Effects of the intermittent intrapulmonary deflation technique on expiratory flow limitation: an in vitro study.

INTRODUCTION: The intermittent intrapulmonary deflation (IID) technique is a recent airway clearance technique that intends to delay the onset of expiratory flow limitation (EFL) during exhalation. We showed in a previous study that IID increased the expiratory volume of COPD patients compared to quiet breathing and positive expiratory pressure (PEP) therapy. We hypothesized that it was due to the attenuation of the EFL. OBJECTIVES: To verify the physiologic effects of IID and PEP techniques on EFL with a mechanical lung model. METHODS: A mechanical lung model was created to assess the effects of IID and PEP techniques. The thorax was simulated by a plexiglas box in which an adult test lung was connected. A calibration syringe simulated the inspiratory phase. Later, with activation of the IID, the expiratory phase was driven by the deflation generated by the device. With PEP, the expiration occurred maintaining an expiratory pressure between 5 and 10 cmH2O. A pneumotachograph and a pressure transducer were placed in series for flow, volumes and pressure measurements. RESULTS: The model reproduced physiological characteristics of EFL. However, the deflation of the model was slowed by IID and PEP, and flow remained almost constant, so flow limitation was reduced. CONCLUSION: The IID and PEP attenuate EFL and increase exhaled volume in the in vitro model.

European Respiratory Society statement on airway clearance techniques in adults with bronchiectasis.

Airway clearance techniques (ACTs) are part of the main management strategy for patients with bronchiectasis. Despite being a priority for patients, accessibility, implementation and reporting of ACTs are variable in clinical settings and research studies. This European Respiratory Society statement summarises current knowledge about ACTs in adults with bronchiectasis and makes recommendations to improve the future evidence base. A task force of 14 experts and two patient representatives (10 countries) determined the scope of this statement through consensus and defined six questions. The questions were answered based on systematic searches of the literature. The statement provides a comprehensive review of the physiological rationale for ACTs in adults with bronchiectasis, and the mechanisms of action along with the advantages and disadvantages of each ACT. Evidence on ACTs in clinical practice indicates that the most frequently used techniques are active cycle of breathing techniques, positive expiratory pressure devices and gravity-assisted drainage, although there is limited evidence on the type of ACTs used in specific countries. A review of 30 randomised trials for the effectiveness of ACTs shows that these interventions increase sputum clearance during or after treatment, reduce the impact of cough and the risk of exacerbations, and improve health-related quality of life. Furthermore, strategies for reducing the risk of bias in future studies are proposed. Finally, an exploration of patients' perceptions, barriers and enablers related to this treatment is also included to facilitate implementation and adherence to ACTs.

Systems on Top of Nasal Cannula Improve Oxygen Delivery in Patients with COVID-19: a Randomized Controlled Trial.

BACKGROUND: Treating hypoxemia while meeting the soaring demands of oxygen can be a challenge during the COVID-19 pandemic. OBJECTIVE: To determine the efficacy of the surgical facemask and the double-trunk mask on top of the low-flow oxygen nasal cannula on arterial partial pressure of oxygen (PaO2) in hypoxemic COVID-19 patients. DESIGN: Randomized controlled trial. PARTICIPANTS: Hospitalized adults with COVID-19 and hypoxemia treated with the low-flow nasal cannula were enrolled between November 13, 2020, and March 05, 2021. INTERVENTIONS: Patients were randomized in a 1:1:1 ratio to receive either the nasal cannula alone (control) or the nasal cannula covered by the surgical facemask or the double-trunk mask. Arterial blood gases were collected at baseline and 30 min after the use of each system. The oxygen output was adapted afterwards to retrieve the baseline pulse oxygen saturation. The final oxygen output value was recorded after another 30-min period. MAIN MEASURES: The primary outcome was the absolute change in PaO2. Secondary outcomes included changes in oxygen output, arterial partial pressure of carbon dioxide (PaCO2), vital parameters, and breathlessness. KEY RESULTS: Arterial blood samples were successfully collected in 24/27 (8 per group) randomized patients. Compared to the nasal cannula alone, PaO2 increased with the surgical facemask (mean change: 20 mmHg, 95% CI: 0.7-38.8; P = .04) and with the double-trunk mask (mean change: 40 mmHg; 95% CI: 21-59; P < .001). Oxygen output was reduced when adding the surgical facemask (median reduction: 1.5 L/min [95% CI: 0.5-4.5], P < .001) or the double-trunk mask (median reduction: 3.3 L/min [95% CI: 2-5], P < .001). The double-trunk mask was associated with a PaCO2 increase of 2.4 mmHg ([95% CI: 0-4.7], P = .049). Neither mask influenced vital parameters or breathlessness. CONCLUSIONS: The addition of the surgical facemask or the double-trunk mask above the nasal cannula improves arterial oxygenation and reduces oxygen consumption.

