Table Of ContentVOLUME5 I NUMBER1 I 2014
Lung Health Professional
MAGAZINE
COPDReadmissionsShort
Summary
NewOpenAccess,Online
COPDJournalComingthis
May
PulmonaryRehabilitation:
AdvancesinthePast10Years
ProgressinLungCancer
ScreeningoverthePast
10Years
COPD8usaEnduringMaterial
COPD:What’sItAllAbout
Feature Story:
COPD COPDFoundation:ADecadeofProgress
FOUNDATION Page29
Letter from the Managing Editor:
KatelynTurner
014isanexcitingyearfortheCOPD Members,ispleasedtoprovideyouwithan
Foundation,becausewearecelebrating opportunitytoreceivecontinuingmedical
our10-yearanniversary!Throughoutthe educationcredits.Pleasereadmoreaboutthis
year,wewillbefeaturingarticlesthat excitingopportunityonPage26.
commemoratethepastdecadeofprogressfor
theCOPDFoundationandCOPD FeatureonaDecadeofProgress:
btcaHtyrehehoothaaaumianlncmltlktkufoehsaanosllPifwllhritatoootryffhfheeeyoisoCuoCnsuruOiOgroaefPPnnu1oaeD0trDlrthyahopFFolrooo,uassuunrsdnnnwiesddibhnuaavlpootetept,iriomiosoarannantn,grk.dryeIseIpIlwsLeeowaocnugauniocnrnft.ogcituOcetrostnoage wIaBDaianonarsaddmercwCPdetraoxiotM-crtrFeiitootcemfieunbadnEbeAdday.ruebcrCoJDauerOJtlt.oliPeoGhonDuenn,rrFWSRafco.Nreou.adtWnttaTTdulurhaCsreeteihriyan,roroetan,CiltlcaPOClrePBO,eSsDPw,ihFDdRieFRcnTht,
wcairoetnhtgirynaoutueorfuusclloytlolreeaalclgeuwievhsionagmnwdaokpneadteiitrefhnuatlpsp—aerwntei.calerseand cdgcoieonvcmtiamrnduigenbuiuosttfyeaCd.nOtihPneisDridtfehrvoouimgethwhtetsioratobhoewunCtOptehPresDppeacsttive,
NewCOPDJournal:
LungCancerScreeningandPulmonaryRehab:
Wfoecuasreeseoxnciotuerdotopehnavaeccaensostjhoeurranratlicilnetthheatfield IamsogratefultoDr.AmirSharafkhanehand
ofCOPD.ChronicObstructivePulmonary Dr.RichardCasaburiforsubmittingarticles
Diseases:JournaloftheCOPDFoundation onlungcancerscreeningoverthepastdecade
wWairelt’lircpelreposvrtiohdauetdtrtheoesiheraarlvicebhreaarnrsieeadsindtdoorrineaoaltdbesoruasbrsadccrciebsesttoo. (rimPepahogarebt2(a2Pn)a,tgaaernt8di),c1lr0eessy,peaeacnrtdsivofeiftlysw.telaTlgheiesnytoofaropeuurlmonary
featuringleadersfromacrosstheglobewho conversationofour10-yearanniversary.
afirnedatllhilseaadrteircsleinotnhPeafgieeld15o.fCOPD.Youcan Asusgaglewsatyiso,nsplfeoarsteofpeieclsffroereftuotsureendismsueesyooufr
C0PD8usaEnduringMaterial: LHP.Iwelcomeyourinput.
TChOePDC8OUPSDAFSociuenndtaitfiiocnP,laanlonnigngwiCtohmtmhiettee Pktlueranseensfein)cdospudgfgouensdtaitoinosnt.oo:rq
LungFlealthProfessionalmagazineispublished4timesannuallyandisavailablefromthe
COPDFoundationfreeofcharge.Ifyouwouldliketobeaddedasasubscriber,pleaseemail
KatelynTurneratkturner(S>copdfoundation.orgorcalltheC.O.P.D.InformationLine
1-866-316-COPD(2673).
