Promoting Physical Activity and Exercise in Patients With Asthma and Chronic Obstructive Pulmonary Disease

      Highlights

      • Asthma and chronic obstructive pulmonary disease (COPD) are significant public health burdens.
      • Physical activity (PA) and exercise are integral to health and maintenance in asthma and COPD patients.
      • PA and exercise can improve patient outcomes.
      • PA and exercise should be addressed at every clinic visit.
      • Consider pulmonary rehabilitation for COPD and asthma patients with breathlessness.

      Abstract

      Chronic lower respiratory diseases, including asthma and chronic obstructive pulmonary disease, are a significant public health burden owing to their high incidence and prevalence. Nurse practitioners in primary care routinely see patients with these diagnoses. Although inhaled pharmacotherapy is the mainstay of treatment for individuals with these diseases, providing an overall approach to health and wellness, which includes physical activity and exercise, is imperative in optimizing patient outcomes. The purpose of this article is to provide nurse practitioners in primary care with foundational information regarding the promotion of physical activity and exercise for patients with asthma and chronic obstructive pulmonary disease.

      Keywords

      Introduction

      Asthma and chronic obstructive pulmonary disease (COPD) place substantial strain on the health care system due to their high prevalence and overall burden.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      Nurse practitioners (NPs) in primary care play a pivotal role in caring for patients with these diseases. Although inhaled pharmacotherapy is the mainstay of treatment for individuals with asthma and COPD,

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      regular physical activity (PA) and exercise can improve patient outcomes.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      • Nguyen H.Q.
      • Chu L.
      • Amy Liu I.L.
      • et al.
      Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease.
      • Carson K.V.
      • Chandratilleke M.G.
      • Picot J.
      • Brinn M.P.
      • Esterman A.J.
      • Smith B.J.
      Physical training for asthma.
      The purpose of this article is to provide an evidence-based approach to PA and exercise in patients with asthma and COPD.

      Burden of Asthma and COPD

      Asthma is a chronic disorder of the airways characterized by reversible and intermittent airway obstruction, airway inflammation, and hyperreactivity of the airways.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      Asthma remains one of the most prevalent chronic respiratory disorders, and prevalence rates over the past 3 decades are rising in all age, gender, and racial groups in North America.
      • Akinbami L.J.
      • Moorman J.E.
      • Bailey C.
      • et al.
      Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010.
      The higher prevalence of asthma may be linked to greater allergen sensitization, urban living, poor air quality, obesity, and sedentary lifestyle.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      Comorbid obesity is particularly relevant because the high prevalence of obesity in industrialized nations and its association with worse asthma outcomes, such as more severe or difficult-to-control asthma, poorer asthma-related quality of life, poorer response to asthma controller treatments such as corticosteroids, and higher exacerbation rates.
      • Hasegawa K.
      • Tsugawa Y.
      • Lopez B.L.
      • Smithline H.A.
      • Sullivan A.F.
      • Camargo C.A.
      Body mass index and risk of hospitalization among adults presenting with asthma exacerbation to the emergency department.
      Focusing on ways to improve asthma control through lifestyle interventions that promote PA and exercise behaviors and using evidence-based treatment options will help reduce the burden of asthma on the United States health care system.
      COPD is also an inflammatory disease of the airways, but differs from the inflammation in asthma in that it is more neutrophilic (as compared with eosinophilic inflammation, which predominates in asthma).

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      In COPD, the small airways are most affected. Chronic bronchitis occurs due to inflammatory changes in the airways, and emphysema occurs when inflammatory cells cause destruction in the lung tissue and alveoli. Most patients have components of both chronic bronchitis and emphysema; however, there are patients in whom one phenotype predominates. Although primarily caused by smoking, COPD can also be caused by second-hand smoke exposure, occupational exposures, air pollution, and a deficiency of the protein α1-anti-trypsin. The typical patient is over 40 years of age with a history of a known exposure, usually tobacco smoking, and who has breathlessness with or without cough along with sputum production.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      Like asthma, the economic and social burden of COPD is high and continues to increase due to an aging population and exposure to known risk factors.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      It is a leading cause of morbidity and mortality, and, combined with asthma, is the third leading cause of death in the US.
      • Xu J.
      • Murphy S.L.
      • Kochanek K.D.
      • Bastian B.A.
      Deaths: final data for 2013.
      Exacerbations of COPD account for the highest proportion of the overall burden of COPD on the health care system.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      Inactivity is common in patients with COPD and is an independent risk factor for acute exacerbations, 30-day hospital readmissions, and mortality.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      • Nguyen H.Q.
      • Chu L.
      • Amy Liu I.L.
      • et al.
      Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease.
      Therefore, improving PA levels is considered a major component in the overall approach to management of COPD.
      Although some patients have clinical features of both asthma and COPD (termed asthma-COPD overlap syndrome),

