Review

Authors: Thierry Troosters, Wim Janssens, Heleen Demeyer...

Pulmonary rehabilitation has established a status of evidence-based therapy for patients with symptomatic COPD in the stable phase and after acute exacerbations. Rehabilitation should have the possibility of including different disciplines and be offered in several formats and lines of healthcare. This review focusses on the cornerstone intervention, exercise training, and how training interventions can be adapted to the limitations of patients. These adaptations may lead to altered cardiovascular or muscular training effects and/or may improve movement efficiency. Optimising pharmacotherapy (not the focus of this review) and oxygen supplements, whole-body low- and high-intensity training or interval training, and resistance (or neuromuscular electrical stimulation) training are important training modalities for these patients in order to accommodate cardiovascular and ventilatory impairments. Inspiratory muscle training and whole-body vibration may also be worthwhile interventions in selected patients. Patients with stable but symptomatic COPD, those who have suffered exacerbations and patients waiting for or who have received lung volume reduction or lung transplantation are good candidates. The future surely holds promise to further personalise exercise training interventions and to tailor the format of rehabilitation to the individual patient's needs and preferences.

Topics: Humans; Pulmonary Disease, Chronic Obstructive; Lung; Exercise Therapy; Exercise; Exercise Tolerance

PubMed: 37286219
DOI: 10.1183/16000617.0222-2022

Review

Authors: Jenna L Taylor, Jonathan Myers, Amanda R Bonikowske...

Chronic heart failure (HF) is a major cause of morbidity, mortality, disability, and health care costs. A hallmark feature of HF is severe exercise intolerance, which is multifactorial and stems from central and peripheral pathophysiological mechanisms. Exercise training is internationally recognized as a Class 1 recommendation for patients with HF, regardless of whether ejection fraction is reduced or preserved. Optimal exercise prescription has been shown to enhance exercise capacity, improve quality of life, and reduce hospitalizations and mortality in patients with HF. This article will review the rationale and current recommendations for aerobic training, resistance training, and inspiratory muscle training in patients with HF. Furthermore, the review provides practical guidelines for optimizing exercise prescription according to the principles of frequency, intensity, time (duration), type, volume, and progression. Finally, the review addresses common clinical considerations and strategies when prescribing exercise in patients with HF, including considerations for medications, implantable devices, exercise-induced ischemia, and/or frailty.

Topics: Humans; Quality of Life; Exercise Therapy; Heart Failure; Resistance Training; Chronic Disease; Exercise Tolerance; Prescriptions; Stroke Volume

PubMed: 37071253
DOI: 10.1007/s10741-023-10310-9

Review

Authors: Thomas Glaab, Christian Taube

Unexplained exertional dyspnoea or fatigue can arise from a number of underlying disorders and shows only a weak correlation with resting functional or imaging tests. Noninvasive cardiopulmonary exercise testing (CPET) offers a unique, but still under-utilised and unrecognised, opportunity to study cardiopulmonary and metabolic changes simultaneously. CPET can distinguish between a normal and an abnormal exercise response and usually identifies which of multiple pathophysiological conditions alone or in combination is the leading cause of exercise intolerance. Therefore, it improves diagnostic accuracy and patient health care by directing more targeted diagnostics and facilitating treatment decisions. Consequently, CPET should be one of the early tests used to assess exercise intolerance. However, this test requires specific knowledge and there is still a major information gap for those physicians primarily interested in learning how to systematically analyse and interpret CPET findings. This article describes the underlying principles of exercise physiology and provides a practical guide to performing CPET and interpreting the results in adults.

Topics: Adult; Dyspnea; Exercise Tolerance; Humans; Practice Guidelines as Topic; Respiratory Function Tests

PubMed: 35022059
DOI: 10.1186/s12931-021-01895-6

Review

Authors: Michael K Stickland, J Alberto Neder, Jordan A Guenette...

A cardiopulmonary exercise test (CPET) is ideally suited to quantify exercise tolerance and evaluate the pathophysiological mechanism(s) of dyspnea and exercise limitation in people with chronic respiratory disease. Although there are several statements on CPET and many outstanding resources detailing the cardiorespiratory and perceptual responses to exercise, limited information is available to support the health care provider in conducting a practical CPET evaluation. This article provides the health care provider with practical and timely information on how to use CPET data to understand dyspnea and exercise intolerance in people with chronic respiratory diseases. Information on CPET protocol, as well as how to evaluate maximal patient effort, peak rate of oxygen consumption, ventilatory demand, pulmonary gas exchange, ventilatory reserve, operating lung volumes, and exertional dyspnea, is presented. Two case examples are also described to highlight how these parameters are evaluated to provide a clinical interpretation of CPET data.

