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Pulmonary rehabilitation (PR) is a comprehensive intervention based on a thorough patient assessment followed by personalised interventions designed to improve the physical and psychological condition of patients with chronic respiratory diseases and to promote the long-term adherence to health-enhancing behaviours [1]. While the clinical importance of physical activity is recognised across all stages of disease, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019 strategy for chronic obstructive pulmonary disease (COPD) states that patients that remain highly symptomatic and/or those with a history of moderate or severe exacerbations despite optimal pharmacotherapy are indicated for PR [2]. Improvements in symptoms, increases in quality of life and gains in functional capacity after PR are independent of age, sex or the baseline degree of airflow limitation [3, 4]. However, it is known that patients with higher symptoms of dyspnoea, worse functional capacity and poor health status at baseline are more likely to be good responders to PR [5]. While PR is traditionally applied in clinically stable patients, there is increasing evidence for its beneficial effects following hospitalisations [6] and in those with frequent exacerbations [5]. In patients with very severe disease awaiting lung transplantation significant improvements in exercise capacity and health status were reported after short-term comprehensive PR [7]. Moreover, an increasing number of specific (non-)­pharmacological interventions are available and can be combined with PR in the subgroup of patients with very advanced disease, including neuromuscular electrical stimulation (NMES), noninvasive ventilatory support and anabolic agents. Finally, PR may be an appropriate setting to introduce advance care planning (ACP) [8]. The role of these personalised and targeted interventions will be highlighted in this case report., A cachectic patient with very severe COPD and chronic respiratory failure may benefit from comprehensive and personalised pulmonary rehabilitation including neuromuscular electrical stimulation, noninvasive ventilation and anabolic steroids http://bit.ly/31Ss7WZ