Week 13, Topic 1 Exercise Prescription for Pulmonary Patients

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Week 13, Topic 1Exercise Prescription for
Pulmonary Patients

• Prof. Warren Payne

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Benefits of exercise training for patients with
pulmonary disease

• Benefits include
• Increased endurance exercise capacity
• Increased functional status
• Decreased severity of dyspnea
• Improved quality of life

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Benefits of exercise training for patients with
pulmonary disease

• Can be achieved regardless of severity of
  pulmonary disease
• Need for individualized programs is very high

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Exercise Prescription

• Standard principles of Frequency, Intensity,
  Duration, Mode, Rate of Progression
• Focus of the following is COPD

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Mode of Exercise

• Any mode using large muscle groups is appropriate
• Walking recommended because of relation to ADL
• Importance of indoor alternatives

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Frequency of Exercise

• Recommended goal of 3-5 days per week
• More frequent sessions may be required for those
  with severe disability in order to achieve
  desired training effect

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Intensity of Exercise

• No clear consensus
• Strategies for selecting exercise intensity for
  pulmonary patients
• Exercise at 50 of peak oxygen uptake
• Maximum limits as tolerable by symptoms

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Exercise at 50 of Peak Oxygen Uptake

• Consistent with minimal intensity recommended for
  healthy adults
• Due to deconditioned status of most pulmonary
  patients, this intensity should increase
  performance and decrease dyspnea
• Increased likelihood of adherence
• Decreased probability of injury

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Maximal limits as tolerable by symptoms

• Patients with moderate-to-severe COPD can sustain
  ventilation at a high percentage of their maximal
  minute ventilation
• Intensity can be sustained for only a few minutes
• Improvement in exercise tolerance will be
  achieved over time

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Intensity of Exercise Summary

• Need to acknowledge deconditioned status of most
  patients
• Base on GXT data as well as goals
• Use supervision and appropriate adjustment during
  early sessions

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Duration of Exercise

• Goal of 20-30 min
• Likely to need to start with an intermittent or
  interval approach

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Special Considerations

• Patients with obstructive airway disease (asthma,
  COPD and CF) should use pursed-lips breathing as
  well as consider the use of supplemental oxygen

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Pursed-lips Breathing

• Technique
• Breath in through nose
• Breath out through center of lips
• Blow air out with firm, steady effort
• Take twice as long to breath out as in

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Pursed-lips Breathing

• Benefits
• Decreased frequency, increased TV
• Sense of control over oxygenation
• Control over distress

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Supplemental Oxygen

• Measurement of PaO2 or SaO2 during GXT and
  during initial exercise sessions
• Supplemental oxygen required if PaO2 reduces to
  55 mmHg or less /or SaO2 decreases to 88 or
  less while breathing room air or exercise

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Alternative Modes of Exercise Training

• Continuous positive airway pressure
• Upper body resistance training
• Ventilatory muscle training

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Continuous Positive Airway Pressure (CPAP)

• Dynamic hyperinflation as a consequence of
  exercise in patients with COPD
• Reduces capacity to inspire due to elastic recoil
  of the lung parenchyma
• CPAP can counterbalance the elastic recoil,
  unload respiratory muscles and reduce the sense
  of dyspnea

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Continuous Positive Airway Pressure (CPAP)

• CPAP delivered at 5-10 cm H20 can increase PWC in
  patients with COPD and CF
• CPAP can be delivered via facemask during exercise

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Upper Body Resistance Training

• Integral part of pulmonary rehabilitation
  programs
• High repetition, low intensity
• Focus on arms and shoulders
• Manual resistance or light weights (1-2kg)
• Coordination of breathing with movements with
  expiration linked to greatest exertion

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Ventilatory Muscle Training (VMT)

• Focus on increased respiratory muscle strength
  /or endurance
• Strength High inspiratory resistance, few reps
  (near max inspiratory effort against an occluded
  airway)
• Endurance Low to moderate inspiratory resistance
  for 15-30 min
• This training can accompany other forms of
  training

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Major indications of VMT

• Patients who remain symptomatic or functionally
  limited despite otherwise optimal therapy
• Patients with decreased respiratory muscle
  strength

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Program Design and Supervision

• Provision of inpatient programs for those with
  severe or unstable status
• Need for flexibility in program design to take
  into account patient availability and local
  conditions/capacity
• Formal programs 6 to 8 weeks
• Follow up community programs
• Social and support benefits as for CVD programs

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Monitoring Exercise Training Intensity

• Traditionally HR
• May add pulse oximeter
• Dyspnea rating target 5 (severe) on a 0-10 scale
  during submaximal exercise lasting 10 minutes