Pulmonary Rehabilitation

1
Pulmonary Rehabilitation

• March 9, 2006
• Howard M. Mintz, M.D.

2
ATS Guidelines PR 1999What and Why

• Reduce symptoms
• Increase physical and social activities
• Improve quality of life
• Decrease disability
• Questionable increase in survival
• Economic savings

3
(No Transcript)
4
Exclusion Criteria for PR

• Advanced arthritis
• Cognitive deficits
• Recent MI
• Severe pulmonary hypertension
• Poor motivation
• Current smokers

5
ATS Guidelines PR 1999

• Secondary co morbidities are the reason that PR
  works
• PR really changes items other than respiratory
  function
• See table

6
Changes in PFTs with PR

• Innumerable studies have demonstrated that
  typically measured parameters of pulmonary
  function such as the FEV1, FVC, FEV1/FVC do not
  change with pulmonary rehabilitation
• Are we looking at the wrong parameters?
• Arm Exercise and Hyperinflation in Patients with
  COPD. Gigliotti, et.al. Chest 2005
  1281225-1232. Instead of looking at static lung
  volumes, they examined the response to exercise
  and changes in exercise induced inspiratory
  capacity as a measure of hyperinflation.
  Inspiratory capacity diminishes with upper
  extremity and lower extremity exercise and PR
  decreases the dynamic hyperinflation.

7
(No Transcript)
8
(No Transcript)
9
Assessment for PR

• Individualized programs are best suited for
  success
• PE, history, medication review, spirometry to
  assess degree of obstructive disease
• Educational assessment to better understand that
  patients knowledge of their disease process
• Determination of baseline exercise capacity,
  whats necessary, check for desaturation,
  consider cardiac comorbidity, respiratory muscle
  strength, nutritional status, cognitive
  functional assessment

10
Site for PR
11
Exercise Training in PR

• High intensity training is more effective in
  producing training effect
• Most PR programs stress endurance training
  instead of high intensity training, typical
  pattern would be 20-30 minutes two to five times
  weekly
• Research would suggest intensity of training
  should be at 60 of maximal oxygen consumption.
• Seldom do patients undergo a formal exercise
  stress test prior to PR and instead a target HR
  is guide
• HR is poorly substitute since HR in severe lung
  disease is highly variable because of the
  medications, comorbid conditions, and underlying
  lung impairment.
• Symptom guided exercise program is a reasonable
  alternative

12
Does Pulmonary Rehabilitation Work?
13
Exercise Training

• Lower extremity exercise
• Upper extremity exercise
• Continuous or intermittent
• Weight training
• Inspiratory and expiratory muscle training
• Task specific training

14
What Does the Data Reveal?1

• Controlled Trial of Supervised Exercise Training
  in Chronic Bronchitis, Sinclair, et. al. Br Med
  J 1980, Feb 23280 (6213)519-521). 33 subjects
  with severe chronic bronchitis. Exercise
  consisted of 12 minute walk and stair climbing
  with once weekly supervision. Exercise group
  attained a 24 increase in maximum exercise
  capacity after 8-12 months. No improvement in the
  control group. No changes in respiratory muscle
  strength nor PFTs.

15
What Does the Data Reveal?2

• Randomized Controlled Trial of Respiratory
  rehabilitation, Goldstein, Lancet 1994 Nov 19
  344(8934)1394-1397). Prospective randomized
  controlled trial of 89 patients (45 females and
  44 males), mean age 66, stable COPD.
  Rehabilitation vs. conventional community care.
  24 week program, 8 as inpatient and 16 as
  outpatient with supervision. Outcome measurements
  were exercise tolerance and quality of life. 6
  minute walk, submaximal cycle time, perception of
  dyspnea all improved in the rehabilitation group
  in comparison to conventional treatment.

