1. Chronic Obstructive Pulmonary Disease By: Chantel Berenyi 2-16-12

2. Why I chose COPD? o Internship at McKay-Dee Hospital in Cardiac Rehab o Career path

3. Overview  What is COPD?  Disease Prevalence  Signs & Symptoms  Diagnosis  Tests & Evaluations  Complications  Treatment  Effects on exercise response  Effects of medications on exercise  Effects of training  Exercise testing  Exercise prescription  Summary & conclusions

4.  COPD is defined as a chronic inflammatory disease of the lung that is characterized by progressive and irreversible airflow limitation  There are two main forms (most have a combination):  Chronic bronchitis: involves a long-term cough with mucus  Inflammations of bronchial tubes  Irritations of cilia in bronchial-lining  Airways become clogged by debris  Heavy secretion of mucus  http://www.youtube.com/watch?v=o7mgL- xupRQ&feature=related http://www.youtube.com/watch?v=o7mgL- xupRQ&feature=related What is COPD?

5.  Emphysema: involves destruction of the lungs over time  Alveoli lose elasticity (flabby balloon)  Alveoli over expand to compensate, causing the to rupture and form cysts  CO2 cannot be expelled properly with damaged alveoli  Stagnant air develops causing shortness of breath  http://www.youtube.com/watch?v=lmZZlkrSu5o http://www.youtube.com/watch?v=lmZZlkrSu5o What is COPD?

6. Causes of CODP  SMOKING (leading cause)  80% of individuals with COPD are current or former smokers  Environmental factors  Secondhand smoke & pollution  Exposure to certain gases or fumes  Frequent use of cooking fire w/o ventilation  Lack of the protein “alpha-1 antitrypsin”

7.  Projected to be the world’s third most important cause of mortality by 2020  An estimated 24 million Americans have COPD  kills more than 120,000 Americans each year—that’s 1 death every 4 minutes  An estimated 64 million people have COPD worldwide (2004)  More than 3 million people worldwide died of COPD in 2005  The disease now affects men and women almost equally  Total deaths from COPD are projected to increase by >30% in the next 10 yrs Prevalence

8. http://www.cdc.gov/copd/data.htm

9. Signs & Symptoms  Cough, with or without mucus  Fatigue  Weak quadriceps muscles  Low body weight  Cachexia  Many respiratory infections  Shortness of breath (dyspnea) that gets worse with mild activity  Trouble catching breath  Wheezing

10.  Best test for COPD- spirometry (FEV1/FVC)  FEV1 (forced expiratory volume in one second) Involves the amount of air which can be forcibly exhaled from lungs in the first second of a forced exhalation  FVC (forced vital capacity) Involves blowing out as hard as possible after taking the deepest breath possible into a small machine that tests lung capacity  COPD= <.70  http://www.youtube.com/watch?v=kiQcbXK7f5c http://www.youtube.com/watch?v=kiQcbXK7f5c  Using a stethoscope- listen to lungs  X-ray and CT scans of lungs (but can still look normal)  Blood tests- measure amounts of oxygen and carbon dioxide in blood Diagnosing COPD

11. Spirometry

12.  No cure for COPD  Stop smoking- best way to slow down lung damage  Medications:  Inhalers (bronchodilators)  Ipratropium (Atrovent)  Tiotropium (Spiriva)  Salmeterol (Serevent)  Formoterol (Foradil)  Albuterol  Inhaled steroids- reduce lung inflammation  Anti-inflammatory medication  Montelukast (Singulair)  Roflimulast Treatment for COPD

13.  Severe cases or during flare-ups:  Steroids by mouth or through a vein  Bronchodilators through a nebulizer  Oxygen therapy  Assistance during breathing from a machine  Antibiotics (infections can make COPD worse) Treatment for COPD

14.  May need oxygen therapy at home or constantly in oxygen in blood is too low (< SpO₂ 80%)  Pulmonary rehabilitation  Can teach you to breath differently allowing you to stay active  Strengthen the lungs  Help maintain muscular strength in legs Treatment for COPD

15.  Exacerbations: increase in coughing, shortness of breath and/or amount or color of mucus coughed up  More frequent lung infections (pneumonia)  Increased risk of osteoporosis  Depression or anxiety (reduction in independence)  Problems with loosing too much weight  Heart failure (right side of heart)  A collapsed lung  Sleep problems (not enough oxygen) Complications

16.  Hyperinflation (crucial aspect): impeded exhalation, incomplete lung emptying, and air trapping  When exercising: Dynamic hyperinflation is superimposed on static hyperinflation  Reduction in inspiratory capacity  Smaller tidal volume  Increased elastic and threshold work of breathing  Dynamic hyperinflation is directly linked to breathlessness Effects on Exercise Response

17.  Exercise limited by cardiovascular factors:  Deconditioned  Impaired left ventricle function (low SpO2)  Reduced pulmonary blood flow (low SpO2)  Lactic acid accumulation at low work rates (peripheral muscle deconditioning)  Increased CO2 output (bicarbonate buffering)  Increased ventilator requirement Effects on Exercise Response

18.  Study conducted on the effects of walking on COPD patients  Evaluated the cardiac and respiratory responses as well as electrical activity of lower limb muscles during walking  6 min walk test  Walking distance & speed were significantly lower in COPD patients  However, COPD patients walked at a higher % of peak VO2  Surface EMG data taken on muscles were about same for both  Specifically the vastus lateralis & rectus femoris were more fatigued  CONCLUSIONs:  6 min walk test was performed at a relatively higher intensity in patients with COPD compared with healthy controls  Walking cause those with COPD to be more vulnerable to muscle fatigue Effects of Walking

