Despite overwhelming evidence of its benefits, pulmonary rehab utilization is surprisingly low among COPD patients. This article will provide 7 key components that RTs can use to effectively design and implement a COPD pulmonary rehab program.

By Bill Pruitt, MBA, RRT, CPFT, FAARC 


Chronic obstructive pulmonary disease (COPD) is a widespread disease that costs billions of dollars in direct healthcare costs and indirect costs (ie, lost work time, decreased productivity). The 2025 Global Initiative for Chronic Lung Diseases (GOLD) guidelines state that COPD is a common, preventable, and treatable disease but due to underdiagnosis and misdiagnosis, many patients receive incorrect treatment or no treatment at all.1 Exposure to tobacco smoke and inhalation of toxic particles and gases from household (homes using wood and other biomass fuels for heating/cooking) and outdoor sources (air pollution or occupational exposure to dust, chemicals) are targeted as the main causes of COPD. In addition, some patients develop COPD due to a genetic cause which leads to alpha-1-antitrypsin deficiency.1 

Diagnosis of COPD should be considered in patients who have dyspnea, chronic cough with/without sputum production, a history of frequent infections in the lower airways, and spirometry results showing a post-bronchodilator FEV1/FVC <70%. Note that the GOLD 2025 guidelines have spirometry as a mandatory test in making the diagnosis of COPD.1

Globally, COPD is in the top three causes of death. The GOLD 2025 definition states that: “COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production and/or exacerbations due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.”1

Pulmonary rehabilitation (PR) is a comprehensive, interactive program that begins with a thorough assessment of the patient and moves on to a patient-specific plan that includes individualized exercise training, patient education (including self-management), and encouragement to change unhealthy behaviors. PR’s outcomes should be measured and delivery of these components should be accomplished by a multidisciplinary team of healthcare professionals. Effective engagement in PR is expected to improve the physical and psychological condition of patient with chronic respiratory disease, and to encourage long-term commitment to healthy behaviors.2 PR has been shown to reduce dyspnea, increase exercise capacity, improve health-related quality of life (HRQoL), improve the patient’s emotional state, provide social support, reduce hospital admissions, and reduce risk of death after hospitalization.2

Successful and effective PR programs should include these 7 key components:

1. Comprehensive Patient Assessment


“A thorough patient evaluation should precede PR to tailor interventions effectively. This includes assessing medical history, physical capabilities, and psychological status.” 3 

The GOLD 2025 guidelines recommend including the following in the patient assessment:

  • A detailed history and physical exam with an emphasis on the cardiopulmonary systems and including the patient’s smoking status;
  • Measurement of post-bronchodilator spirometry;
  • Assessment of exercise capacity (by cycle ergometry or treadmill, 6-minute walk testing, and/or shuttle walk tests);
  • Measurement of health status and the impact of breathlessness with questionnaires such as the COPD Assessment Test (CAT), Chronic Respiratory Questionnaire (CRQ), or St George’s Respiratory Questionnaire (SGRQ). Identifying anxiety and depression should also be performed using tools such as the Hospital Anxiety and Depression Scale (HADS) and the Primary Care Evaluation of Mental Disorders (PRIME-MD);
  • Assessment of inspiratory/expiratory muscle strength and lower limb strength (particularly in cases involving muscle wasting);
  • Discussion of patient goals and expectations for what they hope to achieve in work, home, and/or leisure activities by the end of the program.

2. Multidisciplinary Approach


Pulmonary rehab programs should involve a team of healthcare professionals, including physicians, physical therapists, respiratory therapists, nurses, and psychologists, to address the multifaceted needs of patients.1,3 Even though no clear guidelines exist regarding the structure of the team itself, several key members are essential to developing a successful pulmonary rehabilitation program.

The team usually includes pulmonologists, respiratory therapists, physical therapists, occupational therapists, exercise physiologists, nurses, psychologists, behavior specialists, and nutritionists, allowing for a multidisciplinary approach. For instance, a PR program at UCLA, for instance, consists of personalized twice-a-seek sessions that include pulse-oximetry-monitored exercise, RT-coached breathing techniques, access to supplemental oxygen, PT-coached stretching and strength training, fitness/health education including inhaler use, and psychologist-led mental health screening/counseling.7

3. Exercise Training


“Exercise training should be customized to the individual’s capabilities and limitations, aiming to improve both endurance and muscle strength.” 3 

Supervised exercise training is the cornerstone of PR and has been shown to impact endurance, HRQoL, and dyspnea.3 Supervised, progressive walking and/or use of a stationary cycle with progressive increases in resistance/load have been used to increase endurance through aerobic exercise. 

Resistance training helps strengthen muscles and is used along with endurance training to increase muscle mass. The ideal approach for resistance training is not known, but PR programs have been working with conventional strength training machines, pulleys, free weights, and elastic resistance bands with good effect. 

