Miguel Guimarães

Pulmonary rehabilitation in COPD: from exercise training to "real life"

The objective of this study was to assess the efficacy of exercise training by means of a rehabilitative walking protocol. Twenty patients with COPD staged as III/IV according to the Global Initiative for Chronic Obstructive Lung Disease were included. Patients were evaluated at baseline and at the end of the exercise program regarding oxygen desaturation, sensation of dyspnea/fatigue, quality of life and six-minute walk distance. The comparison between the six-minute walk distance prior to and after training proved the efficacy of the protocol, which also resulted in a decrease in oxygen desaturation and in the sensation of dyspnea. This protocol can be easily put into practice.

Classification of Chronic Obstructive Pulmonary Disease (COPD) according to the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: Comparison with GOLD 2011

ABSTRACT Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality worldwide. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) project has been working to improve awareness, prevention and management of this disease. The aim of this study is to evaluate how COPD patients are reclassified by the 2017 GOLD system (versus GOLD 2011), to calculate the level of agreement between these two classifications in allocation to categories and to compare the performance of each classification to predict future exacerbations. Two-hundred COPD patients (>40 years, post bronchodilator forced expiratory volume in one second/forced vital capacity<0.7) followed in pulmonology consultation were recruited into this prospective multicentric study. Approximately half of the patients classified as GOLD D [2011] changed to GOLD B [2017]. The extent of agreement between GOLD 2011 and GOLD 2017 was moderate (Cohens Kappa = 0.511; p < 0.001) and the ability to predict exacerbations was similar (69.7% and 67.6%, respectively). GOLD B [2017] exacerbated 17% more than GOLD B [2011] and had a lower percent predicted post bronchodilator forced expiratory volume in one second (FEV1). GOLD B [2017] turned to be the predominant category, more heterogeneous and with a higher risk of exacerbation versus GOLD B [2011]. Physicians should be cautious in assessing the GOLD B [2017] patients. The assessment of patients should always be personalized. More studies are needed to evaluate the impact of the 2017 reclassification in predicting outcomes such as future exacerbations and mortality.

The smoking rate and its repercussions on an asthmatic population sample.

SETTING The smoking rate in Portugal is 19.2% and 33% in Europe. There is no precise data on the smoking rate of the asthmatic population. AIM To determine the smoking rate and its repercussions on an asthmatic population sample. DESIGN One hundred and ten asthmatic patients observed in asthma consultations were classified as non-smokers, former-smokers or smokers. Subsequently, based on functional and clinical criteria, they were classified as having Severe Persistent (SPA), Moderate Persistent (MoPA), Mild Persistent (MiPA) and Intermittent (IA) Asthma. RESULTS 8% of 110 patients (65% female) aged 18 to 78 years were smokers, 9% former-smokers, 83% non-smokers. Among the asthmatics: - smokers: 0% SPA, 56% MoPA, 33% MiPA, 11% IA; - former smokers: 10% SPA, 30%MoPA, 50% MiPA, 10% IA; - non-smokers: 7% SPA, 27% MoPA, 36% MiPA, 30% IA. Patients with exposure to smoking had worse functional evaluation than those without exposure. CONCLUSION In this population sample the rate of current smoking habits (8% of current smokers) was considerably low than in Portugal (19.2%). Analysis and comparison of asthma severity and functional evaluation detected worse results in both current and former smokers. These reinforce the role of tobacco exposure in asthma aggravation and worsening of its prognosis. Further studies may be important to prove and alert the asthmatic population, in particular, to the well-known risks of smoking.

