ATS Guidelines Highlight Benefits of Pulmonary Rehabilitation

Chronic respiratory diseases impact more than 545 million people worldwide, severely diminishing health-related quality of life and functional status while escalating healthcare costs.

Alarmingly, less than 5% of COPD patients who could benefit from pulmonary rehabilitation actually participate in such programs.

Guidelines published in 2023 by the American Thoracic Society address pulmonary rehabilitation for adults suffering from chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), and pulmonary hypertension (PH).

A review of those guidelines published in JAMA this week provides a summary of those guidelines and what they could mean for the future of chronic respiratory disease care.

Krishna Pandya, M.D.

Krishna Pandya, M.D., a third-year fellow at the University of Pennsylvania’s Division of Pulmonary, Allergy and Critical Care, and the corresponding author of the JAMA review, noted a major barrier to pulmonary rehabilitation is access.

“One of the ways in which these guidelines are new and important is that they are the first to evaluate the role of telerehabilitation programs in chronic respiratory disease,” she told MHE. “Transportation to pulmonary rehabilitation centers can be both costly and logistically challenging for patients. Telerehabilitation may overcome some of these issues to improve access on the patient-side.”

Another important barrier directly addressed by these guidelines is the need for changes in health policy to support pulmonary rehabilitation programs.

“The guidelines highlighted that COPD patients who initiate pulmonary rehabilitation after hospitalization for a COPD exacerbation are significantly less likely to be readmitted and significantly less likely to die in the following year,” Pandya said. “JAMA recently published a paper showing that universal initiation of PR [pulmonary rehabilitation] within 90 days of a hospitalization for a COPD exacerbation would save Medicare $1 billion to $1.25 billion dollars a year. So, not only is pulmonary rehabilitation beneficial from the patient perspective but also is beneficial from an overall policy perspective.”

The evidence for telerehabilitation is based primarily on studies enrolling patients with COPD. In patients with COPD, there were no differences between the effectiveness of telerehabilitation and traditional in-person rehabilitation for walk distance, health-related quality of life and shortness of breath.

“Telerehabilitation participants were actually more likely to complete a PR program,” Pandya said. “Further research is needed to evaluate telerehabilitation in other types of chronic respiratory diseases, for example interstitial lung disease and pulmonary hypertension.”

Patients with distinct types of chronic respiratory diseases, such as ILD or PH, can also benefit from customized rehabilitation programs tailored to their specific needs.

“Pulmonary rehabilitation programs are patient-tailored and aim to be individualized to patient needs and abilities,” Pandya said. “In the guidelines we discuss that patients with COPD, ILD, and PH all had clinically significant improvements in quality of life and in their 6-minute walk distance, which is a measure of someone’s functional capacity is associated with patient outcomes, after participating in pulmonary rehabilitation.”

Yet, there remains room for improvement, Pandya said. “We know that patient needs may vary based on their underlying lung disease,” she noted. “For example, in ILD, we know that moderate resting hypoxemia is associated with higher mortality, as compared to patients with COPD. There is currently an ongoing trial in ILD evaluating the effect of supplemental oxygen on exercise capacity and activity. Better understanding these disease-specific considerations may allow us to better equip rehabilitation centers with tools to improve tailored programs.”

The guidelines acknowledge several future research avenues, such as establishing optimal durations and components of rehabilitation programs and further exploring the effects of supplemental oxygen during exercise. Currently, while adverse events resulting from rehabilitation appear to be low, comprehensive evaluations are needed to understand the safety profiles fully.

“The goals of the guidelines were to summarize evidence, highlight the advantages of, and show important considerations regarding pulmonary rehab for our patients with lung disease, ultimately, with the hope to increase patient referrals to this critical treatment that improves patient outcomes,” Pandya said. “In addition to the summary, the guidelines were discussed in podcast format to increase awareness for busy clinicians.”

Additionally, the guidelines thoroughly highlight for policymakers the potential benefits of pulmonary rehabilitation including the improvement in quality of life, functional capacity and reduction of hospitalization for patients, while also providing the benefit of cost-savings.

“Though telerehabilitation can help to partially fill the gap of access to the underserved, this is not a perfect solution as our patients may not necessarily have access to stable internet/video,” Pandya said. “Therefore, increasing funding to expand access in underserved areas, higher reimbursements, incentivization of new centers and investing in creative solutions such as home-based pulmonary rehabilitation programs may all improve access.”