Virtual Pulmonary Rehabilitation in the United States: Clinical Practice Experience

Pulmonary rehabilitation (PR) was reported to improve respiratory health in patients with chronic pulmonary diseases and decrease respiratory-related healthcare use (1). Despite the well-documented benefits, PR was underused and had a low referral rate together with low uptake (2–4) because of limited access issues (i.e., patient frailty, transportation, and program availability). Given the well-documented benefits of PR and the increasing impact of chronic pulmonary diseases on the morbidity and mortality of patients, strategies to improve the access and capacity of PR are needed. Since the COVID-19 pandemic, in-person outpatient services have been limited to mitigate the risk of transmission. Consequently, the implementation of virtual pulmonary rehabilitation (VPR) unexpectedly surged, resulting in the nationwide implementation of VPR within U.S. Department of Veterans Affairs (VA) facilities.

We read with great interest the article in this issue of AnnalsATS by Moy and colleagues (pp. 1140–1146) describing the characteristics of VPR in the United States (5). Their study presents the most robust data reflecting use of VPR among 30 clinical facilities across the nation, with a high online survey response rate of 77%. This was the first such report that revealed how VPR was delivered in the United States, where a majority of VPR was offered by VA facilities. The results demonstrated that delivery of VPR in the United States is not standardized. Most VPR programs provided similar key components of PR but differ in their in-person assessments, in-person standardized exercise testing, and providing consistent protocols for exercise progression. Surprisingly, limited access due to rurality was still a major issue for VPR service because of technological illiteracy and wi-fi bandwidth availability in rural areas. In addition, 50% of the VPR programs did not include safety assessment, the most critical element of patient care, which was disappointing.

Somehow, we missed the survey; hence, the VPR distribution map did not include our program at the Michael E. DeBakey VA Medical Center in Houston, Texas. We would like to share our practical experience in providing VPR to patients with chronic pulmonary diseases. Our team provides VPR (also known as “telehealth rehabilitation”) for veterans with pulmonary diseases before the pandemic (6). In the original program, a physical therapist, a respiratory therapist, and a pulmonologist assessed patients during in-person visits at the clinic at enrollment. Once enrolled, patients participated in VPR from their homes and returned to the clinic for in-person exit assessment. With the start of the pandemic, we provided all sessions virtually without in-person assessment to comply with U.S. federal guidance on social distancing (7). However, we assessed safety at the beginning of VPR in every session, which included blood pressure, heart rate, oxygen saturation, respiratory rate and pattern, signs of exacerbation, self-reported dyspnea, edema, chest discomfort/chest pain, cough, sputum characteristics, weight change, skin color, inhaler use, pain, and blood glucose. Impaired balance and fall risk were assessed during performance tests (e.g., modified in-home 6-minute-walk test, sit-to-stand). From our experiences, there were few emergencies that necessitated the provider to call 911 during the VPR sessions (e.g., chest pain, critically elevated blood pressure). Our hospital has a strict safety and emergency protocol when using telehealth service. All emergency calls must be reported to the VPR medical director and primary care provider and documented. Safety assessment enabled providers to progress the patients safely and effectively. We did not know that 50% of the programs provided VPR service without safety assessment. However, we assessed for safety much more during VPR visits than during the in-person visits.

The survey result revealed that VPR failed to reach rural patients. Approximately 12% of veterans who participated on our VPR annually lived in rural areas, which was in agreement with Moy and colleagues’ study that VPR is largely applied for urban patients. Technical barriers are common in elderly patients with chronic illness who live in rural areas. Fortunately, the VA provides a loaned, user-friendly iPad (Apple) equipped with cellular access for those patients who do not own any device, enabling the patients with limited resources and technological skills to access the VPR service.

Another key concern with clinical application of VPR is the potential substitute of physical activity promotion for structured PR. We do not perceive that this can take place spontaneously. The two are sharply distinguished from each other. Exercise intolerance is an important factor limiting the patients from engaging in physical activity. Patients with moderate to severe chronic respiratory disease are unlikely to opt out of VPR for a general wellness program because of their limited physical ability. According to standardized guidelines by the American Thoracic Society and the European Respiratory Society, PR offers symptom-specific, patient-individualized activities, whereas the wellness program can provide only general physical activity for mild or early stages of the diseases (8). The Global Initiative for Chronic Obstructive Lung Disease guidelines for PR clearly distinguish between PR and physical activity promotion. However, the patients who complete the VPR and progress well are encouraged to participate in a wellness program to self-maintain their regular physical activity. Physical inactivity is common and independently predicts poor outcomes in patients with pulmonary diseases (9). Regular physical activity is known to delay disease progression and minimize hospitalization in this population (10).

The study findings greatly contributed to the future direction of VPR and feasible approaches to improve the service. An initial in-person assessment and exercise testing to individualize the exercise prescription are essential components of any PR model (11). The study found that assessments were not performed according to the current standard of evidence-based practice. More than 25% of program respondents conducted evaluations only virtually. VPR programs should be standardized according to the evidence-based PR definition. We believe that hybrid PR should be encouraged and implemented because it provides thorough and objective assessment at the initial and exit evaluations better than the virtual assessment. From our experience, the in-person assessments additionally reinforce the patient’s commitment to all program activities.

The standardization of exercise protocols and progression are challenging because of the heterogeneity of health conditions and comorbidities, thus making it somewhat difficult to standardize the VPR. A home-based setting is inherently varied and not as standardized as a center-based setting. In a center-based setting, exercise progression can be standardized because of exercise-specific parameters (e.g., treadmill speed, inclination, duration, stationary bicycle revolutions per minute). In VPR, exercise progression is commonly based on the number of exercise repetitions, the number of sets, the level of difficulty, walking distance, walking steps, and the level of self-reported exertion and dyspnea. The diversity of home exercise equipment is one of the challenges to standardizing VPR. Some patients have access to a treadmill, stationary bicycle, weight station, and safe area to walk, whereas some do not have any of these. In our VPR, we adhere to the standard American College of Sports Medicine guidelines for individuals with pulmonary diseases (12) in conjunction with individual symptom-limited considerations for exercise progression as well as precautions and contraindications.

In conclusion, Moy and colleagues’ study reveals benefits and pitfalls of VPR, and the results call for standardization of the VPR and its use. Virtual health care is a promising future of PR because it reduces the cost and travel required by patients who are already frail. Incorporation of digital health technology potentially improves outcomes in providing VPR (e.g., blood pressure, heart rate, oxygen saturation as measured by pulse oximetry, spirometry, dyspnea, arrhythmias) (13, 14).