PULMONARY COMPLICATIONS OF DIABETES AND ITS PHYSIOTHERAPY MANAGEMENT

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Suman Sheraz1*, Aisha Razzaq2, Arshad Nawaz Malik3

1*Assistant Professor, Department of Physical Therapy, Riphah College of Rehabilitation and Allied Health Sciences, Islamabad, Pakistan

2Assistant Professor, Department of Physical Therapy, Riphah College of Rehabilitation and Allied Health Sciences, Islamabad, Pakistan

3Professor, Department of Physical Therapy, Riphah College of Rehabilitation and Allied Health Sciences, Islamabad, Pakistan

ABSTRACT

Background of the Study: Diabetes is a chronic metabolic disease, causing an overwhelming increase in global disability and mortality. Its widespread and devastating effects on the heart, kidneys, balance, and muscle strength are well known but its effects on pulmonary functions are not discussed as much. It can lead to various pulmonary complications like diabetic ketoacidosis (DKA), pulmonary infections, asthma, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA). These complications can cause breathing difficulties, coughing, chest pain, and wheezing.

Methodology: Diabetes contributes to other health problems such as hypertension, cardiac conditions, and stroke. To reduce the risk of developing respiratory complications, people with diabetes should work closely with their healthcare team to manage their condition, maintain blood sugar control, quit smoking, and exercise regularly.

Result: Physiotherapy plays a crucial role in reducing pulmonary complications and improving the health-related life quality of individuals.

Conclusion: The current review will highlight the adverse effects of diabetes on the lungs, the respiratory comorbidities associated with diabetes, and physical therapy’s role in pulmonary complications.

Keywords: Chronic obstructive pulmonary diseases, diabetic ketoacidosis, diabetes mellitus, inspiratory muscle training, narrative review, obstructive sleep apnea, physiotherapy management, pulmonary complications.

Introduction

Diabetes Mellitus (DM) is a metabolic condition affecting more than 500 million people globally with the highest number in China and India. Its expected prevalence can cross 783 million by 20451,2. The diabetes prevalence is 13.7% in adult population of Pakistan3. The International Diabetic Federation estimates 4.2 million deaths caused by diabetes and diabetes related    complications4. Diabetes affects the body both on a macro-vascular level causing heart disease Stroke, and peripheral vascular diseases and on micro vascular levels affecting lungs, kidneys, eyes and extremities leading to lower-extremity amputations5. The lungs have the largest area of microvascular network with larger pulmonary reserves. Diabetic pulmonary complications are underrated as these develop slowly4. Recent COVID-19 infection highlighted this issue as the morbidity and mortality were quite high in diabetics. Diabetes makes the lungs vulnerable to develop many infectious and obstructive pulmonary diseases and can worsen the already existing Diseases. Therefore, it is need of the time to highlight the effects of diabetes on the lungs, the possible functional mechanisms behind it, the risk of pulmonary disease in diabetes and its physical therapy treatment

Pulmonary complications in diabetes

Diabetes mellitus causes a Reduction in carbon monoxide transfer and pulmonary capillary blood flow which leads to a reduction in pulmonary function. The diabetics have impaired stroke volume and aerobic capacity as compared to the non-diabetics5.

Chronic inflammation

Diabetes causes the accumulation of inflammatory mediators like interleukin-6 (IL-6) and C-reactive protein (CRP) and Poor diabetic control is associated with reduced Force Expiratory Volume-1(FEV1).

  1. Force Vital Capacity (FVC): compared to healthy controls might be associated with the inflammatory mediators.
  2. Reduced muscle strength: Insulin resistance leads to hyperinsulinemia, leading to increased bronchial muscle spasm, that slowly decreases muscle strength and causes airway hypersensitivity. Hyperinsulinemia reduces lung volume and Force Expiratory Volume-1 (FEV1) through certain inflammatory mediators6.
  3. Autonomic neuropathy: Diabetes causes the noradrenergic denervation of the respiratory muscles. These neuromuscular respiratory muscles pathologies can deteriorate the ventilatory pump efficiency leading to low lungs functionality.
  4. Increased infection: Hyperglycemia causes increased glucose levels in the pulmonary vessels, making them vulnerable to respiratory infections.
  5. Reduce lung elasticity and recoil: Reduction in the lung elastic proteins which supports the intrathoracic airflow. So, these individuals have increased risk for developing Chronic Obstructive lung Disease6.

