Pedro Vergara

Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity.

PURPOSE To create a maximum tolerated 45-minute aerobic training program for patients with chronic obstructive pulmonary disease (COPD) and to compare its outcomes with those of commonly prescribed moderate exercise. DESIGN Prospective, randomized trial. SETTING A work physiology laboratory. PATIENTS AND METHODS The maximum exercise intensities that 7 COPD patients could sustain for 45 minutes were determined on a bilevel exercise ergometer. The patients then exercised 45 minutes daily, 5 days a week for 6 weeks, working 2.03+/-0.4 kJ/kg per session. They were matched with 6 COPD patients who pushed an O2 cart for 45 minutes daily, 5 days a week for 6 weeks, working 1.44+/-.35 kJ/kg per session. RESULTS A 45 minute maximal regimen was established by alternating 1-minute peak exercise at peak VO2-levels with 4 minutes at the ventilatory anaerobic threshold or at 40% of peak VO2. Maximal bilevel training significantly decreased dyspnea at rest (p< or =.01) and the blood lactate level during submaximal exercise (p<.001), and increased peak VO2 and total physical work (p<.01), maximum inspiratory and expiratory pressures (p<.01), and grip and forearm strength and endurance (p<.01). The training also increased maximum voluntary ventilation while decreasing the ventilatory equivalent during exercise (p<.001). The O2 cart pushers significantly improved only on the 12-minute walk (p<.05). CONCLUSIONS A maximally intense anaerobic exercise program can be created for most COPD patients that can significantly improve both skeletal and respiratory muscle strength and endurance as well as dyspnea and physiologic parameters.

Mechanical insufflation-exsufflation vs. tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis: a pilot study.

Sancho J, Servera E, Vergara P, Marín J: Mechanical insufflation-exsufflation vs. tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis: A pilot study. Am J Phys Med Rehabil 2003;82:750–753. Objective To compare the effects of mechanical insufflation-exsufflation vs. suctioning via tracheostomy tubes on respiratory variables for six amyotrophic lateral sclerosis patients. Design In this prospective crossover study, six consecutive patients with amyotrophic lateral sclerosis who required continuous mechanical ventilation via tracheostomy tubes and developed chest infections underwent measurement of pulse oxyhemoglobin saturation (SpO2), peak inspiratory pressure (PIP), mean airway pressure (Pawm), and work of breathing performed by the ventilator (WOBv) at baseline and 5 and 30 min after tracheal suctioning and 5 min after mechanical insufflation-exsufflation. Results The baseline values were 93.50 ± 2.26% for SpO2 in ambient air, 18.50 ± 4.23 cm H2O for PIP, 4.67 ± 1.37 cm H2O for Pawm, and 1.03 ± 0.25 J/liters for WOBv. Only WOBv changed significantly, decreasing after tracheal suctioning (P < 0.05), whereas all variables improved significantly after mechanical insufflation-exsufflation. Conclusion For ventilator-dependent patients with amyotrophic lateral sclerosis, mechanical insufflation-exsufflation via a tracheostomy tube with an inflated cuff may be more effective in eliminating airway secretions than conventional tracheal suctioning.

Alternatives to endotracheal intubation for patients with neuromuscular diseases.

