European Respiratory Society

Pulmonary Rehabilitation

Edited by Anne E. Holland, Simone Dal Corso and Martijn A. Spruit
Pulmonary Rehabilitation

Pulmonary rehabilitation is an effective treatment for people with a range of chronic lung diseases. In recent years, there have been substantial advances in the science underpinning pulmonary rehabilitation. Advances have been seen in the patient groups in whom it is indicated; in the breadth of programme content; in new methods of delivery; and not least, in important outcomes. This Monograph brings together scientific and clinical expertise in pulmonary rehabilitation, with the aim of optimising its delivery in clinical practice.

  1. Page v
  2. Page vii
  3. Page ix
  4. Page 1
    Abstract
    Chris Burtin (chris.burtin@uhasselt.be)

    Decreased exercise capacity, skeletal muscle dysfunction and a physically inactive lifestyle are associated with symptoms of fatigue and dyspnoea in patients with chronic lung disease. Many of these extrapulmonary features have been identified as treatable traits for PR, a comprehensive individualised nonpharmacological intervention that includes exercise training, education and behaviour change. PR improves exercise capacity, symptoms and QoL to a clinically relevant extent. In patients with COPD, it also appears to be a cost-effective intervention and is suggested to improve mortality. PR can be delivered in various settings, such as hospital based, community based, home based and telerehabilitation. The choice of setting needs to be made in light of the complexity of the patient. Unfortunately, referral to PR is very low worldwide, making the enhancement of access to PR the number one challenge for the near future in the field of PR.

    Cite as: Burtin C, Wadell K. The rationale for pulmonary rehabilitation. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 1–10 [https://doi.org/10.1183/2312508X.10017320].

  5. Page 11
    Abstract
    Samantha Harrison (S.L.Harrison@tees.ac.uk)

    People with chronic lung disease (CLD) have physical, psychological and social needs. The primary focus of PR is on reducing symptoms of breathlessness, but programmes need to be tailored to address the holistic needs of individuals. Those who attend PR have positive experiences, describing improvements in symptoms and mood. They also emphasise the social opportunities PR affords, describing the friendships they have formed and the experiences they have shared. However, many individuals with CLD do not attend PR for a variety of reasons, including time and travel difficulties. Patients often do not understand what PR involves; in consultations, patients have recommended that the programme's content and aims should be clearly outlined. HCPs may require education to be able to deliver this information accurately and positively. It may also be necessary to offer PR in a flexible way to encourage acceptance; for example, providing classes at evenings and weekends, offering alternative modes of delivery (e.g. online and home-based rehabilitation) and making alternative activities available (e.g. dance, yoga). HCPs can promote engagement in PR by attending to individuals' specific needs and celebrating their successes. Sustainability may be encouraged by enabling opportunities for continued peer-support.

    Cite as: Harrison SL, Powell P, Lahham A. Patient experiences. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 11–22 [https://doi.org/10.1183/2312508X.10017420].

  6. Page 23
    Abstract
    Corresponding author: Andre Nyberg (andre.nyberg@umu.se)

    Patient assessment and outcome measurement are essential features of PR for people with chronic respiratory diseases and should minimally include exercise capacity, symptoms and HRQoL. Irrespective of assessment strategy choice, measurement properties such as validity, reliability and responsiveness need to be considered. The availability of MCIDs and normative values facilitates the interpretation of results. A wide range of different assessment methods, tests and tools are available. Notably, many are easy to use, valid, reliable and responsive, and have known cut-off values for clinical relevance. For exercise capacity, both laboratory- and field-based assessment strategies can be used, and specific tests for limb and respiratory muscle function are available. Assessment of symptoms should at least include dyspnoea and fatigue, but additional domains such as anxiety and depression and multiple symptoms tools can broaden patient evaluation. Both generic and disease-specific assessments are recommended and are commonly used within PR to determine the impact of various HRQoL dimensions on the patient.

    Cite as: Nyberg A, Probst V, Vaes AW. Assessment. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 23–52 [https://doi.org/10.1183/2312508X.10017520].

  7. Page 53
    Abstract
    Kylie Hill (K.Hill@curtin.edu.au)

    In people with COPD, there is convincing evidence that exercise training reduces dyspnoea and fatigue and improves exercise capacity and HRQoL. Core components include aerobic (endurance) training and resistance (strength) training. Prescription of exercise for people with COPD should be individualised using the results of the person's pre-training assessment and should consider the impact of any comorbidities. Principles such as specificity, overload, recovery, progression, variation, reversibility, and warm-up and cool-down should be considered. The intensity of walking-based training can be prescribed using the results of field-based walking tests. The intensity of cycle-based training can be prescribed using the results of an incremental cycle ergometry test, or estimated using the results of field-based walking tests. The intensity of resistance training is often prescribed as a proportion of one repetition maximum. During training, people should be monitored and the intensity of exercise progressed according to the severity of dyspnoea and leg fatigue.

