Pulmonary rehabilitation is a comprehensive, evidence-based intervention designed for individuals with chronic respiratory diseases, aimed at reducing physical, psychological, and social disability while improving overall quality of life and functional capacity [1]. This multidisciplinary program integrates supervised physical exercise, therapeutic education, psychological support, dietetic counseling, and, when necessary, smoking cessation support. It is strongly recommended for patients with conditions such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, severe asthma, pulmonary hypertension, and neuromuscular disorders, particularly following exacerbations or major thoracic surgery like lobectomy or lung transplantation [2]. Programs typically last 6 to 12 weeks, with sessions held two to three times per week, and can be delivered in specialized centers, hospitals, or increasingly through tele-rehabilitation at home [3]. Eligibility is determined by a multidisciplinary team after a thorough assessment of symptoms, functional limitations, and patient motivation, ensuring safe and effective participation [4]. The benefits are well-documented, including improved exercise tolerance, reduced dyspnea, enhanced quality of life, and decreased hospitalizations, making it a cornerstone in the management of chronic lung diseases [5]. Key evaluation tools include the six-minute walk test (6MWT) and cardiopulmonary exercise testing, while long-term success often depends on supervised maintenance programs [6].

Definition and Core Objectives

Pulmonary rehabilitation is a comprehensive, structured therapeutic program designed for individuals with chronic respiratory diseases, aiming to reduce physical, psychological, and social disability while enhancing overall quality of life and functional capacity [1]. This evidence-based intervention is grounded in a multidisciplinary approach, integrating supervised physical exercise, therapeutic education, psychological support, dietetic counseling, and, when necessary, support for smoking cessation. It is considered a cornerstone in the management of chronic lung conditions and is strongly recommended for patients experiencing significant functional limitations or dyspnea despite optimal medical treatment [4].

Definition

Pulmonary rehabilitation, also known as respiratory rehabilitation, is a coordinated, multidisciplinary program tailored for individuals suffering from chronic respiratory diseases. Its primary aim is to mitigate the physical, psychological, and social disability associated with respiratory illness, thereby improving patients' quality of life and functional capacity [9]. The program is not solely focused on lung function improvement but rather on enhancing the patient's ability to perform daily activities and manage their condition effectively. It is delivered through a structured framework that includes supervised physical training, patient education, psychological support, and nutritional guidance, ensuring a holistic approach to care. This intervention is particularly effective in breaking the vicious cycle of dyspnea, inactivity, and deconditioning that often plagues individuals with chronic respiratory conditions.

Core Objectives

The fundamental goals of pulmonary rehabilitation are multifaceted, targeting both physiological and psychosocial aspects of chronic respiratory disease. These objectives are designed to empower patients, improve their health status, and reduce the burden on healthcare systems.

  • Improve exercise tolerance and physical capacity: A central objective is to enhance the patient's ability to perform physical activities by increasing endurance and muscle strength. This is achieved through supervised exercise training, which combats the deconditioning commonly seen in chronic respiratory diseases like chronic obstructive pulmonary disease (COPD) [5]. Improved physical capacity allows patients to engage in daily tasks with less fatigue and breathlessness.

  • Reduce dyspnea and respiratory symptoms: The program aims to alleviate the sensation of breathlessness (dyspnea), a primary and debilitating symptom for many patients. Techniques such as controlled breathing, pacing, and energy conservation are taught to help patients manage their symptoms more effectively during activities of daily living [5].

  • Enhance autonomy in daily activities: By improving physical function and symptom management, pulmonary rehabilitation helps patients regain independence. This increased autonomy allows them to perform routine tasks, participate in social activities, and maintain a more active lifestyle, which is crucial for long-term well-being.

  • Decrease the frequency of exacerbations and hospitalizations: A significant benefit of the program is its ability to stabilize the patient's condition, leading to fewer acute exacerbations and a reduced need for hospital admissions. This is partly due to improved self-management skills and early recognition of worsening symptoms, which are key components of therapeutic education [5].

  • Improve overall quality of life: The ultimate goal is to enhance the patient's holistic well-being. This includes not only physical health but also emotional and social health. By addressing anxiety, depression, and social isolation through psychological support, the program contributes to a more positive perception of health and greater life satisfaction [5].

  • Promote self-management and autonomy: The program equips patients with the knowledge and skills to manage their disease independently. This includes understanding their condition, using medications correctly, and adopting healthy behaviors, which are essential for long-term disease control and prevention of complications [14].

  • Optimize recovery after hospitalization or surgery: Pulmonary rehabilitation is particularly beneficial following an exacerbation of respiratory disease or major thoracic surgery, such as lobectomy or lung transplantation. It facilitates a faster and more complete recovery by restoring physical function and confidence [2].

The success of pulmonary rehabilitation hinges on its personalized nature, with programs tailored to the individual's specific needs, disease severity, and personal goals, ensuring the most effective and sustainable outcomes.

Indications and Patient Eligibility

Pulmonary rehabilitation is indicated for a wide range of individuals suffering from chronic respiratory diseases who experience significant functional limitations or reduced quality of life despite optimal medical treatment. Patient eligibility is determined through a comprehensive assessment that evaluates clinical status, functional capacity, symptom burden, and motivation to participate in a structured program. The goal is to identify those most likely to benefit from this evidence-based intervention, ensuring both safety and effectiveness [4].

Primary Indications for Pulmonary Rehabilitation

The primary indications for pulmonary rehabilitation are rooted in chronic respiratory conditions that lead to disabling dyspnea, reduced exercise tolerance, and impaired daily functioning. These include:

  • Chronic obstructive pulmonary disease (COPD): This is the most common indication, particularly in patients with moderate to severe disease who experience breathlessness during daily activities. Pulmonary rehabilitation is strongly recommended for individuals with COPD, whether in a stable phase or recovering from an acute exacerbation [17]. It is especially beneficial after hospitalization for exacerbation to improve recovery and reduce the risk of future admissions [2].

  • Idiopathic pulmonary fibrosis (IPF) and other interstitial lung diseases: Patients with restrictive lung diseases such as idiopathic pulmonary fibrosis often suffer from progressive dyspnea and hypoxemia during exertion. Pulmonary rehabilitation helps improve exercise capacity, manage symptoms, and enhance quality of life, even in the presence of irreversible lung damage [19].

