Does exercise help copd: COPD Guidelines For Exercise & Pulmonary Rehab
COPD Guidelines For Exercise & Pulmonary Rehab
Pulmonary rehabilitation is a program that can help you learn how to breathe easier and improve your quality of life. It includes breathing retraining, exercise training, education, and counseling.
Why should I exercise?
Regular exercise has many benefits. Exercise, especially aerobic exercise, can:
- Improve your circulation and help the body better use oxygen
- Improve your COPD symptoms
- Build energy levels so you can do more activities without becoming tired or short of breath
- Strengthen your heart and cardiovascular system
- Increase endurance
- Lower blood pressure
- Improve muscle tone and strength; improve balance and joint flexibility
- Strengthen bones
- Help reduce body fat and help you reach a healthy weight
- Help reduce stress, tension, anxiety, and depression
- Boost self-image and self-esteem; make you look fit and feel healthy
- Improve sleep
- Make you feel more relaxed and rested
Talk to your healthcare provider first
Always check with your healthcare provider before starting an exercise program. Your healthcare provider can help you find a program that matches your level of fitness and physical condition.
Here are some questions to ask:
- How much exercise can I do each day?
- How often can I exercise each week?
- What type of exercise should I do?
- What type of activities should I avoid?
- Should I take my medicine at a certain time around my exercise schedule?
What type of exercise is best?
Exercise can be divided into 3 basic types:
- Stretching: Slow lengthening of the muscles. Stretching the arms and legs before and after exercising helps prepare the muscles for activity and helps prevent injury and muscle strain. Regular stretching also increases your range of motion and flexibility.
- Cardiovascular or aerobic: Steady physical activity using large muscle groups. This type of exercise strengthens the heart and lungs, and improves the body’s ability to use oxygen. Over time, aerobic exercise can help decrease your heart rate and blood pressure, and improve your breathing (since your heart won’t have to work as hard during exercise). Aerobic exercises include: walking, jogging, jumping rope, bicycling (stationary or outdoor), cross-country skiing, skating, rowing, and low-impact aerobics or water aerobics.
- Strengthening: Repeated muscle contractions (tightening) until the muscle becomes tired. Strengthening exercises for the upper body are especially helpful for people with COPD, as they help increase the strength of your respiratory muscles.
How often should I exercise?
The frequency of an exercise program is how often you exercise. In general, to achieve maximum benefits, you should gradually work up to an exercise session lasting 20 to 30 minutes, at least 3 to 4 times a week. Exercising every other day will help you keep a regular exercise schedule.
What should I include in my program?
Every exercise session should include a warm-up, conditioning phase, and a cool down. The warm-up helps your body adjust slowly from rest to exercise. A warm-up reduces the stress on your heart and muscles, slowly increases your breathing, circulation (heart rate), and body temperature. It also helps improve flexibility and reduce muscle soreness.
The best warm-up includes stretching, range of motion activities, and beginning of the activity at a low intensity level.
The conditioning phase follows the warm-up. During this phase, the benefits of exercise are gained and calories are burned. During the conditioning phase, you should monitor the intensity of the activity. The intensity is how hard you are exercising, which can be measured by checking your heart rate. Your healthcare provider can give you more information on monitoring your heart rate.
Over time, you can work on increasing the duration of the activity. The duration is how long you exercise during one session.
The cool-down phase is the last phase of your exercise session. It allows your body to gradually recover from the conditioning phase. Your heart rate and blood pressure will return to near resting values. Cool-down does not mean to sit down. In fact, do not sit, stand still, or lie down right after exercise. This might cause you to feel dizzy, lightheaded, or have heart palpitations (fluttering in your chest).
The best cool-down is to slowly decrease the intensity of your activity. You might also do some of the same stretching activities you did in the warm-up phase.
Rated Perceived Exertion (RPE) Scale
The RPE scale is used to measure the intensity of your exercise. The RPE scale runs from 0-10. The numbers below relate to phrases used to rate how easy or difficult you find an activity. For example, 0 (nothing at all) would be how you feel when sitting in a chair; 10 (very, very heavy) is how you feel at the end of an exercise stress test or after a very difficult activity.
0 – Nothing at all
0.5 – Just noticeable
1 – Very light
2 – Light
3 – Moderate
4 – Somewhat heavy
5 – Heavy
7 – Very heavy
10 -Very, very heavy
In most cases, you should exercise at a level that feels 3 (moderate) to 4 (somewhat heavy). When using this rating scale, remember to include feelings of shortness of breath, as well as how tired you feel in your legs and overall.
General exercise guidelines
- Gradually increase your activity level, especially if you have not been exercising regularly.
- Remember to have fun. Choose an activity you enjoy. Exercising should be fun and not a chore. You’ll be more likely to stick with an exercise program if you enjoy the activity. Here are some questions you can think about before choosing a routine:
- What physical activities do I enjoy?
- Do I prefer group or individual activities?
- What programs best fit my schedule?
- Do I have physical conditions that limit my choice of exercise?
- What goals do I have in mind? (losing weight, strengthening muscles, or improving flexibility, for example)
- Wait at least 1½ hours after eating a meal before exercising.
- When drinking liquids during exercise, remember to follow your fluid restriction guidelines.
- Dress for the weather conditions and wear protective footwear.
- Take time to include a five-minute warm-up, including stretching exercises, before any aerobic activity and include a five- to 10-minute cool down after the activity. Stretching can be done while standing or sitting.
- Schedule exercise into your daily routine. Plan to exercise at the same time every day (such as in the mornings when you have more energy). Add a variety of exercises so you do not get bored.
- Exercise at a steady pace. Keep a pace that allows you to still talk during the activity.
- Exercise does not have to put a strain on your wallet. Avoid buying expensive equipment or health club memberships unless you are certain you will use them regularly.
- Stick with it. If you exercise regularly, it will soon become part of your lifestyle. Make exercise a lifetime commitment. Finding an exercise “buddy” will also help you stay motivated.
- Keep an exercise record.
Breathing during activity
Always breathe slowly to save your breath. Inhale through your nose, keeping your mouth closed. This warms and moisturizes the air you breathe and at the same time filters it. Exhale through pursed lips.
- Breathe out slowly and gently through pursed lips. This permits more complete lung action when the oxygen you inhale is exchanged for the carbon dioxide you exhale.
- Try to inhale for two seconds and exhale for four seconds. You might find slightly shorter or longer periods are more natural for you. If so, just try to breathe out twice as long as you breathe in.
- Exercise will not harm your lungs. When you experience shortness of breath during an activity, this is an indication that your body needs more oxygen. If you slow your rate of breathing and concentrate on exhaling through pursed lips, you will restore oxygen to your system more rapidly.
- Start with a short walk. See how far you can go before you become breathless. Stop and rest whenever you are short of breath.
- Count the number of steps you take while you inhale. Then exhale for twice as many steps. For example, if you inhale while taking two steps, exhale through pursed lips while taking the next four steps. Learn to walk so breathing in and exhaling out will become a habit once you find a comfortable breathing rate.
- Try to increase your walking distance. If you can set specific goals, you’ll find you can go farther every day. Many people have found that an increase of 10 feet a day is a good goal.
- Set reasonable goals. Don’t walk so far that you can’t get back to your starting point without difficulty breathing. Remember, if you are short of breath after limited walking, stop and rest.
- Never overdo it. Always stop and rest for two or three minutes when you start to become short of breath.
- Hold the handrail lightly to keep your balance and to help yourself climb.
- Take your time.
- Step up while exhaling or breathing out with pursed lips. Place your whole foot flat on each step. Go up two steps with each exhalation.
- Inhale or breathe in while taking a rest before the next step.
- Going downstairs is much easier. Hold the handrail and place each foot flat on the step. Count the number of steps you take while inhaling, and take twice as many steps while exhaling.
Breathing Exercises for COPD Patients
Exercise and Nutrition for COPD
If you have chronic obstructive pulmonary disease (COPD), it may be harder for you to eat well and to exercise. Your energy may be limited, making it harder to be physically active or to do things like prepare and eat meals.
But exercise and good nutrition can help you live better with COPD. Learn why — and what you can do to stay healthier.
How Exercise Can Help You
Exercise — especially exercise that works your lungs and heart — has many benefits for people who have COPD. Exercise can:
- Improve how well your body uses oxygen. That’s important because people with COPD use more energy to breathe than other people do.
- Ease your symptoms and improve your breathing
- Strengthen your heart, lower your blood pressure, and improve your circulation
- Improve your energy, making it possible to stay more active
- Improve your sleep and make you feel more relaxed
- Help you maintain a healthy weight
- Enhance your mental and emotional outlook
- Reduce your social isolation, if you exercise with others
- Strengthen your bones
4 Types of Exercises for COPD
These four types of exercise can help you if you have COPD. How much you focus on each type depends on the COPD exercise program your health care provider suggests for you.
Stretching exercises lengthen your muscles, increasing your flexibility.
Aerobic exercises use large muscle groups to move at a steady, rhythmic pace. This type of exercise works your heart and lungs, improving their endurance. This helps your body use oxygen more efficiently and, with time, can improve your breathing. Walking and using a stationary bike are two good aerobic exercises if you have COPD.
Strengthening exercises involve tightening muscles until they begin to tire. When you do this for the upper body, it can help increase the strength of your breathing muscles.
Breathing exercises for COPD help you strengthen breathing muscles, get more oxygen, and breathe with less effort. Here are two examples of breathing exercises you can begin practicing. Work up to 5 to 10 minutes, three to four times a day.
- Relax your neck and shoulder muscles.
- Breathe in for 2 seconds through your nose, keeping your mouth closed.
- Breathe out for 4 seconds through pursed lips. If this is too long for you, simply breathe out for twice as long as you breathe in.
Use pursed-lip breathing while exercising. If you have shortness of breath, try slowing your rate of breathing and focus on breathing out through pursed lips.
- Lie on your back with knees bent. You can put a pillow under your knees for support.
- Place one hand on your belly below your rib cage. Place the other hand on your chest.
- Inhale deeply through your nose for a count of three. Your belly and lower ribs should rise, but your chest should remain still.
- Tighten your stomach muscles and exhale for a count of six through slightly puckered lips.
COPD and Exercise Guidelines
- Set realistic goals.
- Slowly increase the number of minutes and days you exercise. A good goal is to exercise 20 to 40 minutes, two to four times a week.
- Start out slow. Warm up for a few minutes.
- Choose activities you enjoy, and vary them to help you stay motivated.
- Find an exercise partner.
- Keep a record of your exercise to help you stay on track.
- As you end your exercise, cool down by moving more slowly.
COPD and Exercise Precautions
It’s good to be careful when exercising with COPD, but remember that shortness of breath doesn’t always mean you should stop altogether. Ask your doctor about when you should stop exercising and rest.
Here are other exercise precautions:
- Always consult a doctor or other health care provider before starting a COPD exercise program. If you have a change in any medications, talk to your doctor before continuing your exercise routine.
- Balance exercise with rest. If you feel tired, start at a lower level. If you feel very tired, rest and try again the next day.
- Wait at least an hour and a half after eating before beginning to exercise.
- When you drink fluids while exercising, remember any fluid restrictions you have.
- Avoid hot or cold showers after exercising.
- If you’ve been away from exercise for several days, start up slowly, and gradually return to your regular routine.
Exercises to avoid when you have COPD:
- Heavy lifting or pushing
- Chores such as shoveling, mowing, or raking
- Pushups, sit-ups, or isometric exercises, which involve pushing against immovable objects
- Outdoor exercises when the weather is very cold, hot, or humid
- Walking up steep hills
Ask your doctor whether exercises like weightlifting, jogging, and swimming are OK for you to do.
COPD and Exercise: When to Stop
If you have any of these signs or symptoms, stop your COPD exercise program right away. Sit down, and keep your feet raised while resting. If you don’t feel better right away, call 911. Even if you do feel better, make sure you tell your doctor right away about any of these symptoms.
How a Healthy Diet Can Help You
If you have COPD, your respiratory muscles burn 10 times as many calories as those of other people. That’s because it takes so much energy just for you to breathe. On top of that, you may take medications or have depression that can reduce your appetite.
If you have COPD, a healthy diet can help manage your condition and help you feel better. Here are three reasons why:
1. If you don’t get enough calories and are underweight:
- You may be more likely to get an infection.
- You may become weak and tired more often.
- The muscles that control your breathing may weaken.
2. If you’re overweight:
- Your heart and lungs must work harder.
- Your body may demand more oxygen.
- Your breathing may become more difficult, especially if you carry weight around your middle.
3. When you have COPD, a diet full of healthy foods:
- Helps you maintain a healthy weight
- Provides your body the energy it needs
- Supplies enough calories, keeping breathing and other muscles strong
- Helps your body fight infections by strengthening your immune system
When you have COPD, you may need to make some diet changes. But always do this under the guidance of a registered dietitian or other health care provider who can prepare a nutrition action plan tailored to your exact needs.
COPD and Diet
Here are a few COPD and diet guidelines to get started:
Eat a variety of healthy foods such as vegetables, fruits, whole grains, dairy products, and proteins. High-fiber foods are especially important. They help with digestion, control blood sugar levels, reduce cholesterol levels, and can help control weight.
