How To Train For A Marathon

Dr. Frits Franssen

CIRO, Horn & MUMC, Maastricht

Niet-medicamenteuze

behandeling van COPD

Dr. Christel Haenebalcke

AZ Sint-Jan Brugge-Oostende AV, campus Brugge

‘

_{Pulmonary rehabilitation is a comprehensive intervention}

based on a thorough patient assessment followed by

patient-tailored therapies, which include, but are not limited

to, exercise training, education and behavior change,

designed to improve the physical and emotional condition

of people with chronic respiratory disease and to promote

the long-term adherence of health-enhancing behaviors’

American Thoracic Society / European Respiratory

Society Statement on pulmonary rehabilitation 2013,

updated definition:

‘The purpose of pulmonary rehabilitation is to minimize

symptoms, maximize exercise performance, promote

autonomy, increase participation in everyday activities,

improve the overall quality of life, improve long-term

health-enhancing behavior, and provide tools to elicit behavior

change in physical activity and symptom management in

people with chronic respiratory disease’

American Thoracic Society / European Respiratory

Society Statement on pulmonary rehabilitation 2013,

purpose:

Frequency of most important outcomes of PR

Spruit et al., Eur Respir J 2014 A survey of 430 PR centres in 40 countries

‘

_{To address the complexity of chronic respiratory diseases,}

pulmonary rehabilitation should be conducted by a dedicated,

interdisciplinary team including physicians and other

healthcare professionals, such as physiotherapist, respiratory

therapist, nurse, psychologist, exercise physiologist,

nutritionist, occupational therapist, and social worker. Each

program should be carefully constructed for the patient by the

pulmonary rehabilitation team after a thorough baseline and

ongoing assessment’

American Thoracic Society / European Respiratory

Society Statement on pulmonary rehabilitation 2013,

precautions:

Frequency of healthcare professionals in PR programmes

‘A pulmonary rehabilitation program is patient-centered and

therefore varies in components, complexity and duration

according to the clinical needs of the individual. Pulmonary

rehabilitation should be integrated throughout the clinical course

of a patient’s disease and modified to the complexity of disease

phenotypes including unique co-morbidities. Indeed, pulmonary

rehabilitation may be initiated either during a clinically stable

phase of the disease or during or directly following an acute

exacerbation of the disease or hospitalization’

American Thoracic Society / European Respiratory

Society Statement on pulmonary rehabilitation 2013,

positioning:

Spruit et al., Eur Respir J 2014

62 jarige dame met COPD, voorheen werkzaam in stoffeerderij

Voorgeschiedenis: fibromyalgie, migraine, depressie

In juni 2014 opgenomen met 1e

exacerbatie. Daarvoor niet

gediagnosticeerd. Kortademig bij inspanning, mMRC 2, chronisch hoesten, Zo’n 5 kilogram

afgevallen, veel spanningen

Medicatie: formoterol/budesonide 2dd, glycopyronium 1dd,

venlafaxine 1dd, sumatriptan zn

Rookstop juni 2014, 48 pakjaren

Verwijzing voor

longrevalidatie

FEV₁, l (%) 1.1 (55%) FVC, l (%) 2.7 (103%) FEV₁/FVC 0.43 FRC, l (%) 3.9 (152%) RV, l (%) 3.0 (166%) TLC, l (%) 5.6 (123%) DL_CO, mmol/kg/min (%) 3.9 (49%) K_CO, mmol/kg/min (%) 0.86 (56%) P_aO2, kPa 10.2 ± 1.6 p_aCO2, kPa 5.2 ± 0.6

Assessment voorafgaand aan longrevalidatie

BMI, kg/m2 _19.3 FFMI, kg/m2 _13.5 T-score L2-L4 -1.5 T-score heup -2.2 6MWD 315 (52%) Saturatie 94 > 84% W_max 48 (49%) VO_2max 671 (57%) RER 1.11 HF_max 127 (80%) VE_max 31 (67%) BORG dyspnoe 0.5 - 9 BORG benen 1 - 6 Saturatie 94 > 88% CAT 23 HADS angst 11 HADS depressie 8

Fysiotherapeut: ‘Mevrouw staat

nu 7 minuten op de loopband en

de saturatie is 83%’. Mag ik haar

zuurstof geven?

