Enhanced endoplasmic reticulum RyR1 receptor phosphorylation leads to diaphragmatic dysfunction in septic rats / 南方医科大学学报

OBJECTIVE@#To explore the role of endoplasmic reticulum ryanodine receptor 1 (RyR1) expression and phosphorylation in sepsis- induced diaphragm dysfunction.@*METHODS@#Thirty SPF male SD rats were randomized equally into 5 groups, including a sham-operated group, 3 sepsis model groups observed at 6, 12, or 24 h following cecal ligation and perforation (CLP; CLP-6h, CLP-12h, and CLP-24h groups, respectively), and a CLP-24h group with a single intraperitoneal injection of KN- 93 immediately after the operation (CLP-24h+KN-93 group). At the indicated time points, diaphragm samples were collected for measurement of compound muscle action potential (CMAP), fatigue index of the isolated diaphragm and fitted frequencycontraction curves. The protein expression levels of CaMK Ⅱ, RyR1 and P-RyR1 in the diaphragm were detected using Western blotting.@*RESULTS@#In the rat models of sepsis, the amplitude of diaphragm CMAP decreased and its duration increased with time following CLP, and the changes were the most obvious at 24 h and significantly attenuated by KN-93 treatment (P < 0.05). The diaphragm fatigue index increased progressively following CLP (P < 0.05) irrespective of KN- 93 treatment (P>0.05). The frequency-contraction curve of the diaphragm muscle decreased progressively following CLP, and was significantly lower in CLP-24 h group than in CLP-24 h+KN-93 group (P < 0.05). Compared with that in the sham-operated group, RyR1 expression level in the diaphragm was significantly lowered at 24 h (P < 0.05) but not at 6 or 12 following CLP, irrespective of KN-93 treatment; The expression level of P-RyR1 increased gradually with time after CLP, and was significantly lowered by KN-93 treatment at 24 h following CLP (P < 0.05). The expression level of CaMKⅡ increased significantly at 24 h following CLP, and was obviously lowered by KN-93 treatment (P < 0.05).@*CONCLUSION@#Sepsis causes diaphragmatic dysfunction by enhancing CaMK Ⅱ expression and RyR1 receptor phosphorylation in the endoplasmic reticulum of the diaphragm.

Feasibility of a single-port thoracoscopy-assisted five-step laparoscopic procedure via transabdominal diaphragmatic approach for No.111 lymphadenectomy in patients with Siewert type II esophageal gastric junction adenocarcinoma / 中华胃肠外科杂志

Objective: We aimed to explore the feasibility of a single-port thoracoscopy- assisted five-step laparoscopic procedure via transabdominal diaphragmatic(TD) approach(abbreviated as five-step maneuver) for No.111 lymphadenectomy in patients with Siewert type II esophageal gastric junction adenocarcinoma (AEG). Methods: This was a descriptive case series study. The inclusion criteria were as follows: (1) age 18-80 years; (2) diagnosis of Siewert type II AEG; (3) clinical tumor stage cT2-4aNanyM0; (4) meeting indications of the transthoracic single-port assisted laparoscopic five-step procedure incorporating lower mediastinal lymph node dissection via a TD approach; (5) Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1; and (6) American Society of Anesthesiologists classification I, II, or III. The exclusion criteria included previous esophageal or gastric surgery, other cancers within the previous 5 years, pregnancy or lactation, and serious medical conditions. We retrospectively collected and analyzed the clinical data of 17 patients (age [mean ± SD], [63.6±11.9] years; and 12 men) who met the inclusion criteria in the Guangdong Provincial Hospital of Chinese Medicine from January 2022 to September 2022. No.111 lymphadenectomy was performed using five-step maneuver as follows: superior to the diaphragm, starting caudad to the pericardium, along the direction of the cardio-phrenic angle and ending at the upper part of the cardio-phrenic angle, right to the right pleura and left to the fibrous pericardium , completely exposing the cardio-phrenic angle. The primary outcome includes the numbers of harvested and of positive No.111 lymph nodes. Results: Seventeen patients (3 proximal gastrectomy and 14 total gastrectomy) had undergone the five-step maneuver including lower mediastinal lymphadenectomy without conversion to laparotomy or thoracotomy and all had achieved R0 resection with no perioperative deaths. The total operative time was (268.2±32.9) minutes, and the lower mediastinal lymph node dissection time was (34.0±6.0) minutes. The median estimated blood loss was 50 (20-350) ml. A median of 7 (2-17) mediastinal lymph nodes and 2(0-6) No. 111 lymph nodes were harvested. No. 111 lymph node metastasis was identified in 1 patient. The time to first flatus occurred 3 (2-4) days postoperatively and thoracic drainage was used for 7 (4-15) days. The median postoperative hospital stay was 9 (6-16) days. One patient had a chylous fistula that resolved with conservative treatment. No serious complications occurred in any patient. Conclusion: The single-port thoracoscopy-assisted five-step laparoscopic procedure via a TD approach can facilitate No. 111 lymphadenectomy with few complications.

Respiratory muscle strength should be continuously monitored for patients on mechanical ventilation / 中华危重病急救医学

Mechanical ventilation (MV) is an effective treatment for respiratory failure. In recent years, it has been found that MV can not only cause ventilation-associated lung injury (VALI), but also cause ventilation-induced diaphragmatic dysfunction (VIDD). Although the injury site and etiology are not the same, they are interrelated and mutually causal, and eventually lead to weaning failure. Studies have indicated that diaphragmatic function protection strategy should be implemented in patients on MV. That is, the entire process from assessing the ability of spontaneous breathing before MV, to the initiation of spontaneous breathing and to weaning during MV. For patients on MV, continuous monitoring of respiratory muscle strength should be conducted. Early prevention, early intervention and timely detection of VIDD may reduce the occurrence of difficult weaning, resulting in improved prognosis. This study mainly discussed the risk factors and pathogenesis of VIDD.