Drink plenty of water. Not only does it help prevent gas when you eat high-fiber foods, but water helps thin mucus so you can cough it up easier. Most people need six to eight 8-ounce glasses of water a day. Check with your doctor, though, because some health conditions require that you limit your fluids.
Choose decaffeinated and noncarbonated beverages. Limit alcohol, which can interact with medications, can slow breathing, and may make it harder to cough up mucus.
Ask about certain foods. Certain nutrients, such as omega-3 fatty acids, may help reduce inflammation and improve lung function. Ask your doctor.
Avoid salt. Salt (sodium) makes your body retain water, which increases swelling. This makes breathing more difficult. To get less salt, try to:
- Read food labels and choose foods with fewer than 300 milligrams (mg) of sodium per serving.
- Use no-salt spices.
- Avoid adding salt while cooking.
Avoid foods that cause gas or bloating. Everyone knows how uncomfortable that full-stomach feeling is. And it may make breathing more difficult. To minimize gas or bloating, avoid foods and drinks such as:
- Beans, broccoli, Brussels sprouts, cabbage, and cauliflower
- Carbonated beverages
- Fried, spicy, or greasy foods
Avoid empty foods. Junk foods such as chips and candy don’t provide any nutritional value.
If you need to gain weight, choose more high-protein, high-calorie foods such as cheese, peanut butter, eggs, milk, and yogurt. Ask about nutritional supplements to increase the number of calories and nutrients you get each day.
COPD and Easier Eating
If you have COPD, mealtime can feel like a chore. Try these tips for easier eating:
- Choose foods that are easier to prepare. It’s more important to eat than to prepare fancy foods.
- Get help with meal preparation. Ask your family or friends for help, or check with local government agencies or church organizations about meal deliveries. Many are low-cost; some are free.
- Freeze extra portions and take them out when you’re very tired.
- Eat your main meals earlier in the day, when you have extra energy.
Breathe easier at mealtime:
- Eat sitting up, not lying down. This prevents extra pressure on your lungs.
- If you use continuous oxygen, wear your cannula while eating to provide the energy your body needs for eating and digestion.
- Take small bites, chew slowly, and breathe deeply while chewing.
- Choose easy-to-chew foods.
- Eat smaller, more frequent meals.
- Drink fluids at the end of the meal so you don’t fill up too fast.
Stimulate your appetite:
- Keep healthy foods visible and within easy reach.
- Eat a variety of healthy foods, especially your favorites.
- Use colorful place settings or play background music while eating.
- Eat with other people as often as you can.
- Walk or do light exercises.
How to Monitor Your Weight With COPD
To help monitor and maintain a healthy weight if you have COPD:
- Weigh yourself once or twice a week, or as often as your doctor suggests. If you take water pills, called diuretics, you should weigh yourself every day.
- Contact your doctor if you gain or lose 2 pounds in one day or 5 pounds in one week.
- Make changes in your diet under the guidance of a health care professional.
- If you need to lose weight, ask about special exercises that may also strengthen your chest muscles.
Physical Activity and COPD | American Lung Association
Regular exercise is part of a healthy lifestyle, even if you have chronic obstructive pulmonary disease (COPD). You might feel like it is not safe, or even possible to exercise, but the right amount and type of exercise has many benefits. Be sure to ask your doctor before you start or make changes to your exercise routine.
Moderate exercise can improve:
It might seem odd that exercising when you are short of breath actually improves it—but it works! Exercises help your blood circulate and helps your heart send oxygen to your body. It also strengthens your respiratory muscles. This can make it easier to breath.
Before you start exercising, talk to your doctor about what types and amounts of exercise are right for you.
What Type of Exercises Are Generally Good for People with COPD?
Pulmonary Rehabilitation can be a great way to stay active and learn how to exercise with COPD. This program consists of education and exercise classes that teach you about your lungs and your disease, and how to exercise and be more active with less shortness of breath. The classes take place in a group setting, giving you the chance to meet others with your condition while both giving and receiving support.
Stretching relaxes you and improves your flexibility. It’s also a good way to warm up before and cool down after exercising. Practice holding a gentle stretch for 10 to 30 seconds, slowly breathing in and out. Repeat this a few times.
Aerobic exercise is good for your heart and lungs and allows you to use oxygen more efficiently. Walking, biking and swimming are great examples of aerobic exercise. Try and do this type of exercise for about a half an hour a few times a week.
Resistance training makes all your muscles stronger, including the ones that help you breathe. It usually involves weights or resistance bands, but you don’t need to go to a gym to do resistance training. Ask your doctor or respiratory therapist to show you some exercises you can do at home. To get stronger, do these exercises three to four times a week.
It is generally safe for people with COPD to exercise but you should not exercise if:
- You have a fever or infection
- Feel nauseated
- Have chest pain
- Are out of oxygen
Contact your doctor right away if you are experiencing any of these symptoms.
Should I Use My Oxygen When I Exercise?
If you use supplemental oxygen, you should exercise with it. Your doctor may adjust your flow rate for physical activity, which will be different than your flow rate when you are resting. Work with your doctor to adjust your oxygen for physical activity.
Here are some other tips for breathing during exercise:
- Remember to inhale (breathe in) before starting the exercise and exhale (breathe out) through the most difficult part of the exercise.
- Take slow breaths and pace yourself.
- Purse your lips while breathing out.
Need Help Getting Started?
If you want guidance on starting an exercise routine you can contact the specialists listed below. Make sure the specialist is certified by an exercise-related professional organization, such as the American College of Sports Medicine.
- Physical therapist
- Exercise physiologist
- Personal trainer
There are many places to exercise. For example:
- In your home (make sure the space is safe)
- Around your neighborhood
- Local fitness center
- Local shopping mall (especially in the morning, prior to opening)
- Community center
- Wellness center
- Yoga or Pilates studio
Talk to the staff at your fitness facility about your COPD before you start exercising.
5 Things You Should Know About Exercise if You Have COPD
Chronic obstructive pulmonary disease (COPD) is an umbrella term for lung conditions that block airflow. Chronic bronchitis and emphysema are the two main types of COPD. For people with COPD, physical activity can be challenging because the disease makes breathing difficult. Yet regular exercise can actually improve COPD symptoms.
“People with COPD have shortness of breath when they exercise,” says Daniel Ouellette, MD, a pulmonologist with the Henry Ford Health System in Michigan. “Exercise that involves aerobic activity, such as taking a walk or going to the gym, can provoke significant distress for people with COPD.”
As a result, people with COPD may be less inclined to exercise. That, Dr. Ouellette says, leads to a vicious cycle. When people avoid physical activity, their bodies become deconditioned. They are even more likely to experience shortness of breath and fatigue if they try to exercise in the future.
According to the American Lung Association, moderate exercise can help strengthen respiratory muscles and make it easier to breathe. Aerobic exercise, in particular, is good for the heart and lungs, and it helps the body use oxygen more efficiently.
“I try to reassure people that exercise is beneficial and that it will improve their ability to do things,” says Ouellette.
Here are five things to keep in mind if you have COPD and need to break the cycle of inactivity:
1. Talk to Your Doctor First
“People with COPD can have other conditions, such as heart disease, where exercise might need to be monitored or carefully regulated,” says Ouellette. “It’s important for a healthcare professional to test people before they embark on an exercise program to make sure it is safe for them.”
Besides your doctor, there are specialists who can help you come up with an exercise routine that’s right for you. These may include a physical therapist, exercise physiologist, or personal trainer.
2. Pulmonary Rehabilitation Is a Great Starting Point
“It’s hard for anyone to embark on an exercise program unless they have some success and some confidence building,” says Ouellette. “What I recommend for most of my patients who have significant COPD is to enroll in a pulmonary rehabilitation program. ”
Pulmonary rehabilitation combines exercise training, education, and support. While it cannot cure lung disease, it can decrease symptoms and improve your quality of life.
“These are structured programs that have testing at the beginning to make sure that exercise is safe,” Ouellette says. “Pulmonary rehabilitation offers supervised exercise in a controlled setting. People can gradually increase the number of things that they do and improve their exercise tolerance.”
Your doctor can refer you to a qualified pulmonary rehab program. When choosing a program, remember that the cost can vary greatly. Find out what your insurance will cover, and if you have to meet certain requirements.
3. Take a Walk
“The best exercise for most of our patients is simply walking,” says Ouellette. “After people compete the basic pulmonary rehab program, I encourage them to try to translate the exercise skills they’ve learned to their everyday activities. Taking a daily walk is a way you can do that. ”
According to research published in October 2016 in the Journal of the COPD Foundation, patients who walked at least 60 minutes per day reduced their COPD rehospitalization rate by 50 percent.
“In some geographic areas, it’s very hot in the summer or very cold in the winter; and it can be difficult to exercise outside,” Ouellette says. Think of places where you can walk regardless of the weather, such as a shopping mall or fitness center with an indoor track.
Besides walking, Ouellette also recommends bicycle riding and dancing.
4. What’s Good for the Body Is Good for the Mind
Roberto Benzo, MD, a pulmonologist at the Mayo Clinic in Minnesota, points out that exercise has emotional as well as physical benefits. “People learn not only to move more, but they also deal with their emotions as they move,” he says.
Living with COPD can pose emotional challenges, and “exercise is a very good antidepressant,” Dr. Benzo adds. “Consistency is important. Treat this time as a moment for you.”
5. Resistance Training Is Important, Too
While aerobic exercise is especially good for the heart and lungs, resistance or strength training helps make muscles stronger.
Resistance training improves muscular fitness by exercising a specific muscle or muscle groups against external resistance, such as weights or resistance bands.
“COPD patients often have a loss of muscle mass or muscle strength,” Ouellette says. “If you add conditioning programs that include strength training, particularly upper body strength, you will have additional benefits.”
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Practical recommendations for exercise training in patients with COPD
The recent statement on pulmonary rehabilitation of the American Thoracic Society/European Respiratory Society (ATS/ERS) describes pulmonary rehabilitation as 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 behaviour change, designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviour” (personal communication; M. Spruit, CIRO+, Horn, the Netherlands).
Pulmonary rehabilitation has been demonstrated to improve exercise tolerance, reduce symptoms of dyspnoea and increase health-related quality of life. Therefore, pulmonary rehabilitation is regarded as one of the most effective non-pharmacological treatments in patients with chronic obstructive pulmonary disease (COPD) [1, 2]. This article guides the reader through some of the key points on how to set up a pulmonary rehabilitation programme for patients with COPD. The common process of pulmonary rehabilitation, consisting of assessment, intervention and outcome, will be revealed and discussed. Since exercise training is regarded as one of the cornerstones of pulmonary rehabilitation, based on the highest scientific evidence levels (table 1), this article provides an overview on different methods for assessing patients’ exercise capacity, as well as introducing the most common and some new exercise modalities applied to patients with COPD. Special emphasis is placed on practical recommendations that can be directly applied in clinical practice.
Patients with COPD may respond to exercise training in different ways compared to healthy subjects since the determinants of exercise limitation appear to be widely multi-factorial. Such factors may include gas exchange abnormalities, dynamic lung hyperinflation, insufficient energy supply to the peripheral and respiratory muscles, morphological alterations in leg and diaphragm muscle fibres and reduced functional metabolic capacities [4, 5]. Exercise performance will be limited by the weakest component(s) of this physiological chain.
A good way to start the implementation of a pulmonary rehabilitation programme is to make sure that patients undergo an adequate assessment of their physical capacity. When conducting assessment tests it is important to find out the main causes of exercise limitation. The information provided by these tests is helpful in designing an individually tailored exercise programme. Continuous and interval endurance training, as well as strength training, may be regarded as the major exercise components. The application of additional exercise methods, for example breathing exercises, inspiratory muscle training, neuromuscular electrical stimulation or whole body vibration training, may also be useful techniques which will be discussed later.
Exercise tolerance can be assessed by a cardiopulmonary exercise test using either cycle ergometry or a treadmill, measuring a number of physiological variables, including peak oxygen uptake (V′O2), peak heart rate and peak work performance. A less complex approach is to use a self-paced, timed walking test (e.g. 6-min walk test (6MWT)). This test requires at least one practice test before data can be interpreted. Shuttle walking tests are also a useful option. They provide more in-depth comprehensive information than an entirely self-paced test, but are easier to perform than a cardiopulmonary exercise test . Additional assessment of muscle strength of the lower and upper extremities also adds important information and provides a comprehensive insight into patients’ limitations derived from extrapulmonary manifestations of COPD.
Cardiopulmonary exercise testing
Incremental cycle ergometry
This test is widely used in clinical practice. A progressively increasing work rate protocol enables rapid acquisition of diagnostic data. Because the response of some of the major interesting variables, such as minute ventilation, V′O2 and carbon dioxide uptake, lags behind changes in work rate, it is important to employ a protocol in which work rate increases at a constant rate. For the same reason it is useful to start the testing phase from a baseline of unloaded pedalling at 0 W. The ATS/American College of Chest Physicians (ACCP) statement on exercise testing recommends starting with a resting phase of 3 min followed by 3 min of unloaded pedalling before the incremental phase . The intensity should then be increased every minute by 5−25 W until the patient reaches volitional exhaustion. Alternatively, a ramp protocol could be used, usually increasing intensity every few seconds. However, the total increment per minute in the ramp protocol should be similar to that of the previous protocol showing a similar metabolic response . In general, exercise tests in which the incremental phase is completed between 8–12 min are efficient and provide useful diagnostic information. Outcome parameters from the test such as peak work rate, peak heart rate or peak V′O2 can be used to derive exercise intensities for an endurance training protocol on a cycle ergometer.
