Reliability of maximal respiratory nasal pressure tests in healthy young adults.

INTRODUCTION: Sniff nasal inspiratory (SNIP) and expiratory pressure (SNEP) may complement the assessment of respiratory muscle strength. Thus, specifying their reliability is relevant to improving the clinical consistency of both tests. OBJECTIVE: To assess the reliability of SNIP and SNEP in healthy young adults. METHODS: This cross-sectional study included self-reported healthy aged 18 to 29 years. SNIP was performed using a plug to occlude one nostril, while SNEP was conducted using a facemask. Participants performed 20 SNIP and SNEP maneuvers with 30-second intervals in between. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimum detectable change (MDC) assessed the reliability of SNIP and SNEP. Analyses were conducted between the highest peak pressure and the first reproducible maneuver in men and women. RESULTS: The total sample comprised 32 participants: 16 men and 16 women. The ICC, SEM, and MDC for SNIP maneuvers were 0.994 (95%CI 0.988 to 0.997), 1.820 cmH2O, and 5.043 cmH2O, respectively. For SNEP, these parameters were 0.950 (95%CI 0.897 to 0.976), 6.03 cmH2O, and 16.716 cmH2O. The SNIP and SNEP in men showed ICC of 0.992 (95%CI 0.977 to 0.997) and 0.877 (95%CI 0.648 to 0.957), SEM of 2.07 and 7.66 cmH2O, and MDC of 5.74 and 21.23 cmH2O. In women, SNIP and SNEP presented ICC of 0.992 (95%CI 0.977 to 0.997) and 0.957 (95%CI 0.878 to 0.985), SEM of 1.15 and 6.11 cmH2O, and MDC of 3.19 and 16.95 cmH2O. Also, 60% of the highest SNIPs occurred among the 11th and 20th maneuvers in men and women. In men, 55% of the highest SNEPs occurred among the 11th and 20th maneuvers; this value was 50% in women. CONCLUSION: SNIP and SNEP showed excellent reliability. The reliability of SNIP and SNEP in men was good and excellent, respectively, whereas both tests had excellent reliability in women. Also, women reached the highest peak pressure faster than men in both tests.

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.

After-effects of thixotropic conditionings on operational chest wall and compartmental volumes of patients with Parkinson's disease.

Individuals with Parkinson's disease (PD) present respiratory dysfunctions, mainly due to decreased chest wall expansion, which worsens with the course of the disease. These findings contribute to the restrictive respiratory pattern and the reduction in chest wall volume. According to literature, inspiratory muscle thixotropic conditioning maneuvers may improve lung volumes in these patients. The study aimed to determine the after-effects of respiratory muscle thixotropic maneuvers on breathing patterns and chest wall volumes of PD. A crossover study was performed with twelve patients with PD (8 males; mean age 63.9±8.8 years, FVC%pred 89.7±13.9, FEV1%pred 91.2±15, FEV1/FVC%pred 83.7±5.7). Chest wall volumes were assessed using OEP during thixotropic maneuvers. Increases in EIVCW (mean of 126mL, p = 0.01) and EEVCW (mean of 150mL, p = 0.005) were observed after DITLC (deep inspiration from total lung capacity) due to increases in pulmonary (RCp) and abdominal (RCa) ribcage compartments. Changes in ICoTLC (inspiratory contraction from TLC) led to significant EIVCW (mean of 224mL, p = 0.001) and EEVCW (mean of 229mL, p = 0.02) increases that were mainly observed in the RCp. No significant changes were found when performing DERV (deep expiration from residual volume) and ICoRV (Inspiratory contraction from RV). Positive correlations were also observed between the degree of inspiratory contraction during ICoTLC and EEVRCp (rho = 0.613, p = 0.03) and EIVRCp (rho = 0.697, p = 0.01) changes. Thixotropy conditioning of inspiratory muscles at an inflated chest wall volume increases EIVCW and EEVCW in the ten subsequent breaths in PD patients. These maneuvers are easy to perform, free of equipment, low-cost, and may help patients improve chest wall volumes during rehabilitation.