Foradultpatientsdiagnosedwithemphysema
duetoalpha^antitrypsin (AAT)deficiency
The future of alpha-1
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WhenpatientsareprescribedPROLASTIN®-C(alpha-proteinaseinhibitor
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everyyearforthepast25years3 Formoreinformation,call1-800-305-7881
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ImportantSafetyInformation
cPhRrOoLnAicSTaIugNm®e-nCtat(ialopnhaa,n-dprmoatienintaesneancinehitbhietrorapy[hinumaadnu]l)tswiisthinedmipcahtyedsemfoar Tinhe>1m%ostofcsoubmjmeoctnsdwreurgercheillaltse,dmaaldaviesres,ehreeaadcatcihones,druarshi,nghoctlinfilcuaslh,trainalds
due to deficiency of alpha,-proteinase inhibitor (alpha,-antitrypsin pruritus.Themostseriousadversereactionobservedduringclinicalstudies
deficiency). withPROLASTIN-Cwasanabdominalandextremityrashinonesubject.
Theeffectofaugmentationtherapywithanyalpha,-proteinaseinhibitor PROLASTIN-Cismadefromhumanplasma.Productsmadefromhuman
(alpha,-PI) on pulmonary exacerbations and on the progression of plasmamaycarryariskoftransmittinginfectiousagents,eg,virusesand,
emphysemainalpha,-antitrypsindeficiencyhasnotbeendemonstrated theoretically,theCreutzfeldt-Jakobdisease(CJD)agent.
tihnhaesrraannpodytombfoierzeenldu,ensgtcaodbniltsireosalhsleeedd.icnlipnaitciaelnttrsialisn.wPhRoOmLAsSeTvIeNr-eCalipshnao,t-PiInddiecfaitceidenacsy ARmleaafnzeaergmeeinmceSe,nst:Zhp1a.rnoDggartaGa,monWinafinlienn,dePirvRiOdALu,aAlSsSTawIniNdthhDaIauRlsEphCaRT-A1p.roaEgnftrfiaetmcr.tysp2s.ionCfadamefpidocisiseenMacAsy,.e
PROLASTIN-CmaycontaintraceamountsofIgA.Patientswithknown COPD.2009;6:31-40.3.Dataonfile,Grifols.
asscnoeetnvviteebrrroaeediinedIhsigycApaettrodseeedIfngisiAcin,itepinawvctihyiti,eycnhthasancwvdaienthaabnaaenptghirpyberloaeadtsiceeetrnsitcraigisarnkienapcosatfttiioIedngneAst..vselwPoiRptiOhnLgAsSeplToeItceNtni-tvCiealoliyrs ©Pinlhe2iab0si1et3orGsr[eihefoulmsbarInin]ce.)ffAslullulrmiPmgrhaetssrcyrreisbeoirfnvegdP.IRnOfPLoRrA1mS9aT3tI-i1No2-n1Co3n(aadlpjhaac,e-nptrpoatgeei.nase
GRIFOLS
www.grifols.com
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PROLASTIN®-C CONTRAINDICATIONS
Alpha^ProteinaseInhibitor
(Human) IgA deficient patients with antibodies
againstIgA.
HIGHLIGHTSOFPRESCRIBINGINFORMATION
WARNINGSANDPRECAUTIONS
These highlights do not include all the • IgAdeficientpatientswithantibodiesagainst
information needed to use PROLASTIN@-C IgAare atgreaterriskofdevelopingsevere
(Alpha1-Proteinase Inhibitor [Human]) safely hypersensitivityandanaphylacticreactions.
and effectively. See full prescribing • This product is made from human plasma
informationforPROLASTIN-C. and may contain infectious agents, e.g.
PROLASTIN®-C (AlpharProteinase Inhibitor viruses and, theoretically, the Creutzfeldt-
[Human])LyophilizedPreparation Jakobdiseaseagent.
ADVERSEREACTIONS
ForIntravenousUseOnly
The most common drug related adverse
InitialU.S.Approval:1987 reactions during clinical trials in > 1% of
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hotflush,andpruritus.
