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!