Is oxidative stress associated with disease severity, pulmonary function and metabolic syndrome in chronic obstructive pulmonary disease? / ¿Está el estrés oxidativo asociado a la gravedad de la enfermedad, a la función pulmonar y al síndrome metabólico en la enfermedad pulmonar obstructiva crónica?

OBJECTIVE: To investigate associations between oxidant/antioxidant biomarkers with the disease severity, pulmonary function and diagnosis of metabolic syndrome (MetS) in patients with COPD. METHODS: Seventy-four subjects were included, 39 with COPD (age 69±7 years; female 41%) and 35 for control group (age 69±7 years; female 43%). They were diagnosed with MetS and allocated in one of 4 subgroups: COPD and control, with and without MetS, respectively. Advanced oxidation protein products (AOPP), paraoxonase-1, catalase activity, sulfhydryl group and total lipid hydroperoxide were assayed. Pulmonary function was performed with a plethysmograph. RESULTS: COPD severity (GOLD≥3) and pulmonary function were associated with sulfhydryl group and AOPP (P≤.03 for all). The prevalence of MetS was associated with AOPP in COPD (P=.04). Individuals with COPD and MetS showed higher AOPP compared to COPD without MetS (P<.0001). CONCLUSION: COPD severity, worse pulmonary function and presence of metabolic syndrome are associated with oxidative stress in individuals with COPD.

Effects of exercise training in water and on land in patients with COPD: a randomised clinical trial.

OBJECTIVES: To compare the effects of two similar 6-month protocols of high-intensity exercise training, in water and on land, in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Randomised controlled trial. SETTING: University-based outpatient clinic. PARTICIPANTS: Thirty-six patients with predominantly moderate-to-severe COPD completed the study. INTERVENTION: Patients were evaluated at baseline, at 3 months and at the end of the programme (i.e. 6 months). For both groups, the 6-month protocol consisted of high-intensity endurance and strength exercises with gradual increase in time and/or workload, totalling 60 sessions. MAIN OUTCOMES: Objective monitoring of physical activity in daily life (PADL, primary outcome), lung function, peripheral and respiratory muscle strength, body composition, maximal and submaximal exercise capacity, functional status, quality of life, and symptoms of anxiety and depression. RESULTS: After 6 months of training, a significant improvement in PADL was seen for both groups [mean difference (95% confidence interval): land group 993 (358 to 1628) steps/day; water group 1669 (404 to 2934) steps/day]. Significant improvements were also seen in inspiratory, expiratory and peripheral muscle strength; maximal and submaximal exercise capacity; quality of life and functional status for both groups. There were no significant improvements in lung function, body composition, and symptoms of anxiety and depression for either group. No difference was found in the magnitude of improvement between the two types of training for any outcome. CONCLUSION: High-intensity exercise training in water generates similar effects compared with training on land in patients with moderate-to-severe COPD, rendering it an equally beneficial therapeutic option for this population. CLINICAL TRIAL REGISTRATION NUMBER: NCT01691131.

Agreement of different reference equations to classify patients with COPD as having reduced or preserved 6MWD.

BACKGROUND: Interpretation of the six-minute walk distance (6MWD) is enhanced by using recommended reference equations. Whenever possible, the choice of equation should be region-specific. A potential problem is that different equations for the 6MWD may have been developed for the same population, and it may be complicated to choose the most suitable. OBJECTIVE: To verify the agreement of different reference equations in classifying patients with Chronic Obstructive Pulmonary Disease (COPD) as having reduced or preserved 6MWD. METHODS: 159 patients with COPD performed the six-minute walk test according to international standardization. They were classified as having reduced 6MWD if it was below the lower limit of normal. Five Brazilian equations (Iwama; Britto1; Britto2; Dourado; Soares) and the two non-Brazilian equations most cited worldwide (Troosters; Enright) were used. The agreement for patients classified as reduced or preserved 6MWD was verified by Cohen's Kappa (pair-to-pair) analysis. The proportion of patients classified as having reduced walked distance was compared by the Chi-squared test. RESULTS: Agreement between equations varied largely in classifying subjects as having reduced or preserved 6MWD (Kappa: 0.10-0.82). Brazilian equations with the highest agreement were Iwama, Britto1 and Britto2 (Kappa>0.75). The proportion of patients classified as having reduced 6MWD was statistically similar only between equations in which the agreement was higher than 0.70. CONCLUSION: Even reference equations from the same country vary considerably in the classification of reduced or preserved 6MWD, and it is recommended that the region-specific ones be used as they give with higher agreement for similar and comparable interpretation of the patients' functional exercise capacity.

