Maintenance Pulmonary Rehabilitation in COPD is Beneficial for Two Years

Maintenance Pulmonary Rehabilitation Increases Walking Distance

Background: Whether maintenance pulmonary rehabilitation programs help to sustain the short-term benefits is unclear.

Study: Researchers in Spain studied patients with COPD over 3 years after they completed a standard 8-week pulmonary rehabilitation program. Subjects were randomized (divided by chance) into two groups: those who received maintenance therapy and those in a control group (no maintenance).

Cycle ergometer for maintenance pulmonary rehabilitation

Cycle ergometer

What was the maintenance program?  Patients exercised at home three times a week doing: 15 minutes of chest physiotherapy; 30 minutes of lifting weights (which were bought by patients); and 30 minutes of riding a stationary cycle (provided by the hospitals). A physiotherapist called the patients every 15 days; during the alternate week, patients went to the hospital for a supervised training session.

Patients assigned to maintenance pulmonary rehabilitation did arm training with weights

Woman with COPD doing arm curls with hand weights.

What did the control group do? Patients in the control group were advised to exercise at home without any supervision. They were encouraged to walk or buy a stationary cycle for home use.

The study results were published in the March 1, 2017, issue of the American Journal of Respiratory and Critical Care Medicine (pages 622-629).

Results: For the total of 138 patients, average age was 64 years, and the amount of air exhaled in one second (FEV1) was 34% predicted. There were 68 patients in the treatment group, and 70 in the control group. More than 50% of those who started the study failed to complete the 3 years. Main reasons for stopping were a COPD flare-up (exacerbation), other medical problems (called co-morbidities), and death.

Those in the treatment group improved significantly more than the control group for: 1. distance walked in 6 minutes and 2. the BODE index [B = body mass index (weight and height); O = FEV1; D = breathlessness; E = 6-minute walking distance]. However, there were no differences in health-related quality of life between the two groups.

Conclusions:  The authors concluded that the 3-year maintenance pulmonary rehabilitation program provided improvements in walking distance and the BODE index compared with usual care. These improvements lasted for 2-years; after that, there no longer was a beneficial effect.

My Comments: This study is notable because it has the longest follow-up period of any published randomized trial of maintenance pulmonary rehabilitation. The findings support the benefits of continued exercise following completion of a pulmonary rehabilitation program.

One limitation of the study is that it primarily involved men so that it cannot be assumed that women would experience the same benefits.  However, women may be more compliant than men and are likely to live longer.  

I recommend participation in pulmonary rehabilitation to all of my patients with COPD and strongly encourage maintenance after completing our 12-week program.

Endobronchial Valve Therapy for Diffuse Emphysema

Benefits of Endobronchial Valve Therapy: Results of the IMPACT Study

Reason for the Study: Placement of an endobronchial valve into the breathing tube has been shown to improve lung function and shortness of breath in those with emphysema mainly in the upper parts of the lung (called heterogenous emphysema). Whether this therapy is beneficial in those with diffuse emphysema (damage throughout the upper and lower parts of the lung) is unclear.

Study: This study was conducted in Austria, Germany, and the Netherlands. All subjects had severe emphysema with lung function [how much air was exhaled in one second (FEV1)] between 15% to 45% of the predicted value. A CT scan was performed in all subjects to assess the extent of emphysema. Only those with less than 15% difference in emphysema scores between the target lobe of the lung and the same lobe on the other lung were included.

All subjects were assigned by chance to receive placement of the Zephyr endobronchial valve (EBV) in one lobe of the lung OR usual care.

The study was reported in the November 1, 2016, issue of the American Journal of Respiratory and Critical Care Medicine, volume 194, pages 1073-1082.

Endobronchial valve used in the study

Zephyr endobronchial valve used in the study

Results: Of the 93 subjects, 50 received usual care and 43 received endobronchial valve placement. 17 subjects who were initially assigned to have a valve placed could not participate because they were found to have collateral ventilation (See post on 12/27/15 on measuring collateral ventilation and what it means).

On average, four valves were placed in each of the 43 subjects in the EBV group. After 3 months of treatment, there was improvement of 14% in FEV1 in the EBV group, while FEV1 declined by 3% in the usual care group. This 17% difference between groups was statistically significant.

Zephyr valve prevents air from entering the lung. Air can only move out of the lung, resulting in collapse of emphysema lung.

Zephyr endobronchial valve prevents air from entering the lung. Air can only move out of the lung, resulting in collapse of emphysema lung.

More subjects in the EBV group improved in walking distance for 6 minutes by 26 meters or more (50% versus 14% in usual care) and for quality of life by 4 points or greater (57% versus 25% for usual care).

Adverse Events: Over the 3 months period, 44% of the EBV group and 12% in the usual care group had serious adverse events. There were 12 pneumothoraces (air in the lining around the lung) in 11 subjects in the EBV group. All of these required the subject to be treated in the hospital with a tube placed between ribs to drain the air. In five of these subjects, one or more valves had to be removed.

Pneumothorax in right lung. Black arrow shows collapsed lung.

Pneumothorax in right lung. Black arrow shows collapsed lung.

Diagram of pneumothorax in left lung

Diagram of pneumothorax in left lung

Conclusions: Endobronchial valve therapy can provide meaningful improvements in lung function, exercise tolerance, and quality of life in those with diffuse emphysema without collateral ventilation. Some subjects experienced serious adverse events, mainly pneumothorax (see chest xray above and diagram on left). 

