Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study.

BACKGROUND: Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving transcutaneous electrical stimulation of the diaphragm (TEDS) is increasing but none report results for diaphragmatic measurements, and they lack power. We hypothesised that the use of TEDS would decrease diaphragmatic dysfunction and improve respiratory muscle strength in patients in ICU. METHODS: We conducted a controlled trial to assess the impact of daily active electrical stimulation versus sham stimulation on the prevention of diaphragm dysfunction during the weaning process from mechanical ventilation. The evaluation was based on ultrasound measurements of diaphragm thickening fraction during spontaneous breathing trials. We also measured maximal inspiratory muscle pressure (MIP), peak cough flow (PEF) and extubation failure. RESULTS: Sixty-six patients were included and randomised using a 1:1 ratio. The mean number of days of mechanical ventilation was 10 ± 6.8. Diaphragm thickening fraction was > 30% at the SBT for 67% of participants in the TEDS group and 54% of the Sham group (OR1.55, 95% CI 0.47-5.1; p = 0.47). MIP and PEF were similar in the TEDS and Sham groups (respectively 35.5 ± 11.9 vs 29.7 ± 11.7 cmH20; p = 0.469 and 83.2 ± 39.5 vs. 75.3 ± 34.08 L/min; p = 0.83). Rate of extubation failure was not different between groups. CONCLUSION: TEDS did not prevent diaphragm dysfunction or improve inspiratory muscle strength in mechanically ventilated patients. TRIAL REGISTRATION: Prospectively registered on the 20th November 2019 on ClinicalTrials.gov Identifier NCT04171024.

Oxygen Uptake and Heart Rate On-Kinetics during Prehabilitation in Patients with Scheduled Non-Small Cell Lung Cancer Resection.

BACKGROUND: Oxygen uptake (V̇O2) and heart rate (HR) kinetics during a constant work-rate test (CWRT) are used to evaluate the response to exercise in healthy subjects as well as subjects with various pathologies. OBJECTIVES: This study aimed to explore the feasibility of these measures and their responsiveness to a prehabilitation program in patients with non-small cell lung cancer (NSCLC). METHOD: This study is preregistered (NCT04041297) ancillary analysis of a subgroup of individuals with NSCLC included in the Preo-Dens study (NCT03936764). Thirty individuals performed a moderate-CWRT before and after a 15-session prehabilitation program between July 2019 and April 2021. V̇O2 and HR on-kinetics were extracted from the first 240 s of breath-by-breath data using Box-Jenkins transfer functions. RESULTS: Pre/post V̇O2 on-kinetic feature values were reliable for 25/30 participants, and pre/post HR kinetic feature values were reliable for 19/30. V̇O2 time constant (τ) and mean response time reduced from pre-post prehabilitation (mean difference -7.8 s; 95% CI: -14.6 to -1.0, and -8.4 s; 95% CI: -14.7 to -2.0, respectively). For HR on-kinetics, τ did not change from pre-post prehabilitation (median difference -4.0 s; 95% CI: -36.0 to +11.0). V̇O2 and HR response amplitudes reduced significatively from pre-post prehabilitation (mean difference -38.6 mL/min; 95% CI: -73.3 to -3.9, and -3.1 beats/min; 95% CI: -6.4 to -0.2, respectively). CONCLUSION: V̇O2 on-kinetic analysis during moderate-CWRT is feasible in individuals with scheduled NSCLC resection, and results are responsive to prehabilitation. These results support a true speeding of the adaptation of aerobic metabolism after a 15-session prehabilitation program.

Effects of exercise training in people with non-small cell lung cancer before lung resection: a systematic review and meta-analysis.

