Mobility impact and methods of diaphragm monitoring in patients with chronic obstructive pulmonary disease: a systematic review

The objectives of the study were to identify the factors that limit diaphragmatic mobility and evaluate the therapeutic results of the monitoring methods previously used in patients with chronic obstructive pulmonary disease. The PubMed, Web of Science, Scopus, and LILACS databases were used. A gray literature search was conducted with Google scholar. PRISMA was used, and the bias risk analysis adapted from the Cochrane Handbook for clinical trials and, for other studies, the Downs and Black checklist were used. Twenty-five articles were included in the qualitative synthesis analysis on physiotherapeutic techniques and diaphragmatic mobility. Eight clinical trials indicated satisfactory domains, and on the Downs and Black scale, 17 cohort studies were evaluated to have an acceptable score. Different conditions must be observed; for example, for postoperative assessments the supine position is suggested to be the most appropriate position to verify diaphragm excursion, although it has been shown to be associated with difficulty of restriction and matching in samples. Therefore, we identified the need for contemporary adjustments and strategies that used imaging instruments, preferably in the dorsal position. Therapeutic evidence on the association between the instrumental method and diaphragmatic mobility can be controversial. The ultrasound measurements indicated some relevance for different analyses, for pulmonary hyperinflation as well as diaphragm thickness and mobilization, in COPD patients. In particular, the study suggests that the ultrasound technique with B-mode for analysis and M-mode for diaphragmatic excursion be used with a 2 - 5 MHz with the patient in the supine position. However, the methods used to monitor diaphragm excursion should be adapted to the conditions of the patients, and additional investigations of their characteristics should be performed. More selective inclusion criteria and better matching in the samples are very important. In addition, more narrow age, sex and weight categories are important, especially in patients with chronic obstructive pulmonary disease.

Diaphragm quantitative electromyography in difficult-to-treat asthmatic patients / Eletromiografia quantitativa do diafragma em pacientes com asma de difícil controle

ABSTRACT Quantitative electromyography is an important tool to evaluate myopathies, and some difficult-to-treat asthmatic patients may have a subclinical corticosteroid myopathic process, using only inhaled corticosteroid, according to some studies. In this report, diaphragm quantitative electromyography was used to evaluate asthmatic difficult-to-treat patients, comparing them with a control group. Significant differences were obtained in amplitude, duration and size index of motor unit action potentials, with lower parameters in the asthmatic patients, which may indicate a myopathic process.

RESUMO Eletromiografia quantitativa é uma ferramenta importante para a avaliação de miopatias, e alguns pacientes asmáticos de difícil controle podem ter um processo miopático subclínico, mesmo usando apenas corticosteroides inalatórios, de acordo com alguns artigos. Nesse artigo a eletromiografia quantitativa do diafragma foi usada para avaliar os pacientes asmáticos de difícil controle, comparando com um grupo controle. Diferenças significativas nas amplitudes, durações e índices de tamanho dos potenciais de unidades motoras foram encontradas, com parâmetros mais baixos nos pacientes asmáticos, o que pode indicar um processo miopático.

Is phrenic nerve conduction affected in patients with difficult-to-treat asthma? / A neurocondução do nervo frênico está alterada na asma de difícil controle?

ABSTRACT Objective The aim of this study was to obtain data on phrenic neuroconduction and electromyography of the diaphragm muscle in difficult-to-treat asthmatic patients and compare the results to those obtained in controls. Methods The study consisted of 20 difficult-to-treat asthmatic patients compared with 27 controls. Spirometry, maximal inspiratory and expiratory pressure, chest X-ray, phrenic neuroconduction and diaphragm electromyography data were obtained. Results The phrenic compound motor action potential area was reduced, compared with controls, and all the patients had normal diaphragm electromyography. Conclusion It is possible that a reduced phrenic compound motor action potential area, without electromyography abnormalities, could be related to diaphragm muscle fiber abnormalities due to overload activity.

RESUMO Objetivo O objetivo do presente estudo foi obter dados da neurocondução do frênico e exame com agulha do diafragma em pacientes com asma de difícil controlee comparar com um grupo normal. Métodos O estudo consiste em realizar radiografia de tórax, espirometria, pressão máxima inspiratória e expiratória, neurocondução do nervo frênico e eletromiografia do músculo diafragma em 20 pacientes asmáticos de difícil controle e comparar com 27 controles. Resultados Encontramos redução da área do potencial de ação muscular composto do nervo frênico e a eletromiografia do musculo diafragma estava normal em todos os pacientes. Conclusão É possível que a redução da área do potencial de ação muscular composto do nervo frênico nos pacientes com asma de difícil controle associado a eletromiografia normal do músculo diafragma esteja relacionada as alterações da fibra muscular do mesmo devido à sobrecarga de atividade.

