**4. Implications**

364 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

In an attempt to reduce the severity of breathlessness and to improve exercise tolerance, IMT has been applied in many COPD patients (Weiner, Magadle, Beckerman, Weiner, & Berar-Yanay, 2003). Several different respiratory muscle training devices are available, ranging from sophisticated computerized systems to simple hand-held resistive devices. In addition, the relative benefits of strength versus endurance training, inspiratory versus expiratory training and effect in patients of differing severity are unknown (Garrod &

There are studies comparing the effect of different types of intervention (Geddes, Reid, Crowe, O'Brien, & Brooks, 2005). In order to standardize studies that showed sham IMT and low intensity IMT at similar percentages of maximum inspiratory pression (PImax). Bégin et al., (Begin & Grassino, 1991) measured these loads using the tidal inspiratory pressure (PI) of individuals with COPD. Sham IMT was defined as that using the same type of device as the intervention group at an intensity less than or equal to the mean plus one standard deviation (SD). Since PI is directly proportional to the partial pressure of carbon dioxide in the arterial blood (PCO2) of patients with COPD (Begin & Grassino, 1991), sham IMT for normocapneic individuals was defined as intensity p8.3 cm H2O (mean PI +1 SD) and for individuals with moderate hypercapnia, as intensity p11.5 cm H2O (Geddes et al., 2005).

Using IMT in combination with other interventions and using flow-dependent resistive training is important in the pulmonary rehabilitation program (Geddes et al., 2008). However, there are no established thresholds for what constitutes a clinically meaningful change in inspiratory muscle strength or endurance, other methods must be utilized to infer clinical benefit (Shoemaker et al., 2009). Geddes et al. (2005) recommended using IMT at least a total of 30 minutes daily but can be spread over more than one session a day. Training should occur at least 5 days a week. While gains may be measurable after as short

Fig. 6. Equipment to maneuver

*Types of intervention: Sham, low- and high-intensity IMT* 

Lasserson, 2007)

In the research reviewed, there are strong arguments that pulmonary rehabilitation is beneficial for improving the quality of life related to health at the beginning of the program. Furthermore pulmonary rehabilitation reduces symptoms and increases participation in everyday activities. However, it is necessary to do more randomized controlled trials to clarify which components of the lung rehabilitation are essential. Future studies to discover the ideal length of treatment, the necessary degree of supervision, training intensity and how long the treatment effect persists.

Without no doubt, it is necessary to individualize programs for this population taking into account their different levels of severity. The prescription should begin at low intensity and short duration, for both parameters gradually increasing to the threshold of fatigue.

In summary, incremental aerobic resistance physical exercises are better than constant load physical exercises at an intensity range from 90% to 50 % of VO2 max, with a frequency of two or four days a week, the session is from 30 to 60 minutes during a period of treatment from eight to twelve weeks. Exercise training induces several symptomatic and functional adaptations resulting in an increased aerobic capacity, although clinical relevance is not collected in the study population. Maybe, for further studies we should take intrinsic patient factor (severity of COPD) into account over a longer period of time and how extrinsic factors of the exercises affect disease progression. Moreover, it is important to determine whether these physiological benefits of COPD patients who have performed an incremental aerobic resistance physical exercises program supervised justify the increased costs. Therefore, a cost/effectiveness analysis is necessary to determining whether the type of intervention program is supervised or not.

It is essential to investigate physical activity in daily life in patients with COPD in accordance to the GOLD stages. Pulmonary rehabilitation programs should incorporate the

Types of Physical Exercise Training for COPD Patients 367

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