Unsupervised Exercise in Interstitial Lung Disease

BackgroundLittle research is available to provide practical guidance to health-care providers for exercise preparticipation screening and referral of patients with interstitial lung diseases (ILDs), including lymphangioleiomyomatosis (LAM), to participate in remote, unsupervised exercise programs.Research QuestionWhat exercise preparticipation screening steps are essential to determine whether a patient with LAM is medically appropriate to participate in a remote, unsupervised exercise program?Study Design and MethodsSixteen experts in LAM and ILD participated in a two-round modified Delphi study, ranking their level of agreement for 10 statements related to unsupervised exercise training in LAM, with an a priori definition of consensus. Additionally, 60 patients with LAM completed a survey of the perceived risks and benefits of remote exercise training in LAM.ResultsSeven of the 10 statements reached consensus among experts. Experts agreed that an in-person clinical exercise test is indicated to screen for exercise-induced hypoxemia and prescribe supplemental oxygen therapy as indicated prior to initiating a remote exercise program. Patients with recent pneumothorax should wait to start an exercise program for at least 4 weeks until after resolution of pneumothorax and clearance by a physician. Patients with high cardiovascular risk for event during exercise, severe resting pulmonary hypertension, or risk for falls may be more appropriate for referral to a rehabilitation center. A LAM-specific remote exercise preparticipation screening tool was developed from the consensus statements and agreed upon by the panelists.InterpretationA modified Delphi study approach was useful to develop disease-specific recommendations for safety and preparticipation screening prior to unsupervised, remotely administered exercise in LAM. The primary product of this study is a clinical decision aid for providers to use when medically screening patients prior to participation in the newly launched LAMFit remote exercise program. Little research is available to provide practical guidance to health-care providers for exercise preparticipation screening and referral of patients with interstitial lung diseases (ILDs), including lymphangioleiomyomatosis (LAM), to participate in remote, unsupervised exercise programs. What exercise preparticipation screening steps are essential to determine whether a patient with LAM is medically appropriate to participate in a remote, unsupervised exercise program? Sixteen experts in LAM and ILD participated in a two-round modified Delphi study, ranking their level of agreement for 10 statements related to unsupervised exercise training in LAM, with an a priori definition of consensus. Additionally, 60 patients with LAM completed a survey of the perceived risks and benefits of remote exercise training in LAM. Seven of the 10 statements reached consensus among experts. Experts agreed that an in-person clinical exercise test is indicated to screen for exercise-induced hypoxemia and prescribe supplemental oxygen therapy as indicated prior to initiating a remote exercise program. Patients with recent pneumothorax should wait to start an exercise program for at least 4 weeks until after resolution of pneumothorax and clearance by a physician. Patients with high cardiovascular risk for event during exercise, severe resting pulmonary hypertension, or risk for falls may be more appropriate for referral to a rehabilitation center. A LAM-specific remote exercise preparticipation screening tool was developed from the consensus statements and agreed upon by the panelists. A modified Delphi study approach was useful to develop disease-specific recommendations for safety and preparticipation screening prior to unsupervised, remotely administered exercise in LAM. The primary product of this study is a clinical decision aid for providers to use when medically screening patients prior to participation in the newly launched LAMFit remote exercise program. Take-home PointsStudy Question: How should providers prescreen patients with LAM for medical appropriateness to participate in a remote, unsupervised exercise program?Results: In this modified Delphi study, 7 of 10 statements achieved expert consensus for LAM-specific exercise preparticipation screening prior to initiating a remote, unsupervised exercise program.Interpretation: A remote exercise preparticipation screening tool was developed to aid LAM providers in determining medical appropriateness for an unsupervised exercise program. Study Question: How should providers prescreen patients with LAM for medical appropriateness to participate in a remote, unsupervised exercise program? Results: In this modified Delphi study, 7 