    Cite as: Hill K, de Brandt J. Exercise prescription for people with stable COPD. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 53–66 [https://doi.org/10.1183/2312508X.10017620].

  8. Page 67
    Abstract
    Rainer Gloeckl (rgloeckl@schoen-klinik.de)

    Exercise training for people with chronic respiratory disease is no longer a “one size fits all” model of care. In recognition of the heterogeneous impact that individual preferences, clinical features and physiological adaptations have on training outcomes, many attempts have been made to expand the treatment landscape to deliver a more personalised and effective experience. Several alternative interventions are attracting increasing interest due to their potential to: 1) enhance engagement with exercise, 2) enhance the stimulus of exercise on skeletal muscles, 3) overcome important limitations to performing exercise, and 4) effectively manage clinically relevant comorbidities. Examples of these approaches include whole-body vibration training, respiratory muscle training, heliox supplementation, high-flow therapy, noninvasive ventilation, partitioning, eccentric training, t'ai chi and neuromuscular electrical stimulation. Significant barriers remain to be overcome before these approaches are commonplace within clinical practice. This chapter provides an overview of the current evidence, as well as some practical recommendations on how to apply these alternative training strategies.

    Cite as: Gloeckl R, Osadnik C. Alternative training strategies for patients with chronic respiratory disease. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 67–82 [https://doi.org/10.1183/2312508X.10017720].

  9. Page 83
    Abstract
    Ingeborg Farver-Vestergaard (Ingeborg.Farver-Vestergaard@rsyd.dk)

    Reduced occupational performance, malnutrition and psychological distress are common in chronic respiratory disease and act as barriers to achieving and maintaining optimal outcomes of PR. Evidence-based interventions within the areas of occupational therapy, nutritional modulation and psychological support can be included in PR programmes with the purpose of targeting such issues. However, such interventions are represented to a lesser degree than, for example, exercise interventions in PR programmes worldwide. Moreover, while elaborate guidelines for the exercise component of PR exist, relatively little attention has been given to describing other interventional components. Developing official guidelines for occupational therapy, nutritional modulation and psychological support in PR is therefore an important task for its future organisation with the purpose of providing optimal multidisciplinary care.

    Cite as: Farver-Vestergaard I, Johannesen G, ter Beek L. Occupational therapy, nutritional modulation and psychological support. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 83–98 [https://doi.org/10.1183/2312508X.10017820].

  10. Page 99
    Abstract
    Anke Lenferink (a.lenferink@utwente.nl)

    Education and self-management interventions are interdependent concepts included as part of a PR programme delivery. The goal of the content provided is to acquire knowledge, skills and strategies that facilitate behaviour change and optimise care, both during and beyond a PR programme. While there are several options for delivery, the application of approaches that guide patient engagement and empowerment and align with adult learning principles is desirable, including those employing greater use of technology and digital resources. Patient-specific factors that influence uptake and engagement with education and self-management interventions include health literacy, psychological symptoms and cognitive impairment, as well as the degree of social support. These factors should be considered by HCPs when devising strategies to facilitate engagement and uptake, and to encourage the longevity of effects of education and self-management interventions in PR.

    Cite as: Lenferink A, Lee AL. Education and self-management. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 99–116 [https://doi.org/10.1183/2312508X.10017920].

  11. Page 117
    Abstract
    Renae McNamara (renae.mcnamara@health.nsw.gov.au)

    Multimorbidity is highly prevalent in people with chronic respiratory diseases, including COPD, asthma, bronchiectasis and ILD, who are attending PR programmes. A comprehensive assessment is essential, and modifications to PR programmes are often necessary to provide an individualised and safe patient-centred programme. Offering alternative exercise options and tailoring the exercise training intervention to the individual's physical ability and limitations may improve uptake, adherence, engagement and the known benefits of PR. Irrespective of the type, number and severity of comorbidities, people with chronic respiratory disease attending PR can achieve important changes in exercise capacity and HRQoL.

    Cite as: McNamara RJ, Dale MT. Multimorbidity. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 117–131 [https://doi.org/10.1183/2312508X.10018020].

