Other Clinical Conditions Influencing Exercise Prescription Cardiac Wellness Institute of Calgary...

Other Clinical Conditions Influencing Other Clinical Conditions Influencing Exercise PrescriptionExercise Prescription

Cardiac Wellness Institute of Calgary

Updated May 2010

Material to be CoveredMaterial to be Covered

ACSM’s Resource Manual for Guidelines for ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6Exercise Testing and Prescription (6thth ed.) ed.)

Chapters 7, 8, 23, 24, 36, 37, 38 Chapters 7, 8, 23, 24, 36, 37, 38

ACSM’s Guidelines for Exercise Testing and ACSM’s Guidelines for Exercise Testing and Prescription (8Prescription (8thth ed.) ed.)

Chapter 10Chapter 10

Diabetes MellitusDiabetes Mellitus

ACSM’s Resource Manual for Guidelines for ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6Exercise Testing and Prescription (6 thth Edition) - Edition) - Chapters 8, 24, 37 Chapters 8, 24, 37

ACSM’s Guidelines for Exercise Testing and ACSM’s Guidelines for Exercise Testing and Prescription (8Prescription (8thth Edition) - Chapter 10 Edition) - Chapter 10


Complex metabolic disorderComplex metabolic disorder

Characterized by:Characterized by:– Abnormal glucose metabolism defects in insulin Abnormal glucose metabolism defects in insulin

release, action, or both release, action, or both

– Secondary microvascular degenerationSecondary microvascular degeneration


IDDM (Type I):IDDM (Type I):

– Caused by an acute or gradual loss of insulin-Caused by an acute or gradual loss of insulin-producing beta cells in the pancreasproducing beta cells in the pancreas

– Maintain high levels of plasma glucose Maintain high levels of plasma glucose

– Subject to ketoacidosisSubject to ketoacidosis

– loss of water and sugar through urineloss of water and sugar through urine Secondary thirst, weight loss and increased Secondary thirst, weight loss and increased

appetiteappetite


NIDDM (Type II)NIDDM (Type II)

– Decreased sensitivity of peripheral receptors Decreased sensitivity of peripheral receptors especially in SM and liverespecially in SM and liver

– Decreased plasma glucoseDecreased plasma glucose

– Plasma insulin usually increasesPlasma insulin usually increases


CharacteristicsCharacteristics Type IType I Type IIType II

Age of onsetAge of onset < 20 < 20 > 40> 40

FrequencyFrequency 0.5%0.5% 4-5%4-5%

Family HxFamily Hx ProbableProbable FrequentFrequent

SymptomsSymptoms Thirst, polyuria, Thirst, polyuria, weight loss, weight loss, appetiteappetite

Mild or frequently Mild or frequently nonenone

ObesityObesity ++ ++++

Serum insulinSerum insulin Low to zeroLow to zero High (initially)High (initially)

Insulin TxInsulin Tx AlwaysAlways 20-30%20-30%

Diagnostic Criteria for Diagnostic Criteria for DiabetesDiabetes

Symptoms of diabetes plus casual plasma Symptoms of diabetes plus casual plasma glucose concentration of ≥200 mg/dL glucose concentration of ≥200 mg/dL (11.1mmol/L) (11.1mmol/L)

Fasting plasma glucose of ≥126 mg/dL (7.0 Fasting plasma glucose of ≥126 mg/dL (7.0 mmol/L) (fasting is defined as no caloric intake mmol/L) (fasting is defined as no caloric intake for at least 8 hours)for at least 8 hours)

2 hour plasma glucose ≥200 mg/dL2 hour plasma glucose ≥200 mg/dL-1-1 during during oral glucose tolerance test (OGTT)oral glucose tolerance test (OGTT)

ComplicationsComplications

Wide-ranging ComplicationsWide-ranging Complications

– Hypo or hyperglycemiaHypo or hyperglycemia

– RetinopathyRetinopathy

– Hypertension and CADHypertension and CAD

– Autonomic neuropathyAutonomic neuropathy

– Peripheral neuropathyPeripheral neuropathy

– NephropathyNephropathy

TreatmentTreatment

IDDM IDDM – Subcutaneous injections of insulin (SA and LA)Subcutaneous injections of insulin (SA and LA)

