Lara Maris Nápolis

Clinical, Anthropometric and Upper Airway Anatomic Characteristics of Obese Patients with Obstructive Sleep Apnea Syndrome

Background: Obese subjects are at increased risk of developing obstructive sleep apnea syndrome (OSAS). However, the individual role of local (i.e., upper airway-related) and general (clinical and whole-body anthropometric) characteristics in determining OSAS in obese patients is still controversial. Objectives: To contrast the clinical, anthropometric and upper airway anatomical features of obese subjects presenting or not presenting with OSAS. Methods: Thirty-seven obese (BMI ≧30 kg/m2) males with OSAS and 14 age- and gender-matched obese controls underwent clinical and anthropometric (BMI, waist-to-hip ratio and neck circumference) evaluation. In a subgroup of subjects (18 and 11 subjects, respectively), magnetic resonance imaging (MRI) during wakefulness was used to study the upper airway anatomy. Results: OSAS patients showed significantly higher BMI, waist-to-hip ratio and neck circumference as compared to controls (p < 0.05). They also referred to nonrepairing sleep, impaired attention, and previous car accidents more frequently (p < 0.05). The transversal diameter of the airways (TDAW) at the retroglossal level by MRI was found to be an independent predictor of the presence and severity of OSAS (p < 0.05). Parapharyngeal fat increase, however, was not related to OSAS. A TDAW >12 mm was especially useful to rule out severe OSAS (apnea-hypopnea index >30, negative predictive value = 88.9%, likelihood ratio for a negative test result = 0.19). Conclusions: MRI of the upper airway can be used in association with clinical and anthropometric data to identify obese males at increased risk of OSAS.

Neuromuscular electrical stimulation improves exercise tolerance in chronic obstructive pulmonary disease patients with better preserved fat-free mass

BACKGROUND: High-frequency neuromuscular electrical stimulation increases exercise tolerance in patients with advanced chronic obstructive pulmonary disease (COPD patients). However, it is conceivable that its benefits are more prominent in patients with better-preserved peripheral muscle function and structure. OBJECTIVE: To investigate the effects of high-frequency neuromuscular electrical stimulation in COPD patients with better-preserved peripheral muscle function. Design: Prospective and cross-over study. METHODS: Thirty COPD patients were randomly assigned to either home-based, high-frequency neuromuscular electrical stimulation or sham stimulation for six weeks. The training intensity was adjusted according to each subjects tolerance. Fat-free mass, isometric strength, six-minute walking distance and time to exercise intolerance (Tlim) were assessed. RESULTS: Thirteen (46.4%) patients responded to high-frequency neuromuscular electrical stimulation; that is, they had a post/pre ΔTlim >10% after stimulation (unimproved after sham stimulation). Responders had a higher baseline fat-free mass and six-minute walking distance than their seventeen (53.6%) non-responding counterparts. Responders trained at higher stimulation intensities; their mean amplitude of stimulation during training was significantly related to their fat-free mass (r  =  0.65; p<0.01). Logistic regression revealed that fat-free mass was the single independent predictor of Tlim improvement (odds ratio [95% CI]  =  1.15 [1.04-1.26]; p<0.05). CONCLUSIONS: We conclude that high-frequency neuromuscular electrical stimulation improved the exercise capacity of COPD patients with better-preserved fat-free mass because they tolerated higher training stimulus levels. These data suggest that early training with high-frequency neuromuscular electrical stimulation before tissue wasting begins might enhance exercise tolerance in patients with less advanced COPD.

Clinical value of anthropometric estimates of leg lean volume in nutritionally depleted and non-depleted patients with chronic obstructive pulmonary disease