16
What Does the Data Reveal?3

• Quality of Life in Patients with COPD Improves
  After Rehabilitation at Home. Wijkstra,et al.
  Eur Respiratory J 1994 Feb7(2)269-273. Severe
  COPD patients with FEV1 of 1.3 /- 0.4 liters and
  FEV1/FVC 37 /-7.9. 43 patients with 28
  receiving home rehabilitation for 12 weeks, and
  15 usual care. Significant improvement in
  dyspnea, emotional well being, and mastery of
  tasks. No improvement in PFTs and the
  improvement in quality of life was independent of
  the improvement in exercise tolerance.

17
What Does the Data Reveal?4a

• Rehabilitation for Patients with COPD Meta
  Analysis of Randomized Controlled Trials.
  Salman, J. Gen Internal Medicine 2003
  Mar18(3)213-221. Studies were included in
  patients were symptomatic, FEV1lt70, FEV1/FVC
  lt70, at least 4 weeks duration. Outcome
  measurements included exercise capacity or SOB.
• 69 trials, only 20 included in final analysis
• 20 of the trails showed improved walking distance
  compared to control group
• 12 trials showed improvement in less shortness of
  breath
• Respiratory muscle training only did not show a
  significant improvement in dyspnea nor walking
  distance

18
What Does the Data Reveal?4b

• Trials that included at least lower extremity
  exercises showed improvement in dyspnea and
  walking distance.
• Those patients with the most severe disease only
  improved with programs lasting six months or
  longer
• Those patients with mild to moderate disease
  improved with both short rehabilitation and long
  rehabilitation programs
• Mild upper extremity weight training has been
  shown to give added benefit in addition to
  walking with decreased minute ventilation and
  increased ergometer distance (16)

19
Skeletal Muscles and Enzyme Changes with PR 1

• Exercise Training Fails to Increase Skeletal
  Muscle Enzymes in Patients with COPD. Belman Am.
  Rev Resp Disease 1981 Mar123(3)256-261. Six
  week training period. 7 patients did upper
  extremity exercises, and 7 patients did lower
  extremity exercise. Pre-exercise biopsies were
  taken and post-exercise training biopsies of the
  trained limbs. Enzymes citrate synthase, 3-beta
  hydroxyacyl coenzyme A dehyrogenase, and pyruvate
  kinase. The patients demonstrated a training
  effect, but no changes in enzymes were detected.
  Hypothesized that patients with COPD were unable
  to train at enough intensity. Distinctly
  different than normal subjects.

20
Skeletal Muscles and Enzyme Changes with PR 2a

• Skeletal Muscle Adaptation to Endurance Training
  in Patients with COPD. Maltais. Am. J. Resp Crit
  Care Med 1996 Aug154(2pt1)442-7. Patients with
  severe COPD, FEV1 36 /- 11. 30 minutes of
  calibrated exercise on a ergocyle for 12 weeks.
  Pretraining aerobic capacity was severely reduced
  but increased by 14 with training. Training
  effect manifest by decrease in VE for the same
  level of workload and a decrease in lactic acid
  production. Muscle biopsies were obtained pre and
  post training of the vastus lateralis.
• Two oxidative enzymes, citrate synthase (CS) and
  3-hydroxyacyl-CoA dehydrogenase (HADH) were
  measured, pre and post.

21
Skeletal Muscles and Enzyme Changes with PR 2b

• Three glycolytic enzymes were measured lactate
  dehyrogenase, hexokinase, and phosphofructokinase
  were measured.
• The two oxidative enzyme levels increased, while
  the glycolytic enzymes remained the same in pre
  and post training muscle biopsies
• The increase in the oxidative enzyme levels was
  associated with a decrease in lactate production
  at the same level of exercise.
• Training even in patients with moderate to severe
  COPD can improve skeletal muscle oxidative
  capacity.

22
Skeletal Muscles and Enzyme Changes with PR 3

• Reductions in Exercise Lactic Acidosis and
  Ventilation as a Result of Exercise Training in
  Patients with Obstructive Lung Disease.
  Casaburi. Am Rev Respir Dis 1991 Jan143(1)9-18.
  