Constant work rate test
This type of test protocol is gaining popularity due to its clinical relevance and its more sensitive response to therapeutic interventions in comparison with an incremental test protocol . Before conducting a constant work rate test it is necessary to perform a maximal cardiopulmonary (incremental) exercise test. For the constant work rate test, the patient cycles at ∼70% of their peak work rate until exhaustion. The time the patient is able to sustain cycling is regarded as the outcome parameter.
6-min walk test
The 6MWT is probably the most popular field walking test used for patients with respiratory disorders. It evaluates the global and integrated responses of all systems involved during exercise, including the pulmonary and cardiovascular system, neuromuscular units and muscle metabolism. It is generally believed that the self-paced 6MWT assesses the sub-maximal level of functional capacity, although reaching high levels of cardiopulmonary stress. The 6-min walking distance (6MWD) seems to better reflect the function exercise level for daily physical activities than maximal incremental tests . Furthermore, oxygen desaturation during the 6MWT may also reflect oxygen desaturation during the patients’ activities of daily living .
The 6MWT requires a 30-m hallway but no exercise equipment. The test measures the distance that a patient is able to walk quickly on a flat, hard surface in a period of 6 min back and forth around cones. A rigorous standardisation of the test procedure , especially concerning the verbal communication before and during the test, is very important to minimise a potential bias by the tester. Some of the basic instructions that should be mentioned before the test include the patient being encouraged to “…walk as far as possible for 6 min” and that they “…probably will get out of breath or become exhausted”. Therefore, the patient is “permitted to slow down, to stop and to rest if necessary”. During the test the tester should only use standard phrases of encouragement every minute with an even tone of voice; for example, “You are doing well. You have 3 minutes to go”. At the beginning and the end of the test the patient’s oxygen saturation, heart rate, perceived dyspnoea and leg fatigue on a Borg scale are generally documented, as well as the total distance walked (in metres) during the test.
Incremental shuttle walking tests
The incremental shuttle walking test (ISWT) is also a field walking test; however, it differs from the 6MWT as it uses an audio signal from a CD player to determine the walking pace of the patient back and forth on a 10-m course . The walking speed increases every minute, and the test ends when the patient is not able to reach the turnaround point within the required time. The distance walked is noted as a primary outcome parameter. The power output is similar to a symptom-limited, maximal, incremental treadmill test. An advantage of the ISWT is that it shows a better correlation with peak V′O2 than the 6MWD as this test determines the maximum exercise capacity. Disadvantages include less widespread use and more potential for cardiovascular risks, since it evokes maximal exertion from the patients.
A related variation of the ISWT is the endurance shuttle walking test (ESWT). Patients are asked to walk at a speed equivalent to 85% of the peak speed achieved during the ISWT until exhaustion . Walking time is taken as outcome. The ESWT shows major improvements following pulmonary rehabilitation and is more sensitive to changes than the field tests of maximal capacity .
Another simple test procedure to determine functional exercise capacity is a sit-to-stand test. The test involves either the number of sit-to-stand repetitions from a standard chair within 30 s, respectively 60 s, or quantifies the time that a patient needs to perform, for example, five repetitions in a row. These tests may also determine functional status as easily as the 6MWT in regard to neurophysiologic effectiveness [15, 16]. Moreover a recent study has even shown a strong correlation between the result from a sit-to-stand test and mortality .
Peripheral muscle strength testing
As COPD is a disease with extrapulmonary, systemic manifestations such as muscle dysfunction , it is also important to assess peripheral muscle function. Muscle strength is usually expressed as the maximal voluntary isometric force of a muscle. As a reflection of lower limb strength, the quadriceps femoris muscle is, mostly, tested. Important requirements for a valid measurement are a proper fixation of the patient so that they cannot make any evasion movement; compensatory movements, and strong encouragement to ensure the highest possible muscle contraction. Devices such as an isokinetic dynamometer, a special chair using a strain gauge fixed at the ankle, or hand-held dynamometers can be used to determine muscle strength. Handgrip force, measured by a handgrip dynamometer, can be considered as an indicator for upper extremity strength. All strength measurements can be expressed in relation to normal values [19, 20].
IMPLEMENTING AN EXERCISE TRAINING PROGRAMME IN PULMONARY REHABILITATION
The “conventional” modalities used to exercise patients with COPD participating in pulmonary rehabilitation programmes mainly include endurance (continuous or interval) training and strength training.
Endurance training is probably the most common exercise modality in patients with COPD. The main objective of endurance training is to improve aerobic exercise capacity as aerobic activities are part of many everyday tasks in these patients. It has been shown that endurance training also improves peripheral muscle function in patients with COPD . In addition, there is some evidence that high-intensity endurance training induces greater physiological benefits than lower-intensity exercise . However, most patients with severe COPD are not able to sustain high-intensity exercise due to serious symptoms, such as dyspnoea and fatigue . Therefore, alternative exercise protocols, such as interval training, have gained increasing interest especially in patients with advanced COPD.
versus interval training
Historically, the rationale for interval training included the ability to impose high-power bursts of exercise on peripheral muscles without overloading the cardio-respiratory system. As outlined previously, people with COPD respond to training in a different way to healthy subjects as they are restricted by the complex interaction of different determinants of exercise limitation.
A recent systematic review included eight randomised controlled trials with a total of 388 COPD patients and compared the effects of continuous and interval training in a meta-analysis (mean forced expiratory volume in 1 s 33–55% predicted) . The authors summarised that both exercise modalities led to comparable improvements in exercise capacity and health-related quality of life. Continuous and interval endurance training also significantly improved the capillary-to-fibre ratio as well as the fibre-type distribution within the vastus lateralis muscle in similar amounts. Accordingly, there is a significant reduction in the proportion of anaerobic fast-twitch (type IIb) muscle fibres following both training regimes yielding a higher percentage of aerobic slow-twitch (type I) muscle fibres . The benefits in terms of improving exercise tolerance, quality of life and muscle fibre morphology and typology were comparable across patients with COPD in Global Initiative of Chronic Obstructive Lung Disease (GOLD) stages II, III and IV .
Nevertheless, in patients with very severe COPD there is evidence that interval training is associated with fewer symptoms of dyspnoea during exercise and fewer unintended breaks [26, 27]. Therefore patients with severe COPD may markedly increase the total exercise duration with significantly lower metabolic and ventilatory stress, as well as lower rates of dynamic hyperinflation when performing interval training compared to continuous training .
Although interval training consists of a sequence of on-and-off high-intensity muscular loads, its tolerability in the context of perceived respiratory and peripheral muscle discomfort has been shown to be better than that of constant load exercise .
This may indicate a better feasibility of interval training protocols, especially in patients with severe airflow obstruction. In general, many patients are frustrated by the burden of physical limitation in daily life. To avoid frustration during exercise training it may be important to offer exercise protocols that are feasible to each specific patient. It is speculated that this could reveal a psychological advantage to improve the patients’ motivation and maybe also increase long-term adherence to exercise training programmes. Nevertheless, especially older, patients with COPD initially have to familiarise themselves with this exercise mode and resting intervals in order to follow the right sequence of work and rest intervals for the required period.
An easy approach to target training intensity for continuous and interval endurance training on a bicycle would be to derive exercise intensity from a certain percentage of the peak work load (e.g. 70%). To further adjust cycling load to an effective, as well as feasible, intensity the patients’ perceived exertion on the modified Borg scale (0−10) should be aimed at 4 to 6. table 2 shows some practical recommendations for the implementation of continuous and interval endurance training programmes.
Practical recommendations for the implementation of continuous and interval endurance training programmes
So how to find the right endurance training protocol for your patient? table 3 shows some non-evidence-based indications of when the use of an interval training protocol may be more appropriate. If a patient is in a borderline status at some of these points it is recommended to let the patient decide which exercise protocol they would prefer. The patient could try both modalities on the first days of a pulmonary rehabilitation programme and share their own opinion. Integrating the patient in the planning of their exercise programme may also improve their willingness to adhere to the intervention.
Practical indications for considering the use of an interval training approach
versus walking-based endurance training
Walking is one of the most important activities of daily living in patients with COPD. However, most endurance training programmes are based only on cycle endurance training. In addition to the higher costs and space requirement involving a treadmill in comparison to a cycle ergometer, another possible explanation for this fact could be that patients with COPD exhibit a greater ventilatory response during walking compared to cycling . Thus, minimising dyspnoea sensations and the potential of oxygen desaturation during high intensity exercise are arguments in favour of providing cycling-based endurance training. However, walking-based endurance training programmes are also very effective in improving exercise capacity and quality of life in people with COPD [32, 33]. Compared to equipment-dependent training, such as cycle training, non-treadmill walking is an easily available training modality, particularly for those living in places with limited resources. Furthermore, exercising the patients’ walking skills might be more effective to the patient than exercising cycling skills that are unlikely to be essential to everyday life. A recent study has even shown that supervised, progressive walking training resulted in a significantly larger increase in endurance walking capacity compared to supervised, progressive stationary cycle training . Similar effects were found on peak walking and cycling capacity, endurance cycling capacity and health-related quality of life.
Since walking endurance capacity in patients with COPD is especially impaired, this could be the rationale for the implementation of walking-based endurance training to improve the patients walking capabilities.
Up-to-date detailed recommendations for prescribing walking training can rarely be found in the literature. A common reference point that was used in several studies [34, 35] was to set the walking speed at ∼80% of peak V′O2, which was achieved in a shuttle walking test. To avoid the complex and time consuming procedure of a ergospirometry during the shuttle walk test, peak V′O2 can be approximately derived by the following equation: peak V′O2 mL·min−1·kg−1=4.19+0.025×ISWT distance . It has been shown that this intensity is feasible in most patients and is effective in improving exercise capacity . If patients are not able to walk continuously for at least 10 min at the given speed, the intensity could be decreased stepwise by ∼10% until the patient is able to walk without taking a rest.
It is easy to set and control the proper walking speed when patients are exercising on a treadmill. If patients walk on the ground it is much more difficult to accurately stick to the individualised pace. Other methods such as using a metronome or listening to music, the rhythm of which is adjusted to the individual walking speed, might be useful [35, 37]. Also a given track with distance marks could be helpful. If no supportive devices are available to determine walking speed, a perceived exertion on the Borg scale from 4 from 6 could be targeted. Furthermore, an interval approach could also be applied. To date, walking interval training has not been investigated. Due to practical reasons, longer interval walking periods of 1–2 min duration might be more appropriate.
Oxygen supplementation during exercise
The benefits of long-term oxygen therapy (LTOT) in patients with COPD associated with hypoxaemia are well known. In these patients, LTOT prolongs survival and reduces hospitalisations, as well as the risk of comorbidities [38, 39]. More recently, the usefulness of oxygen therapy in improving outcomes from pulmonary rehabilitation in patients with COPD has been evaluated in several studies. In general, a distinction must be made between immediate effects of oxygen on exercise performance and its usefulness in the exercise-training component of pulmonary rehabilitation. As an adjunct to exercise training, supplemental oxygen therapy has been studied in patients who are severely hypoxaemic at rest or with exercise. The rationale for these studies is that supplemental oxygen therapy improves peripheral muscle oxygenation , dyspnoea  and exercise capacity  in patients with COPD and hypoxaemia, possibly allowing them to train at higher intensities. While the use of oxygen improves maximal exercise performance acutely in the laboratory, studies testing its effect in enhancing the exercise-training effects have produced inconsistent results. This may reflect differences in methodology among the studies, especially with regard to training workload . However, the use of continuous supplemental oxygen for patients with COPD and severe resting hypoxaemia is clearly indicated and recommended as a part of routine clinical practice. Oxygen saturation measured by pulse oximetry >90% and/or an arterial oxygen pressure >55 mmHg should be targeted .
The use of supplemental oxygen as an adjunct to exercise training could also be useful in patients who do not meet inclusion criteria for LTOT and do not experience exercise-induced hypoxaemia. In a double-blinded randomised trial, patients without significant exercise-induced oxygen desaturation were randomised to receive either room air or oxygen during high-intensity exercise training . Exercise performance improved significantly more in the group receiving oxygen. This improvement was accompanied by a reduction in respiratory rate.
The long-term effects when supplemental oxygen is discontinued and the effect on other outcomes such as health-related quality of life remain to be determined.
