Pulmonary Rehabilitation for COPD

Given finite healthcare resources it is important to ensure that they are put to the best use. Value in health care represents the relationship between health outcomes achieved and resources used. In a highly prevalent condition it is important to ensure that the highest value interventions are employed effectively In COPD these are influenza vaccination, smoking cessation and pulmonary rehabilitation (www.impressresp.com)(1,2). Skeletal muscle impairment is a common and important feature of respiratory disease. In COPD it is associated with reduced quality of life (3), exercise capacity and survival (4). Muscle endurance is also reduced and this has been confirmed using non-volitional techniques (magnetic femoral nerve stimulation) (5). Muscle fatigue is an important symptom limiting exercise (6).The main driver is physical inactivity and this occurs in early in the course of the disease (7) in particular this may be before it has been diagnosed (8). Physical inactivity may itself drive lung disease progression (9). As well as a loss of muscle bulk there is a shift away from a Type I fibre, oxidative endurance muscle phenotype (10). The underlying biology is complex and in addition to inactivity, inflammation, corticosteroids, reduced anabolic hormones, corticosteroid treatment, hypoxia, poor nutrition and increased resting energy expenditure may all play a role (11). There is a recent ATS/ERS statement on limb muscle dysfunction in COPD (12). Exercise has a wide range of beneficial effects. It can improve exercise capacity, lipid profile, reduce falls, reduce cardiac risk, improve depression, insulin sensitivity, and systemic inflammation as well as protecting against cognitive decline and osteoporosis.