Respiratory Disorders in Parkinson's Disease.

BACKGROUND: Parkinson's disease (PD) non motor symptoms may present early in the disease course and worsen with advancing disease. Respiratory changes can affect individuals to remain physically active, contributing to a reduction of functionality and quality of life. OBJECTIVE: The aim of this systematic review is to synthesize evidence of respiratory disorders in patients with PD. METHODS: An electronic search was performed up to November 2020 on PubMed-MEDLINE, Embase, Web of Science, Lilacs, Cinahl, and Cochrane using the following keyword combination: [("Parkinson disease") AND ("respiratory function tests" OR "evaluation") AND ("respiratory system" OR "respiration disorders" OR "respiratory muscles")]. RESULTS: The electronic search resulted in 601 references in English or Portuguese. The selection process and data extraction were made by two independent reviewers. We selected 19 studies including cross-sectional studies that investigated the respiratory disorders in patients with PD through pulmonary function, respiratory muscle strength, or physical capacity evaluation. We excluded studies that considered patients with other diseases. Eighteen studies evaluated the pulmonary function in patients with PD, eleven studies verified the influence of PD on respiratory muscle strength, and three studies assessed the physical capacity through functional tests. CONCLUSION: The evidence showed that PD patients have higher chances to present a pulmonary dysfunction, either obstructive or restrictive, when compared to healthy subjects. In addition, these patients present lower respiratory muscle strength and a consequent decrease in physical capacity in endurance exercises. The respiratory impairment in PD seems to be directly related to the progression of the disease.

Effects of Inspiratory Muscle Training and Calisthenics-and-Breathing Exercises in COPD With and Without Respiratory Muscle Weakness.

BACKGROUND: Patients with COPD may experience respiratory muscle weakness. Two therapeutic approaches to the respiratory muscles are inspiratory muscle training and calisthenics-and-breathing exercises. The aims of the study are to compare the effects of inspiratory muscle training and calisthenics-and-breathing exercises associated with physical training in subjects with COPD as an additional benefit of strength and endurance of the inspiratory muscles, thoracoabdominal mobility, physical exercise capacity, and reduction in dyspnea on exertion. In addition, these gains were compared between subjects with and without respiratory muscle weakness. METHODS: 25 subjects completed the study: 13 composed the inspiratory muscle training group, and 12 composed the calisthenics-and-breathing exercises group. Subjects were assessed before and after training by spirometry, measurements of respiratory muscle strength and test of inspiratory muscle endurance, thoracoabdominal excursion measurements, and the 6-min walk test. Moreover, scores for the Modified Medical Research Council dyspnea scale were reported. RESULTS: After intervention, there was a significant improvement in both groups of respiratory muscle strength and endurance, thoracoabdominal mobility, and walking distance in the 6-min walk test. Additionally, there was a decrease of dyspnea in the 6-min walk test peak. A difference was found between groups, with higher values of respiratory muscle strength and thoracoabdominal mobility and lower values of dyspnea in the 6-min walk test peak and the Modified Medical Research Council dyspnea scale in the inspiratory muscle training group. In the inspiratory muscle training group, subjects with respiratory muscle weakness had greater gains in inspiratory muscle strength and endurance. CONCLUSIONS: Both interventions increased exercise capacity and decreased dyspnea during physical effort. However, inspiratory muscle training was more effective in increasing inspiratory muscle strength and endurance, which could result in a decreased sensation of dyspnea. In addition, subjects with respiratory muscle weakness that performed inspiratory muscle training had higher gains in inspiratory muscle strength and endurance but not of dyspnea and submaximal exercise capacity. (ClinicalTrials.gov registration NCT01510041.).

Limitation of Activities of Daily Living and Quality of Life Based on COPD Combined Classification.

