Evaluation of the Level of Physical Activity and Muscle Strength of Quadriceps in Patients Hospitalized for E-COPD: A Longitudinal Study.

Physical inactivity and peripheral muscle dysfunction are considered two of the main contributors to hospitalizations due to exacerbation and, above all, predictors of mortality for these requirements in patients with COPD. Therefore, longitudinal studies are needed to determine the impact of exacerbations during hospitalization on these two factors, especially after three months of hospital discharge. The objectives of the present study were to assess the level of physical activity in daily life (PADL) and isometric muscle strength of the quadriceps in patients hospitalized for exacerbation of COPD and to verify changes after 3 months of hospital discharge. This is a longitudinal observational study that assessed the PADL level with an accelerometer, after 24 h of the hospitalization and the beginning of the drug treatment and assessed the quadriceps muscle strength with a manual dynamometer, after 72 h of hospitalization, in 32 patients with COPD (66 ± 7.61 years), in addition to repeating both assessments with 30 days of hospital discharge and after 3 months of follow-up. Cognition, dyspnea, general health, physical performance and lung function were assessed to characterize the sample. As main results, there was increase in active time (344 ± 260 - 447 ± 199 min; p = 0.04) and number of steps (4.241 ± 374 - 6.216 ± 400 steps; p = 0.02) after three months. In addition, inactive time showed significant reduction 30 days after hospital discharge (1.151 ± 249 - 1.065 ± 198 min; p = 0.02). The level of physical activity showed significant improvement due to the increase in active time and number of steps after three months of hospital discharge and to the reduction of inactive time 30 days after hospital discharge.

Benefits of interventions for respiratory secretion management in adult palliative care patients-a systematic review.

BACKGROUND: Respiratory secretions impact negatively on palliative patients. Unfortunately, a gold standard therapy is not yet available. The purpose of this study was to identify which interventions are in use to control respiratory secretions in patients with chronic disease with a poor prognosis and verify their effects on outcomes relevant for palliative care patients. METHODS: A systematic review of the literature with narrative summary was conducted. We searched eight electronic databases in April (6th), 2016. Citation-tracking and reference list searches were conducted. We included randomized controlled trials, crossover trials, observational and qualitative studies regarding interventions for respiratory secretion management in adult patients with chronic diseases that met inclusion criteria indicating short prognosis. RESULTS: Six randomized controlled trials, 11 observational studies, ten crossover trials and one qualitative study were found. Interventions included mechanical insufflation-exsufflation (MIE), expiratory muscle training, manually-assisted cough, tracheotomy, chest physiotherapy, suctioning, air stacking, electrical stimulation of abdominal muscles, nebulized saline, positive expiratory pressure masks, percussive ventilation, high frequency chest wall oscillations. The interventions with most promising benefits to patients in palliative care were manually-assisted cough and mechanical insufflation-exsufflation to promote expectoration and percussive ventilation to improve mucous clearance. CONCLUSION: Therapies, such as manually assisted cough, mechanical insufflation-exsufflation and percussive ventilation, which aim to deal with respiratory secretion, were the most promising treatment for use in palliative care for specific diseases. Nevertheless, the evidence still needs to improve in order to identify which treatment is the best.

Increased sympathetic modulation and decreased response of the heart rate variability in controlled asthma.

OBJECTIVE: To compare the autonomic modulation of heart rate (HR) in asthmatic and healthy volunteers to correlate it with the forced expiratory volume in the first second (FEV1). METHODS: Ten healthy and 14 asthmatic volunteers were included in this cross-sectional study. The volunteers underwent a cardiopulmonary exercise test, spirometry and a register of both resting heart rate variability (HRV) in the supine and seated positions along with HRV during the respiratory sinus arrhythmia maneuver (M-RSA). RESULTS: At rest in supine, asthmatic volunteers presented a higher HR (77.1 ± 9.9 vs. 68.7 ± 8.7 bpm), shorter interval between two R waves (R-Ri) (807.5 ± 107.2 vs. 887.5 ± 112.7 ms) when compared with the healthy volunteers, respectively. Moreover, in the frequency domain of HRV, there was increased low frequency (LF) index (50.4 ± 17.1 vs. 29.2 ± 11.1 n.u.) and decreased high frequency (HF) index (49.4 ± 17.1 vs. 70.7 ± 11.1 n.u.). During the M-RSA, the asthmatic presented higher HR (82.6 ± 10.0 vs. 72.4 ± 7.6 bpm) and lower values of R-Ri (746.4 ± 92.1 vs. 846.4 ± 81.4 ms) and approximate entropy (ApEn) (0.7 ± 0.0 vs. 0.8 ± 0.1). FEV1 was strongly correlated with the change of the continuous beat-to-beat variability of HR (SD2) index from the seated to the supine position (r = 0.78). CONCLUSION: Controlled asthma in adults appears to induce an increased sympathetic modulation and attenuated response to the postural changes and the M-RSA. Furthermore, there is a correlation between the airways' obstruction and HRV, especially during postural changes.