☐

_{Verlagen van intensiteit}

☐

Interval training

☐

_{Stoppen met training}

☐

Zuurstof tijdens fysieke activiteiten

☐

_{Zuurstof tijdens loopband training}

☐

Looptest met zuurstof

☐

_{Geen actie}

☐

_…

Prevalence of exercise-induced desaturation in COPD

6MWT is more sensitive than maximal incremental cycle testing!

20%

29%

51%

Poulain et al., Chest 2003

Adrianopoulos et al., Respir Physiol Neurobiol. 2014

Predicting exercise-induced desaturation in COPD

Prevalence: 39%

Patients (%F) 402 (43) Age, y 64.3 ± 8.0 BMI, kg/m2 _{25.6 ± 5.5} FFMI, kg/m2 _{17.2 ± 2.4} FEV₁, l 1.4 ± 0.6 FEV₁, % pred 51.9 ± 18.8 FRC, % pred 143.8 ± 34.1 DL_CO, % pred 53.9 ± 19.7 P_aO₂, kPa 10.1 ± 1.6 p_aCO₂, kPa 5.0 ± 0.6 6MWD, m 454 ± 103

Is exertional desaturation predictive for outcomes in COPD?

Kim et al., Respiration 2013

33.8 ml/y 11.6 ml/y

COPD patients with exercise-induced desaturation have a greater rate of decline in FEV₁ and change in health-related quality of life

1 _{Casanova et al., Chest 2008;} 2 _{Takigawa et al., Respir Med 2007}

In addition to resting p_aO₂, oxygen desaturation predicts mortality

Exercise-induced desaturation predicts mortality in COPD

Sat > 90%

Sat < 90%

NVALT Richtlijn:

Zuurstofbehandeling thuis 2000

CBO Richtlijn:

‘Current evidence on ambulatory oxygen therapy reveals

improvements in dyspnoea post-exercise and in the dyspnoea and

fatigue domain of quality of life.’

‘However, evidence for the clinical utility and effectiveness in improving

mortality and exercise capacity was not evident.’

‘Methodologically rigorous RCTs with sufficient power are required to

investigate the role of ambulatory oxygen in the management of

COPD’

Training with supplemental oxygen during pulmonary

rehabilitation in patients with exercise hypoxaemia

Randomised trial Inclusion: COPD, normoxemia at rest (mean p_aO₂ ± 10 kPa), desaturation below 90% at maximum

exercise

Exclusion: mPAP > 25 mmHg, neuromuscular or

cardiovascular disease

Compressed air: 4 l/min, during training sessions

Oxygen: 4 l/min, during training sessions

Programme: Multidisciplinary, inpatient PR, 5 days per week,

10 weeks

All patients were ex-smokers

Rooijackers et al., Eur Respir J 1997

*

*

*

Maximal load Cycling time 6MWD

Although acute oxygen supplementation improved exercise performance,

supplemental oxygen during training did not add to the effects or training on room air

Training with supplemental oxygen during pulmonary

Rooijackers et al., Eur Respir J 1997

Health status significantly improved after pulmonary rehabilitation, but there was no difference between the oxygen-trained and room air-trained group

Supplemental oxygen during pulmonary

rehabilitation: effects on health status

Garrod et al., Thorax 2000

Supplemental oxygen during pulmonary

rehabilitation in patients with exercise hypoxaemia

Randomised trial Inclusion: FEV₁ < 40%_, desaturation >4% and to < 90% during exercise testing