Comparison of diaphragmatic mobility between COPD patients with and without thoracic hyperkyphosis: a cross-sectional study / Comparação da mobilidade diafragmática em pacientes com DPOC com e sem hipercifose torácica: um estudo transversal

ABSTRACT Objective: To compare diaphragmatic mobility, lung function, and respiratory muscle strength between COPD patients with and without thoracic hyperkyphosis; to determine the relationship of thoracic kyphosis angle with diaphragmatic mobility, lung function, and respiratory muscle strength in COPD patients; and to compare diaphragmatic mobility and thoracic kyphosis between male and female patients with COPD. Methods: Participants underwent anthropometry, spirometry, thoracic kyphosis measurement, and evaluation of diaphragmatic mobility. Results: A total of 34 patients with COPD participated in the study. Diaphragmatic mobility was significantly lower in the group of COPD patients with thoracic hyperkyphosis than in that of those without it (p = 0.002). There were no statistically significant differences between the two groups of COPD patients regarding lung function or respiratory muscle strength variables. There was a significant negative correlation between thoracic kyphosis angle and diaphragmatic mobility (r = −0.47; p = 0.005). In the sample as a whole, there were statistically significant differences between males and females regarding body weight (p = 0.011), height (p < 0.001), and thoracic kyphosis angle (p = 0.036); however, there were no significant differences in diaphragmatic mobility between males and females (p = 0.210). Conclusions: Diaphragmatic mobility is lower in COPD patients with thoracic hyperkyphosis than in those without it. There is a negative correlation between thoracic kyphosis angle and diaphragmatic mobility. In comparison with male patients with COPD, female patients with COPD have a significantly increased thoracic kyphosis angle.

RESUMO Objetivo: Comparar a mobilidade diafragmática, a função pulmonar e a força muscular respiratória em pacientes que apresentam DPOC com e sem hipercifose torácica; verificar a relação do ângulo da curvatura torácica com a mobilidade diafragmática, variáveis da função pulmonar e de força muscular respiratória dos pacientes com DPOC; e comparar a mobilidade diafragmática e a cifose torácica entre os gêneros nesses pacientes. Métodos: Foram realizadas as seguintes avaliações: antropometria, espirometria, mensuração do ângulo da curvatura torácica e mobilidade diafragmática. Resultados: Participaram do estudo 34 pacientes com DPOC. No grupo de pacientes com DPOC e hipercifose torácica, a mobilidade diafragmática foi estatisticamente menor quando comparada à do grupo DPOC sem hipercifose torácica (p = 0,002). Não houve diferenças estatisticamente significantes entre esses grupos em relação a variáveis de função pulmonar e de força muscular respiratória. Houve uma correlação negativa significante entre o ângulo da curvatura torácica e a mobilidade diafragmática (r = −0,47; p = 0,005). Quando comparados homens e mulheres da amostra geral, houve diferenças estatisticamente significantes em relação à massa corpórea (p = 0,011), estatura (p < 0,001) e ângulo da curvatura da cifose torácica (p = 0,036), mas não em relação à mobilidade diafragmática (p = 0,210). Conclusões: Os pacientes com DPOC e hipercifose torácica apresentaram menor mobilidade diafragmática quando comparados com os pacientes com DPOC sem hipercifose torácica. O ângulo da curvatura torácica se correlacionou negativamente com a mobilidade diafragmática. O grupo feminino apresentou um aumento significante no ângulo da curvatura torácica quando comparado ao grupo masculino.

Is polysomnographic examination necessary for subjects with diaphragm pathologies?

OBJECTIVES: While respiratory distress is accepted as the only indication for diaphragmatic plication surgery, sleep disorders have been underestimated. In this study, we aimed to detect the sleep disorders that accompany diaphragm pathologies. Specifically, the association of obstructive sleep apnea syndrome with diaphragm eventration and diaphragm paralysis was evaluated. METHODS: This study was performed in Süreyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital between 2014-2016. All patients had symptoms of obstructive sleep apnea (snoring and/or cessation of breath during sleep and/or daytime sleepiness) and underwent diaphragmatic plication via video-assisted mini-thoracotomy. Additionally, all patients underwent pre- and postoperative full-night polysomnography. Pre- and postoperative clinical findings, polysomnography results, Epworth sleepiness scale scores and pulmonary function test results were compared. RESULTS: Twelve patients (7 males) with a mean age of 48 (range, 27-60) years and a mean body mass index of 25 (range, 20-30) kg/m2 were included in the study. Preoperative polysomnography showed obstructive sleep apnea syndrome in 9 of the 12 patients (75%), while 3 of the patients (25%) were regarded as normal. Postoperatively, patient complaints, apnea hypopnea indices, Epworth sleepiness scale scores and pulmonary function test results all demonstrated remarkable improvement. CONCLUSION: All patients suffering from diaphragm pathologies with symptoms should undergo polysomnography, and patients diagnosed with obstructive sleep apnea syndrome should be operated on. In this way, long-term comorbidities of sleep disorders may be prevented.

