Pulmonary rehabilitation in lung transplantation: Its effects on pulmonary function, physical fitness, and quality of life

Table 1 Pulmonary rehabilitation in lung transplantation recipients based on rehabilitation phases

Rehabilitation phase	Objective	Intervention/program
Pre-transplant (pre-LTx)	(1) Maintain or improve functional capacity and muscle strength before surgery; and (2) Reduce the risk of post-operative complications, accelerate recovery, and improve QoL	(1) Aerobic training and upper- and lower-limb strength training performed 2-3 times per week for 6-8 weeks; exercise intensity progressively increased according to individual tolerance; inspiratory breathing exercises; interval, resistance, or single-leg training modalities; (2) Initial assessment: Hemodynamic stability, oxygen requirements, bone mineral status, BMI, comorbidities, respiratory mechanics, functional capacity (6MWT, CPET), muscle strength, and QoL; and (3) Education and supportive care: Familiarization with surgical procedures; secretion management, controlled coughing techniques, incentive spirometry, wound care and pain management, and early mobilization; disease-specific education (oxygen therapy, pharmacological treatment, activities of daily living, pacing, and energy conservation); psychological support, nutritional counseling, and occupational therapy
Post-LTx hospitalization	(1) Reduce weakness associated with ICU-acquired weakness; and (2) Improve lower-extremity muscle strength, balance, and gait performance to minimize the risk of falls	(1) Initiated within 24 hours postoperatively: Early mobilization, breathing exercises, airway clearance, and postural optimization; (2) Respiratory reconditioning, evaluation of supplemental oxygen requirements, strengthening of upper-extremity and lower-extremity ROM, and management of neuropathic pain; (3) Supervised ambulation and bed-to-chair transfer training, with careful management of chest tubes and pain; (4) Gradual lower-extremity resistance training, with attention to upper-limb ROM and loading restrictions during the first approximately 6 weeks; and (5) Provision of medical and adaptive equipment at hospital discharge
Early post-LTx phase (0-12 months)	(1) Improve exercise capacity, muscle strength, QoL, participation in daily activities; and (2) Prevent complications associated with immunosuppression, diabetes, osteoporosis, and tendinopathy	(1) Early initiation of outpatient PR following hospital discharge; (2) Baseline assessment of functional capacity and muscle strength; (3) Progressive exercise training with gradual increases in intensity and duration; (4) Hygiene education to prevent infection and reduce the risk of graft rejection; (5) Interval training, warm-up, and stretching exercises to prevent tendon injury; and (6) Monitoring of comorbidities and postoperative medication adjustments
Long-term post-LTx phase (> 12 months)	(1) Maintain or further improve exercise capacity and muscle function; and (2) Address long-term effects of chronic rejection, reduce dyspnea, and enhance QoL	(1) Combined aerobic and resistance training of the upper and lower extremities, performed 3-5 times per week; (2) Gradual progression of exercise duration (30-120 minutes per week) at an intensity of 50-80% of peak work rate; (3) Remote monitoring or telehealth-based supervision; (4) Emphasis on structural muscle adaptations, including mitochondrial function, strength, type I and II muscle fiber composition, and fiber cross-sectional area; and (5) Supervised outpatient programs for patients experiencing functional decline or chronic rejection

LTx: Lung transplantation; QoL: Quality of life; ICU: Intensive care unit; BMI: Body mass index; 6MWT: Six-minute walk test; CPET: Cardiopulmonary exercise testing; ROM: Range of motion; PR: Pulmonary rehabilitation.