PROLASTIN-Cisan alpharproteinase inhibitor ToreportSUSPECTEDADVERSEREACTIONS,
thatisindicatedforchronicaugmentationand contact Grifols Therapeutics Inc. at 1-800-
maintenancetherapyinadultswithemphysema 520-2807 or FDA at 1-800-FDA-1088 or
duetodeficiencyofalpharproteinaseinhibitor www.fda.gov/medwatch.
(alpharantitrypsin deficiency). The effect of
USEINSPECIFICPOPULATIONS
augmentation therapy with any alphar
proteinase inhibitor (AlpharPI) on pulmonary • Pregnancy: No human oranimal data. Use
exacerbations and on the progression of onlyifclearlyneeded.
emphysemainalpharantitrypsindeficiencyhas
not been demonstrated in randomized,
controlled clinical trials. PROLASTIN-C is not
GRIFOLS
indicatedastherapyforlungdiseaseinpatients
in whom severe AlpharPI deficiency has not GrifolsTherapeuticsInc.
ResearchTrianglePark,NC27709USA 08941114-BS
beenestablished. U.S.LicenseNo.1871 Revised:June2012
Lung Health Professional
MAGAZINE VOLUME5 I NUMBER1 I 2014
TableofContents
Page
LetterfromtheManagingEditor 2
KatelynTurner
COPDReadmissionsShortSummary 6
COPDFoundationStaff
PulmonaryRehabilitation:AdvancesinthePast10Years* 8
Dr.RichardCasahuri
NewOpenAccess,OnlineCOPDJournalComingthisMay 15
ManagingEditor: CathyCarlomagno
KatelynTurner ProgressinLungCancerScreeningoverthePastIOYears* 22
COPDFoundation Dr.AmirSharafkhaneh
BGyuersotnTEdhiotmora:show,MD EClOisPhaDM8aulsanagEanduringMaterial 26
NCoelwuYmobrikaPresbyterian FSceoatttuCreerr:etCa,OBPS,DRRFTo,uPnadtaJteilloenn,:RAN,DGeecraarddeTuorfinPor,oMgDr,eJsosh*nW.Walsh 29
Contributors: COPD:What’sItAllAbout
ElishaMalanga GerardTurino,MD,translationbySaraG.Alegri'a,Ed.D.
COPDFoundation
KatyaHernandez
OriginalImpressions,Inc.
FabianaTalbot
COPDFoundation
*ThisarticleisspecialfortheCOPDFoundation's10-yearanniversary.
NCoOPpaDrtFoofuntdhiastimoang.aTzihneecmonatyenbtesroefptrhoidsumcaegdaiznianneyarfeornmotbyinatneyndmeedatnospwriotvhioduetpperrisoornwarlitmteednicpaelrmaidsvsiiceo,nwohfitchhe
nsehcoeuslsdarbielyobretfaliencetdthdoirseectolfytfhreomCOaPpDhysFiocuinand.atEidoint.orMiaoldealnsdaardevefrotrisiilnlgustorpaitnivieonpsurepxopsreesssoendlyh.erTehiendCoOPnoDt
Foundation,thismagazine,theiremployees,officers,Boardmembers,writersstaffandanycontributorsdonot
ethnidsomrasgeaozrimnaekoerraenpyrebsreoncthautrieontshartegmaarydihnagvaenbyecelniniicnacllturdiealdawditohrpthreodmuacitlifnegatoufretdh,ismemnatgiaozniende,.oNroatdhvienrgtiisnetdhiisn
magazineorincludedinthemailingofthismagazineconstitutesmedicaladvice.Pleaseconsultwithyour
COPD physicianregardinganymedicaldecisions.
LetterstotheEditor:LungHealthProfessionalMagazinewouldliketohearfromyou.Sendlettersto3300Ponce
deLeonBlvd.,Miami,FL,33134oremailusatkturner(g)copdfoundation.org
FOUNDATION Advertising:Formoreinformationonadvertising,[email protected].
