Pulmonary Rehabilitation

1. Pulmonary Rehabilitation Varga János MD, PhD National Koranyi Institute for TB and Pulmonology, Budapest Department of Pulmonary Rehabilitation University of Szeged, 20/OCT/2016

2. 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

3. Current COPD Therapy Glass is half empty • Current pharmacotherapy: • No effect on progression • No effect on mortality Courtesy of Casaburi R

4. 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

5. Troosters T et al. Am J Crit Care Med, 2005

6. Physical Activity in COPD Chance to Survive (COPD) Garcia-Aymerich Thorax 2006 1.0 0.75 Mortality (Survival rate%) 0.50 High Average Low 0.25 Very low 0.0 0 5 10 15 20 Time (Years) Very low: Mainly sedentery, no physical activity in freetime Low: < 2 hours/week low intensity physical activity

7. 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 VO2 (L/min) Thorax, 2010 Maltais F, et al. Am J Respir Crit Care Med. 1996;153:288-293.

8. Muscle atrophy and mitochondrial dysfunction during COPD exacerbation Cell Physiol Biochem 2010

9. COPD Patients are Inactive Physical inactivity in patients with COPD, controlled multicentric pilot study N=100 Troosters et al., Respir. Med., 2010

10. Physical Inactivity in COPD Correlation between physical activity and lung function, muscle force and walking distance N=50 R Courtesy of Troosters T Troosters ERS 2007 Watz AJRCCM 2008 Pitta AJRCCM 2005 Garcia-Rio AJRCCM 2009

11. Physical Inactivity in COPD The Effect of Metabolic Syndrome on Physical Activity Physical inactivity enchances the chance of development of co-morbidities Courtesy of Troosters T Troosters ERS 2007 Watz AJRCCM 2008 Watz Chest 2009

12. Physical Inactivity in COPD Acute Exacerbation COPD exacerbation Low physical activity enchances the risk of new exacerbation. The importance of early pulmonary rehabilitation after exacerbation. Day 2 Day 7 Month 1 Pitta Chest 2006 Garcia-Aymerich Thorax 2003 Seymour JM Thorax 2010

13. Limiting Factors in Exercise Tolerance in COPD • Abnormal lung mechanics • Respiratory muscle dysfunction • Peripherial muscle dysfunction • Limitation in gas exchange, oxygen delivery • Cardiac dysfunction

14. Flow Limitation Dynamic airway compression during exercise

15. Flow Limitation Dynamic airway compression during exercise FEV1:98%pred FEV1:29%pred

16. Dynamic Airway Compression and Hyperinflation during Exercise Varga J et al., ERS 2006

17. Controlled breathing techniques • Perth lip breathing (PLB) • Diaphragmatic breathing • Turn the trunc to 45 degrees

20. 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

21. Limiting Factors in Exercise Tolerance in COPD • Abnormal lung mechanics • Respiratory muscle dysfunction • Peripherial muscle dysfunction • Limitation in gas exchange, oxygen delivery • Cardiac dysfunction

22. Exercise training has favourable effect in COPD. High intensity continous training is more effective compared to low intensity training. • 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.

23. The Effectivity of Training in COPD Casaburi, ARRD 1991

24. The Role of Peroxisome Proliferator-Activated Receptor-Gamma Coactivator 1α (PGC-1α) on Muscle Function Handschin C Nature 2008

25. Reduction of Exercise-induced Dynamic Hyperinflation with Exercise Training at Submaximal Intensity 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

26. The Role of Dynamic Hyperinflation on Hemodinamics in COPD

27. Interval vs. High Intensity Continous Training Varga J et al. Resp. Med. 2007

28. Interval vs. High Intensity Continous Training Varga J et al. Resp. Med. 2007

29. The Effectivity of Training Programs-Interval Training Relationship „Power-duration” curve, ventilation, oxygen uptake

30. Electrostimulation of muscles (NMES): Weak funtional condition

31. „Nordic walking”: Maximal exercise capacity and physical activity

32. Daily activity monitoring

33. Limiting Factors in Exercise Tolerance in COPD • Abnormal lung mechanics • Respiratory muscle dysfunction • Peripherial muscle dysfunction • Limitation in gas exchange and oxygen delivery • Cardiac dysfunction

34. Oxygen Favourable Effect during Exercise in Non-hypoxemic Patients with COPD Somfay A, Porszasz J, Lee SM and Casaburi R. Effect of Hyperoxia on Gas Exchange andLactate 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.

35. Exercise training with oxygen have superior effect in selected exercise physiologic parameters in respiratory failure in COPD.

36. Physical activity in hypoxaemic COPD patients

37. Cognitive function Hypoxia, hypercapnia, smoking, comorbidities (vascular disorders) had influence on cognitive function in COPD COPD itself

38. Measurement of Feeding State: • Determination of body composition • Body weight • Calory intake • Gastrointestinal symptoms • Functional capacity • Physical examination

39. Rehabilitation in Interstitial Lung Diseases, IPF: Similarity and Difference based on COPD Respir. Med. 2008

40. 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

41. Pulmonary Arterial Pressure Increment during Exercise in COPD Varga J et al. ERS 2009, P3259

42. Sleep Apnea Monitoring Saturation Heart rate AHI

43. Complex rehabilitation, adequate staff

44. Thank you for your attention! E-mail: varga@koranyi.hu