Impact of COVID-19's on Cardiovascular Rehabilitation Programs in Brazil: An Online Survey-Based Cross-Sectional Study. / Impacto da COVID-19 nos Programas de Reabilitação Cardiovascular no Brasil: Um Estudo Transversal Baseado em uma Pesquisa Online.

BACKGROUND: The COVID-19 pandemic had an impact on cardiovascular rehabilitation (CR) programs in Brazil. OBJECTIVES: To describe the characteristics of CR programs in Brazil, the impacts of the first epidemiological wave of COVID-19 (first 60 days) on the programs and present the initiatives used to overcome the impacts. METHOD: This cross-sectional and retrospective study utilized a specific online survey. Participants were coordinators of CR programs. Variables were presented by Brazilian geographic region and as the following categories: demographic, clinical and operational characteristics. The significance level for statistical analysis was set at 5%. RESULTS: Fifty-nine CR programs were responsible for 5,349 patients, of which only 1,817 were post-acute cardiovascular events, which corresponded to 1.99% of hospitalized patients in the month prior to the survey (n=91,231). The greatest impact was the suspension of on-site activities, which occurred similarly in areas with the highest and the lowest rates of COVID-19 in the period. Forty-five programs (75%) were shortly interrupted, while three (5%) were ended. All 42 programs that already used remote rehabilitation strategies noticed a substantial increase in activities, based primarily on the use of media and video calling. Only three (5%) considered safe to see patients during the first 60 days. CONCLUSIONS: There was a reduction in the number of CR programs with the COVID-19 pandemic. Telerehabilitation activities increased during the first two months of the COVID-19 pandemic, but this was not enough to overcome the reduction in CR program activities across Brazil.

FUNDAMENTO: A pandemia da COVID-19 teve um impacto sobre os programas de reabilitação cardiovasculares (RC) no Brasil. OBJETIVOS: Descrever características dos programas de RC no Brasil, os impactos da primeira onda epidemiológica da COVID-19 (primeiros 60 dias) sobre os programas, e apresentar as iniciativas usadas para superar esses impactos. MÉTODOS: Este estudo transversal e retrospectivo usou um questionário online específico. Os participantes eram coordenadores de programas de RC. As variáveis foram apresentadas por região geográfica do Brasil, como as seguintes categorias: característica demográficas, clínicas e operacionais. O nível de significância estatística foi definido em 5%. RESULTADOS: Cinquenta e nove programas de RC atendiam 5349 pacientes, dos quais somente 1817 eram pacientes após eventos cardiovasculares agudos, o que correspondia a 1,99% dos pacientes internados no mês anterior à pesquisa (n=91.231). O maior impacto foi a suspensão das atividades presenciais, o que ocorreu de maneira similar em áreas com as taxas mais altas e áreas com as taxas mais baixas de COVID-19 no período. Quarenta e quatro (75%) programas foram interrompidos de forma breve, e três (5%) foram encerrados. Todos os 42 programas que já utilizavam estratégias de reabilitação remota notaram aumento substancial nas atividades, baseadas principalmente no uso da mídia e chamadas por vídeo. Somente três (5%) consideraram seguro atender pacientes durante os primeiros 60 dias. CONCLUSÕES: Houve redução no número de programas de RC devido a pandemia da COVID-19. Atividades de telerreabilitação aumentaram durante os primeiros dois meses da pandemia da COVID-19, mas que não foi suficiente para superar a redução nas atividades dos programas de RC no Brasil.

Cardiopulmonary Exercise Testing in Post-COVID-19 Patients: Where Does Exercise Intolerance Come From? / Teste Cardiopulmonar em Pacientes Pós-COVID-19: De Onde vem a Intolerância ao Exercício?

BACKGROUND: Post-COVID-19 exercise intolerance is poorly understood. Cardiopulmonary exercise testing (CPET) can identify the underlying exercise limitations. OBJECTIVES: To evaluate the source and magnitude of exercise intolerance in post-COVID-19 subjects. METHODS: Cohort study assessing subjects with different COVID-19 illness severities and a control group selected by propensity score matching. In a selected sample with CPET prior to viral infection, before and after comparisons were performed. Level of significance was 5% in the entire analysis. RESULTS: One hundred forty-four subjects with COVID-19 were assessed (median age: 43.0 years, 57% male), with different illness severities (60% mild, 21% moderate, 19% severe). CPET was performed 11.5 (7.0, 21.2) weeks after disease onset, with exercise limitations being attributed to the peripheral muscle (92%), and the pulmonary (6%), and cardiovascular (2%) systems. Lower median percent-predicted peak oxygen uptake was observed in the severe subgroup (72.2%) as compared to the controls (91.6%). Oxygen uptake differed among illness severities and controls at peak and ventilatory thresholds. Conversely, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse were similar. Subgroup analysis of 42 subjects with prior CPET revealed significant reduction in only peak treadmill speed in the mild subgroup and in oxygen uptake at peak and ventilatory thresholds in the moderate/severe subgroup. By contrast, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse did not change significantly. CONCLUSIONS: Peripheral muscle fatigue was the most common exercise limitation etiology in post-COVID-19 patients regardless of the illness severity. Data suggest that treatment should emphasize comprehensive rehabilitation programs, including aerobic and muscle strengthening components.