INTRODUCTION: Exercise training before lung resection for non-small cell lung cancer is believed to decrease postoperative complications (POC) by improving cardiorespiratory fitness. However, this intervention lacks a strong evidence base. AIM: To assess the effectiveness of preoperative exercise training compared with usual care on POC and other secondary outcomes in patients with scheduled lung resection. METHODS: A systematic search of randomised trials was conducted by two authors. Meta-analysis was performed, and the effect of exercise training was estimated by risk ratios (RR) and mean differences, with their CIs. Clinical usefulness was estimated according to minimal important difference values (MID). RESULTS: Fourteen studies involving 791 participants were included. Compared with usual care, exercise training reduced overall POC (10 studies, 617 participants, RR 0.58, 95% CI 0.45 to 0.75) and clinically relevant POC (4 studies, 302 participants, Clavien-Dindo score ≥2 RR 0.42, 95% CI 0.25 to 0.69). The estimate of the effect of exercise training on mortality was very imprecise (6 studies, 456 participants, RR 0.66, 95% CI 0.20 to 2.22). The main risks of bias were a lack of participant blinding and selective reporting. Exercise training appeared to improve exercise capacity, pulmonary function and also quality of life and depression, although the clinical usefulness of the changes was unclear. The quality of the evidence was graded for each outcome. CONCLUSION: Preoperative exercise training leads to a worthwhile reduction in postoperative complications. These estimates were both accurate and large enough to make recommendations for clinical practice.

Muscle weakness, functional capacities and recovery for COVID-19 ICU survivors.

BACKGROUND: Few studies have evaluated muscle strength in COVID-19 ICU survivors. We aimed to report the incidence of limb and respiratory muscle weakness in COVID-19 ICU survivors. METHOD: We performed a cross sectional study in two ICU tertiary Hospital Settings. COVID-19 ICU survivors were screened and respiratory and limb muscle strength were measured at the time of extubation. An ICU mobility scale was performed at ICU discharge and walking capacity was self-evaluated by patients 30 days after weaning from mechanical ventilation. RESULTS: Twenty-three patients were included. Sixteen (69%) had limb muscle weakness and 6 (26%) had overlap limb and respiratory muscle weakness. Amount of physiotherapy was not associated with muscle strength. 44% of patients with limb weakness were unable to walk 100 m 30 days after weaning. CONCLUSION: The large majority of COVID-19 ICU survivors developed ICU acquired limb muscle weakness. 44% of patients with limb weakness still had severely limited function one-month post weaning.

Energy conservation technique improves dyspnoea when patients with severe COPD climb stairs: a randomised crossover study.

In this randomised, crossover trial, 22 patients with severe chronic obstructive pulmonary disease climbed six flights of stairs (108 steps) twice, under two test conditions: (1) energy conservation technique (ECT): participants were asked to rest for at least 5 seconds every three steps and (2) control condition: participants climbed the stairs at their own pace. Significant lower dyspnoea (primary outcome), leg discomfort, minute ventilation and capillary blood lactate under the ECT condition were found, with no change in total task time. CLINICAL TRIAL REGISTRATION: NCT03564028.

ICU outcomes can be predicted by noninvasive muscle evaluation: a meta-analysis.

BACKGROUND: The relationship between muscle function in critically ill patients assessed using bedside techniques and clinical outcomes has not been systematically described. We aimed to evaluate the association between muscle weakness assessed by bedside evaluation and mortality or weaning from mechanical ventilation, and the capacity of each evaluation tool to predict outcomes. METHODS: Five databases (PubMed, Embase, CINAHL, Cochrane Library, Science Direct) were searched from January 2000 to December 2018. Data were extracted and random effects meta-analyses were performed. RESULTS: 60 studies were analysed, including 4382 patients. Intensive care unit (ICU)-related muscle weakness was associated with an increase in overall mortality with odds ratios ranging from 1.2 (95% CI 0.60-2.40) to 4.48 (95% CI 1.49-13.42). Transdiaphragmatic twitch pressure had the highest predictive capacity for overall mortality, with a sensitivity of 0.87 (95% CI 0.76-0.93) and a specificity of 0.36 (95% CI 0.27-0.43). The area under the curve (AUC) was 0.74 (95% CI 0.70-0.78). Muscle weakness was associated with an increase in mechanical ventilation weaning failure rate with an odds ratio ranging from 2.64 (95% CI 0.72-9.64) to 19.07 (95% CI 9.35-38.9). Diaphragm thickening fraction had the highest predictive capacity for weaning failure with a sensitivity of 0.76 (95% CI 0.67-0.83) and a specificity of 0.86 (95% CI 0.78-0.92). The AUC was 0.86 (95% CI 0.83-0.89). CONCLUSION: ICU-related muscle weakness detected by bedside techniques is a serious issue associated with a high risk of death or prolonged mechanical ventilation. Evaluating diaphragm function should be a clinical priority in the ICU.