AfSTCOPDFOUNDATION
CUPDsuREAmDMmISSiIONtS
Integrating COPD into PatientCentered Hospital Readmission
Reduction Programs
OnOctober11,2013theCOPDFoundationconvenednationalhealthserviceresearchexperts,policymakersand
foremostexpertsinCOPDclinicalcaretohelphospitalsystems,integrateddeliverysystems,academiccenters
andallthoseresponsiblefordesigningcaremodelsandprogramsforreducingreadmissionsanswerchallenging
questionsandultimatelyimproveoutcomesforthoselivingwithCOPD
isanumbrellatermusedtodescribeprogressivelungdiseases
includingemphysema,chronicbronchitis,refractory(non-reversible)asthma,andsomeformsofbronchiectasis.This
diseaseischaracterizedbyincreasingbreathlessness
HPorsopgirtaalmReadmissionsReduction CLDEOAEDPIANDTGCHIASUItSSTEEHOFEiSTLHIRlMDk HO8FOSPR0ITVAOL0IZMA,TEIO0NSP0RERY0EAR
• RequiresCMStoreduceIPPSreimbursementsto fit b\
hospitalswithexcessreadmissions
• SincebecomingeffectiveonOctober1,2012it 1IN5HOSPITALIZED
hasappliedtothreeconditions INDIVIDUALSOVER40 ABOUT20%
• COPDwillbeincludedinprogrambeginning HASADIAGNOSIS OFHOSPITALIZEDPATIENTS
inFY15.Apatientcenteredsystemforreducing OF COPD AREREADMITTEDWITHIN
hospitalreadmissionsmustaccountfortheneeds 30 DAYS
ofthepatientwithCOPD,withoutignoringthe
realityofacomplexpatientandthedemandsof
todaysdeliveryenvironment.
• Interventionsdesignedtoreducetheriskof
subsequenthospitalizationsinpatientsrecently
• heAmfoesfsaeapcsituc,traooelmrismzhueeandnrisfmtuo.ryre,CtwOheaPtnDneoemdaadtydoihttaaivkoeenaballelnhepafoirstsm,ibnisloe RCIANOTTEMSHMWEUEPRNEOIOHTIRGIEHEESSSTT AAINSNOTCHAELRSU3E.D8CEMIODLLNICODNOASTPRAYDYS
caused.
Featuring
V^ARE
g§TRANSITIONALCAREMODEL IRANSi'TPSriIoVg#rIlafm3
Thesummitwasattendedbyroughly100in-person
attendeesandover125participantswatchingvialive REGISTEREDIN-PERSONATTENL)EES
videostream.
• Thesummitkickedoffwiththefirstpanel,chairedbyTom Physician 20
Kallstrom,RRT,presentinganoverviewofcurrentCOPD nurse 18|
measures,hospitalreadmissionstatistics,majordeterminantsof PharmaceuticalCompany 18
COPDrelatedto30-Dayhospitalreadmissions,andresearchand RepiratoryTherapist 17
demonstrationprojectsaddressingCOPD. DME/Manufacturer 9
• TpinrhieetsieasnteitcvaoetniadonndpsaPnorefolT,jhemceotTdBreaOrnOasStiteTid.onbaylDCra.rJeillMoOhdaerl,,iTnhceluCdaerdeTransitions HHoesaplitthaclarAedmPirnosviitdreartGoerneral 96|1
• Thethirdpanel,moderatedbyDr.JerryKrishnanandJohn Patient 4
Walsh,includedadiscussiononfuturecollaborationtoaddress Insurer 2 (
COPDrelatedreadmissionreductionresearchandinformation Total 103
dissemination.
MOVING FORWARD
Withallstakeholdergroupspresent,thefinalsessionincludedarichfinaldiscussion.Four
themesemergedasaframeworkformovingforward:
1. COPDcannotbeignoredinprogramsdesignedtoimprovepost-dischargeoutcomes
2. 30-dayPlus(30dayreadmissionsrepresentonlyoneofseveralimportantoutcomes;otheroutcomes
includepatientexperience,functionalcapacity,andmortality)
3. Interventionstoimproveoutcomesneedtobetailoredtothesettinginwhichitistobeapplied,Community
BuildingandPatientVoiceisneededtoensurethatpatient-centeredinterventions,ratherthandisease-
specificstrategies,aredeveloped,tested,andimplementedtoimproveoutcomesimportanttopatients.