FUNDAMENTO: A intolerância ao exercício pós-COVID-19 não é bem entendida. O teste de esforço cardiopulmonar (TECP) pode identificar as limitações ao exercício subjacentes. OBJETIVOS: Avaliar a etiologia e a magnitude da intolerância ao exercício em sujeitos pós-COVID-19. MÉTODOS: Estudo de coorte que avaliou sujeitos com níveis de gravidades diferentes da doença COVID-19 e um grupo de controle selecionado por pareamento por escores de propensão. Em uma amostra seleta com TECP anterior à infecção viral disponível, foram realizadas comparações antes e depois. O nível de significância foi de 5% em toda a análise. RESULTADOS: Foram avaliados cento e quarenta e dois sujeitos com COVID-19 (idade mediana: 43 anos, 57% do sexo masculino), com níveis de gravidade de doença diferentes (60% leve, 21% moderada, 19% grave). O TECP foi realizado 11,5 (7,0, 21,2) semanas após o aparecimento da doença, com as limitações ao exercício sendo atribuídas aos sistemas muscular periférico (92%), pulmonar (6%), e cardiovascular (2%). Menor valor mediano do consumo de oxigênio pico percentual foi observado no subgrupo com níveis graves de doença (72,2%) em comparação com os controles (91,6%). O consumo de oxigênio foi diferente entre os grupos com diferentes níveis de gravidade de doença e o controle no pico e nos limiares ventilatórios. Inversamente, os equivalentes ventilatórios, a inclinação da eficiência do consumo de oxigênio, e o pico do pulso de oxigênio foram semelhantes. A análise do subgrupo de 42 sujeitos com TECP prévio revelou uma redução significativa no pico de velocidade da esteira no subgrupo com nível leve de doença, e no consumo de oxigênio no pico e nos limiares ventilatórios nos subgrupos com níveis moderado/grave. Por outro lado, os equivalentes ventilatórios, a inclinação da eficiência do consumo de oxigênio e o pico do pulso de oxigênio não apresentaram alterações significativas. CONCLUSÕES: A fadiga do músculo periférico foi a etiologia de limitação de exercício mais comum em pacientes pós-COVID-19 independentemente da gravidade da doença. Os dados sugerem que o tratamento deve enfatizar programas de reabilitação abrangentes, incluindo componentes aeróbicos e de fortalecimento muscular.

Teste Cardiopulmonar em Pacientes Pós-COVID-19: De Onde vem a Intolerância ao Exercício? / Cardiopulmonary Exercise Testing in Post-COVID-19 Patients: Where Does Exercise Intolerance Come From?

Resumo Fundamento A intolerância ao exercício pós-COVID-19 não é bem entendida. O teste de esforço cardiopulmonar (TECP) pode identificar as limitações ao exercício subjacentes. Objetivos Avaliar a etiologia e a magnitude da intolerância ao exercício em sujeitos pós-COVID-19. Métodos Estudo de coorte que avaliou sujeitos com níveis de gravidades diferentes da doença COVID-19 e um grupo de controle selecionado por pareamento por escores de propensão. Em uma amostra seleta com TECP anterior à infecção viral disponível, foram realizadas comparações antes e depois. O nível de significância foi de 5% em toda a análise. Resultados Foram avaliados cento e quarenta e dois sujeitos com COVID-19 (idade mediana: 43 anos, 57% do sexo masculino), com níveis de gravidade de doença diferentes (60% leve, 21% moderada, 19% grave). O TECP foi realizado 11,5 (7,0, 21,2) semanas após o aparecimento da doença, com as limitações ao exercício sendo atribuídas aos sistemas muscular periférico (92%), pulmonar (6%), e cardiovascular (2%). Menor valor mediano do consumo de oxigênio pico percentual foi observado no subgrupo com níveis graves de doença (72,2%) em comparação com os controles (91,6%). O consumo de oxigênio foi diferente entre os grupos com diferentes níveis de gravidade de doença e o controle no pico e nos limiares ventilatórios. Inversamente, os equivalentes ventilatórios, a inclinação da eficiência do consumo de oxigênio, e o pico do pulso de oxigênio foram semelhantes. A análise do subgrupo de 42 sujeitos com TECP prévio revelou uma redução significativa no pico de velocidade da esteira no subgrupo com nível leve de doença, e no consumo de oxigênio no pico e nos limiares ventilatórios nos subgrupos com níveis moderado/grave. Por outro lado, os equivalentes ventilatórios, a inclinação da eficiência do consumo de oxigênio e o pico do pulso de oxigênio não apresentaram alterações significativas. Conclusões A fadiga do músculo periférico foi a etiologia de limitação de exercício mais comum em pacientes pós-COVID-19 independentemente da gravidade da doença. Os dados sugerem que o tratamento deve enfatizar programas de reabilitação abrangentes, incluindo componentes aeróbicos e de fortalecimento muscular.

Abstract Background Post-COVID-19 exercise intolerance is poorly understood. Cardiopulmonary exercise testing (CPET) can identify the underlying exercise limitations. Objectives To evaluate the source and magnitude of exercise intolerance in post-COVID-19 subjects. Methods Cohort study assessing subjects with different COVID-19 illness severities and a control group selected by propensity score matching. In a selected sample with CPET prior to viral infection, before and after comparisons were performed. Level of significance was 5% in the entire analysis. Results One hundred forty-four subjects with COVID-19 were assessed (median age: 43.0 years, 57% male), with different illness severities (60% mild, 21% moderate, 19% severe). CPET was performed 11.5 (7.0, 21.2) weeks after disease onset, with exercise limitations being attributed to the peripheral muscle (92%), and the pulmonary (6%), and cardiovascular (2%) systems. Lower median percent-predicted peak oxygen uptake was observed in the severe subgroup (72.2%) as compared to the controls (91.6%). Oxygen uptake differed among illness severities and controls at peak and ventilatory thresholds. Conversely, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse were similar. Subgroup analysis of 42 subjects with prior CPET revealed significant reduction in only peak treadmill speed in the mild subgroup and in oxygen uptake at peak and ventilatory thresholds in the moderate/severe subgroup. By contrast, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse did not change significantly. Conclusions Peripheral muscle fatigue was the most common exercise limitation etiology in post-COVID-19 patients regardless of the illness severity. Data suggest that treatment should emphasize comprehensive rehabilitation programs, including aerobic and muscle strengthening components.