Psychometric properties of the sit-to-stand test for patients with pulmonary hypertension: A systematic review protocol.

BACKGROUND: Pulmonary hypertension (PH) is a complex syndrome characterized by increased pulmonary arterial pressure and classified into five groups, according to dyspnea on exertion and systemic muscle dysfunction. These symptoms can be identified using the sit-to-stand test (STS), which indirectly evaluates exercise tolerance and lower limb muscle strength. Previous studies used the STS in PH; however, psychometric properties to understand and validate this test were not described for patients with PH. OBJECTIVE: To evaluate the psychometric properties (validity, reliability, and responsiveness) of different STS protocols in patients with PH. METHODS AND ANALYSES: This is a systematic review protocol that will include studies using STS in patients with PH. Searches will be conducted on PubMed/MEDLINE, EMBASE, SciELO, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases following PICOT mnemonic strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). Rayyan software will be used for study selection. The Risk of bias will be assessed using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) tool, while the quality of evidence will be assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Two researchers will independently conduct the study, and a third researcher will be consulted in case of disagreement. The psychometric properties will be evaluated according to the COSMIN. This protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, no. CRD42021244271). CONCLUSION: This systematic review will attempt to identify and show the available evidence on STS for different groups of PH and report validity, reliability, and responsiveness of different protocols.

Weaning from mechanical ventilation in people with neuromuscular disease: a systematic review.

OBJECTIVE: This systematic review aimed in assessing the effects of different weaning protocols in people with neuromuscular disease (NMD) receiving invasive mechanical ventilation, identifying which protocol is the best and how different protocols can affect weaning outcome success, duration of weaning, intensive care unit (ICU) and hospital stay and mortality. DESIGN: Systematic review. DATA SOURCES: Electronic databases (MEDLINE, EMBASE, Web of Science and Scopus) were searched from January 2009 to August 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials (RCTs) and non-RCT that evaluated patients with NMD (adults and children from 5 years old) in the weaning process managed with a protocol (pressure support ventilation; synchronised intermittent mandatory ventilation; continuous positive airway pressure; 'T' piece). PRIMARY OUTCOME: Weaning success. SECONDARY OUTCOMES: Weaning duration, ICU stay, hospital stay, ICU mortality, complications (pneumothorax, ventilation-associated pneumonia). DATA EXTRACTION AND SYNTHESIS: Two review authors assessed the titles and the abstracts for inclusion and reviewed the full texts independently. RESULTS: We found no studies that fulfilled the inclusion criteria. CONCLUSIONS: The absence of studies about different weaning protocols for patients with NMD does not allow concluding the superiority of any specific weaning protocol for patients with NMD or determining the impact of different types of protocols on other outcomes. The result of this review encourages further studies. PROSPERO REGISTRATION NUMBER: CRD42019117393.

Effects of diaphragmatic control on multiparametric analysis of the sniff nasal inspiratory pressure test and inspiratory muscle activity in healthy subjects.

BACKGROUND: We investigated the influence of diaphragmatic activation control (diaphC) on the relaxation rate, contractile properties and electrical activity of the inspiratory muscles of healthy subjects. Assessments were performed non-invasively using the sniff inspiratory pressure test (SNIP) and surface electromyography, respectively. METHODS: Twenty-two subjects (10 men and 12 women) performed 10 sniff maneuvers in two different days: with and without diaphC instructions. For the SNIP test with diaphC, the subjects were instructed to perform intense activation of the diaphragm. The tests with the best SNIP values were used for analysis. RESULTS: The maneuver with diaphC when compared to the maneuver without diaphC exhibited significant lower values for: SNIP (p <0.01), maximum relaxation rate (MRR) (p <0.01), maximum rate of pressure development (MRPD) (p <0.01), contraction times (CT) (p = 0.02) and electrical activity of the sternocleidomastoid (SCM) (p <0.01), scalene (SCL) (p = 0.01) and intercostal (CI) (p = 0.03) muscles. In addition, the decay constant (tau, τ) and relaxation time (½ RT) did not present any changes. CONCLUSION: The diaphragmatic control performed during the SNIP test influences the inspiratory pressure and the contractile properties of inspiratory muscles. This occurs due to changes in the pattern of muscle recruitment, which change force velocity characteristics of the test. Thus, instruction on diaphC should be encouraged for better performance of the SNIP test and for evaluation targeting the diaphragm muscle activity.

