Safe Exercise and LAM

Report
Safe Exercise and IPF
Dr Gisli Jenkins
Reader in Pulmonary Biology
Consultant Respiratory Physician
Club 25 mile TT champion
Can any exercise be safe?
• Exercise risks:
– environment,
– the type of exercise
– personal physiology
• Walking has the 2nd mortality rate/mile
travelled after motorcyling.
• Two “testers” per year die in competition in
UK
• 1 cyclist dies every three days in the UK
Riskiest sport?
Sporting Risks
Sport
Time period
Deaths
Population
estimate
Mortality
Rate/100,000
Odds of dying
(1 in)
Base Jumping
1995-2005
9
20,850
43.17
2,317 jumps
Swimming
1997-2006*
31
1,754,182
1.77
56,587
Cycling
1997-2006*
19
1,754,182
1.08
92,325
Running
1997-2006*
18
1,754,182
1.03
97,455
Skydiving
2006
21
2,122,749
0.99
101,083 jumps
Football
1997-2006*
9
1,754,182
0.97
103,187
0.86
116,000 flights
Hang-gliding
Tennis
1997-2006*
15
1,754,182
0.86
116,945
SCD in
Marathons
1975-2005
26
3,292,268
0.79
126,626
runners
Horse Riding
1997-2006*
10
1,754,182
0.57
175,418
American
Football
1994-1999
6
1,100,142
0.55
182,184
Scuba Diving
Table Tennis
200,000 dives
0.40
250,597
Rick Climbing
0.13
320,000 climbs
Canoeing
0.13
750,000 outings
0.06
1,556,757 visits
Skiing
1997-2006*
2002/2003
6
1,754,182
37
http://www.medicine.ox.ac.uk/bandolier/booth/Risk/sports.html
Activity Risk
Activity associated with death Risk
Annual Risk
Maternal death in pregnancy
1 in 8,200 maternities
Hang-gliding
1 in 116,000 flights
Surgical anaesthesia
1 in 185,000 operations
Scuba Diving
1 in 200,000 dives
Rock Climbing
1 in 320,000 climbs
Canoeing
1 in 750,000 outings
Rail travel accidents
1 in 43,000,000 passenger journeys
Aircraft accidents
1 in 125,000,000 passenger journeys
Fairground rides
1 in 834,000,000 rides
http://www.hse.gov.uk/education/statistics.htm#death
Benefits of Exercise
•
•
•
•
•
•
•
•
Reduces body fat
Strengthens bones
Aids co-ordination and flexibility
Improves stamina and concentration
Fights depression and anxiety
Improves cardiac function
Improves VO2 max
Lower lactate threshold
Exercise in chronic lung disease
• Reduced exercise tolerance
– Exhaustion and fatigue occur earlier
– Exertional goals harder to achieve
• Increased paraphernalia
Exercise is Good for YOU!
• Pulmonary rehabilitation improves symptoms of
dyspnoea in patients with COPD
• Pulmonary rehabilitation improves HRQOL in
patients with COPD
• Pulmonary rehabilitation reduces health-care
utilisation in patients with COPD
• Longer pulmonary rehabilitation programs
produce greater sustained benefits than shorter
programs
• Not clear whether pulmonary rehabilitation
improves survival
Pulmonary Rehabilitation Guidelines Chest 2007
Exercise is Good for YOU!
Outcome
Baseline
12 weeks
24 weeks
FEV1 (%)
48±17
47±17
46±17
BMI kg/m2
24±7
24±7
24±7
VO2 max (L/min)
1.11±0.47
1.18±0.52
1.2±0.57
6MWD (m)
390±140
445±142
463±146
Dyspnoea
16±6
20±6
22±6
Fatigue
15±6
17±6
18±6
Emotion
29±8
32±8
33±9
Salhi et al Chest 2010
It really is!
8 weeks training and Sat > 85%
Holland et al Thorax 2008
How much exercise should you do?
How much exercise should you do?
• High intensity can be defined as 60-80% of
peak rate achieved in incremental maximum
exercise test.
• 45 minutes of 1X4
– (1 minute peak VO2 4 mins at 40% VO2)
• Or 45 minutes at anaerobic threshold.
Pulmonary Rehabilitation Guidelines Chest 2007
Risk
• Maximal symptom-limited exercise testing is
relatively safe.
