combined exercise and inspiratory muscle training in patients

1. Combined exercise and
inspiratory muscle training in
patients with Heart Failure
Hiba Anis
MPT 3rd Sem
Jamia Millia Islamia

2. Introduction
• Exercise intolerance and dyspnoea are the major symptoms of patients with chronic heart failure
(CHF) and are associated with a poor quality of life (QoL). (Drexler et al 1992)
• Early diaphragmatic fatigue with a decrease in both inspiratory muscle strength (PImax) and
endurance have also been documented, associated reduced functional status of patients with CHF.
(McParland et al., 1992)
• In addition to impaired central haemodynamics, symptoms may be attributed to changes in
peripheral skeletal muscles which include a shift from type I to type IIb fibres, reduced oxidative
capacity, and muscle atrophy.
• Aerobic training (AT) programmes may partially reverse these changes, improve or maintain
functional capacity, and restore QoL in patients with moderate to severe CHF (Adamopoulos et
al., 1993)
• These exercise programs are recommended by the European Society of Cardiology (ESC)
guidelines for the diagnosis and treatment of acute and chronic heart failure, and the European
Association for Cardiovascular Prevention and Rehabilitation (EACPR).

3. • Also, studies confirm that AT may only have a minimal effect on peripheral skeletal and respiratory
muscle weakness compared to that of selective muscle training.
• Thus, addition of peripheral muscle dynamic resistance training (RT) to AT is safe and had a more
pronounced effect on limb muscle strength, exercise capacity and QoL compared to that of AT
alone
• Furthermore, combined inspiratory muscle training (IMT) with AT results in incremental benefits
in inspiratory muscle performance and functional status in comparison to AT

5. Aim
• The aim of the study was to investigate the potential additive benefits
of IMT on standard Aerobic Training on primary outcomes such as
respiratory muscle function, exercise capacity, sensation of dyspnoea,
and QoL, as well as on secondary outcomes which included
pulmonary lung volumes, LV function and structure, and serum
biomarkers of inflammation and myocardial stress

6. Methodology
Inclusion criteria
• age >18,
• stable moderate to severe CHF with systolic dysfunction (LVEF ≤35%),
• NYHA functional class II–III, and
• a signed informed consent (compatible with each centre’s ethics committee regulations).
Exclusion criteria
• pulmonary limitation [forced vital capacity (FVC) <60%% of age- and gender-predicted
values or forced expiratory volume in 1 s (FEV1)/FVC <60%%],
• active smoking,
• recent thorax surgery,
• angina pectoris (CCS III–IV),
• treatment with corticosteroids,
• abuse of any substances and cognitive impairment,
• inability to perform an exercise test, or any major non-cardiac problem that would adversely
affect survival during the study

8. • Primary endpoint measurements included
• exercise capacity assessed by peak oxygen consumption (peak VO2) using a
cardiopulmonary exercise test (CPET),
• dyspnoea (Borg scale 0–10) measured at the end of exercise testing,
• QoL with the Minnesota Living with Heart Failure Questionnaire (MLwHFQ),
• PImax and inspiratory muscle work capacity [sustained maximal inspiratory pressure
(SPImax)] which represents an endurance index
• Secondary endpoint measurements included
• LV function and volume,
• spirometric parameters of lung function, and
• serum biomarkers of inflammation [C-reactive protein (CRP)] and myocardial stress [N
terminal-pro brain natriuretic peptide (NT-proBNP)].

9. Training protocol
• Aerobic training
• Patients in both the AT/IMT and AT/SHAM group underwent AT for
• 45 min on an ergometer at 70–80% maximum HR for three times a week for 12 weeks in the
hospital.
• Warm-up and cooldown periods lasted 5 min each.
• Inspiratory muscle training
• inspiratory-incremental resistive loading device was used for IMT
• the training protocol was in accordance with skeletal muscle training principles, termed as test
of incremental respiratory endurance (TIRE)
• The test had different levels of training, with six inspiratory efforts at each level. Initially, the
first level presented templates at 60 s rest intervals over its six inspiratory efforts, but at the
second level through to the sixth level, this rest period was reduced to 45, 30, 15, 10, and 5 s.
After the sixth level, the rest period was kept at 5 s. The duration of training was 30 min.
• Supervised training was performed three times a week for 12 weeks in the hospital

10. Results
• At baseline there were no statistically significant differences between the AT/IMT and the
AT/SHAM group
• PFT:
• Neither group showed a significant improvement of FVC, FEV1, or FEV1/FVC
• Between-group analysis revealed that SPImax differed significantly after the
intervention, with a greater benefit for the AT/IMT group

