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 for post-COVID-19 respiratory sequelae

  Many Australians recovering from COVID-19 experience lingering breathlessness, reduced exercise tolerance, cough, chest tightness, fatigue or anxiety around physical activity. These symptoms can persist after the acute infection has resolved, even when chest imaging appears reassuring and routine oxygen levels are normal. Pulmonary rehabilitation offers a structured pathway to rebuild function while identifying people who need further respiratory or cardiac assessment.

  For clinicians, patients and health services, the focus is practical: establish a safe baseline, understand the individual’s goals, and provide supervised exercise, education and self-management support. In Australia, delivery may occur through a hospital outpatient department, community health service, private respiratory clinic or telehealth program, with access shaped by geography, referral pathways and Medicare arrangements.

  Identifying persistent respiratory impairment

  Assessment should begin with a detailed history covering the original illness, hospitalisation, oxygen requirement, vaccination status, comorbidities and current limitations. A person who becomes breathless walking to the letterbox may need a different plan from someone who can manage daily activities but cannot return to weekend sport or a physically demanding job.

  Clinical review can include spirometry, diffusion capacity testing, pulse oximetry, functional exercise assessment and, where indicated, chest imaging or cardiac investigations. Clinicians should also screen for post-exertional symptom exacerbation, sleep disturbance, dysfunctional breathing, anxiety, depression and musculoskeletal limitations. Understanding lung function trajectories can add useful perspective when interpreting a patient’s current respiratory measurements.

  A careful baseline prevents rehabilitation from becoming a generic fitness program. It also helps distinguish deconditioning from conditions such as asthma, interstitial lung disease, pulmonary vascular disease, myocarditis or ongoing infection. Unexplained desaturation, syncope, significant chest pain or rapidly worsening breathlessness warrants medical investigation before increasing exercise intensity.

  Building a safe rehabilitation program

  A post-COVID rehabilitation plan commonly combines aerobic conditioning, resistance training, breathing retraining, flexibility work and education. Walking, cycling and low-impact strengthening can be introduced at an intensity that produces manageable symptoms, then progressed according to recovery, oxygen response and day-to-day function. Short intervals may be more suitable than continuous exercise for people with marked fatigue.

  Breathing control can help patients who over-breathe or develop an uncomfortable pattern during exertion. Pursed-lip breathing, relaxed diaphragmatic breathing and pacing techniques may reduce distress, although they should complement assessment rather than replace it. Energy conservation is especially relevant for people who describe a “crash” after routine tasks; planned rest, task prioritisation and gradual activity increases are often more useful than pushing through symptoms.

  Making care work across Australia

  Australian services need to account for long travel distances and uneven access to respiratory specialists. A patient in regional New South Wales, Far North Queensland or Western Australia may face several hours of travel for a hospital-based program. Hybrid models using video appointments, home exercise logs, wearable monitoring and local allied health support can reduce this burden when clinical risk is low and equipment is appropriate.

  Programs should also fit the way care is organised locally. A GP may coordinate referrals to a public hospital, private physiotherapist or community respiratory service, while pulmonary rehabilitation capacity can vary between metropolitan and rural areas. Telehealth is useful for follow-up and coaching, but it should not replace in-person assessment when oxygen desaturation, falls risk or diagnostic uncertainty is present.

  Culturally safe care matters in Aboriginal and Torres Strait Islander communities, where trust, continuity and local partnership can influence engagement. Working with Aboriginal health services, involving family where appropriate and allowing flexible appointment structures can make rehabilitation more acceptable. Clear language such as “getting your puff back” may be more approachable than technical terminology, provided the clinical message remains accurate.

  Measuring progress beyond spirometry

  Improvement should be tracked through outcomes that matter in everyday life. Six-minute walk distance, sit-to-stand performance, dyspnoea scores, fatigue ratings, oxygen saturation and activity levels can be recorded at baseline and reviewed at planned intervals. Patients may also value being able to shop independently, return to paid work, manage children, walk the dog or attend a local footy match.

  Psychological recovery deserves equal attention. Fear of breathlessness can lead to avoidance, while poor sleep and low mood can reduce participation. Education about symptom monitoring, relaxation strategies and realistic pacing can support confidence. Where symptoms suggest significant distress, referral to a psychologist, occupational therapist or specialist long-COVID service may be appropriate.

  Programs should avoid assuming a steady upward trend. Recovery can fluctuate, particularly after infection, poor sleep or excessive activity. A flexible approach allows temporary reduction in workload without framing this as failure. Regular communication between the GP, physiotherapist, respiratory physician and other involved clinicians helps identify changes that need reassessment.

  Practical recommendations for clinicians and services

  A coordinated model is more likely to produce safe, useful care than isolated exercise advice. The following principles can guide program design:

  • Complete medical and functional screening before prescribing moderate or vigorous exercise.
  • Set goals linked to daily activities, employment, family responsibilities and community participation.
  • Use graded aerobic and resistance training alongside breathing techniques, education and pacing.
  • Offer culturally safe, accessible options for rural, remote and Aboriginal and Torres Strait Islander patients.
  • Review symptoms, oxygen response and functional outcomes regularly, with a clear pathway for escalation.

  For Australian patients, the first step is usually a GP review that documents persistent symptoms and identifies whether respiratory testing, imaging or specialist referral is needed. The rehabilitation team can then create a written plan covering exercise frequency, warning signs, recovery periods and follow-up. Before the next appointment, record one week of walking or household activity, including breathlessness, fatigue and recovery time, to provide a practical baseline for care.

  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)