Effects of surgical facemasks on perceived exertion during submaximal exercise test in healthy children.

Only a few data associated to wearability of facemask during exercise are available in children. The aim of the study was to evaluate the effect of wearing a facemask on perceived exertion (primary aim), dyspnea, physical performance, and cardiorespiratory response during a submaximal exercise test in children aged between 8 and 12 years. This study was performed in 2021 in healthy volunteer children from 8 to 12 years. They performed prospectively two 1-min sit-to-stand tests (STST), with or without a surgical facemask. The perceived exertion (modified Borg scale), dyspnea (Dalhousie scale), heart rate, and pulsed oxygen saturation were recorded before and after STST. The STST measured the submaximal performance. Thirty-eight healthy children were recruited (8-9 years: n = 19 and 10-11 years: n = 19). After the STST, the perceived exertion increased with or without a facemask (8-9 years group: + 1 [0.6; 1.4] and + 1.6 [1.0; 2.1] - 10-11 years group: + 1.3 [0.7; 1.8] and + 1.9 [1.3; 2.6]) and it was higher with the facemask. The difference between the two conditions in perceived exertion was not clinically relevant in any group (mBorgf: 0.56 pts and 0.68 pts, respectively). The different domains of dyspnea assessed with Dalhousie scale were not influenced by the facemask. The submaximal performance measured by the STST was not changed by the mask whatever the age group. The cardio-respiratory demand was not clinically modified.Conclusion: The surgical facemask had no impact on dyspnea, cardiorespiratory parameters, and exercise performance during a short submaximal exercise in healthy children.

Impact of surgical mask on performance and cardiorespiratory responses to submaximal exercise in COVID-19 patients near hospital discharge: A randomized crossover trial.

BACKGROUND: Wearing a surgical mask in hospitalized patients has become recommended during care, including rehabilitation, to mitigate coronavirus disease 2019 (COVID-19) transmission. However, the mask may increase dyspnoea and raise concerns in promoting rehabilitation activities in post-acute COVID-19 patients. OBJECTIVE: To evaluate the impact of the surgical mask on dyspnoea, exercise performance and cardiorespiratory response during a 1-min sit-to-stand test in hospitalized COVID-19 patients close to discharge. METHODS: COVID-19 patients whose hospital discharge has been planned the following day performed in randomized order two sit-to-stand tests with or without a surgical mask. Outcome measures were recorded before, at the end, and after two minutes of recovery of each test. Dyspnoea (modified Borg scale), cardiorespiratory parameters and sit-to-stand repetitions were measured. RESULTS: Twenty-eight patients aged 52 ± 10 years were recruited. Compared to unmasked condition, dyspnoea was significantly higher with the mask before and at the end of the sit-to-stand test (mean difference[95%CI]: 1.0 [0.6, 1.4] and 1.7 [0.8, 2.6], respectively). The difference was not significant after the recovery period. The mask had no impact on cardiorespiratory parameters nor the number of sit-to-stand repetitions. CONCLUSION: In post-acute COVID-19 patients near hospital discharge, the surgical mask increased dyspnoea at rest and during a submaximal exercise test but had no impact on cardiorespiratory response or exercise performance. Patients recovering from COVID-19 should be reassured that wearing a surgical facemask during physical or rehabilitation activities is safe. These data may also mitigate fears to refer these patients in rehabilitation centres where mask-wearing has become mandatory.

The effect of tongue elevation muscle training in patients with obstructive sleep apnea: A randomised controlled trial.