4. Aninfrastructuretopromoteandsustaincollaborationsbetweenpatients,caregivers,providers,payers,
researchers,andotherstakeholdersisneededtoidentifystrategiesofcareneededtoimprovepost-discharge
outcomesinpatientshospitalizedforCOPDexacerbations.
Thestakeholdersexpressedinterestinseveralspecificoutcomes
• Creatingacommonrepositoryforcurrentprogramsandknowledgetoenhancecommunitylearningand
urgedtheCOPDFoundationtoleadthewaybycreatingaplatformforcollaboration
• Adesireforariskstratificationtoolforin-hospitalandpulmonaryrehabilitationuse,and
• Futurecollaborationbetweenstakeholderstoshareinformationincludingawebinarseriesandfuture
summits.Individualsimplementingdifferentmodelsshouldbeinvitedtopresenttheirexperiencewith
specifictoolsandtoolkitsanddiscusstheresults.
CONCLUSION
Allstakeholdersneedtocollaboratetodevelopinnovativeandpracticalsolutions.Therearemany
unansweredquestionsthatnecessitatefurtherresearchbutwhiletherearegapsinknowledgewhich
needtobefilled,theclockistickingforhospitalstoimplementchangestoreduceCOPDrelatedhospital
readmissions.Wemustproceedtoshareandimplementbestpracticeswhilestrivingtomeasureresultsand
Pulmonary Rehabilitation:
Advances in the Past 10 Years
RichardCasaburi,PhD,MD thasbeenthebestoftimes.Ithasbeenthe dysfunctiondevelopmentinCOPD,other
RehabilitationClinicalTrials worstoftimes.Pulmonaryrehabilitationhas mechanismssuchasinflammation,oxidative
Center Iundergoneaseriesoftectonicshiftsinthe stress,nutritionaldeficiencyandhypoxemia
LRoesseAanrgcehleIsnstBiitoutmeedaitcal pscaisetnt1i0fiyceabrass,iseaocfhthoenethiemrappryo.viWnhgatthehas likelyplayarole5.
HCeanrtbeorr-UCLAMedical peomteerntgieadlitsoabnenienftietrCveOntPiDonpuatnimeanttsc.heAtdtihneits LCiOmPbDmuasncdlheadsyismfpuonrcttiaonnticslipnriecvalaliemnptliicnations
Torrance,CA sametime,eventsintheUnitedStateshave suchasreducedexercisetolerance;itisalso
conspiredtomakepulmonaryrehabilitation stronglycorrelatedwithpoorqualityoflife
eThviesnelsesssayavwaiilllapbrloevtiodtehaenpeoovpelreviwehwoofnteheedseit. aadnvdarnecdeusciendosuurrvuinvadle.rsTthaenrdeinhgavoefbtheeenexrteecnetnt
developmentsandsuggesthowthefieldis andnatureofthestructuralandbiochemical
likelytomoveforward. aClOtePraDtiaonnsdianlsloimibntmhuescmleecshainnipastmisentswith
Inthepast10years,pulmonaryrehabilitation underlyingthesealterations.
professionalshavefoundtheirvoice.Working
throughnationalandinternational Structuralalterationsincludegeneralizedfiber
organizationssuchastheAmericanAssociation atrophy,ashiftfromtypeI(aerobic)fibersto
ofCardiovascularandPulmonary typeIIx(anaerobic)fibers,adecreasein
Rehabilitation,theAmericanCollegeofChest capillarity,reducedmitochondrialdensityand
Physicians,theEuropeanRespiratorySociety functionalityandincreasedapoptosis.
