Exercise and the Management of
COPD: Practical considerations in
the
rehabilitation
process.
EMPHYSEMA
EMPHYSEMA
A presentation for
HEED 221
Neil D. Eves
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Characterized
functionally by:
• Airflow
obstruction
• A decrease in
maximal
expiratory flow
rates.
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Definition
• Similar between Europe and
North America
COPD is characterized by airflow
limitation that is not fully reversible.
The airflow limitation is in most
cases is both progressive and
associated with an abnormal
inflammatory response of the lungs
to noxious particles or gases.
EMPHYSEMA
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Emphysema : A condition characterized by abnormal
enlargement of the spaces distal to the terminal
bronchiole, accompanied by the destruction of their
walls and without obvious fibrosis.
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Chronic Bronchitis : Varying degrees of airflow obstruction due to
inflamation and increased bronchomotor tone. After long periods
of irritation, excessive mucous is produced constantly, the
bronchial tubes become thickened.
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
• COPD is generally a silent and unknown killer in
Canada, and threatens to be one of the main causes of
disability and death in the new millennium.
• COPD is the fourth leading cause of death for men and
seventh for women, and killed 9,618 Canadians in 1997
(LCDC, Health Canada);
• A rapidly advancing disease – the number of deaths from
COPD has quadrupled since 1971, and, while it is
projected that male mortality will begin to stabilize into
2016, female estimates show a triple-fold increase
between 1996 and 2016.
• Expected to be the 3rd leading cause of death worldwide
by 2020.
Prevalence of chronic bronchitis or
emphysema (COPD) (diagnosed by a health
care professional), Canada, 1998/99.
Source: Statistics Canada, National Population Health Survey, Health Share File.
Injury 7.9%
Circulatory
Diseases
35.3%
Other
17.6%
Other Respiratory
1.5%
Influenza &
pneumonia 3.6%
Other
Cancer
20.3%
Proportions of all
deaths due to specific
problems among men
and women, Canada,
1998.
COPD 5.0%
Lung Cancer 8.9%
Pie Graph 2
Men
Source: Centre for Chronic
Disease Prevention and
Control, Health Canada using
data from the Mortality File,
Statistics Canada
Women
Circulatory
Diseases
37.5%
Other
21.0%
Other Respiratory
1.6%
Injury 4.2%
COPD 3.6%
Influenza &
pneumonia 4.8%
Lung Cancer 6.0%
Other
Cancer
21.5%
Col 2: 21.5
Col 2: 6
Col 2: 4.8
Col 2: 3.6
Col 2: 1.6
Proportion of total health care costs (direct,
indirect and research) of major health
problems, Canada, 1993
Source: Laboratory Centre for Disease Control, Health Canada. Economic Burden of Illness in Canada.
www.hc-sc.gc/hpb/lcdc/publicat/burden/1997
What causes COPD?
• CIGARETTE SMOKING!!
• Exposure to indoor pollutants
and biomass fuels
• Smoke from cooking in poorly
ventilated conditions
Exercise Tolerance in COPD
Exercise tolerance in COPD is greatly
reduced:
• Ventilatory limitations
• Exertional symptoms
• Metabolic and Gas exchange
abnormalities
• Cardiac impairment
• Peripheral muscle dysfunction
• Any combination of the above
COPD Symptoms
• Dyspnea
• Leg Fatigue
Ventilatory Limitation
Dynamic Hyperinflation
Dynamic Hyperinflation
NORMAL
COPD
Heart Function and COPD
• High PVR
• Poor right heart
function
• Left Heart Function?
• Dynamic
hyperinflation
• Result?
Pulmonary Rehabilitation
• Even in the face of irreversible
abnormalities of lung
architecture pulmonary
rehabilitation can:
• Reduce symptoms
• Increase functional ability
• Improve quality of life
Pulmonary Rehabilitation
These benefits occur not because of
• Reduced airway obstruction
• Decreased dynamic hyperinflation
But due to improvements in secondary
morbidities that are treatable
• Reversal of muscle deconditioning
• Increased respiratory muscle strength
• Desensitization to dyspnea
Benefits of Pulmonary
Rehabilitation
Goldstein
(1994)
n=89
8 wk inpatient rehabilitation
program followed by 16 wk
partially supervised home training
versus control group (conventional
care)
Treatment group: increases in 6MWD and
submaximal exercise time. Significant
improvements in dyspnea, emotion and
mastery component of the CRQD.