of 10 statements achieved expert consensus for LAM-specific exercise preparticipation screening prior to initiating a remote, unsupervised exercise program. Interpretation: A remote exercise preparticipation screening tool was developed to aid LAM providers in determining medical appropriateness for an unsupervised exercise program. Background: Patients with interstitial lung diseases (ILDs), including lymphangioleiomyomatosis (LAM), have unique risks for adverse health events during exercise training outside of a medically supervised setting. Traditionally, patients with ILD have been referred to supervised, center-based pulmonary rehabilitation programs for availability of supplemental oxygen, assistance with oxygen titration, and direct supervision during exercise. However, center-based programs may not be as accessible as home-based programs and may not be preferred by all patients with LAM. Consensus recommendations were developed as guidance for exercise preparticipation screening in LAM to determine medical appropriateness to participate in a remote, unsupervised exercise program. Methods: A multidisciplinary panel of experts in LAM and ILD participated in a two-round modified Delphi study and ranked their level of agreement for statements related to safety and risk mitigation during exercise training in LAM. Results: Ten statements were formulated and modified based on expert survey results and discussion at an in-person panel meeting. Seven of the 10 final statements reached consensus among experts. A LAM-specific, remote exercise preparticipation screening tool was developed from the consensus statements and agreed upon by the full panel. Conclusions: The panel provides a list of recommendations and a consensus LAM-specific exercise preparticipation screening tool for provider use prior to patient enrollment in the LAMFit remote exercise program. • An in-person clinical exercise test is indicated to screen for exercise-induced hypoxemia and prescribe supplemental oxygen therapy as needed prior to initiating a remote exercise program. • Patients with recent pneumothorax should wait to start an exercise program for at least 4 weeks until after resolution of pneumothorax and clearance by a physician. • Patients with high cardiovascular risk for event during exercise, severe resting pulmonary hypertension, or risk for falls may be more appropriate for referral to exercise under supervision in a rehabilitation center. With the rapid uptake and growing availability of new models of exercise programming and telerehabilitation in chronic respiratory diseases, the exercise setting is an important new variable to consider in exercise risk stratification. In settings where exercise training occurs without direct supervision, health-care providers have a reduced capacity to respond to an adverse event (AE) or medical emergency. However, a hybrid or remote exercise or pulmonary rehabilitation (PR) delivery model reduces barriers to referral, attendance, and affordability.1Bondarenko J. Babic C. Burge A.T. Holland A.E. Home-based pulmonary rehabilitation: an implementation study using the RE-AIM framework.ERJ Open Res. 2021; 7: 00469-02020Crossref Scopus (7) Google Scholar, 2Seron P. Oliveros M.J. Gutierrez-Arias R. et al.Effectiveness of telerehabilitation in physical therapy: a rapid overview.Physical Therapy. 2021; 101pzab053Crossref Scopus (214) Google Scholar, 3Cox N.S. Dal Corso S. Hansen H. et al.Telerehabilitation for chronic respiratory disease.Cochrane Database Syst Rev. 2021; 1CD013040PubMed Google Scholar The 2023 American Thoracic Society (ATS) clinical practice guideline on "Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease" strongly recommends offering a choice between telerehabilitation and center-based PR for stable patients with chronic respiratory disease but acknowledges that the majority of telerehabilitation studies to date are in COPD.4Rochester C.L. Alison J.A. Carlin B. et al.Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society Clinical Practice Guideline.Am J Respir Crit Care Med. 2023; 208: e7-e26Crossref PubMed Scopus (45) Google Scholar Compared with COPD, less evidence is available to support the development of guidelines for exercise programming in interstitial lung disease (ILD).3Cox N.S. Dal Corso S. Hansen H. et al.Telerehabilitation for chronic respiratory disease.Cochrane Database Syst Rev. 2021; 1CD013040PubMed Google Scholar ILD comprises a heterogeneous group of disorders that share some, but not all, similarities in risks for events during exercise. Individual disease pathology, sequelae, and other system comorbidities can contribute additional risks for exertional complications. Thus, a patient-centered and disease-specific approach to exercise preparticipation risk screening is preferred for risk mitigation. Patients with the rare, female-predominant ILD lymphangioleiomyomatosis (LAM) commonly experience exertional hypoxemia as the disease progresses,5Child C.E. Kelly M.L. Sizelove H. et al.A remote monitoring-enabled home exercise prescription for patients with interstitial lung disease at risk for exercise-induced desaturation.Respir Med. 2023; 218107397Abstract Full Text Full Text PDF Scopus (1) Google Scholar,6Queiroz D.S. da Silva C. Amaral A.F. et al.Desaturation-distance ratio during submaximal and maximal exercise tests and its association with lung function parameters in patients with lymphangioleiomyomatosis.Front Med (Lausanne). 