• Question was does the intensity of the exercise
  determine the benefit.
• Moderate COPD. Training at two levels of
  intensity, about 70 W x 45 minutes and 30 W at a
  proportionally longer period of time.
• After training, those in high intensity were able
  to increase level of work without increase in
  lactate and less VE with 73 increase in
  endurance.
• Low intensity group was able to increase
  endurance by only 9.
• The absence of development of lactic acidosis is
  not required by a training effect.

23
Predictors of Improvement with PR

• Predictors of Improvement in the 12 Minute
  Walking Distance Following a Six Week Outpatient
  Pulmonary Rehabilitation Program. Zuwallack.
  Chest 1991 Apr99 (4)805-808
• 50 ambulatory outpatients exposed to six weeks of
  PR
• 12 MD increased by 27.7 /- 32.5
• 12 MD distance increased by 462 feet /-427 feet.
  
• No significant relationship between age, sex,
  ABGs, oxygen requirements, and PFTs
• Patients with highest ventilator reserve (1-
  VEmax/MVV x 100) had the most improvement in 12
  MD
• The smaller the initial 12 MD and the greater the
  initial FEV1, the better the rehab potential
• Poor initial 12 MD is not a predictor of poor PR
  potential
• Studies showed the most improvement in those
  patients receiving the most intense exercise
  prescriptions

24
Upper Extremity Exercise 1

• Upper Extremity Exercise Training in COPD.
  Ries. Chest 1988 Apr 93(4)688-692
• Patients with COPD have more difficulty with
  upper extremity exercise
• Mechanism for increase in dyspnea includes
  fixation of the rib cage and abdominal wall with
  upper extremity exercises resulting in a
  physiologic stiffening of the rib cage.
• Most PR programs emphasize lower extremity
  training
• 45 patients divided into three groups
  gravity-resistance training (GR), modified
  proprioceptive neuromuscular facilitation upper
  extremity training (PNF), and no specific upper
  extremity training

25
Upper Extremity Exercise 2

• 28 patients completed the study. GR and PNF
  showed improved performance of task specific
  exercises.
• Breathlessness and perceived fatigue diminished.
• No change in ventilatory muscle strength or
  simulated activities of ADL.
• In order to help patients with COPD improve ADL
  skills of upper extremities, the prescription
  must be specific.

26
Upper Extremity Exercise

• Supported Arm Exercises vs Unsupported Arm
  Exercises in the Rehabilitation of Patients with
  Severe Chronic Airflow Obstruction. Martinez.
  Chest 1993 May 103(5)1397-402.
• Patients were divided into those with unsupported
  arm training (USA) and supported arm training
  (SAT). USA patients basically lifted light
  weights. SAT used a hand ergometer.
• All patients were enrolled in comprehensive PR
  including lower extremity, inspiratory muscle
  training, teaching, and psychological support.
• Groups were equally matched from disease severity
  and exercise capacity.
• 12 MW, respiratory muscle function, bicycle
  ergometer power output similar in the two groups
  at the end of the training period.
• USA patients had a decrease in VO2 and the
  metabolic costs. USA is much more akin to ADL
  skills and thus should be incorporated into PR

27
Upper Extremity Exercise Dynamic Hyperinflation
1

• Arm Exercise and Hyperinflation in Patients with
  COPD. Gigliotti, et.al. Chest 2005
  1281225-1232.
• 12 patients with moderate to severe COPD, mean
  FEV1 1.59 liters /- 0.58 liters and FEV1/FVC 46
  /- 12.
• No changes in the static PFTs nor ABGs per and
  post PR
• Hypothesis was that PR increased exercise
  tolerance and decreased dyspnea because of
  changes in dynamic hyperinflation.
• Dynamic hyperinflation is the phenomenon in which
  exercise causes increases in the FRC decreases
  in the IC

