Recuperación laboral clínica y funcional a 3 meses del alta en pacientes hospitalizados por neumonía por SARS-CoV-2: relación con la terapia recibida / Clinical and functional recovery and return to work 3 months after discharge in patients hospitalized for SARS-CoV-2 pneumonia: relationship with the therapy received

Resumen Introducción: La presentación clínica de neumonía por COVID-19 ha sido bien documentada; sin embargo, sus repercusiones a largo plazo son aún motivo de investigación. Objetivo: Evaluar la recuperación laboral, clínica y funcional respiratoria, a 3 meses del egreso de pacientes hospitalizados por neumonía por SARS-CoV-2, en relación con la terapia ventilatoria recibida. Pacientes y Métodos: Se analizó una cohorte prospectiva de 116 pacientes con neumonía por COVID-19 del Hospital Naval Almirante Nef de Viña del Mar, con seguimiento clínico y funcional respiratorio 3 meses después de su alta. Resultados: Mediana del seguimiento: 100 días. Constitución de la cohorte: 75 hombres, mediana de edad 60 años, 50% obesos, 34,5% fumadores y 13,8% con comorbilidad respiratoria. 16% recibió rehabilitación. Se reportó disnea en 48,3% y fatigabilidad en 33,6%. Solo 54,8% retornó al trabajo. El 65,2% que utilizó oxigenoterapia (O2) volvió a trabajar comparado con 44% que utilizó cánula nasal de alto flujo (CNAF) y 33,3% con ventilación mecánica invasiva (VMI). Mayoritariamente el grupo de O2 volvió a la vida normal en comparación con CNAF y VMI (71,4 versus 17,5% y 11,1% respectivamente). La función pulmonar fue normal en 39 pacientes (33,6%). La serie que volvió a vida normal tuvo mayor porcentaje de DLCO y test de caminata de 6 minutos normales. En comparación con la serie O2, la serie CNAF tuvo mayor frecuencia de alteración de DLCO (OR = 5) seguido por la serie VMI (OR = 3,6). Conclusión: A 3 meses de seguimiento, se evidenció ausentismo laboral, persistencia de síntomas y alteración funcional respiratoria (DLCO), especialmente en quienes recibieron soporte ventilatorio adicional a oxigenoterapia.

Introduction: The clinical presentation of COVID-19 pneumonia has been well documented; however, its long-term repercussions are still a matter of investigation. Objective: to evaluate the occupational, clinical and functional respiratory recovery, 3 months after the discharge of patients hospitalized for SARS-CoV-2 pneumonia, in relation to the ventilatory therapy received. Patients and Methods: A prospective cohort of 116 patients with COVID-19 pneumonia from Hospital Naval Almirante Nef (Viña del Mar, Chile) was analyzed, with clinical and functional respiratory follow-up at 3 months after being discharged. Results: Median follow-up: 100 days. Composition of the cohort: 75 men, median age 60 years-old, 50% obese, 34.5% smokers and 13.8% with respiratory comorbidity. 16% received rehabilitation. Dyspnea was reported in 48.3% and fatigue in 33.6%. Only 54.8% returned to work. 65.2% who used oxygen therapy (O2) returned to work compared to 44% who used high-flow nasal cannula (HFNC) and 33.3% with invasive mechanical ventilation (IMV). Mostly the O2 group returned to normal life compared to HFNC and VMI (71.4 versus 17.5% and 11.1% respectively). Lung function was normal in 39 patients (33.6%). The series that returned to normal life had higher percentage of normal DLCO and six-minute walk test. Compared to the O2 series, the CNAF series had a higher frequency of DLCO alteration (OR = 5) followed by the VMI series (OR = 3.6). Conclusion: At 3 months of follow-up, absenteeism from work, persistence of symptoms and respiratory functional alteration (DLCO) were evident, especially in those who received ventilatory support in addition to oxygen therapy.