My Comments: Placement of endobronchial valves for those with advanced emphysema is common and considered standard of care in in many European countries. In the United States, this procedure is investigational as it has not been approved by the Food and Drug Administration. Studies are underway in the US to further evaluate endobronchial valve therapy.

Emotional Intelligence is Associated with Wellbeing and Self-Management

Emotional Intelligence Is Important in COPD

Background: Emotional intelligence is the ability to understand and manage personal thoughts and feelings. It can influence your communication with others. It is a trainable skill that has been used in corporate business to improve well-being and performance.

first author of study evaluating emotional intelligence.

Dr., Roberto Benzo of the Mayo Clinic.

Study: Dr. Roberto Benzo from the Mayo Clinic studied 310 patients with COPD who were 69 years of age on average. The key breathing test (FEV1) was 42% of the predicted value on average. All subjects answered numerous questionnaires. The study findings were published in the Annals of the American Thoracic Society in January 2016 (volume 13, pages 10-16).

Findings: Emotional intelligence was significantly and independently associated with self-management abilities, quality of life (shortness of breath, fatigue, emotions and mastery) after adjusting for age and breathing test results.

Conclusions: Dr. Benzo and his team concluded that emotional intelligence is important for those with COPD. The authors commented that attention to it may address the current gap that exists in the treatment of emotional parts of COPD which is related to decreased quality of life and increased health care use.

Store employee tying shoe of elderly shopper.

Store employee tying shoe of elderly shopper

My Comments: I congratulate Dr. Benzo and his colleagues on addressing a novel feature of COPD that has not received much attention in daily care and management efforts.

Emotional intelligence affects:

  • Performance at school or work. Emotional intelligence can help you navigate the social complexities of the workplace, lead and motivate others, and excel in your career. In fact, when it comes to gauging job candidates, many companies now view emotional intelligence as being as important as technical ability and use testing before hiring.
  • Physical health. If you’re unable to manage your emotions, you probably are not managing your stress either. This can lead to serious health problems. Uncontrolled stress can raise blood pressure, suppress the immune system, increase the risk of heart attack and stroke, contribute to infertility, and speed up the aging process. The first step to improving emotional intelligence is to learn how to relieve stress.
  • Mental health. Uncontrolled emotions and stress can also impact your mental health, making you vulnerable to anxiety and depression. If you are unable to understand, be comfortable with, and manage your emotions, you’ll be at risk of being unable to form strong relationships which can leave you feeling lonely and isolated.
  • Relationships. By understanding your emotions and how to control them, you’re better able to express how you feel and understand how others are feeling. This allows you to communicate more effectively and forge stronger relationships, both at work and in your personal life.

Acupuncture for Relief of Breathlessness

Can Acupuncture Help my Breathing?

Dear Dr. Mahler:

I want to know your thoughts on using acupuncture to help my breathing.   I was told 6 years ago that I had COPD, and my breathing continues to slowly get worse. I was taking Spiriva and Advair for years, and use ProAir several times a day. My doctor recently had me stop both Spiriva and Advair, and tried me on Anoro.  It may have helped a little, but I really can’t do the things that I want because I get winded easily. On some days, I am short of breath just getting out of bed or getting dressed. I did pulmonary rehabilitation in the past, but can’t exercise because of back pain due to spinal stenosis. I tried acupuncture a few years ago for my back pain, and it helped a lot. Do you think that it can help my breathing problem?

Betty from Red Bank, NJ

Dear Betty:

According to traditional Chinese medicine, qi is the life force that flows through pathways in our body. If there is an  imbalance between complementary forces – yin (means shady side) and yang (means sunny side) – qi is disrupted and illness develops. Acupuncture involves the placement of thin needles into the skin to correct imbalances in qi.  There are at least 350 different acupuncture points in the body where energy flow can be accessed. Generally, at each treatment, 5 – 20 needles are inserted at various acupuncture sites and left in place for 10 – 20 min. Usually, there are 6 – 12 treatments over a few months.

Multiple needles placed into skin of individual.

Multiple needles placed into skin of individual.

Acupuncture is most commonly used for pain relief, and is generally safe when done by an appropriately trained practitioner using clean technique and single-use needles.

Effects of Acupuncture in COPD

Different studies have examined the effects of acupuncture for those who have COPD. In November 2014, Coyle and colleagues from Australia reviewed the results of 16 studies which compared acupuncture with no treatment in patients with COPD (medical journal: Alternative Therapies in Health and Medicine)(http://www.ncbi.nlm.nih.gov/pubmed/25478799). Overall, patients had less breathlessness and had better quality of life after acupuncture compared with placebo (sham or pretend treatment). In a few studies, investigators measured levels of endorphins (naturally occurring narcotic substances made in our bodies), and found that they increased after acupuncture, while there was no change in these levels after placebo. It is possible that the release of endorphins (just like taking morphine) with acupuncture may have contributed to a feeling that breathing was easier and quality of life was improved.

Should You Try Acupuncture?

I suggest that you share this information  with your doctor and ask about any possible risks. Also, you will need to find out if there is a licensed acupuncturist in your area. If there is, you may wish to call her/his office and ask specifically about that person’s experience in treating those with COPD. Acupressure points for relieving breathing problems are shown below (sites A – E).

Acupressure points for relieving breathing problems.

Acupressure points for relieving breathing problems

Acupressure points for relieving breathing problems.

Acupressure points for relieving breathing problems.

Acupressure points for relieving breathing problems.

Acupressure points for relieving breathing problemPlease let me know if you try acupuncture and whether it is helpful for you.

Please let me know if you try acupuncture and if it helps you.  Best wishes,

Donald A. Mahler, M.D.