  • Severe asthma: For patients with uncontrolled or severe asthma, pulmonary rehabilitation can be beneficial when symptoms significantly limit physical activity or quality of life, particularly if there is a component of deconditioning or anxiety related to breathing difficulties.

  • Pulmonary hypertension (PH): Individuals diagnosed with pulmonary hypertension may benefit from carefully supervised programs that focus on safe levels of aerobic exercise, oxygenation monitoring, and cardiovascular stability to improve functional status and reduce symptoms [20].

  • Neuromuscular disorders: Conditions such as amyotrophic lateral sclerosis (ALS) or muscular dystrophy that affect respiratory muscle strength and ventilation are also valid indications. In these cases, the program supports respiratory function, delays complications, and promotes independence [1].

  • Post-thoracic surgery: Pulmonary rehabilitation is frequently recommended after major thoracic procedures such as lobectomy, pneumonectomy, or lung transplantation to accelerate recovery, restore lung function, and prevent postoperative complications like atelectasis or pneumonia [22].

  • Bronchiectasis: Patients with chronic bronchiectasis can benefit from airway clearance techniques, exercise training, and education modules integrated into pulmonary rehabilitation programs to improve sputum clearance and reduce infection frequency [23].

  • Post-COVID-19 syndrome (long COVID): Emerging evidence supports the use of pulmonary rehabilitation in patients experiencing persistent respiratory symptoms, fatigue, and exercise intolerance following severe SARS-CoV-2 infection, particularly those with residual lung damage or deconditioning [2].

Situational Indications

Beyond specific diagnoses, certain clinical situations warrant referral to pulmonary rehabilitation:

  • After hospitalization for respiratory exacerbation: A strong indication exists for initiating pulmonary rehabilitation shortly after discharge—typically within 4 to 6 weeks—once the patient is clinically stable. This timing allows for optimal recovery while minimizing the risk of relapse [25].

  • Significant functional limitation: Any patient with chronic respiratory disease who reports a meaningful reduction in daily activities due to breathlessness or fatigue, regardless of spirometric severity, should be considered eligible. Functional assessments such as the six-minute walk test (6MWT) help quantify this limitation [26].

  • High symptom burden: Patients with persistent dyspnea, even at rest or with minimal exertion, as measured by validated scales like the modified Medical Research Council (mMRC) scale or the COPD Assessment Test (CAT), are prime candidates.

Patient Eligibility Criteria

Eligibility for pulmonary rehabilitation is not solely based on diagnosis but involves a multidimensional evaluation conducted by a multidisciplinary team including pneumologists, physiotherapists, dietitians, and psychologists. Key criteria include:

  • Clinical stability: The patient must be in a stable phase of their disease without active exacerbation. Programs are generally initiated 4 to 6 weeks after an acute episode to avoid risks associated with exercising during inflammatory flare-ups [25].

  • Ability to participate actively: Patients must demonstrate sufficient cognitive and physical capacity to engage in supervised exercise and educational sessions. Voluntary participation and personal commitment are essential for adherence and long-term success.

  • Motivation and psychological readiness: Motivation plays a crucial role in program outcomes. Patients should express willingness to learn self-management strategies and adopt healthier behaviors. Screening for anxiety, depression, or post-traumatic stress disorder—particularly after intensive care unit (ICU) stays—is vital, as these conditions can hinder engagement [28].

  • Absence of major contraindications: Certain comorbidities may preclude participation or require program modifications. These include unstable heart failure, uncontrolled angina pectoris, severe arrhythmias, or significant musculoskeletal impairments that prevent safe exercise [25].

  • Documented functional impairment: Objective evidence of reduced exercise tolerance—such as low distance on the 6MWT, reduced peak oxygen consumption (VO₂ max) on cardiopulmonary exercise testing, or high dyspnea scores—is used to confirm eligibility and tailor program intensity [30].

Importance of Early and Individualized Referral

Current guidelines from organizations such as the Haute Autorité de Santé (HAS), the Société de pneumologie de langue française (SPLF), and the French Society of Anesthesia and Intensive Care Medicine (SFAR) emphasize early and individualized referral to pulmonary rehabilitation [31], [32]. Delayed access remains a barrier, with only about 10% of eligible patients in France receiving this intervention [26]. Early initiation—ideally integrated into the care pathway soon after diagnosis or exacerbation—maximizes benefits by preventing deconditioning, improving self-efficacy, and reducing future healthcare utilization.

Eligibility should be reassessed periodically, especially in progressive diseases like IPF or pulmonary hypertension, where program content and delivery mode (e.g., transitioning to home-based or tele-rehabilitation) may need adjustment over time [34]. The ultimate aim is to provide equitable access to a high-value, non-pharmacological therapy that enhances patient autonomy, reduces disability, and improves long-term outcomes across the spectrum of chronic respiratory diseases [35].

Key Components of Pulmonary Rehabilitation Programs

Pulmonary rehabilitation is a comprehensive, structured intervention that integrates multiple evidence-based components to improve the health and well-being of individuals with chronic respiratory diseases. These components are delivered through a coordinated, multidisciplinary approach and are tailored to the individual patient's needs, goals, and clinical status. The program’s effectiveness stems from the synergistic integration of physical, educational, psychological, and nutritional elements, all aimed at enhancing functional capacity, reducing symptoms, and improving quality of life. Key components include initial assessment, supervised exercise training, therapeutic education, psychological and behavioral support, nutritional management, and long-term follow-up strategies [36][37].

Initial Comprehensive Assessment

The foundation of any pulmonary rehabilitation program is a thorough initial evaluation that establishes a baseline of the patient’s physical, psychological, and social condition. This assessment is essential for personalizing the rehabilitation plan and ensuring patient safety. It includes the measurement of symptoms such as , functional capacity, and quality of life, as well as an evaluation of the patient’s self-management skills and personal goals [36]. Objective tests such as the six-minute walk test (6MWT) and cardiopulmonary exercise testing are used to quantify exercise tolerance and identify physiological limitations [30]. Spirometry is also performed to assess lung function, particularly the forced expiratory volume in one second (FEV1), although improvements in this parameter are not typically expected from rehabilitation. The assessment also screens for comorbidities, including cardiovascular conditions and musculoskeletal limitations, which may influence the design of the exercise regimen [25].

