Pulmonary rehabilitation and nutritional support in COPD patients

with altered body composition and poor exercise capacity

Dr. Ioannis Vogiatzis

National and Kapodistrian University of Athens
1st Department of Respiratory Medicine Pulmonary Rehabilitation Unit
Sotiria Hospital
75 Mikras Asias str
11527 Athens
GREECE
gianvog@phed.uoa.gr

AIMS

 To describe the factors limiting exercise tolerance in severe COPD patients.

 To emphasize the value of high-intensity interval exercise training in COPD patients
with peripheral muscle weakness.
 To make recommendations for anabolic hormone and specific nutritional
supplementation for COPD patients with altered body composition.

SUMMARY

Physical exercise training is the cornerstone of any cardiopulmonary rehabilitation programme.

Training sessions may combine aerobic and resistance muscle re-conditioning sessions.
Aerobic exercise training can include either continuous or interval exercise modes. In addition
resistance training consists of arm, leg and trunk exercises [1, 2, 3].

In view of the fact that the intensity of the training stimulus is a critical determinant of the
magnitude of physiological adaptations that occur in response to regular exercise, high intensity
continuous exercise training may not be feasible for those COPD patients who are unable to
sustain high intensities for long periods of time due to symptom limitations [4]. Accordingly,
when exercising continuously without any rest periods, severe COPD patients can tolerate
relatively moderate work rates (50–80% of their maximum exercise capacity) for
approximately 5-15 min, at the end of which they are symptom limited [4]. At intensities of 75-
85% of peak exercise capacity, COPD patients can sustain only 4-5 min of exercise [5] and
only up to approximately 13-15 min for lower intensities (50-60% of peak exercise capacity)
[5]. As such, implementing continuous exercise training for patients with severe COPD may
prove ineffective, as they will have to interrupt exercise in order to rest for several minutes
before they start exercising again. In contrast, interval training can enable patients to complete
short periods of high-intensity exercise that would not be possible with a continuous exercise
mode.

Indeed, when COPD patients exercise for short period of time (e.g. 30 s) alternated with equal
periods of rest intervals, patients are able to complete the total amount of work with lower
symptoms of dyspnoea and leg discomfort compared with moderate constant-load exercise
training [5]. Delayed occurrence of lactic acidosis observed during interval exercise appears to
be beneficial by reducing respiratory drive, thereby lowering dyspnoea sensations and the
occurrence of peripheral muscle fatigue [6]. Thus, interval exercise is more affordable by
patients with advanced disease.
A recent study demonstrated that interval exercise training allows severe COPD patients to
exercise at a sufficiently high intensity to obtain true physiological training effects manifested
by improvements in muscle fibre size, typology and capillarization [7].

Furthermore, patients with severe COPD are often exposed to the risk of profound peripheral
muscle de-conditioning as a result of disease severity and progression. Intense sensations of leg
discomfort often deter COPD patients from participating in daily activities that require body
mobility and strength. Since skeletal muscle weakness has a negative impact on exercise
tolerance in the majority of patients with severe COPD, an intervention of resistance exercise
during pulmonary rehabilitation is deemed essential [8]. Accordingly, rehabilitation experts
often prescribe resistance muscle training programmes, as clinical outcomes are definitely
promising for the severe COPD patient [9].

Accordingly, short-term progressive resistance muscle training can be beneficial for severe
COPD patients in terms of enhancing muscle strength and increasing the performance of some
daily activities. Progressive resistance exercise can increase arm and leg muscle strength and
improve the performance of tasks, such as stair climbing and rising from sitting [10]. However,
the effects of progressive resistance exercise on measures of body composition, psychological
function and societal participation still remain inconclusive.

Exercise training should be tailored to address the individual patient’s limiting factors (central
cardiorespiratory and/or peripheral muscle) to exercise. In patients with intense dyspnoea
symptoms, interval exercise is more appropriate than continuous exercise [5]. Resistance
exercise should be complementary to interval exercise so as to improve the strength of both the
upper and the lower body muscles. In patients with profound muscle weakness, interval and
resistance exercise should constitute a training priority.

A multidisciplinary therapeutic approach is absolutely required in severe patients with COPD

and nutritional abnormalities. Certainly, several factors need to be targeted, such as smoking
cessation, improvements in daily physical activity levels and exercise performance, a reduction
in the number of acute exacerbations, and avoidance of the use of systemic corticosteroids as
much as possible. In addition, anabolic hormones and specific nutritional supplements should
also be recommended in those patients.

More specifically, nutritional intervention in patients with COPD should aim to provide a
sufficient amount of energy, proteins, and amino acids to promote protein synthesis, thereby
counterbalancing the increased catabolism and atrophy observed in their muscles [11].
Supplements containing high levels of branched-chain amino acids will be very beneficial in
COPD patients with severe malnutrition and muscle mass loss [12, 13]. The advantages of
certain compounds, for example, whey proteins, rely on several other features such as their high
content in leucine to initiate protein synthesis, their rapid rate of absorbance in the gut, and their
amino acid composition to become a substrate for de novo protein synthesis, which are all key
factors that significantly influence the outcome of nutritional support in patients [14].

Testosterone is an anabolic hormone, which increases protein synthesis and reduces proteolysis,
while it also enhances lipolysis. Megestrol, which is a synthetic compound derived from
progesterone, has been shown to induce orexigenic effects and improvements in body weight
in patients with COPD and low body weight, while increasing fat tissue compartment, with no
functional improvement [15]. Growth hormone via IGF-1 activation promotes protein synthesis
and decreases protein catabolism, together with an increase in calcium resorption and the
immune response in patients [12, 16]. GH exerts beneficial effects on total body and muscle
weights and muscle strength of specific muscle groups [12, 16]. Another group of drugs with
potential beneficial effects on muscle mass are the segretagogues of GH that induce its release.
The effects of ghrelin are identical to those exerted by GH, such as induction of protein
synthesis, prevention of protein oxidation and degradation, and lipolysis [12, 17].
Increasing the dietary fiber content may also represent another possible intervention in patients
with chronic respiratory diseases and nutritional abnormalities. In this respect, gut immunity
and systemic inflammation levels are reduced probably as a result of alterations in the gut
microbiome induced by dietary fiber intake [17, 18].

As established by international recommendations, vitamin D supplementation exerts beneficial

effects on the bones and muscles, while preventing falls in elderly subjects and patients at high
risk of vitamin D deficiency such as those with chronic lung diseases [19].

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