Clinical Question

Is virtual pulmonary rehabilitation effective for patients with chronic lung disease?

Evidence-Based Answer

For patients with chronic obstructive pulmonary disease (COPD), virtual pulmonary rehabilitation (delivered via telephone, computer or smartphone application, website, video conference, or virtual group) is equivalent to in-person pulmonary rehabilitation at reducing symptoms of breathlessness and increasing six-minute walking distance (6MWD). Participants in both virtual and in-person pulmonary rehabilitation programs show similar improvements on quality-of-life questionnaires. Telerehabilitation participants are more likely to complete the program compared with their in-person counterparts.¹ (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Compared with traditional (in-person) pulmonary rehabilitation programs, the effectiveness of telehealth-based rehabilitation, or telerehabilitation, has not been well established.² The COVID-19 pandemic has highlighted the increased need for delivery of virtual health care, not only for patients with preexisting chronic lung disease, but also for those with potential long-term respiratory complications of COVID-19.^3,4 The authors of this review sought to assess the benefits and risks of pulmonary telerehabilitation for patients with chronic lung disease.

The review included 15 controlled trials of adults (N = 1,904; mean ages = 62 to 75 years) from North America and Europe comparing initial or maintenance telerehabilitation programs with either traditional pulmonary rehabilitation or no rehabilitation.¹ Inclusion criteria required that all rehabilitation programs incorporate some type of exercise training, and programs designated as telerehabilitation had to deliver 50% or more of the rehabilitation via telehealth methods. Nearly all (99%) of the participants had COPD. Telerehabilitation methods varied by study.

In four trials (n = 556) that assessed 6MWD six to 12 weeks after completion of a primary rehabilitation program, telerehabilitation participants achieved a similar average 6MWD (range = 8 m to 434 m; n = 292) compared with those in traditional programs (range = 11 m to 445 m; n = 264). The mean difference (MD) in 6MWD between the two groups was 0.06 m (95% CI, −10.82 m to 10.94 m; moderate-certainty evidence).

At six to eight weeks of follow-up, improvements in mean quality-of-life scores were similar between primary telerehabilitation and in-person groups (with lower scores indicating better quality of life). Trials used the St. George's Respiratory Questionnaire (MD = −1.26; 95% CI, −3.97 to 1.45; n = 274; two trials; low-certainty evidence) and the COPD Assessment Test (MD = −1.37; 95% CI, −3.10 to 0.36; n = 224; two trials; moderate-certainty evidence). Symptoms of breathlessness improved similarly in both groups, as indicated by increases in the Chronic Respiratory Questionnaire dyspnea domain scores (MD = 0.13; 95% CI, −0.13 to 0.40; n = 426; three trials; low-certainty evidence). Telerehabilitation participants were more likely to complete their programs than those in traditional rehabilitation programs (odds ratio = 5.36; 95% CI, 3.12 to 9.21; n = 516; three trials), with completion defined as achieving a minimum of either 60% or 70% of prescribed exercises.

Compared with control groups who received no rehabilitation, pulmonary telerehabilitation may increase 6MWD for those in both initial (MD = 22.17 m longer after eight weeks; 95% CI, −38.89 m to 83.23 m; n = 94; two trials; low-certainty evidence) and maintenance programs (MD = 78.1 m longer at four to 12 months of follow-up; 95% CI, 49.6 m to 106.6 m; n = 209; two trials; low-certainty evidence). Overall, there were no apparent increased or distinct adverse effects of telerehabilitation compared with in-person programs and control groups.

Limitations of this review included small sample sizes and heterogeneity of models for delivering telerehabilitation. Most of the studies did not include long-term outcome data and did not include patients with lung diseases other than COPD. Despite the limitations, these results are applicable in the primary care setting because of increased virtual health care delivery needs resulting from the COVID-19 pandemic.⁵ Challenges to the widespread use of telerehabilitation include variable insurance coverage, lack of evidence-based guidelines for telerehabilitation, and limited access to technology that enables remote monitoring and supervision of patients.⁶ High-quality studies are needed to determine optimal delivery modes, cost-effectiveness, availability, and patient receptiveness to pulmonary telerehabilitation.

The practice recommendations in this activity are available at https://www.cochrane.org/CD013040.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, the U.S. Air Force, the Department of Defense, or the U.S. government.