Effects of low and high resistance training intensities on clinical outcomes in patients with COPD - a randomized trial.

AIM: To compare the effects of two different intensities of combined resistance and aerobic training on physical-functional aspects and perceptual aspects of health status in patients with Chronic Obstructive Pulmonary Disease (COPD). DESIGN: This was a randomized parallel group trial. METHODS: Thirty-one patients were assessed regarding: symptoms (COPD Assessment Test - CAT), quality of life (Saint George's Respiratory Questionnaire - SGRQ); exercise capacity (six-minute walk test and constant-workload resistance test - CWRT); and muscle strength (one-repetition maximum test and isometric muscle strength for knee extensors - Kext and elbow flexors - EFlex). Patients were randomized in two groups to perform a combined training: 1) LL/HR = Low-load/high-repetition resistance training (n = 16; 68 ± 9.3 years; FEV1 = 50.0 ± 15.7%pred); and 2) HL/LR = High-load/low-repetition resistance training (n = 15; 70 ± 6.5 years; FEV1 = 46.8 ± 14.5%pred), and underwent 36 sessions. RESULTS: Symptoms, quality of life and exercise capacity presented significant improvement (p < .05) in both groups. Both intensities of resistance training improved symptoms (∆CAT: LL/HR = -3.9; HL/LR = -2.8) and exercise capacity (∆ tolerance time in CWRT: LL/HR = +450.9s; HL/LR = +583.4s) above minimal clinically important difference value. Nevertheless, improvement in quality of life (∆SGRQ: LL/HR = -3.8; HL/LR = -10) and in isometric muscle strength (∆KExt: LL/HR = +15.8 N; HL/LR = +37.7 N and (∆EFlex: LL/HR = +9.5 N; HL/LR = +29.9 N) was observed only in the HL/LR group, which also presented a larger number of responders considering isometric muscle strength. CONCLUSION: High-intensity resistance training in a combined training was more effective in ameliorating several aspects of patients with COPD, responding more and better to physical-functional aspects and perceptual aspects of health status.

Validity of the Brazilian version of the COPD assessment test in patients with chronic obstructive pulmonary disease.

INTRODUCTION: COPD Assessment Test (CAT) is a questionnaire defined as one of the main options in the assessment of the impact of Chronic Obstructive Pulmonary Disease on patients' life, according to the Global Initiative on Obstructive Lung Diseases. However, the Consensus-based Standards for the Selection of Health Measurement Instruments-COSMIN 2018 has recently determined a correlation coefficient greater than 0.70 and an optimal sample size must have a hundred subjects, hence, validity of the Brazilian version of this instrument is still not yet proven. OBJECTIVE: To verify the validity of the Brazilian version of the Questionnaire CAT in patients with Chronic Obstructive Pulmonary Disease, comparing it to the Saint George's Respiratory Questionnaire (SGRQ) and correlate it with other outcomes. MATERIALS AND METHODS: Observational transversal study with 101 COPD diagnosed subjects who underwent anthropometric data collection, life habits, CAT and SGRQ questionnaires, modified Medical Research Council (mMRC) dyspnoea scale. Spirometry, six-minute walking test (6MWT) and body mass index, Dyspnoea and exercise capacity (BODE). Each evaluative measure was compared to the total CAT score. The validity was considered for a significant Pearson correlation coefficient (r) greater than 0.7. RESULTS: It was observed a strong correlation between the total CAT score and the total SGRQ score (r = 0.703; P < 0.001), as well as moderate correlation with mMRC (r = 0.518; P < 0.001). SGRQ Symptoms (r = 0.627; P < 0.001). SGRQ Activity (r = 0.636; P < 0.001) and SGRQ Impact (r = 0.655; P < 0.001). There were similar correlations between CAT and other variables (6MWT, mMRC and BODE) and SGRQ and the same variables. CONCLUSION: The CAT questionnaire is a valid, reliable and easy-to-use instrument for assessing symptoms and can record the impact of COPD on the patient's quality of life.