Indicaciones de rehabilitación respiratoria en niños y adolescentes con enfermedades respiratorias crónicas / Indications for respiratory rehabilitation in children and adolescents with chronic respiratory diseases

Resumen El aumento de la expectativa de vida de niños y adolescentes con enfermedades respiratorias crónicas ha llevado a implementar estrategias como la rehabilitación respiratoria (RR). El presente artículo profundiza en las distintas indicaciones de la RR en distintos niveles de atención médica, distinto grado de dependencias tecnológicas y diversas patologías como: Fibrosis Quística, Bronquiolitis Obliterante, Enfermedades Neuromusculares, anomalías de caja torácica y escoliosis.

The increase in the life expectancy of children and adolescents with chronic respiratory diseases has led to implement strategies such as respiratory rehabilitation (RR). This article delves into the different indications of RR at different levels of medical care, different level of technological dependencies and different pathologies such as: Cystic Fibrosis, Bronchiolitis Obliterans, Neuromuscular Diseases, Rib cage abnormalities and Scoliosis.

Efficacy of Interventions to Improve Respiratory Function After Stroke.

BACKGROUND: The aim of this study was to systematically review all current interventions that have been utilized to improve respiratory function and activity after stroke. METHODS: Specific searches were conducted. The experimental intervention had to be planned, structured, repetitive, purposive, and delivered with the aim of improving respiratory function. Outcomes included respiratory strength (maximum inspiratory pressure [PImax], maximum expiratory pressure [PEmax]) and endurance, lung function (FVC, FEV1, and peak expiratory flow [PEF]), dyspnea, and activity. The quality of the randomized trials was assessed by the PEDro scale using scores from the Physiotherapy Evidence Database (www.pedro.org.au), and risk of bias was assessed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: The 17 included trials had a mean PEDro score of 5.7 (range 4-8) and involved 616 participants. Meta-analyses showed that respiratory muscle training significantly improved all outcomes of interest: PImax (weighted mean difference 11 cm H2O, 95% CI 7-15, I2 = 0%), PEmax (8 cm H2O, 95% CI 2-15, I2 = 65%), FVC (0.25 L, 95% CI 0.12-0.37, I2 = 29%), FEV1 (0.24 L, 95% CI 0.17-0.30, I2 = 0%), PEF (0.51 L/s, 95% CI 0.10-0.92, I2 = 0%), dyspnea (standardized mean difference -1.6 points, 95% CI -2.2 to -0.9; I2 = 0%), and activity (standardized mean difference 0.78, 95% CI 0.22-1.35, I2 = 0%). Meta-analyses found no significant results for the effects of breathing exercises on lung function. For the remaining interventions (ie, aerobic and postural exercises) and the addition of electrical stimulation, meta-analyses could not be performed. CONCLUSIONS: This systematic review reports 5 possible interventions used to improve respiratory function after stroke. Respiratory muscle training proved to be effective for improving inspiratory and expiratory strength, lung function, and dyspnea, and benefits were carried over to activity. However, there is still no evidence to accept or refute the efficacy of aerobic, breathing, and postural exercises, or the addition of electrical stimulation in respiratory function.

Breath-stacking and incentive spirometry in Parkinson's disease: Randomized crossover clinical trial.

Patients with Parkinson's disease often exhibit respiratory disorders and there are no Respiratory Therapy protocols which are suggested as interventions in Parkinson's patients. The aim of this study is to evaluate the effects of Breathing-Stacking (BS) and incentive spirometer (IS) techniques in volume variations of the chest wall in patients with Parkinson's Disease (PD). 14 patients with mild-moderate PD were included in this randomized cross-over study. Volume variations of the chest wall were assessed before, immediately after, then 15 and 30 min after BS and IS performance by optoelectronic plethysmography. Tidal volume (VT) and minute ventilation (MV) significantly increased after BS and IS techniques (p < 0.05). There was greater involvement of pulmonary and abdominal compartments after IS. The results suggest that these re-expansion techniques can be performed to immediately improve volume.

[Therapeutic strategies to increase the effectiveness of cough]. / Estrategias terapéuticas para aumentar la eficacia de la tos en pacientes con enfermedades neuromusculares.

