Safe Exercise and IPF - Papworth Hospital.pptx

					 Safe Exercise and IPF

        Dr Gisli Jenkins
  Reader in Pulmonary Biology
Consultant Respiratory Physician
           Club 25 mile TT champion
       Can any exercise be safe?
• Exercise risks:
  – environment,
  – the type of exercise
  – personal physiology
• Walking has the 2nd mortality rate/mile
  travelled after motorcyling.
• Two “testers” per year die in competition in
  UK
• 1 cyclist dies every three days in the UK
Riskiest sport?
                                   Sporting Risks
  Sport              Time period      Deaths           Population   Mortality      Odds of dying
                                                       estimate     Rate/100,000   (1 in)


  Base Jumping       1995-2005        9                20,850       43.17          2,317 jumps
  Swimming           1997-2006*       31               1,754,182    1.77           56,587
  Cycling            1997-2006*       19               1,754,182    1.08           92,325
  Running            1997-2006*       18               1,754,182    1.03           97,455
  Skydiving          2006             21               2,122,749    0.99           101,083 jumps
  Football           1997-2006*       9                1,754,182    0.97           103,187
  Hang-gliding                                                      0.86           116,000 flights
  Tennis             1997-2006*       15               1,754,182    0.86           116,945
  SCD in             1975-2005        26               3,292,268    0.79           126,626
  Marathons                                                                        runners
  Horse Riding       1997-2006*       10               1,754,182    0.57           175,418
  American           1994-1999        6                1,100,142    0.55           182,184
  Football
  Scuba Diving                                                                     200,000 dives
  Table Tennis       1997-2006*       6                1,754,182    0.40           250,597
  Rick Climbing                                                     0.13           320,000 climbs
  Canoeing                                                          0.13           750,000 outings
  Skiing             2002/2003        37                            0.06           1,556,757 visits
http://www.medicine.ox.ac.uk/bandolier/booth/Risk/sports.html
                                 Activity Risk
Activity associated with death Risk    Annual Risk



Maternal death in pregnancy            1 in 8,200 maternities

Hang-gliding                           1 in 116,000 flights

Surgical anaesthesia                   1 in 185,000 operations
Scuba Diving                           1 in 200,000 dives

Rock Climbing                          1 in 320,000 climbs

Canoeing                               1 in 750,000 outings

Rail travel accidents                  1 in 43,000,000 passenger journeys

Aircraft accidents                     1 in 125,000,000 passenger journeys

Fairground rides                       1 in 834,000,000 rides



http://www.hse.gov.uk/education/statistics.htm#death
            Benefits of Exercise
•   Reduces body fat
•   Strengthens bones
•   Aids co-ordination and flexibility
•   Improves stamina and concentration
•   Fights depression and anxiety
•   Improves cardiac function
•   Improves VO2 max
•   Lower lactate threshold
  Exercise in chronic lung disease
• Reduced exercise tolerance
  – Exhaustion and fatigue occur earlier
  – Exertional goals harder to achieve
• Increased paraphernalia
           Exercise is Good for YOU!
• Pulmonary rehabilitation improves symptoms of
  dyspnoea in patients with COPD
• Pulmonary rehabilitation improves HRQOL in
  patients with COPD
• Pulmonary rehabilitation reduces health-care
  utilisation in patients with COPD
• Longer pulmonary rehabilitation programs
  produce greater sustained benefits than shorter
  programs
• Not clear whether pulmonary rehabilitation
  improves survival
Pulmonary Rehabilitation Guidelines Chest 2007
            Exercise is Good for YOU!

Outcome                  Baseline    12 weeks    24 weeks
FEV1 (%)                 48±17       47±17       46±17
BMI kg/m2                24±7        24±7        24±7
VO2 max (L/min)          1.11±0.47   1.18±0.52   1.2±0.57
6MWD (m)                 390±140     445±142     463±146
Dyspnoea                 16±6        20±6        22±6
Fatigue                  15±6        17±6        18±6
Emotion                  29±8        32±8        33±9



Salhi et al Chest 2010
                             It really is!




8 weeks training and Sat > 85%


Holland et al Thorax 2008
How much exercise should you do?
How much exercise should you do?
• High intensity can be defined as 60-80% of
  peak rate achieved in incremental maximum
  exercise test.
• 45 minutes of 1X4
    – (1 minute peak VO2 4 mins at 40% VO2)
• Or 45 minutes at anaerobic threshold.



