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FRESH AIR implementation studies

Anastasaki, Marilena & Trigoni, Maria & Pantouvaki, Anna & Trouli, Marianna & Mavrogianni, Maria & Chavannes, Niels & Pooler, Jillian & van Kampen, Sanne & Jones, Rupert & Lionis, Christos & Tsiligianni, Ioanna. (2019). Establishing a pulmonary rehabilitation programme in primary care in Greece: A FRESH AIR implementation study. Chronic Respiratory Disease. 16. 147997311988293. 10.1177/1479973119882939. 

For more on FRESH AIR go to

 2018 WHO paper identifies lack of GP referral to pulmonary rehabilitation as a problem

"Scoping review WHO conducted a scoping review on rehabilitation and PHC using the PubMed database. The search string rehabilitation [Title/Abstract] AND “primary health care” OR “primary care” [Title/Abstract] was used, including studies published in English between 2008 and 2018. Of the 530 abstracts that were examined, 246 were excluded. A further 78 were excluded following full text review, resulting in 212 included in the final analysis. Key findings Most of the literature reviewed (89%) came from high-income settings. Thematically, 64% of analysed studies mentioned referral to rehabilitation by the primary care workforce, while others referenced rehabilitation carried out in a primary care setting (25%), or explored the idea of rehabilitation in the primary care context (11%). One key issue repeatedly mentioned in the literature was under-referral to rehabilitation by the primary care workforce. For example, several studies focused on the under-utilization of pulmonary rehabilitation for COPD, despite overwhelming evidence of its benefits for all symptomatic COPD patients (31, 38– 41). A systematic review of surveys and audits found that only 3–16% of eligible COPD patients were referred to pulmonary rehabilitation (42). Reasons for underreferral include lack of knowledge about pulmonary rehabilitation, particularly among GPs, and insufficient resources (3, 43)"

See paper: Access to rehabilitation in primary health care: an ongoing challenge. Working Draft.  2018.  Technical Series on Primary Health Care 

Read our desktop helper on how to refer

 Unfortunately Pulmonary rehab is not specified in a 2019  WHO Factsheet but we will continue to make the case for raising its profile.

Assessment tools 

There are some general toolkits:

Assessment tools (general)

Assessing breathlessness

Assessing quality of life and disease control
  • CAT COPD Assessment Test
  • CCQ Clinical COPD Questionnaire
  • ACT Asthma Control Test
  • ACQ Asthma Control Questionnaire
  • Activation levels (Judith Hibbard): NHS siteKings FundInsignia,  HIbbard J et al Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers.Health Serv Res. 2004 Aug; 39(4 Pt 1): 1005–1026. doi:  10.1111/j.1475-6773.2004.00269.x


PR guidelines

Note that there is not yet much evidence about implementation in low and middle income countries, but a systematic review protocol references what is known to date:

Exercise guidelines and exercise prescription

Idea for the aerobic component of the FITT principle exercises:

  • Aim is 30 mins but probably start with 20 mins

  • Try splitting the 20 mins of aerobic exercises into separate exercises:
    • 10 mins walking at prescribed pace
    • 5 mins step ups / cycle
    • 5 mins marching / star jacks

  • Minimal transition time between exercises

Behavioural factors 

Barriers to adherence 

"In a large national dataset, we have shown that patients living in more deprived areas are less likely to complete PR. However, deprivation was not associated with clinical outcomes in patients who complete therapy. Interventions targeted at enhancing referral, uptake and completion of PR among patients living in deprived areas could reduce morbidity and healthcare costs in such hard-to-reach populations."


Note: there is now a published Cochrane protocol Young J et al 2017  Interventions to promote referral, uptake and adherence to pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD)


Role of psychology and psychologists

The diverse and evolving role of a psychologist within a respiratory multidisciplinary team (MDT) is described, providing a working model for service provision. The rationale for appointing a psychologist within a respiratory MDT is presented first, citing relevant policy and research and outlining the wider psychosocial impact of respiratory disease. This is followed by an insight into the psychologist’s role by highlighting important areas, including key therapy themes and the challenge of patient engagement. The way in which the psychologist supports the collective aims and aspirations of respiratory colleagues to provide a more holistic package of care is illustrated throughout.




Self management 

Treating tobacco dependence



Referral criteria

Perceived exertion

The simplest is a visual analogue scale from 0-10 that you can make. Other tools are available but subject to copyright.  These include

Written (general)

Self management plans


References regarding PR and cost effectiveness 

Referral letters

Mosleh SM, Bond CM, Lee AJ, Kiger A, Campbell NC. Effectiveness of theory-based invitations to improve attendance at cardiac rehabilitation: A randomized controlled trial. Eur J Cardiovasc Nurs [Internet]. 2014;13(3):201–10. Available from:


References from our desktop helper and position paper


  • Cochrane Review McCarthy B et al 2015 Issue 2This review highlights that pulmonary rehabilitation improves the health-related quality of life of people with COPD. Results strongly support inclusion of pulmonary rehabilitation as part of the management and treatment of patients with COPD.  Future studies should concentrate on identifying the most important components of pulmonary rehabilitation, the ideal length of a programme, the intensity of training required and how long the benefits of the programme last.

Pulmonary rehabilitation reduced hospital admissions and mortality compared with usual community care (no rehabilitation). Quality of life was also improved and the effect was substantially larger than the minimal important difference. Pulmonary rehabilitation appears to be a highly effective and safe intervention in COPD patients after suffering an exacerbation.

Overall, evidence of high quality shows moderate to large effects of rehabilitation on health-related quality of life and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of rehabilitation on hospital readmissions and mortality and introduced heterogeneity as compared with the last update of this review. Such heterogeneity of effects on hospital readmissions and mortality may be explained to some extent by the extensiveness of rehabilitation programmes and by the methodological quality of the included studies. Future researchers must investigate how the extent of rehabilitation programmes in terms of exercise sessions, self-management education and other components affects the outcomes, and how the organisation of such programmes within specific healthcare systems determines their effects after COPD exacerbations on hospital readmissions and mortality.

Although results from RCTs suggested that PR reduces subsequent exacerbations, pooled results from the cohort studies did not favour PR, likely reflecting the heterogeneous nature of individuals included in observational research and the varying standards of PR programmes.


Cost-effectiveness and affordability - the business case

  • Glasziou P et al. Evidence for underuse of effective medical services around the world. Lancet. Elsevier Ltd; 2017;390(10090):169–77.  Particularly wasteful is the global failure to capitalise on effective non-pharmalogical therapies, which, although less intensively marketed, are in many cases equally or more effective than their pharmacological counterparts. For example, pulmonary rehabilitation, which involves progressive exercise and education, has been shown to reduce hospital re-admissions and deaths for patients with chronic obstructive pulmonary disease by 70%; daily application of sunscreen can cut invasive melanoma rates by 50%; and insecticide impregnated bednets can prevent 50% of malaria cases.[McGlynn, EA, Asch, SM, Adams, J et al. The quality of health care delivered to adults in the United States. N Engl J Med20033482635–2645]. Unlike their pharmaceutical counterparts, non-drug treatments are less intensively studied, more poorly described in research, weakly regulated, and inadequately marketed, particularly when the treatment or prevention is cheap or free."  

  • Griffiths et al 2001 This outpatient pulmonary rehabilitation programme produces cost per QALY ratios within bounds considered to be cost effective and is likely to result in financial benefits to the health service.

This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation.

 Note that the shortcut to these resource pages on pulmonary rehabilitation is







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