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 update recommends that the management and treatment of COPD be made to combine the impact of disease and future risk of exacerbation. These patients have worsening quality of life and limitation of activities of daily living (ADLs), which can be manifested as a decrease in S(pO2) and progressive dyspnea. The aim of this study was to determine whether the COPD combined classification proposed by GOLD 2011 is able to differentiate patients with ADL limitation, such as oxygen desaturation or dyspnea, and impaired quality of life. METHODS: This was an observational, cross-sectional study. Forty-four subjects were categorized in 4 GOLD groups (A-D). The mean age was 69 ± 8.8 y, with FEV1 of 1.33 ± 0.53 L (49 ± 15.7% of predicted). The Modified Medical Research Council dyspnea and London Chest Activity of Daily Living (LCADL) scales and the St George Respiratory Questionnaire (SGRQ) were applied. The 6-min walk test and ADL simulation in an appropriate laboratory were also conducted. RESULTS: There was no association between the COPD combined evaluation groups and the presence of oxygen desaturation and dyspnea (chi-square test), although a higher prevalence of oxygen desaturation was noticed in group D subjects. With regard to dyspnea, there were subjects with dyspnea in all groups when ADLs were performed. No correlation between dyspnea and oxygen desaturation variation was found. Group B and D subjects showed higher ADL dyspnea (total LCADL scores of 28% and 30%) compared with group A subjects. Group D subjects showed poorer quality of life (total SGRQ score of 49.3%) compared with less symptomatic groups. CONCLUSIONS: The COPD combined classification was not efficient in determining oxygen desaturation and dyspnea while subjects were performing ADLs. The subjects in the symptomatic groups with increased risk of exacerbation showed poorer quality of life and higher dyspnea levels. (ClinicalTrials.gov registration NCT01977469).

Validity of the six-minute step test of free cadence in patients with chronic obstructive pulmonary disease.

OBJECTIVES: to evaluate the concurrent validity of the six-minute step test (6MST) in assessing exercise capacity of COPD patients using the six-minute walk test (6MWT) as a gold-standard. The predictive validity of the 6MST was assessed to determine a cut-off point for identification of low exercise capacity. METHOD: thirty-two COPD patients (50-87 years old) with mild to very severe obstruction performed the 6MST and 6MWT twice. RESULTS: Concurrent validity: a strong positive correlation (Pearson) between the number of ascents on the first (T1), second (T2) and the best of both (T1 or T2) tests during the 6MWT was observed. Although a moderate negative correlation with BODE index and FEV1 was found, it was considered insufficient to test the validity, therefore ROC curves were not applied. The predictive validity (ROC) of the 6MST to identify low physical capacity (compared with the 6MWT) using the performance of T1 or T2, or solely T1 was considered accurate, and the area under the curve was 0.8 (IC95% 0.62-0.98) and 0.85 (IC95% 0.70-0.99), respectively. To classify patients, the cut-off points of 86 and 78 steps were chosen, with both values showing 90% of sensitivity and specificity of 64% and 68% for T1 or T2, or solely T1, respectively. CONCLUSION: The number of steps on the 6MST was valid to verify exercise capacity in COPD patients and the cut-off point of 78 steps was able to identify patients with poor exercise tolerance. Values under this cut-off point are considered to identify patients with a poorer prognosis.

Validity of the six-minute step test of free cadence in patients with chronic obstructive pulmonary disease / Validade do teste de degrau de seis minutos de cadência livre em pacientes com doença pulmonar obstrutiva crônica

Objectives: to evaluate the concurrent validity of the six-minute step test (6MST) in assessing exercise capacity of COPD patients using the six-minute walk test (6MWT) as a gold-standard. The predictive validity of the 6MST was assessed to determine a cut-off point for identification of low exercise capacity. Method: thirty-two COPD patients (50-87 years old) with mild to very severe obstruction performed the 6MST and 6MWT twice. Results: Concurrent validity: a strong positive correlation (Pearson) between the number of ascents on the first (T1), second (T2) and the best of both (T1 or T2) tests during the 6MWT was observed. Although a moderate negative correlation with BODE index and FEV1 was found, it was considered insufficient to test the validity, therefore ROC curves were not applied. The predictive validity (ROC) of the 6MST to identify low physical capacity (compared with the 6MWT) using the performance of T1 or T2, or solely T1 was considered accurate, and the area under the curve was 0.8 (IC95% 0.62-0.98) and 0.85 (IC95% 0.70-0.99), respectively. To classify patients, the cut-off points of 86 and 78 steps were chosen, with both values showing 90% of sensitivity and specificity of 64% and 68% for T1 or T2, or solely T1, respectively. Conclusion: The number of steps on the 6MST was valid to verify exercise capacity in COPD patients and the cut-off point of 78 steps was able to identify patients with poor exercise tolerance. Values under this cut-off point are considered to identify patients with a poorer prognosis. .

