Targeting dyspnoea through exercise intensity: insights from pulmonary rehabilitation and beyond, a narrative review

Dyspnoea is a severe symptom, causing immediate distress and significantly impairing health-related quality of life, particularly in chronic conditions. Pulmonary rehabilitation is a cornerstone in the management of chronic obstructive pulmonary disease, as supported by evidence highlighting its efficacy in improving dyspnoea, aerobic capacity, and health-related quality of life. In this multidisciplinary approach, much of those physical effects are enabled by a physiotherapist-led intensive training strategy: exercise training. In recent years, numerous studies have supported the benefits of exercise training as an effective intervention for several other chronic diseases (including interstitial lung disease, long-covid, obesity, neuromuscular disorders). Despite differences in pathophysiology, these populations share common mechanisms responsible for the chronicity of dyspnoea, including deconditioning and peripheral muscle dysfunction, which can be targeted by exercise training. After exploring the physiological mechanisms by which exercise training alleviates chronic dyspnoea, this state-of-the-art narrative review aimed to provide a readable practical synthesis to help both those learning about exercise training in pulmonary rehabilitation and those treating the individuals affected by chronic dyspnoea. A comprehensive search strategy was employed to identify relevant studies, with publications ranging from January 2020 to April 2025 from MEDLINE, the Cochrane Database, and ClinicalTrials.gov. We support the importance of the higher intensities of exercise training as a pivotal component in enhancing the individualised therapeutic potential of exercise training across diverse disease states. We also summarise evidence on muscle-level adaptations and special attention is given to the potential role of eccentric contractions in enhancing mechanical efficiency and reducing fatigue resistance, which could be a promising area for future research. Finally, we provide practical guidance on subjects' selection, baseline assessment, intensity prescription and monitoring.