Safe Exercise and IPF

1. Safe Exercise and IPF Dr Gisli Jenkins Reader in Pulmonary Biology Consultant Respiratory Physician Club 25 mile TT champion

2. 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

3. Riskiest sport?

4. Sporting Risks http://www.medicine.ox.ac.uk/bandolier/booth/Risk/sports.html

5. Activity Risk http://www.hse.gov.uk/education/statistics.htm#death

6. 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

7. Exercise in chronic lung disease • Reduced exercise tolerance • Exhaustion and fatigue occur earlier • Exertional goals harder to achieve • Increased paraphernalia

8. 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

9. Exercise is Good for YOU! Salhi et al Chest 2010

10. It really is! 8 weeks training and Sat > 85% Holland et al Thorax 2008

11. How much exercise should you do?

12. 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

13. 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 RespCrit 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

14. 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 RespCrit Care Med 2003

15. 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 RespCrit Care Med 2003

16. 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 RespCrit Care Med 2003

17. 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

18. So what exercise should you do? • Swimming • Cycling • Running • Rowing • Weights • Power breathe

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. Strength training Weights - Yes Power breathe - No

27. 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

28. You have cardiac disease (Do CPET first) • You have pulmonary hypertension (Do CPET first) • You experience: • chest pains • palpitations • dizzyness • confusion • Sats <85%