Strategies for Improving Exercise Tolerance in COPD

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If someone were to ask what keeps you from exercising when you have COPD, chances are you would say dyspnea (commonly referred to as breathlessness). In COPD, dyspnea and muscle fatigue are the primary deterrents to starting an exercise program. This is unfortunate because the best way to improve exercise tolerance and decrease breathlessness in COPD is to exercise regularly. So, how do you manage to exercise if your muscles give out and you can't catch your breath?

Although you should always check with your doctor before implementing any of the methods listed below, the following strategies may help you exercise longer and reduce breathlessness during exercise:

Non-Invasive Positive Pressure Ventilation

Although somewhat impractical, studies have shown that people who exercise regularly using non-invasive positive pressure ventilation (NIPPV) may have a training advantage over those who don't. Not only does NIPPV allow COPD patients to exercise longer, but they are able to reach a higher workload during exercise sessions than when they exercise unassisted. Hopefully, advances in medical technology will lead to oxygen being delivered more comfortably during NIPPV, rather than with a tight-fitting nasal mask.

Using NIPPV at night may be a far more practical answer. Studies suggest that when combined with pulmonary rehabilitation, patients who use nocturnal NIPPV show improvements in the 6-minute walk test, FEV1, dynamic hyperinflation and arterial blood gases. Patients may also see an improvement in their physical function, social function, mental health, and vitality.

Electrical Stimulation

COPD patients who have better-preserved muscle strength and muscle function may benefit from high frequency neuromuscular electrical stimulation (hf-NMES). Studies suggest that it improves exercise capacity by allowing patients to tolerate a higher level of exercise intensity. It may also improve breathlessness.

The best way to approach hf-NMES is to use it before tissue wasting (common in advanced COPD) occurs, although it may be beneficial for patients who are severely disabled with incapacitating dyspnea, as well.

Electrical stimulation can be used in the home, or as part of a formal, pulmonary rehabilitation program.

Oxygen Supplementation

A study published in Thorax suggests that supplemental oxygen during exercise provides only minimal relief from dyspnea and does little to improve exercise tolerance in COPD. However, subsequent studies suggest that it may improve exercise endurance, decrease the perception of dyspnea and decrease lung hyperinflation in patients with normal blood oxygen levels.

There is ongoing speculation about which delivery method -- nasal cannula or transtracheal -- is best during exercise. Research backing the use of the transtracheal method is rather outdated; however, proponents of transtracheal oxygen delivery maintain their belief that it works best.

Pulmonary Rehabilitation

Pulmonary rehabilitation is an important part of COPD treatment and is recommended for all patients who are in the moderate to very severe stages of COPD. Pulmonary rehabilitation can help COPD patients:

  • Improve exercise tolerance
  • Reduce breathlessness
  • Improve the quality of life
  • Reduce hospitalizations and hospitalization time
  • Reduce anxiety and depression
  • Improve arm function
  • Improve respiratory muscle strength (when combined with general exercise)


There are a number of medications available that have been shown to improve exercise tolerance and reduce exercise-induced breathlessness in COPD. The more commonly studied are:

  • Albuterol -- One of the characteristics of COPD is airflow limitation. Dynamic hyperinflation is a major consequence of airflow limitation during exercise in COPD and an important contributor to breathlessness. Research shows that inhaled albuterol, a short-acting beta agonist, reduces exercise-related dynamic hyperinflation and improves other important ventilatory functions.
  • Spiriva -- Combined with pulmonary rehabilitation, the anticholinergic bronchodilator Spiriva (tiotropium) improves exercise endurance, breathlessness, and health status compared to using pulmonary rehabilitation alone.
  • Salmeterol -- Salmeterol, a long-acting beta agonist, improves breathlessness during exercise but does not necessarily increase exercise duration.
  • Nebulized ipratropium bromide -- Compared to a placebo, nebulized ipratropium bromide (an anticholinergic) increases exercise endurance time, reduces dyspnea and decreases dynamic hyperinflation. Additionally, after using ipratropium bromide, patients in clinical studies showed an increase in FEV1, FVC and inspiratory capacity (the volume of air that can be inhaled after normal exhalation).

    Interval Training

    During interval training, a patient repeats sequences of high-intensity exercise interspersed with light exercise (most studied in COPD) or rest. Interval training in COPD results in positive training effects for some patients and is often used as part of a pulmonary rehabilitation program.

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