– Dietary regulation Dietary regulation

– Exercise dailyExercise daily

NIDDMNIDDM– Weight lossWeight loss

– Oral hypoglycemicsOral hypoglycemics

– Possibly insulinPossibly insulin

Benefits of ExerciseBenefits of Exercise

Improved insulin sensitivityImproved insulin sensitivity

Decreased risk of CV disease:Decreased risk of CV disease:

– Improved blood lipidsImproved blood lipids

– caloric expenditure (improve BMI)caloric expenditure (improve BMI)

– BP in those with hypertensionBP in those with hypertension

Increased fitnessIncreased fitness

− Aerobic, strength and endurance, flexibilityAerobic, strength and endurance, flexibility

Improved psychological well beingImproved psychological well being


NIDDMNIDDM– Reduced blood glucose and HgA1c levelsReduced blood glucose and HgA1c levels

– Improved glucose toleranceImproved glucose tolerance

– Improved insulin response to oral glucoseImproved insulin response to oral glucose IDDMIDDM

– Improvement in insulin sensitivity may be transientImprovement in insulin sensitivity may be transient

Response to Exercise Response to Exercise

Acute exercise results in Acute exercise results in glucose use glucose use

Therefore Therefore glucose production necessary to glucose production necessary to maintain normal levelsmaintain normal levels

Compromised in the diabetic stateCompromised in the diabetic state

Screening ProceduresScreening Procedures

History and Physical ExamHistory and Physical Exam Diabetes EvaluationDiabetes Evaluation Cardiovascular ExamCardiovascular Exam

– Often includes clinical exercise testing Often includes clinical exercise testing

Clinical Exercise Testing Clinical Exercise Testing Other ConsiderationsOther Considerations

Modality – change to standard protocols or arm Modality – change to standard protocols or arm ergometryergometry

Hypertensive responseHypertensive response Presence of silent ischemiaPresence of silent ischemia Postural hypotension or blunted HR responsePostural hypotension or blunted HR response Glucose monitoring and adjust insulinGlucose monitoring and adjust insulin Sub-max exercise to determine training intensitySub-max exercise to determine training intensity

Exercise Prescription:Exercise Prescription:

FrequencyFrequency– 3-7 d/wk3-7 d/wk

– Low – mod intensity if 7 days/week (IDDM)Low – mod intensity if 7 days/week (IDDM)

IntensityIntensity– Target Heart Rate or MET levelTarget Heart Rate or MET level

50 -8050 -80% Karvonen method or VO% Karvonen method or VO22 max RPE/talk max RPE/talk testtest

12-16 on a 6-20 scale12-16 on a 6-20 scale

FITT IntensityFITT IntensityOther ConsiderationsOther Considerations

THR always 10bpm below:THR always 10bpm below:

– 1mm horizontal or downsloping ST segment 1mm horizontal or downsloping ST segment depressiondepression

– Anginal symptoms or other CV insufficiencyAnginal symptoms or other CV insufficiency

– SBP SBP 240mmHg, plateau SBP or 240mmHg, plateau SBP or SBPSBP

– DBP DBP 110mmHg110mmHg

FITT IntensityFITT IntensityOther ConsiderationsOther Considerations

THR always 10bpm below:THR always 10bpm below:

– frequency ventricular dysrhythmiasfrequency ventricular dysrhythmias

– Other significant ECG disturbancesOther significant ECG disturbances

– Radionuclide evidence LV dysfunctionRadionuclide evidence LV dysfunction

– Mod/sev wall motion abnormal with exerciseMod/sev wall motion abnormal with exercise

– Other signs/symptoms of intoleranceOther signs/symptoms of intolerance

Exercise PrescriptionExercise Prescription

TimeTime– 20-60 minutes/session 20-60 minutes/session

– 5-10 min WU and CD5-10 min WU and CD

TypeType– Aerobic:Aerobic: may require non-wt bearing may require non-wt bearing

– Resistance:Resistance: may be contraindicated, if not as per may be contraindicated, if not as per guidelines for cardiac patientsguidelines for cardiac patients

