COPD

Question 1

Definition of COPD

Answer 1

• 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)

Question 2

prevalence of copd in the uk

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

Answer 2

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

Question 3

How does COPD relate to onset of smoking cessation

Answer 3

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

Question 4

3 concepts related to COPD

Answer 4

• exercise limitiation
• dyspnoea spiral
• hypoxic drive

Question 5

explain how COPD limits exercise

through V/Q mismatch and increased work of breathing

Answer 5

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

Question 6

explain dyspnoea spiral and how it relates lactic acid to breathlessness

Answer 6

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

Question 7

hypoxic drive to breathe

Answer 7

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.

Question 8

results of exercise limitation of copd

Answer 8

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

Question 9

symptoms of copd

Answer 9

nhs uk 2018

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

Question 10

levels of depression in copd

Answer 10

mills 2001 45%

Question 11

what are the 5 goals of pulmonary rehab

Answer 11

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

Question 12

what are the 6 components of pulmonary rehab

Answer 12

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

Question 13

HILL AND BURTIN statement

Answer 13

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

Question 14

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

Answer 14

dyspnoea= vestbo et al 2013

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

Question 15

definition of pulmonary rehab

Answer 15

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

Question 16

conditions of PR 8

Answer 16

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

Question 17

what are the 3 sources of guidelines for PR

Answer 17

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

Question 18

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

Answer 18

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

Question 19

managament of COPD recomendation

Answer 19

vestbo et al 2013 GOLD global obstructive lung disease guidelines

Question 20

GOLD assessment of copd recommendations

Answer 20

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

Question 21

GOLD reducing risk factors

Answer 21

• smoking cessation
• consider other pollutants
• use available vaccines

Question 22

managing stable copd gold

Answer 22

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

Question 23

manage exacerbation COPD

Answer 23

pharma

Question 24

level of depression in copd

Answer 24

45% Mills 2001

Question 25

copd activity avoidance reference

Answer 25

von leypoldt and janssens 2016

Question 26

copd classifications stages1-4

Answer 26

``` 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 ```

Question 27

assessing copd recommendations

Answer 27

ACSM 2013 recommends pulmonary function, arterial oxyhg stats, o2 stats and dyspnoea on borg Aacvpr RECOMMENDS functional performance, balance, orthopaedic and musculoskeletal limitations

Question 28

ref for 6mwt reliable in copd

Answer 28

jenkins 2007

Question 29

CPET ref

Answer 29

borel et al 2013 | gold standard is max incremental or constant work rate

Question 30

lee and holland 2015 aerobic guideline

Answer 30

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

Question 31

ACSM aerobic guideline

Answer 31

-light intensity given 30-40% | and progression increasing 5-10 minutes status every 1-2 weeks for 4-6 weeks

Question 32

aerobic training evidence references

Answer 32

``` 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 ```

Question 33

interval training recommendation

Answer 33

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

Question 34

study for interval training

Answer 34

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

Question 35

physiological changes from aerobic training in copd

Answer 35

- 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)

Question 36

santos et al 2015 RCT for aerobic

Answer 36

-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

Question 37

Paneroni et al 2017 very severe copd

Answer 37

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

Question 38

leung et al 2010

Answer 38

-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

Question 39

ats and aacvpr recommendation for aerobic

Answer 39

suggest longer sessions than bts at 20-60 minutes

Question 40

location of program recommendation

Answer 40

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

Question 41

location of program references

Answer 41

mccarthy et al 2015 | maltais et al 2008

Question 42

mccarthy et al 2015 location of program

Answer 42

-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

Question 43

malatis et al 2008

Answer 43

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

Question 44

strength for copd guidelines

Answer 44

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

Question 45

strength for copd evidence references

Answer 45

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

Question 46

vonbank et al 2012 strength rct

Answer 46

-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

Question 47

ramos et al 2014 elastic tubing

Answer 47

``` -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 ```

Question 48

partitioning references

Answer 48

l and h 2015 | d and 6 2006 and 2008

Question 49

lee and holland 2015 on partitioning

Answer 49

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

Question 50

dolmage and goldstein 2006

Answer 50

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

Question 51

d and g 2008

Answer 51

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

Question 52

pulmonary r versus usual care ref

Answer 52

mccarthey et al 2015 | rejbi et al 2010

Question 53

mccarthey et al 2015 pr

Answer 53

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

Question 54

rejbi et al 2010 pr

Answer 54

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

Question 55

supplemental o2 recommendation

Answer 55

bts stats under 90%

Question 56

what stage of copd should pr be implemented

Answer 56

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%

Question 57

water based copd training

Answer 57

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)

Question 58

nice pathway for copd

Answer 58

``` when to consider exercise referral diagnosis manage stable copd manage exacerbation palliative care ```

Question 59

behaviour intervention on self efficacy

Answer 59

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

Question 60

Lepsen et al 2015

Answer 60

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

Question 61

b. Beauchamp et al 2011

Answer 61

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

Question 62

beauchamp et al 2013

Answer 62

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.