Prevalência de hábitos tabágicos e sua repercussão numa população de asmáticos

Resumo Introducao – A prevalencia de habitos tabagicos em Portugal e na Europa ronda os 19,2 e 33%, respectivamente. Nao existem, porem, dados precisos quanto a prevalencia de habitos tabagicos na popoulacao asmatica. Objectivos – Determinar a prevalencia de habitos tabagicos e sua repercussao numa amostra populacional asmatica. Material e metodos – Cento e dez doentes asmaticos observados em consultas consecutivas de asma foram classificados como nao fumadores, ex-fumadores ou fumadores, de acordo com os seus habitos tabagicos. Subsequentemente, baseados numa avaliacao clinica e funcional, foram incluidos num de quatro grupos: asma persistente severa (APS), persistente moderada (APM), persistente ligeira (APL) e intermitente (AI). Resultados – Entre os 110 doentes (65% do sexo feminino), com idades compreendidas entre os 18 e 78, 8% eram fumadores, 9% ex-fumadores e 83% nao fumadores. Distribuicao entre os asmaticos: – Fumadores – 0% APS, 56% APM, 33% APL, 11%AI; – Ex-fumadores – 10% APS, 30% APM, 50% APL, 10%AI; – Nao fumadores – 7%APS, 27%APM, 36%APL, 30%AI; A avaliacao funcional foi globalmente pior em doentes com exposicao (actual ou previa) a tabaco. Conclusao – A prevalencia de habitos tabagicos nesta amostra populacional foi de 8%, consideravelmente inferior a sua prevalencia na populacao portuguesa (19,2%). A analise e comparacao do grau de severidade de asma e da sua avaliacao funcional revelou resultados piores na populacao de fumadores e ex-fumadores. Estes reforcam o papel da exposicao ao tabaco como factor de agravamento da asma e, consequentemente, do seu prognostico. Estudos posteriores podem revelar-se importantes na comprovacao dos bem conhecidos riscos dos habitos tabagicos, contribuindo para alertar a populacao asmatica neste sentido. Rev Port Pneumol 2008; XIV (5): 617-624

Does any association exist between Chronic Obstructive Pulmonary Disease and Erectile Dysfunction? The DECODED study

INTRODUCTION Erectile dysfunction (ED) is the inability to achieve or maintain an erection for satisfactory sexual activity. Recent studies have shown an association between ED and chronic obstructive pulmonary disease (COPD). However, this issue is often ignored. We aimed to evaluate the ED prevalence in COPD patients and its risk factors and to study the impact of dyspnea in sexual activity. METHODS Cross-sectional study that included sexually active male patients with COPD. The International Index of Erectile Function (IIEF-5) questionnaire evaluated ED and the Respiratory Experiences with Sexuality Profile (RESP) was used to evaluate the impact of dyspnea on sexual activity. Risk factors for mild-moderate or moderate ED were determined using logistic regression. RESULTS 84 patients were consecutively assessed for eligibility, 67 were included (median age: 65 years, 13% never-smokers). Twenty two percent had COPD 2011-GOLD A; 22% GOLD B, 14% GOLD C and 42% GOLD D. Fifty-eight patients (87%) had some degree of ED: 26 (45%) mild, 20 (34%) mild-moderate and 12 (21%) moderate ED. ED occurred in all GOLD stages of COPD, mainly in GOLD B and D stages. Higher CAT score was independently associated to mild-moderate/moderate ED. Most patients (85%) reported dyspnea during their sexual activity but 72% had never talked about it with their physician. CONCLUSIONS ED is highly prevalent among COPD patients and it is more severe in patients with higher CAT scores. Dyspnea affects their sexual activity but this is not a topic often discussed between patients and doctors, something which needs to be improved.

Alpha-1 antitrypsin deficiency caused by a novel mutation (p.Leu263Pro): Pi*ZQ0gaia - Q0gaia allele.

Severe alpha-1 antitrypsin deficiency (AATD) is generally associated with PI*ZZ genotype and less often with combinations of PI*Z, PI*S, and other rarer deficiency or null (Q0) alleles. Severe AATD predisposes patients to various diseases, including pulmonary emphysema. Presented here is a case report of a young man with COPD and AATD. The investigation of the AATD showed a novel mutation p.Leu263Pro (c.860T>C), which was named Q0gaia (Pi*ZQ0gaia). Q0gaia is associated with very low or no detectable serum concentrations of AAT.

Forma rara de apresentação de corpo estranho traqueobrônquico simulando asma grave – Caso clínico

Resumo O broncoespasmo e um dos sintomas classicos de asma que pode ocorrer tambem em outras patologias. A aspiracao de corpos estranhos traqueobronquicos no adulto e uma dessas situacoes, que embora rara pode permanecer oculta por periodos de tempo prolongados. Os autores apresentam o caso clinico de um jovem asmatico vitima de acidente de trabalho do qual resultou aspiracao de corpo estranho pouco usual e so posteriormente reconhecido.

