Emilio Servera

Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity.

PURPOSE To create a maximum tolerated 45-minute aerobic training program for patients with chronic obstructive pulmonary disease (COPD) and to compare its outcomes with those of commonly prescribed moderate exercise. DESIGN Prospective, randomized trial. SETTING A work physiology laboratory. PATIENTS AND METHODS The maximum exercise intensities that 7 COPD patients could sustain for 45 minutes were determined on a bilevel exercise ergometer. The patients then exercised 45 minutes daily, 5 days a week for 6 weeks, working 2.03+/-0.4 kJ/kg per session. They were matched with 6 COPD patients who pushed an O2 cart for 45 minutes daily, 5 days a week for 6 weeks, working 1.44+/-.35 kJ/kg per session. RESULTS A 45 minute maximal regimen was established by alternating 1-minute peak exercise at peak VO2-levels with 4 minutes at the ventilatory anaerobic threshold or at 40% of peak VO2. Maximal bilevel training significantly decreased dyspnea at rest (p< or =.01) and the blood lactate level during submaximal exercise (p<.001), and increased peak VO2 and total physical work (p<.01), maximum inspiratory and expiratory pressures (p<.01), and grip and forearm strength and endurance (p<.01). The training also increased maximum voluntary ventilation while decreasing the ventilatory equivalent during exercise (p<.001). The O2 cart pushers significantly improved only on the 12-minute walk (p<.05). CONCLUSIONS A maximally intense anaerobic exercise program can be created for most COPD patients that can significantly improve both skeletal and respiratory muscle strength and endurance as well as dyspnea and physiologic parameters.

Mechanical insufflation-exsufflation vs. tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis: a pilot study.

Sancho J, Servera E, Vergara P, Marín J: Mechanical insufflation-exsufflation vs. tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis: A pilot study. Am J Phys Med Rehabil 2003;82:750–753. Objective To compare the effects of mechanical insufflation-exsufflation vs. suctioning via tracheostomy tubes on respiratory variables for six amyotrophic lateral sclerosis patients. Design In this prospective crossover study, six consecutive patients with amyotrophic lateral sclerosis who required continuous mechanical ventilation via tracheostomy tubes and developed chest infections underwent measurement of pulse oxyhemoglobin saturation (SpO2), peak inspiratory pressure (PIP), mean airway pressure (Pawm), and work of breathing performed by the ventilator (WOBv) at baseline and 5 and 30 min after tracheal suctioning and 5 min after mechanical insufflation-exsufflation. Results The baseline values were 93.50 ± 2.26% for SpO2 in ambient air, 18.50 ± 4.23 cm H2O for PIP, 4.67 ± 1.37 cm H2O for Pawm, and 1.03 ± 0.25 J/liters for WOBv. Only WOBv changed significantly, decreasing after tracheal suctioning (P < 0.05), whereas all variables improved significantly after mechanical insufflation-exsufflation. Conclusion For ventilator-dependent patients with amyotrophic lateral sclerosis, mechanical insufflation-exsufflation via a tracheostomy tube with an inflated cuff may be more effective in eliminating airway secretions than conventional tracheal suctioning.

Alternatives to endotracheal intubation for patients with neuromuscular diseases.

Servera E, Sancho J, Zafra MJ, Catalá A, Vergara P, Marín J: Alternatives to endotracheal intubation for patients with neuromuscular diseases. Am J Phys Med Rehabil 2005;84:851–857. Objective:To evaluate the usefulness of continuous noninvasive mechanical ventilation and mechanical coughing aids to avoid endotracheal intubation and tracheostomy during episodes of acute respiratory failure in patients with neuromuscular disease. Design:We conducted a prospective cohort study at the respiratory medicine ward of a university hospital to study the success rate of the use of continuous noninvasive mechanical ventilation and manually and mechanically (CoughAssist) assisted coughing to avert endotracheal intubation in 24 consecutive episodes of acute respiratory failure for 17 patients with neuromuscular disease. The noninvasive mechanical ventilation and coughing aids were used to reverse decreases in oxyhemoglobin saturation and relieve respiratory distress that occurred despite oxygen therapy and appropriate medication. Noninvasive mechanical ventilation was delivered by volume ventilators (Breas PV 501) alternating nasal/oronasal and oral interfaces. Results:Noninvasive management was successful in averting death and endotracheal intubation in 79.2% of the acute episodes. There were no significant differences in respiratory function between the successfully treated and unsuccessfully treated groups before the current episode. Bulbar dysfunction was the independent risk factor for failure of noninvasive treatment (P < 0.05; odds ratio, 35.99%; 95% confidence interval, 1.71–757.68). Conclusions:Intubation can be avoided for some patients with neuromuscular disease in acute respiratory failure by some combination of noninvasive mechanical ventilation and mechanically assisted coughing. Severe bulbar involvement can limit the effectiveness of noninvasive management. ABBREVIATIONS: ALS: amyotrophic lateral sclerosis; ETI: endotracheal intubation; FEV1: forced expiratory volume in 1 sec; FVC: forced vital capacity; %FVC: percentage predicted FVC; MIC: maximum insufflation capacity; NIV: noninvasive ventilation; NMD: neuromuscular disease; PCF: peak cough flow; PCFMIC: manually assisted PCF; PImax: maximum mouth inspiratory pressure; PEmax: maximum expiratory pressure; SpO2: pulse oxyhemoglobin saturation