Cough is a natural reflex that protects respiratory airways against infections or mucus retention. Cough maintains an adequate cleaning of the airways and is a mainstay of respiratory therapy. It can be triggered voluntarily by the patient or by a specific cough device. Peak cough flow (PCF) is used to assess the effectiveness of the cough. When this value is below 160 L/min, cough is considered inefficient and becomes a risk factor for respiratory problems. Patients with weak cough, especially those with neuromuscular disease, have in common a low tidal volume and a decreased maximum insufflation capacity. Both factors directly affect the inspiratory phase previous to cough, which is considered vital to obtain the optimum flow for a productive cough. Different therapeutic measures may help to increase cough efficiency among patients with cough weakness. These interventions may be performed using manual techniques or by mechanical devices. The aim of this review is to analyze the different techniques available for cough assistance, set a hierarchy of use and establish a scientific basis for their application in clinical practice.

Estrategias terapéuticas para aumentar la eficacia de la tos en pacientes con enfermedades neuromusculares / Therapeutic strategies to increase the effectiveness of cough

Cough is a natural reflex that protects respiratory airways against infections or mucus retention. Cough maintains an adequate cleaning of the airways and is a mainstay of respiratory therapy. It can be triggered voluntarily by the patient or by a specific cough device. Peak cough flow (PCF) is used to assess the effectiveness of the cough. When this value is below 160 L/min, cough is considered inefficient and becomes a risk factor for respiratory problems. Patients with weak cough, especially those with neuromuscular disease, have in common a low tidal volume and a decreased maximum insufflation capacity. Both factors directly affect the inspiratory phase previous to cough, which is considered vital to obtain the optimum flow for a productive cough. Different therapeutic measures may help to increase cough efficiency among patients with cough weakness. These interventions may be performed using manual techniques or by mechanical devices. The aim of this review is to analyze the different techniques available for cough assistance, set a hierarchy of use and establish a scientific basis for their application in clinical practice.

Complicações respiratórias na esclerose múltipla / Respiratory complications in multiple sclerosis

A Esclerose Múltipla (EM) é uma doença autoimune que afeta primariamente o SNC e que acomete as vias motoras, causando frequentemente sintomas de fraqueza muscular respiratória. As complicações respiratórias são reconhecidas como a principal causa de morbidade e mortalidade em indivíduos com EM avançada. Este artigo apresenta uma revisão narrativa da literatura sobre as complicações respiratórias na EM, com enfoque nos sintomas respiratórios, função pulmonar e efeito do treinamento da musculatura respiratória. Foi realizada uma revisão da literatura nas bases de dados Cochrane, Lilacs, Medline e Scielo do período de 2000 a 2010. A avaliação da função pulmonar se faz necessária na rotina clínica de pacientes com EM, bem como a reabilitação precoce da musculatura respiratória, visando prevenir possíveis disfunções respiratórias decorrentes da diminuição progressiva da força muscular.

Multiple sclerosis (MS) is a primary autoimmune disease of the CNS that affects motor pathways, frequently determining symptoms of respiratory muscle weakness. Respiratory complications are recognized as the leading cause of morbidity and mortality in individuals with advanced MS. This article presents a narrative review of the literature on respiratory complications in MS with a focus on respiratory symptoms, pulmonary function and effect of respiratory muscle training. We performed a literature review in the Cochrane database, Lilacs, Medline and Scielo in the period of 2000 to 2010. The evaluation of lung function is necessary in the clinical practice involving patients with MS as well as the early management of respiratory muscles in order to prevent possible respiratory dysfunction resulting from the progressive decrease in muscle strength.

Mechanical analysis of an oscillatory positive expiratory pressure device used in respiratory rehabilitation.

