Francis-Edouard Gravier

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.

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.

Exercise testing in patients with diaphragm paresis

PURPOSE Diaphragm paresis (DP) is characterized by abnormalities of respiratory muscle function. However, the impact of DP on exercise capacity is not well known. This study was performed to assess exercise tolerance in patients with DP and to determine whether inspiratory muscle function was related to exercise capacity, ventilatory pattern and cardiovascular function during exercise. METHODS This retrospective study included patients with DP who underwent both diaphragmatic force measurements, and cardiopulmonary exercise testing (CPET). RESULTS Fourteen patients were included. Dyspnea was the main symptom limiting exertion (86%). Exercise capacity was slightly reduced (median VO2peak: 80% [74.5%-90.5%]), mostly due to ventilatory limitation. Diaphragm and overall inspiratory muscle function were correlated with exercise ventilation. Moreover, overall inspiratory muscle function was related with oxygen consumption (r=0.61) and maximal workload (r=0.68). CONCLUSIONS DP decreases aerobic capacity due to ventilatory limitation. Diaphragm function is correlated with exercise ventilation whereas overall inspiratory muscle function is correlated with both exercise capacity and ventilation suggesting the importance of the accessory inspiratory muscles during exercise for patients with DP. Further larger prospective studies are needed to confirm these results.

Impact of prehabilitation on morbidity and mortality after pulmonary lobectomy by minimally invasive surgery: a cohort study

Background Thoracic surgery is currently the optimal treatment for non-small cell lung cancer (NSCLC). However, it may be responsible for numerous postoperative complications and is often used in patients with multi co morbidities. In recent years, the optimization of a patients physical capacity before surgery has been the subject of several studies. The objective of this study was to determine whether participation in a prehabilitation program would improve outcomes after surgery and lower morbidity according to the Clavien-Dindo classification. Methods This retrospective cohort study was performed between 1st January 2014 and 31st January 2016 at Rouen University Hospital. All adult patients with NSCLC (IIIa or <) who had pulmonary lobectomy by minimally invasive surgery and cardiopulmonary exercise testing [CPET (VO2max ≤20 mL/min/kg)] were included. Results The cohort included 38 patients. Two groups were formed: one group with prehabilitation (n=19) and one group without prehabilitation (n=19). Four patients were not included leaving 34 patients for the final analysis. Most patients with a Clavien-Dindo grade of ≤2 had received prehabilitation compared to patients who had not received prehabilitation, respectively 17/19 vs. 8/15; P=0.0252. Patients who had received prehabilitation had fewer postoperative complications than patients who had not received prehabilitation, respectively 8/19 vs. 12/15; P=0.0382. Conclusions We have shown that prehabilitation has a positive impact on the occurrence and severity of postoperative complications after pulmonary lobectomy by minimally invasive surgery. Further studies conducted in larger populations are warranted to confirm these results.

Six-Minute Stepper Test to Set Pulmonary Rehabilitation Intensity in Patients with COPD

Dear Editor, We would like to thank Malaguti et al. for their interest in our study (1). The aim of the study was to develop a predictive equation based on the six-minute stepper test (6MST) to determine the appropriate intensity at which to begin pulmonary rehabilitation, particularly for use in centers with limited access to comprehensive cardiopulmonary exercise testing (CPET). We chose to use the 6MST because it is reliable (2–5), easy to set up (it does not require a 30-meter corridor, unlike the 6-minute walk test), is not a maximal test (unlike the incremental shuttle test), and is therefore feasible in an outpatient setting after cardiac evaluation. We agree that the use of heart rate (HR) to determine the target exercise training intensity for patients with COPD is debatable. Nonetheless, individualized training at the HR corresponding to the ventilatory threshold (Vt) has been shown to be effective in patients with obstructive disease (6). Since the Vt does not occur at the same percentage of VO2 peak in every patient, it can be used to determine specific metabolic stress levels for each individual. Moreover, as it corresponds to a breakdown in ventilation transition, good compliance with the training is more likely. We could have chosen to use perceived dyspnea, however, similarly to HR, the use of perceived dyspnea alone to determine exercise intensity in patients with COPD remains controversial (7). As suggested, dyspnea could be added to HR to refine the predictive equations from the multivariate regression, however we chose not to do this because of the small size of our study sample (8). A multicenter study that includes dyspnea in the equation is underway (NCT02842463). We agree with Malaguti et al. that the ventilatory threshold is not always detected in patients with COPD. Moreover, the capacity of human observers to determine this parameter is debatable (9). We acknowledged this in our discussion and suggested the relationship between the 6MST and CPET in the early stages of COPD (i.e., patients who achieve the ventilatory threshold and do not need a comprehensive CPET) should be investigated further. We disagree with the comment made by Malaguti et al. regarding the low level of functional impairment in our patients.

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.

Postpneumonectomy Compression of the Mitral Annulus: Rare Vascular Complication in Sportive Patient

Numerous postpneumonectomy complications exist. We present a rare clinical case of postpneumonectomy exertional dyspnea revealing compression of the mitral annulus by the descending aorta. The patient was 42-year-old former smoker with pulmonary emphysema. He has been operated on, in 2012 (i.e., right pneumonectomy). Before the surgery, the patient was a recreational runner. However, after some months, it was difficult for the patient to resume running. Cardiopulmonary exercise testing indicated moderate exercise intolerance with important oxygen desaturation. More interestingly, a decrease of low oxygen pulse was noticed from the first ventilatory threshold with no electrical modification on the electrocardiogram. This decrease was indicative of a decline in stroke volume. The thoracic scan revealed a right pneumonectomy pocket with a liquid abnormal content. Moreover, the mediastinum had shifted toward the pneumonectomy space and the left lung was distended and emphysematous. Echocardiography revealed a major change in the mediastinal anatomy. The mitral annulus was observed to be compressed by the rear wall of the descending aorta. The diagnosis of postpneumonectomy syndrome or platypnea-orthodeoxia syndrome was ruled out in this patient. Mitral annular compression by the descending aorta is rare complication, which must be researched in patients with postpneumonectomy exertional dyspnea.