Identifying decreased diaphragmatic mobility and diaphragm thickening in interstitial lung disease: the utility of ultrasound imaging / Identificação da diminuição da mobilidade diafragmática e do espessamento diafragmático na doença pulmonar intersticial: utilidade da ultrassonografia

Objective: To investigate the applicability of ultrasound imaging of the diaphragm in interstitial lung disease (ILD). Methods: Using ultrasound, we compared ILD patients and healthy volunteers (controls) in terms of diaphragmatic mobility during quiet and deep breathing; diaphragm thickness at functional residual capacity (FRC) and at total lung capacity (TLC); and the thickening fraction (TF, proportional diaphragm thickening from FRC to TLC). We also evaluated correlations between diaphragmatic dysfunction and lung function variables. Results: Between the ILD patients (n = 40) and the controls (n = 16), mean diaphragmatic mobility was comparable during quiet breathing, although it was significantly lower in the patients during deep breathing (4.5 ± 1.7 cm vs. 7.6 ± 1.4 cm; p < 0.01). The patients showed greater diaphragm thickness at FRC (p = 0.05), although, due to lower diaphragm thickness at TLC, they also showed a lower TF (p < 0.01). The FVC as a percentage of the predicted value (FVC%) correlated with diaphragmatic mobility (r = 0.73; p < 0.01), and an FVC% cut-off value of < 60% presented high sensitivity (92%) and specificity (81%) for indentifying decreased diaphragmatic mobility. Conclusions: Using ultrasound, we were able to show that diaphragmatic mobility and the TF were lower in ILD patients than in healthy controls, despite the greater diaphragm thickness at FRC in the former. Diaphragmatic mobility correlated with ILD functional severity, and an FVC% cut-off value of < 60% was found to be highly accurate for indentifying diaphragmatic dysfunction on ultrasound.

Objetivo: Investigar a aplicabilidade da ultrassonografia do diafragma na doença pulmonar intersticial (DPI). Métodos: Por meio da ultrassonografia, pacientes com DPI e voluntários saudáveis (controles) foram comparados quanto à mobilidade diafragmática durante a respiração profunda e a respiração tranquila, à espessura diafragmática no nível da capacidade residual funcional (CRF) e da capacidade pulmonar total (CPT) e à fração de espessamento (FE, espessamento diafragmático proporcional da CRF até a CPT). Foram também avaliadas correlações entre disfunção diafragmática e variáveis de função pulmonar. Resultados: Entre os pacientes com DPI (n = 40) e os controles (n = 16), a média da mobilidade diafragmática foi comparável durante a respiração tranquila, embora tenha sido significativamente menor nos pacientes durante a respiração profunda (4,5 ± 1,7 cm vs. 7,6 ± 1,4 cm; p < 0,01). Os pacientes apresentaram maior espessura diafragmática na CRF (p = 0,05), embora tenham também apresentado, devido à menor espessura diafragmática na CPT, menor FE (p < 0,01). A CVF em porcentagem do previsto (CVF%) correlacionou-se com a mobilidade diafragmática (r = 0,73; p < 0,01), e um valor de corte < 60% da CVF% apresentou alta sensibilidade (92%) e especificidade (81%) na identificação de mobilidade diafragmática reduzida. Conclusões: Com a ultrassonografia, foi possível demonstrar que a mobilidade diafragmática e a FE estavam mais reduzidas nos pacientes com DPI do que nos controles saudáveis, apesar da maior espessura diafragmática na CRF nos pacientes. A mobilidade diafragmática correlacionou-se com a gravidade funcional da DPI, e um valor de corte < 60% da CVF% mostrou ser altamente acurado na identificação da disfunção diafragmática por ultrassonografia.

Evaluation of diaphragmatic mobility following intra-abdominal sub-diaphragmatic fixation of a double-layered mesh in rats

PURPOSE: To evaluate the tissue integration of a double-sided mesh after fixation in diaphragm and to study the diaphragmatic mobility by ultrasound. METHODS: Twenty male Wistar rats were used. The animals were assigned into two equal groups according to the day of euthanasia. The animals were anesthetized and a 1.5 x 1.5 cm of double-layer mesh was inserted between the diaphragm and the liver. For the evaluation of the diaphragm mobility a sonographic method was used. Measurements on specific breathing parameters were taking place. Pathological evaluation took place after the animal's euthanasia. RESULTS: Extra-hepatic granuloma was not differentiated overtime, (χ2=0.04, p>0.05). Neither fibrosis was significantly differentiated, (χ2=0.04, p>0.05). Intra-hepatic granuloma was significantly differentiated overtime, (χ2=10.21, p<0.05). Concerning Te parameter, means were significantly differentiated over time, F (3, 30) = 5.12, (p<0.01). Ttot parameter, it was differentiated over time, F (3, 8)=4.79, (p<0.05). IR parameter was also longitudinally differentiated, F (3, 30)=3.73, (p<0.05). CONCLUSION: The measurements suggest a transient malfunction of diaphragmatic mobility despite the fact that inflammatory reaction, fibrosis and extra-hepatic granuloma were not significantly differentiated with the passage of time.