Prescription Guidelines: RTPrescription Guidelines: RT

1 set, 10-15 reps, 8-10 exercises1 set, 10-15 reps, 8-10 exercises 2-3 days/week2-3 days/week RPE 11-14RPE 11-14 Rate pressure product (RPP) during RT Rate pressure product (RPP) during RT

exceed RPP during aerobic exercise trainingexceed RPP during aerobic exercise training Avoid Valsalva, tight gripAvoid Valsalva, tight grip Exhale on exertionExhale on exertion

Exercise PrescriptionExercise PrescriptionOther ConsiderationsOther Considerations

Encourage to wear medical alert IDEncourage to wear medical alert ID Encourage to exercise with a partnerEncourage to exercise with a partner Ensure adequate hydrationEnsure adequate hydration Reinforce proper footwearReinforce proper footwear Exercise with caution in temperature extremesExercise with caution in temperature extremes May need to limit isometric exerciseMay need to limit isometric exercise

Precautions for Avoiding Precautions for Avoiding Hypoglycemic EventsHypoglycemic Events

Aware of signs and symptomsAware of signs and symptoms

– DiaphoresisDiaphoresis

– PallorPallor

– TremorTremor

– TachycardiaTachycardia

– PalpitationsPalpitations

– Visual disturbanceVisual disturbance

– Mental confusionMental confusion

– WeaknessWeakness

– LightheadednessLightheadedness

– FatigueFatigue

– HeadacheHeadache

– Memory loss Memory loss

– Seizure or comaSeizure or coma

Precautions for Avoiding Precautions for Avoiding Hypoglycemic EventsHypoglycemic Events

Measure blood glucose before, during and after Measure blood glucose before, during and after exerciseexercise– < 100mg/dL (5.5 mmol/L) eat CHO snack< 100mg/dL (5.5 mmol/L) eat CHO snack

– Delay exercise if >300 mg/dL or > 240 mg/dL with postive Delay exercise if >300 mg/dL or > 240 mg/dL with postive ketonesketones

Adjust insulin dosages associated with exerciseAdjust insulin dosages associated with exercise− Avoid exercise during periods of peak insulin activityAvoid exercise during periods of peak insulin activity

Insulin should not be injected into an exercising Insulin should not be injected into an exercising musclemuscle

Exercise late in the evening Exercise late in the evening risk of nocturnal risk of nocturnal hypoglycemiahypoglycemia

Precautions for Avoiding Precautions for Avoiding Hyperglycemic EventsHyperglycemic Events

Aware of signs and symptoms of hyperglycemia:Aware of signs and symptoms of hyperglycemia:– DehydrationDehydration

– Hypotension and reflexHypotension and reflextachycardiatachycardia

– Frequent urination Frequent urination

– Impaired consciousnessImpaired consciousness

– NauseaNausea

Measure blood glucose and ketones before, Measure blood glucose and ketones before, during and after exerciseduring and after exercise− Postpone exercise if blood glucose >300mg/dL (~16.5mmol/L)or Postpone exercise if blood glucose >300mg/dL (~16.5mmol/L)or

240 mg/dL (~ 13 mmol/L) with ketones240 mg/dL (~ 13 mmol/L) with ketones

– VomitingVomiting

– Abdominal painAbdominal pain

– Hyperventilation Hyperventilation

– Odor of acetone Odor of acetone on breathon breath

HypertensionHypertension

ACSM’s Resource Manual for Guidelines for Exercise ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6Testing and Prescription (6 thth Edition) - Chapters 38 Edition) - Chapters 38


HypertensionHypertension

Prevalence: 15-20% in western civilizationPrevalence: 15-20% in western civilization BP is determined by BP is determined by Cardiac Output and Total Cardiac Output and Total

Peripheral ResistancePeripheral Resistance

Classification of HypertensionClassification of Hypertension

Essential (Primary) hypertension:Essential (Primary) hypertension:

– No single causeNo single cause Secondary hypertension:Secondary hypertension:

– Hypertension secondary to other disorders of Hypertension secondary to other disorders of the renal, endocrine, and nervous systemsthe renal, endocrine, and nervous systems