Topics: Dyspnea; Exercise Test; Exercise Tolerance; Humans; Oxygen Consumption; Respiratory Function Tests

PubMed: 35065052
DOI: 10.1016/j.chest.2022.01.021

Review

Authors: Steven Hsu, James C Fang, Barry A Borlaug...

Heart failure (HF) fundamentally reflects an inability of the heart to provide adequate blood flow to the body without incurring the cost of increased cardiac filling pressures. This failure occurs first during the stressed state, but progresses until hemodynamic derangements become apparent at rest. As such, the measurement and interpretation of both resting and stressed hemodynamics serve an integral role in the practice of the HF clinician. In this review, we discuss conceptual and technical best practices in the performance and interpretation of both resting and invasive exercise hemodynamic catheterization, relate important pathophysiologic concepts to clinical care, and discuss updated, evidence-based applications of hemodynamics as they pertain to the full spectrum of HF conditions.

Topics: Cardiac Catheterization; Exercise Test; Exercise Tolerance; Heart Failure; Hemodynamics; Humans; Stroke Volume

PubMed: 34389460
DOI: 10.1016/j.cardfail.2021.07.012

Review

Inspiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease (COPD) as Part of a Respiratory Rehabilitation Program Implementation of Mechanical Devices: A Systematic Review.

Authors: Eva Vázquez-Gandullo, Antonio Hidalgo-Molina, Francisca Montoro-Ballesteros...

Chronic Obstructive Pulmonary Disease (COPD) is a complex and heterogeneous disease, with pulmonary and extrapulmonary manifestations, which leads to the need to personalize the assessment and treatment of these patients. The latest updates of national and international guidelines for the management of COPD reveal the importance of respiratory rehabilitation (RR) and its role in improving symptoms, quality of life, and psychosocial sphere of patients. Within RR, the inspiratory muscle training (IMT) has received special interest, showing benefits in maximum inspiratory pressure, perception of well-being, and health status in patients with chronic heart disease, respiratory diseases, and dyspnea during exercise. The aim of this review is to assess the efficacy of IMT in COPD patients through the use of inspiratory muscle training devices, compared with respiratory rehabilitation programs without inspiratory muscle training. In the last years, many mechanical devices focused on inspiratory muscle training have been developed, some of them, such as the AirOFit PRO™, PowerBreath, or FeelBreathe, have shown clear benefits. The active search for candidate patients to undergo the RR program with inspiratory muscle training using this type of device in COPD patients represents an advance in the treatment of this disease, with direct benefits on the quality of life of the patients. In this article, we review the available evidence on IMT in these patients and describe the different devices used for it.

Topics: Breathing Exercises; Exercise Tolerance; Humans; Pulmonary Disease, Chronic Obstructive; Quality of Life; Respiratory Muscles

PubMed: 35564959
DOI: 10.3390/ijerph19095564

Effects of continuous aerobic training associated with resistance training on maximal and submaximal exercise tolerance, fatigue, and quality of life of patients post-COVID-19.

Authors: Bruna T S Araújo, Ana Eugênia V R Barros, Daiara T X Nunes...

BACKGROUND AND PURPOSE

Dyspnea, fatigue, and reduced exercise tolerance are common in post-COVID-19 patients. In these patients, rehabilitation can improve functional capacity, reduce deconditioning after a prolonged stay in the intensive care unit, and facilitate the return to work. Thus, the present study verified the effects of cardiopulmonary rehabilitation consisting of continuous aerobic and resistance training of moderate-intensity on pulmonary function, respiratory muscle strength, maximum and submaximal tolerance to exercise, fatigue, and quality of life in post-COVID-19 patients.

METHODS

Quasi-experimental study with a protocol of 12 sessions of an outpatient intervention. Adults over 18 years of age (N = 26) with a diagnosis of COVID-19 and hospital discharge at least 15 days before the first evaluation were included. Participants performed moderate-intensity continuous aerobic and resistance training twice a week. Maximal and submaximal exercise tolerance, lung function, respiratory muscle strength, fatigue and quality of life were evaluated before and after the intervention protocol.

RESULTS

Cardiopulmonary rehabilitation improved maximal exercise tolerance, with 18.62% increase in peak oxygen consumption (VO2peak) and 29.05% in time to reach VO peak. VE/VCO slope reduced 5.21% after intervention. We also observed increased submaximal exercise tolerance (increase of 70.57 m in the 6-min walk test, p = 0.001), improved quality of life, and reduced perceived fatigue after intervention.

DISCUSSION

Patients recovered from COVID-19 can develop persistent dysfunctions in almost all organ systems and present different signs and symptoms. The complexity and variability of the damage caused by this disease can make it difficult to target rehabilitation programs, making it necessary to establish specific protocols. In this work, cardiopulmonary rehabilitation improved lung function, respiratory muscle strength, maximal and submaximal exercise tolerance, fatigue and quality of life. Continuous aerobic and resistance training of moderate intensity proved to be effective in the recovery of post-COVID-19 patients.

