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CHAPTER ESSAY QUESTIONS: CHRONIC OBSTRUCTIVE PULMONARY
DISEASE INSTRUCTIONS
1. What is the pathophysiology of COPD?
“Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable progressive
lung disease, with significant extrapulmonary effects (e.g., cardiovascular disease, osteoporosis,
anxiety and depression, metabolic syndrome and diabetes, impaired cognitive function, weight
loss, and limb muscle dysfunction), mainly characterized by the prescence of persistent
expiratory airflow limitation that is progressive and not fully reversible…The major risk factors
for the development of COPD include significant exposure to noxious particles or gases from
smoking cigarettes or other types of tobacco, marijuana, environmental tobacco smoke,
occupational exposures, and outdoor and indoor pollution” (Ehrman et. al., 2019). Cigarette
smoking can affect the bronchi, bronchioles, and parenchyma within the body. “Within the large
airways, cigarette smoke causes the bronchial mucus glands to become enlarged and the glad
ducts to become dilated” (Ehrman et al., 2019). Excessive coughing or sputum production are
characteristic symptoms of chronic bronchitis. This is defined as the presence of a productive
cough on most days during 3 consecutive months in each of 2 successive years. Emphysema is
also possible, which is a pathological or anatomical diagnosis marked by abnormal permanent
enlargement of the respiratory bronchioles and the alveoli, the air spaces distal to the terminal
bronchioles, and is accompanied by destruction of the lung parenchyma without obvious fibrosis.
Most patients who are diagnosed with COPD have characteristics of emphysema or chronic
bronchitis.
COPD patients have a decrease in their forced expiratory volume and forced vital
capacity. Emphysema causes destruction to the alveolar walls. This creates loss of the tethering
or supportive effect and diminished elastic recoil of the lungs. This can lead to reduction in the
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airflow and increases the work of the respiratory muscles and time necessary for expiration.
Therefore, resulting in hyperinflation of the lungs and flattening of the diaphragm. “For
individuals with normal lung function, the end expiratory lung volume decreases fom its resting
value by approximately 200 to 400 mL with moderate exercise. In contrast, most patients with
COPD demonstrate an increase in the end-expiratory lung volume in the rest to exercise
transition, leading to dynamic hyperinflation of the lungs. This dynamic hyperinflation leads to
further diaphragm shortening and weakness and may contribute to dyspnea and reduced exercise
intolerance” (Ehrman et al., 2019).
In addition, skeletal muscle dysfunction may occur within the lower limbs of the body.
“Patients with COPD have diminished peripheral muscle strength, as evidenced by a 20% to
30% reduction in quadriceps strength compared with age-matched controls, regardless of disease
severity. The decrease in strength is accompanied by reductions in muscle cross-sectional area
and muscle mass, both of which are independent predictors of mortality in COPD” (Ehrman et.
al., 2019).
2. Explain exercise testing for COPD and why it is important.
“Evidence-based guidelines confirm the utility of cardiopulmonary exercise testing in adults
with COPD as well as other chronic lung diseases in providing objective measure of exercise
capacity, mechanisms of exercise intolerance, prognosis, and disease progression and treatment
responses. Incremental exercise tests may be used to assess cardiopulmonary function and CRF”
(Riebe et al., 2018). “In patients with mild or moderate disease, symptoms generally do not
present until increased demand is placed on the respiratory system (e.g. with exercise)” (Ehrman
et al., 2019). When an individual is performing exercise and diagnosed with COPD (or under
suspension of being diagnosed) it is vital to take measurements prior to conducting the test,
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continuously during the physical activity, at termination and recovery following the termination
of the test. Minimum monitoring can include blood pressure, a 12 lead electrocardiogram (ECG),
arterial oxygen saturation, measurement of exertional symptoms such as dyspnea and leg fatigue.
Exercise testing may be conducted on a treadmill or a cycle ergometer. In addition, there are
some field tests that could be completed such as a 6-minute walk test or incremental and
endurance shuttle walk tests. “For the purpose of endurance testing, a fixed percentage of the
maximum work rate was applied as a constant work rate, and time to exhaustion was measured
as the outcome of interest. The standard approach to constant work rate cycle ergometer was
been to initiate the test at 75% to 80% maximum work rate…An optimal test duration of 8-12
minutes if often quoted for maximal incremental exercise testing. According to the power-
duration curve, there is a nonlinear relationship between insanity of a task and the duration for
which the task can be performed. Thus, a too low intensity results in prolonged exercise duration,
masking ventilator limitation and limiting ability to detect true intervention effects” (Cooper,
Abraxado, Legg & Kesten, 2010).
Exercise test responses in patients with COPD compared with normal health subjects
include decreased peak work rate, peal oxygen consumption, peak heart rate, peak ventilation,
ventilatory reserve, arterial partial pressure of oxygen, arterial oxygen saturation, inspiratory
capacity, and tidal volume. There is an increase in heart rate reserve, ventilator equivalent for
carbon dioxide, leg fatigue, dyspnea, dynamic hyperinflation, and breathing frequency. The
ventilator threshold is decreased or absent, and lactate threshold will occur at a lower work rate.