BACKGROUND: Oropharyngeal myofunctional therapy is a multi-component therapy effective to reduce the severity of obstructive sleep apnoea (OSA). However, existing protocols are difficult to replicate in the clinical setting. There is a need to isolate the specific effectiveness of each component of the therapy. OBJECTIVE: To assess the effects of a 6 weeks tongue elevation training programme in patients with OSA. METHODS: We conducted a multicentre randomised controlled trial. Eligible participants were adults diagnosed with moderate OSA who presented low adherence to continuous positive airway pressure therapy (mean use <4 h per night). The intervention group completed a 6 weeks tongue elevation training protocol that consisted in anterior tongue elevation strength and endurance tasks with the Iowa Oral Performance Instrument. The control group completed a 6 weeks sham training protocol that involved expiratory muscle training at very low intensity. Polygraphy data, tongue force and endurance, and OSA symptoms were evaluated pre- and post-intervention. The primary outcome was apneoa-hypopnea index (AHI). RESULTS: Twenty-seven patients (55 ± 11 years) were recruited. According to modified intention-to-treat analysis (n = 25), changes in AHI and c did not significantly differ between groups. Daytime sleepiness (Epworth Sleepiness Scale) and tongue endurance significantly improved in the intervention group compared to the control group (p = .015 and .022, respectively). In the intervention group, 75% of participants had a decrease in daytime sleepiness that exceeded the minimal clinically important difference. CONCLUSION: Six weeks of tongue elevation muscle training had no effect on OSA severity.

Physical therapy treatment of hypermobile Ehlers-Danlos syndrome: A systematic review.

Physiotherapy techniques are regularly prescribed in the hypermobile type Ehlers-Danlos syndrome (hEDS) and they are appreciated by the patients. The objective of this systematic review was to investigate the effect of the different physiotherapy techniques related to the children and adult patients with hEDS. PubMed, SPORTDiscus, Cochrane Library, PEDro, Scopus, and Embase databases were analyzed from inception to April 2020. Characteristics of the studies (authors), patients (sample size, sex, age, Beighton score), and nonpharmacological treatment (length of the program, number of session, duration of the session, and type of intervention), and the results with the dropout rate were extracted. From the 1045 retrieved references, 6 randomized controlled trial with a sample size ranging from 20 to 57 patients were included in the systematic review. There was a huge heterogeneity in the interventions. The durations of the program were from 4 to 8 weeks. Pain or proprioception demonstrated significant improvements in the intervention group regardless of the type of intervention. A benefit of the inspiratory muscle training was observed on functional exercise capacity. The quality of life was systematically improved. Physiotherapy benefits on proprioception and pain in patients with hEDS even if robust randomized control studies are missing.

Screening for oropharyngeal dysphagia in adult patients with neuromuscular diseases using the Sydney Swallow Questionnaire.

INTRODUCTION/AIMS: Oropharyngeal dysphagia is common in patients with neuromuscular diseases (NMDs). Its early recognition is vital for proper management. We tested a large cohort of adult NMD patients for oropharyngeal dysphagia using the Sydney Swallow Questionnaire (SSQ). We also looked for possible differences in characteristics of oropharyngeal dysphagia in various NMD groups and diseases. Finally, we compared results of this screening with those from their corresponding medical records for eventual "clinical history" of dysphagia. METHODS: We asked patients to fill in the SSQ during follow-up outpatient visits at our neuromuscular reference center. A total score above the cutoff score of 118.5 out of 1700 was indicative of oropharyngeal dysphagia. RESULTS: Of the 304 adult patients assessed for eligibility, 201 NMD patients (96 women and 105 men, aged 49.0 ± 16.2 years) were included and tested in this study. Oropharyngeal dysphagia was detected in 45% of all the NMD patients when using the SSQ, whereas only 12% had a positive medical record for dysphagia. The median SSQ scores for patients with myotonic syndromes (including myotonic dystrophy type 1), with amyotrophic lateral sclerosis, and with facioscapulohumeral dystrophy were above the cutoff score. The SSQ scores obtained revealed distinct oropharyngeal dysphagia characteristics in the different NMD groups and diseases. DISCUSSION: The SSQ tests positively for oropharyngeal dysphagia in a higher proportion of NMD patients compared with their medical records. The distinct oropharyngeal dysphagia characteristics we revealed in different NMD groups and diseases may help to elaborate adapted clinical approaches in the management of oropharyngeal dysphagia.

Effects of rehabilitation methods on lower-limb muscle function and functional performance in patients with cystic fibrosis: A systematic review.

