The Efficacy of Personalized Pulmonary Rehabilitation Programs on Recovery Outcomes in COPD Patients During Acute Exacerbations

Summary

After personalized pulmonary rehabilitation in 200 patients with chronic obstructive pulmonary disease (COPD), the rehabilitation outcomes were assessed using standardized rating scales and composite scores, and the results demonstrated significant clinical efficacy.

Abstract

Pulmonary rehabilitation (PR) is a core component of chronic obstructive pulmonary disease (COPD) management; however, its implementation during acute exacerbations remains variable, particularly with respect to individualized approaches. This study aimed to evaluate the association between inpatient personalized PR and recovery-related clinical outcomes in hospitalized patients with acute exacerbations of COPD (AECOPD). A single-center retrospective cohort study was conducted at a tertiary care hospital between January 2021 and June 2024. Hospitalized patients aged ≥40 years with spirometry-confirmed COPD who experienced AECOPD and completed an inpatient personalized PR program were included. The rehabilitation program was initiated within 48–72 h of clinical stabilization and tailored based on baseline symptom burden, functional capacity, dyspnea severity, oxygen saturation, and exercise tolerance. Primary outcomes included changes in the COPD assessment test (CAT), modified medical research council (mMRC) dyspnea scale, and 6-minute walk test (6MWT) distance from baseline to program completion. Secondary outcomes included length of hospital stay and 30-day readmission rates. A total of 200 patients were included in the analysis. Mean CAT scores decreased from 25.4 ± 4.6 at baseline to 17.2 ± 3.8 following rehabilitation (p < 0.001). Mean mMRC dyspnea scores improved from 3.1 ± 0.8 to 2.0 ± 0.7 (p < 0.001). Functional exercise capacity increased, with the mean 6MWT distance improving from 210 ± 68 m to 310 ± 75 m (p < 0.001). The average length of hospital stay was reduced from 10.5 ± 3.2 days to 6.3 ± 2.1 days (p < 0.001), and 30-day readmission rates decreased from 25% to 10% (p < 0.001). In this retrospective cohort, inpatient personalized PR implemented during AECOPD was associated with improvements in symptom burden, dyspnea severity, functional exercise capacity, and selected healthcare utilization outcomes.

Introduction

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by persistent airflow limitation and chronic respiratory symptoms, most commonly resulting from long-term exposure to noxious particles or gases, particularly cigarette smoke. COPD encompasses chronic bronchitis and emphysema and is associated with substantial morbidity, impaired functional capacity, and reduced health-related quality of life. Acute exacerbations of COPD (AECOPD) are defined by an acute worsening of respiratory symptoms such as dyspnea, cough, and sputum production, often requiring hospitalization. These events play a critical role in the natural history of COPD, accelerating lung function decline, increasing healthcare utilization, and contributing to higher mortality risk¹. Effective COPD management, therefore, aims not only to alleviate symptoms but also to reduce the frequency and severity of exacerbations.