2021; 8659416Google Scholar similar to other ILDs.7Dowman L. Hill C.J. May A. Holland A.E. Pulmonary rehabilitation for interstitial lung disease.Cochrane Database Syst Rev. 2021; CD006322PubMed Google Scholar Pulmonary manifestations of LAM include cystic lung destruction,8McCarthy C. Gupta N. Johnson S.R. Yu J.J. McCormack F.X. Lymphangioleiomyomatosis: pathogenesis, clinical features, diagnosis, and management.Lancet Respir Med. 2021; 9: 1313-1327Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar slow annual FEV1 decline, and progressive gas exchange impairment.9Gupta N. Lee H.S. Ryu J.H. et al.The NHLBI LAM Registry: prognostic physiologic and radiologic biomarkers emerge from a 15-year prospective longitudinal analysis.Chest. 2019; 155: 288-296Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar Patients with LAM are generally younger than patients with other chronic respiratory diseases, with an average age of onset of symptoms of 38.9 ± 0.73 years.10Ryu J.H. Moss J. Beck G.J. et al.The NHLBI lymphangioleiomyomatosis registry: characteristics of 230 patients at enrollment.Am J Respir Crit Care Med. 2006; 173: 105-111Crossref PubMed Scopus (392) Google Scholar Many patients are still heavily involved in career and family responsibilities.11Belkin A. Albright K. Fier K. Desserich J. Swigris J.J. "Getting stuck with LAM": patients perspectives on living with lymphangioleiomyomatosis.Health Qual Life Outcomes. 2014; 12: 79Crossref Scopus (9) Google Scholar Traditionally, patients with ILD, including LAM, have been referred to supervised, center-based PR programs for availability of supplemental oxygen, assistance with oxygen titration, and direct supervision during exercise. However, center-based PR programs may not be as accessible as home-based programs and may not be preferred by patients with LAM. The recent 2023 ATS Guideline authors suggest that exercise-based PR for adults with ILD should be delivered in a setting in which supplemental oxygen can be administered during training, given the primary risk for exertional desaturation.4Rochester C.L. Alison J.A. Carlin B. et al.Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society Clinical Practice Guideline.Am J Respir Crit Care Med. 2023; 208: e7-e26Crossref PubMed Scopus (45) Google Scholar If sufficient supplemental oxygen is available to support exercise training, a home-based approach removes many of the participation barriers encountered by patients with LAM and ILD.12Hoffman M. Mellerick C. Symons K. Glaspole I. Holland A.E. Pulmonary rehabilitation for interstitial lung disease: referral and patient experiences.Chron Respir Dis. 2021; 1814799731211046022Crossref Scopus (10) Google Scholar Most adults with LAM are young to middle-aged at the time of diagnosis,11Belkin A. Albright K. Fier K. Desserich J. Swigris J.J. "Getting stuck with LAM": patients perspectives on living with lymphangioleiomyomatosis.Health Qual Life Outcomes. 2014; 12: 79Crossref Scopus (9) Google Scholar and thus are less likely to have age-related challenges to digital health literacy and barriers to use of wearable fitness trackers,13Holko M. Litwin T.R. Munoz F. et al.Wearable fitness tracker use in federally qualified health center patients: strategies to improve the health of all of us using digital health devices.NPJ Digit Med. 2022; 5: 1-6Crossref Scopus (33) Google Scholar both important factors to the success of a digitally enabled care approach in chronic respiratory disease.14Slevin P. Kessie T. Cullen J. Butler M.W. Donnelly S.C. Caulfield B. Exploring the barriers and facilitators for the use of digital health technologies for the management of COPD: a qualitative study of clinician perceptions.QJM. 2020; 113: 163-172Google Scholar,15Polgar O. Patel S. Walsh J.A. et al.Digital habits of pulmonary rehabilitation service-users following the COVID-19 pandemic.Chron Respir Dis. 2022; 1914799731221075647Crossref PubMed Scopus (6) Google Scholar Our research team recently demonstrated that a remote, asynchronously monitored home exercise program is safe in LAM, with no study-related AEs and