OBJECTIVE: To investigate the effects of rehabilitation methods on leg muscle function and functional performance in cystic fibrosis. DATA SOURCES: A literature search was conducted in PubMed (MEDLINE), Scopus and the Cochrane Library from inception to October 12, 2020. A secondary hand search through reference lists from identified articles was conducted. REVIEW METHODS: Three authors independently checked the full-text copies for eligibility of relevant articles. Randomized controlled trials were included. Methodological quality was assessed using the Physiotherapy Evidence Database scale. The PRISMA guidelines were followed. Results suggestive of leg muscle function (e.g. strength, power, endurance, and fatigue) and functional performance were reported. RESULTS: The search identified 8 studies (233 patients). The overall quality of these articles was good. Rehabilitation modalities investigated were physical exercises (aerobic, anaerobic and resistance training) (n = 7) and neuromuscular electrical stimulation (n = 1). Most studies (n = 4) reported on the effects of combined aerobic and resistance training and showed improvement on leg strength when exercises were supervised. Aerobic training alone or the use of neuromuscular electrical stimulation also enhanced leg strength, whereas anaerobic training did not. Two studies evaluated leg fatigue and found no improvement compared to standard care. One study assessed the effect of exercises on functional performance and found no improvement when compared to standard care. No studies emphasized the impact of rehabilitation methods on leg muscle endurance or power. CONCLUSION: Combined aerobic and resistance training enhances leg muscle strength in cystic fibrosis. There is insufficient data on other leg muscle outcomes, nor on alternative rehabilitation strategies.

Assessment and rehabilitation of tongue motor skills with myofunctional therapy in obstructive sleep apnea: a systematic review and meta-analysis.

STUDY OBJECTIVES: The first objective was to compare tongue motor skills between patients with obstructive sleep apnea (OSA) and healthy subjects. Secondly, the effect of oropharyngeal myofunctional therapy (MFT) on the tongue muscular qualities of patients with OSA was evaluated. METHODS: Searches were conducted in five electronic databases until July 2023. Risk of bias was assessed via the Joanna Briggs Institute appraisal checklist for cross-sectional studies (aim #1) and the PEDro scale for randomized controlled trials (aim #2). Pooled standardized mean differences (SMD) and 95% confidence intervals were calculated using a random-effects model. RESULTS: Thirteen studies including 520 adults and one study including 92 children addressed aim #1. Compared to healthy adults, individuals with OSA had no significant difference in tongue protrusion strength (9 studies, n=366, SMD [95%CI]; -0.00 [-0.45, 0.44]) or endurance (5 studies, n=125; 0.31 [-0.26, 0.88]) but presented a lower tongue elevation strength (6 studies, n=243; 1.00 [0.47, 1.53]) and elevation endurance (3 studies, n=98; 0.52 [0.11, 0.94]). In pediatric, tongue elevation strength was lower but elevation endurance was higher in children with OSA than healthy children. Two randomized controlled trials (28 adults, 54 children) addressed aim #2 and were of poor methodological quality. In these studies, MFT improved tongue motor skills in patients with OSA. CONCLUSIONS: Tongue elevation motor skills are decreased in adults with OSA whereas tongue protrusion motor skills seem preserved. Very few data are available in children. There is also too little data about the impact of myofunctional therapy on tongue motor skills. SYSTEMATIC REVIEW REGISTRATION: Prospero registration number: CRD42022307148.

The intermittent intrapulmonary deflation technique for airway clearance in patients with cystic fibrosis: A randomized trial.

BACKGROUND: Cystic fibrosis (CF) is a muco-obstructive lung disease characterized by thick sputum with abnormal rheological properties. The intermittent intrapulmonary deflation (IID) is a new instrumental airway clearance technique (ACT) that aims to decrease the sputum viscoelastic properties. This study assessed the benefits of adding the IID technique to a conventional ACT in patients with CF hospitalized for intravenous antibiotic therapy. METHODS: Participants with CF accustomed to autogenic drainage (AD) as their standard ACT received, in a randomized order, a 30-min session of either AD alone or AD combined with IID (AD+IID). Sputum was collected during each ACT regimens and for a 24-hour period following both sessions. Sputum wet weight, dry weight, solids content and rheological properties were analyzed. Cough events occurring during and over 2 h post ACT were compared between both regimens. RESULTS: Seventeen patients with CF (aged 29 ± 11 years; FEV1%: 57.1 ± 20.1) were analysed. The sputum wet weight collected during AD alone was significantly higher than during AD+IID (8.11 ± 6.93 vs 5.40 ± 4.11 respectively, p = 0.01). The sputum rheological properties did not significantly differ between group. There were more cough episodes during AD alone compared to AD+IID (median [IQR]: 8 [5-15.5] vs 5 [3.5-11.0] respectively, p = 0.02). CONCLUSIONS: In participants with CF accustomed to AD, adding the IID technique in combination to AD does not confer a clear benefit on airway clearance in the short term. Clinical Trials register: NCT04157972.