andtheAmericanThoracicSociety,highprofile Bioenergeticalterationsincludedecreased
Statements,State-of-the-ArtReviewsand aerobiccapacity(butpreservedglycolytic
AGreumhieadrbeiillciiantnaetsTihohnaovraaetclbioecnegSnolcpaisuetbtlay,icshphiueeldvm1e’4od.nAWaisrtsyheimnblthye cshapipegachcieiertsyr)(a.tReOsB,oSwtahhnirdcehaRcNmtiSav)yeaoorxveyesgryewnnhtehalenmsditznieisdtsruaeotgen
status,cementingitsroleasmainlinetherapy. aOnxtiidoaxtiidvaendtacmapaagceitmyaaynddayimealgdeoxciedllativestress.
Todistilltheaccumulatedevidence,pulmonary components,eventuallyleadingtocelldeath;
rehabilitationhasbeendocumentedtobethe contractileperformancemaybetherebybe
mosteffectivewaytodecreasedyspnea, impaired.
improveexercisetoleranceandimprove
htmeerxaaecglaentteihmd-tesrunedttlheaootposetfediboqfenuonsrae.lafiliMtltoyarivoenafoitlvliheafeerbsl,ieenpopCuuhlOtamPcroDomnam.acerosTylhwoeeglilc wModifousrsCeckaOslrePea,tDffeaaspttaiiitgngiuueCeenOthoPsaf,Dste.hbveeeIemnnnuiasfncsotluuhebnossdstoeatfnowtaiiomtacblhcuufslrreaavatcettiriloeoonnw
rehabilitationhasbeenshowntodecrease hasbeenfoundtobetheprimaryfactor
exacerbations,hospitalizationandother limitingexerciseendurance.Forthese
measuresofhealthcareuse,reducedepression patients,improvinglungfunction(e.g.,by
andanxietyandimprovecognitivefunction bronchodilatoradministration)wouldnotbe
andself-efficacy.Whethersurvivalisimproved expectedtoincreaseexercisetolerance6.
ilesavraugnleculaeetnaero,tuhlgiashrogaeunltdycbooefmcseauuhffsaievceireyanetntddtouomraibteziepodenrttrfoioarlsmed. fOafctyiigcmulpeionirgstemaxonecrreeciilsniekcetllhiynaitncoailbnerweaaslelkairimcnihtg,itnmaguskfssac.clteoItrin
Target:DysfunctionoftheLimb dedsyesrfvuensctmieonntiwoornstehnastmduursicnlge
Muscles exacerbationsofCOPDandrecovery
Althoughphysicalinactivityisof isslow.
primaryimportanceinlimbmuscle
ThisarticleisspecialfortheCOPDFoundation's10-yearanniversary.
8 LUNGHEALTHPROFESSIONALMAGAZINE•VOLUME5INUMBERII2014
NowAvailableat
Inhale and exhale CVS/Pharmacy
more with every breath.
TheRespiratoryTrainerstrengthensyour
respiratorymusclestohelpyoubreatheeasier,
feelbetterandimproveathleticperformance
andtheactivitiesofdailyliving.
TheRespiratoryTrainerusesdualpurpose
training-LowIntensityEnduranceAerobic
TrainingandHighIntensityAnaerobicInterval
Training,whilestrengtheningyourinspiration
andexpirationmuscles.
LimbmuscledysfunctioninCOPDis showntobeadditive,performingexercise
remediable,atleastinpart,byprogramsof programswiththeadditionofoptimal
exercisetraining.Thisremediation bronchodilation,helioxbreathingor
constitutestheprimaryphysiologictargetof supplementaloxygen,shouldallowtheCOPD
pulmonaryrehabilitation. patienttotoleratehigherexerciseintensities
and,thereby,inducegreatergainsin
Target:DynamicHyperinflation ambulatorymusclefunction.Aninteresting
newoptionofbreathingretainingthrough
Edxyesrpcniesae)iinstooflteernantchee(cahnidefitcsocmopnlsaeiqnuteonftCOPD caoimmpeudtaetrieznecdouvreangtiilnagtiaosnl-ofweeerdbdaecekpdeirsplays10,
patients.Pulmonaryrehabilitation breathingpatternduringexercise,may
successfullyimprovesexercisetolerance;the similarlyreducedynamichyperinflation.
