Pulmonary Rehabilitation Guidelines for Adults With Chronic Respiratory Disease
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From the JAMA Network, this is JAMA Clinical Reviews, interviews and ideas about innovations in medicine, science, and clinical practice. Here's your host. Hello, and welcome to our listeners around the world. You're listening to the JAMA Clinical Reviews podcast. Thanks for being here. I am Dr. David Simel, JAMA Associate Editor and Professor Emeritus of Medicine at the Durham Veterans Affairs Medical Center and Duke University.

In this podcast, we will be discussing pulmonary rehabilitation for adults with chronic respiratory disease. I'm joined today by Dr. Michaela Anderson, who is an assistant professor of medicine in the Division of Pulmonary Allergy and Critical Care Medicine at the University of Pennsylvania. Dr. Anderson is the lead author of our Clinical Guidelines Synopsis on Pulmonary Rehabilitation, published in the February 5, 2025 edition of JAMA.

Dr. Anderson, thank you for joining us today. Thanks so much for the opportunity to be here. Well, let's start with an understanding of the components of pulmonary rehabilitation. What does pulmonary rehabilitation include? Centers are going to have slightly different program duration and visit frequency. Usually, these programs are 8 to 12 weeks long, and they consist of visits a few times per week.

The program is really a multidisciplinary patient-tailored program, so it can be very much individualized to what a patient needs. It generally includes three components, a component of exercise training alongside some components of education and behavior change. The exercise training is probably a little self-evident, but I think it's important to highlight that it is individualized. So it's not that every patient gets on a treadmill for 30 minutes or on a bike for 30 minutes.

The rehab program really individualizes what your patient can do in that time period. For general providers, I would keep in mind that there is the ability to individualize this for patients with musculoskeletal limitations. So folks who have knee osteoarthritis or hip osteoarthritis, their program can still be individualized to their needs. And so this individualized approach makes it highly applicable to a very diverse patient population.

The other components are education and behavior change. So education can be things like improved inhaler technique or appropriate inhaler technique, learning to live with and manage supplemental oxygen on exertion, just managing the logistics of that. And then even learning breathing techniques for how to get patients out of that sort of cycle of shortness of breath and anxiety that they sometimes experience.

And then lastly is the behavior change component. And so all pulmonary rehab programs have a component of smoking cessation counseling for patients who are smokers. And so those are the three major structured components of pulmonary rehab. Folks also often highlight the sort of unstructured component of pulmonary rehab, which is that you're bringing patients with chronic respiratory disease to one place.

And sometimes they find that there's some social support they get from being around other people who have similar diseases, similar challenges and similar limitations.

When a patient goes to a center for their pulmonary rehabilitation, what type of individuals, what healthcare professionals will they interact with? So it's really a multidisciplinary team. So it's physical therapists, but also respiratory therapists, nurses. There's often dieticians available, and there's always a medical provider who's overseeing the rehab program. For patients with chronic respiratory diseases, what are the measurable outcomes that you

clinicians and researchers use to evaluate whether or not pulmonary rehabilitation is making a difference. These guidelines primarily relied on six-minute walk distance or changes in six-minute walk distance to assess whether rehab was beneficial. So they really compared changes in six-minute walk distance in the pulmonary rehab group to changes in six-minute walk distance in the usual care group.

And this may sound abstract, but actually six-minute walk distance is a good measure of exercise performance and functional capacity, both of which are important for patients on a day-to-day basis. It's their ability to kind of walk from here to there to go to the grocery store and get through the grocery store without taking a break.

So it is an important measure of function, but it's also very closely associated with outcomes in chronic respiratory disease. So to really hit that point home, I would emphasize that six-minute walk distance or change in six-minute walk distance is an acceptable outcome by the FDA for clinical trials in pulmonary hypertension because it's just such an important outcome in pulmonary hypertension. We

We also use six-minute walk distance as part of our assessments of lung transplant candidacy. So it's a really important measure of functional capacity associated with both morbidity and mortality.

Now, it's great to have an improvement in functional capacity or exercise capacity, but how much of an improvement is actually meaningful to the patients? And so there is data that improvement in a walk distance by 30 meters is actually going to be associated with and benefit to the patient. The patient will actually sense an improvement in their functional capacity. And so that's the threshold that was used throughout these guidelines to assess whether the intervention was beneficial.

