NIHR Global Health Research Unit on Respiratory Health (RESPIRE)

Publication reviews the effectiveness, components and delivery of pulmonary rehabilitation in low-resource settings

RESPIRE PhD student, GM Monsur Habib, publishes a systematic review in npj Primary Care Respiratory Medicine

The article highlights the feasibility of conducting pulmonary rehabilitation in low- and middle-income countries (LMICs) with positive effects on outcomes such as exercise tolerance and quality of life. He also examined strategies and models of care for delivering pulmonary rehabilitation in low-resource settings.

Chronic Respiratory Diseases (CRDs) pose a common cause of disabling symptoms such as breathlessness in LMIC. Causes include smoking, use of indoor biomass fuels and occupational exposures, but the impact of these is made worse by poor awareness and insufficient resources in terms of infrastructure for diagnosis, availability of essential drugs, skilled health professionals and overall healthcare priorities.

Pulmonary rehabilitation (PR) is an effective way to improve quality of life for people with CRD. PR provides patients with a tailored exercise programme, along with education and supported self-management and lifestyle change.  We know from studies in high income countries, that PR reduces hospital admissions, duration of hospital stays and emergency medical help. It can also reduce symptoms and improve the health-related quality of life for patients.

Literature Review

The paper, published this week, aimed to review what and how PR services are delivered in LMICs and how effective they are when delivered in low-resource settings.

Systematically searching the literature, thirteen articles met the criteria for inclusion, which reported trials of 661 adults with CRDs, mainly chronic obstructive pulmonary disease (COPD). The trials had taken place in Turkey, Brazil, India, Egypt, Iran, South Africa and Venezuela.


Overall, PR was reported as being effective in terms of improving exercise capacity, health-related quality of life, and breathlessness, though the authors were concerned that none of the studies were of high quality which meant there may have been some bias in the results.  

The exercise programmes typically included endurance, interval, upper limb, and resistance/strength training.  Education, skills training (i.e. inhaler technique) and strategies for coping with breathlessness were also identified as PR treatment methods.

Most of the PR services were delivered in hospital settings, some were in the community, and some included home exercise. By providing PR services at home particularly to rural communities, this can reduce the cost and travel time for patients.

Feasibility of conducting PR in LMICs

This review has highlighted that conducting PR in LMICs in possible, and with positive effects. There is a need for PR services that are effective across many different types of CRDs. These need to be deliverable and sustainable in low-resources settings with minimal equipment. Other barriers to delivery include cost, distance, and access to healthcare services.

This article has been led by RESPIRE PhD student and Partner, GM Monsur Habib, President of the Bangladesh Primary Care Respiratory Society. Other authors on the paper include RESPIRE PhD student, Salahuddin Ahmed, RESPIRE Fellow, Md. Nazim Uzzaman, and Professor Hilary Pinnock, RESPIRE Lead on Chronic Respiratory Disorders.

GM Monsur said:

Pulmonary rehabilitation has the potential to make a real difference to the lives of people living with chronic respiratory disease in LMICs.   We need to add to the evidence of how to implement PR in low resource settings, and focus on building capacity for PR in our communities.

Read this article

Read this article in npj Primary Care Respiratory Medicine

Cite this article

Habib, G.M., Rabinovich, R., Divgi, K. et al. Systematic review of clinical effectiveness, components, and delivery of pulmonary rehabilitation in low-resource settings. npj Prim. Care Respir. Med. 30, 52 (2020).