Noninvasive ventilation acutely improves endothelial function in exacerbated COPD patients.

PURPOSE: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is associated with an elevated risk of cardiovascular events, which can be linked to endothelial dysfunction. In this study, we aimed to investigate whether noninvasive ventilation (NIV) acutely changes endothelial function in hospitalized AECOPD patients. METHODS: Twenty-one AECOPD patients were assessed in a hospital ward setting from 24 to 48 h after admission. NIV was applied using a ventilator with bilevel pressure support. Before and after NIV protocol, patients were evaluated regarding (1) endothelium-dependent function, assessed non-invasively using the flow-mediated dilation (FMD) method; (2) arterial blood gas analysis. Other baseline evaluations included clinical and anthropometric data, and laboratory tests. RESULTS: The total group showed a significant improvement in FMD as a result of NIV effect (P = 0.010). While arterial carbon dioxide and oxygen were not altered, oxygen saturation increased after NIV (P = 0.045). The subgroup comparison of responders (FMD ≥ 1%) and non-responders (FMD < 1%) showed significant baseline differences in body mass index (BMI) (P = 0.019) and predicted forced expiratory volume in one second (FEV1) (P = 0.007). In univariate and multivariate analyses, both BMI and FEV1 were determinant for endothelial response to NIV. CONCLUSION: NIV acutely improves endothelial function in hospitalized AECOPD patients. Overweight and COPD severity may represent important characteristics for the magnitude of peripheral vascular response.

Effects of Zero PEEP and < 1.0 FIO2 on SpO2 and PETCO2 During Open Endotracheal Suctioning.

BACKGROUND: Hyperoxygenation and hyperinflation, preferably with a mechanical ventilator, is the most commonly used technique to prevent the adverse effects of open endotracheal suctioning on arterial oxygenation and pulmonary volume. However, limited data are available on the effects of oxygen concentrations < 100% and PEEP with zero end-expiratory pressure (0 PEEP) to improve oxygenation and to maintain adequate ventilation during open endotracheal suctioning. The aim of this study was to analyze the behavior of [Formula: see text] and end-tidal CO2 pressure ([Formula: see text]) in open endotracheal suctioning using the 0 PEEP technique with baseline [Formula: see text] (0 PEEP baseline [Formula: see text]) and 0 PEEP + hyperoxygenation of 20% above the baseline value (0 PEEP [Formula: see text] + 0.20) in critically ill subjects receiving mechanical ventilation. METHODS: This was a prospective, randomized, single-blind crossover study, for which 48 subjects with various clinical and surgical conditions were selected; of these, 38 subjects completed the study. The subjects were randomized for 2 interventions: 0 PEEP baseline [Formula: see text] and 0 PEEP [Formula: see text] + 0.20 during the open endotracheal suctioning procedure. Oxygenation was assessed via oxygen saturation as measured with pulse oximetry ([Formula: see text]), and changes in lung were monitored via [Formula: see text] using volumetric capnography. RESULTS: In the intragroup analysis with 0 PEEP baseline [Formula: see text], there was no significant increase after open endotracheal suctioning in either [Formula: see text] (P = .63) or [Formula: see text] (P = .11). With 0 PEEP [Formula: see text] + 0.20, there was a significant increase in [Formula: see text] (P < .001), with no significant changes in [Formula: see text] (P = .55). In the intergroup comparisons, there was a significant increase compared to the basal values only with the 0 PEEP + 0.20 method at 1 min after hyperoxygenation (P < .001), post-immediately (P < .001), at 1 min after (P < .001), and at 2 min after open endotracheal suctioning (P < .001). CONCLUSIONS: The appropriate indication of the hyperinflation strategy via mechanical ventilation using 0 PEEP with or without hyperoxygenation proved to be efficient to maintain [Formula: see text] and [Formula: see text] levels. These results suggest that the technique can minimize the loss of lung volume due to open endotracheal suctioning. (ClinicalTrials.gov registration NCT02440919).