Associated ComplicationsAssociated Complications

Primary risk factor for cardiovascular diseasePrimary risk factor for cardiovascular disease

– Changes extent and presence of calciumChanges extent and presence of calcium

End-organ damageEnd-organ damage

– LVHLVH

– Arteriosclerosis in retinaArteriosclerosis in retina

– Renal failureRenal failure

Lifestyle Modifications for Lifestyle Modifications for HypertensionHypertension

Weight LossWeight Loss Limit alcohol intakeLimit alcohol intake Increase aerobic physical activityIncrease aerobic physical activity Reduce sodium intakeReduce sodium intake Maintain adequate intake of dietary potassium Maintain adequate intake of dietary potassium

Lifestyle Modifications for Lifestyle Modifications for Hypertension ContinuedHypertension Continued

Maintain adequate intake of dietary calcium and Maintain adequate intake of dietary calcium and magnesium for general healthmagnesium for general health

Stop smokingStop smoking Reduce intake of dietary saturated fat and Reduce intake of dietary saturated fat and

cholesterol for overall cardiovascular healthcholesterol for overall cardiovascular health


Reduce BPReduce BP– Reduced Cardiac OutputReduced Cardiac Output

– Reduced Total Peripheral ResistanceReduced Total Peripheral Resistance

– Changes Changes in body compositionin body composition

Improve risk factor profileImprove risk factor profile

Response to ExerciseResponse to Exercise

Gradually increase SBP Gradually increase SBP – Response Response >> in those with hypertension in those with hypertension

– Should increase Should increase >> 10mmgHg and not decrease 10mmgHg and not decrease

Decrease or no changeDecrease or no change DBP DBP Typical range 180-210/60-85Typical range 180-210/60-85 Exaggerated response (>230/100) may predict Exaggerated response (>230/100) may predict

future hypertension and/or CADfuture hypertension and/or CAD


To diagnose should have three separate To diagnose should have three separate readingsreadings

If high risk would require CV Exam often If high risk would require CV Exam often includes clinical exercise testing includes clinical exercise testing

Clinical Exercise TestingClinical Exercise TestingOther ConsiderationsOther Considerations

Standard methods and protocolsStandard methods and protocols Medications taken at normal timeMedications taken at normal time ECG may show LVHECG may show LVH Possible dysrhythmias due to diuretic treatmentPossible dysrhythmias due to diuretic treatment Observe for exaggerated pressure responseObserve for exaggerated pressure response

– SBP > 260 mmHgSBP > 260 mmHg

– DBP 115 mmHgDBP 115 mmHg


FrequencyFrequency– Most, preferably all days of the weekMost, preferably all days of the week


40-<60% heart rate reserve (HRR) or VO40-<60% heart rate reserve (HRR) or VO22 max max

Aim for 700 – 2000 kcal/weekAim for 700 – 2000 kcal/week


TimeTime

– 30-60 minutes/session; intermittent: minimum of 10-30-60 minutes/session; intermittent: minimum of 10-minute bouts accumulated to 30-60 minutes minute bouts accumulated to 30-60 minutes

– 5-10 min WU and CD5-10 min WU and CD

TypeType

– AerobicAerobic

– Resistance:Resistance: may be contraindicated, if not as per may be contraindicated, if not as per guidelines for cardiac patientsguidelines for cardiac patients

Need to monitor BP with isometric activityNeed to monitor BP with isometric activity


Do not exercise if resting BP:Do not exercise if resting BP:– SBP > 200 mmHg orSBP > 200 mmHg or

– DBP > 110 mmHgDBP > 110 mmHg

Some antihypertensives may cause post Some antihypertensives may cause post exercise hypotension therefore adequate CD exercise hypotension therefore adequate CD importantimportant

Diuretics may cause a Diuretics may cause a ↓ ↓ in Kin K++ which may result which may result in arrhythmiasin arrhythmias

Avoid Valsalva maneuvers during RTAvoid Valsalva maneuvers during RT

Peripheral Arterial Disease Peripheral Arterial Disease (PAD)(PAD)