Objetivos: Avaliar a validade concorrente do desempenho no teste de degrau de seis minutos (TD6) em analisar a capacidade física da DPOC, relacionando-o com o teste de caminhada de seis minutos (TC6), bem como verificar a presença de validade de critério preditiva do TD6, determinando um valor de corte para identificar baixa capacidade física. Método: Trinta e dois pacientes com DPOC estágios leve-muito grave, de ambos os sexos, entre 50-87 anos, realizaram dois TD6 e dois TC6. Resultados: Validade concorrente: observou-se correlação forte positiva (Pearson) entre o número de subidas do primeiro (T1), segundo (T2) e do melhor dos dois (T1 ou T2) TD6 com a distância percorrida no TC6. Embora constatamos correlações negativas entre os desempenhos no TD6 com o índice BODE e VEF1, essas não foram suficientes para caracterizar validade, não sendo traçadas as curvas ROC. A validade preditiva (curvas ROC) do TD6 para identificar baixa capacidade física (comparação com o TC6), utilizando o desempenho do T1 ou T2 ou somente do T1, foi considerada acurada para alguns propósitos, sendo a área abaixo da curva de 0,8 (IC95% 0,62-0,98) e 0,85 (IC95% 0,70-0,99), respectivamente. Para classificar os pacientes, escolhemos o ponto de corte de 86 e 78 degraus, apresentando sensibilidade de 90% e 90% e especificidade de 64% e 68%, para T1 ou T2 e somente T1, respectivamente. Conclusão: O desempenho no TD6 apresentou-se válido para verificar capacidade física na DPOC e identificou pacientes com baixa capacidade física, utilizando como ponto de corte 78 degraus, em que valores abaixo disso representaram pior prognóstico. .

Determination of exacerbation predictors in patients with COPD in physical therapy - a longitudinal study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) typically presents the characteristic clinical condition of exacerbation, with more intense symptoms associated with greater functional loss and consequently lower chances of patient survival. OBJECTIVES: This study sought to determine the predictors of exacerbation, alone or in combination, in patients with chronic obstructive pulmonary disease (COPD) who received physical therapeutic treatment over 6 months. METHOD: This was an observational, longitudinal and prospective study in which 63 COPD patients residing within the municipality of São Carlos, SP, Brazil were evaluated. These patients had COPD stages II and III and were entered into a physical therapy program, consisting of 3 periods of assessment over 6 months. We evaluated the occurrence of acute exacerbation as well as the patients' body mass index (BMI), fat-free mass (FFM), fat-free mass index, forced expiratory volume in 1 second (FEV1), dyspnea, distance walked (DW) in the 6-minute walk test (6MWT) and handgrip strength. RESULTS: When applying Cox settings with each covariate separately, the results revealed 5% significance only for the DW in the 6MWT, which demonstrated an interaction between BMI and FFM. Comparison of the 3 periods of assessment across the covariates measured showed a significant difference only for the DW between evaluations in the 3rd and 6th months. CONCLUSION: Upon analyzing the predictors of risk over 6 months of follow-up in patients with COPD, we found that the DW in the 6MWT was associated with the risk of exacerbation, although this risk also depended on the covariates BMI and FFM.

COPD patients' oxygen uptake and heart rate on-kinetics at cycle-ergometer: correlation with their predictors of severity.

