Patient education for individuals with Interstitial Lung Disease: A scoping review.

Objectives Interstitial Lung Disease (ILD) is a severe and rapidly progressing disease with a high fatality rate. Patient education (PE) has been demonstrated to promote long-term adherence to exercise and lifestyle improvements by assisting patients in developing self-management techniques. Our scoping review's goal was to chart out the prevailing level of research about the content, processes, and effectiveness of PE for patients with ILD. Methods The relevant databases were searched using the rules provided by Arksey and O'Malley in 2005 and the Joanna Briggs Institute reviewers' manual 2015: an approach for JBI scoping reviews. Individuals with ILD, published in English between the years of inception and 2020, and describing PE administered by various healthcare practitioners were among the 355 studies found and reviewed. Thirteen studies met these criteria. Results PE delivery process, delivery techniques, quality of life assessments, common PE themes, and healthcare professional participation were all recognized and cataloged. Conclusion Despite the fact that healthcare professionals (physicians, nurses, and physiotherapists) provide PE to patients with ILD regularly, the PE provided varies greatly (contents of PE, process of delivery and delivery techniques). During the scoping review, a significant variation in the themes was addressed. They could not provide any evidence-based specific recommendations for all healthcare practitioners due to the studies' heterogeneity and lack of effectiveness measures.


Introduction
Interstitial lung disease (ILD) is a condition that leads to an incremental inability to maintain normal levels of blood oxygen due to impaired gas exchange through the alveolar-capillary membrane. 13][4][5][6] The experience with ILD is that of a long way to diagnosis, intense symptomatic burden, insufficient information of the disease and anxiety. 5lmonary rehabilitation (PR) is a fundamental mode of treatment to improve exercise tolerance and minimize symptoms in patients with chronic lung disease. 7,8Evidence supports the effectiveness of PR in ILD and guidelines for the management of ILD have adopted PR as a priority intervention.PR encompasses a range of interventions focussed on the individual needs of the patient.One important component of PR is Patient Education (PE).PE helps patients develop self-management strategies and has shown to improve long-term adherence to exercise and lifestyle changes.PE offers insight into the knowledge that patients need for the best possible treatment for chronic diseases. 9The educational programs seek to strengthen disease management [10][11][12][13][14][15] and enhance self-efficacy. 16,179][20][21] The instructional content should be readily available and strategically focused on providing efficient, costeffective, and high-quality health education.Quality education in health seeks to enhance the lives of individuals through the encouragement of improvement in attitudes, values, awareness, skills, and behaviour. 22Oxygen therapy, exacerbation control, energy conservation, symptom management, mood disorders, medications, lung transplants, and end-of-life care are all topics covered in educational programs for ILD patients. 23 can be broken down into five distinct phases.The patient's prior knowledge, misconceptions, learning abilities, cognition, comprehension, attitudes, and motivation are all assessed in the first stage.Following the assessment, the patient's approaches, problems, and learning needs will be diagnosed.The third phase is to work with the patient to organize education, set goals, and choose educational interventions.It is critical to discuss the type of education, the frequency, who will offer the education, and when and how it will be addressed during the planning process.
Scoping reviews analyze the scope and depth of available data on a particular topic, as well as the nature of published studies, in order to provide a comprehensive overview of broad, varied literature.Scoping reviews also allow researchers to go further into specific research topics in order to conduct more thorough systematic reviews.When time is restricted and there is no clear information or knowledge about a topic to start a systematic review, a scoping review is undertaken.
A continuing assessment of patient needs and priorities provides the framework for further education.Since PR was developed and designated for patients with chronic obstructive pulmonary disease (COPD), which has a disease mechanism and symptoms that are fundamentally different from ILD. PE issues defined for patients with COPD, such as the physiological basis for exercise limitation, symptoms, treatment, disease severity, and outcomes, may not be relevant or significant for patients with other pulmonary disorders, such as ILD.Although healthcare practitioners routinely deliver PE verbally to patients with ILD, little is known about the actual content and mechanisms of this provision, as well as its overall efficacy.There is a need to map the available research because there is a lack of evidence about the administration and content of PE delivered in ILD patients.Therefore, the goal of this scoping review was to define and map the current information of the content, processes, and efficiency of PE provided for patients with ILD.

