Protocolos de rehabilitación y fisioterapia en pacientes afectados por COVID-19

La COVID-19 representa una emergencia internacional por los crecientes números de contagiados y fallecidos a nivel mundial. Los pacientes recuperados pueden sufrir afectaciones y secuelas respiratorias, cardiacas y neurológicas, lo que afecta su calidad de vida. El objetivo de este artículo consistió en reconstruir los protocolos de rehabilitación y fisioterapia respiratoria, cardiovascular, neurológica y neuromuscular para pacientes afectados por COVID-19, a partir de evidencias científicas reportadas. Para ello, se realizó una revisión bibliográfica en las principales bases de datos internacionales (PubMed, SciELO, Google Académico, ente otras). Para la búsqueda se utilizaron las palabras claves: COVID-19, síndrome de distrés respiratorio agudo, fisioterapia, rehabilitación respiratoria, Rehabilitación cardiovascular, rehabilitación neuromuscular y neurológica, en inglés y en español. Estos protocolos atribuyen mejorías significativas de las secuelas y en la calidad de vida de los pacientes. Se recomiendan ejercicios de fisioterapia respiratoria en posición decúbito-prono, entrenamiento de músculos inspiratorios, ejercicios aeróbicos y entrenamiento moderado de fuerza muscular. Los resultados de la aplicación de estos protocolos son satisfactorios en la recuperación de los pacientes.

A COVID-19 representa uma emergência internacional devido ao número crescente de pessoas infectadas e falecidas em todo o mundo. Os pacientes recuperados podem sofrer efeitos e sequelas respiratórias, cardíacas e neurológicas, o que afeta sua qualidade de vida. O objetivo deste artigo foi reconstruir os protocolos de reabilitação respiratória, cardiovascular, neurológica e neuromuscular e de fisioterapia para pacientes afetados pela COVID-19, com base em evidências científicas relatadas. Para tanto, foi realizada uma revisão bibliográfica nas principais bases de dados internacionais (PubMed, SciELO, Google Scholar, entre outras). As palavras-chave foram utilizadas para a busca: COVID-19, síndrome do desconforto respiratório agudo, fisioterapia, reabilitação respiratória, reabilitação cardiovascular, reabilitação neuromuscular e neurológica, nos idiomas inglês e espanhol. Esses protocolos atribuem melhorias significativas nas sequelas e na qualidade de vida dos pacientes. São recomendados exercícios de fisioterapia respiratória em posição prona, treinamento muscular inspiratório, exercícios aeróbicos e treinamento moderado de força muscular. Os resultados da aplicação desses protocolos são satisfatórios na recuperação dos pacientes.

The COVID-19 represents an international emergency due to the increasing numbers of infected and deceased people worldwide. Recovered patients may suffer respiratory, cardiac and neurological effects and sequelae, which affects their quality of life. The objective of this article was to reconstruct the respiratory, cardiovascular, neurological and neuromuscular rehabilitation and physiotherapy protocols for patients affected by COVID-19, based on reported scientific evidence. For it, a bibliographic review was carried out in the main international databases (PubMed, sciELO, Google Scholar, among others). The key words were used for the search: COVID-19, acute respiratory distress syndrome, physiotherapy, respiratory rehabilitation, cardiovascular rehabilitation, neuromuscular and neurological rehabilitation, in English and Spanish. These protocols attribute significant improvements in sequelae and in the quality of life of patients. Respiratory physiotherapy exercises in the prone position, inspiratory muscle training, aerobic exercises and moderate muscle strength training are recommended. The results of the application of these protocols are satisfactory in the recovery of patients.

Fisioterapia respiratoria en sujetos adultos cursando internación por neumonía adquirida en la comunidad. Revisión bibliográfica / Respiratory physiotherapy in adult subjects hospitalized for community-acquired pneumonia. Literature review

Introducción: La neumonía adquirida en la comunidad (NAC) es una infección respiratoria en la cual es frecuente observar la indicación de fisioterapia respiratoria (FR). Sin embargo, en la actualidad las recomendaciones respecto a su uso en NAC son controvertidas, no existiendo evidencia que respalde su uso y permita conocer su real alcance. Objetivos: Revisar la evidencia respecto al impacto de la FR en pacientes adultos que cursan internación por NAC. Resultados: 5 estudios cumplieron los criterios de inclusión de esta revisión. Las maniobras de FR incluyeron ejercicios respiratorios, drenaje postural, percusión, vibración, espirometría incentivada, resistencia espiratoria, asistencia torácica durante movimientos respiratorios, tos dirigida y presión positiva intermitente. En los estudios incluidos la FR no disminuyó la mortalidad ni mejoró los valores espirométricos en los pacientes con NAC, así como tampoco los días hasta la curación ni la estadía hospitalaria. Respecto a los costos, el uso de FR en pacientes con NAC presentó un incremento significativo de los mismos. Conclusión: No hay evidencia que respalde el uso de manera rutinaria de FR en los pacientes adultos con NAC. Consideramos que se requieren de futuras investigaciones que permitan conocer el impacto de la FR en pacientes adultos con NAC, así como establecer consensos respecto a su indicación, selección de maniobras, estandarización de técnicas, tiempos y dosificación.

Introduction: Community-acquired pneumonia (CAP) is a respiratory infection in which the indication for respiratory physiotherapy (RF) is frequently observed. However, currently the recommendations regarding its use in CAP are controversial, and there is no evidence to support its use and allow us to know its real scope. Objectives: To review the evidence regarding the impact of RF in adult patients who are hospitalized for CAP. Results: 5 studies met the inclusion criteria of this review. RF maneuvers included breathing exercises, postural drainage, percussion, vibration, incentive spirometry, expiratory resistance, chest support during respiratory movements, directed cough, and intermittent positive pressure. In the included studies, RF did not reduce mortality or improve spirometric values in patients with CAP, nor did it improve days to cure or hospital stay. Regarding costs, the use of RF in patients with CAP presented a significant increase in costs. Conclusion: There is no evidence to support the routine use of RF in adult patients with CAP. We believe that future research is required to determine the impact of RF in adult patients with CAP, as well as to establish consensus regarding its indication, selection of maneuvers, standardization of techniques, times, and dosage.

