COPD and Exercise: Breathing and Exercise Programs for COPDIf you have trouble breathing, exercise may be the last thing you feel like doing. But exercises for COPD can help your breathing, allowing you to stay as active as possible and improving your quality of life. Before beginning with a COPD exercise program, be sure to talk with your doctor or other health care provider.

How Exercises for COPD Can Help You

Exercise -- especially exercise that works your lungs and heart -- has many benefits for those with chronic obstructive pulmonary disease (COPD). Exercise can:

Improve how well your body uses oxygen, which is important since people with COPD use more energy to breathe than other people do.

Decrease 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 exercises can help you if you have COPD. How much you focus on each type of exercise may depend upon the COPD exercise program your health care providers suggests for you. Before starting these programs speak with your health care provider.

Stretching exercises lengthen your muscles, increasing your flexibility. Stretching can also help prepare your muscles for other types of exercise, decreasing your chance of injury.

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 by working your respiratory muscles. This helps your body use oxygen more efficiently and, with time, can improve your breathing. Walking and using a stationary bike are two good choices of aerobic exercise if you have COPD.

Strengthening exercises involve tightening muscles repeatedly to the point of fatigue. 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 doing for five to 10 minutes, three to four times a day.

Pursed lip breathing:

1. Relax your neck and shoulder muscles.2. Breathe in for two seconds through your nose, keeping your mouth closed.

3. Breathe out for four seconds through pursed lips. If this is too long for you, simply breathe out twice as long as you breathe in.

Use pursed-lip breathing while exercising. If you experience shortness of breath, first try slowing your rate of breathing and focus on breathing out through pursed lips.

Diaphragmatic breathing:

1. Lie on your back with knees bent. You can put a pillow under your knees for support.2. Place one hand on your belly below your rib cage. Place the other hand on your chest.

3. Inhale deeply through your nose for a count of 3. (Your belly and lower ribs should rise, but your chest should remain still.)

4. Tighten your stomach muscles and exhale for a count of 6 through slightly puckered lips.

Abstract and Introduction

Abstract

Pulmonary rehabilitation (PR) is the standard of care for persons with disabling symptoms and deconditioning associated with chronic lung disease. PR includes exercise training, education, psychosocial/behavioral intervention, and outcome assessment. Outcomes of PR include improved respiratory symptom control, muscle function, exercise tolerance, and quality of life, as well as reduced respiratory hospitalizations and emergency room visits. The advanced practice nurse (APN) plays a key role in managing the patient with chronic lung disease. Interventions include establishing an accurate diagnosis, providing clinical management, teaching prevention strategies, strengthening patient partnership, and referring appropriate patients to PR.

Introduction

Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, affects 16 million people in the United States each year. COPD-related mortality increased 42% between 1979 and 1998, making COPD the fourth leading cause of death in the United States.[1]

The costs of COPD were over $30 billion in 2000.[2] Persons with COPD and other chronic lung diseases often experience physical and emotional barriers to normal functioning. Physical barriers include increased airway resistance, abnormal breathing mechanics, inadequate gas exchange, weakness of respiratory and skeletal muscles, diaphragmatic flattening, poor endurance, and dyspnea.[3] Emotional barriers include anxiety, depression, and fear of dyspnea. If left untreated, these factors can lead to a dependent, unsatisfying lifestyle. PR offers education, monitored exercise, and support to reverse disabling weakness, provide dyspnea control, improve quality of life, and decrease healthcare utilization.

Introduction

Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, affects 16 million people in the United States each year. COPD-related mortality increased 42% between 1979 and 1998, making COPD the fourth leading cause of death in the United States.[1] The costs of COPD were over $30 billion in 2000.[2] Persons with COPD and other chronic lung diseases often experience physical and emotional barriers to normal functioning. Physical barriers include increased airway resistance, abnormal breathing mechanics, inadequate gas exchange, weakness of respiratory and skeletal muscles, diaphragmatic flattening, poor endurance, and dyspnea.[3] Emotional barriers include anxiety, depression, and fear of dyspnea. If left untreated, these factors can lead to a dependent, unsatisfying lifestyle. PR offers education, monitored exercise, and support to reverse disabling weakness, provide dyspnea control, improve quality of life, and decrease healthcare utilization.

Pulmonary Rehabilitation Outcomes

Although PR does not improve lung function, it does improve physical functioning, psychological coping, and respiratory symptom control. Reversal of muscle deconditioning and improved pacing result in increased walking distance with less dyspnea. Arm training improves upper body function and exercise performance by decreasing ventilatory demand during arm work and by improving arm endurance.[4] This training is particularly important in COPD because some muscles of the shoulder girdle support both ventilation and the performance of activities of daily living (ADLs). Emotional benefits of PR include less fear of dyspnea and desensitization to breathlessness, leading to improved quality of life.

