A recent survey conducted by the National Heart, Lung, and Blood Institute suggests that despite a growing awareness of chronic obstructive pulmonary disease (COPD), only 64 percent of respondents had ever heard of it. Yet, according to the Global Initiative for Chronic Obstructive Lung Disease, COPD “is the fourth leading cause of chronic morbidity and mortality in the United States” with an estimated 24 million Americans affected (1).”

Once a disease primarily affecting men, it now kills roughly equal numbers of men and women in the United States. In 2000, COPD was responsible for 8 million physician office visits, 1.5 million emergency department visits, and 726,000 hospitalizations –about 13 percent of all hospitalizations in the United States (2).

COPD patients come in all shapes and sizes, which makes working with this population both challenging and rewarding. They struggle to breathe and fear not being able to get their next breath. Some want to be coddled, while others don’t. Some can self-monitor well, but with others, you have to control every aspect and push them to stay on task. Still others push themselves too hard, and you have to slow them down.

What are the rewards? Those come when a patient finally “understands” pursed-lip breathing and can tolerate more exercise; also, when they can finally feel their confidence return and start doing more at home and in the exercise lab or start gaining weight and strength.

Exercise for People with COPD

We all know that over time, COPD can severely limit any type of exercise. “Breathlessness and exercise intolerance are the most common symptoms in COPD and progress relentlessly as the disease advances. Pathophysiological factors known to contribute to exertional dyspnea in COPD patients include intrinsic positive end-expiratory pressure (PEEPi), increased restriction of the thorax, inspiratory muscle weakness, increased ventilatory demand relative to capacity, gas exchange abnormalities, dynamic air compression, and cardiovascular factors (3).”

Studies have proven that those with COPD who remain physically active can, to some extent, reverse this downward cycle of dyspnea and inactivity.

So what is the best exercise for people with COPD? Most programs address muscle weakness with endurance training. Walking, bicycling, and arm ergometry are the main forms utilized. Frequency and intensity vary from one patient to the next, with a goal of 20 to 30 minutes continuous exercise and an intensity of around 60 percent of maximum heart rate.

Considering the severity of disease and comorbidities, achieving that intensity can be a challenge. Those with severe COPD usually require interval training where they work for 2 to 3 minutes and rest for the same amount of time. Weight training is also very important for COPD patients for building muscle mass, as well as overall strengthening and toning.

Another key component of an exercise program is the strengthening of the inspiratory muscles using resistant bands or light weights. Increasing inspiratory muscle strength also increases exercise tolerance. Recommended frequency is 3 to 5 times per week with weight training every other day or twice per week.

Results from a study published May 30, 2009, in the BMC Pulmonary Medicine Journal concluded that those in the case study group (moderate to severe COPD patients who received three years of pulmonary rehabilitation) had a significantly slower decline of forced expiratory volume in one second (FEV1) compared to those in the control group.

Additionally, the case study group demonstrated an improvement in exercise endurance time in a shorter period of time which was maintained throughout the study, in contrast to the control group (4). While it is doubtful we will ever see three-year programs, it is clear that long term exercise can delay worsening of COPD symptoms.

An exciting new option for those with severe end-stage COPD is the use of neuromuscular electrical stimulation (NMES). Passive stimulation using low-voltage NMES that target locomotor muscle groups would be better tolerated than whole body exercise (3). NMES can be used with inpatients and with those on ventilators. It can also be offered as a part of a home exercise program.

Patient-specific Nutrition

Another area to focus on is nutrition. Most studies on nutrition for COPD looked at what nutrients offer protective effects, and very few looked for those foods that had negative implications. Nutrition, as a modifiable risk factor in COPD, could be a protective or harmful factor in the progression of the disease (2). With COPD patients, there are two common nutritional scenarios.

First, there is the end-stage emphysema patient whose breathing exertion is so great that they struggle to eat enough to maintain muscle mass and body weight. These patients, through their increased work of breathing, can increase their resting energy expenditure (REE) up to 10 to 15 percent, with a resultant need to increase their caloric input (1). These patients require a high protein and fat diet, which should include protein drinks and frequent small meals.

Second, there is the overweight chronic bronchitis patient. Data from the Third National Health and Nutrition Examination Survey showed that impaired glucose regulation was associated with impaired lung function (2). In addition, it is also found that higher glucose levels impact lipolysis or fat burning (4). These patients have increased belly fat, which limits their diaphragmatic movement and increases their work of breathing.

Their goal is to lose the weight, especially the belly fat, and improve their metabolism to decrease insulin resistance and increase lipolysis. Nutritional needs include a low carbohydrate, low-fat diet that is plentiful in water, vegetables, and fiber.

Promoting Coping Skills

A final focus area is how our thoughts influence our behavior and how to offer hope to our patients with COPD. As the diagnosis of COPD is experienced by the patient, they see their world shutting down. With the progression of the dyspnea cycle, their once relaxing hobbies become chores and their fears and worries increase. Depression and anxiety are common symptoms for patients with COPD. The medications they take, their feeling of loss of control, and social isolation all contribute to an increasing lack of self-confidence and self-worth.

Many times when patients enter a pulmonary rehabilitation program, all they can see are their limitations: what they can’t do. It is important to help them realize they have alternatives. Showing them ways to adapt, modify or just do it differently can keep them doing what they love and build their confidence.

Behavior-modifying strategies like sitting instead of standing or how to bend over and breathe gives them their control back. Many patients become so negative in their thinking and waste a lot of energy being emotional, angry, sad or scared.

I specifically work with these patients on how to change their negative thoughts and focus on the positives they want in their lives. Something as simple as changing their thoughts can change their life. We, as respiratory therapists, can offer hope to these patients, not a false hope of “everything will be OK,” but rather a true hope, that life is what they make it, and that no matter what their abilities or disease process, they always have choices and hope.

Sources:
1. St. Florian, Ilaria, MS, RD; Nutrition and COPD – Dietary Considerations for Better Breathing; Today’s Dietitian; 2009; February; Vol. 11 No. 2 P. 54.

2. http://seniorjournal.com/NEWS/Health?2009?20090402-COPDSymptoms.htm

3. Ambrosino, N. Strambi S.; New strategies to improve exercise tolerance in chronic obstructive pulmonary disease; Eur Respir J 2004; 24:313-322.

4. Stav, D. et al; Three years of pulmonary rehabilitation: inhibit the decline in airflow obstruction, improves exercise endurance time and body mass index in chronic obstructive pulmonary disease; BMC Pulmonary Medicine 2009, 9:26

–– Carol Rudd has been an RRT staff therapist of 35 years. She currently coordinates the INSPIRE Pulmonary Rehabilitation Program at Sacred Heart Hospital in Eau Claire, Wis. Direct questions and comments to editorial@therapytimes.com.