High flow nasal therapy during early pulmonary rehabilitation in patients with acute severe exacerbation of COPD: beneficial or illusory?

In study "Effect of high-flow nasal therapy during early pulmonary rehabilitation in patients with severe AECOPD: a randomized controlled study" by Tung et al., authors concluded HFNT utilization led to enhanced exercise tolerance and a reduction of systemic inflammation. Nevertheless, some points requires additional discussion, the conclusion of the trial seems overstated. The baseline differences between groups induces substantial modifications in the conclusions of this trial. HFNT does not seem to add any benefit on exercise tolerance or systemic inflammation, nor on pulmonary function. The only difference that remained significant in homogenous statistical significance is dyspnea on the mMRC scale but clinical significance is highly questionable.

Nasal high flow does not improve exercise tolerance in COPD patients recovering from acute exacerbation: A randomized crossover study.

BACKGROUND AND OBJECTIVE: We hypothesized that by reducing respiratory work and improving gas exchange, nasal high flow (NHF) would improve exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) following respiratory exacerbation. METHODS: This was a monocentric, randomized, controlled crossover study. Patients with severe to very severe COPD carried out two high-intensity constant work-rate exercise tests (CWRET) with and without NHF on two consecutive days. The primary outcome was the mean difference in endurance time between both conditions. The secondary aims included vastus lateralis oxygenation (StO2 ), dyspnoea, leg discomfort, maximal inspiratory pressure (MIP), transcutaneous CO2 pressure (PtcCO2 ), respiratory rate (RR), heart rate (HR) and pulsed O2 saturation (SpO2 ), as well as the patients' opinions of the device. RESULTS: A total of 19 patients were included (mean forced expiratory volume in 1 s = 28.7 ± 10.8%, age = 62.1 ± 9.1 years). No significant differences in endurance time during the CWRET were found between the two test conditions (-66.58 (95% CI: -155.9 to 22.7) s, P = 0.12). StO2 , PtCO2 and HR were reduced at the end of the exercise with NHF (-2.1% (95% CI: -4.3 to -0.0); -1.3 mm Hg (95% CI: -2.5 to -0.2); -2.7 bpm (95% CI: -5.0 to -0.5), respectively, P ≤ 0.05). No significant differences were found for any of the other secondary outcomes. Half of the patients evaluated the device as being moderately to very uncomfortable. CONCLUSION: NHF during exercise did not increase endurance time in patients with COPD following exacerbation. CLINICAL TRIAL REGISTRATION: NCT03058081 at clinicaltrials.gov.

Changes in Cycle-Ergometer Performance during Pulmonary Rehabilitation Predict COPD Exacerbation.

Early diagnosis of COPD exacerbations is vital. Exacerbations are characterised by an increase in dyspnoea that could be affect physical capacity. Changes in the physical capacity of patients with COPD during pulmonary rehabilitation could provide a predictive indication regarding the occurrence of exacerbation. This was a retrospective study of forty for patients with COPD who participated in a pulmonary rehabilitation programme between January 2015 and October 2018. Patients to have experienced at least one exacerbation during their pulmonary rehabilitation programme are included. The performance variable and dyspnoea on the cycle ergometer and the treadmill were collected during the five sessions prior to the exacerbation and the three sessions following the exacerbation. Seventy exacerbations were analysed. We found a significant decrease in the performance on the cycle ergometer during the last session before exacerbation compared with previous sessions (mean difference: 74.5% (95%CI 12.6-136.5); p < 0.01). The optimal threshold value was a 17% decrease in performance compared to the previous training session. Sensitivity was 0.46 (95%CI 0.34-0.59), specificity was 0.83 (95%CI 0.72-0.91) and the area under the curve was 0.65 (95%CI 0.56-0.74) (p < 0.01). The analysis of performance data from cycle ergometer is a potentially useful method to predict the occurrence of exacerbation.

