advances for rehabilitation in copd
TRANSCRIPT
Content
• Rehabilitation (how) does it work ?
• How to train the ventilatory limited patient ?
Chronic Obstructive Pulmonary Disease
NHLBI/WHO Global Initiative for Chronic Obstructive LungDisease (GOLD) Definition:
Chronic obstructive pulmonary disease is characterized byairflow limitation that is not fully reversible.
It is a preventable and treatable disease with some significant
extrapulmonary manifestations.
Skeletal muscle dysfunction
Weight loss
Cardiovascular disease
Depression and Fatigue
Osteoporosis
Interaction between pulmonary and extrapulmonary factors
0 1 2 3 40
20
40
60
80
100
120
140
160
180
VO2 (L/min)
VE
(L
/min
)
Muscle Dysfunction
Early lactic acidosis
Dynamic Hyperinflation
Breathing frequency
Casaburi R and ZuWallack R. N Engl J Med 2009;360:1329-1335
Targets of Exercise Training
• Improving aerobic function of ambulation muscles
• Reducing ventilatoryrequirement and respiratory rate during exercise
• Prolonging expiration time
• Reducing dynamic hyperinflation and dyspnea
Casaburi et al. N Engl J Med 2009
Content Rehabilitation Program
• Exercise Training
– Endurance exercise to improve cardiorespiratory fitness
– Resistance training to improve muscular strength and endurance (peripheral and respiratory muscles)
• Supplemental interventions during exercise training
– Oxygen
– Heliox
• Breathing exercises
• Occupational therapy
• Nutritional advise
• Psychological support
• Patient-education / self-management (inactivity)
Rehabilitation, the evidence: Exercise tolerance
Wmax VO2max Walking Whole body end0
10
20
30
0
10
20
30
40
50
60
70
80
90
100
110
(% b
aseli
ne)
(% b
aselin
e)
Adapted fromTroosters AJRCCM 2005
Exercise tolerance: Weighted mean difference and IQR
Rehabilitation, the evidence
Dy
s
Fa
t
Em
o
Ma
s
-1
0
1
2
3
H
RQ
oL
(M
CID
-un
its)
6M
WD
0
25
50
75
6
MW
D (
m)
Lacasse Eura Medicophys 2007 (Cochrane)
CRDQ 6MWD
Patients admitted nHospital admissions
RespAll
Days spent in hospRespAll
Days per admission
1.92.2
18.121.0
9
41
±
1.41.5
19.320.77.6
1.41.7
9.410.4
6
40
±
1.31.1
10.29.73.4
Controls Rehabilitation
NS
**
**0.1
Griffiths Lancet 2000
Rehabilitation, the evidence: Health care resources
Rehabilitation: the evidence
Evidence from systematic review of meta-analysis of randomised controlled trials (level la) • Improvements in exercise tolerance • Clinically relevant improvement in health related
quality of life (HRQoL).
Evidence from at least one RCT(level lb) • Reductions in number of days spent in hospital • Pulmonary rehabilitation is cost effective
Exercise training, the core of rehabilitation
How do we train patients with severe airflow
obstruction, dynamic hyperinflation and
complaints of dyspnea on exertion?
Knowing exercise limitations to guide training
How to train the ventilatory limited patient ?
Improve the lung function / maximum
ventilatory capacity
Reduce the ventilatory needs
– Increase the delivery
– Reduce the demand
Improve lung function
Casaburi et al Chest 2005
TIO REHAB TIO+REHAB
0
50
100
150
Exerc
ise e
nn
du
ran
ce
(% i
ncre
ase)
w4 w9 w13 w17 w21 w25
200
300
400
500
600
700
Tim
e P
A o
uts
ide r
eh
ab
(min
)
*
*
*
Kesten J COPD 2008
HeliOx
FEV1 1.540.73 1.890.73
FVC 3.761.13 3.861.18
Air HeliOx
0
10
20
30
40
50
60
70
0
2
4
6
8
10
12
14
16
18
Endurance time VE
Eves AJRCCM 2006
90
60
30
00 10 20
Ven
tila
tio
n (
L.m
in-1
)
Time (min)
HE
Improve maximal voluntary ventilation
Training at higher intensity
0 2 4 6 8 10 12 14 16 18 20 22
40
60
80
100
120
Session (n)
WR
(%
max)
0
4
8
12
16
20
24
Air HH
*
*
*
FEV1
TLC
DLCO
VO2peak
47
129
66
55
±
±
±
19
20
22
11
46
122
64
59
±
±
±
14
17
14
13
Air (n=19) He/O2(n=19)
Eves Chest 2009
Endurance time
Lung Transplantation
Gender
Age
BMI
FEV1
Q-Force
MEP
MIP
Handgrip
6MWD
Wmax
/
yrs
kg/m2
%pred
Nm
cm H2O
cm H2O
kgF
m
%pred
1yPost-LTXn=22
Healthyn=30
12
59
23
79
100
159
-76
36
483
74
/
±
±
±
±
±
±
±
±
10
5
4
18*
36*
44*
48
16
66*
22*
18
58
25
116
164
193
-97
42
690
182
/
±
±
±
±
±
±
±
±
12
6
4
18
41
47
53
10
83
57
Langer et al. Journal of Heart and Lung Transplantation 2009
-40%
-20%
-20%
-15%
-30%
-60%
Physical activity counseling w/ feedback SenseWear
Study Design RCTExercise Training after LTX
Transplantation
Pre-LTX105 days
Control
Exercise Training
Post-LTX28 days
3m/6mPost-Random
Baseline Characteristics
Post-LTX
Training (n=15) Control (n=13)
Male / Female 8 / 7 7 / 6
Early acute rejection (yes / no) 6 / 7 3 / 9
SLTX / SSLTX 1 / 14 3 / 10
Diagnosis COPD / ILD 12 / 3 11 / 2
Age 56 ± 4 56 ± 7
BMI (kg/m²) 20,7 ± 4,6 21,6 ± 4,2
FEV1, (% pred) 72 ± 18 74 ± 16
3 sessions per week
Resistance exercise
CyclingTreadmill walking Stair climbing
Exercise Training
Results
Pre
-LTX
Post
-LTX
3mPost
-LTX
6mPost
-LTX
40
50
60
70
80
90
**
Qu
ad
ricep
sfo
rce
%p
red
Pre
-LTX
Post
-LTX
3mPost
-LTX
6mPost
-LTX
300
400
500
600
Training
Control
**
6-m
inu
te
walk
ing
dis
tan
ce (
m)
Knowing exercise limitations to guide training
How to train the ventilatory limited patient ?