The Impact of Positive Expiratory Pressure Therapy on Hyperinflation in Patients With COPD.

BACKGROUND: Lung hyperinflation is a typical clinical feature of patients with COPD. Given the association between breathing at elevated lung volumes and the manifestation of severe debilitating symptoms, therapeutic interventions such as positive expiratory pressure (PEP) therapy and its variations (temporary, oscillatory) have been devised to mitigate lung hyperinflation. However, the efficacy of these interventions remains to be conclusively demonstrated. METHODS: A systematic review with meta-analysis of randomized trials was conducted following the PRISMA guidelines. Seven databases were screened with no date or language restriction. Two authors independently applied eligibility criteria and assessed the risk of bias of included studies using the Cochrane risk-of-bias tool. Outcomes were lung hyperinflation measures detected through changes in inspiratory capacity (IC), functional residual capacity (FRC), total lung capacity (TLC), and residual volume (RV), as well as FEV1, FVC, dyspnea, and physical capacity. Pooled standardized mean differences (SMDs) or mean differences (MDs) and 95% CI were calculated using a random-effects model. RESULTS: Seven trials, all with a high risk of bias, were included. Compared to control group, RV significantly decreased (4 studies, n = 231; SMD -0.42 [95% CI -0.77 to -0.08], P = .02), dyspnea improved (n = 321, SMD -1.17 [95% CI -1.68 to -0.66], P < .001), and physical capacity increased (5 studies, n = 311; MD 30.1 [95% CI 19.2-41.0] m, P < .001) with PEP therapy. There was no significant difference between PEP therapy and the control group in TLC, FVC, or FEV1. Only one study reported changes in inspiratory capacity as well as FRC. CONCLUSIONS: In patients with COPD, the effect of PEP therapy on lung hyperinflation is unclear owing to the non-consistent change in lung hyperinflation outcomes, insufficient data, and lack of high-quality trials. Dyspnea and physical capacity might improve with PEP therapy.

Consensus on Nasal Irrigation in Infants: A Delphi Study.

INTRODUCTION: Nasal irrigation is regularly used in infants to relieve upper airway symptoms. However, because there is no consensus on good practice, nasal irrigation in infants is described and applied heterogeneously among clinicians and between clinical trials. OBJECTIVE: The aim of this study was to establish consensus regarding the use of nasal irrigation in infants. METHODS: A panel of Belgian physiotherapists and physicians experienced in performing nasal irrigation in infants were surveyed using the Delphi technique. Three survey rounds were used. Participants rated their level of (dis)agreement to each statement in each round using a 6-point Likert scale. Consensus was defined for statements which collected at least 75% of responses in agreement or disagreement. The questionnaire of Round 1 was built on nasal irrigation practice habits previously collected from parents, childcare workers, and healthcare professionals. Questionnaires from rounds 2 and 3 were amended based on experts written feedback. RESULTS: Thirty experts (12 physicians and 18 physiotherapists) completed all 3 questionnaires. Consensus was achieved for 47 of 75 statements (63%) distributed over the following domains: "contraindications," "indications and frequency of use," "irrigation means," "solution preparation," "solution volume," "realization of the technique," and "assessment of the efficacy of nasal irrigation." CONCLUSION: This study provides the first well-constructed consensus on good practice on nasal irrigation in infants. Consensus on several statements across different domains were established but require validation in future trials. This study also proposes direction for future research focusing on statements that did not reach consensus.

Short-Term Effect of Intermittent Intrapulmonary Deflation on Air Trapping in Patients With COPD.

