Maximal respiratory pressure after COVID-19 compared with reference material in healthy adults: A prospective cohort study (The SECURe study).

After COVID-19 long term respiratory symptoms and reduced lung function including maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) have been reported. However, no studies have looked at MIP and MEP in all disease groups and the reference materials collection methods differ substantially. We aimed to determine MIP and MEP in individuals after COVID-19 infection with different disease severity using reference material of healthy control group obtained using the same standardized method. Patients with COVID-19 were included March 2020-March 2021 at Rigshospitalet, Denmark. MIP and MEP were measured using microRPM. Predicted MIP and MEP were calculated using reference material obtained from 298 healthy adults aged 18-97 years using the same method. In SECURe, 145 participants were measured median 5 months after COVID-19 diagnosis and of these 16% had reduced MIP and/or MEP. There was reduced spirometry and total lung capacity, but not reduced diffusion capacity in those with abnormal MIP and/or MEP compared with normal MIP and MEP. Of those with reduced MIP and/or MEP at 5 months, 80% still had reduced MIP and/or MEP at 12 months follow-up. In conclusion, few have reduced MIP and/or MEP 5 months after COVID-19 and little improvement was seen over time.

Evaluation of a new hyperbaric oxygen ventilator during pressure-controlled ventilation.

Introduction: The stability of a new hyperbaric ventilator (Shangrila590, Beijing Aeonmed Company, Beijing, China) at different clinically relevant pressures in a hyperbaric chamber during pressure-controlled ventilation (PCV) was investigated. Methods: The ventilator was connected to a test lung in the multiplace hyperbaric chamber. The inspiratory pressure (PI) of the ventilator was set to 1.0, 1.5, 2.0, 2.5 and 3.0 kPa (approximately 10, 15, 20, 25 and 30 cmH2O). The compliance and resistance of the test lung were set to 200 mL·kPa⁻¹ and 2 kPa·L⁻¹·s⁻¹, respectively. Experiments were conducted at 101, 203 and 284 kPa ambient pressure (1.0, 2.0 and 2.8 atmospheres absolute respectively). At each of the 5 PI values, the tidal volume (VT), peak inspiratory pressure (Ppeak) and peak inspiratory flow (Fpeak) displayed by the ventilator and the test lung were recorded for 20 cycles. Test lung data were considered the actual ventilation values. The ventilation data were compared among the three groups to evaluate the stability of the ventilator. Results: At every PI, the Ppeak detected by the ventilator decreased slightly with increasing ambient pressure. The Fpeak values measured by the test lung decreased substantially as the ambient pressure increased. Nevertheless, the reduction in VT at 284 kPa and PI 30 cmH2O (compared to performance at 101 kPa) was comparatively small (approximately 60 ml). Conclusions: In PCV mode this ventilator provided relatively stable VT across clinically relevant PI values to ambient pressures as high as 284 kPa. However, because Fpeak decreases at higher ambient pressure, some user adjustment might be necessary for precise VT maintenance during clinical use at higher PIs and ambient pressures.

Respiratory muscular strength in children with mucopolysacaridosis: comparison with predictive equations.

BACKGROUND: Mucopolysaccharidoses (MPS) are rare metabolic diseases that impair respiratory function leading to respiratory failure. This study aimed to compare maximal inspiratory and expiratory pressures (MIP and MEP) obtained in children with MPS and compare with predicted values from previous studies involving healthy children. METHODS: This is a cross-sectional study, in which the chest deformity was evaluated; MIP, MEP through digital manometer, and lung function through spirometry. MIP and MEP were compared with five different predict equations and with a control group of healthy children. Agreement between respiratory muscle weakness regarding absolute values of MIP and MEP in relation to predictive values by the equations included in the study were assessed by Kappa coefficient. RESULTS: MPS group was composed of 22 subjects. 45.5% had pectus carinatum, 36.4% pectus excavatum, and presented lower MIP (37.14±36.23 cmH2O) and MEP (60.09±22.3 cmH2O) compared with control group (22 healthy subjects) (MIP: 91.45±35.60; MEP: 95.73±22.38). Only the MEP equations proposed by Tomalak et al. were close to those found in our MPS children (P=0.09). In the MPS group it was observed a weak agreement between inspiratory weakness through absolute and predicted values in only two equations: Tomalak et al. and Domenèch-Clar et al. (for both: k=0.35, P value =0.03); and for MEP a moderate agreement was found using all predictive equations. CONCLUSIONS: In MPS children MRP data should not be normalized using the reference equations for healthy ones, is more coherent to longitudinally follow absolute pressures and lung volumes in this group.