They did also look at other potentially more patient-centered outcomes, and we can talk more about how they did that and which ones were significant. But they also looked at both symptoms of shortness of breath and also at self-reported health-related quality of life. And these are really important for patients because when you look at the guidelines, what you'll be able to say to patients are,

that participation in pulmonary rehab will not only make you walk further, but it will make you feel better and improve your quality of life. In certain groups, they also looked at readmissions and survival. Do you have some tips for how a generalist physician may be working in a rural area could get a six-minute walk distance test in their office?

Yeah, so there are pretty clear standards for how you do a six-minute walk distance. And you can look at the American Thoracic Society guidelines for the individual kind of criteria. But you really just have to have a little bit of space and a timer. You can have the patient walk back and forth across this specified distance, and you can measure how many laps they do to figure out just how far they walked. So it's actually a very low-cost tool for assessing functional capacity.

Well, which type of patients with chronic lung disease might benefit from pulmonary rehabilitation? Yeah, so the guidelines really looked at the benefit of pulmonary rehabilitation in four populations of people. First was those with stable COPD or chronic obstructive pulmonary disease. Second was in patients who had been hospitalized for an acute exacerbation of COPD and

Third was patients with interstitial lung disease. And fourth was patients with pulmonary hypertension.

And they concluded that there was a strong evidence base, and they made a strong recommendation for pursuing pulmonary rehabilitation in patients with stable COPD after an exacerbation for a COPD or an interstitial lung disease. The recommendation was tempered a little bit in patients with pulmonary hypertension. Patients with pulmonary hypertension, it's a conditional recommendation to pursue pulmonary rehabilitation.

How intense in terms of frequency of sessions and for how long should a person participate? The centers are going to have slightly different duration and frequency of visits. In general, there's not one duration or frequency that's proven to be better than others. So I recommend patients complete whatever program their center is offering. The question is really,

what to do after completing that initial program. And that's a little bit unclear. We know that the benefits of pulmonary rehab do decrease over time, but there's really low quality evidence evaluating whether initiation of a maintenance program of pulmonary rehab after completing initial program is any better than usual care.

So what we recommend is that all patients should continue to exercise regularly, and the decision on whether that exercise is on their own or in a maintenance program should really be made in discussion with the patients. This is at least partly because participation in pulmonary rehab does have significant costs or burden to the patients, particularly when it comes to transportation and time.

And so it is important that patients be a part of the decision as to whether or not continuing to take on that burden of travel time and cost is worthwhile in their care. In your synopsis, you highlighted the data that showed less than 5% of persons with chronic obstructive lung disease are actually referred for pulmonary rehab. How does a generalist do a referral?

That number is pretty astounding. So I think it's important to put that number into a little bit of context for listeners. So about 25% of patients who are candidates for cardiac rehabilitation actually participate in cardiac rehabilitation.

That number is only 5% of patients with COPD who are participating in pulmonary rehab. So we are significantly underutilizing this really important resource. We have to think a little bit about what these programs are, and then that helps us understand why access may be limited.

So these programs are generally occurring in a hospital, very rarely in a physician's office. They are not going to take place in freestanding physical therapy or these privately owned physical therapy offices. And that gets back to what we talked a little bit about before, which is that it's a multidisciplinary intervention. So it requires not only physical therapists, but also respiratory therapists, nurses, dieticians, and a medical provider on site.

So it can be difficult to find these programs. They are almost universally associated with hospitals. But I do have two quick recommendations for listeners on how to find them. The first is you can very easily Google Pulmonary Rehabilitation American Lung Association. And that takes you to a website of frequently asked questions there.

And at the bottom of that, it says, how do I find a pulmonary rehab program? And if you click on the link, it takes you to a finder. So that's the second way of actually just finding a list of pulmonary rehab programs is you can go directly to the website that has the finder on it. So you can go to livebetter.org. The website is co-sponsored by the American Thoracic Society and the COPD Foundation.

It has a map. You put in the patient's location by zip code or town name, and it will give you a list of all nearby pulmonary rehab programs. So access might certainly be a problem, and especially for persons who don't live near larger hospital centers. What do we know about the effectiveness of telerehabilitation?

