Clément Médrinal

Inspiratory muscle training is used in some intensive care units, but many training methods have uncertain efficacy: a survey of French physiotherapists.

QUESTIONS How common is inspiratory muscle training by physiotherapists in the intensive care unit (ICU)? Which patients receive the training? What methods are used to administer the training? Is maximal inspiratory pressure used to evaluate the need for the training and the patients outcome after training? DESIGN Cross-sectional survey of all ICUs in France. PARTICIPANTS Two hundred and sixty-five senior physiotherapists. RESULTS The response rate was 99% among eligible units. Therapist experience in ICU was significantly associated with the use of inspiratory muscle training (p=0.02). Therapists mainly used inspiratory muscle training either systematically or specifically in patients who failed to wean from mechanical ventilation. The training was used significantly more in non-sedated patients (p<0.0001). The most commonly nominated technique that respondents claimed to use to apply the training was controlled diaphragmatic breathing (83% of respondents), whereas 13% used evidence-based methods. Among those who applied some form of inspiratory muscle training, 16% assessed maximal inspiratory pressure. Six respondents (2%, 95% CI 1 to 5) used both an evidence-based method to administer inspiratory muscle training and the recommended technique for assessment of inspiratory muscle strength. CONCLUSION Most physiotherapists in French ICUs who apply inspiratory muscle training use methods of uncertain efficacy without assessment of maximal inspiratory pressure. Further efforts need to be made in France to disseminate information regarding evidence-based assessment and techniques for inspiratory muscle training in the ICU. The alignment of inspiratory muscle training practice with evidence could be investigated in other regions.

Comparison of oxygen uptake during cycle ergometry with and without functional electrical stimulation in patients with COPD: protocol for a randomised, single-blind, placebo-controlled, cross-over trial

Introduction Chronic obstructive pulmonary disease (COPD) has systemic repercussions that can lead to peripheral muscle dysfunction. Muscle atrophy reduces aerobic capacity, greatly limiting activities of daily living and quality of life. Pulmonary rehabilitation is the gold standard treatment for these patients, however, patients may not be able to reach sufficient training intensities for benefits to occur. Technologies such as functional electrical stimulation (FES) are currently being adapted and tested to enhance exercise training. We hypothesise that FES coupled with cycling (FES-cycling) will improve maximal uptake of oxygen (VO2) and aerobic capacity more than endurance training with placebo stimulation. Methods A randomised, single-blind, placebo-controlled crossover trial will be carried out to evaluate the effects of FES-cycling on VO2 during endurance exercise on a cycle ergometer in patients with COPD. 25 patients with COPD will carry out two 30 min sessions at a constant load; one session with active and one with placebo FES. The primary outcome is oxygen uptake recorded with a metabolic measurement system. Secondary outcomes include ventilation equivalent for oxygen, ventilation equivalent for carbon dioxide, cardiac output, lactate values, perceived dyspnoea and perceived muscle fatigue. Results and conclusions Approval has been granted by our Institutional Review Board (Comité de Protection des Personnes Nord-Ouest 3). The results of the trial will be presented at national and international meetings and published in peer-reviewed journals. Trial registration number NCT02594722.

Six-minute Stepper Test to Set Pulmonary Rehabilitation Intensity in Patients with COPD – A Retrospective Study

ABSTRACT Pulmonary rehabilitation (PR) improves outcomes in patients with chronic obstructive pulmonary disease (COPD). Optimal assessment includes cardiopulmonary exercise testing (CPET), but consultations are limited. Field tests could be used to individualize PR instead of CPET. The six-minute stepper test (6MST) is easy to set up and its sensitivity and reproducibility have previously been reported in patients with COPD. The aim of this study was to develop a prediction equation to set intensity in patients attending PR, based on the 6MST. The following relationships were analyzed: mean heart rate (HR) during the first (HR1–3) and last (HR4–6) 3 minutes of the 6MST and HR at the ventilatory threshold (HRvt) from CPET; step count at the end of the 6MST and workload at the Ventilatory threshold (VT) (Wvt); and forced expiratory volume in 1 second and step count during the 6MST. This retrospective study included patients with COPD referred for PR who underwent CPET, pulmonary function evaluations and the 6MST. Twenty-four patients were included. Prediction equations were HRvt = 0.7887 × HR1–3 + 20.83 and HRvt = 0.6180 × HR4–6 + 30.77. There was a strong correlation between HR1–3 and HR4–6 and HRvt (r = 0.69, p < 0.001 and r = 0.57, p < 0.01 respectively). A significant correlation was also found between step count and LogWvt (r = 0.63, p < 0.01). The prediction equation was LogWvt = 0.001722 × step count + 1.248. The 6MST could be used to individualize aerobic training in patients with COPD. Further prospective studies are needed to confirm these results.

