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%