Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Adaptation from the American Thoracic Society Clinical Practice Guideline.

Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Adaptation from the American Thoracic Society Clinical Practice Guideline.

Pulmonary Disease, Chronic Obstructive* / rehabilitation
Exercise Therapy
Lung

NA

NA

01/06/2026

Jan-25

The process of adapting the guide is marked, in a transversal way, by the management of conflicts of interest. As the governing body of the process, the Spanish Society of Pneumonology and Thoracic Surgery (SEPAR, as per the Spanish acronym) will oversee the organization, budget, planning, and training. From there, the development group of the guideline adaptation emerges, which is composed of the methodological group, the management committee, the panel of experts, and the group of patients and stakeholders.

The first step is the selection of the guide, as well as the selection and prioritization of questions and outcomes, which is the responsibility of the management committee. Subsequently, a systematic literature search will be conducted to update the evidence, and the methodological group will oversee the selection and synthesis of the evidence.

Then, in charge of the entire adaptation development group, the process of adoption, adaptation, or formulation of de novo recommendations will be carried out. An external review will be done by the patient group and stakeholders. And, finally, the dissemination, implementation, and updating will be in charge of the management committee.

This Clinical Practice Guideline adaptation will cover adult patients with Chronic Lung Disease (such as Chronic Obstructive Pulmonary Disease, Interstitial Lung Diseases, and asthma), evaluating pulmonary rehabilitation or telerehabilitation in terms of improvement in physical condition, quality of life, mortality, adverse events, and disease-related scales. It does not include pediatric patients or interventions other than rehabilitation or telerehabilitation.

Based on the date of publication (2023), the rigorous methodology proved by an AGREE II evaluation, and the recommendations addressed, the management committee decided to adapt the American Thoracic Society Clinical Practice Guideline in Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease.

The question formulation will be based on the topics addressed by the American Thoracic Society Clinical Practice Guideline, such as Chronic obstructive pulmonary disease patients and pulmonary rehabilitation, chronic obstructive pulmonary disease patients and pulmonary rehabilitation following hospitalization for an exacerbation, interstitial lung disease patients and pulmonary rehabilitation
Chronic respiratory disease patients and tele-rehabilitation, chronic respiratory disease patients and maintenance pulmonary rehabilitation, chronic Pulmonary Disease patients and adherence (>75% assistance) to a Pulmonary Rehabilitation Programme, and asthma patients and the Pulmonary Rehabilitation Programme.

Based on the Clinical Practice Guideline of the American Thoracic Society, a brainstorming session was conducted to establish the questions that should be considered for prioritisation in this adaptation. This process was carried out iteratively, with participation from the members of the management committee and the panel of experts.

A survey in Google Forms will be shared by the management committee with the panel of experts and with the group of patients and stakeholders, for prioritisation of the outcomes. They will be asked to 1) review the list of outcomes and 2) rank each outcome on a scale of 1 to 9. In this scale, the outcomes will be graded as a) 1 to 3 as “Limited importance”, b) 4 to 6 as “Important but not critical”, or c) 7 to 9 as “Critical importance”. After the management committee, the panel of experts, and the group of patients and stakeholders have voted, the mean score for each outcome will be used to determine its relative importance. Then the management committee will rank the highest rated outcomes so that only the top 5–7 outcomes will be included in the evidence review and evidence profile. The guideline recommendation will primarily be influenced by critical outcomes.

The Guideline Adaptation Development Group had previously identified the American Thoracic Society guideline as the reference document for this process. Given that this guideline was published in 2023 (based on a literature search conducted in MEDLINE on September 13, 2021, following the search strategy of the American Thoracic Society in their Guideline), a systematic literature search will be undertaken, by an expert librarian, to identify relevant systematic reviews published between September 2021 and January 2025. The search will employ MeSH terms, keywords, and methodological filters, and will be carried out across MEDLINE, tailored to each of the specific clinical questions being addressed. Title and abstract screening will be performed independently and in duplicate by members of the expert panel. Any discrepancies will be resolved by consensus or by a third reviewer. A specific search for cost-effectiveness studies will also be carried out, prioritizing studies in the Spain/European environment.

According to each of the questions, a list of eligibility criteria will be developed for each search. Initially, only systematic literature reviews will be included, and if none are identified, randomized controlled trials that may address each question will be included.

Each record will be evaluated in two main stages: first, by reading the title and abstract to exclude irrelevant references; and second, by assessing the full text of potentially eligible references to determine whether they meet the eligibility criteria. Title and abstract, and full text screening will be performed independently by two reviewers of the panel of experts. Any discrepancies at either stage will be resolved by discussion and consensus. The study selection process will be conducted using the Rayyan software. One reviewer will extract the main characteristics of the included studies. A second reviewer will cross-check the extracted data for accuracy. In case of doubt, another reviewer will be involved, and consensus will be reached by discussion.

The Grading of Recommendations Assessment Development and Evaluation (GRADE) approach will be used to appraise the quality of evidence and to formulate and grade recommendations. The adaptation guideline development group (adaptation GDG) will review the information and judgments of the Evidence to Decision (EtD) Frameworks from the source guideline and assess if evidence from the local context relevant needs to be integrated into the EtD table. As EtDs exist for the prioritized questions, the adaptation GDG will check for completeness on all relevant EtD criteria, and the judgements in the source recommendation will be reviewed.

Reasons for disagreement will be described (eg, if there is new evidence that supports modifying a judgment, context-related variations in resources, local considerations of patient values, etc.). The adaptation GDG will integrate the context-specific evidence under research evidence in the corresponding EtD criterion and make judgements based on this information (4). Finally, the adaptation GDG will develop the recommendation and also complete the conclusion sections in the EtD as well as tailor them to the target context as needed, following the GRADE-ADOLOPMENT guidance (4).

14. Dissemination and updating
The management committee will be responsible for dissemination. The guide will be published in SEPAR's electronic media and the Guidelines International Network (GIN) databases.

Pilar Cejudo Ramos
[email protected]