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Respiratory muscle training in chronic

obstructive pulmonary disease Antrenamentul
mușchilor respiratori în boala pulm....

Article in Pneumologia · September 2017

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 REVIEWS

Respiratory muscle training

in chronic obstructive
pulmonary disease
Antrenamentul mușchilor respiratori în boala pulmonară
obstructivă cronică
Gabriela Jimborean1, Abstract Rezumat
Edith Simona Ianoși1,
Chronic obstructive pulmonary disease (COPD) associates Boala pulmonară cronică obstructivă (BPOC) asociază printre
Alina Croitoru2, weakness and loss of muscle mass as an extra-respiratory complicațiile sale extrarespiratorii slăbiciunea și pierderea
Simona Szasz3, complication. This muscle wasting is related in COPD to masei musculare. Această afectare musculară apărută în
Paraschiva Postolache4 systemic inflammation, chronic hypoxia, deconditioning, BPOC este secundară inflamației sistemice, hipoxiei cronice,
1. University of Medicine and malnutrition, disorder in ventilation mechanism, or decondiționării, malnutriției, tulburării mecanismului de
Pharmacy from Târgu-Mureș, steroid myopathy. Pulmonary rehabilitation (PR) is a ventilație sau steroizilor. Reabilitarea pulmonară (RP) este
Department of Pneumology multidisciplinary program meant to improve physical, un program multidisciplinar menit să îmbunătățească
2. “Carol Davila” University psychological and social performances in COPD patients. performanțele fizice, psihologice și sociale ale pacienților
of Medicine and Pharmacy, Respiratory muscle training (RMT) is a specific method cu BPOC. Antrenamentul musculaturii respiratorii (AMR)
Department of Pneumology,
Bucharest which provides significant benefits inside PR programs. este o metodă specifică ce oferă beneficii semnificative în
3. University of Medicine and
It may improve both respiratory muscle strength and cadrul programelor de RP și poate îmbunătăți atât forța
Pharmacy from Târgu-Mureș, endurance. RMT will start in special rehabilitation centers musculară, cât și rezistența. AMR va fi ințiat în centre speciale
Department of Reumatology upon recommended protocols under supervision and it de reabilitare, pe baza protocoalelor recomandate, sub
4. “Grigore T. Popa” University will be continued for long-term at home. Several studies supraveghere, și va fi continuat pe termen lung la domiciliu.
of Medicine and Pharmacy, showed that RMT decreases dyspnea, enhances the Mai multe studii au arătat că AMR scade dispneea, crește
Iași, Faculty of Medicine,
1st Medical Department, effort capacity (according to the 6-minute walk test) capacitatea de efort (evaluată prin testul de mers de 6 minute)
Respiratory Rehabilitation and improves the quality of life in COPD patients. și îmbunătățește calitatea vieții la pacienții cu BPOC.
Clinic
Keywords: respiratory muscle training, pulmonary Cuvinte-cheie: antrenament musculatură respiratorie,
Corresponding author: rehabilitation, COPD reabilitare pulmonară, BPOC
Edith Simona Ianoși
E-mail: [email protected]

