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Positioning pulmonary rehabilitation within the GOLD 2025 guidelines

This is an excerpt from Guidelines for Pulmonary Rehabilitation Programs 6th Edition by AACVPR.

By Brian Carlin, MD, MAACVPR

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides yearly updates in the field of COPD, with recommended management strategies for patients with COPD. The current GOLD recommendations (2025) for the management of a patient with COPD continue to include the ­recommendation for the use of ­pulmonary rehabilitation as part of the ­comprehensive ­treatment of this disease (25). Pulmonary ­rehabilitation is considered an option for ­moderate disease when symptoms become present on a daily basis. As the symptom burden increases, the need for ­pulmonary rehabilitation increases.

Increasing Availability

While known as an essential component of the management of a patient with COPD, pulmonary rehabilitation is underrecognized and underused. Less than 5% of Medicare patients with COPD have been enrolled in a pulmonary rehabilitation program (37). Too few pulmonary rehabilitation programs are currently available to meet this need. Even in areas where pulmonary rehabilitation programs are available, they are underutilized by health care professionals. Many health care providers and patients remain unaware of the potential benefits that can be gained following pulmonary rehabilitation as well as whether a program exists in the local community. Increased education of health care professionals and patients on the rationale, indications, and proven benefits should help to address this underutilization. Adequate reimbursement for pulmonary rehabilitation should also help to alleviate the burden. Strategies for the promotion of pulmonary rehabilitation like those used in high proficiency programs have been published (38).

Widening Applicability

Widening the applicability of pulmonary rehabilitation for patients with chronic lung diseases apart from COPD should naturally follow the growing evidence base supporting its use. This should include those patients with interstitial lung disease, pulmonary hypertension, lung cancer, asthma, non–cystic fibrosis bronchiectasis, and other chronic lung diseases (39, 40). Also included should be those patients with COPD who are in a milder stage of their disease, those following an exacerbation or hospitalization, and those who are at the end of their lives, in collaboration with palliative care.

Maintaining Long-Term Benefits and Promoting Self-Efficacy

The exercise benefits of pulmonary rehabilitation tend to decrease after completion of the formal program for a variety of reasons, including poor adherence to exercise and activity prescription, underlying exacerbations, influence of comorbid conditions, and deterioration from the disease itself. The comprehensive multicomponent pulmonary rehabilitation program must address this issue. Potential solutions include providing a longer pulmonary rehabilitation program, reintroduction of a modified form of pulmonary rehabilitation after an exacerbation, incorporation of structured exercise and increased activity in the home setting, and promotion of self-management strategies that encourage the patient to be more responsible for their health (41-43).

TELEHEALTH AND TELEREHABILITATION

Since the SARS-CoV-2 epidemic, telehealth services have dramatically increased throughout medical care. These services now include the implementation and development of telerehabilitation. With the increase in these services becoming more available, a greater number of patients should have access to pulmonary rehabilitation. These telerehabilitation services should provide the same level of evaluation and management of each patient as is performed in center-based programs. Various strategies for performance of these programs have been suggested (44-47). Given the rapid evolution of this field, increased research attempting to establish optimal models of telerehabilitation for patients with chronic lung disease must be undertaken. A recent position statement of the AACVPR recognizes the importance of telecardiac and telepulmonary rehabilitation services and has summarized current thoughts on how such services would be provided (48).

More Excerpts From Guidelines for Pulmonary Rehabilitation Programs 6th Edition

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