Incidencia de parálisis diafragmática secundaria a bloqueo supraclavicular de plexo braquial medida por ecografía en una institución de cuarto nivel / Incidence of Diaphragmatic Paralysis Secondary to Supraclavicular Brachial Plexus Blockade Measured by Ultrasound in a Fourth Level Institution / Incidência de paralisia diafragmática secundária ao bloqueio supraclavicular do plexo braquial medida por ultrassonografia em uma instituição de quarto nivel

Introducción. La anestesia regional es una técnica importante, innovadora y popular para el manejo anestésico y analgésico. En el bloqueo supraclavicular del plexo braquial existe incidencia 50-60% de parálisis diafragmática. La presentación clínica es variable de acuerdo con factores externos e internos del paciente. Existen múltiples técnicas radiológicas en el diagnóstico, siendo de gran utilidad la ecografía por su fácil acceso. El objetivo es determinar la incidencia de parálisis diafragmática secundaria a bloqueo supraclavicular del plexo braquial guiado por ecografía en una institución de cuarto nivel. Metodología. Estudio analítico, longitudinal, prospectivo; se seleccionaron 110 pacientes. Criterios de inclusión: pacientes mayores de 18 años sometidos a cirugía de miembro superior con bloqueo supraclavicular de plexo braquial. Criterios exclusión: pacientes ASA (American Society of anesthesiologist) 4 y 5, gestantes, IMC >35 kg/m2, pacientes con antecedentes neuromusculares, enfermedad pulmonar restrictiva u obstructiva, parálisis nervio frénico o disfunción diafragmática. Se realizó un análisis mediante test estadísticos, describiendo los diferentes grados de parálisis diafragmática. Resultados. En los pacientes que cumplieron con los criterios de inclusión, la incidencia de parálisis diafragmática fue de 65% (37% parálisis total y 28% parcial), el 1.81% presentó síntomas respiratorios sin cambios hemodinámicos. Discusión. El bloqueo del plexo braquial por vía supraclavicular es una técnica relacionada con parálisis diafragmática, la ecografía ha permitido reducir la incidencia de esta complicación, es un método útil en el diagnóstico postoperatorio. Conclusiones. La parálisis diafragmática post bloqueo plexo braquial supraclavicular es una complicación observada principalmente en pacientes con previo compromiso pulmonar, por lo cual es de importancia la vigilancia estricta.

Introduction. Regional anesthesia is an important, innovative, and popular technique for anesthetic and painkiller management. In supraclavicular brachial plexus blockade, there is a 50-60% rate of diaphragmatic paralysis. Clinical presentation is variable according to the patient's internal and external factors. There are multiple radiological techniques in diagnosis, with ultrasounds being very useful due to their easy access. The objective is to determine the incidence of diaphragmatic paralysis secondary to supraclavicular brachial plexus blockade guided by ultrasound in a fourth level institution. Methodology. Prospective, longitudinal, analytical study. 110 patients were selected. Inclusion criteria: patients over 18 years of age subject to upper limb surgery with supraclavicular brachial plexus blockade. Exclusion criteria: ASA (American Society of Anesthesiologists) 4 and 5 patients, pregnant women BMI >35 kg/m2 patients with neuromuscular background, restrictive or obstructive pulmonary disease, phrenic nerve paralysis, or diaphragmatic dysfunction. An analysis was carried out via statistical tests, describing the different degrees of diaphragmatic paralysis. Results. In patients who met the inclusion criteria, the incidence of diaphragmatic paralysis was 65% (37% with total and 28% with partial paralysis), 1.81% showed respiratory symptoms without hemodynamic changes. Discussion. Supraclavicular brachial plexus blockade is a technique related to diaphragmatic paralysis. Ultrasound has allowed for the incidence of this complication to be reduced. It is a useful method in post-operative diagnosis. Conclusions. Diaphragmatic paralysis after supraclavicular brachial plexus blockade is a complication mainly observed in patients with previous pulmonary problems. Therefore, it must be strictly monitored.

Introdução. A anestesia regional é uma técnica importante, inovadora e popular para o manejo anestésico e analgésico. No bloqueio supraclavicular do plexo braquial há uma incidência de 50-60% de paralisia diafragmática. A apresentação clínica é variável de acordo com fatores externos e internos do paciente. Existem múltiplas técnicas radiológicas no diagnóstico, sendo a ultrassonografia muito útil devido ao seu fácil acesso. O objetivo é determinar a incidência de paralisia diafragmática secundária ao bloqueio supraclavicular do plexo braquial guiado por ultrassom em uma instituição de quarto nível. Metodologia. Estudo analítico, longitudinal, prospectivo; 110 pacientes foram selecionados. Critérios de inclusão: pacientes maiores de 18 anos submetidos à cirurgia de membro superior com bloqueio supraclavicular do plexo braquial. Critérios de exclusão: pacientes ASA (American Anesthesiology Society) 4 e 5, gestantes, IMC>35 kg/m2 pacientes com história neuromuscular, doença pulmonar restritiva ou obstrutiva, paralisia do nervo frênico ou disfunção diafragmática. Foi realizada uma análise por meio de testes estatísticos, descrevendo os diferentes graus de paralisia diafragmática. Resultados. Nos pacientes que atenderam aos critérios de inclusão, a incidência de paralisia diafragmática foi de 65% (37% paralisia total e 28% parcial), 1.81% apresentavam sintomas respiratórios sem alterações hemodinâmicas. Discussão. O bloqueio do plexo braquial supraclavicular é uma técnica relacionada à paralisia diafragmática, a ultrassonografia tem reduzido a incidência dessa complicação e é um método útil no diagnóstico pós-operatório. Conclusões. A paralisia diafragmática após bloqueio do plexo braquial supraclavicular é uma complicação observada principalmente em pacientes com envolvimento pulmonar prévio, pelo que é importante vigilância rigorosa.