ACSM’s Resource Manual for Guidelines for Exercise ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6Testing and Prescription (6 thth Edition) - Chapters 38 Edition) - Chapters 38


Peripheral Arterial DiseasePeripheral Arterial Disease(PAD)(PAD)

Common manifestation of atherosclerosisCommon manifestation of atherosclerosis Prevalence: 10% in age 60+Prevalence: 10% in age 60+ Have similar risk factor profile as CV diseaseHave similar risk factor profile as CV disease

Peripheral Arterial DiseasePeripheral Arterial Disease(PAD)(PAD)

Acute: Acute:

– Muscle blood flow supply/demand mismatchMuscle blood flow supply/demand mismatch Chronic:Chronic:

– DeconditioningDeconditioning

– Impaired oxidative metabolismImpaired oxidative metabolism

– Lack of blood flow limits ability to do ADLsLack of blood flow limits ability to do ADLs

Diagnosis of PADDiagnosis of PAD

Symptoms – ClaudicationSymptoms – Claudication

– Intermittent muscular pain relieved with restIntermittent muscular pain relieved with rest Based on history and physical examBased on history and physical exam

– Risk factorsRisk factors

– Hemodynamic assessmentHemodynamic assessment Auscultation of femoral arteriesAuscultation of femoral arteries ABIABI ArteriographyArteriography

Ankle/Brachial IndexAnkle/Brachial Index

Resting SBP in ankle and arm by DopplerResting SBP in ankle and arm by Doppler

Used to measure the severity of PADUsed to measure the severity of PAD

Abnormal ABI: <0.9 at rest or 20% Abnormal ABI: <0.9 at rest or 20% ↓ ↓ after after exerciseexercise

Severity not correlated to treadmill performanceSeverity not correlated to treadmill performance

Associated ComplicationsAssociated Complications

Detrimental effects on functional statusDetrimental effects on functional status– < 1-3 blocks< 1-3 blocks

– VOVO22 max typically 10-16 ml/kg/min max typically 10-16 ml/kg/min

Prevents ability to do ADLsPrevents ability to do ADLs Ischemic ulceration Ischemic ulceration Gangrene and tissue lossGangrene and tissue loss

TreatmentTreatment

Medical management is marginally effectiveMedical management is marginally effective

– Trental (Trental ( blood viscosity), Cilostazol blood viscosity), Cilostazol Lifestyle Modification to reduce risk factors Lifestyle Modification to reduce risk factors

(hypertension, smoking, and diabetes)(hypertension, smoking, and diabetes) Surgery or angioplastySurgery or angioplasty


Improved functional toleranceImproved functional tolerance

15-30% 15-30% in oxygen consumption in oxygen consumption

Improved walking abilityImproved walking ability

– speed and duration speed and duration

– Delayed onset of claudication (improvements of 106-Delayed onset of claudication (improvements of 106-177% of pain free walking)177% of pain free walking)

– Improved perception of physical functioningImproved perception of physical functioning

Increased level of habitual exerciseIncreased level of habitual exercise


Improved functional tolerance may result from:Improved functional tolerance may result from:

– peripheral blood flowperipheral blood flow

– improved muscle metabolismimproved muscle metabolism

– walking efficiencywalking efficiency

Improved functional tolerance may result from:Improved functional tolerance may result from:

− peripheral blood flowperipheral blood flow

− Improved muscle metabolismImproved muscle metabolism

− Walking efficiencyWalking efficiency


With onset of activity there is a mismatch of local With onset of activity there is a mismatch of local muscle blood flow supply/demandmuscle blood flow supply/demand

Results in localized ischemic pain that limits Results in localized ischemic pain that limits activityactivity


CV screening should be done to assess the CV screening should be done to assess the presence or extent of CADpresence or extent of CAD– History and physical examHistory and physical exam

– Includes clinical exercise testing Includes clinical exercise testing

Clinical Exercise Testing Clinical Exercise Testing Other Other ConsiderationsConsiderations

Protocols should be adaptedProtocols should be adapted

– Discontinuous to achieve VODiscontinuous to achieve VO22 max max

– Consider arm ergometryConsider arm ergometry

– Slower speed and less rapidly changing gradeSlower speed and less rapidly changing grade