Effects of an optimised approach to home-based respiratory care in individuals with amyotrophic lateral sclerosis: a study protocol for a randomised controlled trial.

INTRODUCTION: This study aims to investigate the effects of an optimal home-based respiratory care protocol in individuals with amyotrophic lateral sclerosis (ALS). METHODS AND ANALYSIS: This is a randomised, blinded controlled trial involving patients diagnosed with ALS, both sexes, age between 18 and 80 years. Patients will be randomly allocated into the conventional respiratory care (CRC) group and the optimised respiratory care home-based (ORC) group. Primary outcomes will be peak cough flow, the number of exacerbations and ALS Functional Rating Scale Revised. Secondary outcomes will include chest wall volumes, maximal respiratory pressures, sniff nasal inspiratory pressure, nasal expiratory pressure and forced vital capacity (FVC), forced expiratory volume in the 1st second (FEV1) and FEV1/FVC. The CRC group will receive educational information about respiratory care at the clinic. The ORC group will receive conventional care and home-based care. The clinical status of all individuals will be monitored weekly through telephone calls. A 6-month intervention is planned, the outcomes will be assessed every 3 months and 3 and 6 months follow-up after final evaluation. The primary and secondary results will be described as average or median for continuous variables and absolute and relative frequencies for qualitative variables. Treatment effects or differences between the outcomes (baseline, 3 months and 6 months) of the study groups will be analysed using an analysis of variance. The level of significance will be set as p≤0.05. ETHICS AND DISSEMINATION: The research ethics committee approved the study. It is expected to evaluate respiratory function in patients with ALS in the short, medium and long terms with home-based care protocol applied. The disease's rapid progression is a limitation for performing a long-term clinical study. TRIAL REGISTRATION NUMBER: RBR-3z23ts; Pre-results.

Supervised exercise protocol for lower limbs in subjects with chronic venous disease: an evaluator-blinded, randomized clinical trial.

BACKGROUND: Chronic venous insufficiency (CVI) causes pathophysiological changes in the lower-limb muscles, particularly the calf muscles, and limits ankle range of motion (ROM). These changes reduce functional activities and decrease quality of life (QOL). Although several studies have shown the benefits of exercise (strengthening the calf muscles to improve calf-muscle pumping and QOL) in patients with CVI, few studies are randomized controlled trials. This has led to a weak indication of exercise for the treatment of patients with CVI. The aim of this study is to analyze the effects of a supervised exercise program to improve calf-muscle endurance as well as QOL in patients with CVI. METHODS/DESIGN: This is an evaluator-blind, randomized clinical trial with an 8-week duration and a follow-up evaluation at week 16. A pilot study with subjects with a CVI diagnosis will be performed to calculate sample size. The participants will be randomly allocated (1:1) into a treatment or a control group (usual care/no intervention). The treatment intervention consists of a bi-weekly supervised exercise program of the lower limbs that will include aerobic training, strengthening and cardiovascular exercises. The participants from both groups will participate in a health education lecture. Primary outcomes are changes in calf-muscle endurance and QOL score. Secondary outcomes are changes in exercise capacity, ankle ROM, electrical muscle activity and cardiac output. The first statistical comparison will be performed after 8 weeks' intervention. DISCUSSION: Patients with CVI may have an impaired calf-muscle pump and decreased exercise capacity. A randomized controlled trial evaluating a supervised exercise program should provide much needed information on the management of CVI to promote health and independence. TRIAL REGISTRATION: This study was registered on the Brazilian Clinical Trials Database (REBEC) (RBR-57xtk7). The results will be disseminated at scientific events, presentations, and publications in peer-reviewed journals.

