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American Thoracic Society International Conference 2022: Highlights in Pulmonary Rehabilitation

American Thoracic Society International Conference 2022: Highlights in Pulmonary Rehabilitation

Francois Abi Fadel MD ATSF 1,2

1-Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
2-Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA 

The American Thoracic Society International Conference 2022 included thirty-five sessions spanning across two mini-symposium sessions, one thematic posters session, one poster discussion session, one RAPiD session, one Meet the Experts session and two Scientific Symposiums.  

The first Mini Symposium, A16 was entitled: “Pulmonary Rehabilitation: Transforming Our Practice in 2022”.

Pitzner-Fabricius et al. studied the effect of regular exercise on asthma control and its corticosteroid-sparing effect, finding that high-intensity interval training yielded a sustainable 24% reduction in daily inhaled corticosteroid dose without compromising asthma control [1].

Benso et al. reported their randomized study results regarding the effect of home-based rehabilitation with health coaching on chronic obstructive pulmonary disease outcomes and highlighted that unsupervised home-based rehabilitation with monitoring technology and health coaching improved quality of life, daily physical activity, and self-management in moderate to severe COPD [2]. This study confirmed the importance of home-based rehabilitation especially in the context of the COVID-19 pandemic.

In the same line, Soriano et al. studied the effect of a home-based respiratory physiotherapy and telephone based psychological support on pulmonary and mental health outcomes in patients discharged from the hospital for severe COVID-19 pneumonia. It confirmed an improvement in 6MWT, in Pulmonary function tests (FVC and FEV1), and in social and physical function with lower prevalence of anxiety, depression and post traumatic stress in the intervention group [3].

Gloeckl et al in a subgroup analysis of their randomized controlled trial, reported the influence of adherence to an App-based pulmonary rehabilitation maintenance program on physical activity and quality of life in COPD patients. The App contained a physical exercise training program educational content, and relaxation tutorials. They reported that patients who had good adherence to the App (high-frequent App users) increased their daily step counts with an improvement in quality of life [4].

The second Mini Symposium C16 was entitled: “Emerging Evidence for Rehabilitation in COVID-19.”

Daynes et al. explored among patients hospitalized for COVID-19 the differences between those who feel recovered and those who required additional support (Pulmonary Rehabilitation) in a three-month follow-up. They reported that 69% of patients determined a need for rehabilitation confirming that they had not fully recovered.  A significant difference in age, gender, ventilation status and number of comorbidities was seen between those that required rehabilitation compared to those that did not. However, no differences were noted regarding length of hospital stay, pre-existing respiratory conditions or ethnicity [5].

O'Beirne et al. reported outcomes following a comprehensive pulmonary rehabilitation program for patients with ongoing symptoms post COVID-19 infection, confirming significant and clinically meaningful improvement in 6-minute walk test (6MWT) distance, arm grip strength (AGS), Chronic Obstructive Pulmonary Disease (COPD) Assessment Tool (CAT), St. George's Respiratory Questionnaire (SGRQ) scores, Hospital Anxiety and Depression Scale (HADS) and the Post-COVID-19 Functional Scale (PCFS) [6].

Nakazawa et al. reported the effects and safety of exercise training during the acute phase of moderate COVID-19 infection. They confirmed that an exercise program that included either a flexibility exercise, a strength exercise, or a postural exercise once a day, was safe and improved exercise capacity, symptoms, and quality of life [7].

The Thematic poster session, B58 was entitled: “Pulmonary Rehabilitation: New Horizons”.

Rozenberg et al. reported Preliminary findings that muscle size and quality with ultrasound have moderate relationships with lower extremity functional measures in Idiopathic Pulmonary Fibrosis (IPF). They assessed the agreement between muscle size and fat infiltration between ultrasound and the reference standard magnetic resonance imaging (MRI) [8].

Vargas Ramirez et al. reported that Patients enrolled in Pulmonary Rehabilitation after COVID-19 had predominantly a restrictive pattern with compromise of distance in the 6MWT [9].

Francelin et al. reported in their study that the development of ICU acquired weakness in critically ill patients with COVID-19 was associated with days under mechanical ventilation and days to start the rehabilitation. Each day to start rehabilitation in the ICU for patients with COVID 19 resulted in an 11% increase in the odds of developing ICU acquired weakness [10].

In the same line Dulcey et al. confirmed that a well-structured exercise program for patients in the post-acute phase of a mild to critical course of COVID-19 infection and admitted to a comprehensive pulmonary rehabilitation program showed improvement in aerobic capacity, lung volumes and quality of life [11].

The RAPiD, Rapid Abstract Poster Discussion Session, C108 was entitled: “The Impact of Rehabilitation on Mind and Body”.

In a randomized trial, Lombardi et al. showed that hospital rehabilitation using elastic bands provides early improvement and maintenance within the first 30 days of endothelial function in patients with acute exacerbation of COPD. The Endothelial function was assessed by brachial artery ultrasonography and Flow Mediated Dilatation (FMD) [12].