Fisioterapia respiratoria en sujetos adultos cursando internación por neumonía adquirida en la comunidad. Revisión bibliográfica

Introducción: La neumonía adquirida en la comunidad (NAC) es una infección respiratoria en la cual es frecuente observar la indicación de fisioterapia respiratoria (FR). Sin embargo, en la actualidad las recomendaciones respecto a su uso en NAC son controvertidas, no existiendo evidencia que respalde su uso y permita conocer su real alcance. Objetivos: Revisar la evidencia respecto al impacto de la FR en pacientes adultos que cursan internación por NAC. Resultados: 5 estudios cumplieron los criterios de inclusión de esta revisión. Las maniobras de FR incluyeron ejercicios respiratorios, drenaje postural, percusión, vibración, espirometría incentivada, resistencia espiratoria, asistencia torácica durante movimientos respiratorios, tos dirigida y presión positiva intermitente. En los estudios incluidos la FR no disminuyó la mortalidad ni mejoró los valores espirométricos en los pacientes con NAC, así como tampoco los días hasta la curación ni la estadía hospitalaria. Respecto a los costos, el uso de FR en pacientes con NAC presentó un incremento significativo de los mismos. Conclusión: No hay evidencia que respalde el uso de manera rutinaria de FR en los pacientes adultos con NAC. Consideramos que se requieren de futuras investigaciones que permitan conocer el impacto de la FR en pacientes adultos con NAC, así como establecer consensos respecto a su indicación, selección de maniobras, estandarización de técnicas, tiempos y dosificación.

Introduction: Community-acquired pneumonia (CAP) is a respiratory infection in which the indication for respiratory physiotherapy (RF) is frequently observed. However, currently the recommendations regarding its use in CAP are controversial, and there is no evidence to support its use and allow us to know its real scope. Objectives: To review the evidence regarding the impact of RF in adult patients who are hospitalized for CAP. Results: 5 studies met the inclusion criteria of this review. RF maneuvers included breathing exercises, postural drainage, percussion, vibration, incentive spirometry, expiratory resistance, chest support during respiratory movements, directed cough, and intermittent positive pressure. In the included studies, RF did not reduce mortality or improve spirometric values in patients with CAP, nor did it improve days to cure or hospital stay. Regarding costs, the use of RF in patients with CAP presented a significant increase in costs. Conclusion: There is no evidence to support the routine use of RF in adult patients with CAP. We believe that future research is required to determine the impact of RF in adult patients with CAP, as well as to establish consensus regarding its indication, selection of maneuvers, standardization of techniques, times, and dosage.

Development, and reliability and validity testing of a knowledge needs questionnaire of respiratory rehabilitation training for in-service healthcare workers / 中国康复理论与实践

ObjectiveTo develop a questionnaire on the knowledge needs of respiratory rehabilitation training for in-service healthcare workers, and test its reliability and validity. MethodsA theoretical framework was constructed based on the contents of the respiratory rehabilitation course modules of American Association of Cardiopulmonary Rehabilitation and American Association for Respiratory Care. The first draft of the questionnaire was prepared through literature searches and analyses, semi-structured interviews, and expert group discussions. The reliability and validity of the questionnaire was tested by interviewing 17 respiratory rehabilitation professionals and 16 respiratory rehabilitation experts by correspondence, and investigating 380 cases of in-service healthcare workers engaged in respiratory rehabilitation. ResultsThe knowledge needs questionnaire of respiratory rehabilitation training for in-service healthcare workers included progress in respiratory rehabilitation, physiological basis and diagnosis of chronic lung diseases, individualized assessment and management principles of chronic lung diseases, treatment of chronic lung diseases and guideline-recommended medications, oxygen therapy, exercise assessment and exercise prescription, tobacco addiction and cessation, nutritional assessment and weight management, psychological screening and intervention, self-management and health behavior promotion, and effectiveness assessment of respiratory rehabilitation, totaling eleven dimensions and 52 items. The total Cronbach's α was 0.921, the total folded half reliability was 0.904, the total retest reliability was 0.922, and the Cronbach's α of each dimension ranged from 0.909 to 0.953; the folded half reliabilities ranged from 0.882 to 0.924, and the retest reliabilities ranged from 0.908 to 0.950. The validity of the questionnaire's content was 0.902. In exploratory factor analysis, eleven metric factors were extracted, and their cumulative variance contribution rate was 75.324%. ConclusionThe questionnaire on the knowledge needs of respiratory rehabilitation training for in-service healthcare workers is reliable and valid, and can be used to assess the knowledge needs of healthcare workers participating in in-service training in respiratory rehabilitation.

Rehabilitation of a Patient with Severe COVID-19 Using Extracorporeal Membrane Oxygenation：A Case Report / The Japanese Journal of Rehabilitation Medicine

Coronavirus disease 2019 (COVID-19) has been spreading globally since 2019；however, comprehensive rehabilitation of elderly patients with COVID-19 pneumonia remains a challenge. A 76-year-old American woman with COVID-19 pneumonia was admitted to our hospital. Because her disease was complicated by acute respiratory distress syndrome (ARDS), she was treated with intensive care, including invasive ventilation and extracorporeal membrane oxygenation (ECMO). During and after intensive care, she exhibited physical symptoms such as weakness, pain, shortness of breath, and difficulty in movement and exercise. Furthermore, during approximately 3.5 months of hospitalization, she received swallowing and speech therapies along with physical therapy. These rehabilitation therapies enabled her to get home in the United States. Her rehabilitation schedule had to be carefully planned according to her symptoms and infectiousness of COVID-19. This paper highlights few important points regarding the difficulty in rehabilitation including that of physical function, mental health, and cognitive function of patients with COVID-19. Furthermore, this report provides a problem-solving approach for long-term rehabilitation in elderly patients with COVID-19 pneumonia.

