Thoracoabdominal asynchrony associates with exercise intolerance in fibrotic interstitial lung diseases.

BACKGROUND AND OBJECTIVE: The precise coordination of respiratory muscles during exercise minimizes work of breathing and avoids exercise intolerance. Fibrotic interstitial lung disease (f-ILD) patients are exercise-intolerant. We assessed whether respiratory muscle incoordination and thoracoabdominal asynchrony (TAA) occur in f-ILD during exercise, and their relationship with pulmonary function and exercise performance. METHODS: We compared breathing pattern, respiratory mechanics, TAA and respiratory muscle recruitment in 31 f-ILD patients and 31 healthy subjects at rest and during incremental cycle exercise. TAA was defined as phase angle (PhAng) >20°. RESULTS: During exercise, when compared with controls, f-ILD patients presented increased and early recruitment of inspiratory rib cage muscle (p < 0.05), and an increase in PhAng, indicating TAA. TAA was more frequent in f-ILD patients than in controls, both at 50% of the maximum workload (42.3% vs. 10.7%, p = 0.01) and at the peak (53.8% vs. 23%, p = 0.02). Compared with f-ILD patients without TAA, f-ILD patients with TAA had lower lung volumes (forced vital capacity, p < 0.01), greater dyspnoea (Medical Research Council > 2 in 64.3%, p = 0.02), worse exercise performance (lower maximal work rate % predicted, p = 0.03; lower tidal volume, p = 0.03; greater desaturation and dyspnoea, p < 0.01) and presented higher oesophageal inspiratory pressures with lower gastric inspiratory pressures and higher recruitment of scalene (p < 0.05). CONCLUSION: Exercise induces TAA and higher recruitment of inspiratory accessory muscle in ILD patients. TAA during exercise occurred in more severely restricted ILD patients and was associated with exertional dyspnoea, desaturation and limited exercise performance.

Diaphragmatic ultrasound findings correlate with dyspnea, exercise tolerance, health-related quality of life and lung function in patients with fibrotic interstitial lung disease.

BACKGROUND: Fibrotic interstitial lung disease (FILD) patients are typically dyspneic and exercise-intolerant with consequent impairment of health-related quality of life (HRQoL). Respiratory muscle dysfunction is among the underlying mechanisms of dyspnea and exercise intolerance in FILD but may be difficult to diagnose. Using ultrasound, we compared diaphragmatic mobility and thickening in FILD cases and healthy controls and correlated these findings with dyspnea, exercise tolerance, HRQoL and lung function. METHODS: We measured diaphragmatic mobility and thickness during quiet (QB) and deep breathing (DB) and calculated thickening fraction (TF) in 30 FILD cases and 30 healthy controls. We correlated FILD cases' diaphragmatic findings with dyspnea, exercise tolerance (six-minute walk test), lung function and HRQoL (St. George's Respiratory Questionnaire). RESULTS: Diaphragmatic mobility was similar between groups during QB but was lower in FILD cases during DB when compared to healthy controls (3.99 cm vs 7.02 cm; p <  0.01). FILD cases showed higher diaphragm thickness during QB but TF was lower in FILD when compared to healthy controls (70% vs 188%, p <  0.01). During DB, diaphragmatic mobility and thickness correlated with lung function, exercise tolerance and HRQoL, but inversely correlated with dyspnea. Most FILD cases (70%) presented reduced TF, and these patients had higher dyspnea and exercise desaturation, lower HRQoL and lung function. CONCLUSION: Compared to healthy controls, FILD cases present with lower diaphragmatic mobility and thickening during DB that correlate to increased dyspnea, decreased exercise tolerance, worse HRQoL and worse lung function. FILD cases with reduced diaphragmatic thickening are more dyspneic and exercise-intolerant, have lower HRQoL and lung function.

Accuracy of Invasive and Noninvasive Parameters for Diagnosing Ventilatory Overassistance During Pressure Support Ventilation.