Topics: Adult; Humans; Adolescent; Quality of Life; Exercise Tolerance; Resistance Training; COVID-19; Fatigue

PubMed: 36088642
DOI: 10.1002/pri.1972

Review

Authors: Thomas Reilly, Barry Drust, Neil Clarke...

One of the consequences of sustaining exercise for 90 minutes of football match-play is that the capability of muscle to generate force declines. This impairment is reflected in the decline of work-rate towards the late part of the game. Causes of this phenomenon, which is known as fatigue, and some of its consequences are considered in this article. The stores of muscle glycogen may be considerably reduced by the end of the game, especially if there has not been a tapering of the training load. Thermoregulatory strain may also be encountered, resulting in a fall in physical performance, or there may be a reduced central drive from the nervous system. The decline in muscle strength may increase the predisposition to injury in the lower limbs. Central fatigue may also occur with implications for muscle performance. Strategies to offset fatigue include astute use of substitutions, appropriate nutritional preparation and balancing pre-cooling and warm-up procedures. There is also a role for endurance training and for a pacing strategy that optimizes the expenditure of energy during match-play.

Topics: Exercise Tolerance; Football; Humans; Muscle Fatigue

PubMed: 18416591
DOI: 10.2165/00007256-200838050-00001

Randomized Controlled Trial

Authors: L Ferracini Cabral, T Da Cunha D'Elia, D De Sousa Marins...

BACKGROUND

Although pursed-lip breathing (PLB) has been advocated to reduce respiratory rate and improve oxygen saturation in patients with chronic obstructive pulmonary disease (COPD) at rest, the evidence of its effects on dynamic hyperinflation (DH) and exercise tolerance is scarce.

AIM

To evaluate the effect of PLB on exercise tolerance, breathing pattern, dynamic hyperinflation and arterial oxygenation in COPD patients during high-intensity exercise.

DESIGN

Randomized crossover study.

SETTING

Laboratory of Respiration Physiology, Federal University of Rio de Janeiro.

POPULATION

Forty stable COPD patients aged 40-75 years and with FEV1<60%.

METHODS

In a randomized order, all patients performed PLB and control breathing (CB) during constant work-rate exercise in an electrically-braked cycloergometer. Dynamic hyperinflation, oxygen saturation and breathing pattern were recorded at rest, in isotime and in peak exercise.

RESULTS

The nine patients who increased their endurance time by more than 25% during PLB (6.42 ± 2.36 vs. 10.51 ± 3.83 min; P < 0.05) were considered as the Improver sub-group. Compared to the Non-improver subgroup, these patients presented a lower expiratory peak flow - EPF (40.2 ± 8.6 vs. 53.3 ± 17.8 % predicted, P<0.05). The ROC Curve analysis of the EPF as a percentage of the predicted values (%pred) was performed to identify cut-off values that had greater sensitivity and specificity in differentiating between IMPROVER and NON-IMPROVER. We observed 61% sensitivity and 89% specificity with a 47.7% pred EPF. At isotime, PLB yielded higher inspiratory capacity (IC) and oxygen saturation (1.19 ± 0.33 to 1.35 ± 0.39 L; P < 0.05 and 93.1 ± 4.6 to 94.0 ± 4.1%; P<0.05), and lower respiratory rate than CB only in Improver. Non-improver patients showed thoracoabdominal asynchrony during PLB in isotime. At peak exercise, PLB improved the arterial oxygenation in Improver, but there were no changes in the breathing pattern in the analyzed subgroups.

CONCLUSION

In COPD patients with low PEF, pursed-lip breathing reduces dynamic hyperinflation and improves exercise tolerance, breathing pattern and arterial oxygenation at submaximal intensity exercise.

CLINICAL REHABILITATION IMPACT

This study points to a possible application of PLB in a selected group of COPD patients aiming at improving the exercise tolerance. PEF measurements can help to indicate PLB for COPD patients.

Topics: Adult; Aged; Cross-Over Studies; Exercise Test; Exercise Tolerance; Female; Humans; Male; Middle Aged; Plethysmography; Pulmonary Disease, Chronic Obstructive; Respiration; Spirometry

PubMed: 24691248
DOI: No ID Found

Review

Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology.

Authors: Vandana Sachdev, Kavita Sharma, Steven J Keteyian...

Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities-peripheral vascular, skeletal muscle, and cardiovascular-that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research.

Topics: Aged; Humans; United States; Heart Failure; Quality of Life; Stroke Volume; American Heart Association; Exercise Tolerance; Medicare; Exercise; Cardiology

PubMed: 36943925
DOI: 10.1161/CIR.0000000000001122