Non-pharmacological approach to comorbidities in COPD

1. Grazie per aver scelto di utilizzare a scopo didattico questo materiale delle Guidelines 2011 libra.Le ricordiamo che questo materiale è di proprietà dell’autore e fornito come supporto didattico per uso personale.

2. Non-pharmacological approach to comorbidities in COPD Thierry.troosters@med.kuleuven.be

3. Outline • Inactivity driving morbidity in COPD • Preventing morbidity by remaining active • Treating morbidity by becoming active

4. Functional status in COPD Predicting Functional status GOLD IV Mean 289 GOLD III Mean 365 GOLD II Mean 405 R 0.34 p < 0.01 (ECLIPSE) R 0.30 p < 0.01 (Leuven) 60 50 40 Percentage of patients (3x100%) 30 20 10 0-30 90-150 570-630 330-390 450-510 210-270 Agusti Respir Res 2010 UZ Leuven Rehab d-base 2010

5. Functional status in COPD Predicting Functional status R 0.53 p < 0.01 (Leuven) Factors associated to 6MWD N=496 partial R2 p QF (Nm.kg-1) 0.21 0.001 FEV1 (%pred) 0.11 0.001 PImax (cmH2O) 0.01 0.01 UZ Leuven Rehab d-base 2010

6. Functional status in COPD N=279 N=159

7. Long term inactivity, driving morbidity Physical inactivity drives morbidity -36% -43% moderate PA Troosters Respir Med 2010 Watz AJRCCM 2008

8. Long term inactivity, driving morbidity KU-Leuven Rainbow study (Undiagnosed COPD )

9. Long term inactivity, driving morbidity KU-Leuven Rainbow study (Undiagnosed COPD ) Amount and Intensity of physical activity are important to maintain health Physical activity should be considered as a ‘vital sign’ Haskell Circulation 2007 CDC Physical activity plan March 2010

10. Inactivity a source of comorbidity? COPD CF

11. Inactivity a source of comorbidity? COPD Wagner Respirology 2006

12. Inactivity and Morbidity • Deconditioning • Cardiovascular morbidity • Insulin resistance • Cancer (Colon/Breast/Lung) • Arterial Hypertension • Bone and joint disease (Osteoporosis Arthritis) • Depression

13. Inactivity and Morbidity Hypertens. Gastro-Int. Osteopor. Diabetes Arthritis Cardiac Cancer Psych Lipids Comorbidity (%) 36 22 28 - 70 - - - - 32 Van Manen J Clin Epidemiol 2001 Mapel Arch Intern Med 2000 Soriano Chest 2005 Sidney Chest 2005 Walsh ATS 2006 13 65 22 18 50 23 45 - 18 52 5 12 - 2 16 - - - 9 16 9 17 10 - 38 15 32 26 - 62 6 18 4 - 4 Chatila PATS 2008

14. Comorbidity in COPD: physical (in)-activity COPD Age, gender, socialsuport, socioeconomic state, educational level Symptoms (Dyspnea) Barriers (symptoms) Airflow obstruction Dynamic hyperinflation Anxiety Physical (in-)activity (behavior) Exercise capacity Self-efficacy Health beliefs COMORBIDITY Mental state Muscle dysfunction Endocrine dysfunction Hematological abnormalities Cardiovascular morbidity Osteoporosis Steroids Exacerbations Sleep-disordered Breathing Steroids Oxidative stress Exacerbations Inflammation Exacerbations Pulmonary hyertension Inflammation Hypoxia Mortality

15. Preventing morbidity by PA? • No long term prospective data in COPD • Epidemiological suggestions • Data in other diseases (e.g. diabetes)

16. Preventing morbidity by PA? 1.0 Tio 14.9% Control 16.5% 0.75 SFC12.6% Placebo 15.2% 0.50 Mortality (Probability Survival) High Average Low 0.25 Very Low Very low: Mainly sitting work, no PA in leisure time Low: < 2h/week low intensity physical activity 0.0 0 5 10 15 20 Time (Years) Garcia-Aymerich Thorax 2006

17. Preventing morbidity by PA? All groups received standard package of guidelines regarding healthy life style (written and annual session of 30') Intensive life style = 16 face to face sessions followed by monthly session Knowler NEJM 2002

18. FB - R (n=18) UC - R (n=17) ± ± ± ± ± ± 67 112 63 17 20 8 62 114 61 14 14 9 FEV1 TLC Age Preventing morbidity by PA? How could this be achieved in COPD? • Raise awareness in milder patients • Assess Physical activity • Provide feedback on PA levels • Discuss this with your patients Hospes Patient Educ Counsel 2008

19. Treating co-morbidity by exercise training? Exercise tolerance: Weighted mean difference and IQR Adapted fromTroosters AJRCCM 2005

20. Treating co-morbidity by exercise training? Rehabilitation has a clear effect on • HRQoL and symptoms • Exercise tolerance • Skeletal muscle weakness • Depressed mood status • Exacerbations

21. Rehabilitation has the potential to improve PA Weighted mean +17% Troosters Eur Respir Rev 2010

22. Rehabilitation impact on comorbidity? Exercise training and Arterial Stiffness, marker of CV risk N=10 4 weeks of PR 5d/week Endurance training * Vivodtzef Chest 2010

23. Rehabilitation impact on comorbidity? Exercise training and Arterial Stiffness, marker of CV risk * Vivodtzef Chest 2010

24. Rehabilitation impact on comorbidity? Heart Transplantation Lung Transplantation N=8/8 N=6/10 ** ** L2-L3 Bone mineral density (% change vs pre TX) Braith Transplantation 2006 Mitchel Transplantation 2003

25. Do co-morbidities complicate rehabilitation? Crisafulli ERJ 2010

26. Do co-morbidities complicate rehabilitation? Proportion of patients with clinical benefit Exercise training yields significant effects, also in patients with comorbidity Crisafulli ERJ 2010

27. Summary • Comorbidity in COPD is at least partially driven by physical inactivity • BESIDES SMOKING CESSATION, early interventions aiming at keeping patients active could potentially prevent comorbidity • Exercise training as a stimulus may treat some comorbidity (muscle weakness, vascular, type II diabetes, osteoporosis, depression) • Patients with comorbidities are good candidates for exercise training