Wellington Pereira Yamaguti

Diaphragmatic Breathing Training Program Improves Abdominal Motion During Natural Breathing in Patients With Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

OBJECTIVE To investigate the effects of a diaphragmatic breathing training program (DBTP) on thoracoabdominal motion and functional capacity in patients with chronic obstructive pulmonary disease. DESIGN A prospective, randomized controlled trial. SETTING Academic medical center. PARTICIPANTS Subjects (N=30; forced expiratory volume in 1s, 42%±13% predicted) were randomly allocated to either a training group (TG) or a control group (CG). INTERVENTIONS Subjects in the TG completed a 4-week supervised DBTP (3 individualized weekly sessions), while those in the CG received their usual care. MAIN OUTCOME MEASURES Effectiveness was assessed by amplitude of the rib cage to abdominal motion ratio (RC/ABD ratio) (primary outcome) and diaphragmatic mobility (secondary outcome). The RC/ABD ratio was measured using respiratory inductive plethysmography during voluntary diaphragmatic breathing and natural breathing. Diaphragmatic mobility was measured by ultrasonography. A 6-minute walk test and health-related quality of life were also evaluated. RESULTS Immediately after the 4-week DBTP, the TG showed a greater abdominal motion during natural breathing quantified by a reduction in the RC/ABD ratio when compared with the CG (F=8.66; P<.001). Abdominal motion during voluntary diaphragmatic breathing after the intervention was also greater in the TG than in the CG (F=4.11; P<.05). The TG showed greater diaphragmatic mobility after the 4-week DBTP than did the CG (F=15.08; P<.001). An improvement in the 6-minute walk test and in health-related quality of life was also observed in the TG. CONCLUSIONS DBTP for patients with chronic obstructive pulmonary disease induced increased diaphragm participation during natural breathing, resulting in an improvement in functional capacity.

Avaliação ultra-sonográfica da mobilidade do diafragma em diferentes posturas em sujeitos saudáveis

OBJECTIVE To assess, using ultrasound, the effects that changes in body position have on diaphragmatic mobility in healthy subjects during spontaneous breathing. METHODS The study involved seven healthy female volunteers, all of whom were nonsmokers, well nourished, and free of any cardiopulmonary disease. They were submitted to pulmonary function testing and ultrasound evaluation of the mobility of the right diaphragm by the craniocaudal displacement of the left branch of the portal vein using an ultrasound device in mode B. The mobility of the right diaphragm was evaluated in right decubitus and in left decubitus. The order of evaluation was previously determined in a random drawing. RESULTS The average mobility of the right diaphragm in right decubitus (51.30 +/- 9.69 mm) was significantly higher (p = 0.03) than that observed in left decubitus (45.93 +/- 10.37 mm). CONCLUSION The results suggest that, during spontaneous ventilation, the dependent portion of the diaphragm presents greater mobility than does the nondependent portion, and that the technique used was sufficiently sensitive to detect variations in diaphragmatic mobility related to changes in posture.

Mobilidade diafragmática durante espirometria de incentivo orientada a fluxo e a volume em indivíduos sadios

OBJECTIVE To compare the diaphragmatic mobility of healthy subjects during incentive spirometry with a volume-oriented device, during incentive spirometry with a flow-oriented device, and during diaphragmatic breathing. To compare men and women in terms of diaphragmatic mobility during these three types of breathing exercises. METHODS We evaluated the pulmonary function and diaphragmatic mobility of 17 adult healthy volunteers (9 women and 8 men). Diaphragmatic mobility was measured via ultrasound during diaphragmatic breathing and during the use of the two types of incentive spirometers. RESULTS Diaphragmatic mobility was significantly greater during the use of the volume-oriented incentive spirometer than during the use of the flow-oriented incentive spirometer (70.16 ± 12.83 mm vs. 63.66 ± 10.82 mm; p = 0.02). Diaphragmatic breathing led to a greater diaphragmatic mobility than did the use of the flow-oriented incentive spirometer (69.62 ± 11.83 mm vs. 63.66 ± 10.82 mm; p = 0.02). During all three types of breathing exercises, the women showed a higher mobility/FVC ratio than did the men. CONCLUSIONS Incentive spirometry with a volume-oriented device and diaphragmatic breathing promoted greater diaphragmatic mobility than did incentive spirometry with a flow-oriented device. Women performed better on the three types of breathing exercises than did men.