OBJECTIVE: Evaluate the accuracy of criteria for diagnosing pressure overassistance during pressure support ventilation. DESIGN: Prospective clinical study. SETTING: Medical-surgical ICU. PATIENTS: Adults under mechanical ventilation for 48 hours or more using pressure support ventilation and without any sedative for 6 hours or more. Overassistance was defined as the occurrence of work of breathing less than 0.3 J/L or 10% or more of ineffective inspiratory effort. Two alternative overassistance definitions were based on the occurrence of inspiratory esophageal pressure-time product of less than 50 cm H2O s/min or esophageal occlusion pressure of less than 1.5 cm H2O. INTERVENTIONS: The pressure support was set to 20 cm H2O and decreased in 3-cm H2O steps down to 2 cm H2O. MEASUREMENTS AND MAIN RESULTS: The following parameters were evaluated to diagnose overassistance: respiratory rate, tidal volume, minute ventilation, peripheral arterial oxygen saturation, rapid shallow breathing index, heart rate, mean arterial pressure, change in esophageal pressure during inspiration, and esophageal and airway occlusion pressure. In all definitions, the respiratory rate had the greatest accuracy for diagnosing overassistance (receiver operating characteristic area = 0.92; 0.91 and 0.76 for work of breathing, pressure-time product and esophageal occlusion pressure in definition, respectively) and always with a cutoff of 17 incursions per minute. In all definitions, a respiratory rate of less than or equal to 12 confirmed overassistance (100% specificity), whereas a respiratory rate of greater than or equal to 30 excluded overassistance (100% sensitivity). CONCLUSION: A respiratory rate of 17 breaths/min is the parameter with the greatest accuracy for diagnosing overassistance. Respiratory rates of less than or equal to 12 or greater than or equal to 30 are useful clinical references to confirm or exclude pressure support overassistance.

Unilateral diaphragm paralysis: a dysfunction restricted not just to one hemidiaphragm.

BACKGROUND: Most patients with unilateral diaphragm paralysis (UDP) have unexplained dyspnea, exercise limitations, and reduction in inspiratory muscle capacity. We aimed to evaluate the generation of pressure in each hemidiaphragm separately and its contribution to overall inspiratory strength. METHODS: Twenty-seven patients, 9 in right paralysis group (RP) and 18 in left paralysis group (LP), with forced vital capacity (FVC) < 80% pred, and 20 healthy controls (CG), with forced expiratory volume in 1 s (FEV1) > 80% pred and FVC > 80% pred, were evaluated for lung function, maximal inspiratory (MIP) and expiratory (MEP) pressure measurements, diaphragm ultrasound, and transdiaphragmatic pressure during magnetic phrenic nerve stimulation (PdiTw). RESULTS: RP and LP had significant inspiratory muscle weakness compared to controls, detected by MIP (- 57.4 ± 16.9 for RP; - 67.1 ± 28.5 for LP and - 103.1 ± 30.4 cmH2O for CG) and also by PdiTW (5.7 ± 4 for RP; 4.8 ± 2.3 for LP and 15.3 ± 5.7 cmH2O for CG). The PdiTw was reduced even when the non-paralyzed hemidiaphragm was stimulated, mainly due to the low contribution of gastric pressure (around 30%), regardless of whether the paralysis was in the right or left hemidiaphragm. On the other hand, in CG, esophagic and gastric pressures had similar contribution to the overall Pdi (around 50%). Comparing both paralyzed and non-paralyzed hemidiaphragms, the mobility during quiet and deep breathing, and thickness at functional residual capacity (FRC) and total lung capacity (TLC), were significantly reduced in paralyzed hemidiaphragm. In addition, thickness fraction was extremely diminished when contrasted with the non-paralyzed hemidiaphragm. CONCLUSIONS: In symptomatic patients with UDP, global inspiratory strength is reduced not only due to weakness in the paralyzed hemidiaphragm but also to impairment in the pressure generated by the non-paralyzed hemidiaphragm.

Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation-Evolving Concepts.

Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient's respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.

Vocal Impact in Patients With Unilateral Diaphragmatic Paralysis.