Preclinical validation of occupational and environmental safety of an isolation system for noninvasive ventilation in COVID-19 and other aerosol-transmitted infections.

Background: The current SARS-CoV-2 pandemic has provoked the collapse of some health systems due to insufficient intensive care unit capacity. The use of continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) therapies has been limited in consideration of the risk of occupational infection in health-care professionals. Aims: In preclinical experimental simulations, evaluate occupational and environmental safety of the newly developed isolation system for aerosol-transmitted infections (ISATI). Method: Simulations were conducted to test ISATI's capability to isolate aerosolized molecular (caffeine), and biological (SARS-CoV-2 synthetic RNA) markers. Caffeine deposition was analyzed on nitrocellulose sensor discs by proton nuclear magnetic resonance spectroscopy. Synthetic SARS-CoV-2 detection was performed by reverse transcription-polymerase chain reaction. Results: ISATI demonstrated efficacy in isolating molecular and biological markers within the enclosed environment in simulated conditions of CPAP, HFNO and mechanical ventilation therapy. Neither the molecular marker nor substantial amounts of synthetic SARS-CoV-2 RNA were detected in the surrounding environment, outside ISATI, indicating appropriate occupational safety for health-care professionals. Conclusion: Aerosolized markers were successfully contained within ISATI in all experimental simulations, offering occupational and environmental protection against the dissemination of aerosolized microparticles under CPAP or HFNO therapy conditions, which are indicated for patients with acute respiratory infections.

Do London Chest Activity of Daily Living Scale and St George's Respiratory Questionnaire Reflect Limitations During Activities of Daily Living in Patients With COPD?

PURPOSE: It is unclear whether activities of daily living (ADL) and quality-of-life scales reflect real ADL limitations. The aim of the study was to assess the limitation during ADL simulation and to identify whether the London Chest Activity of Daily Living (LCADL) Scale and St George's Respiratory Questionnaire (SGRQ) are able to reflect the patient's real limitations during ADL simulation. METHODS: Forty-eight patients with chronic obstructive pulmonary disease (age = 69 ± 8 y; forced expiratory volume in the first second of expiration [FEV1] = 1.37 ± 0.49 L) were assessed by SGRQ and LCADL Scale. Activities of daily living simulations were performed: showering (ADL1); lifting and lowering containers above the shoulder girdle (ADL2); and raising and lowering pots below the pelvic girdle (ADL3). RESULTS: SpO2 and ΔSpO2 in ADL2 were statistically lower than in ADL3. Ventilatory demand was statistically higher in ADL2 and ADL3 than in ADL1. Metabolic equivalent values were similar between the ADLs with values above 3.6. Oxygen desaturation was present in 41.7% (ADL1) and 33.3% (ADL2) of the patients. The LCADL% showed a moderate positive correlation with dyspnea in ADL3 and metabolic demand in ADL1. The SGRQ score presented a moderate positive correlation with dyspnea in all ADL simulations and metabolic demand in ADL1 and ADL3. Dyspnea in ADL3 and metabolic demand in ADL1 explained 33% of the variability in LCADL%. The dyspnea and metabolic demand in ADL3 explained 67% of the variability in SGRQ. CONCLUSION: Activities of daily living lead to oxygen desaturation and high ventilatory demand. London Chest Activity of Daily Living Scale reflected 33% and SGRQ reflected 67% of the functional limitation during ADL simulation, such as dyspnea and the metabolic demand during ADL.

Cardiorespiratory repercussions according to the abdominal circumference measurement of men with obstructive respiratory disorder submitted to respiratory physiotherapy.