Effects of different early rehabilitation techniques on haemodynamic and metabolic parameters in sedated patients: protocol for a randomised, single-bind, cross-over trial

Introduction Early rehabilitation has become widespread practice for patients in intensive care; however, the prevalence of intensive care unit-acquired weakness remains high and the majority of physiotherapy is carried out in bed. Several inbed rehabilitation methods exist, but we hypothesise that techniques that provoke muscle contractions are more effective than passive techniques. Methods A randomised, controlled cross-over study will be carried out to evaluate and compare the effectiveness of early rehabilitation techniques on cardiac output (CO) in sedated patients in intensive care. 20 intubated and sedated patients will undergo 4 10 min rehabilitation sessions. 2 sessions will involve ‘passive’ techniques based on mobilisations and inbed cycle ergometry and 2 involving electrostimulation of the quadriceps muscle and Functional Electrical Stimulation-cycling (FES-cycling). The primary outcome is CO measured by Doppler ultrasound. The secondary outcomes are right ventricular function, pulmonary systolic arterial pressure, muscle oxygenation and minute ventilation during exercise. Results and conclusion Approval has been granted by our Institutional Review Board (Comité de Protection des Personnes Nord-Ouest 3). The results of the trial will be presented at national and international meetings and published in peer-reviewed journals. Trial registration number NCT02920684.

Effect of backpack carrying on forced vital capacity in cystic fibrosis: A randomized crossover-controlled trial

Background Backpack carrying impacts lung function in healthy children but the effect in children with cystic fibrosis (CF) is unknown. Methods Three backpack positions were tested: no backpack (NB), a 12.5% body-weight backpack carried bilaterally (BB) or unilaterally (UB), at rest and during a 10 minute walk. Primary outcome was forced vital capacity (FVC). Secondary outcomes included comparison of cardio-respiratory variables within and between groups. Results Nine children with CF (13.3±2.6 years; FEV1 66±22%) and 18 healthy children (13.8±1.8 years; FEV1 107±30%) were included. FVC was reduced with UB compared to NB (68.5±23.3% vs 72.1±24.3%, p = 0.024) in children with CF. FEV1, MIP and MEP decreased more with UB in children with CF than in healthy peers. Increases in VO2, VCO2 and minute ventilation with UB were greater in the CF group during walking. Conclusions Unilateral backpack wearing affects FVC in children with CF and requires greater cardio-respiratory adjustments compared to healthy peers.

Functional Electrical Stimulation—A New Therapeutic Approach to Enhance Exercise Intensity in Chronic Obstructive Pulmonary Disease Patients: A Randomized, Controlled Crossover Trial

