Pulmonary Rehabilitation
Varga János MD, PhD
National Koranyi Institute for TB and
Pulmonology, Budapest
Department of Pulmonary Rehabilitation
University of Szeged,
04/DEC/2014
Current COPD Therapy
Glass is half
empty
The role of current
pharmacotherapy:
•Reduction in breathlessness
•Improvement in exercise
tolerance
Courtesy of
Casaburi R
•Reduction in exacerbation
•Improvement in quality of life
Current COPD Therapy
Glass is half
empty
Current pharmacotherapy:
•No effect on progression
•No effect on mortality
Courtesy of
Casaburi R
What is the Next Step in the
Treatment of COPD Therapy?
• New bronchodilator therapy ?
• New anti-inflammatory therapy ?
• Reduction the number of exacerbations
?
• Alveolar grow factor ?
• Stem cells ?
Courtesy of
• Care ?
Casaburi R
Time to renew
conception ?
Troosters T et al. Am J Crit Care Med, 2005
Mortality (Survival rate%)
Physical Activity in COPD
Chance to Survive (COPD)
1.0
Garcia-Aymerich Thorax 2006
0.75
0.50
High
Average
Low
Very low
0.25
0.0
0
5
10
15
Time (Years)
Very low: Mainly sedentery, no physical activity in freetime
Low: < 2 hours/week low intensity physical activity
20
Peripherial Muscle Dysfunction in
COPD
•
•
•
•
•
•
•
•
Low muscle mass
Abnormality in capilarisation
Low oxidative enzime activity
Low ratio of type I muscle fibers
Inflammation in muscles
Corticosteroid myopathy
Low level of anabolic hormones
Abnormality in vasoregulation
Lactate increment
during exercise
VO2 (L/min)
Thorax, 2010
Maltais F, et al. Am J Respir Crit Care Med. 1996;153:288-293.
Muscle atrophy and
mitochondrial
dysfunction during
COPD exacerbation
Cell Physiol Biochem 2010
COPD Patients are Inactive
Physical inactivity in patients with COPD, controlled
multicentric pilot study
N=100
Troosters et al., Respir. Med., 2010
Physical inactivity in COPD
Correlation between physical activity and lung
function, muscle force and walking distance
1.0
 EELV (l)
Steps.day-1 ( n )
12000
10000
8000
6000
0.5
0.0
4000
N=50
2000
FEV1
0
Ctrl
I
II
III
IV
%pred
TL,CO
%pred
R
0.28*
-0.5
1
2
3
4
Daily activity (Quartile VMU)
0.38*
QF
Courtesy of
Troosters T
Troosters ERS 2007
Watz AJRCCM 2008
%pred
0.45*
6MWD
%pred
0.76*
Pitta AJRCCM 2005
Garcia-Rio AJRCCM 2009
Physical Inactivity in COPD
The Effect of Metabolic Syndrome on Physical Activity
No Metabol syndrome
Physical activity level
1.9
Steps.day-1 ( n )
12000
10000
8000
6000
4000
2000
Metabolic syndrome
1.7
1.5
1.3
1.1
0
Ctrl
I
II
III
IV
CB
I
II
III
IV
Severity
Courtesy of
Troosters T
Troosters ERS 2007
Watz AJRCCM 2008
Physical inactivity
enchances the chance of
development of comorbidities
Watz Chest 2009
Physical Inactivity in COPD Acute
Exacerbation
Low physical activity enchances
the risk of new exacerbation.
The importance of early
pulmonary rehabilitation after
exacerbation.
Day 2
Day 7 Month 1
Pitta Chest 2006
Garcia-Aymerich Thorax
2003
Seymour JM Thorax
2010
Limiting Factors in Exercise
Tolerance in COPD
•
•
•
•
•
Abnormal lung mechanics
Respiratory muscle dysfunction
Peripherial muscle dysfunction
Limitation in gas exchange, oxygen delivery
Cardiac dysfunction
Flow Limitation
Dynamic airway
compression during
exercise
1.6
1.4
F lo w (L /s )
1.2
1.0
Vmax
0.8
0.6
0.4
R A R =0.34
VEE
R A R =0.55
0.2
VEE
0.0
-0.2
0.0
0.2
0.4
0.6
V olum e (L)
0.0
0.2
0.4
0.6
0.8
1.0
FEV1:98%pred
FEV1:29%pred
Flow
Limitation
Dynamic
airway
compression
during
exercise
0.9
#
# +
+
#
#
#
Group D,WD
EELV/TLC(%)
0.8
0.7
0.6
*
*
*
*
*
*
0.5
0.4
0.3
7
$ @+ #
$ @#
$ @
Borg dyspnoe score
6
5
$ @
Group D
Dynamic
Airway
Compression
and
Hyperinflation
during Exercise
*
*
4
Varga J et
al., ERS
2006
*
3
*
2
1
0
Group WD,H
#
#
#
rest unloaded stop-6
$ #@
$@
$
stop-4
stop-2
stop
Controlled breathing techniques
• Perth lip breathing (PLB)
• Diaphragmatic breathing
• Turn the trunc to 45 degrees
Respiratory Endurance Training
COPD (n=11)
FEV1: 36±14 %pred
3x10 minutes respiratory
endurance training
MIP: 47±16 vs. 59±20
H2Ocm
MEP:90±45 vs.
