The phase angle cut-off point capable of discriminating hemodialysis patients with reduced exercise tolerance: a cross-sectional study.

BACKGROUND: Phase angle (PhA) is a prognostic marker of all-cause mortality in chronic kidney disease. However, no study has investigated this marker as a predictor of exercise intolerance in hemodialysis (HD) patients. The aim of this study was to determine a cut-off point for the PhA capable of discriminating HD patients with reduced exercise tolerance. METHODS: Thirty-one patients (80.6% men, median age 69 years) were included. The evaluations were performed on three different days, before the HD session. The outcomes evaluated were: biochemical markers, inflammatory and nutritional status, body composition, peripheral muscle strength and exercise tolerance. Performance ≤50% of the predicted value in the six-minute step test (6MST) was defined as reduced exercise tolerance. RESULTS: Patients presented an average of 67.6 steps (50.5% of predicted) in the 6MST. Fifteen patients (48.4%) were classified with reduced exercise tolerance. The receiver operating characteristic curve indicated a cut-off point of 3.73° for the PhA (sensitivity = 87%, specificity = 81%, and area under the curve = 0.88 [95% CI: 0.76-1.00]; p < 0.001). Patients with reduced exercise tolerance had worse inflammatory and nutritional status, lower PhA and greater impairment of peripheral muscle strength. CONCLUSION: The cut-off point of 3.73° for the PhA is sensitive and specific to discriminate HD patients with reduced exercise tolerance. TRIAL REGISTRATION: This study was registered in the Clinical Trials database (no. NCT03779126, date of first registration 19/12/2018).

Functional recovery of chronically critically ill patients in the first days after discharge from the intensive care unit: Feasibility of the 6-minute step test.

BACKGROUND: Survivors of chronic critical illness often experience weakness and functional dependence to various degrees after their intensive care unit (ICU) stay. Evaluating their functional status with the traditional six-minute walk test is challenging due to space constraints or patient intolerance. OBJECTIVE: Our aim was to evaluate the feasibility of using the six-minute step test (6MST) as a measure of functional capacity in chronically critically ill patients early after ICU discharge. METHODS: This prospective study was undertaken in a private Brazilian hospital. From July 2019 to July 2020, all chronically critically ill patients were asked to participate 48 hours after ICU discharge. On the day of study inclusion and a week later, those who consented underwent functional assessment comprised of the 6MST, peripheral muscle strength using handgrip strength (HGS), and mobility using the ICU mobility scale (IMS). RESULTS: A total of 40 patients were included. The 6MST was feasible in 40% on the first evaluation and 57% on the second. The median 6MST was 0 [0-5] on the first evaluation and 3.5 [0-7.75] on the second (P = 0.005). The median HGS increased from 11.50 [9.25-18] on the first evaluation to 14.5 [10-20] on the second (P = 0.006). The median IMS was 4.5 [3.25-7] on the first evaluation and 6 [3.25-7] on the second (P<0.001). Despite the significant improvement, all parameters measured remained well below normal. CONCLUSION: The 6MST was a feasible measure of functional capacity in chronically critically ill patients early after ICU discharge. Patients had functional capacity well below predicted values.

Mentoring in research: development of competencies for health professionals.

BACKGROUND: Mentoring programmes in health research are beneficial for both mentors and mentees and are essential for the development of the next generation of research leaders. This study describes the self-assessment of research skills in health professionals participating in a research mentoring programme and determines the correlation between the participants' self-assessment of research skills and professional characteristics. METHOD: This was a quasi-experimental, time-series study conducted in a Brazilian tertiary hospital. Thirty-five health professionals holding a master's or PhD degree were included. The participants answered a survey in which they self-assessed their research skills distributed into eight domains, with one group responding before training and another group responding after training. The level of significance was set at 5% (p < 0.05). RESULTS: Those who received training scored better in research skills related to two domains: critical analysis of the literature and identification of appropriate research methods (p = 0.0245). CONCLUSION: Trained professionals performed better in the domains of critical thinking and knowledge and management of steps in the research process.

