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exercise prescription > COPD > Flashcards

COPD Flashcards

1
Q

Definition of COPD

A
  • common preventable disease characterised by persistent airflow limitation usually progressive and associated to enhanced chronic inflammatory response.
  • exacerbation and co-morbidities are common and contribute to overall severity
  • chronic airflow limitiation caused by a mix of small airway disease (bronchitis) and parenchymal destruction (emphysema)
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2
Q

prevalence of copd in the uk

  • how many it kills
  • smoking related
  • how many have it
A

30,000 people in the UK killed with COPD every yr
2nd biggest killer after cancer
20% not smoking related
3 million have it with 2 million undiagnosed
BLF,2018

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3
Q

How does COPD relate to onset of smoking cessation

A

NICE 2010

  • dont smoke or not suscptible to smoke then at 75 your lung capacity will be at 75%
  • stop at 45 will be at 45% at 75
  • stop at 65 then lung capacity will be 15% at 75
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4
Q

3 concepts related to COPD

A
  • exercise limitiation
  • dyspnoea spiral
  • hypoxic drive
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5
Q

explain how COPD limits exercise

through V/Q mismatch and increased work of breathing

A

COPD leads to V/Q mismatch due to increase physiological lung dead space over tidal volume VD/VT meaning decrease o2stats, higher co2 so decrease pH. this activates chemoreceptors so increase ventilatory requirenment causing breathlessness/ dyspnoea.

copd increases work of breathing due to airflow obstruction (bronchitis) and decrease elastic recoil (parenchymal destruction) which decreases ventilatory capacity causing dyspnoea

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6
Q

explain dyspnoea spiral and how it relates lactic acid to breathlessness

A

acts in a cycle so:
disease causes disability ie breathlessness that causes inactivity which causes deconditioning and atrophy of muscles, leading to more breathlessness, causing more disability so cycles round to reducing inactivity further

also atrophy of muscles leads to anaerobic metabolism at low work rates increasing lactic acid and stimulation of ventilation causing more breathlessness

causes dynamic hyperinflation during exercise so cant respire properly

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7
Q

hypoxic drive to breathe

A

lose the drive to breathe due to CO2 (hypercapnia)- body starts to use oxygen receptors instead of co2 receptors to regulate breathing. –as high levels of arterial co2 over time mean the chemoreceptors become less sensitive to change so rely on the o2 receptors causing increase respiratory rate. Therefore, cant put on high oxygen as will lose the drive to breathe.

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8
Q

results of exercise limitation of copd

A 
Lee and holland 2014 
lower cardio respiratory fitness (vo2  0.5-1.6l/min norm 3.5)
altered respiraotry mechanism
gas exchange abnormalities
respiratory and peripheral muscle abnormality
dyspnoea
fatigue and impaired exercise capacity
reduced pa
nutritional deficit
comorbid
balance impair
sleep deficit
depression, anxiety and reduced SE
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9
Q

symptoms of copd

A

nhs uk 2018

wheeze, dyspnoea, cough, chest infections, weight loss, fatigue and oedema

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10
Q

levels of depression in copd

A

mills 2001 45%

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11
Q

what are the 5 goals of pulmonary rehab

A
  1. alleviate symptoms
  2. decrease disbailitiy
  3. restore functional capabilities
  4. increase quality of life
  5. maintain long term benefits
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12
Q

what are the 6 components of pulmonary rehab

A

1.physical training
2.disease education
3.nutritional intervention
4.psychological intervention
5. social intervention
6. behavioural intervention
NICE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE 2010

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13
Q

HILL AND BURTIN statement

A

also includes smoking cessation and states more than just prescribing exercise but also the psychosocial and lifestyle changes that copd brings that needs targeting
2013

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14
Q

what is the most disabiling symptom of copd and how can it be helped

A

dyspnoea= vestbo et al 2013

foward-lean position sitting, pursed lip breathing and use of a rollator (hill and burtin 2013)

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15
Q

definition of pulmonary rehab

A

an individually tailored, multi-disciplinary programme of care to optimise patients physical and social performance and autonomy
NICE 2010

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16
Q

conditions of PR 8

A

NICE 2010 states
1)make PR available to all includiing those with recent hospitlisation for acute exacerbation
2. tailor multi-component multidisciplinary intervention that targets the 6 components of rehab
3.hold at times to suit patient to improve concordance and effectiveness
4. offer to all patients who consider themselves functionally disabled by COPD (But is not suitable for those unable to walk, unstable angina or recent mi)
5.patients should be made aware of the benefits of PR and the commitement required to gain these
6. should be at least 6 weeks duration, min 2xweekly supervised sessions
7. supervised, individually tailored, progressive both aerobic and restistance training
8 defined and structured

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17
Q

what are the 3 sources of guidelines for PR

A

American college of sports med 2013
american thoracic society/ european respiratory society 2013
american association of cardiovascular and pulmonary rehab 2011

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18
Q

what are the British Thoracic society 2001 recommendations for exercise training in pr