Tumor fibroso solitario gigante de pleura / Giant solitary fibrous tumor of the Pleura

Resumen Objetivo: Reportar el caso de una masa gigante en hemitórax izquierdo de 19 cm de diámetro en un paciente de 59 años que debutó con disnea, tos y dolor torácico, confirmándose por estudio imagenológico. Materiales y Método: Registro clínico de un paciente al cual se le diagnostica tumor fibroso solitario de pleura, siendo intervenido quirúrgicamente para exéresis de la lesión. Resultados: Se realiza toracotomía posterolateral izquierda para exéresis de tumor gigante, requiriendo además, resección de diafragma y pericardiectomía parcial con evolución favorable. Discusión: El tumor fibroso solitario es una neoplasia rara derivada del mesénquima que afecta más comúnmente a la pleura, típicamente bien circunscrita, pediculada, con vasos dentro del pedículo tumoral, pudiendo llegar a ser de gran tamaño, siendo considerados gigantes cuando tienen más de 15 cm de diámetro. Conclusión: El diagnóstico correcto es de vital importancia, ya que con la resección quirúrgica es potencialmente curable. El tratamiento quirúrgico puede efectuarse por toracotomía o videotoracoscopia, dependiendo del tamaño del tumor. A pesar del comportamiento benigno, requiere seguimiento a largo plazo debido a la tendencia a la recidiva.

Aim: To report the case of a 19 cm diameter giant mass in the left hemithorax in a 59-year-old patient who presented with dyspnea, cough and chest pain, confirmed by imaging study. Materials and Method: Clinical record of a patient who was diagnosed with a solitary fibrous tumor of the pleura, undergoing surgery to excise the lesion. Results: A left posterolateral thoracotomy was performed to excise the giant tumor, also requiring resection of the diaphragm and partial pericardiectomy with favorable evolution. Discussion: The solitary fibrous tumor is a rare neoplasm derived from the mesenchyme that most commonly affects the pleura, typically well circumscribed, pedunculated, with vessels within the tumor pedicle, and can become large, being considered giant when they are larger than 15 cm diameter. Conclusión: The correct diagnosis is of vital importance, since surgical resection it a potentially curable treatment. Surgical treatment can be performed by thoracotomy or videothoracoscopy, depending on the size of the tumor. Despite the benign behavior, it requires long-term follow-up due to the tendency to recur.

Postura, mobilidade diafragmática e função pulmonar em crianças e adolescentes obesos Autores Patrícia Clara Pereira dos Santos / Posture, diaphragmatic mobility and pulmonary function in obese children and adolescents

Introdução: A sobrecarga corporal devida à obesidade contribui no surgimento de alterações no sistema musculoesquelético e respiratório. Objetivo: Analisar as evidências científicas referentes à influência da obesidade sobre a postura do tronco, a resposta cinético-funcional do diafragma e a função pulmonar em crianças e adolescentes. Métodos: Trata-se de uma revisão de literatura, utilizando as bases de dados Medline, Cochrane, Embase, Lilacs e Web of Sciences, nos idiomas inglês, português e espanhol, nos últimos 10 anos. Foram utilizados os descritores: "obesidade', "postura", "diafragma", "função pulmonar", "adolescentes", "adultos jovens". Os critérios de exclusão foram: estudos que abordaram distúrbios neuromusculares associados, cifoescoliose, fibrose cística, enfisema pulmonar, asma e DPOC e artigos não disponíveis na íntegra. Resultados: Foram identificados 226 estudos, porém 10 foram analisados. Os resultados apontaram que a postura do tronco nos obesos é hipercifótica, hiperlordótica e com anteversão pélvica, além de apontar indícios de repercussão na dinâmica respiratória, com redução da mobilidade do diafragma e dos volumes e capacidades pulmonares. Conclusão: A obesidade contribui para a ocorrência de hipercifose, hiperlordose e anteversão da pelve, bem como na diminuição da atividade do diafragma e função pulmonar. (AU)

Ultrasound assessment of diaphragm thickness in athletes / Evaluación por ultrasonido del grosor del diafragma en atletas

SUMMARY: The main purpose of this study was to examine the correlation between the aerobic and anaerobic performance of diaphragm thickness in athletes. That study was conducted with 15 team athletes (TA) (age 21.80 ± 2.40 years), 15 individual athletes (IA) (age 18.93 ± 2.31 years) and the control group (CON) 10 people living sedentary lifestyles (age 23.60 ± 2.91 years). In this study, diaphragm muscle thickness (B-mode ultrasonography), respiratory function (spirometry and maximum inspiratory (MIP) and expiratory pressures (MEP), aerobic capacity yo-yo intermittent endurance Test 1 (YYIET-1), and anaerobic power by Monark 834 E were assessed. The diaphragm thickness was determined from the intercostalspace between the 8th and 9th ribs at the expiration time by ultrasound and from the intercostal space between the 10th and 11th ribs at inspiration and then, the thickness of the diaphragm was measured from the diaphragm is seen best. There was a positive correlation between DiTins (r= 0.477) and DiTins-ex (r= 0.473) parameters of TA. In IA, there was a significant correlation between DiTins and DiTins-ex parameters and Peak Power (r= 0.495 and 0.435, respectively) and average power (r= 0.483 and 0.446, respectively). No significant correlation in all parameters of the CON group (p<0.05). As a result, it was determined that athletes with high diaphragm thickness had higher anaerobic performance, and athletes with thinner diaphragm thickness had better VO2Max capacity. The diaphragm thickness of the athletes in individual branches was thicker than the team athletes, and their anaerobic performance was also higher.