Functional Electrical Stimulation Changes Muscle Oxygenation in Patients with Chronic Obstructive Pulmonary Disease During Moderate-Intensity Exercise: A Secondary Analysis.

We previously showed that functional electrical stimulation during cycle ergometry (FES-cycling) increased oxygen consumption (VO2), indicating that metabolism during exercise was increased. However, the effects on muscle oxygenation have never been studied. The aim of this secondary analysis was to analyse changes in muscle oxygenation during an FES-cycling session. Eight patients with chronic obstructive pulmonary disease who were participating in a pulmonary rehabilitation programme were enrolled. Each participant carried out 30 minutes of cycle ergometry with a constant load at 50% of peak oxygen uptake, either (i) with FES or (ii) without (Placebo-FES). Oxygenation of the vastus lateralis (VL) muscle over time was measured using near-infrared spectroscopy (NIRS) during both sessions. External power output on the cycle ergometer was the same in both conditions. There were no differences in dyspnoea between the groups, although the concentrations of deoxygenated haemoglobin and myoglobin (deoxy(Hb + Mb)) in the VL were significantly greater during Placebo-FES than FES-Cycling (respectively +212 ± 65% vs. +84 ± 29%; p < 0.001), as was the decrease in muscle oxygen saturation (StO2) (p < 0.001). When adjusted for VO2, there was a greater increase over time in the deoxy(Hb + Mb)/VO2 ratio during Placebo-FES than FES-cycling (p < 0.0001). FES-cycling could be a useful strategy to decrease muscular deoxy(Hb + Mb) and limit decreases in muscle StO2, however this should be confirmed in larger studies.

Nasal High Flow for Stable Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis.

There is a growing body of evidence supporting the use of nasal high flow (NHF) to treat acute respiratory failure, particularly in Chronic Obstructive Pulmonary Disease (COPD) patients. Conversely, there are sparse data evaluating its effects in stable COPD patients.We identified randomized controlled trial comparing the effects of delivering air or oxygen via NHF, compared with delivering the same gas without NHF, in stable COPD patients through a systematic search using MEDLINE, CENTRAL, Science Direct, and others sources until January 2019. Study selection, data extraction and assessment of the risk of bias (using the Cochrane Risk of Bias tool) was performed by two independent authors.We included 6 studies (339 participants). Our meta-analysis showed a significant reduction of arterial carbon dioxide pressure (PaCO2) at long (two studies, MD -3 mmHg, [95% Confidence interval (CI) -4 to -2]) and short-term (two studies, MD -3 mmHg [95% CI -4 to -2]). NHF significantly improved quality of life on the St George's Respiratory Questionnaire (two studies, MD -5 out of 100, [95% CI -8 to -2]). NHF significantly reduced the rate of acute exacerbation at 1 year (one study, rate ratio: 0.6, [95% CI 0.6 to 0.7]). NHF did not significantly improve exercise capacity, hospitalization rate or mortality, but improved breathing pattern.NHF reduced PaCO2, acute exacerbation and improved quality of life in stable COPD patients. Further long-term studies are needed to confirm the present results and provide more data on patient-centered outcome such as quality of life, exacerbation, hospitalization and mortality.

Comparison of exercise intensity during four early rehabilitation techniques in sedated and ventilated patients in ICU: a randomised cross-over trial.

