Maximum Intensity Exercise Training in Patients with Chronic Obstructive Pulmonary Disease

doi:10.1378/chest.100.3.618

Chest

Volume 100, Issue 3, September 1991, Pages 618-623

https://doi.org/10.1378/chest.100.3.618 Get rights and content

We studied high intensity, symptom-limited, endurance exercise training in 52 patients with COPD participating in a pulmonary rehabilitation program. The patients had moderate to severe airway obstruction and reduced exercise tolerance with ventilatory limitation. The target workload for endurance exercise testing was 95 percent of the baseline maximum treadmill work load. At training weeks 1, 4 and 8, they were training at 85, 84, and 86 percent respectively, of baseline maximum. After rehabilitation, there was an increase in maximal treadmill work load, $\dot{V} o_{2} max$ , and endurance exercise time, and a decrease in perceived symptoms. Patients who did not reach anaerobic threshold (group 2) were able to train at a higher percentage of maximum exercise tolerance than patients who reached anaerobic threshold (group 1). The increase in exercise performance of both groups, however, was similar. We conclude that patients with moderate to severe COPD can perform exercise training successfully at intensity targets which represent higher percentages of maximum than typically recommended in normal individuals or other patients.

(Chest 1991; 100:618-23)

Section snippets

Subjects

The study population consisted of 57 patients with COPD who were assigned to pulmonary rehabilitation as part of a randomized clinical trial comparing education alone vs comprehensive pulmonary rehabilitation including individualized exercise training. All patients met the following entry criteria: (1) clinical diagnosis of COPD confirmed by history, physical examination, spirometry and chest roentgenogram; (2) stable condition while receiving an acceptable medical regimen prior to entry; (3)

RESULTS

Baseline data from 52 of the 57 patients were analyzed. Five patients were excluded because they did not reach a maximum symptom limit during the initial incremental exercise test due to low oxygen saturation (one), elevated systolic/diastolic blood pressure and low SaO₂ (one), cardiac arrhythmia (one), dry mouth (one) and gagging on the mouthpiece (one).

Attendance at scheduled rehabilitation program sessions was good. Patients attended a mean of 10.7 out of 12 clinic visits (88.9 percent).

DISCUSSION

The results of this study demonstrate that many patients with moderate to severe obstructive lung disease can undergo exercise training successfully at target intensities which are a considerably higher percentage of maximum than those typically recommended in normal individuals or patients with other diseases. Patients with ventilatory limitation to maximum exercise tolerance who did not develop significant metabolic acidosis during incremental exercise testing were able to train at levels

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Cited by (113)

