Leila Donária

Energy expenditure during daily activities as measured by two motion sensors in patients with COPD

BACKGROUND In patients with chronic obstructive pulmonary disease (COPD), energy expenditure (EE) assessment during the performance of daily activities is not yet studied in depth. The aim of this study was to determine which daily activities are more demanding to patients with COPD and to compare the accuracy of EE estimation given by the pedometer Digiwalker SW701 (DW) and the multisensor SenseWear Armband (SAB). METHODS Thirty-six patients with COPD (20 men; FEV1 48 ± 15%predicted; BMI 25.7 ± 8 kg/m(2)) were submitted to a modified version of the Glittre ADL-test, which included five activities performed for 1 min each: walking on the level, walking on the level carrying a backpack, walking up/downstairs, rising/sitting in chairs and moving objects in and out of a shelf. During the protocol subjects wore both devices concomitantly, and indirect calorimetry (IC) was simultaneously performed as the criterion method to assess EE. RESULTS The most demanding daily activity for individuals with COPD was walking up/downstairs (4.9 ± 1.7 kcal versus 3.7 ± 1.4 to 4.2 ± 1.8 kcal for the other tasks; p < 0.05). EE estimation by the SAB did not show difference in comparison to IC for the sum of the five activities (SAB = 22.7 ± 7 kcal versus IC = 21 ± 8 kcal; p > 0.05), although overestimation was found in activities involving walking. DW showed significant EE underestimation in the sum of the activities (9.6 ± 4.3 kcal; p < 0.05 versus IC) and for each activity. CONCLUSION Walking up/downstairs was the most energy-demanding daily activity for patients with COPD. Furthermore, during daily activities, the multisensor showed adequate overall estimation of energy expenditure, as opposed to the pedometer.

Sedentary Behavior Is an Independent Predictor of Mortality in Subjects With COPD

BACKGROUND: The terms sedentary behavior and physical inactivity have been confusingly mixed. Although the association between physical inactivity and mortality has been shown previously in subjects with COPD, this association had not yet been investigated with regard to sedentarism. The aim of this work was to investigate the impact of sedentary behavior on mortality of subjects with COPD and to propose a cutoff point of sedentarism with prognostic value. METHODS: In this retrospective cohort study, sedentary behavior was assessed with 2 activity monitors (DynaPort and Sensewear armband) in 101 subjects with COPD from 2006 to 2011. Vital status was then ascertained in 2015. The following 6 variables of sedentary behavior were analyzed: average of metabolic equivalent of task (MET)/d (reflecting intensity); time spent/d lying, sitting, and lying + sitting (reflecting duration of sedentary postures); and time spent/d in activities requiring <1.5 MET and <2 MET (reflecting intensity and duration of sedentary time). Cutoff points for sedentarism and their respective prognostic values were investigated for each variable. RESULTS: Forty-one subjects (41%) died over a median (interquartile range) follow-up period of 62 (43–88) months. After adjusting for potential confounders in the Cox regression model, cutoff points from variables that combine duration of sedentary time and intensity <1.5 MET or <2 MET were associated with the increased risk of mortality. The strongest independent cutoff for predicting mortality was ≥8.5 h/d spent in sedentary activities <1.5 MET (area under the curve 0.76; hazard ratio 4.09, 95% CI 1.90–8.78; P < .001). CONCLUSIONS: Sedentary behavior was an independent predictor of mortality in subjects with COPD, even adjusting for moderate-to-vigorous physical activity and a number of other variables. Mortality was higher in subjects with COPD who spend ≥8.5 h/d in activities requiring <1.5 MET. These findings may open room for future studies aiming at decreasing sedentary time as a promising strategy to reduce mortality risk in subjects with COPD.

