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Pulmonary rehabilitation is a supervised programme of exercise and education for people whose breathing limits what they can do. It usually runs twice a week for six to twelve weeks. It improves breathlessness, fatigue, emotional wellbeing and exercise capacity by more than most medicines do, and after a hospital admission for a flare-up it reduces the chance of going back in. It is for people with COPD, bronchiectasis, pulmonary fibrosis and other long-term lung conditions, and it can be delivered at a centre or at home. This page explains what to expect, then sets out the standards and evidence behind it.
What pulmonary rehabilitation is
Pulmonary rehabilitation is a supervised programme of exercise and education for people whose breathing limits what they can do. It is the single most effective treatment available for breathlessness in chronic lung disease, and for most people it does more for day-to-day life than any additional inhaler.
The idea behind it is simple. Breathlessness makes people avoid effort; avoiding effort makes the muscles weaker; weaker muscles demand more from the lungs, so the same walk causes more breathlessness. Rehabilitation breaks that cycle by training the muscles, so the same activity costs less breath.
Who it is for
Programmes accept adults with chronic respiratory disease who are breathless on everyday activity. That includes:
- chronic obstructive pulmonary disease (COPD), including after a flare-up that needed hospital treatment
- bronchiectasis
- interstitial lung disease, including idiopathic pulmonary fibrosis
- asthma with persistent breathlessness or deconditioning
- pulmonary hypertension, in specialist programmes
- before and after lung surgery, including lung cancer resection and transplantation
- persisting breathlessness and fatigue after COVID-19 or a period in intensive care
Australian and New Zealand guidelines recommend pulmonary rehabilitation for people with COPD both in the stable state and after an exacerbation, and for people with several other chronic respiratory diseases.1 A low lung-function reading is not a barrier and a high one is not a disqualification — symptoms and function determine benefit, not spirometry.
What a programme involves
| Element | Typical form |
|---|---|
| Duration | Six to twelve weeks, most commonly eight. |
| Frequency | Two supervised sessions a week, plus at least one unsupervised session at home. |
| Exercise | Endurance work — walking, cycling or stepping — plus strength work for the legs and arms. |
| Education | Understanding your condition, inhaler technique, managing flare-ups, breathing techniques, clearing sputum, energy conservation, nutrition, mood and future planning. |
| Assessment | A walking test and questionnaires at the start and again at the end, so the change is measured rather than assumed. |
The exercise sessions
Each session has a warm-up, endurance training, strength training and a cool-down. Endurance work is prescribed from your walking test, so it is set at a level that is hard for you specifically.
You are meant to get breathless. Being moderately to severely breathless during training — around three to five on the ten-point breathlessness scale — is the intended dose, not a sign that something is wrong. Staff monitor your oxygen levels, and for people who drop low, oxygen may be used during exercise.
Strength training matters as much as walking. Leg weakness is one of the strongest predictors of poor exercise tolerance and of hospital admission in COPD, and it responds well to straightforward resistance training.
What it changes
In COPD, pulmonary rehabilitation produces large, clinically important improvements in breathlessness, fatigue, emotional wellbeing and the sense of control people have over their condition, along with improvements in exercise capacity.2 The effect sizes exceed those of most drug treatments for the same symptoms.
Started within a few weeks of a hospital admission for a flare-up, rehabilitation reduces the chance of being readmitted.3 This is the highest-value moment in the whole pathway and the one most often missed.
What people report is usually more concrete: getting up a slope without stopping, carrying shopping from the car, sleeping better, and being less frightened.
Coming after a flare-up or a hospital stay
If you have been in hospital with a chest exacerbation, the ideal is to start rehabilitation soon after discharge rather than waiting until you feel fully recovered. UK quality standards set the expectation that people referred after an admission are enrolled within thirty days of discharge.4 Waiting for a good spell usually means waiting for the next bad one.
If you cannot get to a centre
Home-based programmes with telephone or video support produce comparable improvements in exercise capacity and quality of life to centre-based programmes for people with stable COPD.5 UK standards now require that people who decline centre-based rehabilitation are offered an alternative rather than discharged.4 Distance is a reason to change the model, not to miss out.
After the programme ends
The gains fade if training stops. Most of the improvement in exercise capacity is lost within six to twelve months without ongoing activity, which is why every programme should end with a specific plan: what you will do, how often, and where. A maintenance group, a walking group, a home programme with review, or a gym referral all work; nothing does not.
