Promoting Physical Activity and Exercise

in Patients With Asthma and Chronic

Obstructive Pulmonary Disease
Susan J. Corbridge, PhD, ACNP, and Sharmilee M. Nyenhuis, MD

ABSTRACT
Chronic lower respiratory diseases, including asthma and chronic obstructive
pulmonary disease, are a significant public health burden owing to their high incidence
and prevalence. Nurse practitioners in primary care routinely see patients with these
diagnoses. Although inhaled pharmacotherapy is the mainstay of treatment for
individuals with these diseases, providing an overall approach to health and wellness,
which includes physical activity and exercise, is imperative in optimizing patient
outcomes. The purpose of this article is to provide nurse practitioners in primary care
with foundational information regarding the promotion of physical activity and
exercise for patients with asthma and chronic obstructive pulmonary disease.

Keywords: asthma, COPD, exercise, physical activity

Ó 2016 Published by Elsevier Inc.

INTRODUCTION the past 3 decades are rising in all age, gender,

and racial groups in North America.5 The higher

A sthma and chronic obstructive pulmonary

disease (COPD) place substantial strain on
the health care system due to their high
prevalence and overall burden.1,2 Nurse practitioners
(NPs) in primary care play a pivotal role in caring for
patients with these diseases. Although inhaled
pharmacotherapy is the mainstay of treatment for
individuals with asthma and COPD,1,2 regular
physical activity (PA) and exercise can improve
patient outcomes.1,3,4 The purpose of this article is to
provide an evidence-based approach to PA and
exercise in patients with asthma and COPD.
BURDEN OF ASTHMA AND COPD
Asthma is a chronic disorder of the airways charac-
terized by reversible and intermittent airway obstruc-
tion, airway inflammation, and hyperreactivity of the
airways.2 Asthma remains one of the most prevalent
chronic respiratory disorders, and prevalence rates over
American Association of Nurse Practitioners (AANP) members may
receive 1.0 continuing education contact hours, approved by AANP, by
reading this article and completing the online posttest and evaluation at
aanp.inreachce.com.
www.npjournal.org
prevalence of asthma may be linked to greater allergen
sensitization, urban living, poor air quality, obesity,
and sedentary lifestyle.2 Comorbid obesity is
particularly relevant because the high prevalence of
obesity in industrialized nations and its association with
worse asthma outcomes, such as more severe or
difficult-to-control asthma, poorer asthma-related
quality of life, poorer response to asthma controller
treatments such as corticosteroids, and higher exacer-
bation rates.6
Focusing on ways to improve asthma control
through lifestyle interventions that promote PA and
exercise behaviors and using evidence-based treat-
ment options will help reduce the burden of asthma
on the United States health care system.
COPD is also an inflammatory disease of the air-
ways, but differs from the inflammation in asthma in
that it is more neutrophilic (as compared with eosin-
ophilic inflammation, which predominates in asthma).2
In COPD, the small airways are most affected. Chronic
bronchitis occurs due to inflammatory changes in the
airways, and emphysema occurs when inflammatory
cells cause destruction in the lung tissue and alveoli.
The Journal for Nurse Practitioners - JNP 41
Most patients have components of both chronic
bronchitis and emphysema; however, there are patients
in whom one phenotype predominates. Although
primarily caused by smoking, COPD can also be
caused by second-hand smoke exposure, occupational
exposures, air pollution, and a deficiency of the protein
a1-anti-trypsin. The typical patient is over 40 years of
age with a history of a known exposure, usually to-
bacco smoking, and who has breathlessness with or
without cough along with sputum production.1
Like asthma, the economic and social burden of
COPD is high and continues to increase due to an
aging population and exposure to known risk factors.1
It is a leading cause of morbidity and mortality, and,
combined with asthma, is the third leading cause of
death in the US.7 Exacerbations of COPD account for
the highest proportion of the overall burden of COPD
on the health care system.1 Inactivity is common in
patients with COPD and is an independent risk factor
for acute exacerbations, 30-day hospital readmissions,
and mortality.1,3 Therefore, improving PA levels is
considered a major component in the overall approach
to management of COPD.
Although some patients have clinical features of
both asthma and COPD (termed asthma-COPD
overlap syndrome),1 in this article we aim to provide
foundational information regarding PA and exercise
in the more classic presentations of both diseases.
PA AND EXERCISE IN PATIENTS WITH ASTHMA
Several population-based studies have shown patients
with asthma engage in less PA and are more sedentary
than their non-asthmatic counterparts.8,9 The