OBJECTIVES: This study aimed to investigate the possible vocal impact confirmed by diagnostic tests, the degree of perception of possible vocal impairment by patients with Unilateral Diaphragmatic paralysis (UDP) and its correlation with ventilatory weakness. METHODS: The researchers conducted an analytical, observational and case-control study with 70 individuals, including 35 UDP patients and 35 healthy patients in a control group, who underwent the following assessments: 1) Self-assessment of voice handicap (VHI-10); 2) Self-Assessment of Quality of Life (SF-36); 3) Self-Assessment of Dyspnea (MRC); 4) Objective vocal measures (Maximum Phonation Time (MPT) in /a/, /s/, /z/ and glottal-to-noise excitation ratio); 5) Functional respiratory pressures (Spirometry and maximum ventilatory pressures); 6) General degree of dysphonia - G on the GRBAS Scale. The sex, age and body mass index (BMI) of the individuals were the variables used to match the sample of this study. RESULTS: When compared with controls, patients with UDP had a restrictive functional pattern and inspiratory weakness, with symptoms of dyspnea and worsening quality of life. When associated with a possible vocal impact, these patients had voice handicap and decreased MPT values for all phonemes, especially /a/. There was also a correlation between vocal performance and inspiratory weakness. However, it should be noted that, despite having vocal impairment, many patients did not report the perception of this fact, somehow neglecting such impairment. CONCLUSIONS: In addition to the expected weakness of the ventilatory muscles, patients with UDP had clinically verified vocal impact, and those who had greater inspiratory weakness also had greater voice impairment. Finally, it is relevant that not all patients perceived such vocal impact, which showed a very reduced perception of this impairment in patients with UDP.

Quantitative CT Analysis in Chronic Hypersensitivity Pneumonitis: A Convolutional Neural Network Approach.

RATIONALE AND OBJECTIVES: Chronic hypersensitivity pneumonitis (cHP) is a heterogeneous condition, where both small airway involvement and fibrosis may simultaneously occur. Computer-aided analysis of CT lung imaging is increasingly used to improve tissue characterization in interstitial lung diseases (ILD), quantifying disease extension, and progression. We aimed to quantify via a convolutional neural network (CNN) method the extent of different pathological classes in cHP, and to determine their correlation to pulmonary function tests (PFTs) and mosaic attenuation pattern. MATERIALS AND METHODS: The extension of six textural features, including consolidation (C), ground glass opacity (GGO), fibrosis (F), low attenuation areas (LAA), reticulation (R) and healthy regions (H), was quantified in 27 cHP patients (age: 56 ± 11.5 years, forced vital capacity [FVC]% = 57 ± 17) acquired at full-inspiration via HRCT. Each class extent was correlated to PFTs and to mosaic attenuation pattern. RESULTS: H showed a positive correlation with FVC%, FEV1% (forced expiratory volume), total lung capacity%, and diffusion of carbon monoxide (DLCO)% (r = 0.74, r = 0.78, r = 0.73, and r = 0.60, respectively, p < 0.001). GGO, R and C negatively correlated with FVC% and FEV1% with the highest correlations found for R (r = -0.44, and r = -0.46 respectively, p < 0.05); F negatively correlated with DLCO% (r = -0.42, p < 0.05). Patients with mosaic attenuation pattern had significantly more H (p = 0.04) and lower R (p = 0.02) and C (p = 0.0009) areas, and more preserved lung function indices (higher FVC%; p = 0.04 and DLCO%; p = 0.05), but did not show more air trapping in lung function tests. CONCLUSION: CNN quantification of pathological tissue extent in cHP improves its characterization and shows correlation with PFTs. LAA can be overestimated by visual, qualitative CT assessment and mosaic attenuation pattern areas in cHP represents patchy ILD rather than small-airways disease.

A Convolutional Neural Network Approach to Quantify Lung Disease Progression in Patients with Fibrotic Hypersensitivity Pneumonitis (HP).