Respiratory pattern of diaphragmatic breathing and pilates breathing in COPD subjects

BACKGROUND: Diaphragmatic breathing (DB) is widely used in pulmonary rehabilitation (PR) of patients with chronic obstructive pulmonary disease (COPD), however it has been little studied in the scientific literature. The Pilates breathing (PB) method has also been used in the rehabilitation area and has been little studied in the scientific literature and in COPD. OBJECTIVES: To compare ventilatory parameters during DB and PB in COPD patients and healthy adults. METHOD: Fifteen COPD patients (COPD group) and fifteen healthy patients (healthy group) performed three types of respiration: natural breathing (NB), DB, and PB, with the respiratory pattern being analyzed by respiratory inductive plethysmography. The parameters of time, volume, and thoracoabdominal coordination were evaluated. After the Shapiro-Wilk normality test, ANOVA was applied followed by Tukey's test (intragroup analysis) and Student's t-test (intergroup analysis; p<0.05). RESULTS: DB promoted increase in respiratory volumes, times, and SpO2 as well as decrease in respiratory rate in both groups. PB increased respiratory volumes in healthy group, with no additional benefits of respiratory pattern in the COPD group. With respect to thoracoabdominal coordination, both groups presented higher asynchrony during DB, with a greater increase in the healthy group. CONCLUSIONS: DB showed positive effects such as increase in lung volumes, respiratory motion, and SpO2 and reduction in respiratory rate. Although there were no changes in volume and time measurements during PB in COPD, this breathing pattern increased volumes in the healthy subjects and increased oxygenation in both groups. In this context, the acute benefits of DB are emphasized as a supporting treatment in respiratory rehabilitation programs. .

Effectiveness of diaphragmatic stimulation with single-channel electrodes in rabbits / Efetividade da estimulacao diafragmatica com eletrodos monocanais em coelhos

Every year, a large number of individuals become dependent on mechanical ventilation because of a loss of diaphragm function. The most common causes are cervical spinal trauma and neuromuscular diseases. We have developed an experimental model to evaluate the performance of electrical stimulation of the diaphragm in rabbits using single-channel electrodes implanted directly into the muscle. Various current intensities (10, 16, 20, and 26 mA) produced tidal volumes above the baseline value, showing that this model is effective for the study of diaphragm performance at different levels of electrical stimulation.

A cada ano um grande número de pessoas perde a função do diafragma tornando-se dependentes de ventilação mecânica. As principais causas são o trauma raquimedular da região cervical e as doenças neuromusculares. Desenvolvemos um modelo experimental para avaliar o desempenho da estimulação elétrica do diafragma em coelhos com eletrodos monocanais implantados diretamente neste músculo. Foram aplicadas diferentes intensidades de correntes (10, 16, 20 e 26 mA), as quais geraram volumes correntes acima dos valores basais, mostrando que este modelo é eficaz para estudar o desempenho do diafragma sob diferentes tipos de estimulação elétrica.

Efeitos da estimulação diafragmática transcutânea sincronizada em pacientes com doença pulmonar obstrutiva crônica (DPOC): um estudo piloto / Effects of transcutaneous diaphragmatic synchronized pacing in patients with chronic obstructive pulmonary disease (COPD)