This article aims to characterize the mechanical behavior of the Acapella Blue, a respiratory rehabilitation device designed to aid sputum clearance. In this scope, the present study initially describes in detail the peak-to-peak oscillation amplitude (App) and peak frequency (fp) behavior, as well as positive pressure level (Ppl), in the flow range more comonly found in practice. The parameters were evaluated in all 5 adjustment levels of the equipment in intervals of 50 mL/s. The device characterization has shown fp up to 23 Hz, App from 0.2 to 2.8 cmH(2)O and Ppl ranging from 1.2 to 13.5 cmH(2)O. The studied device may produce oscillation in the ranges of ciliary movements and respiratory system resonance frequency of patients with respiratory diseases. Data obtained in this work may help to optimize the use of the Acapella Blue device in respiratory rehabilitation. Suggestions for the practical use of the device are also presented.

Comportamiento clinico y espirometrico de pacientes con distrofia muscular de Duchenne / Clinical and spirometric alterations in patients with Duchenne muscular dystrophy

En 36 pacientes afectados de Distrofia Muscular de Duchenne, estudiamos el patrón de crescimiento, las anomalías espirométricas, la evolución de la clase funcional motora (CFM), las complicaciones infecciosas y los tratamientos efectuados. Las edades fueron de 6 a 19 años y la CFM fue de 1 a 9. Los hallazgos fueron: 1) respecto de la altura, hasta los 12 años se constató una pendiente de 5,69 + 0,58 cm/año (r 0,87 p < 0,001) con detención ulterior. Veinticuatro de los 36 pacientes se ubicaron por debajo del percentilo 5; 2) el trastorno espirométrico hallado fue de tipo restrictivo; la CVF expresada en por ciento del valor teórico mostró una caída lineal con la edad, con una correlación (r 0,51, p < 0,01) negativa del orden de - 3,5 + 0,83 por ciento/ano; 3) el deterioro de la CFM fue marcado entre los 6 y 12 años con una pendiente de 0,84 + 0,14 puntos/año (r 0,73 p < 0,001). A partir de los 14 años, la pendiente fue de 0,21 + 0,08 (r 0,49, p < 0,05). Todos los pacientes mayores de 14 años habían alcanzado una CFM mayor de 7; a partir de dicha CFM se observó una caída progresiva de la CVF con una pendiente de - 15,29 + 3,39 por ciento de CVF/CFM. (r 0,56, p < 0,001); 4) se documentaron 9 pacientes con episodios infecciosos pulmonares de los cuales 5 fueron infecciones canaliculares y 4 neumopatías. Cinco casos debieron ser internados a causa de insuficiencia respiratoria aguda hipercápnica de los cuales 3 requirieron ARM y fallecieron; 5) sólo el 50 por ciento de los pacientes concurrieron para el tratamiento de rehabilitación. Cuarto pacientes aceptaron la cirugía correctora de las alteraciones de los pies mientras que ninguno de los pacientes con deformación de la columna se sometió a estabilización espinal.

Comportamiento clinico y espirometrico de pacientes con distrofia muscular de Duchenne / Clinical and spirometric alterations in patients with Duchenne muscular dystrophy

En 36 pacientes afectados de Distrofia Muscular de Duchenne, estudiamos el patrón de crescimiento, las anomalías espirométricas, la evolución de la clase funcional motora (CFM), las complicaciones infecciosas y los tratamientos efectuados. Las edades fueron de 6 a 19 años y la CFM fue de 1 a 9. Los hallazgos fueron: 1) respecto de la altura, hasta los 12 años se constató una pendiente de 5,69 + 0,58 cm/año (r 0,87 p < 0,001) con detención ulterior. Veinticuatro de los 36 pacientes se ubicaron por debajo del percentilo 5; 2) el trastorno espirométrico hallado fue de tipo restrictivo; la CVF expresada en por ciento del valor teórico mostró una caída lineal con la edad, con una correlación (r 0,51, p < 0,01) negativa del orden de - 3,5 + 0,83 por ciento/ano; 3) el deterioro de la CFM fue marcado entre los 6 y 12 años con una pendiente de 0,84 + 0,14 puntos/año (r 0,73 p < 0,001). A partir de los 14 años, la pendiente fue de 0,21 + 0,08 (r 0,49, p < 0,05). Todos los pacientes mayores de 14 años habían alcanzado una CFM mayor de 7; a partir de dicha CFM se observó una caída progresiva de la CVF con una pendiente de - 15,29 + 3,39 por ciento de CVF/CFM. (r 0,56, p < 0,001); 4) se documentaron 9 pacientes con episodios infecciosos pulmonares de los cuales 5 fueron infecciones canaliculares y 4 neumopatías. Cinco casos debieron ser internados a causa de insuficiencia respiratoria aguda hipercápnica de los cuales 3 requirieron ARM y fallecieron; 5) sólo el 50 por ciento de los pacientes concurrieron para el tratamiento de rehabilitación. Cuarto pacientes aceptaron la cirugía correctora de las alteraciones de los pies mientras que ninguno de los pacientes con deformación de la columna se sometió a estabilización espinal. (AU)