Decanulación en Paciente Pediátrica con Enfermedad Neuromuscular: reporte de caso

RESUMEN La enfermedad de multiminicores es un trastorno neuromuscular hereditario caracterizado por la presencia de múltiples 'cores' en biopsia muscular y características clínicas de una miopatía congénita. El presente caso trata de una paciente de 10 años de edad, con diagnóstico de enfermedad neuromuscular multiminicores, traqueostomizada desde los 7 años de edad por destete fallido y debilidad muscular. La paciente fue derivada al Departamento de Rehabilitación Cardio-respiratoria del hospital de Clínicas de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción, presentando en su primera evaluación dependencia crónica de oxígeno (por más de 12 meses), tos débil y no funcional con flujo pico tosido e inferior a 160 L/m, insuficiencia respiratoria crónica e hipercapnia (53 mmHg de CO2ET). Durante su seguimiento en nuestro departamento fueron seguidas las pautas de Rehabilitación Respiratoria contempladas en el Proyecto de evaluación, tratamiento y seguimiento de pacientes con Enfermedades Neuromusculares, y aprobado por el Consejo Superior de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción, dichas pautas están fundamentadas en los estudios y publicaciones científicas del Dr. John Bach (Rudgers University, Newart, Nueva Jersey-EEUU) y su equipo colaborador del Grupo Iberoamericano de Cuidados Respiratorios en Enfermedades Neuromusculares. Como resultado final del tratamiento y seguimiento aplicado por más de un año la paciente fue decanulada exitosamente, en un consultorio para pacientes ambulatorios, sin descompensaciones hemodinámicas, con una excelente tolerancia y sin requerimiento de internaciones hospitalarias.

ABSTRACT Multiminicores disease is a hereditary neuromuscular disorder characterized by the presence of multiple 'nuclei' on muscle biopsy and clinical features of a congenital myopathy. The present case concerns a 10-year-old patient, diagnosed with multiminicores disease, tracheostomized since she was seven due to failed weaning and muscle weakness. The patient was referred to the Department of Cardio-respiratory Rehabilitation of the Clínicas Hospital from the National University of Asunción, presenting in her first evaluation chronic oxygen dependence (for more than 12 months), weak and non-functional cough with cough peak flow less than 160 L / m, chronic respiratory failure and hypercapnia (52 mmHg CO2ET). We did the follow-up in order to the Respiratory Rehabilitation guidelines contemplated in the Project for the evaluation, treatment and follow-up of patients with Neuromuscular Diseases, which was approved by the Superior Council of the Medical Sciences School from the National University of Asunción, these guidelines are based on scientific studies and publications done by Dr. John Bach (Rudgers University, Newart, New Jersey-USA) and his collaborating team from the Ibero-American Group for Respiratory Care in Neuromuscular Diseases. As a result, the patient was successfully decannulated, in an outpatient clinic, without hemodynamic decompensations, with excellent tolerance and without the requirement of hospital admissions.

Rehabilitación respiratoria para pacientes con distrofia muscular de Duchenne en etapas de pérdida de la marcha / Respiratory rehabilitation for patients with Duchenne muscular dystrophy in stages of loss of gait

Duchenne muscular dystrophy (DMD) is one of the most common neuromuscular diseases. Its evolution with well-defined stages related to motor and functional alterations, allows easily establishing relationships with respiratory function through a simple laboratory assessment including vital capacity (VC) measurements as well as peak cough flows. Without any treatment with respiratory rehabilitation, the main cause of morbidity and mortality is ventilatory failure, secondary to respiratory pump muscles weakness and inefficient cough. The VC plateau is reached during the non-ambulatory stages, generally after 13 years old. Respiratory rehabilitation protocols, including air stacking techniques, manual and mechanical assisted coughing and non-invasive ventilatory support, can effectively addressed the VC decline as well as the decrease in peak cough flows, despite advancing to stages with practically non-existent lung capacity. Non-invasive ventilatory support may be applied after 19 years old, initially at night and then extending it during the day. In this way, survival is prolonged, with good quality of life, avoiding ventilatory failure, endotracheal intubation and tracheostomy. This article proposes staggered interventions for respiratory rehabilitation based on the functional stages expected in the patient with DMD who has lost ambulation.

La distrofia muscular de Duchenne (DMD) es una de las enfermedades neuromusculares más frecuentes. Su curso evolutivo con etapas de declinación en la funcionalidad motora bien definidas, permite fácilmente establecer relaciones con la función respiratoria a través de un laboratorio de evaluación sencilla, básicamente de la capacidad vital (CV) y la capacidad tusígena. Sin intervenciones en rehabilitación respiratoria, la principal causa de morbimortalidad es la insuficiencia ventilatoria secundaria a debilidad de músculos de la bomba respiratoria e ineficiencia de la tos. En las etapas no ambulantes, se alcanza la meseta de la CV, generalmente después de los 13 años, su declinación junto con la disminución de la capacidad tusígena puede ser enfrentada efectivamente con la utilización de protocolos de rehabilitación respiratoria. Estos deben considerar la restitución de la CV con técnicas de insuflación activa o apilamiento de aire, tos asistida manual y mecánica, más soporte ventilatorio no invasivo, inicialmente nocturno después de los 19 años y luego diurno, pese a avanzar a etapas con capacidad pulmonar prácticamente inexistente. De esta manera, se prolonga la sobrevida, con buena calidad de vida, evitando el fallo ventilatorio, eventos de intubación endotraqueal y traqueostomía. Este artículo, hace propuestas escalonadas de intervención en rehabilitación respiratoria basadas en las etapas funcionales esperables en el paciente con DMD que ha perdido la capacidad de marcha.

Early respiratory rehabilitation for critically ill children with mechanical ventilation / 中国小儿急救医学

Objective@#To develop the early respiratory rehabilitation techniques in pediatric intensive care unit(PICU) for children with mechanical ventilation.@*Methods@#A respiratory rehabilitation team was established, and early respiratory rehabilitation intervention methods for critically ill children were also developed.Early bedside rehabilitation were implemented after the vital signs of mechanical ventilation children were stable for 24 hours, and the rehabilitation effect and adverse events were observed.@*Results@#According to the patient′s condition, 23 patients in PICU received early respiratory rehabilitation after incubations, including 10 males and 13 females, aged 57.0(17.5, 91.5) months.There was no adverse event in 729 rehabilitation practices.The average consulting time was 8.0(4.0, 18.0) days after incubations.The average incubation time was 693.5(345.2, 1 027.1)hours of all the patients.As to 16 patients who were weaned before charged out, the average incubation time was 566.2(243.4, 928.7)hours, and the average incubation time from respiratory rehabilitation performance to weaning was 168.0(6.0, 564.0) hours.In 19 patients who only received limbs massage and passive movements, the average incubation time was 381.7(309.6, 541.4) hours and the average incubation time from respiratory rehabilitation performance to weaning was 187.2(81.5, 382.9) hours.However the difference between these who received respiratory rehabilitation and only received limbs massage and passive movements was not statistically significant.@*Conclusion@#It′s safe and feasible to perform the early respiratory rehabilitation in PICU for critically ill children with mechanical ventilation.