12. • Cardiopulmonary exercise test
• Between-group comparison did not show significant differences of the AT/IMT group
as compared with the AT/SHAM group after the intervention in any of the CPET
parameters.
• Within-group analysis showed a significant improvement of peak VO2 in both the
groups, while exercise time, respiratory exchange ratio (RER), and VE improved
significantly only in the AT/IMT group

13. • Quality of life, echocardiographic measurements, and New York Heart Association
functional class
• Between-group analysis showed significant differences in the score of the MLwHFQ in
favour of the AT/IMT group.
• Within group analysis showed that the MLwHFQ score improved significantly in the
AT/IMT group improvement did not reach statistical significance

14. • Dyspnoea and serum biomarkers
• Between-group analysis showed a significant difference in NTproBNP in favour of
the AT/IMT group .
• Between-group analysis showed significant differences in dyspnoea and CRP in
favour of the AT/IMT group.
• Within-group analysis showed that dyspnoea improved significantly in the AT/IMT
group but not in the AT/SHAM group, CRP decreased significantly only in the
AT/IMT group, while NT-proBNP did not change significantly in either of the groups,
although it tended to decrease in the AT/IMT group

15. Conclusion
• This multicentre randomized trial demonstrates that addition of IMT to AT results in
additional improvement in respiratory muscle function, dyspnoea, QoL, and inflammatory
and cardiac biomarkers, but not in cardiopulmonary exercise parameters in moderate heart
failure.
• These findings should provide an impetus for clinical application of IMT in patients with
CHF and for initiation of larger randomized trials to elucidate the underlying
pathophysiological mechanisms of respiratory muscle training recruitment, especially in
patients with advanced heart failure

17. Aim
• It was hypothesized that combined AT with RT and IMT (ARIS training program) could
result in a significant additional improvement in both peripheral skeletal and respiratory
muscle function with concomitant enhanced benefits in exercise capacity, dyspnea and
QoL compared to that of standard AT. A secondary aim was to assess the safety of such a
program in the population tested.

18. Methodology
• Inclusion criteria included
• CHF due to ischemic or dilated cardiomyopathy,
• left ventricular ejection fraction (LVEF) ≤40%,
• New York Heart Association (NYHA) functional class II and III and
• haemodynamic stability of at least 3 months prior to participation.
• Exclusion criteria included
• infection,
• pulmonary limitation (forced expiratory volume in 1 s and/or vital capacity b60% of
predicted),
• current smoking,
• significant cardiac arrhythmia,
• exercise limited by angina or peripheral arterial occlusive disease or
• mobility problems preventing exercise training or testing.

20. • Primary end-point measurements included
• inspiratory muscle strength (PImax) and inspiratory work capacity
• quadriceps muscle function: Quadriceps muscle strength (QMS) was evaluated with peak
quadriceps muscle torque (QMTpeak) and the 1 repetition maximum (1RM)
• exercise capacity assessed with peak oxygen consumption (peak VO2) during a
cardiopulmonary exercise test (CPET),
• dyspnea evaluated with the Borg scale (6–20) and
• QoL using the Minnesota Living with Heart Failure Questionnaire (MLwHFQ).
• Secondary endpoints measurements included
• left ventricular function and structure evaluated using resting echocardiography.

21. Training protocol
• Patients in both the ARIS and the AT group were trained 3 times a week for 12 weeks.
• Warming-up and cooling down exercises lasted 5 min each for both groups. In the ARIS group an
additional 2 min of rest-stretch was allowed among different exercise stations.
• Aerobic training group :
• using a bike at an intensity of 70–80% of maximal heart rate (HR).
• Patients started with 20 min AT during the first week and increased exercise time by a
minimum of 1 min in each training session.
• 45 min AT was achieved during the first 6 weeks of training and patients continued to exercise
at this training time for the remaining 6 weeks of the program. In this group, the total exercise
time was 55 min.

22. • ARIS group:
• using a bike at an intensity of 70–80% of maximal heart rate (HR).
• 30 min AT was achieved within the first 3 weeks of training and patients continued to exercise
for this training time for the remaining 9 weeks of the program
• patients also underwent 15 min RT and 20 min IMT.
• Thus, the total exercise time including warming and cooling down periods reached 1 h and 15
min
• Resistance training: consisted of dynamic quadriceps muscle and upper limb resistance
exercises.
• Three exercise sets of 10–12 quadriceps resistance exercises were performed for both lower
extremities using a quadriceps armchair at an intensity of 50% of 1RM recalculated every 2
weeks of training
• Upper limb exercises included elbow flexion, shoulder flexion and abduction using dumbbells
of 1–2 kg, with 2 sets of exercises for each muscle group performed with 10–12 repetitions
each.