Introduction Histochemical changes found were a decrease in type I

Chronic obstructive pulmonary disease (COPD) is a and IIa muscle fibers (fibers with oxidative potential and
common disease which manifests by progressive airflow greater resistance to fatigue) and an increase in type IIb
limitation determined by airway changes induced by nox- fibers (susceptible to fatigue), sarcopenia and a reduction
ious particles (cigarette smoke, gases)(1). of intramuscular capillaries density(9-11). Functional abnor-
The most important symptoms in COPD patients are malities consist in a reduction of muscular oxidative and
dyspnea, chronic cough and physical activity diminution glycolytic capacity by decreasing the oxidative enzymes
produced by airflow limitation, mucous glands hyperse- and increasing LDH with lactic acid excess. There will be
cretion, air trapping and static hyperinflation. Dyspnea an early lactic acidosis in the skeletal muscle with regres-
worsens during effort by additional dynamic hyperinfla- sion of the aerobic pathway and advantage from the anaer-
tion. Consecutively, the patients reduce their level of obic glycolysis. This produces a disturbance in ATP
daily activities (deconditioning). Physical inactivity leads metabolism with loss of energy-rich molecules(12).
to more dyspnea and reduces the effort tolerance, creat- During exercise, respiratory rate is much increased in
ing a vicious cycle. relation with hyperinflation and low inspiratory capacity.
COPD patients may experience respiratory muscle Due to thoracic distension, COPD patients can’t increase
weakness and even decrease in muscular mass as an extra- tidal volume, so they are increasing the respiratory rate.
respiratory complication related to several associated Respiratory muscles (diaphragm) must generate a very high
conditions: systemic inflammation and oxidative stress, intrathoracic pressure. Consecutively, diaphragm dysfunc-
hypoxia, hypercapnia, lactic acidosis, muscle decondition- tion appears causing the reduction in the pressure-gener-
ing, dysfunction in ventilation mechanism, malnutrition ating capacity of the diaphragm. Cellular and molecular
or steroid myopathy(2-6). alterations have been described, especially loss in myosin
Muscle fatigue and muscle loss are the result of struc- heavy chains and high levels of protein derivative from
tural and functional changes(7-9). Structural muscle abnor- muscle protein degradation(8). Also the diaphragm adapts
malities are characterized by dystrophy and muscle by decreasing the length of the sarcoma and increasing the
weakness responsible mostly with tiredness to exercise. mitochondrial concentration(13).

128 VOL. 66 • No. 3/2017

 Pneumologia
REVISTA SOCIETĂŢII ROMÂNE DE PNEUMOLOGIE

Inflammation and hypoxia lead to the emergence of the

“reactive nitrogen species” that causes oxidative stress and
disorders in muscle contractility. Impaired contractile pro-
teins reduce calcium sensitivity and the generated force of
the diaphragm. Muscle fatigue will arise even in patients
with mild to moderate COPD(8-10). This may be reversible by
hypoxia correction and physical training exercises(8,9).
Respiratory muscle damage has clinical manifestations:
dyspnea, fatigue, and effort limitation, the development of
hypercapnic respiratory failure, while expiratory muscles are
linked to the effectiveness of cough(14).
Targeted respiratory muscle training (RMT) can be used
as a specific technique in the pulmonary rehabilitation (PR)
programs, especially in COPD patients.

Discussion
Pulmonary rehabilitation is a multidisciplinary pro- Figure 1. Incentive spirometer device
gram meant to improve physical, psychological and social
performances in patients with chronic respiratory diseases
including COPD(15,16).
Respiratory muscle training is a valuable method which
provides additional benefits to PR. It may improve both
muscle strength and endurance with clinical benefits in
COPD patients who remain symptomatic, despite optimal
therapy(14-16). The goal of RMT is the improvement of the
respiratory muscle function, hypoxia, hypoventilation and
dyspnea alleviation(16,17).
There are two types of exercises: IMT (Inspiratory
Muscle Training) and EMT (Expiratory Muscle
Training). Depending on the type of exercise, training
may be on force (consisting of series of repeated breaths for Figure 2. Threshold device: PEP (Positive Expiratory Pressure)
increased resistance) or endurance (forced ventilation held and IMT (Inspiratory Muscle Training)
for several minutes)(14).
Generally, inspiratory muscle training is used in patients
with dyspnea as the predominant symptom and the expiratory ing visual feedback for the patient. It is successfully used
muscles training in patients with productive cough. also in the perioperative period of the thoracic surgery.
Before starting the RMT, respiratory muscle strength The “threshold inspiratory device”, or “targeted inspira-
will be assessed for each patient by measuring the maximal tory resistive trainers”, provides adjustable inspiratory
inspiratory/expiratory mouth pressure (PImax /PEmax). The pressure for a targeted intensity of the airflow. This device
general recommendations are to perform inspiratory mus- incorporates a one-way valve that provides a graduate
cle training when the MIP value is below 60 cm H20. resistance (cm H20) to inspiratory flow(14,17). The pressure
RMT uses different respiratory devices based on respira- is adjusted by rotating the distal extremity. This device is
tion against an incremental resistance (“incentive spirometer”, very easy to use by the patient. Threshold IMT training is
“threshold inspiratory muscle trainer”, “flutter valve”)(17-19). performed daily for 15-30 minutes, at an intensity of 30-60
For the IMT, the patient will inspire through a device of PImax. There is also a threshold device for the expiratory
against a load equivalent to 30-60% of their maximal sus- muscle training (Figure 2).
tainable inspiratory pressure (the initial PImax)(17-19). The Isocapnic hyperventilation is a method of endurance
exercises will be performed 15-30 minutes/day, at home or training consisting in sustained forced ventilation for sev-
in the rehabilitation centers, continued by rising gradually eral minutes through a dispositive as POWERbreathe
the resistance with 5% per week upon the patient’s breath- (Figure 3)(14). The advantage of this device is that it also has
ing effort tolerance. These maneuvers should be performed an electronic interface that can be connected to the com-
initially under the supervision of a healthcare provider. puter to track the progress of the patient easier.
The “incentive spirometer” is a device which contains RMT will be performed regularly, about 30 minutes/day
some balls that rise upwards depending on the strength of (divided in two training sessions or several sessions of 3-5
the respiratory flow (Figure 1). During this type of training, minutes with a 1-2 minute rest period between sessions).
the patient has to generate a target inspiratory-expirator The intensity and frequency of the exercise will depend on
flow which propels rise several balls at the top of the device. patient tolerance and respiratory impairment. The workout
As the respiratory capacity improves, the balls rise up high- must be supervised by a physiotherapist and the exercise
er. The advantage is that the device provides an encourag- program will be individualized to each patient. The respira-