Changes in Oxyhemoglobin Concentration in the Prefrontal Cortex during Cognitive-Motor Dual Tasks in People with Chronic Obstructive Pulmonary Disease.

Cognitive and motor impairment are well documented in chronic obstructive pulmonary disease (COPD) patients, but their relationship has not been studied. This study evaluated and compared cognitive and motor performance during dual tasks and related dorsolateral prefrontal cortex (PFC) changes in oxygenated hemoglobin (ΔO2Hb), a proxy measure of neural activity, in patients with COPD and age-matched healthy individuals. Participants performed three single tasks: (1) backwards spelling cognitive task; (2) 30 m preferred paced walk; (3) 30 m fast walk, and two dual tasks: (4) preferred paced walk + backwards spelling; (5) fast paced walk + backwards spelling. The ΔO2Hb from left and right dorsolateral PFC were measured using functional near-infrared spectroscopy. Gait velocity was measured using a Zeno walkway. Compared to healthy adults (n = 20), patients with COPD (n = 15) had higher ΔO2Hb during single preferred (-0.344 ± 0.185 vs. 0.325 ± 0.208 µM; p = 0.011) and fast paced walk (-0.249 ± 0.120 vs. 0.486 ± 0.182 µM; p = 0.001) in right PFC. Among healthy adults, ΔO2Hb were higher bilaterally during preferred paced walking dual versus single task (right: 0.096 ± 0.159 vs. -0.344 ± 0.185 µM, p = 0.013; left: 0.114 ± 0.150 vs. -0.257 ± 0.175 µM, p = 0.049) and in right PFC during fast walking dual versus single task (0.102 ± 0.228 vs. -0.249 ± 0.120, p = 0.021). Patients with COPD did not increase O2Hb during dual versus single tasks. Patients with COPD exhibited slower velocity than older adults during all walking tasks. The lack of further increase in O2Hb from single to dual tasks in patients with COPD, may indicate reduced cognitive-motor capacity and contribute to poorer motor performance limiting safe ambulation. Dual tasking rehabilitation may improve neural efficiency to offset these risks.

Weaning from mechanical ventilation in people with neuromuscular disease: protocol for a systematic review.

INTRODUCTION: Neuromuscular diseases (NMD) are characterised by progressive muscular impairment. The muscle weakness is directly related to respiratory muscles weakness, causing reduction in vital capacity, especially when associated with mechanical ventilation (MV). Conventional MV weaning in NMD is generally difficult. Weaning process can be conducted in protocols such as: 'T' piece or Pressure Support Ventilaton. Weaning failure is frequent because of muscle weakness. Protocol aim is to assess the effects of different weaning protocols in NMD patients receiving invasive MV in weaning success rate, duration of weaning, intensive care unit (ICU) stay, hospital stay and ICU mortality. METHODS AND ANALYSIS: A search will be carried in the Cochrane Neuromuscular Specialised Register, MEDLINE, EMBASE, Web of Science, Scopus, United States National Institutes of Health Clinical Trials Registry, ClinicalTrials.gov and WHO International Clinical Trial Registry Protal, of randomised controlled trials (RCTs) and quasi-RCTs. Inclusion criteria of individuals are adults (above 16 years old) and children (from 5 to 16 years old), with clinical diagnosis of NMD (muscular dystrophy, amyotrophic lateral sclerosis, congenital myasthenia, myasthenia gravis, congenital myopathy, spinal muscular atrophy, Guillian Barré Syndrome, severe inherited neuropathies, metabolic myopathies, inflammatory myopathies, mitochondrial diseases) of any gender. All patients ventilated for at least 48 hours due to respiratory failure and clinically considered ready for weaning. Other respiratory or cardiovascular diagnosis associated will not be included. Intervention assessed will be weaning from MV using a protocol with 30 min to 2 hours of spontaneous breathing trial at the end point. All comparisons of different protocols will be considered. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary data will not be collected, since it will be a systematic review. All studies included should have ethical committee approval. The results will be disseminated through a peer-reviewed publication and in conferences and congresses or symposia. PROSPERO REGISTRATION NUMBER: CRD42019117393.