decreased levels of PA are related to the fear of
triggering asthma symptoms, weather affecting
asthma, time constraints, and the belief that PA
should be avoided in asthma and not because of their
degree of airway obstruction.9
In up to 90% of patients with asthma, exercise is a
trigger of asthma symptoms such as cough, wheezing,
or shortness of breath. During exercise, there is a net
loss of heat, water, or both, due to hyperventilation
of air that is cooler and dryer than the lung, which
leads to bronchoconstriction.2 With proper
premedication before exercise and the use of warm-
up and cool-down exercises (15 minutes each), the
incidence of exercise-induced asthma symptoms is
42 The Journal for Nurse Practitioners - JNP
low.10 Extensive literature exists supporting the safety
and benefits of exercise conditioning on
cardiopulmonary fitness, asthma symptoms, and
asthma-related quality of life.4 Both the American
College of Sports Medicine (ACSM) and American
Thoracic Society (ATS) recommend regular exercise
for patients with asthma.11,12
Currently, the ACSM recommends engaging in
aerobic exercise at least 2-3 days per week, yet
< 50% of patients meet this recommendation.
Aerobic exercises, such as walking or exercises that
use large muscle groups, are recommended for
patients with asthma, whereas other exercises, such as
running, cycling, and basketball, may be more likely
to cause symptoms of exercise-induced asthma.
Currently, there is no consensus on the optimum
intensity of exercise, but exercising at 50% of peak
oxygen uptake or at limits as tolerated by symptoms is
recommended. The optimal duration of exercise is
20-30 minutes of continuous activity, although
patients starting an exercise program may need to
work up to this goal gradually. The ACSM guidelines
endorse the use of exercise prescriptions for patients
with asthma, although most existing data are in
patients with COPD.
Although a formal pulmonary rehabilitation (PR)
program is frequently recommended in patients with
COPD (see below), there have been few trials eval-
uating PR among adults with asthma.13 Thus far,
existing data suggest that exercise training and
rehabilitation improve exercise tolerance and/or
health status/quality of life in persons with asthma.11
The ATS recommends PR for patients whose lung
disease (including asthma) results in loss of
independence; anxiety or breathlessness with
activities; or limitations in social, leisure, indoor, or
outdoor activities. It is important to distinguish
between formal exercise defined by objective
physiologic changes and routine gradual, moderate-
intensity physical activities, such as walking or playing.
It is possible that a more frequent (ie, daily)
moderate-intensity activity like walking is what
confers the protective effects in asthma. Walking
interventions in patients with asthma can improve
quality of life and asthma control.14 Whether other
outcomes are impacted, such as reduced health care
utilization, needs further study.
Volume 13, Issue 1, January 2017
 About half of asthma may be triggered or wors-
ened by exposure to allergens, such as house dust
mites, molds, pests (cockroaches, rodents), animal
dander, and pollen.2 Moreover, these allergens may
also cause rhinitis, inflammation in the nasal passages
that makes it difficult for patients to engage in
physical activity.2 An evaluation by an allergist/
immunologist should be considered before starting an
exercise program, to help identify triggering
allergens, review avoidance measures, and consider
addition of pharmacologic treatments if necessary (see
Table 1 for additional practical tips for patients).
The National Asthma Education and Prevention
Program guidelines for the management of asthma
recommend that clinicians advise patients to avoid,
to the extent possible, exertion or exercise outside
when levels of air pollution are high.2 The
relationship between increased levels of air pollution
and asthma risk and impairment are well
documented, with increases in asthma exacerbations
and emergency care visits.2 The relationship
between PA, exercise, and air pollution is not as
clear. One foundational epidemiologic study found
that heavy outdoor exercise in a high ozone
concentration was associated with a higher risk of
asthma in school-aged children.15 Air pollution
Table 1. General Tips: Physical Activity and Exercise for
Asthma Patients

Take all asthma medications as prescribed.

Ask your doctor about taking medicine before you exercise
to prevent symptoms.

Always have your asthma rescue medication on hand when
exercising.

Perform a prolonged aerobic warm-up and cool-down (15
minutes each).

Postpone exercise if asthma symptoms are not well-
controlled of if you have a cold or respiratory infection.

Check the air quality index (https://airnow.gov/index.cfm?
action¼aqibasics.aqi/) before exercising outdoors. If air
pollution or pollen (if you are allergic) levels are high, try
not to work or play hard outside.