19.  Review of 18 controlled trials conducted to see if resistance training improves elements of performance of daily activities  Found effects favoring the addition of 12 weeks of progressive resistance training exercise to aerobic exercise for increases in LBM  Progressive Resistance Exercise showed no effect on oxygen uptake  Found an improvement in walking distance in field-walking tests  Found an improvement in timed stair-climbing performance  Found overall improvements in arm & leg muscle strength Effects of Progressive Resistance Exercise

20.  Conducted to see the hemodynamic adaption during high- intensity intermittent exercise in COPD patients  30 min exercise session, alternating a 4 min work set at first ventilatory threshold with a 1 min set at 90% of maximal tolerated power output  Found an increase in VO2, cardiac output & ventilation during first minutes of exercise, but remained STABLE thereafter  Pulmonary arterial pressure increased from rest and significantly decreased thereafter  Total pulmonary vascular resistance decreased from rest to the end of the test  CONCLUSION:  High intensity 1 min bouts of work of intermittent work exercise are well tolerated w/o pushing pulmonary arterial pressure too high Effects of Intermittent Exercise

21.  Beta2-adrenoceptor agonists:  Relax bronchial smooth muscle & produce bronchodilation  Methylxanthines:  Produce bronchodilation & CNS stimulation  Thiazide diuretics:  Control fluid retention  Glucocorticoids (steroids):  Reduce inflammation & improve pulmonary function Effects of Medications

22. MedicationsHeart rateBlood Pressure ECGExercise capacity Selective Beta2- adrenoceptor agonists (Sympathomimetic Agent) ↑ or (R&E) ↑, ↓, or (R&E) ↑ or HR (R&E) Methylanthines (Bronchodialators) (R&E) ↑ EC Thiazide Diuretics (R&E) or ↓ (R&E) or PVCs (R) May cause PVCs and “false positive” test results if hypokalemia occurs May cause PVCs if hypomagnesemia occurs (E) Glucocorticoids (steroids) (R&E) Antidepressants ↑ or (R&E) ↓ or (R&E)Variable (R)

23.  Assessment of physiological function:  Cardiopulmonary capacity  Pulmonary function  Determination of arterial blood gases/ arterial O2 saturation (direct/indirect)  Modifications:  Extended stages  Smaller increments  Slower progression  Example: Naughton Protocol- only speed not grade increases every 2 min instead of every 3 min  6 minute walk test  Popular for assessing functional exercise capacity  Walking is usually best, COPD patients usually lack muscle strength for stationary cycling & arm ergometry may cause increased dyspnea Exercise Testing for COPD

24.  Almost any level of physical activity can improve oxygen utilization, work capacity and anxiety  Benefits of exercise  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 Effects of Exercise Training

25.  Recommended mode of exercise: walking, cycling, swimming or conditioning exercises (tai chi)  enjoyable & improves ability to perform daily activities  Oxygen administered if SpO2 < 88%  Goal is have SpO2 >90% during exercise  Modifications to duration & frequency might be necessary  5-10 min sessions vs. 20-30 min  6 week exercise program w/ group intervention is helpful  Rehabilitation exercises should be LIFELONG  COPD patients are at risk for relapsing Exercise Programming

27.  COPD is a chronic inflammatory disease of the lung that is characterized by progressive and irreversible airflow limitation (no cure)  COPD is usually a combination of Bronchitis & Emphysema  An estimated 24 million Americans have COPD  Smoking is the leading cause of COPD  Best test for COPD- spirometry Conclusions

28.  Inhalers, steroids & anti-inflammatory medication are used to help off set symptoms  Hyperinflation is a crucial aspect of COPD  Progressive resistance & intermittent exercise can be beneficial  Walking may improve endurance better than cycling  6 min walk test is most popular for testing COPD patients  Numerous benefits of exercise  Rehabilitation should be a lifelong process Conclusions

29.  Durstine, Larry J., Moore, Geoffrey E., Painter, Partricia L., & Roberts, Scott O. (2009). ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities. Champaign, IL: Human Kinetics.  LifeExtension (2011). Chronic Obstructive Pulmonary Disease, Emphysema and Chronic Bronchitis. Retrieved from http://www.lef.org/protocols/respiratory/copd_01.htmhttp://www.lef.org/protocols/respiratory/copd_01.htm  Lonsdorfer-Wolf, E., Bougault, V., Doutreleau, S., Charloux, A., Lonsdorfer, J., & Oswald-Mammosser, M. (2004). Intermittent exercise test in chronic obstructive pulmonary disease patients: how do the pulmonary hemodynamics adapt?. Medicine & Science In Sports & Exercise, 36(12), 2032-2039.  Marquis, N., Debigare R, Bouyer L, et. al. 2009. Physiology of walking in patients with moderate to severe chronic obstructive pulmonary disease. Med. Sci. Sports Exerc. 41:1540-1548.  O'Shea, S., Taylor, N., & Paratz, J. (2009). Progressive resistance exercise improves muscle strength and may improve elements of performance of daily activities for people with COPD: a systematic review. Chest, 136(5), 1269-1283. doi:10.1378/chest.09-0029  The Credit Valley Hospital (2011). Screening for COPD. Retrieved from http://www.cvh- on.ca/podcasting/video.phphttp://www.cvh- on.ca/podcasting/video.php  Thompson, Walter R., Gordon, Neil F., & Pescatello, Linda S. (2009) ACSM’s Guidelines for Exercise Testing and Prescription, 8 th edition.  WebMD. (2011) COPD-Ongoing Concerns. Retrieved from http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-ongoing-concerns http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-ongoing-concerns  World Health Organization (2011). Chronic Obstructive Pulmonary Disease (COPD). Retrieved from http://www.who.int/mediacentre/factsheets/fs315/en/index.html http://www.who.int/mediacentre/factsheets/fs315/en/index.html References

30. ANY QUESTIONS??