Treatment-related risk factors for development of skin breakdown in subjects with acute respiratory failure undergoing noninvasive ventilation or CPAP.

BACKGROUND: Noninvasive ventilation (NIV) has been recognized as an effective strategy in preventing endotracheal intubation in subjects with acute respiratory failure (ARF). Some interface-related complications have also been recognized, such as skin breakdown (SB). The aim of this study was to determine the frequency of SB and identify potential treatment-related risk factors for its development in adults with ARF undergoing NIV or CPAP. METHODS: A cross-sectional study was conducted in a general hospital. Subjects were retrospectively enrolled in this study if they were > 18 y old and developed ARF caused by any condition in which NIV or CPAP was indicated for at least one application for a period longer than 2 h. The outcomes were the prevalence of SB and the evaluation of related risk factors. Data were extracted from the electronic medical records. A stepwise forward logistic regression model was used to identify independent risk factors for SB development. RESULTS: A total of 375 subjects (160 males) met the inclusion criteria and were enrolled in the study. Fifty-four subjects (14.4%) developed SB. The mean number of applications of NIV or CPAP carried out for > 2 h was higher in subjects with SB (7.1 ± 13.3 h) than in those without SB (4.4 ± 13.3 h) (P = .03). Subjects with SB also presented a higher total duration of NIV use (44.6 ± 118.5 h) compared with subjects without SB (21.8 ± 45.5 h) (P = .01). Subjects who developed SB presented a higher use of oronasal mask (92.6%) compared with the group that did not (21.5%) (P < .001). CONCLUSIONS: In patients with ARF undergoing NIV or CPAP, oronasal mask use for > 26 h was independently associated with development of SB.

Effects of proportional assisted ventilation on exercise performance in idiopathic pulmonary fibrosis patients

BACKGROUND Patients with idiopathic pulmonary fibrosis (IPF) present an important ventilatory limitation reducing their exercise capacity. Non-invasive ventilatory support has been shown to improve exercise capacity in patients with obstructive diseases; however, its effect on IPF patients remains unknown. OBJECTIVE The present study assessed the effect of ventilatory support using proportional assist ventilation (PAV) on exercise capacity in patients with IPF. METHODS Ten patients (61.2+/-9.2 year-old) were submitted to a cardiopulmonary exercise testing, plethysmography and three submaximal exercise tests (60% of maximum load): without ventilatory support, with continuous positive airway pressure (CPAP) and PAV. Submaximal tests were performed randomly and exercise capacity, cardiovascular and ventilatory response as well as breathlessness subjective perception were evaluated. Lactate plasmatic levels were obtained before and after submaximal exercise. RESULTS Our data show that patients presented a limited exercise capacity (9.7+/-3.8 mL O(2)/kg/min). Submaximal test was increased in patients with PAV compared with CPAP and without ventilatory support (respectively, 11.1+/-8.8 min, 5.6+/-4.7 and 4.5+/-3.8 min; p<0.05). An improved arterial oxygenation and lower subjective perception to effort was also observed in patients with IPF when exercise was performed with PAV (p<0.05). IPF patients performing submaximal exercise with PAV also presented a lower heart rate during exercise, although systolic and diastolic pressures were not different among submaximal tests. Our results suggest that PAV can increase exercise tolerance and decrease dyspnoea and cardiac effort in patients with idiopathic pulmonary fibrosis.

Effects of Neuromuscular Electrical Stimulation During Hemodialysis on Peripheral Muscle Strength and Exercise Capacity : A Randomized Clinical Trial