Use scale for subjective ratings of painUse scale for subjective ratings of pain Record time of pain onset and point of maximal Record time of pain onset and point of maximal

painpain Assess with functional status questionnaires Assess with functional status questionnaires

Subjective Grading Scale Subjective Grading Scale for PVD Painfor PVD Pain

Grade 1Grade 1 - Definite discomfort or pain, but only of - Definite discomfort or pain, but only of initial or modest levels (established, but minimal)initial or modest levels (established, but minimal)

Grade 2Grade 2 - Moderate discomfort or pain from - Moderate discomfort or pain from which the patient’s attention can be diverted, for which the patient’s attention can be diverted, for example by conversationexample by conversation

Grade 3Grade 3 - Intense pain (short of grade 4) from - Intense pain (short of grade 4) from which the patient’s attention cannot be divertedwhich the patient’s attention cannot be diverted

Grade 4Grade 4 - Excruciating and unbearable pain - Excruciating and unbearable pain


FrequencyFrequency– Weight-bearing aerobic exercise 3-5 d/wkWeight-bearing aerobic exercise 3-5 d/wk


Moderate intensity (40- <60% HRR or VOModerate intensity (40- <60% HRR or VO22 max max

A pain score of 3/4. Individuals should have time to A pain score of 3/4. Individuals should have time to allow ischemic pain to subside before resuming allow ischemic pain to subside before resuming exercise.exercise.


TimeTime– 30-60 minutes/session (can start with 10-minute bouts 30-60 minutes/session (can start with 10-minute bouts

and exercise intermittently to accumulate 30-60 and exercise intermittently to accumulate 30-60 minutes)minutes)

– 5-10 min WU and CD5-10 min WU and CD TypeType

– Aerobic: Aerobic: Weight bearing exercise preferred; Non-weight Weight bearing exercise preferred; Non-weight

bearing may be used for WU and CDbearing may be used for WU and CD Non-weight bearing activity is encouragedNon-weight bearing activity is encouraged

– Resistance: Resistance: As per guidelines for cardiac patientsAs per guidelines for cardiac patients


ProgressionProgression

– Start with work load that brings on Start with work load that brings on claudication pain at a level of ¾ on PVD pain claudication pain at a level of ¾ on PVD pain scalescale

– work load when duration work load when duration >> 10 minutes 10 minutes

– Start with 35 mins, which may be intermittentStart with 35 mins, which may be intermittent

– Progress to 50 mins, 3-5 days/wkProgress to 50 mins, 3-5 days/wk


A cold environment may aggravate the A cold environment may aggravate the symptoms of claudication; therefore a longer symptoms of claudication; therefore a longer warm-up may be requiredwarm-up may be required

Beta blockers may Beta blockers may time to claudication time to claudication

Improved tolerance may unmask CV ischemiaImproved tolerance may unmask CV ischemia

Pulmonary DiseasePulmonary Disease

ACSM’s Resource Manual for Guidelines for ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6Exercise Testing and Prescription (6 thth Edition) - Edition) - Chapters 7, 23, 36 Chapters 7, 23, 36


Pulmonary DiseasePulmonary Disease

Diseases of the respiratory tract are classified Diseases of the respiratory tract are classified as:as:

– Obstructive DiseaseObstructive Disease

– Restrictive DiseaseRestrictive Disease

– Vascular DiseaseVascular Disease

Chronic Obstructive Airway Chronic Obstructive Airway Disease (COPD)Disease (COPD)

Results from non-uniform narrowing in the Results from non-uniform narrowing in the airways secondary to inflammationairways secondary to inflammation

Narrowing Narrowing resistance and results in uneven resistance and results in uneven distribution of minute ventilation (VE) distribution of minute ventilation (VE)

Characterized by:Characterized by:– Expiratory flow obstructionExpiratory flow obstruction