A pesquisa descrita neste artigo teve por objetivo avaliar quali-quantitativamente os efeitos da estimulação diafragmática transcutânea sincronizada em portadores de DPOC. Para isso, desenvolveu-se um sistema de estimulação elétrica controlado pelo sinal respiratório, a partir das variações de temperatura durante os eventos de inspiração e expiração, medidas por meio de dois termistores do tipo NTC inseridos dos lados interno e externo de uma máscara de respirador. Seis voluntários portadores de DPOC, de ambos os sexos, com idade entre 56 e 71anos, foram submetidos a 10 sessões estimulatórias de 20 minutos. O padrão do sinal estimulatório continha pulsos com duração de 90μs e repouso de 400μs, gerados em intervalos regulares e modulados em bursts com período ativo de 1470μs e inativo de 600μs, apresentando perfil trapezoidal com tempos de subida, descida e platô de 500ms cada. Todos os pacientes foram submetidos a uma avaliação inicial contendo: teste de força muscular respiratória avaliada por meio de PImáx e PEmáx, teste de função pulmonar e aplicação do questionário de qualidade de vida SGRQ. Após 10 sessões, houve um aumento na força muscular inspiratória em todos os pacientes, onde a PImáx sofreu um incremento médio de 66,67± 12,11cmH2O para 91,67 ± 25,03 cmH2O, a PEmáx de 92,50 ± 10,84 cmH2O para 116,67 ± 8,16 cmH2O. Também observou-se melhora da qualidade de vida no domínio sintoma, de 49,10± 19,40 para 28,60± 25,20; no domínio atividade, de 83,40± 12,50 para 67,57± 18,80; no domínio impacto, de 54,10± 11,34 para 38,00± 27,07; e escore total, de 65,50± 7,60 para 44,47± 22,31. A partir desses resultados, concluiu-se que a estimulação elétrica diafragmática sincronizada pode promover resultados positivos em portadores de DPOC.

The research described in this paper has the goal of evaluating the effects of transcutaneous diaphragmatic synchronized pacing in patients with COPD. In order to achieve the experimental protocol, it has been developed a system for electrical stimulation triggered by the respiratory signal obtained from the temperature variations during inspiration and expiration events, using two NTC thermistors coupled inside and outside of a respirator mask. It was studied six volunteers with COPD, of both sexes, aged between 56 to 71 years, who were submitted to 10sessions of 20minutes. The stimulatory parameters were set to: active phase of the pulse of 90μs, and inactive phase of 400μs, generated at regular intervals and modulated in bursts with active and inactive periods of 1470μs and 600μs, respectively; presenting trapezoidal envelope with rise time, fall time and plateau of 500ms. All patients underwent an initial assessment including: test of respiratory muscle strength seen through the MIP and MEP tests, lung function test and application of SGRQ quality of life questionnaire. After 10 sessions, there is an increasing inspiratory muscle strength in all patients, where MIP has an average increase of 66.67± 12.11cmH2O to 91.67 ± 25.03 cmH2O, MEP from 92.50 ± 10.84 cmH2O to 116.67 ± 8.16 cmH2O, and also observed a better quality of life in the symptom domain of 49.10± 19.40 to 28.60± 25.20, in the activity domain of 83.40± 12.50 to 67.57± 18.80, and in the impact domain of 54.10± 11.34 to 38.00± 27.07 and total score of 65.50± 7.60 to 44.47± 22.31. Therefore, we concluded that the transcutaneous diaphragmatic synchronized pacing can promote positive outcomes in patients with COPD.

Effects of controlled and pressure support mechanical ventilation on rat diaphragm muscle / Efeitos da ventilação mecânica controlada e por pressão de suporte no músculo diafragma de ratos

PURPOSE: The objective of this study was to analyze the effects of Pressure Controlled Ventilation mode (PCV-C) and PSV mode in diaphragm muscle of rats. METHODS: Wistar rats (n=18) were randomly assigned to the control group or to receive 6 hours of PCV and PSV. After this period, animals were euthanized and their diaphragms were excised, frozen in liquid nitrogen and stored in at -80º C for further histomorphometric analysis. RESULTS: Results showed a 15 percent decrease in cross-sectional area of muscle fibers on the PCV-C group when compared to the control group (p<0.001) and by 10 percent when compared to the PSV group (p<0.05). Minor diameter was decreased in PCV-C group by 9 percent when compared with the control group (p<0.001) and by 6 percent when compared to the PSV group (p<0.05). When myonuclear area was analyzed, a 16 percent decrease was observed in the PCV-C group when compared to the PSV group (p<0.05). No significant difference between the groups was observed in myonuclear perimeter (p>0.05). CONCLUSION: Short-term controlled mechanical ventilation seems to lead to muscular atrophy in diaphragm fibers. The PSV mode may attenuate the effects of VIDD.

OBJETIVO: Avaliar os efeitos do modo ventilatório controlado por pressão controlada (PCV-C) e do modo PSV sobre o músculo diafragma de ratos. MÉTODOS: Ratos (n = 18) da linhagem Wistar foram distribuídos no grupo controle (RE) ou para receber AVM por 6 horas no modo PCV-C e no modo PSV. Após esse período, os animais foram eutanasiados, o diafragma retirado e encaminhado para a análise histológica e morfométrica. RESULTADOS: Os resultados revelaram uma redução da área das fibras musculares de 15 por cento no grupo PCV-C em comparação ao controle (p<0,001) e de 10 por cento quando comparado ao grupo PSV (p<0,05). Já com relação ao diâmetro menor observou-se uma redução de 9 por cento do grupo PCV-C em comparação ao controle (p<0,001) e de 6 por cento em relação ao grupo PSV (p<0,05). Quando avaliada a área dos mionúcleos, notou-se uma redução de 16 por cento desse parâmetro no grupo PCV-C, comparado ao PSV (p<0,05). Não houve diferença significativa no perímetro dos mionúcleos entre os grupos estudados (p>0,05). CONCLUSÃO: O grupo PCV-C apresentou atrofia muscular em um período curto de ventilação mecânica. O modo PSV parece atenuar os efeitos da DDIV.