OBJECTIVES: To assess whether there is a correlation between oxygen uptake (VO2) and heart rate (HR) on-kinetics in the constant-load cycle-ergometer test (CLT) and the BODE index and its isolated variables in patients with chronic obstructive pulmonary disease (COPD). METHOD: Fourteen male patients between 55 and 78 years of age with moderate to severe COPD were evaluated. Each patient underwent spirometry, the six-minute walk test (6MWT), the cycle-ergometer incremental test (IT) and CLT on alternate days. The exhaled gases were collected, and the VO2 and HR on-kinetics were analyzed. The BODE index was calculated. RESULTS: It was noted that the VO2 tau (τ) and mean response time (MRT) were significantly higher than HR τ and MRT. Moderate and strong correlations between τ and MRT of the VO2 and HR and the BODE index was noted (r=0.75 and r=0.78; r=0.62 and r=0.63, respectively), and there were correlations between the VO2 τ and MRT and the forced expiratory volume in one second (FEV1) (r=-0.60; r=-0.53) and the distance traveled at 6MWT (DT-6MWT) (r=-0.61; r=-0.44) and DT-6MWT % predicted (r=-0.62; r=-0.46). The HR τ and MRT were correlated with DT-6MWT (r=-0.59; r=-0.58) and DT-6MWT % predicted (r=-0.62; r=-0.62). CONCLUSION: The slowing of cycle-ergometer VO2, and especially of HR on-kinetics, may be key markers of disease severity. Furthermore, airflow obstruction and reduced exercise capacity are associated with the slowing of patients' VO2 and HR on-kinetics.

The minimal important difference of the pulmonary functional status and dyspnea questionnaire in patients with severe chronic obstructive pulmonary disease.

BACKGROUND: The modified version of the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M) is used in patients with COPD to obtain information about their functional status. It consists of 3 components (change in activities, dyspnea and fatigue) ranging from 0 to 100 and has been shown to be responsive following pulmonary rehabilitation (PR). The interpretation of changes in PFSDQ-M score after an intervention is difficult in the absence of the minimal important difference (MID) of the PFSDQ-M. This study aims at investigating the MID of the PFSDQ-M. METHODS: We enrolled 301 patients with COPD (FEV1 42 ± 15%pred) that completed the PFSDQ-M before and after a 3-month PR program (∆Chronic Respiratory Disease Questionnaire (CRDQ) +16 ± 12 points, ∆Six-minute walking distance (6MWD) +47 ± 89 m, both p < 0.001). An anchor-based approach consisted of calculating the correlation between the ∆PFSDQ-M and anchors with an established MID (∆CRDQ and ∆6MWD). Linear regression analyses were performed to predict the MID from these anchors. Secondly several distribution-based approaches (Cohen's effect size, empirical rule effect size and standard error of measurement method) were used. RESULTS: Anchor-based estimates for the different PFSDQ-M-components were between -3 and -5 points based on CRDQ score and -6 (only calculated for change in activities) based on 6MWD. Using the distribution-based methods, the estimates of MID ranged from -3 to -5 points for the different components. CONCLUSIONS: We concluded that the estimate of MID of the PFSDQ-M after pulmonary rehabilitation corresponds to a change of 5 points (range - 3 to -6) in each component in patients with severe COPD.

Ausculta pulmonar: uma perspectiva teórica / Pulmonary auscultation: a theoretical perspective

A invenção do estetoscópio em 1816 por Laennec revolucionou a medicina no diagnóstico clínico das doenças pulmonares, pois possibilitou a ausculta clara dos sons respiratórios e a identificação desses sons de acordo com o comprometimento pulmonar. Atualmente, mesmo com toda a inovação tecnológica, a ausculta pulmonar ainda é parte imprescindível da semiologia do tórax no diagnóstico clínico de várias doenças pulmonares, sendo importante identificar e entender os sons respiratórios. Todavia, não há um consenso na literatura sobre a melhor terminologia empregada na classificação desses sons. O objetivo desta revisão foi apresentar as diferentes denominações empregadas aos sons respiratórios, considerando as implicações no aprendizado e na prática dos profissionais da saúde. Foi realizado um levantamento bibliográfico de estudos publicados em periódicos nacionais e internacionais e concluído que, apesar de várias tentativas, ainda há a necessidade de uma padronização da nomenclatura empregada, priorizando termos simples que facilitem o aprendizado e consequentemente, o diagnóstico clínico e o direcionamento das condutas empregadas, especialmente para o fisioterapeuta respiratório.