Breathe through the nose as much as possible when
exercising.

When exercising outdoors, avoid areas that contain high
concentrations of allergens and irritants (eg, fields, trees,
busy roads, factories).

When exercising indoors, keep windows and doors closed
to reduce allergen exposure.
www.npjournal.org
should be taken into consideration when asthma
patients engage in PA, especially in outdoor urban
environments. To limit the effects of poor air quality
during PA and exercise, patients should be advised to
check air pollution levels (Table 1). On poor air
quality days, patients should be instructed to avoid
outdoor PA and exercise, engage in indoor PA and
exercise, or reduce the intensity and duration of the
outdoor activity. Further, patients should be advised
to avoid engaging in PA and exercise in high-
pollution areas, such as within 50 feet of a road, and
when pollution levels tend to be highest, often
midday or afternoon.
In addition to engaging in aerobic exercise, other
alternative exercises, such as yoga or breathing
exercises, should be considered. Both yoga and
diaphragmatic breathing exercises have been shown
to lead to improvements in asthma-related quality of
life and asthma symptoms.16,17 The mechanistic
pathways of how these exercises improve asthma are
not fully elucidated, and randomized, controlled trials
with larger samples sizes and high reporting quality
are needed to confirm these preliminary effects.16
PA AND EXERCISE IN PATIENTS WITH COPD
As previously stated, patients with COPD
commonly have sedentary lifestyles. The ensuing
cycle, often described as a “downward spiral,” is that
breathlessness contributes to inactivity, poor fitness,
decreased cardiovascular function, skeletal muscle
mass decline, social isolation and depression, all of
which contribute to further breathlessness, inactivity,
immobility, and premature mortality.1 Exercise
programs can break this cycle and benefit patients
with COPD.1 Consider a formal PR program for all
COPD patients who have breathlessness, exercise
intolerance, and low PA levels.18 The ATS and
European Respiratory Society define PR as: “a
comprehensive intervention based on a thorough
patient assessment followed by patient-tailored
therapies that include, but are not limited to, exer-
cise training, education, and behavior change,
designed to improve the physical and psychological
condition of people with chronic respiratory disease
and to promote the long-term adherence to health-
enhancing behaviors.”18(p1374) PR is highly effective
and has many benefits, including improved exercise
The Journal for Nurse Practitioners - JNP 43
tolerance, reduced perceived breathlessness,
improved health-related quality of life, improve-
ment in depressive and anxiety symptoms, improved
sleep quality, enhanced effect of long-acting bron-
chodilators, decreased hospitalizations and number
of days in the hospital, improved recovery time after
an exacerbation, and improved survival.1,18 In
addition, exercise programs have been shown to
improve arm function through strength and
endurance training,1 and many patients with COPD
report difficulty with activities that require lifting
their arms above their head (eg, hair combing,
reaching overhead cabinets).
PR programs use a multidisciplinary approach to
tailor an individualized program, including
professionals with expertise in exercise training,
psychosocial evaluation and counseling, respiratory
medications and oxygen therapy, nutrition, patient
education, and smoking cessation. Programs are
typically coordinated by nursing or respiratory ther-
apy departments and often include a pulmonologist.
Patients benefit from PR programs whether in an
outpatient, inpatient, or home setting.18 For
outpatient and inpatient programs, sessions are
conducted in small groups, usually 2 or 3 times per
week, and range from 4 to 10 weeks, with longer
programs having larger effects than shorter ones.1
Because patients need to attend several times a week,
finding a program close to their homes is important,
as the decision to participate may be influenced by
location and transportation possibilities. Insurance
coverage may also factor in the decision to
participate; however, Medicare does cover PR for
patients with moderate to very severe COPD
(Medicare.gov).
Formal PR programs require an order from the
referring provider. In addition to the referral, perti-
nent recent test results are needed, including an
electrocardiogram, pulmonary function test, and
6-minute walk test (a test done to determine if there
is an oxygen requirement with exercise). Highly
motivated patients receive the most benefit from
participation in PR,1 so this should be considered
before referral. If patients are still smoking, they
should be enrolled in a smoking-cessation program,
because continued smoking has been shown to be the
greatest predictor of PR dropout.19 The exercise
44 The Journal for Nurse Practitioners - JNP
benefits of PR will be lost without continued
physical activity such as an at-home maintenance
program,1 so addressing continued activity at each
visit is vital.
If patients choose not to participate in a structured
PR program, health care providers should advise
them to remain physically active and exercise on their
own. Although providing advice for PA has not been
studied in patients with COPD, significant benefits,
including decreased hospital readmission rates and
improvement in health-related quality of life,3,20 as
well as the strong health benefits of PA and
exercise in older adults,21 strongly support this
suggestion. PA should be encouraged at the initial
diagnosis of COPD; maintaining as high a physical
activity level as possible is associated with a better
prognosis.20
NPs should start with patient education that
covers the overall health benefits of daily activity with
a focus on how it may positively impact COPD. In
addition to the benefits just mentioned, regular PA
and exercise can improve balance and prevent falls,21
which is important in this population as certain
patients with COPD have a high susceptibility to
falls; in particular, females and those with older age, a
history of previous falls, and/or a diagnosis of
coronary artery disease.22
Furthermore, many patients with COPD struggle
with depression and anxiety, which are associated
with reduced exercise capacity and greater dyspnea.23
Depression in COPD patients is also an independent
risk factor for hospitalization.24 Although PR has
been shown to decrease depressive and anxiety
symptoms, data are limited on the effects of general
PA on these symptoms in patients with COPD and
further research is needed in this area.
A general approach to providing PA and exercise
education in patients with COPD includes aerobic,
stretching, and strengthening exercises.12 A good
starting point is to slowly begin aerobic activity
through walking to develop endurance, strength, and
balance. In general, patients should start with slow
walking and increase a little every day, paying
attention to their breathlessness and stopping to rest
whenever they are short of breath. Additional
practical tips for patients for walking are included
in Table 2.
Volume 13, Issue 1, January 2017
Table 2. General Tips: Physical Activity and Exercise for
COPD Patients

