Review Reports - Home-Based Respiratory Care for COPD Patients

Round 1

Reviewer 1 Report

The manuscript is interesting in the field of COPD management based on HRC. However, the manuscript should be restructured and enriched before publication:

1. The section of overview of HRC should be added after introduction section. This section will describe the role of HRC in COPD, the criteria of HRC for eligible patients with COPD, the general consideration for treatment and education...

2. The section of HRC with pharmacological treatment should be done after the overview section.

3. The section with non pharmacological treatment should include NIV, rehabilitation, smoking cessation.

4. The section of exacerbations remains unchanged.

5. The section of HRC of COPD patients during Covid-19 pandemic or contracting Covid-19 should be done.

Author Response

Dear Reviewer

Please find attached here the revised version of our manuscript entitled " Home-Based Respiratory Care for COPD Patients", resubmitted for your consideration for publication in Sinusitis. You will find our point-by-point responses to the editorial revisions below. All changes in the revised text have been highlighted.

Please feel free to contact us with any questions or concerns, and we eagerly await your response.

The manuscript is interesting in the field of COPD management based on HRC. However, the manuscript should be restructured and enriched before publication:

The section of overview of HRC should be added after introduction section. This section will describe the role of HRC in COPD, the criteria of HRC for eligible patients with COPD, the general consideration for treatment and education...

R: We thank the reviewer for the careful reading of the manuscript and constructive comments. We have revised the text which we present below:

Introduction page 1, line 27 “Management of chronic fatigue, poor exercise tolerance, and depression are often inadequately addressed in COPD patients [Hermiz].

New section Home-based Respiratory Care page 2, line 8-22: “Home-based programmes promote easier access to pulmonary rehabilitation, better patient monitoring and early recognition of acute exacerbations [Holland]. Ideally, screening of patients for HRC should depend on a predefined risk management strategy. The identification of risk factors of COPD poor outcomes, vulnerable populations, and impaired mobility favors the inclusion in HRC programs. This strategy aims to implement preventative health actions in high-risk populations, with the objective of identifying, controlling, or eliminating related dysfunctions [3]. Due to the multicausality of these events, one of the major barriers to effective management of exacerbation in COPD is the lack of reliable predictive biomarkers. However, there are validated models and risk scales that are likely to contribute to predict the risk of acute exacerbations [4]. Despite the compelling evidence supporting pulmonary rehabilitation for chronic respiratory diseases, the minority Therefore, HRC should be available to provide full extent of health benefits and well-being, particularly to patients with higher risk of exacerbations, multiple comorbidities, and limited access to health services.

The section of HRC with pharmacological treatment should be done after the overview section.

R: New section Pharmacological Treatment page 2, line 23-32: Pharmacological Treatment

“Adherence to inhaled therapy is strongly associated with mortality and hospital admission due to exacerbations in COPD (Vestbo). Adherence evaluation based on counting remaining doses in the returned inhalers is not fully reliable (Simmons). Regular monitoring to inhaler technique and treatment compliance during home respiratory follow-up might contribute to improve clinical outcomes.

Treatment decisions should be developed taking into account patient’s individual preferences and current clinical guidelines. Pharmacological treatment can reduce symptoms, reduce the frequency and severity of exacerbations, and improve quality of life and exercise tolerance [2]. “

The section with non pharmacological treatment should include NIV, rehabilitation, smoking cessation.

R: We have the manuscript revised accordingly

New section Smoking Cessation page 2, line 33-43:

“A significant proportion of patients keep smoking after COPD diagnosis [2]. Increasing patient’s knowledge about the disease is a major goal in HRC and might contribute to smoking cessation. A tobacco cessation support programme can achieve better results in the home scenario with increased risk perception and multidisciplinary care. A comprehensive approach to smoking cessation is individualized and includes behavioral interventions, accounting for smoking motivation, the environment in which smoking occurs, available resources to quit, and individual preferences (Marlow). Motivational Enhancement and carbon dioxide feedback delivered by home health care nurses resulted in more quit attempts and significantly greater reductions in the number of cigarettes smoked per day through a 12 months follow-up (Borreli).”

