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Pulmonary Rehabilitation for Cardiorespiratory Diseases other than COPD

Pulmonary Rehabilitation for Cardiorespiratory Diseases other than COPD

Authors: Dr Enya Daynes1 and Dr Claire M Nolan2,3 Affiliations:

1. NIHR Leicester Biomedical Research Centre - Respiratory, Leicester,
2. Brunel University London, College of Health Medicine and Life Sciences, Department of Health Sciences, UK
3. Harefield Respiratory Research Group, Guy’s and St Thomas’ NHS Foundation Trust, UK

The benefit of pulmonary rehabilitation (PR) for COPD is well-established1 and PR programmes have been widely implemented.2 By extension, people with cardiorespiratory diseases other than COPD have been able to attend PR. This article provides an overview of the evidence for PR in select conditions and highlights disease-specific considerations.


A systematic review demonstrated that exercise training compared a control intervention significantly improves disease-specific quality of life and exercise capacity, but not asthma control, asthma symptom-free days, emotional function or airway obstruction (moderate quality evidence).3 Subsequent trials demonstrated that PR confers significant benefit in Asthma COPD Overlap Syndrome,4 severe asthma5 and obese individuals with poorly controlled asthma.6 These results should be interpreted with caution due to small sample size.

There are concerns that exercise may induce bronchial hyper-reactivity and exercise-induced bronchoconstriction. A systematic review of exercise training versus usual care demonstrated no increased risk of these events in the exercise group.7 However, prior to PR referral patients should be medically optimised and have stable disease to minimise risk of adverse events.8

Interstitial lung disease (ILD)

A Cochrane review demonstrated that PR compared to usual care significantly improves short- (post-PR) and long- term (six to 11 months) exercise capacity, breathlessness and health-related quality of life but not survival (low to moderate certainty evidence).9 Sub-group analysis demonstrated similar results in idiopathic pulmonary fibrosis (IPF), but not in participants with severe disease or exercise-induced desaturation. A matched-cohort study demonstrated a similar magnitude of improvement in core PR outcomes and completion in IPF compared to COPD and in IPF, PR non-response and non-completion was associated with increased risk of mortality.10

Profound exercise-induced desaturation is typical of select ILDs. Accordingly, an oxygen assessment should be undertaken prior to commencing PR and/or consideration given to providing PR in a setting where oxygen can be administered.11


A systematic review demonstrated that PR (standalone intervention or alongside other interventions) compared to control interventions significantly improves short-term exercise capacity and short- and long-term health-related quality of life but not cough.12 There were insufficient data to include some variables in the meta-analysis but individual studies reported improvements in endurance capacity, dyspnoea, exacerbation frequency and time to first exacerbation favouring PR, but this requires confirmation. Matched cohort studies demonstrated a similar magnitude of improvement in core PR outcomes13 and mood disorder14 in bronchiectasis compared to COPD.

As bronchiectasis is characterised by sputum production, a review of airway clearance technique and routine prior to starting PR is recommended.15 Local infection control policies should be followed to minimise risk of cross-infection of multi-resistant organisms during PR.8

Pulmonary hypertension

A Cochrane review demonstrated that exercise training compared to usual care significantly improves exercise capacity and health-related quality of life (low quality evidence).16 Sub-group analyses demonstrated similar results for pulmonary arterial hypertension group 1 for exercise, and that in- and out-patient PR are associated with improved exercise capacity, but in-patient PR is associated with a greater magnitude of improvement. Only one study reported one adverse event (light-headedness) during exercise. A more recent systematic review confirmed that exercise training compared to usual care significantly improves exercise capacity. 17

To minimise adverse events, people with pulmonary hypertension referred to PR should have a two-month period of stable disease with no episodes of fainting17 nor changes in pulmonary hypertension drug therapy or dose for two months18. In addition, the exercise component of PR should be supervised by specialist exercise professionals8, 18, 19 and remote supervision of exercise training is not recommended for people with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension.8

Chronic heart failure (CHF) 

CHF shares a similar symptom burden to chronic respiratory disease, namely breathlessness and fatigue.20 Exercise therapy for CHF is safe and recommended in national and international guidelines.21 There are limited data on the effect of PR in CHF: one trial demonstrated that PR compared to usual care significantly improves exercise capacity and symptom severity, but not health-related quality of life or quadriceps strength.22 The magnitude of improvement was similar to COPD for exercise capacity, quadriceps and breathlessness, but people with CHF had less improvement in fatigue compared to COPD.

The programme may be adapted as follows: 8, 22, 23 exercise ECG; disease-specific education focused on managing breathlessness and psychological needs; workforce training to understand recognition, assessment and management of decompensated heart failure and the inclusion of a heart failure nurse in the PR team.


BTS guidance state that PR may be indicated in people post-COVID-19 with respiratory symptoms.24 To date one study has demonstrated improvements in exercise capacity using telerehabilitation however alternative models have yet to be explored. 25 Several cohort studies have demonstrated that rehabilitation following hospitalisation is associated with significant improvements in exercise capacity, breathlessness, and health-related quality of life.26-30 However, as there is no control group it is not known if this is due to natural recovery. Further research is required to investigate the effect of PR in this group.

Programme adaptations/considerations may include:8, 24 

  • Patient selection:
    • Consider patients with functional limitation and ongoing symptoms for ongoing Covid-19 rehabilitation
    • PR precautions/contraindications: unexplained chest pain, recent diagnosis of acute deep venous thrombosis, pulmonary embolism, myocarditis, cardiovascular instability, hypoxia, new neurological
  • Assessment of symptom burden: Usual outcomes and consider fatigue, dysfunctional breathing, psychological disorder, swallow/speech difficulties, peripheral neuropathy, musculoskeletal dysfunction
  • Exercise programme:


  • Adapt to meet each individual’s
  • Individuals with post-intensive care syndrome have multisystemic symptoms and deficits, which may require individualisation of exercise and education components.
  • Fatigue and post-exertional symptom exacerbation should be closely monitored through symptom, exertion, activity scores and diaries
  •  Education programme: Consider disease-specific education, respiratory care, fatigue management, musculoskeletal problems, nutritional management, psychological care, social issues g. return to work, sexual relationships, isolation).



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