Materials and methods
The methodology framework used in this study was initially outlined by Arksey and O'Malley 24 and revised Joanna Briggs Institute reviewers' manual 2015: methodology for JBI scoping reviews. 25The scoping review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for reporting scoping reviews (PRISMA-ScR). 26The framework was divided into five independent phases: formulating the research question; locating relevant studies; identifying studies; organizing and extracting data; and, at last, summarizing and presenting the results.

Formulating the research questions
The specific research questions were as follows: 1. What are the contents (topics) of the PE provided for patients living with ILD?
2. What processes or methods were used when providing PE to patients living with ILD?

Locating relevant studies
We undertook a comprehensive PubMed and Scopus literature search to identify studies describing the PE provided for patients with ILD.Inclusion criteria consisted of studies including patients with ILD (aged > 18 years) referred for PR in any health care setting.The PR sessions have to be inclusive of PE administration using either booklets, leaflets, websites, mobile applications or verbal/practical demonstration.Articles published in English from inception to 2020.The content of the PE (topics addressed, different processes of the PE intervention, location of delivery, mode, who delivered PE, and technique of delivery), provided through a pulmonary rehabilitation program.Types of sources: Any type of research design, such as quantitative, qualitative, or mixed methods were included in the study.Articles written in languages other than English, editorials and commentaries were excluded.
Search strategy: Initially, a PubMed and Scopus search was undertaken, followed by a screening of the titles and abstracts of retrieved papers, as well as the search terms utilized to describe them.A thorough search was then conducted across all of the involved databases utilizing all identified keywords and index terms.In order to locate more pertinent sources, the reference lists of the included papers and reports were examined as well.Grey literature from databases and conference proceedings was also investigated, and duplicate publications were found and eliminated.The titles and abstracts of articles were examined to determine whether they met the inclusion criteria.If an article satisfied the criteria or needed further review before being excluded, its full text was retrieved.A third reviewer (AM) resolved any differences between the two independent reviewers' (RA and VK) assessments of whether the full-text paper fulfilled the inclusion criteria.Using specific terms for each database, the search on PubMed and Scopus concentrated on the three main ideas of ILD, physiotherapy, and patient education (PE).
Identifying the studies Following the initial screening, 14,727 articles were evaluated through assessing their titles and abstracts against established inclusion and exclusion criteria.When one reviewer (RA) was unsure whether to include or exclude an article, it was independently reviewed by another reviewer (VK).355 articles were subsequently found to be eligible for full-article review.The 355 papers were then evenly allocated alphabetically between the two reviewers (RA and VK).
Each full text article was thoroughly reviewed against the inclusion and exclusion criteria implementing the PRISMA extension for Scoping Reviews (PRISMA ScR) flow approach. 27(Figure 1) Organising and extracting data: To organize the data collected systematically, a data extraction form was developed.This form consisted of a table with predefined categories that corresponded to the scoping review's objectives and research questions.These categories included information about the author, year of publication, country, study design, sample size, the content of the PE, processes of delivery, effectiveness (outcomes).The data from each article was documented in these specific categories for a thorough analysis.(Table 1-3)

Process of delivery:
[31] Qualitative findings: 3][34][35][36] These study designs aimed at highlighting the core topics and themes required for the development of educational booklets concerning the patient point of view. 32,33[34][35] Most of the qualitative studies were conducted either by a face-to-face communication, [32][33][34][35] via a telephonic interview, 33,34 website surveys, 36 questionnaire prescription 34 to design the components of PE in ILD for patient centred approach.
3][34][35][36] Holland AE et al., in a qualitative review enlisting core topics essential for inclusion in the PE program for ILD patients stating the need for ILD specific PE packages for patients. 33

