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Although most often pulmonary rehabilitation is conducted in a hospital or clinic, alternative strategies include home-based care, telerehabilitation, internet-based programs, and programs that require minimal resources. Some programs combine cardiac and pulmonary rehabilitation. Clinical trials are underway to demonstrate the efficacy of these models (1).

Regardless of which model is used, expert consensus has established the essential components of pulmonary rehabilitation, which are divided into 4 domains (1):

• Patient assessment

• Program components

• Method of delivery

• Quality assurance

Before pulmonary rehabilitation begins, a health care provided makes an initial assessment of patient needs. This assessment is conducted in a hospital or clinic pulmonary rehabilitation center and includes the following:

• An exercise test

• A field exercise test

• Quality-of-life measurements

• Dyspnea assessment

• Nutritional status evaluation

• Occupational status evaluation

An adequate pulmonary rehabilitation program includes both endurance training and resistance training. The prescription is tailored to the patient's status and goals and progress is assessed regularly. The care team ideally includes an individual who has expertise in exercise, and health care providers who are trained in delivering rehabilitation.

In the past, pulmonary rehabilitation was reserved for patients with

• Severe COPD (chronic obstructive pulmonary disease)

However, an increasing body of evidence suggests a benefit to patients with

• Asthma

• Bronchiectasis

• COVID-19

• Cystic fibrosis (CF)

• Interstitial lung disease (ILD)

• Lung cancer

• Neuromuscular disorders

• Pulmonary hypertension

• Sarcoidosis

Patients with pulmonary hypertension benefit from exercise-based rehabilitation with improvements in exercise capacity (3). In a study of patients with COVID-19, pulmonary rehabilitation accelerated the recovery of pulmonary function (4).

Studies done in patients with COPD have suggested that pulmonary rehabilitation should start before COPD becomes severe (ie, as identified by degree of airflow obstruction) because there appears to be a poor correlation between disease severity and exercise performance. Furthermore, even patients with less severe disease are likely to benefit from reduced dyspnea, improved exercise tolerance, improved muscle strength, conditioning, improvement of cardiac and pulmonary physiology, reduced dynamic hyperinflation, and the psychosocial benefits that accompany pulmonary rehabilitation (5). However, most recent guidelines recommend consideration for referral to pulmonary rehabilitation for stable, moderate to severe COPD as defined by GOLD report (6).

Contraindications are relative and include comorbidities (eg, untreated angina, left ventricular dysfunction) that could complicate attempts to increase a patient’s level of exercise. However, these comorbidities do not preclude application of other components of pulmonary rehabilitation.

There are no complications of pulmonary rehabilitation beyond those expected from physical exertion and exercise.

Pulmonary rehabilitation is best administered as part of an integrated program of

• Exercise training

• Education

• Psychosocial and behavioral interventions

Pulmonary rehabilitation is delivered by a team of physicians, nurses, respiratory therapists, physical and occupational therapists, and psychologists or social workers. The intervention should be individualized and targeted to the patient's needs. Pulmonary rehabilitation can be started at any stage of disease with the goal of minimizing disease burden and symptoms.

Exercise training involves aerobic exercise and respiratory muscle and upper and lower extremity strength training. There is increasing evidence to support doing both strength training and interval training of the extremities. Interval training is alternating short bursts (eg, 30 seconds) of intense activity with longer periods (eg, 2 minutes) of less intense activity.

Inspiratory muscle training (IMT) is often a component of pulmonary rehabilitation. IMT uses devices that impose a resistive load that is set at a fraction of an individual's maximal inspiratory pressure. When combined with pulmonary rehabilitation, IMT may improve a patient's inspiratory muscle pressure, but this improvement does not result in decreased shortness of breath, or in improvements in quality of life or functional parameters (7).

Neuromuscular electrical stimulation (NMES) uses a device that applies transcutaneous electrical impulses to selected muscles to stimulate contraction. NMES can be effective in patients with severe lung disease because it minimizes circulatory demand and does not cause the dyspnea that often limits these patients from participating in typical exercise training. Thus, neuromuscular electrical stimulation is uniquely suited for patients with significant deconditioning or for patients with an acute exacerbation of respiratory failure. Small prospective studies have demonstrated functional benefit of combining NMES with traditional pulmonary rehabilitation (8).

Education has many components. Counseling about the need for smoking cessation is important. Nutritional counseling can be given if needed. Teaching breathing strategies (such as pursed-lip breathing, in which exhalations are begun against closed lips to decrease respiratory rate, thereby decreasing gas trapping) and the principles of conserving physical energy are helpful. Explaining treatment, including using drugs correctly and planning for end of life care, are needed.

Psychosocial interventions involve counseling and feedback for the depression, anxieties, and fear that hinder the patient’s full participation in activities. Behavioral modification strategies and an emphasis on self-management are critical components of pulmonary rehabilitation. Strategies include techniques for goal-setting and problem solving, decision-making, medication adherence, and the maintenance of routine exercise and physical activity (1).

Although the most optimal maintenance strategy is unknown, continued participation in an exercise program is essential to maintain the benefits of pulmonary rehabilitation.

1. 1. Holland AE, Cox NS, Houchen-Wolloff L, et al: Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 18(5):e12–e29, 2021. doi: 10.1513/AnnalsATS.202102-146ST

2. 2. Lindenauer PK, Stefan MS, Pekow PS, et al: Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries. JAMA 323(18):1813–1823, 2020. doi: 10.1001/jama.2020.4437

3. 3. Morris NR, Kermeen FD, Holland AE: Exercise-based rehabilitation programmes for pulmonary hypertension. Cochrane Database Syst Rev 1(1):CD011285, 2017. doi: 10.1002/14651858.CD011285.pub2

4. 4. Zhu P, Wang Z, Guo X, et al: Pulmonary rehabilitation accelerates the recovery of pulmonary function in patients With COVID-19. Front Cardiovasc Med 8:691609, 2021. doi: 10.3389/fcvm.2021.691609

5. 5. Rochester CL, Vogiatzis I, Holland AE, et al: An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation. Am J Respir Crit Care Med 192:1373–1386, 2015. doi: 10.1164/rccm.201510-1966ST.

6. 6. Global Initiative for Chronic Obstructive Lung Disease: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2022 report).

7. 7. Beaumont M, Mialon P, Le Ber C, et al: Effects of inspiratory muscle training on dyspnoea in severe COPD patients during pulmonary rehabilitation: controlled randomised trial. Eur Respir J  51:1701107, 2018. doi: 10.1183/13993003.01107-2017

8. 8. Benavides Córdoba VA, Orozco LM, Mosquera R, et al: Addition of neuromuscular electrical stimulation to conventional pulmonary rehabilitation treatment in patients with COPD. Eur Respir J 56 (Suppl. 64):714, 2020. doi: 10.1183/13993003.congress-2020.714