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Strategies of Muscle Training in Very Severe COPD Patients

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Strategies of Muscle Training in Very Severe COPD Patients Eur Respir J 2011; 38: 971–975 DOI: 10.1183/09031936.00075011 CopyrightßERS 2011 SERIES: ‘‘NOVELTIES IN PULMONARY REHABILITATION’’ Edited by E. Clini and N. Ambrosino Number 2 in this Series Strategies of muscle training in very severe COPD patients I. Vogiatzis*,#," ABSTRACT: There is strong evidence that exercise training, constituting the cornerstone of AFFILIATIONS pulmonary rehabilitation, improves exercise tolerance, dyspnoea sensations, functional capacity *Dept of Physical Education and Sport Sciences, and quality of life in patients with severe chronic obstructive pulmonary disease. However, #1st Dept of Respiratory Medicine, intolerable sensations of breathlessness and/or peripheral muscle discomfort may prevent such and patients from tolerating high-intensity exercise levels for sufficiently long periods of time to obtain "1st Dept of Critical Care Medicine, true physiological training effects. National and Kapodistrian University of Athens, Athens, Greece. Accordingly, the major issue that arises is the selection of the appropriate training strategy, which is tailored to the cardiovascular, pulmonary and peripheral muscle limitations of the CORRESPONDENCE individual patient and is aimed at maximising the effect of exercise conditioning. I. Vogiatzis Within this context, the present article explores the application of strategies that optimise Thorax Foundation Critical Care 3 Ploutarhou Str. 106 75 exercise tolerance by reducing dyspnoea sensations, namely noninvasive mechanical ventilation, Athens oxygen and/or heliox supplementation. Administration of heliox or oxygen during exercise also Greece increases peripheral muscle oxygen delivery, thereby delaying the onset of peripheral muscle E-mail: [email protected] fatigue. Particular emphasis is also given to interval exercise and resistance-muscle training as Received: both modalities allow the application of intense loads on peripheral muscles with tolerable levels May 03 2011 of dyspnoea sensations. Accepted after revision: In patients with profound muscle weakness and intense breathlessness upon physical exertion, May 05 2011 execution of short bouts of interval or local muscle strength conditioning, along with oxygen First published online: July 07 2011 breathing, may constitute a feasible and effective approach to pulmonary rehabilitation. KEYWORDS: Chronic obstructive pulmonary disease, dyspnoea, exercise capacity, interval exercise, peripheral muscle weakness reathlessness and peripheral muscle dis- for sufficiently long periods of time to yield true comfort are the most common symptoms physiological training effects [3]. Consequently, it is B limiting exercise tolerance in patients with important to implement strategies to optimise severe chronic obstructive pulmonary disease exercise tolerance in severe COPD with the objec- (COPD). Exercise training constitutes the corner- tive of enhancing the patient’s ability to tolerate as stone of pulmonary rehabilitation as there is sustained and intense a workload as possible. These strong evidence that its implementation improves strategies aim at reducing the intensity of dyspnoea both exercise tolerance and health-related quality sensations, either by allowing patients to sustain a of life in these patients [1]. The intensity of exercise higher absolute exercise-training intensity or by is a key determinant of true physiological training prolonging the cumulative time a given exercise effects: in order to optimise this outcome, it is task can ordinarily be sustained. Such strategies necessary that the intensity of exercise be as high include noninvasive mechanical ventilation (NIV), as possible [2]. Nevertheless, in patients with oxygen and/or heliox supplementation and interval severe COPD, intolerable sensations of breath- cycling modality. In addition, progressive resistance lessness and/or peripheral muscle discomfort muscle training will be discussed within the scope may prevent high-intensity levels being tolerated of reducing leg muscle discomfort. European Respiratory Journal Print ISSN 0903-1936 c Previous articles in this Series: No. 1: Burtin C, Decramer M, Gosselink R, et al. Rehabilitation and acute exacerbations. Eur Respir J 2011; 38: 702–712. Online ISSN 1399-3003 EUROPEAN RESPIRATORY JOURNAL VOLUME 38 NUMBER 4 971 SERIES: NOVELTIES IN PULMONARY REHABILITATION I. VOGIATZIS NONINVASIVE MECHANICAL VENTILATION muscle unloading via PAV during high-intensity exercise (70– Noninvasive positive-pressure mechanical ventilation has been 80%ofpeak)anddemonstratedimprovedperipheralmuscle shown to reduce the load on the respiratory muscles and the oxygenation assessed by near-infrared spectroscopy despite