OBJECTIVE To evaluate the effect of quadriceps functional electrical stimulation (FES)-cycling on exertional oxygen uptake (V˙o2) compared with placebo FES-cycling in patients with chronic obstructive pulmonary disease (COPD). DESIGN A randomized, single-blind, placebo-controlled crossover trial. SETTING Pulmonary rehabilitation department. PARTICIPANTS Consecutive patients (N=23) with COPD Global Initiative for Chronic Obstructive Lung Disease stage 2, 3, or 4 (mean forced expiratory volume during the first second, 1.4±0.4L [50.3% predicted]) who had recently begun a respiratory rehabilitation program. INTERVENTION Two consecutive 30-minute sessions were carried out at a constant load with active and placebo FES-cycling. MAIN OUTCOME MEASURES The primary outcome was mean V˙o2 during the 30-minute exercise session. The secondary outcomes were respiratory gas exchange and hemodynamic parameters averaged over the 30-minute endurance session. Lactate values, dyspnea, and perceived muscle fatigue were evaluated at the end of the sessions. RESULTS FES-cycling increased the physiological response more than the placebo, with a greater V˙o2 achieved of 36.6mL/min (95% confidence interval [CI], 8.9-64.3mL/min) (P=.01). There was also a greater increase in lactate after FES-cycling (+1.5mmol/L [95% CI, .05-2.9mmol/L]; P=.01). FES-cycling did not change dyspnea or muscle fatigue compared with the placebo condition. CONCLUSIONS FES-cycling effectively increased exercise intensity in patients with COPD. Further studies should evaluate longer-term FES-cycling rehabilitation programs.

Home-based Neuromuscular Electrical Stimulation as an Add-on to Pulmonary Rehabilitation Does Not Provide Further Benefits in Patients With Chronic Obstructive Pulmonary Disease: A Multicenter Randomized Trial

OBJECTIVE To assess the additional effect of a home-based neuromuscular electrical stimulation (NMES) program as an add-on to pulmonary rehabilitation (PR), on functional capacity in subjects with chronic obstructive pulmonary disease (COPD). DESIGN Single-blind, multicenter randomized trial. SETTING Three PR centers. PARTICIPANTS Subjects with severe to very severe COPD (N=73; median forced expiratory volume in 1 second, 1L (25th-75th percentile, 0.8-1.4L) referred for PR. Twenty-two subjects discontinued the study, but only 1 dropout was related to the intervention (leg discomfort). INTERVENTION Subjects were randomly assigned to either PR plus quadricipital home-based NMES (35Hz, 30min, 5 time per week) or PR without NMES for 8 weeks. MAIN OUTCOME MEASURE The 6-minute walk test (6MWT) was used to assess functional capacity. RESULTS Eighty-two percent of the scheduled NMES sessions were performed. In the whole sample, there were significant increases in the distance walked during the 6MWT (P<.01), peak oxygen consumption (P=.02), maximal workload (P<.01), modified Medical Research Council dyspnea scale (P<.01), and Saint Georges Respiratory Questionnaire total score (P=.01). There was no significant difference in the magnitude of change for any outcome between groups. CONCLUSIONS Home-based NMES as an add-on to PR did not result in further improvements in subjects with severe to very severe COPD; moreover, it may have been a burden for some patients.

Effect of high-flow nasal therapy during acute aerobic exercise in patients with chronic obstructive pulmonary disease after exacerbation: protocol for a randomised, controlled, cross-over trial

Introduction Early pulmonary rehabilitation is recommended after a severe exacerbation of chronic obstructive pulmonary disease (COPD). However, this is difficult to implement, particularly for exercise training. High-flow nasal therapy (HFNT) may reduce the work of breathing and dyspnoea and may improve exercise tolerance. Methods and analysis This is a single-centre, prospective, controlled, randomised, cross-over study. Eligible patients will have a diagnosis of COPD (postbronchodilator forced expiratory volume in 1 s/forced vital capacity ratio of <0.7). Two constant work rate exercise tests at 80% of the peak work rate will be carried out on two consecutive days with and without HFNT. The primary outcome will be the difference in endurance time between the two conditions. Secondary outcomes will be the change in muscle oxygenation during exercise, dyspnoea and muscle fatigue, respiratory muscle strength after exercise, respiratory rate, cardiac frequency, transcutaneous CO2 pressure and pulsed O2 saturation. Nineteen patients will be included. Data will be analysed as intention to treat by a blinded statistician. Ethics and dissemination Ethics approval has been obtained from the Ethics Committees Nord-Ouest III, Caen, France (N° ID RCB: 2016-A01325-46). The study will begin in April 2017 for a duration of 2 years. The results of the trial will be presented at national and international meetings and published in peer-reviewed journals. Trial registration number NCT03058081.