28
Upper Extremity Exercise Dynamic Hyperinflation
2

• Consequences of dynamic hyperinflation include a
  reduction in airway closure minimizing expiratory
  flow resistance (maladaptive response), increase
  in muscle fatigue by changing the length tension
  relationship
• 12 patients underwent incremental (5W/min),
  symptom limited arm exercises with hand
  ergometer.
• Significant education and training period that
  included lower extremity exercises and typical
  components of PR

29
Upper Extremity Exercise Dynamic Hyperinflation
3

• 6 week outpatient PR.
• Expired gas analysis was performed along with
  other routine measurements
• During the last 30 seconds of exercise, the
  patients performed two inspiratory capacity
  manuevers for measurement of end-expiratory lung
  volume. TLC does not change during exercise in
  patients with COPD, thus IC reliably estimates
  changes in EELV.
• Patients rated dyspnea with Borg scale 0-10

30
Upper Extremity Exercise Dynamic Hyperinflation
4

• Hand ergometer training consisted of work load of
  80 of maximal level to symptom limited with 80
  set by pre PR testing.
• Study showed significant increases in minute
  ventilation, oxygen consumption, CO2 production,
  HR, exercise dyspnea with upper extremity
  exercise.
• Increase in work rate demonstrated with plt0.001.
• IC decreased by 0.93 /- liters with upper
  extremity exercise in the control period
• Following PR, IC decreased by 0.59 liters /-
  0.27 liters (plt0.0001)

31
Upper Extremity Exercise Dynamic Hyperinflation
5

• The RR interval increased with PR, and thus
  there was more expiratory time, associated with
  less dynamic hyperinflation (plt0.03)
• Dyspnea as assessed by the Borg scale diminished
  (plt0.02) follow PR
• HR decreased following PR
• Oxygen consumption and CO2 production did not
  change with PR
• Minute ventilation decreased with PR, (plt0.01)
• Arm or leg cycling in COPD results in dynamic
  hyperinflation and is a predictor of exercise
  tolerance

32
Inspiratory Muscle Training in PR

• The inspiratory muscles can be strengthened with
  inspiratory muscle training
• The data on effectiveness of inspiratory muscle
  training is mixed
• Inspiratory muscle training seems to decrease
  dyspnea
• Inspiratory muscle training has not been
  uniformly shown to increase exercise endurance.

33
Inspiratory Muscle Training in COPD 1

• The Effects of 1 Year of Specific Inspiratory
  Muscle Training in Patients with COPD.
  Beckerman, et.al. Chest 2005 1283177-3182.
• Inspiratory muscle dysfunction likely result of
  geometric changes in diaphragm, chest wall,
  systemic factors, and possible changes in
  muscles.
• Hypothesis was that one year of SIMT would
  improve dyspnea, exercise tolerance, quality of
  life, reduce hospital costs and admissions
• 42 patients with mean FEV1 of 1.21 liters /- 0.4
  liters and FEV1 predicted of 42 /- 2.6
• Testing with spirometry, 6 MW, Borg scale for
  dyspnea
• Health-Related Quality of Life with St. Georges
  Resp Questionaire

34
Inspiratory Muscle Training in COPD 2

• Training of 2 sessions of 15 minutes six times
  weekly for 12 months with POWERbreathe,
  inspiratory muscle trainer. 1st month direct
  supervision at center, then home training for 11
  months with weekly calls or visits. Attendance
  was 63 /-7 in training group and 59 /- in
  the control.
• After 3 months of training, PImax increased in
  the trained group with smaller incremental
  improvement over the next 9 months. Plt0.005
• After 3 months of training, 6MW in trained group
  with smaller incremental improvement over the
  next 9 months. Plt0.005
• POD declined slowly and did not reach a
  statistically significant level of plt0.05 until 9
  months of training
• SGRQ improved after 6 months in trained group and
  was maintained over 12 months
• No significant differences in hospitalizations
  between the trained and control group, but
  average days for each hospitalization was lower
  in trained group, plt0.05.

