Exercise reduces shortness of breath and improves heart rate variability in COPD patients

When we think of respiratory health we often concentrate our thoughts on the lungs and the act of breathing. However, respiratory health also encompasses the heart and our circulatory vessels that pump blood carrying oxygen inhaled through the lungs to all parts of our bodies.

Often the impact of chronic shortness of breath therefore is not just seen in lung function tests but in tests to evaluate the efficiency/health of the heart and circulatory system. One such measure is called heart rate variability (HRV). In simple terms, HRV is the amount of time between heartbeats. In general, if there is a large gap in time between heartbeats the HRV is considered to be good. On the flip side, if there is a short gap in time between heartbeats, the HRV is considered bad.

When physicians evaluate HRV, they are most interested to see whether a person’s heartbeats are getting closer together or farther apart. When they are getting closer together, physicians become concerned as this indicates the heart is working harder than it did before. Poor HRV (meaning shorter and shorter gaps of time between heartbeats) is a significant predictor of cardiovascular events such as heart attacks and strokes.

For COPD patients, heart rate variability tends to be poor which makes sense given that the lungs have to work harder to breathe which places greater stress on the heart and therefore the heart has to beat faster/more often in order to help the rest of body perform normal every day functions. As a result, COPD patients experience a greater incidence of cardiovascular events compared to non-COPD populations.

Exercise has been shown in previous studies in non-COPD populations to improve HRV (meaning exercise helps the heart slow down or said another way it helps the heart beat less frequently). Exercise has also been shown in previous studies to reduce COPD patient shortness of breath. So a group of Brazilian researchers recently decided to evaluate whether exercise could also help COPD patients specifically improve heart rate variability. [1]

The study authors described the purpose of their research project as follows,” Nowadays, exercise training is a well-recognized method to treat symptomatic patients with COPD. Its objective is to improve impaired disease outcomes such as exercise capacity, functional status, health-related quality of life and peripheral muscle force, as well as physical activity in daily life. However, little is known about the effects of exercise training programs on HRV changes in patients with COPD.”

In their study, the research team divided 40 COPD patients into two groups. One group of 20 patients participated in a high intensity exercise program patterned on principles and practices of the COPD treatment pulmonary rehabilitation (high intensity group). The other group of 20 patients engaged in a low intensity exercise program that did not push patients as much as a traditional rehab program does (low intensity group). The researchers desired to see whether either program made a notable difference in heart rate variability and whether one level of intensity was more effective in improving HRV than the other.

The study team discovered that the high intensity exercise group experienced a notable mean improvement in heart rate variability (24% on one particular measure known as the SDNN index, and 27% on another measure known as the rMSDD) while the low intensity group saw their HRV worsen between 12-13% on these same two measures. This led the researchers to conclude that high intensity exercise (ala similar to the intensities practiced in pulmonary rehabilitation programs) not only reduce shortness of breath symptoms but also improves heart rate variability. In the researchers own words, “The present study showed that a 12-week high-intensity exercise training program including endurance and strengthening exercises was able to improve HRV outcomes such as the rMSSD and SDNN variables, whereas a low-intensity program of similar duration was not.”

So what did the two different exercise programs entail? According to the study authors, “In the HI group, circuit training including cycling, walking and strength training was performed based on a protocol previously described. For ergometry cycling, the training intensity was set at 60% of the initial maximal work rate; for treadmill walking, at 75% of the average walking speed during the baseline 6-min walking test (6MWT); and for strength training, at 70% of the baseline 1 repetition maximum test (1RM). Increase in work rates and/or duration was assured on a weekly basis, guided by a predetermined schedule and driven by the patients’ perception of their symptoms (Borg-symptom scores). In the LI group, patients progressively performed 5 different sets of exercises including breathing exercises, strengthening of the abdominal muscles (crunches) and calisthenics. Each set consisted of 12 different exercises which were repeated 15 times each. Every 7 sessions, patients began a new set of exercises with an increment on the intensity. Close supervision was provided during both training protocols, which were attended three times per week, for 12 weeks, with 1-h training sessions.”

As we have discussed in many previous articles, exercise is incredibly beneficial to COPD patients and those who otherwise suffer from chronic shortness of breath regardless of disease severity. We have many times recommended COPD patients seek entry to a pulmonary rehabilitation program in their local area if their pulmonologist will provide a referral.

For those people who cannot access a pulmonary rehab program (and unfortunately that’s about 99% of COPD patients and nearly 100% of an expanded audience of people who suffer from chronic shortness of breath but do not carry a COPD diagnosis), we created our Breathe Better for Life guidebook and CD-ROM, www.breathebetterforlife.com, to put the principles and practices of pulmonary rehabilitation directly in your hands. In the guide we created a 12 week exercise program patterned after the guidelines of the American Thoracic Society, the European Respiratory Society and the American College of Sports Medicine for those with poor respiratory health. Our accompanying CD-ROM provides narrated, pictorial step-by-step instructions for the various strength training, stretching and breathing exercises recommended in the guidebook.

Regardless of what exercise program you follow, it is vitally important for COPD patients to start and maintain an exercise program for the long haul. Many research studies have proven the benefits of a regular exercise program for COPD patients (reduced shortness of breath, fewer hospitalizations, improved quality of life, and improved physical strength and stamina to name a few). This study’s results seem to indicate that following a pulmonary rehabilitation style exercise program can also improve heart rate variability and in so doing lessen the potential for a cardiovascular event.