[Relationship between frailty and functional status in lung transplant candidates]. / Relación entre la fragilidad y la capacidad funcional en los pacientes candidatos a trasplante de pulmón.

INTRODUCTION: Lung transplant (LT) is one of the therapeutic options for patients with terminal respiratory diseases. It is highly important to incorporate the functional status and frailty assessment into the selection process of candidates for LT. OBJECTIVES: Identify the prevalence of frailty in the LT waiting list. Study the relationship between frailty, functional status, Lung Allocation Score (LAS) and muscular dysfunction. METHODOLOGY: Descriptive transversal study of patients on the waiting list for LT. POPULATION: 74 patients with chronic respiratory diseases assessed by the lung transplant committee and accepted to be transplanted in a university hospital in Barcelona. The outcome variables were frailty status was evaluate for SPPB test, functional capacity was evaluate for the six-minute walking test (6MWT) and muscular dysfunction. The results were analyzed with the statistical package STATA 12. RESULTS: Sample of 48 men and 26 women, with a median age of 56.55 years (SD 10.87. The prevalence of frailty assessed with the SPPB was 33.8% (8.1% are in frailty and 25.7% are in a state of pre-frailty). There is a relationship between the SPPB, 6MWT and maximal inspiratory pressure, but not with others force values. There is a relationship between the risk of frailty (scores below 9 in SPPB) and the meters walked in 6 but not with the LAS. CONCLUSIONS: The risk of frailty in patients with terminal chronic respiratory diseases is high. Frailty is related with functional capacity, but not with LAS.

Effects of pulmonary function improvement devices in the pediatric population with cerebral palsy: Systematic review and meta-analysis of randomized clinical trials.

INTRODUCTION: Enhancing lung function can significantly improve daily life functionality for children with cerebral palsy, leading to increased interest in respiratory physiotherapy training devices in clinical practice. This study aims to evaluate the efficacy of devices (inspiratory muscle training and feedback devices) for improving pulmonary function through various respiratory parameters. METHODS: A systematic review with meta-analysis of randomized clinical trials was conducted in seven databases up until May 2023. The included studies focused on training inspiratory muscle function using specific devices (inspiratory muscle training and feedback devices) in children with cerebral palsy. The main outcomes were maximum expiratory pressure and maximum inspiratory pressure. Secondary outcomes included forced vital capacity, forced expiratory volume in 1 s, peak expiratory flow, and the Tiffenau index. The effects of respiratory treatment were calculated through the estimation of the effect size and its 95% confidence intervals. The risk of bias in the included studies was assessed using the Cochrane Collaboration's tool for assessing the risk of bias (RoB2). RESULTS: Nine studies were included in the systematic review with meta-analysis, involving a total of 321 children aged between 6 and 18 years after secondary analyses were conducted. Feedback devices were found to be more effective in improving maximum expiratory pressure (effect size -0.604; confidence interval -1.368 to 0.161), peak expiratory flow, forced expiratory volume in 1 s, and forced vital capacity. Inspiratory muscle training devices yielded better effectiveness in improving maximum inspiratory pressure (effect size -0.500; confidence interval -1.259 to 0.259), the Tiffeneau index, and quality of life. CONCLUSION: Both devices showed potential in improving pulmonary function in children with cerebral palsy. Further high-quality clinical trials are needed to determine the optimal dosage and the most beneficial device type for each pulmonary function parameter.

External Jet Nebulization and Measured Ventilator Performance.