Ries et al
(1995)
n=119
8 wk comprehensive outpatient
Rehabilitation program versus
educational control
Treatment group: increases in VO2max
and treadmill endurance time. Decreased
overall and exertional dyspnea.
Wedzicha
(1996)
n=126
8 wk exercise and education
versus education alone.
Exercise training and education led to
increases in shuttle walk distance,
activities of daily living and exertional
dyspnea compared to control group
Pulmonary Rehabilitation and
Dyspnea
Pulmonary Rehabilitation and
Survival
Economic Benefits of Pulmonary
Rehabilitation
• Controlled research trials
have shown a trend
toward a decrease in the
use of health care
resources after
rehabilitation
• Decreased hospitalizations
• Decreased number of
hospital days for
pulmonary related
illnesses
Essential Components of
Pulmonary Rehabilitation
Four major components
• Exercise Training
• Education
• Psychosocial/behavioral
interventions
• Outcome assessment
Exercise Training Programs
Aerobic training
• Intensity: 60-90% of predicted
maximal heart rates
• Intensity: 50-80% of VO2max
• Individualization
• Duration 20-45 minutes
• Frequency 3-4 times per week
• However, 2 times per week has
been shown to be beneficial
• Mode: Specificity
• Variety
Exercise Training Programs
Greater improvements in maximal
and submaximal exercise responses
obtained by training at high vs. low
intensities
• Increases oxidative enzymes
• Increases maximal oxygen
uptake
During submaximal exercise
• Decreased lactic acidosis
• Decreased ventilation
Interval training for COPD?
• 50-80% of VO2max for 30 minutes tough for some
patients
• 60%-80% of VO2max for 2-3 minutes with equal rest
has been used.
Vogiatzis I, Nanas S, Roussos C. et al., ERJ 20(1):12-9,
2002
• 30s @ 100% VO2max: 30s of rest x 40
• 50% VO2max for 40 min
• 2 days/wk for 12 weeks
• Similar improvements in maximal PO ~ 25%
• Similar improvements in total quality-of-life score of
the Chronic Respiratory Disease Questionnaire
• Similar reductions in ventilation ~12%.
Upper Extremity Training
• Endurance training of upper
extremity to improve arm
function also important
• Ergometry
• Free weights
• Therabands
Strength Training
• A few studies performed
by all show benefits.
• 50-85% of 1 RM increases
peripheral muscle function
• Improved quality of life
• Reduced ventilation
Respiratory Muscle Training
• Inspiratory muscle function
compromised in COPD
• May contribute to dyspnea
• Start at low resistance and
increase to achieve 60-70%
of PImax
• 30% PImax has been shown
to give an effect
• Definitely improves
respiratory muscle strength
• However, not conclusive
whether it reduces dyspnea
or improves exercise
capacity.
Risks Factors to Exercise
•
•
•
•
Desaturation
Dizziness
Lightheadedness
High Blood
Pressure
• Ischemia
• Atrial
Fibrillation
Education
• Benefits directly
attributable to
educational component
not fully documented
• Encourages participation
in health care
• Better understanding of
their disease
• Help patients and
families explore ways to
cope with changes
Psychosocial and Behavioural
Interventions
• Anxiety, depression, fear, and reductions in self-efficacy
(the ability to cope with illness) contribute to the
handicap of COPD
• Interventions :- regular patient education, support
groups focusing on specific problems
• Instruction in relaxation,
stress reduction and panic
control may help reduce
dyspnea and anxiety
• Families also encouraged to
come to support groups
Benefits of PR on Psychosocial
Outcomes
• Benefits not clearly defined
• Significant reductions in symptoms
depression and anxiety one month
after pulmonary rehabilitation. In a
non controlled study (Emery et al.,
1991)
• In a controlled randomized trial no
significant changes in depression
were observed (Ries et al., 1995)
• Increased self efficacy has also been
demonstrated after pulmonary
rehabilitation
Outcome Assessment
•
•
•
•
Incremental exercise test
Submaximal exercise test
Walking tests
Exertional and overall
dyspnea
• Health related quality of
life