A 
aerobic:
duration 4-12 weeks 
supervised 2-5x per week
duratation 20-30 minutes
intensity: 60% peak velocity or peak vo2= better than using HR
large muscle groups
ensure progressive overload programme

strength:
beneficial in addition to aerobic
improves endurance rather than max capacity
can begin unloaded if severe

other factors

  • can be done at home but out patient clinic more effective as supervised technique and social,
  • supplemental o2 recommended if stats under 90%^
  • education ineffective by itself but important
  • coping and SE strategies
  • nutrition ineffective alone but useful with exercise
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19
Q

managament of COPD recomendation

A

vestbo et al 2013 GOLD global obstructive lung disease guidelines

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20
Q

GOLD assessment of copd recommendations

A
  • recommends spirometry
  • determine the impact of disease on patient health status
  • severity of airflow limitation
  • risk of future exacerbations
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21
Q

GOLD reducing risk factors

A
  • smoking cessation
  • consider other pollutants
  • use available vaccines
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22
Q

managing stable copd gold

A
  • relieve symptoms with bronchodilator
  • prevent progression
  • improve exercise tolerance
  • improve health status
  • prevent exacerbations
  • reduce mortality
  • level FEV1 may be inadequate descriptor
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23
Q

manage exacerbation COPD

A

pharma

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24
Q

level of depression in copd

A

45% Mills 2001

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25
Q

copd activity avoidance reference

A

von leypoldt and janssens 2016

26
Q

copd classifications stages1-4

A 
nice 2010
stage 1=80% fev1 predicted+ symptoms present
stage 2=50-79% fev1 predicted
stage 3= 30-49%
stage 4=<30% or <50% with resp failure
27
Q

assessing copd recommendations

A

ACSM 2013 recommends pulmonary function, arterial oxyhg stats, o2 stats and dyspnoea on borg

Aacvpr RECOMMENDS functional performance, balance, orthopaedic and musculoskeletal limitations

28
Q

ref for 6mwt reliable in copd

A

jenkins 2007

29
Q

CPET ref

A

borel et al 2013

gold standard is max incremental or constant work rate

30
Q

lee and holland 2015 aerobic guideline

A

3 times week supervised and unsupervised, duration 8 weeks, 20-60 minutes at >60% wr dyspnoea 4-6, 12-14

31
Q

ACSM aerobic guideline

A

-light intensity given 30-40%

and progression increasing 5-10 minutes status every 1-2 weeks for 4-6 weeks

32
Q

aerobic training evidence references

A 
casaburi et al 1991 
leung et al 2010 for model 
vogiatzis et al 2011 for physiology changes 
santos et al 2015 for intensity
paneroni et al 2017 for very severe copd
33
Q

interval training recommendation

A

all 3 reccommend interval training if cant sustain high intensity cont exercise
l& H 2015 recommends if cant tolerate over 5 minutes then use 20-180s bouts, 20-180s rest

34
Q

study for interval training

A

beauchamp et al 2010
8 studies
3-16 weeks, 2-5 times per week
cont=50-80% peak wr 20-40 minutes
interval =>80% peak wr 20s-3 min alternating to 30-75% for 30s to 3 min
-interval training and cont had similar improvements in vo2 peak, 6mwt and hrqol
-small sample size used in primary studies

35
Q

physiological changes from aerobic training in copd

A
  • Casaburi et al 1991 decreased lactic acidosis and ventilation due to exercise training as increases aerobic metabolism (casaburi)
  • increases muscle oxidative fibres, shift to type II and increase CA of all in patients classified ii to iv gold (vogiatzis et al 2011)
36
Q

santos et al 2015 RCT for aerobic

A

-out patient PR for 8 weeks
-aerobic 30 min 3x weekly
- compared group 60 &80%
-both groups also given strength programme 3 sets, 8reps, 50% 1rpm
- flexbility 3x 5s stretch 7 muscles
-5 education and skill training sessions
-randomised, subject blind
-both groups showed sig differences and improved all outcomes of dyspnoea and hrqol
-but no sig difference between 60and 80 for hrqol, sympto control and exercise tolerance test
-only 1 adverse for 60
concluded not additional benefit at 80% max work rate
- small sample size only 34

37
Q

Paneroni et al 2017 very severe copd

A

sr and ma
program durations 4-52 weeks
1-5 sessions per week, 15-40 minutes
10 studies
intervention group increased 6mwt exercise tolerance and stgrq hrwol
but few studies on severe patients and more needed

38
Q

leung et al 2010

A

-2 groups initially walking at 75% of max speed
- both 30-45 min session 3x week over 8 weeks
-and cycling group at 60% of max wr then progressively increased
-walking group increased their endurance walking time by 279 seconds more then cycling for the endurance shuttle walk test
concluded walking improves functional exercise more then cycling in people with copd
-but no control group and training effect

39
Q

ats and aacvpr recommendation for aerobic

A

suggest longer sessions than bts at 20-60 minutes

40
Q

location of program recommendation

A

BTS done at home or outpatient clinic but latter more effective as proper technique, social support prevent isolation