Smoking status and its relationship with exercise capacity, physical activity in daily life and quality of life in physically independent, elderly individuals.

OBJECTIVE: To investigate the relationship between smoking status and exercise capacity, physical activity in daily life and health-related quality of life in physically independent, elderly (≥60 years) individuals. DESIGN: Cross-sectional, observational study. SETTING: Community-dwelling, elderly individuals. PARTICIPANTS: One hundred and fifty-four elderly individuals were categorised into four groups according to their smoking status: never smokers (n=57), passive smokers (n=30), ex-smokers (n=45) and current smokers (n=22). MAIN OUTCOME MEASURES: Exercise capacity [6-minute walk test (6MWT)], physical activity in daily life (step counting) and health-related quality of life [36-Item Short Form Health Survey (SF-36) questionnaire] were assessed. RESULTS: Current and ex-smokers had lower mean exercise capacity compared with never smokers: 90 [standard deviation (SD) 10] % predicted, 91 (SD 12) % predicted and 100 (SD 13) % predicted distance on 6MWT, respectively [mean differences -9.8%, 95% confidence intervals (CI) -17.8 to -1.8 and -9.1%, 95% CI -15.4 to -2.7, respectively; P<0.05 for both]. The level of physical activity did not differ between the groups, but was found to correlate negatively with the level of nicotine dependence in current smokers (r=-0.47, P=0.03). The median score for the mental health dimension of SF-36 was worse in passive {72 [interquartile range (IQR) 56 to 96] points} and current [76 (IQR 55 to 80) points] smokers compared with ex-smokers [88 (IQR 70 to 100) points] (median differences -16 points, 95% CI -22.2 to -3.0 and -12 points, 95% CI -22.8 to -2.4, respectively; P<0.05 for both). CONCLUSIONS: Among elderly individuals, current smokers had lower exercise capacity than never smokers. Although the level of physical activity did not differ between the groups, an association was found with smoking. Tobacco exposure was associated with worse scores for the mental health dimension of SF-36 in physically independent, elderly individuals.

Effects of arm bracing posture on respiratory muscle strength and pulmonary function in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To analyze the effect of arm bracing posture on respiratory muscle strength and pulmonary function in patients with Chronic Obstructive Pulmonary Disease (COPD). METHODS: 20 patients with COPD (11 male; 67 ± 8 years; BMI 24 ± 3 Kg · m⁻²) were submitted to assessments of Maximal Inspiratory and Expiratory Pressures (MIP and MEP, respectively) and spirometry with and without arm bracing in a random order. The assessment with arm bracing was done on standing position and the height of the support was adjusted at the level of the ulnar styloid process with elbow flexion and trunk anterior inclination of 30 degrees promoting weight discharge in the upper limbs. Assessment without arm bracing was also performed on standing position, however with the arms relaxed alongside the body. The time interval between assessments was one week. RESULTS: MIP, MEP and maximal voluntary ventilation (MVV) were higher with arm bracing than without arm bracing (MIP 64 ± 22 cmH2O versus 54 ± 24 cmH2O, p = 0,00001; MEP 104 ± 37 cmH2O versus 92 ± 37 cmH2O, p = 0,00001 and MVV 42 ± 20 L/min versus 38 ± 20 L/min, p = 0,003). Other variables did not show statistical significant difference. CONCLUSION: The arm bracing posture resulted in higher capacity to generate force and endurance of the respiratory muscles in patients with COPD.