BACKGROUND: During invasive ventilation, external flow jet nebulization results in increases in displayed exhaled tidal volumes (VT). We hypothesized that the magnitude of the increase is inaccurate. An ASL 5000 simulator measured ventilatory parameters over a wide range of adult settings: actual VT, peak inspiratory pressure (PIP), and time to minimum pressure. METHODS: Ventilators with internal and external flow sensors were tested by using a variety of volume and pressure control modes (the target VT was 420 mL). Patient conditions (normal, COPD, ARDS) defined on the ASL 5000 were assessed at baseline and with 3.5 or 8 L/min of added external flow. Patient-triggering was assessed by reducing muscle effort to the level that resulted in backup ventilation and by changing ventilator sensitivity to the point of auto-triggering. RESULTS: Results are reported as percentage change from baseline after addition of 3.5 or 8 L/min external flow. For ventilators with internal flow sensors, changes in displayed exhaled VT ranged from 10% to 118%, however, when using volume control, actual increases in actual VT and PIP were only 4%-21% (P = .063, .031) and 6%-24% (P = .25, .031), respectively. Changes in actual VT correlated closely with changes in PIP (P < .001; R2 = 0.68). For pressure control, actual VT decreased by 3%-5% (P = .031) and 4%-9% (P = .031) with 3.5 and 8 L/min respectively, PIP was unchanged. With external flow sensors at the distal Y-piece junction, volume and pressure changes were statistically insignificant. The time to minimum pressure increased at most by 8% (P = .02) across all modes and ventilators. The effects on muscle pressure were minimal (∼1 cm H2O), and ventilator sensitivity effects were nearly undetectable. CONCLUSIONS: External flow jet nebulization resulted in much smaller changes in volume than indicated by the ventilator display. Statistically significant effects were confined primarily to machines with internal flow sensors. Differences approached the manufacturer-reported variation in ventilator baseline performance. During nebulizer therapy, effects on VT can be estimated at the bedside by monitoring PIP.

Reducing Airway Occlusion Time Without Losing Accuracy to Predict Successful Mechanical Ventilator Liberation During the Measurement of the Timed Inspiratory Effort Index.

BACKGROUND: In 2013, a new predictor of successful mechanical ventilation liberation named timed inspiratory effort (TIE) index was devised with the normalization of the maximum inspiratory pressure (obtained within 60 s of unidirectional airway occlusion) with the time at which the value was reached. The aim of this study was to verify whether the presence of a sequence of a certain number of inspiratory effort values between 30-60 s > 1.0 cm H2O/s could predict weaning success in a performance comparable to the TIE index. METHODS: This was a retrospective observational study using 4 databases of previous studies on the TIE index. All patients receiving mechanical ventilation for ≤ 24 h were eligible. Liberation from mechanical ventilation-extubation decisions was made based on performance with spontaneous breathing trials. P < .05 was considered significant. The performance of the TIE index was evaluated by calculating the area under the receiver operating characteristics (AUROC) curve. RESULTS: From 349 eligible patients, 165 subjects were selected for analysis. The AUROC for the TIE index in the studied sample was 0.92 (95% CI 0.87-0.97, P < .001). A sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s was found in 51.5% of the subjects, with successful ventilatory liberation occurring in 95.3%. The highest specificity values belonged to the sequence of ≤ 4 and ≤ 5 inspiratory efforts > 1.0 cm H2O/s; the highest positive predictive value and positive likelihood ratio belonged to the sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s. The mean time that could have been spared if the procedure were interrupted after the first sequence of 4 inspiratory efforts > 1.0 cm H2O/s was 23 ± 3 s. CONCLUSIONS: The presence of a sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s during the TIE index measurement was a reliable predictor of weaning success, which could allow timely interruption of the procedure and entail a substantial reduction in airway occlusion time.

Reliability and Validity of Maximal Respiratory Pressures.

BACKGROUND: Maximal respiratory pressure is used to assess the inspiratory and expiratory muscles strength by using maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax). This study aimed to summarize and evaluate the reliability and validity of maximal respiratory pressure measurements. METHODS: This systematic review followed the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) recommendations and was reported by using the PRISMA checklist. Studies published before March 2023 were searched in PubMed and EMBASE databases. RESULTS: A total of 642 studies were identified by using the online search strategy and manual search (602 and 40, respectively). Twenty-three studies were included. The level of evidence for test-retest reliability was moderate for PImax and PEmax (intraclass correlation coefficient > 0.70 for both), inter-rater reliability was low for PImax and very low for PEmax (intraclass correlation coefficient > 0.70 for both), and the measurement error was very low for PImax and PEmax. In addition, concurrent validity presented a high level of evidence for PImax and PEmax (r > 0.80). CONCLUSIONS: Only concurrent validity of maximal respiratory pressure measured with the manometers evaluated in this review presented a high level of evidence. The quality of clinical studies by using maximal respiratory pressure would be improved if more high-quality studies on measurement properties, by following well established guidelines and the COSMIN initiative, were available.

