Pulmonary Rehabilitation* Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines

Andrew L. Ries, MD, MPH, FCCP (Chair); Gerene S. Bauldoff, RN, PhD, FCCP; Brian W. Carlin, MD, FCCP; Richard Casaburi, PhD, MD, FCCP; Charles F. Emery, PhD; Donald A. Mahler, MD, FCCP; Barry Make, MD, FCCP; Carolyn L. Rochester, MD; Richard ZuWallack, MD, FCCP; Carla Herrerias, MPH


CHEST. 2007;131(5):4S-42S. 

In This Article

Intensity of Aerobic Exercise Training

Exercise training is one of the key components of pulmonary rehabilitation. The exercise prescription for the training program is guided by the following three parameters: intensity; frequency; and duration. The characteristics of exercise programs in pulmonary rehabilitation for patients with COPD have not been extensively investigated.

As noted by the previous panel and a 2005 review,[74] for most patients with COPD with limited maximum exercise tolerance, training intensities at higher percentages of maximum (ie, peak exercise) are well-tolerated, and physiologic training effects (eg, increase in aerobic capacity and anaerobic threshold with reduced ventilatory demand) have been documented as a result of (relatively) high-intensity aerobic training. Although it has not been conclusively demonstrated in patients with COPD, higher intensity training may result in better physiologic training effects, including reduced minute ventilation (VE) and heart rate (HR), and, thus, less dyspnea at submaximal exercise. In this context, the term high-intensity training for patients with COPD refers to patients exercising close to individual peak levels and is relative to the markedly reduced peak exercise levels in these patients. In previous studies, high-intensity training targets have been operationally defined to be at least 60 to 80% of the peak work rate achieved in an incremental maximum exercise test.[75,76] This should not be interpreted to represent training at high absolute work levels.

There have only been two randomized studies[77,78] published since the previous panel report that have evaluated the intensity of exercise during pulmonary rehabilitation in patients with COPD. Gimenez and colleagues[77] randomized 13 patients to high-intensity or moderate-intensity lower extremity exercise training daily for a period of 6 weeks. High-intensity exercise was performed on a cycle ergometer using a protocol of 1-min periods at peak oxygen uptake (VO2) followed by 4-min periods at 40 to 45% of peak VO2. The moderate-intensity exercise group pushed an oxygen cart for a similar duration of 45 min per session. High-intensity training resulted in greater physiologic improvements (eg, improvement in maximum VO2). High-intensity exercise, but not low-intensity exercise, also resulted in decreased dyspnea at rest and during submaximal exercise, and increased the 12-min walk distance. Vallet and colleagues[78] randomized 24 subjects to exercise at an HR achieved at the anaerobic or gas exchange threshold (high intensity) or at an HR of 50% of maximal cardiac frequency reserve (low intensity). Stationary cycle ergometry was performed for 45 min 5 days per week for 4 weeks. Subjects who trained at the higher gas exchange threshold intensity exhibited improvement in maximum exercise VO 2 and a greater decrease in VE compared to those who trained with low-intensity exercise.

The physiologic benefits of higher intensity exercise training with the associated reduction in VE at similar workloads may be expected to result in better outcomes from pulmonary rehabilitation. The few small controlled randomized studies[77,78] available confirm these expectations. However, the effects of high-intensity training on other key patient-centered outcomes such as quality of life, shortness of breath, and ability to perform ADLs have not been investigated rigorously.

Moreover, the impact of exercise intensity on the important outcome of maintenance of exercise training has not been evaluated. As in other populations, it is possible that lower intensity exercise training may be associated with better long-term adherence than higher intensity training.

11. Lower extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower intensity training in patients with COPD. Grade of recommendation, 1B

12. Both low-intensity and high-intensity exercise training produce clinical benefits for patients with COPD. Grade of recommendation, 1A


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