  12. Page 132
    Abstract
    Matthew Maddocks (matthew.maddocks@kcl.ac.uk)

    People with chronic respiratory disease often suffer from a high symptom burden, level of disability and uncertainty about their future. However, individuals with non-malignant disease receive far less palliative care than those with cancer. The unmet need for palliative care may be improved be considering its role alongside PR as a mainstay of respiratory care. Palliative care should be integrated early, based on need rather than prognosis. Early identification and assessment of palliative care needs is, therefore, vital. Areas where palliative care could bring added benefit include management of chronic breathlessness, advance care planning, and psychosocial support for the patient and family. Practical opportunities needed to include palliative care into PR include: 1) building knowledge of both specialities and advocacy among clinicians; 2) referring onwards where appropriate; 3) providing educational content for programmes; 4) training and upskilling clinicians in symptom management and advanced communication; 5) facilitating support groups; and 6) in-reach consultation for individual cases.

    Cite as: Maddocks M, Oare Lindell K, Janssen DJ. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 132–144 [https://doi.org/10.1183/2312508X.10018120].

  13. Page 145
    Abstract
    Vinicius Cavalheri (vinicius.cavalheri@curtin.edu.au)

    The potential benefits of PR are well known, and PR has become an integral part of chronic respiratory disease management. Due to substantial evidence of the positive effects on health outcomes, PR programmes for people with COPD have been widely implemented. People with chronic lung diseases other than COPD have, over the years, been able to enrol in such programmes. However, it has become clear that, although there are many similarities for the rationale and delivery of PR between people with COPD and those with chronic lung diseases other than COPD, there are also differences that should be considered. The current chapter describes the clinical considerations for implementation of PR in people with ILD, asthma, bronchiectasis, pulmonary arterial hypertension and lung cancer. An overview of each disease is provided, and aspects of PR including patient selection and assessment, the setting of the exercise training component of a PR programme, prescription of the exercise training programme and nonexercise components, as well as maintenance or follow-up, are discussed for these patient populations. Given the unique features of each population with chronic lung disease described in this chapter, PR programmes should be adapted to better accommodate people with chronic lung diseases other than COPD.

    Cite as: Cavalheri V, Vainshelboim B, Evans RA, et al. Special considerations in conditions other than COPD. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 145–164 [https://doi.org/10.1183/2312508X.10018220].

  14. Page 165
    Abstract
    William D.-C. Man (w.man@rbht.nhs.uk)

    Acute exacerbations requiring hospitalisation result in physical inactivity, exercise intolerance, and a deterioration in muscle function and health status that place COPD patients at high risk of readmission. High-quality clinical trial evidence shows improvements in exercise capacity and QoL with PR delivered immediately upon initiation, or within 3 weeks, of exacerbation treatment. Evidence for reductions in hospital readmissions and mortality is of lower quality, which may be due to the extensiveness or components of the programme. Few or no mild adverse events have been reported, but qualitative studies suggest that referral to an outpatient centre-based programme on the day of hospital discharge is not acceptable to many patients. Under-referral and barriers at a health service level have also limited implementation of PR during or following hospitalisation in routine clinical practice. Research to address these issues is underway, as it has the potential to make a significant impact on health services, given the known efficacy of peri- or post-exacerbation PR in clinical trials.

    Cite as: Man WD-C, Jones AW. Exacerbations of COPD. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 165–181 [https://doi.org/10.1183/2312508X.10018320].

  15. Page 182
    Abstract
    Samantha Harrison (S.L.Harrison@tees.ac.uk)

    People with COPD fall more than healthy adults of the same age, and approximately half of all individuals who suffer an acute exacerbation will experience a fall. Balance is a major risk factor for falls, and while the exact mechanisms underpinning poor balance in people with COPD are unknown, reduced muscle strength, poor neuromuscular coordination of core muscles and musculoskeletal pain may play a role. Guidelines recommend assessing balance in PR. HCPs should enquire whether individuals aged ≥65 years have fallen in the past year, while being mindful of the fall-related stigma that is common in older adults. Screening for balance impairment can be performed quickly using the timed up and go test, a standing balance test or a repeated chair–stand test. If indicated, the Berg Balance Scale or the mini-Balance Evaluation Systems Test offers a comprehensive balance assessment and informs targeted balance training, which has been delivered successfully alongside PR.

    Cite as: Harrison SL, Oliveira CC, Loughran K, et al. Falls and balance in patients with COPD. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 182–194 [https://doi.org/10.1183/2312508X.10018420].