Impact of pre-sarcopenia and sarcopenia on biological and functional outcomes in individuals with chronic obstructive pulmonary disease: a cross-sectional study / Impacto de la presarcopenia y la sarcopenia en los resultados biológicos y funcionales en personas con enfermedad pulmonar obstructiva crónica: un estudio transversal

Introduction: The impact of pre-sarcopenia, sarcopenia on important clinical and biological outcomes in individuals with Chronic obstructive pulmonary disease (COPD) have not been fully investigated. Objective: To analyze the impact of pre-sarcopenia and sarcopenia on balance, muscle mass, peripheral and respiratory muscle strength and inflammatory and oxidative stress biomarkers in individuals with COPD. Methods: sixty-one patients diagnosed with COPD were included, stratified into three groups: without sarcopenia (n = 33; 69 ± 6 years), with pre-sarcopenia (n = 15; 66 ± 6 years) and with sarcopenia (n = 13; 71 ± 7 years), according to the European Working Group on Sarcopenia in Older People. It was assessed respiratory muscle strength, through maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), handgrip strength (HGS) and body composition analysis with bioimpedance. Inflammatory and oxidative stress biomarkers were analysed from peripheral blood. Results: The prevalence of pre-sarcopenia and sarcopenia in individuals with COPD was 36% and 25%, respectively. Individuals with sarcopenia exhibit inferior muscle mass, peripheral muscle strength, respiratory muscle strength, and balance compared to their counterparts (p<0.05 for all). In addition, individuals with sarcopenia presented lower levels of protein oxidation (p=0.015) and higher levels of interleukin-1ɓ (p=0.035) compared to those without sarcopenia. Individuals with pre-sarcopenia presented lower levels of antioxidant activity (p=0.045) and higher levels of C-reactive protein (p=0.035). Conclusion: Individuals with COPD who have sarcopenia exhibit diminished muscle mass, impaired balance, and reduced peripheral and respiratory muscle strength in comparison to those with pre-sarcopenia or without sarcopenia. In addition, the presence of sarcopenia and pre-sarcopenia is probably linked by biological mechanisms related to systemic inflammation and oxidative stress.(AU)

Evaluation of patients with chronic obstructive pulmonary disease by maximal inspiratory pressure and diaphragmatic excursion with ultrasound sonography.

BACKGROUND: Decreased respiratory muscle strength and muscle mass is key in diagnosing respiratory sarcopenia. However, the role of reduced diaphragm activity, expressed as the maximal level of diaphragmatic excursion (DEmax), in diagnosing respiratory sarcopenia in patients with chronic obstructive pulmonary disease (COPD) remains unclear. This study aimed to characterize patients with COPD and low DEmax and maximal inspiratory pressure (MIP), a measure of inspiratory muscle strength, and assess the role of DEmax in respiratory sarcopenia. METHODS: Patients with COPD underwent spirometry, exercise tolerance (VO2peak) test, and MIP measurement. DEmax and sternocleidomastoid thickness at the maximal inspiratory level (TscmMIL) were assessed using ultrasound sonography. RESULTS: Overall, 58 patients with COPD (median age, 76 years; median %FEV1, 51.3 %) were included, 28 of whom showed a %MIP of ≥80 %, defined as having preserved MIP. Based on the %MIP of 80 % and median value of DEmax (48.0 mm) as thresholds, the patients were stratified into four groups: both-high (n = 18), %MIP-alone low (n = 11), DEmax-alone low (n = 10), and both-low (n = 19) groups. The both-low group exhibited the lowest %FEV1, Δinspiratory capacity, VO2peak, and TscmMIL, and these values were significantly lower than those of the both-high group. Except for %FEV1, these values were significantly lower in the both-low group than in the %MIP-alone low group despite adjusting DEmax level for body mass index. CONCLUSION: Measuring DEmax along with MIP can characterize patients with COPD, reduced exercise capacity, and decreased accessory respiratory muscle mass and can help diagnose respiratory sarcopenia.