Impact on the ability of healthcare professionals to correctly identify patient-ventilator asynchronies of the simultaneous visualization of estimated muscle pressure curves on the ventilator display: a randomized study (Pmus study).

BACKGROUND: Patient-ventilator asynchronies are usually detected by visual inspection of ventilator waveforms but with low sensitivity, even when performed by experts in the field. Recently, estimation of the inspiratory muscle pressure (Pmus) waveforms through artificial intelligence algorithm has been proposed (Magnamed®, São Paulo, Brazil). We hypothesized that the display of these waveforms could help healthcare providers identify patient-ventilator asynchronies. METHODS: A prospective single-center randomized study with parallel assignment was conducted to assess whether the display of the estimated Pmus waveform would improve the correct identification of asynchronies in simulated clinical scenarios. The primary outcome was the mean asynchrony detection rate (sensitivity). Physicians and respiratory therapists who work in intensive care units were randomized to control or intervention group. In both groups, participants analyzed pressure and flow waveforms of 49 different scenarios elaborated using the ASL-5000 lung simulator. In the intervention group the estimated Pmus waveform was displayed in addition to pressure and flow waveforms. RESULTS: A total of 98 participants were included, 49 per group. The sensitivity per participant in identifying asynchronies was significantly higher in the Pmus group (65.8 ± 16.2 vs. 52.94 ± 8.42, p < 0.001). This effect remained when stratifying asynchronies by type. CONCLUSIONS: We showed that the display of the Pmus waveform improved the ability of healthcare professionals to recognize patient-ventilator asynchronies by visual inspection of ventilator tracings. These findings require clinical validation. TRIAL REGISTRATION: ClinicalTrials.gov: NTC05144607. Retrospectively registered 3 December 2021.

Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study / Influencia de la congestión pulmonar leve en la movilidad diafragmática y las actividades de la vida diaria en la enfermedad renal crónica: un estudio experimental y clínico

Background: Pulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions. Methods: Thirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed. Results: Mild pulmonary congestion caused a 26.1% decline in DM (R2=.261; P=.004) and 20% reduction in walking time (R2=.200; P=.01), indicating decreases of 2.23mm and 1.54min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P=.002), walking (P=.034) and active time (P=.002), and number of steps taken (P=.01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P=.037) and lungs (P=.02), attenuation of exploratory behavior (P=.01) and significant decrease in traveled distance (P=.034). Thoracic ultrasonography of CKD mice showed presence of B-lines. (AU)

Antecedentes: La congestión pulmonar es un fuerte predictor de mortalidad y eventos cardiovasculares en la enfermedad renal crónica (ERC); sin embargo, aún no se han investigado los efectos de la forma leve sobre la funcionalidad. El objetivo de este estudio fue evaluar la influencia de la congestión pulmonar leve en la movilidad diafragmática (MD) y las actividades de la vida diaria (AVD) en sujetos en hemodiálisis (HD), así como comparar el comportamiento de las AVD en los días de diálisis y no diálisis. Paralelamente, inducir de forma experimental la ERC en ratones y analizar las repercusiones pulmonares y funcionales resultantes. Métodos: Treinta sujetos en HD fueron sometidos a ecografía torácica y abdominal, evaluación antropométrica, función pulmonar y renal, evaluación de la fuerza de los músculos respiratorios y análisis de síntomas. Para medir las AVD se utilizó un acelerómetro triaxial durante 7 días consecutivos. Se aleatorizaron 20 ratones machos en el grupo control y con ERC. Se realizó ecografía torácica, análisis de TNF-α en tejido renal y pulmonar, comportamiento exploratorio y evaluaciones de funcionalidad. Resultados: La congestión pulmonar leve provocó una disminución del 26,1% en la MD (R2=,261; P=,004) y una reducción del 20% en el tiempo de caminata (R2=0,200; P=,01), lo que indica disminuciones de 2,23mm y 1,54minutos, respectivamente, por cada unidad de aumento de las colas de cometa pulmonares. En cuanto a las AVD los sujetos mostraron diferencias estadísticamente significativas para estar de pie (P=,002), caminar (P=,034) y tiempo activo (P=,002) y número de pasos dados (P=,01) en los días con y sin HD. En el modelo experimental la ERC resultó en un aumento de los niveles de TNF-α en los riñones (P=,037) y los pulmones (P=,02), la atenuación del comportamiento exploratorio (P=,01) y una disminución significativa en la distancia recorrida (P=,034). La ecografía torácica de ratones con ERC mostró la presencia de líneas B. (AU)

Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study.

BACKGROUND: Pulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions. METHODS: Thirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed. RESULTS: Mild pulmonary congestion caused a 26.1% decline in DM (R2=.261; P=.004) and 20% reduction in walking time (R2=.200; P=.01), indicating decreases of 2.23mm and 1.54min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P=.002), walking (P=.034) and active time (P=.002), and number of steps taken (P=.01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P=.037) and lungs (P=.02), attenuation of exploratory behavior (P=.01) and significant decrease in traveled distance (P=.034). Thoracic ultrasonography of CKD mice showed presence of B-lines. CONCLUSION: The mild pulmonary congestion reduced DM and walking time in subjects undergoing HD. Individuals were less active on dialysis days. Furthermore, the experimental model implies that the presence of pulmonary congestion and inflammation may play a decisive role in the low physical and exploratory performance of CKD mice.

Efficacy of neuromuscular electrical stimulation with combined low and high frequencies on body composition, peripheral muscle function and exercise tolerance in patients with chronic kidney disease undergoing haemodialysis: a protocol for a randomised, double-blind clinical trial.

INTRODUCTION: Neuromuscular electrical stimulation (NMES) as an adjunctive strategy to increase isolated muscular strength or endurance has been widely investigated in patients with chronic kidney disease (CKD) undergoing haemodialysis (HD). However, the efficacy of combined low and high frequencies, to improve both muscular strength and endurance, is unknown. This trial aims to evaluate the efficacy of this combined NMES strategy in this population. METHODS AND ANALYSIS: This is a randomised controlled trial with blinded assessments and analysis. A total of 56 patients with CKD undergoing HD will be recruited and randomised to an NMES protocol. The evaluations will be performed on three different days at baseline and after 24 sessions of follow-up. Assessments will include the background, insulin-like growth factor, lactate measurement, malnutrition and inflammation score evaluation, an electrical bioimpedance examination, global muscular evaluation by means of the Medical Research Council scale, handgrip strength evaluation, muscular isokinetic evaluation of lower limbs, 6 min step test performance and quality of life (QoL) questionnaire with emphasis on physical function. The patients will be allocated in one of the following four groups: 1) combined low and high frequencies; 2) low frequency; 3) high frequency; and 4) sham stimulation with minimal intensity to generate only sensory perception (with no visible contraction). In all groups, the intensity throughout the session will be the highest tolerated by patient (except for control group). The primary endpoint is the change of peripheral muscle function (muscular strength and endurance). The secondary endpoints will be the changes of body composition; muscle trophism; exercise tolerance; QoL; and nutritional, inflammatory, and metabolic markers. The findings of this study are expected to provide valuable knowledge on how to optimise the NMES intervention, with improvements in both muscle strength and endurance. ETHICS AND DISSEMINATION: This protocol has been approved by the Ethics Committee on Research with Humans of Hospital Sírio-Libanês (approval no. 24337707). Written informed consent will be obtained from each participant. The results of the study will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03779126.

Effectiveness of a quality improvement strategy with implementation of a specific visual tool to promote ICU early mobilization.