Delivery technique:
A few studies mentioned prescribing PE orally as a part of the rehabilitation or treatment program, although content was not disclosed. 30,31A few mentioned the use of websites such as Pulmonary Fibrosis Foundation

Quality of life:
Niemitz M et al., (2019) used self-reported scales to rate self-efficacy, scales for patients and caregivers to rate healthrelated quality of life (chILD-QOL), satisfaction with PE. 28 The majority of the studies used disease-specific, healthrelated quality of life tools as an outcome measure.Scales such as St. George Respiratory Questionnaire (SGRQ), 29,30 Chronic Respiratory Disease Questionnaire (CRQ), 29,30 Short Form-36 (SF-36), 29,30 King's brief Interstitial Lung Disease questionnaire (K-BILD), 35 University of California, Shortness of Breath Questionnaire (UCSD SOBQ), 35  International Physical Activity Questionnaire (IPAQ), 30 A Tool to Assess Quality of Life in Idiopathic Pulmonary Fibrosis (ATAQ IPF) scores, 30 Idiopathic Pulmonary Fibrosis (IPF) specific SGRQ scores. 30ysical status, dyspnoea, lung function: Authors have used indicators such as 6 MWD to determine ILD patients' physical status. 30For dyspnea stages, Beck's Depression Inventory (BDI), 30 and Modified Borg Scale (MBS) 31 were used.For the assessment of performance indicators, spirometric indicators like Forced Vital Capacity (FVC), Forced Expiratory Reserved Volume in 1 Second (FEV1) and diffusing capacity of lung of carbon monoxide (DLCO) were used. 30 patients with ILD, PE is an integral component of care.Before beginning, a physiotherapist has an overall objective or goal for PE.The learning objectives for knowledge acquisition, solving problems, learning skills and behavioural change can be helpful.The method used could be visual and realistic, including demonstrations. 29,30[36] 4. Discussion About the disease In line with the research questions laid down by us in our review, the first question focuses on the contents (topics) of PE provided for patients living with ILD.Patients require healthcare professionals to devote time with them after diagnosis, as highlighted by the studies included in this scoping review. 29,30,40The patients with ILD should be given with a brief introduction regarding the disease and its course.They should be provided with an insight of what happens to the lungs because of the disease, various triggers, irritants and causes of ILD.They should be given a brief knowledge about the signs and symptoms, situations during exacerbations and how to manage them. 29,30,32,40nagement A multidisciplinary approach towards treating ILD patients is of utmost importance concerning managing the disease course.This involves the participation of the healthcare team, the patient themselves, and their caregivers. 28,29,36,39PE must include awareness regarding the medications prescribed their effects on the body systems.Reactive oxygen species are responsible for tissue damage in ILDs, despite the fact that oxygen deficiency also occurs in these circumstances.
Recognizing the significance of reactive oxygen species offers novel opportunities for therapeutic intervention.
Reference 41 Supplemental oxygen is one such component the patient should be made aware about.Since patients frequently receive oxygen therapy at home, the findings in this review recommend that patients should obtain PE regarding oxygen dosage and concentration during exacerbations and before engaging in strenuous activities.A large subgroup of people with ILD are normoxic at rest but rapidly desaturate on exertion.This can limit exercise capacity and worsen dyspnoea.When mobilizing or doing other tasks, using ambulatory or short-burst oxygen may help enhance exercise capacity and relieve dyspnoea. 43Including a discussion of these concepts within the PE approaches both via face-to-face discussions by the pulmonologist, rheumatologist, immunologist, physiotherapist, and the staff nurses and reiterated in a written form using booklets or flyers is essential.Oxidative stress, which results from exposure to oxidizing agents including cigarette smoke, air pollution, and infections, has been linked to a variety of lung conditions.Therefore, the onset or advancement of these diseases has been linked to dietary components and nutrients that may have protective effects against oxidative processes and inflammatory reactions.
A dietician should be involved for discussion regarding the various areas the patients can reach out to and maintain and help establish an individualized diet plan for better living.
Exercise intolerance is an essential feature of ILD associated with poor quality of life and closely linked to mortality.Given the well-documented short-term effects of PR on lung function, quality of life, and improvements in activities of daily living, PE resources must emphasize the necessity of assessment and the advantages of exercise throughout the disease's course.Dysnoea and fatigue are key debilitating factors experienced by patients with ILD.The physiotherapist should spend time with the patients in educating them about the evaluation of the factors causing dyspnoea and fatigue and the non-pharmacological solutions to those problems which eventually affect the ADL's and functional abilities of ILD patients. 32,34,35,36In the studies included in this review, there must be a possible overlap between PR providers, which is likely to lack specificity.
There is lack of clarity regarding the contents of PE delivered to the patients with ILD by the physiotherapists.Individual perception of the patients, such as dyspnea, depression, and health-related quality of life (HRQoL), is more strongly interrelated.Consequently, the management of dyspnea and depressive symptoms could be an essential tool for optimizing the HRQoL of patients with ILD.Self-care is one such component that needs to be addressed to overcome exacerbations.Patients need to be briefed about the various techniques that can be used to self-manage their symptoms when in times of need. 11There is no clear perspective in the current literature regarding the management of mental health among ILD patients.There is a lack of evidence and clarity regarding who provided the PE to the ILD patients and the duration spent doing the same in literature.Also, the effect of PE post-intervention on follow-up has not been addressed in any of the available literature.Outcome assessment tools need to be established for PE in ILD to know the knowledge of PE retained by the patients and its effects on their quality of life during follow-up.