Robinson et al. reported in a convergent parallel mixed-methods study patient perceptions of a Web-based physical activity intervention for COPD. Patients found the phone calls, personalized step-count goals, and graphical feedback of their daily step counts to be motivating for behavior change, highly impactful, easy to use and useful to support their exercise and walking. Also, patients favored this type of web-based intervention over attending in-person programs, however they reported some difficulties using the website and troubleshooting technical issues [13].

Windt et al. in their prospective outpatient study regarding the efficacy of pulmonary rehabilitation in long Covid showed in nine patient significant improvements in the 6MWT gait speed, IMT strength, and Baecke fitness questionnaire. No significant difference was seen in VO2 max nor the SF-36 questionnaire [14].

In the same line Rangel et al. evaluated the effects of 12 weeks of pulmonary rehabilitation in post COVID-19 patients confirming an improvement in lung functions and mechanics but also in skeletal muscles and immune response [15].

Flynn et al. compared in their study an 8-wk clinic-based PR (C-PR) program with an 8-wk home-based virtual PR (V-PR) program in ten adults with COPD, showing in preliminary data similar outcomes and similar adherence in both programs [16].

In their pilot randomized controlled study, Liang et al. found that a self-managed music-guided exercise intervention has the potential to improve muscle strength and adherence in ICU survivors and prevent further post-ICU deterioration [17].

Patel et al. found that mechanically ventilated ICU patients for < 96 hours who received early mobilization with first therapy session at an average of 1.1 days post intubation when compared to the usual group who received their first therapy session at 4.7 days had less ICU acquired weakness upon discharge from the hospital and at one year and a higher physical component score at one year [18].

The Poster Discussion Session, D28 was entitled: “Assessing the Pathophysiology and Psychology of Patients for Rehabilitation.”

Seibert et al. shared their study results showing that Standardization of hand grip strength measurements to z-scores using population norms for age and sex better correlates with functional and subjective measures of COPD severity as compared to maximum handgrip strength alone or percent predicted values [19].

Yohannes et al. found in their study that over a third of COPD patients had clinically relevant anxiety symptoms with a higher prevalence in women than men. Anxiety was associated with impaired quality of life. The authors recommended early recognition and treatment of anxiety in pulmonary rehabilitation patients [20].

The Scientific Symposiums, A87 and B90 were entitled respectively: “Emerging Program Models for Pulmonary Rehabilitation” and “Facilitating Participation in Pulmonary Rehabilitation Among People with Multiple Medical and Psychosocial Complexities”.

The first one described how several new program models of pulmonary rehabilitation have emerged including home-based PR and telerehabilitation as alternatives for traditional center-based comprehensive PR. Those programs bring new opportunities for PR to include more patients and ensure broad and long-term referrals and success. All those programs shared with the traditional PR, similar patient assessment at baseline and outcomes, program contents, and quality assurance, however it was tailored to individual patient needs.

In the second scientific symposium speakers focused on exploring the effect of PR on people with multiple complexities and co-morbidities such as obesity, complex cardiac history, cognitive impairments, and ethnic minorities who are often deterred from participating in PR, resulting in missed opportunities. The objectives were to try to identify and apply opportunities and novel strategies encouraging health professionals to facilitate participation in PR among this patient population.

Finally, Meet the Experts Session, ME22 was entitled: “Adapting Pulmonary Rehabilitation for Adults with Severe Asthma”. It covered an overview on how pulmonary rehabilitation may be adapted for the severe asthma population. It described phenotypes, psychosocial factors, barriers, and facilitators of exercise, but also the relationship of physical inactivity with worse outcomes in adults with severe asthma.