Early progressive mobilization is a safe strategy in the intensive care unit (ICU), however, it is still considered challenging by the inherent barriers and poor adherence to early mobilization protocol. The aim of this study was to evaluate the effectiveness of a quality improvement (QI) multifaceted strategy with implementation of a specific visual tool, the "mobility clock", in reducing non-compliance with the institutional early mobilization (EM) protocol in adult ICUs. A single-center QI with a retrospective before-after comparison study was conducted using data from medical records and hospital electronic databases. Patients from different periods presented similar baseline characteristics. After the QI strategy, a decline in "non-compliance" with the protocol was observed compared to the previous period (10.11% vs. 26.97%, p < 0.004). The proportion of patients walking was significantly higher (49.44% vs. 29.21%, p < 0.006) and the ICU readmission rate was lower in the "after" period (2.25% vs. 11.24%; p = 0.017). The multifaceted strategy specifically designed considering institutional barriers was effective to increase out of bed mobilization, to reduce the "non-compliance" rate with the protocol and to achieve a higher level of mobility in adult ICUs of a tertiary hospital.

The Six-Minute Stepper Test Is Valid to Evaluate Functional Capacity in Hospitalized Patients With Exacerbated COPD.

Background: The six-minute stepper test (6MST) is a self-paced test considered a valid tool to assess functional capacity in stable COPD patients. However, a high floor effect, where a large proportion of participants reach the minimum score when using the measurement instrument, might compromise the test validity in the hospital setting. Therefore, this study aimed at verifying the concurrent validity of 6MST 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 were considered for inclusion. On the first day, when patients reached minimum clinical criteria considered as the use of non-invasive ventilation less than 2 h for 6 h/period, dyspnea at rest less than 7 (very severe) on the modified Borg scale, a respiratory rate less than 25 breaths per minute, oxygen pulse saturation greater than 88% (considering use of supplemental oxygen) and absence of paradoxical breathing pattern, they underwent a lung function evaluation and answered three questionnaires: Chronic Respiratory Questionnaire (CRQ), Modified Medical Research Council Dyspnea Scale (MMRC), and COPD Assessment Test (CAT). Then, on two consecutive days, patients performed 6MST or six-minute walk test (6MWT), in random order. Each test was performed twice, and the best performance was recorded. Also, the patient's severity was classified according to the BODE index. Inspiratory capacity measurements were performed before and after each test execution. Results: Sixteen patients (69.4 ± 11.4 years) with a mean FEV1 of 49.4 ± 9.9% predicted were included (9 females). There was a strong correlation of the performance in 6MST (number of cycles) with 6MWT (distance walked in meters) in absolute values (r = 0.87, p < 0.001) as well as with the percentage of predicted normal 6MWT (r = 0.86, p < 0.001). There was a strong correlation between the performance in 6MST with the dynamic hyperinflation (r = 0.72, p = 0.002) and a moderate correlation between 6MST with the percentage of reduction of inspiratory capacity (r = 0.68, p = 0.004). We also identified that 6MST showed moderate negative correlations with CAT (r = -0.62, p = 0.01) and BODE index (r = -0.59, p = 0.01). Conclusion: It could be concluded that 6MST is valid for evaluating functional capacity in hospitalized patients with exacerbated COPD.

Neuromuscular Electrical Stimulation in Patients With Severe COVID-19 Associated With Sepsis and Septic Shock.