Common worries
“My oxygen drops when I walk.”
Desaturation on exertion is common, particularly in interstitial lung disease, and it is managed rather than avoided. Programmes monitor oxygen saturation and can provide supplemental oxygen during training where it is needed.
“I use a wheelie walker.”
Walking aids are used within programmes and often increase the distance achieved. Bring yours.
“I am on home oxygen.”
Home oxygen is not a barrier. Your prescription may be adjusted for exercise.
“I have already done one.”
Repeat programmes are appropriate after a significant deterioration, after a hospital admission, or where gains have been lost. It is not a once-in-a-lifetime treatment.
Warning signs
Part 1 · References
- Alison JA, McKeough ZJ, Johnston K, et al; Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. Australian and New Zealand pulmonary rehabilitation guidelines. Respirology 2017;22(4):800–819.
- McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2015;(2):CD003793.
- Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016;(12):CD005305.
- Singh SJ, Buxton M, Daynes E, et al. British Thoracic Society quality standard for pulmonary rehabilitation. BMJ Open Respir Res 2026;13(1):e003872.
- Holland AE, Mahal A, Hill CJ, et al. Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial. Thorax 2017;72(1):57–65.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
- Cardiorespiratory Rehabilitation — the combined heart and lung programme run at this clinic
- Cardiac Rehabilitation — the equivalent programme after a cardiac event
- COPD — the condition most often referred
- Airway Clearance — clearing a wet chest, and how it fits alongside training
- Prescribing Exercise from Test Results — turning a walking test into a training programme
- Six-Minute Walk Test — the field test used at entry and exit
- Exercise at Home — maintaining the gains once the programme ends
Clinical evidence
Part 1 covers the same programme without the technical detail. What follows is the standards framework, the prescription and the evidence base, written for clinicians.
Standards and guidelines
Four documents carry most of the weight in Australian and UK practice.
| Document | Status |
|---|---|
| Australian and New Zealand Pulmonary Rehabilitation Guidelines (Alison et al., Respirology 2017) | The principal local guideline, produced by the Australian Pulmonary Rehabilitation Network of Lung Foundation Australia with TSANZ, using GRADE. Recommends PR for COPD in the stable state and post-exacerbation, and extends recommendations to bronchiectasis, ILD and other chronic respiratory disease.1 |
| BTS Clinical Statement on Pulmonary Rehabilitation (Man et al., Thorax 2023) | Updates the 2013 BTS guideline with current practice on referral breadth, delivery models, prehabilitation, post-COVID and post-intensive-care rehabilitation.2,3 |
| BTS Quality Standard for Pulmonary Rehabilitation (Singh et al., BMJ Open Respir Res 2026) | Replaces the 2014 quality standards. Sets minimum standards of care, and is embedded in the National Respiratory Audit Programme and the PRSAS accreditation scheme.4 |
| ATS clinical practice guideline on pulmonary rehabilitation (2023) | International reference for indications across diagnoses.5 |
The 2026 BTS quality standard is organised around service fundamentals and participant-facing standards. Its headline expectations are that people with symptomatic chronic respiratory disease are offered timely rehabilitation; that referrals following admission are enrolled within thirty days of discharge; that everyone eligible receives a multi-system assessment; that centre-based rehabilitation is available; that those who decline it are offered an alternative rather than discharged; and that completers are supported into ongoing exercise maintenance.4 It also specifies workforce fundamentals, including a minimum of two staff at supervised group sessions, one competent to manage the deteriorating respiratory patient.4
Referral and case-finding
Referral criteria are functional, not spirometric. The operative question is whether breathlessness limits activity, and the commonest referral failures are structural rather than clinical: non-COPD diagnoses not thought of, post-exacerbation referral not made before discharge, and people who declined once never re-offered.
Exclusions are narrow. Unstable cardiac disease, uncontrolled arrhythmia, severe uncontrolled hypertension and conditions that make exercise unsafe are genuine contraindications; cognitive impairment, frailty, walking-aid use, home oxygen and continued smoking are not. Participants should be medically optimised before referral.2
Assessment
- Exercise capacity. Six-minute walk test or incremental shuttle walk test, performed to the ERS/ATS technical standard, including the practice walk — omitting it overstates the improvement at discharge.6 An endurance shuttle walk test is the most responsive field measure of change.