physiologicmechanismsbywhichitdoesso
havebecomeclearer.Becauseflowrates ExerciseTrainingStrategies
duringexhalationareslow,whenexercise
demandsgreaterrespiratoryrateandtidal Exercisetrainingisthecoreofpulmonary
volume,apointisreachedatwhichthetime rehabilitation.Trainingstrategieshave
allottedforexpirationisinsufficientto advancedasourunderstandingofthe
completetheexhalation.Theconsequenceis importance(andthemechanisms)ofmuscle
vproolgurmeesss,ivaeplyheinncormeeasnionngeknndo-wexnpiasradtyonryamliucng daydsdfruenscstdieofnichiatssienvboolvtehdm5.usItcliseiemnpdourrtaanntcetoand
hyperinflation7.Theproblemcomeswhen strengthasbothareimportantinactivitiesof
dynamichyperinflationengendersend- dailyliving,thoughmuscleenduranceseems
inspiratorylungvolumesthatapproachthe tobeamoreimportantdeterminantofoverall
maximumabilitytoinspire(thetotallung functionandqualityoflife.Ingeneral,
capacity).Dyspneaincreasesmarkedlyatthis endurancetraining(cycling,walking)
point,andexercisemustterminate. increasesendurancecapabilitiesyielding
increasedaerobicenzymeconcentrations,
Thisunderstandinghasledtotherational mitochondrialnumberandcapillarity.
hdyepseirginnfolfasttiroanteagsieaswtaoylteossiemnpdryonveameixcercise cRaelsiisstthaennciecst)rianicnrinegas(ewsemiughstcllieftsitnrg,ength,
tolerance.Itcanbereasonedthatany yieldingfiberhypertrophy.Whilethe
interventionthateitherallowsalongertimefor molecularmechanismsmediatingthecause
exhalationorspeedstherateofexpirationwill andeffectrelationshipbetweenmuscular
lessenthetendencyfordynamichyperinflation exerciseandstructuralandbiochemical
and,consequently,improveexercisetolerance8. changesremainsmysterious,changesin
Practicalinterventionshavebeenfoundto certainmediators,suchasinsulin-likegrowth
accomplishdynamichyperinflationreduction. factor-i(IGFl)andmyostatin,seemlikelyto
fBaosttherberxopnicrhaotdoirlyatfloorws;asnudpphleelmioexntbarleaotxhyignegnallow beinvolved5.
slowsbreathing.Importantly,aprogramof ResponsestoexercisetrainingamongCOPD
pulmonaryrehabilitationhasalsobeenfoundto patientsseemquitevariable;itislikelythat
reducedynamichyperinflationbymeansof thereisageneticcomponentofthis
slowingbreathing9.Themechanismisthought variability11.Astoendurancetraining,astrong
torelatetoreductioninlacticacidosis(a determinantoftrainingresponsesisthe
stimulustobreathing)atagivenlevelof toleratedexerciseintensity.Inadditiontothe
exercise,thoughothermechanismsmayalsobe strategiesdesignedtodecreasedynamic
involved. hyperinflationmentionedabove,other
approacheshavebeentriedinanattemptto
Thislineofevidenceexplainsatleastpartof allowhighertrainingintensities.Interval
themechanismbywhichpulmonary training,inwhichhighintensityandlow
rehabilitationimprovesexercisetolerance. intensityexerciseperiodsarealternated,
Importantly,italsosuggestsstrategiesthat allows(transient)tolerationofworkratesthat
willallowrehabilitativeexerciseprogramsto couldnotbetoleratedinaconstantworkrate
bemoreeffective.Becauseinterventions task.Interestingly,inseveralstudies,interval
reducingdynamichyperinflationhavebeen trainingwasnotfoundtobemoreeffective
10 LUNGHEALTHPROFESSIONALMAGAZINE•VOLUME5INUMBERII2014