Pulmonary rehabilitation (PR) is a cornerstone of comprehensive COPD management and has consistently demonstrated benefits in improving exercise tolerance, symptom burden, and health-related quality of life^2,3. Standard PR programs typically include structured exercise training, patient education, nutritional counseling, and psychosocial support. Although PR is well established in stable COPD, its application during or immediately following AECOPD presents unique challenges, as hospitalized patients are often physiologically vulnerable, deconditioned, and heterogeneous with respect to symptom severity, comorbidity burden, and baseline functional status. As a result, standardized, one-size-fits-all PR protocols may be suboptimal during the acute and early recovery phases of exacerbation. Personalized PR extends conventional PR by tailoring rehabilitation strategies to individual patient characteristics. This approach involves adjusting exercise intensity, modality, and progression based on patient-specific factors such as baseline functional capacity, symptom severity, comorbid conditions, and psychosocial status². By aligning rehabilitation components with individual needs and tolerance levels, personalized PR may enhance safety, adherence, and clinical effectiveness, particularly during AECOPD, when physiological stress and functional impairment are pronounced. Despite increasing interest in individualized rehabilitation across clinical disciplines, evidence supporting personalized PR during acute COPD exacerbations remains limited. Existing studies have demonstrated the overall efficacy of PR in COPD; however, most investigations focus on stable disease or post-discharge settings, with relatively few examining individualized PR approaches implemented during hospitalization for AECOPD^3,4. Moreover, the extent to which personalization provides additional benefit beyond standard inpatient care or conventional PR protocols during acute exacerbations has not been adequately characterized. This represents an important knowledge gap, given the critical opportunity for targeted intervention during hospitalization, when early rehabilitation may influence short-term recovery and downstream clinical outcomes. In this context, the present retrospective study aimed to evaluate the association between personalized PR and recovery outcomes in hospitalized patients with AECOPD. Specifically, we assessed changes in symptom burden, functional exercise capacity, and health-related quality of life using standardized outcome measures, including the COPD assessment test (CAT), the modified medical research council (mMRC) dyspnea scale, and the 6-minute walk test (6MWT)⁵⁻¹⁰. By examining the real-world implementation of personalized PR during acute exacerbations, this study aimed to bridge this knowledge gap by evaluating the efficacy of personalized PR programs on recovery outcomes in patients with COPD during acute exacerbations. We hypothesize that personalized PR may result in huge upgrades in key healing metrics, together with symptom scores, useful workout capability, and fashionable quality of life, as compared to traditional care. By reading information from a cohort of patients with COPD who underwent custom-designed PR at some point of AECOPD, this examination seeks to provide sturdy evidence on the capacity advantages of tailoring PR interventions to individual affected character desires in the course of vital periods of exacerbation¹¹.

Protocol

Obtained ethical approval for this retrospective study from the Institutional Ethics Committee of TongDe Hospital of Zhejiang Province (Approval No.: 2024-268-JY). Conducted all procedures in accordance with the ethical standards of the institutional research committee and the principles of the Declaration of Helsinki. Waived the requirement for written informed consent due to the retrospective nature of the study and the use of anonymized clinical data, as approved by the ethics committee.

1. Study design

1. Identify patients hospitalized with acute exacerbations of COPD between January 2021 and June 2024. Include patients using a continuous enrollment strategy throughout the study period.
2. Retrieve demographic, clinical, rehabilitation, and outcome data from electronic medical records.
3. Include only patients who completed an inpatient personalized PR program during hospitalization (Figure 1).

2. Patient selection

1. Inclusion criteria
   1. Identify patients aged ≥40 years with a confirmed diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria.
   2. Confirm COPD diagnosis using post-bronchodilator spirometry showing FEV₁/FVC < 0.70.
   3. Define AECOPD as an acute worsening of respiratory symptoms (dyspnea, cough, and/or sputum production) requiring hospitalization.
   4. Confirm AECOPD diagnosis through clinical evaluation documented by a pulmonologist.
   5. Verify completion of a personalized inpatient PR program during the hospital stay.
2. Exclusion criteria
   1. Exclude patients with severe or unstable cardiovascular disease (e.g., advanced heart failure, recent myocardial infarction).
   2. Exclude patients with uncontrolled metabolic disease, active malignancy, or severe systemic illness limiting exercise participation.
   3. Exclude patients with cognitive impairment preventing participation in rehabilitation activities.
   4. Exclude patients who discontinued the PR program due to early discharge, transfer, or non-compliance.
   5. Exclude patients enrolled in external or concurrent PR programs.

3. Personalized PR program

NOTE: Deliver the PR program in the inpatient ward or hospital-based rehabilitation unit. Initiate rehabilitation within 48–72 h after clinical stabilization of AECOPD, as determined by the treating physician. Continue the program until hospital discharge.