- Symptoms. mMRC dyspnoea grade, and a disease-specific measure — the CAT in COPD, the Chronic Respiratory Questionnaire or the St George’s Respiratory Questionnaire.
- Muscle function. Quadriceps strength, or five-repetition sit-to-stand as a practical surrogate.
- Oxygenation. Resting and exertional oxygen saturation. Profound exercise-induced desaturation is more common in idiopathic pulmonary fibrosis than in COPD and changes the prescription.2
- Multi-system review. Anxiety and depression, nutritional status, sputum burden and inhaler technique. The BTS quality standard makes a multi-system assessment an explicit expectation rather than good practice.4
Exercise prescription
| Variable | Prescription |
|---|---|
| Frequency | Two supervised sessions per week minimum, with at least one home session; eight weeks is the common duration and the minimum below which benefit falls away. |
| Endurance intensity | Sixty to eighty per cent of peak work rate, or a Borg CR10 dyspnoea rating of three to five. Interval training is an equivalent-outcome alternative for people who cannot sustain continuous work. |
| Endurance time | Thirty minutes of walking or cycling per session, accumulated in intervals if necessary. |
| Resistance training | Upper and lower limb, 60–70% of one-repetition maximum, two to three sets of eight to twelve repetitions, two to three days per week. Progressed by load, not by repetitions alone. |
| Progression | Weekly, driven by symptom score at the prescribed workload rather than by protocol. Ground-based walking training progresses by speed and distance; treadmill and cycle by workload. |
| Supplemental oxygen | Considered for participants who desaturate on exertion, to permit training at an effective intensity. It is a training adjunct, not a treatment of the desaturation itself. |
Adjuncts — non-invasive ventilation during training, neuromuscular electrical stimulation, inspiratory muscle training, heliox, high-flow nasal oxygen — have a narrow evidence base and specific indications. Inspiratory muscle training is reasonable where inspiratory muscle weakness is demonstrated, and is not a substitute for whole-body training.
Specific populations
| Population | What changes |
|---|---|
| Post-exacerbation COPD | Highest-value window. Early commencement reduces readmission.7 Expect lower starting capacity, greater day-to-day variability and higher drop-out; shorten sessions rather than delaying the start. |
| Interstitial lung disease | Profound exertional desaturation is common; oxygen during training is frequently required. Gains are real but decay faster than in COPD, making maintenance planning more important, not less. |
| Bronchiectasis | Airway clearance should be integrated into, not replaced by, the programme. Sputum load determines session sequencing. See Airway Clearance. |
| Pulmonary hypertension | Specialist programmes only, with lower intensities, close monitoring and avoidance of Valsalva during resistance work. See Pulmonary Hypertension. |
| Prehabilitation before thoracic surgery | Time to surgery is short, so conventional programme structures need adaptation rather than direct application.2 See Pre-Surgical Rehabilitation. |
| Post-COVID and post-intensive-care | Multi-system deficits requiring individualised prescription. Fatigue and post-exertional symptom exacerbation should be tracked with symptom, exertion and activity scores, and progression paced accordingly.2 |
| Coexisting cardiac disease | Common, and a reason to run a combined programme rather than to exclude. Cardiac monitoring parameters and the cardiac warning-sign set apply alongside the respiratory ones. |
Delivery models
Centre-based group rehabilitation remains the reference model and must be available.4 Home-based rehabilitation with structured remote support has demonstrated equivalence in stable COPD.8 Telerehabilitation and hybrid models are established alternatives. The requirement that matters is fidelity: an alternative model must retain assessment, individualised prescription, progression and the education component, or it is exercise provision rather than rehabilitation.
The evidence base
The Cochrane review of pulmonary rehabilitation in COPD found improvements in dyspnoea, fatigue, emotional function and mastery that exceeded the minimal important difference, and concluded that further trials comparing rehabilitation with usual care are unlikely to change that conclusion.10 Post-exacerbation rehabilitation reduces hospital readmission.7 Home-based delivery has shown equivalence in a randomised equivalence trial.8
The weaknesses in the evidence are worth stating plainly. Trials underrepresent the very frail and the very old. Maintenance of benefit beyond twelve months is poorly supported. And the evidence base in non-COPD diagnoses, while positive, rests on far fewer participants than the COPD literature.
Where practice falls short
Access, not efficacy, is the problem. The intervention with the largest effect on breathlessness available to respiratory medicine reaches a minority of eligible people, and the shortfall is concentrated in exactly the groups with the most to gain: post-exacerbation patients, rural and remote populations, and people whose diagnosis is not COPD.