BACKGROUND: Intermittent intrapulmonary deflation is an airway clearance technique that generates negative pressure during expiratory phases. This technology is intended to reduce air trapping by delaying the onset of air-flow limitation during exhalation. The objective of this study was to compare the short-term effect of intermittent intrapulmonary deflation versus positive expiratory pressure (PEP) therapy on trapped gas volume and vital capacity (VC) in patients with COPD. METHODS: We designed a randomized crossover study in which the participants with COPD received a 20-min session of both intermittent intrapulmonary deflation and PEP therapy on separate days and in random order. Lung volumes were measured via body plethysmography and helium dilution techniques, and spirometric outcomes were reviewed before and after each therapy. The trapped gas volume was estimated via functional residual capacity (FRC), residual volume (RV), and by the difference between FRC obtained through body plethysmography and helium dilution. Each participant also performed 3 VC maneuvers, from total lung capacity to RV with both devices. RESULTS: Twenty participants with COPD (mean ± SD ages 67 ± 8 y; FEV1 48.1 ± 17.0%) were recruited. There was no difference between the devices in FRC or trapped gas volume. However, the RV decreased more during intermittent intrapulmonary deflation compared with PEP. The intermittent intrapulmonary deflation mobilized a larger expiratory volume than PEP during the VC maneuver (mean difference 389 mL, 95% CI 128-650 mL; P = .003). CONCLUSIONS: The RV decreased after intermittent intrapulmonary deflation compared with PEP, but this effect was not captured by other estimates of hyperinflation. Although the expiratory volume obtained during the VC maneuver with intermittent intrapulmonary deflation was greater than that obtained with PEP, the clinical importance as well as the long-term effects remain to be determined.(ClinicalTrials.gov registration NCT04157972.).

Breathing Control Exercises Delivered in a Group Setting for Patients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial.

Breathing control exercises are an important component of occupational therapy in patients with chronic obstructive pulmonary disease (COPD). Delivering these exercises in group settings may enhance their benefits. Therefore, this study assessed the effectiveness of breathing control exercises delivered in a group format to patients with severe COPD remitting from an acute pulmonary exacerbation. This randomized controlled trial of 6 weeks' duration compared the addition of breathing exercise sessions delivered in a group setting to a standard exercise inpatient rehabilitation program (usual care) versus usual care alone. The standard exercise program consisted of endurance and strength training and therapeutic patient education. The intervention group received, in addition to usual care, 20 sessions of 30 min duration of breathing control exercises in a group setting. The primary outcome was quality of life (Saint George's Respiratory Questionnaire). Secondary outcomes were the COPD assessment test, modified Borg scale, handgrip strength test, and five-time sit-to-stand test. Thirty-seven patients aged 69 ± 7 years were recruited. After the 6-week period, all outcomes significantly improved and exceeded the minimal clinically important difference in the intervention group only. Between-group changes were significant for each outcome. Conclusions: breathing control exercises in a group setting provide clinically relevant benefits in patients with severe COPD who are remitting from an acute pulmonary exacerbation.

Ex-vivo effects of intrapulmonary percussive ventilation on sputum rheological properties.

Intrapulmonary percussive ventilation (IPV) has been postulated to enhance mucociliary clearance by improving tracheobronchial sputum rheological properties. The IPV effects on linear (viscoelasticity) and non-linear (flowing) rheological properties of 40 sputum samples collected from 19 patients with muco-obstructive lung diseases were investigated ex-vivo. Each sputum sample was split into 4 aliquots. These aliquots were independently placed in a circuit connected on one side to an IPV device and on the other side to a lung model that simulated spontaneous adult breaths. IPV was superimposed on simulated breathing. Three aliquots were exposed to a different IPV setting, modifying either percussion frequency or amplitude (4 Hz-200 L/min, 10 Hz-200 L/min, 10 Hz-140 L/min). One aliquot was only exposed to breathing (IPV was switched off, control condition). Each aliquot underwent 5 min of the pre-fixed mechanical stimulation before being recollected to proceed to rheological analysis. Neither percussion frequencies nor amplitudes had a significant impact on any sputum rheological properties studied. These results need to be confirmed in vivo.

Role of Broca's area in implicit motor skill learning: evidence from continuous theta-burst magnetic stimulation.