high participant satisfaction, and improves symptoms of dyspnea, fatigue, and exercise intolerance.5Child C.E. Kelly M.L. Sizelove H. et al.A remote monitoring-enabled home exercise prescription for patients with interstitial lung disease at risk for exercise-induced desaturation.Respir Med. 2023; 218107397Abstract Full Text Full Text PDF Scopus (1) Google Scholar In community-academic partnership16Eldredge L.K.B. Markham C.M. Ruiter R.A.C. Fernández M.E. Kok G. Parcel G.S. Planning Health Promotion Programs: An Intervention Mapping Approach. John Wiley & Sons, 2016Google Scholar with The LAM Foundation, we will now implement "LAMFit," a program to expand access to the health benefits of exercise for more individuals with LAM. Current population-based models for exercise preparticipation screening, including the 2015 American College of Sports Medicine Exercise Preparticipation Health Screening Tool17Riebe D. Franklin B.A. Thompson P.D. et al.Updating ACSM's recommendations for exercise preparticipation health screening.Med Sci Sports Exerc. 2015; 47: 2473-2479Crossref PubMed Scopus (423) Google Scholar and the 2018 Physical Activity Guidelines for Americans,18Piercy K.L. Troiano R.P. Physical activity guidelines for Americans from the US Department of Health and Human Services.Circ Cardiovasc Qual Outcomes. 2018; 11e005263Crossref PubMed Scopus (260) Google Scholar are based on an individual's current physical activity levels, the presence of signs or symptoms and/or known cardiovascular, metabolic, or renal disease, and planned exercise intensity, all of which are risk modulators of exercise-related cardiovascular events.19Riebe D. Ehrman J.K. Liguori G. Magal M. Medicine AC. of S. ACSM's Guidelines for Exercise Testing and Prescription. Wolters Kluwer, 2018Google Scholar Notably, both of these resources do not advise on risk factors related to chronic respiratory diseases. There is a gap in the literature of available screening tools to assist providers when prescreening patients with LAM and other chronic respiratory diseases who want to initiate an unsupervised home exercise program. The purpose of this study was to develop an expert consensus exercise preparticipation screening tool specifically for patients with LAM, to be used by LAM providers when determining medical appropriateness to participate in the remote, unsupervised LAMFit exercise program. To synthesize the opinions of health-care providers, patients, and other stakeholders in the LAM community related to screening for medical appropriateness for unsupervised exercise in LAM, we conducted a two-round modified Delphi study consisting of a first-round online survey and a second round in-person meeting for panel discussion. A Delphi study methodology is an acceptable method for generating consensus when there is a paucity of available literature and an urgent need to develop guidelines.20Fink A. Kosecoff J. Chassin M. Brook R.H. Consensus methods: characteristics and guidelines for use.Am J Public Health. 1984; 74: 979-983Crossref PubMed Google Scholar,21Niederberger M. Spranger J. Delphi technique in health sciences: a map.Front Public Health. 2020; 8: 457Crossref PubMed Scopus (433) Google Scholar A modified RAND/UCLA Appropriateness Method22Fitch K. The RAND/UCLA Appropriateness Method user's manual.http://catdir.loc.gov/catdir/enhancements/fy1003/00045830-d.htmlDate accessed: July 22, 2024Google Scholar (Fig 1) was used to structure each round, as it is a rigorous Delphi-style method with extensive use cases in health care for generating consensus about the appropriateness of procedures and the prospective development of clinical decision aids.23De Schreye R. Houttekier D. Deliens L. Cohen J. Developing indicators of appropriate and inappropriate end-of-life care in people with Alzheimer's disease, cancer or chronic obstructive pulmonary disease for population-level administrative databases: a RAND/UCLA appropriateness study.Palliat Med. 2017; 31: 932-945Crossref PubMed Scopus (0) Google Scholar, 24Milton-Jones H. Soussi S. 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Disciplinary trends in the use of the Delphi method: a bibliometric analysis.PLoS One. 2023; 18e0289009Crossref Scopus (9) Google Scholar Key components and methodological priorities of the RAND/UCLA Appropriateness Method are provided in e-Table 1. Study procedures were approved by the University of Washington Institutional Review Board (#STUDY00017539). Purposive sampling28Patton M.Q. Qualitative evaluation and research methods.2nd ed. Published online 1990Google Scholar was used to identify and invite a diverse panel of 16 providers, researchers, and other professionals in LAM and ILD. Our panel size was informed by other Delphi studies in health care,29Isla D. Felip E. Garrido P. et al.A Delphi consensus panel about clinical management of early-stage EGFR-mutated non-small cell lung cancer (NSCLC) in Spain: a Delphi consensus panel study.Clin Transl Oncol. 