RESUMEN: El objetivo principal de este estudio fue examinar la correlación entre el rendimiento aeróbico y anaeróbico del grosor del diaframa en atletas. Dicho estudio se realizó con 15 deportistas de equipo (TA) (edad 21,80 ± 2,40 años), 15 deportistas individuales (IA) (edad 18,93 ± 2,31 años) y el grupo control (CON) 10 personas con sedentarismo (edad 23,60 ± 2,91 años). Se midió, el grosor del diaframa (ultrasonografía en modo B), la función respiratoria (espirometría y presiones máximas inspiratorias (MIP) y espiratorias (MEP), prueba de resistencia intermitente yo- yo de capacidad aeróbica 1 (YYIET-1) y resistencia anaeróbica potencia por Monark 834 E. El grosor del diafragma se determinó a partir del espacio intercostal entre las costillas 8 y 9 en el momento de la espiración por ultrasonido y del espacio intercostal entre las costillas 10 y 11 en la inspiración. Hubo una correlación positiva entre los parámetros DiT ins (r= 0,477) y DiTins-ex (r= 0,473) de TA. En IA, hubo una correlación significativa entre los parámetros DiTins y DiTins-ex y el pico Potencia (r= 0,495 y 0,435, respectivamente) y potencia media (r= 0,483 y 0,446, respectivamente). No hubo correlación significativa en todos los parámetros del grupo CON (p<0,05). Como resultado, se determinó que los atletas con mayor espesor del diaframa tenían un mayor rendimiento anaeróbico, y los atletas con menor espesor del diaframa tenían una mejor capacidad de VO2Max. El grosor del diafragma de los atletas en ramas individuales fue mayor que el de los atletas de equipo, y su rendimiento anaeróbico también fue mayor.

Hernia diafragmática: Un desafío diagnóstico / Diaphragmatic Hernia: A Diagnostic Challenge

Introducción: La hernia diafragmática traumática es una complicación grave del traumatismo abdominal o torácico. Se considera una entidad poco frecuente. El diagnóstico es difícil y, a menudo, puede pasar inadvertido. Objetivo: El propósito de este caso clínico es demostrar la necesidad de sospechar la presencia de hernia diafragmática en los pacientes con trauma toracoabdomial. Presentación del Caso: Paciente de 75 años que sufre accidente de tránsito, con evaluación inicial sin alteraciones clínico-radiológicas, que posteriormente presentan evolución desfavorable con hallazgo radiográfico de una hernia diafragmática traumática. Conclusiones: La hernia diafragmática cuando se presenta constituye un verdadero reto para el diagnóstico por parte del personal médico; pues esta requiere de un alto índice de sospecha y el uso adecuado de las imágenes diagnósticas. Se considera una entidad importante para la evaluación del paciente traumatizado(AU)

Introduction: Traumatic diaphragmatic hernia is a serious complication of abdominal or thoracic trauma. It is considered a rare pathology. The diagnosis is difficult and can often go unnoticed. Objective: The purpose of this clinical case is to demonstrate the need to suspect the presence of diaphragmatic hernia in patients with thoracoabdomial trauma. Case Presentation: Seventy-five-year-old patient who suffers a traffic accident. At initial evaluation no clinical-radiological alterations were observed, but later the patient presented an unfavorable evolution with radiographic finding of a traumatic diaphragmatic hernia. Conclusions: Diaphragmatic hernia, when present, is a real challenge for the diagnosis by the medical staff since it requires a high index of suspicion and an adequate use of diagnostic images. It is considered an important entity in the evaluation of the trauma patient(AU)

Bilateral diaphragmatic paralysis and Lyme neuroborreliosis. Ten-years of follow-up / Parálisis diafragmática bilateral y neuroborreliosis de Lyme. Diez años de seguimiento

Abstract Borrelia burgdorferi infection (Lyme disease) is one of the few identifiable causes of neuralgic amyotrophy (AN). Bilateral diaphragmatic paralysis is considered rare in borreliosis, and the pattern of long-term recovery of diaphragm function is also uncertain. Transdiaphragmatic pressure is the gold standard for diagnosing bilateral diaphragmatic paralysis, a study that has been reported on a few occasions. We pres ent a case of AN associated with borrelia infection and bilateral diaphragmatic paralysis that provides a detailed follow-up of the spirometric evolution, the maximum static pressures in the mouth, and the transdiaphragmatic pressure from the onset of symptoms and in the long term. This case allows us to know one of the possible evolutionary profiles of diaphragmatic dysfunction in AN due to borreliosis.

Resumen La infección por Borrelia burgdorferi (enfermedad de Lyme) es una de las pocas causas identificables de amiotrofia neurálgica. La parálisis diafragmática bilateral es considerada rara en la borreliosis y el patrón de recuperación a largo plazo de la función del diafragma también es incierto. La presión transdiafragmática es el patrón de oro para el diagnóstico de parálisis diafragmática bilateral, un estudio que ha sido informado en pocas ocasiones. Se presenta un caso de amiotrofia neurálgica asociado a infección por Borrelia y parálisis diafrag mática bilateral, que aporta un seguimiento detallado de la evolución espirométrica, de las presiones estáticas máximas en la boca y de la presión transdiafragmática desde el inicio de los síntomas y a largo plazo. Este caso permite conocer uno de los posibles perfiles evolutivos de la disfunción diafragmática en la amiotrofia neurálgica por borreliosis.