Impacto da COVID-19 nos Programas de Reabilitação Cardiovascular no Brasil: Um Estudo Transversal Baseado em uma Pesquisa Online / Impact of COVID-19's on Cardiovascular Rehabilitation Programs in Brazil: An Online Survey-Based Cross-Sectional Study

Resumo Fundamento A pandemia da COVID-19 teve um impacto sobre os programas de reabilitação cardiovasculares (RC) no Brasil. Objetivos Descrever características dos programas de RC no Brasil, os impactos da primeira onda epidemiológica da COVID-19 (primeiros 60 dias) sobre os programas, e apresentar as iniciativas usadas para superar esses impactos. Métodos Este estudo transversal e retrospectivo usou um questionário online específico. Os participantes eram coordenadores de programas de RC. As variáveis foram apresentadas por região geográfica do Brasil, como as seguintes categorias: característica demográficas, clínicas e operacionais. O nível de significância estatística foi definido em 5%. Resultados Cinquenta e nove programas de RC atendiam 5349 pacientes, dos quais somente 1817 eram pacientes após eventos cardiovasculares agudos, o que correspondia a 1,99% dos pacientes internados no mês anterior à pesquisa (n=91.231). O maior impacto foi a suspensão das atividades presenciais, o que ocorreu de maneira similar em áreas com as taxas mais altas e áreas com as taxas mais baixas de COVID-19 no período. Quarenta e quatro (75%) programas foram interrompidos de forma breve, e três (5%) foram encerrados. Todos os 42 programas que já utilizavam estratégias de reabilitação remota notaram aumento substancial nas atividades, baseadas principalmente no uso da mídia e chamadas por vídeo. Somente três (5%) consideraram seguro atender pacientes durante os primeiros 60 dias. Conclusões Houve redução no número de programas de RC devido a pandemia da COVID-19. Atividades de telerreabilitação aumentaram durante os primeiros dois meses da pandemia da COVID-19, mas que não foi suficiente para superar a redução nas atividades dos programas de RC no Brasil.

Abstract Background The COVID-19 pandemic had an impact on cardiovascular rehabilitation (CR) programs in Brazil. Objectives To describe the characteristics of CR programs in Brazil, the impacts of the first epidemiological wave of COVID-19 (first 60 days) on the programs and present the initiatives used to overcome the impacts. Method This cross-sectional and retrospective study utilized a specific online survey. Participants were coordinators of CR programs. Variables were presented by Brazilian geographic region and as the following categories: demographic, clinical and operational characteristics. The significance level for statistical analysis was set at 5%. Results Fifty-nine CR programs were responsible for 5,349 patients, of which only 1,817 were post-acute cardiovascular events, which corresponded to 1.99% of hospitalized patients in the month prior to the survey (n=91,231). The greatest impact was the suspension of on-site activities, which occurred similarly in areas with the highest and the lowest rates of COVID-19 in the period. Forty-five programs (75%) were shortly interrupted, while three (5%) were ended. All 42 programs that already used remote rehabilitation strategies noticed a substantial increase in activities, based primarily on the use of media and video calling. Only three (5%) considered safe to see patients during the first 60 days. Conclusions There was a reduction in the number of CR programs with the COVID-19 pandemic. Telerehabilitation activities increased during the first two months of the COVID-19 pandemic, but this was not enough to overcome the reduction in CR program activities across Brazil.

Relação da Função Pulmonar e da Força Inspiratória com Capacidade Aeróbica e com Prognóstico na Insuficiência Cardíaca / Relationship of Lung Function and Inspiratory Strength with Exercise Capacity and Prognosis in Heart Failure

Resumo Fundamento A espirometria é subutilizada na insuficiência cardíaca (IC) e não está claro o grau de associação de cada defeito com a capacidade de exercício e com o prognóstico desses pacientes. Objetivo Determinar a relação da %CVF prevista (ppCVF) e do VEF1/CVF contínuos com: 1) pressão inspiratória máxima (PImáx), fração de ejeção do ventrículo esquerdo (FEVE) e desempenho ao exercício; e 2) prognóstico, para o desfecho composto de morte cardiovascular, transplante cardíaco ou implante de dispositivo de assistência ventricular. Métodos Coorte de 111 participantes com IC (estágios AHA C/D) sem pneumopatia; foram submetidos a espirometria, manovacuometria e teste cardiopulmonar máximo. As magnitudes de associação foram verificadas por regressões lineares e de Cox (HR; IC 95%), ajustadas para idade/sexo, e p <0,05 foi considerado significativo. Resultados Com idade média 57±12 anos, 60% eram homens, 64% em NYHAIII. A cada aumento de 10% no VEF1/CVF [β 7% (IC 95%: 3-10)] e no ppCVF [4% (2-6)], foi associado à reserva ventilatória (VRes); no entanto, apenas o ppCVF associado à PImáx [3,8cmH2O (0,3-7,3)], à fração de ejeção do ventrículo esquerdo (FEVE) [2,1% (0,5-3,8)] e ao VO2 pico [0,5mL/kg/min (0,1-1,0)], considerando idade/sexo. Em 2,2 anos (média), ocorreram 22 eventos; tanto FEV1/FVC (HR 1,44; IC 95%: 0,97-2,13) quanto ppCVF (HR 1,13; 0,89-1,43) não foram associados ao desfecho. Apenas no subgrupo FEVE ≤50% (n=87, 20 eventos), VEF1/CVF (HR 1,50; 1,01-2,23), mas não ppCVF, foi associado a risco. Conclusão Na IC crônica, ppCVF reduzido associou-se a menor PImáx, FEVE, VRes e VO2 pico, mas não distinguiu pior prognóstico em 2,2 anos de acompanhamento. Entretanto, VEF1/CVF associou-se apenas com VRes, e, em participantes com FEVE ≤50%, o VEF1/CVF reduzido mostrou pior prognóstico proporcional. Portanto, VEF1/CVF e ppFVC contribuem para melhor fenotipagem de pacientes com IC.

Abstract Background Spirometry is underused in heart failure (HF) and the extent to which each defect associates with exercise capacity and prognosis is unclear. Objective To determine the distinct relationship of continuous %predicted FVC (ppFVC) and FEV1/FVC with: 1) maximal inspiratory pressure (MIP), left ventricular ejection fraction (LVEF), exercise performance; and 2) prognosis for the composite of cardiovascular death, heart transplantation or left ventricular assist device implant. Methods A cohort of 111 HF participants (AHA stages C/D) without diagnosed pneumopathy, spirometry, manovacuometry and maximum cardiopulmonary test. The association magnitudes were verified by linear and Cox (HR; 95% CI) regressions, age/sex adjusted. A p<0.05 was considered significant. Results Age was 57±12 years, 60% men, 64% in NYHA III. Every 10%-point increase in FEV1/FVC [β 7% (95% CI: 3-10)] and ppFVC [4% (2-6)] associated with ventilatory reserve (VRes), however only ppFVC associated with MIP [3.8 cmH2O (0.3-7.3)], LVEF [2.1% (0.5-3.8)] and VO2peak [0.5 mL/kg/min (0.1-1.0)], accounting for age/sex. In 2.2 years (mean), 22 events occurred, and neither FEV1/FVC (HR 1.44; 95% CI: 0.97-2.13) nor ppFVC (HR 1.13; 0.89-1.43) was significantly associated with the outcome. Only in the LVEF ≤50% subgroup (n=87, 20 events), FEV1/FVC (HR 1.50; 1.01-2.23), but not ppFVC, was associated with greater risk. Conclusions In chronic HF, reduced ppFVC associated with lower MIP, LVEF, VRes and VO2peak, but no distinct poorer prognosis over 2.2 years of follow-up. Distinctively, FEV1/FVC was associated only with VRes, and, in participants with LVEF ≤50%, FEV1/FVC reduction proportionally worsened prognosis. Therefore, FEV1/FVC and ppFVC add supplementary information regarding HF phenotyping.