This study aimed to investigate the clinical usefulness of an anthropometrically based method for estimating leg lean volume (LLV) in patients with chronic obstructive pulmonary disease (COPD) who presented or not with nutritional depletion. We prospectively evaluated a group of forty-eight patients (thirty-eight males) with moderate to severe COPD (Global Initiative for Chronic Obstructive Lung disease stages II-IV) who underwent a 6 min walking test and knee isokinetic dynamometry. Leg lean mass (muscle mass plus bone) was determined by dual-energy X-ray absorptiometry (DEXA) with derivation of its respective volume: these values were compared with those obtained by the truncated cones method first described by Jones and Pearson in 1969. As expected, depleted patients (n 19) had reduced exercise capacity and impaired muscle performance as compared to non-depleted subjects (P < 0.01). The mean bias of the LLV differences between anthropometry and DEXA were 0.40 litre (95 % CI - 0.59, 1.39) and 0.50 litre (95 % CI - 1.08, 2.08) for depleted and non-depleted patients, respectively. Anthropometrically and DEXA-based estimates correlated similarly with muscle functional attributes. A ROC curve analysis revealed that leg height-corrected LLV values had acceptable sensitivity and specificity to identify depleted patients (area under the curve 0.93 (range 0.86-1.00); P < 0.001). Moreover, patients with LLV <or= 9.2 litres/m (the best cut-off value according to the ROC curve) had significantly lower exercise capacity and muscle performance than their counterparts (P < 0.05). In conclusion, an anthropometrically based method of estimating LLV (Jones and Pearson method) was shown to present with clinically acceptable accuracy and external validity in depleted and non-depleted patients with stable COPD.

Asbestos-related disease: progression of parenchymal abnormalities on high-resolution CT.

Purpose To evaluate the changes over time in the pattern and extent of parenchymal abnormalities in asbestos-exposed workers after cessation of exposure and to compare 3 proposed semiquantitative methods with a careful side-by-side comparison of the initial and the follow-up computed tomography (CT) images. Materials and Methods The study included 52 male asbestos workers (mean age±SD, 62.2 y±8.2) who had baseline high-resolution CT after cessation of exposure and follow-up CT 3 to 5 years later. Two independent thoracic radiologists quantified the findings according to the scoring systems proposed by Huuskonen, Gamsu, and Sette and then did a side-by-side comparison of the 2 sets of scans without awareness of the dates of the CT scans. Results There was no difference in the prevalence of the 2 most common parenchymal abnormalities (centrilobular small dotlike or branching opacities and interstitial lines) between the initial and follow-up CT scans. Honeycombing (20%) and traction bronchiectasis and bronchiolectasis (50%) were seen more commonly on the follow-up CT than on the initial examination (10% and 33%, respectively) (P=0.01). Increased extent of parenchymal abnormalities was evident on side-by-side comparison in 42 (81%) patients but resulted in an increase in score in at least 1 semiquantitative system in only 16 (31%) patients (all P>0.01, signed test). Conclusions The majority of patients with previous asbestos exposure show evidence of progression of disease on CT at 3 to 5 years follow-up but this progression is usually not detected by the 3 proposed semiquantitative scoring schemes.

Relationship between peripheral muscle structure and function in patients with chronic obstructive pulmonary disease with different nutritional status.

Malaguti, C, Napolis, LM, Villaça, D, Neder, JA, Nery, LE, and Dal Corso, S. Relationship between peripheral muscle structure and function in patients with chronic obstructive pulmonary disease with different nutritional status. J Strength Cond Res 25(7): 1795-1803, 2011—The purpose of this study was to investigate the relationships between peripheral muscle structure (mass) and function (strength, endurance, and maximal aerobic capacity) in patients with chronic obstructive pulmonary disease (COPD) with different nutritional states. Thirty-nine patients (31 male) with moderate-severe COPD (63.5 ± 7.3 [SD] years) and 17 controls (14 male; 64.7 ± 5.5 [SD] years) underwent isokinetic (peak torque [PT]), isometric (isometric torque [IT]), and endurance strength (total work [TW]) measurements of the knee extensor muscles and a maximal cardiopulmonary exercise test to evaluate the maximal aerobic capacity (peak oxygen uptake [&OV0312;O2] peak). Muscle mass (MM) was determined using dual-energy x-ray absorptiometry. Patients with COPD presented with reduced muscle function as compared with the healthy controls: PT (105.9 ± 33.9 vs. 134.3 ± 30.9, N·m−1, respectively, p < 0.05), TW (1,446.3 ± 550.8 vs. 1,792.9 ± 469.1 kJ, respectively, p < 0.05), and &OV0312;O2peak (68.1 ± 15.1 vs. 93.7 ± 14.5, % pred, respectively, p < 0.05). Significant relationships were found between muscle structure and function (strength and endurance) in the patient subgroup with preserved MM and in the control group: PT·MM−1(r2 = 0.36; p = 0.01 vs. r2= 0.32; p = 0.01, respectively) and TW·MM−1 (r2 = 0.32; p = 0.01 vs. r2 = 0.22; p = 0.05, respectively). Strength corrected for mass normalized this function in both patient subgroups, whereas endurance was normalized only in the patient subgroup without muscle depletion. Maximal aerobic capacity remained reduced, despite the correction, in both patient subgroups (depleted or nondepleted) compared with the healthy controls (&OV0312;O2peak.MM−1: 9.1 ± 3.7 vs. 21.8 ± 4.9 vs. 28.5 ± 4.2 ml·min·kg−1, respectively, with p < 0.01 among groups). Muscle atrophy seems to be the main determinant of strength reduction among patients with moderate-severe COPD, whereas endurance reduction seems to be more related to imbalance between oxygen delivery and consumption than to the local muscle structure itself. Peripheral MM did not constitute a good predictor for maximal aerobic capacity in this population. The main practical application of this study is to point out a crucial role for the strategies able to ameliorate cardiorespiratory and muscular fitness in patients with COPD, even in those patients with preserved MM.

