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The Roles of Bronchodilators, Supplemental Oxygen, and Ventilatory Assistance in the Pulmonary Rehabilitation of Patients with Chronic Obstructive Pulmonary Disease

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The Roles of Bronchodilators, Supplemental Oxygen, and Ventilatory Assistance in the Pulmonary Rehabilitation of Patients with Chronic Obstructive Pulmonary Disease The Roles of Bronchodilators, Supplemental Oxygen, and Ventilatory Assistance in the Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease Richard L ZuWallack MD Introduction What Pulmonary Rehabilitation Does and How It Works Enhancing the Effectiveness of Pulmonary Rehabilitation Exercise Training Bronchodilators Supplemental Oxygen Noninvasive Ventilation Summary In patients with chronic obstructive pulmonary disease, pulmonary rehabilitation significantly improves dyspnea, exercise capacity, quality of life, and health-resource utilization. These benefits result from a combination of education (especially in the promotion of collaborative self-management strategies and physical activity), exercise training, and psychosocial support. Exercise training increases exercise ca- pacity and reduces dyspnea. Positive outcomes from exercise training may be enhanced by 3 interven- tions that permit the patient to exercise train at a higher intensity: bronchodilators, supplemental oxygen (even for the nonhypoxemic patient), and noninvasive ventilatory support. Key words: broncho- dilators, oxygen, mechanical ventilation, pulmonary rehabilitation, chronic obstructive pulmonary disease, COPD, dyspnea, exercise capacity, quality of life, exercise training, exercise capacity, noninvasive ventilation. [Respir Care 2008;53(9):1190–1195. © 2008 Daedalus Enterprises] Introduction bilitation as “an evidence-based, multidisciplinary, and com- prehensive intervention for patients with chronic respiratory A recent statement from the American Thoracic Society diseases who are symptomatic and often have decreased daily and European Respiratory Society defines pulmonary reha- life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, Richard L ZuWallack MD is affiliated with the Section of Pulmonary and and reduce health-care costs by stabilizing or reversing sys- Critical Care, St Francis Hospital and Medical Center, Hartford, Con- temic manifestations of the disease.”1 Although individual necticut, and with the School of Medicine, University of Connecticut, pulmonary rehabilitation programs differ considerably in set- Farmington, Connecticut. ting, staff, composition, approach, and duration, most have Dr ZuWallack presented a version of this paper at the 23rd Annual New components of patient assessment, exercise training, educa- Horizons Symposium at the 53rd International Respiratory Congress of tion (especially promoting self-management strategies), psy- the American Association for Respiratory Care, held December 1-4, chosocial intervention, and outcome assessment. 2007, in Orlando, Florida. The author reports no conflicts of interest related to the content of this What Pulmonary Rehabilitation Does paper. and How It Works Correspondence: Richard L ZuWallack MD, Section of Pulmonary and Critical Care, St Francis Hospital and Medical Center, 114 Woodland It is still surprising to some that pulmonary rehabilita- Street, Hartford CT 06105. E-mail: [email protected]. tion, which has no significant effect on the physiologic and 1190 RESPIRATORY CARE • SEPTEMBER 2008 VOL 53 NO 9 BRONCHODILATORS,OXYGEN, AND VENTILATORY ASSISTANCE IN PULMONARY REHABILITATION functional respiratory impairments of individuals with motivation. In pulmonary rehabilitation, training intensity chronic lung disease, often substantially improves multiple up to or exceeding 60% of maximum symptom-limited outcomes important to patients.2 In fact, for patients with exercise capacity is a reasonable goal.1 Interventions that chronic obstructive pulmonary disease (COPD), pulmo- allow the patient to exercise-train at a higher intensity nary rehabilitation improves dyspnea, exercise capacity, should promote greater post-rehabilitation improvement. and health status more than any other therapy, including The following discussion will focus on 3 available ther- bronchodilators or supplemental oxygen. Newer studies apies that may enhance the benefits from pulmonary re- also suggest that pulmonary rehabilitation also reduces habilitation exercise training: bronchodilators, supplemen- subsequent health-care utilization.3,4 tal oxygen, and noninvasive ventilation (NIV). These Pulmonary rehabilitation works because patients with interventions may enhance the benefits of exercise training chronic respiratory disease usually have associated mor- by allowing the symptom-limited COPD patient to train at bidity and comorbidity that are often very responsive to a higher intensity. therapy. For example, patients