OBJECTIVE To evaluate the effects of neuromuscular electrical stimulation of high and low frequency and intensity, performed during hemodialysis, on physical function and inflammation markers in patients with chronic kidney disease (CKD). DESIGN Randomized clinical trial. SETTING Hemodialysis clinic. PARTICIPANTS Patients with CKD (N=51) were randomized into blocks of 4 using opaque sealed envelopes. They were divided into a group of high frequency and intensity neuromuscular electrical stimulation and a group of low frequency and intensity neuromuscular electrical stimulation. INTERVENTIONS The high frequency and intensity neuromuscular electrical stimulation group was submitted to neuromuscular electrical stimulation at a frequency of 50Hz and a medium intensity of 72.90mA, and the low frequency and intensity neuromuscular electrical stimulation group used a frequency of 5Hz and a medium intensity of 13.85mA, 3 times per week for 1 hour, during 12 sessions. MAIN OUTCOME MEASURES Peripheral muscle strength, exercise capacity, levels of muscle trophism marker (insulin growth factor 1) and levels of proinflammatory (tumor necrosis factor α) and anti-inflammatory (interleukin 10) cytokines. RESULTS The high frequency and intensity neuromuscular electrical stimulation group showed a significant increase in right peripheral muscle strength (155.35±65.32Nm initial vs 161.60±68.73Nm final; P=.01) and left peripheral muscle strength (156.60±66.51Nm initial vs 164.10±69.76Nm final; P=.02) after the training, which did not occur in the low frequency and intensity neuromuscular electrical stimulation group for both right muscle strength (109.40±32.08Nm initial vs 112.65±38.44Nm final; P=.50) and left muscle strength (113.65±37.79Nm initial vs 116.15±43.01Nm final; P=.61). The 6-minute walk test distance (6MWTD) increased in both groups: high frequency and intensity neuromuscular electrical stimulation group (435.55±95.81m initial vs 457.25±90.64m final; P=.02) and low frequency and intensity neuromuscular electrical stimulation group (403.80±90.56m initial vs 428.90±87.42m final; P=.007). The groups did not differ in peripheral muscle strength and 6MWTD after the training protocol. In the high frequency and intensity neuromuscular electrical stimulation group, a correlation was observed between the initial and final values of 6MWTD and muscle strength. In the low frequency and intensity neuromuscular electrical stimulation group, correlations occurred only between the 6MWTD and the initial muscle strength. Only the low frequency and intensity neuromuscular electrical stimulation group increased levels of insulin growth factor 1 (252.38±156.35pg/mL initial vs 336.97±207.34pg/mL final; P=.03), and only the high frequency and intensity neuromuscular electrical stimulation group reduced levels of interleukin 10 (7.26±1.81pg/mL vs 6.32±1.54pg/mL; P=.03). The groups showed no differences in tumor necrosis factor α levels. CONCLUSIONS Patients with CKD on hemodialysis improve exercise capacity after peripheral neuromuscular electrical stimulation of high and low frequency and intensity. However, the benefits on muscle and inflammatory outcomes seem to be specific for the adopted electrical stimulation strategy.

Comparação entre as medidas de cirtometria tóraco-abdominal realizadas em decúbito dorsal e em ortostatismo

With the objective to evaluate possible differences in the values obtained in the thoracoabdominal cirtometry in orthostatism compared with the results in supine, 30 subjects with mean age 27.8±4.4 years were evaluated according to the following parameters: anthropometry, pulmonary function test and thocacoabdominal cirtometry. Shapiro-Wilk test was used to verify data normality and the t test was performed in order to compare the thoracoabdominal cirtometry measurements in supine and in orthostatism positions. There were no significant differences in axillar and xiphoid mobility between measurements obtained in supine and orthostatism. The abdominal mobility measured in orthostatism (2.54±1.39 cm) was significantly lower (34.35%) when compared to the mobility obtained in supine (3.71±1.78 cm; p<0.001). The thoracic cirtometry can be performed in orthostatism as an alternative for the evaluation of patients with orthopnea. The abdominal cirtometry can also be performed in this posture, with the expected one-third reduction in the abdominal mobility obtained in supine.

Unidirectional Expiratory Valve Method to Assess Maximal Inspiratory Pressure in Individuals without Artificial Airway.