Part 2 · References
- Alison JA, McKeough ZJ, Johnston K, et al; Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. Australian and New Zealand pulmonary rehabilitation guidelines. Respirology 2017;22(4):800–819.
- Man W, Chaplin E, Daynes E, et al. British Thoracic Society clinical statement on pulmonary rehabilitation. Thorax 2023;78(Suppl 4):s2–s15.
- Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013;68(Suppl 2):ii1–ii30.
- Singh SJ, Buxton M, Daynes E, et al. British Thoracic Society quality standard for pulmonary rehabilitation. BMJ Open Respir Res 2026;13(1):e003872.
- 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.
- Holland AE, Spruit MA, Troosters T, et al. An official European Respiratory Society / American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J 2014;44(6):1428–1446.
- Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016;(12):CD005305.
- Holland AE, Mahal A, Hill CJ, et al. Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial. Thorax 2017;72(1):57–65.
- Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF. Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2010;91(2):221–225.
- McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2015;(2):CD003793.
- National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline NG115. London: NICE; 2018 (updated 2019).
- Yang IA, George J, McDonald CF, et al. The COPD-X plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Brisbane: Lung Foundation Australia and the Thoracic Society of Australia and New Zealand.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Equipment & outcome measures
What a pulmonary rehabilitation service needs in the room, and what it should be measuring. The minimum list is what makes a programme safe and prescribable; the additional list is what makes it better. Nothing here substitutes for local governance, and equipment does not compensate for staffing.
Minimum equipment
A programme can be delivered safely and to standard with the following. The list is deliberately short — the barrier to running pulmonary rehabilitation is rarely capital equipment.
| Item | Why it is a minimum |
|---|---|
| A measured walking course | A flat, straight, hard-surfaced corridor of 30 m for the six-minute walk test, or a 10 m course with cones set 0.5 m inside each end for the shuttle tests, laid out to the ERS/ATS technical standard.1 A shorter or curved course changes the distance achieved and makes the result non-comparable. |
| Cones, floor tape and a measuring wheel or tape | Course marking. Mark it once and keep the layout fixed — a course that moves between assessments invalidates the change score. |
| Pulse oximeter | Non-negotiable. Resting and exertional saturation determine whether training oxygen is needed and when a session stops. |
| Sphygmomanometer and stethoscope | Baseline and on-demand observations. |
| Stopwatch or timer | Timed tests and interval work. |
| Calibrated audio for the shuttle tests | The ISWT and ESWT are externally paced. Verify playback speed annually; a drifting track silently changes every result. |
| Modified Borg CR10 dyspnoea scale and an RPE scale | Laminated, large print, at eye level. This is the primary prescription variable in pulmonary rehabilitation. |
| Armless standard-height chairs | Rest during walking tests, and the five-repetition sit-to-stand. |
| Free weights and resistance bands | 0.5–5 kg dumbbells, ankle weights and graded bands cover the resistance prescription for most participants. |
| An adjustable step | Step-ups are the cheapest progressive lower-limb endurance and strength stimulus available. |
| Scales, height and waist measure | Nutritional risk is part of the multi-system assessment. |
| Emergency provision | Oxygen with delivery devices, an automated external defibrillator with trained staff, a means of summoning help, a first-aid kit, and participants’ own relievers kept with them. |
| Documentation | Assessment proforma, individual prescription card, home exercise diary and a discharge plan template. Unrecorded prescription cannot be progressed. |
Additional equipment where resources allow
| Item | What it adds |
|---|---|
| Cycle ergometer and treadmill | Precise, reproducible workload. Cycling is useful where balance, desaturation or musculoskeletal limitation restricts walking, though it trains a narrower pattern than ground-based walking. |
| Arm ergometer | Unsupported and supported upper-limb endurance work, relevant where arm activity provokes disproportionate breathlessness. |
| Ambulatory oxygen — cylinders or a portable concentrator | Allows training at an effective intensity in participants who desaturate. Frequently the difference between a token session and a therapeutic one, particularly in interstitial lung disease. |
| Hand-held dynamometer | Quadriceps and grip strength as an objective measure rather than a repetition count. Quadriceps weakness is a strong predictor of exercise limitation and admission in COPD. |
| Cardiopulmonary exercise testing | Peak VO2 and ventilatory thresholds; the reference method for prescription, and required in transplant assessment. |
| Spirometer | Confirms diagnosis and severity where referral information is incomplete. |
| Inspiratory muscle training devices | Threshold or tapered-flow loading where inspiratory muscle weakness is demonstrated — an adjunct, never a substitute for whole-body training. |
| Neuromuscular electrical stimulation | A narrow indication: participants too breathless or unstable for conventional training. |
| Oscillating PEP and airway clearance adjuncts | Where sputum load determines session sequencing, particularly in bronchiectasis. |
| Telehealth kit | A video platform, loan oximeters and step counters, and a structured remote-contact schedule. This is what converts “we offer home-based” from an aspiration into a service. |
| Education resources | Lung Foundation Australia patient materials, placebo inhaler devices for technique teaching, and written action plans. |
Outcome measures
Measure at entry, and repeat the same measure by the same method at discharge. A programme that does not measure cannot demonstrate benefit, cannot identify non-responders, and cannot defend its funding.
