Chronic Obstructive Pulmonary Disease

By: Chantel Berenyi2-16-12

Why I chose COPD?

o Internship at McKay-Dee Hospital in Cardiac Rehab

o Career path

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Overview

What is COPD? Disease Prevalence Signs & Symptoms Diagnosis Tests & Evaluations Complications Treatment

Effects on exercise response

Effects of medications on exercise

Effects of training Exercise testing Exercise prescription Summary &

conclusions

COPD is defined as a chronic inflammatory disease of the

lung that is characterized by progressive and irreversible

airflow limitation

There are two main forms (most have a combination):

Chronic bronchitis: involves a long-term cough with

mucus

Inflammations of bronchial tubes

Irritations of cilia in bronchial-lining

Airways become clogged by debris

Heavy secretion of mucus

http://www.youtube.com/watch?v=o7mgL-xupRQ&feature=

related

What is COPD?

Emphysema: involves destruction of the lungs over

time

Alveoli lose elasticity (flabby balloon)

Alveoli over expand to compensate, causing the

to rupture and form cysts

CO2 cannot be expelled properly with damaged

alveoli

Stagnant air develops causing shortness of breath

http://www.youtube.com/watch?v=lmZZlkrSu5o

What is COPD?

Causes of CODP

SMOKING (leading cause) 80% of individuals with COPD

are current or former smokers

Environmental factors Secondhand smoke & pollution

Exposure to certain gases or fumes

Frequent use of cooking fire w/o ventilation

Lack of the protein “alpha-1 antitrypsin”

Projected to be the world’s third most important cause of

mortality by 2020

An estimated 24 million Americans have COPD

kills more than 120,000 Americans each year—that’s 1 death

every 4 minutes

An estimated 64 million people have COPD worldwide (2004)

More than 3 million people worldwide died of COPD in 2005

The disease now affects men and women almost equally

Total deaths from COPD are projected to increase by >30% in

the next 10 yrs

Prevalence

http://www.cdc.gov/copd/data.htm

Signs & Symptoms

Cough, with or without mucus

Fatigue Weak quadriceps muscles Low body weight Cachexia Many respiratory infections Shortness of breath

(dyspnea) that gets worse with mild activity

Trouble catching breath Wheezing

Best test for COPD- spirometry (FEV1/FVC) FEV1 (forced expiratory volume in one second) Involves the

amount of air which can be forcibly exhaled from lungs in the first

second of a forced exhalation

FVC (forced vital capacity) Involves blowing out as hard as possible

after taking the deepest breath possible into a small machine that

tests lung capacity

COPD= <.70

http://www.youtube.com/watch?v=kiQcbXK7f5c

Using a stethoscope- listen to lungs

X-ray and CT scans of lungs (but can still look normal)

Blood tests- measure amounts of oxygen and carbon dioxide

in blood

Diagnosing COPD

Spirometry

No cure for COPD Stop smoking- best way to slow down lung damage Medications:

Inhalers (bronchodilators) Ipratropium (Atrovent) Tiotropium (Spiriva) Salmeterol (Serevent) Formoterol (Foradil) Albuterol

Inhaled steroids- reduce lung inflammation Anti-inflammatory medication

Montelukast (Singulair) Roflimulast

Treatment for COPD

Severe cases or during flare-ups:

Steroids by mouth or through a vein

Bronchodilators through a nebulizer

Oxygen therapy

Assistance during breathing from a machine

Antibiotics (infections can make COPD worse)

Treatment for COPD

May need oxygen therapy at home or constantly in oxygen in blood is too low (< SpO₂ 80%)

Pulmonary rehabilitation Can teach you to breath differently allowing you

to stay active

Strengthen the lungs

Help maintain muscular strength in legs

Treatment for COPD

Exacerbations: increase in coughing, shortness of breath and/or amount or color of mucus coughed up

More frequent lung infections (pneumonia)

Increased risk of osteoporosis

Depression or anxiety (reduction in independence)

Problems with loosing too much weight

Heart failure (right side of heart)

A collapsed lung

Sleep problems (not enough oxygen)

Complications

Hyperinflation (crucial aspect): impeded exhalation, incomplete lung emptying, and air trapping

When exercising: Dynamic hyperinflation is superimposed on static hyperinflation

Reduction in inspiratory capacity

Smaller tidal volume

Increased elastic and threshold work of breathing

Dynamic hyperinflation is directly linked to breathlessness

Effects on Exercise Response

Exercise limited by cardiovascular factors: Deconditioned

Impaired left ventricle function (low SpO2)

Reduced pulmonary blood flow (low SpO2)

Lactic acid accumulation at low work rates

(peripheral muscle deconditioning)

Increased CO2 output (bicarbonate buffering)

Increased ventilator requirement

Effects on Exercise Response

Study conducted on the effects of walking on COPD patients Evaluated the cardiac and respiratory responses as well as

electrical activity of lower limb muscles during walking 6 min walk test Walking distance & speed were significantly lower in COPD patients However, COPD patients walked at a higher % of peak VO2 Surface EMG data taken on muscles were about same for both

Specifically the vastus lateralis & rectus femoris were more fatigued

CONCLUSIONs: 6 min walk test was performed at a relatively higher intensity in

patients with COPD compared with healthy controls Walking cause those with COPD to be more vulnerable to muscle

fatigue

Effects of Walking

Review of 18 controlled trials conducted to see if resistance training improves elements of performance of daily activities

Found effects favoring the addition of 12 weeks of progressive resistance training exercise to aerobic exercise for increases in LBM

Progressive Resistance Exercise showed no effect on oxygen uptake

Found an improvement in walking distance in field-walking tests

Found an improvement in timed stair-climbing performance

Found overall improvements in arm & leg muscle strength

Effects of Progressive Resistance Exercise

Conducted to see the hemodynamic adaption during high-intensity intermittent exercise in COPD patients