123±72 H2Ocm
Limiting Factors in Exercise
Tolerance in COPD
•
•
•
•
•
Abnormal lung mechanics
Respiratory muscle dysfunction
Peripherial muscle dysfunction
Limitation in gas exchange, oxygen delivery
Cardiac dysfunction
Exercise training has favourable effect in
COPD. High intensity continous training is
more effective compared to low intensity
training.
•Casaburi R, Patessio A, Ioli F et al.: Reduction in exercise lactic
acidosis and ventilation as a result of exercise training in patients with
chronic obstructive lung disease. Am Rev Respir Dis 1991; 143:9-18.
•Casaburi R, Porszasz J, Burns MR et al.: Physiologic benefits of exercise
training in rehabilitation of patients with severe chronic obstructive
pulmonary disease. Am J Respir Crit Care Med 1997;155(5):1541-51.
The Effectivity of Training in COPD
Casaburi, ARRD 1991
The Role of Peroxisome ProliferatorActivated Receptor-Gamma Coactivator 1α
(PGC-1α) on Muscle Function
Handschin C
Nature 2008
Reduction of Exercise-induced Dynamic
Hyperinflation with Exercise Training at
Submaximal Intensity
Porszasz J, Emtner M, Goto S, Somfay A, Whipp BJ and Casaburi R.
Exercise Training Decreases Ventilatory Requirements and ExerciseInduced Hyperinflation at Submaximal Intensities in Patients with
COPD.
Chest 2005;128;2025-2034
The Role of Dynamic Hyperinflation on
Hemodinamics in COPD
Interval vs. High Intensity
Continous Training
Varga J et al. Resp. Med. 2007
Interval vs. High Intensity
Continous Training
Varga J et al. Resp. Med. 2007
The Effectivity of Training Programs-Interval
Training
Relationship „Power-duration” curve, ventilation, oxygen uptake
Electrostimulation of
muscles (NMES):
Weak funtional condition
„Nordic
walking”:
Maximal exercise
capacity and physical
activity
Daily activity
monitoring
Limiting Factors in Exercise
Tolerance in COPD
•
•
•
•
Abnormal lung mechanics
Respiratory muscle dysfunction
Peripherial muscle dysfunction
Limitation in gas exchange and oxygen
delivery
• Cardiac dysfunction
Oxygen Favourable Effect
during Exercise in Nonhypoxemic Patients with COPD
Somfay A, Porszasz J, Lee SM and Casaburi R. Effect of
Hyperoxia on Gas Exchange and Lactate Kinetics Following
Exercise Onset in Nonhypoxemic COPD Patients.
Chest 2002;121;393-400
Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R.
Benefits of supplemental oxygen in exercise training in
nonhypoxemic chronic obstructive pulmonary disease patients.
Am J Respir Crit Care Med 2003;168(9):1034-42.
Exercise training with oxygen have superior effect in
selected exercise physiologic parameters in
respiratory failure in COPD.
Physical
activity in
hypoxaemic
COPD
patients
Cognitive
function
Hypoxia,
hypercapnia,
smoking,
comorbidities
(vascular
disorders) had
influence on
cognitive function
in COPD
COPD itself
Measurement of
Feeding State:
•Determination of body
composition
•Body weight
•Calory intake
•Gastrointestinal symptoms
•Functional capacity
•Physical examination
Rehabilitation in Interstitial Lung Diseases,
IPF: Similarity and Difference based on
COPD
Respir. Med. 2008
Age-dependent PAP change in
Healthy Subjects
<30 év 30-50
year
>50 year
<30 év
30-50 >50 year
year
Kovacs G
et al. ERJ
2009;
34(4):88894.
Pulmonary Arterial Pressure Increment during
Exercise in COPD
Terhelés indukálta pulmonális artériás nyomásemelkedés
100
*
PAP (Hgmm)
80
#
#;p<0,05 csoportok között
*
60
40
20
0
Kontroll csoport
Nyugalomban
Csúcsteljesitménynél
COPD
Varga J et al. ERS
2009, P3259
Sleep Apnea Monitoring
Saturation
Heart rate
AHI
Complex rehabilitation,
adequate staff
Thank you
for your
attention!