Exercise and the Management of COPD: Practical considerations in the rehabilitation process.

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Exercise and the Management of COPD Practical
considerations in the rehabilitation process.
A presentation for HEED 221 Neil D. Eves
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CHRONIC OBSTRUCTIVE PULMONARY DISEASE

• Characterized functionally by
• Airflow obstruction
• A decrease in maximal expiratory flow rates.

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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.

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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.

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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.

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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.

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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.
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Proportions of all deaths due to specific
problems among men and women, Canada, 1998.
Women
Men
Source Centre for Chronic Disease Prevention and
Control, Health Canada using data from the
Mortality File, Statistics Canada
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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
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What causes COPD?

• CIGARETTE SMOKING!!
• Exposure to indoor pollutants and biomass fuels
• Smoke from cooking in poorly ventilated conditions

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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

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COPD Symptoms

• Dyspnea
• Leg Fatigue

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Ventilatory Limitation
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Dynamic Hyperinflation
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Dynamic Hyperinflation
NORMAL
COPD
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Heart Function and COPD

• High PVR
• Poor right heart function
• Left Heart Function?
• Dynamic hyperinflation
• Result?

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Pulmonary Rehabilitation

• Even in the face of irreversible abnormalities of
  lung architecture pulmonary rehabilitation can
• Reduce symptoms
• Increase functional ability
• Improve quality of life

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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

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Benefits of Pulmonary Rehabilitation

• Goldstein n89 8 wk inpatient rehabilitation Treat
  ment group increases in 6MWD and
• (1994) program followed by 16 wk submaximal
  exercise time. Significant
• partially supervised home training improvements
  in dyspnea, emotion and
• versus control group (conventional mastery
  component of the CRQD.
• care)
• Ries et al n119 8 wk comprehensive
  outpatient Treatment group increases in VO2max
• (1995) Rehabilitation program versus and
  treadmill endurance time. Decreased
• educational control overall and exertional
  dyspnea.
• Wedzicha n126 8 wk exercise and
  education Exercise training and education led to
  
• (1996) versus education alone. increases in
  shuttle walk distance,
• activities of daily living and exertional
• dyspnea compared to control group

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Pulmonary Rehabilitation and Dyspnea
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Pulmonary Rehabilitation and Survival
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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

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Essential Components of Pulmonary Rehabilitation

• Four major components
• Exercise Training
• Education
• Psychosocial/behavioral interventions
• Outcome assessment

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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

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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

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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 _at_ 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.

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Upper Extremity Training

• Endurance training of upper extremity to improve
  arm function also important
• Ergometry
• Free weights
• Therabands

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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

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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.

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Risks Factors to Exercise

• Desaturation
• Dizziness
• Lightheadedness
• High Blood Pressure
• Ischemia
• Atrial Fibrillation

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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

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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

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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

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Outcome Assessment

• Incremental exercise test
• Submaximal exercise test
• Walking tests
• Exertional and overall dyspnea
• Health related quality of life