  16. Page 195
    Abstract
    Marilyn Moy (marilyn.moy@va.gov)

    For patients with chronic lung disease, increasing community-based physical activity is aligned with their goals for participating in PR programmes. Physical activity assessment integrates physiological and psychological status over time in the home environment; this is unique compared with conventional clinic-based outcomes assessed episodically, such as exercise capacity, dyspnoea and HRQoL. There is currently no generally accepted method for how physical activity should be measured in PR. Assessment methods range from self-report on questionnaires to direct observation with motion sensors, with all containing advantages and disadvantages. Despite the lack of consensus, some practical aspects are recognised such as assessing physical activity during ≥4 week days with ≥8 h wearing time per day in free-living conditions. An integrated approach with evidence-based factors influencing physical activity is important. Interventions for improving physical activity using pedometer feedback should consider exercise capacity and nutritional status. Physical activity promotion is desired to provide a multidisciplinary approach according to various clinical settings of PR programmes.

    Cite as: Moy ML, Sievi NA, Kawagoshi A. Measuring and enhancing physical activity in patients with chronic lung disease. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 195–204 [https://doi.org/10.1183/2312508X.10018520].

  17. Page 205
    Abstract
    Leandro Mantoani (leandromantoani@yahoo.com.br)

    Chronic disease management and PR programmes have the potential to change patient lifestyle and, as a result, impact outcomes. Behaviour changes are needed all the time but are particularly timely immediately after meaningful events, such as hospitalisation. PR programmes are especially suited to start a health behaviour change intervention, as patients can craft a lifestyle according to their own priorities and capacities. When interventions target a behaviour change, it is preferable to aim to achieve small goals, as major changes in behaviour have proved to be less effective. Long-term programmes are necessary when targeting lifestyle changes. Self-monitoring, goal setting and motivational interview-based health coaching have been widely used to achieve benefits in different outcomes. As behaviour change is now a recognised desired outcome of PR, an essential factor at this point is to train providers in learning and applying behaviour change interventions.

    Cite as: Mantoani LC, Benzo R. Health behaviour change. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 205–217 [https://doi.org/10.1183/2312508X.10018620].

  18. Page 218
    Abstract
    Carlos A. Camillo (Carlos.a.camillo@outlook.com)

    In previous chapters of this book, compelling evidence of the benefits of PR for people with respiratory diseases has been discussed. To achieve such benefits, however, the rehabilitation team needs to constantly adapt the interventions to be patient-tailored therapies. Exercise training responses vary according to the disease, individual characteristics, timing and prognosis of participants. Some people might require longer training periods, alternative exercise modalities and/or “add-ons” to enhance training benefits. Yet the challenge does not end when PR is done. People need to stay active to sustain the benefits of PR. In this chapter, we will discuss the trajectories of PR, as well as what can be done in different scenarios: from the nonresponder who needs to continue supervised training or begin palliative care to the responder who needs to continue to exercise in order to maintain the benefits of PR in the long term.

    Cite as: Camillo CA, Spencer LM. What happens after pulmonary rehabilitation? In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 218–230 [https://doi.org/10.1183/2312508X.10018720].

  19. Page 231
    Abstract
    Alex van ’t Hul (alex.vanthul@radboudumc.nl)

    This chapter provides information on a number of practical issues that may be relevant for HCPs who are considering or have just started setting up a PR programme. Both organisational aspects and content aspects are addressed. The organisational aspects covered include: staffing, applying multidisciplinary approaches, considerations for different PR settings and infection control measures. In terms of content, attention is paid to the core components of PR: pre-rehabilitation assessment, exercise training, education and programme evaluation. Organisational aspects of establishing emerging models of PR such as home-based programmes and telerehabilitation are also discussed, together with options for supporting maintenance exercise. The chapter ends with information that can help in making a choice with regard to the implementation strategy and how the success of the implementation can be determined.

    Cite as: van ’t Hul AJ, Wootton SL. How to establish a programme. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 231–245 [https://doi.org/10.1183/2312508X.10018820].

  20. Page 246
    Abstract
    Michael C. Steiner (ms346@leicester.ac.uk)

    PR is a highly effective intervention comprising exercise therapy, disease education, behaviour change and psychological support. Recent guidelines have attempted to define PR, but the multicomponent character of the intervention means the precise content and delivery of PR is open to interpretation. Robust quality control (QC) and quality assurance (QA) processes measured against evidence-based quality standards or indicators can ensure that clinical care is provided to a high-quality standard. Providing transparent evidence of the quality of service to patients, referrers and health policy makers will assist the enhancement of referral rates and PR availability known to be poor in many countries and many healthcare settings. The presence of robust QC and QA will also permit the rapid development and evaluation of innovations in the delivery of PR services, such as have been required, for example, during the COVID-19 pandemic.

