pulmonary rehabilitation varga jános md, phd national koranyi institute for tb and pulmonology,...
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Pulmonary Rehabilitation
Varga János MD, PhDNational Koranyi Institute for TB and
Pulmonology, Budapest
Department of Pulmonary Rehabilitation
University of Szeged,04/DEC/2014
Current COPD Therapy
Glass is half empty
The role of current pharmacotherapy:
•Reduction in breathlessness
•Improvement in exercise tolerance
•Reduction in exacerbation
•Improvement in quality of life
Courtesy of Casaburi R
Current COPD Therapy
Glass is half empty
Current pharmacotherapy:
•No effect on progression
•No effect on mortality
Courtesy of Casaburi R
What is the Next Step in the Treatment of COPD Therapy?
• New bronchodilator therapy ?
• New anti-inflammatory therapy ?
• Reduction the number of exacerbations ?
• Alveolar grow factor ?
• Stem cells ?
• Care ?
Time to renew conception ?
Courtesy of Casaburi R
Troosters T et al. Am J Crit Care Med, 2005
0.50
Mort
alit
y (
Surv
ival ra
te%
)
0.75
1.0
0.25
0.0
0 5 10 15 20
HighAverageLowVery low
Very low: Mainly sedentery, no physical activity in freetime Low: < 2 hours/week low intensity physical activity
Time (Years)
Physical Activity in COPDChance to Survive (COPD)
Garcia-Aymerich Thorax 2006
Peripherial Muscle Dysfunction in COPD
• Low muscle mass• Abnormality in capilarisation• Low oxidative enzime activity• Low ratio of type I muscle fibers• Inflammation in muscles• Corticosteroid myopathy• Low level of anabolic hormones• Abnormality in vasoregulation
Lactate increment during exercise
Maltais F, et al. Am J Respir Crit Care Med. 1996;153:288-293.
VO2 (L/min)
Thorax, 2010
Cell Physiol Biochem 2010
Muscle atrophy and mitochondrial
dysfunction during COPD exacerbation
COPD Patients are InactivePhysical inactivity in patients with COPD, controlled
multicentric pilot study
Troosters et al., Respir. Med., 2010
N=100
Physical inactivity in COPDCorrelation between physical activity and lung function, muscle force and walking distance
Troosters ERS 2007Watz AJRCCM 2008
Ctrl I II III IV0
2000
4000
6000
8000
10000
12000
Ste
ps.d
ay-1
( n
)
1 2 3 4
-0.5
0.0
0.5
1.0
Daily activity (Quartile VMU)
E
EL
V (
l)
Garcia-Rio AJRCCM 2009Pitta AJRCCM 2005
FEV1 %pred 0.28*
TL,CO %pred 0.38*
QF %pred 0.45*
6MWD %pred 0.76*
N=50 R
Courtesy of Troosters T
Physical Inactivity in COPDThe Effect of Metabolic Syndrome on Physical Activity
Troosters ERS 2007Watz AJRCCM 2008
Ctrl I II III IV0
2000
4000
6000
8000
10000
12000
Ste
ps.d
ay-1
( n
)
Watz Chest 2009
CB I II III IV1.1
1.3
1.5
1.7
1.9No Metabol syndrome
Metabolic syndrome
Severity
Ph
ysic
al a
ctiv
ity
leve
l
Physical inactivity enchances the chance of development of co-morbidities
Courtesy of Troosters T
Physical Inactivity in COPD Acute Exacerbation
Day 2Day 2 Day 7Day 7 Month 1Month 1
Low physical activity enchances the risk of new exacerbation.
Pitta Chest 2006Garcia-Aymerich Thorax 2003
The importance of early pulmonary rehabilitation after exacerbation.