Pleural plaques in asbestos-exposed workers: reproducibility of a new high-resolution CT visual semiquantitative measurement method.

Objective To assess the reproducibility of a new high-resolution computed tomography (CT) visual semiquantitative method for pleural plaques in asbestos-exposed workers. Material and Methods We performed thin-section CT in 752 chrysotile asbestos mining workers and ex-workers. Institutional review board approval and signed written informed consent from subjects were obtained. Two readers independently evaluated the 752 CT scans and identified 57 workers (mean age±SD, 61.8 years±8.1; range, 37 to 81 years) who had pleural plaques and no other pleural or parenchymal abnormality. Three independent radiologists then quantified the plaque burden in these 57 workers using a scoring system based on the evaluation of the maximum thickness of parietal pleural plaques and percentage of parietal pleural surface involvement. We also calculated the proportion between the number of CT slices with diaphragmatic plaques and the total number of slices in which the diaphragm was seen (pdiaph). The intraobserver and interobserver agreements were analyzed using weighted Kappa coefficient. Results Interobserver agreements were good for the pleural plaque score (k=0.61, 0.75, and 0.79) and ranged from good (k=0.61) to excellent (k=0.86) for the pdiaph. Intraobserver agreements ranged from good to excellent for the pleural plaque score (k=0.79 and 1.00) and for the pdiaph (k=0.79 and 0.93). Conclusion The method proposed for high-resolution CT pleural plaque quantification in asbestos-exposed workers has a high reproducibility.

Lung diffusing capacity relates better to short‐term progression on HRCT abnormalities than spirometry in mild asbestosis

BACKGROUND Pulmonary function tests (PFT), particularly spirometry and lung diffusing capacity for carbon monoxide (DL(CO) ), have been considered useful methods for the detection of the progression of interstitial asbestos abnormalities as indicated by high-resolution computed tomography (HRCT). However, it is currently unknown which of these two tests correlates best with anatomical changes over time. METHODS In this study, we contrasted longitudinal changes (3-9 years follow-up) in PFTs at rest and during exercise with interstitial abnormalities evaluated by HRCT in 63 ex-workers with mild-to-moderate asbestosis. RESULTS At baseline, patients presented with low-grade asbestosis (Huuskonen classes I-II), and most PFT results were within the limits of normality. In the follow-up, most subjects had normal spirometry, static lung volumes and arterial blood gases. In contrast, frequency of DL(CO) abnormalities almost doubled (P < 0.05). Twenty-three (36.5%) subjects increased the interstitial marks on HRCT. These had significantly larger declines in DL(CO) compared to patients who remained stable (0.88 vs. 0.31 ml/min/mm Hg/year and 3.5 vs. 1.2%/year, respectively; P < 0.05). In contrast, no between-group differences were found for the other functional tests, including spirometry (P > 0.05). CONCLUSIONS These data demonstrate that the functional consequences of progression of HRCT abnormalities in mild-to-moderate asbestosis are better reflected by decrements in DL(CO) than by spirometric changes. These results might have important practical implications for medico-legal evaluation of this patient population.

