Marcelo Velloso

Funcionalidade do paciente com doença pulmonar obstrutiva crônica e técnicas de conservação de energia

Chronic obstructive pulmonary disease is a progressive and debilitating disease that is typically diagnosed only after a long period of gradual worsening. Dyspnea is the symptom that most often interferes with the execution of professional, family, social and daily-life activities of patients with chronic obstructive pulmonary disease. Such limitations can lead to a sedentary lifestyle and worsen overall quality of life. This article aims to address the functional limitations these patients deal with in carrying out their daily-life activities, establishing guidelines that health professionals can use to help their patients achieve maximum functionality. Guidelines for the use of energy conservation techniques are widely used in pulmonary rehabilitation programs. However, these guidelines should also be used in outpatient clinics and hospitals. A great number of human activities involve the legs and arms. The arms are involved in virtually all everyday activities - from the most simple to the most complex. Some studies have shown that upper-body exercises in which the arms are not supported cause thoracoabdominal asynchrony and dyspnea in shorter times and with less oxygen consumption than in exercises involving the legs. Even simple tasks can result in high oxygen consumption and minute ventilation, which accounts for the sensation of dyspnea reported by the patients. In view of these facts, it is appropriate to evaluate the impact that such incapacity has on daily life in patients with chronic obstructive pulmonary disease. Techniques of energy conservation that can be used as tools to minimize the discomfort of such patients are herein discussed, and those considered most appropriate are highlighted.

Influence of 4 interfaces in the assessment of maximal respiratory pressures.

BACKGROUND: The measurement of maximal respiratory pressure (MRP) is a procedure widely used in clinical practice to evaluate respiratory muscle strength through the maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax). Its clinical applications include diagnostic procedures and evaluating responses to interventions. However, there is great variability in the equipment and measurement procedures. Understanding the impacts of the characteristics of different interfaces can augment the repeatability of this method and help to establish widely applicable predictive equations. The aim of this study was to evaluate the influence of 4 different interfaces on a subjects capacity to generate MRP and the impact of these interfaces on the repeatability of these measurements. METHODS: Fifty healthy subjects (mean ± SD age 26.36 ± 4.89 y) with normal spirometry were evaluated. MRP was measured by a digital manometer connected to 4 interfaces using different combinations of mouthpieces and tubes. The following variables were analyzed: maximum mean pressure, peak pressure, plateau pressure, and plateau variation. Analysis of variance for repeated measures or a Friedman test was used to compare the 4 interfaces, with P < .008 after Bonferroni adjustment considered significant. RESULTS: There was no significant difference between the 4 interfaces with respect to maximum mean pressure, peak pressure, plateau pressure, or plateau variation for PImax (P ≥ .49) or PEmax (P ≥ .11), nor did the number of tests performed to fulfill the criteria of repeatability for PImax (P = .69) or PEmax (P = .47) differ among the 4 interfaces. CONCLUSIONS: PImax and PEmax values seem not to be influenced by the different interfaces studied, suggesting that patient comfort and availability of interfaces can be considered.

Ventilatory and muscular assessment in healthy subjects during an activity of daily living with unsupported arm elevation

INTRODUCTION Patients with chronic obstructive pulmonary disease (COPD) report dyspnea when performing activities of daily living (ADLs) with elevated upper limbs. To elucidate the determinants of dyspnea, it is important to study the changes in the respiratory pattern of these patients and the electromyographic activity of their accessory muscles of respiration during ADLs. In the literature, there are no reports of a normative parameter, therefore it is necessary to study how these variables behave in healthy subjects. OBJECTIVES To verify, in healthy subjects, the existence of changes in the respiratory pattern and activation of the sternocleidomastoid (SCM) muscle during an ADL with unsupported arm elevation. METHODS Thirteen male subjects, 60.57 (± 6.42) years old, with normal spirometry values for age and sex, were evaluated using surface electromyography (EMG) and respiratory inductive plethysmography (RIP) collected at rest and during the activity of combing their hair with elevated and unsupported upper limbs. The data distribution was assessed using Shapiro-Wilks test. ANOVA was used to compare the phases, and when the difference was significant (p<0.05), Tukeys test was applied. RESULTS The RIP during the ADL showed a significant increase in tidal volume, minute ventilation, respiratory frequency and mean inspiratory flow. Thoracoabdominal asynchrony was identified in percentage of asynchrony in inspiration, expiration, and Phase Angle (p<0.05). The EMG showed an increase in SMC muscle recruitment (p<0.05). CONCLUSIONS Healthy subjects increased their SCM muscle activation and changed their breathing pattern when performing the ADL with unsupported arm elevation, resulting in thoracoabdominal asynchrony.