Co-morbidities associated with Diabetes Mellitus

  1. Chronic Obstructive Pulmonary Diseases

Chronic obstructive lung diseases occur more frequently as a co-morbidity with diabetes mellitus. It causes a 4-fold increase in leukotriene B4 as compared to COPD alone. The co-existence of COPD and DM together increases the risk of stroke7.

  1. Tuberculosis

Diabetic individuals are at high risk (20.7%) for developing the Tuberculosis than non-diabetics. A study conducted on 0.8 million reported diabetic cases shows 7.7% were infected with tuberculosis. diabetic individuals are 3 times more at risk of developing the active Tuberculosis. TB also causes hypoglycemia itself. Diabetes and TB have a bidirectional relationship. Hypoglycemia can cause syncope, seizures, and mortality in worst scenario8.

  1. COVID-19

Evidence shows that among the severely ill COVID-19 patients, 24% were diabetics. Poor glycemic control increases the risk to have secondary viral and bacterial infections. Death rate is 3 folds high in the COVID-19 patients having diabetes9.

  1. Influenza

Influenza causes infection and the destruction of the myocardial tissue in diabetic patients which can cause a risk of heart disease and stroke10.

  1. Diabetic ketoacidosis

Diabetic ketoacidosis is the acute and critical diabetic complication diagnosed by biochemical traits of hyperglycemia, ketonemia, and academia10. Characteristic features are hypokalemia, hypo magnesia and hypophosphatemia which can cause tachypnea, hyperpnea, pulmonary oedema and respiratory muscle failure leading to high morbidity and mortality11.

  1. Obstructive sleep apnea

The obstructive sleep apnea has 50% prevalence among diabetic patients and affects the sleep quality of patients12.It is also a risk factor for diabetes. Disturbed sleep leads to insulin resistance and diabetes leads to neuropathy which leads to OSA. Both these conditions lead to increased risk of dyslipidemia, hypertension and cardiovascular diseases13.

  1. Interstitial pulmonary fibrosis:

The prevalence of Interstitial fibrosis is 10-42% among the patients with the diabetes mellites14. Studies claim that the diabetes causing the thickening of the alveolar septa and fibrosis, can be a single independent risk factor for causing the IPF. It is characterized by multiple micro-injuries to the epithelium causing micro fibroblast thickening of lung interstitium15.

Role of exercise in diabetic pulmonary complications

Poor glycemic control leads to increased risk for different infections and devastating outcomes10. Physical therapy helps in improving the inspiratory muscle function, improving glycemic control, and improving the strength of the pulmonary musculature.

  1. Inspiratory muscle training

Type II diabetes is associated with Inspiratory muscle weakness. Inspiratory muscle training is resistance training to inspiratory muscle with max. inspiratory effort through the mouth with the nose closed. It can be done through the manual power Breather or electronic trainer. An electronic inspiratory muscle trainer consists of software software-operated biofeedback system with an electronic pressure manometer. Inspiratory muscle strength training improves aerobic capacity in diabetic sleep apnea patients16. The 15-25 min training session is recommended at 30% maximum inspiratory capacity, 5 days per week for almost 8 weeks. The training can result in improvement of quality of life and reduction in blood glucose level17.

  1. Aerobic exercises

Aerobic exercises including walking, cycling, swimming, and running have beneficial effects on glycemic control, oxidative capacity and dyslipidemia and improve exercise endurance. High-interval training is particularly effective in this respect. It is generally recommended to have 20-60min session of >60% maximum exercise capacity for 3-5 times/week. The effect of the aerobic exercises on the control of infections is inconclusive18.

  1. Rebound exercise

The rebound exercises are performed regularly on the mini trampoline and have beneficial effects on the insulin resistance, lipid profile and waist circumference of diabetic patients19.

  1. Resistance exercises

Resistance exercises have been proven to be more effective than aerobic exercises in improving maximum oxygen consumption. Its beneficial effects are found in glycemic and lipid control. It improves the local muscle strength. It can be done against the gravity, body weights or additional weight. It is recommended to start it with 60-70% of 1 repetition maximum, with 1-3 sets of 8-10 repetitions for 2-3 days a week20.

  1. Tele-physical therapy

Tele-rehabilitation is an emerging approach for treatment of respiratory conditions in type 2 diabetes mellitis. The protocol is applied through the video conference calls either using mobile apps or zoom meetings. The training comprised of breathing exercises, aerobic exercises, resistance exercises and stretching and strengthening of upper extremity muscles. The exercises show improvement in glucose control, respiratory functions, Physical fitness and life quality in T2DM21.

