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

1. Exercise and the Management of COPD: Practical considerations in the rehabilitation process. A presentation for HEED 221 Neil D. Eves

2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE Characterized functionally by: • Airflow obstruction • A decrease in maximal expiratory flow rates.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. Injury 7.9% Circulatory Diseases 35.3% Other 17.6% Other Respiratory 1.5% Influenza & pneumonia3.6% Other Cancer 20.3% COPD 5.0% Lung Cancer 8.9% Circulatory Diseases 37.5% Other 21.0% Other Respiratory 1.6% Injury 4.2% COPD 3.6% Influenza & pneumonia 4.8% Other Cancer 21.5% Lung Cancer 6.0% 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

9. 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

10. What causes COPD? • CIGARETTE SMOKING!! • Exposure to indoor pollutants and biomass fuels • Smoke from cooking in poorly ventilated conditions

11. 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

12. COPD Symptoms • Dyspnea • Leg Fatigue

13. Ventilatory Limitation

14. Dynamic Hyperinflation

15. Dynamic Hyperinflation NORMAL COPD

16. Heart Function and COPD • High PVR • Poor right heart function • Left Heart Function? • Dynamic hyperinflation • Result?

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

18. 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

19. Benefits of Pulmonary Rehabilitation Goldstein n=89 8 wk inpatient rehabilitation Treatment 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 n=119 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 n=126 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

20. Pulmonary Rehabilitation and Dyspnea

21. Pulmonary Rehabilitation and Survival

22. 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

23. Essential Components of Pulmonary Rehabilitation Four major components • Exercise Training • Education • Psychosocial/behavioral interventions • Outcome assessment

24. 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

25. 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

26. 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%.

27. Upper Extremity Training • Endurance training of upper extremity to improve arm function also important • Ergometry • Free weights • Therabands

28. 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

29. 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.

30. Risks Factors to Exercise • Desaturation • Dizziness • Lightheadedness • High Blood Pressure • Ischemia • Atrial Fibrillation

31. 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

32. 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

33. 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

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