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      in this article we aim to provide foundational information regarding PA and exercise in the more classic presentations of both diseases.

      PA and Exercise in Patients With Asthma

      Several population-based studies have shown patients with asthma engage in less PA and are more sedentary than their non-asthmatic counterparts.
      • Vangeepuram N.
      • McGovern K.J.
      • Teitelbaum S.
      • et al.
      Asthma and physical activity in multiracial girls from three US sites.
      • Avallone K.M.
      • McLeish A.C.
      Asthma and aerobic exercise: a review of the empirical literature.
      The decreased levels of PA are related to the fear of triggering asthma symptoms, weather affecting asthma, time constraints, and the belief that PA should be avoided in asthma and not because of their degree of airway obstruction.
      • Avallone K.M.
      • McLeish A.C.
      Asthma and aerobic exercise: a review of the empirical literature.
      In up to 90% of patients with asthma, exercise is a trigger of asthma symptoms such as cough, wheezing, or shortness of breath. During exercise, there is a net loss of heat, water, or both, due to hyperventilation of air that is cooler and dryer than the lung, which leads to bronchoconstriction.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      With proper premedication before exercise and the use of warm-up and cool-down exercises (15 minutes each), the incidence of exercise-induced asthma symptoms is low.
      • Del Giacco S.R.
      • Firinu D.
      • Bjermer L.
      • Carlsen K.H.
      Exercise and asthma: an overview.
      Extensive literature exists supporting the safety and benefits of exercise conditioning on cardiopulmonary fitness, asthma symptoms, and asthma-related quality of life.
      • Carson K.V.
      • Chandratilleke M.G.
      • Picot J.
      • Brinn M.P.
      • Esterman A.J.
      • Smith B.J.
      Physical training for asthma.
      Both the American College of Sports Medicine (ACSM) and American Thoracic Society (ATS) recommend regular exercise for patients with asthma.
      • Spruit M.A.
      • Singh S.J.
      • Garvey C.
      • et al.
      An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.
      American College of Sports Medicine
      Exercise prescription for populations with other chronic diseases and health conditions.
      Currently, the ACSM recommends engaging in aerobic exercise at least 2-3 days per week, yet < 50% of patients meet this recommendation. Aerobic exercises, such as walking or exercises that use large muscle groups, are recommended for patients with asthma, whereas other exercises, such as running, cycling, and basketball, may be more likely to cause symptoms of exercise-induced asthma. Currently, there is no consensus on the optimum intensity of exercise, but exercising at 50% of peak oxygen uptake or at limits as tolerated by symptoms is recommended. The optimal duration of exercise is 20-30 minutes of continuous activity, although patients starting an exercise program may need to work up to this goal gradually. The ACSM guidelines endorse the use of exercise prescriptions for patients with asthma, although most existing data are in patients with COPD.
      Although a formal pulmonary rehabilitation (PR) program is frequently recommended in patients with COPD (see below), there have been few trials evaluating PR among adults with asthma.
      • Renolleau-Courtois D.
      • Lamouroux-Delay A.
      • Delpierre S.
      • et al.
      Home-based respiratory rehabilitation in adult patients with moderate or severe persistent asthma.
      Thus far, existing data suggest that exercise training and rehabilitation improve exercise tolerance and/or health status/quality of life in persons with asthma.
      • Spruit M.A.
      • Singh S.J.
      • Garvey C.
      • et al.
      An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.
      The ATS recommends PR for patients whose lung disease (including asthma) results in loss of independence; anxiety or breathlessness with activities; or limitations in social, leisure, indoor, or outdoor activities. It is important to distinguish between formal exercise defined by objective physiologic changes and routine gradual, moderate-intensity physical activities, such as walking or playing.
      It is possible that a more frequent (ie, daily) moderate-intensity activity like walking is what confers the protective effects in asthma. Walking interventions in patients with asthma can improve quality of life and asthma control.
      • Boyd A.
      • Yang C.T.
      • Estell K.
      • et al.
      Feasibility of exercising adults with asthma: a randomized pilot study.
      Whether other outcomes are impacted, such as reduced health care utilization, needs further study.
      About half of asthma may be triggered or worsened by exposure to allergens, such as house dust mites, molds, pests (cockroaches, rodents), animal dander, and pollen.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      Moreover, these allergens may also cause rhinitis, inflammation in the nasal passages that makes it difficult for patients to engage in physical activity.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      An evaluation by an allergist/immunologist should be considered before starting an exercise program, to help identify triggering allergens, review avoidance measures, and consider addition of pharmacologic treatments if necessary (see Table 1 for additional practical tips for patients).
      Table 1General Tips: Physical Activity and Exercise for Asthma Patients
      • Take all asthma medications as prescribed.
      • Ask your doctor about taking medicine before you exercise to prevent symptoms.
      • Always have your asthma rescue medication on hand when exercising.
      • Perform a prolonged aerobic warm-up and cool-down (15 minutes each).
      • Postpone exercise if asthma symptoms are not well-controlled of if you have a cold or respiratory infection.
      • Check the air quality index (https://airnow.gov/index.cfm?action=aqibasics.aqi/) before exercising outdoors. If air pollution or pollen (if you are allergic) levels are high, try not to work or play hard outside.
      • Breathe through the nose as much as possible when exercising.
      • When exercising outdoors, avoid areas that contain high concentrations of allergens and irritants (eg, fields, trees, busy roads, factories).
      • When exercising indoors, keep windows and doors closed to reduce allergen exposure.
      The National Asthma Education and Prevention Program guidelines for the management of asthma recommend that clinicians advise patients to avoid, to the extent possible, exertion or exercise outside when levels of air pollution are high.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      The relationship between increased levels of air pollution and asthma risk and impairment are well documented, with increases in asthma exacerbations and emergency care visits.