Process of delivery:
In line with the research questions laid down by this review, the second question focuses on processes or methods used when providing PE to patients living with ILD.According to the content gathered from literature, various modalities of PE delivery to ILD patients can be used.There is lack of clarity regarding the process of PE delivery among ILD patients.
As of other chronic respiratory diseases, PE in ILD can be delivered verbally by the multidisciplinary healthcare team during their follow-up visits. 30,31,44,45PE delivery through cutting-edge technology such as telerehabilitation allows the entire multidisciplinary team to collaborate and discuss the patient's whereabouts and caregiver involvement. 46 contrast to other chronic respiratory disorders, PE can be delivered in ILD using a web-based platform that employs an innovative and digital design. 28,37To communicate the contents of PE, healthcare practitioners can use instructional manuals, brochures, handouts, and other materials. 29,30This can make the process easier as it becomes convenient for the patients and refer to the contents whenever possible.Educational booklets and handouts can also be a fantastic resource for disseminating PE knowledge in a diverse country like India, where there is a shortage of social-based platforms and smartphone use among individuals living in rural and remote sections of the country where internet penetration is very low.Educational booklets can be made exciting and understandable to the local population with the optimal use of illustrations, making it self-explanatory.By include progress/log charts in the booklet, we can keep track of adherence.
Booklets can be a source to track, evaluate, and grade the performance for further progression.