Effects of restraint position on changes of diaphragmatic mechanical characteristic in rats / 法医学杂志

OBJECTIVE@#To observe effects of restraint position on the changes of diaphragmatic mechanical characteristic in rats, and try to explore the role of nitric oxide (NO).@*METHODS@#Rat model of restraint position was established. Rats were divided into control group, restraint position 12h and 24h groups. The markers of respiratory functions in vivo and the biomechanical markers of diaphragmatic characteristic ex vivo were evaluated. Serum NO levels were measured with spectrophotometry. The expressions of nNOS and iNOS mRNA in diaphragm were detected using RT-PCR.@*RESULTS@#Compared with control group, respiratory rate, tidal volume and minute ventilation were significantly decreased in the restraint position 12h and 24h groups. Pt of diaphragm significantly decreased and force-generating capacity reduced at low frequency stimulation in 12h group. Force-generating capacity over the full range reduced at low and high frequency stimulation in 24h group. Pt of diaphragm in control and restraint position groups increased after L-NNA pre-incubation. Force-frequency relationship after L-NNA pre-incubation reduced in 24h group. NO level in serum increased significantly in the restraint position groups. Diaphragmatic nNOS mRNA expression was upregulated significantly in the restraint position groups.@*CONCLUSION@#Restraint position induces the decreasement of diaphragmatic contractility and the decreasement is mediated by NO from diaphragm or circulation blood.

Influence of Diaphragmatic Mobility on Hypercapnia in Patients with Chronic Obstructive Pulmonary Disease

A reduction in diaphragm mobility has been identified in patients with chronic obstructive pulmonary disease (COPD) and has been associated with a decline in pulmonary function parameters. However, little information exists regarding the potential role of diaphragm mobility on hypercapnia in COPD. A new method of assessing the mobility of the diaphragm, using ultrasound, has recently been validated. The purpose of the present study was to investigate the relationship between diaphragm mobility and pulmonary function parameters, as well as that between arterial blood gas values and diaphragm mobility, in COPD patients. Thirty seven COPD patients were recruited for pulmonary function test, arterial blood gas analysis and diaphragm mobility using ultrasound to measure the craniocaudal displacement of the left branch of the portal vein. There were significant negative correlations between diaphragmatic mobility and PaCO2 (r = -0.373, P = 0.030). Diaphragmatic mobility correlated with airway obstruction (FEV1, r = 0.415, P = 0.011) and with ventilatory capacity (FVC, r = 0.302, P = 0.029; MVV, r = 0.481, P = 0.003). Diaphragmatic mobility also correlated significantly with pulmonary hyperinflation. No relationship was observed between diaphragm mobility and PaO2 (r = -0.028, P = 0.873). These findings support a possibility that the reduction in diaphragm mobility relates to hypercapnia in COPD patients.

Disfunção diafragmática e mortalidade em pacientes portadores de DPOC / Diaphragmatic dysfunction and mortality in patients with COPD

OBJETIVO: Verificar se indivíduos portadores de DPOC com disfunção diafragmática apresentam maior risco de mortalidade quando comparados àqueles sem disfunção diafragmática. MÉTODOS: Foi avaliada a função pulmonar, a mobilidade diafragmática, a qualidade de vida e o índice conhecido como Body mass index, airway Obstruction, Dyspnea, and Exercise capacity (BODE) em 42 pacientes portadores de DPOC. Os pacientes foram alocados em dois grupos de acordo com a gravidade do acometimento da mobilidade do diafragma: grupo de baixa mobilidade (BM; mobilidade < 33,99 mm) e grupo de alta mobilidade (AM; mobilidade > 34,00 mm). O índice BODE e a qualidade de vida foram quantificados nos dois grupos. Todos os pacientes foram acompanhados prospectivamente por um período de até 48 meses a fim de identificarmos o número de óbitos decorrentes de complicações respiratórias devido a DPOC. RESULTADOS: Dos 42 pacientes avaliados, 20 foram classificados no grupo BM, e 22 foram alocados no grupo AM. Não houve diferenças significativas quanto à faixa etária, hiperinsuflação pulmonar e fatores relacionados à qualidade de vida entre os grupos. Entretanto, o grupo BM apresentou maior pontuação no índice BODE em relação ao grupo AM (p = 0,01). O acompanhamento dos pacientes ao longo de 48 meses permitiu identificar quatro óbitos na população estudada, sendo todos os casos no grupo BM (15,79 por cento; p = 0,02). CONCLUSÕES: Esses resultados sugerem que pacientes portadores de DPOC com disfunção diafragmática, caracterizada por uma baixa mobilidade do diafragma, apresentam maior risco de mortalidade quando comparados àqueles sem disfunção diafragmática.