Servera E, Sancho J, Zafra MJ, Catalá A, Vergara P, Marín J: Alternatives to endotracheal intubation for patients with neuromuscular diseases. Am J Phys Med Rehabil 2005;84:851–857. Objective:To evaluate the usefulness of continuous noninvasive mechanical ventilation and mechanical coughing aids to avoid endotracheal intubation and tracheostomy during episodes of acute respiratory failure in patients with neuromuscular disease. Design:We conducted a prospective cohort study at the respiratory medicine ward of a university hospital to study the success rate of the use of continuous noninvasive mechanical ventilation and manually and mechanically (CoughAssist) assisted coughing to avert endotracheal intubation in 24 consecutive episodes of acute respiratory failure for 17 patients with neuromuscular disease. The noninvasive mechanical ventilation and coughing aids were used to reverse decreases in oxyhemoglobin saturation and relieve respiratory distress that occurred despite oxygen therapy and appropriate medication. Noninvasive mechanical ventilation was delivered by volume ventilators (Breas PV 501) alternating nasal/oronasal and oral interfaces. Results:Noninvasive management was successful in averting death and endotracheal intubation in 79.2% of the acute episodes. There were no significant differences in respiratory function between the successfully treated and unsuccessfully treated groups before the current episode. Bulbar dysfunction was the independent risk factor for failure of noninvasive treatment (P < 0.05; odds ratio, 35.99%; 95% confidence interval, 1.71–757.68). Conclusions:Intubation can be avoided for some patients with neuromuscular disease in acute respiratory failure by some combination of noninvasive mechanical ventilation and mechanically assisted coughing. Severe bulbar involvement can limit the effectiveness of noninvasive management. ABBREVIATIONS: ALS: amyotrophic lateral sclerosis; ETI: endotracheal intubation; FEV1: forced expiratory volume in 1 sec; FVC: forced vital capacity; %FVC: percentage predicted FVC; MIC: maximum insufflation capacity; NIV: noninvasive ventilation; NMD: neuromuscular disease; PCF: peak cough flow; PCFMIC: manually assisted PCF; PImax: maximum mouth inspiratory pressure; PEmax: maximum expiratory pressure; SpO2: pulse oxyhemoglobin saturation

Kyphoscoliosis ventilatory insufficiency: noninvasive management outcomes.

OBJECTIVE To determine the effects on symptoms, pulmonary function, sleep, and other clinical variables of treating kyphoscoliosis-associated chronic alveolar hypoventilation with nocturnal nasal ventilation. DESIGN Sixteen patients with kyphoscoliosis were treated with nocturnal nasal ventilation delivered by volume-cycled (seven patients) and pressure-cycled (nine patients) ventilators. Dyspnea, morning headaches, fatigue, hypersomnolence, and perceived sleep quality were assessed. RESULTS All pretreatment symptoms improved significantly with nasal ventilation. Likewise, PaO2 (mm Hg), PaO2/FlO2, PaCO2 (mm Hg), pH, and forced vital capacity (in milliliters and as a percentage of predicted normal) significantly improved with treatment. Maximum inspiratory pressures and maximum expiratory pressures also significantly increased. Tidal volumes increased significantly and breathing frequency decreased (not significant). Although perceived sleep quality improved, as well as sleep oxyhemoglobin saturation, there was no significant change in sleep architecture. Hospitalization days for respiratory difficulties also decreased from 10.9 +/- 13.3 days in the 6 mo before intermittent positive-pressure ventilation to 0 days during the first 6 mo of treatment. CONCLUSIONS Although not apparently affecting sleep architecture, nocturnal nasal ventilation can significantly improve nocturnal and daytime blood gases, pulmonary function, and symptoms of hypoventilation for patients with severe kyphoscoliosis.

Effects of inspiratory muscle training in patients with heart failure with preserved ejection fraction.

Background Heart failure with preserved ejection fraction (HFpEF) is remarkably common in elderly people with highly prevalent comorbid conditions. Despite its increasing in prevalence, there is no evidence-based effective therapy for HFpEF. We sought to evaluate whether inspiratory muscle training (IMT) improves exercise capacity, as well as left ventricular diastolic function, biomarker profile and quality of life (QoL) in patients with advanced HFpEF and nonreduced maximal inspiratory pressure (MIP). Design and methods A total of 26 patients with HFpEF (median (interquartile range) age, peak exercise oxygen uptake (peak VO2) and left ventricular ejection fraction of 73 years (66–76), 10 ml/min/kg (7.6–10.5) and 72% (65–77), respectively) were randomized to receive a 12-week programme of IMT plus standard care vs. standard care alone. The primary endpoint of the study was evaluated by positive changes in cardiopulmonary exercise parameters and distance walked in 6 minutes (6MWT). Secondary endpoints were changes in QoL, echocardiogram parameters of diastolic function, and prognostic biomarkers. Results The IMT group improved significantly their MIP (p < 0.001), peak VO2 (p < 0.001), exercise oxygen uptake at anaerobic threshold (p = 0.001), ventilatory efficiency (p = 0.007), metabolic equivalents (p < 0,001), 6MWT (p < 0.001), and QoL (p = 0.037) as compared to the control group. No changes on diastolic function parameters or biomarkers levels were observed between both groups. Conclusions In HFpEF patients with low aerobic capacity and non-reduced MIP, IMT was associated with marked improvement in exercise capacity and QoL.

