The patient is a 64-year-old male. He presented with difficulty in breathing and was diagnosed with COPD (chronic obstructive pulmonary disease) ten years back. He is a farmer and an active smoker, of 18 packs / year for 35 years. He began to experience dyspnoea when performing moderate exertion, dyspnoea grading of 3 as denoted by modified medical research council mMRC (Modified Medical Research Council) and productive cough with sputum, usually in the morning. He is on long-term oxygen therapy of 4 litres of oxygen for 16 hours per day for 2 years. He has a history of hospitalisation six times and 5 - 6 emergency consultations for acute exacerbation in the last 3 years. The patient was on regular treatment with long-acting inhaled beta-2 agonist (LABA) inhaler and long-acting anticholinergics or long-acting muscarinic receptor antagonists (LAMA) and corticosteroid (ICS) inhalers 200-400 micrograms (μg) three times a day and mometasone 400 μg, continuously. The patient’s body mass index (BMI) was 20.3 Kg / m2. His blood pressure was 140 / 80 mmHg, heart rate (HR) 74 bpm, respiratory rate (RR) 22 rpm and peripheral oxygen saturation (SpO2) at rest was 95 %. Pulmonary auscultation revealed a diffusely reduced breath sounds, and no alterations were found in cardiac auscultation. The patient’s post-bronchodilator pulmonary function test was 52.2 % of forced expiratory volume in 1 second (FEV1). In the six-minute walk test(6mwt), the patient walked a total distance of 294.4 meters, with variations in heart rate from 74bpm to 128bpm. Whenever peripheral oxygen saturation was reduced to 88 %, the patient had taken rest. The patient took rest two times, at the end of the second minute thirtyfive seconds and the end of the fourth minute forty-five seconds. The body-mass index, airflow obstruction, dyspnoea and exercise (BODE) mortality index were used to measure 4 years survival interpretation.1 Saint George’s Respiratory Questionnaire chronic obstructive pulmonary disease (COPD) version (SGRQ-C) was used to measure the quality of life (QoL). After the initial assessment, the patient was enrolled in the pulmonary rehabilitation program. The first three months were supervised, exercise training constituted weekly educational sessions and meeting with the psychology support group and nutrition advice before beginning the exercise intervention. 2 The patient visited the institution three days per week for exercise training. The exercise constituted aerobic on the treadmill and intensity, in the beginning, was 80 % of the 6MWT speed, and Borg’s scale of perceived exertion was 4 as prescribed by American Thoracic Society (ATS). 3 The components of the program were warm-up sessions, conditioning, resistance exercise and a cool-down session. The patient was also advised home exercise program, which included resistance training using weighted sandbags for three sessions per week. The resistance added was based on 1 repetition maximum (RM) and 10RM. 80 % of 10 RM was the training intensity for resistance training for a larger group of muscles. 4 The weight was added gradually and ensured their rated perceived exertion (RPE) was at 4 during exercise. The patient’s outcomes were recorded after three months of training. After 12 weeks of supervised outpatient exercise intervention, the patient was advised home exercise program for the next 6 months. 5
Beta-blockers in COPD: time for reappraisal