Limitations
During this scoping review, we identified significant diversity in the themes.The systematic reviews were unable to address the complexities of PE, limiting their capacity to give meaningful, evidence-based recommendations for PE.Also, a systematic review on educational programs in ILD management did not address PE topics with ILD patients. 30While existing recommendations recognize crucial educational topics such as chronic pulmonary disease, dyspnea treatment, fatigue, oxygen therapy, and smoking cessation, none of these themes have been investigated in PE intervention clinical trials. 29,30,40The study's limitations also included specific PE topics that were often not recognized clearly by a physiotherapist.3][34][35][36] None of the studies gave details about the type of training obtained by physiotherapists and other healthcare professionals to provide effective PE.Whether health practitioners had been trained in PE and the study authors chose not to provide this knowledge in the paper or whether the clinicians had been trained in PE is unknown.
Holland AE has enlisted the physician-centered perspective regarding core topics for PE prescription in her review. 32The review discusses in detail the opinions of the patients and physicians regarding PE among ILD patients.She concluded that ILD patients appreciate the ability to undergo PR training, but they identify specific topics that do not currently cover their needs.Patients and clinicians did not agree upon the most important topics for inclusion.The construction of a comprehensive ILD PR curriculum should consider utilizing patients' knowledge and clinician approaches. 32couple of studies involved family members and caregivers with the patients themselves during the PE sessions. 28aregivers must be included in PE sessions to better grasp the disease process and help their loved ones emotionally. 28,29,36,40e scoping review revealed that none of the studies addressed the location of PE delivery and follow-up periods for the educational sessions.The lack of recommendations on where and when to deliver PE for patients with ILD leads to this disparity.This is another significant gap in the literature.
The goals and priorities defined in the scoping review included PE but was not the primary intervention in the included studies. 30The important findings were the cost-effectiveness of using healthcare facilities, exercise tolerance, quality of life, 29,30 and coping mechanisms. 33The majority of research have classified PE as a self-management program, 30 however because the authors have not defined PE, explaining it as a self-management program is regrettably unclear.
Self-management can imply different things to different people, and it's rarely defined in the literature.Some consider it synonymous with PE; others see PE as part of self-management.
The authors used a variety of PE delivery techniques and procedures, which can be divided into two categories: verbal and written approaches. 30,31The authors have addressed education topic with ILD patients, who are by far the most common recipients of PE. 30 None of the studies mentioned the PE delivery mechanism or methodology.Healthcare practitioners, especially physiotherapists, employ various treatment strategies in PE, including the method of teaching that is undecisive. 32,33,34Depending on the goals of PE, additional verbal methods can be further suited to adopt a teambased approach or a counselling approach. 47other common form of PE was giving patients booklets, 31 which were typically given in addition to discussion.However, they did not provide specific information on the contents of the booklet.9][50][51][52][53][54][55] Few studies addressed the use for patients and caregivers of ILD-specific PE based on the web. 28In future research, the emphasis should be on developing a patient disclosure guideline by ensuring that the print content is designed in plain language and simple design, ensuring consistency in PE.
The studies mainly used measures such as health-related quality of life questionnaires [28][29][30] and physiological performance measures as likely markers of PE efficacy.None of the studies have used outcomes measures explicitly to determine the effectiveness of PE.None concentrated on the influence of the PE alone.In addition, there are a limited range of valid PE instruments for patients with chronic diseases, while other methods are valid, reproducible, and sensitive to determine health status, quality of life [28][29][30] and physiological function and are well-established.One study discussed using self-reported scales to assess self-efficacy, quality of life and patient satisfaction for children with ILD. 28ue to the heavy dependency on verbal contact in health care meetings, clear verbal communication, especially in PE, is essential for all health professionals.A 'Teach Back' informal approach for assessing the efficacy of PE ensures patients understand the directions.Future research could concentrate on those relevant methods that a health provider and a patient both settled on, for assessment of the efficacy of PE intervention with a PE specific goal, for example, information development, acquisition of skills, or behavioural change. 41,42ne of the studies have recorded disease and mortality, time for the first admission, number of hospital admissions and readmissions, reason for admission and overall hospital stays of days, appointments with the general practitioner and doctor visits, and prescription dispensations.

Conclusion
The aim of this scoping review was to examine and summarize the most recent information about the content, methods, and overall efficacy of patient education (PE) given to individuals with ILD.Our review revealed that providing PE as part of ILD care requires physiotherapists alongside other medical professionals.However, there is insufficient details about the precise material and procedures used by these professionals.Precise explanations of the educational subjects addressed, the environment, goals, and techniques for PE delivery for individuals with ILD are lacking in the literature.The absence of consistent, evidence-based recommendations on educational materials specifically designed for patients with ILD may be the cause of this ambiguity, given the variability of the studies that have been observed.
Also, the duration of PE provided or outcome measures to determine the PE's effectiveness is not specified.Further studies are needed to identify best practices for both the content and the processes of PE interventions and thereby optimize the quality of life of ILD patients.

