BACKGROUND: Lower limb aerobic exercise is the core component of pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) patients. The optimal intensity and type (eg, interval or continuous) of exercise training remains to be determined. OBJECTIVES: We aimed to evaluate the optimal intensities and types of lower limb aerobic exercise in patients with COPD. DESIGN: Systematic review and network meta-analysis of randomized controlled trials. DATA SOURCES AND METHODS: The PubMed, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant data. The interventions were classified according to their intensity and type as high-intensity interval training (HIIT), high-intensity continuous training (HICT), moderate-intensity continuous training (MICT), and low-intensity continuous training (LICT). We assessed exercise capacity using peak work rate (Wpeak) and the 6-min walking test (6-MWT). Lung function was evaluated by measuring peak minute ventilation (VE) and the percentage of predicted FEV1 (FEV1pred%). Dyspnea was assessed using the Modified Medical Research Council (mMRC) scale. Quality of life was measured with the Chronic Respiratory Questionnaire (CRQ). RESULTS: Fifteen studies were identified (979 subjects). HIIT showed the greatest improvement in Wpeak, 6-MWT, VE, and mMRC compared to usual care (MD 18.48 (95% CI 12.35 to 24.60), 67.73 (34.89 to 100.57), 6.26 (2.81 to 9.72), and -0.53 (-0.89 to -0.17), respectively) and showed the improvement in CRQ (MD 10.80 (95% CI 1.65 to 19.95)). MICT showed improvement in Wpeak and 6-MWT (MD 18.28 (95% CI 11.20 to 25.22), 61.92 (28.34 to 95.51)) similar to HICT (MD 16.08 (95% CI 8.19 to 23.84), 64.64 (28.70 to 00.57)) and showed the highest improvement in CRQ compared to usual care (MD 10.83 (95% CI 1.68 to 19.98)). LICT significantly improved Wpeak compared to usual care (MD 13.47 (95% CI 4.77 to 22.13)). The quality of evidence for outcomes varied from very low to moderate. CONCLUSION: HIIT and MICT might be optimal training approaches for patients with COPD. LICT exhibited limited clinical efficacy. While HICT was as effective as MICT, it caused more dyspnea. TRIAL REGISTRATION: This systematic review and network meta-analysis was prospectively registered with PROSPERO (No. CRD 42024520134).

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