Post on 23-Feb-2016
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Safe Exercise and IPF
Dr Gisli JenkinsReader in Pulmonary Biology
Consultant Respiratory PhysicianClub 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 RisksSport Time period Deaths Population
estimateMortality Rate/100,000
Odds of dying(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 Marathons
1975-2005 26 3,292,268 0.79 126,626 runners
Horse Riding 1997-2006* 10 1,754,182 0.57 175,418
American Football
1994-1999 6 1,100,142 0.55 182,184
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 RiskActivity 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
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
Exercise is Good for YOU!
Salhi et al Chest 2010
It really is!
Holland et al Thorax 2008
8 weeks training and Sat > 85%
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 reducedWhang 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 populationPneumothorax 0.15% per 1000 patient years.Injury 0.39% per 1000 patient yearsAsthma attack 0.84% per 1000 patient yearsHaemoptysis 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
• 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”)
Strength Training
Pulmonary Rehabilitation Guidelines Chest 2007
• 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
Upper Extremity Training?
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
02)
Strength training
Weights - Yes Power breathe - 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%