Some Advice on Respiratory Rehabilitation for Coronavirus Disease 2019 / 中国康复理论与实践

At the end of 2019, coronavirus disease 2019 (COVID-19) caused by a new coronavirus SARS-CoV-2 spread rapidly. There is still no specific medicine for it. It is important to consider the functional improvement and rehabilitation. This article discussed on respiratory rehabilitation in management of patients with COVID-19.

Recomendaciones en rehabilitación respiratoria 2018: Sección Rehabilitación Respiratoria Asociación Argentina Medicina Respiratoria / Recommendations in Respiratory Rehabilitation 2018: Respiratory Rehabilitation Section Argentine Association of Respiratory Medicine

La Rehabilitación Respiratoria (RR), dirigida a las personas con enfermedad respiratoria crónica, reduce las exacerbaciones y hospitalizaciones, mejora los síntomas, la tolerancia al ejercicio y calidad de vida. Miembros de la Sección de RR de la Asociación Argentina de Medicina Respiratoria, se reunieron con el objetivo de preguntarse cuáles son los temas principales de controversia para dar respuesta desde la medicina basada en evidencia (sistema GRADE). Se eligieron diez preguntas. Resultados: La RR se debe indicar en pacientes con EPOC estadio GOLD 1 (1C). La adherencia es fundamental y se relaciona a sus beneficios (1C). La actividad física debe ser evaluada y estimulada (1B). Los beneficios de la RR dentro del mes posterior a una exacerbación de EPOC, reduce los síntomas y exacerbaciones y mejora la calidad de vida (1B). La RR está indicada en algunas enfermedades respiratorias crónicas no-EPOC (1B). Se deben indicar estrategias de entrenamiento especiales en desnutridos (3B) y obesos (3C). Los pacientes deben ser evaluados con prueba de ejercicio, escalas de disnea y calidad de vida (1A). El rol del entrenador de salud es novedoso ya que disminuye hospitalizaciones y mejora la calidad de vida (2C). Las comorbilidades afectan el resultado de la RR (3B). La RR reduce la mortalidad (1B) y la ansiedad-depresión (2B). La RR domiciliaria es efectiva (1A). La RR es fundamental en el tratamiento de enfermedades respiratorias crónicas. Se han actualizado las recomendaciones en RR en base a la evidencia científica con el objetivo que la RR pueda aplicarse en nuestro país.

Respiratory Rehabilitation (RR) is indicated in patients with chronic pulmonary diseases to reduce exacerbations and hospitalizations, and to improve symptoms, exercise tolerance and quality of life. Members of RR Section of the Asociación Argentina de Medicina Respiratoria, joined to review critical issues and controversies by an evidence-based system (GRADE). Ten questions were elected.213 Results: RR must be indicated in GOLD 1 COPD (1C). Adherence in RR is critical and related to benefits (1C). Physical activity must be evaluated and stimulated (1B). RR implemented after one month of COPD exacerbation hospitalization, reduces symptoms and exacerbations and improves quality of life(1B). RR is indicated in some no-COPD chronic respiratory diseases (1B). Special training strategies must be used in undernourished (3B) and obeses patients (3C). Exercise tests, dyspnea and quality of life questionnaires must be used to evaluate patients (1A). Health trainer is an original strategy to reduce hospitalizations and improve quality of life (2C). Comorbilities impacts on RR outcomes (3B). RR reduces mortality (1B) and ansiety-depression (2B). Domiciliary RR is efective (1A). RR is a key component of chronic pulmonary diseases treatment. Based in new scientific evidence, local recomendations have been done regarding to improve access in our country.

Central Hypoventilation Syndrome in Posterior Circulation Stroke Treated by Respiratory Rehabilitation: a Case Report

Central hypoventilation syndrome is a rare and fatal condition resulting from various central nervous system disorders that is characterized by a failure of automatic breathing. We report a case of central hypoventilation syndrome following posterior circulation stroke whose pulmonary function was improved by respiratory rehabilitation. A 59-year-old woman with a history of hemorrhagic stroke of the bilateral cerebellum was hospitalized due to pneumonia. A portable ventilator was applied via tracheostomy, recurrent episodes of apnea and hypercapnia impeded weaning. A respiratory rehabilitation program including chest wall range of motion exercise, air stacking exercise, neuromuscular electrical stimulation (NMES) on abdominal muscles, upper extremity ergometer, locomotor training, high-frequency chest wall oscillator, mechanical insufflation, and exsufflation was employed, as spirometry showed a severe restrictive pattern. A spontaneous breathing trial was started, and a portable ventilator was applied for 8 hours, only during nighttime, to prevent sudden apneic event. After 4 weeks of treatment, follow-up spirometry showed much improved respiratory parameters. This case suggests that respiratory rehabilitation can improve pulmonary function parameters and quality of life in central hypoventilation syndrome.

