Effect of implementing a treatable traits approach on care of high risk chronic respiratory disease (the TAPPET trial)

Medical management of asthma, bronchiectasis or COPD according to local standard of care and receive an 8-week intervention consisting of home pulmonary rehabilitation and self-management. The 8-week intervention will include: Home visits: The program will commence with a home visit (within 2 weeks of study enrolment, 60 to 120 minutes) by a physiotherapist, exercise physiologist or nurse who will establish exercise goals and supervise the first exercise session. The home visit will also undertake a review of inhaler technique and airway clearance. Participants will complete a modified incremental step test (MIST) in the initial home visit to support exercise prescription. Participants will have a second home visit at 8 weeks where the physiotherapist will reassess exercise capacity using the MIST and discuss a long-term exercise plan including referral to local maintenance exercise programs. Unsupervised exercise training: The program will deliver an unsupervised aerobic and strength training program for 8 weeks to target key sources of systemic inflammation (skeletal muscle and adipose tissue). For the aerobic training, a walking program will be prescribed with participants set a walking distance to be completed in a given time, with distance measurement aided by pedometers. At least 30 minutes of aerobic exercise is recommended for each session, for at least 5 sessions per week. Strength training will utilise functional activities and equipment that are readily accessible at home (e.g. sit-to-stand from a dining chair), with at least two upper-limb and two lower-limb exercises prescribed for completion twice weekly (15 to 30 minutes total per session). Home exercise diary: Exercise goals and details of completed unsupervised exercise sessions will be documented in a home exercise diary each week. Prior to each unsupervised exercise session, participants will be prompted to complete a checklist (based on signs of a moderate or severe exacerbation e.g. increased dyspnoea, cough or sputum, using more reliever medication) in the diary to ensure clinical stability. Participants will be instructed to contact their local clinician if they have symptoms of an exacerbation to ensure appropriate exercise participation during and following chest infections. Weekly telephone calls: The initial home visit will be followed by seven once-weekly telephone calls (approximately 30 minutes each) by a physiotherapist. The physiotherapist will: (1) review symptoms and facilitate self-management of exacerbations as per the diary checklist; (2) review the home exercise diary; (3) progress the exercise prescription; and (4) deliver self-management education targeting systemic inflammation and chest infections including diet and weight management, understanding medications and infection control. Each physiotherapist will maintain a call log and complete a summary at the end of the intervention to report on intervention delivery including number and duration of telephone calls, exercise progression, goals set and achieved, self-management education, referrals to other treatments and services and long-term exercise plan. Action plans: Asthma Australia and Lung Foundation Australia have designed action plans that when completed with a health professional help people with asthma, bronchiectasis and COPD recognise early symptoms of an exacerbation and outline the actions to take. These action plans will be checked by the clinician during the initial home visit and re-visited during the telephone calls. If a participant does not have an action plan and/or existing rescue pack of antibiotics and/or oral corticosteroids to be used in conjunction with their action plan the local research team will coordinate an action plan and/or script to be prepared by the site principal Investigator or other local site physician where applicable. If any participants prefer for this to be completed in consultation with their local GP, the local research team will provide a letter for the participant to take to their GP confirming study participation and requirement for review of action plan and rescue pack script. Disease management checklists: Asthma Australia and Lung Foundation have designed checklists to optimise self-management of asthma, bronchiectasis or COPD. These cover aspects of exercise, inhaler technique, airway clearance, review of medications, comorbidities, smoking cessation, vaccinations, nutrition or mental health support. The local site team will review the relevant checklist with the participant during the second home visit including additional treatment referrals at the local health service partner or other services provided by Asthma Australia and Lung Foundation Australia. Educational resources: Our previous trials in COPD have provided printed educational resources of ‘Better Living with Exercise’ and ‘Better Living with COPD’ developed by Lung Foundation Australia. The provision of resources will be expanded to include written and printed educational material on asthma and bronchiectasis from Asthma Australia and Lung Foundation Australia respectively.