Relationship of Lung Function and Inspiratory Strength with Exercise Capacity and Prognosis in Heart Failure. / Relação da Função Pulmonar e da Força Inspiratória com Capacidade Aeróbica e com Prognóstico na Insuficiência Cardíaca.

BACKGROUND: Spirometry is underused in heart failure (HF) and the extent to which each defect associates with exercise capacity and prognosis is unclear. OBJECTIVE: To determine the distinct relationship of continuous %predicted FVC (ppFVC) and FEV1/FVC with: 1) maximal inspiratory pressure (MIP), left ventricular ejection fraction (LVEF), exercise performance; and 2) prognosis for the composite of cardiovascular death, heart transplantation or left ventricular assist device implant. METHODS: A cohort of 111 HF participants (AHA stages C/D) without diagnosed pneumopathy, spirometry, manovacuometry and maximum cardiopulmonary test. The association magnitudes were verified by linear and Cox (HR; 95% CI) regressions, age/sex adjusted. A p<0.05 was considered significant. RESULTS: Age was 57±12 years, 60% men, 64% in NYHA III. Every 10%-point increase in FEV1/FVC [ß 7% (95% CI: 3-10)] and ppFVC [4% (2-6)] associated with ventilatory reserve (VRes), however only ppFVC associated with MIP [3.8 cmH2O (0.3-7.3)], LVEF [2.1% (0.5-3.8)] and VO2peak [0.5 mL/kg/min (0.1-1.0)], accounting for age/sex. In 2.2 years (mean), 22 events occurred, and neither FEV1/FVC (HR 1.44; 95% CI: 0.97-2.13) nor ppFVC (HR 1.13; 0.89-1.43) was significantly associated with the outcome. Only in the LVEF ≤50% subgroup (n=87, 20 events), FEV1/FVC (HR 1.50; 1.01-2.23), but not ppFVC, was associated with greater risk. CONCLUSIONS: In chronic HF, reduced ppFVC associated with lower MIP, LVEF, VRes and VO2peak, but no distinct poorer prognosis over 2.2 years of follow-up. Distinctively, FEV1/FVC was associated only with VRes, and, in participants with LVEF ≤50%, FEV1/FVC reduction proportionally worsened prognosis. Therefore, FEV1/FVC and ppFVC add supplementary information regarding HF phenotyping.

FUNDAMENTO: A espirometria é subutilizada na insuficiência cardíaca (IC) e não está claro o grau de associação de cada defeito com a capacidade de exercício e com o prognóstico desses pacientes. OBJETIVO: Determinar a relação da %CVF prevista (ppCVF) e do VEF1/CVF contínuos com: 1) pressão inspiratória máxima (PImáx), fração de ejeção do ventrículo esquerdo (FEVE) e desempenho ao exercício; e 2) prognóstico, para o desfecho composto de morte cardiovascular, transplante cardíaco ou implante de dispositivo de assistência ventricular. MÉTODOS: Coorte de 111 participantes com IC (estágios AHA C/D) sem pneumopatia; foram submetidos a espirometria, manovacuometria e teste cardiopulmonar máximo. As magnitudes de associação foram verificadas por regressões lineares e de Cox (HR; IC 95%), ajustadas para idade/sexo, e p <0,05 foi considerado significativo. RESULTADOS: Com idade média 57±12 anos, 60% eram homens, 64% em NYHAIII. A cada aumento de 10% no VEF1/CVF [ß 7% (IC 95%: 3-10)] e no ppCVF [4% (2-6)], foi associado à reserva ventilatória (VRes); no entanto, apenas o ppCVF associado à PImáx [3,8cmH2O (0,3-7,3)], à fração de ejeção do ventrículo esquerdo (FEVE) [2,1% (0,5-3,8)] e ao VO2 pico [0,5mL/kg/min (0,1-1,0)], considerando idade/sexo. Em 2,2 anos (média), ocorreram 22 eventos; tanto FEV1/FVC (HR 1,44; IC 95%: 0,97-2,13) quanto ppCVF (HR 1,13; 0,89-1,43) não foram associados ao desfecho. Apenas no subgrupo FEVE ≤50% (n=87, 20 eventos), VEF1/CVF (HR 1,50; 1,01-2,23), mas não ppCVF, foi associado a risco. CONCLUSÃO: Na IC crônica, ppCVF reduzido associou-se a menor PImáx, FEVE, VRes e VO2 pico, mas não distinguiu pior prognóstico em 2,2 anos de acompanhamento. Entretanto, VEF1/CVF associou-se apenas com VRes, e, em participantes com FEVE ≤50%, o VEF1/CVF reduzido mostrou pior prognóstico proporcional. Portanto, VEF1/CVF e ppFVC contribuem para melhor fenotipagem de pacientes com IC.

Test of incremental respiratory endurance as home-based, stand-alone therapy in chronic obstructive pulmonary disease: A case report.