35
Inspiratory muscle strength as assessed by the
PImax before and after the training period in the
study group and in the control group
Beckerman, M. et al. Chest 20051283177-3182
36
The mean /- SEM perception of dyspnea (Borg
score) during breathing against load in all COPD
patients before and after the training period
Beckerman, M. et al. Chest 20051283177-3182
37
The mean /- SEM distance walked in 6 min
before and after the training period in the study
group and in the control group
Beckerman, M. et al. Chest 20051283177-3182
38
Changes in health-related quality-of-life scores
determined by the SGRQ before and after the
training period in the study group and in the
control group
Beckerman, M. et al. Chest 20051283177-3182
39
Hospital admissions, days spent in the hospital,
and the use of primary-care consultations during
the training period in the study group and in the
control group
Beckerman, M. et al. Chest 20051283177-3182
40
Expiratory Muscle Training in COPD 1

• Specific Expiratory Muscle Training in COPD.
  Chest 2003 124468-473. Weiner, et.al.
• Expiratory muscles impaired in COPD
• Contraction of expiratory muscles increases
  intrathoracic pressures, decreases lung volumes,
  and increase expiratory flow rates.
• Expiratory muscle training has been shown to
  decrease dyspnea in children with neuromuscular
  disease and improve cough in adults with MS.
• Study was designed to answer three questions 1.
  Does SEMT increase exercise tolerance 2. Does
  SEMT training decrease dyspnea, 3. Can one
  demonstrate a training SEMT increase

41
Expiratory Muscle Training in COPD 2

• Randomized study of 26 patient with mean FEV1 of
  1.32 liters /- 0.4 liters with FEV1 of 37 of
  predicted /- 2.4.
• Exercise sessions of 30 minutes six times weekly
• Expiratory muscle endurance as measured by
  PemPeak increased by 33, plt0.001
• 6MW increased in the treated group b 19, plt0.05
• No significant change in perception of dyspnea
  with expiratory muscle training
• Literature does not substantiate a significant
  individual benefit for this modality

42
Breathing Retraining, Education, Other Modalities

• Shallow, rapid breathing may be deleterious to
  ventilation and gas exchange. Pursed lipped
  breathing and other techniques may help.
• Yoga training has been shown to improve exercise
  tolerance in comparison to breathing exercise,
  only 11 patients in both groups
• Patients instructed in diaphragmatic breathing
  training actual had more dyspnea and increase in
  work of breathing (7 patients)
• Educations goal is to improve compliance, no
  studies convincingly show improvements
• Psychological support cannot be shown to have any
  specific benefit although depression is about 2.5
  times more prevalent in patients with COPD. Group
  therapy has not been demonstrated to have
  benefit.
• Energy conservation techniques, planning,
  prioritization, and assistive devices.
• Discussion of end of life issues.
• Nutrition

43
Nutrition and COPD

• Weight loss to level of lt90 of IBW occurs in 25
  to 43 with about 14 of patients having weight
  loss in excess of 50 of premorbid weight
• Weight loss with loss of lean body mass is
  associated with skeletal muscle dysfunction that
  contributes to dyspnea, decreased mobility, and
  increase risk of falls.
• Significant weight loss typically begins about
  3.5 years prior to death
• Unintentional weight loss and mortality

30 weight loss 30 mortality in 3 years
50 weight loss 50 mortality in 5 years
44
Nutrition and COPD

• At an FEV1 of lt35 of predicted, those patient
  with gtIBW have a 50 higher exercise capacity
  than patients with lt90 of ideal body weight
• Body weight is correlated with exercise capacity
  with plt0.0001.
• Reversal of weight loss has been associated with
  improved outcomes such as increased survival and
  improvements in 12 MWD, hand grip, PEmax, and
  PImax.
• Difficulty to restore body weight
• Patients with low body weight have more gas
  trapping, lower DLCO, and lower exercise capacity
  when matched for patients with similar pulmonary
  functions but normal weight

