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Adapting Pulmonary Rehabilitation for People Living with COPD & Frailty

An increasing number of people globally are living with chronic obstructive pulmonary disease (COPD), particularly within older age groups. A significant proportion (1 in 5) are also living with frailty. This combination of COPD and frailty is associated with poorer outcomes including increased mortality, reduced health and physical activity, and lower completion of exercise-based interventions, including pulmonary rehabilitation. As engagement in exercise can result in improved outcomes for this group, the adaption of pulmonary rehabilitation services to better support people with COPD and frailty is required.


This BreathePlus project is developing an adapted service with the potential to better support people living with COPD and frailty through their pulmonary rehabilitation and improve their health outcomes. It will also contribute to the design of feasible and acceptable methods for a future effectiveness trial.


This work is supported by several public members, including Margaret Ogden and five members of the Harefield Breathing Group. We have also worked together with the Cicely Saunders Institute Public Involvement Group, and the BRC PPI Respiratory research group.


This project is adopted by the Applied Research Collaborative South London.


To design and test the feasibility of a pulmonary rehabilitation intervention that has been adapted for people living with COPD and frailty. 


This early-stage intervention development project comprised four key components:

1. A qualitative interview study with people living with COPD and frailty to explore their experiences, needs, and preferences

2. A realist review to synthesise evidence around exercise interventions for people living with COPD and frailty, with a focus on how they work, for who and in what contexts

3. A secondary data analysis to explore different measures of frailty in people with COPD attending pulmonary rehabilitation

4. A feasibility trial to test the feasibility of conducting a randomised, controlled trial of this modified service in a mixed-methods study (trail registry: ISRCTN 13051922)

Summary of Findings

1. Qualitative interview study

We interviewed 19 people with COPD and frailty referred for pulmonary rehabilitation, of whom 9 did not complete the service. People with COPD and frailty report experiencing accumulating, multidimensional loss (e.g. functional abilities, relationships, confidence). This group are motivated to complete pulmonary rehabilitation but often require additional support and flexibility owing to fluctuating and unpredictable health.

Person-centred approaches should be considered to minimize disruptive health events and support pulmonary rehabilitation participation and completion. Service adaptations could allow more flexibility to meet the changing needs of this group and enable communication around how pulmonary rehabilitation might align with their priorities.

Read the full paper here:


2. Realist review

We included 20 papers in the final synthesis. Important contextual factors to consider for exercise-based interventions with people with COPD and frailty included: negative beliefs about themselves and exercise-based interventions; heterogeneous presentation and comorbidities; decreased reserves and multidimensional loss, and experiencing unpredictable health and disruptions.

In these circumstances, mechanisms that may help maximise outcomes from exercise-based interventions included: trusting relationships; creating a shared understanding of needs; having the capacity to address multidimensional concerns; being able to individualise approaches to needs and priorities; and flexible approaches to intervention delivery. Development and evaluation of new and adapted interventions should consider these principles.

Read the full paper here:


3. Secondary analysis

TBC; this component is currently underway.


4. Feasibility trial

TBC; this component is currently underway.


Read the protocol paper here:

Our Partners

Guy's and St Thomas'  logo

Guy's and St Thomas' NHS Foundation Trust

Hillingdon Hospitals

The Hillingdon Hospitals NHS Foundation Trust


Royal Brompton & Harefield NHS Foundation Trust

Project status: Ongoing

Principal Investigator


Funding Body: National Institute for Health Research

Amount: £565,413.00

Period: December 2017 - November 2021