Peripheral muscle dysfunction and muscle weakness are highly prevalent comorbidities of COPD, contributing to exercise intolerance and symptom intensity [46, 47]. It is assumed that resistance training can reverse peripheral muscle dysfunction and thereby reduce, at least in part, the burden of COPD impairment . Resistance training as an adjunct to endurance is recommended in all patients especially those with peripheral muscle weakness. Because strength training has a greater potential to improve muscle mass and strength than endurance training [49, 50], a combination of these two exercise modalities is highly recommended. Strength training also provokes less dyspnoea during exercise, which most probably makes it easier to tolerate than aerobic training . Therefore, a combination of resistance training with interval endurance training can be a useful alternative training strategy in patients severely restricted in their ability to perform endurance training due to marked ventilatory limitation.
A systematic review that included 18 randomised controlled trials showed consistent improvements in muscle strength despite a large variation of exercise characteristics, such as number of repetitions, exercise intensity or the method of strength training itself (e.g. conventional strength training machines, pulleys, free weights, Thera-Band; Hygenic Corporation, Akron, OH, USA) . Therefore, the ideal exercise modalities for strength training in patients with COPD remain unknown. It appears that there is more than one mechanism to improve strength skills. Another important and clinically relevant finding of this article was that the effects of strength training may also be translated into meaningful changes in functional performance such as climbing stairs, standing up or arm elevation activities .
The ATS/ERS statement on pulmonary rehabilitation recommends performing two to four sets of six to 12 repetitions at intensities ranging from 50% to 85% of the one repetition maximum (1RM) 2−3 days per week (table 4) . However, the principle of deriving strength training intensities from the 1RM must be critically considered. Due to a large inter-individual discrepancy and a wide range of variability of the number of possible repetitions at a certain percentage of the 1RM, the ideal resistance for many individuals may be over- or underestimated [54, 55]. Therefore, the main focus could rather be on targeting local muscular exhaustion within the range of six to 12 repetitions (in other words determine a six to 12 repetition maximum) rather than reaching a certain percentage of the 1RM. Of course the patient must be instructed on this obligatory goal of achieving muscular exhaustion, otherwise they may not be willing to expose themselves to this exertion. An easy and very practical approach to determine optimal resistance for strength training is that the physiotherapist sets a training load so the patient is able to repeat an exercise six to maximally 12 times and has to stop due to muscle fatigue. With a little experience from the physiotherapist this is a very quick and useful approach that does not necessarily require determining the 1RM. However, it is recommended to use both upper and lower limb resistance weight training conducted with moderate speed at 1–2 s for both concentric and eccentric. When the subject can perform the current workload for one or two repetitions over the desired number of six to 12 repetitions on two consecutive training sessions it is recommended to apply a 2–10% increase in load .
Practical recommendations for the implementation of strength training
BEYOND “CONVENTIONAL” EXERCISE MODALITIES
In recent years some additional exercise modalities beyond endurance and strength training have gained increasing interest. Due to the limited space of this article some of these new training components will only be briefly introduced.
Inspiratory muscle training
As a consequence of COPD, strength and endurance  of the diaphragm can also be reduced and contribute to hypercapnia, dyspnoea and reduced walking capacity . Inspiratory muscle training may enhance the dysfunction of the diaphragm and improve some of its consequent burden. Various meta-analyses [59, 60] have shown that inspiratory muscle training can improve inspiratory muscle strength and endurance, as well as reduce dyspnoea. Scientific data on its benefits on functional exercise capacity and quality of life are less consistent, but evidence is emerging . In patients suffering from inspiratory muscle weakness, defined as maximal inspiratory pressure (PImax) <60 cmH2O, the addition of inspiratory muscle training to a general exercise training programme improved PImax and tended to improve exercise performance . More studies that investigate inspiratory muscle training, especially in patients with inspiratory muscle weakness, are needed.
By far, the most commonly used inspiratory muscle training technique is the one of “threshold loading” devices (table 5). These devices generally have a spring-loaded valve requiring the patient to inhale strongly enough to open the valve and to breathe in against an individualised load. The optimal training intensity is still unknown but an initial resistance of ≥30% of PImax is recommended . Resistance should then be increased stepwise, as tolerated. At present the optimal exercise duration is uncertain, most studies provided a total exercise time of 15−20 min per day . It might be helpful to split inspiratory muscle training into two to three short exercise sessions per day.
Practical recommendations for the implementation of inspiratory muscle training (IMT)
Neuromuscular electrical stimulation
During neuromuscular electrical stimulation (NMES) the muscles get stimulated electronically via adhesive electrodes placed on the skin. As the metabolic response during a NMES session is significantly lower compared to a resistance exercise training session in patients with COPD , this technique may be particularly relevant to severely deconditioned or bed-bound patients . The most consistent finding of NMES training in COPD is a 20−30% gain in quadriceps strength as compared with control subjects [66, 67]. Most exercise protocols aim for the muscles of the thigh and the calf muscle. In NMES studies the duty cycle ranges between 2 to 10 s on and 4 to 50 s off for 20−60 min and one to two sessions per day 3−7 days per week (table 6) . To set the initial stimulus the intensity will be increased until a visible strong muscle contraction occurs or to the maximum level of the patients’ toleration. A novel finding is that it seems that there is a certain threshold for responders and non-responders to NMES. The gains in functional exercise capacity were heavily dependent on the ability of the patient to increase and sustain a progressively higher current intensity. The relationship between the change in walking test distance was characterised by a threshold of 10 mA increase from the beginning until the end of a 6-week NMES intervention below which changes in exercise capacity with NMES were practically absent .
Practical recommendations for the implementation of neuromuscular electrical stimulation
Whole body vibration training
During whole body vibration training subjects exercise on a vibrating platform that produces sinusoidal oscillations. At high intensities this vibration evokes muscle contractions on the entire flexor and extensor chain of muscles in the legs and all the way up to the trunk. Instead of voluntary muscle control like in common resistance training, the muscle contractions during high-intensity vibration training are caused by stretch reflexes . The user has no direct influence on muscle activity itself and can only control body posture movement.
To date there is some evidence that whole body vibration training yields improvements of similar magnitude in regards of exercise capacity, muscle force and quality of life in comparison to conventional strength training . Another study concluded that in patients with advanced COPD, whole body vibration training seems to be an effective and feasible exercise modality that may even enhance functional exercise capacity significantly more when performed in addition to endurance and strength training . The underlying mechanisms are not yet investigated, but it is speculated that improvements in neuromuscular activation may play an important role. table 7 provides some practical guidelines for the use of whole body vibration training.
Practical recommendations for the implementation of whole body vibration training
Breathing retraining (or breathing exercises)
Breathing retraining is a simple approach aiming to alter respiratory muscle recruitment in order to reduce dyspnoea and improve respiratory muscle performance. Breathing retraining techniques described over time have mainly included pursed-lip breathing, diaphragmatic breathing and expiratory muscle strengthening. The improvements with breathing retraining discussed in the literature have included improvements in dyspnoea, work on breathing, ventilation, lung volume, functional performance and activities in daily living. However, many argue the improvements may not be due to breathing retraining alone but rather due to the adjunctive therapies such as medications, use of oxygen, and exercise training itself . However, in a meta-analysis by Holland et al.  it was concluded that breathing exercises improve functional exercise capacity in patients with COPD compared to no intervention despite the fact that there are no consistent effects on dyspnoea or health-related quality of life. Breathing exercises may be useful to improve exercise tolerance in selected individuals with COPD who are unable to undertake exercise training .
Assessing the effectiveness of the exercise training programme
Any pulmonary rehabilitation programme should include given outcome assessments, required for the objective evaluation of programme effectiveness, and of patient progress during the testing period. As currently practiced, pulmonary rehabilitation typically includes several different components, including not only exercise training but also education, nutritional and psychosocial support, and instruction in various respiratory and chest physiotherapy techniques. As an example, different outcomes to be assessed concerning their effectiveness after pulmonary rehabilitation include (but are not restricted to): overall exercise capacity (exercise tests), upper and lower limbs strength, symptoms (breathlessness and fatigue), health-related quality of life (specific questionnaires), and the improvement in physical activity performed in daily life not only in exercise tests.
In all stages of COPD, exercise training performed in the context of a pulmonary rehabilitation programme has been shown to be effective in a number of outcomes of patients with COPD, such as improved exercise tolerance, muscle strength, quality of life, and reduced dyspnoea and fatigue. Pulmonary rehabilitation is now a well-recognised therapy that should be available to all patients with symptomatic COPD, and exercise training is the cornerstone of a pulmonary rehabilitation programme. This article has provided specific details on the rationale of why and especially how to implement exercise training in patients with COPD, including the prescription of training mode, intensity and duration, as well as suggestions of guidelines for training progression.
National Emphysema Foundation – Exercise
Shortness of breath and weakness are two common problems of people with chronic lung diseases. As a result, many people avoid participating in physical activities that cause them shortness of breath. In turn, these people become weaker and their shortness of breath greater with even less activity.
A program of regular exercise can help break this vicious cycle.
Even in small amounts, exercise can help strengthen your muscles and make them more efficient—requiring less oxygen to perform the same activities. Further, by stretching muscles that are not regularly used, including the breathing muscles, everyday activities such as walking will become easier and lung function will improve.
While exercise may seem overwhelming at first, even walking at a very slow pace will benefit your overall quality of life. Exercise will improve your appetite, giving you the “fuel” and building blocks you need to repair and maintain your body’s lung function. Mild to moderate exercise has also been proven to improve mental function.
The benefits of light to moderate exercise will be apparent rather quickly after beginning a regular exercise routine. However, these positive effects can be lost just as quickly as they appeared. As such, once you begin the healthy habit of regular exercise, you should continue daily unless otherwise advised by your doctor or physician.
April 15, 2013
In-Home Exercises May Benefit Homebound COPD Patients
A pilot-study of chronic obstructive pulmonary disease (COPD) patients who meet the definition of homebound has found that just two months of aerobic conditioning and functional strength training can produce measurable improvements in quality of life.
February 27, 2012
Special Bike Helps Emphysema Patients Increase Mobility
An updated version of the world’s first bicycle may help some people with emphysema and chronic obstructive pulmonary disease (COPD) get around more easily.
August 02, 2011
Walking Speed May Signal Decline in Health
A drop in walking speed may signal a decline in overall health for patients with chronic obstructive pulmonary disease (COPD), according a recent study presented at the 2011 American Thoracic Society International Conference in Denver.
July 18, 2011
COPD Patients May Benefit From Wii Fit Exercises
People with chronic obstructive pulmonary disease (COPD) may benefit from exercising with Nintendo’s Wii Fit video game, according to a recent study out of the University of Connecticut Health Center.
February 07, 2011
COPD Linked to Walking Problems
Chronic obstructive pulmonary disease (COPD) may cause abnormalities in patients’ muscular systems that affect the way they walk, according to recent research published in the journal of Respiratory Medicine.
March 19, 2010
Cycling to Better Health
With the diagnosis of CPOD and associated breathing troubles, many patients often find that it is much more difficult to lead an active life.
Exercises for the upper limbs with COPD
Review Question: We examined the effect of arm training on dyspnea and quality of life in people with chronic obstructive pulmonary disease (COPD).
Relevance: people with COPD often have difficulty doing arm exercises due to shortness of breath. Hence, hand training is used to increase arm endurance; however, the impact of these exercises on shortness of breath and quality of life remains unclear.We wanted to look at arm workouts lasting at least 4 weeks and analyzed them in three ways: a) comparing with no exercise or simulation intervention; b) comparing a combination of arm and leg training with just leg training; and c) comparing different types of arm training (eg, endurance training versus strength training).
Study characteristics: included 15 studies with 425 participants with COPD.However, information sufficient for analysis in the three areas described above was obtained from only 12 studies.
Main results: when comparing hand training with no or sham training, participants with COPD showed a slight improvement in dyspnea. However, this improvement was not unambiguous when comparing combined arm and leg workouts with leg-only workouts. None of the studies compared the effects of different types of arm training on dyspnea.In all three comparisons, arm training had no effect on quality of life. When hand endurance training was considered separately, there was an improvement in the ability to move and carry light objects compared to no training. These effects were not seen with arm strength training.
Quality of evidence: The quality of the included studies ranged from low to moderate due to the small number of participants (12 to 43 participants in the study), insufficient information on research methods, and incomplete data on outcomes.
Conclusions: some types of arm training may lead to small improvements in shortness of breath, but do not improve the quality of life for people with COPD. More specifically, hand endurance training in people with COPD can improve the ability to move light objects.
How to restore the lungs after suffering a coronavirus
Even those who had a coronavirus infection were not serious and avoided admission to the hospital, they say that the disease does not pass without a trace: shortness of breath lasts for a long time, and someone complains that wheezing is heard when breathing, similar to crunch of crumpled paper.How to recover faster, how to avoid complications? Olga Bogush, a pulmonologist at the Pirogov Center (CDC “Arbatsky”), gave advice to the readers of “RG”.