Effects of different modalities of inspiratory muscle training as an add-on to conventional treatment of patients with chronic obstructive pulmonary disease (COPD): study protocol for a randomized controlled trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) leads to peripheral and respiratory muscle dysfunctions. Nowadays, inspiratory muscle training can be geared toward strength or endurance gains. This study aims to investigate the effects of an inspiratory muscle training (IMT) protocol using different therapeutic modalities to be implemented in pulmonary rehabilitation programs. The effects of IMT on exercise capacity were considered as the primary endpoint, and the effects of IMT on inspiratory muscle function, health-related quality of life, and daily physical activity level were considered as the secondary outcomes. METHODS: This study is a blinded-investigator randomized controlled clinical trial. Sixty subjects will be randomly allocated into three groups: (1) pulmonary rehabilitation (PR) associated with inspiratory muscle training without any load (PRWIMT), (2) PR associated with inspiratory muscle training with a linear load (PRIMTLL), and (3) PR associated with inspiratory muscle training with isocapnic voluntary hyperpnea (PRIMTIVH). The protocol will be performed 5 days a week (3 days with supervision) for 10 weeks. The study will assess anthropometric data, lung function, respiratory muscle strength, and functional capacity by the Incremental Shuttle Walking Test and the Six-Minute Walk Test, lung volumes during the submaximal endurance test, peripheral muscle strength of the upper and lower limbs, dyspnea, and quality of life related to health, before and after the training protocol. Normality will be tested using the Kolmogorov-Smirnov test, and variables will be compared by two-way analysis of variance. The significance level was set at p < 0.05. Ethics approval was obtained from the Institutional Ethics Committee in Research (1.663.411). The study results will be disseminated through presentation at specific scientific conferences and publication in peer-reviewed journals. DISCUSSION: The different IMT protocols used in our study will be able to guide respiratory therapists to understand and to include in conventional PR programs the most effective respiratory muscle training type in subjects with COPD. TRIAL REGISTRATION: Brazilian Clinical Trials Registry, RBR-94v6kd . Registered on 11 March 2017.

Surface electromyography (sEMG) of extradiaphragm respiratory muscles in healthy subjects: A systematic review.

The aim of this systematic review was to examine procedures used and outcome measures reported from surface EMG (sEMG) of extradiaphragm inspiratory muscles in healthy people. Relevant articles were searched using the concepts "electromyography (EMG)", "respiratory muscles (sternocleidomastoid [SM], scalene, intercostal [IC] and parasternal)" and "healthy" in the electronic databases: MEDLINE, PubMed, EMBASE, Cochrane CENTRAL and Database of Systematic Reviews, CINAHL, SPORTDiscus, LILACS, and PEDro. Twenty-five papers were included and quality assessment was performed using an adapted Downs and Black checklist. Twenty-eight percent of included papers were classified as moderate quality and the rest were low quality. The SM was the muscle most often investigated. Description of EMG techniques were often incomplete for features such as the procedure before electrode placement, description of the surface electrodes, the EMG detection mode and amplification. Of note, descriptions of the IC muscle electrode positioning varied widely. Comparison of outcomes among studies was challenging because of the very diverse EMG outcomes reported. There are many controversies regarding methods and technique used to assess sEMG of extradiaphragm inspiratory muscles. Therefore, studies with higher methodological quality utilizing standardized EMG procedures including electrode positioning will enable accurate and reliable comparison among studies of the extradiaphragm inspiratory muscles.