Research of the respiratory rehabilitation and TCM exercises combined with conventional western medicine therapy on the lung function for the patients with COPD / 国际中医中药杂志

Objective@#To observe the effect of the respiratory rehabilitation and TCM exercises combined with conventional western medicine therapy for the patients with COPD.@*Methods@#A total of 84 patients with COPD were randomized into the control group and observation group, 42 in each group. The control group were treated with conventional Western medicine treatment, and the observation group was treated with traditional Chinese exercises "sixth tactic" treatment on the basis of control group treatment. All patients were taken one year course of treatment. The changes in lung function, AECOPD occurrence, changes in symptom scores, Hamilton heart questionnaire integration were observed; and possible changes in the factors affecting the efficacy was analyzed by Logistic regression.@*Results@#There were not significant differences in FEV1, FEV1/FVC, PEF and SpO2 between the two groups before treatment. After 1 year of treatment, the FEV1 (1.58 ± 0.21 L vs.1.33 ± 0.22 L, t=8.092), FEV1/FVC (82.92% ± 8.42% vs. 62.81% ± 8.94%, t=10.013), PEF (358.27 ± 27.03 L/min vs. 324.13 ± 32.03, t=6.272), SpO2 (99.58% ± 2.72% vs. 91.92% ± 2.89%, t=10.142) in the observation group were significantly higher than those in the control group (P<0.05). After treatment, Chinese medicine syndrome scores (6.3 ± 2.2 vs. 9.2 ± 2.0, t=4.652), HAMA score (6.0 ± 1.7 vs. 9.0 ± 2.0, t=4.563), HAMD score (6.1 ± 2.0 vs. 8.7 ± 1.7, t=5.094) in the observation group were superior to the subcontrol group (P<0.05). Regression analysis showed that there was a linear correlation between patient group, course of disease and outcome effect (P<0.05).@*Conclusions@#The respiratory rehabilitation and traditional Chinese medicine exercises "sixth tactic" combined with conventional treatment could release anxiety, depression and negative emotions, and improve clinical symptoms of the patients with COPD.

Rehabilitación respiratoria y exacerbaciones de EPOC: ¿una utopía hecha realidad? / Respiratory Rehabilitation and COPD Exacerbations: Does a Utopia Come True?

La exacerbación de EPOC está asociada a empeoramiento de la calidad de vida, de síntomas y actividad física, lo que provoca deterioro acelerado de la función pulmonar, incremento de la morbi-mortalidad. La reducción de la actividad física está asociada a disfunción muscular esquelética, especialmente de los miembros inferiores y ha sido asociada como factor independiente de riesgo de mortalidad y mayor deterioro acelerado de la función pulmonar. Por otra parte, el entrenamiento físico, parte medular de un programa de rehabilitación respiratoria (RR), es una intervención fundamental en el manejo del paciente con EPOC estable. Es objetivo de las guías GOLD la prevención de las exacerbaciones, su temprana detección y el tratamiento adecuado. Este artículo revisa la evidencia científica publicada de estudios de diseño adecuados en la prevención de las exacerbaciones en la EPOC por la RR, su beneficio como complemento del tratamiento agudo y el impacto si es aplicado inmediatamente post-exacerbación. La RR es una estrategia reconocida como prevención de las exacerbaciones de EPOC (Recomendación 1A). Existe fuerte evidencia que sostiene implementar el entrenamiento dentro del mes post-exacerbación de EPOC (Recomendación 1B) con mejoría de síntomas, de la tolerancia al ejercicio y calidad de vida. La aplicación de entrenamiento durante una exacerbación de EPOC (hospitalizada o no) debe seguir siendo estudiada ya que el nivel de evidencia es intermedio y su recomendación es por ahora débil (Recomendación 2C).

Exacerbations of COPD are associated with worsening of quality of life, symptoms and physical activity, and therefore with accelerated deterioration of the lung function and increased morbidity and mortality. The reduced physical activity is associated with skeletal muscle dysfunction, especially in the lower limbs and has been associated as an independent risk factor for increased mortality and accelerated decline in lung function. Moreover, physical training, a core part of a respiratory rehabilitation program (RR) is a key intervention in the management of patients with stable COPD. Objectives of the GOLD guidelines are prevention, early detection and adequate treatment of exacerbations. This article reviews the published scientific evidence of appropriately designed studies on preventing COPD exacerbations through RR, its benefits as a complement of acute treatment and the impact if it is prescribed immediately after an exacerbation. RR is a recognized strategy for the prevention of COPD exacerbations (Recommendation 1A). There is strong evidence supporting the implementation of training within one month after a COPD exacerbation (Recommendation 1B) as measured through the improvement of symptoms, exercise tolerance and quality of life. Training during a COPD exacerbation (hospitalized or not) has to be further studied because the evidence shows an intermediate level and the current recommendation is weak (Recommendation 2C).

Rehabilitación respiratoria en pacientes EPOC: experiencia en Atención Primaria de Salud / Respiratory rehabilitation in COPD patients: Experience in a rural Primary Health Care Center

Respiratory rehabilitation improves physical capacity and quality of life in COPD patients as it has been previously reported. In Chile there are few and unpublished experiences on respiratory rehabilitation programs (RRP) implemented in primary health care (PHC). Our aim was to evaluate RRP outcome in COPD patients carried out in a rural PHC center. Methods: A prospective descriptive study of RRP in a PHC center implemented in Talagante (a village located 40 km from Santiago). COPD patients were enrolled in the study from July 2012 to May 2014. Patients having the inclusion criteria were admitted to a 12 weeks-long RPP This program included a 90 minute-long sessions of aerobic training (walking), strength training of upper and lower limbs (dumbbell, ankle support and elastic bands) and respiratory muscle training (threshold valve), twice a week. Quality of life, strength of trained muscles, six-minutes walking test (TM6), BODE index and dyspnea index, were measured before and after completing RRP Results were expressed as mean ± SD. Results: Out of 79 patients initially assessed, 54 were admitted to the RRP and 39 patients completed the program and were included in the analysis. Their mean age was 67.3 ± 8.5 years, 64% were female. In average BMI was 26.97 ± 4.3 kg/m², and FEVi was 1.17 ± 0.57 liters. We demonstrated a statistically significant improvement after RRP in 6-minute walk test (445.9 ± 77.9 m versus 498.2 ± 82.8 m, p < 0.001); Saint George’s Respiratory Questionnaire score (45.1 ± 16.1 versus 18.5 ± 11.5, p < 0.0001), PIMax (48.95 ± 18.8 versus 57.2 ± 19.4 cm H2O, p < 0.0001), BODE index (2.76 ± 1.37 versus 1.53 ± 1.0, p < 0.0001), and mMRC dyspnea scale (2.54 ± 0.75 versus 1.18 ± 0.56, p < 0.0001). Conclusions: Our results are consistent with those reported in the literature, demonstrating that COPD patients get beneficial effects with the respiratory rehabilitation program. We also showed that RRP can be implemented in primary health care using simple tools, with reasonable costs.