Patients with chronic lung disease are frequent users of healthcare resources. PR reduces the number of hospitalizations and number of hospital days for patients with COPD.[4] One randomized, controlled trial compared the effect of education (n = 62) vs outpatient comprehensive PR (n = 57) in patients with COPD. The rehabilitation group had 2.4 fewer hospital days after rehabilitation compared with the education group, who had an additional 1.3 hospital days.[5] In addition to reducing hospital days, PR also reduces emergency room visits, physician office visits, and calls to physicians.[6]

What Is Pulmonary Rehabilitation?

According to the American Thoracic Society, PR is "a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to

optimize physical and social performance and autonomy."[7] Patients are taught to partner with their care providers to prevent and minimize respiratory infections and disease-related deterioration, resulting in decreased use of costly healthcare resources. The 4 major components of PR are exercise training, education, psychosocial and behavioral intervention, and outcome assessment.[8]

Patient training by both the APN and the PR program staff helps patients understand disease self-management techniques, partner with the primary care provider and pulmonologist, utilize coping strategies, and adhere to therapies. In the PR setting, patients receive training about respiratory and chest physiotherapy, including effective cough methods, chest percussion, vibration, and postural drainage. Breathing retraining (pursed lip and diaphragmatic breathing) is used to reduce the work of breathing, improve oxygen transport, and control dyspnea. Patients are evaluated for supplemental oxygen and receive training on safe oxygen operation and portability. Nutritional guidance is given to improve generalized weakness, enhance ventilatory muscle strength, and improve immune function. Psychosocial support and relaxation training are used to control depression and anxiety. Patients are encouraged to become actively involved with their APN in managing their healthcare, and to become independent in ADLs and less dependent on healthcare providers and medical resources (Table 1).

COPD and Exercise Guidelines

You may find that it helps to exercise at the same time each day; late morning or early afternoon may be a time when you have more energy. Here are some other basic guidelines for exercise when you have COPD:

Set realistic goals. Gradually 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, but 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 take precautions when exercising with COPD, but remember that shortness of breath doesn't always mean you should stop altogether. Instead, slow down and continue exercising. If shortness of breath becomes severe, then stop exercising.

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 with 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 one and a half hours after eating before beginning to exercise.

Remember any fluid restrictions you have when you drink fluids while exercising.

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.

Push-ups or 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 weight lifting, jogging, or swimming are OK for you to do when you have COPD.

COPD and Exercise: When to Stop

If you experience 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 quickly, call your doctor.

Nausea Dizziness

Weakness

Rapid or irregular heart beat

Severe shortness of breath

Pain

Pressure or pain in your chest or your arm, neck, jaw, or shoulder

Exercise Recommendations for COPD

Exercise is described by the National Institutes of Health (NIH) as a planned, structured, repetitive body movement that is done to improve or maintain one or more aspects of physical fitness.[9] The benefits of regular physical activity include reduced risk of cardiovascular disease and related risk factors, improved cardiorespiratory function, increased maximal oxygen uptake and oxygen transport, and lowered myocardial oxygen demand. Persons with COPD can achieve added benefit from improved tolerance of dyspnea, reduced fear associated with exercise-induced dyspnea, as well as improvement in mobility, confidence, and management of ADLs. Ries and Archibald[10] have found that exercise near maximal levels can be well tolerated by persons with COPD. Because patients are able to exercise at higher workloads, dyspnea becomes better tolerated. Casaburi and colleagues[11] found that high-intensity exercise training for patients with severe COPD yields more efficient exercise and lower minute ventilation with improved overall exercise tolerance.

The NIH recommends regular physical activity for all persons with or without lung disease, at a level appropriate to one's capacity, needs, and interest. The APN can outline individualized and realistic exercise goals. An appropriate exercise goal is at least 30 minutes of moderate-intensity physical activity on most (preferably all) days of the week. Intermittent or short intervals of activity (at least 10 minutes) have similar cardiovascular and health benefits if performed at a level of moderate intensity (brisk walking, cycling, swimming, home repair, yard work) with an accumulated duration of at least 30 minutes per day.[12] Important factors that contribute to successful, ongoing exercise routines include feeling benefit and enjoyment from the exercise, affordability of any exercise-related costs, and safety and convenience of the exercise.

