Yes, patients should have an in-person assessment before initiating remotely delivered pulmonary rehabilitation
An in-person clinical exercise test is indicated to screen for exercise-induced hypoxemia and prescribe supplemental oxygen therapy as needed prior to initiating a remote exercise program 1. This represents expert consensus from a 2024 Delphi study published in Chest involving multidisciplinary experts in interstitial lung disease and pulmonary rehabilitation.
Why In-Person Assessment is Critical
The primary safety concern driving this recommendation is exercise-induced desaturation, which cannot be adequately assessed remotely without prior in-person evaluation. The expert panel reached consensus that:
- Screening for exertional hypoxemia requires direct observation during a standardized exercise test (such as 6-minute walk test or cardiopulmonary exercise testing) 1
- Oxygen prescription must be determined based on in-person exercise testing to ensure adequate supplemental oxygen availability during home-based exercise 1
- Medical screening prior to starting an exercise program was identified as a crosscutting safety theme by both patients and experts 1
Important Nuance on Exercise Testing
The standard 6-minute walk test may not be vigorous enough to detect exertional desaturation in patients who are more fit or have less severe disease 1. Some individuals may require maximal cardiopulmonary exercise testing (CPET) to adequately screen for exertional desaturation 1.
What the In-Person Assessment Should Include
Based on the consensus recommendations, the initial in-person evaluation should assess:
- Exercise-induced hypoxemia through standardized exercise testing
- Cardiovascular risk for events during exercise
- Recent pneumothorax (patients should wait ≥4 weeks after resolution before starting) 1
- Severe resting pulmonary hypertension
- Fall risk
- Exertional dyspnea and exercise tolerance through patient-centered questioning 1
Who Should Not Start Remote Rehabilitation
Certain patients are more appropriate for center-based supervision rather than remote delivery 1:
- High cardiovascular risk for events during exercise
- Severe resting pulmonary hypertension
- Significant fall risk
- Recent pneumothorax (within 4 weeks)
These patients should be referred to supervised, center-based programs until medically optimized.
Supporting Context from Broader Guidelines
The 2023 American Thoracic Society guideline on pulmonary rehabilitation strongly recommends offering a choice between telerehabilitation and center-based PR for stable patients with chronic respiratory disease 2. However, this recommendation acknowledges that most telerehabilitation evidence comes from COPD populations, with less data available for interstitial lung diseases.
Real-World Practice Patterns
Current practice data shows that assessments of exercise capacity, respiratory status, exertional oxygen requirements, and physical function are primarily conducted in-person, even in programs using hybrid delivery models 3. The majority of telerehabilitation programs in the literature included a face-to-face rehabilitation assessment 4.
Common Pitfalls to Avoid
- Do not assume resting oxygen saturation predicts exertional needs - exercise testing is required to determine oxygen requirements during activity
- Do not use remote assessment alone for initial evaluation - the reduced capacity to respond to adverse events in unsupervised settings necessitates in-person screening
- Do not skip assessment in patients who appear stable - even patients with mild to moderate disease may have undetected exertional desaturation 1
After Initial Assessment
Once the in-person assessment confirms medical appropriateness and establishes oxygen needs, remote monitoring during the program should track 1:
- Oxygen saturation (SpO₂) - rated highly valuable by experts
- Dyspnea on exertion - rated highly valuable
- Health-related quality of life - rated highly valuable
- Heart rate
Despite 83.3% of patients and 81.3% of experts being comfortable with remote exercise training without direct supervision, this comfort level was contingent upon proper initial screening 1.