Josy Davidson

Avaliação da força muscular respiratória em crianças e adolescentes com sobrepeso/obesos

OBJECTIVE: Evaluate respiratory muscle strength in overweight/obese children and adolescents. METHODS: This cross-sectional study enrolled patients between four and 15 years old, classified according to the National Center for Health Statistics curve for body mass index (BMI): Overweight/Obese Group (OG, BMI> 85th percentile) and Normal Weight Group (NG, BMI between 5th and 85th percentile). Manuvacuometer was used to measure maximal inspiratory pressure (MaxInspP) and maximal expiratory pressure (MaxExpP). Three measurements were obtained using the maximum pulmonary effort and the higher value was considered. Variables were compared by t test chi-square test. Adjustment of possible covariants was made by analysis of covariance, being significant p<0.05. RESULTS: 69 children were included: 37 (54%) in the OG and 32 (46%) in the NG. Obese patients were younger: 9.8±2.3 versus 10.9±1.9 years (p=0.031). MaxInspP was 71.4±24.9cmH2O in the OG and 89.6±19.6cmH2O (p=0.002). MaxExpP was 71.9±24.8cmH2O in the OG and 95.6±19.6cmH2O in the NG (p<0.001). There was no difference between groups regarding gender and physical activity. After adjustment for age, only the MaxExpP was significantly different between groups (p=0.003). CONCLUSIONS: Maximal expiratory pressure was lower in overweight/obese patients, indicating that obesity may alter pulmonary mechanics.

Functional capacity during exercise in very‐low‐birth‐weight premature children

The functional capacity of children born prematurely with very‐low‐birth weight was compared with that of children born at full‐term using the six‐minute walk test (6MWT) and the ten‐minutes shuttle walk test (10MSWT). The factors affecting walking distance were analyzed.

Photogrammetry: an accurate and reliable tool to detect thoracic musculoskeletal abnormalities in preterm infants

OBJECTIVE To analyse the accuracy and reproducibility of photogrammetry in detecting thoracic abnormalities in infants born prematurely. DESIGN Cross-sectional study. SETTING The Premature Clinic at the Federal University of São Paolo. PARTICIPANTS Fifty-eight infants born prematurely in their first year of life. OUTCOME MEASURES Measurement of the manubrium/acromion/trapezius angle (degrees) and the deepest thoracic retraction (cm). Digitised photographs were analysed by two blinded physiotherapists using a computer program (SAPO; http://SAPO.incubadora.fapesp.br) to detect shoulder elevation and thoracic retraction. Physical examinations performed independently by two physiotherapists were used to assess the accuracy of the new tool. RESULTS Thoracic alterations were detected in 39 (67%) and in 40 (69%) infants by Physiotherapists 1 and 2, respectively (kappa coefficient=0.80). Using a receiver operating characteristic curve, measurement of the manubrium/acromion/trapezius angle and the deepest thoracic retraction indicated accuracy of 0.79 and 0.91, respectively. For measurement of the manubrium/acromion/trapezius angle, the Bland and Altman limits of agreement were -6.22 to 7.22° [mean difference (d)=0.5] for repeated measures by one physiotherapist, and -5.29 to 5.79° (d=0.75) between two physiotherapists. For thoracic retraction, the intra-rater limits of agreement were -0.14 to 0.18cm (d=0.02) and the inter-rater limits of agreement were -0.20 to -0.17cm (d=0.02). CONCLUSION SAPO provided an accurate and reliable tool for the detection of thoracic abnormalities in preterm infants.

Precision and Accuracy of Oxygen Flow Meters Used at Hospital Settings

BACKGROUND: Oxygen therapy is an important therapeutic resource for patients with hypoxemia. When changing oxygen flow meters, we have observed that sometimes, even with the same oxygen flow setting as before, a different SpO2 is obtained. OBJECTIVE: To analyze the precision and accuracy of flow meters used in hospital settings. METHODS: An experimental study was performed to test oxygen flow meters from a tertiary hospital, by using a calibrated flow analyzer. Used and new flow meter accuracy was tested by reading in the gas analyzer a single measurement at flow rates of 1, 3, 5, and 10 L/min in 91 flow meters, and they were compared using the Student t test or Mann-Whitney U test. Flow meter precision was tested by reading in the flow analyzer 3 repetitive measurements set at flow rates of 1, 3, 5, and 10 L/min in 11 flow meters, and the reproducibility of these measurements was conducted by using the intraclass correlation coefficient and the Friedman test. RESULTS: The mean measured flow rates were slightly lower than the stipulated flow rate at 1 L/min, very close for 3 L/min, and higher for the 5 and 10 L/min flow rates. There was a large variability among the measurements from different flow meters, mainly at low flow rates (1 and 3 L/min). There was no difference between new and used flow meters at the flow rates measured, except at 10 L/min. Flow meters precision analysis showed a good reproducibility in 3 repetitive measurements for each flow rate (minimum 0.95, maximum 0.99 intraclass correlations). CONCLUSIONS: The flow meters tested showed good precision and poor accuracy.