It is recommended to perform strengthening exercises for both the upper and lower limbs.4-5 This should be done under the guidance and coaching of a physical therapists and occur 2-3 days a week.4-5 In recent years new and different approaches to exercise have been included in PR, such as aquatic exercise training, downhill walking, and whole body vibration, where the patient exercises on a vibrating platfom.3-4 

Other exercises that are recommended include inspiratory and expiratory muscle training, diaphragmatic breathing exercises, and pursed lip breathing exercises. Lastly, neuromuscular electrical stimulation (NMES) has also been utilized whereby the muscles get stimulated via adhesive electrodes placed on the skin. Published studies using NMES in COPD patients have shown a 20-30% gain in quadriceps strength as compared with control subjects.4 Conventional oxygen therapy, high-flow oxygen therapy (HFOT) and noninvasive ventilation (NIV) have also been incorporated to provide support during exercise sessions and have improved outcomes.1,3

Maintaining improved endurance and strength after the conclusion of the formal PR program is an issue. Efforts need to be made to encourage continued exercise (and maintain behavioral changes) in order to maintain better health with reduced symptoms and burden of the disease.

4. Education and Self-management


“Providing individuals with education about their condition and training in self-management strategies is crucial for long-term adherence to health-enhancing behaviors.” 3 

Effective patient education should include smoking cessation, basic information about COPD, correct use of inhaler devices, early recognition of exacerbation, self-management skills, information on proper nutrition, when to call for help, advance directives, and end-of-life issues (including palliative and hospice care).1

electrical stimulation (NMES) has also been utilized whereby the muscles get stimulated via adhesive electrodes placed on the skin. Published studies using NMES in COPD patients have shown a 20-30% gain in quadriceps strength as compared with control subjects.4 Conventional oxygen therapy, high-flow oxygen therapy (HFOT) and noninvasive ventilation (NIV) have also been incorporated to provide support during exercise sessions and have improved outcomes.1,3

Maintaining improved endurance and strength after the conclusion of the formal PR program is an issue. Efforts need to be made to encourage continued exercise (and maintain behavioral changes) in order to maintain better health with reduced symptoms and burden of the disease.

5. Psychosocial Support


“Addressing psychological aspects such as anxiety and depression is essential as these can significantly impact the overall well-being and rehabilitation outcomes.” 3 

Tools such as cognitive behavioral therapy and mind-body techniques (ie, mindfulness-based therapy, yoga, t’ai chi, and relaxation) can help reduce issues with panic, anxiety, and depression.1,3 CBT—”a structured and purposeful talk therapy widely used for patients with chronic diseases and psychological problems”—was superior in reducing anxiety symptoms compared to usual care, and CBT plus PR was more effective than PR alone in short-term follow-up.8

6. Accessibility


“Efforts should be made to increase the availability and accessibility of PR programs to all eligible people, recognizing the current underutilization of these services.” 3 

Barriers to accessing PR include distance and location of PR programs, cultural norms and customs (often an issue for women), limited finances, and transportation. Beyond hospital-based PR programs, other locations that have shown effectiveness include community-based and home-based programs, as well as PR being performed through telehealth/telemedicine, video conferencing, telephone-only, and website with telephone support, etc.1

7. Outcome Measurement


“Regular assessment of outcomes, including exercise capacity, symptom relief and HRQoL, is recommended to evaluate the effectiveness of PR interventions.” 3 

Measurement and reporting of outcomes provides a means to evaluate cost/benefit of new approaches, allow for comparisons between PR programs, contributes to the data collection needed in research, and supports the justification for staffing, facilities, etc. Reporting outcomes also aids in increasing referrals to PR programs. It is estimated that 3-16% of eligible patients receive a referral for PR and only 2-4% take part in a PR program, despite the following facts:

  • There is strong evidence supporting the benefit of PR on increasing HRQoL, exercise capacity, and COPD symptoms
  • The American Thoracic Society/European Respiratory Society (ATS/ERS), British Thoracic Society, and GOLD guidelines all support use of PR in management of COPD
  • Medicare part B covers up to two one-hour sessions in PR per day for up to 36 days for patients with moderate to severe COPD.6 

Conclusion

PR for COPD patients has been shown to be effective and life-changing for many. PR programs have well-defined standards and best practices provided in peer-reviewed publications and PR can be provided at a fairly low cost—particularly due to little need for expensive capital equipment. Despite the published evidence, the guidelines recommendations, and the financial support behind and promoting PR, utilization is surprisingly low. Respiratory therapists should take every opportunity to promote PR as it can change the day-by-day life of their COPD patients.

RT

Bill Pruitt, MBA, RRT, CPFT, FAARC, is a writer, lecturer, and consultant. Bill has over 40 years of experience in respiratory care in a wide variety of settings and has over 20 years teaching at the University of South Alabama in Cardiorespiratory Care. Now retired from teaching, Bill continues to provide guest lectures, participates in podcasts, and writes professionally. For more info, contact [email protected].


References

  1. GOLD 2025 Report. https://goldcopd.org/2025-gold-report.
  2. Rochester CL, et. al. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society clinical practice guideline. AJRCCM. 2023 Aug 15;208(4):e7-26.
  3. Candia C, et al. The history of pulmonary rehabilitation: learning from the past to shape a brighter future. Breathe. 2025 Sep 16;21(3).
  4. Gloeckl R, et al. Practical recommendations for exercise training in patients with COPD. European Resp Review. 2013 May 31;22(128):178-86.
  5. Nici L, et. al. On pulmonary rehabilitation and the flight of the bumblebee: the ATS/ERS Statement on Pulmonary Rehabilitation. Eur Respir J 2006; 28: 461–462.
  6. Fu WW, et al. Use of pulmonary rehabilitation after COPD hospitalization: an analysis of statewide patient and hospital data. Annals of the American Thoracic Society. 2024 Dec;21(12):1698-705.