  1. Pitzner-Fabricius A, Dall C.H., Henriksen M., Hansen E.S., Toennesen L.L., Hostrup M., Backer N.V.; The Effects of High-Intensity Interval Training on Inhaled Corticosteroid Dose in Patients with Asthma - a Randomized Controlled Trial Am J Respir Crit Care Med 2022;205:A1026.
  2. Benzo R., Hoult J.P., Mcevoy C.E., Clark M., Benzo M.V., Johnson M.M., Novotny P., Effect of Home-Based Rehabilitation with Health Coaching on Chronic Obstructive Pulmonary Disease Outcomes: A Randomized Study. Am J Respir Crit Care Med 2022;205:A1027.
  3. Soriano A.N., Coico-Lama A.H., Flores E.C., Galvez-Buccollini J., Gianella G., Hartinger S., Lescano A.G., Checkley W., Effects of Home-Based Respiratory Physiotherapy and Telephone-Based Psychological Support on Pulmonary and Mental Health Outcomes in Peru: A Feasibility Randomized Controlled Trial. Am J Respir Crit Care Med 2022;205:A1029
  4. Gloeckl R., Spielmanns M., Jarosch I., Leitl D., Schneeberger T., Boeselt T., Huber S., Kaur-Bollinger P., Ulm B., Mueller C., Bjoerklund J., Spielmanns S., Windisch W., Koczulla A.. Influence of Adherence to an App-Based Pulmonary Rehabilitation Maintenance Program on Physical Activity and Quality of Life in COPD Patients - a Subgroup Analysis of a Randomized Controlled Trial. Am J Respir Crit Care Med 2022;205:A1030
  5. Daynes E., Houchen-Wolloff L., Gardiner N., Singh S.J., Rehabilitation for Patients Hospitalized with COVID19. Am J Respir Crit Care Med 2022;205:A3711
  6. O'Beirne S.L., O'Mahony A.M., Tonge P., Jackson N., Kidney D., Nolan G.. Outcomes Following Comprehensive Pulmonary Rehabilitation After COVID-19 Infection. Am J Respir Crit Care Med 2022;205:A3713.
  7. Nakazawa A., Sasaki T., Arayama Y., Inukai S., Komatsu S., Ogura T Effects and Safety of Exercise Training During the Acute Phase of Moderate COVID-19. Am J Respir Crit Care Med 2022;205:A3714
  8. Rozenberg D., Sussman M., Koh R.G.L., Nourouzpour S., Wickerson L., Singer L.G., Shapera S., Fisher J.H., Fukushi M., Martinu T., Naraghi A., De Perrot M., Batt J., Mathur S., Kumbhare D. Skeletal Muscle Size and Fat Infiltration of the Limb Muscles in Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med 2022;205:A3179
  9. Vargas Ramirez L., Herrera V.M., Rodríguez Corredor L.K., Chacon J. Respiratory Functional Compromise After COVID-19 in Patients Admitted to a Pulmonary Rehabilitation Program. Am J Respir Crit Care Med 2022;205:A3182
  10. Francelin H., Santos D.P., Lunardi A.C., Peso .C.N., Schujmann D.S., Fu C.. Association Between Days of Start Rehabilitation and Development of ICU-Acquired Weakness in Critical Ill Patients with COVID-19. Am J Respir Crit Care Med 2022;205:A3186
  11. Dulcey L., Theran J.S., Parales R.G., Esparza J.S., Moreno H.A., Pineda J.A., Caltagirone R., Aguas M.. Innovative Program of Physical and Cardiopulmonary Conditioning in Patients After the Diagnosis of Covid-19 in a Health Institution. Am J Respir Crit Care Med 2022;205:A5646
  12. Leonardi N., Kabbach E.Z., Schafauser N.S., Heubel A.D., Sentanin A.C., Castello-Simões V., Di Lorenzo V.A.P., A. B. Silva1, Mendes R.G. Hospital Rehabilitation Using Elastic Bands Provides Early Improvements and Maintenance of Endothelial Function in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD): a Randomized Controlled Trial. Am J Respir Crit Care Med 2022;205:A4959.
  13. Robinson S.A., Sliwinski S., Mongiardo M., Wiener R.S., Shimada S., Moy M. Patient Perceptions of a Web-Based Physical Activity Intervention for COPD: A Mixed-Methods Study. Am J Respir Crit Care Med 2022;205:A4961.
  14. Windt M.R., Flanagan L., Mullaney H. Prospective Out-Patient Study of Pulmonary Rehabilitation for Long COVID: Pilot Study. Am J Respir Crit Care Med 2022;205:A496.
  15. Rangel M.A., Moraes Ferreira R., Silva Reis A, Albertini R., Cesar Ferreira S., Cesar Ferreira AlvesR., Simoes Fernandes W., Frison C., Vieira R.P.  Pulmonary Rehabilitation in Post-Covid-19 Patients Improves Lung Function and Mechanics and Skeletal Muscle, and Immune Response. Am J Respir Crit Care Med 2022;205:A5790
  16. Flynn S., Cornelison S., Pu W., Ohar J.A. Feasibility of Software Enabled Virtual Pulmonary Rehabilitation Program. Am J Respir Crit Care Med 2022;205:A4963
  17. Liang Z., Hilary H., Sena Moore K., Ferreira T.B., Ji M., Signorile J. Self-Managed Music-Guided Exercise Intervention Improved Upper and Lower Extremity Muscle Strength and Adherence for ICU Survivors - A Pilot Randomized Controlled Study. Am J Respir Crit Care Med 2022;205:A4971.
  18. Patel B.K., Wolfe K.S., Patel S.B., Dugan K., Esbrook C., Pawlik A., Teele M., Kemple C., Zeleny E.,  Pohlman A., Hall J.B., Kress J.P. One-Year Quality of Life and Neuromuscular Outcomes in a Clinical Trial of Early Mobilization. Am J Respir Crit Care Med 2022;205:A497
  19. Seibert K., Dolezal B.A., Hoesterey D.T., Browne J.D., Gomez D., Saiphoklang N., Jung D., JPhillips J.E., Barjaktarevic I., Cooper C.B. Standardized Interpretation of Hand Grip Strength Improves Correlation with Functional Impairment and Symptom Burden in COPD Patients. Am J Respir Crit Care Med 2022;205:A5213
  20. Yohannes A.M., Casaburi R., Dryden S., Hanania N.A.. Sex Differences in Prevalence and Determinants of Anxiety in Patients with COPD Initiating Pulmonary Rehabilitation. Am J Respir Crit Care Med 2022;205:A5215