– Dyspnea at rest and with exertionDyspnea at rest and with exertion

– Reversible airway hyperactivity Reversible airway hyperactivity

COPD disordersCOPD disorders

Chronic Bronchitis:Chronic Bronchitis:– Inflammatory disorder of the small airways in the Inflammatory disorder of the small airways in the

lungslungs– Characterized by coughing, wheezing and sputum Characterized by coughing, wheezing and sputum

productionproduction

– arterial Oarterial O2 2 saturation and saturation and COCO22 levels due to levels due to hypoventilationhypoventilation

– Flow rates can be improved with bronchodilatorsFlow rates can be improved with bronchodilators– Considered a “blue bloater” due to stocky habitus with Considered a “blue bloater” due to stocky habitus with

central and peripheral cyanosis central and peripheral cyanosis – Eventually can lead to right heart failureEventually can lead to right heart failure

COPD disordersCOPD disorders Emphysema:Emphysema:

– Gradual destruction of lung tissue as well as airway Gradual destruction of lung tissue as well as airway inflammation inflammation

– Abnormal enlargement of the airspaces by destruction of the Abnormal enlargement of the airspaces by destruction of the alveolar wallsalveolar walls

– Loss of lung elasticity and elastic recoil pressureLoss of lung elasticity and elastic recoil pressure

– Unresponsive to bronchodilatorsUnresponsive to bronchodilators Pursed lips breathingPursed lips breathing

– Usually not cyanotic and little sputum productionUsually not cyanotic and little sputum production

– High VEHigh VE

– ““Pink puffer” due to significant dyspnea and barrel-chest with Pink puffer” due to significant dyspnea and barrel-chest with marked lung hyperinflationmarked lung hyperinflation

COPD DisordersCOPD Disorders

Asthma:Asthma:– Characterized by increased airway reactivity to Characterized by increased airway reactivity to

various stimulivarious stimuli

– Airways respond with Airways respond with mucous and constriction mucous and constriction

– Results in non-productive cough and wheezingResults in non-productive cough and wheezing

– Symptoms controlled by inhaled and oral Symptoms controlled by inhaled and oral bronchodilatorsbronchodilators

DiagnosisDiagnosis

Pulmonary Function TestingPulmonary Function Testing– SpirometrySpirometry

Airway patency and air volume in/out of lungsAirway patency and air volume in/out of lungs Forced vital capacity (FVC), forced expiratory Forced vital capacity (FVC), forced expiratory

volume in 1 second (FEVvolume in 1 second (FEV1.01.0) and FEV) and FEV11/FVC/FVC– Lung volumeLung volume

Total lung capacity (TLC), residual volume (RV)Total lung capacity (TLC), residual volume (RV)– Diffusing capacityDiffusing capacity

Rate at which gases diffuse from the lung (alveoli) Rate at which gases diffuse from the lung (alveoli) to the blood in the pulmonary capillariesto the blood in the pulmonary capillaries

DiagnosisDiagnosis

Cardiopulmonary Exercise Testing (CPX)Cardiopulmonary Exercise Testing (CPX)

– Maximal exercise toleranceMaximal exercise tolerance

– Ventilatory limitationsVentilatory limitations

– Pulmonary gas exchangePulmonary gas exchange

– CV responses to exerciseCV responses to exercise

TreatmentTreatment

Medical managementMedical management

Discontinuation of smokingDiscontinuation of smoking

ExerciseExercise


Psychological benefitsPsychological benefits– Mastering something difficultMastering something difficult

– Social interactionSocial interaction

– Distraction Distraction

Improved functional toleranceImproved functional tolerance– Perceived exercise tolerance increasesPerceived exercise tolerance increases

– Exercise endurance improvesExercise endurance improves

– Improvement in ability to do ADLsImprovement in ability to do ADLs

– Avoid downward spiral of deconditioning Avoid downward spiral of deconditioning


Tissues Tissues VO VO22 and CO and CO22 production production

Cardiac Output and VE Cardiac Output and VE to meet the demands to meet the demands Typically exercise capacity is not limited by the Typically exercise capacity is not limited by the

pulmonary system as Opulmonary system as O22 transport capacity > transport capacity > that of the heartthat of the heart