Estudo comparativo de alteraçöes respiratórias e a eficácia da fisioterapia entre a colecistectomia laparoscópica e convencional / Comparative study of respiratory alterations and efficacy of physical therapy on conventional and laparoscopic cholecystectomy

Procurou-se estabelecer, no presente estudo, a análise comparativa entre colecistectomia laparoscópica e a colecistectomia convencional, ressaltando as alteraçöes e complicaçöes respiratórias entre os períodos pré e pós operatórios e avaliando a eficácia da fisioterapia. Esta análise foi realizada em 20 pacientes portadores de colecistite crônica calculosa. Pode-se concluir que ambas as técnicas cirúrgicas säo seguras e eficazes, mas observou-se que a colecistectomia convencional trouxe maiores alteraçöes nas provas de funçäo pulmonar, principalmente nos pacientes que näo obtiveram acompanhamento fisioterápico

[Clinical and spirometric alterations in patients with Duchenne muscular dystrophy]. / Comportamiento clínico y espirométrico de pacientes con distrofia muscular de Duchenne.

In 36 patients with Duchenne muscular dystrophy we studied the growth pattern, the type and severity of the spirometric abnormalities, the evolution of the Motor Functional Class (MFC), the infectious complications and treatments. Their age ranged from 6 to 19 years and the MFC was from 1 to 9. Regarding height, up to 12 years we verified a slope of 5.69 +/- 0.58 cm/year (r 0.872 p < 0.001) and a posterior detention was observed. Of the 36 patients, 24 were below the percentile 5. The restrictive disorder prevailed. The forced vital capacity (FVC) expressed in % of the theoretical value showed a lineal fall with age, with a negative correlation (r 0.51, p < 0.01) of -3.5 +/- 0.83%/year. The deterioration of the MFC was marked starting from 6 years; with a slope of 0.84 +/- 0.14 points between 6 to 12 years (r 0.73 p x 0.001). Up to 14 years, the slope was 0.212 +/- 0.084 (r 0.49, p < 0.05). Patients older than 14 years had reached a greater CFM of 7; starting from this MFC a progressive fall of the VC was observed with a slope of -15.29 +/- 3.39% of CVF/CF (r 0.56, p < 0.001). Nine patients with respiratory infections were documented. Four were pneumonia and 3 of them required mechanical ventilation and died. Only 50% of the patients accepted rehabilitating treatment. Four patients accepted surgery of the alterations of the feet while the patients with deformation of the column underwent spinal stabilization.

Hemoptisis, clasificación y manejo / Hemoptysis, classification and management

La hemoptisis es un evento raro, pero si es masiva, amenaza la vida del paciente y la causa de murte usualmente es por aspiración de sangre. La identificación del cuadro y la clasificación inicial deben realizarse rápida y simultáneamente con las medidas tendientes a controlar el sangrado y a mantener la vía aérea permeable. Esto dependerá de la cantidad de sangre expectorada, de la patología de fondo, y de la oportunidad con que se inicien las medidas anteriores. Aunque la cirugía permanece como la terapéutica definitiva, las medidas conservadoras usualmente controlan el sangrado agudo y proporcionan tiempo para otras alternativas terapéuticas especialmente en pacientes que no son candidatos para cirugía. Con esta clasificación y plan de manejo, esperamos facilitar la toma de decisión de un Servicio de Urgencias