Patient Selection for Pulmonary Rehabilitation

Patients with symptomatic, moderate-to-severe chronic lung disease may be candidates for a PR program. Appropriate patients for PR include those with:

Chronic lung disease and disabling symptoms such as dyspnea, fatigue, and panic associated with shortness of breath

Adequate motivation

An accurate diagnosis of chronic lung disease, including PFT within the past year. (In some states Medicare guidelines outline eligibility for PR, such as a forced vital capacity or forced expiratory volume in 1 second [FEV1] of less than 65% of predicted for the patient.)

Clinically stable, maximally managed disease

Access to transportation

Inappropriate patients for PR referral include those who are clinically unstable (uncontrolled hypertension or hypotension; arrhythmia; unstable angina; uncontrolled diabetes; or severe neurologic, orthopaedic, or cognitive impairment). If their conditions are stabilized and controlled, these patients may be considered for PR.

The APN can identify a local PR program for patient referral by contacting the local affiliate of the American Lung Association or the American Association of Cardiovascular and Pulmonary Rehabilitation.

Facilitation of a referral to PR begins by calling the local PR program to discuss agency referral and admission criteria. To facilitate referral, the PR program will ask for patient insurance information, the most recent patient history and physical examination findings, PFT results, electrocardiogram (ECG) results, and any exercise studies. The PR provider will inform the APN of any insurance requirements or restrictions. If the patient is a member of a health maintenance organization, the APN may need to facilitate the authorization process for service coverage.

Before initiating or designing an exercise program, assessment should include history and physical exam, PFT, resting ECG, and blood gas analysis or oximetry. History should include evaluation for respiratory infections, including pneumonias and exacerbations of COPD. Physical examination should include vital signs, heart sounds, breath sounds, excursion, weight, evaluation of pulses and peripheral edema, and assessment of dyspnea severity. Exercise testing may be part of the APN's assessment if the patient has moderate disability, deconditioning, or history or evidence of heart disease, hypertension, arrhythmias, or other clinical findings that warrant evaluation. Clinical exercise testing is indicated to establish safe levels of exercise performance, determine barriers to safe exercise (cardiac arrhythmias, cardiac ischemia, or hypoxemia), assess level of disability, determine oxygen requirements, and identify the origin of dyspnea (pulmonary vs cardiac).

Exercise testing may include incremental bicycle ergometry, graded exercise treadmill test, or a 6- or 12-minute walk test. Detection of abnormal vital signs, dysrhythmias, or ST segment changes on ECG indicate the need for referral to a cardiologist for further medical evaluation and clearance prior to beginning an exercise program. Patients may have absolute or relative contradictions to exercise testing. Contraindications include recent complicated myocardial infarction, poorly controlled arrhythmias, acute or poorly controlled disease process, or unstable

hypertension. PR can be considered for these patients once they are clinically stable and optimally managed medically.

Components of an Exercise Program

To achieve and maintain the full benefits of exercise, a regimen for the COPD patient should consist of 3 main components: aerobic conditioning, resistance training, and flexibility exercises. Walking, jogging, rowing, cycling, and swimming are examples of aerobic activities. Walking can be recommended by the APN for most patients with COPD. Aerobic training can improve endurance and exercise performance, increase oxygen uptake (VO2) utilization, increase cardiac output, decrease heart rate response, and decrease minute ventilation.

Resistance training includes hand-weight exercises, wall pulleys, elastic bands, or working against body weight or gravity (eg, wall push-ups). An inexpensive alternative to hand weights is soup cans. Resistance training improves endurance, increases muscle tone, improves joint stability and injury prevention, improves posture, increases bone density and strength, and improves activity tolerance.

Flexibility exercise refers to stretching, range of motion, and movement exercises. Flexibility reduces soreness and risk of muscle injury.

Exercise Prescription

Depending on patient tolerance and baseline level of physical condition, the APN may recommend aerobic exercise beginning with 5-20 minutes of walking or stationary bicycling for 3-5 days for the first week (Table 2). Severely deconditioned patients may rest for 3-5 minutes after each 5 minutes of walking (or less if necessary). One to 3 minutes are added per week as tolerated until the goal is reached (30 or more minutes per day on at least 3 days per week). Exercise prescription or guidelines should specify mode (type, such as walking), frequency (times per week), duration (length of time in minutes), and intensity (speed or other measure of intensity such as Borg scale or talk test). Patients are instructed to begin with stretching or 5-10 minutes of warm-up at a slow pace and end with a 5-minute cool down, followed by stretching. Patients should be informed that in the initial stages of exercise, muscle soreness may occur from aerobic and resistance training, and may last for 2-3 weeks.