Assessment of Respiratory Muscle Weakness in Subjects With Neuromuscular Disease

INTRODUCTION: Neuromuscular diseases (NMD) are a group of rare heterogeneous disorders that may be accompanied by respiratory muscle weakness. The simplest measurements of respiratory muscle strength are maximum inspiratory pressure (PImax) and maximum expiratory pressure (PEmax) of the mouth. Inspiratory muscle weakness can also be evaluated by the sniff test (sniff nasal inspiratory pressure method). This study tested the agreements in PImax and PEmax (measured by using a plethysmograph and portable equipment) as well as the correlations of PImax and PEmax by using the sniff nasal inspiratory pressure method, lung function, and arterial blood gas parameters in subjects with NMD. METHODS: This prospective, noninterventional study measured respiratory parameters in all the subjects with NMD who underwent measurement of maximum respiratory pressures. RESULTS: A total of 55 subjects with NMD were included. There were no statistically significant differences in PImax and PEmax measured by using a plethysmograph and portable equipment. Moreover, PImax showed a good correlation with the sniff nasal inspiratory pressure method. CONCLUSIONS: Measurements of PImax and PEmax by using portable equipment were equivalent to those performed by using the accepted standard, plethysmography, in the subjects with NMD. Noninvasive evaluation of the sniff test with the portable equipment correlates with PImax, which makes this approach a good method for measuring the maximum strength of inspiratory muscles in patients with NMD.

Role of the impulse oscillometry in the evaluation of tracheal stenosis

INTRODUCTION AND OBJECTIVES Tracheal stenosis is a rare and challenging disease. Bronchoscopy is the gold standard for diagnosis and assessment but brings inherent risks. Spirometry is commonly used to access obstructions but is not always feasible due to patient related factors. We therefore considered impulse oscillometry (IOS) as a non-invasive method to quantify airway obstruction and its potential use for diagnosis and follow-up of tracheal stenosis. MATERIALS AND METHODS Patients with confirmed tracheal stenosis were recruited between January 1st, 2015 and December 31st, 2016. Before bronchoscopy, all subjects underwent IOS and spirometry; for patients submitted to interventional bronchoscopy the same techniques were also performed after the procedure. We assessed the correlation between IOS measurements and airway narrowing as well as between IOS and spirometry values. RESULTS Twenty-one patients were included. Tracheal narrowing was inversely correlated with X5% (r -0.442, p 0.045) and positively correlated with FEV1/PEF (r 0.467, p 0.033). The stenosis length was inversely correlated with PEF and PEF% (r -0.729, p=0.001 and r -0.707, p=0.002, respectively). There was a strong correlation between spirometric and IOS values. We did not find any significant differences between pre- and post-intervention IOS values for patients assessed after interventional bronchoscopy. CONCLUSIONS Our study showed a weak correlation between X5% and tracheal narrowing making it unclear whether IOS can be used for physiological assessment of patients with tracheal stenosis. Stenosis length correlated with PEF making it a potential predictor of successful surgical approach. The correlation between IOS and spirometric values makes IOS a potential alternative in patients with suspected tracheal stenosis who are not able to perform spirometry. Larger scale studies should clarify the role of IOS in this pathology.

Reference equations for the 6-minute walk distance in healthy Portuguese subjects 18–70 years old

INTRODUCTION Six-minute walk test (6MWT) is used for evaluating functional exercise capacity. To the best of our knowledge, there are no reference equations to predict six-minute walk distance (6MWD) for the Portuguese population. The aims of the present study were to measure anthropometric data and 6MWD in a sample of healthy Portuguese population, to establish reference equations to predict 6MWD and to compare our equations with those obtained by previously published studies. METHODS We conducted an observational prospective study. We consecutively recruited 158 healthy 18-70 years old subjects from Porto district, who performed two 6MWTs using a standardized protocol. The best 6MWD was used for further analysis. RESULTS The mean 6MWD was 627.8m (SD=73.3m). The variables that were significantly associated with the 6MWD were age, sex, BMI and ΔHR (Heart Rateat the end of the test-HRat rest). We found three explanatory models for 6MWD, the best with an explanatory power of 38%: 6MWD=721.7-1.6×Age-4.0×BMI+0.9×ΔHR+58.4×Sex. We verified that 6MWD decreased 1.6m per year of age, and 4.0m per unit of BMI and increased 0.892m per beat per minute. Moreover, on average, males walk 58.4m more than females (p<0.001). Applying equations from other studies to our population resulted in an overestimation or underestimation of the 6MWD. CONCLUSION The present study was the first to describe the 6MWD in healthy Portuguese people aged 18-70 years old and to propose predictive equations. These can contribute to improving the evaluation of Caucasian Mediterranean patients with diseases that affect their functional capacity.