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 Strategies for Post-COVID Fibrosis

  Post-COVID fibrosis can leave people with breathlessness, reduced exercise tolerance, persistent cough and a marked loss of confidence in daily movement. The pattern varies widely: some patients have residual interstitial changes on imaging, while others experience dysfunctional breathing, muscle deconditioning or fatigue without extensive structural damage.

  Pulmonary rehabilitation provides a structured pathway for rebuilding function after acute COVID-19. It combines individually prescribed exercise, breathing techniques, education, nutrition and psychological support. For Australian patients, the most effective programme is often one that can adapt to public hospital services, private allied-health care, telehealth and the realities of distance between regional communities.

  Assessment should begin with a careful review of symptoms, oxygen saturation, lung function, imaging and functional capacity. Clinicians also need to consider pulmonary embolism, cardiac disease, asthma, vocal cord dysfunction, sleep disorders and long COVID symptoms that are not explained by fibrosis alone.

  A respiratory physician, physiotherapist, nurse, occupational therapist and general practitioner may all contribute. Clear communication between these professionals helps prevent inappropriate exertion, identifies deterioration early and gives patients a practical plan for returning to work, family responsibilities and community life.

  Establishing A Safe Baseline

  Before exercise begins, clinicians should document resting and exertional oxygen saturation, heart rate, blood pressure, respiratory rate and perceived breathlessness. A six-minute walk test is useful when the patient is stable, although a shorter sit-to-stand assessment may be more appropriate for severe weakness or limited mobility.

  Pulmonary function testing can show restriction, impaired diffusion capacity or mixed patterns. High-resolution CT findings need to be interpreted alongside symptoms and trajectory rather than treated as the sole measure of disability. Repeat imaging is generally guided by clinical change and specialist review.

  A baseline assessment should also explore fatigue, sleep quality, mood, cognition, nutritional status and the patient’s usual activity before infection. Someone who was active in Sydney’s commuting culture may need a different return-to-function plan from a person whose work involved long distances, manual tasks or limited access to local health services in regional Queensland.

  Building Exercise Capacity Gradually

  Aerobic conditioning commonly starts with walking, cycling or low-impact seated exercise at an intensity that produces manageable breathlessness. Intervals can be more tolerable than continuous exercise, particularly for people who desaturate or fatigue quickly. Duration and frequency should rise gradually, with recovery periods built into each session.

  Resistance training is important because prolonged hospitalisation, isolation and inactivity can cause substantial muscle loss. Sit-to-stand movements, step-ups, elastic bands and light weights can restore lower-limb and shoulder strength. Exercise selection should reflect everyday goals, such as climbing stairs, carrying groceries or returning to a job site.

  Oxygen therapy may be required during exertion for selected patients with clinically significant desaturation. Prescriptions should be based on testing and reviewed as function changes, rather than continued automatically. Physiotherapists can teach pacing, rest positioning and controlled breathing so that exercise becomes safer and less intimidating.

  Managing Breathlessness And Fatigue

  Breathing retraining may include relaxed diaphragmatic breathing, pursed-lip breathing and techniques that reduce upper-chest tension. These strategies do not reverse fibrotic change, but they can reduce panic, improve ventilatory efficiency and help patients regain control during activity.

  Energy conservation is equally important. Patients can divide demanding tasks, sit for personal care, arrange frequently used items within easy reach and alternate physical and cognitive activities. A graded return to work should account for commuting, heat exposure, shift patterns and access to rest areas.

  Fatigue after COVID-19 may fluctuate from day to day. A rehabilitation plan that increases activity too quickly can produce a delayed symptom flare. Monitoring the relationship between exertion and symptoms over the following 24 to 48 hours helps clinicians adjust the workload without encouraging prolonged inactivity.

  Coordinating Medical And Allied Health Care

  The rehabilitation team should review medication, vaccination status, smoking exposure, reflux symptoms and comorbidities that may restrict exercise. Asthma and airway disease can coexist with post-infectious parenchymal abnormalities, so wheeze should not automatically be attributed to fibrosis. Discussion of inflammatory airway disease may also benefit from current evidence on corticosteroid resistance in severe asthma.

  Patients with progressive breathlessness, falling oxygen levels, chest pain, syncope, haemoptysis or new unilateral leg swelling need prompt medical assessment. Rehabilitation is supportive care and does not replace investigation of a new or worsening respiratory problem.

  In Australia, referral pathways differ between major centres such as Melbourne, Brisbane and Perth and smaller regional hospitals. A shared care model can link a tertiary interstitial lung disease clinic with local physiotherapy, a GP and community nursing. Telehealth can support supervision and education when travel would otherwise make attendance unrealistic.

  Adapting Programmes To Australian Conditions

  Outdoor walking is attractive and inexpensive, but air quality matters. Bushfire smoke, dust storms, traffic pollution and extreme summer heat can aggravate respiratory symptoms. Indoor exercise, air-quality alerts and early-morning scheduling may be safer during poor conditions, especially in parts of New South Wales, Victoria and South Australia affected by seasonal smoke.

  Healthcare affordability also influences adherence. Public pulmonary rehabilitation may have waiting lists, while private sessions can involve out-of-pocket costs under Australia’s mixed funding system. Clinicians should explain available hospital, community, private and telehealth options, including whether a Chronic Disease Management plan or local service can contribute to care.

  Culturally safe communication is essential when supporting Aboriginal and Torres Strait Islander patients, particularly where transport, family responsibilities and access to specialist services shape attendance. Programmes should involve patients in decisions about location, family participation, language support and culturally appropriate health education.

  Features That Improve Participation

  • Flexible home and clinic-based sessions
  • Clear written instructions and symptom thresholds
  • Telehealth support for regional participants
  • Exercise plans linked to personal daily goals

  Tracking Progress Over Time

  Useful outcomes include walking distance, sit-to-stand repetitions, oxygen requirements, breathlessness scores, fatigue, sleep and confidence with daily activities. Patient-reported measures can reveal meaningful improvement even when imaging remains unchanged. A person may still show fibrotic markings on CT while returning to shopping, gardening or paid employment.

  Progress reviews are often appropriate every four to eight weeks, depending on severity and service capacity. The team can increase resistance, extend walking intervals or introduce more complex tasks when recovery is stable. Conversely, a plateau may signal untreated sleep apnoea, anaemia, mood disturbance, medication effects or ongoing cardiopulmonary disease.

  Long-term self-management should include an action plan for symptom flares, vaccination advice, smoking cessation support and guidance on maintaining activity. Local walking groups, council recreation centres and respiratory support organisations may help patients continue beyond a formal programme, provided the activity remains medically appropriate.

  Measures Worth Recording

  • Exertional oxygen saturation and recovery time
  • Six-minute walk or sit-to-stand performance
  • Breathlessness, fatigue and sleep quality
  • Ability to manage work and household tasks

  A practical programme for post-COVID lung injury combines careful assessment with gradual conditioning, breathing control and coordinated follow-up. In Australia, success also depends on flexible delivery, attention to air quality, realistic funding pathways and respect for regional and cultural circumstances. The immediate goal is safe improvement in function; the lasting takeaway is to build a sustainable routine that patients can carry into everyday life.

  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)