Normal values for maximal respiratory pressures in children and adolescents: A systematic review with meta-analysis.

BACKGROUND: The non-invasive assessment of maximal respiratory pressures (MRP) reflects the strength of the respiratory muscles. OBJECTIVE: To evaluate the studies which have established normative values for MRP in healthy children and adolescents and to synthesize these values through a meta-analysis. METHODS: The searches were conducted until October 2023 in the following databases: ScienceDirect, MEDLINE, CINAHL, SciELO, and Web of Science. Articles that determined normative values and/or reference equations for maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) in children and adolescents published in English, Portuguese, or Spanish regardless of the year of publication were included. Two reviewers selected titles and abstracts, in case of conflict, a third reviewer was consulted. Articles that presented sufficient data were included to conduct the meta-analysis. RESULTS: Initially, 252 studies were identified, 28 studies were included in the systematic review and 19 in the meta-analysis. The sample consisted of 5798 individuals, and the MIP and MEP values were stratified by sex and age groups of 4-11 and 12-19 years. Values from females 4-11 years were: 65.8 cmH2O for MIP and 72.8 cmH2O for MEP, and for males, 75.4 cmH2O for MIP and 84.0 cmH2O for MEP. In the 12-19 age group, values for females were 82.1 cmH2O for MIP and 90.0 cmH2O for MEP, and for males, they were 95.0 cmH2O for MIP and 105.7 cmH2O for MEP. CONCLUSIONS: This meta-analysis suggests normative values for MIP and MEP in children and adolescents based on 19 studies.

Maximal Respiratory Pressure Reference Equations in Healthy Adults and Cut-off Points for Defining Respiratory Muscle Weakness

Introduction: Maximal inspiratory and expiratory pressures (PImax/PEmax) reference equations obtained in healthy people are needed to correctly interpret respiratory muscle strength. Currently, no clear cut-off points defining respiratory muscle weakness are available. We aimed to establish sex-specific reference equations for PImax/PEmax in a large sample of healthy adults and to objectively determine cut-off points for respiratory muscle weakness. Methods: A multicentre cross-sectional study was conducted across 14 Spanish centres. Healthy non-smoking volunteers aged 18–80 years stratified by sex and age were recruited. PImax/PEmax were assessed using uniform methodology according to international standards. Multiple linear regressions were used to obtain reference equations. Cut-off points for respiratory muscle weakness were established by using T-scores. Results: The final sample consisted of 610 subjects (314 females; 48 [standard deviation, SD: 17] years). Reference equations for PImax/PEmax included body mass index and a squared term of the age as independent variables for both sexes (p<0.01). Cut-off points for respiratory muscle weakness based on T-scores ≥2.5 SD below the peak mean value achieved at a young age were: 62 and 83cmH2O for PImax and 81 and 109cmH2O for PEmax in females and males, respectively. Conclusion: These reference values, based on the largest dataset collected in a European population to date using uniform methodology, help identify cut-off points for respiratory muscle weakness in females and males. These data will help to better identify the presence of respiratory muscle weakness and to determine indications for interventions to improve respiratory muscle function. (AU)

Effects of Modified Diaphragmatic Training on Gastroesophageal Reflux Disease Questionnaire Score, Diaphragmatic Excursion, and Maximum Inspiratory Pressure in Adults with Gastroesophageal Reflux Disease After COVID-19: A Single-Blinded Randomized Control.

