U.S. Department of

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Can Exercise Help LAM
U.S. Department of Health and Human Services
Angelo M. Taveira-DaSilva, M.D.,
Ph.D. Translational Medicine Branch National
Heart, Lung, and Blood Institute National
Institutes of Health Bethesda, Maryland LAM
Foundation 2009 International Conference Cincinnat
i, Ohio April 18, 2009
National Institutes of Health
National Heart, Lung, and Blood Institute
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You Need To Exercise Jack. Forget it, I Dont
Want to be Like You. You Are Too Thin
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Well.If you insist
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Factors Limiting Exercise Capacity in LAM

• Shortness of breath
• Low oxygen levels (pulse O2 saturation falls)
• Skeletal muscle fatigue

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Why Shortness of Breath?

• During exercise deeper and faster breathing is
  needed
• Airflow obstruction causes a decline in
  expiratory flow (FEV1) and makes it hard to
  breathe
• Maximal breathing capacity (MBC), which roughly
  equalsFEV1x40, is decreased
• Breathing reserve is low

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Airflow Obstruction in LAM
3liters
4 liters
FEV13 liters MBC120 liters
FEV11.5 liters MBC60 liters
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Flow Limitation During Exercise
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Causes of Exercise Limitation in LAM

• Oxygen is needed during exercise
• Decreased lung diffusion capacity (DLCO) impairs
  the ability to exchange oxygen

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Lungs as Oxygen and CO2 Exchangers
4 l/m
O2
CO2
VCO2
VCO2
5 l/min
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Lung Cysts Do Not Exchange O2
70m2
Normal lung
LAM lung 11
Oxygen Diffusion Impairment

• Normally lung surface equals a tennis court
  (70m2)
• In LAM, lung surface is smaller because of the
  cysts
• There is less O2 exchanging area
• Not enough oxygen is transferred into the blood

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What Happens During Exercise

• More oxygen is needed
• More CO2 is produced by the muscles
• More breathing is required
• Heart has to pump more blood
• Red cells are needed to carry oxygen
• Muscles need to take in O2

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What Happens During Exercise

• More breathing is required
• Ventilation/minvolume x breathing rate
• Pumping more blood needs a faster heart rate and
  greater pumping volume per beat
• Cardiac output (CO)stroke volume x heart rate

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Resting Oxygen Requirements

• O2 supply per minuteCO x oxygen content in
  blood
• 5 litresx200ml1liter of O2 available
• Demand at rest250 ml (3.5 ml/kg)/minute
• O2 reserve1,000-250750 ml
• Anemia decreases supply of O2 because 1 gm of
  hemoglobin carries 1.39 ml of O2. Correction of
  anemia increases exercise capacity

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Exercise Oxygen Requirements

• Supply per minuteCO increases, blood oxygen
  content does not change
• 12 litresx200ml2,400 ml of O2 available
• Demand at peak exercise for a person weighing 55
  kg1,650 (30 ml/kg)/minute
• Reserve2,400-1,650750 ml

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Factors Increasing O2 Requirements

• Fever, infections
• Stress
• Hyperthyroidism
• Obesity
• Pregnancy
• Food especially carbohydrates

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Excess Weight

• Excess weight increases O2 consumption
• 64 kg (140 lbs)x3.5224 ml/min/ breathing 5l
  /min
• 84kg (184lbs)x3.5294 ml/min breathing 6.5 l/min
• Abdominal obesity is associated with impaired
  lung function

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Muscle Function

• Leg muscle atrophy impairs exercise capacity
• In patients with lung diseases there is skeletal
  muscle dysfunction
• Aerobic capacity is reduced
• Early muscle fatigue occurs

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How to Decrease Breathing Requirements

• Low carbohydrate diet
• Optimize body mass index (
• Supplemental oxygen
• Improve ventilation by dilating airways
  bronchodilators

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Dynamic Hyperinflation

• Fast breathing decreases time to exhale
• Air is trapped in the lungs
• Lungs, rib cage and diaphragm are stretched out
• Work of breathing increases
• O2 requirements increase

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Airflow Limitation During Exercise
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Bronchodilators and Exercise
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How Should You Exercise

• Aerobic exercise
• Biking or walking on treadmill
• Weight lifting
• Leg exercises

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Objectives of Exercise Programs
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Designing an Exercise Program

• Baseline CPET or 6MWT
• 8 week program
• 24 sessions 2-3 hour
• 3 times a week
• Treadmill and bike at 60 VO2max
• Repeat CPET or 6MWT at the end of program

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Exercise Program

• Weight lifting
• Leg exercises
• Maintenance exercises
• Support groups

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Benefits of Exercise

• FEV1 and DLCO will not increase (?) BUT
• Muscle function will improve
• Breathlessness will decrease
• O2 requirements decrease
• Less breathing for same level of exercise
• Higher exercise level is possible

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Benefits of Exercise

• Stress decreases
• Well being and QOL improve
• Activity level may favor outcome of lung TX

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Oriental Exercise ProgramsYoga

• More research is needed
• Results of available studies are conflicting
• Yoga intervention for adults with
  mild-to-moderate asthma a pilot study-no benefit
• The Buteyko breathing technique improves symptoms
  and reduce bronchodilator use in asthma

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Yoga and Tai Chi

• Hatha Yoga improves muscle function and
  oxygenation
• Hatha yoga improved vital capacity of college
  students
• Tai Chi Chuan training improves pulmonary
  function in asthmatic children

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Recommendations

• Try to achieve an ideal body weight
• Follow a low carbohydrate, high protein diet
• Avoid high carbohydrate loads
• Undergo pulmonary rehabilitation and titrate O2
  requirements Saturation88-90

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Recommendations

• Design and maintain exercise program consisting
  of
• Aerobic exercise
• Leg exercises

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Well.Dont You Feel Better Now?