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Broncodilatazione ed esercizio fisico

Broncodilatazione ed esercizio fisico. Enrico Clini. Functional abnormalities Airway obstruction Static and dinamic hyperinflation Skeletal muscle dysfunction Deconditioning Hypoxia , metabolic changes Comorbidities and nutritional status Cardiovascular , metabolic , …

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Broncodilatazione ed esercizio fisico

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  1. Broncodilatazione ed esercizio fisico Enrico Clini

  2. Functionalabnormalities Airwayobstruction Static and dinamichyperinflation Skeletalmuscledysfunction Deconditioning Hypoxia, metabolicchanges Comorbidities and nutritional status Cardiovascular, metabolic, … Systemicinflammation Cardiovasculareffect (?) Mechanisms of exerciselimitation in COPD

  3. Static and dynamic hyperinflation in COPD

  4. Skeletal muscle involvement in COPD Bernard S, et al. AJRCCM 1998

  5. Organized the first multidisciplinary pulmonary rehabilitation program Thomas L. Petty, MD Master FCCP 1932-2009

  6. Poor physical activity and low exercise performance are associated with mortality in COPD patients Celli B, et al. RespirMed 2008 Garcia-Rio et al. Chest 2012

  7. Key question Is there a link between bronchodilation and exercise function or performance in patients with COPD ?

  8. Outline • The effect of single BD on exercise performance • The effect of combined BDs on exercise performance • Optimising bronchodilation during training in a rehabilitation course

  9. Outline • The effect of single BD on exercise performance • The effect of combined BDs on exercise performance • Optimising bronchodilation during training in a rehabilitation course

  10. EDRA 2014 • Ottimizzando la terapia inalatoria con I broncodilatatori è possibile incidere sul miglioramento della ventilazione polmonare • Nei soggetti con BPCO i broncodilatatori (sia SA che LA) sono in grado di aumentare la capacità di esercizio • Liesker JJ et al. Chest 2002; 121: 597-608 • Benchè i farmaci steroidi inalatori vengano impiegati per la cura dei pazienti BPCO gravi con riacutizzazioni ricorrenti, essi NON possiedono di per se favorevoli effetti sulla capacità individuale di esercizio • Yang IA et al. Cochrane Database Syst Rev 2007; CD002991

  11. Longer duration of bronchodilation is associated with greater airway calibre stabilization Beeh, AdvTher 2010

  12. TDI score

  13. EDRA 2014 • Ottimizzando la terapia inalatoria con I broncodilatatori è possibile incidere sul miglioramento della ventilazione polmonare • Nei soggetti con BPCO i broncodilatatori (sia SA che LA) sono in grado di aumentare la capacità di esercizio • Liesker JJ et al. Chest 2002; 121: 597-608 • Benchè i farmaci steroidi inalatori vengano impiegati per la cura dei pazienti BPCO gravi con riacutizzazioni ricorrenti, essi NON possiedono di per se favorevoli effetti sulla capacità individuale di esercizio • Yang IA et al. Cochrane Database Syst Rev 2007; CD002991

  14. Bronchodilators (Sal or Ipr) Placebo

  15. Improvers = defined as those with ΔET by at least 25 sec. (median value of the ΔET between BD-ICS and Placebo)

  16. Improvers = defined as those with ΔET by at least 25 sec. (median value of the ΔET between BD-ICS and Placebo)

  17. Tiotropium reduces dynamic hyperinflation and improves exercise performance in COPD Placebo Tiotropium O’Donnell D, et al. ERJ 2004

  18. 2,25 hr 2,25 hr 8 hr 8 hr

  19. Lung volumes Exercise endurance

  20. Beeh et al, BMC PulmMed 2015

  21. LA-bronchodilatorsimproveexerciseresponse and maintaineffect over time INDACATEROL TIOTROPIUM O’Donnell D, et al. RespirMed 2011 Maltais F, et al. Chest 2005

  22. Outline • The effect of single BD on exercise performance • The effect of combined BDs on exercise performance • Optimising bronchodilation during training in a rehabilitation course

  23. New LABA-LAMA combinations • Indacaterol-glycopirronium u.i.d. • On the market • More effective than monocomponents • Vilanterol-Umeclidinium u.i.d. • On the market • More effective than monocomponents • Olodaterol-tiotropium u.i.d. • Under registration • Formoterol-Aclidinium t.i.d • Under registration

  24. 33 randomised-controlled trial included, 1007 pts • 50% of the studies showed a significant effect of bronchodilator therapy on exercise capacity • High-dose anticholinergic agents have significant and better effects in the majority of studies (steady-state exercise protocols) compared with low-dose • SABA (and better than LABA) have favourable effects on exercise capacity in more than 65% of studies • Theophyllines have negative effects on exercise capacity • Effects of dual bronchodilation on exercise is still to be elucidated

  25. FOR-TIO FOR-Pla

  26. Beeh M, et al. Int J COPD 2012

  27. What is relevant to the patient ? AUMENTO DEI GIORNI “ATTIVI” (+16 rispetto a TIO) Inda /glico Inda /glico

  28. Outline • The effect of single BD on exercise performance • The effect of combined BDs on exercise performance • Optimising bronchodilation during training in a rehabilitation course

  29. Casaburi R, ZuWallack R. NEJM 2009

  30. Exercise training principles • Total training load must reflect theindividual’s specific requirements • Total training load must exceed loads encountered during daily life to improve aerobic capacity and muscle strength • Training load must progress as improvement occurs

  31. CHEST 2005; 128:2025–2034 Constant work rate exercise tolerance: 6.6  18.2 minutes

  32. Optimizing medical treatment before exercise training with bronchodilator therapy, long-term oxygen therapy, and treatment of comorbidities may maximize the effectiveness of exercise training intervention

  33. + 5,35 min + 6,60 min

  34. “ The present study documented improvements in spirometry and a trend towards reduced exacerbations.” “… tiotropium in combination with PR significantly improved dyspnea at the end of the program but did not show any additional benefit in 6MWT compared to PR and placebo. We encountered methodological issues regarding the 6MWT…..”

  35. Bronchodilation and Training (Rehab) Question 1- Effective for all ? Bronchodilator therapy may be especially effective in enhancing exercise performance in individuals with a ventilatory exercise limitation Question 2- Why might increase effectiveness ? With optimal broncodilation the primary locus of exercise limitation may change from dyspnea to leg fatigue…allowing individuals to exercise their peripheral muscles to a greater degree Question 3- So what ? The use of maintenance bronchodilator therapy within the context of a PR program for COPD results in augmentation of exercise tolerance benefits

  36. Summary • BDs of different mechanism of action may positively impact on the exercise performance in COPD patients • Combining BDs may be feasible and useful but direct effects on exercise performance need to be further elucidated • Optimal bronchodilation is recommended during a rehabilitation course and may impact on the individual’s clinical response to exercise

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