Take all of your medications as prescribed.

Take your short-acting rescue inhaler at least 15 minutes
before engaging in physical activity and exercise and
always carry it with you.

Avoid prolonged sitting. Stand up and move at least every
20 minutes.

Make physical activity a regular part of your day; getting up
to change the TV channel instead of using the remote
control or getting out of the chair to get a glass of water
instead of asking someone to get it for you. Small changes
can make a big difference.

Make time for exercise.

Exercising every other day will help maintain a regular
schedule, which is important to overall fitness and is the
best way to notice results.

Do not overdo it, and always stop and rest when you
become short of breath.

Warm up for at least 5 minutes before exercising by doing
light stretching or range of motion activities or beginning
the activity at low intensity.

Include a cool-down period at the end of each exercise
session by decreasing the intensity of your activity or doing
some of the stretching or range of motion activities you did
in your warm-up.

Wait at least 2 hours after eating to exercise.
General tips for walking:

Start slowly and try to increase a little every day.

Stop and rest whenever you are short of breath.

Try to go a little farther every day; however, remember
that you need to get back to your starting point so do
not overestimate the distance.

Try to work up to 20 minutes at a time.

Take a cell phone with you and walk with a friend or
relative, if possible.

If you use oxygen, be mindful of the tubing so you do
not trip and fall.

If you are walking outside, be mindful of any cracks or
uneven pavement, so you do not trip and fall.

Dress for the weather and wear comfortable shoes.

Avoid extreme weather conditions, including windy,
rainy, icy, or cold days and days with poor air quality (in
general, days in the green and yellow zone are
acceptable). For specific information on daily air quality,
see: https://airnow.gov/index.cfm?action¼aqibasics.aqi/.

