Which medically stable adult patients with chronic respiratory disease—including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), post‑coronavirus disease 2019 (COVID‑19) sequelae, bronchiectasis, or recovering from lung resection or transplantation—who have adequate oxygenation (resting peripheral capillary oxygen saturation of at least eighty‑eight percent or can maintain this with supplemental oxygen of four liters per minute or less), no acute exacerbation within the past four weeks, no uncontrolled cardiovascular disease such as unstable angina, recent myocardial infarction, or severe arrhythmias, no musculoskeletal or neurological contraindications (e.g., severe osteoporosis, recent fractures, profound peripheral neuropathy, significant gait instability), and no severe cognitive impairment or delirium, are eligible for robotic‑assisted pulmonary rehabilitation?

Eligible Populations for Robotic-Assisted Pulmonary Rehabilitation

Current clinical practice guidelines do not endorse robotic-assisted pulmonary rehabilitation because systematic evidence demonstrating superior functional outcomes is absent. 1 The American Thoracic Society (2023) acknowledges that robotic technologies are "currently being adapted and tested" but lack the robust evidence base of traditional pulmonary rehabilitation. 2

Guideline-Endorsed Alternative: Telerehabilitation

The American Thoracic Society issues a strong recommendation (moderate-quality evidence) that adults with stable chronic respiratory disease be offered telerehabilitation as an equivalent alternative to center-based pulmonary rehabilitation. 3, 1 This applies to:

Disease-Specific Populations

• Stable COPD patients (strong recommendation, moderate-quality evidence) 3, 1
• Interstitial lung disease patients (strong recommendation, moderate-quality evidence) 3, 1
• Post-hospitalization COPD exacerbation within 3 weeks of discharge (strong recommendation, moderate-quality evidence) 3, 1
• Pulmonary hypertension patients who are stable on optimized medical therapy (conditional recommendation, low-quality evidence) 3

Clinical Stability Requirements

Patients must meet these safety criteria before any technology-based rehabilitation:

• Adequate oxygenation: Resting SpO₂ ≥88% or maintainable with ≤4 L/min supplemental oxygen 3
• No acute exacerbation within the past 4 weeks 3
• Cardiovascular stability: No unstable angina, recent myocardial infarction, or severe arrhythmias 3
• Musculoskeletal safety: No severe osteoporosis, recent fractures, profound peripheral neuropathy, or significant gait instability 3
• Cognitive capacity: No severe cognitive impairment or delirium that would prevent following exercise instructions 3

When to Deploy Technology-Based Rehabilitation

Telerehabilitation should be offered specifically for patients who cannot access center-based programs due to transportation barriers, rural location, or mobility limitations. 2, 1 Telerehabilitation achieves equivalent outcomes for exercise capacity and quality of life compared with traditional center-based programs, with higher completion rates (93% vs. 70%). 4

Critical Implementation Requirements

Any technology-based intervention—whether robotic or telehealth—must deliver all core pulmonary rehabilitation components, not serve as a standalone mobility aid: 2, 1

• Structured, progressive exercise training for both lower and upper extremities at appropriate intensity 2, 5
• COPD self-management education including disease knowledge, breathing strategies, and written action plans 2, 5
• Patient-tailored behavioral support to promote long-term adherence 2
• Multidisciplinary team coordination with healthcare professionals from multiple disciplines 2
• Program duration of 6–12 weeks, with 12-week programs producing greater sustained benefits 5

Common Pitfalls to Avoid

• Do not use robotic devices as standalone mobility aids without comprehensive exercise training, education, and behavioral support—this violates core pulmonary rehabilitation principles 2, 1
• Do not substitute inspiratory muscle training devices alone for comprehensive exercise training, as evidence does not support routine ventilatory muscle training as a standalone intervention 2, 5
• Do not deploy technology for WHO/NYHA class IV pulmonary hypertension or severe hemodynamic impairment, as efficacy and safety remain uncertain in these subgroups 3
• Do not initiate rehabilitation during acute exacerbations—wait at least 4 weeks post-exacerbation for stable COPD 3

Maintenance Rehabilitation Considerations

After completing initial pulmonary rehabilitation, the American Thoracic Society conditionally recommends (low-quality evidence) either supervised maintenance pulmonary rehabilitation or usual care. 3, 1 Monthly supervised sessions modestly preserve walking endurance and health status for up to 12 months, though benefits typically disappear by 24 months. 5

Evidence Limitations

The 2007 ACCP/AACVPR guidelines, the 2013 ATS/ERS statement, and the 2023 ATS Clinical Practice Guideline do not mention robotic mobility assistance in any evidence-based recommendation, indicating no endorsed role for robotics in chronic respiratory disease management. 1, 5 Current technology recommendations focus exclusively on telehealth, pedometers, and remote monitoring. 5

Until robotic mobility assistance demonstrates outcomes equivalent to standard programs in rigorous trials, clinicians should offer patients a choice between center-based pulmonary rehabilitation and telerehabilitation. 1