BACKGROUND: Although diaphragmatic training has been shown to improve gastroesophageal reflux disease (GERD) symptoms, its effectiveness in adults with GERD after COVID-19 has not been evaluated. This study examined the effectiveness of modified diaphragmatic training (MDT) on GERD questionnaire (GERDQ) score, diaphragmatic excursion, and maximum inspiratory pressure (MIP) in adults with GERD after COVID-19. METHODS: This single-blinded randomized control trial was conducted at Persahabatan Hospital from February to April 2023. The medical records of 364 patients with persistent gastrointestinal symptoms were evaluated; among these potential participants, 302 had symptoms before, and 62 after, COVID-19 infection. Fifty of these patients fulfilled the study inclusion and exclusion criteria and were randomly assigned to the intervention (n = 25) or control (n = 25) groups. Four weeks of diaphragmatic training were followed by MDT or standard diaphragmatic training. A follow-up assessment was conducted 30 days after the beginning of the training. RESULTS: The GERDQ score was significantly decreased in the pre-post-intervention group (10.44 ± 2.00 vs 1.84 ± 2.17) and the control group (8.64 ± 0.57 vs 3.32 ± 1.49), with p < 0.001. The intervention group showed significant improvements in the right diaphragmatic excursion (RDE) (44% vs 11.87%), left diaphragmatic excursion (LDE) (46.61% vs 13.62%), and MIP (75.26% vs 23.97%) compared with the control group. CONCLUSION: MDT in adults after COVID-19 with GERD enhanced diaphragmatic excursion and MIP and decreased symptoms of gastroesophageal reflux by 8.60 points of GERDQ. Respiratory symptoms and other side effects were comparable between the groups.

Maximal Respiratory Pressure Reference Equations in Healthy Adults and Cut-off Points for Defining Respiratory Muscle Weakness.

INTRODUCTION: Maximal inspiratory and expiratory pressures (PImax/PEmax) reference equations obtained in healthy people are needed to correctly interpret respiratory muscle strength. Currently, no clear cut-off points defining respiratory muscle weakness are available. We aimed to establish sex-specific reference equations for PImax/PEmax in a large sample of healthy adults and to objectively determine cut-off points for respiratory muscle weakness. METHODS: A multicentre cross-sectional study was conducted across 14 Spanish centres. Healthy non-smoking volunteers aged 18-80 years stratified by sex and age were recruited. PImax/PEmax were assessed using uniform methodology according to international standards. Multiple linear regressions were used to obtain reference equations. Cut-off points for respiratory muscle weakness were established by using T-scores. RESULTS: The final sample consisted of 610 subjects (314 females; 48 [standard deviation, SD: 17] years). Reference equations for PImax/PEmax included body mass index and a squared term of the age as independent variables for both sexes (p<0.01). Cut-off points for respiratory muscle weakness based on T-scores ≥2.5 SD below the peak mean value achieved at a young age were: 62 and 83cmH2O for PImax and 81 and 109cmH2O for PEmax in females and males, respectively. CONCLUSION: These reference values, based on the largest dataset collected in a European population to date using uniform methodology, help identify cut-off points for respiratory muscle weakness in females and males. These data will help to better identify the presence of respiratory muscle weakness and to determine indications for interventions to improve respiratory muscle function.

Impacto de un Programa de Recuperación Funcional en Músculos Ventilatorios y Apendiculares en Pacientes Post-ventilación Mecánica por COVID-19 / Impact of a Functional Recovery Program on Ventilatory and Appendicular Muscles in Patients Post-mechanical Ventilation for COVID-19

Los pacientes con COVID-19 subsidiarios de ventilación mecánica (VM), evolucionan con consecuencias funcionales en la musculatura ventilatoria y apendicular que no necesariamente se abordan de manera diferenciada. El objetivo de esta investigación fue evaluar el impacto de un programa de recuperación funcional en estos pacientes y determinar si las intervenciones afectan de manera diferenciada a las funciones ventilatorias y musculatura apendicular, utilizando pruebas de bajo costo. Se evaluaron 47 pacientes con COVID-19 que estuvieron en VM. Posterior a una espirometría basal se les realizó; presión inspiratoria máxima (PIMáx), fuerza de prensión palmar (FPP), prueba de pararse y sentarse (PPS) y Prueba de caminata en 6 minutos (PC6m), antes y después del plan de intervención. Este programa incluyó ejercicios aeróbicos y de fuerza supervisados por dos sesiones semanales de 60 minutos durante 3 meses. Después del programa, se observaron mejoras significativas en la capacidad vital forzada (CVF), el volumen espiratorio en el primer segundo (VEF1) y la PIMáx. Se encontraron relaciones significativas entre estas mediciones y la distancia recorrida de la PC6m, la FPP y la PPS. En conclusión, el programa de recuperación funcional en pacientes con COVID-19 que requirieron VM, beneficia tanto la función ventilatoria como la fuerza muscular apendicular. Las pruebas de fuerza muscular apendicular pueden ser útiles para evaluar la recuperación ya que pueden entregar información diferenciada de sus rendimientos. Por último, se necesita más investigación para comprender mejor la respuesta de estos pacientes a la rehabilitación.

