Chronic Obstructive Pulmonary Disease By: Chantel Berenyi 2-16-12 Why I chose COPD? o Internship at McKay-Dee Hospital in Cardiac Rehab o Career path 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 What is COPD? 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=o7mgLxupRQ&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 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” Prevalence 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 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 Diagnosing COPD 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 Spirometry Treatment for COPD 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 Complications 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) Effects on Exercise Response 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 of Walking 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 Progressive Resistance Exercise 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 Intermittent Exercise Conducted to see the hemodynamic adaption during highintensity 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 Medications 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 Medications Heart rate Blood Pressure ECG Exercise capacity Selective Beta2adrenoceptor 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 occurs May cause PVCs if hypomagnesemia occurs (E) ⟷ Glucocorticoids (steroids) ⟷ (R&E) ⟷ (R&E) ⟷ (R&E) ⟷ Antidepressants ↑ or ⟷ (R&E) ↓or ⟷ (R&E) Variable (R) Exercise Testing for COPD 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 Effects of Exercise Training 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 Exercise Programming 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 Conclusions 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 References 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.cvhon.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 ANY QUESTIONS??