RATIONALE: Despite strategies acting on peripheral airway obstruction in chronic obstructive pulmonary disease (COPD), exercise intolerance remains inadequately improved. We hypothesised that laryngeal narrowing is a potential treatment target of expiratory pressure load training (EPT) to improve exercise intolerance in COPD. METHODS: The effect of 3-month EPT was assessed in 47 patients with COPD divided into Global Initiative for Chronic Obstructive Lung Disease (GOLD) mild-to-moderate (I to II) and severe-to-very severe (III to IV), randomly allocating 1:1 to EPT or control groups. The primary outcome was endurance time in the constant work rate exercise test in GOLD III to IV patients. RESULTS: Compared with controls, EPT increased: (1) endurance time, with estimated treatment effect: +703 (95% CI 379 to 1031) s, p = 0.0008 (GOLD I to II); +390 (95% CI 205 to 574) s, p = 0.0006 (GOLD III to IV); (2) peak oxygen uptake (p = 0.0086 in GOLD I-II; p = 0.0004 in GOLD III-IV); (3) glottic dilatation ratio at maximum collapse on laryngoscopy in the submaximal exercise (p = 0.0062 in GOLD I to II; p = 0.0001 in GOLD III to IV); and (4) the inflection point of expiratory tidal volume relative to minute ventilation during the incremental exercise (p = 0.0015 in GOLD I to II; p = 0.0075 in GOLD III to IV). Across GOLD grades, the responses of glottic dilatation ratio at maximum collapse and the expiratory tidal volume at the inflection point were selected as more influential variables correlating with the improvement in peak oxygen uptake and endurance time, respectively. CONCLUSION: These results show that EPT improved aerobic capacity and endurance time with larger laryngeal widening and adequate ventilation despite advanced COPD. TRIAL REGISTRATION NUMBER: Umin000041250.
Reproduced with permission from the BMJ Publishing Group.

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