(Ehrman et al, 2019).
3. What are ACSM guidelines for exercise prescription for those who have COPD?
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Aerobic training is recommended for anyone, at any stage of COPD. For aerobic training
ACSM recommends a frequency of 3 to 5 days per week for 20 to 60 minutes at a moderate to
vigorous intensity. This can be classified as “50-80% peak work rate or 4-6 on the Borg CR10
Scale”, where 4 is somewhat severe and 6 just below very severe breathlessness. (Riebe et al.,
2018). When beginning a program for the first time, it may be necessary to begin at lower
intensities. In addition, performing consistent exercise may be a challenge, therefore performing
aerobic activity throughout the day to equate for a total of 20 to 60 minutes may be a good start
to work to consistent exercise performance. It is also recommended for the individual to perform
resistance training 2-3 times per week. Strength intensity can be done at 60-70% of 1 repetition
maximum for beginners or >80% of 1 repetition maximum experienced weight trainers. Both of
which can be performed with 15-20 repetitions for <2 sets in the form of weight machines, free
weights, or body weight exercises. Lastly, individuals should be incorporating flexibility training
to decrease muscle stiffness and soreness and improve range of motion. Incorporation can be
done at minimum 2-3 days per week, and requiring holding a static, dynamic, or PNF stretch for
10-30 seconds for 2-4 repetitions (Riebe et al., 2018).
4. Read the case study on p. 333 of the Ehrman et al. text and answer Questions 1, 2, and 5.
a. How would the results of Mr. DM’s graded exercise test be expected to differ
from those of a healthy age-matched nonsmoker?
The results of this patient’s graded exercise test would be expected to differ from those of
a healthy age-matched non-smoker. Because Mr. DM is a smoker his results are expected to be
lower, especially while being diagnosed with Stage 2 COPD. There are multiple factors that can
conclude to these results occurring. These can include a decreased peak work rate, peak oxygen
consumption, peak heart rate, peak ventilation, heart rate reserve, ventilator reserve, arterial
partial pressure of oxygen, and arterial oxygen saturation. The patient is also at risk for other
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health issues such as dyspnea and lower extremity fatigue, there could be a 20-30% decrease in
quadriceps strength (Ehrman et. al., 2019). Within 2 minutes of his exercise test, Mr. DM’s heart
rate had reached 83% of his maximum predicted heart rate. In addition, he had elevated blood
pressure of 194/100 at maximal exercise. His oxygen saturation at maximal exercise decreased to
85% and the peak oxygen consumption was 14.7mL/kg/min which was 67% of the predicted
value.
b. What improvements can be expected in the graded exercise test and the other
outcome measures because of this patient’s participation in a program of
exercise rehabilitation using the exercise prescription outlined
If Mr. DM stays consistent through his exercise rehabilitation, then he will be expected to
have improvements on his graded exercise test. In addition, it would be expected for the patient
to have improvement in his quality of life, and ease with daily activities of living. The patient
will have increases in range of motion, flexibility, strength and endurance from participation in
an exercise rehabilitation. During rehabilitation, the patient should have been participating in
resistance training, and focusing on the following areas: lower extremity aerobic exercise,
ventilator muscle training, upper extremity resistance training, and whole-body resistance
training. In addition, the patient’s peak VO2, lactate and ventilator threshold, and breathing
patterns should all have increased improvements. Improvements will also occur with lower
extremity fatigued, perceived dyspnea, and peak oxygen consumption. The patient will also have
an improved body composition, and reduced risk of comorbidities and mortality associated with
obesity. (Ehrman et. al., 2019)
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c. Would involvement in an exercise program result in improvements in these
pulmonary function tests? Why or why not?
Involvement in an exercise program wouldn’t necessarily show improvements within his
pulmonary function tests. If there is incorporation of ventilator muscle training it increases the
probability of having improvements, although this is not guaranteed. This could also be used in
conjunction with pulmonary rehabilitation in order to improve inspiratory muscle strength and
endurance, enhance quality of life, alleviate dyspnea, increase self-efficacy, and increase
functional capacity. Muscle development will occur from the exercise training, which can assist
in re-development of the internal organs to allow for better outcomes after weeks of training.
(Ehrman et. al., 2019).
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Sources
Cooper, C. (2010). Development and implementation of treadmill exercise testing protocols in
COPD. International Journal of Chronic Obstructive Pulmonary Disease, 375.
doi:10.2147/copd.s11153
Ehrman, J. K., Gordon, P. M., Visich, P. S., & Keteyian, S. J. (2019).KClinical exercise
physiology. Champaign, IL: Human Kinetics.
Riebe, D., Ehrman, J. K., Liguori, G., & Magel, M. (2018) ACSMs guidelines for exercise testing
and prescription. Philadelphia: Wolters Kluwer.
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