Effects of positive expiratory pressure on chest wall volumes in subjects with stroke compared to healthy controls: a case-control study.

BACKGROUND: Alterations in respiratory system kinematics in stroke lead to restrictive pattern associated with decreased lung volumes. Chest physical therapy, such as positive expiratory pressure, may be useful in the treatment of these patients; however, the optimum intensity to promote volume and motion changes of the chest wall remains unclear. OBJECTIVE: To assess the effect of different intensities of positive expiratory pressure on chest wall kinematics in subjects with stroke compared to healthy controls. METHODS: 16 subjects with chronic stroke and 16 healthy controls matched for age, gender, and body mass index were recruited. Chest wall volumes were assessed using optoelectronic plethysmography during quiet breathing, 5 minutes, and recovery. Three different intensities of positive expiratory pressure (10, 15, and 20cmH2O) were administered in a random order with a 30 minutes rest interval between intensities. RESULTS: During positive expiratory pressure, tidal chest wall expansion increased in both groups compared to quiet breathing; however, this increase was not significant in the subjects with stroke (0.41 vs. 1.32L, 0.56 vs. 1.54L, 0.52 vs. 1.8L, at 10, 15, 20cmH2O positive expiratory pressure, for stroke and control groups; p<0.001). End-expiratory chest wall volume decreased in controls, mainly due to the abdomen, and increased in the stroke group, mainly due the pulmonary rib cage. CONCLUSION: Positive expiratory pressure administration facilitates acute lung expansion of the chest wall and its compartments in restricted subjects with stroke. Positive expiratory pressure intensities above 10cmH2O should be used with caution as the increase in end-expiratory volume led to hyperinflation in subjects with stroke.

Observational practice of incentive spirometry in stroke patients.

BACKGROUND: Stroke may lead to several health problems, but positive effects can be promoted by learning to perform physical therapy techniques correctly. OBJECTIVE: To compare two different types of observational practice (video instructions and demonstration by a physical therapist) during the use of incentive spirometry (IS). METHOD: A total of 20 patients with diagnosis of stroke and 20 healthy individuals (56±9.7 years) were allocated into two groups: one with observational practice with video instructions for the use of IS and the other with observational practice with demonstration by a physical therapist. Ten attempts for the correct use of IS were carried out and the number of errors and the magnitude of response were evaluated. The statistic used to compare the results was the three-way ANOVA test. RESULTS: The stroke subjects showed less precision when compared to the healthy individuals (mean difference 1.80±0.38) 95%CI [1.02-2.52], p<0.0001. When the type of practice was analyzed, the stroke subjects showed more errors with the video instructions (mean difference 1.5±0.5, 95%CI [0.43-2.56] (p=0.08)) and therapist demonstration (mean difference 2.40±0.52, 95%CI [1.29-3.50] (p=0.00)) when compared to the healthy individuals. CONCLUSION: The stroke subjects had a worse performance in learning the use of volume-oriented incentive spirometry when compared to healthy individuals; however, there was no difference between the types of observational practice, suggesting that both may be used to encourage the use of learning IS in patients with stroke.

Acute effects of Expiratory Positive Airway Pressure (EPAP) on different levels in ventilation and electrical activity of sternocleidomastoid and parasternal muscles in Chronic Obstructive Pulmonary Disease (COPD) patients: a randomized controlled trial