Seymour JM Thorax 2010
Limiting Factors in Exercise Tolerance in COPD
• Abnormal lung mechanics
• Respiratory muscle dysfunction
• Peripherial muscle dysfunction
• Limitation in gas exchange, oxygen delivery
• Cardiac dysfunction
Flow Limitation
Dynamic airway compression during
exercise
Flow Limitation
Dynamic airway
compression during
exercise
FEV1:98%pred
FEV1:29%pred
EE
LV
/TL
C(%
)
0.3
0.4
0.5
0.6
0.7
0.8
0.9
* * * * * *
# # # # #+ +Group D,WD
Exercise phases
rest unloaded stop-6 stop-4 stop-2 stop
Bo
rg d
ysp
no
e sc
ore
0
1
2
3
4
5
6
7
Group D Group WD Group H
*
*
*
*
$ $ $ $ @@@@+ ##
$$$# # # #@ @
Group D
Group WD,H
Varga J et al., ERS 2006
Dynamic Airway
Compression and
Hyperinflation during Exercise
Controlled breathing techniques
• Perth lip breathing (PLB)
• Diaphragmatic breathing
• Turn the trunc to 45 degrees
Respiratory Endurance Training
COPD (n=11)
FEV1: 36±14 %pred
3x10 minutes respiratory endurance training
MIP: 47±16 vs. 59±20 H2Ocm
MEP:90±45 vs. 123±72 H2Ocm
• Abnormal lung mechanics
• Respiratory muscle dysfunction
• Peripherial muscle dysfunction
• Limitation in gas exchange, oxygen delivery
• Cardiac dysfunction
Limiting Factors in Exercise Tolerance in COPD
•Casaburi R, Patessio A, Ioli F et al.: Reduction in exercise lactic acidosis and ventilation as a result of exercise training in patients with chronic obstructive lung disease. Am Rev Respir Dis 1991; 143:9-18.
•Casaburi R, Porszasz J, Burns MR et al.: Physiologic benefits of exercise training in rehabilitation of patients with severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997;155(5):1541-51.
Exercise training has favourable effect in COPD. High intensity continous training is more effective compared to low intensity training.
The Effectivity of Training in COPD
Casaburi, ARRD 1991
The Role of Peroxisome Proliferator-Activated Receptor-Gamma Coactivator
1α (PGC-1α) on Muscle Function
Handschin C Nature 2008
Porszasz J, Emtner M, Goto S, Somfay A, Whipp BJ and Casaburi R.Exercise Training Decreases Ventilatory Requirements and Exercise-Induced Hyperinflation at Submaximal Intensities in Patients with COPD.Chest 2005;128;2025-2034
Reduction of Exercise-induced Dynamic Hyperinflation with Exercise Training at
Submaximal Intensity
The Role of Dynamic Hyperinflation on Hemodinamics in COPD
Varga J et al. Resp. Med. 2007
Interval vs. High Intensity Continous Training
Varga J et al. Resp. Med. 2007
Interval vs. High Intensity Continous Training
Relationship „Power-duration” curve, ventilation, oxygen uptake
The Effectivity of Training Programs-Interval Training
Electrostimulation of muscles (NMES):
Weak funtional condition
„Nordic walking”:
Maximal exercise capacity and physical activity
Daily activity monitoring
• Abnormal lung mechanics
• Respiratory muscle dysfunction
• Peripherial muscle dysfunction
• Limitation in gas exchange and oxygen delivery
• Cardiac dysfunction
Limiting Factors in Exercise Tolerance in COPD
Somfay A, Porszasz J, Lee SM and Casaburi R. Effect of Hyperoxia on Gas Exchange and Lactate Kinetics Following Exercise Onset in Nonhypoxemic COPD Patients.Chest 2002;121;393-400
Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients. Am J Respir Crit Care Med 2003;168(9):1034-42.
Oxygen Favourable Effect during Exercise in Non-hypoxemic
Patients with COPD
Exercise training with oxygen have superior effect in selected exercise physiologic parameters in respiratory failure in COPD.
Physical activity in hypoxaemic COPD patients
Hypoxia, hypercapnia,
smoking, comorbidities
(vascular disorders) had influence on
cognitive function in COPD
COPD itself
Cognitive function
Measurement of Feeding State:•Determination of body composition•Body weight•Calory intake•Gastrointestinal symptoms•Functional capacity•Physical examination
Respir. Med. 2008
Rehabilitation in Interstitial Lung Diseases, IPF: Similarity and Difference based on
COPD
Age-dependent PAP change in Healthy Subjects
Kovacs G et al. ERJ 2009; 34(4):888-94.
<30 év 30-50 year
>50 year <30 év 30-50 year
>50 year
Pulmonary Arterial Pressure Increment during Exercise in COPD
Terhelés indukálta pulmonális artériás nyomásemelkedés
PA
P (
Hgm
m)
0
20
40
60
80
100
NyugalombanCsúcsteljesitménynél
Kontroll csoport COPD
*
* #
#;p<0,05 csoportok között
Varga J et al. ERS 2009, P3259
Sleep Apnea Monitoring
Saturation
Heart rate
AHI
Complex rehabilitation, adequate staff
Thank you for your attention!