Introduction Maximal Inspiratory Pressure (MIP) is considered an effective method to estimate strength of inspiratory muscles, but still leads to false positive diagnosis. Although MIP assessment with unidirectional expiratory valve method has been used in patients undergoing mechanical ventilation, no previous studies investigated the application of this method in subjects without artificial airway. Objectives This study aimed to compare the MIP values assessed by standard method (MIPsta) and by unidirectional expiratory valve method (MIPuni) in subjects with spontaneous breathing without artificial airway. MIPuni reproducibility was also evaluated. Methods This was a crossover design study, and 31 subjects performed MIPsta and MIPuni in a random order. MIPsta measured MIP maintaining negative pressure for at least one second after forceful expiration. MIPuni evaluated MIP using a unidirectional expiratory valve attached to a face mask and was conducted by two evaluators (A and B) at two moments (Tests 1 and 2) to determine interobserver and intraobserver reproducibility of MIP values. Intraclass correlation coefficient (ICC[2,1]) was used to determine intraobserver and interobserver reproducibility. Results The mean values for MIPuni were 14.3% higher (-117.3 ± 24.8 cmH2O) than the mean values for MIPsta (-102.5 ± 23.9 cmH2O) (p<0.001). Interobserver reproducibility assessment showed very high correlation for Test 1 (ICC[2,1] = 0.91), and high correlation for Test 2 (ICC[2,1] = 0.88). The assessment of the intraobserver reproducibility showed high correlation for evaluator A (ICC[2,1] = 0.86) and evaluator B (ICC[2,1] = 0.77). Conclusions MIPuni presented higher values when compared with MIPsta and proved to be reproducible in subjects with spontaneous breathing without artificial airway.

Comparação da mobilidade diafragmática em pacientes com DPOC com e sem hipercifose torácica: um estudo transversal

OBJECTIVE:To compare diaphragmatic mobility, lung function, and respiratory muscle strength between COPD patients with and without thoracic hyperkyphosis; to determine the relationship of thoracic kyphosis angle with diaphragmatic mobility, lung function, and respiratory muscle strength in COPD patients; and to compare diaphragmatic mobility and thoracic kyphosis between male and female patients with COPD. METHODS:Participants underwent anthropometry, spirometry, thoracic kyphosis measurement, and evaluation of diaphragmatic mobility. RESULTS:A total of 34 patients with COPD participated in the study. Diaphragmatic mobility was significantly lower in the group of COPD patients with thoracic hyperkyphosis than in that of those without it (p = 0.002). There were no statistically significant differences between the two groups of COPD patients regarding lung function or respiratory muscle strength variables. There was a significant negative correlation between thoracic kyphosis angle and diaphragmatic mobility (r = -0.47; p = 0.005). In the sample as a whole, there were statistically significant differences between males and females regarding body weight (p = 0.011), height (p < 0.001), and thoracic kyphosis angle (p = 0.036); however, there were no significant differences in diaphragmatic mobility between males and females (p = 0.210). CONCLUSIONS:Diaphragmatic mobility is lower in COPD patients with thoracic hyperkyphosis than in those without it. There is a negative correlation between thoracic kyphosis angle and diaphragmatic mobility. In comparison with male patients with COPD, female patients with COPD have a significantly increased thoracic kyphosis angle.

Functional evolution of critically ill patients undergoing an early rehabilitation protocol

Objective Evaluation of the functional outcomes of patients undergoing an early rehabilitation protocol for critically ill patients from admission to discharge from the intensive care unit. Methods A retrospective cross-sectional study was conducted that included 463 adult patients with clinical and/or surgical diagnosis undergoing an early rehabilitation protocol. The overall muscle strength was evaluated at admission to the intensive care unit using the Medical Research Council scale. Patients were allocated to one of four intervention plans according to the Medical Research Council score, the suitability of the plan’s parameters, and the increasing scale of the plan expressing improved functional status. Uncooperative patients were allocated to intervention plans based on their functional status. The overall muscle strength and/or functional status were reevaluated upon discharge from the intensive care unit by comparison between the Intervention Plans upon admission (Planinitial) and discharge (Planfinal). Patients were classified into three groups according to the improvement of their functional status or not: responsive 1 (Planfinal > Planinitial), responsive 2 (Planfinal = Planinitial) and unresponsive (Planfinal < Planinitial). Results In total, 432 (93.3%) of 463 patients undergoing the protocol responded positively to the intervention strategy, showing maintenance and/or improvement of the initial functional status. Clinical patients classified as unresponsive were older (74.3 ± 15.1 years of age; p = 0.03) and had longer lengths of intensive care unit (11.6 ± 14.2 days; p = 0.047) and hospital (34.5 ± 34.1 days; p = 0.002) stays. Conclusion The maintenance and/or improvement of the admission functional status were associated with shorter lengths of intensive care unit and hospital stays. The results suggest that the type of diagnosis, clinical or surgical, fails to define the positive response to an early rehabilitation protocol.