41
Q

location of program references

A

mccarthy et al 2015

maltais et al 2008

42
Q

mccarthy et al 2015 location of program

A

-cochrane
-review 65rct
compared hospital to community found sig difference in treatment effect between subgroups for all domains of the CRQ with higher values on average for hospital based compared to community based

43
Q

malatis et al 2008

A

4 week education program followed by 8 week program in hospital or home then 40 week follow up
-aerobic and strength 3xweek for 8 weeks 60% using ergo cycles at home 30-40 mins
-a and s 3x 8 week 80% 25-30 in hospital
home group regular calls
-found home based to be safe option with equivalent improvement in hrqol and exercise capacity
-similar number adverse.
-252 patients large
but study unblinded

44
Q

strength for copd guidelines

A

BTS 2001, beneficial in addition to aerobic training but optimal format unclear

Acsm and ats recommend using elderly guidelines, >2 x week, 60-70% 1pm, 1-4 sets, 10-15 reps, 8-10 exercises

45
Q

strength for copd evidence references

A

lee and holland 2015
vonbank et al 2012
Ramos et al 2014

46
Q

vonbank et al 2012 strength rct

A

-12 weeks
-36 patients
-endurance training, strength training or both
-strength training=2xweek, 8 exercises, 2 sets, 18-15 reps
-aerobic cycle, 2x 20 mins then increase up to 60 mins 60% vo2
-results: vo2 peak percentage of preducted increased 6.3% et, 6.5% ct not sig in st
-muscle strength improved in all groups with sig higher st and ct compared to et (39.3, 43.3 and 20.4)
-hrqol sig greatest improvement in ct
small sample size only 36

47
Q

ramos et al 2014 elastic tubing

A 
-49 patients
8 weeks 3x
versus conventional training
-et increased 6mwd by 73m compared to only 42m 
no sig diff in hrqol and muscle strength
48
Q

partitioning references

A

l and h 2015

d and 6 2006 and 2008

49
Q

lee and holland 2015 on partitioning

A

alternative method to enhance the beneficial effects of endurance training whist minimising the ventilatory load

50
Q

dolmage and goldstein 2006

A

found that 2 leg cycling 70% intensity compared to 1 leg 35% demonstrated equivalent metabolic demands for peak vo2 at lower venilation requirenment and dyspnoea

51
Q

d and g 2008

A

when applied for 7 weeks, 3x week greater increase peak vo2 for 1 leg (15mins per leg) versus 2 leg (30 mins) and for 1 leg greater peak ventilation and lower submax hr and ventilation

52
Q

pulmonary r versus usual care ref

A

mccarthey et al 2015

rejbi et al 2010

53
Q

mccarthey et al 2015 pr

A

cochrane
65
sig outcomes for qol and crq domains of fatigue, dyspnoea, empotional function and mastery for pe compared to usual care
-for each crq domain for pr also exceed minimial important clinical difference
-for 6mwd showed 43.94m increase exceeding landh 30m

54
Q

rejbi et al 2010 pr

A

12 week pr
3x3 months
2sessions of seminar discussions
training schedule 45 mins individualised
copd patients showed a 23% increase in 6mwd and 13% increase in vo2 and anaerobic threshold no change in lung function

55
Q

supplemental o2 recommendation

A

bts stats under 90%

56
Q

what stage of copd should pr be implemented

A

nice 2010 states pr available for all

puhan et al 2011 found pr post a and e immediately reduced the rate of hospital readmission by 42% and mortality by 16%

57
Q

water based copd training

A

l& h recommend as buoyancy reduced load and hydrostatic force helps increase blood flow, moist air helps to breathe
wadell et al 2004 assoc. to increased hrwol and sig improvement in exercise capacity compared to land (179m improved for eswt)

58
Q

nice pathway for copd

A 
when to consider exercise referral
diagnosis
manage stable copd
manage exacerbation
palliative care
59
Q

behaviour intervention on self efficacy

A

larson et al 2014
• 4 months of upper body resistance training with 12 month follow up
• 3 groups: upper body resistance training with self efficacy, ubr with health education or health education with gentle chair exercises
• 49 copd older adults
• Self efficacy group were the only group after 4 months to increase time spent in lpa, other two decreased but changes were not sustained at 12 months. Sig different
• Concluded it produced a modest short-term increase
• SE 16 sessions using mastery experience with feedback of progress, vicarious experience with videos of other people doing upperbody resistance training, verbal and social persuasion with buddy groups to call each other at weekends

60
Q

Lepsen et al 2015

A

meta analysis of Rt and ET versus ET alone
13 studies
equal improvement in hrqol, walking distance and exercise capacity, however, muscle strength for leg was higher in rt and et.
but risk of bias

61
Q

b. Beauchamp et al 2011

A

systematic review found that programs longer 12-18 months associated to more favourable outcomes with HRQOL but more information needed for exercise capacity

62
Q

beauchamp et al 2013

A

found that a 6 week pulmonary rehabilitation program that included balance training three times a week improved balance performance, muscle strength and self-reported physical function compared to a control group of just pulmonary rehabilitation.

exercise prescription (8 decks)

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