Access is definitely an issue. And I would actually expand the significance of your question because it's actually not just an issue in rural areas. It can certainly be an issue even in less rural areas where transportation options are limited. If you need a family member to take off a day of work or the costs of gas plus parking are high, it can be difficult to get to pulmonary rehab. And so

finding ways to deliver pulmonary rehab to these groups is really important so that we can ensure that everyone has access to the potential benefits. So there is, as you referred to, a growing body of evidence on telerehabilitation, although the numbers are smaller. I would keep in mind that this evidence is almost exclusively in patients with COPD, so whether these findings also apply to other lung diseases is unknown.

However, patients who completed a telerehabilitation program had similar improvements in six-minute walk distance, health-related quality of life, and shortness of breath compared to patients who participated in on-site, in-center pulmonary rehabilitation.

There are additional benefits to telerehabilitation, particularly completion rates are actually higher with telerehabilitation at about 93% completion rates compared to center-based pulmonary rehab, which is typically closer to 70% completion rates.

Now, there are very small numbers, but they did look at whether there was any benefit in terms of hospital admissions. There did seem to be a benefit. Patients who participated in telerehabilitation seemed to be less likely to end up hospitalized compared to patients who participated in center-based programs. So there is certainly a role for telerehabilitation, particularly in the management of COPD, but

It does still require some access. So you have to have a computer or a laptop or an iPad. You do have to have internet access. And so there are still some challenges there.

But the guidelines suggest that it should be considered as an alternative to center-based pulmonary rehab. And I think it's particularly important in the population you described, which is folks in rural areas without a nearby center, but also potentially folks who just have logistical challenges in getting to pulmonary rehab multiple times a week. So one question that patients and their physicians might have is,

is the care of patients participating who desaturate with exercise. Is access to oxygen a requirement for pulmonary rehabilitation? And how does that affect telerehabilitation modalities? Access is not mandatory. I think it's worth it to...

quickly specify the population we're really talking about here. So the American Thoracic Society put out guidelines in 2020 about the use of supplemental oxygen in chronic respiratory disease. This group of people who have resting oxygen saturations greater than 89%, but whose oxygen levels dip into the lower 80s on exertion. There is some debate about what the optimal supplementation strategy should be for this group.

The guidelines make a conditional recommendation, meaning that many patients would prefer to use supplemental oxygen in this scenario, but not all patients. And so it really requires a shared decision-making approach to decide whether these folks should be using supplemental oxygen on exertion. So these folks do not absolutely need to have supplemental oxygen at home in order to participate in pulmonary rehabilitation or in telerehabilitation.

But it does remain an area in need of additional research. And so that answer may change over the coming years. Well, if we were to implement the recommendations of the guidelines broadly, it suggests there's a large quality chasm that we will overcome. But what are the risks of pulmonary rehab?

There are really minimal physical risks to patients. So we have long hypothesized that there would be increases in musculoskeletal issues or cardiac complications, but none of the clinical trials have demonstrated a significant increase in either of those complications associated with participation in pulmonary rehab.

I do think the major burden or cost is really the logistics of getting to pulmonary rehab multiple times a week. And I think that's really where the adverse effects are present. Is there anything else you would like our listeners to know about pulmonary rehabilitation for chronic lung diseases?

Yeah, I think that we've talked a lot about pulmonary rehabilitation from a patient and a provider perspective, but I also think it's worth talking about pulmonary rehab from a policy perspective.

There was a great analysis published in JAMA just within the last few years, and they looked at whether participation in pulmonary rehab after a hospitalization for an acute exacerbation of COPD was cost-effective. And what they found was that participation in pulmonary rehab within 90 days of discharge for a hospitalization for an acute COPD exacerbation would save Medicare about $5,700 per patient,

which comes out to $1 to $1.2.5 billion saved annually by Medicare. So this is not only an intervention that makes people feel better, walk farther, and decreases risks of readmission. It's also an intervention that can save Medicare a significant amount of money.

Well, thank you, Dr. Anderson, for joining us today to talk about pulmonary rehabilitation for chronic lung disease. A video that demonstrates the teaching of proper self-administration of inhaler medications can be found in the Clinical Guidelines Synopsis published in JAMA online. I am Dr. David Simel. You can find a link to the article in this episode's description. This episode was produced by Shelley Steffens at the JAMA Network.

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