Outline Definition Epidemiology Clinical Aspects Treatment Effects of Exercise Exercise Testing Exercise Prescription Summary and Conclusion References
Chronic Obstructive Pulmonary Disorder Chronic: It’s long-term and doesn’t go away Obstructive: The flow of air from the lungs is limited Pulmonary: Another word for lungs and breathing Disease: It’s a health problem that needs to be taken seriously
What is COPD and what causes it A progressive condition that includes chronic bronchitis or emphysema or both. Smoking is the primary cause of COPD. 80% of the people affected by COPD are current or former smokers. Other risk factors are: occupational and environmental pollutants, alpha antitrypsin deficiency, allergies and asthma, poor nutrition, periodontal disease and low birth weight.
So what does that mean? Chronic Bronchitis Airflow is limited by narrowed airways. The narrowed airways are caused when damaged airways get tight, swollen, and filled with mucus. Emphysema The tiny air sacs get over- stretched and break down. When this happens old air gets trapped inside and new air cannot get in.
Epidemiology COPD is the most prevalent chronic pulmonary disease and affects an estimated 24 million Americans. COPD is the fourth most common cause of death in the United States and is the only cause in the top ten that continues to rise. COPD accounts for approximately 100,000 deaths each year. By 2020, it is estimated to be the third leading cause of death in the United States and the fifth leading cause of disability in the world. It is most commonly found in white males over the age of 60.
Clinical Aspects Symptoms Cough that produces mucus, may be blood streaked Shortness of breath aggravated by exertion or mild activity Wheezing Rales (small clicking, bubbling, or rattling sounds in the lung) Fatigue Ankle, feet and leg edema that affects both sides Reddish cheeks Reddish face, palms, or mucous membranes (such as the inside of the mouth) Headaches Vision abnormalities
Laboratory Diagnosis Spirometry is the best way to test for COPD. It is simple and can be interpreted immediately. Listening to the lungs with a stethoscope can sometimes work too but sometimes the lungs sound normal even when COPD is present. X-rays and CT scans can also be performed; but these can also look normal even if COPD is present. Sometimes a blood test called a “blood gas” is required to measure the amounts of oxygen and carbon dioxide in the blood.
Treatment Medical Bronchodilators are prescribed to open the airways Inhaled steroids to reduce lung inflammation. In severe cases or during flare-ups steroids may be needed intravenously or by mouth. Antibiotics can also be prescribed when a patient has an infection prevent COPD from becoming worse. Oxygen therapy may also be needed at home if the patient has low oxygen levels in their blood.
Treatments Surgical Removal of parts of diseased lung in patients with emphysema. Lung transplants may be required in severe cases
Effects on Ability to Exercise Hyperinflation resulting from impeded exhalation, incomplete lung emptying, and air trapping. Static hyperinflation can be caused from daily living and when exercise occurs dynamic hyperinflation can be superimposed on static hyperinflation. Dynamic hyperinflation is related to increased breathing frequency and affects the mechanical efficiency of ventilation leading to breathlessness.
Effects on Ability to Exercise In patients with emphysema there is a impairment of gas exchange due to the destruction of the alveolar-capillary membrane. Breathing efficiency is thus worsened by an increase in VD/VT and can also cause hypoxemia during exercise. Chronic hypoxemia can also cause erythrocytosis which can further complicate circulation during exercise. Smokers will have an increase in carboxyhemoglobin, impairing the blood oxygen transport system. Other symptoms of COPD can also affect different individuals personally.
Effects of Medication on Exercise Beta2-adrenoceptor (sympathomimetic) agonist reduce peripheral vascular resistance and can cause tachycardia, palpitations and tremulousness. Methylxanthines can cause tachycardia, cardiac dysrhythmias, and CNS stimulation with increased respiratory drive and a risk of seizures. Thiazide diuretics and loop diuretics can cause hypokalemia that can in turn cause cardiac dysrhythmias and muscle weakness Glucocorticoids (prednisone) can cause skin atrophy and fragility, osteoporosis, muscle atrophy, and myopathy. Antidepressants cause resting and exercise tachycardia. COPD often coexists with cardiovascular diseases so the effects of medications taken for cardiovascular disease needs to be reviewed as well.
