Fernando Sergio Studart Leitão Filho

Outpatient vs. home-based pulmonary rehabilitation in COPD: a randomized controlled trial

BackgroundChronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality affecting a large number of individuals in both developed and developing countries and it represents a significant financial burden for patients, families and society. Pulmonary rehabilitation (PR) is a multidisciplinary program that integrates components of exercise training, education, nutritional support, psychological support and self-care, resulting in an improvement in dyspnea, fatigue and quality of life. Despite its proven effectiveness and the strong scientific recommendations for its routine use in the care of COPD, PR is generally underutilized and strategies for increasing access to PR are needed. Home-based self-monitored pulmonary rehabilitation is an alternative to outpatient rehabilitation. In the present study, patients with mild, moderate and severe COPD submitted to either an outpatient or at-home PR program for 12 weeks were analyzed.MethodsPatients who fulfilled the inclusion criteria were randomized into three distinct groups: an outpatient group who performed all activities at the clinic, a home-based group who performed the activities at home and a control group. PR consisted of a combination of aerobic exercises and strengthening of upper and lower limbs 3 times a week for 12 weeks.ResultsThere was a significant difference in the distance covered on the six-minute walk test (p < 0.05) and BODE index (p < 0.001) in the outpatient and at-home groups after participating in the rehabilitation program compared to baseline.ConclusionA home-based self-monitoring pulmonary rehabilitation program is as effective as outpatient pulmonary rehabilitation and is a valid alternative for the management of patients with COPD.RiassuntoRazionaleLa broncopneumopatia cronica ostruttiva (BPCO) è una causa frequente di morbilità e mortalità che colpisce un’ampia quota di popolazione sia nel mondo industrializzato che nei Paesi in via di sviluppo e rappresenta un peso economico di rilievo per pazienti, familiari e collettività. La riabilitazione respiratoria (PR) è un programma multidisciplinare che inegra componenti di riallenamento all’esercizio fisico, educazionale, supporto nutrizionale, supporto psicologico ed autoaiuto, che porta ad un miglioramento della dispnea, della affaticabilità e della qualità della vita. Nonostante la provata efficacia e le forti raccomandazioni delle società scientifiche al suo impiego routinario nel trattamento della BPCO, la PR è generalmente sottoutilizzata e si rendono perciò necessarie strategie per aumentarne l’utilizzo. La PR effettuata a domicilio ed auto-monitorata dal paziente stesso è un’alternativa alla classica riabilitazione ambulatoriale. In questo studio sono stati valuati pazienti con BPCO di grado lieve, moderato e grave sottoposti a un programma di PR ambulatoriale o domiciliare.MetodiI pazienti eligibili allo studio sono stati randomizzati in tre gruppi: un gruppo ambulatoriale che effettuava tutte le attività in ospedale, un gruppo domiciliare che effettuava il programma a domicilio ed un gruppo di controllo. Il programma di PR consisteva in una combinazione di esercizi aerobici e di rafforzamento della muscolatura degli arti superiori e inferiori per 3 volte la settimana per 12 settimane.RisultatiSia nel gruppo che ha partecipato al PR ambulatoriale che in quello domiciliare si sono rilevate differenze significative rispetto alle misure di base nella distanza coperta con il test del cammino di 6 minuti (p < 0.05) che nell’indice BODE (p < 0.001).ConclusioniUn programma di riabilitazione respiratoria automonitorato eseguito a domicilio ha efficacia sovrapponibile ad un programma ambulatoriale e può perciò essere considerato una valida alternativa nella gestione del paziente con BPCO.

General Characteristics and Risk Factors of Cardiovascular Disease among Interstate Bus Drivers

Workers in the transportation industry are at greater risk of an incorrect diet and sedentary behavior. The aim of our study was to characterize a population of professional bus drivers with regard to clinical and demographic variables, lipid profile, and the presence of cardiovascular risk factors. Data from 659 interstate bus drivers collected retrospectively, including anthropometric characteristics, systolic and diastolic blood pressure, lipid profile, fasting blood glucose, meatoscopy, and audiometry. All participants were male, with a mean age of 41.7 ± 6.9 years, weight of 81.4 ± 3.3 kg, and BMI 27.2 ± 3.3 Kg/m2; the mean abdominal and neck circumferences were 94.4 ± 8.6 cm and 38.9 ± 2.2  cm; 38.2% of the sample was considered hypertensive; mean HDL cholesterol was 47.9 ± 9.5 mg/dL, mean triglyceride level was 146.3 ± 87.9 mg/dL, and fasting glucose was above 100 mg/dL in 249 subjects (39.1%). Drivers exhibited reduced audiometric hearing at 4–8 kHz, being all sensorineural hearing loss. The clinical characterization of a young male population of interstate bus drivers revealed a high frequency of cardiovascular risk factors, as obesity, hypertension, hyperlipidemia, and hyperglycemia, as well as contributing functional characteristics, such as a low-intensity activity, sedentary behavior, long duration in a sitting position, and high-calorie diet, which lead to excessive weight gain and associated comorbidities.