BACKGROUND: In the ICU, out-of-bed rehabilitation is often delayed and in-bed exercises are generally low-intensity. Since the majority of rehabilitation is carried out in bed, it is essential to carry out the exercises that have the highest intensity. The aim of this study was to compare the physiological effects of four common types of bed exercise in intubated, sedated patients confined to bed in the ICU, in order to determine which was the most intensive. METHODS: A randomised, single-blind, placebo-controlled crossover trial was carried out to evaluate the effects of four bed exercises (passive range of movements (PROM), passive cycle-ergometry, quadriceps electrical stimulation and functional electrical stimulation (FES) cycling) on cardiac output. Each exercise was carried out for ten minutes in ventilated, sedated patients. Cardiac output was recorded using cardiac Doppler ultrasound. The secondary aims were to evaluate right heart function and pulmonary and systemic artery pressures during the exercises, and the microcirculation of the vastus lateralis muscle. RESULTS: The results were analysed in 19 patients. FES cycling was the only exercise that increased cardiac output, with a mean increase of 1 L/min (15%). There was a concomitant increase in muscle oxygen uptake, suggesting that muscle work occurred. FES cycling thus constitutes an effective early rehabilitation intervention. No muscle or systemic effects were induced by the passive techniques. CONCLUSION: Most bed exercises were low-intensity and induced low levels of muscle work. FES cycling was the only exercise that increased cardiac output and produced sufficient intensity of muscle work. Longer-term studies of the effect of FES cycling on functional outcomes should be carried out. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02920684 . Registered on 30 September 2016. Prospectively registered.

Functional Electrical Stimulation-A New Therapeutic Approach to Enhance Exercise Intensity in Chronic Obstructive Pulmonary Disease Patients: A Randomized, Controlled Crossover Trial.

OBJECTIVE: To evaluate the effect of quadriceps functional electrical stimulation (FES)-cycling on exertional oxygen uptake (V˙o2) compared with placebo FES-cycling in patients with chronic obstructive pulmonary disease (COPD). DESIGN: A randomized, single-blind, placebo-controlled crossover trial. SETTING: Pulmonary rehabilitation department. PARTICIPANTS: Consecutive patients (N=23) with COPD Global Initiative for Chronic Obstructive Lung Disease stage 2, 3, or 4 (mean forced expiratory volume during the first second, 1.4±0.4L [50.3% predicted]) who had recently begun a respiratory rehabilitation program. INTERVENTION: Two consecutive 30-minute sessions were carried out at a constant load with active and placebo FES-cycling. MAIN OUTCOME MEASURES: The primary outcome was mean V˙o2 during the 30-minute exercise session. The secondary outcomes were respiratory gas exchange and hemodynamic parameters averaged over the 30-minute endurance session. Lactate values, dyspnea, and perceived muscle fatigue were evaluated at the end of the sessions. RESULTS: FES-cycling increased the physiological response more than the placebo, with a greater V˙o2 achieved of 36.6mL/min (95% confidence interval [CI], 8.9-64.3mL/min) (P=.01). There was also a greater increase in lactate after FES-cycling (+1.5mmol/L [95% CI, .05-2.9mmol/L]; P=.01). FES-cycling did not change dyspnea or muscle fatigue compared with the placebo condition. CONCLUSIONS: FES-cycling effectively increased exercise intensity in patients with COPD. Further studies should evaluate longer-term FES-cycling rehabilitation programs.

Do pelvic floor muscle function parameters differ in women according to continence status? A systematic review.

BACKGROUND: Current literature highlights the difficulty in identifying which pelvic floor muscle (PFM) functions are correlated with urinary incontinence (UI). AIM: In this study, we compared parameters of PFM function (strength, endurance, tone, control, reaction, and/or coordination) according to continence status in women (presence or absence, type and/or severity of urinary incontinence). EVIDENCE ACQUISITION: A systematic review was conducted following the 2020 PRISMA guidelines. Three databases (Pubmed, Web of Science, and LiSSa) were searched from inception to December 31, 2021. Assessment of risk of bias was performed using the Joanna Briggs Institute critical appraisal checklist. EVIDENCE SYNTHESIS: The initial research yielded 4733 studies. Forty-two studies met the inclusion criteria, including 4015 participants. No statistical association was found between PFM function and the presence or absence of UI, the different type of UI or the different levels of severity of UI. The heterogeneity in methodologies and analyzes of the results only with the P-value are important limitations of this review. CONCLUSION: It appears that muscle function is not always associated with presence or absence of UI. No association is found between PFM function and type or severity of UI. These results reinforce the need to carry out a bio-psycho-social evaluation of UI that does not only focus on PFM functions. As such, the results reported herein can be considered a resource for more specific research.