      National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the diagnosis and management of asthma (EPR-3; source document); 2007.

      The relationship between PA, exercise, and air pollution is not as clear. One foundational epidemiologic study found that heavy outdoor exercise in a high ozone concentration was associated with a higher risk of asthma in school-aged children.
      • McConnell R.
      • Berhane K.
      • Gilliland F.
      • et al.
      Asthma in exercising children exposed to ozone: a cohort study.
      Air pollution should be taken into consideration when asthma patients engage in PA, especially in outdoor urban environments. To limit the effects of poor air quality during PA and exercise, patients should be advised to check air pollution levels (Table 1). On poor air quality days, patients should be instructed to avoid outdoor PA and exercise, engage in indoor PA and exercise, or reduce the intensity and duration of the outdoor activity. Further, patients should be advised to avoid engaging in PA and exercise in high-pollution areas, such as within 50 feet of a road, and when pollution levels tend to be highest, often midday or afternoon.
      In addition to engaging in aerobic exercise, other alternative exercises, such as yoga or breathing exercises, should be considered. Both yoga and diaphragmatic breathing exercises have been shown to lead to improvements in asthma-related quality of life and asthma symptoms.
      • Cramer H.
      • Posadzki P.
      • Dobos G.
      • Langhorst J.
      Yoga for asthma: a systematic review and meta-analysis.
      • Franca-Pinto A.
      • Mendes F.A.
      • de Carvalho-Pinto R.M.
      • et al.
      Aerobic training decreases bronchial hyperresponsiveness and systemic inflammation in patients with moderate or severe asthma: a randomised controlled trial.
      The mechanistic pathways of how these exercises improve asthma are not fully elucidated, and randomized, controlled trials with larger samples sizes and high reporting quality are needed to confirm these preliminary effects.
      • Cramer H.
      • Posadzki P.
      • Dobos G.
      • Langhorst J.
      Yoga for asthma: a systematic review and meta-analysis.