Rationale and Objectives To evaluate associations between longitudinal changes of quantitative CT parameters and spirometry in patients with fibrotic hypersensitivity pneumonitis (HP). Materials and Methods Serial CT images and spirometric data were retrospectively collected in a group of 25 fibrotic HP patients. Quantitative CT analysis included histogram parameters (median, interquartile range, skewness, and kurtosis) and a pretrained convolutional neural network (CNN)-based textural analysis, aimed at quantifying the extent of consolidation (C), fibrosis (F), ground-glass opacity (GGO), low attenuation areas (LAA) and healthy tissue (H). Results At baseline, FVC was 61(44-70) %pred. The median follow-up period was 1.4(0.8-3.2) years, with 3(2-4) visits per patient. Over the study, 8 patients (32%) showed a FVC decline of more than 5%, a significant worsening of all histogram parameters (p≤0.015) and an increased extent of fibrosis via CNN (p=0.038). On histogram analysis, decreased skewness and kurtosis were the parameters most strongly associated with worsened FVC (respectively, r2=0.63 and r2=0.54, p<0.001). On CNN classification, increased extent of fibrosis and consolidation were the measures most strongly correlated with FVC decline (r2=0.54 and r2=0.44, p<0.001). Conclusion CT histogram and CNN measurements provide sensitive measures of functional changes in fibrotic HP patients over time. Increased fibrosis was associated with FVC decline, providing index of disease progression. CNN may help improve fibrotic HP follow-up, providing a sensitive tool for progressive interstitial changes, which can potentially contribute to clinical decisions for individualizing disease management.

Persistence of symptoms and return to work after hospitalization for COVID-19.

Many patients hospitalized with COVID-19 were unable to return to work or their return was delayed due to their health condition. The aim of this observational study was to evaluate the impact of moderate-to-severe and critical COVID-19 infection on persistence of symptoms and return to work after hospital discharge. In this study, two thirds of hospitalized patients with pulmonary involvement reported persistence of symptoms six months after COVID-19 infection, such as memory loss (45.5%), myalgia (43.9%), fatigue (39.4%), and dyspnea (25.8%), and 50% slowly returned to work, with repercussions due to fatigue and/or loss of energy.

Clinical, radiological, and transbronchial biopsy findings in patients with long COVID-19: a case series.

This brief communication demonstrates the correlation of persistent respiratory symptoms with functional, tomographic, and transbronchial pulmonary biopsy findings in patients with COVID-19 who had a long follow-up period. We report a series of six COVID-19 patients with pulmonary involvement who presented with persistent dyspnea within 4-15 months of discharge. We performed transbronchial biopsies, and the histopathological pattern consistently demonstrated peribronchial remodeling with interstitial pulmonary fibrosis. Therefore, lung biopsy may be useful in the approach of patients with long COVID-19, although the type of procedure, its precise indication, and the moment to perform it are yet to be clarified. (Brazilian Registry of Clinical Trials-ReBEC; identifier: RBR-8j9kqy [http://www.ensaiosclinicos.gov.br]).

Persistent interstitial lung abnormalities in post-COVID-19 patients: a case series.

A new concept of multisystem disease has emerged as a long-term condition following mild-severe COVID-19 infection. The main symptoms of this affection are breathlessness, chest pain, and fatigue. We present here the clinical case of four COVID-19 patients during hospitalization and 60 days after hospital discharge. Physiological impairment of all patients was assessed by spirometry, dyspnea score, arterial blood gas, and 6-minute walk test 60 days after hospital discharge, and computed tomographic scan 90 days after discharge. All patients had fatigue, which was not related to hypoxemia or impaired spirometry values, and interstitial lung alterations, which occurred in both mechanically ventilated and non-mechanically ventilated patients. In conclusion, identifying the prevalence and patterns of permanent lung damage is paramount in preventing and treating COVID-19-induced fibrotic lung disease. Additionally, and based on our preliminary results, it will be also relevant to establish long-term outpatient programs for these individuals.

Preoperative evaluation for lung resection in patients with bronchiectasis: should we rely on standard lung function evaluation?