Effects of Exercise Acute effects Increased verbal processing Dynamic hyperinflation – further reduces inspiratory capacity and smaller tidal volume Chronic effects Cardiovascular reconditioning Reduced ventilatory requirement at a given work rate Improved ventilatory efficiency Reduced hyperinflation Desensitization to dyspnea Increased muscle strength Improved flexibility Improved body composition Better balance Enhanced body image
Exercise Testing Maximal testing is safe with appropriate monitoring. The cycle ergometer is best for controlling external work rate, measuring gas exchange and blood sampling. But patients might be more willing to perform treadmill testing. During testing a near-linear increase in work rate should be attempted with incremental adjustments being made to speed and grade. The goal is to be able to get between 8-12 minutes of exercise data.
Exercise Testing StageSpeed (km/hr)Speed (mph)Gradient 12.741.710 24.022.512 35.473.414 46.764.216 58.055.018 68.855.520 79.656.022 810.466.524 911.267.026 1012.077.528 The Bruce Protocol Equipment required: treadmill, stopwatch, pencil, paper for recording Procedure: The treadmill is started at 1.7 mph and at an incline of 10%. At three minute intervals the incline of the treadmill increases by 2% and the speed increases as in the table to follow.
Exercise Prescription Exercise rehabilitation should include several different professionals including respiratory therapists, physical therapists and exercise professionals, and occupational therapists. Respiratory therapists will evaluate, teach, and ensure effective use of bronchodilator medications and oxygen therapy. Physical therapists and exercise professionals will evaluate exercise endurance, muscle strength, flexibility and body composition along with monitoring the exercise prescription and monitoring exercise performance. Occupational therapists will evaluate activities of daily living and quality of life so they are able to teach energy conservation and body mechanics aimed at reducing the oxygen requirement for specific activities All therapists will teach improved breathing efficiency with methods such as pursed lips and diaphragm breathing.
Exercise Prescription Pursed lips method Breathe in slowly through your nose for 1 count Purse your lips as if you were going to whistle Breathe out gently through pursed lips for 2 slow counts (breathe out twice as escape naturally- don't force the air out of your lungs Keep doing pursed lip breathing until you're no longer short of breath Diaphragm breathing Put one hand on your upper chest, and the other on your belly just above your waist Breathe in slowly through your nose - you should be able to feel the hand on your belly moving out. The hand on your chest shouldn't move. Breathe out slowly through your pursed lips - you should be able to feel the hand on your belly moving in as you exhale (breathe out).
Exercise Prescription Modes of exercise can be walking, cycling, swimming, or conditioning exercises such as tai chi. The mode should be enjoyable to the patient and directly improve ability to perform usual daily activities. For patients with oxyhemoglobin desaturation of less than 88% or a documented reduction in arterial oxygen tension of less than 55 mmHg oxygen should be administered during exercise. The goal for oxygen therapy is to maintain oxyhemoglobin saturation above 90%.
Exercise Prescription Aerobic – large muscle activities 1-2 sessions, 3-5 days/week 30 min/sessions with an emphases of duration rather than intensity Strength – free weights, isokinetic/isotonic machines Low resistance, high reps 2-3 days/week Flexibility – stretching, tai chi 3 days/week Neuromuscular – walking, balance exercises, breathing exercises
Exercise Prescription Often patients with COPD cannot perform 20-30 min of exercise so 5 or 10 min intervals of exercise may be necessary in the beginning. Group interaction is helpful in the reconditioning process since an individual with COPD is at a particular risk of relapsing into a state of inactivity and physical deconditioning.
Summary COPD is a major killer in the world. It cannot be controlled but quality of life can be enhanced through medications and lifestyle changes. Exercise training is a crucial aspect of clinical management and the rehabilitation of individuals suffering from COPD.
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