[Availability of physical therapy assistance in neonatal intensive care units in the city of São Paulo, Brazil].

Objective To describe the characteristics of physical therapy assistance to newborns and to provide a profile of physical therapists working in intensive care units in the city of São Paulo, Brazil. Methods This cross-sectional study was conducted in every hospital in São Paulo city that had at least one intensive care unit bed for newborns registered at the National Registry of Health Establishments in 2010. In each unit, three types of physical therapists were included: an executive who was responsible for the physical therapy service in that hospital (chief-physical therapists), a physical therapist who was responsible for the physical therapy assistance in the neonatal unit (reference-physical therapists), and a randomly selected physical therapist who was directly involved in the neonatal care (care-physical therapists). Results Among the 67 hospitals eligible for the study, 63 (94.0%) had a physical therapy service. Of those hospitals, three (4.8%) refused to participate. Thus, 60 chief-PTs, 52 reference-physical therapists, and 44 care-physical therapists were interviewed. During day shifts, night shifts, and weekends/holidays, there were no physical therapists in 1.7%, 45.0%, and 13.3% of the intensive care units, respectively. Physical therapy assistance was available for 17.8±7.2 hours/day, and each physical therapist cared for 9.4±2.6 newborns during six working hours. Most professionals had completed at least one specialization course. Conclusion Most neonatal intensive care units in the city of São Paulo had physical therapists working on the day shift. However, other shifts had incomplete staff with less than 18 hours of available physical therapy assistance per day.

Medida da freqüência respiratória e do volume corrente para prever a falha na extubação de recém-nascidos de muito baixo peso em ventilação mecânica

OBJECTIVE: To verify if respiratory rate (RR), tidal volume (TV) and respiratory rate and tidal volume ratio (RR/TV) could predict extubation failure in very low birth weight infants submitted to mechanical ventilation. METHODS: This prospective observational study enrolled newborn infants with gestational age <37 weeks and birth weight <1,500g, mechanically ventilated from birth during 48 hours to 30 days and thought to be ready for extubation. As soon as the physicians decided for extubation, the neonates received endotracheal continuous positive airway pressure (CPAP) for 10 minutes while spontaneous RR, TV and RR/TV were measured using a fixed-orifice pneumotachograph positioned between the endotracheal tube and the ventilator circuit. Thereafter, the neonates were extubated to nasal CPAP. Extubation failure was defined as the need for reintubation within 48 hours. RESULTS: Of the 35 studied infants, 20 (57%) were successfully extubated and 15 (43%) required reintubation. RR and RR/TV before extubation had a trend to be higher in unsuccessfully extubated infants. TV was similar in both groups. Sensitivity and specificity of these parameters as predictors of extubation failure were 50 and 67% respectively for RR, 40 and 67% for TV and 40 and 73% for RR/TV. CONCLUSIONS: RR, TV and RR/TV showed low sensitivity and specificity to predict extubation failure in mechanically ventilated very low birth weight infants.

Tubing Length for Long-Term Oxygen Therapy

BACKGROUND: Most patients on long-term oxygen therapy use stationary oxygen delivery systems. It is not uncommon for guidelines to instruct patients to use tubing lengths no longer than 19.68 ft (6 m) when using an oxygen concentrator and 49.21 ft (15 m) when using cylinders. However, these concepts are not based on sufficient evidence. Thus, our objective was to evaluate whether a 98.42-ft (30-m) tubing length affects oxygen flow and FIO2 delivery from 1 cylinder and 2 oxygen concentrators. METHODS: The 3 oxygen delivery systems were randomly selected, and 1, 3, and 5 L/min flows and FIO2 were measured 5 times at each flow at the proximal and distal outlets of the tubing by a gas-flow analyzer. Paired Student t test was used to analyze the difference between flows and FIO2 at proximal and distal outlets of tubing length. RESULTS: A total of 45 flows were measured between proximal and distal outlets of the 98.42-ft (30-m) tubing. Flows were similar for 1 and 3 L/min, but distal flow was higher than proximal flow at 5 L/min (5.57 × 5.14 L/min, P < .001). FIO2 was lower at distal than proximal outlet tubing at flows 1, 3, and 5 L/min, but the mean difference between measurements was less than 1%. CONCLUSIONS: Tubing length of 98.42 ft (30 m) may be used by patients for home delivery oxygen with flows up to 5 L/min, as there were no important changes in flows or FIO2.