Relevance to clinical practice
This scoping study will enable researchers to develop a patient-centered education manual/website that may be an instructional guide for delivering PE to ILD patients.Patients can get personalized help and better understand their disease, diagnosis, signs and symptoms, medications, coping methods, and pulmonary recovery (exercises and progression).The pulmonary rehabilitation education manual will act as a source of reinforcement and will assist in maintaining pulmonary rehabilitation compliance.

Ethical approval
Ethical approval is not required for the study.

Consent
Not applicable.

Sanjay T Parmar SDM College of Physiotherapy, Dharwad, India
The justification for performing a scoping review to map the existing knowledge gaps in PE for patients with ILD is explained in the introduction.You could explain on why previous studies on PE for ILD patients is insufficient or inadequate, emphasizing the necessity for additional study. 1.
The introduction discusses the lack of studies on the content, delivery, and efficacy of PE for ILD patients.
To highlight the need of filling this knowledge gap, you could briefly discuss how it might affect clinical practice or patient outcomes.

2.
There is discussion of a transparent method for selecting and screening articles, which includes independent evaluation by multiple reviewers.You could discuss any steps performed, such inter-rater reliability tests or calibration exercises, to guarantee consistency and reliability amongst reviewers.

3.
The study emphasizes critical elements such medication management, oxygen therapy, nutrition, and exercise and acknowledges the significance of a multidisciplinary approach in the management of ILD.You may be more specific about how each member of the healthcare team contributes to patient education and care coordination.

4.
Some terms or concepts mentioned, such as "reactive oxygen species" and "telerehabilitation" may need further explanation.

5.
The conclusions and implications of the review should include combining the major themes that were covered throughout, such as the importance of outcome measures, the lack of standardized approaches to PE delivery.

6.
Are the rationale for, and objectives of, the Systematic Review clearly stated?To enhance the credibility and robustness of your manuscript, I strongly recommend including appropriate references to support these statements.This will not only strengthen your argument but also provide readers with sources for further reading.

Results
Comment 5: There appears to be a major discrepancy in your study's reporting.In the PRISMA flowchart, it is stated that 12,642 articles were included in the scoping review.However, in the results section, it is mentioned that a total of 13 articles were included in the review.This inconsistency needs to be addressed and clarified to maintain the credibility and accuracy of your study.
Comment 6: There is a significant and unacceptable discrepancy between the narrative description of the study selection process and the PRISMA flowchart in your manuscript.In the narrative, it is mentioned that 355 articles were selected for full-text review.However, the PRISMA flowchart states that 12,642 articles were included in the scoping review.This is a major inconsistency that undermines the credibility and integrity of your scientific writing.Such a blunder in reporting the methodology is not acceptable in scientific literature and must be corrected immediately.Accurate and consistent reporting of the study selection process is crucial for the transparency and reproducibility of your research.

Discussion
Comment 7: The discussion section lacks a brief summary of the main findings of your review in the first paragraph.This summary is crucial as it provides readers with an immediate understanding of the key outcomes of your study.Furthermore, there is no mention of Patient Education (PE) during Pulmonary Rehabilitation (PR) throughout the discussion, which is a significant oversight given the focus of your review.
In the management section, the text begins appropriately with a discussion on the multidisciplinary approach but abruptly shifts to discussing reactive oxygen species without proper context or references.This sudden transition disrupts the flow and coherence of the section.Additionally, the statements about reactive oxygen species are not supported by any references, which is a significant omission in a scientific manuscript.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Are
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Figure 2 .
Figure 2. Demographic characteristics for study designs.

Figure 3 .
Figure 3. Components for patient education identified in literature for individuals with ILD.

Figure 4 .
Figure 4. Involvement of healthcare professionals identified in PE programs for Individuals with ILD.

Table 1 .
Overview of quantitative study designs.