Complex actions can be regarded as a concatenation of simple motor acts, arranged according to specific rules. Because the caudal part of the Broca's region (left Brodmann's area 44, BA 44) is involved in processing hierarchically organized behaviors, we aimed to test the hypothesis that this area may also play a role in learning structured motor sequences. To address this issue, we investigated the inhibitory effects of a continuous theta-burst TMS (cTBS) applied over left BA 44 in healthy subjects, just before they performed a serial RT task (SRTT). SRTT has been widely used to study motor skill learning and is also of interest because, for complex structured sequences, subjects spontaneously organize them into smaller subsequences, referred to as chunks. As a control, cTBS was applied over the vertex in another group, which underwent the same experiment. Control subjects showed both a general practice learning effect, evidenced by a progressive decrease in RT across blocks and a sequence-specific learning effect, demonstrated by a significant RT increase in a pseudorandom sequence. In contrast, when cTBS was applied over left BA 44, subjects lacked both the general practice and sequence-specific learning effects. However, surprisingly, their chunking pattern was preserved and remained indistinguishable from controls. The present study indicates that left BA 44 plays a role in motor sequence learning, but without being involved in elementary chunking. This dissociation between chunking and sequence learning could be explained if we postulate that left BA 44 intervenes in high hierarchical level processing, possibly to integrate elementary chunks together.

Performance of Different Low-Flow Oxygen Delivery Systems.

BACKGROUND: The delivery of a high and consistent [Formula: see text] is imperative to treat acute hypoxemia. The objective of this study was to analyze the effective inspired oxygen concentration delivered by different low-flow oxygen therapy systems challenged with different oxygen flows and respiratory patterns in an experimental lung model. METHODS: An adult lung model ventilated in volume control mode simulated different respiratory patterns to obtain mean inspiratory flow of 22.5, 30.0, 37.5, or 45.0 L/min. The oxygen concentration sampled inside the lung model by nasal cannula, simple face mask, non-rebreather mask, and double-trunk mask above nasal cannula tested at oxygen flows of 10, 12.5, and 15 L/min was quantified. The 3 masks were sealed tight onto the model's airway opening. They were also tested with standardized leaks to determine their clinical performance. RESULTS: All oxygen delivery systems delivered higher oxygen concentration with increasing oxygen flows, regardless of the respiratory pattern. Within each device, the increase in inspiratory flow decreased oxygen concentration when using nasal cannula (P = .03), the simple face mask (P = .03), but not the non-rebreather mask (P = .051) nor the double-trunk mask (P = .13). In sealed condition, the double-trunk mask outperformed the non-rebreather mask and simple face mask (P < .001); mean oxygen concentration was 84.2%, 68.5%, and 60.8%, respectively. Leaks amplified oxygen concentration differences between the double-trunk mask and the other masks as the oxygen delivery decreased by 4.6% with simple face mask (95% CI 3.1-6.1%, P < .001), 7.8% with non-rebreather mask (95% CI 6.3-9.3%, P < .001), and 2.5% with double-trunk mask (95% CI 1-4%, P = .002). With leaks, the oxygen concentration provided by the simple face mask and the non-rebreather mask was similar (P = .15). CONCLUSIONS: Lung oxygen concentration values delivered by the double-trunk mask were higher than those obtained with other oxygen delivery systems, especially when leaks were present.

Prevalence and risk factors of musculoskeletal pain in patients with chronic obstructive pulmonary disease: A systematic review.

OBJECTIVES: This systematic review aimed to discuss the prevalence and the risk factors of the musculoskeletal pain in chronic obstructive pulmonary disease (COPD). DATA SOURCE AND STUDY SELECTION: Four databases were analysed (Scopus, PubMed, Cochrane and EMBASE). We excluded systematic reviews, meta-analyses, conference abstracts and case reports. Two authors independently checked for the eligibility of the relevant articles. The risk of bias was evaluated using the Newcastle Ottawa Quality Assessment Scale and the Joanna Briggs Institute critical appraisal checklist. The selection and evaluation of studies followed the PRISMA guidelines. RESULTS: Twenty studies were retrieved, including from 21 to 7952 patients with COPD. The prevalence of pain was highly heterogeneous across studies: 7-89.7%. Pain was mostly reported in the lumbar (7-69%) and cervical spine (11-48.3%) and the chest (44-82.8%). The main risk factors for developing pain were old age, sex (female), level of physical activity (low) and comorbidities. CONCLUSION: Pain is a very common symptom in patients with COPD. Despite this, few clinical trials have investigated the pain. It appears to be located primarily in the lumbar, cervical and thoracic regions and facilitated by being a female, a low level of physical activity, comorbidity(ies) and old age.