45
Nutrition, COPD, and Anabolic Steroids 1

• Reversal of COPD-Associated Weight Loss Using
  the Anabolic Agent Oxandrolone. Yeh, et. al.
  Chest 2002 122421-428.
• Oxandrolone oral anabolic steroid shown to be
  useful in patients with chronic infections,
  burns, severe trauma, extensive surgery, offset
  catabolism associated with corticosteroids.
• Oxandrolone has a high anabolic activity and low
  androgenic activity (Testosteron 11 ratio
  oxandrolone 31 to 131.
• Safety demonstrated in over 30 years of us.

46
Nutrition, COPD, and Anabolic Steroids 1

• Community study, 25 sites in USA, 10 mgm of
  oxandrolone for 4 months, males and females
• History of involuntary weight loss and IBW lt90
  with COPD and FEV1lt50 of predicted
• No specific exercise program or nutritional
  support offered
• 128 patient entered study but only 55 analyzed
  for 4 months
• IBW 79 /- 9.2 of predicted
• Mean FEV1 34 /- 15.83
• At 2 months, 72/82 patients had gained mean of
  6.0 lbs /-4.36 lbs
• At month 4, 46/55 patients had gained 6.0 lbs /-
  5.83 lbs (plt0.0)
• Males and females had equal response and body
  cell mass increased substantially while body fat
  did not

47
Nutrition, COPD, and Anabolic Steroids 2

• No changes in spirometry
• No changes in 6 MW
• No changes in VAS for dyspnea
• Subgroup did demonstrate an increase in 6 MW and
  performance status, but it is unclear why these
  patients were separated

48
Meta-Analysis for Nutritional Support in COPD

• Nutritional Support for Individuals with COPD.
  Ferreira, et al. Chest 2000 117672
• RCT reviewed and 272 abstracts with 9 felt
  adequate for data extraction with 272 subjects
  (144 study and 133 control)
• At least 2 weeks of nutritional support (any
  caloric supplementation)
• Did this impact FEV1 or 6 MW? NO!!

49
Anabolic Steroids and PR in COPD 1

• A Role for Anabolic Steroids in the
  Rehabilitation of Patients With COPD?
  Creutzberg, et al. Chest 20031241733-1742
• Low levels of testosterone are seen in COPD
  patients especially those receiving
  glucocorticosteroids
• Glucocorticosteroids contribute to respiratory
  and peripheral muscle weakness seen in COPD
  independent of muscle wasting
• Anabolic steroids might work through effects on
  erythropoietin
• Does the anabolic steroids nandrolone 50 mgm IM q
  2 weeks benefit patients undergoing 8 weeks of PR?

50
Anabolic Steroids and PR in COPD 2

• Measured were body composition, muscle function,
  exercise capacity, erythropoietic values, and
  laboratory values
• Subgroup analysis looked at patients receiving
  oral glucocorticoids
• PR rehabilitation improved the following
  variables in both the patients receiving
  Nandrolone and those receiving placebo, but the
  addition of the Nandrolone did not confirm an
  additive benefit Maximum inspiratory muscle
  strength, maximum isometric hand grip, maximum
  isometric leg strength, work load, maximum oxygen
  consumption, SGRQ scores

51
Greater improvements in maximal (Max) inspiratory
muscle strength (top) and peak workload (bottom)
after 8 weeks of treatment with ND vs placebo
combined with a standardized pulmonary
rehabilitation program in patients receiving oral
glucocorticosteroids
Creutzberg, E. C. et al. Chest 20031241733-1742
52
(No Transcript)
53
Assessing Effectiveness of PR

• Dyspnea indices
• Quality of life indices
• Measurement of exercise capacity, 6 MW, 12 MW, 10
  m Intermittent Shuttle test, incremental cycle
  ergometer