Mechanical insufflation-exsufflation: Pressure, volume, and flow relationships and the adequacy of the manufacturer's guidelines

Gómez-Merino E, Sancho J, Marín J, Servera E, Blasco ML, Belda JF, Castro C, Bach JR: Mechanical insufflation-exsufflation: Pressure, volume, and flow relationships and the adequacy of the manufacturer’s guidelines. Am J Phys Med Rehabil 2002:81;579–583. Objective Pulmonary complications of neuromuscular disease can be averted by increasing peak cough flows with the use of a forced exsufflation device. The purpose of this study was to examine the pressure, volume, and flow relationships for a range of settings generated by this device, and compare them with clinically efficacious values and the manufacturer’s guidelines. Methods The In-exsufflator was connected to a standard lung model. The resulting forced deflation volumes, flows, and pressures were averaged over 10 cycles at each setting. Results The set insufflation pressures significantly correlated with the generated insufflation pressures and volumes and the exsufflation volumes and flows. Increasing set insufflation time significantly increased generated insufflation pressures, flows, and volumes and exsufflation volumes. Increasing set exsufflation time did not significantly increase generated exsufflation flows. At set pressures of 40 to −40 cm H2O, insufflation time of 3 sec, and exsufflation time of 2 sec, the exsufflation flow was 4.09 l/sec. A plateau insufflation volume of 3.8 l was reached after 4.9 sec of insufflation. Conclusions In-exsufflator performance was very consistent. Its clinical effectiveness can be explained by its generation of exsufflation flows >2.7 l/sec. Increasing insufflation times more than exsufflation times is more important for optimal function. Current manufacturer use guidelines may not yield optimal exsufflation flows.

Noninvasive respiratory muscle aids during PEG placement in ALS patients with severe ventilatory impairment

UNLABELLED Although no clear recommendations are given about when percutaneous endoscopic gastrostomy (PEG) should be placed in amyotrophic lateral sclerosis (ALS) patients, some experts underline the risk of respiratory complications when patients had severe ventilatory muscle impairment (SVMI). AIM To evaluate the efficacy of noninvasive ventilation (NIV) and mechanically assisted cough (MAC) to avoid respiratory complications related to PEG placement in ALS patients with SVMI. MATERIAL AND METHODS Prospective study including ALS patients who had chosen to have PEG placement timed by swallowing dysfunction with the aid of NIV and MAC if needed. PEG was carried out under volume-cycled NIV through a nasal mask. MAC was applied prior to and at the end of the procedure. RESULTS Thirty ALS patients (60.43±12.03years) were included. Prior to PEG placement: BMI 25.0±4.6kg/m(2), ALSRFS-R 19.5±5.0, Norris bulbar sub-score 15.1±6.6, %FVC 35.9±18.1%, PCF 2.3±1.2L/s, PImax -35.6±24.6cmH(2)O, and PEmax 40.5±23.9cmH(2)O. Three patients had PEG placement under tracheotomy ventilation because NIV SpO(2) was below 88%. No patient died during the procedure nor did any have respiratory complications. Survival at 1month was 100%. CONCLUSION Respiratory support provided by volume-cycled NIV and MAC permits successful PEG placement in most ALS patients with SVMI.

Non-invasive ventilation effectiveness and the effect of ventilatory mode on survival in ALS patients

Abstract Non-invasive ventilation (NIV) prolongs survival in amyotrophic lateral sclerosis (ALS), but there are no data with which to compare the effectiveness of the different ventilator modes – volume (Vol-NIV) or pressure-cycled (Pres-NIV) ventilation – in ALS. We aimed to determine whether the ventilatory mode has an effect on ventilation effectiveness and survival of ALS patients using NIV. We used a retrospective study that included all ALS patients for whom NIV was indicated in two referral units: one using Vol-NIV and the other using Pres-NIV. Demographic, functional and nocturnal gas exchange parameters at NIV initiation were recorded. Eighty-two ALS patients ventilated using Pres-NIV and 62 using Vol-NIV were included. No differences were found in survival from NIV initiation between Vol-NIV (median 15.00 (7.48–22.41) months) and Pres-NIV (median 15.00 (10.25–19.75) months, p = 0.533) patients. Effective NIV was achieved in 72.41% Vol-NIV patients and in 48.78% Pres-NIV patients (p < 0.001). Ventilator mode (OR 12.066 (4.251–32.270), p < 0.001) and severity of bulbar dysfunction (OR 1.07 (1.011–1.133), p = 0.02) were the variables correlated with effective NIV. In conclusion, although Vol-NIV provides more effective ventilation, Vol-NIV and Pres-NIV present similar survival in ALS. Effectiveness of NIV is related to the severity of bulbar dysfunction.