OBJECTIVES: The scant data about non-cystic fibrosis bronchiectasis, including tuberculosis sequelae and impairment of lung function, can bias the preoperative physiological assessment. Our goal was to evaluate the changes in lung function and exercise capacity following pulmonary resection in these patients; we also looked for outcome predictors. METHODS: We performed a non-randomized prospective study evaluating lung function changes in patients with non-cystic fibrosis bronchiectasis treated with pulmonary resection. Patients performed lung function tests and cardiopulmonary exercise tests preoperatively and 3 and 9 months after the operation. Demographic data, comorbidities, surgical data and complications were collected. RESULTS: Forty-four patients were evaluated for lung function. After resection, the patients had slightly lower values for spirometry: forced expiratory volume in 1 s preoperatively: 2.21 l ± 0.8; at 3 months: 1.9 l ± 0.8 and at 9 months: 2.0 l ± 0.8, but the relationship between the forced expiratory volume in 1 s and the forced vital capacity remained. The gas diffusion measured by diffusing capacity for carbon monoxide did not change: preoperative value: 23.2 ml/min/mmHg ± 7.4; at 3 months: 21.5 ml/min/mmHg ± 5.6; and at 9 months: 21.7 ml/min/mmHg ± 8.2. The performance of general exercise did not change; peak oxygen consumption preoperatively was 20.9 ml/kg/min ± 7.4; at 3 months: 19.3 ml/kg/min ± 6.4; and at 9 months: 20.2 ml/kg/min ± 8.0. Forty-six patients were included for analysis of complications. We had 13 complications with 2 deaths. To test the capacity of the predicted postoperative (PPO) values to forecast complications, we performed several multivariate and univariate analyses; none of them was a significant predictor of complications. When we analysed other variables, only bronchoalveolar lavage with positive culture was significant for postoperative complications (P = 0.0023). Patients who had a pneumonectomy had a longer stay in the intensive care unit (P = 0.0348). CONCLUSIONS: The calculated PPO forced expiratory volume in 1 s had an excellent correlation with the measurements at 3 and 9 months; but the calculated PPO capacity for carbon monoxide and the PPO peak oxygen consumption slightly underestimated the 3- and 9-month values. However, none of them was a predictor for complications. Better tools to predict postoperative complications for patients with bronchiectasis who are candidates for lung resection are needed. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrials.gov: NCT01268475.

Diaphragmatic ultrasound: a review of its methodological aspects and clinical uses.

The diaphragm is the main muscle of respiration, acting continuously and uninterruptedly to sustain the task of breathing. Diaphragmatic dysfunction can occur secondary to numerous pathological conditions and is usually underdiagnosed in clinical practice because of its nonspecific presentation. Although several techniques have been used in evaluating diaphragmatic function, the diagnosis of diaphragmatic dysfunction is still problematic. Diaphragmatic ultrasound has gained importance because of its many advantages, including the fact that it is noninvasive, does not expose patients to radiation, is widely available, provides immediate results, is highly accurate, and is repeatable at the bedside. Various authors have described ultrasound techniques to assess diaphragmatic excursion and diaphragm thickening in the zone of apposition. Recent studies have proposed standardization of the methods. This article reviews the usefulness of ultrasound for the evaluation of diaphragmatic function, addressing the details of the technique, the main findings, and the clinical applications.

Dynamic hyperinflation induced by the 6-minute pegboard and ring test in hospitalized patients with exacerbated COPD.

BACKGROUND: The six-minute pegboard and ring test (6-PBRT) has been used to evaluate functional capacity of the upper limbs in stable chronic obstructive pulmonary disease (COPD) patients. To the best of our knowledge, no studies have evaluated dynamic hyperinflation (DH) during exercise with upper limbs in the hospital setting. The aim of this study was to evaluate physiological responses and DH induced by 6-PBRT in hospitalized patients with acute exacerbation of COPD (AECOPD). METHODS: A cross-sectional study was conducted in a tertiary hospital enrolling patients who were hospitalized due to AECOPD. All included participants underwent an evaluation of lung function and 6-PBRT when they reached minimum clinical criteria. Ventilatory and hemodynamics parameters were monitored during 6-PBRT and until 6 minutes of rest after the test. Symptoms of dyspnea and upper limb fatigue were also measured. RESULTS: Eighteen patients (71.3±5.1 years) with a mean FEV1 of 43.2±18.3% were included in the study (11 females). Prevalence of DH after 6-PBRT was 50% (considering the drop of 150 ml or 10% of inspiratory capacity, immediately after the end of the test). There was a significant increase in respiratory rate, minute volume, dyspnea, and upper limb fatigue after the end of 6-PBRT (p<0.05). Dyspnea recovered more precociously than the perception of fatigue, being reestablished within four minutes of rest. An increase in heart rate, systolic and diastolic blood pressures was also induced by 6-PBRT (p<0.05), requiring 6 minutes of recovery to return to baseline. No adverse events were observed during 6-PBRT. We concluded that 6-PBRT induces physiological changes during its execution, at safe levels, requiring a maximum of 6 minutes for recovery. Finally, the test proved to be safe and applicable for patients hospitalized due to AECOPD.