Evaluation of effects of shoulder girdle training on strength and performance of activities of daily living in patients with chronic obstructive pulmonary disease

Background Patients with chronic obstructive pulmonary disease (COPD) have some limitations during activities of daily living that involve the arms. There is little information on the benefits of shoulder girdle training and its repercussions for activities of daily living in patients with COPD. The purpose of this study was to investigate whether shoulder girdle training with diagonal movements increases upper limb muscle strength and improves performance of activities of daily living in patients with COPD. Methods Thirty-five patients with moderate to severe COPD (forced expiratory volume in one second 1.22 ± 0.49 L) and aged 36–80 years were recruited. Endurance time, maximal sustained weight, oxygen saturation, heart rate, respiratory rate, dyspnea, and arm fatigue were evaluated during an incremental upper limb test and eight simulated activities of daily living before and after an 8-week exercise training program. Results A significant gain was observed for upper limb strength (P < 0.05). At the peak of the upper limb incremental test, the respiratory rate dropped from 33 to 27 breaths per minute, the Borg dyspnea score decreased from 2 to 0.5, and the upper limb fatigue score decreased from 3 to 2 (P < 0.05). No change was seen in any of these parameters during performance of activities of daily living. Conclusion Although shoulder girdle training increased upper limb strength, no improvement was detected in performance of activities of daily living.

Effects of noninvasive ventilation on dynamic hiperinflation of patients with COPD during activities of daily living with upper limbs

BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) complain of dyspnea on activities of daily living (ADLs) with the upper limbs. Dynamic hyperinflation (DH) is one of the ventilatory mechanisms that may contribute towards dyspnea. To minimize the DH it is indicated the use of noninvasive ventilation (NIV). OBJECTIVES To verify whether there is DH and dyspnea during the performance of ADL with the upper limbs with and without the use of NIV. METHODS 32 patients with moderate-to-severe COPD, aged 54 to 87 years (mean 69.4, SD 7.4) were evaluated. The subjects lift up containers weighing between 0.5 and 5.0 kg over a five-minute period, starting from the waist level and putting them onto a shelf located above head height, with and without the use of NIV (BiPAP®; IPAP 10cmH₂O; EPAP 4 cmH₂O). The inspiratory capacity (IC) and dyspnea (Borg scale) were evaluated on all the patients. The IC was measured before and after simulation of the ADL. In order to analyze the data, Students t test for dependent samples and the Wilcoxon test were used. RESULTS There were statistically significant reductions in IC after the ADL with and without NIV (p=0.01). The dyspnea increased after the ADL with and without the NIV, however between both interventional procedures protocols no between-group difference was observed. CONCLUSIONS The simulation of an ADL with the upper limbs resulted in an increase in DH and dyspnea. The NIV supplied with pre-established pressure was not enough to prevent the DH and dyspnea.

Pressões respiratórias máximas: equipamentos e procedimentos usados por fisioterapeutas brasileiros

A mensuracao das pressoes respiratorias maximas - metodo de avaliacao das condicoes de forca dos musculos respiratorios - e um teste voluntario e esforco-dependente, com aplicacoes clinicas de ordem diagnostica e terapeutica. Ha uma grande variedade de equipamentos e interfaces para sua execucao, o que acarreta uma relativa ausencia de padronizacao. O objetivo deste estudo foi identificar os diferentes equipamentos, procedimentos e forma de interpretar a mensuracao das pressoes respiratorias maximas entre fisioterapeutas brasileiros. Dezenove fisioterapeutas respiratorios, de 13 diferentes instituicoes, situadas em tres regioes do pais, responderam a um questionario sobre esses aspectos. Os resultados mostram que prevaleceu o uso de manovacuometro analogico (60%), com tubo de silicone (60%) e interface do tipo bocal tubular (53,4%), contendo orificio de fuga de 1 a 2 mm de diâmetro (86,6%), associado ao uso de clipe nasal (100%). Na mensuracao, foi observado um numero minimo de tres testes aceitaveis e reprodutiveis (80%) e, para a analise dos valores encontrados, todos usam valores de referencia ou equacoes preditivas. Os dados sugerem que existe uma relativa uniformidade em relacao a mensuracao das pressoes respiratorias maximas entre fisioterapeutas brasileiros.

Breathing exercises: influence on breathing patterns and thoracoabdominal motion in healthy subjects

BACKGROUND: The mechanisms underlying breathing exercises have not been fully elucidated. OBJECTIVES: To evaluate the impact of four on breathing exercises (diaphragmatic breathing, inspiratory sighs, sustained maximal inspiration and intercostal exercise) the on breathing pattern and thoracoabdominal motion in healthy subjects. METHOD: Fifteen subjects of both sexes, aged 23±1.5 years old and with normal pulmonary function tests, participated in the study. The subjects were evaluated using the optoelectronic plethysmography system in a supine position with a trunk inclination of 45° during quiet breathing and the breathing exercises. The order of the breathing exercises was randomized. Statistical analysis was performed by the Friedman test and an ANOVA for repeated measures with one factor (breathing exercises), followed by preplanned contrasts and Bonferroni correction. A p<0.005 value was considered significant. RESULTS: All breathing exercises significantly increased the tidal volume of the chest wall (Vcw) and reduced the respiratory rate (RR) in comparison to quiet breathing. The diaphragmatic breathing exercise was responsible for the lowest Vcw, the lowest contribution of the rib cage, and the highest contribution of the abdomen. The sustained maximal inspiration exercise promoted greater reduction in RR compared to the diaphragmatic and intercostal exercises. Inspiratory sighs and intercostal exercises were responsible for the highest values of minute ventilation. Thoracoabdominal asynchrony variables increased significantly during diaphragmatic breathing. CONCLUSIONS: The results showed that the breathing exercises investigated in this study produced modifications in the breathing pattern (e.g., increase in tidal volume and decrease in RR) as well as in thoracoabdominal motion (e.g., increase in abdominal contribution during diaphragmatic breathing), among others.