Supervised Exercise Training and Reconditioning

Exercise training is the cornerstone of pulmonary rehabilitation and is designed to improve muscle strength, endurance, and overall physical function. The program typically includes both aerobic and resistance training, tailored to the patient’s capabilities and supervised by qualified professionals such as or . Aerobic activities such as walking, cycling, or using a treadmill are prescribed at moderate intensity to enhance cardiovascular fitness and reduce breathlessness during daily activities [14]. Resistance training targets both upper and lower limb muscles to improve strength and reduce fatigue, which is particularly important for patients with conditions like chronic obstructive pulmonary disease (COPD) or neuromuscular disorders [42]. For severely deconditioned patients, alternative methods such as neuromuscular electrical stimulation (NMES) may be used to improve muscle strength without placing excessive demand on ventilation [43]. The intensity and progression of exercise are carefully monitored using tools like the to assess perceived exertion and ensure safety [30].

Therapeutic Education and Self-Management

Therapeutic education empowers patients to understand and manage their condition effectively. This component includes instruction on disease mechanisms, proper use of , recognition of early signs of exacerbation, and strategies for symptom control [45]. Educational modules often cover topics such as energy conservation techniques, breathing control methods, and the importance of vaccination and smoking cessation [46]. Patients learn to develop personalized action plans for managing flare-ups, which has been shown to reduce hospital admissions [5]. The goal is to foster self-efficacy and long-term adherence to healthy behaviors, enabling patients to maintain their gains beyond the formal program [14].

Psychological and Behavioral Support

Psychological support is a critical component, as many patients with chronic respiratory diseases experience anxiety, depression, or social isolation. The prevalence of these conditions is particularly high in individuals with , where up to 50% may suffer from clinically significant anxiety or depression [49]. Cognitive-behavioral therapy (CBT) is often used to address maladaptive thoughts related to breathlessness, such as fear of suffocation, and to implement graded exposure techniques that help patients gradually resume physical activity [50]. Relaxation techniques, including and , are taught to reduce hyperventilation and promote emotional regulation [51]. Group sessions provide peer support and reduce feelings of isolation, contributing to improved mental health and program adherence [3].

Nutritional Management

Nutritional imbalances—such as undernutrition (cachexia) or obesity—are common in chronic respiratory disease and significantly impact respiratory function and exercise tolerance. Undernutrition leads to muscle wasting, including in the diaphragm and other respiratory muscles, increasing the work of breathing and worsening dyspnea [53]. Conversely, obesity increases mechanical load on the respiratory system and is associated with conditions like the [54]. A registered evaluates the patient’s nutritional status and designs an individualized plan that addresses energy and protein needs. For cachectic patients, hypercaloric and hyperproteic supplementation (1.2–1.7 g/kg/day) is recommended to preserve muscle mass [55]. For obese patients, a moderate caloric deficit is advised to promote gradual weight loss while preserving lean mass [56]. The diet is also optimized for anti-inflammatory effects, emphasizing a Mediterranean-style pattern rich in fruits, vegetables, whole grains, and omega-3 fatty acids [57].

Long-Term Follow-Up and Maintenance

Sustaining the benefits of pulmonary rehabilitation requires ongoing support and maintenance strategies. Without intervention, gains in exercise capacity and quality of life tend to decline within 6 to 12 months after program completion [6]. Supervised maintenance programs, whether in-person or delivered via tele-rehabilitation, have been shown to preserve improvements in functional status and reduce hospitalizations [34]. These programs may include regular exercise sessions, periodic reassessments using the 6MWT or symptom questionnaires like the CAT, and continued access to educational and psychological support [60]. Remote monitoring technologies allow for real-time tracking of patient progress and early detection of deterioration, facilitating timely intervention [61]. The integration of maintenance into the overall care pathway is essential for maximizing the long-term impact of pulmonary rehabilitation.

Role of the Multidisciplinary Team

Pulmonary rehabilitation is fundamentally a collaborative effort that relies on a coordinated, multidisciplinary team to deliver comprehensive care tailored to the complex needs of individuals with chronic respiratory diseases. This team-based approach ensures that all aspects of the patient’s condition—physical, psychological, nutritional, and social—are addressed through integrated interventions. The success of pulmonary rehabilitation hinges on seamless communication and shared decision-making among various healthcare professionals, each bringing specialized expertise to optimize patient outcomes [42]. The team typically includes pneumologists, physiotherapists (or kinesiologists), inhalothérapeutes, nurses, diététiciens, psychologists, and sometimes ergotherapists or tabacologues, depending on patient needs [37].

Core Responsibilities and Professional Roles

Each member of the multidisciplinary team plays a distinct yet interconnected role in the patient’s rehabilitation journey. The pneumologist is typically responsible for diagnosing the underlying respiratory condition, determining eligibility for the program, and overseeing medical management throughout the rehabilitation process. They collaborate closely with other team members to adjust medications, manage comorbidities, and ensure clinical stability before and during participation in the program [4]. The physiotherapist serves as a central figure in designing and supervising individualized exercise regimens, including endurance training, strength conditioning, and respiratory muscle training. They also teach patients techniques such as pursed-lip breathing and diaphragmatic breathing to manage dyspnea during daily activities [65].

Inhalothérapeutes focus on optimizing airway clearance, ensuring proper use of inhalation devices, and managing oxygen therapy during exercise when needed. Their input is critical in preventing complications related to hypoxemia during physical exertion, especially in patients with advanced disease [66]. Nurses provide continuous monitoring, administer treatments, and reinforce patient education, acting as a bridge between the medical team and the patient. They play a key role in identifying early signs of exacerbation and supporting adherence to self-management plans [67].