54
Exercise Testing in PR 1

• Pulmonary rehabilitation is not free, and you
  need to document effectiveness. What is simple,
  reproducible, and cost effective?
• Incremental exercise on bicycle ergometer or
  treadmill to 85 of maximal predicted heart rate
  (HR, RR, BP, ECG, SaO2, (/- exhaled gas
  analysis). Reproducible and sensitive to changes
  associated with PR.
• Submaximal testing on bicycle ergometer or
  treadmill used to assess endurance. More effort
  dependent, captures response to PR.

55
Exercise Testing in PR 2

• 6 minute walking test and 12 minute walking test
  can be conducted anywhere
• 6 MW and 12 MW are less reproducible. Walk as far
  as you can, at your own pace for 6 or 12 minutes.
  Simple. Well tolerated, consistent with ADL.
• 6 MW and 12 MW correlate with peak exercise
  tolerance of graded (incremental exercise) tests.
  Learning effect.
• 10 meter Shuttle Walking Test. Walks up and down
  10 meter (Shuttle) with increasing speed by
  external beeping. Incremental test thus measure
  exercise capacity and not so much endurance. Self
  pacing is eliminated. Correlation is r 0.88 in
  comparison to maximal oxygen consumption during
  incremental testing.
• Very responsive to changes associated with PR.

56
Comparison of 6 MW, 10m IST, CET 1

• Physiologic Responses to Incremental and
  Self-Paced Exercise in COPD. Turner, et al Chest
  2004 126766-773
• Comparison of HR, SaO2, and dyspnea with these
  three exercise modalities
• Hypothesis was that there would be no differences
  in peak HR or dyspnea scores in patients with
  moderate to severe COPD
• 20 stable subjects, 18 with FEV1 lt40 of
  predicted, FEV1/FVC 33.7 /- 10.7. 19 were ex
  smokers and 1 current smoker. 12/20 previously
  had PR.
• Each subject underwent the 3 exercise forms
  within a two week period in a randomly selected
  order. 10m IST and 6 MW both have a learning curve

57
Comparison of 6 MW, 10m IST, CET 2

• CET pedaling at 60-75 revolutions per minute
  against 20 W workload with increase of 8 W every
  minute until subject unable to keep rpm pace or
  voluntarily stopped.
• 6MW on 45 m course, indoors, level surface.
• 10 m IST with initial walking speed of 0.5m/sec
  and increase in speed every minute by 0.17m/sec.
  Verbal cues to increase walking speed and triple
  beeps. Failure to maintain speed, terminated
  period or voluntary
• HR before and every minute of exercise, SaO2
  before and end of exercise, Borg scale before and
  every minute of exercise.
• 6MW subjects can stop for fatigue or dyspnea

58
Comparison of 6 MW, 10m IST, CET 3

• 6 MW HR increased more rapidly and in alinear
  fashion
• 10m IST and CET heart rate increased slower and
  linear fashion
• Peak heart rate and dyspnea scores did not differ
  with the three forms of exercise
• SaO2 was lower with 6 MW and 10m IST than with
  the CET (plt0.001)
• 9/20 subjects has SaO2s lt85 with 6 MW or 10m
  IST, but was gt85 at termination in all patients
  with CET
• Strong correlation between distances walked with
  6 MW and 10m ICS with r0.91.