      PA and Exercise in Patients With COPD

      As previously stated, patients with COPD commonly have sedentary lifestyles. The ensuing cycle, often described as a “downward spiral,” is that breathlessness contributes to inactivity, poor fitness, decreased cardiovascular function, skeletal muscle mass decline, social isolation and depression, all of which contribute to further breathlessness, inactivity, immobility, and premature mortality.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      Exercise programs can break this cycle and benefit patients with COPD.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      Consider a formal PR program for all COPD patients who have breathlessness, exercise intolerance, and low PA levels.
      • Rochester C.L.
      • Vogiatzis I.
      • Holland A.E.
      • et al.
      An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation.
      The ATS and European Respiratory Society define PR as: “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors.”
      • Rochester C.L.
      • Vogiatzis I.
      • Holland A.E.
      • et al.
      An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation.
      (p1374) PR is highly effective and has many benefits, including improved exercise tolerance, reduced perceived breathlessness, improved health-related quality of life, improvement in depressive and anxiety symptoms, improved sleep quality, enhanced effect of long-acting bronchodilators, decreased hospitalizations and number of days in the hospital, improved recovery time after an exacerbation, and improved survival.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      • Rochester C.L.
      • Vogiatzis I.
      • Holland A.E.
      • et al.
      An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation.
      In addition, exercise programs have been shown to improve arm function through strength and endurance training,

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      and many patients with COPD report difficulty with activities that require lifting their arms above their head (eg, hair combing, reaching overhead cabinets).
      PR programs use a multidisciplinary approach to tailor an individualized program, including professionals with expertise in exercise training, psychosocial evaluation and counseling, respiratory medications and oxygen therapy, nutrition, patient education, and smoking cessation. Programs are typically coordinated by nursing or respiratory therapy departments and often include a pulmonologist. Patients benefit from PR programs whether in an outpatient, inpatient, or home setting.
      • Rochester C.L.
      • Vogiatzis I.
      • Holland A.E.
      • et al.
      An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation.
      For outpatient and inpatient programs, sessions are conducted in small groups, usually 2 or 3 times per week, and range from 4 to 10 weeks, with longer programs having larger effects than shorter ones.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      Because patients need to attend several times a week, finding a program close to their homes is important, as the decision to participate may be influenced by location and transportation possibilities. Insurance coverage may also factor in the decision to participate; however, Medicare does cover PR for patients with moderate to very severe COPD (Medicare.gov).
      Formal PR programs require an order from the referring provider. In addition to the referral, pertinent recent test results are needed, including an electrocardiogram, pulmonary function test, and 6-minute walk test (a test done to determine if there is an oxygen requirement with exercise). Highly motivated patients receive the most benefit from participation in PR,

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      so this should be considered before referral. If patients are still smoking, they should be enrolled in a smoking-cessation program, because continued smoking has been shown to be the greatest predictor of PR dropout.
      • Brown A.T.
      • Hitchcock J.
      • Schumann C.
      • Wells J.M.
      • Dransfield M.T.
      • Bhatt S.P.
      Determinants of successful completion of pulmonary rehabilitation in COPD.
      The exercise benefits of PR will be lost without continued physical activity such as an at-home maintenance program,

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      so addressing continued activity at each visit is vital.
      If patients choose not to participate in a structured PR program, health care providers should advise them to remain physically active and exercise on their own. Although providing advice for PA has not been studied in patients with COPD, significant benefits, including decreased hospital readmission rates and improvement in health-related quality of life,
      • Nguyen H.Q.
      • Chu L.
      • Amy Liu I.L.
      • et al.
      Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease.
      • Vaes A.W.
      • Garcia-Aymerich J.
      • Marott J.L.
      • et al.
      Changes in physical activity and all-cause mortality in COPD.
      as well as the strong health benefits of PA and exercise in older adults,

      World Health Organization. Physical activity and older adults. 2015. http://www.who.int/dietphysicalactivity/factsheet_olderadults/en/. Accessed May 25, 2016.

