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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThere is substantial new evidence that pulmonary rehabilitation (PR) is beneficial for patients with chronic obstructive pulmonary disease and other chronic lung diseases. This article discusses the physiologic approach to PR.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EChronic Obstructive Pulmonary Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary \u0026amp; Respiratory Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EChronic Obstructive Pulmonary Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThere is substantial new evidence that pulmonary rehabilitation (PR) is beneficial for patients with chronic obstructive pulmonary disease (COPD) and other chronic lung diseases. Richard Casaburi, PhD, MD, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA, discussed the physiologic approach to PR.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EPR is a nonpharmacologic therapy that has emerged as a standard of care for patients with COPD. Evidence shows that it improves exercise tolerance, symptoms of dyspnea, and health-related quality of life better than any other current COPD therapy. It also decreases exacerbations and hospitalizations, reduces depression and anxiety, and improves cognitive function and self-efficacy. The benefits of PR accrue regardless of COPD severity, sex, age, body weight, socioeconomic status, or the presence of comorbidities.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EAlthough its proven effectiveness is broadly accepted, reimbursement strategies prevent many patients from receiving treatment. It is now understood that hospitals need to charge the real cost of the service, including doctors, staff, equipment, and facility use. A recent review reported that PR programs service \u2264 1.2% of the population of patients with COPD, irrespective of the country [Desveaux L et al. \u003Cem\u003ECOPD\u003C\/em\u003E. 2014], something that needs to be corrected, Dr Casaburi noted.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EA PR therapy program is a comprehensive, multidisciplinary, patient-centered intervention that includes patient assessment, education, chest physical therapy, controlled breathing exercises, exercise training, nutritional therapy, and ongoing psychosocial support. Despite early doubts regarding the effectiveness of exercise training\u2014mostly owing to exercise physiology studies showing little change in aerobic muscle enzymes after exercise\u2014it is now a generally accepted treatment strategy. Endurance exercise training increases mitochondrial numbers, aerobic enzymes, and capillary density and improves muscle efficiency. Effective programs include intense training sessions 3 to 5 times a week, each lasting 30 to 60 minutes, for 6 to 12 weeks. The program can be enhanced with good bronchodilator medication, supplemental oxygen, heliox breathing, interval training, and pressure support ventilation.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EAs an example, combining PR with an inhaled anticholinergic bronchodilator (tiotropium) improves airflow and reduces lung hyperinflation in patients with COPD. In a randomized double-blind placebo-controlled trial (n = 93), daily tiotropium supplementation improved endurance time on the treadmill (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E), dyspnea, and respiratory scores and reduced albuterol use; improvements were sustained for 3 months following completion of PR [Casaburi R et al. \u003Cem\u003EChest\u003C\/em\u003E. 2005].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/45\/4\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Tiotropium in Combination With Pulmonary Rehabilitation Improves Exercise Endurance\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-780546732\u0022 data-figure-caption=\u0022Tiotropium in Combination With Pulmonary Rehabilitation Improves Exercise Endurance\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/45\/4\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/45\/4\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/45\/4\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15519\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003ETiotropium in Combination With Pulmonary Rehabilitation Improves Exercise Endurance\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003E* \u003Cem\u003EP\u003C\/em\u003E \u0026lt; .05.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAdapted from Casaburi R et al. Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD. \u003Cem\u003EChest\u003C\/em\u003E. 2005;127:809\u2013817. Reproduced with permission from the American College of Chest Physicians.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-8\u0022\u003EIn a double-blind trial, supplemental oxygen (3 L\/min) given to nonhypoxemic patients with COPD undergoing high-intensity training improved exercise capacity when compared with that from compressed air [Emtner M et al. \u003Cem\u003EAm J Respir Crit Care Med.\u003C\/em\u003E 2003]. Patients receiving oxygen had a 40% greater gain in endurance, as determined by constant work rate exercise testing.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EIn a randomized blinded trial of 82 patients with stable COPD, combining helium with oxygen supplementation (72% He, 28% O\u003Csub\u003E2\u003C\/sub\u003E) during exercise increased patients\u0027 walking distance by 76.3% and reduced their Borg scores more so than breathing air or other gas combinations [Laude EA et al. \u003Cem\u003EAm J Respir Crit Care Med.\u003C\/em\u003E 2006].\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EAlternating periods of high-intensity training with lower-intensity training has been shown to improve training outcomes in healthy people, but to date, no COPD studies have found this approach to be superior to constant work rate training, probably because there is no standardized method of raising and lowering work rate. There is, however, some evidence that large-amplitude rapid sinusoidal fluctuation in work rate might be suitable for programs of rehabilitative exercise training in COPD [Porszasz J et al. \u003Cem\u003EExp Physiol\u003C\/em\u003E. 2013].\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EAn ambulatory ventilation system has been developed that provides inspiratory pressure support triggered by the patient\u0027s inspiration. This wearable 1-lb noninvasive open ventilation system, when combined with compressed oxygen, prolongs exercise endurance, reduces respiratory muscle activation (by electromyogram), improves oxygenation, and decreases dyspnea in patients with COPD with exercise-induced hypoxemia [Porszasz J et al. \u003Cem\u003EAm J Respir Crit Care Med.\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EThe second area of study in COPD is dysfunction of the muscles of ambulation, including muscle structure and function, etiology of muscle dysfunction, and interventions to improve muscle function. Skeletal muscle dysfunction in patients with COPD is the result of several conditions, including low muscle mass, poor capillarity, muscle inflammation, and vasoregulatory abnormalities, which lead to early-onset lactic acidosis that worsens dynamic hyperinflation and early muscle fatigue that limits exercise tolerance.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EPatients with COPD are susceptible to dynamic hyperinflation. Exercise training may be effective because it decreases dynamic hyperinflation by delaying the attainment of a critically high inspiratory lung volume [Porszasz J et al. \u003Cem\u003EChest\u003C\/em\u003E. 2005]. This can significantly improve exercise tolerance.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EThe distinction between strength and endurance training is important. Endurance training promotes aerobic metabolism and is associated with greater quality-of-life improvements; strength training promotes fiber hypertrophy. Both facilitate specific activities of daily living. There are pharmacologic agents that induce changes similar to strength but not endurance training. Muscle weakness in men with COPD may be due the prevalence of low testosterone levels. Testosterone supplementation (100 mg of testosterone enanthate injected weekly) with resistance exercise not only normalized serum testosterone concentration but also significantly (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .001) improved lean body mass and leg strength more than placebo plus no exercise, testosterone plus no exercise, and placebo plus exercise [Casaburi R et al. \u003Cem\u003EAm J Respir Crit Care Med.\u003C\/em\u003E 2004].\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EActivity monitors are useful for objective measurement of daily activity in patients with severe COPD, who are known to have low physical activity levels early in disease progression [Troosters T et al. \u003Cem\u003ERespir Med.\u003C\/em\u003E 2010]. Activity level appears to be the best predictor of mortality in COPD patients (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .001) [Waschki B et al. \u003Cem\u003EChest\u003C\/em\u003E. 2011].\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EGoing forward, optimization of current treatment, funding for large trials on how to maximize long-term benefits, resolution of the reimbursement issues, training of rehabilitation specialists, and improved access are needed.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/45\/4.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzohv1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzohv1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}