– COVID-19 proceeds in different ways. In patients who have been ill in mild or asymptomatic form, the consequences most often do not occur. If the patient was diagnosed with bilateral pneumonia caused by coronavirus, if more than 25% of the lungs were affected, there is a risk of fibrosis. Fibrosis is the replacement of normal lung tissue with connective tissue.Scars appear in the lung, inextensible areas are formed, and the respiratory surface decreases. If there are 2-3 such areas and they are small, the patient may not notice this. But if the fibrosis is large, breathing problems begin. The most common symptom is shortness of breath. Fibrosis occurs not only under the influence of a viral infection. Chronic obstructive pulmonary disease, for example, affects many experienced smokers. In severe cases, this leads to respiratory failure. It is possible and necessary to fight for the return of lung health.Physical rehabilitation is the cornerstone. Unfortunately, we do not have special medicines, any special technologies that help the lungs to work in the same way as before the disease. For example, vitamin D, which is now popular, does not protect against COVID-19 and its effects. The lung tissue must regenerate itself, and our task is to help it. The main thing that a person can do at home is to engage in their physical recovery.
First of all, this is breathing exercises. It is necessary to perform exercises aimed at restoring the respiratory muscles, to develop the muscles that are responsible for inhaling and exhaling.There are many such practices. I recommend to my patients gymnastics by Alexandra Strelnikova, it works well for any chronic lung diseases. The Ministry of Health’s recommendations for rehabilitation indicate that yoga breathing can be practiced. Interestingly, these breathing practices are very different, but both are good for the lungs. And, of course, it is possible to limit yourself only to breathing exercises as long as severe weakness persists. Strelnikova’s gymnastics, by the way, can be performed first and sitting and even lying down – it still works.When severe weakness persists, you can even do very simple things while lying down: for example, inflate balls or slowly exhale through a thin tube, the end of which is lowered into water. There are special simulators that train inhalation and exhalation – they are beautiful and useful. Although quite expensive. I think it is quite possible to do without them – just use the means at hand and not be lazy. But gradually, having got stronger, it is imperative to add physical activity.
Ordinary gymnastics is good.If you have a simulator at home – a stepper, a treadmill, a bicycle – that’s great. But even just regular walking, hand waving, torso bending and other elementary exercises will help you recover faster.
When the quarantine regime ends and you can walk, you need to add any physical activity in the fresh air. At first, I would recommend aerobic exercise – not intense, but lasting at least half an hour or an hour. The simplest and safest thing is walking at a brisk pace, you can use a bicycle.It will be possible to connect strength exercises later, when the body recovers from an illness. Vibration massage is also good: ask someone to lightly pat their hands on the back for a few minutes.
Infographics “RG” / Leonid Kuleshov / Irina Nevinnaya
“The lungs can be trained” – ME “Grodno University Clinic”
We breathe without hesitation, and meanwhile, according to various estimates, our lungs pump from 300 to 900 liters of air per day.It turns out that what we breathe, and how we do it, greatly affects our well-being and performance.
Most diseases of the respiratory system are associated with one or another harmful effect on a person of environmental factors – for example, chronic bronchitis of a smoker, professional chronic bronchitis, chronic obstructive pulmonary disease, etc. The goal of primary prevention is not to expose yourself to those circumstances that make you sick. For example, if a person does not smoke and is not going to smoke, this is the primary prevention, including lung cancer.If a person does not work in hazardous industries, leads a healthy lifestyle – this is also prevention.
But if a person does get sick, everything possible must be done so that the disease does not progress. In such cases, secondary prophylaxis is needed.
What is secondary prevention?
– This is health support not only with the help of drugs, but also breathing exercises.
Everyone is accustomed to the fact that you can train muscles, arms, legs, but in the same way you can train your lungs.The better the lungs are ventilated, the better they are supplied with blood, the better the state of health, the less the manifestation of the disease.
- Relax and stand up straight, hands should be lowered along the body.
- Exhale and then take a slow deep breath. As your lungs fill with air, your shoulders begin to lift. Then a sharp exhalation is made, and the shoulders drop accordingly.
- The next time you inhale, when your lungs fill up, your shoulders are slowly pulled back, your shoulder blades are brought together, your arms close behind your back.Then you need to slowly exhale, while the arms and shoulders are pushed forward, and the chest is compressed. Keep your shoulders and arms relaxed.
- With a deep breath, we tilt to the right, the chest on the left is stretched accordingly. With an exhalation, we return to the original position. We make the same tilt to the left. When performing this exercise, you need to keep your back straight, and not bend your neck and arms.
- When inhaling, slowly tilt your head back, while the spine bends strictly in the thoracic region.With an exhalation, tilt your head forward so that you can see the knees, the spine also bends in the thoracic region. And the arms hang freely along the body.
- We take a deep breath and, with a leisurely exhalation, smoothly twist the spine clockwise, while the right hand is pulled behind the back, and the left one goes forward. We take a breath and take the original position. We do the same, but counterclockwise. Make sure that the hips remain motionless at the same time.
- First, alternately with the right and left shoulders, make circular movements, similar to those done by rowers in a kayak.Then we make rotational movements simultaneously with both shoulders. Breathing is arbitrary.
The breathing warm-up should be done for 6-10 minutes. After its completion, you should relax and rest for about 5 minutes. After rest, you can start doing breathing exercises for the lungs from the complex below.
Basic breathing exercises that develop the chest, various groups of its muscles and ligaments
These exercises are quite simple, but extremely effective.You should not try to master a lot of exercises right away. As experience and practice shows, the breathing exercises provided below develop the muscles and ligaments of the chest, lung tissue. Perform each exercise for 3-5 minutes.
Not only does this exercise ventilate and cleanse your lungs, it enhances the health of your entire body by refreshing it. The lesson is very useful for people whose profession requires you to strain your lungs a lot: singers, actors, musicians playing wind instruments, orators, teachers, etc.e. It is performed as follows, first a full breath is taken and the breath is held for a few seconds. The lips are compressed as if for a whistle, while the cheeks do not swell, then exhale a little air with considerable force and stop for a second, then exhale a little more in the same way and continue so on until all air is completely exhaled. It is very important to exhale the air forcefully.
Develops and strengthens the respiratory muscles, as well as the lungs in general.Performing it constantly will expand the chest. At the same time, temporary holding of breath helps to cleanse the lungs and promotes the best absorption of oxygen by the blood. To perform the exercise, you need to stand up straight and take a full breath. Breathing in the chest should be held as long as possible, and then exhale the air with force through the open mouth. Next, do a cleansing breath.
Excitation of lung cells
Allows you to stimulate the activity of air cells in the lungs.It must be done with care and should not be overused by beginners. Many people feel a little dizziness after doing it. Therefore, you should always be ready to stop executing it. To perform it, you need to stand straight with your arms at your sides. Slowly and gradually we inhale the air until the lungs overflow with air and hold our breath. Then, with the palms of our hands, we hit the chest and begin to slowly exhale air. At the same time, we drum on the chest with our fingertips. We finish the exercise with cleansing breath.
Joyful upper breath
This exercise is believed to improve mood. For control, you need to put your hands on your collarbones, then when you inhale, air will fill only the upper parts of the lungs, and the chest will rise up. When you exhale, it returns to its original position. At the same time, the abdomen remains motionless, and the chest does not expand.
Calming Lower Breathing
When inhaling, air fills the lower parts of the lungs and therefore the stomach protrudes, while exhaling it is drawn in.At the same time, the chest remains motionless. In combination with this exercise, medium breathing is performed, which increases the tone of the body. When you inhale, air fills the parts of the lungs, and the chest expands, and when you exhale, it returns to its original position. During the exercise, the abdomen remains motionless.
To see a positive result from any exercise, you need to do it regularly, and not give up what you started halfway through. Perseverance, desire, and willpower are essential ingredients for effective success.
Material prepared by a pulmonologist
of the pulmonology department of the Grodno University Clinic, E.Ya. Kulaga
90,000 Two 5-minute exercises will help strengthen and protect the lungs (video)
Simple breathing exercises can help make your lungs more efficient and even manage shortness of breath.
American pulmonologists recommend developing lungs, especially in conditions of self-isolation and a sedentary lifestyle.
Breathing exercises help slow down a person’s breathing and increase the efficiency of the lungs. They are especially useful for smokers, asthmatics, patients with chronic lung conditions that cause shortness of breath, and may even help calm someone who is feeling anxious.
The main thing is that people should start practicing breathing exercises when their breathing is normal, and not when they are experiencing an attack of shortness of breath.
Experts recommend two breathing techniques: with extended lips and with the help of the abdomen.Ideally, you should do both exercises for 5-10 minutes each, daily.
Breathing with extended lips, video link here:
1. Sit in a chair and relax your neck and shoulder muscles.
2. Breathe slowly through your nose, keeping your mouth closed. Breathe in for 2 seconds.
3. Pull your lips out as if whistling or blowing out a candle. Exhale slowly for 4 seconds.
4. Repeat the above steps for the required amount of time.
Breathing with the diaphragm (abdomen) lying or sitting, video link here:
1. Place both hands on your stomach to feel each breath.
2. Close your mouth and inhale slowly through your nose, feeling your stomach rise and swell like a balloon.
3. Exhale slowly through pursed lips, each exhalation taking about two to three times longer than inhalation.
Repeat these exercises for 5-10 minutes. Keep your hands on your stomach to improve your understanding of correct breathing technique.
Earlier, “Kubanskie Novosti” told how to breathe correctly so as not to get sick.
Chronic obstructive pulmonary disease (COPD) – Discussion with the patient
All patients should be well informed about the course of the disease, symptoms of exacerbation and decompensation.Their expectations for disease, treatment and prognosis must be realistic. It is important to remember that no drug has been shown to be effective in long-term modification of decreased lung function, so the primary goal of pharmacotherapy is to control symptoms and prevent complications.
One Cochrane review found that self-help interventions that include an action plan for an exacerbation of COPD are associated with improved health-related quality of life and fewer hospitalizations for respiratory problems.The exploratory analysis revealed a small but significantly large difference in mortality rates associated with respiratory diseases in self-care compared with traditional care, although there was no increased risk of death from other causes.  Lenferink A, Brusse-Keizer M, van der Valk PD, et al. Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Aug 4; (8): CD011682.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011682.pub2/full
One randomized controlled trial found that telephone health coaching to promote behavioral change in patients with mild COPD in a primary health care setting resulted in improved self-care management, but did not improve health-related quality of life. … Jolly K, Sidhu MS, Hewitt CA, et al. Self management of patients with mild COPD in primary care: randomized controlled trial. BMJ. 2018 Jun 13; 361: k2241.
The patient should remain as healthy and active as possible. Stop active or passive smoking and avoid exposure to toxic fumes from the environment.
Regular medical examinations are necessary to optimize treatment.If any symptoms worsen, immediate medical attention is required. Patients on continuous oxygen therapy may need to increase the flow of oxygen during flights.
Physical activity is recommended for all patients with COPD and should be encouraged to maintain it.  Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf
One systematic review and meta-analysis of randomized controlled trials found that exercise alone may improve physical activity in COPD, but improvement can be achieved with additional physical activity counseling.  Lahham A, McDonald CF, Holland AE. Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials.Int J Chron Obstruct Pulmon Dis. 2016 Dec 8; 11: 3121-36.
Another systematic review and meta-analysis found that a combination of aerobic exercise and strength training was more effective than strength training or endurance training alone in terms of increasing the distance traveled in 6 minutes. Vooijs M, Siemonsma PC, Heus I, et al. Therapeutic validity and effectiveness of supervised physical exercise training on exercise capacity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Clin Rehabil. 2016 Nov; 30 (11): 1037-48.
Chronic Obstructive Pulmonary Disease (COPD) – Management Approach
For updated information on the diagnosis and treatment of coexisting conditions during a pandemic, see Treatment of comorbid conditions in the context of COVID-19.
The ultimate goals of COPD treatment are to prevent and control symptoms in order to reduce the severity and number of exacerbations, to improve respiratory capacity to increase exercise tolerance and reduce mortality.  Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
This is a step-by-step approach to therapy, but it is important to remember that treatment should be individualized according to your general health and underlying medical conditions.
The therapeutic approach includes risk factor reduction, appropriate assessment of the disease, patient education, drug and non-drug treatment of COPD in the stable phase, prevention and treatment of exacerbations of COPD.
Continuous assessment and monitoring of the disease
Continuous monitoring and assessment of COPD ensures that the treatment goal is achieved.In the case of using independent, or professional monitoring of the disease, the patient’s quality of life and feeling of well-being improve, and the rate of hospitalizations is significantly reduced.  Lemmens KM, Nieboer AP, Huijsman R. A systematic review of integrated use of disease-management interventions in asthma and COPD. Respir Med. 2009 May; 103 (5): 670-91.
The following aspects of the medical history should be considered:
Influence of risk factors and preventive measures:
Occupational exposure (smoke, dust, etc.)
Vaccination against influenza or pneumococcal infection.
Progression of the disease and the development of complications:
Decreased exercise tolerance
Deterioration in sleep quality
Skipping work or other activities.
Pharmacotherapy and other medical treatment:
How often the life-saving inhaler is used
Any new medications
Compliance with medical regimen
Possibility to use inhalers correctly Side effects
History of exacerbations
Urgent emergency room visits
Recent corticosteroid use
The frequency, severity and possible causes of exacerbations should be assessed.
In addition, if symptoms increase significantly, lung function should be assessed annually, or even more frequently.