      strongly support this suggestion. PA should be encouraged at the initial diagnosis of COPD; maintaining as high a physical activity level as possible is associated with a better prognosis.
      • Vaes A.W.
      • Garcia-Aymerich J.
      • Marott J.L.
      • et al.
      Changes in physical activity and all-cause mortality in COPD.
      NPs should start with patient education that covers the overall health benefits of daily activity with a focus on how it may positively impact COPD. In addition to the benefits just mentioned, regular PA and exercise can improve balance and prevent falls,

      World Health Organization. Physical activity and older adults. 2015. http://www.who.int/dietphysicalactivity/factsheet_olderadults/en/. Accessed May 25, 2016.

      which is important in this population as certain patients with COPD have a high susceptibility to falls; in particular, females and those with older age, a history of previous falls, and/or a diagnosis of coronary artery disease.
      • Roig M.
      • Eng J.J.
      • MacIntyre D.L.
      • et al.
      Falls in people with chronic obstructive pulmonary disease: an observational cohort study.
      Furthermore, many patients with COPD struggle with depression and anxiety, which are associated with reduced exercise capacity and greater dyspnea.
      • Martinez Rivera C.
      • Costan Galicia J.
      • Alcazar Navarrete B.
      • et al.
      Factors associated with depression in COPD: a multicenter study.
      Depression in COPD patients is also an independent risk factor for hospitalization.
      • Iyer A.S.
      • Bhatt S.P.
      • Garner J.J.
      • et al.
      Depression is associated with readmission for acute exacerbation of chronic obstructive pulmonary disease.
      Although PR has been shown to decrease depressive and anxiety symptoms, data are limited on the effects of general PA on these symptoms in patients with COPD and further research is needed in this area.
      A general approach to providing PA and exercise education in patients with COPD includes aerobic, stretching, and strengthening exercises.
      American College of Sports Medicine
      Exercise prescription for populations with other chronic diseases and health conditions.
      A good starting point is to slowly begin aerobic activity through walking to develop endurance, strength, and balance. In general, patients should start with slow walking and increase a little every day, paying attention to their breathlessness and stopping to rest whenever they are short of breath. Additional practical tips for patients for walking are included in Table 2.
      Table 2General Tips: Physical Activity and Exercise for COPD Patients
      • Take all of your medications as prescribed.
      • Take your short-acting rescue inhaler at least 15 minutes before engaging in physical activity and exercise and always carry it with you.
      • Avoid prolonged sitting. Stand up and move at least every 20 minutes.
      • Make physical activity a regular part of your day; getting up to change the TV channel instead of using the remote control or getting out of the chair to get a glass of water instead of asking someone to get it for you. Small changes can make a big difference.
      • Make time for exercise.
      • Exercising every other day will help maintain a regular schedule, which is important to overall fitness and is the best way to notice results.
      • Do not overdo it, and always stop and rest when you become short of breath.
      • Warm up for at least 5 minutes before exercising by doing light stretching or range of motion activities or beginning the activity at low intensity.
      • Include a cool-down period at the end of each exercise session by decreasing the intensity of your activity or doing some of the stretching or range of motion activities you did in your warm-up.
      • Wait at least 2 hours after eating to exercise.
      General tips for walking:
      • Start slowly and try to increase a little every day.
      • Stop and rest whenever you are short of breath.
      • Try to go a little farther every day; however, remember that you need to get back to your starting point so do not overestimate the distance.
      • Try to work up to 20 minutes at a time.
      • Take a cell phone with you and walk with a friend or relative, if possible.
      • If you use oxygen, be mindful of the tubing so you do not trip and fall.
      • If you are walking outside, be mindful of any cracks or uneven pavement, so you do not trip and fall.
      • Dress for the weather and wear comfortable shoes.
      • Avoid extreme weather conditions, including windy, rainy, icy, or cold days and days with poor air quality (in general, days in the green and yellow zone are acceptable). For specific information on daily air quality, see: https://airnow.gov/index.cfm?action=aqibasics.aqi/.
      • Develop a contingency plan for inclement weather days such as walking in the mall or a community recreation center.
      COPD = chronic obstructive pulmonary disease.
      Strengthening exercises for the upper body, including using light weights and resistive bands, may be particularly helpful in patients with COPD because these types of exercises help increase respiratory muscle strength.

      Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18, 2016.

      Skeletal muscle impairment is also one of the extrapulmonary effects of COPD; because patients often have difficulty with activities of daily living that involve the upper extremities, the ACSM recommends light resistive exercise with a focus on the muscles of the shoulder girdle.
      American College of Sports Medicine
      Exercise prescription for populations with other chronic diseases and health conditions.
      In addition to more traditional exercise, such as walking, data suggest that Tai Chi (a Chinese martial art that focuses on slow sequential movements) can increase exercise capacity and health-related quality of life in COPD patients
      • Wu W.
      • Liu X.
      • Wang L.
      • Wang Z.
      • Hu J.
      • Yan J.
      Effects of Tai Chi on exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis.
      and can improve balance and prevent falls in the elderly.

      National Council on Aging. Tai Chi for falls prevention. 2016. https://www.ncoa.org/wp-content/uploads/Tai-Chi-Guidance-Document-030316.pdf. Accessed May 25, 2016.

      Yoga has also been shown to have a positive effect on lung function and exercise capacity in patients with COPD.
      • Liu X.C.
      • Pan L.
      • Hu Q.
      • Dong W.P.
      • Yan J.H.
      • Dong L.
      Effects of yoga training in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis.
      Scheduling exercise to fit into a patient’s daily routine and choosing a time of day when they are less fatigued (perhaps morning) will likely help them maintain consistency, which is important in improving overall fitness level and seeing results (which may in turn motivate them to continue being physically active). If the patient uses oxygen with activity as determined by a formal 6-minute walk test, the NP should determine at the initial clinic visit that they have a portable tank and remind them of the importance of wearing oxygen at their activity-prescribed flow rate. Pursed-lip breathing may also help during exercise and can help to slow breathing rate and reduce breathlessness. NPs should review the technique with patients by telling them to first inhale slowly through the nose, and then to exhale through pursed lips for twice as long as they inhaled. This technique is not only helpful with exercise but may be beneficial for everyday tasks that involve lifting, bending forward, or climbing stairs. Table 2 lists other general educational points related to PA in patients with COPD.
      In addition to more traditional PA and formal pulmonary rehabilitation options for patients with COPD, new models are emerging for innovative, online, technology-based exercise programs for patients with COPD.
      • Spruit M.A.
      • Singh S.J.
      • Garvey C.
      • et al.
      An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.
      Models using video conferencing, mobile phone apps, and bluetooth-based activity monitors are growing in use and may be especially helpful in rural areas or when transportation is an issue, or in helping patients remain active after they complete a formal PR program; however, more research is needed in this area.

      Summary: Role of the NP in Promotion of PA and Exercise Strategies

      PA and exercise play an integral part in the overall health and maintenance of patients with asthma and COPD and should be addressed at every clinic visit. Work collaboratively with your patients, using a patient-centered approach, and design an individualized plan based on the severity of your patient’s disease and symptoms. For patients whose symptoms are not well controlled, consider an evaluation to a specialist to optimize management before increasing the level of PA or starting a formal exercise program. Provide patient education regarding PA and exercise, starting with the foundational points provided in this article, and consider a formal PR program, especially for patients with COPD. For all patients, provide information on appropriate use of their prescribed medication before and during PA and exercise. Always review the patient’s progress at each visit and continue to motivate and provide support. Be attuned to future research regarding PA and exercise in patients with asthma and COPD and modify your practice based on the evidence. Consider emerging, innovative, and evidence-based models to enhance PA and exercise for patients, including home-based online groups, mobile-phone applications, and other telehealth options.

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      Biography

      Susan J. Corbridge, PhD, ACNP, FAANP, is director of graduate clinical studies and clinical associate professor in the Department of Biobehavioral Health Science at the University of Illinois at Chicago College of Nursing. She can be reached at [email protected].
      Sharmilee M. Nyenhuis, MD, is an assistant professor in the Division of Pulmonary, Critical Care, Sleep & Allergy Medicine at the University of Illinois Hospital in Chicago.