The diététicien assesses nutritional status and develops personalized dietary plans to address imbalances such as malnutrition or obesity, both of which significantly impact respiratory function and exercise tolerance [68]. For instance, in patients with cachexia, hypercaloric and hyperprotein diets are prescribed to preserve muscle mass, while in those with obesity, moderate caloric restriction is implemented to reduce ventilatory load [57]. Meanwhile, the psychologist addresses mental health challenges such as anxiety, depression, and post-traumatic stress following intensive care stays, which are prevalent in chronic respiratory populations [49]. Using cognitive behavioral therapy (CBT) and other evidence-based strategies, they help patients overcome fear of breathlessness and improve engagement in rehabilitation [71].

Interprofessional Collaboration and Care Coordination

Effective collaboration among team members is essential for delivering patient-centered care. Regular multidisciplinary meetings allow for the integration of clinical findings, progress assessments, and goal adjustments based on ongoing evaluations such as the six-minute walk test (6MWT) or Borg scale for dyspnea [30]. The use of standardized tools like the COPD Assessment Test (CAT) and Saint George’s Respiratory Questionnaire (SGRQ) enables consistent measurement of symptom burden and quality of life across disciplines [73].

Communication is further enhanced through shared documentation platforms such as the Dossier Médical Partagé (DMP), which facilitates continuity of care between hospital and community settings [74]. The team also works in close partnership with general practitioners and home care services to ensure smooth transitions, particularly after hospitalization or for patients enrolled in tele-rehabilitation programs [75]. In some regions, structured networks such as RespiFIL support coordination across specialized centers, promoting best practices and equitable access to care [76].

Integration of Specialized Support Services

Beyond core team members, additional specialists may be involved based on individual patient profiles. For example, ergotherapists assist in adapting daily activities to minimize dyspnea and conserve energy, working in tandem with physiotherapists to enhance functional independence [77]. In cases where return-to-work is a goal, vocational counseling and collaboration with occupational health services are essential, particularly when the respiratory condition is recognized as occupational in origin [78]. The inclusion of tabacologues is crucial for patients who continue to smoke, as smoking cessation remains one of the most effective interventions in slowing disease progression [17].

Moreover, the team integrates therapeutic education into every phase of rehabilitation, empowering patients to manage their condition autonomously. Educational modules cover topics such as inhaler technique, symptom recognition, action plans for exacerbations, and lifestyle modifications [45]. These sessions are often co-led by multiple professionals to ensure consistency and reinforce learning. Group discussions and peer support further enhance motivation and reduce feelings of isolation, contributing to improved psychological well-being [81].

In summary, the multidisciplinary team in pulmonary rehabilitation functions as an integrated unit where each professional contributes unique expertise toward a common goal: improving the patient’s functional capacity, quality of life, and long-term health outcomes. Through coordinated assessment, individualized intervention, and continuous evaluation, this collaborative model exemplifies best practices in chronic disease management and underscores the importance of holistic, patient-centered care.

Exercise Training and Functional Assessment

Exercise training and functional assessment are central components of pulmonary rehabilitation, forming the cornerstone of its ability to improve physical capacity, reduce dyspnea, and enhance overall quality of life in patients with chronic respiratory diseases. These elements are not only essential for initiating a personalized program but also for monitoring progress and adjusting interventions throughout the rehabilitation journey. The integration of structured physical activity with objective functional evaluations ensures that treatment is evidence-based, individualized, and responsive to patient needs.

Exercise Training: Modalities and Physiological Benefits

Exercise training in pulmonary rehabilitation is a supervised, progressive program tailored to the patient's clinical condition, functional limitations, and personal goals. It typically includes aerobic conditioning, resistance training, and neuromuscular electrical stimulation (NMES), all designed to counteract the deconditioning commonly seen in chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, and pulmonary hypertension. Aerobic exercises—such as walking or cycling—are performed at moderate intensity, usually 40% to 60% of peak oxygen consumption (VO₂ max) or 50% to 80% of heart rate reserve, and are critical for improving cardiovascular endurance and reducing breathlessness during daily activities [82].

Resistance training targets both upper and lower limb muscles, enhancing muscle strength and endurance. This is particularly important because peripheral muscle weakness contributes significantly to exercise intolerance in patients with respiratory disease. For those unable to perform voluntary exercise due to severe deconditioning or fatigue, neuromuscular electrical stimulation (NMES) of the quadriceps has proven effective in increasing muscle strength and improving quality of life without imposing additional ventilatory load [43]. The combination of aerobic and resistance training leads to improved metabolic efficiency, reduced lactic acid production, and enhanced ventilatory control, collectively contributing to decreased perception of dyspnea and increased functional independence [84].

Functional Assessment: Key Evaluation Tools

Functional assessment is fundamental to the success of pulmonary rehabilitation, providing objective data that guide program design and track outcomes. The most widely used tool is the six-minute walk test (6MWT), a simple, reproducible measure of submaximal exercise capacity that reflects real-world functional performance. It assesses the distance a patient can walk in six minutes and integrates cardiopulmonary function, musculoskeletal fitness, motivation, and coordination. The 6MWT is used at baseline to establish functional status, during the program to monitor progress, and at completion to evaluate therapeutic response [85]. Studies show that improvements in 6MWT distance correlate strongly with enhanced quality of life and reduced dyspnea [86].

In addition to field tests, laboratory-based assessments such as incremental exercise testing on a cycle ergometer or treadmill provide more detailed physiological insights. These tests measure peak oxygen uptake (VO₂ max), anaerobic threshold, ventilatory efficiency, and gas exchange, allowing clinicians to identify the primary physiological limitation to exercise—whether ventilatory, cardiac, muscular, or mixed. Parameters like the Oxygen Uptake Efficiency Slope (OUES) offer reliable estimates of aerobic capacity even when patients cannot reach maximal exertion, making them especially useful in frail populations [87]. These assessments are crucial for prescribing exercise at targeted intensities and detecting exercise-induced hypoxemia, which may necessitate supplemental oxygen during training sessions [88].

Personalization Based on Disease-Specific Adaptations

Exercise programs must be adapted according to the underlying respiratory pathology, as different diseases impose distinct physiological challenges. In idiopathic pulmonary fibrosis, for example, patients often experience early oxygen desaturation during exertion due to impaired gas exchange. Therefore, exercise is conducted at lower intensities with continuous monitoring of peripheral oxygen saturation (SpO₂), and long-term oxygen therapy is frequently required during training to maintain SpO₂ ≥ 90% [89]. Sessions may be shorter or fractionated (e.g., 2 × 15 minutes) to prevent excessive fatigue and ensure safety.