    Cite as: Steiner MC, Camp PG. Quality assurance and control. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 246–257 [https://doi.org/10.1183/2312508X.10018920].

  21. Page 258
    Abstract
    Corresponding author: Linzy Houchen-Wolloff (linzy.Houchen@uhl-tr.nhs.uk)

    PR is the cornerstone of treatment for patients with chronic respiratory disease and is a highly cost-effective intervention. Despite the known benefits, access to, completion of and engagement with PR is very poor across the globe. This chapter presents a précis of the data available worldwide for participation in PR, including in the USA and Canada, Europe, Australia and New Zealand, in indigenous populations and LMICs. Several patient disparities in access are outlined, including sex, ethnicity and socioeconomic status. Alongside this, many patient, organisational and HCP barriers to engaging with or providing rehabilitation have been identified in the literature. Some of these factors have been partly addressed by novel ways of providing PR (e.g. home-based programmes for those with transport barriers), although there is still much to do to ensure that all eligible patients worldwide have access to this important intervention.

    Cite as: Houchen-Wolloff L, Spitzer KA, Candy S. Access to services around the world. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 258–272 [https://doi.org/10.1183/2312508X.10019020].

  22. Page 273
    Abstract
    Jennifer Alison (jennifer.alison@sydney.edu.au)

    Low-resource settings are defined as those where there is limited equipment and facilities for exercise testing and/or training, poor funding and infrastructure, low levels of staffing and/or lack of staff with qualifications for providing PR. Emerging evidence suggests that endurance and resistance training programmes that require minimal equipment suitable for low-resource settings, such as walking training and elastic resistance bands, may improve functional exercise capacity, muscle strength and HRQoL. However, the number and overall quality of studies is low and further robust research is needed. In low-resource settings, ongoing issues include the lack of availability of HCPs with the expertise to provide PR, no evaluation of the effectiveness of education or self-management components of PR in these settings, and difficulties for patients to attend supervised sessions. However, there is some weak evidence that following centre-based assessment and education, unsupervised home PR programmes may improve health outcomes for people with COPD.

    Cite as: Alison JA, Cruz J, Gimeno-Santos E. Low-resource settings. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 273–293 [https://doi.org/10.1183/2312508X.10019120].

  23. Page 294
    Abstract
    Claire Nolan (c.nolan@rbht.nhs.uk)

    The evidence to support conventional PR in the management of COPD is well-described, but problems exist. Emerging programme models have the potential to address barriers to access and participation. Models investigated to date include programmes delivered in patients’ homes that, for the purposes of this article, are categorised as requiring and not requiring internet access. In COPD, the evidence to support improvements in exercise capacity, breathlessness and HRQoL derived from emerging programmes is accumulating and appears to be similar to conventional PR. However, there is uncertainty as to whether these programmes are as effective as conventional PR because of heterogenous interventions and statistical concerns. Accordingly, there is a need for continued research exploring clinical benefit, psychological and health outcomes, and health-economic impact as well as patient and HCP experience. Identification of the optimal model(s) may facilitate adoption into clinical practice, the efficacy of which is an important component of future research.

    Cite as: Hanssen H, Nolan CM. Emerging models. In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 294–310 [https://doi.org/10.1183/2312508X.10019220].

  24. Page 311
    Abstract
    Carolyn Rochester (carolyn.rochester@yale.edu)

    PR remains underutilised, and access to PR is limited for several health system- and patient-related reasons. Opportunities exist to improve both patient and health system outcomes. In PR programmes of the future, performance of a more comprehensive patient assessment followed by targeting of PR interventions to patients’ individual identified “treatable traits”, needs, goals, learning styles and readiness to undertake health-enhancing behaviour change should improve patient outcomes. Use of a broader range of PR programme models including centre-based PR, home- and/or community-based PR and telerehabilitation based on patients’ needs, preferences and local availability should further improve uptake of and access to PR, reduce healthcare disparities and foster implementation of PR in parts of the world where it is currently lacking. In turn, this should lead to improved outcomes for patients and health systems. Core competencies of PR HCPs, demonstration of clinical benefits, and the quality and safety of the programme interventions must be assured.

    Cite as: Rochester CL, Langer D, Singh SJ. What does the future hold? In: Holland AE, Dal Corso S, Spruit MA, eds. Pulmonary Rehabilitation (ERS Monograph). Sheffield, European Respiratory Society, 2021; pp. 311–325 [https://doi.org/10.1183/2312508X.10019320].

  25. Page 326
  26. Page 332
  27. Page 338
  28. Page 342