30 min exercise session, alternating a 4 min work set at first ventilatory threshold with a 1 min set at 90% of maximal tolerated power output

Found an increase in VO2, cardiac output & ventilation during first minutes of exercise, but remained STABLE thereafter

Pulmonary arterial pressure increased from rest and significantly decreased thereafter

Total pulmonary vascular resistance decreased from rest to the end of the test

CONCLUSION: High intensity 1 min bouts of work of intermittent work

exercise are well tolerated w/o pushing pulmonary arterial pressure too high

Effects of Intermittent Exercise

Beta2-adrenoceptor agonists: Relax bronchial smooth muscle & produce

bronchodilation

Methylxanthines: Produce bronchodilation & CNS stimulation

Thiazide diuretics: Control fluid retention

Glucocorticoids (steroids): Reduce inflammation & improve pulmonary function

Effects of Medications

Medications Heart rate

Blood Pressure

ECG Exercise capacity

Selective Beta2-adrenoceptor agonists (Sympathomimetic Agent)

↑ or ⟷ (R&E)

↑, ↓, or ⟷ (R&E)

↑ or ⟷ HR (R&E) ⟷

Methylanthines (Bronchodialators)

⟷ (R&E) ⟷ (R&E) ⟷ (R&E) ↑EC

Thiazide Diuretics ⟷ (R&E) ⟷ or ↓ (R&E)

⟷ or PVCs (R) May cause PVCs and “false positive” test results if hypokalemia occursMay cause PVCs if hypomagnesemia occurs (E)

⟷

Glucocorticoids (steroids)

⟷ (R&E) ⟷ (R&E) ⟷ (R&E) ⟷

Antidepressants ↑ or ⟷ (R&E)

↓or ⟷ (R&E)

Variable (R)

Assessment of physiological function: Cardiopulmonary capacity Pulmonary function Determination of arterial blood gases/ arterial O2 saturation

(direct/indirect) Modifications:

Extended stages Smaller increments Slower progression Example: Naughton Protocol- only speed not grade increases

every 2 min instead of every 3 min 6 minute walk test

Popular for assessing functional exercise capacity Walking is usually best, COPD patients usually lack muscle

strength for stationary cycling & arm ergometry may cause increased dyspnea

Exercise Testing for COPD

Almost any level of physical activity can improve oxygen utilization, work capacity and anxiety

Benefits of exercise Cardiovascular reconditioning Reduced ventilatory requirement at a given work rate Improved ventilatory efficiency Reduced hyperinflation Desensitization to dyspnea Increased muscle strength Improved flexibility Improved body composition Better balance Enhanced body image

Effects of Exercise Training

Recommended mode of exercise: walking, cycling, swimming or conditioning exercises (tai chi)

enjoyable & improves ability to perform daily activities Oxygen administered if SpO2 < 88%

Goal is have SpO2 >90% during exercise Modifications to duration & frequency might be

necessary 5-10 min sessions vs. 20-30 min

6 week exercise program w/ group intervention is helpful

Rehabilitation exercises should be LIFELONG COPD patients are at risk for relapsing

Exercise Programming

COPD is a chronic inflammatory disease of the

lung that is characterized by progressive and

irreversible airflow limitation (no cure)

COPD is usually a combination of Bronchitis &

Emphysema

An estimated 24 million Americans have COPD

Smoking is the leading cause of COPD

Best test for COPD- spirometry

Conclusions

Inhalers, steroids & anti-inflammatory medication are

used to help off set symptoms

Hyperinflation is a crucial aspect of COPD

Progressive resistance & intermittent exercise can be

beneficial

Walking may improve endurance better than cycling

6 min walk test is most popular for testing COPD patients

Numerous benefits of exercise

Rehabilitation should be a lifelong process

Conclusions

Durstine, Larry J., Moore, Geoffrey E., Painter, Partricia L., & Roberts, Scott O. (2009). ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities. Champaign, IL: Human Kinetics.

LifeExtension (2011). Chronic Obstructive Pulmonary Disease, Emphysema and Chronic Bronchitis. Retrieved from http://www.lef.org/protocols/respiratory/copd_01.htm

Lonsdorfer-Wolf, E., Bougault, V., Doutreleau, S., Charloux, A., Lonsdorfer, J., & Oswald-Mammosser, M. (2004). Intermittent exercise test in chronic obstructive pulmonary disease patients: how do the pulmonary hemodynamics adapt?. Medicine & Science In Sports & Exercise, 36(12), 2032-2039.

Marquis, N., Debigare R, Bouyer L, et. al. 2009. Physiology of walking in patients with moderate to severe chronic obstructive pulmonary disease. Med. Sci. Sports Exerc. 41:1540-1548.

O'Shea, S., Taylor, N., & Paratz, J. (2009). Progressive resistance exercise improves muscle strength and may improve elements of performance of daily activities for people with COPD: a systematic review. Chest, 136(5), 1269-1283. doi:10.1378/chest.09-0029

The Credit Valley Hospital (2011). Screening for COPD. Retrieved from http://www.cvh-on.ca/podcasting/video.php

Thompson, Walter R., Gordon, Neil F., & Pescatello, Linda S. (2009) ACSM’s Guidelines for Exercise Testing and Prescription, 8th edition.

WebMD. (2011) COPD-Ongoing Concerns. Retrieved from http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-ongoing-concerns

World Health Organization (2011). Chronic Obstructive Pulmonary Disease (COPD). Retrieved from http://www.who.int/mediacentre/factsheets/fs315/en/index.html

References

ANY QUESTIONS??