In contrast, patients with pulmonary arterial hypertension (PAH) require careful hemodynamic evaluation before starting exercise, including echocardiography or right heart catheterization, to assess right ventricular function and disease severity [20]. Exercise is strictly supervised and limited to moderate intensity to avoid sudden increases in pulmonary artery pressure. Activities focus on low-intensity aerobic exercises such as walking or cycling, with emphasis on gradual warm-up and cool-down phases. Isometric exercises that cause acute spikes in pulmonary pressure are avoided. Continuous monitoring of heart rate and SpO₂ is mandatory, and any signs of chest pain, dizziness, or syncope require immediate cessation of activity [91].

Integration with Multidisciplinary Care and Progress Monitoring

The effectiveness of exercise training and functional assessment is maximized through integration within a multidisciplinary team that includes physiotherapists, pulmonologists, psychologists, and dietitians. Regular communication ensures that changes in functional status are shared across disciplines, enabling coordinated adjustments to the rehabilitation plan. For instance, if a patient shows poor adherence due to anxiety or depression, psychological support can be intensified to address barriers such as fear of breathlessness (dyspnea phobia), which significantly impacts exercise participation [92].

Progress is monitored using a combination of objective and subjective indicators. Objective measures include changes in 6MWT distance, VO₂ max, muscle strength (e.g., handgrip dynamometry), and ventilatory parameters. Subjective assessments involve validated scales such as the mMRC dyspnea scale, the Borg scale for perceived exertion, and quality-of-life questionnaires like the COPD Assessment Test (CAT) and the Saint George’s Respiratory Questionnaire (SGRQ) [93]. Adjustments to exercise intensity are made based on these evaluations, ensuring that training remains safe, effective, and progressively challenging.

Long-Term Maintenance and Program Adjustments

To sustain the benefits of exercise training beyond the initial rehabilitation phase, supervised maintenance programs are essential. Evidence from Cochrane reviews indicates that supervised maintenance is more effective than usual care in preserving improvements in exercise tolerance and quality of life [6]. These programs may continue in clinical settings or transition to home-based or tele-rehabilitation models, supported by remote monitoring technologies. Regular reassessment using the same functional tools allows for ongoing personalization and helps prevent relapse into sedentary behavior.

Ultimately, the synergy between exercise training and functional assessment enables a dynamic, responsive approach to pulmonary rehabilitation. By grounding interventions in objective data and adapting them to individual patient profiles, clinicians can optimize outcomes across a spectrum of chronic respiratory conditions, promoting lasting improvements in physical function, symptom control, and overall well-being.

Psychological and Behavioral Support

Psychological and behavioral support is a fundamental component of pulmonary rehabilitation, addressing the profound emotional, cognitive, and social challenges faced by individuals with chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, and pulmonary hypertension [5]. These conditions are frequently accompanied by significant psychological comorbidities, including anxiety, depression, and post-traumatic stress, which can severely impact a patient’s quality of life, functional capacity, and adherence to treatment. The integration of psychological interventions within the multidisciplinary framework of pulmonary rehabilitation is essential for breaking the vicious cycle of dyspnea, inactivity, and emotional distress.

Common Psychological Challenges in Chronic Respiratory Disease

Patients with chronic respiratory conditions often face a range of psychological difficulties that can impede their participation in and benefit from rehabilitation. One of the most prevalent is anxiety related to dyspnea, where the fear of breathlessness leads to avoidance of physical activity, resulting in progressive deconditioning and worsening of symptoms [96]. This fear, sometimes escalating to a full-blown phobia of suffocation (anginophobia), creates a self-reinforcing loop: the more a patient avoids activity, the weaker they become, and the more breathless they feel when attempting exertion [92].

Depression is another major comorbidity, affecting up to 30% of patients with COPD and even higher rates in severe cases [98]. Depression not only diminishes quality of life but also reduces motivation to engage in rehabilitation, increases the risk of hospitalization, and is associated with higher mortality. The loss of independence, social isolation, and the burden of managing a chronic illness contribute significantly to this condition. Furthermore, patients who have experienced severe exacerbations requiring intensive care may develop post-traumatic stress disorder (PTSD), with up to 30% reporting symptoms such as flashbacks, nightmares, and hypervigilance related to their medical trauma [28]. These psychological barriers must be identified and addressed to ensure the success of any pulmonary rehabilitation program.

Cognitive-Behavioral Strategies for Managing Dyspnea and Anxiety

To combat the fear of breathlessness and improve adherence to exercise, cognitive-behavioral therapy (CBT) is a cornerstone of psychological support in pulmonary rehabilitation. CBT techniques are specifically adapted to help patients reframe their perception of dyspnea and reduce avoidance behaviors. Cognitive restructuring is used to challenge and modify catastrophic thoughts, such as "I will stop breathing if I walk," replacing them with more realistic and empowering beliefs like "Dyspnea is uncomfortable but not dangerous, and my body can adapt with training" [50].

A key behavioral technique is gradual exposure, where patients are systematically and safely exposed to physical activities that provoke dyspnea, starting with very low-intensity exercises and progressively increasing the challenge. This process, conducted in a supervised and supportive environment, helps patients learn that dyspnea is temporary and manageable, thereby reducing their fear response [101]. This method is often integrated directly into the exercise training component of the program, with close collaboration between the psychologist and the physiotherapist to ensure safety and efficacy.

Role of Psychological Support in Enhancing Quality of Life and Social Functioning

Psychological support plays a vital role in improving not only mental health but also the overall quality of life and social reintegration of patients. Social isolation is a common consequence of respiratory disease, driven by breathlessness, fatigue, and the stigma associated with conditions like COPD [102]. The psychologist works to counteract this isolation by helping patients identify and modify dysfunctional thought patterns, reduce social avoidance, and develop adaptive coping strategies. Group therapy sessions and support groups are particularly effective in this regard, providing a space for shared experiences, mutual encouragement, and reduced feelings of stigma [103].