Develop a contingency plan for inclement weather days
such as walking in the mall or a community recreation
center.
COPD ¼ chronic obstructive pulmonary disease.
Strengthening exercises for the upper body,
including using light weights and resistive bands, may
be particularly helpful in patients with COPD because
these types of exercises help increase respiratory
www.npjournal.org
muscle strength.1 Skeletal muscle impairment is also
one of the extrapulmonary effects of COPD; because
patients often have difficulty with activities of daily
living that involve the upper extremities, the ACSM
recommends light resistive exercise with a focus on
the muscles of the shoulder girdle.12 In addition to
more traditional exercise, such as walking, data
suggest that Tai Chi (a Chinese martial art that focuses
on slow sequential movements) can increase exercise
capacity and health-related quality of life in COPD
patients25 and can improve balance and prevent falls
in the elderly.26 Yoga has also been shown to have a
positive effect on lung function and exercise capacity
in patients with COPD.27
Scheduling exercise to fit into a patient’s daily
routine and choosing a time of day when they are less
fatigued (perhaps morning) will likely help them
maintain consistency, which is important in
improving overall fitness level and seeing results
(which may in turn motivate them to continue being
physically active). If the patient uses oxygen with
activity as determined by a formal 6-minute walk
test, the NP should determine at the initial clinic visit
that they have a portable tank and remind them of
the importance of wearing oxygen at their activity-
prescribed flow rate. Pursed-lip breathing may also
help during exercise and can help to slow breathing
rate and reduce breathlessness. NPs should review the
technique with patients by telling them to first inhale
slowly through the nose, and then to exhale through
pursed lips for twice as long as they inhaled. This
technique is not only helpful with exercise but may
be beneficial for everyday tasks that involve lifting,
bending forward, or climbing stairs. Table 2 lists
other general educational points related to PA in
patients with COPD.
In addition to more traditional PA and formal
pulmonary rehabilitation options for patients with
COPD, new models are emerging for innovative,
online, technology-based exercise programs for
patients with COPD.11 Models using video
conferencing, mobile phone apps, and bluetooth-
based activity monitors are growing in use and may
be especially helpful in rural areas or when trans-
portation is an issue, or in helping patients remain
active after they complete a formal PR program;
however, more research is needed in this area.
The Journal for Nurse Practitioners - JNP 45
SUMMARY: ROLE OF THE NP IN PROMOTION OF PA
AND EXERCISE STRATEGIES
PA and exercise play an integral part in the overall
health and maintenance of patients with asthma and
COPD and should be addressed at every clinic visit.
Work collaboratively with your patients, using a
patient-centered approach, and design an individu-
alized plan based on the severity of your patient’s
disease and symptoms. For patients whose symptoms
are not well controlled, consider an evaluation to a
specialist to optimize management before increasing
the level of PA or starting a formal exercise program.
Provide patient education regarding PA and exercise,
starting with the foundational points provided in this
article, and consider a formal PR program, especially
for patients with COPD. For all patients, provide
information on appropriate use of their prescribed
medication before and during PA and exercise.
Always review the patient’s progress at each visit and
continue to motivate and provide support. Be
attuned to future research regarding PA and exercise
in patients with asthma and COPD and modify your
practice based on the evidence. Consider emerging,
innovative, and evidence-based models to enhance
PA and exercise for patients, including home-based
online groups, mobile-phone applications, and other
telehealth options.
References
1. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science
Committee. Global Strategy for the Diagnosis, Management and Prevention
of Chronic Obstructive Pulmonary Disease. 2016. http://goldcopd.org/global
-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 18,
2016.
2. National Heart Lung and Blood Institute. National Asthma Education and
Prevention Program. Full Report of the Expert Panel: Guidelines for the
diagnosis and management of asthma (EPR-3; source document); 2007.
3. Nguyen HQ, Chu L, Amy Liu IL, et al. Associations between physical activity
and 30-day readmission risk in chronic obstructive pulmonary disease. Ann
Am Thorac Soc. 2014;11:695-705.
4. Carson KV, Chandratilleke MG, Picot J, Brinn MP, Esterman AJ, Smith BJ.
Physical training for asthma. Cochrane Database Syst Rev. 2013;9:CD001116.