OBJECTIVE: To determine whether COPD patients with diaphragmatic dysfunction present higher risk of mortality than do those without such dysfunction. METHODS: We evaluated pulmonary function, diaphragm mobility and quality of life, as well as determining the Body mass index, airway Obstruction, Dyspnea, and Exercise capacity (BODE) index, in 42 COPD patients. The patients were allocated to two groups according to the degree to which diaphragm mobility was impaired: low mobility (LM; mobility < 33.99 mm); and high mobility (HM; mobility > 34.00 mm). The BODE index and the quality of life were quantified in both groups. All patients were followed up prospectively for up to 48 months in order to determine the number of deaths resulting from respiratory complications due to COPD. RESULTS: Of the 42 patients evaluated, 20 were allocated to the LM group, and 22 were allocated to the HM group. There were no significant differences between the groups regarding age, lung hyperinflation or quality of life. However, BODE index values were higher in the LM group than in the HM group (p = 0.01). During the 48-month follow-up period, there were four deaths within the population studied, and all of those deaths occurred in the LM group (15.79 percent; p = 0.02). CONCLUSIONS: These findings suggest that COPD patients with diaphragmatic dysfunction, characterized by low diaphragm mobility, have a higher risk of death than do those without such dysfunction.

Relação entre a excursão do músculo diafragma e as curvaturas da coluna vertebral em crianças respiradoras bucais / The relationship between excursion of the diaphragm and curvatures of the spinal column in mouth breathing children

OBJETIVO: Verificar a relação entre a excursão do músculo diafragma e as curvaturas da coluna vertebral em crianças respiradoras bucais. MÉTODOS: Foram avaliadas 52 crianças de 5 a 12 anos de idade, de ambos os sexos. Por meio de avaliação otorrinolaringológica, foram divididas em dois grupos: respiradores bucais e respiradores nasais. Todos os participantes foram submetidos a exame de videofluoroscopia do músculo diafragma e a avaliação postural. A excursão do diafragma foi analisada pelo programa Adobe Photoshop®, e a avaliação postural através de fotografias em norma lateral esquerda, sendo analisadas pelo Software de Avaliação Postural. RESULTADOS: Os grupos estudados apresentaram diferença estatisticamente significante quanto ao comportamento das curvaturas da coluna vertebral (lordose cervical: p = 0,003; lordose lombar: p = 0,001; cifose torácica: p = 0,002; posição da pelve: p = 0,001) e da excursão do músculo diafragma (diafragma lado direito: p = 0,001; diafragma lado esquerdo: p = 0,001). O grupo respirador bucal apresentou diminuição da lordose cervical, aumento da cifose torácica, aumento da lordose lombar e anteversão da posição da pelve. A distância excursionada pelo músculo diafragma em crianças respiradoras bucais é menor que em crianças respiradoras nasais. Não houve significância estatística ao relacionar o comportamento das curvaturas da coluna vertebral com a excursão do músculo diafragma. CONCLUSÃO: Não há relação entre as curvaturas da coluna vertebral com a excursão do músculo diafragma nos grupos estudados.

OBJECTIVE: To investigate the relationship between excursion of the diaphragm muscle and spinal curvatures in mouth breathing children. METHODS: A total of 52 children of both sexes, aged from 5 to 12 years, were studied. After otorhinolaryngological assessment, the children were divided into two groups: mouth breathers and nose breathers. All of the children underwent videofluoroscopic examination of the diaphragm muscle and postural assessment. Diaphragm excursion was analyzed using Adobe Photoshop® software, and postural assessment was recorded using photographs in left lateral view, which were then analyzed using SAPO postural assessment software. RESULTS: The groups studied exhibited statistically significant differences in terms of spinal curvatures (cervical lordosis: p = 0.003; lumbar lordosis: p = 0.001; thoracic kyphosis: p = 0.002; position of the pelvis: p = 0.001) and diaphragm excursion (right side diaphragm: p = 0.001; left side diaphragm: p = 0.001). The mouth breathing group exhibited reduced cervical lordosis, increased thoracic kyphosis, increased lumbar lordosis and the position of the pelvis was tilted forward. The distance traveled outwards by the diaphragm muscles of mouth breathing children was shorter than that traveled by the muscles of nose breathing children. The relationship between the behavior of spinal curvatures and diaphragm excursion had no statistical significance. CONCLUSION: There was no relationship between spinal curvatures and diaphragm excursion in the groups studied here.