23. • IMT consisted of high-intensity endurance training at 60% of SPImax using a
computer biofeedback trainer with patients progressing through the exercise by
reducing the rest time interval between inspiratory efforts. Individual PImax and
SPImax were recalculated in each training session .

24. Result
• In the AT group, 45 min AT was achieved during the first 6 weeks of training and patients
continued to exercise at this training time for the remaining 6 weeks of the program. In
this group, the total exercise time was 55 min.
• Lower limb and respiratory muscle function
• Between-group analysis revealed that QMTpeak, 1RM, QME and SPImax differed
significantly after the intervention. In particular, participants in the ARIS group were
more benefited as compared with that of in the AT group

25. • CPET
• Between-group comparison showed significant difference of the ARIS group as
compared with that of the AT group after the intervention, concerning treadmill exercise
time and circulatory power
• within-group analysis showed that exercise time and Circulatory Power improved
significantly in both the ARIS and AT groups. Further within-group analysis revealed a
significant increase in peak VO2, treadmill exercise time, ventilatory threshold and
SBPpeak as well as a decrease in VE/VCO2 slope in the ARIS group.
• Echocardiography
• Between-group comparison did not show a significant difference of the ARIS group as
compared with that of the AT group in LV indices after the intervention.
• Within group analysis showed a significant improvement in LVEF and LVESD in both
the ARIS and the AT groups whilst LVEDD improved significantly only in the ARIS
group

26. • Quality of life, dyspnea and NYHA classification
• Between-group analysis showed significant differences in MLwHFQ and
dyspnea after the intervention.
• Within-group analysis showed that MLwHFQ and NYHA improved only in the
ARIS group whilst dyspnea did not significantly change in any of the groups

27. Conclusion
• The triple exercise model was safe and resulted in additional benefits in both
quadriceps and inspiratory muscle indices, cardiopulmonary exercise parameters,
dyspnea and quality of life when compared to aerobic training only.
• The present findings advocate for the addition of both resistance and inspiratory
muscle training to standard aerobic training in patients with CHF

28. Discussion
• Suggested mechanisms of selective IMT-induced improvement in exercise capacity of
CHF patients include reduction of dyspnoea and/or potential diaphragmatic unloading
with consequent peripheral effects.
• previous studies have shown that decrease in the work of breathing with a ventilator or
IMT resulted in an increase in limb blood flow (possibly through modification of a
diaphragmatic ‘metaboreflex’) and exercise performance in CHF patients
• It is therefore possible that recruitment of respiratory muscles might further attenuate
ergoreflex sensitivity resulting in lower sympathoexcitation and peripheral resistance
• Mancini et al. previously showed that respiratory muscle endurance was reduced even in
CHF patients who preserved PImax. Thus, the additional improvement in lower limb and
inspiratory muscle indices might have contributed to the incremental benefits shown in
exercise performance.

29. • a benefit in dyspnea was shown for the ARIS group when compared to that of the AT
group. These changes may explain the additional improvement in QoL with triple
training. Although peak VO2 improved significantly in both groups, ARIS training
resulted in a small but significant benefit in CP over the AT group. CP expresses both
peak VO2 and SBPpeak and might reflect the performance of the cardiac pump in the
context of its function at peak exercise and is considered as a surrogate of cardiac output
and a powerful predictor of mortality

30. References
• Drexler, H., Riede, U., Münzel, T., König, H., Funke, E., & Just, H. (1992).
Alterations of skeletal muscle in chronic heart failure. Circulation, 85(5),
1751–1759. https://doi.org/10.1161/01.cir.85.5.1751
• Adamopoulos, S., Coats, A. J., Brunotte, F., Arnolda, L., Meyer, T.,
Thompson, C. H., Dunn, J. F., Stratton, J., Kemp, G. J., & Radda, G. K.
(1993). Physical training improves skeletal muscle metabolism in patients
with chronic heart failure. Journal of the American College of
Cardiology, 21(5), 1101–1106. https://doi.org/10.1016/0735-
1097(93)90231-o
• McParland, C., Krishnan, B., Wang, Y., & Gallagher, C. G. (1992).
Inspiratory muscle weakness and dyspnea in chronic heart failure. The
American review of respiratory disease, 146(2), 467–472.
https://doi.org/10.1164/ajrccm/146.2.467

31. Thank you!