Cardiovascular risk and mortality in end-stage renal disease patients undergoing dialysis: sleep study, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life: a prospective, double blind, randomized controlled clinical trial.

BackgroundChronic kidney disease (CKD) is one of the most serious public health problems. The increasing prevalence of CKD in developed and developing countries has led to a global epidemic. The hypothesis proposed is that patients undergoing dialysis would experience a marked negative influence on physiological variables of sleep and autonomic nervous system activity, compromising quality of life.Methods/DesignA prospective, consecutive, double blind, randomized controlled clinical trial is proposed to address the effect of dialysis on sleep, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life in patients with CKD. The measurement protocol will include body weight (kg); height (cm); body mass index calculated as weight/height2; circumferences (cm) of the neck, waist, and hip; heart and respiratory rates; blood pressures; Mallampati index; tonsil index; heart rate variability; maximum ventilatory pressures; negative expiratory pressure test, and polysomnography (sleep study), as well as the administration of specific questionnaires addressing sleep apnea, excessive daytime sleepiness, depression, anxiety, stress, and quality of life.DiscussionCKD is a major public health problem worldwide, and its incidence has increased in part by the increased life expectancy and increasing number of cases of diabetes mellitus and hypertension. Sleep disorders are common in patients with renal insufficiency. Our hypothesis is that the weather weight gain due to volume overload observed during interdialytic period will influence the degree of collapsibility of the upper airway due to narrowing and predispose to upper airway occlusion during sleep, and to investigate the negative influences of haemodialysis in the physiological variables of sleep, and autonomic nervous system, and respiratory mechanics and thereby compromise the quality of life of patients.Trial registrationThe protocol for this study is registered with the Brazilian Registry of Clinical Trials (ReBEC RBR-7yhr4w and World Health Organization under Universal Trial Number UTN: U1111-1127-9390 [http://www.ensaiosclinicos.gov.br/rg/RBR-7yhr4w/]).

Clinical significance in COPD patients followed in a real practice

BackgroundChronic obstructive pulmonary disease (COPD) is an important public health issue in many countries which is estimated to become the fifth cause of disability and the third cause of mortality in the world within 2020.The objective of this study was to identify the clinical characteristics in the real clinical practice of a sample of patients with COPD followed in a pulmonology clinic.MethodsThe initial sample contained 207 subjects with respiratory claims that searched for specialized treatment and initiated regular monitoring between 2004 and 2009 in a private clinic localized in Cascavel, in the state of Parana, Brazil. Demographic data (weight, height, body mass index - BMI), history of comorbidities, use of respiratory and non respiratory drugs were also registered.ResultsThe main cause related to the development of COPD was current or prior smoking (92.0%); the most frequently reported symptom was dyspnea (95.0%), followed by cough (86.1%), wheezing (69.4%) and sputum production (40.0%). During the follow up, 51 patients developed the need for oxygen therapy (28.3%). In 96 patients, there were periods of acute exacerbation, resulting in 37 hospitalizations. In addition to COPD, a significant number of comorbidities were identified, being cardiovascular disease and neurological disorders the most prevalent ones.ConclusionsBased on the data collected, we could outline the profile of patients with COPD, showing characteristics of an elderly population, with multiple comorbidities, suggesting a health related quality of life lower than expected.

Sleep study, respiratory mechanics, chemosensitive response and quality of life in morbidly obese patients undergoing bariatric surgery: a prospective, randomized, controlled trial