Improve the lung function / maximum
ventilatory capacity
Reduce the ventilatory needs
– Increase the delivery
– Reduce the demand
Training at higher intensity
0 2 4 6 8 10 12 14 16 18 20 22
40
60
80
100
120
Session (n)
WR
(%
max)
0
4
8
12
16
20
24
Air O20
4
8
12
16
20
24
Air HH
*
*
*
Emtner AJRCCM 2003
Increased O2 delivery
Lower lactate
Reduced ventilatory drive
Endurance time
Knowing exercise limitations to guide training
How to train the ventilatory limited patient ?
Improve the lung function / maximum
ventilatory capacity
Reduce the ventilatory needs
– Increase the delivery
– Reduce the demand
- Enhance the stress to the muscle for a given VO2 (walking vs cycling)
0.0
1.0
2.0
3.0
Cycle @ 80% Wpeak
Walk @ 80% VO2peak
R 50% 100% End
0102030
-10
-20-30-40-50
Qtw
pot
(%base
line
)
Pepin AJRCCM 2005
Reduce the demandV
O2
L/m
in
- Enhance the stress to the muscle for a given VO2 (walking vs cycling)
- Reduce the amount of muscle mass at work (resistance training, NMES).
Probst ERJ 2006
10
15
20
25
30
35
Walking Cycling Stairs Quadr
*
Reduce the demand
VO
2L
/min
0
10
20
30
40
50
6MWD VO2max CRDQ
STRENGTH
ENDURANCE
(%
in
itia
l o
r p
oin
ts)
Spruit et al. Eur.Respir.J. 2002; 19:1072-1078
- Enhance the stress to the
muscle for a given VO2
(walking vs cycling)
- Reduce the amount of muscle
mass at work (resistance
training, NMES, single leg)
Dolmage Chest 2008
Single Leg Exercise
Reduce the demand
Single leg exercise
Dolmage et al Chest 2006
two legs one leg
0
5
10
15
20
25
30
35
COPD
Healthy
En
du
ran
ce T
ime (
min
)
@ 8
0%
Wp
eak
Single leg training
Dolmage Chest 2008
*
30 min of conventional cycling training versus single leg cycling (15 min each leg)
3 times per week
7 weeks
FEV1 37 and 40%pred
0
5
10
15
20
25
30
35
Wpeak0
5
10
15
20
25
VO2peak0
2
4
6
8
10
Tlim@80%
% i
nit
ial
% i
nit
ial
min
- Enhance the stress to the muscle for a given VO2
- Reduce the amount of muscle mass at work
- Shorten the bouts of exercise to keep ventilation lower
than needed in steady state (interval training)
Slow oxygen uptake (ventilatory) kinetics : your friend in
pulmonary rehab…
Reduce the demand
Sabapathy Thorax 2004
Interval exercise, often more realistic
0.0
0.5
0.7
0.9
1.1
VO
2(L
/min)
Time (min)
0 2 4 6 8 54 56 58 60 62
25
50
75
100
Tw
Q (
%ch
an
ge)
Pe
pin
20
06
Sa
ey 2
00
5 P
L
Sa
ey 2
00
5 IP
R
Ma
do
r 2
00
3
Ma
do
r 2
00
1
Ma
n 2
00
3
Conclusions
• Pulmonary rehabilitation works: ‘GRADE A’-level of evidence
• Exercise training can be fine-tuned to the exercise limitations of patients
• Several options available for ventilatorylimited patients
IncreaseVentilatory Capacity:
BronchodilatorsHeliox
High intensityPeripheral
MuscleTraining
Exercise training
ReduceVentilatoryRequirements:
O2 supplementationSmall muscle massShort intervals
High intensityPeripheral
MuscleTraining
One-leg exerciseInterval training
Resistance training
Thank you for your attention
Greetings from the Leuven Pulmonary Rehabilitation team