BACKGROUND: Neuromuscular electrical stimulation (NMES) can be applied to critically ill patients. However, its results on muscle strength and functionality in patients with COVID-19 are unknown. OBJECTIVE: Evaluate the effects of intervention with NMES on muscle mass and functionality of patients with severe COVID-19 associated with sepsis and septic shock. METHODS: Seven patients with COVID-19 associated with sepsis or septic shock were selected, but only 5 patients completed all days of the intervention with NMES. The intervention was performed by a single physiotherapist on 7 consecutive days in a daily session of 40 min. The outcome measures were the femoris cross-sectional area; thickness of the anterior compartment of the quadriceps muscle; rectus femoris echogenicity; International Classification of Functioning, Disability, and Health (ICF)-muscle strength; PFIT-s, DEMMI, and the SOMS; feasibility, and safety. The patients were evaluated on days 1, 5, and 8. RESULTS: The rectus femoris cross-sectional area decreased significantly from days 1 to 8, but showed maintenance of the thickness of the anterior compartment of the quadriceps muscle from days 1 to 8. The MRC score increased significantly from days 1 to 5 and kept this improvement until day 8. All patients showed an increase in the MRC score and reduction of the ICF-muscle strength, meaning improved muscle strength from days 1 to 8. The PFIT-s increased significantly from days 1 to 5 and improved until day 8 compared to day 5. DEMMI and SOMS score increased significantly on day 8 compared to days 1 and 5. CONCLUSION: Rehabilitation with NMES showed improvement in muscle strength and functionality of patients in this study with a potential protective effect on muscle mass loss in patients with critical COVID-19 associated with sepsis and septic shock. This study is the first report of the potential effects of neuromuscular electrical stimulation in patients with severe COVID-19 associated with sepsis and septic shock.

Noninvasive ventilation and high-flow nasal cannula in patients with acute hypoxemic respiratory failure by covid-19: A retrospective study of the feasibility, safety and outcomes.

BACKGROUND: Noninvasive ventilation (NIV) and High-flow nasal cannula (HFNC) are the main forms of treatment for acute respiratory failure. This study aimed to evaluate the effect, safety, and applicability of the NIV and HFNC in patients with acute hypoxemic respiratory failure (AHRF) caused by COVID-19. METHODS: In this retrospective study, we monitored the effect of NIV and HFNC on the SpO2 and respiratory rate before, during, and after treatment, length of stay, rates of endotracheal intubation, and mortality in patients with AHRF caused by COVID-19. Additionally, data regarding RT-PCR from physiotherapists who were directly involved in assisting COVID-19 patients and non-COVID-19. RESULTS: 62.2 % of patients were treated with HFNC. ROX index increased during and after NIV and HFNC treatment (P < 0.05). SpO2 increased during NIV treatment (P < 0.05), but was not maintained after treatment (P = 0.17). In addition, there was no difference in the respiratory rate during or after the NIV (P = 0.95) or HFNC (P = 0.60) treatment. The mortality rate was 35.7 % for NIV vs 21.4 % for HFNC (P = 0.45), while the total endotracheal intubation rate was 57.1 % for NIV vs 69.6 % for HFNC (P = 0.49). Two adverse events occurred during treatment with NIV and eight occurred during treatment with HFNC. There was no difference in the physiotherapists who tested positive for SARS-COV-2 directly involved in assisting COVID-19 patients and non-COVID-19 ones (P = 0.81). CONCLUSION: The application of NIV and HFNC in the critical care unit is feasible and associated with favorable outcomes. In addition, there was no increase in the infection of physiotherapists with SARS-CoV-2.

Cold bubble humidification of low-flow oxygen does not prevent acute changes in inflammation and oxidative stress at nasal mucosa.

Some clinical situations require the use of oxygen therapy for a few hours without hypoxemia. However, there are no literature reports on the effects of acute oxygen therapy on the nasal mucosa. This study aimed to evaluate the acute effects of cold bubble humidification or dry oxygen on nasal Inflammation, oxidative stress, mucociliary clearance, and nasal symptoms. This is a randomized controlled cross-sectional study in which healthy subjects were randomly allocated into four groups: (1) CA + DRY (n = 8): individuals receiving dry compressed air; (2) OX + DRY (n = 8): individuals receiving dry oxygen therapy; (3) CA + HUMID (n = 7): individuals receiving cold bubbled humidified compressed air; (4) OX + HUMID (n = 8): individuals receiving cold bubbled humidified oxygen therapy. All groups received 3 L per minute (LPM) of the oxygen or compressed air for 1 h and were evaluated: total and differential cells in the nasal lavage fluid (NLF), exhaled nitric oxide (eNO), 8-iso-PGF2α levels, saccharin transit test, nasal symptoms, and humidity of nasal cannula and mucosa. Cold bubble humidification is not able to reduced nasal inflammation, eNO, oxidative stress, mucociliary clearance, and nasal mucosa moisture. However, subjects report improvement of nasal dryness symptoms (P < 0.05). In the conclusion, cold bubble humidification of low flow oxygen therapy via a nasal cannula did not produce any effect on the nasal mucosa and did not attenuate the oxidative stress caused by oxygen. However, it was able to improve nasal symptoms arising from the use of oxygen therapy.

