Exercise Prescription for COPD & Asthma

1. Exercise Prescription for COPD & Asthma Dr. Roland Leung MBBS MD FRACP FCCP FHKCP FHKAM(Medicine) Specialist in Respiratory Medicine

2. 何謂慢性阻塞性肺病 • 慢性阻塞性肺病簡稱「慢阻肺病」， 是常見的肺病 • 一種肺功能受損的疾病 • 病人肺部的氣流進出受阻，令患者呼吸困難 • 慢阻肺病十分常見。早期病徵不明顯，往往在診斷時，病情己步入中至晚期

3. 「2000-2003香港肺功能研究計劃」 10萬人病情屬中度嚴重,還沒有接受任何醫療診治 100,000人

4. 為什麼慢性支氣管炎及肺氣腫會阻塞呼吸道? 慢性支氣管炎氣管長期受刺激及發炎，內膜腫脹及有痰液黏於管內，阻塞氣道。 肺氣腫肺部受到長期刺激，支氣管及氣泡經常發炎，肺氣泡受到破壞，影響換氣功能。

5. 慢阻肺病有什麼徵狀? 持續咳嗽咳嗽時有痰或黏液由於氣管的病變，例如支氣管壁腫脹及氣管平滑肌收縮，加上黏液腺肥大以致分泌增加，患者經常咳嗽及多痰。

6. 慢阻肺病有什麼徵狀? 呼吸困難(如上樓梯、行樓梯及梳洗更衣時) • 氣促會隨肺功能的退化愈趨嚴重，影響患者的日常生活。 • 在空氣質素轉差或有急性支氣管炎的時候，病徵會表現得更為嚴重。

8. 慢阻肺病影響個人、家庭及社會 • 全球每年有近三百萬人死於慢阻肺病 • 根據世界衛生組織資料，慢阻肺病是全球第四大殺手病，排名僅次於心臟病發、中風及急性肺炎 • 死於慢阻肺病的人數較癌症為多，並與死於愛滋病的人數相同

9. 本港第五大殺手病 • 據二零零一年的衞生署年報指出，慢阻肺病是本港第五大殺手 • 急症入院主因之一，每十張醫管局病床之中，大概有一張是慢阻肺病病人佔有

10. 引致慢阻肺病之危險因素 • 四十歲以上 • 吸煙或其他類型的煙草（包括二手煙） • 長期暴露於塵多的環境，或工作期間吸入某些化學物品 • 長期暴露於煙霧（如用作煮食的生物燃料產生的煙霧)

11. Airflow Limitation in COPD :Hyperinflation and Exercise

12. Inspiratory reserve volume Inspiratory capacity Tidal volume Expiratory reserve volume Vital capacity Functional residual capacity Review of Terminology Total lung capacity Residual volume

13. =4 sec Tidal Volume at rest Breathing frequency at rest: 12 – 15 / min Inspiration IRV EILV VT Healthy Mild COPD SevereCOPD EELV ERV Healthy subjects: breathing rest time Expiration COPD patients: less breathing rest time

14. Static Hyperinflation Dynamic Hyperinflation „Normal“ IRV IC TLC VT ERV FRC RV Air trapping from exertion „Seconds - Minutes“ Air trapping at rest „Years - Decades“ Dynamic Hyperinflation

15. age 40-50 50-55 55-60 60-70

16. To the COPD patient, this is a breathtaking view.

17. EXACERBATIONS Clinical Course of COPD COPD Expiratory Flow Limitation Air Trapping Hyperinflation Breathlessness Deconditioning Inactivity Reduced Exercise Capacity Poor Health-Related Quality of Life Disability Disease progression Death

18. Post bronchodilation Effect of Exercise on Dyspnea Dyspnea Intensity (Borg Scale) Very severe Severe Somewhat severe Moderate Slight Very slight None at all End-exercise Exercise Stops Exercise time Isotime Pre-exercise

19. Relieves patients’ breathlessness during physically demanding exercise SPIRIVA reduces activity-induced breathlessness by 19% (P<0.001)

20. SPIRIVA increases exercise endurance time Exhibited 42% difference in mean exercise endurance time

21. Pulmonary Rehabilitation • This is the process of maximising the patients physical , mental and social wellbeing by an individualised program of exercises and education

22. Why PR? • All COPD patients benefit from exercise training programs. • Improvement in both exercise tolerance and symptoms of dyspnoea and fatigue. • Evidence to show reduce exacerbations and hospital admissions. BTS & GOLD

23. Pulmonary Rehabilitation • Ideally Comprises of: • Exercise • Empowerment • Diet • Psychological well-being

24. PR & Exercise • Supervised training 2 - 5 times per week • Minimum 20 - 30 minutes each time (may take a time to reach this level) • Course duration of 4 - 12 weeks • It should involve both upper & lower limb exercises both for endurance and strength

25. Components of Exercise Prescription • Mode (Type of exercise) • Intensity • Duration • Frequency • Progression of Exercise Programme

26. PR & Exercise • STRETCHING of the major muscle groups of both upper and lower extremities. • AEROBIC EXERCISES e.g. walking, cycling, rowing, swimming, etc. • FREQUENCY - is 2 to 5 times per week with aim of daily routine. • INTENSITY- “maximum limit tolerated by symptoms” or to 60 to 75% ofmaximal heart rate • DURATION - 20 to 30 min of continuous exercise OR if this is not possible, interval training = two to three min of high-intensity training alternating with equal periods ofrest.

27. PR & Diet • COPD can be adversely affected if the patient is malnourished or overweight. The former leads to muscle bulk loss (diaphragm & accessory muscles of respiration) and the latter an extra burden on the cardio-respiratory system

28. SPIRIVA demonstrates superior improvements in breathlessness post rehab Combined rehab with SPIRIVA results in extended, superior outcomes in breathlessness compared with rehab alone Casaburi, et al Chest 2005

29. 物理治療方法

34. EIA in Children: Scope of the Problem • EIB may interfere with physical activity and personal morale. Children with asthma About 20% have asthma symptoms only during exercise More than 80% have EIB Adapted from American Lung Association. Available at: http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22782; Randolph C Curr Probl Pediatr 1997;27:53–77.

35. History of asthmasymptoms    Positive exercise test Beta2-agonist reversibility Diagnostic Criteria for EIA Coughing, wheezing, or shortness of breath with exercise 10% to 20% decrease in FEV1* Relief of airway obstruction with exercise after use of inhaled beta2-agonist *After 5 minutes of exercise at 85%–90% of maximum Adapted from Gotshall RW Drugs 2002;62:1725–1739.

36. Possible Role of Cysteinyl Leukotrienes in EIA Exercise/activity andother triggers • Mast cell mediators • Leukotrienes • Histamine • Prostaglandins Bronchospasm Inflammation Airway obstruction Adapted from Gotshall RW Drugs 2002;62:1725–1739; Randolph C Curr Probl Pediatr 1997:27:53–77.

37. Possible Therapeutic Options for EIA SABAs = short-acting beta2-agonists; LABAs = long-acting beta2-agonists; ICS = inhaled corticosteroids; LTRAs = leukotriene receptor antagonists *May require combination therapy Adapted from Gotshall RW Drugs 2002;62:1725–1739; Hancox RJ et al Am J Respir Crit Care Med 2002;165:1068–1070.

38. Exercise Prescription for Asthmatics • Make sure the underlying asthma is well-controlled • exercise is not recommended during exacerbation • Pre-medication before exercise is essential • confidence • self assurance • Adequate warm-up • Educate the parents and caregivers • anxiety • Exercise most suitable for asthmatics • swimming • slow jogging

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