Physiological Responses to Arm Activity in Individuals With Chronic Obstructive Pulmonary Disease Compared With Healthy Controls: A SYSTEMATIC REVIEW.

PURPOSE: The mechanisms underlying physiological limitations during arm activity in individuals with chronic obstructive pulmonary disease (COPD) are unknown. The objective of this systematic review was to describe cardiorespiratory responses, symptoms, chest wall kinematics, muscle activity, and lung volumes during arm activity in individuals with COPD relative to the responses of healthy controls. METHODS: Original research articles that compared cardiorespiratory responses, symptoms, muscle activity, chest wall kinematics, and lung function during arm activity between individuals with COPD and healthy controls were identified after searches of 5 electronic databases and reference lists of pertinent articles. Two reviewers performed the electronic and manual searches with 1 screening title and abstracts. Two investigators screened the full texts to determine eligibility for inclusion. One reviewer performed the data extraction and tabulation using a standardized form with a second reviewer double-checking the data extracted. RESULTS: Of the 54 full-text articles assessed for eligibility, 6 met the inclusion criteria. Reduced cardiorespiratory responses during peak arm exercise in individuals with COPD compared with healthy controls were evident. Compared with healthy controls, individuals with COPD had increased dyspnea and hyperinflation during peak arm exercise. Increased effort of the trapezius muscle during arm activities was also found in persons with COPD compared with healthy controls. CONCLUSIONS: There is limited evidence describing physiological responses during arm activity in individuals with COPD. Findings of this systematic review suggest that individuals with COPD have decreased cardiorespiratory responses during peak arm exercise compared with controls but increased dyspnea, hyperinflation, and arm muscle effort.

Reprodutibilidade da determinação do limiar anaeróbico em pacientes com insuficiência cardíaca

BACKGROUND The anaerobic threshold (AT) provides information on functional capacity in heart failure (HF). However, the visual determination of the AT by ventilatory methods is subjective, being susceptible to differences between examiners. OBJECTIVE To evaluate the inter- and intra-examiner reproducibility in the determination of the AT in patients with mild to moderate HF, using visual-graphic and V-slope methods. To compare and correlate the results. METHODS After performing a cardiopulmonary exercise test on a treadmill, visual-graphic and V-slope methods were used for the analysis of the AT. To assess the reproducibility, three examiners determined the AT twice by each method, on different days. For statistical analysis, we used intra-class correlation coefficient (ICC) with p <0.05. RESULTS We evaluated a total of 16 subjects, with a mean age of 45.9 +/- 9.7 years, left ventricle ejection fraction of 20.5 +/- 8.1%, and peak exercise oxygen consumption of 20.6 +/- 7.8 mL/kgmin-1. The intra-examiner reproducibility was high in both methods for the three examiners, with ICC values between 0.87 and 0.99. The inter-examiner reproducibility was moderate in both visual-graphic method (ICC = 0.69) and V-slope method (ICC = 0.64). When comparing methods, the ICC found was 0.91. CONCLUSION AT determination by visual-graphic and V-slope methods showed high and moderate inter- and intra-examiner reproducibility, respectively. Moreover, both methods showed good agreement when compared with each other. These results suggest that both methods can be used in a reproducible way in AT assessment of patients with mild to moderate HF.

Reference Values for the 6-min Walk Distance in Healthy Children Age 7 to 12 Years in Brazil: Main Results of the TC6minBrasil Multi-Center Study

INTRODUCTION: Brazil is a country with great climatic, socioeconomic, and cultural differences that does not yet have a reference value for the 6-min walk test (6MWT) in healthy children. To avoid misinterpretation, the use of equations to predict the maximum walk distance should be established in each country. OBJECTIVES: We sought to establish reference values and to develop an equation to predict the 6-min walk distance for healthy children in Brazil. METHODS: This is a cross-sectional multi-center study that included 1,496 healthy children, aged 7 to 12 y, assessed across 11 research sites in all regions of Brazil, and recruited from public and private schools in their respective regions. Each child was assessed for weight and height. Walk distance was our main outcome. An open-source software environment for statistical computing was used for statistical analysis. RESULTS: We observed a higher average distance walked by boys (531.1 m) than by girls (506.2 m), with a difference of 24.9 m (P < .001). We established 6MWT reference values for boys with the following equation: Distance = (16.86 × age) + (1.89 × Δ heart rate) − (0.80 × weight) + (336.91 × R1) + (360.91 × R2). For girls the equation is as follows: Distance = (13.54 × age) + (1.62 × Δ heart rate) − (1.28 × weight) + (352.33 × R1) + (394.81 × R2). CONCLUSION: Reference values were established for the 6MWT in healthy children aged 7–12 y in Brazil.