Bleeding frequency during physiotherapy in thrombocytopenic patients undergoing hematopoietic stem cell transplantation.

BACKGROUND: During hematopoietic stem cell transplantation (HSCT) the patients perform activities of low and moderate intensity because have reduced hematological lineages, leaving them susceptible to hemorrhagic events. The objective of this study was to describe the frequency of bleeding events, severity, and possible association with physical exercise in thrombocytopenic patients. METHODS: A retrospective study with seventy-seven HSCT patients hospitalised, that had a platelet count ≤ 50,000 /µL and received physical exercise during physiotherapy intervention. RESULTS: Regarding bleeding events, only six were related to physical exercise, and bleeding events occurred more frequently at platelet levels ≤ 10,000 /µL. The most frequent bleeding event was epistaxis, considered of low severity, and with the moderate possibility of being related to physical exercise; followed by extremity hematoma, considered of medium severity and highly related to physical exercise. In this study, there was no occurrence of bleeding events considered of high severity. CONCLUSION: Bleeding frequency in supervised physical exercise during physiotherapy in adults with thrombocytopenia undergoing HSCT is minor and relatively rare but occurs more frequently in patients with platelet count ≤10,000 /µL. These results encourage the maintenance of physical activity in this population who is at high risk of developing immobility-related complications.

Skeletal Muscle Wasting and Function Impairment in Intensive Care Patients With Severe COVID-19.

Background: Intensive care patients commonly develop muscle wasting and functional impairment. However, the role of severe COVID-19 in the magnitude of muscle wasting and functionality in the acute critical disease is unknown. Objective: To perform a prospective characterization to evaluate the skeletal muscle mass and functional performance in intensive care patients with severe COVID-19. Methods: Thirty-two critically ill patients (93.8% male; age: 64.1 ± 12.6 years) with the diagnosis of the severe COVID-19 were prospectively recruited within 24 to 72 h following intensive care unit (ICU) admission, from April 2020 to October 2020, at Hospital Sírio-Libanês in Brazil. Patients were recruited if older than 18 years old, diagnosis of severe COVID-19 confirmed by RT-PCR, ICU stay and absence of limb amputation. Muscle wasting was determined through an ultrasound measurement of the rectus femoris cross-sectional area, the thickness of the anterior compartment of the quadriceps muscle (rectus femoris and vastus intermedius), and echogenicity. The peripheral muscle strength was assessed with a handgrip test. The functionality parameter was determined through the ICU mobility scale (IMS) and the International Classification of Functioning, Disability and Health (ICF). All evaluations were performed on days 1 and 10. Results: There were significant reductions in the rectus femoris cross-section area (-30.1% [95% IC, -26.0% to -34.1%]; P < 0.05), thickness of the anterior compartment of the quadriceps muscle (-18.6% [95% IC, -14.6% to 22.5%]; P < 0.05) and handgrip strength (-22.3% [95% IC, 4.7% to 39.9%]; P < 0.05) from days 1 to 10. Patients showed increased mobility (0 [0-5] vs 4.5 [0-8]; P < 0.05), improvement in respiratory function (3 [3-3] vs 2 [1-3]; P < 0.05) and structure respiratory system (3 [3-3] vs 2 [1-3]; P < 0.05), but none of the patients returned to normal levels. Conclusion: In intensive care patients with severe COVID-19, muscle wasting and decreased muscle strength occurred early and rapidly during 10 days of ICU stay with improved mobility and respiratory functions, although they remained below normal levels. These findings may provide insights into skeletal muscle wasting and function in patients with severe COVID-19.