  1. LHP’s pulmonary Rehabilitation:

LHP’S Pulmonary rehabilitation is a special type of breathing exercise program to improve lung expansion, elasticity and volumes and vital capacity in pulmonary fibrosis patients. It focuses on the respiratory muscles’ exercises by deep breathing in 3 steps, first entire lung, next unilateral lower lobe and then upper lobe is engaged and repeated. It results in the reduced oxygen consumption, improve lung function and increase exercise endurance over time22.

  1. Physiotherapy for sleep apnea:

This modern technique is available in form of smartphone application. Its first part is respiratory muscle and upper airway exercise’s part including strengthening of respiratory muscles and intrinsic, extrinsic tongue muscles and second part is general endurance of pharyngeal muscles to improve tone and mobility preventing airway closure during sleep23. The benefit of this program is that the individual can perform this at home. The efficacy of these exercise in diabetes is yet to be established.

Conclusion

Diabetes is a highly prevalent metabolic condition having diverse negative effects to multiple body systems. Diabetes makes the lungs vulnerable to develop many infectious and obstructive pulmonary diseases and can worsen the already existing diseases. The underlying mechanism can be inflammation, autonomic neuropathy, microvascular complications, reduced muscle strength thus leading to dyspnea, reduced exercise tolerance. Physiotherapeutic intervention intends to improve respiratory function, exercise capacity, prevent complications and improve the overall activity of life. Physical therapy can help to reduce the risk of respiratory complications and improve performance in diabetic individuals through increased glycemic control and improved aerobic capacity. The close interaction between diabetes and respiratory complications demands the need of interplay between the endocrinologist, pulmonologist and physiotherapist and dieticians to get comprehensive care and improve the holistic quality of life of patient.

AUTHORS’ CONTRIBUTION: 

The following authors have made substantial contributions to the manuscript as under:

Conception or Design: Suman Sheraz, Arshad Nawaz Malik, Aisha Razzaq

Acquisition, Analysis or Interpretation of Data: Aisha Razzaq 

Manuscript Writing & Approval: Aisha Razzaq

All authors acknowledge their accountability for all facets of the research, ensuring that any concerns regarding the accuracy or integrity of the work are duly investigated and resolved.

ACKNOWLEDGEMENTS: We thank all the participants in this study.

INFORMED CONSENT: N/A

CONFLICT OF INTEREST: The author (s) have no conflict of interest regarding any of the activity perform by PJR.