Computed tomography in hypersensitivity pneumonitis: main findings, differential diagnosis and pitfalls.

INTRODUCTION: Hypersensitivity pneumonitis (HP) is a disease with variable clinical presentation in which inflammation in the lung parenchyma is caused by the inhalation of specific organic antigens or low molecular weight substances in genetically susceptible individuals. Alterations of the acute, subacute and chronic forms may eventually overlap, and the diagnosis based on temporality and presence of fibrosis (acute/inflammatory HP vs. chronic HP) seems to be more feasible and useful in clinical practice. Differential diagnosis of chronic HP with other interstitial fibrotic diseases is challenging due to the overlap of the clinical history, and the functional and imaging findings of these pathologies in the terminal stages. Areas covered: This article reviews the essential features of HP with emphasis on imaging features. Moreover, the main methodological limitations of high-resolution computed tomography (HRCT) interpretation are discussed, as well as new perspectives with volumetric quantitative CT analysis as a useful tool for retrieving detailed and accurate information from the lung parenchyma. Expert commentary: Mosaic attenuation is a prominent feature of this disease, but air trapping in chronic HP seems overestimated. Quantitative analysis has the potential to estimate the involvement of the pulmonary parenchyma more accurately and could correlate better with pulmonary function results.

Is the 6-minute pegboard and ring test valid to evaluate upper limb function in hospitalized patients with acute exacerbation of COPD?

Background: The 6-minute pegboard and ring test (6-PBRT) is a useful test for assessing the functional capacity of upper limbs in patients with stable COPD. Although 6-PBRT has been validated in stable patients, the possibility of a high floor effect could compromise the validity of the test in the hospital setting. The aim of this study was to verify the convergent validity of 6-PBRT in hospitalized patients with acute exacerbation of COPD (AECOPD). Methods: A cross-sectional study was conducted in a tertiary hospital. Patients who were hospitalized due to AECOPD and healthy elderly participants, voluntarily recruited from the community, were considered for inclusion. All participants underwent a 6-PBRT. Isokinetic evaluation to measure the strength and endurance of elbow flexors and extensors, handgrip strength (HGS), spirometry testing, the modified Pulmonary Functional Status Dyspnea Questionnaire (PFSDQ-M), the COPD assessment test (CAT), and symptoms of dyspnea and fatigue were all measured as comparisons for convergent validity. Good convergent validity was considered if >75% of these hypotheses could be confirmed (correlation coefficient>0.50). Results: A total of 17 patients with AECOPD (70.9±5.1 years and forced expiratory volume in 1 second [FEV1] of 41.8%±17.9% of predicted) and 11 healthy elderly subjects were included. The HGS showed a significant strong correlation with 6-PBRT performance (r=0.70; p=0.002). The performance in 6-PBRT presented a significant moderate correlation with elbow flexor torque peak (r=0.52; p=0.03) and elbow extensor torque peak (r=0.61; p=0.01). The total muscular work of the 15 isokinetic contractions of the elbow flexor and extensor muscles showed a significant moderate correlation with the performance in 6-PBRT (r=0.59; p=0.01 and r=0.57; p=0.02, respectively). Concerning the endurance of elbow flexors and extensors, there was a significant moderate correlation with 6-PBRT performance (r=-0.50; p=0.04 and r=-0.51; p=0.03, respectively). In relation to the upper-extremity physical activities of daily living (ADLs) assessed by means of PFSDQ-M, there was a significant moderate correlation of 6-PBRT with three domains: influence of dyspnea on ADLs (r=-0.66; p<0.001), influence of fatigue on ADLs (r=-0.60; p=0.01), and change in ADLs in relation to the period before the disease onset (r=-0.51; p=0.03). The CAT was also correlated with 6-PBRT (r=-0.51; p=0.03). Finally, the performance in 6-PBRT showed a significant moderate correlation with the increase in dyspnea (r=-0.63; p=0.01) and a strong correlation with the increase in fatigue of upper limbs (r=-0.76; p<0.001) in patients with AECOPD. Convergent validity was considered adequate, since 81% from 16 predefined hypotheses were confirmed. There was no correlation between 6-PBRT and patients' height. The performance in 6-PBRT was worse in patients with AECOPD compared to healthy elderly individuals (248.7±63.0 vs 361.6±49.9 number of moved rings; p<0.001). Conclusion: The 6-PBRT is valid for the evaluation of functional capacity of upper limbs in hospitalized patients with AECOPD.

Impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer.

OBJECTIVE: To evaluate the impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer. METHODS: Breast cancer patients in whom thoracic radiotherapy was indicated after surgical treatment and chemotherapy were submitted to HRCT, respiratory evaluation, and exercise capacity evaluation before radiotherapy and at three months after treatment completion. Respiratory muscle strength testing, measurement of chest wall mobility, and complete pulmonary function testing were performed for respiratory evaluation; cardiopulmonary exercise testing was performed to evaluate exercise capacity. The total radiotherapy dose was 50.4 Gy (1.8 Gy/fraction) to the breast or chest wall, including supraclavicular lymph nodes (SCLN) or not. Dose-volume histograms were calculated for each patient with special attention to the ipsilateral lung volume receiving 25 Gy (V25), in absolute and relative values, and mean lung dose. RESULTS: The study comprised 37 patients. After radiotherapy, significant decreases were observed in respiratory muscle strength, chest wall mobility, exercise capacity, and pulmonary function test results (p < 0.05). DLCO was unchanged. HRCT showed changes related to radiotherapy in 87% of the patients, which was more evident in the patients submitted to SCLN irradiation. V25% significantly correlated with radiation pneumonitis. CONCLUSIONS: In our sample of patients with breast cancer, thoracic radiotherapy seemed to have caused significant losses in respiratory and exercise capacity, probably due to chest wall restriction; SCLN irradiation represented an additional risk factor for the development of radiation pneumonitis.

Stability and Agreement of a Microtransducer and an Air-Filled Balloon Esophageal Catheter in the Monitoring of Esophageal Pressure.

BACKGROUND: The use of esophageal catheters with microtransducer promises advantages over traditional catheters with air-filled balloons. However, performance comparisons between these 2 types of catheters are scarce and incomplete. METHODS: A catheter with a 9.5-cm air-filled balloon at the distal tip and a catheter with a microtransducer mounted within a flexible silicone rubber were tested in vitro and in vivo. In vitro, the response times of both catheters were compared, and the drift of the baseline pressure of the microtransducer catheter was evaluated over a 6-h period. In vivo, 11 healthy volunteers had both catheters inserted, and the drift of the baseline esophageal pressure was measured over a 3-h period. Also, the correlation and agreement of the baseline and changes in the esophageal pressure of both catheters were evaluated. RESULTS: In vitro, the microtransducer catheter had a response time significantly higher (262 × 114 Hz, P < .01) and a good pressure stability, with a mean baseline pressure drift of 1.4 cm H2O. In vivo, both catheters presented a small and similar baseline esophageal pressure drift (P = 0.08). For measurements of baseline and changes in esophageal pressure, the correlation and agreement between the catheters were poor, with a large bias between them. CONCLUSIONS: The catheter with the microtransducer had a small baseline pressure drift, similar to the air-filled balloon catheter. The low agreement between the catheters does not allow the microtransducer catheter to be used as a surrogate for the traditional air-filled balloon catheter.