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The WHO Rehabilitation 2030: a call for action1 makes the case for accessible and affordable rehabilitation as an essential component of health services that is crucial to achieving Sustainable Development Goal 3: good health and well-being. Additionally, the WHO Rehabilitation in health systems: guide for action2 recommends that governments across the world encourage and support rehabilitation programmes and increase their accessibility, quality, and outcomes. The development of rehabilitation in low-income and middle-income countries (LMICs) is a particular focus of strategies to achieve Universal Health Coverage. Unfortunately, the need for rehabilitation greatly exceeds capacity, especially in LMICs.

There is a substantial burden of chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD), in low- and middle-income countries (LMICs). LMICs have particular challenges in delivering cost-effective prevention, diagnosis, and management of COPD. Optimal care can be supported by effective implementation of guidelines. This American Thoracic Society workshop considered challenges to implementation of COPD guidelines in LMICs. We make 10 specific recommendations: 1) relevant organizations should provide LMIC-specific COPD management guidance; 2) patient and professional organizations must persuade policy-makers of the importance of lung function testing programs in LMICs; 3) healthcare education and training should emphasize the early-life origins of COPD; 4) urgent action is required by governments to reduce airborne exposures, including exposures to tobacco smoke and indoor and outdoor air pollution; 5) guidance for COPD in LMICs should explicitly link across Essential Medicine Lists and the World Health Organization package of essential noncommunicable disease interventions for primary health care in low-resource settings and should consider availability, affordability, sustainability, and cost-effective use of medicines; 6) the pharmaceutical industry should work to make effective COPD and tobacco-dependence medicines globally accessible and affordable; 7) implementation of locally adapted, cost-effective pulmonary rehabilitation programs should be an international priority; 8) the World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases should specify how improvements in respiratory health will be achieved; 9) research funders should increase the proportion of funding allocated to COPD in LMICs; and 10) the respiratory community should leverage the skills and enthusiasm of earlier-career clinicians and researchers to improve global respiratory health.

There is a substantial burden of chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD), in low- and middle-income countries (LMICs). LMICs have particular challenges in delivering cost-effective prevention, diagnosis, and management of COPD. Optimal care can be supported by effective implementation of guidelines. This American Thoracic Society workshop considered challenges to implementation of COPD guidelines in LMICs. We make 10 specific recommendations: 1) relevant organizations should provide LMIC-specific COPD management guidance; 2) patient and professional organizations must persuade policy-makers of the importance of lung function testing programs in LMICs; 3) healthcare education and training should emphasize the early-life origins of COPD; 4) urgent action is required by governments to reduce airborne exposures, including exposures to tobacco smoke and indoor and outdoor air pollution; 5) guidance for COPD in LMICs should explicitly link across Essential Medicine Lists and the World Health Organization package of essential noncommunicable disease interventions for primary health care in low-resource settings and should consider availability, affordability, sustainability, and cost-effective use of medicines; 6) the pharmaceutical industry should work to make effective COPD and tobacco-dependence medicines globally accessible and affordable; 7) implementation of locally adapted, cost-effective pulmonary rehabilitation programs should be an international priority; 8) the World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases should specify how improvements in respiratory health will be achieved; 9) research funders should increase the proportion of funding allocated to COPD in LMICs; and 10) the respiratory community should leverage the skills and enthusiasm of earlier-career clinicians and researchers to improve global respiratory health.

We described physical activity measures and hourly patterns in patients with chronic obstructive pulmonary disease (COPD) after stratification for generic and COPD-specific characteristics and, based on multiple physical activity measures, we identified clusters of patients. In total, 1001 patients with COPD (65% men; age, 67 years; forced expiratory volume in the first second [FEV1], 49% predicted) were studied cross-sectionally. Demographics, anthropometrics, lung function and clinical data were assessed. Daily physical activity measures and hourly patterns were analysed based on data from a multisensor armband. Principal component analysis (PCA) and cluster analysis were applied to physical activity measures to identify clusters. Age, body mass index (BMI), dyspnoea grade and ADO index (including age, dyspnoea and airflow obstruction) were associated with physical activity measures and hourly patterns. Five clusters were identified based on three PCA components, which accounted for 60% of variance of the data. Importantly, couch potatoes (i.e. the most inactive cluster) were characterised by higher BMI, lower FEV1, worse dyspnoea and higher ADO index compared to other clusters (p < 0.05 for all). Daily physical activity measures and hourly patterns are heterogeneous in COPD. Clusters of patients were identified solely based on physical activity data. These findings may be useful to develop interventions aiming to promote physical activity in COPD. ; The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: RM is supported by the National Council of Scientific and Technological Development (CNPq), Brazil (246704/2012-8). DB holds a Canada Research Chair, Canada. SSCK was funded by the Medical Research Council, UK. WD-CM was funded by the Medical Research Council, UK, and the National Institute for Health Research, UK. MSP was supported by an unrestricted research grant from Astra Zeneca. KCF is supported by the Coordination for the Improvement of Higher Education Personnel (CAPES), Brazil. SZ, DM, SD and JDL were supported by the following foundations: 'Gottfried und Julia Bangerter-Rhyner-Stiftung', 'Freiwillige Akademische Gesellschaft Basel' and 'Forschungsfonds der Universitat Basel', Switzerland. DS was supported by GSK and by the Medical Research Council, UK (G0701628). FP is supported by CNPq, Brazil. PRE was supported by an NHMRC Research Fellowship, Australia (1042341). MIP's contribution to this manuscript was funded by the NIHR Respiratory Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College, UK. EFMW was supported by Point-One funding from AgentschapNL, Dutch Ministry of Economic affairs, the Netherlands. AWV was supported by 'Stichting de Weijerhorst' and Point-One funding from AgentschapNL, Dutch Ministry of Economic affairs, Netherlands. MAS was supported by Point-One funding from AgentschapNL, Dutch Ministry of Economic affairs, the Netherlands. Part of the data was sponsored by GlaxoSmithKline (data from the ECLIPSE cohort sub-study). Data from Ireland was supported by Beaumont Foundation, Ireland and SwordMedical Ltd, Ireland. The Australian sites were supported by a National Health and Medical Research Grant, Australia (grant no.: 570814). Part of the data collection in the UK (data from Leicester) was supported by the National Institute for Health Research (NIHR) Leicestershire, Northamptonshire and Rutland Collaboration for Leadership in Applied Health Research and Care and took place at University Hospitals of Leicester NHS Trust, UK, and by the NIHR Leicester Respiratory Biomedical Research Unit, UK. Data from the PAC-COPD study was funded by grants from the following Spanish institutions: Fondo de Investigacion Sanitaria, Ministry of Health (FIS PI020541); Agencia d'Avaluacio de Tecnologia i Recerca Mediques, Catalonia Government (AATRM 035/20/02); Spanish Society of Pneumology and Thoracic Surgery (SEPAR 2002/137); Catalan Foundation of Pneumology (FUCAP 2003 Beca Maria Rava); Red RESPIRA (RTIC C03/11); Red RCESP (RTIC C03/09), Fondo de Investigacion Sanitaria (PI052486); Fondo de Investigacion Sanitaria (PI052302); Fundacio La Marato de TV3 (No. 041110); and DURSI (2005SGR00392); and by unrestricted educational grants from Novartis Farmaceutica and AstraZeneca Farmaceutica.