Pulmonary Rehabilitation Guidelines Chest 2007
                                                 Risk
• Maximal symptom-limited exercise testing is
  relatively safe.
• Death rate between 2-5/100,000 (1 in 20-50,000)
  ATS/ACCP Statement on CPET Am J Resp Crit Care Med 2003

  • Safer than base jumping or pregnancy
• Risk of sudden cardiac death during moderate to
  vigorous exercise in women is 1:35,000,000
  hours (4000 yrs)
   – Relative risk vs no exercise is 2.38
   – Long term cardiac risk is reduced
   Whang et al JAMA 2006
The Cardiopulmonary Exercise Test
• You can work out your VO2
  peak and max
• You can work out your lactic
  (anaerobic threshold)
• Identify arrythmias
• Identify arterial desaturation


ATS/ACCP Statement on CPET Am J Resp Crit Care Med 2003
                             Is it safe?
• Exercise is a ubiquitous activity
• Absolute contraindications
    – Syncope, unstable angina, uncontrolled systemic hypertension,
      serious cardiac dysrhythmias
• Relative contraindications
    – Primary pulmonary hypertension
• Terminating exercise
• Chest pain, ischaemic ECG, complex ectopy, 2 and 3rd
  degree heart block, >20mmHg drop in systolic bp, HT
  >250mmHg, >120mmHg diastolic
• SpO2 < 80 with symptoms and signs of severe hypoxaemia
  (Sudden pallor, impaired co-ordination, confusion,
  dizziness)
ATS/ACCP Statement on CPET Am J Resp Crit Care Med 2003
                               W W J D?
• Exercised people with LAM on treadmill or cycle
  ergometer
• Test stopped when:
• Sats <88%, exhaustion or oxygen uptake reached
  (VO2 peak)
• 217 patients Exercise termination due to:
• Dyspnoea (40%), leg fatigue (28%), severe
  hypoxaemia (11%), dyspnoea and leg fatigue (7%),
  dizzyness (1%), abdo pain (1%), VO2 max reached
  (6%)

Taveira-DaSilva et al Am J Resp Crit Care Med 2003
        What about pneumothorax and
                 exercise?
• In CF population
Pneumothorax 0.15% per 1000 patient years.
Injury 0.39% per 1000 patient years
Asthma attack 0.84% per 1000 patient years
Haemoptysis 0.12% per 1000 patient years

Pneumothorax seemed to be associated with
  coughing.

Ruf et al J Cystic Fibrosis 2010
    So what exercise should you do?
•   Swimming
•   Cycling
•   Running
•   Rowing
•   Weights
•   Power breathe
                       Aerobic exercise

• Cycling, swimming, walking, rowing

    – High intensity aerobic exercise leads to better
      physiological outcomes (VO2 max)
    – Low intensity aerobic exercise may lead to better
      adherence and still has physiological benefits




Pulmonary Rehabilitation Guidelines Chest 2007
                     Strength Training
• Weights, jumping, sprinting
• Important for maintaining balance, rising from
  a chair, or lifting objects
• Does increase muscle mass in COPD patients
• IS SAFE
• Has NOT been shown to help endurance (big
  argument amongst “Testers”)


Pulmonary Rehabilitation Guidelines Chest 2007
          Upper Extremity Training?
• Strength and endurance training improves
  work capacity (O2 consumption) and reduces
  metabolic (CO2 production) ventilatory
  requirements.

• Inspiratory Muscle Training
• NO, no benefit in COPD, unlikely to be safe in
  LAM

Pulmonary Rehabilitation Guidelines Chest 2007
                   Exercising with O2
• Yes
• Supplemental oxygen should be used during
  exercise training in patients with severe
  exercise induced hypoxaemia

• Supplemental oxygen during high-intensity
  exercise programs without hypoxaemia may
  be beneficial by increasing exercise capacity
  and endurance gains.

Pulmonary Rehabilitation Guidelines Chest 2007
         Swimming with LAM
• Great for people with joint problems
• Swimming can be a problem with lung disease
  due to increasing abdominal pressure on the
  diaphragm.
• Can’t swim and wear O2
           Cycling and Rowing
• Very similar workouts.
• Rowing probably better as
  works lower and upper limbs.
• Both easy on joints.
• However, cycling generally
  more accessible.
• Possible in theory to cycle with
  O2, certainly can do it on an
  stationary bicycle
                   Running
• High impact exercise – not great for joints (esp
  back and lower limb joints)
• Can be done with O2
• No equipment needed (unless running with
  0 2)
Strength training
         Power breathe
         Weights - Yes - No
                 Summary
• Exercising to exhaustion with IPF is safe
• Exercise with O2 supplementation if you
  desaturate
• Do whatever exercise you want!
• Exercise for as long and as hard as you can
• Your exercise program – like all exercise
  programs - will need to be individualised and
  goal focused
• You have cardiac disease (Do CPET first)
• You have pulmonary hypertension (Do CPET first)
• You experience:
   –   chest pains
   –   palpitations
   –   dizzyness
   –   confusion
   –   Sats <85%

				
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