What the New ATS Pulmonary Rehabilitation Guidelines Mean for Clinicians

This post was written by Mike Hess, MPH, RRT, RPFT.

Pulmonary rehabilitation (PR) has long been recognized as one of the most effective interventions for people living with chronic lung disease. It is also one of the most under-utilized and inconsistently applied interventions. One person's PR experience can be vastly different from another's, and much of the previous body of research was based exclusively on PR in the setting of chronic obstructive pulmonary disease (COPD). This has led to tremendous inequalities and access issues for many across the country.

The American Thoracic Society (ATS) sought to bring order to the PR universe by publishing updated clinical practice guidelines in 2023¹. Developed by a multidisciplinary team (including someone living with COPD) in accordance with the rigorous Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology, these guidelines provide formal guidance regarding who should receive PR and how it should be offered. It also provides a roadmap for future research and a clear call for policymakers to take actions that improve access.

A key component of the GRADE process is to establish specific questions that the guideline intends to address². These questions, known as PICO questions, serve to identify the relevant patient population (P), the desired intervention (I; in this case pulmonary rehab), a comparator (C; often the existing standard of care or a null hypothesis), and relevant outcomes (O; encompassing clinical outcomes, costs, risks, and other factors). Once the PICO questions are created, the review panel then carefully analyzes the results of literature reviews for each to answer the questions and evaluate the strength of the available data. These answers are then converted into recommendations, complete with context on how confident the panel is that the benefits of the recommendation outweigh the undesirable effects, as well as the quality of the data. This framework allows for objective analysis while including some room for expert opinion, especially in areas where evidence is less robust.

The ATS panel came up with a total of six PICOs that can be broadly sorted into three buckets. The first focuses on determining who should receive PR. Unsurprisingly, the team made a strong recommendation for adults with stable COPD to receive a course of PR at some point. The evidence was unfortunately low- to moderate-quality due to factors like heterogeneity in delivery and a lack of information on exacerbation reduction. However, patients were found to put a high value on the results they saw, and there were no significant adverse effects in the relevant studies. That gave PR a big upside with few drawbacks. They made a similarly strong recommendation for PR after an acute exacerbation of COPD, finding that its use in that timeframe did seem to reduce the risk of readmission somewhat. There was also some evidence for quality-of-life improvements, and the panel felt that the risks of adverse events were low.

Another strong recommendation went outside the COPD population to encourage the use of PR in interstitial lung disease (ILD). Like with COPD, identified studies found consistent improvements in outcomes like exercise capacity with little risk of adverse effects. Interestingly, the group highlighted that because the 5-year mortality rate for many ILDs is unfortunately high, even improvements that are not sustained can still be quite meaningful to patients.

Where things start to get fuzzier is in the setting of pulmonary hypertension. The group still recommended referrals to PR here, but only on a conditional level. Conditional recommendations mean that fewer patients in the study population would feel the benefits outweigh the burdens, and that the decision to participate should be carefully discussed. This was attributed to the limited evidence specific to this patient group, as well as a higher incidence of adverse events like chest pain, hypotension, and cardiac arrhythmias during exercise. The group felt that participation in a PR program staffed by clinicians well-versed in pulmonary hypertension would reduce those risks, but the data simply were not there to support that for everyone.

Similarly, the use of maintenance PR (after the initial program) had little supporting evidence. In people with COPD (the only studied population across 21 identified trials), there was virtually no statistically significant difference in any outcome. However, the group strongly suggested that some kind of exercise, structured or not, be continued after an initial PR course.

The last question concerned one of the hottest topics in PR right now: The use of telerehabilitation. Telerehabilitation is often looked at as a key avenue to eventually reduce access barriers and bring PR to everyone. The group strongly recommended that telerehab at least be offered in all cases, while noting it was not a one-size-fits-all (or even most) solution. However, the fact that telerehab seemed to provide equivalent outcomes in several studies and had similarly low risks, making it an appealing option for those interested.

Arguably, many of these recommendations simply reinforce what many clinicians probably already felt in their hearts. Pulmonary rehabilitation is a safe, effective intervention for many people living with lung disease. However, the importance of this document goes well beyond that reinforcement. It provides a clear, evidence-based rationale for increasing access to these programs. It provides a scientific basis for policy change at all levels of government (and hospital administration), and it identifies knowledge gaps to stimulate future research. It is a clear step forward in making this powerful intervention accessible to all.