5. Akinbami LJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence,
health care use, and mortality in the United States, 2001-2010. NCHS Data
Brief. 2012:1-8.
6. Hasegawa K, Tsugawa Y, Lopez BL, Smithline HA, Sullivan AF, Camargo CA.
Body mass index and risk of hospitalization among adults presenting with
asthma exacerbation to the emergency department. Ann Am Thorac Soc.
2014;11(9):1439-1444.
7. Xu J, Murphy SL, Kochanek KD, Bastian BA. Deaths: final data for 2013. Natl
Vital Stat. 2016;64:1-119.
8. Vangeepuram N, McGovern KJ, Teitelbaum S, et al. Asthma and physical
activity in multiracial girls from three US sites. J Asthma. 2014;51:193-199.
9. Avallone KM, McLeish AC. Asthma and aerobic exercise: a review of the
empirical literature. J Asthma. 2013;50:109-116.
10. Del Giacco SR, Firinu D, Bjermer L, Carlsen KH. Exercise and asthma: an
overview. Eur Clin Respir J. 2015;2:27984.
46 The Journal for Nurse Practitioners - JNP
11. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/
European Respiratory Society statement: key concepts and advances in
pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188:e13-e64.
12. American College of Sports Medicine. Exercise prescription for populations
with other chronic diseases and health conditions. In: American College of
Sports Medicine Guidelines for Exercise Testing and Prescription. 9th ed.
Baltimore, Md: Wolters Kluwer/Lippincott, Williams and Wilkins; 2014.
13. Renolleau-Courtois D, Lamouroux-Delay A, Delpierre S, et al. Home-based
respiratory rehabilitation in adult patients with moderate or severe persistent
asthma. J Asthma. 2014;51:552-558.
14. Boyd A, Yang CT, Estell K, et al. Feasibility of exercising adults with asthma: a
randomized pilot study. Allergy Asthma Clin Immunol. 2012;8:13.
15. McConnell R, Berhane K, Gilliland F, et al. Asthma in exercising children
exposed to ozone: a cohort study. Lancet. 2002;359:386-391.
16. Cramer H, Posadzki P, Dobos G, Langhorst J. Yoga for asthma: a systematic
review and meta-analysis. Ann Allergy Asthma Immunol. 2014;112:503-510.
e505.
17. Franca-Pinto A, Mendes FA, de Carvalho-Pinto RM, et al. Aerobic training
decreases bronchial hyperresponsiveness and systemic inflammation in
patients with moderate or severe asthma: a randomised controlled trial.
Thorax. 2015;70:732-739.
18. Rochester CL, Vogiatzis I, Holland AE, et al. An official American Thoracic
Society/European Respiratory Society policy statement: Enhancing
implementation, use, and delivery of pulmonary rehabilitation. Am J Respir
Crit Care Med. 2015;192:1373-1386.
19. Brown AT, Hitchcock J, Schumann C, Wells JM, Dransfield MT, Bhatt SP.
Determinants of successful completion of pulmonary rehabilitation in COPD.
Int J Chron Obstruct Pulmon Dis. 2016;11:391-397.
20. Vaes AW, Garcia-Aymerich J, Marott JL, et al. Changes in physical activity
and all-cause mortality in COPD. Eur Respir J. 2014;44:1199-1209.
21. World Health Organization. Physical activity and older adults. 2015. http://
www.who.int/dietphysicalactivity/factsheet_olderadults/en/. Accessed May
25, 2016.
22. Roig M, Eng JJ, MacIntyre DL, et al. Falls in people with chronic obstructive
pulmonary disease: an observational cohort study. Respir Med.
2011;105:461-469.
23. Martinez Rivera C, Costan Galicia J, Alcazar Navarrete B, et al. Factors
associated with depression in COPD: a multicenter study. Lung.
2016;194:335-343.
24. Iyer AS, Bhatt SP, Garner JJ, et al. Depression is associated with readmission
for acute exacerbation of chronic obstructive pulmonary disease. Ann Am
Thorac Soc. 2016;13:197-203.
25. Wu W, Liu X, Wang L, Wang Z, Hu J, Yan J. Effects of Tai Chi on exercise
capacity and health-related quality of life in patients with chronic obstructive
pulmonary disease: a systematic review and meta-analysis. Int J Chron
Obstruct Pulmon Dis. 2014;9:1253-1263.
26. National Council on Aging. Tai Chi for falls prevention. 2016. https://www
.ncoa.org/wp-content/uploads/Tai-Chi-Guidance-Document-030316.pdf.
Accessed May 25, 2016.
27. Liu XC, Pan L, Hu Q, Dong WP, Yan JH, Dong L. Effects of yoga training in
patients with chronic obstructive pulmonary disease: a systematic review and
meta-analysis. J Thorac Dis. 2014;6:795-802.
Susan J. Corbridge, PhD, ACNP, FAANP, is director of
graduate clinical studies and clinical associate professor in the
Department of Biobehavioral Health Science at the University of
Illinois at Chicago College of Nursing. She can be reached at
sjsmith@uic.edu. Sharmilee M. Nyenhuis, MD, is an assistant
professor in the Division of Pulmonary, Critical Care, Sleep &
Allergy Medicine at the University of Illinois Hospital in
Chicago. In compliance with national ethical guidelines, the
authors report no relationships with business or industry that
would pose a conflict of interest.
1555-4155/16/$ see front matter
© 2016 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.nurpra.2016.08.022
Volume 13, Issue 1, January 2017