La rehabilitación respiratoria ha demostrado beneficios en mejorar la capacidad física y calidad de vida en los pacientes con EPOC. Sin embargo, en Chile no existe información de programas de rehabilitación respiratoria (PRR) en la atención primaria de salud. El objetivo de nuestro trabajo fue evaluar los resultados de la implementación de un programa de rehabilitación respiratoria (PRR) en pacientes con EPOC en la atención primaria de salud. Material y Método: Estudio prospectivo descriptivo realizado en un centro de salud familiar de Talagante en pacientes con diagnóstico confirmado de EPOC, durante el período julio de 2012 a mayo de 2014. Fueron ingresados al PRR, de 12 semanas de duración, aquellos pacientes que cumplían los criterios de inclusión. Se realizó entrenamiento aeróbico (caminata), entrenamiento de fuerza de extremidades superiores e inferiores (mancuernas, tobilleras y bandas elásticas) y entrenamiento de musculatura respiratoria (válvula umbral), 2 veces por semana y de 90 min de duración cada sesión. Al iniciar y al finalizar el PRR se evaluó: calidad de vida, fuerza muscular, test de marcha de 6 min (TM6); índice BODE y disnea. Resultados: De un total de 79 pacientes con EPOC evaluados, 54 ingresaron al PRR y 39 finalizaron el programa. La edad promedio fue 67,3 ± 8,5 años, 64% de género femenino, índice de masa corporal: 26,97 ± 4,3 kg/m² y VEF1 1,17 ± 0,57 L. Al comparar los valores iniciales y finales del PRR se encontraron diferencias estadísticamente significativas en: TM6 (445,9 ± 77,9 vs 498,2 ± 82,8 m, p < 0,001); Puntaje del cuestionario de St. George (45,1 ± 16,1 vs 18,5 ± 11,5, p < 0,0001), PIMáx 48,95 ± 18,8 vs 57,2 ± 19,4 cm H2O, p < 0,0001), índice BODE (2,76 ± 1,37 vs 1,53 ± 1,0, p < 0,0001), y escala de disnea mMRC (2,54 ± 0,75 vs 1,18 ± 0,56, p < 0,0001). Conclusiones: Los resultados de nuestro estudio son concordantes con lo descrito en la literatura y demuestran los beneficios significativos obtenidos con la rehabilitación respiratoria en pacientes con EPOC. También, se demuestra que en Chile se puede implementar un PRR en la atención primaria utilizando implementos simples y con un bajo costo.

Enfermedad pulmonar obstructiva crónica entrenamiento domiciliario versus ambulatorio hospitalario

Existe poca experiencia sobre el efecto del entrenamiento domiciliario (rD) en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). El objetivo de este trabajo fue comparar el efecto del rD sobre la tolerancia al ejercicio, disnea y calidad de vida versus el entrenamiento ambulatorio hospitalario (rH). Se compararon dos grupos de pacientes con EPOC. Ambos entrenaron durante 24 sesiones, 8 semanas. Antes y después del entrenamiento se realizaron: espirometría, cuestionarios de disnea (MRC, Mahler y Borg) y calidad de vida (St. George y SF-36), pruebas de ejercicio submáximas (caminata 6 minutos, shuttle de resistencia y resistencia en cicloergómetro -tiempo límite-Tlim) y máximas (shutlle test-ST- y cardiopulmonar). El grupo rH realizó ejercicios aeróbicos y de fuerza para miembros inferiores (MI) y superiores (MS). El grupo rD realizó caminatas al 70% de la velocidad alcanzada en ST y ejercicios de fuerza para MI y MS. Se aleatorizaron 25 rH y 25 rD. La condición basal fue similar en ambos grupos. El Tlim aumentó 125% (p = 0.0001) para grupo rH y 63% (p = 0.0011) para rD, sin diferencias entre sí. También mejoraron distancia en shuttle resistencia (77%, p = 0.0421 en grupo rH y 79%, p = 0.0197 en rD) y distancia en prueba 6 minutos (12% en rD, p = 0.0135). El puntaje en cuestionario St. George se redujo solo en el grupo rH (p = 0.0034); en el rD abandonaron 32% vs. 20% en el rH (p = 0.4521). El entrenamiento domiciliario resultó tan eficaz como el ambulatorio hospitalario en pacientes con EPOC, aunque con mayor tendencia al abandono.

There is little experience on the effect of home training (rD) in patients with chronic obstructive pulmonary disease (COPD). Our aim was to compare the effect of rD on exercise tolerance, dyspnea and quality of life versus hospital outpatient training (rH). Two random groups of 25 patients were evaluated. Both trained during 8 weeks (24 sessions); undergoing various tests before and after, such as spirometry, questionnaires on dyspnea (MRC, Mahler and Borg) and on quality of life (SF-36 and St.George´s), submaximal (6 minutes’ walk, resistance-shuttle and cycle-ergometer endurance time limit, (Tlim), and - maximal exercise tests (shuttle -ST- and cardiopulmonary test). The rH group performed aerobic and strength for lower limbs (MI) and upper (MS) exercises. The rD group performed walks at 70% of the speed reached in ST and strength exercises for MI and MS. The basal condition was similar in both groups. The Tlim increased, 125% (p = 0.0001) for rH group and 63% (p = 0.0011) for rD, showing no significant differences. They also improved distance in shuttle resistance (77%, p = 0.0421 in rH and 79 %, p = 0.0197 in rD group) and in 6 minutes´ test (12% in rD, p = 0.0135). St George scoring was reduced only in the rH group (p = 0.0034); 32% abandoned in rD vs. 20% in rH (p = 0.4521). Effectiveness in rD training was equal to rH for COPD patients, although rD were more likely to abandon the program.