FUNDING STATEMENTS: N/A

ETHICS STATEMENTS: N/A

References

  1. Kaiser AB, Zhang N, Der Pluijm WV. Global prevalence of type 2 diabetes over the next ten years (2018-2028). Diabetes. 2018 Jul 1;67(Supplement_1).
  2. Kumar A, Gangwar R, Ahmad Zargar A, Kumar R, Sharma A. Prevalence of diabetes in India: A review of IDF diabetes atlas 10th edition. Current diabetes reviews. 2024 Jan 1;20(1):105-14.
  3. Adnan M, Aasim M. Prevalence of type 2 diabetes mellitus in adult population of Pakistan: a meta-analysis of prospective cross-sectional surveys. Annals of global health. 2020;86(1).
  4. Harding JL, Pavkov ME, Magliano DJ, Shaw JE, Gregg EW. Global trends in diabetes complications: a review of current evidence. Diabetologia. 2019 Jan;62(1):3-16.
  5. Kopf S, Kumar V, Kender Z, Han Z, Fleming T, Herzig S, Nawroth PP. Diabetic pneumopathy–a new diabetes-associated complication: mechanisms, consequences and treatment considerations. Frontiers in Endocrinology. 2021 Nov 25;12:765201.
  6. ERSOY C. Diabetes mellitus and the lungs. Journal: Turkish Journal of Internal Medicine. 2020(3):59-65.
  7. Gunasekaran K, Murthi S, Elango K, Rahi MS, Thilagar B, Ramalingam S, Voruganti D, Paramasivam VK, Kolandaivel KP, Arora A, Chandran A. The impact of diabetes mellitus in patients with chronic obstructive pulmonary disease (COPD) hospitalization. Journal of Clinical Medicine. 2021 Jan 11;10(2):235.
  8. Bisht MK, Dahiya P, Ghosh S, Mukhopadhyay S. The cause–effect relation of tuberculosis on incidence of diabetes mellitus. Frontiers in Cellular and Infection Microbiology. 2023;13.
  9. Das S, Anu KR, Birangal SR, Nikam AN, Pandey A, Mutalik S, Joseph A. Role of comorbidities like diabetes on severe acute respiratory syndrome coronavirus-2: A review. Life sciences. 2020 Oct 1;258:118202.
  10. Das S, Anu KR, Birangal SR, Nikam AN, Pandey A, Mutalik S, Joseph A. Role of comorbidities like diabetes on severe acute respiratory syndrome coronavirus-2: A review. Life sciences. 2020 Oct 1;258:118202.
  11. Gallo de Moraes A, Surani S. Effects of diabetic ketoacidosis in the respiratory system. World J Diabetes. 2019 Jan 15;10(1):16-22. doi: 10.4239/wjd.v10.i1.16. PMID: 30697367; PMCID: PMC6347653.
  12. Fallahi A, Jamil DI, Karimi EB, Baghi V, Gheshlagh RG. Prevalence of obstructive sleep apnea in patients with type 2 diabetes: a systematic review and meta-analysis. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019 Jul 1;13(4):2463-8.
  13. Jehan S, Myers AK, Zizi F, Pandi-Perumal SR, Jean-Louis G, McFarlane SI. Obesity, obstructive sleep apnea and type 2 diabetes mellitus: Epidemiology and pathophysiologic insights. Sleep Med Disord. 2018;2(3):52-58. Epub 2018 Jun 21. PMID: 30167574; PMCID: PMC6112821
  14. Wang D, Ma Y, Tong X, Zhang Y, Fan H. Diabetes mellitus contributes to idiopathic pulmonary fibrosis: a review from clinical appearance to possible pathogenesis. Frontiers in public health. 2020 Jun 3;8:196.
  15. Bai L, Zhang L, Pan T, Wang W, Wang D, Turner C, Zhou X, He H. Idiopathic pulmonary fibrosis and diabetes mellitus: a meta-analysis and systematic review. Respiratory Research. 2021 Jun 8;22(1):175.
  16. Moawd SA, Azab AR, Alrawaili SM, Abdelbasset WK. Inspiratory muscle training in obstructive sleep apnea associating diabetic peripheral neuropathy: a randomized control study. BioMed Research International. 2020 Jun 12;2020.
  17. Ahmad A, Ali H. Low-intensity inspiratory loaded exercises improve physical health perception in women with type 2 diabetes. Physiotherapy Quarterly. 2020 Apr 1;28(2):9-14.
  18. Miele EM, Headley SA. The effects of chronic aerobic exercise on cardiovascular risk factors in persons with diabetes mellitus. Current diabetes reports. 2017 Oct;17(10):1-7.
  19. Nuhu JM, Maharaj SS. Influence of a mini-trampoline rebound exercise program on insulin resistance, lipid profile and central obesity in individuals with type 2 diabetes. The journal of sports medicine and physical fitness. 2017 Mar 1;58(4):503-9.
  20. Nery C, De Moraes SR, Novaes KA, Bezerra MA, Silveira PV, Lemos A. Effectiveness of resistance exercise compared to aerobic exercise without insulin therapy in patients with type 2 diabetes mellitus: a meta-analysis. Brazilian journal of physical therapy. 2017 Nov 1;21(6):400-15.
  21. Nambi G, Alghadier M, Vellaiyan A, Ebrahim EE, Aldhafian OR, Mohamed SH, Albalawi HF, Chevidikunnan MF, Khan F, Mani P, Saleh AK. Role of Tele-Physical Therapy Training on Glycemic Control, Pulmonary Function, Physical Fitness, and Health-Related Quality of Life in Patients with Type 2 Diabetes Mellitus (T2DM) Following COVID-19 Infection—A Randomized Controlled Trial. InHealthcare 2023 Jun 17 (Vol. 11, No. 12, p. 1791). MDPI.
  22. Shen L, Zhang Y, Su Y, Weng D, Zhang F, Wu Q, Chen T, Li Q, Zhou Y, Hu Y, Jiang X. New pulmonary rehabilitation exercise for pulmonary fibrosis to improve the pulmonary function and quality of life of patients with idiopathic pulmonary fibrosis: a randomized control trial. Annals of palliative medicine. 2021 Jul;10(7):7289297-7297.
  23. Bui-Diem K, Hung CH, Zhu GC, Tho NV, Nguyen-Binh T, Vu-Tran-Thien Q, To-Truong D, Ngo-Thanh H, Duong-Quy S. Physical therapy for sleep apnea: a smartphone application for home-based physical therapy for patients with obstructive sleep apnea. Frontiers in Neurology. 2023 May 25;14:1124059.

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