PURPOSE: To examine the effect of respiratory physiotherapy among men with obstructive respiratory disorder, in relation to abdominal circumference (AC). METHODS: Quasi-experimental study including 26 men split into two groups according to AC(cm): 1) < 102 (ACrisk-free); and 2) ≥ 102 (ACrisk). Heart rate variability (HRV), diastolic blood pressure (DBP), oxygen saturation (SpO2), FEV1/FVC, slow vital capacity (SVC), inspiratory capacity (IC), maximal inspiratory pressure (PImax), thoracoabdominal amplitude (AI) were measured: before (M1); 5 min after the physiotherapy (i.e. breathing exercises for airway clearance and active kinesiotherapy) (M2); and at follow-up, 30 min after physiotherapy (M3). RESULTS: The groups differed in age, body mass index and body fat %. At M2 IC was different between groups (ACrisk-free< ACrisk). There was an increase in HRV indexes, PImax, SpO2, axillary AI, FEV1/FVC, and reduction in HR for ACrisk-free. There was a decrease in AI and an increase in DBP for ACrisk. CONCLUSION: In men with obstructive respiratory disorder, increased AC measurement limited the thoracoabdominal expansibility and induced a rise of the DBP. Respiratory physiotherapy promotes an increase of cardiac modulation and inspiratory capacity for men with obstructive respiratory disorder.

Comparing the Effects of Two Different Levels of Hyperoxygenation on Gas Exchange During Open Endotracheal Suctioning: A Randomized Crossover Study.

BACKGROUND: Endotracheal suctioning is required for mechanically ventilated patients to maintain a patent airway. Studies show that open endotracheal suctioning affects respiratory mechanics and gas exchange. The aim of this study was to compare the effectiveness of hyperoxygenation with FIO2 + 0.20 above baseline and hyperoxygenation with FIO2 1.0 in preventing hypoxemia, and to determine the impact of open endotracheal suctioning on the pulmonary ventilation of critical subjects receiving mechanical ventilatory support. METHODS: This prospective randomized crossover study was conducted in the ICU. Sixty-eight mechanically ventilated subjects with FIO2 ≤ 0.6 and requiring endotracheal suctioning were included in this study. Open endotracheal suctioning was performed using 2 different intervention sequences: hyperoxygenation of 0.20 above baseline FIO2 (FIO2 + 0.20) and 1.0 hyperoxygenation (FIO2 1.0). Oxygenation was assessed via oxygen saturation as measured by pulse oximetry (SpO2 ), and changes in lung ventilation were measured via alveolar gas volume (V̇A), alveolar minute volume (V̇A min), carbon dioxide (CO2) production (V̇CO2 ), mixed exhaled partial pressure of CO2 (P̄ECO2 ), exhaled tidal CO2 volume (VTCO2), end-tidal CO2 (PETCO2 ), anatomical dead space to tidal volume ratio (VD/VT), and anatomical dead space volume of each breath (VD) using volumetric capnography, and breathing frequency (f), heart rate, and mean arterial pressure using a multiparameter monitor. RESULTS: SpO2 levels were significantly higher within interventions (FIO2 + 0.20 and 1.0) 1 min before and after suction. Also, there was a significant increase in PETCO2 , P̄ECO2 , heart rate, and mean arterial pressure immediately after the procedure compared with baseline, and in VTCO2, only for FIO2 + 0.20. Baseline values were not found to be significantly different between the groups in case of any dependent variable. CONCLUSIONS: In mechanically ventilated adult subjects, hyperoxygenation with FIO2 + 0.20 above baseline prevents hypoxemia. Also, transient changes in pulmonary ventilation with open circuit suctioning were confirmed by volumetric capnography analysis. (Trial registration: ClinicalTrials.gov NCT02440919).

