Transcript Breathing Life Into Tomorrow

Treatment options for COPD
ERS/ATS COPD Guidelines
Celli and MacNee Eur Respir J 2004
Exercise intolerance is a major complaint
of COPD patients and has a profound
impacts on quality of life
• Airflow limitation dictates exercise
tolerance
• Airflow limitation is largely irreversible
• Exercise intolerance is irremediable
• Airflow limitation has a useful reversible
component in most COPD patients
• Strategies aimed at reducing the effect of
airflow limitation on exercise tolerance
have been developed
• Peripheral muscle dysfunction has been
shown to contribute to exercise
intolerance
Impact of pulmonary rehabilitation on healthrelated quality of life
Change in HRQoL (MCID)
3
2
MCID
0
-1
0
12
24
36
48
60
>18 months
Time of treatment or follow-up (weeks)
MCID: minimal clinically important difference
Troosters et al. Am J Respir Crit Care Med 2005
Mechanisms limiting exercise performance
Mechanisms of skeletal muscle dysfunction in
COPD
Couillard and Prefaut Eur Respir J 2005
Ambulatory monitoring of
physical activity
Healthy female, age 38
COPD male, age 60
FEV1 % pred.
Daily physical activity correlates with
6-minute walking distance
Healthy subjects
COPD patients
Pitta et al. Am J Respir Crit Care Med 2005
Evidences for skeletal muscle dysfunction in
COPD
• Low muscle mass
• Poor capillarity
• Low aerobic enzyme concentration
• More glycolytic fiber type distribution (less Type I fibers)
• Muscle inflammation
• Corticosteroid myopathy
• Low levels of anabolic hormones
• Vasoregulatory abnormalities
Question
To what extent is
dysfunction due to
deconditioning?
Summary of published differences in 6 minute
walking distance in COPD after rehabilitation with
exercise training
Troosters et al. Am J Respir Crit Care Med 2005
Impact of pulmonary rehabilitation on exercise
training outcomes*
• Endurance exercise time improved an average of
87%
• Peak work rate improved an average of 18% from
baseline
• Peak oxygen uptake improved by 11% compared
with controls
*Based on pooled data from several trials
Troosters et al. Am J Respir Crit Care Med 2005
Mechanisms of impaired
exercise performance in
COPD
Skeletal muscle atrophy
Bernard et al. Am J Respir Crit Care Med 1998
Improvement of skeletal muscle mass and
strength after exercise training in COPD
Bernard et al. Am J Respir Crit Care Med 1999
Fiber distribution in skeletal muscles
60-65%
44%
Couillard and Prefaut Eur Respir J 2005
23%
Exercise training strategies for COPD patients
• Adequate frequency and duration of exercise sessions and
duration of program*
• High intensity targets**
• Employ strategies to make higher intensity training possible
*A minimum of 8 weeks seems to be necessary to achieve
substantial effects
** 3-5 days/week at 40-85% of O2 uptake reserve (as in normal
subjects)?
Ventilatory and circulatory responses
to walking and cycling in COPD
Palange et al. J Appl Physiol 2000
Pathology of COPD
Expiratory airflow limitation
Air trapping
Hyperinflation
Dyspnea
Deconditioning
Exercise intolerance
Reduced activity
Poor health-related quality of life
Strategies to mximize exercise intensity in COPD
• Bronchodilators
• Oxygen breathing
• Helium breathing
• Pressure support ventilation
• Interval training
Stepwise approach to therapy
Dyspnea (Borg Scale)
7
very severe
6
severe
5
somewhat severe
4
moderate
slight
3
very slight
2
nothing at all
1
0
0
2
4
6
8
10
12
Endurance Exercise Time (min)
14
16
Summary of reported effects of rehabilitation
programs with high-intensity endurance training
• Reversal of deconditioning
• Tendency to normalize muscle function
– Increase in aerobic enzymes and capillary density
– Increase in muscle mass and improvement of vasoregulation
• Improvement of exercise tolerance
• Improvement of quality of life