[1] Camillo CA, et al. Improvement of heart rate variability after exercise training and its predictors in COPD. Respiratory Medicine. 2011 February 20 [Epub ahead of print]

Breathing exercises significantly reduce fatigue intensity in COPD patients

In January 2011, a group of Iranian researchers reported that COPD patients who engaged in a regimen of three breathing technique exercises four times a day over a ten day period experienced an average 27% reduction in fatigue intensity. By comparison, the control group in the study (COPD patients who received no breathing technique exercises) reported only a 4% improvement in self-perceived fatigue. [1]

In introducing their study findings, the researchers set the stage by noting, “Two significant symptoms of COPD frequently complained by the patients are dyspnea (shortness of breath) and fatigue. Any patient who feels tired for more than 1 month is considered as affected by chronic fatigue. Chronic fatigue is important and common sensation in patients with COPD that interferes with the quality of life but (is) almost neglected. As the disease advances, hard breathing followed by dyspnea and increasing limitation of the patient’s ability to perform daily activities are worsened, and even for doing simple work during the day, the patient gets out of breath and is affected with early fatigue…

Respiratory exercises such as lip-pursing (pursed-lips breathing) or diaphragm respiration (diaphragmatic breathing), are considered as a part of pulmonary rehabilitation programs, which could lead to an improvement in gas exchange, exercise tolerance and quality of life. The goal of respiratory exercises in patients with COPD is for the patients to replace their ineffective respiratory techniques with effective ones and to discharge the lungs from secretions through deep respiratory exercises and effective coughing.”

In other words, the study team speculated that employing breathing techniques that help re-train COPD patients to breathe more deeply and at a slower speed would reduce the sensation of fatigue and enable the patients to participate in more activities and thereby enjoy a higher quality of life.

A total of 60 COPD patients participated in the study (30 in the breathing exercise group and 30 in the control group). Both groups completed a “fatigue severity scale” survey upon enrollment. Then the breathing exercise group received instruction in three respiratory exercise techniques (pursed-lips breathing, diaphragmatic breathing and “effective coughing” – the technique for effective coughing was not identified in the study but was most likely the Huff Cough technique taught in many pulmonary rehab progams).

The COPD patients in the breathing exercise group received instruction and supervision of the proper breathing and coughing techniques and then were asked to practice these techniques 4 times a day for 10 consecutive days. The control group did not receive the breathing/coughing training and were not instructed to utilize such techniques over the same 10 day period. After the 10 day study period, both groups again completed the fatigue survey and the researchers compared the pre- and post- results within and across each group.

For such a short duration of breathing/coughing technique training, the breathing exercise group recorded significant improvements. For example, at the outset of the study 27 of the 30 COPD patients indicated their fatigue was “severe” (the highest level on the survey), while 3 rated their fatigue as “moderate”. At the end of the study, only 16 reported their fatigue as severe (a 41% drop in the number of COPD patients who considered their fatigue severe), 11 indicated their fatigue was moderate, and 3 reported their fatigue as mild. On average, the breathing exercise group demonstrated a 27% improvement in perceived fatigue.

The control group barely moved in their fatigue perceptions. At the outset of the study, 27 of the 30 COPD patients reported their fatigue as severe. At the end of the study, 26 still perceived their fatigue intensity as severe.

These are pretty remarkable findings especially considering the study did NOT involve the core regimen of physical exercise typically offered in a pulmonary rehabilitation program. The only element of pulmonary rehab used in the study was the training and application of breathing and coughing techniques.

The study authors concluded, “Results of the present research showed a reduction in the fatigue intensity among COPD patients under interference as well as a meaningful reverse relationship between the fatigue intensity and the rate of respiratory exercises. In other words, the higher the rate of respiratory exercise applied, the less the fatigue intensity among the samples under interference. The present research also showed that it was the change of respiratory pattern that caused the reduction of fatigue intensity in COPD patients. Patients with COPD have a shallow, fast and insufficient breathing. Through exercises, this type of respiration has improved to diaphragm respiration in which the breathing speed is reduced leading to an increase of alembic aeration. By lip-pursing respiration also, the breathing depth is increased in patients.

Training of respiratory exercises through face to face procedure while implementing treatment procedures may have significant effects on controlling and improving the symptoms, raising the level of awareness and finally, upgrading their quality of life.”

If you are unfamiliar with pursed-lips breathing, diaphragmatic breathing or the huff cough techniques, consider making an appointment with your pulmonologist or respiratory therapist to learn and practice the techniques. For those interested there is a brief overview of these techniques on our Resplenish dietary supplement web site that you can view by clicking here. In addition, our Breathe Better for Life CD-ROM which accompanies our Breathe Better for Life guidebook contains narrated, pictorial, step-by-step instructions of these techniques. To learn more about Breathe Better for Life, visit www.breathebetterforlife.com.


[1] Zakerimoghadam M, et al. The Effect of Breathing Exercises on The Fatigue Levels of Patients with Chronic Obstructive Pulmonary Disease. Acta Medica Indonesia. January 2011: 43(1); 29-33.