Analysis of three different equations for predicting quadriceps femoris muscle strength in patients with COPD

Abstract Objective: To compare equations for predicting peak quadriceps femoris (QF) muscle force; to determine the agreement among the equations in identifying QF muscle weakness in COPD patients; and to assess the differences in characteristics among the groups of patients classified as having or not having QF muscle weakness by each equation. Methods: Fifty-six COPD patients underwent assessment of peak QF muscle force by dynamometry (maximal voluntary isometric contraction of knee extension). Predicted values were calculated with three equations: an age-height-weight-gender equation (Eq-AHWG); an age-weight-gender equation (Eq-AWG); and an age-fat-free mass-gender equation (Eq-AFFMG). Results: Comparison of the percentage of predicted values obtained with the three equations showed that the Eq-AHWG gave higher values than did the Eq-AWG and Eq-AFFMG, with no difference between the last two. The Eq-AHWG showed moderate agreement with the Eq-AWG and Eq-AFFMG, whereas the last two also showed moderate, albeit lower, agreement with each other. In the sample as a whole, QF muscle weakness (< 80% of predicted) was identified by the Eq-AHWG, Eq-AWG, and Eq-AFFMG in 59%, 68%, and 70% of the patients, respectively (p > 0.05). Age, fat-free mass, and body mass index are characteristics that differentiate between patients with and without QF muscle weakness. Conclusions: The three equations were statistically equivalent in classifying COPD patients as having or not having QF muscle weakness. However, the Eq-AHWG gave higher peak force values than did the Eq-AWG and the Eq-AFFMG, as well as showing greater agreement with the other equations.

Respiratory Muscle Strength During and After Hospitalization for COPD Exacerbation

BACKGROUND: A more profound investigation of respiratory muscle strength during COPD exacerbation was needed, so we investigated respiratory muscle strength and related factors in patients with COPD during and after hospitalization for COPD exacerbation. METHODS: In 19 subjects hospitalized for COPD exacerbation (12 males, mean age 67 ± 11 y, median percent-of-predicted FEV1 26% [IQR 19–32%]) we measured lung function and respiratory and quadriceps muscle strength at admission (day 1), at discharge, and 1 month after discharge. RESULTS: At admission, 68% of the subjects had inspiratory muscle dysfunction (maximum inspiratory pressure < 70% of predicted). Inspiratory muscle strength increased between day 1 (56 cm H2O [IQR 45–64 cm H2O]) and 1 month after discharge (65 cm H2O [IQR 51–74 cm H2O], P = .007). Expiratory muscle strength increased between day 1 (99 cm H2O [65–117 cm H2O]) and discharge (109 cm H2O [77–136 cm H2O], P = .005), and between day 1 and 1 month after discharge (114 cm H2O [90–139 cm H2O], P = .001). Inspiratory capacity increased between discharge (1.59 ± 0.44 L) and 1 month after discharge (1.99 ± 0.54 L, P = .02). There was no significant change in other lung function variables or quadriceps strength. At admission the inspiratory muscle dysfunction and reduction in inspiratory capacity (< 80% of predicted) correlated linearly (phi coefficient 0.62, P = .03), whereas the expiratory muscle strength correlated inversely with FEV1 (Spearman rho −0.61, P = .005) and inspiratory capacity (Spearman rho −0.54, P = .02). CONCLUSIONS: There was a high prevalence of inspiratory muscle dysfunction in patients hospitalized for COPD exacerbation. Inspiratory and expiratory muscle strength increased markedly during and after hospitalization. The degree of air-flow obstruction and hyperinflation were related to inspiratory and expiratory muscle strength.

Development, Validity and Reliability of the Londrina Activities of Daily Living Protocol for Subjects With COPD

BACKGROUND: To avoid symptoms, patients with COPD may reduce the amount of activities of daily living (ADL). Therefore, the aim of the present study was to develop a standardized protocol to evaluate ADL performance in subjects with COPD (Londrina ADL protocol) and to assess the validity and reliability of the protocol in this population. METHODS: The Londrina ADL protocol was created based on activities included in previous studies aimed at investigating outcomes from ADL. Activities were included in the protocol because they could represent other activities of similar patterns and because they could be actually performed, not simulated. Twenty subjects with COPD (12 men, 70 ± 7 y old, FEV1 = 54 ± 15% predicted) wore 2 motion sensors while performing the protocol 4 times, 2 of them wearing a portable gas analyzer. Subjects were also submitted to assessments of lung function, functional exercise capacity, functional status, impact on health status, and physical activity in daily life. RESULTS: The Londrina ADL protocol comprised of 5 activities representing ADL, involving upper limbs, lower limbs, and trunk movements. Londrina ADL protocol duration presented high values of intraclass correlation coefficient, even using a mask for gas analysis (intraclass correlation coefficient >0.90, P < .001). Intensity of movement during the protocol performance was highly correlated to intensity of movement in daily life (r = 0.71). The protocol duration was correlated with functional status and impact on health status variables from questionnaires (0.36 ≤ r ≤ 0.59). There was also correlation between functional exercise capacity and the protocol duration (r = −0.64). CONCLUSIONS: The Londrina ADL protocol was a valid and reliable protocol to evaluate ADL performance in subjects with COPD. It is a protocol that can be used in clinical practice and in future studies to investigate ADL outcomes, including those studies that require gas analysis and the wearing of a mask.

