What are the GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2026 recommendations on physical exercise for individuals with Chronic Obstructive Pulmonary Disease (COPD)?

GOLD 2026 Recommendations on Physical Exercise for COPD

Critical Clarification

The evidence provided does not contain GOLD 2026 guidelines. The most recent guidelines available are from 2007-2013, with supplementary practical recommendations from 2025. I will provide the best available evidence-based recommendations for physical exercise in COPD patients.

Core Exercise Recommendations

Mandatory Exercise Components

Exercise training of the lower extremity muscles (walking, cycling) is mandatory for all COPD patients in pulmonary rehabilitation programs. 1

• Lower-extremity endurance training forms the foundation of any exercise program, with Grade 1A evidence supporting its role in improving exercise capacity, reducing dyspnea, and enhancing quality of life 1
• Both continuous and interval training modalities are effective and should be incorporated based on patient tolerance 1

Training Intensity Specifications

High-intensity training (>70% of maximal workload) produces superior physiologic benefits compared to low-intensity training and should be the target when feasible. 1, 2

• High-intensity training yields greater improvements in peripheral muscle function and ventilatory adaptations 2, 3
• However, both low- and high-intensity training produce clinically meaningful benefits, so lower intensity remains valuable when high intensity is not tolerated 1
• For interval training, work/recovery ratios of 30 seconds/60 seconds at 50% maximum capacity, or 15 seconds/60 seconds at 70% capacity are recommended 4

Program Duration and Maintenance

Pulmonary rehabilitation programs should last 12 weeks minimum, as longer programs produce greater sustained benefits than shorter 6-week programs. 1

• Benefits decline gradually over 12-18 months following program completion 1
• Some benefits, particularly health-related quality of life, remain above baseline at 12-18 months 1
• Maintenance strategies following rehabilitation have modest effects on long-term outcomes and require ongoing attention 1

Specific Exercise Modalities

Upper Extremity Training

Unsupported upper extremity endurance training should be included in all pulmonary rehabilitation programs. 1

• Upper limb strength and endurance training improves arm function with Grade B evidence 1
• This addresses the specific functional limitations COPD patients experience with activities of daily living involving the arms 1

Strength Training

Adding a strength training component to endurance training increases muscle strength and muscle mass with Grade 1A evidence. 1

• Peripheral muscle dysfunction is a key contributor to exercise limitation in COPD 2, 3
• Strength training should target both lower and upper extremity muscle groups 1

Respiratory Muscle Training

Inspiratory muscle training is not routinely recommended as an essential component, but can be beneficial when combined with general exercise training. 1

• For patients with documented respiratory muscle weakness (PImax <60 cmH₂O), inspiratory muscle training using a threshold loading device is recommended 5
• Training parameters: 5-7 days per week, starting at <30% of PImax, 15-20 minutes per day with 2 minutes exercise/1 minute rest intervals 5
• The load should be gradually increased as tolerance improves 5

Breathing Techniques During Exercise

Pursed-lip breathing should be practiced regularly and used during both continuous and interval training. 5

• This technique reduces dynamic hyperinflation and alleviates breathlessness 5
• Method: breathe in slowly through the nose, pucker lips as if blowing a whistle, breathe out slowly through pursed lips 5
• Use during both work and rest intervals in interval training protocols 4

Adjunctive Interventions

Oxygen Supplementation

Supplemental oxygen should be used during exercise training in patients with severe exercise-induced hypoxemia (Grade 1C). 1

• For patients without exercise-induced hypoxemia, supplemental oxygen during high-intensity exercise may improve gains in exercise endurance (Grade 2C) 1
• Oxygen supplementation allows for higher exercise intensities and superior training efficacy 6

Noninvasive Ventilation

Noninvasive ventilation as an adjunct to exercise training in selected patients with severe COPD produces modest additional improvements in exercise performance (Grade 2B). 1

• This intervention remains controversial and should be reserved for patients who cannot tolerate higher intensities due to extreme breathlessness 6

Evidence-Based Outcomes

Benefits with Strongest Evidence (Grade A)

The following outcomes have the highest level of evidence supporting exercise training in COPD 1:

• Improves exercise capacity
• Reduces perceived intensity of breathlessness
• Improves health-related quality of life
• Reduces number of hospitalizations and hospital days
• Reduces anxiety and depression associated with COPD

Moderate Evidence Benefits (Grade B)

• Improves survival 1
• Benefits extend well beyond the immediate training period 1

Program Setting

Outpatient-based programs show the best results and guarantee optimal supervision with a multidisciplinary approach. 2

• Programs may be delivered in inpatient, outpatient, or home-based settings depending on individual patient needs and available resources 3
• Close attention from the rehabilitation team is required to maintain training effects 2

Common Pitfalls to Avoid

• Insufficient training intensity: Many patients are undertrained due to concerns about breathlessness, but high-intensity training is feasible even in advanced COPD 2, 3
• Inadequate program duration: Programs shorter than 12 weeks produce less sustained benefits 1
• Neglecting upper extremity training: This is essential for activities of daily living but often overlooked 1
• Lack of maintenance strategy: Benefits decline without ongoing intervention after program completion 1, 2
• Not using pursed-lip breathing: This simple technique significantly reduces dyspnea during exercise but requires active teaching 5