Journal of the Association of Physicians of India - JAPI

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• he role of exercise in COPD as a treatment modality was introduced around twenty years before. A number of studies and meta-analysis have been performed to decide the indications, intensity, duration and long term effects of exercise.

• What is the difference in the lungs of an athlete and a clerk. Lungs of both of them are normal. Athlete has trained his lungs and body to perform rigorous exercise and able to run 20 kilometre (km) in one stretch while the clerk working in an office is hardly able run for 2 km. Even in normal lungs training and exercise result in a ten fold improvement in performance. Similarly a patient with chronic obstructive airway disease (COPD) who is unable to walk 100metres can be trained under the pulmonary rehabilitation programme to walk greater distances and perform tasks which he could not do previously.

• With disease advancement, co-morbidities and recurrent exacerbations a patient becomes disabled. Disability is a cause of decreased activity, social isolation and depression. Further, decreased activity is an independent predictor of mortality in COPD5. The aim of pulmonary rehabilitation is to break this vicious cycle and help the COPD patients to participate in daily activities. It is known to improve quality of life and exercise tolerance in COPD

• Dyspnoea and exercise intolerance in COPD are due to multiple factors. Expiratory airflow obstruction7 is an important cause but not the only one. Inspiratory muscle dysfunction,8 gas exchange abnormalities9 and cardiac dysfunction10 are other causes. Exercise intolerance can be best explained by the concept of dynamic hyperinflation

• Smoking cessation

• Clearing of secretions

• Breathing techniques Some breathing techniques are useful in providing relief in dyspnoea in patients with severe COPD. The patient is advised to breathe slowly and deeply to reduce dead space and improve carbon dioxide elimination. This pattern of breathing reduces physiological dead space, improves carbon dioxide removal and consequently ventilation. Pursed lip breathing (Figure 1) is assumed by some COPD patients instinctively during an exacerbation. It is a pulmonary rehabilitation approach employed to relieve patient of dyspnoea. Pursed lip breathing involves active expiration against resistance.14 Resistance may be provided at level of lips or tongue and a whistling is produced during expiration.15 It is called as pursed lip breathing

• Diaphragmatic breathing (Figure 2) is another pattern of breathing which distracts the patient from the distress of dyspnoea and alleviates the anxiety.19 This form of breathing is practised when patient is comparatively less distressed. One hand is kept on the chest and another on the abdomen. Patient is instructed to take abdominal breathing by taking a deep slow inspiration and allow the abdominal wall to move outward. The possible mechanism of action of this method is altered respiratory muscle recruitment and reduction in respiratory frequency

• Exercises

• Energy conservation and fatigue obviation

• Rehabilitation in exacerbations

• Patient education

• It has been observed that around 30% of muscle mass gets wasted in an average COPD patient.22 Poor muscle mass leads to early fatigue and decreased exercise tolerance. Muscle wasting is also an indicator of poor survival. Exercise training replaces type II muscle fibres (fast, fatigable, low oxidative) with type I fibres (slow, fatigue-resistant, high oxidative).23 Thus, exercise training builds up muscle mass and strength. It has been known to increase exercise capacity, improve health related quality of life measures and reduces symptoms of dyspnoea.

• Type of exercises

• Who should undertake exercises of pulmonary rehabilitation?

• Intensity and duration of exercise

• Outcome measures

• Maintenance exercises

• Adjuncts to exercise training

• muscle strength and endurance