SUMMARY: Patients with COVID-19 requiring mechanical ventilation (MV) evolve with functional consequences in the ventilatory and appendicular muscles that are not necessarily addressed in a differentiated manner. The objective of this research was to evaluate the impact of a functional recovery program in these patients and determine if the interventions differentially affect ventilatory functions and appendicular muscles, using low- cost tests. 47 patients with COVID-19 who were on MV were evaluated. After a baseline spirometry, they were performed; maximum inspiratory pressure (MIP), handgrip strength (HGS), sit to stand test (STST) and 6-minute walk test (6MWT), before and after the intervention plan. This program included supervised aerobic and strength exercises for two weekly 60-minute sessions for 3 months. After the program, significant improvements were observed in forced vital capacity (FVC), expiratory volume in the first second (FEV1) and MIP. Significant relationships were found between these measurements and the distance traveled of the 6MWT, the HGS and the STST. In conclusion, the functional recovery program in patients with COVID-19 who required MV benefits both ventilatory function and appendicular muscle strength. Appendicular muscle strength tests can be useful to evaluate recovery since they can provide differentiated information about your performances. Finally, more research is needed to better understand the response of these patients to rehabilitation.

Maximal expiratory pressure compared with maximal expiratory pressure during induced cough as a predictor of extubation failure.

OBJECTIVE: To compare the diagnostic performance of maximal expiratory pressure with maximal expiratory pressure during induced cough for predicting extubation failure within 72 hours in patients who completed a spontaneous breathing trial (SBT). METHODS: The study was conducted between October 2018 and September 2019. All patients aged over 18 years admitted to the intensive care unit who required invasive mechanical ventilation for over 48 hours and successfully completed a spontaneous breathing trial were included. The maximal expiratory pressure was assessed with a unidirectional valve for 40 seconds, and verbal encouragement was given. The maximal expiratory pressure during induced cough was measured with slow instillation of 2mL of a 0.9% saline solution. The primary outcome variable was extubation failure. RESULTS: Eighty patients were included, of which 43 (54%) were male. Twenty-two patients [27.5% (95%CI 18.9 - 38.1)] failed extubation within 72 hours. Differences were observed in the maximal expiratory pressure during induced cough between the group who failed extubation, with a median of 0cmH2O (P25-75: 0 - 90), and the group without extubation failure, with a median of 120cmH2O (P25-75: 73 - 120); p < 0.001. CONCLUSION: In patients who completed a spontaneous breathing trial, the maximal expiratory pressure during induced cough had a higher diagnostic performance for predicting extubation failure within 72 hours.Clinicaltrials.gov Registry: NCT04356625.

Cambios en el índice de stress y presión inspiratoria pico posterior a neumoperitoneo en colecistectomía laparoscópica / Changes in Stress Index and Peak Inspiratory Pressure after Pneumoperitoneum in Laparoscopic Cholecystectomy

Introducción: es bien sabido que el neumoperitoneo en cirugía laparoscópica afecta tanto al sistema cardiovascular como al sistema respiratorio, pero no se entiende por completo el grado en el que debemos modificar los parámetros ventilatorios para mini-mizar las complicaciones debido a la insuflación del neumoperitoneo. Estos cambios in-cluyen disminución de la distensibilidad y mayores presiones inspiratorias pico.

Abstract Background: it is well known that pneumoperitoneum in laparoscopic surgery affects both cardiovascular and respiratory system, but it is not fully understood yet the degree in which we have to make changes in the ventilatory settings to minimize the complica-tions due to insufflation of peritoneum, changes including impaired compliance and hig-her peak inspiratory.

Maximal respiratory pressures: Measurements at functional residual capacity in individuals with different health conditions using a digital manometer.