Guia para prática clínica: fisioterapia em pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC): [review] / Clinical practice guideline for physical therapy in patients with Chronic Obstructive Pulmonary Disease (COPD): portuguese version: [review]

INTRODUÇÃO: No contexto da colaboração internacional para desenvolvimento de guias práticos (ou guidelines), a Sociedade Real Holandesa de Fisioterapia (Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF) se propôs a desenvolver um guia para esclarecimento sobre a prática clínica de Fisioterapia em pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC), assim como também optou por estimular a sua tradução para outras línguas, a fim de torná-lo acessível para públicos internacionais. OBJETIVOS: O presente guia é a versão em língua portuguesa do Guia para Prática Clínica de Fisioterapia em pacientes com DPOC desenvolvido pela KNGF, que teve como objetivo descrever a Fisioterapia baseada em evidências para pacientes com DPOC que apresentam limitação da função pulmonar, da função muscular respiratória e periférica, da capacidade de exercício, da depuração mucociliar e da qualidade de vida, além de limitações em relação à atividade física na vida diária pela dispneia e/ou intolerância ao exercício. CONCLUSÃO: O guia propõe-se principalmente a prover recomendações terapêuticas práticas que auxiliem o fisioterapeuta a oferecer o melhor tratamento possível para pacientes com DPOC, consideradas as evidências científicas disponíveis na atualidade.

INTRODUCTION: In the context of international collaboration for the development of practice guidelines, the Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF) has developed guidelines for the clinical practice of physical therapy in patients with Chronic Obstructive Pulmonary Disease (COPD). It has also stimulated its translation into other languages to make it accessible to international audiences. OBJECTIVES: The present document brings the Portuguese version of the KNGF Clinical Practice Guidelines for physical therapy in COPD patients. Its purpose was to describe evidence-based physical therapy for COPD patients with impairments in pulmonary function, peripheral and respiratory muscle function, exercise capacity, mucus clearance and quality of life, in addition to limitations in physical activity in daily life due to dyspnea and/or exercise intolerance. CONCLUSION: The guideline provides practical and therapeutic recommendations based on currently available scientific evidence to help the physical therapist provide the best possible treatment to COPD patients.

Quantifying physical activity in daily life with questionnaires and motion sensors in COPD.

Accurate assessment of the amount and intensity of physical activity in daily life is considered very important due to the close relationship between physical activity level, health, disability and mortality. For this reason, assessment of physical activity in daily life has gained interest in recent years, especially in sedentary populations, such as patients with chronic obstructive pulmonary disease (COPD). The present article aims to compare and discuss the two kinds of instruments more commonly used to quantify the amount of physical activity performed by COPD patients in daily life: subjective methods (questionnaires, diaries) and motion sensors (electronic or mechanical methods). Their characteristics are summarised and evidence of their validity, reliability and sensitivity is discussed, when available. Subjective methods have practical value mainly in providing the patients' view on their performance in activities of daily living and functional status. However, care must be taken when using subjective methods to accurately quantify the amount of daily physical activity performed. More accurate information is likely to be available with motion sensors rather than questionnaires. The selection of which motion sensor to use for quantification of physical activity in daily life should depend mainly on the purpose of its use.

Cardiopulmonary stress during exercise training in patients with COPD.

Exercise training is an essential component of pulmonary rehabilitation. However, the cardiopulmonary stress imposed during different modalities of exercise training is not yet known. In the present study, the cardiopulmonary stress of a 12-week exercise training programme in 11 chronic obstructive pulmonary disease (COPD) patients (forced expiratory volume in one second 42+/-12%pred, age 69+/-6 yrs) was measured. Pulmonary gas exchange and cardiac frequency (f(C)) of three training sessions were measured with a portable metabolic system at the beginning, mid-term and end of the programme. Symptoms were assessed with Borg scores. The exercise intensity was compared with the recommendations for exercise training by the American College of Sports Medicine (ACSM). Training effects were significant (maximum change in work: 14+/-11 Watts, 6-min walk test: 44+/-36 m). Whole body exercises (cycling, walking and stair climbing) consistently resulted in higher cardiopulmonary stress (oxygen uptake (V'(O(2))), minute ventilation and f(C)) than arm cranking and resistance training. Dyspnoea was higher during cycling than resistance training. Patients exercised for >70% (>20 min) of the total exercise time at >40% of the V'(O(2)) reserve and f(C) reserve ("moderate" intensity according to the ACSM) throughout the programme. The cardiopulmonary stress resistance training is lower than during whole-body exercise and results in fewer symptoms. In addition, exercise testing based on guidelines using a fixed percentage of baseline peak performance and symptom scores achieves and sustains training intensities recommended according to the American College of Sports Medicine.