Association between preterm birth and thoracic musculoskeletal static alterations in adolescents

OBJECTIVE: To compare thoracic musculoskeletal static alterations in adolescents born prematurely with those born at term and investigate neonatal and post-neonatal variables associated with thoracic alterations. METHOD: This is a cross-sectional study with 57 adolescents aged 10-15 years born prematurely and 57 adolescents born at term paired by gender and age. Photographs of the head and thorax in the front, back, and right side views were studied using a computer program. The two groups were compared in regards to: elevation of clavicles, elevation of shoulders, protrusion of the head, and anteroposterior and mediolateral thoracic length. Factor associated with thoracic disorders were evaluated by linear regression analysis. RESULTS: The Preterm group had mean gestational age of 32.0±2.8 weeks and the birth weight was 1462±338 and 3342±430 g for the Preterm and Term adolescents, respectively. Preterm adolescents had higher elevation of the left shoulder (22.7±5.4o vs. 20.6±5.3o;sim, p=0.038) and the right shoulder (22.2±4.4o vs. 18.5±5.7o; p<0.001). Smaller protrusion of the head (27.8±6.1o vs. 32.4±7.9o; p=0.008), mediolateral thoracic length (22.9±2.3 cm vs. 25.1±3.1 cm; p<0.001) and anteroposterior thoracic length (19.7±2.2 cm vs. 21.1±3.4 cm; p<0.001) were found in preterm adolescents. By multiple regression analysis, factors associated with higher shoulder elevation were birth weight <1500 g (p<0.001) and mechanical ventilation during neonatal period >5 days (p=0.009). CONCLUSION: Adolescents born prematurely presented greater thoracic musculoskeletal static alterations compared to those born at term. Factors associated with these alterations were: very low birth weight and longer duration of mechanical ventilation in the neonatal unit.

Prevalence and factors associated with thoracic alterations in infants born prematurely

OBJECTIVE To determine the prevalence of thoracic musculoskeletal alterations and associated factors in infants born prematurely. METHODS This was a cross sectional study with infants in the first year of age, born prematurely with birth weight < 2,000 g, who were followed up at the Premature Clinic from February, 2007 to December, 2008. Exclusion criteria were: major congenital malformations as defined by the Centers for Disease Control and Prevention (CDC), grade III/IV intraventricular hemorrhage, or periventricular leucomalacia. Physical examinations performed independently by two physiotherapists were used to assess shoulder elevation and thoracic retractions. Comparisons between groups were performed using the chi-squared test or Fishers exact test for categorical variables, and Mann-Whitneys test or Students t-test were used for continuous variables. Interobserver reliability between the two physiotherapists was assessed by the kappa coefficient. Variables associated with these thoracic musculoskeletal alterations were studied by univariate and multiple logistic analyses. Statistical differences were considered significant when p < 0.05. This study was approved by the ethical committee of the institution, and parents/guardians signed an informed consent. RESULTS 121 infants with a gestational age of 31.1 ± 2.8 weeks and birth weight of 1,400 ± 338 g were included. Thoracic alterations were detected by Physiotherapist 1 in 81 (66.9%) infants, and in 83 (68.6%) by Physiotherapist 2 (kappa coefficient = 0.77). By multivariate logistic regression analysis, factors associated with thoracic musculoskeletal alterations were: respiratory distress syndrome (odds ratio [OR] = 3.246, 95% confidence interval [CI]: 1.237-8.732), bronchopulmonary dysplasia (OR = 11.138, 95% CI: 1.339-92.621), and low length/age ratio (OR = 4.571, 95% CI: 1.371-15.242). CONCLUSION The prevalence of thoracic alterations was high in infants born prematurely, and was associated with pulmonary disease and low length/age ratio.

Segurança e efetividade da fisioterapia respiratória em abscesso pulmonar: estudo de casos

Lung abscess is a necrotic lesion mostly caused by pyogenic germs. Chest physical therapy (CPT) is indicated, but there are few studies available and no consensus on CPT use and techniques for theses cases. The purpose of this study was to assess safety and effectiveness of postural drainage in treating lung abscess in two cases. Patient 1, male, 30 years old, was laid in Trendelenburg, in semi-lateral to ventral decubitus for 30 minutes, three times a day. After five days of therapy, X-ray showed a 90% decrease of sputum, and on the 14th day full drainage was achieved. Case 2 was a female patient, 28 years old, treated at the same position and frequency as case 1. After seven days of therapy, exams showed a great decrease of pus from the abscess. It may thus be said that postural drainage alone is a safe and effective chest physical therapy technique for treating lung abscesses.