Londrina Activities of Daily Living Protocol: Reproducibility, Validity, and Reference Values in Physically Independent Adults Age 50 Years and Older

BACKGROUND: It is important to assess activities of daily living (ADL) in older adults due to impairment of independence and quality of life. However, there is no objective and standardized protocol available to assess this outcome. Thus, the aim of this study was to verify the reproducibility and validity of a new protocol for ADL assessment applied in physically independent adults age ≥50 y, the Londrina ADL protocol, and to establish an equation to predict reference values of the Londrina ADL protocol. METHODS: Ninety-three physically independent adults age ≥50 y had their performance in ADL evaluated by registering the time spent to conclude the protocol. The protocol was performed twice. The 6-min walk test, which assesses functional exercise capacity, was used as a validation criterion. A multiple linear regression model was applied, including anthropometric and demographic variables that correlated with the protocol, to establish an equation to predict the protocols reference values. RESULTS: In general, the protocol was reproducible (intraclass correlation coefficient 0.91). The average difference between the first and second protocol was 5.3%. The new protocol was valid to assess ADL performance in the studied subjects, presenting a moderate correlation with the 6-min walk test (r = −0.53). The time spent to perform the protocol correlated significantly with age (r = 0.45) but neither with weight (r = −0.17) nor with height (r = −0.17). A model of stepwise multiple regression including sex and age showed that age was the only determinant factor to the Londrina ADL protocol, explaining 21% (P < .001) of its variability. The derived reference equation was: Londrina ADL protocolpred (s) = 135.618 + (3.102 × age [y]). CONCLUSIONS: The Londrina ADL protocol was reproducible and valid in physically independent adults age ≥50 y. A reference equation for the protocol was established including only age as an independent variable (r2 = 0.21), allowing a better interpretation of the protocols results in clinical practice.

GOLD B-C-D groups or GOLD II-III-IV grades: Which one better reflects the functionality of patients with chronic obstructive pulmonary disease?

The aim of this article is to investigate which global initiative for chronic obstructive lung disease (GOLD) classification (B-C-D or II-III-IV) better reflects the functionality of patients with moderate to very severe chronic obstructive pulmonary disease (COPD). Ninety patients with COPD were classified according to the GOLD B-C-D and II-III-IV classifications. Functionality was assessed by different outcomes: 6-min walk test (6MWT), activities of daily living (ADL) (London Chest ADL Scale), and daily life activity/inactivity variables assessed by activity monitoring (SenseWear armband, Pittsburgh, Pennsylvania, USA). The 6MWT was the only outcome significantly associated with both the GOLD classifications. Good functionality as assessed by the 6MWT was observed in 80%, 69%, and 43.5% (GOLD B, C, and D, respectively) and 81%, 59%, and 29% (GOLD II, III, and IV, respectively) of the patients. Association (V Cramer’s) and correlation (Spearman) coefficients of 6MWT with GOLD B-C-D and II-III-IV were V = 0.30, r = −0.35, and V = 0.37, r = −0.25, respectively. Neither GOLD classification showed V or r ≥ 0.30 with any other functionality outcome. Both the GOLD B-C-D and II-III-IV classifications do not reflect well COPD patients’ functionality. Despite low association and correlation coefficients in general, both GOLD classifications were better associated with functional exercise capacity (6MWT) than with subjectively assessed ADL and objectively assessed outcomes of physical activity/inactivity.

Spirometry in healthy subjects: do technical details of the test procedure affect the results?