BACKGROUND: Measuring maximal respiratory pressure is a widely used method of investigating the strength of inspiratory and expiratory muscles. OBJECTIVES: To compare inspiratory pressures obtained at functional residual capacity (FRC) with measures at residual volume (RV), and expiratory pressures obtained at FRC with measures at total lung capacity (TLC) in individuals with different health conditions: post-COVID-19, COPD, idiopathic pulmonary fibrosis (IPF), heart failure (CHF), and stroke; and to compare the mean differences between measurements at FRC and RV/TLC among the groups. METHODS: Inspiratory and expiratory pressures were obtained randomly at different lung volumes. Mixed factorial analysis of covariance with repeated measures was used to compare measurements at different lung volumes within and among groups. RESULTS: Seventy-five individuals were included in the final analyses (15 individuals with each health condition). Maximal inspiratory pressures at FRC were lower than RV [mean difference (95% CI): 11.3 (5.8, 16.8); 8.4 (2.3, 14.5); 11.1 (5.5, 16.7); 12.8 (7.1, 18.4); 8.0 (2.6, 13.4) for COVID-19, COPD, IPF, CHF, and stroke, respectively] and maximal expiratory pressures at FRC were lower than TLC [mean difference (95% CI): 51.9 (37.4, 55.5); 60.9 (44.2, 77.7); 62.9 (48.1, 77.8); 58.0 (43.9, 73.8); 57.2 (42.9, 71.6) for COVID-19, COPD, IPF, CHF, and stroke, respectively]. All mean differences were similar among groups. CONCLUSION: Although inspiratory and expiratory pressures at FRC were lower than measures obtained at RV/TLC for the five groups of health conditions, the mean differences between measurements at different lung volumes were similar among groups, which raises the discussion about the influence of the viscoelastic properties of the lungs on maximal respiratory pressure.

Effects of high-intensity inspiratory muscle warm-up on inspiratory muscle strength and accessory inspiratory muscle activity.

This study aimed to determine the effects of work-matched moderate-intensity and high-intensity inspiratory muscle warm-up (IMW) on inspiratory muscle strength and accessory inspiratory muscle activity. Eleven healthy men performed three IMWs at different intensities, namely, placebo, moderate-intensity, and high-intensity, set, respectively, at 15 %, 40 %, and 80 % of maximal inspiratory mouth pressure (MIP). MIP was measured before and after IMW. Electromyography (EMG) was recorded for the sternocleidomastoid muscle (SCM) and intercostal muscles (IC) during IMW. MIP increased significantly in the moderate-intensity condition (104.2 ± 5.1 %, p < 0.05) and high-intensity condition (106.5 ± 6.2 %, p < 0.01) after IMW. The EMG amplitudes of the SCM and IC during IMW were significantly higher in the order of high-intensity, moderate-intensity, and placebo conditions. There was a significant correlation between changes in MIP and EMG amplitude of the SCM (r = 0.60, p < 0.01) and IC (r = 0.47, p < 0.01) during IMW. These findings suggest that high-intensity IMW increases neuromuscular activity in the accessory inspiratory muscles, which may improve inspiratory muscle strength.

A Prospective Study of 73 Patients to Compare Forward Head Angle, Forward Shoulder Angle, Maximal Inspiratory Pressure, and Self-Reported Breathing-Related Symptoms Before and After Open-Heart Surgery.

BACKGROUND Patients who undergo open-heart surgery often experience widespread musculoskeletal and pulmonary complications. These can interfere with their functioning, resulting in soft tissue changes, worsening postural changes, and poor respiratory performance. Therefore, the prospective study aimed to compare forward head angle (FHA) and forward shoulder angle (FSA), maximal inspiratory pressure (MIP), and self-reported breathing dysfunction before and after open-heart surgery. MATERIAL AND METHODS In a prospective observational study of 106 patients, men and women scheduled for open-heart surgery were enrolled. Prior to surgery and before discharge from the hospital, all patients were required to assess FHA and FSA using 2-dimensional motion analysis software, MIP using a respiratory pressure meter, and breathing dysfunction using the 25-item Self Evaluation of Breathing Questionnaire (SEBQ). Paired t test was used to compare differences between before and after surgery. To evaluate associations, logistic regression analysis was performed. RESULTS Of the 106 patients recruited, 73 completed the study. FHA (-Δ6.55±4.77, P.