Recent progress in research on positional asphyxia of restraint / 法医学杂志

Positional asphyxia of restraint means that when an individual was limited in an abnormal body position, asphyxia would take place owing to the disorder of spontaneous respiratory function, and finally it lead to die. So, it belongs to a special type of the mechanical asphyxia. From the cases reported, we could found that it would take place in several conditions. Because the cases were not caused enough recognition, the study has been researched carefully only in recent years. Following the more cases reported, many experts of forensic medicine had investigated it on the mechanism of death and the standard of identification, but they could not reach to agreements. So, they have changed the directions of the researches, began to value the factors of risk and research how to avoid it. In the following text, the mechanism of death, factors of risk, preventive methods, standard of identification and prospecting of positional asphyxia of restraint were reviewed.

The role of diaphgram fatigue in the death from hanging with bound upper limbs of rabbits / 法医学杂志

OBJECTIVE@#To explore the role of diaphgram fatigue in the death from hanging with bound upper limbs of rabbits.@*METHODS@#Rabbits were hanged with upper limbs bound, then the data of EMGdi were gathered@*RESULTS@#By analyzing power spectral of EMGdi in experiment, we compare the ratio change of H/L between pre-experiment and post-experiment. There is a significance decrease of the ratio of H/L, so it indicates that diaphgram fatigue does exist.@*CONCLUSION@#Diaphgram fatigue plays an important role in the death from hanging with limbs of rabbits bound.

Influência da mobilidade diafragmática na capacidade de exercício e dispnéia em pacientes de doença pulmonar obstrutiva crônica / Influence of diaphragm mobility on the exercise capacity and dyspnoea in patients with chronic obstructive pulmonary disease

O objetivo do estudo foi verificar a influência da mobilidade do diafragma na capacidade de exercício e dispnéia em paciente com DPOC. Foram estudados 54 pacientes com DPOC e 20 sujeitos sem DPOC com idade e IMC compatíveis. Nossos resultados mostram que a mobilidade do diafragma foi menor nos pacientes com DPOC quando comparado com o grupo sem DPOC. Os pacientes com DPOC foram então divididos em 2 grupos / This study evaluated the influence of diaphragm mobility on exercise capacity and dyspnoea in patients with COPD. Fifty-four COPD patients and 20 healthy subjects (age and BMI-matched) were studied. Pulmonary function, diaphragm mobility, exercise capacity and dyspnoea were evaluated. Our results showed that COPD patients presented lower diaphragm mobility than healthy individuals. Patients were next split into 2 groups...

Análise da eficácia da eletroestimulação diafragmática em pacientes submetidos à ventilação mecânica prolongada / Analise the efficiency of the diaphragmatic electro stimulation in patients submitted to prolonged mechanic ventilation

Atualmente, acredita-se que a ventilação mecânica prolongada promova alterações no músculo diafragma e que essas alterações são dependentes do tempo de permanência no aparelho. Alguns estudos em ratos demonstram que 48 horas de ventilação mecânica diminuem até 60% a força de contração do músculo diafragma. Atualmente, a eletroestimulação diafragmática vem demonstrando resultados satisfatórios na função diafragmática tornando-se uma opção na reabilitação, no recrutamento muscular e na melhora da ventilação pulmonar. Estudos comprovaram que a atrofia muscular diafragmática é maior em pacientes sob VM prolongada que não foram submetidos à eletroestimulação, sendo indicada para todos os pacientes em VM prolongada, pois ela mostrou-se capaz de recrutar fibras, melhorando seu condicionamento. O objetivo do trabalho foi analisar a eficácia da eletroestimulação diafragmática na manutenção e ganho de força muscular em pacientes submetidos à ventilação mecânica prolongada. Foram estudados 14 pacientes, distribuídos em dois grupos (grupo-controle e grupo estimulado). O protocolo teve duração de sete dias e ambos os grupos foram acompanhados diariamente, sendo analisado, entre outros dados, a pressão inspiratória (PI). Ao término do protocolo, verificamos que o grupo-controle apresentou diminuição estatisticamente significativa da força do músculo diafragma, enquanto o grupo estimulado apresentou ganho de força muscular diafragmática. Após análise dos resultados pudemos concluir que a ventilação mecânica prolongada leva a uma diminuição significativa da força muscular diafragmática elétrica transcutânea, essa perda tende a diminuir. Sendo assim propomos uma intervenção precoce, a fim de diminuir os efeitos deletérios da ventilação mecânica sobre o músculo diafragma e melhorar a função respiratória.