Physiological Limiting Physiological Limiting Factors in COPDFactors in COPD

Impaired lung mechanicsImpaired lung mechanics

Inefficient pulmonary gas exchangeInefficient pulmonary gas exchange

Pulmonary vascular insufficiencyPulmonary vascular insufficiency

Abnormal skeletal muscle metabolismAbnormal skeletal muscle metabolism


History and Physical ExamHistory and Physical Exam Pulmonary EvaluationPulmonary Evaluation Cardiovascular ExamCardiovascular Exam

– Often includes CPX Often includes CPX

Clinical Exercise Testing Clinical Exercise Testing Other ConsiderationsOther Considerations

CPX for specific exercise prescription and CPX for specific exercise prescription and pre/post evaluationpre/post evaluation

Cycle ergometry is often usedCycle ergometry is often used

Monitor arterial oxygen saturation (SaOMonitor arterial oxygen saturation (SaO22))

– <90% may require supplemental O<90% may require supplemental O22 during exercise during exercise

Use scale for subjective ratings of dyspneaUse scale for subjective ratings of dyspnea Keep in mind absolute and relative Keep in mind absolute and relative

contraindicationscontraindications

Dyspnea ScaleDyspnea Scale

NothingNothing 0 0

Very, very slight 0.5Very, very slight 0.5

Very slight 1Very slight 1

SlightSlight 22

ModerateModerate 33

Somewhat severe 4Somewhat severe 4

SevereSevere 5 5

66

Very severe 7Very severe 7

88

99

Very, very severe 10Very, very severe 10

Dyspnea ScaleDyspnea Scale

+1+1 Light, barely noticeable Light, barely noticeable

+2+2 Moderate, bothersome Moderate, bothersome

+3+3 Moderately severe, very uncomfortable Moderately severe, very uncomfortable

+4+4 Most severe or intense dyspnea ever Most severe or intense dyspnea ever experienced experienced


FrequencyFrequency– 3-5 d/wk3-5 d/wk

IntensityIntensity– No consensus as to the optimal exercise intensityNo consensus as to the optimal exercise intensity

– MET level (or THR)MET level (or THR) 60-80% peak work rates60-80% peak work rates

– Maximal limits as tolerated by symptomsMaximal limits as tolerated by symptoms

– 3-5 on Dyspnea Scale3-5 on Dyspnea Scale

– Talk test/RPETalk test/RPE


Time: Time: May need to start with intermittent exercise May need to start with intermittent exercise until patient is able to sustain higher intensities and until patient is able to sustain higher intensities and durations of activitydurations of activity– 30-50 minutes/session 30-50 minutes/session – 5-10 min WU and CD5-10 min WU and CD

TypeType– AerobicAerobic: :

Activities involving large muscle groupsActivities involving large muscle groups Arm ergometryArm ergometry

– ResistanceResistance: : As per guidelines in Chapter 7 – Guidelines for Exercise As per guidelines in Chapter 7 – Guidelines for Exercise

Testing and PrescriptionTesting and Prescription


Maintain SaO2 at Maintain SaO2 at >> 88% 88% Use pursed-lips breathingUse pursed-lips breathing Carry bronchodilators if prescribedCarry bronchodilators if prescribed Exercise indoors during times of inclement Exercise indoors during times of inclement

weather or if environmental irritants existweather or if environmental irritants exist

Alternative Modes of Exercise Alternative Modes of Exercise TrainingTraining

Continuous positive airway pressureContinuous positive airway pressure

Upper body resistance trainingUpper body resistance training

Ventilatory muscle trainingVentilatory muscle training

Guidelines for Guidelines for InspiratoryInspiratory Muscle Training Muscle Training

1. Frequency---Minimum of 4 to 5 d·wk1. Frequency---Minimum of 4 to 5 d·wk-1-1

2. Intensity---30% of maximal inspiratory pressure 2. Intensity---30% of maximal inspiratory pressure (PI(PImaxmax) measured at functional residual capacity) measured at functional residual capacity

3. Duration---Two 15-minute sessions or one 30-3. Duration---Two 15-minute sessions or one 30-minute session per day. If this cannot be minute session per day. If this cannot be achieved, the intensity should be reducedachieved, the intensity should be reduced

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