with lung disease often un- Pulmonary rehabilitation is often complementary to other consciously adopt a sedentary lifestyle, probably because therapies in this regard: of distressing exertional dyspnea and fatigue. Exertional dyspnea usually develops gradually, and a patient might 1. Pulmonary rehabilitation often adds to the improve- attribute it to the normal aging process. The resultant phys- ments in dyspnea, functional status, and health status ical deconditioning and alterations in structure and func- obtained by therapies such as bronchodilators and sup- tion of the peripheral muscles results in even more exer- plemental oxygen. tional dyspnea and fatigue, which, in turn, leads to even 2. Bronchodilators, oxygen, and (occasionally) NIV can more sedentarism. Pulmonary rehabilitation interrupts this enhance the effectiveness of pulmonary rehabilitation vicious circle, especially by increasing exercise capacity exercise training. and promoting physical activity. Exercise training, espe- cially at a higher intensity, can even cause favorable bio- Bronchodilators chemical alterations in exercising muscles, even in pa- tients with COPD with “pump limitation.”5 There are undoubtedly multiple mechanisms by which It is very important to recognize that, although exercise bronchodilators reduce dyspnea in patients with COPD, training is integral to comprehensive pulmonary rehabili- but bronchodilators’ effects on reducing the resistive work tation, other components of pulmonary rehabilitation are of breathing (by increasing airway caliber) and the elastic also important in enhancing outcomes. In the vicious circle work of breathing (by decreasing hyperinflation) are prob- of sedentarism 3 dyspnea/fatigue 3 more sedentarism, ably most important.14-19 It is important to recognize that pulmonary rehabilitation also increases self-efficacy for bronchodilators decrease breathlessness by decreasing lung exercise,6 promotes increased physical activity at home, volumes.20 Hyperinflation, from decreased elastic recoil, and provides techniques for pacing; these also enhance increases the elastic work of breathing and reduces the benefits. mechanical advantage of the respiratory muscles.21 Addi- tionally, the increased metabolic requirements from exer- Enhancing the Effectiveness of Pulmonary cising muscles demand increased minute ventilation, usu- Rehabilitation Exercise Training ally from an increased tidal volume, then an increased respiratory rate. However, expiratory time in COPD is “If little labor, little are our gains; Man’s fortunes are prolonged, which makes it problematic to exhale com- according to his pains.”7 Exercise intolerance is a major pletely when forced to breathe at a higher frequency. The problem in patients with COPD, and strategies to improve combination of exertional dyspnea, the prolonged expira- the functioning of exercising muscles are needed to im- tory time, and the increased respiratory rate lead to more prove this functional limitation.8 This often involves an hyperinflation (dynamic hyperinflation) that further aggra- appropriate, patient-specific exercise prescription. The vates dyspnea. above quotation from Robert Herrick (1591Ϫ1674) can be Saey and colleagues22 demonstrated an important con- applied to the importance of training intensity (although cept that explains some of the variability in improvement without inflicting pain) in getting the most out of pulmo- in exercise capacity following bronchodilator therapy in nary rehabilitation. Even in patients with COPD, who have COPD. Of the 18 patients they studied, 9 demonstrated ventilatory pump and gas-exchange limitations, higher ex- muscle fatigue following constant-work-rate cycle exer- ercise training intensity provides more physiologic benefit cise after placebo inhalation. Muscle fatigue was defined and greater increase in exercise capacity.9-13 Training in- by a post-exercise reduction in quadriceps twitch tensity in the patient with COPD is affected by respiratory, force Ն 15%. After nebulization with a short-acting anti- cardiovascular, and peripheral-muscle impairments, and cholinergic bronchodilator, exercise endurance increased RESPIRATORY CARE • SEPTEMBER 2008 VOL 53 NO 9 1191 BRONCHODILATORS,OXYGEN, AND VENTILATORY ASSISTANCE IN PULMONARY REHABILITATION Fig. 1. Effect of bronchodilator on symptom-limitation during high- intensity constant-load exercise testing in 23 patients with chronic obstructive pulmonary disease. Without bronchodilator they were more frequently limited by breathing discomfort than by leg dis- comfort, whereas the reverse was true when they exercised fol- lowing bronchodilator. With bronchodilator, 3 patients (not shown) listed “other” as their reasons for exercise termination. (Adapted Fig. 2. Effect of long-acting bronchodilator on treadmill endurance from Reference 14.) in patients with chronic obstructive pulmonary
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