Factors associated with the time to recover adequate nutrition in infants hospitalized for bronchiolitis, a French retrospective study.

BACKGROUND: Inadequate feeding is a frequent reason for hospital referring in infants with bronchiolitis and may leads to unnecessary prolonged hospitalization. Our objective was to identify the factors associated with the time to recover adequate feeding (TRAF) and the hospital length of stay (LOS) in infants hospitalized for bronchiolitis. METHODS: We conducted a single-center retrospective study including infants less than 12 months hospitalized for bronchiolitis at Le Havre Hospital (France) between September 2018 and February 2021. A multivariate logistic regression model was computed to investigate the factors associated with (1) TRAF, and (2) LOS. RESULTS: 268 infants were included to assess the TRAF and 478 infants to assess the LOS. The median age was 3.2 months (1.6-5.4) and the sex ratio M/F was 11/20. The use of accessory muscles, nutritional support, and RR ≥70/min or <30/min or apnea are associated (OR=1.5), from virtually no association (OR=1.0) to a significant positive association (OR=2.6) with the TRAF. Intense use of accessory muscles (OR=3.9; 95% CI 1.6-10.4) and "severe" clinical condition (OR=2.8; 95% CI 1.7-4.8) at admission, O2 supplementation (OR=2.0; 95% CI 1.3-3.1) were significantly related to prolonged LOS in the multivariate analysis. CONCLUSIONS: The clinical severity on admission may be related to the TRAF, ranging from none to significant. Other known factors such as oxygen therapy and the new clinical severity scale proposed by the latest French guidelines appeared to be related to the LOS in this work. Further studies are needed to highlight these factors.

The use of menthol for breathlessness: a hot topic full of fresh ideas.

The positive feedback from patients with COPD reinforces the value of menthol to reduce breathlessness in this population https://bit.ly/3v1UQYQ.

Remote Assessment of Quality of Life and Functional Exercise Capacity in a Cohort of COVID-19 Patients One Year after Hospitalization (TELECOVID).

Studies have reported persistent symptoms in patients hospitalized for COVID-19 up to 6 months post-discharge; however, sequalae beyond 6 months are unknown. This study aimed to investigate the clinical status of COVID-19 patients one year after hospital discharge and describe the factors related to poor outcomes. We conducted a single-center, prospective, cohort study of patients in Le Havre hospital (France) between 1 March 2020 and 11 May 2020. Baseline characteristics were collected from medical charts (including KATZ index and Clinical Frailty scale (CFS)), and a remote assessment was conducted 12 months after discharge. The main outcomes were the scores of the physical and mental components (PCS and MCS) of the Short-Form 36 (SF-36) and performance on the one-minute sit-to-stand test (STST1'). Scores <50% of the predicted values were considered as poor, and univariate and multivariate analyses were undertaken to investigate factors related to poor outcomes. Remote assessment was performed for 128 of the 157 (82%) eligible patients. Twenty-two patients were admitted to the intensive care unit (ICU), 45 to the intermediate care unit (IU), and 61 to the general ward (GW). Patients who spent time in ICU were more independent and younger. A large proportion of the sample had poor physical (30%) and mental health (27%) and a poor functional exercise capacity (33%) at the remote assessment. Higher levels of frailty at admission and hospital discharge were, respectively, associated with a higher risk of poor functional exercise capacity (StdOR 3.64 (95%CI 1.39-10.72); p = 0.01) and a higher risk of poor mental health (StdOR 2.81 (95%CI 1.17-7.45); p = 0.03). Long-term outcomes following hospitalization for COVID-19 infection may be negative for at least one year after discharge. Remote follow-up assessment could be highly beneficial for COVID-19 patients.