Effects of pulmonary telerehabilitation in patients with chronic obstructive pulmonary disease

To the Editor: Chronic obstructive pulmonary disease (COPD), characterized by progressive airflow limitation and persistent respiratory symptoms, remains a leading cause of global morbidity and mortality. Current estimates indicate a global COPD prevalence of 4–10%, with a mortality rate of approximately 3%.[1] Pulmonary rehabilitation (PR) is widely recognized as one of the most cost-effective therapeutic interventions for COPD.[2] A recent study[3] demonstrated that pulmonary rehabilitation (PR) plays a pivotal role in the long-term management of chronic obstructive pulmonary disease. However, robust evidence regarding the efficacy of telemedicine-based pulmonary rehabilitation (PTR) interventions remains limited. This meta-analysis evaluates the clinical outcomes of PTR compared to conventional PR in COPD patients. This meta-analysis evaluated the effects of pulmonary telerehabilitation (PTR) as an alternative to conventional PR in COPD patients. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic research was conducted across multiple English-language databases, including PubMed, the Cochrane Library, EMBASE, Scopus, and Web of Science, to identify randomized controlled trials (RCTs) published between January 1, 2010, and January 1, 2025. The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool. Two independent reviewer teams screened studies, extracted data, and performed quality assessments, with discrepancies resolved through discussion with a senior investigator. Literature screening was performed using EndNote X9 software (Clarivate Analytics, Philadelphia, PA, USA), and statistical analyses were conducted using Review Manager 5.3 (Cochrane Collaboration, Copenhagen, Denmark). Continuous outcome measures were analyzed using mean differences (MDs) with 95% confidence intervals (CIs). We aimed to compare the clinical outcomes of pulmonary telerehabilitation to those of conventional pulmonary rehabilitation. The meta-analysis evaluated mean differences in 6-minute walk test distances (6MWDs), modified Medical Research Council (mMRC) and COPD Assessment Test (CAT) scores. Sensitivity analyses were performed to assess the robustness of the findings, and funnel plots were generated to evaluate publication bias. Of the 564 screened studies, 10 RCTs were included in the final analysis [Supplementary Figure 1, Supplementary References, https://links.lww.com/CM9/C471]. The experimental group received PTR via internet-based platforms, telephone, video conferencing, or television, while the control group underwent conventional PR. Key study characteristics are summarized in Supplementary Table 1, https://links.lww.com/CM9/C471. Owing to the inherent challenges in blinding behavioral interventions, all ten included studies adopted an open-label design. However, six trials implemented blinded outcome assessments to enhance objectivity in evaluating endpoints. Notably, half of the studies lacked detailed reporting on allocation concealment methods, raising concerns regarding potential selection bias. Comprehensive risk-of-bias evaluations, including domain-specific assessments (e.g., performance bias, detection bias), are presented in Supplementary Figures 2 and 3, https://links.lww.com/CM9/C471. Heterogeneity assessment demonstrated consistently low variability across all outcome measures (I2 <50%). Our primary analysis of exercise capacity [Figure 1A] incorporated data from eight randomized trials comparing post-intervention 6-minute walk distance (6MWD) between the PTR group (n = 377) and conventional PR group (n = 381), representing a pooled sample of 758 participants. The meta-analysis yielded a non-significant mean difference of 6.50 meters (95% CI: -6.11 to 19.11; P = 0.31). For dyspnea severity assessment [Figure 1B], five studies involving 551 participants (PTR: n = 283; PR: n = 268) utilized the modified Medical Research Council (mMRC) scale. The aggregated results showed no clinically relevant between-group differences (mean difference: 0.01; 95% CI: –0.17 to 0.19; P = 0.89). Quality of life evaluation through the COPD Assessment Test (CAT) [Figure 1C] included six trials encompassing 545 participants (PTR: n = 282; PR: n = 263). Although the pooled mean difference of -1.03 points (95% CI: -2.29 to 0.22) approached the minimal clinically important difference threshold, it failed to achieve statistical significance (P = 0.11). The abovementioned results suggest that while pulmonary telerehabilitation demonstrates comparable efficacy to conventional rehabilitation across multiple domains, neither approach showed superiority in this analysis. Moreover, the absence of statistical heterogeneity (I2 = 0) in the pooled analysis should be interpreted with caution, as this quantitative measure does not necessarily imply complete homogeneity among the included studies. Sensitivity analysis confirmed the stability of these findings [Supplementary Figure 4, https://links.lww.com/CM9/C471]. Funnel plots showed no evidence of publication bias (P >0.05 for all outcomes; Supplementary Figure 5, https://links.lww.com/CM9/C471).Figure 1: Forest plots of study outcomes for the included studies. (A) 6-minute walk test distance at the end of intervention. (B) Modified Medical Research Council dyspnea scale score at the end of intervention. (C) Chronic obstructive pulmonary disease (COPD) Assessment Test score at the end of intervention. CI: Confidence interval; IV: Inverse variance; SD: Standard deviation.COPD not only affects human health and longevity, but also imposes a heavy burden on the economy.[4] This meta-analysis reviewed and described the clinical outcomes of PTR in patients with COPD. Globally, conventional PR programs are accessible to fewer than 2% of COPD patients.[5] Patients with chronic obstructive pulmonary disease are mostly elderly individuals who often struggle with limited mobility and severe respiratory symptoms. These challenges, combined with transportation barriers, time constraints, and financial burdens, can significantly hinder their ability to attend hospital-based outpatient rehabilitation programs. Telerehabilitation, however, can substantially reduce these obstacles, thereby improving participation rates in pulmonary rehabilitation among COPD patients. This short-term telerehabilitation study observed that while improvements in exercise tolerance, dyspnea, and quality of life were not statistically significant, there was a modest clinical improvement in these outcomes. However, it does suggest that telerehabilitation may provide a feasible and clinically effective alternative to center-based pulmonary rehabilitation, particularly for individuals with COPD. Several limitations of the study must be acknowledged. Most included studies did not report blinding or allocation concealment, increasing the risk of bias. The short- to medium-term duration of interventions limits conclusions on long-term efficacy. In conclusion, while PTR shows comparable efficacy to in-person PR for key outcomes, its benefits extend to better adherence, cost savings, reduced caregiver burden, and improved access for mobility-limited patients. Funding This work was supported by the University Science and Technology Innovation Team (No. YKD2022TD013); Joint Fund Project of Natural Science Foundation of Inner Mongolia Autonomous Region (No. 2023LHMS08062); and the Science and Technology Program of Inner Mongolia Autonomous Region (No. 2022YFSH0002). Conflicts of interest None. Data availability Correspondence and requests for materials should be addressed to Yan Gu. The datasets generated and/or analyzed during the current study will be available from the corresponding author upon reasonable request.