Eficácia da liberação do músculo iliopsoas sobre os parâmetros respiratórios em pacientes com dor lombar crônica: um protocolo de ensaio clínico controlado randomizado único cego, dois grupos, pré-teste/pós-teste / Efficacy of iliopsoas muscle release on respiratory parameters in patients with chronic low back pain: a single blinded, two- groups, pre-test/post-test randomized controlled trial protocol

OBJETIVO: Iliopsoas e o músculodiafragma compartilham fixação comum nas vértebras L2, a contração do iliopsoas pode levar à redução da excursão do diafragma levando à dificuldade respiratória. Portanto, o presente estudo controlado fornecerá evidências sobre o efeito da liberação do músculo iliopsoas na melhoria da eficiência respiratória em pacientes com dor lombar crônica. MÉTODO / DESENHO: Um total de trinta e quatro participantes com lombalgia crônica mecânica lombar crônica devido à rigidez dos flexores do quadril, dor lombar crônica e dificuldade respiratória serão recrutados com base nos critérios de seleção e serão alocados aleatoriamente em dois grupos, Grupo A (tratamento conservador + liberação miofascial iliopsoas), Grupo B (tratamento conservador + tratamento simulado). Ambos os grupos receberão a intervenção três vezes por semana durante 3 semanas. As medidas de resultado serão o Questionário de Incapacidade de Roland Morris, a Escala Numérica de Avaliação da Dor e a Capacidade de Difusão do Pulmão, pois o monóxido de carbono será usado como medidas de resultado. DISCUSSÃO: Este estudo ajudará a identificar a eficácia da liberação de iliopsoas na dor lombar e seu efeito nos parâmetros respiratórios. REGISTRO DO ENSAIO: Este ensaio foi registrado prospectivamente em cliniclatrials.gov (CTRI / 2020/04/024661), em 16 de abril de 2020.

BACKGROUND AND PURPOSE: Iliopsoas and diaphragm muscle share common attachment at L2 vertebrae, iliopsoas tightness may lead to reduce diaphragm excursion leading to breathing difficulty. Therefore, the present controlled trial will provide evidence on the effect of the iliopsoas muscle release in upgrading respiratory efficiency in patients with chronic low back pain. METHOD/DESIGN: A total of thirty-four participants with mechanical chronic low back pain due to hip flexor tightness and having breathing difficulty will be recruited based on selection criteria. It will be randomly allocated into Group A (conservative treatment + iliopsoas myofascial release), Group B (conservative treatment + sham treatment). Both the group will receive the intervention three times a week for three weeks. The outcome measures will be the Roland Morris Disability Questionnaire, Numeric Pain Rating Scale, and diffuse capacity of Lung for Carbon monoxide as outcome measures. DISCUSSION: This trial will help identify the effectiveness of iliopsoas release in low back pain and its effect on respiratory parameters. TRIAL REGISTRATION: This trial has been prospectively registered at cliniclatrials.gov (CTRI/2020/04/024661) on 16 April 2020.

Fisiología respiratoria: fisiología de los músculos de la respiración / Physiology of the respiratory muscles

La respiración es un proceso continuo donde los músculos respiratorios tienen un rol central e imprescindible para la vida. Su óptimo funcionamiento involucra diversas estructuras que deben funcionar de forma armónica y coordinada, para que el gasto energético asociado a sus demandas permita aumentos considerables de carga sin afectar mayormente la función esencial de intercambio gaseoso. Comprender la fisiología muscular, desde la base anatómica hasta su comportamiento en el ejercicio y la enfermedad, es fundamental para detectar con anticipación las diversas disfunciones que se producen cuando este equilibrio se descompensa. El objetivo de esta revisión es entregar las bases fisiológicas del comportamiento de la musculatura respiratoria que permitan comprender y aplicar las mejores estrategias de evaluación y tratamiento, cuando la función normal se ve alterada, ya sea por enfermedad, desuso o altas cargas asociadas al ejercicio físico.

Breathing is a continuous process where the respiratory muscles have a central and essential role for life. Its optimal operation involves various structures that must work in a harmonious and coordinated way, so that the energy expenditure associated with their demands allows considerable increases in load without significantly affecting the essential function of gas exchange. Understanding muscle physiology, from the anatomical basis to its behavior in exercise and disease, is essential to anticipate the various dysfunctions that can occur when this balance is decompensated. The objective of this review is to provide physiological bases for the behavior of the respiratory muscles that allow understanding and applying the best evaluation and treatment strategies, when its correct functioning is altered, either due to illness, disuse or high loads associated with physical exercise.

Carga respiratória em obesos e jovens asmáticos: um estudo da cinética diafragmática / Respiratory burden in obese and young asthmatics: a study of diaphragmatic kinetics