Comparação de valores de PFE em uma amostra da população da cidade de São Carlos, São Paulo, com valores de referência / Comparison between PEF values obtained from a population sample in the city of São Carlos, Brazil, and reference values

OBJETIVO: Comparar os valores de referência para PFE sugeridos por outros autores em 1963, 1989 e 2001 (para populações nos EUA, na Inglaterra e em Cuba, respectivamente) com os valores de PFE coletados de uma amostra da população da cidade de São Carlos (SP), verificando se há concordância entre estes. MÉTODOS: Participaram do estudo 243 indivíduos (123 mulheres; 120 homens) na faixa etária entre 20 e 70 anos. A coleta de PFE foi realizada com o indivíduo em pé, utilizando um clipe nasal, através de medidor de PFE portátil. Os valores obtidos foram comparados com os previstos, utilizando-se o teste de Friedman e post hoc de Dunn (p < 0,05). RESULTADOS: Observou-se diferença significativa para todas as faixas etárias, em ambos os sexos, quanto aos valores previstos em 1989; o mesmo ocorreu para as faixas etárias 20-30, 31-40 anos, em ambos os sexos, e 61-70 anos para mulheres quanto aos valores de 2001, assim como para a faixa etária 20-30 anos para homens quanto aos valores previstos em 1963. CONCLUSÕES: Os valores previstos em 1963 são aceitáveis para uma população de indivíduos com as mesmas características da amostra estudada, exceto para os homens de 20-30 anos. Nosso estudo provou ter grande relevância devido ao tamanho da amostra estudada quando comparado ao do trabalho realizado em 1963. A maioria dos valores previstos em 1989 e 2001 superestimou os valores de PFE obtidos nesse estudo, indicando sua inadequação para a população estudada.

OBJECTIVE: To compare the reference values for PEF suggested by other authors in 1963, 1989 and 2001 (for populations in the USA, England and Cuba, respectively) with those obtained from a population sample in the city of São Carlos, Brazil, and to determine whether there is concordance among them. METHODS: A total of 243 volunteers (123 females and 120 males; 20-70 years of age) participated in the study. The PEF measurements were performed with the volunteer standing, using a nose clip, by means of a portable peak flow meter. These measurements were compared with the reference values using the Friedman test and Dunn's post-hoc test (p < 0.05). RESULTS: Significant differences were found in all age groups from both genders regarding the values predicted in 1989; the same occurred in the 20-30 and 31-40 age groups (both genders), as well as in the 61-70 age group (females only), regarding those predicted in 2001, as well as in the 20-30 age group (males only) regarding those predicted in 1963. CONCLUSIONS: The values predicted in 1963 are appropriate for a population of individuals with the same characteristics as the study sample, except for males in the 20-30 age group. Our study is relevant due to the fact that our sample was larger than that evaluated in the 1963 study. The majority of the values predicted in 1989 and 2001 overestimated the PFE values obtained in our study, proving to be inappropriate for the population studied.

Relationship of BODE Index to functional tests in chronic obstructive pulmonary disease

OBJECTIVE: To determine if there is a correlation between the BODE Index and variables assessed during the Activities of Daily Living assessment, performance on lower limber tests, and peripheral muscle impairment of the upper limb in patients with chronic obstructive pulmonary disease. MATERIALS AND METHODS: Ten men (aged 58 to 80 years old) with moderate to very severe obstruction were evaluated and classified by the BODE Index. They were evaluated by pulmonary ventilation (V•E), oxygen consumption (V•O2), and carbonic gas production (V•CO2) on the ADL assessment; Distance Walking (DW) in the Six Minute Walking Test (6MWT) and the Six Minute Walking Test on Treadmill (6MWTT); number of repetitions in the Sit-to-Stand Test; and the Hand Grip Strength Test. Correlations were evaluated between the classification and the tests performed (Pearson and Spearman test, p<0.05). RESULTS: The mean of the total score for the BODE Index was 2.80 (±1.03), with three patients scoring in the first quartile (Q1) and seven scoring in the second quartile (Q2). This Index showed a negative correlation with the 6MWTT (r=-0.86), the Sit-to-Stand Test (r=-0.66), and the Hand Grip Strength Test (r=-0.83). CONCLUSIONS: Our results show that there is no correlation between the BODE Index and the ventilatory and metabolic responses in the Activities of Daily Living assessment. On the other hand, a correlation was observed between the BODE Index and the variables assessed in the 6MWTT, Sit-to-Stand Test, and Hand Grip Strength Test in moderate to very severe Chronic Obstructive Pulmonary Disease patients. This suggests that these tests can be employed as predictors of physical exercise capacity, perhaps as complementary tests to the BODE Index.