unal- intensity of dyspnoea, thereby increasing exercise intensity tered systemic oxygen delivery in patients with advanced COPD. and endurance capacity [4, 5]. In particular, in patients with These findings are indicative that a fraction of the available severe COPD, application of proportional assist ventilation cardiac output might be redirected from ventilatory to locomotor (PAV) has been shown to allow a greater intensity of exercise muscles due to respiratory muscle unloading, thereby enhancing to be sustained for longer periods of time than sham exercise, peripheral muscle oxygen delivery and thus exercise tolerance. thus potentially yielding significant training physiological effects [6]. PAV is a mode of partial ventilatory assistance OXYGEN/HELIOX SUPPLEMENTATION with characteristics of proportionality and adaptability to the Supplemental oxygen has the potential to increase the exercise intensity and timing of spontaneous ventilatory pattern by tolerance of hypoxaemic COPD patients by means of an increase providing inspiratory flow and pressure in proportion to the in arterial oxygen content and vasodilation of the pulmonary patient’s effort [4]. To the extent that intrinsic mechanical circulation [14]. These two mechanisms increase oxygen delivery loading and functional inspiratory muscle weakness in severe to the exercising muscles and may potentially reduce carotid COPD contribute to intense dyspnoea sensations, PAV body stimulation at heavy levels of exercise with or without provides a symptomatic benefit by unloading and assisting lactic acidosis [15]. Ambulatory oxygen therapy has widely been such overburdened ventilatory muscles, thereby reducing the shown to increase exercise performance and to relieve exercise work of breathing and thus dyspnoea sensations [7]. breathlessness in severe COPD patients [16, 17]. Studies indicate that a reduction in the rate of exercise-induced dynamic In addition, continuous positive airway pressure (CPAP) has been hyperinflation plays an important role in the oxygen-related reported to reduce the inspiratory threshold load on the relief of dyspnoea [16, 17]. In addition, improvement in exercise inspiratory muscles of dynamically hyperinflated COPD patients performance via oxygen supplementation was primarily related and also to enhance neuromuscular coupling, thus improving to the reduced ventilatory demand, which, in turn, led to dyspnoea sensations and exercise tolerance [8]. The commonly improved operational lung volumes and delayed attainment of accepted explanation of the effectsofCPAPisthatitcounter- limiting ventilatory constraints on exercise and the onset of balances intrinsic positive end-expiratory pressure, i.e. the inspira- intolerable dyspnoea. Interestingly, supplemental oxygen gen- tory threshold load [8]. In two studies conducted by O’DONNELL erally increases exercise tolerance not only in hypoxaemic but and co-workers [5, 8] in patients with severe COPD, application of also in non-hypoxaemic patients [16]. In fact, modest changes in CPAP of 4–5 cmH O during steady-state sub-maximal exercise 2 sub-maximal ventilation and dynamic ventilatory mechanics resulted in a significant increase in exercise endurance time and a have been documented to result in relatively large improve- highly significant reduction in the sense of breathing effort. ments in symptom intensity and exercise capacity [16]. Besides Moreover, pressure-support ventilation (PSV), a pressure- improving in respiratory function, oxygen supplementation has targeted mode in which each breath is patient triggered and been documented to increase leg muscle oxygen delivery and supported, can effectively assist ventilation when applied nonin- oxygen uptake, thereby justifying the ability of the peripheral vasively to patients with acute and chronic respiratory failure muscle to perform more work [18]. [4]. Application of PSV has been shown to yield consistent In patients with severe COPD, supplementation with normoxic improvements in endurance capacity as assessed by walking heliox decreases turbulence within medium to large airways, distance [9] and by reductions in the intensity of dyspnoea increases expiratory flow rate and reduces the work of during constant-load cycling [10]. breathing, as well as the degree of exercise-induced dynamic DOLMAGE and GOLDSTEIN [11] investigated which of the two hyperinflation and the intensity of dyspnoea, thereby enhan- methods, PAV, CPAP or a combination of the two, was more cing exercise tolerance. However, there is emerging evidence effective in enabling very severe COPD patients to increase [19] indicating that enhanced exercise tolerance with heliox is exercise tolerance when applied during constant-load exercise also due to an increase in locomotor muscle oxygen delivery at 60–70% of maximum power. Although exercise tolerance during
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