Pulmonary rehabilitation: definition, indications, contraindications, components and outcome measures

1Definition and aims

Pulmonary rehabilitation (ATS/ERS, 2013) is "a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors."

• Aims: less breathlessness and fatigue; better exercise capacity and daily function; better quality of life and mood; fewer exacerbations and admissions; lasting self-management.
• Why it works when the lungs cannot be fixed: it treats what can change: weak, deconditioned muscles, poor breathing patterns, fear of breathlessness, inactivity and poor self-management (the breathlessness spiral on the COPD page).

2Indications (who should be referred)

• COPD: anyone limited by breathlessness (usually mMRC 2 or more), and after a hospital admission for an exacerbation, starting soon after discharge (ATS 2023: strong recommendation).
• Interstitial lung disease (ATS 2023: strong recommendation).
• Bronchiectasis, cystic fibrosis, post-TB lung disease.
• Asthma with persistent breathlessness or poor fitness despite good treatment.
• Pulmonary hypertension (ATS 2023: conditional recommendation, supervised).
• Lung cancer; before and after lung resection, lung volume reduction or transplant.
• Chest wall and neuromuscular disease (selected), after ICU stays and after COVID-19.

Age, continued smoking and low oxygen are not reasons to exclude: help the smoker quit during the programme, and give oxygen during exercise if needed.

3Contraindications

• Unstable heart disease: unstable angina, recent heart attack, uncontrolled arrhythmia, severe aortic stenosis, decompensated heart failure.
• Locomotor or neurological problems that make exercise impossible or unsafe.
• Severe cognitive or psychiatric illness that prevents taking part.
• Acute exacerbation or infection: treat first, then start or resume.
• Severe pulmonary hypertension with fainting on exertion, or uncontrolled hypertension: only in specialist, supervised settings.

4Assessment before the programme

• History, comorbidities (heart disease, diabetes, osteoporosis, anxiety and depression), medicines and inhaler technique, smoking.
• Spirometry (severity); breathlessness (mMRC); symptoms and quality of life (CAT, CRQ or SGRQ); mood (HADS).
• Exercise test with SpO₂: 6MWT or incremental shuttle walk test; sets the training speed and shows whether oxygen is needed (SpO₂ falling below about 88%).
• Muscle strength (quadriceps, grip, sit-to-stand), balance and falls risk.
• The patient's own goals (for example "climb to my 2nd-floor flat without stopping").

5Components of management

Exercise training (the core)

• Add-ons: inspiratory muscle training for weak breathing muscles; neuromuscular electrical stimulation of the thighs for very weak or bed-bound patients; flexibility, posture and balance work; oxygen during training if SpO₂ falls below about 88%.

Education and self-management

• Understanding the disease; inhaler and spacer technique; written action plan for exacerbations.
• Breathing strategies (pursed-lip breathing, breathing control, positions of ease) and airway clearance where there is sputum.
• Energy conservation and pacing (see the dyspnoea card).
• Smoking cessation; vaccinations; nutrition (weight gain if underweight, weight loss if obese); travel and oxygen use.
• Managing anxiety and panic; advance care planning in severe disease.

Psychosocial and nutritional support

Screening for and treating anxiety and depression; group sessions for peer support; dietary advice; involving family.

Programme structure

Usually 6–12 weeks, with at least 2 supervised sessions a week plus home exercise; centre-based, home-based or by telerehabilitation (ATS 2023: offer the choice). Then a maintenance plan, because gains fade within months if exercise stops.

6Outcome measures (syllabus 8e)

7Evidence and delivery

• In COPD, pulmonary rehab improves breathlessness, fatigue, quality of life and exercise capacity by more than the smallest important changes (Cochrane, 2015).
• Started soon after an admission for an exacerbation, it reduces readmissions and improves quality of life (Cochrane, 2016).
• Telerehabilitation gives similar results to centre-based rehab (Cochrane, 2021), useful where travel is hard.
• In India: few centres offer it; a home programme using stairs, a chair, water-bottle weights and walking, with breathing exercises and pranayama (see the yoga card), reviewed by phone or video, brings the main parts to most patients.

8Exam corner

Past questions (MUHS, 2016–2026)

• S20 Q3(a), 5 + 5 + 5 marks40-year-old tailor with post-Koch's bronchiectasis of the right lung, copious sputum, breathless on exertion, coming for pulmonary rehabilitation for a week. Impairments, activity and participation; short- and long-term management (see the bronchiectasis page).
• 7-mark questionsPaediatric pulmonary rehabilitation for children with asthma (S18; asthma page). Energy conservation in COPD and its importance (S19). Physiotherapy for a farmer with ILD (S21; ILD page). Relevance of ABG, PFT and X-ray in goal setting in COPD (W24).
• Long answersEvery COPD, bronchiectasis, ILD and post-TB case asks for long-term management: write pulmonary rehab with doses.

Answer skeleton: "pulmonary rehabilitation", 7 marks

1. [1] ATS/ERS definition and aims.
2. [1] Indications and contraindications.
3. [1] Assessment.
4. [3] Components: exercise table with doses, education, psychosocial and nutrition; programme length.
5. [1] Outcome measures.