BACKGROUND: The prevalence of chronic obstructive pulmonary disease (COPD) is increasing worldwide, and at the same time it is associated with increased mortality and reduced quality of life. Efforts to build sustainable rehabilitation approaches to COPD treatment and prevention are crucial. The system of long-term pulmonary rehabilitation care is insufficient. The main reasons for the absence of these outpatient programs are the lack of experience, the lack of interest of insurance companies in secondary prevention programs, and the lack of healthcare facilities in large geographical areas. The possibility of at-home pulmonary rehabilitation models (telemonitoring and telecoaching) could solve this problem. CASE SUMMARY: A 71-year-old man with severe COPD, Global Initiative for Obstructive Lung Diseases stage 3 underwent an 8-wk remotely monitored inspiratory muscle training with a device based on the test of incremental respiratory endurance method. Spirometry, body plethysmography, test of incremental respiratory endurance examination, 6-min walking test, body mass index, airflow obstruction, dyspnea, exercise capacity index, and subjective perception of dyspnea were performed as part of the initial and final examination. The patient performed training at home, and the physiotherapist monitored the patient remotely through a web application that allowed the physiotherapist to evaluate all training parameters in real-time and respond to any problems. After 8 wk of home training, there was a significant increase in all monitored values: maximal inspiratory pressure, a novel parameter sustained maximal inspiratory pressure, forced expiratory volume in 1 s, total lung capacity, forced vital capacity, peak expiratory flow, and inspiratory capacity. There was also an improvement in the perception of dyspnea according to the COPD Assessment Test and a modified Medical Research Council Breathlessness Scale, an increase in exercise tolerance according to the 6-min walking test, and a decrease in the exercise capacity index as a predictor of prognosis. CONCLUSION: Respiratory telerehabilitation was greatly beneficial in a cooperative patient with COPD and may represent an alternative therapeutic approach to the increasing incidence of all lung diseases.

Reduced exercise capacity and self-perceived health status in high-risk patients undergoing lung resection.

BACKGROUND: Lung resection represents the main curative treatment modality of non-small cell lung cancer. Patients with high-risk to develop postoperative pulmonary complications have been classified as "high-risk patients." Characterizing this population could be important to improve their approach and rehabilitation. AIM: To identify the differences between high and low-risk patients in exercise capacity and self-perceived health status after hospitalization. METHODS: A longitudinal observational prospective cohort study was carried out. Patients undergoing lung resection were recruited from the "Hospital Virgen de las Nieves" (Granada) and divided into two groups according to the risk profile criteria (age ≥ 70 years, forced expiratory volume in 1 s ≤ 70% predicted, carbon monoxide diffusion capacity ≤ 70% predicted or scheduled pneumonectomy). Outcomes included were exercise capacity (Fatigue Severity Scale, Unsupported Upper-Limb Exercise, handgrip dynamometry, Five Sit-to-stand test, and quadriceps hand-held dynamometry) and patient-reported outcome (Euroqol-5 dimensions 5 Levels Visual Analogue Scale). RESULTS: In total, 115 participants were included in the study and divided into three groups: high-risk, low-risk and control group. At discharge high-risk patients presented a poorer exercise capacity and a worse self-perceived health status (P < 0.05). One month after discharge patients in the high-risk group maintained these differences compared to the other groups. CONCLUSION: Our results show a poorer recovery in high-risk patients at discharge and 1 mo after surgery, with lower self-perceived health status and a poorer upper and lower limb exercise capacity. These results are important in the rehabilitation field.

Acute and Time-Course Effects of Osteopathic Manipulative Treatment on Vascular and Autonomic Function in Patients With Heart Failure: A Randomized Trial.

OBJECTIVE: The purposed of this study was to valuate the effect of osteopathic manipulative treatment (OMT) on flow-mediated dilation and heart rate variability of patients with heart failure. BACKGROUND: Osteopathic manipulative treatment modulates both the vascular and autonomic nervous system (ANS) in healthy volunteers. However, the acute and time-course effects of the OMT on patients with an overactive ANS remain unclear. METHODS: This randomized controlled trial study included 20 patients with heart failure aged 50 to 60 years, allocated to a single session of OMT (base of the skull, retromaxillary region, heart, and thoracic duct) or sham. Flow-mediated dilation (FMD) at the brachial artery, hemodynamic measures, and heart rate variability were assessed in 3 periods (baseline, immediately after the intervention, and after 15 minutes). Multivariate analysis of variance procedure was used to compare intervention and periods. RESULTS: The OMT group had a greater FMD modulation compared with the sham (FMD,% =  9.5 vs. -5.6, 95% confidence interval (CI): [6.6, -12.35] vs. [-14.25, 2.8]; p = 0.001) and grater peak diameter (PD, mm =  0.77 vs -0.16 mm, 95% CI: [0.31,-1.24] vs [-0.63, 0.29]; P =  0.001), suggesting an important acute and time-course vascular effect from OMT. We also found some relevant heart rate variability modulation after 15 minutes from OMT: high frequency (HF, ms2 = 295 vs -354, 95% CI: [144.2, -769]; P = .001) and low frequency (LF, ms2) = 670 vs 775, 95% CI: [-98, 3591]; P = .001), suggesting a time-course ANS modulation after OMT. CONCLUSIONS: Osteopathic manipulative treatment was effective at increasing brachial blood flow and stimulating the vagal system in patients with heart failure. Moreover, vascular changes seem to precede the autonomic modulation.

Moderate-intensity exercise with blood flow restriction on cardiopulmonary kinetics and efficiency during a subsequent high-intensity exercise in young women: A cross-sectional study.

ABSTRACT: Blood flow restriction (BFR) training applied prior to a subsequent exercise has been used as a method to induce changes in oxygen uptake pulmonary kinetics (O2P) and exercise performance. However, the effects of a moderate-intensity training associated with BFR on a subsequent high-intensity exercise on O2P and cardiac output (QT) kinetics, exercise tolerance, and efficiency remain unknown.This prospective physiologic study was performed at the Exercise Physiology Lab, University of Brasilia. Ten healthy females (mean ±â€ŠSD values: age = 21.3 ±â€Š2.2 years; height = 1.6 ±â€Š0.07 m, and weight = 55.6 ±â€Š8.8 kg) underwent moderate-intensity training associated with or without BFR for 6 minutes prior to a maximal high-intensity exercise bout. O2P, heart rate, and QT kinetics and gross efficiency were obtained during the high-intensity constant workload exercise test.No differences were observed in O2P, heart rate, and QT kinetics in the subsequent high-intensity exercise following BFR training. However, exercise tolerance and gross efficiency were significantly greater after BFR (220 ±â€Š45 vs 136 ±â€Š30 seconds; P < .05, and 32.8 ±â€Š6.3 vs 27.1 ±â€Š5.4%; P < .05, respectively), which also resulted in lower oxygen cost (1382 ±â€Š227 vs 1695 ±â€Š305 mL min-1).We concluded that moderate-intensity BFR training implemented prior to a high-intensity protocol did not accelerate subsequent O2P and QT kinetics, but it has the potential to improve both exercise tolerance and work efficiency at high workloads.