VOL. 66 • No. 3/2017 129

REVIEWS

RMT improves the health-related quality of life in COPD

patients(21,24-26)
The technique for breathing called “pursed lip breath-
ing” controls the shortness of breath and the pace of breath-
ing, making each breath more effective. The increase in
expiratory pressure in this technique may reduce hyperin-
flation by avoiding partial collapse towards the end expira-
tory bronchioles. In this way it keeps the airways open
longer, diminishes the work of breathing and dyspnea and
improves oxygenation(15,22).
Other valuable breathing retraining technique is the
“diaphragmatic breathing” or “abdominal breathing”. The
technique stimulates the abdominal muscles contraction
during exhalation, ameliorates the coordination between
thoracic and abdominal movements, and increases the tidal
volume(15,22). It also helps training the coordination between
the rib cage and the accessory muscles(23).
The studies on respiratory muscle training had a dura-
Figure 3. POWERbreathe device tion ranging from 6-8 weeks to one year, and used RMT
alone or combined with general physical training, with
positive results in terms of dyspnea, PImax, exercise toler-
tory muscle exercise can be performed alone or added to a ance and quality of life(24-26) .
general physical training(14).
RMT will be continued by self-management indefinitely Conclusions
to maintain the training benefits(17, 20). Pulmonary rehabilitation is a multidisciplinary program
After sustained RMT, the external intercostal muscles of meant to improve physical, psychological and social perfor-
patients with COPD have the capacity to express structural mances in COPD patients. Respiratory Muscle Training is a
remodeling. Both the proportion of type I fibers and the size specific method which provides significant benefits inside
of type II fibers increase after training. These structural PR programs. It may improve both muscle strength and
adaptations could partly explain the functional improve- endurance. RMT will start in special rehabilitation centers
ments (increase in muscle strength and endurance) observed upon recommended protocols under supervision and then it
in long-term trained muscles in COPD patients(19). will be continued for long-term at home. Several studies
The clinical benefits of RMT are: improvement of showed that RMT decreases dyspnea, enhances the effort
respiratory muscle function, relieving of dyspnea, capacity (according to the 6-minute walk test) and improves
increasing of effort capacity. There is also evidence that the quality of life in COPD patients. n

1. Global Strategy for the Diagnosis, Management and Prevention of COPD, rehabilitation: joint ACCP/AACVPR evidence-based guidelines. Chest 1997;
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