Relationship between induced sputum cytology and inflammatory status with lung structural and functional abnormalities in asbestosis

BACKGROUND Asbestosis is associated with lung cellular and immunological abnormalities. Induced sputum cytology and local and systemic markers of inflammation may be helpful to characterize disease status and progression in these patients. METHODS Thirty-nine ex-workers with asbestosis on high-resolution CT (HRCT) and 21 non-exposed controls were evaluated. Sputum cytology and IL-8 in serum and sputum were related to lung function impairment. RESULTS Subjects with asbestosis had reduced sputum cellularity but higher macrophage/neutrophil ratio and % macrophage as compared with controls. Sputum and serum IL-8 were also higher in patients with asbestosis (P < 0.05). In addition, evidence of lung architectural distorption on HRCT was associated with increased levels of serum IL-8. Interestingly, absolute macrophage number was negatively correlated with total lung capacity (r = -0.40; P = 0.04) and serum IL-8 to lung diffusing capacity (r = -0.45; P = 0.01). CONCLUSIONS Occupationally exposed subjects with asbestosis on HRCT have cytologic abnormalities in induced sputum and increased local and systemic pro-inflammatory status which are correlated to functional impairment.

Screening of miners and millers at decreasing levels of asbestos exposure: comparison of chest radiography and thin-section computed tomography.

Background Chest radiography (CXR) is inferior to Thin-section computed tomography in the detection of asbestos related interstitial and pleural abnormalities. It remains unclear, however, whether these limitations are large enough to impair CXR´s ability in detecting the expected reduction in the frequency of these asbestos-related abnormalities (ARA) as exposure decreases. Methods Clinical evaluation, CXR, Thin-section CT and spirometry were obtained in 1418 miners and millers who were exposed to progressively lower airborne concentrations of asbestos. They were separated into four groups according to the type, period and measurements of exposure and/or procedures for controlling exposure: Group I (1940–1966/tremolite and chrysotile, without measurements of exposure and procedures for controlling exposure); Group II (1967–1976/chrysotile only, without measurements of exposure and procedures for controlling exposure); Group III (1977–1980/chrysotile only, initiated measurements of exposure and procedures for controlling exposure) and Group IV (after 1981/chrysotile only, implemented measurements of exposure and a comprehensive procedures for controlling exposure). Results In all groups, CXR suggested more frequently interstitial abnormalities and less frequently pleural plaques than observed on Thin-section CT (p<0.050). The odds for asbestosis in groups of decreasing exposure diminished to greater extent at Thin-section CT than on CXR. Lung function was reduced in subjects who had pleural plaques evident only on Thin-section CT (p<0.050). In a longitudinal evaluation of 301 subjects without interstitial and pleural abnormalities on CXR and Thin-section CT in a previous evaluation, only Thin-section CT indicated that these ARA reduced as exposure decreased. Conclusions CXR compared to Thin-section CT was associated with false-positives for interstitial abnormalities and false-negatives for pleural plaques, regardless of the intensity of asbestos exposure. Also, CXR led to a substantial misinformation of the effects of the progressively lower asbestos concentrations in the occurrence of asbestos-related diseases in miners and millers.

Conhecimento da disponibilidade e sobre o uso da ventilação não invasiva em unidades de terapia intensiva de hospitais públicos, privados e de ensino da região metropolitana de São Paulo

OBJECTIVE: To determine the availability of noninvasive positive-pressure ventilation equipment, as well as the level of expertise and familiarity of physicians, nurses and physiotherapists with noninvasive positive-pressure ventilation in the intensive care units of public, private and teaching hospitals in the greater metropolitan area of Sao Paulo, Brazil. METHODS: On-site administration of questionnaires. RESULTS: Noninvasive positive-pressure ventilation equipment was widely available and was more commonly found in private hospitals than in teaching hospitals. Such equipment was least available in public hospitals, in which the predominant method was the use of mechanical ventilators designed for invasive ventilation and adapted to noninvasive positive-pressure ventilation. In private hospitals, continuous flow ventilators were more common, whereas, in teaching hospitals, ventilators specifically designed for noninvasive ventilation were typically employed. All physiotherapists felt themselves capable of initiating noninvasive positive pressure ventilation, compared with 72.6% of physicians and 33.3% of nurses. Physicians and physiotherapists presented high percentages of correct answers when asked about the indications and contraindications for the use of noninvasive positive-pressure ventilation. Over a one year period, more physiotherapists read articles about noninvasive positive-pressure ventilation and participated in related classes than did physicians, who in turn did so more than did nurses. CONCLUSION: Noninvasive positive-pressure ventilation equipment is widely available in the greater metropolitan area of Sao Paulo, although differences exist among public, private and teaching hospitals in terms of the type of equipment used. Physicians and physiotherapists exhibited considerable knowledge regarding the indications and contraindications for the use of noninvasive positive-pressure ventilation. More physiotherapists felt themselves able to initiate noninvasive positive-pressure ventilation, and their knowledge of the subject was more current than was that of physicians or nurses.