Home-based training program in patients with chronic heart failure and reduced ejection fraction: a randomized pilot study.

OBJECTIVES: We aimed to compare the effects of home-and center-based exercise training programs on functional capacity, inspiratory muscle strength, daily physical activity level, and quality of life (QoL) in patients with chronic heart failure (CHF) over a 12-week period. METHODS: This study included 23 patients with CHF (left ventricular ejection fraction 31±6%) randomized to a home-based (n=11) or center-based (n=12) program. Patients underwent 12 weeks of aerobic training (60%-70% heart rate reserve): walking for the home-based and supervised cycling for the center-based group, both combined with resistance training (50% of 1 maximum repetition). At baseline and after 12 weeks of training, we assessed cardiopulmonary test variables, 6-min walk test distance (6 MWD), steps/day with accelerometry, and QoL (Minnesota Living with Heart Failure questionnaire). Maximal inspiratory pressure and handgrip strength were measured at baseline and after 4, 8, and 12 weeks of training. ClinicalTrials.gov: NCT03615157. RESULTS: There were no adverse events during training in either group. The home- and center-based training groups obtained similar improvements in peak oxygen uptake, maximal ventilation, and 6 MWD. However, there were significant between-group differences: center-based training was more effective in improving maximal inspiratory pressure (p=0.042), number of steps/day (p=0.001), and QoL (p=0.039). CONCLUSIONS: Home-based training is safe and can be an alternative to improve the exercise capacity of patients with stable CHF. However, center-based training was superior in improving inspiratory muscle strength, QoL, and daily physical activity.

Failure of Noninvasive Ventilation in Acute Respiratory Failure is Associated with Higher Mortality in Patients with Solid Tumors: A Retrospective Cohort Study.

BACKGROUND: Noninvasive Ventilation (NIV) is a well-established treatment for Acute Respiratory Failure (ARF) in hematological cancer. However, the NIV impact on mortality in patients with solid tumors is unclear. OBJECTIVE: To define the factors associated with NIV failure and mortality and to describe the mortality risk of patients with solid tumors requiring NIV for ARF treatment in the intensive care unit (ICU). METHODS: A retrospective cohort study of patients with solid tumors admitted into an ICU between Jan 2016 and Dec 2017, for cancer treatment, with ARF diagnosis that had used the NIV as first-line treatment. Our primary outcome was ICU and in-hospital mortality. The secondary outcome was NIV failure. A Cox proportional hazards regression was used to identify variables associated with mortality and NIV failure. Kaplan-Meier analyses were performed to demonstrate cumulative survival. RESULTS: A total of 226 patients with solid tumors were included. The ICU and hospital mortality rates were 57.5% and 69.5%, respectively. NIV failed in 52.2% of the patients. The use of vasopressors (HR 2.48 [95% CI: 1.43-4.30] p = 0.001), baseline lactate (HR 1.20 [95% CI: 1.07-1.35] p = 0.003), baseline PaO2/FiO2 ratio (HR1.33 [1.11-1.55] p = 0.002), and NIV success (HR0.17 [95% CI: 0.10-0.27] p = 0.005) was independently associated with hospital mortality. The use of vasopressors (HR 2.58 [95% CI: 1.41-4.73] p = 0.02), NIV duration (HR 0.93 [95% CI: 0.89-0.97] p = 0.003), and baseline lactate (HR 1.13 [95% CI: 1.06-1.20] p = 0.001) was associated with NIV failure. CONCLUSIONS: NIV failure was independently associated with an increase in both ICU and hospital mortality rates. In patients with NIV therapy indication, the duration of this intervention was associated with NIV failure.

A Meta-Analysis of Group-Based Pain Management Programs: Overall Effect on Quality of Life and Other Chronic Pain Outcome Measures, with an Exploration into Moderator Variables that Influence the Efficacy of Such Interventions.

OBJECTIVES: Group-based pain management programs (GPMPs) have been found to significantly improve quality of life and other pain outcome measures in patients with chronic musculoskeletal pain. The aims of this meta-analysis were to reevaluate the overall effect of GPMPs on various pain outcomes for individuals experiencing chronic musculoskeletal conditions and to explore moderator variables that potentially contribute to the overall efficacy of GPMPs. METHODS: Using the R package called metaphor and RevMan, we estimated the overall effectiveness of GPMPs on various pain outcome measures. The differential effectiveness of GPMPs was examined by conducting a mixed-effects meta-analytic model using various study-level characteristics. Moderator analyses included three content moderator variables and seven format moderator variables. Receiver operating characteristic curves investigated optimal points in some of the moderator variable analysis results. RESULTS: Significant overall main effects of GPMPs were found on all the explored outcome measures in this study (P < 0.05). In moderator analyses, it was found that the structure of GPMPs, rather than the content, significantly improved outcomes (P < 0.05). Receiver operating characteristic curve analyses identified the optimal number of GPMP sessions and number of participants per group. DISCUSSION AND CLINICAL RELEVANCE: GPMPs have a statistically significant overall effect on all explored pain outcome measures. The investigation into content and structural moderators suggests that certain GPMP design factors have a greater effect on pain outcomes than do content factors. Therefore, GPMP structural designs appear to be important in reducing pain and improving quality of life for patients with chronic pain and warrant further investigation.

