Pulmonary rehabilitation (PR) is a standard of care for symptomatic patients with chronic respiratory diseases. PR improves outcomes across multiple areas, including reduction in dyspnea, increased exercise performance, improved skeletal muscle function and enhanced quality of life. This session will explore the role of pulmonary rehabilitation in the most severe COPD patients, discussing the influence and possibilities in subjects with severe ventilatory limitation, static and dynamic hyperinflation, hypercapnic respiratory failure, frequent exacerbations, high dyspnea sensation, multimorbidity and frailty. How can we adapt rehabilitation programs to the specific situation of the patients? How do we need to address the inherent challenges for specific patient to fulfill a successful rehabilitation program and to find the balance between cure and care? This session might contribute to improved impact and more effective implementation of PR by health care professionals in the most severe patients.