BackgroundObesity is a major public health problem in both developed and developing countries alike and leads to a series of changes in respiratory physiology. There is a strong correlation between obesity and cardiopulmonary sleep disorders. Weight loss among such patients leads to a reduction in these alterations in respiratory physiology, but clinical treatment is not effective for a long period of time. Thus, bariatric surgery is a viable option.Methods/DesignThe present study involves patients with morbid obesity (BMI of 40 kg/m2 or 35 kg/m2 to 39.9 kg/m2 with comorbidities), candidates for bariatric surgery, screened at the Santa Casa de Misericórdia Hospital in the city of Sao Paulo (Brazil). The inclusion criteria are grade III morbid obesity, an indication for bariatric surgery, agreement to participate in the study and a signed term of informed consent. The exclusion criteria are BMI above 55 kg/m2, clinically significant or unstable mental health concerns, an unrealistic postoperative target weight and/or unrealistic expectations of surgical treatment. Bariatric surgery candidates who meet the inclusion criteria will be referred to Santa Casa de Misericórdia Hospital and will be reviewed again 30, 90 and 360 days following surgery. Data collection will involve patient records, personal data collection, objective assessment of HR, BP, neck circumference, chest and abdomen, collection and analysis of clinical preoperative findings, polysomnography, pulmonary function test and a questionnaire on sleepiness.DiscussionThis paper describes a randomised controlled trial of morbidly obese patients. Polysomnography, respiratory mechanics, chemosensitive response and quality of life will be assessed in patients undergoing or not undergoing bariatric surgery.Trial RegistrationThe protocol for this study is registered with the Brazilian Registry of Clinical Trials - ReBEC (RBR-9k9hhv).

Teste de pressão negativa expiratória: um novo método simples para identificar pacientes com risco para apneia obstrutiva do sono

The objective of this article was to describe a new method for assessing expiratory flow limitation during spontaneous breathing, using the negative expiratory pressure test to identify patients at risk for obstructive sleep apnea. Upper airway collapsibility is evaluated by measuring decreases in flow and in expired volume in the first 0.2 seconds after negative expiratory pressure application at 10 cmH₂O. The negative expiratory pressure test is easily applied and could be adopted for the evaluation of expiratory flow limitation caused by upper airway obstruction in patients with obstructive sleep apnea.

Opto-electronic plethysmography: Noninvasive and accurate measurement of the volume of the chest wall and its different thoraco-abdominal compartments

Source of support: None Summary Background: Opto-electronic plethysmography (OEP) is an innovative, new method to evaluate the ventilation pattern through an external measurement of chest wall surface motion. The OEP system measures changes in the complex shape of the chest wall during breathing by modeling the thoracoabdominal surface with a large number of points belonging to selected anatomical reference sites of the rib cage and abdomen. Material/Methods: The automatic motion analyzer on which it is based uses passive markers composed of a thin film of retro-reflective paper on plastic hemispheres (5–10 mm diameter). The markers are placed on the skin by bi-adhesive hypoallergenic tape. Special video cameras (solid state CCDs) operate up to 140 frames per second synchronized with coaxial infrared flashing LEDs. Dedicated software computes the 3D coordinates of the different markers with high accuracy. No specific calibration is required besides the initial one performed during the installation of the system. The OEP System uses the accurate measurement of the 3-dimensional micro-movement of the points belonging to the chest wall to compute chest wall volumes. Special algorithms compute volume variations of the whole chest wall and of the different compartments. Time courses of these signals can be obtained at different sampling frequencies, up to 140 Hz. Results: Several studies have been conducted under different conditions and have shown that the method provides a very accurate measurement of the volume of the chest wall and its variations during respiration. Conclusions: The OEP System has the great advantage that it can measure breathing patterns in any condition, both in health and disease. It can be used to study respiratory kinematics and, if combined with pressure measurements, it can be used to study statics, dynamics, and energetics.

Observational study on efficacy of negative expiratory pressure test proposed as screening for obstructive sleep apnea syndrome among commercial interstate bus drivers - protocol study

BackgroundObstructive sleep apnea (OSA) is a respiratory disease characterized by the collapse of the extrathoracic airway and has important social implications related to accidents and cardiovascular risk. The main objective of the present study was to investigate whether the drop in expiratory flow and the volume expired in 0.2 s during the application of negative expiratory pressure (NEP) are associated with the presence and severity of OSA in a population of professional interstate bus drivers who travel medium and long distances.Methods/DesignAn observational, analytic study will be carried out involving adult male subjects of an interstate bus company. Those who agree to participate will undergo a detailed patient history, physical examination involving determination of blood pressure, anthropometric data, circumference measurements (hips, waist and neck), tonsils and Mallampati index. Moreover, specific questionnaires addressing sleep apnea and excessive daytime sleepiness will be administered. Data acquisition will be completely anonymous. Following the medical examination, the participants will perform a spirometry, NEP test and standard overnight polysomnography. The NEP test is performed through the administration of negative pressure at the mouth during expiration. This is a practical test performed while awake and requires little cooperation from the subject. In the absence of expiratory flow limitation, the increase in the pressure gradient between the alveoli and open upper airway caused by NEP results in an increase in expiratory flow.DiscussionDespite the abundance of scientific evidence, OSA is still underdiagnosed in the general population. In addition, diagnostic procedures are expensive, and predictive criteria are still unsatisfactory. Because increased upper airway collapsibility is one of the main determinants of OSA, the response to the application of NEP could be a predictor of this disorder. With the enrollment of this study protocol, the expectation is to encounter predictive NEP values for different degrees of OSA in order to contribute toward an early diagnosis of this condition and reduce its impact and complications among commercial interstate bus drivers.Trial registrationRegistro Brasileiro de Ensaios Clinicos (local acronym RBEC) [Internet]: Rio de Janeiro (RJ): Instituto de Informaçao Cientifica e Tecnologica em Saude (Brazil); 2010 - Identifier RBR-7dq5xx. Cross-sectional study on efficacy of negative expiratory pressure test proposed as screening for obstructive sleep apnea syndrome among commercial interstate bus drivers; 2011 May 31 [7 pages]. Available from http://www.ensaiosclinicos.gov.br/rg/RBR-7dq5xx/.

