Grazie per aver scelto di utilizzare a
scopo didattico questo materiale
delle Guidelines 2011 libra.
Le ricordiamo che questo materiale è
di proprietà dell’autore e fornito
come supporto didattico per uso
personale.
Non-pharmacological approach
to comorbidities in COPD
Thierry.troosters@med.kuleuven.be
Outline
• Inactivity driving morbidity in COPD
• Preventing morbidity by remaining active
• Treating morbidity by becoming active
Functional status in COPD
60
GOLD IV Mean 289
GOLD III Mean 365
GOLD II Mean 405
800
50
40
30
20
10
R 0.34 p < 0.01 (ECLIPSE)
R 0.30 p < 0.01 (Leuven)
1000
6MWD (m)
Percentage of patients (3x100%)
Predicting Functional status
600
400
200
0
0
20
40
60
80
100
120
FEV1 (%pred)
Agusti Respir Res 2010
UZ Leuven Rehab d-base 2010
Functional status in COPD
Predicting Functional status
partial R2
p
QF (Nm.kg-1)
0.21
0.001
FEV1 (%pred)
0.11
0.001
PImax (cmH2O)
0.01
0.01
800
6MWD (m)
N=496
R 0.53 p < 0.01 (Leuven)
1000
Factors associated to 6MWD
600
400
200
0
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Quadr/Weight (Nm.kg-1)
UZ Leuven Rehab d-base 2010
Functional status in COPD
150
QF (% pred)
QF (% pred)
150
100
50
0
N=279
N=159
100
50
0
0
25
50
FEV1 (%pred)
75
COPD
Cont
Long term inactivity, driving morbidity
Physical inactivity drives morbidity
Steps.day-1 ( n )
12000
10000
-36% -43% moderate PA
8000
6000
4000
2000
0
Ctrl
Troosters Respir Med 2010
Watz AJRCCM 2008
I
II
III
IV
Long term inactivity, driving morbidity
KU-Leuven Rainbow study (Undiagnosed COPD )
Moderate PA (min)
150
Early COPD
Healthy NON smoking
Age
(Years)
64±6
Healthy
EX smoker
Gender (% Male)
90
Healthy
Smoker 27.1±4.1
BMI
(kg/m²)
Pack Years
49±23
COPD smoker
LAAC intake (%)
9
COPDI/IIEX
GOLD
(N)smoker 33/16
FEV1 (L)
2.61±0.58
FEV1 (%pred)
86±17
FEV1/FVC (%)
62±7
125
100
75
50
40
50
60
70
Age (yrs)
80
Smoking
controls
60±8
62
26.6±4.0
34±21
0
Healthy
controls
62±6
47
25.5±3.5
0
*
°
†
°
*
3.09±0.70
105±14
76±4
3.18±0.72
116±17
78±5
*
°
*
P
Long term inactivity, driving morbidity
KU-Leuven Rainbow study (Undiagnosed COPD )
Amount and Intensity of physical activity
are
important
to maintain health
Healthy
NON smoking
Moderate PA (min)
150
Healthy EX smoker
125
Healthy Smoker
Physical activity should be considered as a
COPD smoker
‘vital sign’
CDC Physical activity plan March 2010
100
COPD EX smoker
75
50
40
Haskell Circulation 2007
50
60
70
Age (yrs)
80
Inactivity a source of comorbidity?
4
3
QF (Nm/kg)
QF (Nm/kg)
5
2
1
4
3
2
1
0
0
0
50
100
Walking time (min)
150
0
10
20
30
40
50
60
Moderate PA (min)
70
80
90
Inactivity a source of comorbidity?
QF (Nm/kg)
4
3
2
1
0
0
50
100
150
Walking time (min)
Wagner Respirology 2006
Inactivity and Morbidity
Deconditioning
 Cardiovascular morbidity
 Insulin resistance
 Cancer (Colon/Breast/Lung)
 Arterial Hypertension
 Bone and joint disease
(Osteoporosis Arthritis)
Depression
Inactivity and Morbidity
Comorbidity (%)
36
13
23
5
-
9
15
6
-
Mapel Arch Intern Med 2000 22
65
45
12
-
17
32
18
-
Soriano Chest 2005 28
22
-
-
-
10
26
4
-
-
18
18
2
9
-
-
-
-
Walsh ATS 2006 70
50
52
16
16
38
62
4
32
Van Manen J Clin Epidemiol 2001
Sidney Chest 2005
Chatila PATS 2008
Comorbidity in COPD: physical (in)-activity
COPD
Symptoms
(Dyspnea)
Airflow obstruction
Dynamic hyperinflation
Age, gender,
socialsuport,
socioeconomicstate,
educationallevel
Barriers
(symptoms)
Anxiety
Exercise
capacity
Physical
(in-)activity
(behavior)
Self-efficacy
Health beliefs
COMORBIDITY
Hematological
abnormalities
Inflammation
Exacerbations
Cardiovascular
morbidity
Pulmonary
hyertension
Osteoporosis
Inflammation
Mortality
Muscle
dysfunction
Steroids
Oxidativestress
Exacerbations
Endocrine
dysfunction
Steroids
Exacerbations
Sleep-disordered
Breathing
Mental
state
Hypoxia
Preventing morbidity by PA?
