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1、Exercise Prescription for COPD&Asthma,Dr.Roland LeungMBBS MD FRACP FCCP FHKCP FHKAM(Medicine)Specialist in Respiratory Medicine,何謂慢性阻塞性肺病,慢性阻塞性肺病簡稱慢阻肺病，是常見的肺病一種肺功能受損的疾病 病人肺部的氣流進出受阻，令患者呼吸困難慢阻肺病十分常見。早期病徵不明顯，往往在診斷時，病情己步入中至晚期,100,000人,2000-2003香港肺功能研究計劃,10萬人病情屬中度嚴重,還沒有接受任何醫療診治,為什麼慢性支氣管炎及肺氣腫會阻塞呼吸道?,慢性支氣管
2、炎氣管長期受刺激及發炎，內膜腫脹及有痰液黏於管內，阻塞氣道。,肺氣腫肺部受到長期刺激，支氣管及氣泡經常發炎，肺氣泡受到破壞，影響換氣功能。,慢阻肺病有什麼徵狀?,持續咳嗽咳嗽時有痰或黏液由於氣管的病變，例如支氣管壁腫脹及氣管平滑肌收縮，加上黏液腺肥大以致分泌增加，患者經常咳嗽及多痰。,呼吸困難(如上樓梯、行樓梯及梳洗更衣時),氣促會隨肺功能的退化愈趨嚴重，影響患者的日常生活。在空氣質素轉差或有急性支氣管炎的時候，病徵會表現得更為嚴重。,慢阻肺病有什麼徵狀?,慢阻肺病影響個人、家庭及社會,全球每年有近三百萬人死於慢阻肺病根據世界衛生組織資料，慢阻肺病是全球第四大殺手病，排名僅次於心臟病發、中風及
3、急性肺炎死於慢阻肺病的人數較癌症為多，並與死於愛滋病的人數相同,本港第五大殺手病,據二零零一年的衞生署年報指出，慢阻肺病是本港第五大殺手急症入院主因之一，每十張醫管局病床之中，大概有一張是慢阻肺病病人佔有,四十歲以上 吸煙或其他類型的煙草（包括二手煙）長期暴露於塵多的環境，或工作期間吸入某些化學物品 長期暴露於煙霧（如用作煮食的生物燃料產生的煙霧),引致慢阻肺病之危險因素,正常人,45歲戒煙,吸煙的COPD病人,65歲戒煙,25,50,75,FEV1比率(相對25歲的男性),100,0,慢阻肺病危機及停止吸煙,75,50,25,年齡(年),死亡,殘疾,Airflow Limitation in
4、 COPD:Hyperinflation and Exercise,Review of Terminology,Totallungcapacity,Residual volume,Tidal Volume at rest,VT,EELV,EILV,IRV,ERV,Mild COPD,Healthy,Breathing frequency at rest:12 15/min,Healthy subjects:breathing rest time,Inspiration,Expiration,Severe COPD,COPD patients:less breathing rest time,D
5、ynamic Hyperinflation,To the COPD patient,this is a breathtaking view.,Clinical Course of COPD,Air Trapping,Expiratory Flow Limitation,Breathlessness,Inactivity,Poor Health-Related Quality of Life,Hyperinflation,Deconditioning,COPD,Disability,Disease progression,Death,Reduced Exercise Capacity,Effec
6、t of Exercise on Dyspnea,Exercise time,Dyspnea Intensity(Borg Scale)Very severeSevereSomewhat severeModerateSlightVery slightNone at all,Pre-exercise,End-exercise,Exercise Stops,Isotime,Relieves patients breathlessness during physically demanding exercise,SPIRIVA reduces activity-induced breathlessn
7、ess by 19%(P0.001),SPIRIVA increases exercise endurance time,Exhibited 42%difference in mean exercise endurance time,Pulmonary Rehabilitation,This is the process of maximising the patients physical,mental and social wellbeing by an individualised program of exercises and education,Why PR?,All COPD p
8、atients benefit from exercise training programs.Improvement in both exercise tolerance and symptoms of dyspnoea and fatigue.Evidence to show reduce exacerbations and hospital admissions.,BTS&GOLD,Pulmonary Rehabilitation,Ideally Comprises of:ExerciseEmpowermentDietPsychological well-being,PR&Exercis
9、e,Supervised training 2-5 times per weekMinimum 20-30 minutes each time(may take a time to reach this level)Course duration of 4-12 weeksIt should involve both upper&lower limb exercises both for endurance and strength,Components of Exercise Prescription,Mode(Type of exercise)IntensityDurationFreque
10、ncyProgression of Exercise Programme,PR&Exercise,STRETCHING of the major muscle groups of both upper and lower extremities.AEROBIC EXERCISES e.g.walking,cycling,rowing,swimming,etc.FREQUENCY-is 2 to 5 times per week with aim of daily routine.INTENSITY-“maximum limit tolerated by symptoms”or to 60 to
11、 75%of maximal heart rate DURATION-20 to 30 min of continuous exercise OR if this is not possible,interval training=two to three min of high-intensity training alternating with equal periods of rest.,PR&Diet,COPD can be adversely affected if the patient is malnourished or overweight.The former leads
12、 to muscle bulk loss(diaphragm&accessory muscles of respiration)and the latter an extra burden on the cardio-respiratory system,SPIRIVA demonstrates superior improvements in breathlessness post rehab,Combined rehab with SPIRIVA results in extended,superior outcomes in breathlessness compared with re
13、hab alone,Casaburi,et al Chest 2005,物理治療方法,EIA in Children:Scope of the Problem,EIB may interfere with physical activity and personal morale.,Adapted from American Lung Association.Available at:http:/www.lungusa.org/site/pp.asp?c=dvLUK9O0E27:5377.,Children with asthmaAbout 20%have asthma symptoms on
14、ly during exercise,More than 80%have EIB,Diagnostic Criteria for EIA,*After 5 minutes of exercise at 85%90%of maximumAdapted from Gotshall RW Drugs 2002;62:17251739.,Relief of airway obstruction with exercise after use of inhaled beta2-agonist,Coughing,wheezing,or shortness of breath with exercise,1
15、0%to 20%decrease in FEV1*,Possible Role of Cysteinyl Leukotrienes in EIA,Mast cell mediatorsLeukotrienesHistamineProstaglandins,Adapted from Gotshall RW Drugs 2002;62:17251739;Randolph C Curr Probl Pediatr 1997:27:5377.,Bronchospasm,Inflammation,Airway obstruction,Exercise/activity andother triggers
16、,Possible Therapeutic Options for EIA,SABAs=short-acting beta2-agonists;LABAs=long-acting beta2-agonists;ICS=inhaled corticosteroids;LTRAs=leukotriene receptor antagonists*May require combination therapyAdapted from Gotshall RW Drugs 2002;62:17251739;Hancox RJ et al Am J Respir Crit Care Med 2002;16
17、5:10681070.,Exercise Prescription for Asthmatics,Make sure the underlying asthma is well-controlledexercise is not recommended during exacerbationPre-medication before exercise is essentialconfidenceself assuranceAdequate warm-up Educate the parents and caregiversanxiety Exercise most suitable for asthmaticsswimmingslow jogging,問題時間,
