On pulmonary rehabilitation and the flight of the bumblebee: the ATS/ERS Statement on Pulmonary Rehabilitation

According to conventional aerodynamic principles, the bumblebee cannot fly. Yet these fuzzy creatures indeed do fly effortlessly from plant to plant gathering pollen in our gardens. This paradox was resolved only when it became clear that the bumblebee's flight is more like a helicopter than an aeroplane. Using similar logic, pulmonary rehabilitation (PR) should not work since it has no direct effect on the forced expiratory volume in one second. Yet this comprehensive intervention demonstrably improves symptoms, exercise performance and quality of life, and decreases healthcare consumption in individuals with chronic respiratory disease. This apparent paradox was resolved when it became clear that patients with chronic respiratory disease experience substantial morbidity from secondary impairments, such as peripheral muscle, cardiac, nutritional and psychosocial dysfunction, which can be mitigated by PR. In recent years, significant advances in the understanding of the primary and secondary impairments associated with chronic respiratory diseases, with particular focus on chronic obstructive pulmonary disease (COPD), have led to a better and increasing consideration of the role played by PR as an integral and important part of disease management. Since the 1997 European Respiratory Society (ERS) 1 and 1999 American Thoracic Society (ATS) 2 Statements on PR, there has been a dramatic increase in the science supporting the effectiveness of this therapeutic approach. Laboratory studies as well as randomised, controlled trials using valid and reproducible outcome measures have provided insight into the reasons why PR works. This rapidly growing evidence base and its implications for the care of patients with …