COPD and Respiratory Rehabilitation

What is Respiratory Rehabilitation?

Respiratory rehabilitation is a multidisciplinary care program for patients with respiratory dysfunction.

This program is calibrated "tailored" for the patient in order to try to optimize his autonomy and his physical and social performance.

Benefits and Indications

Respiratory Rehabilitation and COPD

The COPD patient's reduced tolerance to effort is due to the establishment of a vicious circle in which the patient reduces physical activity due to dyspnea, therefore tends to lose trophism and strength of peripheral muscles.

This negative spiral is also reinforced by concurrent factors such as anxiety and depression.

The patient then develops disability, loss of autonomy, limitation in daily activities, sometimes dramatically reducing their quality of life.

Until the 1990s it was thought that COPD patients were unable to achieve a sufficiently high exercise intensity to train their muscles, especially that of the lower limbs. In those years, respiratory rehabilitation was almost exclusively aimed at strengthening the respiratory muscles (diaphragmatic rehabilitation).

Casaburi in 1991 clearly demonstrated that significant results can be observed in COPD patients, even severe ones, with a comprehensive program of retraining to exertion.

Exercise retraining is currently considered the main aspect of a rehabilitation program.

Who is the ideal patient for respiratory rehabilitation?

COPD patient with dyspnoea and impaired exercise tolerance.
Often this type of patient is initiated into a rehabilitation program only at an advanced stage of the disease.
In fact, even the most serious patients benefit from the rehabilitation program BUT starting a patient at an earlier stage allows effective preventive strategies in arresting the progression of the disease (smoking cessation, nutritional strategies) and greater possibilities to prescribe exercise.

What are the benefits of respiratory rehabilitation?

Patients with mild to moderate COPD have similar improvements to normal with training.
Patients with severe COPD improve endurance and feelings of well-being without significant increases in VO2

Respiratory rehabilitation reduces symptoms, increases work capacity and improves the quality of life in subjects with chronic respiratory diseases even in the presence of irreversible structural alterations.
This is made possible because the disability results in many cases not only or not so much from the lung disease itself but from other associated diseases, for example even if the level of bronchial obstruction or hyperinflation in COPD patients does not change significantly with a program of rehabilitation, muscle training and better gait ensure that the patient can walk faster with less breathlessness

Goals

The objectives of cardiorespiratory rehabilitation in patients suffering from COPD are multifactorial and include:

reduction and control of respiratory symptoms.
Increased exercise capacity.
Improvement of the quality of life.
Reduction of the psychological impact due to functional reduction and disability.
Reduction in the number / severity of exacerbations.

Set up a rehabilitation program

Initial evaluation

First, it is important to have the patient undergo a complete functional assessment, measuring the degree of disability and dyspnea:

WALK TEST: determination of the maximum distance that the patient can walk in a given time (2, 6 or 12 minutes). During exercise it is important to monitor heart rate and blood oxygen saturation (SpO2). The SPO2 value indicates whether the patient's blood is more or less oxygenated at its best; an SPO2 value in the range 100% -94 % is considered normal, a value less than 80% testifies to a severe hypoxic state
It is very important to carefully explain to the patient how to perform the test and to encourage him during the test.
Note: the gait test is more sensitive than the maximal cycle ergometer test in detecting exercise desaturation in COPD patients.
SHUTTLE TEST: measures the tolerance to physical exercise during flat walking.
The patient walks back and forth in a 10 meter long corridor, the speed and rhythm are marked by a sound signal. The test ends when the patient fails to maintain the required speed.
Note: The shuttle test is an easily reproducible test with a significant correlation with VO2max
BORG SCALE: Non-linear numerical scale for assessing dyspnea during exercise. This scale is made up of 10 points which are flanked by descriptors (anchors).
VISUAL ANALOG SCALE (VAS)
Straight horizontal or vertical line (10cm) with dashes at the ends with descriptors (verbal expressions or figures) that define the polarity. Used for the assessment of dyspnea during exercise.

Importance of VO2Max

These and other tests allow you to accurately measure the maximum workload that the subject can bear (VO2max). This parameter, called maximum oxygen consumption, indicates the maximum potential of aerobic metabolism and is a function of both the capacity of oxygen supply to the tissues by the respiratory and cardiovascular system, and the capacity of oxygen extraction by the tissues (Maximum consumption of oxygen = Heart rate x Systolic range x arteriovenous oxygen difference).

The knowledge of the VO2max of the patient with COPD allows to program the training by setting the various parameters of the respiratory rehabilitation program (intensity, duration, frequency):

In normal subjects, aerobic training typically takes place between 60% and 90% of maximal heart rate or between 50% and 80% of VO2max.
Typically these levels are maintained for 20-45 min x 3-4 times per week.
Until recently, it was thought that the ventilatory limitations typical of patients with moderate to severe COPD preclude the possibility of carrying out activities at similar levels. On the basis of the studies conducted in recent years, it has been established that even subjects with moderate-severe COPD can train at a level equal to about 60% of VO2max with significantly better results than those obtained by training at 30%.

Training COPD patients to a level corresponding to 60% -70% of the maximum workload produces:

an increase in exercise capacity (less dyspnea with the same effort)
increase in the number of oxidative enzymes in peripheral muscles (increase in the number and size of mitochondria)
a reduction in blood levels of lactic acid and ventilation for the same workload.

EXERCISE MODES:

Aerobic endurance training
Reinforcement of large muscle groups

RECOMMENDED EXERCISE TYPES:

Treadmill
Exercise bike
Walk
Stairs
Combinations of several bodyweight exercises

TRAINING FREQUENCY

Training at 60% -70% of VO2 max for 20 "-30" for 3-5 times / week.

A similar program can be followed by most COPD patients while others with severe airway obstruction may not tolerate training at this intensity. Alternatively, it is possible to adopt an interval working method, working at 60% -80% of maximum exercise capacity for periods of 2 or 3 minutes interspersed with 2 or 3 minutes of rest.

The overall duration of the respiratory rehabilitation program is 8-12 weeks, at the end of which the subject will be encouraged to remain active so as not to lose the benefits acquired.

COLLABORATION OF THE PATIENT

It is very important that the patient respects the various training parameters (intensity, duration and frequency).

As happens in healthy subjects, also in COPD patients the positive effect of physical exercise is maintained for the duration of the training. On the contrary, a reduction in the intensity, duration or frequency of the respiratory rehabilitation program significantly reduces it. the beneficial effects.

Conclusions

Respiratory rehabilitation:

improves exercise capacity,
reduces dyspnea,
improves the quality of life,
reduces the duration of hospitalizations for respiratory diseases.

It is especially appropriate for patients who have significant symptoms during physical activity and is most effective when part of a multifactorial program: