Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disorder (COPD): Part III

(11/7/17)- When the heart starts to fail, many individual have implanted defibrillators to keep it humming. The defibrillator will continue to work, even after the heart fails.

Because of improved medical care and the latest improvements in medical technology heart failure patients are living longer lives. Heart failure occurs when the heart canít pump enough blood to supply the bodyís needs.

With the aging of the population, the number of Americans with heart failure has climbed to 6.5 million in 2011-14 from 5.7 million in 2009-12, according to the American Heart Association.

About 10% of the population over 60 have heart failure, and this figure continues to climb, even though the death rate from heart attacks continues to decline. Heart failure patients account for about 15% of hospice deaths

(7/25/14)- Women whose waist size was at least 43 inches and men whose waist size was at least 46 inches had a 72% greater risk of developing chronic obstructive pulmonary disease (COPD) compared with those with a normal waist size, a study of more than 113,000 Americans ages 50 to 70 found.

The study, published in the Canadian Medical Association Journal, also found that engaging in physical activity five times or more per week lowered COPD risk by 29% compared with being physically inactive

(2/26/12)- The Food and Drug Administration's pulmonary allergy drug advisory panel approved Forest Laboratories Inc.'s, aclidinium bromide, a long-acting inhaled drug for the treatment of Chronic Obstructive Pulmonary Disorder (COPD). Forest licensed the U.S. rights for the product from Almirall SA.

The FDA does not have to go along with the approval of the advisory panel, but it usually does follow the panel's approval with an approval of its own.

If approved, Forest has proposed marketing aclidinium under the brand name Tudorza Pressair.

(3/8/11)- The U.S. Food and Drug Administration has approved roflumilast, a pill taken daily to decrease the frequency of flare-ups or worsening of symptoms from severe Chronic Obstructive Pulmonary Disorder (COPD).

Roflumilast is an inhibitor of an enzyme called phosphodiesterase type 4 (PDE), but it is not intended to treat another form of COPD which involves primary emphysema.

The pill is marketed by the St. Louis based Forest Pharmaceuticals, a subsidiary of Forest Laboratories.

There were two Phase 3 clinical studies of the pill involving over 1,500 patients aged 40 and older. Those treated had a history of COPD associated with chronic bronchitis and had experienced a worsening of the disease during the 12 months prior to beginning the treatment.

The pill is not recommended for people younger than 18 years of age. The most common adverse affects are diarrhea, nausea, headache, insomnia, back pain, decreased appetite and dizziness.

12 million people have been diagnosed with chronic obstructive pulmonary disease (COPD). Deaths attributed to COPD now total 5 percent of all mortality in the United States with heart disease actually the most common cause of death in persons with COPD. It is the fourth leading cause of deaths in the United States.

(5/3/04)- As we have written in previous articles, COPD, a leading cause of mortality and morbidity, is characterized by a restricted airflow which reduces breathing capacity and causes shortness of breath. Ultimately, these factors interfere with daily activities and have a drastic limiting factor on quality of life.

Exercise training in pulmonary rehabilitation programs target functional capacity. This training is an important add-on to any medical treatment and can prove essential to increased quality of life. Many of these exercise programs involve intense supervision by health care professionals and tend to be costly. In the economic atmosphere that exists today involving a cost conscious approach to health care, these programs may lose out to "quick-fix" programs.

With this in mind, we searched the professional literature to see if these were any reports of pulmonary rehabilitation exercise programs that involve minimal supervision (low cost) and meet optimal criteria for program success. The American Journal of Physical Medicine Rehabilitation (2004; 83:337-343) reported on a study by M. Ferrari et al. which, if it can be replicated in a more rigid randomized, placebo controlled fashion, holds promise for a low resource intensive home-based program involving patients monitoring their own exercise session, improving their exercise tolerance and enhancing their quality of life.

The program included lower and upper limb training on a three times per week basis for 12 weeks. The first two sessions were conducted at a clinic and monitored by a physiotherapist and the remainder was performed at home.

Because many of our readers have difficulty obtaining the primary source of information on this program, we are quoting the "program" directly as outlined in the article.

Lower Back Training

"For lower back training, patients used a simple ergocycle with a mechanical brake. The training session consists of three stages. In the first, the patient pedaled for five minutes without applying the brake. Then the patient was instructed to set the brake to maintain heart rate as close as possible to 70% of the maximum heart rate reached during the preliminary exercise test. This second phase lasted 20 minutes and was followed by 10 minutes of pedaling without applying the brake. The pedaling frequency was about 60 rotations per minute at all times. Heart rate was self-monitored using a pulse meter. If patients were able to cycle for 20 minutes during the second phase of the training, the time on the cycle was extended by 5 minutes to a total exercise time of 40 minutes."

Upper Limb Training

"Upper limb training was performed by repeatedly raising and lowering a dowel from waist to the shoulder, using an interval-training regimen with alternate periods of exercise and rest as tolerated by the patient [e. g 2 minutes of exercise and one minute of rest). When patients were able to perform the upper limb exercise for 10 minutes, a 1kg weight was added to each arm. Stretching exercises for the hamstrings, quadriceps, calves, shoulders, neck and lower back were performed after each session."

The above exercise training program also included a psychosocial counseling and group and individual instruction on the appropriate use of medication and cooperative self management of the lung disease. Research "mavens" will point out that the study involved a small N and that educational counseling component confounds the results, along with the fact that there was no control group. The authors of the research acknowledge this: "Although our results suggest the effectiveness of the program, further controlled, randomized studies are needed to confirm the findings of this nonrandomized investigation."

The investigators conclusion of their study states "Our data shows a 12 week, low cost pulmonary rehabilitation program, performed at home with minimal supervision, can improve quality of life and exercise tolerance in patients with COPD." There is no claim that it cures COPD.

Despite all the criticisms of this study we cited above, one is hard pressed to deny the role of exercise in aiding in the pulmonary rehabilitation process. However, success of these pulmonary exercise programs depends on the persistence of the enrolled individuals to do the exercises over an extended period of time. Minimal supervision may not be the answer in all cases. It is the old case of "different strokes for different folks." Investigators will have to develop programs that match the personalities of individuals to programs. In many cases it will need to include educational components, a not so insignificant factor, for pulmonary programs to work. Lastly, it would seem important to develop preventative programs to lower this devastating syndrome to many elderly individuals.

For other articles in this series see:

Respiratory Infection-A Hidden Killer of the Elderly-Part I
Respiratory Disease-COPD-Part II



Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated November 7, 2017

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