Integrated Disease Management (IDM), which involves multiple healthcare professionals (physiotherapist, pulmonologist, nurse, etc.)that work with the patient has shown an improvement in living standards and a decrease in hospitalization rates.  Kruis AL, Smidt N, Assendelft WJ, et al. Cochrane corner: is integrated disease management for patients with COPD effective? Thorax. 2014 Nov; 69 (11): 1053-5.
In people with chronic obstructive pulmonary disease, what are the effects of integrated disease management interventions? / Cca.html? targetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.1063/full Show Answer
Flare-ups of COPD are defined as an event that begins suddenly and is characterized by worsening of baseline dyspnea, coughing and / or sputum production higher than normal daily variations. For more information, see our topic “Exacerbation of Chronic Obstructive Pulmonary Disease”.
Chronic Disease Therapy: Grade-Based Therapy for the Global Initiative for Chronic Obstructive Lung Disease (GOLD)
GOLD Clinical Guidelines  Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
recommend a step-by-step approach to therapy:
For patients in group A (few symptoms and low risk of exacerbations), short-acting bronchodilators should be used as the first choice. It can be a short-acting or long-acting bronchodilator.This should be continued if symptomatic benefit is documented.
For patients in group B (more symptomatic and lower risk of exacerbations), a long-acting bronchodilator should be given as the first line. If a patient has persistent symptoms with one long-acting bronchodilator, it is recommended to use two bronchodilators. For patients with severe dyspnea, initial treatment with two bronchodilators may be warranted.
For patients in group C (few symptoms but higher risk of exacerbations), first-line treatment should be a long-acting bronchodilator, and GOLD recommends starting a long-acting muscarinic antagonist (LAMA) in this group.
How does umeclidinium bromide compare with placebo for people with chronic obstructive pulmonary disease (COPD)? /Cca.html? TargetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.1829/full exacerbations may benefit from the addition of a second long-acting bronchodilator (long-acting beta-2 agonist (LABA) or LAMA), or using a combination of LABA and an inhaled corticosteroid (ICS).GOLD recommends the LABA / LAMA combination over LABA / ICS because ICS increases the risk of pneumonia in some patients.
How does long-acting muscarinic antagonist (LAMA) plus long-acting beta-agonist (LABA) compare with LABA plus inhaled corticosteroid (ICS) for people with stable chronic obstructive pulmonary disease (COPD)? / Cca.html? TargetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.1708/fullShow Answer
For Group D patients (more symptoms and increased risk of exacerbations), GOLD recommends starting therapy with the LABA / LAMA combination.If patients experience further exacerbations using LABA / LAMA, they can either try escalating LABA / LAMA / ICS, or they can switch to LABA / ICS. If patients treated with LABA / LAMA / ICS still have flare-ups, then additional options include roflumilast or macrolide supplementation, or stopping the ICS.
All patients are applicants for education on this disease, vaccination and measures to quit smoking.
Features of therapy with bronchodilators
The main bronchodilators in the treatment of COPD are beta-agonists.They increase the intracellular concentration of cAMP, which leads to relaxation of respiratory smooth muscles and decreases airway resistance. They are available in both short and long acting formulations. Short-acting beta-agonists are used, as needed, as a common initial drug therapy in the treatment of COPD. These drugs are also used as rescue therapy in patients who are already using long-acting beta-2 agonists.  Chen AM, Bollmeier SG, Finnegan PM, et al.Long-acting bronchodilator therapy for the treatment of chronic obstructive pulmonary disease. Ann Pharmacother. 2008 Dec; 42 (12): 1832-42.
Long-acting B2 agonists improve lung function, dyspnea, relapse rate and hospital admissions, but do not affect mortality rates or the rate of decline in lung function.  Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.2018 [internet publication].
A muscarinic antagonist is a type of anticholinergic that acts as a bronchodilator by blocking cholinergic receptors on respiratory smooth muscles. This relaxes the muscles and reduces airflow restriction. Inhaled muscarinic antagonists are available as short- and long-acting drugs.
How does umeclidinium bromide compare with placebo for people with chronic obstructive pulmonary disease (COPD)? / Cca.html? targetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.1829/full Show Answer Tiotropium, a long-acting muscarinic receptor antagonist, has been shown to reduce the risk of exacerbations compared to placebo or other supportive therapies.  Halpin DM, Vogelmeier C, Pieper MP, et al. Effect of tiotropium on COPD exacerbations: a systematic review. Respir Med. 2016 May; 114: 1-8.
How does tiotropium compare with ipratropium bromide for people with chronic obstructive pulmonary disease (COPD)? /Cca.html? TargetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.2154/full long-acting, such as aclidinium, glycopyrronium and umeclidinium, have at least comparable efficacy to tiotropium in terms of changes from the minimum initial level of forced expiratory air volume in 1 second (FEV1), dyspnea index scale, St. George’s Hospital questionnaire scale to assess respiratory function and use drugs to relieve symptoms. Ismaila AS, Huisman EL, Punekar YS, et al. Comparative efficacy of long-acting muscarinic antagonist monotherapies in COPD: a systematic review and network meta-analysis. Int J Chron Obstruct Pulmon Dis. 2015 Nov 16; 10: 2495-517.
Some studies in patients taking short-acting muscarinic receptor antagonists, as well as in some studies in patients taking long-acting muscarinic receptor antagonists, have evidence of an increased mortality rate associated with cardiovascular disease. Hilleman DE, Malesker MA, Morrow LE, et al. A systematic review of the cardiovascular risk of inhaled anticholinergics in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2009; 4: 253-63.
 Wang MT, Liou JT, Lin CW, et al. Association of cardiovascular risk with inhaled long-acting bronchodilators in patients with chronic obstructive pulmonary disease: a nested case-control study.JAMA Intern Med. 2018 Feb 1; 178 (2): 229-38.
A population-based cohort study found that older men with COPD who are initiated on long-acting muscarinic receptor antagonists have an increased risk of developing urinary tract infections.  Gershon AS, Newman AM, Fischer HD, et al. Inhaled long-acting anticholinergics and urinary tract infection in individuals with COPD. COPD. 2017 Feb; 14 (1): 105-12.http://www.ncbi.nlm.nih.gov/pubmed/27732117?tool=bestpractice.com
Beta-agonists and anticholinergics provide bronchodilatory effect in different ways. Their combination may provide the best therapeutic effect without increasing the side effects of each drug class.  Rabe KF, Timmer W, Sagkriotis A, et al. Comparison of a combination of tiotropium plus formoterol to salmeterol plus fluticasone in moderate COPD. Chest. 2008 Aug; 134 (2): 255-62.
http: // www.ncbi.nlm.nih.gov/pubmed/18403672?tool=bestpractice.com
 Tashkin DP, Littner M, Andrews CP, et al. Concomitant treatment with nebulized formoterol and tiotropium in subjects with COPD: a placebo-controlled trial. Respir Med. 2008 Apr; 102 (4): 479-87.
 Tashkin DP, Pearle J, Iezzoni D, et al. Formoterol and tiotropium compared with tiotropium alone for treatment of COPD. COPD. 2009 Feb; 6 (1): 17-25.
http: // www.ncbi.nlm.nih.gov/pubmed/19229704?tool=bestpractice.com
 Vogelmeier C, Kardos P, Harari S, et al. Formoterol mono- and combination therapy with tiotropium in patients with COPD: a 6-month study. Respir Med. 2008 Nov; 102 (11): 1511-20.
Compared with the long-acting B2 agonist / ICS combination, the long-acting B2 agonist combination with long-acting muscarinic receptor antagonists showed fewer exacerbations, a more pronounced improvement in FEV1 parameters, a lower risk of pneumonia, and a more frequent improvement in quality of life. Horita N, Goto A, Shibata Y, et al. Long-acting muscarinic antagonist (LAMA) plus long-acting beta-agonist (LABA) versus LABA plus inhaled corticosteroid (ICS) for stable chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2017 Feb 10; (2): CD012066.
A systematic review and network meta-analysis found that all fixed-dose combinations of long-acting B2 agonists / long-acting muscarinic receptor antagonists showed similar efficacy and safety. Schlueter M, Gonzalez-Rojas N, Baldwin M, et al. Comparative efficacy of fixed-dose combinations of long-acting muscarinic antagonists and long-acting beta2-agonists: a systematic review and network meta-analysis. Ther Adv Respir Dis. 2016 Apr; 10 (2): 89-104.
In the case of stable COPD, if the decision is made to use single-agent therapy, LAMA may be superior to LABA agents. Rabe KF, Timmer W, Sagkriotis A, et al. Comparison of a combination of tiotropium plus formoterol to salmeterol plus fluticasone in moderate COPD. Chest. 2008 Aug; 134 (2): 255-62.
Clinical trials have shown that LAMA has a greater effect on reducing the incidence of exacerbations than LABA.  Vogelmeier C, Hederer B, Glaab T, et al; POET-COPD Investigators. Tiotropium versus salmeterol for the prevention of exacerbations of COPD.N Engl J Med. 2011 Mar 24; 364 (12): 1093-103.
 Decramer ML, Chapman KR, Dahl R, et al; INVIGORATE investigators. Once-daily indacaterol versus tiotropium for patients with severe chronic obstructive pulmonary disease (INVIGORATE): a randomized, blinded, parallel-group study. Lancet Respir Med. 2013 Sep; 1 (7): 524-33.
The long-term safety of LAMA has been demonstrated in the UPLIFT trial.  Celli B, Decramer M, Kesten S, et al. UPLIFT Study Investigators. Mortality in the 4-year trial of tiotropium (UPLIFT) in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2009 Nov 15; 180 (10): 948-55.
As stated above, GOLD makes recommendations for an initial agent based on the patient’s risk group (A, B, C, or D). Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
Theophylline (a methylxanthine preparation) is a bronchodilator that works by increasing cAMP levels and then relaxing the respiratory smooth muscles. It is not widely used due to its limited efficacy, narrow therapeutic window, high risk profile, and frequent drug interactions.Theophylline is indicated for persistent symptoms in the event of insufficient inhalation therapy to relieve airway obstruction. Theophylline has a potent effect on lung function in moderate to severe COPD.  Ram FS, Jones PW, Castro AA, et al. Oral theophylline for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002; (4): CD003902.
Umeclidinium / Vilanterol is a long acting B2 agonist / muscarinic receptor antagonist combination approved for use in COPD. Celli B, Crater G, Kilbride S, et al. Once-daily umeclidinium / vilanterol 125/25 mcg in COPD: a randomized, controlled study. Chest. 2014 May; 145 (5): 981-91.
Glycopyrronium / formoterol fumarate is another LABA / LAMA combination approved for use in patients with COPD,  Radovanovic D, Mantero M, Sferrazza Papa GF, et al. Formoterol fumarate + glycopyrrolate for the treatment of chronic obstructive pulmonary disease.Expert Rev Respir Med. 2016 Oct; 10 (10): 1045-55.
as indacaterol / glycopyrronium.  Bateman ED, Ferguson GT, Barnes N, et al. Dual bronchodilation with QVA149 versus single bronchodilator therapy: the SHINE study. Eur Respir J. 2013 Dec; 42 (6): 1484-94.
 Buhl R, Gessner C, Schuermann W, et al.Efficacy and safety of once-daily QVA149 compared with the free combination of once-daily tiotropium plus twice-daily formoterol in patients with moderate-to-severe COPD (QUANTIFY): a randomized, non-inferiority study. Thorax. 2015 Apr; 70 (4): 311-9.
This inhaler, used once daily, has been shown to be highly effective compared to glycopyrronium plus tiotropium in patients with moderate to severe COPD,  Rodrigo GJ, Plaza V.Efficacy and safety of a fixed-dose combination of indacaterol and glycopyrronium for the treatment of COPD: a systematic review. Chest. 2014 Aug; 146 (2): 309-17.
and compared with salmeterol / fluticasone to prevent exacerbations of COPD.  Wedzicha JA, Banerji D, Chapman KR, et al; FLAME Investigators. Indacaterol-glycopyrronium versus salmeterol-fluticasone for COPD. N Engl J Med. 2016 Jun 9; 374 (23): 2222-34.
https: // www.nejm.org/doi/10.1056/NEJMoa1516385
Inhaled corticosteroids are indicated for patients with advanced COPD suffering from frequent exacerbations.  Hanania NA, Darken P, Horstman D, et al. The efficacy and safety of fluticasone propionate (250 microg) / salmeterol (50 microg) combined in the Diskus inhaler for the treatment of COPD. Chest. 2003 Sep; 124 (3): 834-43.http://www.ncbi.nlm.nih.gov/pubmed/12970006?tool=bestpractice.com
They need to be added to the bronchodilator therapy patients are already receiving.  Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
Inhaled corticosteroids are believed to be effective because of their anti-inflammatory effect.The use of inhaled corticosteroids reduces the need for rescue therapy and reduces the number of exacerbations, and may also reduce mortality.  Spencer S, Calverley PM, Burge PS, et al. Impact of preventing exacerbations on deterioration of health status in COPD. Eur Respir J. 2004 May; 23 (5): 698-702.
 Sin DD, Wu L, Anderson JA, et al. Inhaled corticosteroids and mortality in chronic obstructive pulmonary disease.Thorax. 2005 Dec; 60 (12): 992-7.
