Chronic respiratory diseases such as COPD, interstitial lung diseases (ILDs), pulmonary hypertension (PH), bronchiectasis, and lung cancer carry significant disease morbidity and mortality with disabling respiratory symptoms, including dyspnea, fatigue, poor exercise tolerance, inability to perform daily activities, and overall poor quality of life.1 These symptoms can lead to chronic depression, anxiety, and fear among patients and increase the risk of hospitalization and poor clinical outcomes overall.
Patients with ILD and PH frequently encounter severe exertional hypoxemia due to ventilation-perfusion mismatch and diffusion limitations. To avoid distressing dyspnea, many patients progressively limit physical activity as an avoidance mechanism to dyspnea, prompting a vicious cycle of peripheral muscle deconditioning and cardiovascular intolerance. Pulmonary rehabilitation (PR) helps break this cycle by improving mechanical ventilatory efficiency, thereby improving exercise capacity and quality of life.1
PR is a widely recognized intervention with several proven health-related benefits across a broad range of chronic respiratory diseases. Initial studies demonstrated benefits among patients with severe COPD in terms of reduced mortality and rehospitalization.2 Current clinical practice guidelines have since expanded recommendations to include other chronic lung diseases, particularly ILD and PH, with the availability of additional randomized controlled trials.1 A meta-analysis of 13 randomized controlled trials demonstrated that PR in various ILDs, including idiopathic pulmonary fibrosis (IPF), improved 6-minute walk distance (6MWD) compared with usual care or control groups, with benefits sustained at six to 12 months in the group without IPF.1 Health-related quality of life and dyspnea scores also improved compared with controls. Current clinical practice guidelines from the American Thoracic Society (ATS) therefore provide a strong recommendation for PR in patients with any ILD, including IPF, based on significant and sustained improvements in exercise capacity, dyspnea, and quality of life.1,3
PH, including pulmonary arterial hypertension (PAH), is similarly associated with exertional dyspnea, hypoxemia, and overall poor exercise tolerance. Both inpatient and outpatient PR programs have been evaluated in populations with PH, particularly among patients with PAH and chronic thromboembolic pulmonary hypertension with WHO functional class II and III.4 Studies have demonstrated improvement in 6MWD and health-related quality of life among patients with PH undergoing PR compared with usual care. Current guidelines therefore provide a conditional recommendation for PR in patients with stable PH.1,4
PR remains one of the most effective interventions available for chronic respiratory disease, yet fewer than 5% of eligible patients receive it.5–6 Despite growing evidence supporting PR in ILD and PH, utilization remains limited by systemic and logistical barriers. Patients often face challenges, including geographic distance from rehabilitation centers, advanced oxygen requirements, transportation difficulties, and severe exertional dyspnea, that limit participation in traditional center-based programs.
Telerehabilitation for PR is an evolving field that offers several potential advantages with outcomes comparable to center-based PR. The 2023 ATS guideline supports either center-based PR or telerehabilitation for adults with stable chronic respiratory disease based on evidence demonstrating similar improvements in exercise capacity, dyspnea, and quality of life.1 A recent systematic review and meta-analysis of 17 randomized controlled trials involving 1,658 participants also demonstrated comparable short-term outcomes between telerehabilitation and center-based PR programs.7 Telerehabilitation may therefore help overcome barriers to PR participation, particularly for patients with advanced oxygen dependence or limited transportation access. However, broader implementation remains constrained by reimbursement limitations and lack of consistent insurance coverage for home-based PR services.8
An additional challenge across both ILD and PH populations is the decline in functional benefits within six to 12 months after completing PR, emphasizing the need for structured long-term maintenance programs.9 Sustained access to maintenance PR, including virtual or home-based options, remains limited by ongoing reimbursement and infrastructure barriers.
Clinicians in chest medicine are uniquely positioned to lead this effort. Pulmonologists can advocate for automated PR referral systems, educate trainees regarding the importance of rehabilitation, collaborate with multidisciplinary teams, and engage policymakers to improve reimbursement and accessibility. The benefits of PR are well-established; the challenge now lies in ensuring equitable access for the patients who need it most.
References
1. Rochester CL, Alison JA, Carlin B, et al. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2023;208(4):e7-e26. doi:10.1164/rccm.202306-1066ST
2. Global Initiative for Chronic Obstructive Lung Disease. Pocket Guide to COPD Diagnosis, Management and Prevention: 2026 Report. Nov. 20, 2025.
3. Chang JA, Curtis JR, Patrick DL, Raghu G. Assessment of health-related quality of life in patients with interstitial lung disease. Chest. 1999;116:1175-1182. doi:10.1378/chest.116.5.1175
4. Morris NR, Kermeen FD, Jones AW, Lee JYT, Holland AE. Exercise-based rehabilitation programmes for pulmonary hypertension. Cochrane Database Syst Rev. 2023;3(3):CD011285. doi:10.1002/14651858.CD011285.pub32023;3:CD011285
5. Garvey C, Bayles MP, Hamm LF, et al. Pulmonary rehabilitation exercise prescription in chronic obstructive pulmonary disease: review of selected guidelines. J Cardiopulm Rehabil Prev. 2016;36(2):75-83. doi:10.1097/HCR.0000000000000171
6. Spitzer KA, Stefan MS, Priya A, Pack QR, Pekow PS, Lagu T. Participation in pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease among Medicare beneficiaries. Ann Am Thorac Soc. 2019;16(1):99-106. doi:10.1513/AnnalsATS.201805-332OC
7. Li Y, Zhang H, Zhao G, et al. Comparing pulmonary telerehabilitation and center-based pulmonary rehabilitation for effectiveness and adherence in chronic obstructive pulmonary disease: systematic review and meta-analysis of randomized controlled trials. J Med Internet Res. 2026;28:e80500. doi:10.2196/80500
8. Cox NS, Dal Corso S, Hansen H, et al. Telerehabilitation for chronic respiratory disease. Cochrane Database Syst Rev. 2021;1(1):CD013040. doi:10.1002/14651858.CD013040.pub2
9. Nolan CM. Maintenance programmes following pulmonary rehabilitation in idiopathic pulmonary fibrosis: exercise, drugs and rock n’ roll. Thorax. 2023;78(8):739-740. doi:10.1136/thorax-2023-220229