2023; 25: 283-291Crossref Scopus (4) Google Scholar,30McAllister-Williams R.H. Arango C. Blier P. et al.The identification, assessment and management of difficult-to-treat depression: an international consensus statement.J Affect Dis. 2020; 267: 264-282Crossref PubMed Scopus (0) Google Scholar as there is no standard size.31Nasa P. Jain R. Juneja D. Delphi methodology in healthcare research: how to decide its appropriateness.World J Methodol. 2021; 11: 116-129Crossref PubMed Google Scholar Physician directors of at least five geographically distinct LAM Centers of Excellence, other clinician scientists with expertise and recent publications in the pathophysiology of LAM and ILD, hypoxia, altitude, and exercise, and leadership from The LAM Foundation were invited to participate. A MEDLINE database search was performed for relevant articles published in the English language between 1992 and 2022. MeSH headings of "exercise" and "exercise training" were combined with other relevant search terms, including guidelines, preparticipation screening, risk of event, remote, physical activity, chronic respiratory disease, interstitial lung disease, and lymphangioleiomyomatosis. Additional online resources were compiled and reviewed from the websites of medical professional associations, including the ATS, European Respiratory Society, American College of Cardiology, American Heart Association, International Society for Heart and Lung Transplantation, American College of Sports Medicine, and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). Full articles of available clinical practice guidelines and evidence-based exercise preparticipation screening tools for chronic diseases were reviewed and summarized by two investigators. Prior to Round 1, all invited expert panelists were asked to read a summary of existing literature regarding exercise preparticipation screening in chronic diseases. Existing tools for exercise preparticipation screening have been developed and disseminated17Riebe D. Franklin B.A. Thompson P.D. et al.Updating ACSM's recommendations for exercise preparticipation health screening.Med Sci Sports Exerc. 2015; 47: 2473-2479Crossref PubMed Scopus (423) Google Scholar,32Ribeiro F. Takahashi C. Vanzella L.M. et al.An investigation into whether cardiac risk stratification protocols actually predict complications in cardiac rehabilitation programs?.Clin Rehabil. 2021; 35: 775-784Crossref Scopus (2) Google Scholar,33Ilarraza-Lomeli H. Rojano-Castillo J. Flores-Carrillo P.S. et al.Risk stratification model for telemedicine-based cardiac rehabilitation.Eur Heart J. 2021; 42 (2687)ehab724Google Scholar but are less specific to LAM and ILD. Population-based screening tools consider cardiovascular risks first and foremost—without intact cardiac electrophysiology and pump function, increasing the cardiovascular workload can result in an abnormal exercise response.34American College of Sports MedicineACSM's guidelines for exercise testing and prescription.Published online 2021Google Scholar Patients with ILD can develop comorbid cardiovascular conditions, especially as they age.35Clarson L.E. Bajpai R. Whittle R. et al.Interstitial lung disease is a risk factor for ischaemic heart disease and myocardial infarction.Heart. 2020; 106: 916-922Crossref Scopus (19) Google Scholar Thus, in addition to risk for exertional desaturation,4Rochester C.L. Alison J.A. Carlin B. et al.Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society Clinical Practice Guideline.Am J Respir Crit Care Med. 2023; 208: e7-e26Crossref PubMed Scopus (45) Google Scholar current literature suggests that patients with LAM and ILD should also be prescreened for cardiovascular risks17Riebe D. Franklin B.A. Thompson P.D. et al.Updating ACSM's recommendations for exercise preparticipation health screening.Med Sci Sports Exerc. 2015; 47: 2473-2479Crossref PubMed Scopus (423) Google Scholar prior to initiating an unsupervised exercise program. A Round 1 survey for experts was developed by the research team utilizing concepts from literature on population-based exercise preparticipation screening, CPR, and LAM-specific exercise physiology. Initial survey questions were reviewed by three content experts in medicine, pulmonology, and LAM, and revisions were made based on feedback. The Round 1 survey for experts consisted of short-answer, ranking, and open-ended questions about the risks and benefits of unsupervised exercise in LAM (Supplemental Material). The Round 1 survey was administered to expert panelists via REDCap (Research Electronic Data Capture), a secure, Web-based platform designed to support research data capture,36Harris P.A. Taylor R. Minor B.L. et al.The REDCap consortium: building an international community of software platform partners.J Biomed Inform. 