What are the longer-term (> 6 months) effects of inhaled corticosteroids in people with stable chronic obstructive pulmonary disease? /Cca.html? TargetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.805/full response Several studies have documented an increased risk of pneumonia in patients with COPD taking inhaled corticosteroids.  Yang IA, Clarke MS, Sim EH, et al.Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Jul 11; (7): CD002991.
This risk is slightly higher for fluticasone compared to budesonide.  Suissa S, Patenaude V, Lapi F, et al. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013 Nov; 68 (11): 1029-36.https://thorax.bmj.com/content/68/11/1029.long
A systematic review and meta-analysis found that, despite a significant increase in the unadjusted risk of pneumonia associated with inhaled corticosteroid use, pneumonia mortality and overall mortality did not increase in randomized controlled trials, but decreased in observational studies.  Festic E , Bansal V, Gupta E, et al.Association of inhaled corticosteroids with incident pneumonia and mortality in COPD patients; systematic review and meta-analysis. COPD. 2016 Jun; 13 (3): 312-26.
On this basis, an individualized approach to treatment should be adopted that assesses the patient’s risk of pneumonia versus the benefits of reducing the number of exacerbations. Yang IA, Clarke MS, Sim EH, et al. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Jul 11; (7): CD002991.
 Welte T. Inhaled corticosteroids in COPD and the risk of pneumonia. Lancet. 2009 Aug 29; 374 (9691): 668-70.
 Kew KM, Seniukovich A. Inhaled steroids and risk of pneumonia for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014 Mar 10; (3): CD010115.
Also of concern is the increased risk of developing tuberculosis and influenza in adult patients with COPD who are receiving inhaled corticosteroid therapy. Dong YH, Chang CH, Lin Wu FL, et al. Use of inhaled corticosteroids in patients with COPD and the risk of TB and influenza: a systematic review and meta-analysis of randomized controlled trials. Chest. 2014 Jun; 145 (6): 1286-97.
According to the GOLD guidelines, inhaled corticosteroids are not recommended as first-line therapy in any patient group A to D. They are only recommended as part of an escalation of therapy if patients continue to experience exacerbations despite taking a long-acting bronchodilator. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
Roflumilast is an oral phosphodiesterase-4 inhibitor that can reduce the number of exacerbations in Group D patients who are at risk of frequent exacerbations without adequate control while taking long-acting bronchodilators. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
This drug is beneficial in improving lung function and reducing the likelihood of exacerbations. However, it has little effect on quality of life and symptoms.  Chong J, Leung B, Poole P. Phosphodiesterase 4 inhibitors for chronic obstructive pulmonary disease.Cochrane Database Syst Rev. 2017 Sep 19; (9): CD002309.
Combinations of bronchodilators and corticosteroids
Combinations of long-acting bronchodilators and inhaled corticosteroids can be used for patients requiring both.
What are the effects of long-acting inhaled therapies for adults with chronic obstructive pulmonary disease (COPD)? / Cca.html? targetUrl = https: //www.cochranelibrary.com/cca/doi/10.1002/cca.2364/full The choice of therapy in this class is based on capacity, individual response and patient choice.  Tricco AC, Strifler L, Veroniki AA, et al. Comparative safety and effectiveness of long-acting inhaled agents for treating chronic obstructive pulmonary disease: a systematic review and network meta-analysis. BMJ Open. 2015 Oct 26; 5 (10): e009183.https://bmjopen.bmj.com/content/5/10/e009183.long
Priority is given to the use of combination therapy with inhaled corticosteroids and long-acting beta-agonists over the use of these drugs alone.  Nannini LJ, Lasserson TJ, Poole P. Combined corticosteroid and long-acting beta (2) -agonist in one inhaler versus long- acting beta (2) -agonists for chronic obstructive pulmonary disease.Cochrane Database Syst Rev. 2012 Sep 12; (9): CD006829.
 Nannini LJ, Poole P, Milan SJ, et al. Combined corticosteroid and long-acting beta (2) -agonist in one inhaler versus inhaled corticosteroids alone for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2013 Aug 30; (8): CD006826.
https: //www.cochranelibrary.com / cdsr / doi / 10.1002 / 14651858.CD006826.pub2 / full
In people with chronic obstructive pulmonary disease (COPD), what are the effects of combined corticosteroid and long-acting beta-agonist (LABA) in one inhaler versus LABA alone? /Cca.html? TargetUrl = https://cochranelibrary.com/ cca / doi / 10.1002 / cca.56 / full
Numerous studies support triple therapy with long-acting B2 agonist / long-acting muscarinic receptor antagonist / IR as such, which is superior to therapy with one or two drugs, such as long-acting B2 agonist / long-acting muscarinic receptor antagonist or long-acting B2 agonist / ICS, regarding the rates of moderate and severe exacerbations of COPD  Singh D, Papi A, Corradi M, et al. Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β2-agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomized controlled trial.Lancet. 2016 Sep 3; 388 (10048): 963-73.
 Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a double-blind, parallel group, randomized controlled trial. Lancet. 2017 May 13; 389 (10082): 1919-29.
 Papi A, Vestbo J, Fabbri L, et al.Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease (TRIBUTE): a double-blind, parallel group, randomized controlled trial. Lancet. 2018 Mar 17; 391 (10125): 1076-84.
 Lipson DA, Barnacle H, Birk R, et al. FULFIL Trial: once-daily triple therapy for patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2017 Aug 15; 196 (4): 438-46.
https: // www.atsjournals.org/doi/full/10.1164/rccm.201703-0449OC
and hospitalization rates.  Lipson DA, Barnhart F, Brealey N, et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med. 2018 May 3; 378 (18): 1671-80.
 Rojas-Reyes MX, García Morales OM, Dennis RJ, et al. Combination inhaled steroid and long-acting beta₂-agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease.Cochrane Database Syst Rev. 2016 Jun 6; (6): CD008532.
Patient education and self-help
All patients should be well informed about the course of the disease, symptoms of exacerbation and decompensation. Their expectations for disease, treatment and prognosis must be realistic. It is important to remember that no drug has been shown to be effective in long-term modification of decreased lung function, so the primary goal of pharmacotherapy is to control symptoms and prevent complications.
One Cochrane review found that self-help interventions that include an action plan for an exacerbation of COPD are associated with improved health-related quality of life and fewer hospitalizations for respiratory problems. The exploratory analysis revealed a small but significantly large difference in mortality rates associated with respiratory diseases in self-care compared with traditional care, although there was no increased risk of death from other causes. Lenferink A, Brusse-Keizer M, van der Valk PD, et al. Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Aug 4; (8): CD011682.
One randomized controlled trial found that telephone health coaching to promote behavioral change in patients with mild COPD in a primary health care setting resulted in improved self-care management, but did not improve health-related quality of life. … Jolly K, Sidhu MS, Hewitt CA, et al. Self management of patients with mild COPD in primary care: randomized controlled trial. BMJ. 2018 Jun 13; 361: k2241.
Physical activity is recommended for all patients with COPD.  Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.2018 [internet publication].
One systematic review and meta-analysis of randomized controlled trials found that exercise alone can improve physical activity in COPD, and more improvement can be achieved with additional physical activity counseling.  Lahham A, McDonald CF, Holland AE. Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials.Int J Chron Obstruct Pulmon Dis. 2016 Dec 8; 11: 3121-36.
Another systematic review and meta-analysis found that a combination of aerobic exercise and strength training was more effective than strength training or endurance training alone in terms of increasing distance traveled in 6 minutes. Vooijs M, Siemonsma PC, Heus I, et al. Therapeutic validity and effectiveness of supervised physical exercise training on exercise capacity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Clin Rehabil. 2016 Nov; 30 (11): 1037-48.
Smoking cessation and vaccination
Patients should be counseled on smoking cessation and, in addition, advised to avoid exposure to tobacco smoke in the work and environment.
Typically a smoking cessation program includes counseling, group meetings and drug therapy.  Gonzales D, Rennard SI, Nides M, et al; Varenicline Phase 3 Study Group. Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA. 2006 Jul 5; 296 (1): 47-55.
http: //www.ncbi.nlm.nih.gov / pubmed / 16820546? tool = bestpractice.com
Some patients may need frequent counseling to be successful. Quitting smoking significantly reduces the rate of progression of COPD and the risk of malignancy. It also reduces the risk of coronary and cerebrovascular disease. Smoking cessation, which includes pharmacotherapy and intensive counseling, has a high success and cost-benefit rate for COPD, with lower quality of life costs per year. Hoogendoorn M, Feenstra TL, Hoogenveen RT, et al. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax. 2010 Aug; 65 (8): 711-8.
 Warnier MJ, van Riet EE, Rutten FH, et al. Smoking cessation strategies in patients with COPD. Eur Respir J. 2013 Mar; 41 (3): 727-34.
 van Eerd EA, van der Meer RM, van Schayck OC, et al.Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016 Aug 20; (8): CD010744.
Patients should be vaccinated against hepatitis virus and Streptococcus pneumoniae.  Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.2018 [internet publication].
 Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jan 24; (1): CD001390.
Influenza vaccination is associated with fewer exacerbations of COPD. Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Jan 24; (1): CD001390.
 Kopsaftis Z, Wood-Baker R, Poole P. Influenza vaccine for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018 Jun 26; (6): CD002733.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002733.pub3/full
What are the effects of influenza vaccine in people with chronic obstructive pulmonary disease (COPD)? /Cca.html? TargetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.2235/full Show Answer
Chronic bronchitis patients with the COPD phenotype often regularly produce thick phlegm.Mucolytics are not associated with increased side effects and may be helpful in exacerbations of COPD.
For people with chronic bronchitis or chronic obstructive pulmonary disease, how do mucolytic agents compare with placebo? /Cca.html? TargetUrl = https: //www.cochranelibrary.com/cca/doi/10.1002/cca.2591/full to a slight decrease in the frequency of exacerbations, but do not improve lung function and quality of life. Mucolytics may be more beneficial to patients than inhaled corticosteroids. Poole P, Chong J, Cates CJ. Mucolytic agents versus placebo for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Jul 29; (7): CD001287.
Using positive expiratory pressure (PEP) therapy to clear secretions during an exacerbation relieves the subjective sensations of shortness of breath, but is not associated with a decrease in hospital admissions or exacerbations. Osadnik CR, McDonald CF, Miller BR, et al. The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicenter, randomized controlled trial. Thorax. 2014 Feb; 69 (2): 137-43.
Pulmonary rehabilitation is indicated for patients in whom symptoms persist despite bronchodilator therapy; it is recommended to start it in the early stages of the disease, when there is a feeling of shortness of breath during normal activity or walking on a flat surface.Its effect is helpful in improving physical stamina and quality of life.
What are the effects of pulmonary rehabilitation after exacerbation in people with chronic obstructive pulmonary disease? /Cca.html? TargetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.1650/full Show answer It also reduces depression and anxiety associated with this disease and reduces hospitalization among patients with COPD.  Casaburi R, ZuWallack R. Pulmonary rehabilitation for management of chronic obstructive pulmonary disease.N Engl J Med. 2009 Mar 26; 360 (13): 1329-35.
Benefit begins to decline after the end of the course if patients do not adhere to the exercise schedule at home.  Guell R, Casan P, Belda J, et al. Long-term effects of outpatient rehabilitation of COPD: a randomized trial. Chest. 2000 Apr; 117 (4): 976-83.
The positive impact of home or group pulmonary rehabilitation on respiratory symptoms and quality of life for patients with COPD can be as high as that of a rehabilitation program in a hospital. Maltais F, Bourbeau J, Shapiro S, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008 Dec 16; 149 (12): 869-78.
 Neves LF, Reis MH, Gonçalves TR. Home or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Cad Saude Publica. 2016 Jun 20; 32 (6): S0102-311X2016000602001.http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2016000602001&lng=en&nrm=iso&tlng=en
Pulmonary rehabilitation also relieves dyspnea and fatigue, improves emotional function, and enhances feelings of control to a moderately large and clinically significant degree,  McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev.2015 Feb 23; (2): CD003793.
and it is important to remember that accelerating the progress of exercise in rehabilitation, compared to the standard of physical therapy practice in hospital admission for COPD, is not recommended and may be associated with an increase in 12-month mortality.  Greening NJ, Williams JE, Hussain SF, et al. An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomized controlled trial.BMJ. 2014 Jul 8; 349: g4315.
There is evidence to support the initiation of pulmonary rehabilitation within 1 month of an exacerbation.  Marciniuk DD, Brooks D, Butcher S, et al. Canadian Thoracic Society COPD Committee Expert Working Group. Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease – practical issues: a Canadian Thoracic Society Clinical Practice Guideline.Can Respir J. 2010 Jul-Aug; 17 (4): 159-68.
 Puhan MA, Gimeno-Santos E, Cates CJ, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016 Dec 8; (12): CD005305.