Influencia da saturacao de O2 na velocidade do teste de distancia percorrida em 6 minutos, em pacientes com DPOC grave / Influence of O2 saturation on the Speed of the Six-minute walking distance test in severe COPD patients

Pacientes com doenca pulmonar obstrutiva cronica (DPOC) frequentemente apresentam capacidade de exercicio reduzida, entretanto, a influencia da saturacao de O2 ao repouso (SpO2r) e/ou da dessaturacao de O2 ao exercicio(DES) na capacidade de exercicio de pacientes com DPOC grave nao esta totalmente esclarecida. O objetivo deste estudo foi analisar a distancia percorrida em seis minutos (DP6) por pacientes com DPOC grave, classificados de acordo com a SpO2r e a DES. Metodos: Foram estudados 20 pacientes (12 homens e 8 mulheres) com DPOC grave ]VEF 30,95]+-6,90(por cento) que apresentaram dessaturacao >- 4(por cento) durante teste DP6. Os pacientes faram divididos em dois grupos, de acordo com a SpO2r: baixa saturacao ao repouso (BSR) ]SpO2<-92 (por cento) (n=11) e baixa saturacao ao exercico (BSE) ]SpO2>92 (por cento) (n=9). Para analise estatistica utilizou-se teste t de Student e o teste de Chi-quadrado. Resultados: DP6 foi 339,09+-111,35m (grupo BSR) e 456,78+-48,54m (grupo BSE), p=0,004. A frequencia de interrupcao do teste da DP6 foi maior no grupo BSR(p=0,01). Houve correlacao significativa entre a SpO2 durante o teste e a velocidade de caminhada a cada minuto no grupo BSR(r=0,86, p=0,03), enquanto no grupo BSE nao houve correlacao significativa (r=0,59, p=0,22). Conclusao: O grupo BSR apresentou menor capacidade de exercicio funcional que o grupo BSE. Alem disso, nos pacientes do grupo BSR ha relacao entre SpO2 e a velocidade de caminhada no teste da DP6

Relacao entre capacidade de ventilatoria e exercicio em pacientes com doenca pulmonar obstrutiva cronica moderada grave / Ventilatory capacity and exercise in patients suffering from moderate-severe chronic obstructive pulmonary disease

Este estudo tem por objetivo verificar a influencia da capacidade ventilatoria na capacidade de exercicio do paciente com doenca pulmonar obstrutiva cronica (DPOC). Participaram do estudo 38 pacientes com DPOC moderada-grave (VEF <60 por cento do previsto e VEF/CVF< 90 por cento do previsto), sendo 19 homens e 19 mulheres, com idade media de 65,00+-9,94 anos, peso 59,78+-15,74 kg, altura 157, 76 +-8,65 com VEF 36,94 +-11,74 do previsto (media+-dpm). Os pacientes foram submetidos a espirometria, prova de pressoes respiratorias maximas e teste da distancia percorrida em seis minutos (DP6min). Foi realizada a prova de ventilacao voluntaria maxima (VVM) e calculados os valores da reserva ventilatoria (RV) e o indice de reserva ventilatoria (IRV) baseados na VVM e no volume minuto (VM). A forca muscular respiratoria foi medida pela pressao inspiratoria maxima (PImax) e pressao expiratoria maxima(PEmax). A capacidade de exercicio foi avaliada pela DP6min. Para analise estatistica utilizou-se a correlacao simples de Pearson (p<0,05). Os pacientes apresentaram DP6min media de 410, 29+-129, 57m, RV 23,64+-11,45 litros, IRV 66,89+-13,84 POR CENTO, VVM 34,01+-12,49 por cento do previsto, PImax -55,26+-22,02 cmH2O e PEmax 100,74+-31,78cmH2O. A RV (r=0,76), a IRV (r=0,71), a VVM (r=0,68) e a PImax (r=0,43) apresentaram correlacao significativa com a DP6min. Portanto, a VVM, a RV, o IRV e a PImax influenciam a capacidade de exercicio submaximo de pacientes com DPOC moderada-grave