The section of exacerbations remains unchanged.

The section of HRC of COPD patients during Covid-19 pandemic or contracting Covid-19 should be done.

R - We agree with the reviewer that the topic COVID19 would add relevance for the reader. We included the follow sentences in the manuscript:

Page 2, line 2: ”Patients with underlying COPD infected by SARS‐CoV‐2 are most likely to worsen the progression the disease and strong efforts should be directed to avoid COVID-19 infection in this population [Zao]”

Page 3, line 14: “Access barriers to pulmonary rehabilitation centers were even more evident during the coronavirus disease 19 (COVID-19) pandemic. The unprecedented worldwide spread of the virus has quickly turned COVID19 into a critical global public health problem and increased patients' vulnerability to physical deconditioning, depression, and social isolation [9]. This scenario has greatly impacted traditional modes of pulmonary rehabilitation. As most COPD patients are notably susceptible to severe complications of COVID-19, the pandemic has fastened the debate on the implementation and delivery of HPR [10].”

Reviewer 2 Report

The manuscript provides a brief summary of the different aspects of home respiratory care. My comments and suggestions are included in the pdf file.

Although I think it is a very interesting topic I suggest a more recent literature to be included as well as a clearer methodology used in the study defined as a "review".

Comments for author File: Comments.pdf

Author Response

Dear Reviewer

Please feel free to contact us with any questions or concerns, and we eagerly await your response.

The manuscript is interesting in the field of COPD management based on HRC. However, the manuscript should be restructured and enriched before publication:

There are variable different reasons why home-based respiratory care or treatment in patients with COPD should be considered. Literature brings suggestions on difficulties of access to the care center, transport, patient's home distance from the hospital etc. Your background should include a better rationale for that matter.

R: We thank the reviewer for the careful reading of the manuscript and constructive comments. We have revised the text which we present below:

Page 01, line 29: Management of chronic fatigue, poor exercise tolerance, and depression are often inadequately addressed in COPD [3]. Barriers to accessing medical centers, such as urban disparities, socioeconomic determinants, mobility limitation and disease severity, contribute to suboptimal clinical management particularly in rural settings [4,5]. Patients with underlying COPD infected by SARS‐CoV‐2 are most likely to worsen the progression the disease and strong efforts should be directed to avoid COVID-19 infection in this population [6].

define which events

R - We have revised the text which we present below:

Page 02, line 17: “Due to the multicausality of acute worsening of respiratory symptoms, one of the major barriers to effective management of acute exacerbations in COPD is the lack of reliable predictive biomarkers.”

There are new updated literature evaluating home-based Pulmonary Rehabilitation in COPD.

R – We included one more reference as support for home-based Pulmonary Rehabilitation:

Page 03, line 11: “A recent systematic review including twelve randomized controlled trials and two comparative observational studies showed comparable effectiveness of HPR and usual pulmonary rehabilitation for safety, quality of life, exercise capacity for patients with chronic obstructive respiratory disease [16].”

Please describe how the monitoring was performed in the study.

R: We have revised the text which we present below:

- Page 04, line 19: Home-based maintenance tele-rehabilitation consisted in individualised action plan, physical exercise sessions, psychological and dietary support during 144 sessions over 12 months. In this study, HRC telemonitoring was considered as effective as hospital rehabilitation.

How many patients were included? WHat the HRC consisted of?

R: We have revised the text which we present below:

Page 04, line 31: “McDowell and colleagues studied the impact of a 5-week-HRC conducted by a nurse in 110 patients with moderate to severe COPD after hospital discharge following an acute exacerbation. Each patient received disease specific education, including recognition of the signs and symptoms of exacerbation; advice on smoking cessation and review of self management techniques. The intervention group showed a significant reduction in anxiety and a better understanding of the disease. Nonetheless, there was not a major reduction in rehospitalizations [28].

Round 2

Reviewer 1 Report

The revised version can be accepted for publication.