Introduction Spirometry should follow strict quality criteria. The American Thoracic Society (ATS) recommends the use of a noseclip; however there are controversies about its need. ATS also indicates that tests should be done in the sitting position, but there are no recommendations neither about position of the upper limbs and lower limbs nor about who should hold the mouthpiece while performing the maneuvers: evaluated subject or evaluator. Objectives To compare noseclip use or not, different upper and lower limbs positions and who holds the mouthpiece, verifying if these technical details affect spirometric results in healthy adults. Methods One hundred and three healthy individuals (41 men; age: 47 [33–58] years; normal lung function: FEV1/FVC = 83±5, FEV1 = 94 [88–104]%predicted, FVC = 92 [84–102]%predicted) underwent a protocol consisting of four spirometric comparative analysis in the sitting position: 1) maximum voluntary ventilation (MVV) with vs without noseclip; 2) FVC performed with vs without upper limbs support; 3) FVC performed with lower limbs crossed vs lower limbs in neutral position; 4) FVC, slow vital capacity and MVV comparing the evaluated subject holding the mouthpiece vs evaluator holding it. Results Different spirometric variables presented statistically significant difference (p<0.05) when analysing the four comparisons; however, none of them showed any variation larger than those considered as acceptable according to the ATS reproducibility criteria. Conclusions There was no relevant variation in spirometric results when analyzing technical details such as noseclip use during MVV, upper and lower limb positions and who holds the mouthpiece when performing the tests in healthy adults.

Patients with chronic obstructive pulmonary disease and their perceptions: How to cope with them?

Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the world, represents an important public health challenge that is both preventable and treatable. COPD is a major cause of chronic morbidity and mortality throughout the world; many people suffer from this disease for years and die prematurely due to it or its complications. Worldwide, the COPD burden is projected to increase in coming decades because of the continued exposure to risk factors and population aging. Menezes et al., in a study including data from five Latin American countries, observed that the prevalence of COPD in the general population older than 40 years varied from 7.8% to 19.7% and that it was more prevalent among men, elderly people, and individuals exposed to tobacco. The characteristic symptoms of COPD are progressive dyspnea, cough, and sputum production, associated with frequent fatigue and impairment in exercise capacity and functional performance. There is a large body of evidence showing that pulmonary rehabilitation (PR) is beneficial to patients with chronic respiratory disease, including COPD. Its benefits include increase in exercise tolerance, reduction in symptoms, and improvement of healthrelated quality of life. A more recent definition describes PR as a ‘‘comprehensive intervention based on a thorough patient assessment followed by patienttailored therapies which include, but are not limited to, exercise training, education and behavior change, designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote the long-term adherence to healthenhancing behaviour.’’ Regardless of the clear benefits provided by PR programs, there is a substantial part of the enrolled patients who do not complete the intervention. There is scant published evidence showing the factors that lead patients with COPD to nonadherence to PR. Young et al. used an interviewer administered questionnaire and suggested that nonadherers were more likely to be depressed, widowed, or divorced, live alone, live in rented accommodation, and be smokers. More recently, another study showed that the referring doctor plays a key role in the uptake of PR programs. The authors discussed that a positive doctors’ approach may increase the level of adherence to PR and would be essential to an effective intervention. In addition, a systematic review performed by Keating and colleagues identified travel and transport difficulties as a predominant barrier to attendance at PR. Lack of perceived rehabilitation benefits and the influence of the doctor were also identified as reasons for nonattendance. In order to achieve better understanding of this issue and to answer simple questions about the opinions of patients enrolled in PR programs, the interest in qualitative studies has been growing in the scientific field. In this issue of Chronic Respiratory Disease, Pinto and colleagues contributed to the scientific literature by writing a systematic review of qualitative researches in patients with COPD about their experiences related to PR. First, the review disclosed the lived-experience from the point of view of patients who completed a PR program. Patient’s reports included a feeling of being supported by health-professionals, peer groups and family, as well as the acquisition of knowledge

Maximum voluntary ventilation is more strongly associated with energy expenditure during simple activities of daily living than measures of airflow obstruction or respiratory muscle strength in patients with COPD

This is a retrospective analysis of data in which we explored the association between energy expenditure (EE) and lung function in patients with chronic obstructive pulmonary disease (COPD). A total of 36 participants ( 20 males; forced expiratory volume in 1 second (FEV1) of 48 ± 15% predicted) underwent measures of indirect calorimetry whilst performing five simple activities of daily living. Maximal voluntary ventilation was the only lung function parameter associated with EE. These data highlight the limited extent to which the FEV1 is related to the functional performance of patients with COPD.