Ventilatory Impairments Associated with Parkinson's Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: The peripheral and central repercussions of Parkinson's disease (PD) affect the neuromuscular system producing a loss of muscle strength that can influence the respiratory system. Although several studies have examined various respiratory aspects of PD, to the best of our knowledge no study to date has systematically reviewed the existing data. OBJECTIVES: To examine the available literature related to the respiratory impairment in PD patients. METHODS: We used PRISMA guidelines when reporting this review. We searched Pubmed, Cinhal, SciELO, and Cochrane Library, from inception until August 2018. Main variables assessed were forced vital capacity percent predicted (FVC%) and forced expiratory volume in 1 s percent predicted (FEV1%) for PD patients. RESULTS: Six studies were included in this systematic review and meta-analysis. The obtained results concluded that PD patients present poorer pulmonary function when compared to healthy controls. When PD patients were compared between ON and OFF states, the results reviewed are in favour of the ON state. In the meta-analysis performed for FVC% and FEV1%, the results fail to find significant differences between PD patients and controls (p = 0.336 and p = 0.281, respectively), and between PD ON and OFF states (p = 0.109 and p = 0.059, respectively). CONCLUSIONS: We conclude that PD patients have impaired respiratory capacities that are related to the PD severity, time since diagnosis, and OFF state. Adequate follow-up of the respiratory function and studies focused on PD phenotypes have to be considered in future studies.

A Meta-Analysis of Therapeutic Pain Neuroscience Education, Using Dosage and Treatment Format as Moderator Variables.

OBJECTIVES: This meta-analysis aimed to assess the overall effect of therapeutic pain neuroscience education (TPNE) on chronic musculoskeletal pain and to further assess whether such an effect differs by TPNE dosage as well as other treatment format components. Dosage included the number of TPNE sessions provided as well as the amount of time per TPNE session. Structural components included TPNE provided alone as treatment or combined with other pain management modalities, as well as the inclusion of group-based treatment sessions. METHODS: Electronic databases were utilized to search for randomized controlled trials that included TPNE. The overall effectiveness of TPNE was estimated on 4 pain outcome measures, including kinesiophobia, pain intensity, pain disability, and pain catastrophizing. The differential effectiveness of TPNE was examined using a mixed-methods moderator analysis on various study-level characteristics to identify potential moderators affecting the overall results. RESULTS: Significant effects of TPNE were found on all the outcome measures. The only moderator that displayed a significant effect was group-based treatment on kinesiophobia (z = -2.23, P < 0.05, 95% confidence interval [CI] -2.70 to -0.20). Between-group analysis revealed that only interventions that included group sessions were found to be statistically significant (z = 2.20, P < 0.05) and displayed a large effect size (d = 0.80, 95% CI 0.09 to 1.50). DISCUSSION: Therapeutic pain neuroscience education had a statistically significant impact on all the explored pain outcome measures. However, when investigating the treatment dosage and format moderator variables, they appeared to not have a statistically significant effect except for group-based interventions on kinesiophobia levels. CONCLUSION: This meta-analysis examined the efficacy of TPNE for patients with chronic pain. It assessed various pain outcome measures following intervention. In addition, this research identified that various moderator variables do not have and do have an impact on the treatment modality of TPNE.

Home-based training program in patients with chronic heart failure and reduced ejection fraction: a randomized pilot study

OBJECTIVES: We aimed to compare the effects of home-and center-based exercise training programs on functional capacity, inspiratory muscle strength, daily physical activity level, and quality of life (QoL) in patients with chronic heart failure (CHF) over a 12-week period. METHODS: This study included 23 patients with CHF (left ventricular ejection fraction 31±6%) randomized to a home-based (n=11) or center-based (n=12) program. Patients underwent 12 weeks of aerobic training (60%-70% heart rate reserve): walking for the home-based and supervised cycling for the center-based group, both combined with resistance training (50% of 1 maximum repetition). At baseline and after 12 weeks of training, we assessed cardiopulmonary test variables, 6-min walk test distance (6 MWD), steps/day with accelerometry, and QoL (Minnesota Living with Heart Failure questionnaire). Maximal inspiratory pressure and handgrip strength were measured at baseline and after 4, 8, and 12 weeks of training. ClinicalTrials.gov: NCT03615157. RESULTS: There were no adverse events during training in either group. The home- and center-based training groups obtained similar improvements in peak oxygen uptake, maximal ventilation, and 6 MWD. However, there were significant between-group differences: center-based training was more effective in improving maximal inspiratory pressure (p=0.042), number of steps/day (p=0.001), and QoL (p=0.039). CONCLUSIONS: Home-based training is safe and can be an alternative to improve the exercise capacity of patients with stable CHF. However, center-based training was superior in improving inspiratory muscle strength, QoL, and daily physical activity.

Risk factors for inspiratory muscle weakness in chronic heart failure

BACKGROUND: Chronic heart failure is commonly associated with inspiratory muscle weakness. However, few studies have investigated the risk factors for inspiratory muscle weakness in individuals with chronic heart failure and systolic dysfunction (left-ventricular ejection fraction [LVEF] <40%). METHODS: Seventy subjects were recruited in a cardiac center. We assessed clinical parameters, smoking history, peripheral muscle strength, pulmonary function, echocardiographic variables, and brain natriuretic peptide. The subjects were classified with inspiratory muscle weakness when the maximum inspiratory pressure was <70% of predicted values. RESULTS: Thirty-six subjects (51%) had inspiratory muscle weakness. The subjects with inspiratory muscle weakness and the subjects with no inspiratory muscle weakness were similar in age, sex, body mass index, medication use, and physical activity. However, the subjects with inspiratory muscle weakness had lower LVEF (P = .003), systolic blood pressure (P = .01), diastolic blood pressure (P = .042), quadriceps muscle strength (P = .02), lung function (P = .035), increased brain natriuretic peptide (P = .02), smoking history (P = .01), and pulmonary hypertension incidence (P = .03). Multivariate logistic regression analysis found a lower LVEF, increased smoking history, and lower systolic blood pressure as significant independent predictors for inspiratory muscle weakness. CONCLUSIONS: The combination of lower LVEF, lower systolic blood pressure, and smoking history predicted inspiratory muscle weakness. Patients with suspected inspiratory muscle weakness should be examined and, if inspiratory muscle weakness exists, then inspiratory muscle training should be provided. Reducing inspiratory muscle weakness has the potential to improve many of the deleterious effects of chronic heart failure. (AU)

Risk Factors for Inspiratory Muscle Weakness in Chronic Heart Failure.