| Measure | Domain | Minimal important difference |
|---|---|---|
| Six-minute walk distance | Functional exercise capacity | Approximately 30 m in COPD.3 Include the practice walk — omitting it inflates the apparent gain. |
| Incremental shuttle walk distance | Maximal exercise capacity | Approximately 48 m.4 |
| Endurance shuttle walk time | Endurance capacity | The most responsive field outcome; improvements are large relative to baseline and it is the measure most likely to detect change in a short programme.5 No single threshold is well established — report the change and the test conditions. |
| COPD Assessment Test (CAT) | Health status | 2 points.6 |
| Chronic Respiratory Questionnaire | Health-related quality of life | 0.5 points per item, per domain.7 |
| St George’s Respiratory Questionnaire | Health-related quality of life | 4 points.8 |
| mMRC dyspnoea grade | Breathlessness on activity | One grade; insensitive to change within a single programme, so useful for description rather than as a primary outcome. |
| Five-repetition sit-to-stand | Lower-limb function | Approximately 1.7 seconds.9 |
| Quadriceps or grip strength | Muscle function | Report as absolute change; population-specific thresholds vary. |
| HADS or an equivalent validated tool | Anxiety and depression | Entry and exit, with a defined referral pathway for those who screen positive. A HADS subscale score of 8 or more is the usual case-finding threshold.10 |
Service-level measures
- Referral, uptake, adherence and completion rates, reported by diagnosis, remoteness and Indigenous status — the mechanism by which inequity becomes visible rather than assumed.
- Time from referral to enrolment, and from hospital discharge to enrolment against the 30-day standard.2
- Proportion of completers with a documented maintenance plan.
- Adverse events and session terminations.
In the United Kingdom these feed the National Respiratory Audit Programme and PRSAS accreditation.2 Australia has no equivalent mandatory audit, so a programme that wants the data has to collect it itself.
Part 3 · References
- Holland AE, Spruit MA, Troosters T, et al. An official European Respiratory Society / American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J 2014;44(6):1428–1446.
- Singh SJ, Buxton M, Daynes E, et al. British Thoracic Society quality standard for pulmonary rehabilitation. BMJ Open Respir Res 2026;13(1):e003872.
- Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF. Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2010;91(2):221–225.
- Singh SJ, Jones PW, Evans R, Morgan MDL. Minimum clinically important improvement for the incremental shuttle walking test. Thorax 2008;63(9):775–777.
- Pepin V, Laviolette L, Brouillard C, et al. Significance of changes in endurance shuttle walking performance. Thorax 2011;66(2):115–120.
- Kon SSC, Canavan JL, Jones SE, et al. Minimum clinically important difference for the COPD Assessment Test: a prospective analysis. Lancet Respir Med 2014;2(3):195–203.
- Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials 1989;10(4):407–415.
- Jones PW. St George’s Respiratory Questionnaire: MCID. COPD 2005;2(1):75–79.
- Jones SE, Kon SSC, Canavan JL, et al. The five-repetition sit-to-stand test as a functional outcome measure in COPD. Thorax 2013;68(11):1015–1020.
- Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67(6):361–370.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Inspire Clinic runs a combined cardiorespiratory rehabilitation programme rather than separate cardiac and pulmonary streams, because a large share of this caseload has both a respiratory and a cardiac diagnosis. Assessment, exercise prescription and outcome measurement follow the pulmonary rehabilitation standards described here.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.