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Pulmonary rehabilitation (PR) for patients with primary pulmonary disease can have a great effect on quality of life, functional capacity, and activities of daily living as well as a potential effect on hospitalizations and mortality. It is a comprehensive program of exercise, education, and lifestyle modification that aims to help improve the physical and psychological condition of patients with chronic pulmonary disease while promoting a program of long-term adherence to health-enhancing behaviors. PR can be done in the acute hospital setting, on inpatient rehabilitation services, and in outpatient rehabilitation settings. The role of the rehabilitation professional is to promote appropriate activity while monitoring medical compliance and enhancing education about the disease process and physiology of patients’ exercise limitations. PR is appropriate for patients with all types of lung disease and for those who will undergo lung surgery or transplantation.
Noninvasive ventilation during pulmonary rehabilitation in COPD patients
2016, Revue des Maladies Respiratoires
La réhabilitation respiratoire est aujourd’hui incontournable dans le traitement des patients atteints de bronchopneumopathie chronique obstructive (BPCO). Certains patients présentent cependant une limitation respiratoire telle qu’il est parfois impossible d’atteindre un niveau de réentraînement suffisant pour obtenir des bénéfices physiologiques.
Chez les patients atteints de BPCO, la modification des débits ainsi que des facteurs biomécaniques induits par la distension limitent l’adaptation ventilatoire à l’effort. Le recours à une ventilation non invasive (VNI) a été évalué chez les patients obstructifs lors de l’effort. Les auteurs rapportent des effets positifs sur la charge de travail des muscles respiratoires ainsi que les paramètres physiologiques et la dyspnée. Les données restent insuffisantes pour permettre de déterminer un quelconque effet de la VNI au terme d’un programme complet de réhabilitation respiratoire.
Au regard de son caractère chronophage, il s’avère nécessaire de mettre en évidence les critères permettant de cibler les patients « répondeurs ».
L’utilisation de la VNI lors du réentraînement à l’effort vise à s’affranchir de la dyspnée afin de permettre une sollicitation musculaire plus importante. À ce jour, il apparaît nécessaire de poursuivre les évaluations au cours de la réhabilitation respiratoire.
Pulmonary rehabilitation is currently the gold standard treatment for patients with chronic obstructive pulmonary disease (COPD). However, the workload achieved may be insufficient to obtain physiological benefits because of the restricted respiratory capacity.
In patients with COPD, changes in flow as well as biomechanical factors (distension) compromise respiratory adaptation to exertion. Some studies have shown that noninvasive ventilation (NIV) during exercise has a positive effect on respiratory muscle workload, physiological parameters and perceived exertion. However the evidence remains insufficient regarding the effects of the NIV during comprehensive pulmonary rehabilitation programs.
The identification of criteria which determine responsive patients is necessary in order to reduce human and time costs and to optimize the use of NIV during exercise.
NIV is used during training to overcome dyspnoea and to increase muscle workload. Further studies are needed to verify the effectiveness of NIV in pulmonary rehabilitation.
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2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
Exercise oxygen flow titration methods in COPD patients with respiratory failure
2012, Respiratory Medicine
Citation Excerpt :
Five patients with severe ventilatory limitation to exercise did not reach the target oxygen uptake during the initial incremental cardiopulmonary exercise test. In such cases, the workload selected was the highest level reached on the incremental test, since it has been demonstrated that such patients can sustain exercise at levels approaching maximum exercise tolerance.23 Oxygen flow was considered adequate when the SpO2 was >90% for >90% of the test.
We compare the adequacy of several titration procedures of oxygen flow in maintaining SpO₂ > 90% during the activities of daily life in patients with very severe COPD.
Thirty-one very severe COPD patients undergoing oxygen-therapy were recruited. Three titration methods were randomly performed: (1) 6-min walking tests; (2) cycle-ergometer constant work-rate tests at a load equivalent to 12 ml/min/kg of oxygen uptake; (3) one single constant work-rate test at 40 W 12-h pulse-oximeter monitoring was performed on four consecutive days with the following oxygen flow during exercise: 1 l·min⁻¹ above the resting prescription (NOTT guidelines) and those established by the titration procedures.
The time spent SpO₂ < 90% was higher for the titration based on NOTT and walking tests than for the oxygen flow established by the constant work-rate tests at 12 ml O₂/min/kg (22.1 ± 18.7, 20.8 ± 19.5 and 6.7 ± 12.7%, respectively). As for the oxygen uptake-based titration, the simplified procedure (a single exercise test at 40 w) generates longer times spent SpO₂ < 90% and SpO₂ < 85%, although it maintains a SpO₂ > 90% for more 90% of the time.
In COPD patients, exercise oxygen flow titrations by NOTT guidelines or walking tests do not allow a suitable oxygenation during the activities of daily life. Two more adequate alternative methods, based on constant work-rate tests, are proposed.
Pulmonary rehabilitation: A review of the recent literature
2012, Chest
Pulmonary rehabilitation (PR) is an evidence-based, multidisciplinary, comprehensive intervention that can be integrated into the management of individuals with chronic lung disease. It aims to reduce symptoms, optimize function, increase participation in daily life, and reduce health-care resource utilization. In this review, we summarize the new developments in PR over the past 5 years. Issues related to patient assessment include a comparison of cycle- and walking-based measures of exercise capacity, the emergence of multidimensional indices, the refinement of the minimal clinically important difference, and the importance of assessing physical activity. Issues related to exercise training focus on strategies to optimize the training load. We also comment on the acquisition of self-management skills, balance training, optimizing access, and maintaining gains following completion of PR.
Exercises commonly used in rehabilitation of patients with chronic obstructive pulmonary disease: Cardiopulmonary responses and effect over time
2011, Archives of Physical Medicine and Rehabilitation
van Helvoort HA, de Boer RC, van de Broek L, Dekhuijzen R, Heijdra YF. Exercises commonly used in rehabilitation of patients with chronic obstructive pulmonary disease: cardiopulmonary responses and effect over time.
To compare conventional exercise-based assessment of pulmonary rehabilitation (PR) with improvement in training exercises employed during a PR program, and to describe the cardiopulmonary response of different training exercises during PR of patients with chronic obstructive pulmonary disease (COPD).
Observational study.
Inpatient PR.
Patients with moderate to very severe COPD (N=18).
Not applicable.
Cardiopulmonary responses to interval cycling, arm exercise, and a test of functional activities of daily living (ADLs) were evaluated during the PR training program using a mobile telemetric breath-by-breath system. The effects of PR were evaluated by comparing pre-PR and post-PR training activities, incremental and constant work-rate cycling, and a 6-minute walk test.
Interval cycling and the ADLs test were moderate-intensity to heavy-intensity exercises (70%–80% of maximal oxygen consumption), while the arm exercise was a low-intensity activity (40% of maximal oxygen consumption). After 12 weeks of PR, cycle load, arm weights, and walking distances during training activities had increased alongside increased muscle mass. At iso-intensities, no cardiopulmonary changes in the training exercises were observed. Exercise duration of constant work-rate cycling and 6-minute walk distance increased by 160% and 14%, respectively, after PR, with concurrent right-shifts of anaerobic threshold and a decrease in heart rate.
Supervised increases in weight, load, and walking distance during training activities were useful clinical outcomes for patients, demonstrating the beneficial effects of progressive training on physical performance. However, for physiologic evaluation of PR, conventional tests, such as maximal incremental cycling, endurance cycling, and a 6-minute walk test, had greater validity. Physiologic evaluation of the training exercises showed that the training program complied with the training recommendations for PR.

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This research was supported by grant R01 HL34732 and Preventive Pulmonary Academic Award K07 HL02215 from the Lung Division, National Heart, Lung and Blood Institute and grant RR00827 from the Division of Research Resources for the Clinical Research Center.

Manuscript received August 15; revision accepted January 18.

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Chest

Clinical InvestigationsMaximum Intensity Exercise Training in Patients with Chronic Obstructive Pulmonary Disease

Section snippets

Subjects

RESULTS

DISCUSSION

Clin Chest Med

Med Clin N Am

Chest

Chest

Position paper of the American Association of Cardiovascular and Pulmonary Rehabilitation: scientific basis of pulmonary rehabilitation.

J Cardiopulmonary Rehabil

Pulmonary rehabilitation.

Pulmonary rehabilitation — guidelines to success.

Pulmonary rehabilitation: structure, components, and benefits.

J Cardiopulmonary Rehabil

Rehabilitation of patients with chronic obstructive pulmonary disease.

Am Rev Respir Dis

Exercise training and testing in patients with chronic obstructive pulmonary disease.

Basics of RD

On the design and effectiveness of training regimens in chronic obstructive lung disease.

Bull Eur ***Physiopathol Respir

Exercise testing and training.

Clinical Investigations
Maximum Intensity Exercise Training in Patients with Chronic Obstructive Pulmonary Disease