Relationship of phase angle and peak torque of knee extensors with the performance in six-minute step test in haemodialysis patients.

BACKGROUND: Chronic kidney disease is a systemic disease affecting not only renal function, but also endocrine, cardiovascular, and skeletal muscle systems, with broad impact on functionality. Therefore, the assessment of body composition, peripheral muscle function, and exercise tolerance is also of great importance in this population. In addition, the development of reliable strategies that use feasible tools in clinical practice is of great importance in the functional diagnosis, clinical management and prescription of physical activity. OBJECTIVE: To assess the relationship between phase angle and peak torque of knee extensors with the performance in six-minute step test of patients with chronic kidney disease undergoing haemodialysis. METHODS: Observational and cross-sectional study at Haemodialysis Centre of Sírio-Libanês Hospital. The evaluations took place 3 days before the haemodialysis sessions. On the first day, patients underwent anthropometric evaluation and biochemical tests (lactate, urea, creatinine, albumin, ferritin and growth factor similar to insulin type 1 [IGF1]). On the second day, performed electrical bioimpedance and exercise tolerance assessed using the six-minute step test. On the last day, the evaluation of knee extensor muscles strength using isokinetic dynamometry was performed. RESULTS: Eighteen subjects were included, with a mean age of 62.3 ± 17.6 years. A positive linear correlation was observed between the phase angle, derived from the electrical bioimpedance, and the performance in six-minute step test in these patients. It was also possible to observe a linear correlation between phase angle and IGF1, handgrip strength, peak torque of knee extensors and quality of life questionnaire. The peak torque of knee extensors also presented a linear correlation with IGF1, the performance in six-minute step test and mal-nutrition and inflammation score. CONCLUSION: Phase angle and peak torque of knee extensors were correlated with the performance in six-minute step test. Therefore, the phase angle seems to be an important marker of reduced peripheral muscle function and exercise tolerance in haemodialysis patients.

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.

Six-minute stepper test in hospitalized elderly patients: Convergent validity, test-retest reliability and safety.

OBJECTIVE: To evaluate the convergent validity of the six-minute stepper test (6MST) with the variables used in the diagnosis of sarcopenia (appendicular muscle mass, handgrip strength and six-meter gait speed test), as well as to evaluate test-retest reliability and safety when applied to hospitalized elderly patients. Finally, we aimed to compare the performance in the 6MST between hospitalized elderly patients and healthy elderly from the community. MATERIALS AND METHODS: Observational and cross-sectional study. Elderly patients admitted to a private hospital and healthy elderly from the community were recruited. On the first day, the patients included underwent the following assessments: anthropometric, handgrip strength (HGS), six-meter gait speed test (6GST) and 6MST. On the second day, before breakfast, patients underwent body composition assessment. The healthy elderly were evaluated on a single day and performed only anthropometric assessment and 6MST. RESULTS: 30 hospitalized patients (age 71.0±7.9 years) and 15 healthy elderly (age 68.1±5.8 years) were included. There was a high correlation of 6MST with 6GST (r = 0.78; p<0.001), moderate correlation with HGS (r = 0.59; p<0.001) and low correlation with appendicular muscle mass (r = 0.45; p = 0.01). There was no statistical difference between the first and second 6MST performed by hospitalized elderly (196.2±91.0 cycles vs. 191.3±103.7 cycles; p = 0.66), in addition to an excellent agreement between these measures (ICC = 0.90; 95% IC 0.78-0.95). Only one adverse event (3.3%) occurred in the sample. CONCLUSION: 6MST showed convergent validity with the functional variables used in the diagnosis of sarcopenia. In addition, excellent test-retest reliability was observed, which indicates the need for a single assessment in hospitalized elderly patients. The prevalence of adverse events during the application of the test is low, without resulting in clinical symptoms; therefore, the test is considered safe for this population. In addition, hospitalized elderly patients perform worse in the 6MST compared to healthy elderly from the community.