59
Pooled data from 20 subjects of the changes in HR
during the 6MWT, ISWT, and incremental CET
Turner, S. E. et al. Chest 2004126766-773
60
Pooled data from 20 subjects of the changes in
dyspnea during a 6MWT, ISWT, and incremental CET
Turner, S. E. et al. Chest 2004126766-773
61
Comparison of 6 MW, 10m IST, CET 4

• Distance walked with 6 MW and 10m IST correlated
  with peak workload during CET with r0.83
  plt0.001 and r0.79 plt0.001 respectively
• Significant correlation between peak oxygen
  consumption on CET and distance walked on 6 MW
  and 10m IST with r0.73, plt0.001, and r0.73,
  plt0.001 respectively.
• Walking is more suitable for detection of
  exercise induced desaturation
• Peak HR and dyspnea scores similar between three
  tests suggesting validity of using simplier
  exercise tests to assess results of PR in
  patients with moderate to severe COPD

62
Measuring Dyspnea

• Most debilitating symptom in COPD
• Measured with Borg scale or visual analog scale
  (VAS)
• Borg scale uses descriptions such as no
  breathlessness to maximal breathlessness.
• VAS is 100 mm in length, one end no
  breathlessness and other maximal breathlessness

63
Dyspnea Assessment

• Functional status can be measured with many
  different questionnaires to assess changes
• Quality of life also assessed with
  questionnaires.
• Usefulness of data is limited in assessing
  benefits to individual patients, group responses
  do improve with PR

64
Durability of Effectiveness of PR

• Normal trained individuals, cessation of training
  for about two weeks causes loss of training
  effect
• Similar lack of durability for patients with COPD
• Study looking at long term effectiveness
  following 12 weeks of pulmonary rehabilitation
  followed by visits monthly, weekly, and no
  rehabilitation. Patients undergoing pulmonary
  rehabilitation had a significant improvement in
  maximal cycle rate and 6 MW. 18 months following
  completion of the PR, neither group receiving
  visits had a sustained benefit, no difference
  between weekly and monthly follow up. Adherence
  to home PR not assessed.
• Another study showed that at 12 months, despite
  monthly follow up and encouragement for home
  therapy, substantial decline in benefit.
  Adherence to home PR not assessed.

65
Enhancing Exercise Performance in PR 1

• Enhancement of Exercise Performance in COPD
  Patients by Hyperoxia. Snider. Chest 2002
  1221830-1836.
• Medicare payment policy for oxygen therapy for
  breathlessness was not considered reimbursable.
• What do the studies suggest about use of
  supplemental oxygen in patients with severe COPD?
• Hyperoxia sufficient oxygen to result in an
  increase in PaO2.
• 16 studies, only one randomized, controlled,
  studies date back to 1956.

66
Enhancing Exercise Performance in PR 2

• 1956 Cotes and Gilson studied 29 patients, all
  coal miners with 18 with pneumoconiosis. 22/29
  walking distance on treadmill at least doubled
  with oxygen. The improvement was minimal on 25,
  and incremental improvement on 30-50, but no
  more up to 100. VE dropped by 26.5
• 1970 Raimondi studied 8 pateints with severe
  COPD, mean FEV1 0f 0.74 liters. 35 supplemental
  oxygen vs RA, 35 improvement in exercise
  endurance.
• 1978 Bradley 26 men and women with mean FEV1 of
  0.52 liters, exercised on treadmill with
  compressed air or 5 lpm of oxygen, 47
  improvement in exercise endurance.

67
Enhancing Exercise Performance in PR 3

• 1982 Wookcock 10 patients with mean FEV1 of 0.71
  liters. Graduated exercise on treadmill with VAS.
  25 increase in distance walked on treadmill and
  24 decline in dyspnea by VAS.
• 1992 Dean measured endurance testing on bicycle
  ergometer and RVSP by Doppler echocardiography.
  RA or 40 FIO2. Duration of exercise increased
  from 10.3 minutes to 14.2 minutes (plt0.005) and
  RVSP at maximal exercise decreased from 71 to 64
  mm Hg (plt0.03). 12 patients studied with mean FEV
  of 0.89 liters.
• 1995 McDonald in only controlled, blinded study
  showed minimum benefit, however, the patients had
  demand valve oxygen instead of continuous and
  limited to 4 lpm
• Should supplemental oxygen be utilized? Should
  patients be tested with and without oxygen
  therapy?

68
PR and survival