Monitoring the intensity of exercise can be simplified by using the "talk test." The patient is instructed to walk or use a stationary bicycle to the point at which he or she can say a full sentence with only mild difficulty. Patients should be instructed to avoid inclines when walking. If the patient experiences dyspnea during exercise, he or she should slow down or stop for a few minutes until breathing returns to baseline, then resume exercise. If breathing does not improve with resting, the patient should contact his or her care provider. Walking or exercising indoors (in a mall or gym) is recommended during extreme weather. Patients should consider walking or exercising with a friend or family member, and consider an exercise log to improve adherence and motivation. There are other, more sophisticated ways to measure exercise intensity.

Breathing Exercises

Patients can be taught to perform pursed-lip breathing by inhaling through the nose for a count of 2 and exhaling through pursed lips (as if blowing out a candle) for a count of 4 or more. This exercise should be practiced for 10 breaths, 4 times daily, and also used when the patient is short of breath or performing activities such as stair climbing. To optimize breathing, patients with COPD should be trained to use pursed-lip breathing during exercise, generally exhaling during the relaxation phase of resistance exercise.

Medication Use During Exercise

Short-acting beta agonists such as albuterol are beneficial for intermittent relief of dyspnea due to bronchospasm. Albuterol can be particularly beneficial when used prior to exercise.[13]. Patients should be instructed to use their bronchodilator inhaler 30-60 minutes before exercising. Instruction should also include a written schedule for inhaled medication and observation of proper inhaler technique.

Oxygen Use During Exercise

Patients with COPD may suffer from inadequate gas exchange, cor pulmonale, and other factors limiting oxygen transport. Exercise training can improve oxygen transport, uptake, and utilization. Long-term oxygen use for hypoxemia increases survival, lowers pulmonary artery pressure and pulmonary vascular resistance, reverses secondary polycythemia, and improves cardiac function, exercise capacity, and tolerance of ADLs.[3]

If supplemental oxygen is needed, it should be given at a flow rate to achieve oxygen saturation of at least 90%. The standard nasal cannula provides an increase of only 3% to 4% in the fraction of inspired oxygen with each liter of flow. There are several commercially available devices that are designed to conserve or optimize oxygen flow. Reservoir cannulas (Oxymizer and Oxymizer Pendant; Chad Therapeutics; Chatsworth, California) store oxygen in a reservoir during exhalation, making the stored oxygen available for each inhalation. These devices are simple, inexpensive, and improve the efficiency of oxygen delivery up to 4-fold.[3] Conserving devices or demand-flow devices deliver a small amount of oxygen (30-35 cc) during inhalation, allowing small, lightweight oxygen systems to last substantially longer, depending on the oxygen flow rate.

Arm Training

Many persons with COPD experience increased dyspnea with upper extremity use. Unsupported arm exercises and activities that require raising arms against gravity to shoulder level or above require competitive use of accessory muscles of breathing. Raising arms also increases oxygen uptake and CO2 production.[14] Consistent performance of arm exercises leads to reduced

ventilatory requirement, therefore allowing gradual improvement in performance of ADLs, with less dyspnea.[15]

Arm training can include the use of an arm cycle ergometer at approximately 50 rpm, initially without resistance for 4-6 minutes during the first week. Two minutes per week are added to achieve a goal of 10-15 minutes 3 times weekly. Arm weights are begun at a light, comfortable level for the patient, from 0.5 lb to 5 lb, depending on level of deconditioning and other musculoskeletal issues (eg, arthritis). Patients may begin with 10-15 repetitions of each exercise. An additional 0.5 lb can be added every 2-3 weeks as the patient tolerates.

Additional Considerations

Once the patient has been referred to PR, the APN should be available to the PR staff for coordination of care. At the completion of the PR program (typically 6 weeks), the APN should work with the patient to facilitate ongoing physical activity through maintenance exercise programs, senior exercise groups, chair aerobic tapes, or other activities. If formal PR is not possible, the APN can work with the patient to understand the breathing control techniques of pursed lip breathing and encourage a suitable level of regular physical activity.

Conclusion

Pulmonary rehabilitation offers a cost-effective method of improving function, controlling dyspnea, and reducing respiratory-related hospitalizations in patients with chronic lung disease. PR is the standard of care for persons with symptomatic and disabling chronic lung disease. The APN is in the key role of facilitating improved independence, function, and well-being by partnering with the patient and facilitating techniques for improved symptom control and enhanced function.