Physiotherapy Care of Patients with Coronavirus Disease 2019 (COVID-19) - A Brazilian Experience.

Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. non-invasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19.

Physiotherapy care of patients with coronavirus disease 2019 (COVID-19) - a brazilian experience

Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. non-invasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19.

Relationship between handgrip strength and pulmonary capacity in patients on hemodialysis / Relação entre a força de preensão manual e a capacidade pulmonar de pacientes em hemodiálise

Abstract Introduction: Chronic kidney disease (CKD) is defined as loss of kidney function, but its progression leads to systemic changes that compromise the quality of life of patients on dialysis. As such, the decline in lung capacity in this population may be one of the factors related to reduced peripheral muscle strength. Objective: Assess the relationship between handgrip strength (HGS), pulmonary function and respiratory muscle strength in patients with CKD on hemodialysis. Method: Thirty patients with CKD were assessed in terms of anthropometric data, pulmonary function, respiratory muscle strength and HGS. Results: A moderate association was observed between HGS and the variables forced vital capacity (r=0.54; p=0.002), maximum voluntary ventilation (r=0.51; p=0.004) and maximum expiratory pressure (r=0.59; p=0.001), and a weak association with forced expiratory volume in 1 second (FEV1) (r=0.46; p=0.009) and maximum inspiratory pressure (r=0.38; p=0.03). Additionally, about 67% of the sample (n=20) exhibited some degree of restrictive ventilatory defect in the pulmonary function test. With respect to muscle strength, 40% of the sample (n=12) displayed below-normal handgrip strength, as well as low mean MIP and MEP. Conclusion: Decreased lung capacity may be related to a decline in HGS in patients with chronic kidney disease on hemodialysis. Thus, therapeutic strategies aimed at lung expansion and respiratory muscle training may contribute to facilitating and favoring rehabilitation in this population.

Resumo Introdução: A doença renal crônica (DRC) é definida pela perda da função renal, contudo a sua progressão leva ao surgimento de alterações sistêmicas que comprometem a qualidade de vida dos pacientes em hemodiálise. Consequentemente, a redução da capacidade pulmonar nessa população pode ser um dos fatores que esteja relacionado ao declínio da força muscular periférica. Objetivo: Avaliar a relação entre a força de preensão manual (FPM) com a função pulmonar e a força muscular respiratória de pacientes com DRC em hemodiálise. Método: 30 pacientes com DRC foram avaliados quanto aos dados antropométricos, função pulmonar, força muscular respiratória e FPM. Resultados: Observou-se uma relação moderada da FPM com as variáveis capacidade vital forçada (r=0,54; p=0,002), ventilação voluntária máxima (r=0,51; p=0,004) e pressão expiratória máxima (r=0,59; p=0,001). Já as correlações entre a FPM com o volume expiratório forçado no primeiro segundo (r=0,46; p=0,009) e a pressão inspiratória máxima (r=0,38; p=0,03) foram fracas. Além disso, aproximadamente 67% da amostra (n=20) apresentou algum grau de restrição ventilatória na prova de função pulmonar. Em relação à força muscular, 40% da amostra (n=12) apresentou FPM abaixo do previsto de normalidade, e as médias da pressão inspiratória máxima e da pressão expiratória máxima em porcentagem também se encontraram reduzidas. Conclusão: A redução da capacidade pulmonar pode estar relacionada com o declínio da FPM nos pacientes com DRC em hemodiálise. Sendo assim, recursos terapêuticos visando à expansão pulmonar e o treinamento muscular respiratório podem ser estratégias para facilitar e favorecer a reabilitação dessa população.