On a professional level, respiratory disease can lead to job loss or early retirement, which in turn affects self-esteem and financial stability. Psychological counseling is instrumental in preparing patients for return-to-work scenarios, managing work-related stress, and facilitating vocational rehabilitation or job retraining when necessary [104]. The psychologist assesses the patient's functional and psychosocial capacity in collaboration with the multidisciplinary team and supports them through the emotional challenges of role transition and identity change.

Integration of Stress Management Techniques

Stress management is a critical aspect of psychological support, as chronic stress can exacerbate respiratory symptoms through hyperventilation and increased muscle tension [105]. Specific techniques are taught to help patients regulate their physiological and emotional responses. Diaphragmatic breathing and pursed-lip breathing are not only physical techniques to improve ventilation but also powerful tools for calming the nervous system and reducing anxiety [51]. Heart rate variability (HRV) biofeedback and coherent breathing, which involves breathing at a rate of about six breaths per minute, have been shown to enhance parasympathetic tone and reduce stress in patients with chronic lung disease [107].

These techniques are integrated into the daily routine of the rehabilitation program and taught as part of the therapeutic education component. Patients learn to use them not only during exercise but also in everyday situations that trigger anxiety, such as climbing stairs or being in crowded places. The psychologist ensures that these skills are practiced consistently and reinforced through individual and group sessions.

Multidisciplinary Collaboration and Early Intervention

The effectiveness of psychological and behavioral support is maximized through close collaboration within the multidisciplinary team. The psychologist works hand-in-hand with the pneumologist, physiotherapist, nurse, and occupational therapist to ensure a coordinated approach to patient care [4]. Regular team meetings allow for the sharing of observations and the adjustment of treatment plans based on the patient’s psychological and physical progress.

Early psychological screening is crucial. Standardized tools such as the Hospital Anxiety and Depression Scale (HADS), the Generalized Anxiety Disorder-7 (GAD-7), and the Patient Health Questionnaire-9 (PHQ-9) are used at the beginning of the program to identify patients who would benefit from targeted psychological intervention [109]. Early intervention can prevent the escalation of symptoms and significantly improve adherence to the rehabilitation program. For patients with severe psychological distress, the psychologist may coordinate with a psychiatrist for pharmacological treatment when necessary.

Long-Term Maintenance and Empowerment

The ultimate goal of psychological and behavioral support is to empower patients to manage their condition independently. This is achieved by building self-efficacy—the belief in one’s ability to succeed in specific situations. Patients are encouraged to set realistic goals, track their progress, and celebrate small victories, which reinforces their confidence and motivation [110]. The use of personal activity logs and goal-setting worksheets is a common practice to support this process.

Long-term success depends on the maintenance of psychological gains. Supervised maintenance programs that include ongoing psychological support have been shown to be more effective than usual care in preserving improvements in quality of life and exercise tolerance [6]. These programs help patients navigate the challenges of daily life with a chronic illness and provide a safety net for relapse prevention. By addressing the psychological and behavioral dimensions of chronic respiratory disease, pulmonary rehabilitation offers a holistic path to improved well-being and autonomy.

Nutritional Management in Respiratory Disease

Proper nutritional management is a critical component of for individuals with chronic respiratory diseases, directly influencing respiratory function, exercise tolerance, and overall quality of life. Malnutrition, whether in the form of undernutrition (cachexia) or obesity, is highly prevalent among patients with conditions such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, and other chronic lung disorders [112]. These nutritional imbalances significantly affect both respiratory mechanics and metabolic efficiency, necessitating a tailored dietary approach within the multidisciplinary framework of pulmonary rehabilitation [113].

Nutritional Imbalances and Their Impact on Respiratory Function

Two primary nutritional imbalances are commonly observed in respiratory patients: dénutrition with cachexia and obesity, each exerting distinct but detrimental effects on respiratory physiology and exercise capacity.

In cases of dénutrition and cachexia, patients often experience increased energy expenditure due to the inefficiency of breathing, anorexia, dyspnea during meals, and systemic inflammation [113]. This leads to a significant loss of lean body mass, particularly affecting the respiratory muscles such as the diaphragm. The resulting muscle weakness reduces the strength of respiratory contractions and thoracic compliance, thereby increasing the work of breathing and exacerbating dyspnea [53]. Furthermore, the loss of peripheral muscle mass severely limits exercise endurance and contributes to early fatigue, undermining the effectiveness of physical training components in exercise training programs [110]. Correcting this imbalance through targeted nutritional supplementation—rich in calories, proteins, and micronutrients—has been shown to improve body weight, muscle strength, and response to rehabilitation [112].

Conversely, obesity, particularly abdominal obesity, imposes mechanical constraints on respiration. Excess adipose tissue in the chest and abdomen reduces lung volumes, especially the expiratory reserve volume, increases airway resistance, and decreases pulmonary and thoracic compliance [118]. This mechanical burden elevates the respiratory load, worsens dyspnea, and can lead to the obesity hypoventilation syndrome (OHS), characterized by chronic hypoventilation and hypercapnia [54]. Additionally, obesity is associated with low-grade systemic inflammation, which can further impair muscle function and increase fatigue during physical activity [120].

Macronutrient Composition and Respiratory Load

The composition of macronutrients, particularly the ratio of carbohydrates to lipids, plays a pivotal role in managing respiratory load. Carbohydrates have a higher respiratory quotient (RQ) of 1.0 compared to lipids, which have an RQ of 0.7. This means that carbohydrates produce more carbon dioxide (CO₂) per unit of oxygen consumed, increasing the ventilatory demand [121]. For patients with compromised ventilatory capacity, such as those with advanced COPD, a high-carbohydrate diet can exacerbate CO₂ retention and dyspnea.

Therefore, a strategic shift toward a diet moderate in carbohydrates (40–45% of total energy) and higher in lipids (35–40%), particularly unsaturated fats, can reduce the respiratory burden [122]. Emphasis is placed on high-quality lipids such as monounsaturated fats (e.g., olive oil, avocados) and omega-3 fatty acids (found in fatty fish, flaxseeds, chia seeds), which not only lower CO₂ production but also possess anti-inflammatory properties [123]. This dietary pattern aligns closely with the Mediterranean diet, which is recommended for its beneficial effects on inflammation and overall cardiopulmonary health [124].