Non-invasive management of an acute chest infection for a patient with ALS.

We describe a man diagnosed with non-bulbar amyotrophic lateral sclerosis (ALS) who uses 24-h non-invasive ventilator at home, and assisted cough through the use of the mechanical insufflation-exsufflation (MAC) device (CoughAssist, J.H. Emerson). This was essential for the removal of bronchial secretions in order to provide successful non-invasive management (and indeed less suffering for the patient) during an acute respiratory tract infection with hypoxemia and failure of manually assisted cough.

Ventilación asistida vía máscara nasal en pacientes hospitalizados en una sala de neumología por descompensación de su obstrucción crónica al flujo aéreo

: Our aim was to evaluate the efficacy of assisted ventilation through a nasal mask (AVN) in treating chronic obstructive pulmonary disease (COPD) patients who were admitted to a pneumology ward due to decompensation, with PaCO2 > 60 mmHg and pH < 7.35. We studied 13 COPD patients who were first observed for 1-2 days until adaptation and then given 2 daily sessions of AVN lasting 4 hours with double positive pressure (DP90) devices through Sullivan mask with a cannula for hyperoxia. Gasometric readings were recorded, along with subjective assessment of condition and problems with the mask. Gasometric readings were taken as follows: the first upon admission to the ward (AW), the second with AVN 2 days after adaptation and the third 3 hours after the second (POST). Statistical analysis was with a Student t-test for paired series. Mean age was 64 +/- 3 years and FEV1 was 0.69 +/- 0.14 l. Interruptions were due to the need for mouth opening even at minimum pressures, and the inability to adapt to the consequent tachypnea. No other problems were reported by the remaining patients and all perceived improvement subjectively. The pH of 7.29 +/- 0.03 at AW increased to 7.41 +/- 0.03 with AVN (p < 0.001) and held steady at 7.39 +/- 0.01 at POST (p < 0.001 POST-AW and p = NS POST-AVN). PaO2/FiO2 was 223 +/- 49 mmHg at AW and 267 +/- 41 mmHg at the POST reading (p = 0.06). PaO2 with AVN was 67 +/- 8 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory Muscle Aids During an Episode of Aspiration in a Patient With Duchenne Muscular Dystrophy

We report the case of a Duchenne muscular dystrophy patient with good bulbar function but severely decreased forced vital capacity (9%) and spontaneous peak cough flow (PCF) (2.35 L/s). The patient needed continuous noninvasive ventilation (NIV) consisting of a volumetric ventilator with a nighttime nasal mask and a daytime mouthpiece. He also required application of manually assisted coughing techniques by insufflation with a resuscitation bag and chest thrust (manually assisted PCF after maximum insufflation capacity of 4.33 L/s). An episode of serious food aspiration was resolved by his main caregiver through NIV and manually assisted coughing. Bronchoscopy under sedation using NIV with a lip seal connection to his volumetric ventilator later revealed that no material remained. This case exemplifies the potential role of skilled respiratory management in some neuromuscular diseases.

Ayudas a los músculos respiratorios durante un episodio de aspiración en un enfermo con distrofia muscular de Duchenne

Presentamos el caso de un enfermo afectado de distrofia muscular de Duchenne con buena funcion bulbar, pero con disminucion importante de la capacidad vital forzada (9%) y del pico de flujo de tos espontaneo (2,35 l/s) que le obligaba a mantener ventilacion no invasiva (VNI) continua (ventilador volumetrico, mascarilla nasal nocturna y pieza bucal en vigilia) y a utilizar ayudas manuales para la tos mediante insuflaciones con ambu y compresion toracica espiratoria (pico de flujo de tos asistida tras maxima capacidad de insuflacion de 4,33 l/s). El paciente presento una aspiracion importante de material digestivo que se resolvio gracias a la asociacion de las ayudas manuales para la tos proporcionadas por su cuidadora principal y a la VNI. En un segundo momento, la VNI con una boquilla sellada como conexion a un ventilador volumetrico permitio realizar una broncoscopia bajo sedacion, en la que se comprobo que no habia material retenido. Este caso es un ejemplo de la utilidad potencial del manejo cualificado de los problemas respiratorios en algunas enfermedades neuromusculares.