• Death rate between 2-5/100,000 (1 in 20-50,000)
ATS/ACCP Statement on CPET Am J Resp Crit Care Med 2003
• Safer than base jumping or pregnancy
• Risk of sudden cardiac death during moderate to
vigorous exercise in women is 1:35,000,000 hours
(4000 yrs)
– Relative risk vs no exercise is 2.38
– Long term cardiac risk is reduced
Whang et al JAMA 2006
The Cardiopulmonary Exercise Test
• You can work out your VO2
peak and max
• You can work out your lactic
(anaerobic threshold)
• Identify arrythmias
• Identify arterial desaturation
ATS/ACCP Statement on CPET Am J Resp Crit Care Med 2003
Is it safe?
• Exercise is a ubiquitous activity
• Absolute contraindications
– Syncope, unstable angina, uncontrolled systemic hypertension,
serious cardiac dysrhythmias
• Relative contraindications
– Primary pulmonary hypertension
• Terminating exercise
• Chest pain, ischaemic ECG, complex ectopy, 2 and 3rd
degree heart block, >20mmHg drop in systolic bp, HT
>250mmHg, >120mmHg diastolic
• SpO2 < 80 with symptoms and signs of severe hypoxaemia
(Sudden pallor, impaired co-ordination, confusion,
dizziness)
ATS/ACCP Statement on CPET Am J Resp Crit Care Med 2003
W W J D?
• Exercised people with LAM on treadmill or cycle
ergometer
• Test stopped when:
• Sats <88%, exhaustion or oxygen uptake reached
(VO2 peak)
• 217 patients Exercise termination due to:
• Dyspnoea (40%), leg fatigue (28%), severe
hypoxaemia (11%), dyspnoea and leg fatigue
(7%), dizzyness (1%), abdo pain (1%), VO2 max
reached (6%)
Taveira-DaSilva et al Am J Resp Crit Care Med 2003
What about pneumothorax and
exercise?
• In CF population
Pneumothorax 0.15% per 1000 patient years.
Injury 0.39% per 1000 patient years
Asthma attack 0.84% per 1000 patient years
Haemoptysis 0.12% per 1000 patient years
Pneumothorax seemed to be associated with
coughing.
Ruf et al J Cystic Fibrosis 2010
So what exercise should you do?
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Swimming
Cycling
Running
Rowing
Weights
Power breathe
Aerobic exercise
• Cycling, swimming, walking, rowing
– High intensity aerobic exercise leads to better
physiological outcomes (VO2 max)
– Low intensity aerobic exercise may lead to better
adherence and still has physiological benefits
Pulmonary Rehabilitation Guidelines Chest 2007
Strength Training
• Weights, jumping, sprinting
• Important for maintaining balance, rising from
a chair, or lifting objects
• Does increase muscle mass in COPD patients
• IS SAFE
• Has NOT been shown to help endurance (big
argument amongst “Testers”)
Pulmonary Rehabilitation Guidelines Chest 2007
Upper Extremity Training?
• Strength and endurance training improves
work capacity (O2 consumption) and reduces
metabolic (CO2 production) ventilatory
requirements.
• Inspiratory Muscle Training
• NO, no benefit in COPD, unlikely to be safe in
LAM
Pulmonary Rehabilitation Guidelines Chest 2007
Exercising with O2
• Yes
• Supplemental oxygen should be used during
exercise training in patients with severe
exercise induced hypoxaemia
• Supplemental oxygen during high-intensity
exercise programs without hypoxaemia may
be beneficial by increasing exercise capacity
and endurance gains.
Pulmonary Rehabilitation Guidelines Chest 2007
Swimming with LAM
• Great for people with joint problems
• Swimming can be a problem with lung disease
due to increasing abdominal pressure on the
diaphragm.
• Can’t swim and wear O2
Cycling and Rowing
• Very similar workouts.
• Rowing probably better as
works lower and upper limbs.
• Both easy on joints.
• However, cycling generally more
accessible.
• Possible in theory to cycle with
O2, certainly can do it on an
stationary bicycle
Running
• High impact exercise – not great for joints (esp
back and lower limb joints)
• Can be done with O2
• No equipment needed (unless running with
02)
Strength training
Weights - Yes
Power breathe - No
Summary
• Exercising to exhaustion with IPF is safe
• Exercise with O2 supplementation if you
desaturate
• Do whatever exercise you want!
• Exercise for as long and as hard as you can
• Your exercise program – like all exercise
programs - will need to be individualised and
goal focused
• You have cardiac disease (Do CPET first)
• You have pulmonary hypertension (Do CPET first)
• You experience:
–
–
–
–
–
chest pains
palpitations
dizzyness
confusion
Sats <85%

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