Adherencia a un programa interdisciplinario de rehabilitación respiratoria / Adherence to interdisciplinary pulmonary rehabilitation program

La participación en un Programa de Rehabilitación Respiratoria (PRR) mejora la disnea, la capacidad funcional y la calidad de vida en pacientes con enfermedad respiratoria crónica. Sin embargo, la adherencia a PRR suele ser baja. Se realizó un estudio retrospectivo con el objetivo de identificar variables relacionadas con la adherencia a un PRR ambulatorio en un centro de la Argentina y secundariamente evaluar los resultados en quienes adhirieron. El PRR incluyó una etapa de "adquisición" que consistió en 16 semanas de entrenamiento físico supervisado, dos veces por semana, y clases sobre los beneficios del tratamiento, el uso de los dispositivos de inhalación, cesación tabáquica, reconocimiento de síntomas y manejo de las exacerbaciones, entre otros. Al finalizar el entrenamiento los pacientes fueron re-evaluados. Se consideró "adherencia al PRR" cuando el paciente completó la etapa de adquisición. De 388 pacientes que iniciaron la primera evaluación, 102 (26.3%) adhirieron al PRR. Se utilizó regresión logística múltiple (Forward Stepwise con ingreso de variables con p < 0.10) para identificar factores relacionados con "adherencia al programa". El modelo final fue el siguiente: poseer obra social (OR = 3.99; IC90% = 2.24-7.12), tiempo de viaje al hospital menor de 60 minutos (OR = 2.07; IC90% = 1.37-3.11) e ingreso económico disponible (OR = 2.11; IC90% = 1.03-4.31). Los pacientes que adhirieron al PRR presentaron mejoría significativa en la prueba de marcha de 6 minutos y en la calidad de vida. Los resultados alertan sobre la baja adherencia y su relación con las variables socioeconómicas.

Participation in a Pulmonary Rehabilitation Program (PRP) improves dyspnea, functional capacity and quality of life in patients with chronic respiratory disease. A retrospective study was carried out to identify variables related to compliance in an out patient PRP at an Argentine center and to evaluate the results in compliant patients. The PRP included an "acquisition" stage consisting of 16 weeks of supervised training twice weekly and lectures on treatment benefits, inhalation devices used, smoking cessation, symptoms recognition and flair up management, among others. Patients were reassessed after this stage. Patients completing the acquisition stage were considered PRP compliant. Of 388 patients evaluated for admission 102 (26.3%) complied with PRP. Multiple logistic regression analysis (Forward Stepwise; p < 0.10 to be eligible for entry into the model) was used to identify factors related to "program compliance". The final model was as follows: having health insurance coverage (OR = 3.99; CI90% = 2.24-7.12), commute time under 60minutes (OR = 2.07; CI90% = 1.37-3.11) and financial capacity (OR = 2.11; CI90% = 1.03-4.31). All patients complied with the PRP showed significant improvement in the six-minute walking test and quality of life. The results warn about low compliance and their relationship with socioeconomic variables.

Consenso Chileno de rehabilitación respiratoria en el paciente con epoc: introducción / Consensus of respiratory rehabilitation in chronic obstructive pulmonary disease patients: introduction

In Chile and the world, the chronic obstructive pulmonary disease (COPD) is a problem of public health, due to its high prevalence, its progressive condition, the deterioration of the quality of life and its great economic impact. The respiratory rehabilitation (RR) is a multidisciplinary treatment and in COPD patients allows to control the vicious circle that limits the capacity of exercise in these patients. The aims of the RR are: to reduce the symptoms, to improve the tolerance to the physical exercise and the quality of life. We sense beforehand the first Chilean Consensus of Respiratory Rehabilitation in COPD patients. These guides have to aim that the RR could apply to them in the whole country, so much in hospitals and in the primary care. For the elaboration of this document, a group ofpulmonary physicians, physical therapists, nurses, nutritionists and psychologists carried out a systematic analysis of the scientific available evidence until December, 2010. The evidence was analyzed according to the system GRADE (Grading of Recommendations Assessment, Development and Evaluation) modified. This consensus is divided into chapters which analyze in depth each one of the topics of the RR. These include the pathophysiology, evaluation and programs, muscle training of lower and upper extremities and inspiratory muscle training, supplemmental oxygen, noninvasive ventilation, education, nutrition, psychological aspects and cost-efficiency.

En Chile y el mundo, la enfermedad pulmonar obstructiva crónica (EPOC) es un problema de salud pública, debido a su alta prevalencia, su condición progresiva, el deterioro de la calidad de vida y el gran impacto económico. La rehabilitación respiratoria (RR) es un tratamiento multidisciplinario y en los pacientes con EPOC permite intervenir el círculo vicioso que limita la capacidad de ejercicio en estos pacientes. Los objetivos de la RR son: reducir los síntomas, mejorar la tolerancia al ejercicio físico y la calidad de vida. Presentamos el primer Consenso Chileno de Rehabilitación Respiratoria en pacientes con EPOC. Estas guías tienen por objetivo que la RR pueda aplicarse en todo el país, tanto en hospitales como en la atención primaria. Para la elaboración de este documento, un grupo de neumonólogos, kinesiólogos, enfermeras, nutricionistas y psicólogos realizó un análisis sistemático de la evidencia científica disponible hasta diciembre de 20l0. La evidencia fue analizada según el sistema GRADE (Grading of Recommendations Assessment, Development and Evaluation) modificado. El consenso se dividió en capítulos los cuales analizan en profundidad cada uno de los tópicos de la RR. Estos incluyen fisiopatologia, evaluación y programas, entrenamiento muscular de: extremidades inferiores, superiores y musculatura inspiratoria, oxígenoterapia, ventilación no invasiva, educación, nutrición, aspectos psicológicos y costo-efectividad.

Entrenamiento muscular de las extremidades inferiores en el paciente con enfermedad pulmonar obstructiva crónica / Lower extremity exercise training in the rehabilitation of patients with chronic obstructive pulmonary disease

Several studies have shown that poor exercise tolerance in Chronic Obstructive Pulmonary Disease (COPD) patients is multifactorial in origin. However, a major exercise-limiting factor in COPD is peripheral muscle dysfunction, particularly the muscles of the lower extremities, characterized by atrophic muscles and reduced fatigue resistance due to morphological and metabolic alterations of peripheral muscles. This chapter therefore evaluated the scientific evidence regarding the beneficial effect of lower extremities exercise in the pulmonary rehabilitation in COPD patients. The technical characteristics of this exercise training were also reviewed. Exercise training of lower limbs was recommended in respiratory rehabilitation of COPD patients. The lower extremities muscle exercise training provides significant benefits to patients with COPD in terms of reduction of dyspnea and improvemet in exercise capacity and in quality of life (quality level of evidence = A, strong recommendation). Higher-intensity exercise training and with interval exercise of the lower extrmities produces greater physiological benefits.

