Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Pulmonary rehabilitation after COVID-19 hospitalization

  Recovery after severe COVID-19 often continues long after discharge. Breathlessness, muscle weakness, fatigue, reduced exercise tolerance, sleep problems, and anxiety may persist even when the acute infection has resolved. Some people also experience post-intensive care syndrome, lung function abnormalities, or symptoms associated with long COVID.

  Pulmonary rehabilitation offers a structured way to rebuild physical capacity and confidence. The program combines exercise training, breathing strategies, education, nutritional guidance, and psychological support. Its purpose is not simply to increase walking distance, but to help people return safely to daily activities and improve health-related quality of life.

  For respiratory clinicians, rehabilitation is an important part of post-COVID care. Assessment should account for the severity of the original illness, pre-existing lung or heart disease, oxygen needs, neurological symptoms, and the patient’s goals. A staged plan can then be adapted as recovery develops.

  Why recovery may remain difficult

  Hospitalization can lead to rapid loss of muscle strength, particularly after prolonged bed rest or intensive care. Mechanical ventilation, sedation, inflammation, and reduced nutrition may compound deconditioning. Even a short hospital stay can make ordinary tasks such as bathing, climbing stairs, or carrying groceries unexpectedly demanding.

  Persistent respiratory symptoms can have several causes. Some patients have impaired diffusion capacity, restrictive changes, airway hyperresponsiveness, or residual abnormalities visible on imaging. Others have relatively preserved lung tests but experience dysfunctional breathing, autonomic symptoms, severe fatigue, or fear of exertion. These differences make individualized evaluation essential.

  Emotional health also influences rehabilitation outcomes. Anxiety about breathlessness may encourage activity avoidance, which causes further physical decline. Low mood, poor sleep, and post-traumatic stress after critical illness can reduce participation. Effective programs address these concerns alongside physical conditioning rather than treating them as separate issues.

  Assessment before exercise begins

  A pre-rehabilitation review usually includes symptom history, medication review, functional capacity, oxygen saturation, heart rate, blood pressure, and an assessment of activities that matter to the patient. Depending on symptoms and clinical history, clinicians may request spirometry, diffusion testing, chest imaging, electrocardiography, or echocardiography.

  Functional tests can provide a useful baseline. The six-minute walk test is widely used, while a sit-to-stand test may be more practical for people with limited mobility. Monitoring should include symptoms, oxygen saturation, pulse response, perceived exertion, and recovery time. A low reading or an unusual cardiovascular response may require further investigation before progression.

  Rehabilitation should be delayed or modified when there is unstable cardiac disease, acute infection, uncontrolled respiratory distress, severe post-exertional symptom worsening, or another condition requiring medical review. Oxygen supplementation, if prescribed, should be used according to the treatment plan. Rehabilitation teams should also identify red flags such as chest pain, fainting, new confusion, or rapidly increasing breathlessness.

  Core elements of a rehabilitation program

  Aerobic conditioning may begin with short, low-intensity intervals of walking, cycling, or other tolerable movement. The duration and frequency can increase gradually as recovery improves. Resistance exercises are equally important because lower-limb and respiratory muscle weakness can limit mobility even when lung function is stable.

  Breathing retraining may help people who breathe rapidly or inefficiently during activity. Techniques can include paced breathing, relaxed diaphragmatic breathing, and coordination of breathing with movement. These methods should be taught by a qualified professional, since excessive focus on breathing can sometimes heighten symptom awareness.

  Education helps patients understand energy conservation, pacing, medication use, oxygen safety, sleep habits, and the difference between expected exertion and warning symptoms. Nutritional assessment may be valuable after weight loss or prolonged hospitalization. Psychological support, occupational therapy, and speech or swallowing assessment can be added when indicated.

  Rehabilitation focus	Typical aim	Ways to monitor progress
  Aerobic training	Improve walking and activity tolerance	Walking duration, distance, exertion score
  Strength training	Restore muscle power and independence	Repetition quality, sit-to-stand performance
  Breathing techniques	Reduce inefficient breathing and distress	Respiratory rate, symptom response
  Education and pacing	Prevent boom-and-bust activity cycles	Daily activity pattern, fatigue recovery
  Psychosocial support	Improve confidence, mood, and participation	Sleep, anxiety, daily function
  Oxygen management	Maintain safe oxygenation during exertion	Saturation, prescribed flow rate, recovery

  Pacing and symptom-guided progression

  A common mistake is increasing exercise too quickly on a good day. Some people with post-COVID symptoms experience delayed fatigue or post-exertional malaise several hours or a day after activity. A rehabilitation plan should therefore examine the response over time, not rely only on performance during a single session.

  Pacing involves balancing activity with planned rest and breaking demanding tasks into manageable steps. Patients may track walking, household tasks, sleep, dizziness, and fatigue to identify patterns. Progression can involve adding a few minutes of activity, increasing repetitions, or reducing rest intervals, but only when symptoms remain stable.

  The target is consistent function rather than maximum performance. A person who can prepare a meal, return to part-time work, or walk around the neighborhood without a prolonged symptom flare may have achieved a meaningful clinical improvement. Shared decision-making keeps the program relevant to real-life priorities.

  Home-based and outpatient care

  Hospital-based outpatient rehabilitation provides direct supervision, equipment, and access to a multidisciplinary team. It may be particularly appropriate for people with significant oxygen requirements, complex comorbidities, marked weakness, or uncertain exercise responses. Regular review also supports adjustment of intensity and management of new symptoms.

  Home-based pulmonary rehabilitation can improve access for people who live far from specialist services or cannot travel easily. Telephone or video follow-up, wearable activity monitoring, and digital exercise resources may support adherence. However, remote programs require clear safety instructions, reliable communication, and a way to assess symptoms and vital signs when clinically necessary.

  The best setting depends on risk, resources, social support, digital access, and patient preference. Programs should coordinate with primary care, respiratory specialists, physiotherapists, occupational therapists, nurses, dietitians, and mental health professionals. Clear documentation helps ensure continuity when care moves between hospital and community services.

  Practical recommendations for clinical teams

  • Screen patients after hospitalization for breathlessness, fatigue, weakness, reduced mobility, anxiety, and delayed symptom flares.
  • Establish baseline function with appropriate exercise testing and document oxygen requirements before increasing activity.
  • Use gradual aerobic and resistance training, with pacing strategies for people vulnerable to post-exertional worsening.
  • Include breathing education, nutrition, sleep support, and psychological care when these factors limit participation.
  • Reassess progress regularly using functional goals, symptom trends, safety data, and the patient’s ability to manage daily life.

  Measuring meaningful recovery

  Outcome measurement should extend beyond lung function. Changes in walking distance, sit-to-stand performance, muscle strength, fatigue severity, breathlessness, mood, and participation can reveal benefits that a spirometry result may miss. Patient-reported outcome measures add insight into confidence, independence, and quality of life.

  Follow-up is particularly important for people with persistent oxygen desaturation, abnormal imaging, cardiac symptoms, neurological problems, or severe fatigue. Recovery may be uneven, with periods of improvement and relapse. A flexible plan allows clinicians to investigate new symptoms while preserving achievable activity.

  Pulmonary rehabilitation after COVID-19 hospitalization works best as a coordinated recovery pathway rather than a short course of exercise alone. Respiratory services, hospitals, and community providers can use structured assessment and individualized support to help patients regain function safely. Explore current respiratory medicine programs, multidisciplinary expertise, and evidence-informed approaches through the APSR 2022 congress resources.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)