2019; 95103208Crossref PubMed Scopus (11195) Google Scholar and remained open for 3 weeks. To maximize response rates, the tailored design method devised by Dillman et al37Dillman D.A. Mail and Internet Surveys: The Tailored Design Method.2nd Ed. John Wiley & Sons Inc, 2007: 523Google Scholar was used with reminder e-mails three additional times, 4 days apart until completion. Recognizing that patients are key stakeholders in a community-engaged approach to the development of a health promotion program,16Eldredge L.K.B. Markham C.M. Ruiter R.A.C. Fernández M.E. Kok G. Parcel G.S. Planning Health Promotion Programs: An Intervention Mapping Approach. John Wiley & Sons, 2016Google Scholar patients with LAM were also invited to complete a separate online survey (different than the Round 1 survey for experts) about their own lived experience and their perceptions of exercise in LAM (Supplemental Material). Since there is little available literature about the patient experience of exercising with LAM, the research team felt that the patient voice was important for experts to consider during panel activities, in addition to their own professional experience in LAM. A convenience sample of patients with LAM were recruited via e-mail, social media, and word of mouth, in collaboration with designated patient liaisons for The LAM Foundation. The survey was administered anonymously via REDCap and remained open for 3 weeks. Importantly, patient survey results were not used in the drafting of statements, and patients did not comment on the statements or the preparticipation screening tool that are the primary outcomes of this study. The patient survey results were summarized as major themes with example raw quotes and provided to experts as background material prior to the in-person panel meeting. Round 1 expert survey results were shared electronically with panelists 4 weeks before the Round 2 panel meeting. For this, two investigators drafted initial statements based on review of published exercise preparticipation screening guidelines in the literature4Rochester C.L. Alison J.A. Carlin B. et al.Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society Clinical Practice Guideline.Am J Respir Crit Care Med. 2023; 208: e7-e26Crossref PubMed Scopus (45) Google Scholar,17Riebe D. Franklin B.A. Thompson P.D. et al.Updating ACSM's recommendations for exercise preparticipation health screening.Med Sci Sports Exerc. 2015; 47: 2473-2479Crossref PubMed Scopus (423) Google Scholar,32Ribeiro F. Takahashi C. Vanzella L.M. et al.An investigation into whether cardiac risk stratification protocols actually predict complications in cardiac rehabilitation programs?.Clin Rehabil. 2021; 35: 775-784Crossref Scopus (2) Google Scholar,38Garvey C. Bayles M.P. Hamm L.F. et al.Pulmonary rehabilitation exercise prescription in chronic obstructive pulmonary disease: review of selected guidelines: an official statement from the American Association of Cardiovascular and Pulmonary Rehabilitation.J Cardiopulm Rehabil Prev. 2016; 36: 75-83Crossref PubMed Scopus (164) Google Scholar and final themes from the primary risks and concerns expressed by LAM experts. Two other content experts in medicine, pulmonology, and LAM reviewed and provided feedback on the initial statements for clinical and methodological appropriateness. Four experts in total participated in an iterative process of review, revision, and interpretation to arrive at the final statements that were reviewed by the expert panel. Round 2 occurred as an in-person meeting at the May 2023 ATS International Conference in Washington, DC. Panelists received complimentary breakfast and no monetary compensation. The moderator presented each statement individually for panel discussion. Final level of agreement assessment occurred via anonymous paper survey at the end of the Round 2 meeting, with options to select "Agree," "Disagree," or "Uncertain" for 9 of the 10 statements. One statement provided numerical options for acceptable desaturation threshold for exertional oxygen use in LAM. Consensus was defined a priori as ≥ 78% of panelists selecting the same option (eg, "Agree") for a statement, similar to the RAND/UCLA Appropriateness mean threshold of ≥ 7 of 9 on a 9-point Likert scale.22Fitch K. The RAND/UCLA Appropriateness Method user's manual.http://catdir.loc.gov/catdir/enhancements/fy1003/00045830-d.htmlDate accessed: July 22, 2024Google Scholar The moderator also presented for panel discussion a draft of the LAMFit preparticipation screening tool based on the primary risks perceived by experts in Round 1.