ABSTRACT Objective To investigate the acute effects of EPAP on the activity of sternocleidomastoid (SCM), parasternal muscles and ventilatory parameters in COPD patients. Method Twenty-four patients with COPD were studied using surface electromyography (sEMG) and a ventilometer. Patients were randomly assigned to EPAP 10 cmH2O-EPAP10 or 15 cmH2O-EPAP15 for 20 minutes. Results The parasternal muscle sEMG activity increased during EPAP10 and EPAP15; however, a greater and significant increase was observed with EPAP10 (mean between-group difference: 12.5% RMS, 95% CI: 9.5 to 15.4, p<0.001). In relation to the baseline, at 10 and 20 minutes and upon recovery, respectively parasternal activity increased by 23.9%, 28.9% and 19.1% during EPAP10 and by 10.7% at 10 and 20 minutes and upon recovery, respectively, 11.4% and 6.9% during EPAP15 at 10 and 20 minutes and upon recovery, respectively. The sEMG activity of SCM muscle showed an opposite pattern, increasing with EPAP15 and decreasing with EPAP10 (mean between-group difference: 15.5% RMS, 95% CI: 12.6 to 18.4, p<0.001). SCM muscle activity during EPAP15, increased by 4.8% and 6.1% at 10 and 20 minutes and decreased by -4.0% upon recovery compared to decreases of –5.6%, –20.6% and –21.3% during EPAP10 at 10, 20 minutes, and recovery. Ventilation at both EPAP intensities promoted significant reductions in respiratory rate (RR) and dyspnea, more pronounced in EPAP15: RR (mean between-group difference: –3,8bpm, 95%CI: –7,5 to –0,2, p=0,015) and dyspnea (mean between-group difference: –1.01, 95%CI: –1.4 to –0.53, p=0.028) . Conclusion In COPD patients, the use of EPAP10 was more effective in reducing accessory inspiratory activity and increasing parasternal activity, which was accompanied by an improvement in ventilation and a reduction in dyspnea.

Acute effects of Expiratory Positive Airway Pressure (EPAP) on different levels in ventilation and electrical activity of sternocleidomastoid and parasternal muscles in Chronic Obstructive Pulmonary Disease (COPD) patients: a randomized controlled trial.

Objective: To investigate the acute effects of EPAP on the activity of sternocleidomastoid (SCM), parasternal muscles and ventilatory parameters in COPD patients. Method: Twenty-four patients with COPD were studied using surface electromyography (sEMG) and a ventilometer. Patients were randomly assigned to EPAP 10 cmH2O-EPAP10 or 15 cmH2O-EPAP15 for 20 minutes. Results: The parasternal muscle sEMG activity increased during EPAP10 and EPAP15; however, a greater and significant increase was observed with EPAP10 (mean between-group difference: 12.5% RMS, 95% CI: 9.5 to 15.4, p<0.001). In relation to the baseline, at 10 and 20 minutes and upon recovery, respectively parasternal activity increased by 23.9%, 28.9% and 19.1% during EPAP10 and by 10.7% at 10 and 20 minutes and upon recovery, respectively, 11.4% and 6.9% during EPAP15 at 10 and 20 minutes and upon recovery, respectively. The sEMG activity of SCM muscle showed an opposite pattern, increasing with EPAP15 and decreasing with EPAP10 (mean between-group difference: 15.5% RMS, 95% CI: 12.6 to 18.4, p<0.001). SCM muscle activity during EPAP15, increased by 4.8% and 6.1% at 10 and 20 minutes and decreased by -4.0% upon recovery compared to decreases of -5.6%, -20.6% and -21.3% during EPAP10 at 10, 20 minutes, and recovery. Ventilation at both EPAP intensities promoted significant reductions in respiratory rate (RR) and dyspnea, more pronounced in EPAP15: RR (mean between-group difference: -3,8bpm, 95%CI: -7,5 to -0,2, p=0,015) and dyspnea (mean between-group difference: -1.01, 95%CI: -1.4 to -0.53, p=0.028) . Conclusion: In COPD patients, the use of EPAP10 was more effective in reducing accessory inspiratory activity and increasing parasternal activity, which was accompanied by an improvement in ventilation and a reduction in dyspnea.