RESUMO Objetivo O objetivo deste estudo foi avaliar a cinética diafragmática, a função respiratória e a dosagem sérica de leptina e citocinas inflamatórias (IL-6 e TNF-α) em três grupos clínicos: obeso, asmático e saudável. Métodos Estudo clínico-exploratório realizado com 73 jovens (12-24 anos, sendo 42,5% do sexo masculino) alocados em três grupos: obesidade (GO, n = 33), índice de massa corporal (IMC z-score) ≥ + 2 e asmáticos leves controlados (GA, n = 26), classificados pela GINA, e grupo controle saudável (GC, n = 14). Os participantes foram submetidos à ultrassonografia diafragmática, espirometria, pressão respiratória máxima, níveis séricos de leptina e níveis de IL-6 e TNF-α em hemocultura total. Resultados A espessura do diafragma foi maior no GO em comparação ao GA e GC (2,0 ± 0,4 vs 1,7 ± 0,5 e 1,6 ± 0,2, respectivamente, com p < 0,05). A ventilação voluntária máxima (VVM) foi significativamente menor no GO e GA em relação ao GC (82,8 ± 21,4 e 72,5 ± 21,2 vs 102,8 ± 27,3, respectivamente, com p < 0,05). O GO tem a maior taxa de leptina entre todos os grupos (com os outros dois grupos, p < 0,05). Os três grupos tinham níveis semelhantes de TNF-α e IL-6. Conclusão A hipertrofia muscular encontrada no diafragma de indivíduos obesos pode ser justificada pelo aumento do trabalho respiratório imposto pela condição crônica da doença. Esse aumento de espessura não ocorreu em asmáticos leves controlados. Os marcadores IL-6 e TNF-α não detectaram evidências de inflamação muscular, embora fosse esperado que a leptina estivesse alterada em indivíduos obesos. Pacientes obesos e asmáticos apresentaram menor resistência pulmonar do que os saudáveis.

ABSTRACT Objective The aim of this study was to assess the diaphragm kinetics, respiratory function, and serum dosage of leptin and inflammatory cytokines (IL-6 and TNF-α) in three clinical groups: obese, asthmatic, and healthy. Methods This is a clinical exploratory study performed on 73 youths (12-24 years of age, 42.5% male) allocated into three groups: obesity (OG, n=33), body mass index (BMIz-score) ≥ +2, asthmatic (AG, n=26) controlled mild asthmatics, classified by GINA, and Healthy Control Group (CG, n=14). The participants were subjected to diaphragmatic ultrasound, spirometry, maximal respiratory pressure, serum leptin levels, and IL-6 and TNF-α whole blood cell culture levels. Results Diaphragm thickness was higher in OG in comparison to AG and CG (2.0±0.4 vs 1.7±0.5 and 1.6±0.2, both with p<0.05). Maximal voluntary ventilation (MVV) was significantly lower in OG and AG in relation to the CG (82.8±21.4 and 72.5±21.2 vs 102.8±27.3, both with p<0.05). OG has the highest leptin rate among the groups (with the other two groups had p<0.05). All groups had similar TNF-α and IL-6 levels. Conclusion The muscular hypertrophy found in the diaphragm of the obese individuals can be justified by the increase in respiratory work imposed by the chronic condition of the disease. Such increase in thickness did not occur in controlled mild asthmatics. The IL-6 and TNF-α markers detected no evidence of muscle inflammation, even though leptin was expected to be altered in obese individuals. Both obese and asthmatic patients had lower pulmonary resistance than the healthy ones.

Effect of acupuncture on diaphragmatic function in patients with AECOPD typeⅡ respiratory failure evaluated by ultrasound detection / 中国针灸

OBJECTIVE@#To observe the therapeutic effect of acupuncture combined with western conventional therapy on type Ⅱ respiratory failure of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and evaluate the effect of acupuncture on diaphragmatic function and prognosis by bedside ultrasound.@*METHODS@#A total of 111 patients with AECOPD type Ⅱ respiratory failure were randomized into an acupuncture group, a conventional treatment group and a non-acupoint acupuncture group, 37 cases in each one. The routine AECOPD nursing care and treatment with western medicine were provided in the 3 groups. Additionally, in the acupuncture group, acupuncture was applied at Dingchuan (EX-B 1), Feishu (BL 13), Taiyuan (LU 9), Danzhong (CV 17) and Zhongwan (CV 12), etc. In the non-acupoint acupuncture group, acupuncture was given at the points 5 to 10 mm lateral to each of the acupoints selected in the acupuncture group. Acupuncture was given once every day, 30 min each time, consecutively for 10 days in the above two groups. Separately, before treatment, on day 3, 7 and 10 of treatment, arterial partial pressure of oxygen (PaO@*RESULTS@#On day 3, 7 and 10 of treatment, PaO@*CONCLUSION@#Acupuncture as adjunctive therapy achieves significant therapeutic effect on AECOPD type Ⅱ respiratory failure. It improves diaphragmatic function, promotes oxygenation and relieves carbon dioxide retention of artery, alleviates clinical symptoms and reduces the time of mechanic ventilation and hospitalization. Besides, the bedside ultrasound detection can objectively reflect the effect of acupuncture on diaphragmatic function in the patients with AECOPD complicated with typeⅡrespiratory failure.

Feasibility of Perioperative Diaphragmatic Ultrasound in Assessment of Residual Neuromuscular Blockade / 中国医学科学院学报

Objective To evaluate the relationship between diaphragmatic ultrasound and postoperative residual neuromuscular blockade(PRNB). Methods The patients undergoing non-thoracic and abdominal surgery under general anesthesia from August to October in 2019 were randomly enrolled from Peking Union Medical College Hospital.Diaphragmatic ultrasound was acquired pre-operation and post extubation.A 4-15 MHz probe was used to measure diaphragmatic thickness at the intersection point of 8-9 intercostal space with right anterior axillary line at the end of inspiration and expiration during quiet breathing and deep breathing(DB),and the diaphragmatic thickness fraction(DTF)was calculated.A 1-5 MHz probe was used to measure diaphragmatic excursion(DE)at the intersection point of right costal margin with midaxillary line during quiet breathing and DB.Train of four ratio(TOFr)was recorded for neuromuscular monitoring.TOFr,observer assessment of alertness and sedation score at extubation,Aldrete score at postanesthesia care unit,and postoperative pulmonary complication were recorded. Results The PRNB rate was 54.7%.The DTF-DB [31.3(21.1,45.0)vs.38.5(26.6,53.9),P=0.045] and DE-DB(2.9±1.4 vs.4.1±1.0,P<0.001)in PRNB group was lower than those in the group without PRNB.DTF-DB(r=0.351,P=0.002)and DE-DB(r=0.580,P<0.001)were correlated with TOFr. Conclusion Perioperative diaphragmatic ultrasound may be helpful for the diagnosis of PRNB.