BACKGROUND: Chronic heart failure is commonly associated with inspiratory muscle weakness. However, few studies have investigated the risk factors for inspiratory muscle weakness in individuals with chronic heart failure and systolic dysfunction (left-ventricular ejection fraction [LVEF] <40%). METHODS: Seventy subjects were recruited in a cardiac center. We assessed clinical parameters, smoking history, peripheral muscle strength, pulmonary function, echocardiographic variables, and brain natriuretic peptide. The subjects were classified with inspiratory muscle weakness when the maximum inspiratory pressure was <70% of predicted values. RESULTS: Thirty-six subjects (51%) had inspiratory muscle weakness. The subjects with inspiratory muscle weakness and the subjects with no inspiratory muscle weakness were similar in age, sex, body mass index, medication use, and physical activity. However, the subjects with inspiratory muscle weakness had lower LVEF (P = .003), systolic blood pressure (P = .01), diastolic blood pressure (P = .042), quadriceps muscle strength (P = .02), lung function (P = .035), increased brain natriuretic peptide (P = .02), smoking history (P = .01), and pulmonary hypertension incidence (P = .03). Multivariate logistic regression analysis found a lower LVEF, increased smoking history, and lower systolic blood pressure as significant independent predictors for inspiratory muscle weakness. CONCLUSIONS: The combination of lower LVEF, lower systolic blood pressure, and smoking history predicted inspiratory muscle weakness. Patients with suspected inspiratory muscle weakness should be examined and, if inspiratory muscle weakness exists, then inspiratory muscle training should be provided. Reducing inspiratory muscle weakness has the potential to improve many of the deleterious effects of chronic heart failure.

Current insights of inspiratory muscle training on the cardiovascular system: a systematic review with meta-analysis.

Background: Cardiorespiratory limitation is a common hallmark of cardiovascular disease which is a key component of pharmacological and exercise treatments. More recently, inspiratory muscle training (IMT) is becoming an effective complementary treatment with positive effects on muscle strength and exercise capacity. We assessed the effectiveness of IMT on the cardiovascular system through autonomic function modulation via heart rate variability and arterial blood pressure. Methods: Randomized controlled trials (RCTs) were identified from searches of The Cochrane Library, MEDLINE and EMBASE to November 2018. Citations, conference proceedings and previous reviews were included without population restriction, comparing IMT intervention to no treatment, placebo or active control. Results: We identified 10 RCTs involving 267 subjects (mean age range 51-71 years). IMT programs targeted maximum inspiratory pressure (MIP) and cardiovascular outcomes, using low (n=6) and moderate to high intensity (n=4) protocols, but the protocols varied considerably (duration: 1-12 weeks, frequency: 3-14 times/week, time: 10-30 mins). An overall increase of the MIP (cmH2O) was observed (-27.57 95% CI -18.48, -37.45, I 2=64%), according to weighted mean difference (95%CI), and was accompanied by a reduction of the low to high frequency ratio (-0.72 95% CI-1.40, -0.05, I 2=50%). In a subgroup analysis, low- and moderate-intensity IMT treatment was associated with a reduction of the heart rate (HR) (-7.59 95% CI -13.96, -1.22 bpm, I 2=0%) and diastolic blood pressure (DBP) (-8.29 [-11.64, -4.94 mmHg], I 2=0%), respectively. Conclusion: IMT is an effective treatment for inspiratory muscle weakness in several populations and could be considered as a complementary treatment to improve the cardiovascular system, mainly HR and DBP. Further research is required to better understand the above findings.

Efeitos de um programa de treinamento domiciliar sobre a capacidade funcional e qualidade de vida de pacientes com insuficiência cardíaca crônica / Effects of a home training program on the functional capacity and quality of life of patients with chronic heart failure

INTRODUÇÃO: O treinamento físico melhora a capacidade funcional e a qualidade de vida em pacientes com insuficiência cardíaca crônica (IC). Entretanto, devido à baixa disponibilidade de centros de reabilitação cardíaca e limitações pessoais (custos de transporte, tempo, preferências), a inclusão e a adesão ao treinamento físico supervisionado são baixas, sendo proposto o treinamento domiciliar como alternativa. OBJETIVO: Comparar os efeitos de dois programas de treinamento: um domiciliar e um supervisionado ao longo de 12 semanas sobre a capacidade funcional, atividade física diária e qualidade de vida em pacientes com IC. MÉTODOS: Foram incluídos 23 pacientes com IC (classe funcional NYHA II e III, fração de ejeção do ventrículo esquerdo ≤40%) randomizados em Grupo Domiciliar (GD, n=11) ou Grupo Supervisionado (GS, n=12). Os pacientes realizaram, ao longo de 12 semanas exercícios aeróbios (60-70% da frequência cardíaca de reserva): caminhada para o GD e cicloergômetro para o GS combinados a exercícios resistidos (50% de uma repetição máxima). As variáveis-desfecho foram: pico de consumo de oxigênio e ventilação máxima do teste cardiopulmonar, distância percorrida no teste da caminhada de seis minutos, força muscular do quadríceps, pressão inspiratória máxima, número de passos/dia e qualidade de vida. RESULTADOS: Após 12 semanas,GD e GS apresentaram aumentos significantes (p=0,025) no pico de consumo de oxigênio (0,8 e 3,7 ml/kg/min, respectivamente), na ventilação máxima (11,5 e 15,6 l/min, respectivamente), na distância percorrida (40 e 25 m, respectivamente), na porcentagem de força muscular do quadríceps (21% e 11%, respectivamente) e na qualidade de vida avaliada por meio do questionário Minnesota Living with Heart Failure (1 e 13, respectivamente), sem diferenças entre GD e GS. Entretanto, o GS mostrou melhora na força muscular inspiratória (p=0,042), aumento no número de passos/dia (p=0,001) e no componente de saúde mental do questionário SF-36 (p=0,001) superior ao GD. CONCLUSÕES: O treinamento domiciliar pode ser uma alternativa ao treinamento supervisionado para melhorar a capacidade funcional e a qualidade de vida em pacientes com IC. Além desses benefícios, o treinamento supervisionado foi superior em aumentar a força muscular inspiratória, o número de passos/dia e melhorar os aspectos de saúde mental em pacientes com IC. (AU)