hospitalization are unknown.PA measured objectively (SenseWear armband), pulmonary function, exercise capacity (Modified Shuttle Test-25) and CF-related quality of life (CFQ-R) were assessed in 65 adults (34 male; mean age 28 years) with CF during a stable phase. A sub-group of these participants undertook additional measurement of PA at hospital discharge for a respiratory exacerbation.Median daily habitual moderate-vigorous PA (MVPA) time was 31-min (IQR:15-53). Participants who accumulated A¢Â‰Â¥30-min MPVA daily experienced fewer hospital days (PA¢Â€Â‰=A¢Â€Â‰0.04), better exercise capacity and higher FEV1 at 12 months (PA¢Â€Â‰A¢Â‰Â¤A¢Â€Â‰0.001). Daily, fewer females than males accrued A¢Â‰Â¥30-min MVPA (PA¢Â€Â‰=A¢Â€Â‰0.02). Compared with those who did not, participants who accumulated 30-min MVPA in bouts A¢Â‰Â¥10-min (nA¢Â€Â‰=A¢Â€Â‰21) recorded better FEV1 (PA¢Â€Â‰=A¢Â€Â‰0.02) and exercise capacity (PA¢Â€Â‰=A¢Â€Â‰0.006), and reduced hospital admissions (PA¢Â€Â‰=A¢Â€Â‰0.04) and hospital days (PA¢Â€Â‰=A¢Â€Â‰0.04) at 12 months. MVPA participation declined significantly 1 month post-hospital discharge (median 12A¢Â€Â‰min (4-34); PA¢Â€Â‰=A¢Â€Â‰0.04).Adults with CF are able to achieve recommended MVPA targets of 30mins/day; however, a significant gender difference in activity time is apparent. Greater time in MVPA is related to more positive clinical outcomes over 12 months. Whether increasing PA levels can improve clinical outcomes in adults with CF warrants further investigation. See Editorial, page 404.

Background and objective Pulmonary rehabilitation (PR) is a cornerstone of care in chronic respiratory diseases; yet its benefits diminish over time. Repeating PR may be beneficial; however, little is known about the characteristics and outcomes of repeaters. This study aimed to establish the proportion of repeaters, identify characteristics that predict repetition and compare the magnitude of benefits achieved between initial and subsequent programmes. Methods Patients with stable chronic respiratory diseases who attended PR over a 9-year period were included. Outcome measures included the 6-min walk distance (6MWD) and the Chronic Respiratory Disease Questionnaire-Self-Reported (CRDQ-SR). Independent predictors of repeating were identified. Results Of 296 patients, 59 (20%) repeated PR, most within 1–3 years. Following the initial programme, repeaters had significant decline in 6MWD (−96.1 ± 84.6 m; P

Background and objectives Little is known about the prevalence of anxiety in interstitial lung disease (ILD), and the contributors to depression are not clear. The aim of this study was to determine the prevalence and predictors of anxiety and depression in people with ILD. Methods One hundred and twenty-four individuals with ILD (age 64 years (standard deviation 12), 48 idiopathic pulmonary fibrosis) participated. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale to determine likely cases and borderline cases. Associations with demographic data, respiratory function, 6-min walk and Modified Medical Research Council Dyspnoea Scale (MMRC) were examined. Results The prevalence of anxiety was 31%, with clinically significant anxiety in 12%. Depression was present in 23% of individuals, with 7% having clinically significant depression. Independent predictors of anxiety were a higher MMRC score (P = 0.005, odds ratio (OR) for case 2.60, 95% confidence interval 1.37 to 4.92) and higher nadir SpO2 during walking (P = 0.003, OR for case 1.16, 1.04–1.30). Independent predictors of depression were a higher MMRC score (P = 0.006, case OR 3.84, 1.25–11.78, borderline case OR 2.44, 1.14–5.19) and a greater number of comorbidities (P = 0.003, case OR 2.02, 0.97–4.21, borderline case OR 2.26, 1.30–3.93). Conclusions Anxiety and depression are present in a significant minority of individuals with ILD. Dyspnoea and comorbidities are important contributors that may be amenable to intervention.

While recommendations for the duration, frequency, mode and intensity of exercise programmes for people with chronic obstructive pulmonary disease (COPD) are specified in consensus statements,criteria for exercise session attendance are less clear.The review questions were: (i) how commonly are a priori criteria and attendance rates reported for people with COPD participating in exercise programmes and (ii) what is the strength of association between attendance and improvements in functional exercise capacity. Database searches identified primary studies of people with COPD participating in exercise or pulmonary rehabilitation programmes of at least 2 weeks duration. Primary outcomes were a priori criteria for attendance, reports of attendance at supervised exercise sessions and mean improvements in functional exercise assessments. Data extraction processes were confirmed prospectively (>80% agreement). Variants of exercise attendance data were described. Linear associations between attendance and improvements in exercise outcomes were explored (Pearson r, P < 0.05). Of the 234 included studies, 86 (37%) reported attendance and 29 (12%) provided a priori criteria for attendance. In the small sample of studies which reported attendance and functional exercise data before and after the intervention, there was little to no relationship between improvements in functional exercise capacity and training volume (prescribed r = 0.03, P = 0.88; attended r = 0.24, P = 0.18). Reporting of exercise programme attendance rates is low and of variable quality for people with COPD. Consistent and explicit reporting of exercise attendance in people with

Background and objective In 2008, a Consensus Statement was published with the aim of optimizing physiotherapy management for people with cystic fibrosis (CF) in Australia. The aim of this study was to measure knowledge and acceptance of the Consensus Statement recommendations. Methods All physiotherapists providing treatment to people with CF in Australia were invited to complete a purpose-designed online survey to assess knowledge and uptake of key treatment recommendations. Results Sixty-eight physiotherapists took part (response rate 49%). Knowledge of treatment recommendations was high for airway clearance (94%) and exercise assessment (76%). Most respondents agreed with these recommendations (airway clearance 97% agreement, exercise 68% agreement). A small number of respondents (18%) correctly identified the current recommendation to segregate patients with different organisms during airway clearance, with most respondents (73%) implementing stricter infection control policies. Low levels of knowledge and agreement were evident for recommendations regarding measurement of blood sugar levels during exercise (36% knowledge and 28% agreement) and delivery of dornase alfa (53% and 65%). Physiotherapists from specialist CF centres were more likely to know the recommendations for blood sugar level measurement during exercise (P = 0.014), dornase alfa (P = 0.001) and non-invasive ventilation (P = 0.07) compared with physiotherapists in other settings. Conclusions Physiotherapists are aware of treatment recommendations for CF in common areas of practice such as airway clearance and exercise. However, knowledge of recommendations is lower for specialized areas of practice and outside of CF centres. Strategies to improve awareness and uptake of the Consensus Statement among physiotherapists outside of CF centres are required.