El diafragma, el hiato y la unión gastroesofágica / The diaphragm, the hiatus and the gastroesophageal junction

RESUMEN La unión del tubo esofágico con el estómago en lo que denominamos el cardias, su tránsito y relacio nes con el hiato diafragmático, las estructuras fibromembranosas que la fijan y envuelven, la existencia de un esfínter gastroesofágico anatómico y su real morfología, así como la interacción de todos estos elementos, han sido materia de controversia por décadas y aún hoy. Este artículo actualiza la descrip ción de tales estructuras.

ABSTRACT The point where the esophagus connects to the stomach, known as the cardia, its transition and re lationship with the diaphragmatic hiatus, its fibromembranous attachments, the existence of an ana tomic gastroesophageal sphincter and its real morphology, and the interaction between all these ele ments, have been subject of debate for decades that still persist. The aim of this article is to describe the updated information of such structures.

Avaliação manual da mobilidade e tonicidade diafragmática em cantores líricos profissionais e não-cantores / Manual evaluation of mobility and diaphragmatic tonicity in professional lyrical singers and non-singers

Introdução: Durante sua carreira o cantor lírico sofre grande demanda e consequente alteração da coordenação dos músculos respiratórios, porém não se sabe se estas exigências podem alterar a mobilidade e tonicidade no principal músculo da respiração, o diafragma. Objetivos: Avaliar e comparar a tonicidade e a mobilidade do diafragma de cantores líricos profissionais e de não-cantores. Participaram do estudo 15 cantores líricos profissionais em plena carreira e 24 adultos não-cantores com idades e IMCs equivalentes. Métodos: Duas avaliações foram empregadas: para avaliar a mobilidade costal foi utilizada a parte referente a avaliação desse parâmetro da Manual Evaluation of the Diaphragm Scale (MED Scale); para avaliar a tonicidade diafragmática a avaliação descrita por Rial e Pinsach em 2015. Resultados: Os resultados mostraram que a distribuição da avaliação manual do diafragma no grupo dos cantores apresentou distribuição significativamente diferente, tendo p < 0,05, com relação à tonicidade bilateral do diafragma, apresentando maior hipertonicidade em relação ao grupo controle, e que não houve diferenças significativas em relação à mobilidade. Conclusão: Os gestos artísticos usados pelos cantores líricos profissionais afetam a tonicidade do diafragma. (AU)

Introduction: The professional lyrical singers during their careers suffer great demand and consequent alteration of the coordination of the respiratory muscles, however it is not known if these requirements can alter the mobility and tonicity in the main muscle of the breath, the diaphragm. Objectives: To evaluate and compare diaphragm tonicity and mobility of professional lyric singers and non-singers. The study included 15 professional lyric singers in their full careers and 24 non-singing adults of equivalent ages and BMIs. Methods: Two forms of manual evaluation of the diaphragm were used: to assess costal mobility, the part of the manual evaluation to evaluate this parameter was used the Manual Evaluation of the Diaphragm Scale (MED Scale); and to evaluate the diaphragmatic tonicity the evaluation described by Rial and Pinsach in 2015. Results: The results showed that the distribution of the manual evaluation of the diaphragm in the group of singers presented a significantly different distribution, with p < 0,05, in relation to the bilateral diaphragm tonicity, presenting them with greater hypertonicity in relation to the control group, and that there were no significant differences regarding mobility. Conclusion: The artistic gestures used by professional lyric singers affect the tone of the diaphragm. (AU)

Marcapasos diafragmático en paciente pediátrico con síndrome de Hipoventilación Central Adquirido / Diaphragm pacing in a pediatric patient with Acquired Central Hypoventilation syndrome

Resumen: Introducción: El marcapasos diafragmático permite reducir o eliminar la necesidad de ventilación mecánica en pacientes con insuficiencia respiratoria crónica que conservan el eje nervio frénico-diafragma in tacto, siempre que no presenten enfermedad pulmonar intrínseca. Aunque su implantación ha sido practicada por décadas, su uso no está ampliamente difundido, y existe poca literatura pu blicada al respecto, la mayoría relacionada con lesión medular alta y síndrome de hipoventilación central congénito. Objetivo: Describir una experiencia de implantación de marcapasos diafragmático en paciente pediátrico con síndrome de hipoventilación central adquirido. Caso Clínico: Pa ciente femenino con síndrome de hipoventilación central secundario a lesión isquémica de tronco cerebral como resultado de disfunción de válvula de derivación ventrículo peritoneal, motivo por el cual durante 5 años se mantuvo con asistencia de ventilación mecánica intrahospitalaria. A los 7 años de edad se implantó marcapasos diafragmático mediante cirugía toracoscópica, lo que per mitió posterior a un periodo de rehabilitación y acondicionamiento respiratorio el destete de la ventilación mecánica y el egreso hospitalario. Conclusiones: El marcapasos diafragmático es una opción factible, potencialmente segura y costo efectiva para disminuir o eliminar la dependencia de ventilación mecánica y mejorar la calidad de vida en pacientes con síndrome de hipoventilación central adquirido.