The GOLD guidelines recommend pulmonary rehabilitation for patient groups B to D. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
The GOLD Guidelines recommend long-term oxygen therapy in stable patients who have:  Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
PaO₂ ≤7.3 kPa (55 mmHg) or SaO₂ ≤88%, with or without hypercapnia, confirmed twice in a 3-week period; or
PaO₂ between 7.3 kPa (55 mm Hg) and 8.0 kPa (60 mm Hg) or SaO₂ 88% in the presence of signs of pulmonary hypertension, peripheral edema indicating congestive heart failure , and polycythemia (hematocrit> 55%).
Oxygen therapy helps to minimize pulmonary hypertension by reducing pulmonary artery pressure and improves physical endurance and quality of life. Also shown to be effective in improving survival  Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2018 [internet publication].
 Celli BR, MacNee W, Agusti A, et al; ATS / ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS / ERS position paper. Eur Respir J. 2004 Jun; 23 (6): 932-46.
 Sin DD, McAlister FA, Man SF, et al. Contemporary management of chronic obstructive pulmonary disease: scientific review.JAMA. 2003 Nov 5; 290 (17): 2301-12.
Oxygen is recommended for patients whose expected PaO₂ during air travel is <6.7 kPa (<50 mmHg)  Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.2018 [internet publication]. https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf In these patients, ambient air saturation at sea level is typically <92%. If in doubt, the patient can be tested to assess the expected PaO₂ during the flight.
There is some evidence that oxygen can relieve dyspnea when given during exercise to individuals with COPD with mild or non-hypoxemic hypoxemia, who are otherwise not eligible for home oxygen therapy. Ekstrom M, Ahmadi Z, Bornefalk-Hermansson A, et al. Oxygen for breathlessness in patients with chronic obstructive pulmonary disease who do not qualify for home oxygen therapy. Cochrane Database Syst Rev. 2016 Nov 25; (11): CD006429.
Surgical procedures (removal of bullae, surgery to reduce lung volume,  van Agteren JE, Hnin K, Grosser D, et al.Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Feb 23; (2): CD012158.
 van Agteren JE, Carson KV, Tiong LU, et al. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016 Oct 14; (10): CD001001.
https: //www.cochranelibrary.com / cdsr / doi / 10.1002 / 14651858.CD001001.pub3 / full
How does bronchoscopic lung volume reduction compare with medical therapy in people with chronic obstructive pulmonary disease? /Cca.html? TargetUrl = https: //cochranelibrary.com/cca/doi/10.1002/cca.1680/fullShow answer and lung transplant) are the last step in the treatment of COPD. They are used to improve pulmonary dynamics, exercise tolerance and quality of life. Sutherland ER, Cherniack RM. Management of chronic obstructive pulmonary disease. N Engl J Med. 2004 Jun 24; 350 (26): 2689-97.
Endobronchial valve placement can lead to clinically significant improvement in appropriately selected COPD patients.  Klooster K, Slebos DJ, Zoumot Z, et al. Endobronchial valves for emphysema: an individual patient-level reanalysis of randomized controlled trials. BMJ Open Respir Res.2017 Nov 2; 4 (1): e000214.
Criteria for referral for lung transplantation include:  Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014 – an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant.2015 Jan; 34 (1): 1-15.
Progressive illness despite maximum treatment, which includes drug therapy, pulmonary rehabilitation and oxygen therapy.
The patient is not a candidate for endoscopic or open lung volume reduction (OSOL) surgery. Concurrent referral of patients with COPD for assessment regarding the need for lung transplantation and the need for OSOL is acceptable.
BODE index (body mass index, airflow obstruction, shortness of breath and physical performance) at the level of 5-6.
PaCO₂> 50 mm. rt. st or 6.6 kPa and / or PaO₂ <60 mm. rt. st or 8 kPa.
Forecasted FEV1 <25%
BODE Index for Predicting Survival in COPD
For some patients with advanced COPD, palliative care and hospice care should be considered.The patient and family should be well aware of the course of the disease, it is suggested that the discussion should be held in the early stages of the disease, before the development of acute respiratory failure.  Carlucci A, Guerrieri A, Nava S. Palliative care in COPD patients: is it only an end-of-life issue? Eur Respir Rev. 2012 Dec 1; 21 (126): 347-54.
One study suggested that low-dose opioid pain relievers and benzodiazepines are safe and are not associated with increased hospital admissions or mortality. Ekstrom MP, Bornefalk-Hermansson A, Abernethy AP, et al. Safety of benzodiazepines and opioids in very severe respiratory disease: a national prospective study. BMJ. 2014 Jan 30; 348: g445.
One Cochrane review concluded that there is no evidence for or against the use of benzodiazepines to relieve dyspnea in patients with advanced cancer or COPD. Simon ST, Higginson IJ, Booth S, et al. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev. 2016 Oct 20; (10): CD007354.
Chronic obstructive pulmonary disease (COPD)
Chronic obstructive pulmonary disease (COPD) is a progressive and ultimately debilitating lung disease, which means the condition gets worse over time.The disease usually causes coughing, wheezing, and shortness of breath, making it difficult to breathe. According to the National Institutes of Health, COPD is the third leading cause of death.
COPD is most common in people over the age of 40 and who have a history of smoking. Various factors can contribute to the development of COPD, including long-term exposure to air pollutants and dust. However, cigarette smoking is the main cause of the disease. In fact, smoking causes about 90% of COPD cases.
COPD: Causes of the disease
COPD is most commonly caused by smoking. Most people are long-term smokers, and research shows that smoking cigarettes increases the risk of disease.
COPD is often a combination of two diseases: chronic bronchitis and emphysema. Both of these diseases are caused by smoking. You may have a mixture of both, though.
Chronic obstructive pulmonary disease (COPD) is a long-term lung disease. It consists of two diseases: emphysema and chronic bronchitis.Long-term coughing is often a symptom of COPD. There are other symptoms that can occur as lung damage progresses.
Many of these symptoms can also develop slowly. More complex symptoms appear when significant lung damage has already occurred. Symptoms can also be episodic and vary in intensity. If you have COPD, or are wondering if you have a medical condition, inquire about your symptoms and talk to your doctor.
Cough is often the first symptom of COPD. According to the Mayo Clinic, chronic bronchitis associated with COPD is diagnosed if your cough persists for three months or more for a year, for at least two years. A cough can occur every day, even if there are no other symptoms of the disease.
A cough is how the body clears mucus and other irritants such as dust or pollen and secretions from the airways and lungs.Usually people cough mucus, it is clear, but often it is yellow in people with COPD. The cough is usually worse in the early morning, and you may cough more when you are physically active or smoke.
Other common symptoms of COPD
As COPD progresses, you may develop symptoms other than coughing. They can occur in the early and middle stages of the disease.
When you exhale and air is forced through narrow or obstructed air passages in your lungs, you may hear a wheezing or musical sound called wheezing.People with COPD are more likely to have excess mucus that blocks their airways. This is due to muscle tightening, which further narrows the airways.
Sweeping can also be a symptom of asthma or pneumonia. Some people with COPD may also have a condition that includes symptoms of both COPD and asthma.
Shortness of breath
As the airways in the lungs become swollen (inflamed) and damaged, they may begin to narrow. You may find it harder to breathe or catch your breath.This symptom of COPD is most noticeable with increased physical activity. It can make even daily tasks challenging, including:
• Simple household chores
In the worst case scenario, it can even happen while on holiday.
You often cannot get enough oxygen in your blood and muscles if you have difficulty breathing. Your body slows down and fatigue starts without the oxygen it needs. You may also feel tired because your lungs are working too hard to get oxygen and carbon dioxide.
Frequent respiratory infections
People with COPD have less reliable immune systems. COPD also makes it difficult to clear light pollutants, dust, and other irritants. When this happens, people with COPD are at greater risk of lung infections such as colds, flu, and pneumonia. It can be difficult to avoid infections, but practicing good hand washing and getting the right vaccinations can reduce your risk.
What are the serious complications associated with COPD?
For people living with COPD, breathing can be difficult. People with COPD can be at risk of serious complications that can not only put their health at risk, but can also be fatal. Here are a few of these complications, along with some tips to prevent them.
Pneumonia occurs when bacteria or viruses enter the lungs, creating an infection. According to the Centers for Disease Control and Prevention, bacterial pneumonia is the most common form of pneumonia. It is ranked evenly with the flu as the eighth leading cause of death. The disease is especially dangerous for people with a weakened lung system, such as those with COPD. For these people, pneumonia can further damage the lungs. This can lead to a chain reaction of diseases that can further weaken the lungs. This downward spiral can lead to a rapid deterioration in the health of people with COPD.
Overall, good health is the key to preventing infection in people with COPD. Here are some tips to reduce your risk of infection:
• Drink plenty of fluids, especially water, to maintain healthy bronchioles by thinning mucus and secretions.
• Quit or avoid smoking to maintain a healthy immune system and lung health.
• Wash your hands consistently.
• Avoid contact with people who are sick.
• Discourage sick friends and family from visiting your home.
• Get pneumonia vaccines and your annual flu vaccine.
Chronic heart failure
Heart failure is one of the most important complications of COPD. Because people with COPD have lower blood oxygen levels, their heart often suffers. According to the American Thoracic Society, this can lead to severe pulmonary hypertension in a small percentage of patients (less than 10%).For many patients, COPD treatment can help prevent the disease from progressing to the point that it causes heart failure. Unfortunately, because many of the symptoms of heart failure can be the same as those of COPD, it can be difficult for patients to realize that they are having heart problems until it is too late.
Since COPD can often be attributed to smoking, it is not surprising that people with COPD often develop lung cancer.However, researchers have actually identified a link between COPD and lung cancer that is separate from the person’s smoking history. This is most likely due to chronic inflammation in the lungs. Genetics can play a role as well. Because lung cancer is often fatal, it is important that people with COPD remove factors that further damage their lungs, especially smoking.
COPD does not cause diabetes, but it can make it harder to manage difficult diabetes symptoms.One of the significant complications associated with both COPD and diabetes is the deleterious interaction between COPD and diabetic drugs. People with diabetes and COPD may find that their symptoms have worsened because diabetes can also restrict their cardiovascular system. Smoking can worsen the symptoms of both diabetes and COPD. It is imperative to stop smoking as soon as possible. Learning to manage blood sugar, usually with the help of your doctor, can help keep COPD symptoms from becoming overwhelming.Uncontrolled diabetes, which causes persistently high blood sugar, can decrease lung function. Work with your doctor to make sure the medications they are prescribing will work together to treat both conditions. It can help you manage these two diseases at once.
The gradual mental decline in many severe COPD patients can be difficult for loved ones. Dementia is especially common in patients older than COPD, making it difficult to manage symptoms.COPD is an intrinsic risk factor for developing dementia. Conditions such as low oxygen, high levels of carbon dioxide, and damage to blood vessels in the brain due to smoking play a role in dementia in COPD.
Respiratory failure is the most common cause of death from COPD. After several months, years, or even decades of struggling with lung problems, the patient’s lungs stop working. Heart failure is also a factor in deaths from COPD, with COPD often contributing to heart problems.
Although there is no known cure for chronic obstructive pulmonary disease (COPD), treatment can help relieve your symptoms and slow it down. The main goals of COPD treatment are:
• Improve well-being
• Improve your quality of life
• Help you stay active
• Prevent and treat complications
• Improve your overall quality of life
95 2 First and the most important thing you should do is quit smoking or not start if you don’t already smoke. You should also minimize air pollution in your environment. Avoid secondhand smoke and avoid getting dust, fumes, and other toxic substances that you may inhale.
Diet and exercise
Eating healthy foods is also important. The fatigue and shortness of breath that comes with COPD can make it difficult to consume. Eat less food more often. Your doctor may suggest nutritional supplements. It can also be helpful to rest before eating.
Exercise is important, but for some it can be difficult.Physical activity can strengthen the muscles that help you breathe. Talk to your doctor about physical activities that are right for you. Pulmonary rehabilitation can also be a way to improve endurance and help with breathing problems, so ask your doctor about your options.
Drugs for smoking cessation
Quitting smoking can improve your health and quality of life, with or without COPD. Because nicotine is highly addictive, many doctors offer nicotine replacement therapy to patients to ease their cigarette cravings.Recommended nicotine replacement procedures are in the form of gums, patches, and inhalers.
Several antidepressants have been clinically proven to reduce or eliminate smoking, but you should be aware of the side effects. If your doctor prescribes medication, be sure to ask what to expect
COPD: When to seek help?
Call a doctor or other emergency services now if:
• Breathing stops.
• Moderate to severe breathing difficulties. This means that the person may have trouble speaking fully or breathing during exercise.
• Severe chest pain, or chest pain gets worse quickly.
• You are coughing up large amounts of bright red blood.
See your doctor right away or go to the emergency room if you are diagnosed with COPD and:
• Cough up a couple tablespoons of blood.
• You have shortness of breath or wheezing that gets worse quickly.
• Chest pains again.
• The cough is deeper or more frequent, especially if you notice an increase in mucus (sputum) or a change in the color of the mucus.
• Increased swelling in the legs or abdomen.
• You have a high fever (38.3 ° C)
• You develop flu symptoms.
Call your doctor soon if:
• Your medication is not working as well as it did.
• Your symptoms are gradually getting worse and you have not seen a doctor for a long time.
• You have a cold and:
o Your fever lasts longer than 2-3 days.