Personalized Nutritional Strategies Based on Patient Profile

Nutritional interventions must be individualized based on the patient’s specific condition, whether they are underweight, overweight, or obese, and must account for the presence of chronic inflammation.

For patients with cachexia, energy intake should be increased by 10–20% above estimated needs to compensate for the elevated metabolic cost of breathing [125]. Protein intake should be optimized at 1.2 to 1.5 g/kg/day, and up to 1.7 g/kg/day in severe cases, to stimulate muscle protein synthesis and prevent catabolism [55]. Oral nutritional supplements are often necessary to meet these targets, especially when appetite is poor or meal preparation is limited by fatigue [127].

In contrast, for patients with obesity, a moderate caloric deficit of 500–750 kcal/day is recommended to achieve gradual weight loss (0.5–1 kg/week) while preserving lean mass [56]. Protein intake should remain high (1.2–1.5 g/kg/day) to protect muscle during weight reduction, and meals should be fractioned into 4–6 smaller portions to avoid gastric distension, which can compress the diaphragm and worsen dyspnea [129].

Addressing Physical Limitations and Enhancing Adherence

Fatigue and physical limitations significantly impact a patient’s ability to prepare and consume balanced meals. To ensure dietary plans are realistic and sustainable, practical strategies are employed. Simplified meal plans featuring easy-to-prepare foods—such as soups, salads, and pre-cooked healthy options—are recommended to minimize exertion [130]. The use of nutritional supplements allows for adequate caloric and protein intake without requiring large meal volumes.

Adherence is further supported through structured therapeutic education, where patients learn about the direct links between diet, energy levels, and breathing efficiency [131]. Educational tools such as sample menus, shopping lists, and digital tracking apps are provided to facilitate daily implementation [132]. Behavioral strategies, including cognitive-behavioral techniques, help patients manage cravings and build long-term healthy habits [133].

The Gut-Lung Axis and Microbiome Modulation

Emerging evidence highlights the importance of the gut-lung axis, a bidirectional communication pathway linking intestinal microbiota to pulmonary health through immune and inflammatory mechanisms [134]. Dysbiosis, or microbial imbalance, is associated with increased systemic inflammation, which can worsen lung damage and trigger exacerbations [135].

Nutrition plays a central role in modulating the gut microbiome. Diets rich in dietary fiber—especially soluble fibers from fruits, vegetables, legumes, and whole grains—are fermented by gut bacteria into short-chain fatty acids (SCFAs) like butyrate, which have potent anti-inflammatory effects and support immune regulation [136]. In clinical practice, this translates into recommending prebiotic-rich foods (e.g., inulin, FOS) and, when appropriate, probiotic supplementation with strains such as Lactobacillus and Bifidobacterium, which have shown promise in reducing respiratory infections and inflammation in patients with COPD and cystic fibrosis [137], [138].

In conclusion, nutritional management in respiratory disease is not merely supportive but a foundational element of pulmonary rehabilitation. By addressing malnutrition, optimizing macronutrient balance, personalizing dietary plans, and leveraging the gut-lung axis, clinicians can significantly enhance respiratory function, exercise tolerance, and long-term outcomes for patients with chronic lung conditions. Collaboration with a specialized dietitian ensures that nutritional strategies are effectively integrated into the broader multidisciplinary care plan [139].

Delivery Settings and Tele-Rehabilitation

Pulmonary rehabilitation programs are delivered in a variety of settings to accommodate patient needs, accessibility, and clinical stability. These delivery models include traditional center-based programs, hospital or outpatient clinics, and increasingly, home-based options utilizing tele-rehabilitation technologies. The flexibility in delivery settings enhances patient access, particularly for those facing mobility challenges, living in rural areas, or recovering from acute exacerbations [1]. The choice of setting is determined through a comprehensive assessment by a multidisciplinary team, ensuring that the program aligns with the patient's functional limitations, motivation, and medical stability [4].

Center-Based and Hospital Programs

Traditional pulmonary rehabilitation is most commonly conducted in specialized centers, hospitals, or rehabilitation clinics, often integrated within pulmonology departments or rehabilitation medicine units. These programs are typically structured, lasting between 6 to 12 weeks, with sessions held two to three times per week [142]. They are frequently hosted in hospital environments, including university hospitals, specialized pulmonary clinics, or rehabilitation centers offering ambulatory, day hospitalization, or inpatient care [143]. In countries like France and Canada, such programs are available through public health systems and may be delivered in healthcare facilities dedicated to chronic disease management. These center-based models provide direct supervision by a multidisciplinary team including physiotherapists, respiratory therapists, nurses, and dietitians, ensuring immediate medical oversight and access to emergency care if needed. This setting is particularly beneficial for patients with severe chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, or those recovering from major thoracic surgery such as lobectomy or lung transplantation [22].

Home-Based and Tele-Rehabilitation Models

Home-based pulmonary rehabilitation, including tele-rehabilitation, has emerged as an effective alternative, especially for patients with difficulty traveling to medical centers. This model combines structured physical exercises, therapeutic education, and symptom management strategies delivered in the patient’s home environment [60]. Tele-rehabilitation leverages digital technologies to enable remote supervision of exercise sessions, real-time monitoring of vital signs, and virtual consultations with healthcare providers. Studies have demonstrated that home-based programs, whether fully remote or involving periodic in-person check-ins, yield outcomes comparable to center-based programs in terms of improved dyspnea, exercise capacity, and quality of life [5]. The use of telehealth platforms supports patient autonomy and reduces barriers related to transportation, making it particularly valuable for individuals in rural areas or those with significant physical limitations.