Table 2 .
Overview of Qualitative study designs.

Table 3 .
Overview of Review articles.
4 Raghu et.al. 2017 Review Feelings and perceptions of patients with IPF identifying three emotional phases: coming to terms (diagnosis), reactive coping (acceptance), and proactive coping (ownership of condition) Identified areas of patient concern: physical problem, family support, interactions with the medical world, and hope for research.Delivery of educational and psychological support: including in pulmonary rehabilitation in groups, community-based conferences, patient support groups, and individual counselling.Involvement of Healthcare professionals.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India Title In your eligibility criteria, you have mentioned that Patient Education (PE) considered during Pulmonary Rehabilitation (PR) is being taken into account.Therefore, to accurately reflect the focus of your study, the title should explicitly indicate that it pertains to Patient Education during Pulmonary Rehabilitation.The current title, "Patient education for individuals with Interstitial Lung Disease: A scoping review," can be misleading as it suggests that PE was delivered during various interventions, not specifically PR.In the abstract, the authors define Interstitial Lung Disease (ILD) as "a severe and rapidly progressing disease with a high fatality rate."Whilethisdefinitioncaptures the severity of some forms of ILD, it is important to note that ILD encompasses a diverse group of lung disorders, each with varying degrees of severity and rates of progression.I recommend refining the definition to better reflect this diversity.A more accurate definition would acknowledge that while some types of ILD, such as Idiopathic Pulmonary Fibrosis (IPF), are indeed rapidly progressing and have a high fatality rate, other forms may progress more slowly and have different prognoses.ILD) refers to a group of lung disorders characterized by inflammation and scarring of the lung tissue, leading to impaired gas exchange.The progression and severity of ILD vary widely depending on the specific type, with some forms, such as Idiopathic Pulmonary Fibrosis (IPF), being rapidly progressive and associated with a high fatality rate, while others may progress more slowly."Comment2:Inmethod, it is suggested that to mention name of searched databases.Comment 3: In the second paragraph of the introduction, the transition to Pulmonary Rehabilitation (PR) is abrupt and disrupts the flow of the narrative.Comment 4: In the last three paragraphs of the introduction, there are several significant statements made without any references to support them.Providing references for these statements is crucial to establish credibility and allow readers to verify the information.Here are the specific areas where references are needed: Pulmonary Rehabilitation (PR) and Chronic Obstructive Pulmonary Disease (COPD): "Since PR was developed and designated for patients with chronic obstructive pulmonary disease (COPD), which has a disease mechanism and symptoms that are fundamentally different from ILD." Reference needed to support the historical context and the distinction between COPD and ILD.PE Issues Defined for COPD Patients: "PE issues defined for patients with COPD, such as the physiological basis for exercise limitation, symptoms, treatment, disease severity, and outcomes, may not be relevant or significant for patients with other pulmonary disorders, such as ILD." References needed to support the differences in educational needs and issues between COPD and ILD patients.Content and Mechanisms of PE Provision: "Although healthcare practitioners routinely deliver PE verbally to patients with ILD, little is known about the actual content and mechanisms of this provision, as well as its overall efficacy."References needed to support the claim about the lack of knowledge regarding the content and mechanisms of PE provision for ILD patients.Need for Mapping Available Research: "There is a need to map the available research because there is a lack of evidence about the administration and content of PE delivered in ILD patients."References needed to justify the need for the scoping review based on the current gaps in the literature.

the rationale for, and objectives of, the Systematic Review clearly stated? No Are sufficient details of the methods and analysis provided to allow replication by others? No Is the statistical analysis and its interpretation appropriate? Partly Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified? ('Living Systematic Review' or a variation of this term should be included in the title.) No Yes Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified? ('Living Systematic Review' or a variation of this term should be included in the title.) Not
applicable Competing Interests: No competing interests were disclosed.Reviewer Expertise: Rehabilitation, Physical Therapy, Physiotherapy, Patient education, and Student teaching.