Prolonging survival in amyotrophic lateral sclerosis: efficacy of noninvasive ventilation and uncuffed tracheostomy tubes.

Sancho J, Servera E, Bañuls P, Marín J: Prolonging survival in amyotrophic lateral sclerosis. Objective:To assess the efficacy of noninvasive ventilatory support and intermittent positive pressure ventilation via uncuffed tracheostomy tubes (uTIPPV) to prolong survival in amyotrophic lateral sclerosis. Design:Survival was prolonged by continuous noninvasive ventilatory support or TIPPV dependence. Once noninvasive ventilatory support was no longer adequate for six noninvasive ventilatory support users, they and 22 others underwent tracheotomy within 1 mo of measurement of spirometry (forced vital capacity and forced volume expired in 1 sec), peak cough flows, maximum insufflation capacity, manually assisted peak cough flows, and mechanically assisted peak cough flows. Glottic function was estimated by maximum insufflation capacity, FVC difference, and bulbar-innervated muscle function by Norris scale bulbar-innervated muscle subscore. Cuffless tubes were replaced by cuffed ones when hypoventilation developed despite increasing uTIPPV volumes. Results:The survival of 22 patients was prolonged by continuous noninvasive ventilatory support dependence for 7.8 ± 8.1 mos (range, 1–36 mos; median, 5 mos) after 13.9 ± 11.2 mos (range, 2–36 mos) of part-time noninvasive ventilatory support. Six of these and 22 others underwent tracheotomy and initially used uTIPPV effectively. For ten of the 28 (35.7%) patients, the tubes had to be replaced by cuffed ones after 5.7 ± 7.8 mos with the other 18 still using tracheostomy intermittent positive pressure ventilation volumes via uncuffed tubes for 20.2 ± 17.6 mos at data collection. Pretracheotomy FVC was significantly lower in the ten patients who eventually required cuffed tubes (0.70 ± 0.44 vs. 1.06 ± 0.43 L, P < 0.05). The bulbar-innervated muscle was significantly lower when the uTIPPV users required cuffed TIPPV than when beginning uTIPPV (Norris scale bulbar-innervated muscle subscore, 3.20 ± 1.30 vs. 8.00 ± 3.20, P < 0.05), respectively. Conclusions:Noninvasive and tracheostomy IPPV via cuffless tubes can prolong survival for patients with amyotrophic lateral sclerosis until excessive air leak and hypoventilation necessitate a cuffed tube.

Recomendaciones sobre la atención al final de la vida en pacientes con EPOC

Over the last 20 years, advances in the treatment of patients with chronic obstructive pulmonary disease (COPD) have improved survival even among patients in the most advanced stages of the disease, such as those requiring domiciliary oxygen therapy. This improvement—in principle a positive development—has given rise to considerable clinical problems associated with the establishment of a therapeutic ceiling and the di culty of determining prognosis in some of these patients. in this situation, the clinician should consider introducing palliative care, that is, care aimed at improving symptom control, communication, physical activity, and emotional support, in order to achieve the best possible quality of life for the patient. Palliative care is generally associated with the advanced stages of a disease’s natural history, but in the case of COPD it is important to emphasize it does not necessarily mean that death is imminent. The lack of a generally accepted deinition for “end-stage COPD” makes it di cult to compare studies. Table 1 deines the basic concepts. improving the management of advanced-stage COPD not only has a direct impact on the quality of care received by the patient, but also has a positive effect on the health care system as a whole in that it reduces hospital admissions shifts the burden of care from the hospital to the community, and reduces unnecessary and unscheduled admissions to intensive care units. Many patients with COPD remain undiagnosed, and some of those diagnosed do not fulill the accepted criteria, and it is therefore extremely di cult to establish how many patients actually have very severe COPD, though it is estimated that the proportion may range between 3% and 15% of the total. The concern with broadening the clinician’s approach beyond actions taken primarily to prolong the patient’s life has developed more recently in the context of COPD in comparison with other diseases. nonetheless, and despite the lack of precise deinitions and the unpredictability of this disease, this broader approach should be an indispensable component of good practice in pulmonology. figure 1 summarizes the inal stages of life in patients with COPD.

Non-invasive management of an acute chest infection for a patient with ALS.

We describe a man diagnosed with non-bulbar amyotrophic lateral sclerosis (ALS) who uses 24-h non-invasive ventilator at home, and assisted cough through the use of the mechanical insufflation-exsufflation (MAC) device (CoughAssist, J.H. Emerson). This was essential for the removal of bronchial secretions in order to provide successful non-invasive management (and indeed less suffering for the patient) during an acute respiratory tract infection with hypoxemia and failure of manually assisted cough.

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Summary