Diversos estudios han demostrado que la pobre tolerancia al ejercicio de los pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) es de origen multifactorial. Sin embargo, un importante factor limitante del ejercicio en los pacientes con EPOC es la disfunción muscular periférica, sobre todo de los músculos de las extremidades inferiores, que se caracteriza por atrofia muscular y reducida resistencia a la fatiga dado por alteraciones morfológicas y metabólicas de los músculos periféricos. En este capitulo se evaluó la evidencia científica que existe en cuanto a los beneficios del entrenamiento muscular de extremidades inferiores (EEII) en la rehabilitación respiratoria en pacientes con EPOC. También se revisan las características técnicas de dicho entrenamiento. Se recomienda la realización de entrenamiento muscular de EEII en rehabilitación respiratoria de pacientes con EPOC. El entrenamiento muscular de extremidades inferiores otorga significativos beneficios a los pacientes con EPOC en cuanto a disminuir la disnea, mejorar la capacidad de ejercicio y la calidad de vida (calidad de la evidencia A, recomendación fuerte). El entrenamiento de EEII de alta intensidad y con intervalos produce significativos beneficios fisiológicos.

Entrenamiento de las extremidades superiores en el paciente con enfermedad pulmonar obstructiva crónica / Upper extremity exercise training in the rehabilitation of patients with chronic obstructive pulmonary disease

In patients with chronic obstructive pulmonary disease (COPD) showed a reduction in force generating capacity of the muscle groups of the upper extremities (UE) and the chest wall compared with healthy subjects. Also, there is evidence that the exercise of the UE is associated with significant metabolic and ventilatory cost, this is particularly evident in patients with moderate and severe COPD. Clinically, patients have a significant increase in dyspnea and fatigue for simple activities of daily life.This chapter therefore evaluated the scientific evidence regarding the beneficial effect of upper extremities exercise in the pulmonary rehabilitation in COPD patients. The technical characteristics of this exercise training were also reviewed. Exercise training of upper extremities was recommended in respiratory rehabilitation of COPD patients as it improves exercise capacity, reducing ventilation and oxygen consumption (quality evidence B, moderate strength recommendation). Exercise training of upper extremities can be associated with lower limb muscle training to obtain every better result for patients. Upper extremities exercises can be done without support, with incremental or constant load.

En los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) se observa una reducción de la capacidad de generación de fuerza de los grupos musculares de las extremidades superiores (EESS) y de la pared torácica comparado con sujetos sanos. Existen evidencias que el ejercicio de las EESS se asocia a un significativo costo metabólico y ventilatorio que es particularmente evidente en los pacientes con EPOC moderada a severa. Clínicamente, estos pacientes tienen disnea y fatiga con actividades sencillas de la vida diaria. En este capitulo se evaluó la evidencia científica que existe en cuanto a los beneficios del entrenamiento muscular de EESS en la rehabilitación respiratoria en pacientes con EPOC. Las características técnicas de dicho entrenamiento también fueron revisadas. Se recomendó la realización de entrenamiento muscular de EESS en la rehabilitación respiratoria de pacientes con EPOC, por cuanto mejora la capacidad de ejercicio, reduce la ventilación y el consumo de oxígeno (calidad de la evidencia: B, fuerza de la recomendación: moderada). El entrenamiento muscular de EESS puede ser asociado al entrenamiento muscular de extremidades inferiores por cuanto se obtienen mejores resultados para el paciente. Los ejercicios de EESS pueden realizarse sin apoyo, con carga incremental o carga constante.

Oxígenoterapia y rehabilitación respiratoria en el paciente con enfermedad pulmonar obstructiva crónica / Oxygen therapy and pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) often have severe shortness of breath that prevents them from performing their everyday activities. Pulmonary rehabilitation programs improve capacity exercise, decrease breathlessness and enhance quality of life. In addition, the use of oxygen has been demonstrated to reduce ventilatory demand and to induce improvements in metabolism, muscle function, and cardiovascular function. The combination of exercise training and supplemental oxygen may provide additional benefit. This chapter therefore evaluated the scientific evidence regarding the beneficial effect of supplemental oxygen in the pulmonary rehabilitation of patients with COPD. Supplemental oxygen should be recommended in all COPD patients with resting hypoxemia during rehabilitative exercise training (quality evidence A, strong recommendation). Also, in COPD patients without resting hypoxemia was recommended to use supplemental oxygen during respiratory rehabilitation, because it allows a longer time of exercise and reduces dyspnea (quality evidence B, weak recommendation).

Los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) a menudo tienen dificultad respiratoria severa que les impide realizar sus actividades cotidianas. Los programas de rehabilitación pulmonar mejoran la capacidad de ejercicio, disminuyen la disnea y mejoran la calidad de vida. En adición, el uso de oxígeno ha demostrado una reducción de la demanda ventilatoria y mejorías en el metabolismo, la función muscular y la función cardiovascular. La combinación de entrenamiento muscular y suplemento de oxígeno puede proporcionar un beneficio adicional. En este capitulo se evaluó la evidencia científica que existe en cuanto al beneficio del uso del suplemento de oxigeno en la rehabilitación respiratoria en pacientes con EPOC. Se recomendó el uso de suplemento de oxígeno en todo paciente con EPOC e hipoxemia de reposo durante el entrenamiento muscular (calidad de la evidencia A, recomendación fuerte). Así también, en los pacientes con EPOC y sin hipoxemia de reposo se recomienda utilizar suplemento de oxígeno durante la rehabilitación respiratoria, porque permite tolerar durante mayor tiempo el entrenamiento muscular y reduce la disnea (calidad de la evidencia B, recomendación débil).