Abstract: Introduction: Diaphragmatic pacemaker is a device that reduces or eliminates the need of mechanical ventilation in patients with chronic respiratory failure who keep the phrenic nerve-diaphragm axis intact, as long as they do not present intrinsic lung disease. Although its implantation has been practiced for deca des, its use is not widespread and to date, there is little published literature about it, mostly related to high spinal cord injury and congenital central hypoventilation syndrome. Objective: To describe an experience of diaphragmatic pacemaker implantation in a pediatric patient with acquired cen tral hypoventilation syndrome. Clinical Case: Female patient with central hypoventilation syndrome secondary to ischemic brainstem lesion as a result of ventriculoperitoneal shunt malfunction. For this reason, for 5 years she was supported by inpatient mechanical ventilation. At 7 years of age, a diaphragmatic pacemaker was implanted by thoracoscopic surgery, which allowed, after a period of rehabilitation and respiratory conditioning, mechanical ventilation withdrawal, and hospital dischar ge. Conclusions: Diaphragmatic pacemaker is a feasible, potentially safe, and cost-effective option for decreasing or eliminating mechanical ventilation dependence and improve life quality in patients with acquired central hypoventilation syndrome.

Ruptura diafragmática y esplénica de origen traumático en un adolescente / Diaphragmatic and splenic rupture of traumatic origin in a teenager

Introducción: La ruptura diafragmática es un reto diagnóstico y terapéutico para los médicos que se enfrentan al manejo de pacientes politraumatizados; debe sospecharse siempre en lesiones traumáticas de localización torácica o abdominal. Objetivo: Informar los elementos diagnósticos y terapéuticos seguidos ante ruptura diafragmática y esplénica de origen traumático. Presentación del caso: Se presenta el caso de un adolescente de 14 años que ingresa por presentar herida punzante por arma blanca de localización abdominal y manifestaciones clínicas que permiten hacer el diagnóstico de la afección tratada. Durante el acto quirúrgico se comprobó la ruptura del diafragma, hernia diafragmática y ruptura esplénica con salida de sangre hacia la cavidad abdominal. Se realizó reducción de la hernia, sutura del diafragma y extirpación del bazo por el estado del órgano en el momento de la cirugía. Conclusiones: La ruptura diafragmática postraumática es una entidad que cada vez se observa con mayor frecuencia en pacientes pediátricos. El examen clínico auxiliado por estudios imagenológicos resulta vital para su diagnóstico, tratamiento precoz y evitar complicaciones. Es importante mantener un alto índice de sospecha ante esta entidad poco frecuente, pero no rara en la edad pediátrica. El paciente tuvo una evolución favorable y fue egresado del servicio de cirugía luego de 10 días de hospitalización(AU)

Introduction: The diaphragmatic rupture is a diagnostic and a therapeutic challenge for physicians who have to face the management of polytraumatized patients; there must always be suspicion on traumatic injuries of thoracic or abdominal location. Objective: To inform the diagnostic and therapeutic elements followed in case of diaphragmatic and splenic rupture of traumatic origin. Presentation of the case: 14-year-old male teenager that was admitted for presenting stabbing wound by sharp weapon, with abdominal location and clinical manifestations that allow making the diagnosis of the condition being treated. During surgery, it was found the rupture of the diaphragm, a diaphragmatic hernia and splenic rupture with output of blood into the abdominal cavity. It was conducted the reduction of the hernia, the suture of the diaphragm and the removal of the spleen due to the state of the organ during the surgery. Conclusions: Post-traumatic diaphragmatic rupture is an entity that it is most often seen in pediatric patients. The clinical examination aided by imaging studies is vital for its diagnosis, early treatment and to avoid complications. It is important to maintain a high index of suspicion to face this rare entity, but not so rare in the pediatric age group. The patient had a favourable evolution and he was discharged of the surgery service after 10 days of hospitalization(AU)

Insuficiencia de la bomba ventilatoria: una perspectiva histórica / Ventilatory pump failure: historical perspective

En humanos, PaCO2 es controlada muy estrictamente. A diferencia de PaO2 y todas las pruebas funcionales respiratorias que cambian con la edad, PaCO2 permanece constante durante toda la vida. Por lo tanto, su desviación sostenida representa una alteración significativa de la homeostasis. La estructura responsable de mantener la PaCO2 dentro de límites muy estrechos es la bomba ventilatoria. Se compone de varias unidades anatómicas y funcionales que van desde la corteza cerebral hasta los músculos respiratorios. Varias condiciones clínicas que involucran estas estructuras pueden conducir a la insuficiencia de la bomba respiratoria, cuyo sello distintivo es la hipercapnia. La relevancia del concepto de bomba respiratoria ha sido reconocida a lo largo de las décadas. Unos pocos trabajos germinales abrieron la puerta a un notable número de proyectos básicos, aplicados y clínicos en torno a la insuficiencia de la bomba respiratoria y su relevancia clínica. Este artículo revisará algunos de estos estudios y narrará el camino hacia nuestro estado actual de conocimiento sobre el tema.

IIn humans, PaCO2 is very strictly controlled. Unlike PaO2 and all respiratory functional tests that change with age, PaCO2 remains constant throughout life. Therefore, its sustained deviation represents a significant alteration of homeostasis. The structure responsible for keeping PaCO2 within very narrow limits is the ventilatory pump. It consists of several anatomical and functional units that go from the cerebral cortex to the respiratory muscles. Several clinical conditions involving these structures can lead to failure of the respiratory pump, whose hallmark is hypercapnia. The relevance of the respiratory pump concept has been acknowledged for decades. A few initial works allowed for a remarkable number of basic, applied and clinical projects regarding the respiratory pump failure and its clinical relevance. This article reviews some of these studies and describes the process that lead to our current state of knowledge on the subject