1. Exercise training (Figure 2)
   1. Prescribe aerobic exercise using treadmill walking or cycle ergometry.
   2. Conduct sessions once daily, 5–6 days per week.
   3. Set session duration to 20–30 min, including warm-up and cool-down periods.
   4. Prescribe exercise intensity at 50–70% of estimated peak capacity or Borg rating of perceived exertion (RPE) 3–5.
   5. Adjust intensity based on:
      1. Heart rate response
      2. Oxygen saturation (maintain SpO₂ ≥ 88%)
      3. Patient-reported dyspnea and fatigue
      4. Incorporate resistance training for major muscle groups using body weight or resistance bands.
      5. Perform resistance training 2–3 sets per muscle group, 2–3 times per week.
      6. Progress exercise intensity gradually according to patient tolerance and daily reassessment.
      7. Supervise all sessions by physiotherapists and respiratory therapists.
2. Respiratory training and education
   1. Teach diaphragmatic breathing and pursed-lip breathing techniques.
   2. Provide education on COPD pathophysiology and exacerbation prevention.
   3. Instruct patients on correct inhaler technique and medication adherence.
   4. Deliver education through individual bedside sessions and written materials.
3. Psychosocial support (Figure 2)
   1. Screen patients for anxiety and depressive symptoms during hospitalization.
   2. Provide basic psychological counseling and relaxation techniques as needed.
   3. Encourage patient engagement and motivation through supportive communication.

4. Personalization criteria

1. Assess baseline functional and symptom status prior to PR initiation.
2. Use the following parameters to personalize rehabilitation intensity and progression.
   1. Baseline 6MWT distance
   2. COPD Assessment Test (CAT) score
   3. Modified medical research council (mMRC) dyspnea grade
   4. Resting and exertional heart rate
   5. Oxygen saturation (SpO₂)
   6. Exercise tolerance during initial sessions
3. Reduce exercise intensity or duration in patients with:
   1. Severe dyspnea (mMRC ≥ 3)
   2. Low baseline 6MWT distance
   3. Desaturation during exercise
   4. Increase exercise workload progressively in patients demonstrating stable vital signs and good tolerance.

5. Outcome measures

1. Measure CAT scores at baseline (before PR initiation) and at completion of the inpatient PR program.
2. Measure mMRC dyspnea scores at baseline and post-PR.
3. Conduct the 6MWT at baseline and after completion of PR following standardized guidelines.
4. Assess health-related quality of life using the St. George’s Respiratory Questionnaire (SGRQ) after PR completion only, due to feasibility limitations during acute hospitalization.
5. Record length of hospital stays from admission to discharge.
6. Record readmission rates of 30 days and 90 days post-discharge.

6. Statistical analysis

1. Summarize continuous variables using mean ± standard deviation and categorical variables using frequencies and percentages.
2. Assess data normality using the Shapiro–Wilk test.
3. Compare pre- and post-intervention outcomes using:
   1. Paired t-test for normally distributed variables
   2. Wilcoxon signed-rank test for non-normally distributed variables
   3. Analyze categorical variables using the chi-square test or Fisher’s exact test, as appropriate.
   4. Perform multivariate regression analysis adjusting for age, sex, smoking history, GOLD stage, and comorbidities.
   5. Interpret outcome changes using minimal clinically important difference (MCID) thresholds where applicable.
   6. Define statistical significance as p < 0.05.
   7. Conduct all analyses using SPSS software, version 25.0.
   8. Apply appropriate correction for multiple comparisons where relevant.

Results

Baseline characteristics
Two hundred acutely ill patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) were enrolled to do the final analysis. The average age of the participating population was 68.5 with a standard deviation of 8.3, in the age bracket between middle-aged and elderly adults. Male left ventricular systolic dysfunction patients comprised 60% (n = 120) and female patients 40% (n = 80). The baseline demographic and clinical features are presente...

Discussion

In this retrospective cohort study, the evaluations included the feasibility and clinical effects of modified PR used in the AECOPD during hospitalization and for the purpose of this study in acute exacerbation management. The results suggest that personalized rehabilitation should be launched at the acute stage, which is associated with a substantial increase in the symptom burden, severity of dyspnea, functional exercise capability, and chosen healthcare use outcomes. Notably, the size of the improvement of the primary...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Elliptical/cross-training machine	Technogym	D9573	Equipped with Technogym Live console, with networking function
Treadmill	Technogym	Live 500	It features a touch screen, strong shock absorption and speed/slope adjustment performance
Upright Bike	Life Fitness	LFISRUBC	It is suitable for scenarios in hospital physical rehabilitation centers where both durability and comfort are required.