Effects of diaphragmatic control on the assessment of sniff nasal inspiratory pressure and maximum relaxation rate

OBJECTIVE: To assess the influence of diaphragmatic activation control (diaphC) on Sniff Nasal-Inspiratory Pressure (SNIP) and Maximum Relaxation Rate of inspiratory muscles (MRR) in healthy subjects. METHOD: Twenty subjects (9 male; age: 23 (SD=2.9) years; BMI: 23.8 (SD=3) kg/m2; FEV1/FVC: 0.9 (SD=0.1)] performed 5 sniff maneuvers in two different moments: with or without instruction on diaphC. Before the first maneuver, a brief explanation was given to the subjects on how to perform the sniff test. For sniff test with diaphC, subjects were instructed to perform intense diaphragm activation. The best SNIP and MRR values were used for analysis. MRR was calculated as the ratio of first derivative of pressure over time (dP/dtmax) and were normalized by dividing it by peak pressure (SNIP) from the same maneuver. RESULTS: SNIP values were significantly different in maneuvers with and without diaphC [without diaphC: -100 (SD=27.1) cmH2O/ with diaphC: -72.8 (SD=22.3) cmH2O; p<0.0001], normalized MRR values were not statistically different [without diaphC: -9.7 (SD=2.6); with diaphC: -8.9 (SD=1.5); p=0.19]. Without diaphC, 40% of the sample did not reach the appropriate sniff criteria found in the literature. CONCLUSION: Diaphragmatic control performed during SNIP test influences obtained inspiratory pressure, being lower when diaphC is performed. However, there was no influence on normalized MRR.

Effects of diaphragmatic control on the assessment of sniff nasal inspiratory pressure and maximum relaxation rate.

OBJECTIVE: To assess the influence of diaphragmatic activation control (diaphC) on Sniff Nasal-Inspiratory Pressure (SNIP) and Maximum Relaxation Rate of inspiratory muscles (MRR) in healthy subjects. METHOD: Twenty subjects (9 male; age: 23 (SD=2.9) years; BMI: 23.8 (SD=3) kg/m²; FEV1/FVC: 0.9 (SD=0.1)] performed 5 sniff maneuvers in two different moments: with or without instruction on diaphC. Before the first maneuver, a brief explanation was given to the subjects on how to perform the sniff test. For sniff test with diaphC, subjects were instructed to perform intense diaphragm activation. The best SNIP and MRR values were used for analysis. MRR was calculated as the ratio of first derivative of pressure over time (dP/dtmax) and were normalized by dividing it by peak pressure (SNIP) from the same maneuver. RESULTS: SNIP values were significantly different in maneuvers with and without diaphC [without diaphC: -100 (SD=27.1) cmH2O/ with diaphC: -72.8 (SD=22.3) cmH2O; p<0.0001], normalized MRR values were not statistically different [without diaphC: -9.7 (SD=2.6); with diaphC: -8.9 (SD=1.5); p=0.19]. Without diaphC, 40% of the sample did not reach the appropriate sniff criteria found in the literature. CONCLUSION: Diaphragmatic control performed during SNIP test influences obtained inspiratory pressure, being lower when diaphC is performed. However, there was no influence on normalized MRR.

Educational interventions for improving control of blood pressure in patients with hypertension: a systematic review protocol.

INTRODUCTION: The aim of this review is to evaluate the effectiveness of educational interventions on improving the control of blood pressure in patients with hypertension. METHODS: Randomised controlled trials including patients over 18 years of age, regardless of sex and ethnicity, with a diagnosis of hypertension (either treated or not treated with antihypertensive medications) will be assessed in our analysis. We will electronically search four databases: MEDLINE, CINAHL, PEDro and ScienceDirect. There will be no language restrictions in the search for studies. The data will be extracted independently by two authors using predefined criteria. Disagreements will be resolved between the authors. The risk of bias will be assessed using the Cochrane risk of bias tool. After searching and screening of the studies, we will run a meta-analysis of the included randomised controlled trials. We will summarise the results as risk ratio for dichotomous data and mean differences for continuous data. ETHICS AND DISSEMINATION: The review will be published in a journal. The findings from the review will also be disseminated electronically and at conference presentations. TRIAL REGISTRATION NUMBER: PROSPERO CRD4201401071.