1. Pulmonary Rehabilitation
Varga János MD, PhD
National Koranyi Institute for TB and Pulmonology, Budapest
Department of Pulmonary Rehabilitation
University of Szeged,
04/DEC/2014

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 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
Lactate increment during exercise
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
VO2 (L/min)
Thorax, 2010
Maltais F, et al. Am J Respir Crit Care Med. 1996;153: 7

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= R
 FEV %pred
0.28*
 TL,CO %pred
0.38*
 QF %pred
0.45*
 6MWD %pred
0.76*
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. Dynamic airway compression during exercise
Flow Limitation
Dynamic airway compression during exercise

15. Dynamic airway compression during exercise
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
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):

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;

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 and Lactate Kinetics Following Exercise Onset in Nonhypoxemic COPD Patients.
Chest 2002;121;
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):

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):
<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!