• No long term prospective data in COPD
• Epidemiological suggestions
• Data in other diseases (e.g. diabetes)
Mortality (Probability Survival)
Preventing morbidity by PA?
1.0
0.75
Tio
Control
SFC
Placebo
14.9%
16.5%
12.6%
15.2%
0.50
High
Average
Low
0.25
Very low: Mainly sitting work, no PA in leisure time
Low: < 2h/week low intensity physical activity
0.0
0
5
10
15
Very Low
20
Time (Years)
Garcia-Aymerich Thorax 2006
Preventing morbidity by PA?
Metformin 850mg Bid
Incidence Diabetes
-1
Placebo
7.5
5.0
2.5
40
(cumm %)
10.0
(MET-hr.wk )
 Physical activity
Intensive lifestyle int.
30
20
10
0
0.0
0
1
2
Time (Yrs)
3
4
0
1
2
3
4
Time (Yrs)
All groups received standard package of guidelines regarding healthy life style
(written and annual session of 30')
Intensive life style = 16 face to face sessions followed by monthly session
Knowler NEJM 2002
Preventing morbidity by PA?
How could this be achieved in COPD?
Raise awareness in milder patients
Assess Physical activity
Provide feedback on PA levels
Discuss this with your patients
8000
7500
7000
6500
FEV1
TLC
Age
FB - R
(n=18)
UC - R
(n=17)
67 ± 17
112 ± 20
63 ± 8
62 ± 14
114 ± 14
61 ± 9
6000
5500
5000
4500
4000
Feedback
UC
Hospes Patient Educ Counsel 2008
Treating co-morbidity by exercise training?
Exercise tolerance: Weighted mean difference and IQR
110
100
90
80
70
60
50
40
30
20
10
0
20
10
0
Wmax
VO2max
Walking
 (% baseline)
 (% baseline)
30
Whole body end
Adapted fromTroosters AJRCCM 2005
Treating co-morbidity by exercise training?
Rehabilitation has a clear effect on
Quadr
80
 QF (Nm)
60
 HRQoL and symptoms
 Exercise tolerance
40
20
0
 Skeletal muscle weakness
 Depressed mood status
-20
-40
-60
 Exacerbations
St
ee
C
le
or
20
on
03
ad
o
20
M
03
er
Se ken
20
w
el
05
l2
00
Se
5
w
(
el
l 2 S)
de
00
Bl
5
o
k
de
20 (I)
Bl
ok 06
20 (C)
06
(C
St
P)
ee
le
Pi
tta
20
08
20
0
Pi
tta 8 (3
M
20
08 )
(6
W
M
al
)
ke
r2
00
D
al
8
la
s
20
09
Physical activity (% change)
Rehabilitation has the potential to improve PA
70
60
50
40
30
20
10
Weighted mean
+17%
0
Troosters Eur Respir Rev 2010
Rehabilitation impact on comorbidity?
Exercise training and Arterial Stiffness, marker of CV risk
PRE
POST
Pulse Wave Velosity
(m.s-1)
12
N=10
4 weeks of PR 5d/week
Endurance training
11
*
10
9
8
7
6
Controls
TR
Vivodtzef Chest 2010
Rehabilitation impact on comorbidity?
Exercise training and Arterial Stiffness, marker of CV risk
PRE
POST
Pulse Wave Velosity
(m.s-1)
12
11
*
10
9
8
7
6
Controls
TR
Vivodtzef Chest 2010
Rehabilitation impact on comorbidity?
Heart Transplantation
N=8/8
0
CO
TR
0
N=6/10
-5
-5
**
-15
-20
-20
+2
m
th
+8
m
on
th
on
+2
m
Mitchel Transplantation 2003
+8
m
-15
on
th
s
-10
s
-10
on
th
s
**
s
L2-L3 Bone mineral density
(% change vs pre TX)
Lung Transplantation
Calcitonin
Cal. + TR
Braith Transplantation 2006
Do co-morbidities complicate rehabilitation?
Crisafulli ERJ 2010
Do co-morbidities complicate rehabilitation?
Proportion of patients with clinical benefit
Exercise training yields significant effects, also in patients with comorbidity
Crisafulli ERJ 2010
Summary
• Comorbidity in COPD is at least partially driven by physical
inactivity
• BESIDES SMOKING CESSATION, early interventions aiming at
keeping patients active could potentially prevent
comorbidity
• Exercise training as a stimulus may treat some comorbidity
(muscle weakness, vascular, type II diabetes, osteoporosis,
depression)
• Patients with comorbidities are good candidates for exercise
training