Since 2023, remote monitoring for chronic respiratory diseases has been reimbursed by the French national health insurance for patients on long-term oxygen therapy or non-invasive ventilation, facilitating secure and continuous care [147]. Tele-rehabilitation platforms often integrate educational modules on topics such as inhaler technique, exacerbation management, and self-management strategies, empowering patients to actively participate in their care. Programs like RÉADAPTsanté and RESPIREZ mieux by the Canadian Lung Association provide online resources to guide patients through home-based rehabilitation, covering exercise routines, breathing techniques, and lifestyle modifications [60], [149]. Additionally, specialized services such as the Regional Home Care Service for Chronic Lung Diseases (SRSAD) in Quebec offer personalized support following evaluation by a pneumologist, enhancing care continuity and accessibility [75].

Comparative Effectiveness and Patient Selection

The effectiveness of tele-rehabilitation is supported by evidence showing reductions in hospitalizations and exacerbations, similar to traditional programs [61]. A Cochrane review confirmed that technology-delivered pulmonary rehabilitation is as effective as center-based programs in improving quality of life and exercise tolerance [61]. However, patient selection remains crucial. Ideal candidates for home-based programs are those who are clinically stable, motivated, and capable of adhering to a self-managed regimen under remote supervision. Patients with significant comorbidities, unstable conditions, or limited digital literacy may benefit more from in-person models. The decision is guided by a thorough initial assessment of the patient’s physical, psychological, and social status, ensuring safe and effective participation [153].

The integration of tele-rehabilitation into standard care pathways reflects a shift toward patient-centered models that prioritize accessibility and long-term engagement. As digital health technologies continue to evolve, tele-rehabilitation is expected to play an increasingly central role in the management of chronic respiratory diseases, complementing traditional programs and expanding reach to underserved populations.

Outcomes, Benefits, and Long-Term Maintenance

Pulmonary rehabilitation delivers a wide range of evidence-based outcomes and benefits for individuals with chronic respiratory diseases, significantly improving physical, psychological, and social functioning. The program’s effectiveness is well established, with documented improvements in exercise tolerance, symptom reduction, and quality of life. These benefits are achieved through a combination of supervised physical training, therapeutic education, psychological support, and dietetic counseling, all tailored to the individual’s needs [5]. A key challenge, however, is the potential for these gains to diminish after the initial program concludes, highlighting the critical importance of structured, supervised maintenance strategies to ensure long-term success [6].

Measurable Clinical Outcomes and Patient-Centered Benefits

The clinical outcomes of pulmonary rehabilitation are both significant and multifaceted. One of the most consistently observed benefits is a marked improvement in exercise tolerance and physical capacity. This is typically measured using the six-minute walk test (6MWT), where patients often demonstrate an increase in the distance walked, reflecting enhanced endurance and functional performance [110]. This improvement occurs even in the absence of major changes in pulmonary function tests like spirometry, indicating that the gains are primarily due to peripheral adaptations such as improved muscle efficiency and cardiovascular conditioning [5]. The reconditioning of peripheral skeletal muscles reduces fatigue and lactic acid production during exertion, which directly contributes to a decreased perception of breathlessness.

A core benefit is the reduction of dyspnea (shortness of breath), a primary symptom that severely limits daily activities for patients with conditions like chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis. The program helps mitigate dyspnea through several mechanisms, including the reconditioning of respiratory muscles, improved ventilatory efficiency, and the teaching of breathing control techniques such as pursed-lip breathing [158]. By reducing the effort required to breathe, patients experience less anxiety and are more willing to engage in physical and social activities. This reduction in dyspnea is closely linked to another major outcome: a significant enhancement in health-related quality of life. Validated questionnaires such as the Saint George’s Respiratory Questionnaire (SGRQ) consistently show improvements in patients’ physical, emotional, and social well-being after completing a rehabilitation program [73].

The benefits extend beyond physical symptoms to include substantial psychological improvements. Patients often experience a reduction in symptoms of anxiety and depression, which are highly prevalent comorbidities in chronic respiratory disease [49]. The structured support and education provided in the program help patients manage the fear of breathlessness, break the cycle of inactivity, and rebuild confidence in their abilities. This psychological support, often delivered by a psychologist as part of a multidisciplinary team, is crucial for long-term adherence and success [81]. Furthermore, pulmonary rehabilitation plays a vital role in reducing the frequency of exacerbations and hospitalizations. By improving disease self-management, enhancing physical resilience, and promoting early recognition of warning signs, patients are better equipped to prevent and manage acute episodes. A Cochrane Review has confirmed that pulmonary rehabilitation after a hospitalization for COPD exacerbation significantly reduces the risk of future hospital admissions, thereby decreasing the overall burden on the healthcare system [2].

Long-Term Maintenance and Strategies for Sustained Success

Despite the clear short-term benefits, the positive effects of pulmonary rehabilitation can begin to wane within six to twelve months after the program ends if not actively maintained. This phenomenon underscores the necessity of a transition from the initial intensive phase to a long-term maintenance strategy. Research, including a 2025 Cochrane Review, has demonstrated that supervised maintenance programs are significantly more effective than usual care in preserving the gains in exercise capacity and quality of life [6]. These maintenance programs typically involve regular, ongoing exercise sessions, often held once or twice a week, and may include continued educational and psychosocial support.

To overcome barriers to attendance, such as transportation difficulties or living in rural areas, alternative delivery models have been developed. Tele-rehabilitation, which uses technology to deliver exercise coaching and monitoring remotely, has been shown to produce outcomes comparable to center-based programs [61]. This approach increases accessibility and can be a vital component of a long-term maintenance plan. Programs like RÉADAPTsanté and RESPIREZ mieux by the Canadian Lung Association provide structured online resources to support patients in maintaining their exercise routines and self-management skills at home [60]. The integration of these maintenance strategies into the standard care pathway is essential for maximizing the long-term value of pulmonary rehabilitation.

The success of long-term maintenance is also influenced by the initial program's design and the patient's individual characteristics. A personalized approach, based on a thorough initial assessment of the patient's functional status, comorbidities, and motivation, is key to creating a sustainable plan [74]. The involvement of a multidisciplinary team, including physiotherapists, dietitians, and psychologists, ensures that all aspects of the patient's health are addressed. Ultimately, the goal is to empower patients to integrate regular physical activity and effective self-management strategies into their daily lives, transforming the temporary gains of rehabilitation into a permanent improvement in their overall health and well-being.

References