Clinical significance in non-cystic fibrosis bronchiectasis followed in a real practice

INTRODUCAO: Bronquiectasia e uma doenca cronica caracterizada pela dilatacao permanente dos bronquios e bronquiolos acompanhada por alteracoes inflamatorias nas paredes dessas estruturas e parenquima pulmonar adjacente. OBJETIVO: O objetivo do presente estudo e realizar uma caracterizacao clinica e funcional de pacientes adultos com bronquiectasias e fibrose nao cistica. Metodos: Um estudo clinico descritivo e retrospectivo foi realizado com pacientes com bronquiectasias e fibrose nao cistica atendidos em um ambulatorio de pulmao entre 2004 e 2012. RESULTADOS: A amostra foi composta por 232 pacientes (134 mulheres, idade media: 52,9 anos ± 17,7, indice de massa corporal: 23,5 ± 4,4 kg/m2). Os sintomas predominantes foram tosse (91,4%), expectoracao (85,8%) e dispneia (76,3%). A maioria dos casos foi de etiologia nao tuberculosa (64,7%). Em relacao a funcao pulmonar, o padrao de respiracao obstrutiva foi predominante (43,5%). As comorbidades mais comuns foram de origem cardiovascular (51,0%). CONCLUSOES: pacientes adultos com bronquiectasias de fibrose nao cistica (principalmente pos-infeccao ou pos-tuberculose de origem) sao caracterizados por um baixo nivel de escolaridade, tosse excessiva, expectoracao, dispneia, fadiga muscular, um padrao de respiracao obstrutiva com hipoxemia frequente e multiplas comorbidades, essencialmente de origem cardiovascular. No entanto, nossos pacientes tem um baixo indice de exacerbacoes e hospitalizacoes que podem ser atribuidos a um protocolo clinico para o acompanhamento.

Photoacoustic technique: a new method for measuring the rheologic properties of human bronchial mucus

Patients affected by obstructive pulmonary diseases exhibit typical characteristics of airway mucus hypersecretion, including sputum production, increased luminal mucus, goblet cell hyperplasia and submucosal gland hypertrophy. The mucociliary system is a sophisticated defense mechanism to maintain the homeostasis of the respiratory tract by means of the bronchial mucus transport, the process in which airway mucus together with substances trapped within are moved out of the lungs. In the end, the mucus together with the substances trapped within are swallowed or coughed up. It is an important defense mechanism of the human body [1]. Mucociliary clearance is influenced by viscosity and elasticity, that are the fundamental rheologic properties of the respiratory mucus and important determinants of its transportability in the mucociliary system [2]. It has been observed that the rheologic properties of mucus are often abnormal in patients with airways disease [3]. A retardation in mucociliary transport may lead to mucus retention, a condition which predisposes to bacterial colonization and may eventually lead to pneumonia. Drugs may alter the process of mucociliary transport, such that it is necessary to know the effect of the drugs on the rheologic properties of human bronchial mucus. Understanding the interaction of a specific drug with human bronchial mucus may lead to a better therapeutic use of such medication. The photoacoustic technique (PAT) is a new method that permits to monitor indirectly the rheologic properties of any mucus sample [3,4]. PAT enables to study the interaction between therapeutic aerosols and bronchial mucus, making it possible to determine the typical time of interaction between the aerosol and the mucus (T0) and the solubilization period (Δt). According to our knowledge it is important to have an experimental technique that permits the monitoring of the rheologic properties of mucus during the interaction with the specific drug.