Compressed air: 4 l/min, during training sessions

Oxygen: 4 l/min, during training sessions

Programme: Outpatient PR, 3 times per week, 6 weeks

11 out of 25 patients used oxygen at home

Garrod et al., Thorax 2000

Supplemental oxygen during pulmonary

rehabilitation in patients with exercise hypoxaemia

Oxygen trained Air trained

Garrod et al., Thorax 2000

Supplemental oxygen during pulmonary

Training with supplemental oxygen during pulmonary

rehabilitation in patients with exercise hypoxaemia

Randomised trial Inclusion: COPD, resting saturation > 90%,

desaturation > 4% and below 90% during incremental shuttle walk test

Exclusion: LTOT, significant musculoskeletal,

cardiac, or cognitive problems

Control: no oxygen or sham during supervised

and unsupervised exercise

Oxygen: 2 l/min, during supervised and

unsupervised exercise

Programme: Supervised high-intensity walking and cycling,

2 days per week, 7 weeks; weekly education

Training with supplemental oxygen during pulmonary

rehabilitation in patients with exercise hypoxaemia

Ringbaek et al., Chron Respir Dis 2013

Ambulatory oxygen has no effect no effect on exercise tolerance,

health status, risk of exacerbation, hospitalization or drop-out

Dyer et al., Chron Respir Dis 2012

Single-blind randomised controlled trial

Inclusion: normoxemic at rest, desaturation >4%

and to <90% during exercise and >10%

improvement with oxygen during endurance shuttle walk test

Room Air: during all activities that induced dyspnea

Oxygen: during all activities that induced dyspnea

Patient selection: the key to success?

Programme: Outpatient PR, 2 times per week, 6-7 weeks

All patients with oxygen naive

Endurance shuttle walk test

Health status, emotion and function

Dyer et al., Chron Respir Dis 2012

Oxygen therapy during pulmonary rehabilitation in

selected patients

Ambulatory oxygen during a 6- to 7-week PR programme

Responders and non-responders to oxygen therapy

Heraud et al., Respir Med 2008

N = 25, FEV₁ 52%, exercise-induced

desaturation

Endurance cycle test with room air and

oxygen Responders: >10% increase

Heraud et al., Respir Med 2008

Importance

of patient

selection?

1)  Exercise-induced desaturation occurs in 30-50% of patients with moderate to severe COPD

2)  Exercise-induced desaturation is associated with worse patient-related outcomes, including increased mortality risk 3)  There is no evidence to support the use of ambulatory oxygen

in COPD patients with exercise-induced desaturation 4)  In general, oxygen therapy does not add to the effects of

pulmonary rehabilitation

5)  Possibly, determining acute response to oxygen supplementation will predict long-term benefit

Conclusions part I:

Dietiste: ‘Mevrouw is in de

eerste weken van de revalidatie

2 kilogram afgevallen. Wat nu?

☐

_{Revalidatie stoppen}

☐

Verlagen van intensiteit van training

☐

_{Krachttraining}

☐

Bijvoeding

☐

_{Anabole steroiden}

☐

Analyse lichaamssamenstelling

☐

_{Geen actie}

☐

_…

Ferreira et al., Chest 1998

Changes in body composition during

pulmonary rehabilitation

van den Borst et al., Thorax 2011

COPD: a wasting disease?

Change in body weight Change in lean mass

Decline in body weight and lean mass is comparable in subjects with OLD, smoking and non-smoking controls

Vanfleteren et al., Am J Respir Crit Care Med 2013

Clustering of objectively identified comorbidities in COPD

Body composition is an important discriminating factor in

unbiased clustering of COPD

Metabolic phenotype

Bronchial wall thickening Atherosclerosis

High fat mass

ERS Taskforce ‘Nutrition in COPD’, Eur Respir J 2014

Cachectic phenotype

Emphysema

Low muscle mass

Osteoporosis

Low fat mass Underweight

Fibre type shift I > II

Classical COPD phenotypes revisited

ERS Taskforce ‘Nutrition in COPD’, Eur Respir J 2014

Nutritional supplementation for stable COPD

Aims:

1)

 

To assess the effect of nutritional support for more than two weeks

on body composition, muscle function, exercise tolerance and

health status in stable COPD

2)

 

To identify treatment regimens and patient populations that

demonstrate the greatests benefits

17 studies, 632 randomised participants

5 studies had nutritional supplementation combined with exercise

Change in body weight

Nutritional supplementation for stable COPD

Ferreira et al., Cochrane Database Syst Rev 2012 Change in fat-free mass

Change in functional exercise capacity

Nutritional supplementation should be considered in the management of undernourished COPD patients

Nutritional supplementation for stable COPD

1)  Body composition is an important discriminating factor in the clustering of COPD patients

2)  New longitudinal studies challenge the concept of COPD as a wasting disease

3)  Updated meta-analysis showed that nutritional

supplementation promotes weight and fat-free mass gain, exercise tolerance and health status, mainly in underweight patients

4)  In the next years, focus will shift towards overweight and obesity and cardiometabolic risk

Conclusions part II: