Motor and respiratory functions are main challenges to patients with multiple sclerosis / Funções motoras e respiratórias representam desafios importantes para pacientes com esclerose múltipla

Abstract Introduction People with multiple sclerosis (MS) present wide and varied symptoms. Objective To investigate the impact of MS on subjects' motor and respiratory functions. Methods One hundred one participants were enrolled in this study. The subjects had previous diagnosis of relapsing-remittent MS (n = 48) or presented no neurologic diseases (n = 53, control group). Assess-ments involved mobility (Timed Get Up and Go) and balance (Berg Balance Scale) tests. A force platform was used to evaluate postural stabilometry. Respiratory functions were assessed with a portable spirometer and a digital manovacuometer. Data analyses were carried out with Student´s t-tests, chi-square, and Pearson correlation index. Significance was set at 5%. Results Compared to control peers, participants with MS showed higher motor dysfunctions affecting mobility, balance, and postural stability. Spirometry indicated normal parameters for pulmonary flows and lung capacities in both groups. The manovacuometer, differently, pointed to a respiratory muscle weakness in 48% of participants with MS. Correlation analyses highlighted that respiratory functions are more associated to dynamic than to static motor tests. Conclusion Pathological changes in MS lead to motor dysfunction on mobility, balance and postural stability. Respiratory tests showed normal pulmonary flows and lung capacities in patients with MS, but with commitment of respiratory muscle strength. Respiratory functions were more impacted by dynamic tasks rather than static motor tasks.

Resumo Introdução Pessoas com esclerose múltipla (EM) apresentam sintomas amplos e variados. Objetivo Investigar o impacto cau-sado pela EM nas funções motoras e respiratórias. Métodos Cento e um participantes foram incluídos neste estudo. Os sujeitos tinham diagnóstico prévio de EM remitente-recorrente (n = 48) ou não apresentavam doenças neurológicas (n = 53, grupo controle). As avaliações envolveram testes de mobilidade (Timed Get Up and Go) e equilíbrio (Berg Balance Scale). Uma plataforma de força foi utilizada para avaliar a estabilometria postural dos sujeitos. As funções respiratórias foram avaliadas com um espirômetro portátil e um manovacuômetro digital. A análise dos dados foi realizada pelos testes t de Student, qui-quadrado e pelo índice de correlação de Pearson. Nível de significância foi estipulado em 5%. Resultados Comparados com controles saudáveis, participantes com EM apresentaram maiores disfunções motoras que afetam mobilidade, equilíbrio e estabilidade postural. A espirometria indicou parâmetros nor-mais para fluxos pulmonares e capacidades pulmonares em ambos os grupos. A manovacuômetria, diferentemente, apontou fraqueza dos músculos respiratórios em 48% dos participantes com EM. Análises de correlação destacaram que as funções respiratórias estão mais associadas a testes motores dinâmicos do que a testes estáticos. Conclusão As alterações patológicas na EM levam à disfunção motora na mobilidade, no equilíbrio e na estabilidade postural. Os testes respiratórios mostraram padrões normais para fluxos pulmonares e capacidades pul-monares em pacientes com EM, mas com comprometimento da força muscular respiratória. As funções respiratórias foram mais afetadas por tarefas motoras dinâmicas do que por tarefas estáticas.

Effects of the breath stacking technique after upper abdominal surgery: a randomized clinical trial / Efeitos da técnica de breath stacking após cirurgia abdominal alta: ensaio clínico randomizado

ABSTRACT Objective: To evaluate the effect of the association of the breath stacking (BS) technique associated with routine physiotherapy on pulmonary function, lung volumes, maximum respiratory pressures, vital signs, peripheral oxygenation, thoracoabdominal mobility, and pain in the surgical incision in patients submitted to upper abdominal surgery during the postoperative period, as well as to analyze BS safety. Methods: This was a randomized clinical trial involving 34 patients divided into a control group (CG; n = 16), who underwent conventional physiotherapy only, and the BS group (BSG; n = 18), who underwent conventional physiotherapy and BS. Both groups performed two daily sessions from postoperative day 2 until hospital discharge. The primary outcomes were FVC and Vt. The safety of BS was assessed by the incidence of gastrointestinal, hemodynamic, and respiratory repercussions. Results: Although FVC significantly increased at hospital discharge in both groups, the effect was greater on the BSG. Significant increases in FEV1, FEV1/FVC ratio, PEF, and FEF25-75% occurred only in the BSG. There were also significant increases in Ve and Vt in the BSG, but not when compared with the CG values at discharge. MIP and MEP significantly increased in both groups, with a greater effect on the BSG. There was a significant decrease in RR, as well as a significant increase in SpO2 only in the BSG. SpO2 acutely increased after BS; however, no changes were observed in the degree of dyspnea, vital signs, or signs of respiratory distress, and no gastrointestinal and hemodynamic repercussions were observed. Conclusions: BS has proven to be safe and effective for recovering pulmonary function; improving lung volumes, maximum respiratory pressures, and peripheral oxygenation; and reducing respiratory work during the postoperative period after upper abdominal surgery.

RESUMO Objetivo: Avaliar o efeito da técnica de breath stacking (BS) associada à fisioterapia de rotina na função pulmonar, volumes pulmonares, pressões respiratórias máximas, sinais vitais, oxigenação periférica, mobilidade toracoabdominal e dor na incisão cirúrgica em pacientes no pós-operatório de cirurgia abdominal alta, bem como analisar a segurança do BS. Métodos: Trata-se de um ensaio clínico randomizado com 34 pacientes divididos em grupo controle (n = 16), que realizou apenas a fisioterapia convencional, e grupo BS (n = 18), que realizou a fisioterapia convencional e BS. Ambos os grupos realizaram duas sessões diárias desde o 2º dia do pós-operatório até a alta hospitalar. Os desfechos primários foram CVF e Vt. A segurança do BS foi avaliada pela incidência de repercussões gastrointestinais, hemodinâmicas e respiratórias. Resultados: Embora a CVF tenha aumentado significativamente no momento da alta hospitalar em ambos os grupos, o efeito foi maior no grupo BS. Aumentos significativos do VEF1, VEF1/CVF, PFE e FEF25-75% ocorreram apenas no grupo BS. Também houve aumentos significativos do Ve e do Vt no grupo BS, mas não em comparação com os valores do grupo controle no momento da alta. A PImáx e a PEmáx aumentaram significativamente em ambos os grupos, com efeito maior no grupo BS. Houve uma diminuição significativa da FR e um aumento significativo da SpO2 apenas no grupo BS. A SpO2 aumentou agudamente após o BS; entretanto, não foram observadas alterações no grau de dispneia, sinais vitais e sinais de desconforto respiratório, e não foram observadas repercussões gastrointestinais e hemodinâmicas. Conclusões: O BS mostrou-se seguro e eficaz na recuperação da função pulmonar; melhoria dos volumes pulmonares, pressões respiratórias máximas e oxigenação periférica; e redução do trabalho respiratório no pós-operatório de cirurgia abdominal alta.

Fisioterapia respiratoria en pacientes adultos post-COVID-19: revisión sistemática de la literatura / Respiratory physiotherapy in post-acute COVID-19 adult patients: Systematic review of literature

Introducción: los pacientes con SARS-CoV-2 presentan signos y síntomas que involucran principalmente el sistema respiratorio. Las secuelas son consecuencia de un deterioro de la calidad de vida, neumonía, fatiga, disnea y dolor articular. Objetivo: tener el sustento científico que permita evidenciar la importancia de la fisioterapia respiratoria y sus efectos sobre los pacientes adultos post-COVID-19 de fase aguda. Material y métodos: se hizo una revisión sistemática de la literatura en cuatro bases de datos (Scopus, Web of Science, PubMed y ScienceDirect). La búsqueda fue realizada en febrero de 2021 con un total de 1229 estudios. Finalmente, se incluyeron cinco estudios que cumplieron con los criterios de elegibilidad: dos ensayos clínicos, dos reportes de caso y un estudio transversal. La calidad metodológica de las publicaciones fue evaluada. Resultados: el entrenamiento de la musculatura respiratoria, las respiraciones dirigidas y el fortalecimiento general dan datos significativos en la mejora de la funcionalidad. La evidencia demuestra que hay efectos positivos de la fisioterapia respiratoria en pacientes adultos post-COVID-19, pues aumenta la resistencia al ejercicio, disminuye la fatiga, se reduce la disnea, mejora la funcionalidad y la calidad de vida. Conclusiones: es necesario que se desarrollen más ensayos clínicos aleatorizados y estudios de grupos de menor rango de edad y con enfoques individualizados.

Background: Patients with SARS-CoV-2 present signs and symptoms that primarily involve the respiratory system. The sequelae result in impaired quality of life, pneumonia, dyspnea, fatigue, and joint pain.

Evaluation of Lung Volume and Effect of Vital Staining as Motivation to Quit Tobacco among Nicotine Dependents of Kanpur, India

Abstract Objective: To quantify and compare respiratory functions and further screen the oral mucosa of tobacco and non-tobacco users. Material and Methods: First control group, non-tobacco users (n=55); Second group, smokers' group (n=168) who currently smoked cigarettes; Third group smokeless/chewing type, tobacco group (n=81); Fourth group, both smokeless and smoking type tobacco users (n=46). Fagerstrom Test for Nicotine Dependences (FTND) and Fagerström Test for Nicotine Dependence-Smokeless Tobacco (FTND-ST) instruments were used to assess nicotine dependence. Subsequently, spirometry and Toluidine Blue (TB) vital staining were performed. Chi-squared and one-way analysis of variance (ANOVA) were used for statistical analysis. Results: Fagerstrom test resulted in 48.8% of subjects with low dependency, followed by an increase in nicotine dependency from low to moderate (29.2%), moderate (15.6%), and highly dependent (6.4%) groups. All respiratory function tests and oral screening confirmed significant changes amongst tobacco and non-tobacco users. The forced vital capacity of non-smoker group was significantly different from other tobacco users' group (p<0.05). Conclusion: Early effects of tobacco use can lead to complications with the respiratory system and oral cavity. Such data can be used to delineate the harm of tobacco and should be used to urge individuals to evade the utilization of tobacco (AU).

Hiperinsuflação manual em crianças / Manual hyperinflation in children

RESUMO A hiperinsuflação manual é utilizada em unidades de terapia intensiva neonatal e pediátrica para promover um flow bias expiratório, porém não há consenso sobre os benefícios da técnica. Assim faz-se necessária uma revisão que apresente suas evidências. Este estudo objetiva revisar a literatura sobre a manobra de hiperinsuflação manual em unidades de terapia intensiva neonatal e pediátrica, para analisar as evidências dessa técnica em relação às formas de aplicação (associadas ou não a outras técnicas), sua segurança, o desempenho dos ressuscitadores manuais e a influência da experiência do fisioterapeuta, além de avaliar a qualidade metodológica dos artigos encontrados. Realizou-se uma busca nas bases de dados: Web of Science, ScienceDirect, PubMedⓇ, Scopus, CINAHL e SciELO. Dois pesquisadores selecionaram os artigos de forma independente. Verificaram-se os estudos duplicados, avaliados por títulos, resumos e, então, leitura na íntegra. Analisou-se a qualidade dos artigos pela escala PEDro. Foram incluídos seis artigos, sendo dois com alta qualidade metodológica. Os principais resultados trouxeram informações sobre a contribuição da válvula de pressão positiva expiratória final no aumento dos volumes pulmonares e a utilização das compressões torácicas para otimizar o flow bias expiratório, a influência negativa da experiência do operador no aumento do pico de fluxo inspiratório, o desempenho de diferentes ressuscitadores manuais durante a realização da técnica e a segurança na aplicação, com manutenção da estabilidade hemodinâmica e aumento da saturação periférica de oxigênio. Os estudos disponíveis apontam para um efeito positivo da manobra de hiperinsuflação manual realizada em crianças internadas em unidades de terapia intensiva. Registro PROSPERO: CRD42018108056.

ABSTRACT Manual hyperinflation is used in neonatal and pediatric intensive care units to promote expiratory flow bias, but there is no consensus on the benefits of the technique. Thus, a review that presents supporting evidence is necessary. This study aims to review the literature on the manual hyperinflation maneuver in neonatal and pediatric intensive care units to analyze the evidence for this technique in terms of the forms of application (associated with other techniques or not), its safety, the performance of manual resuscitators and the influence of the physical therapist's experience, in addition to evaluating the methodological quality of the identified articles. A search was performed in the following databases: Web of Science, ScienceDirect, PubMedⓇ, Scopus, CINAHL and SciELO. Two researchers independently selected the articles. Duplicate studies were assessed, evaluated by title and abstract and then read in full. The quality of the articles was analyzed using the PEDro scale. Six articles were included, two of which had high methodological quality. The main results provided information on the contribution of the positive end-expiratory pressure valve to increasing lung volumes and the use of chest compressions to optimize expiratory flow bias, the negative influence of operator experience on the increase in peak inspiratory flow, the performance of different manual resuscitators when used with the technique and the safety of application in terms of maintaining hemodynamic stability and increasing peripheral oxygen saturation. The available studies point to a positive effect of the manual hyperinflation maneuver in children who are admitted to intensive care units. Registration PROSPERO: CRD42018108056.

Pulmonary Function in Long-Term Survivors of Childhood and Adolescence Osteosarcoma: Case Report / Função Pulmonar em Sobreviventes de Osteossarcoma da Infância e Adolescência: Relato de Caso / Función Pulmonar en Sobrevivientes de Osteosarcoma en la Infancia y la Adolescencia: Relato de Caso

Introduction: Chemotherapy used in osteosarcoma have the potential to cause lung damage. The objectives were to analyze lung volumes and capacities, and respiratory muscle strength of patients treated with chemotherapy and surgery for osteosarcoma. The study was designed as a prospective case-series of patients, through the analysis of spirometry,impulse, oscillometry, and manovacuometry tests. Case report: In twenty-one patients, the median age at diagnosis was 15 years, and at inclusion, 30 years. The median disease-free survival time was 10 years. Eight different chemotherapeutic agents were used: cisplatin, doxorubicin, methotrexate, carboplatin, ifophosphamide, epidoxorubicin, cyclophosphamide and etoposide. There were test abnormalities in 14 patients (66.6%), with mild obstructive disorders on spirometry in three patients (14.3%), and obstructive patterns on oscillometry in seven patients (33.3%). On spirometry, the mean ± standard deviation (SD) values of forced vital capacity (FVC) were 91.9%±12.2; for forced expiratory volume in one second (FEV1) were 87.4%±12.2 and FEV1/FVC ratios, 95.4%±7.9. On oscillometry, mean ± SD values for resistance at 5 Hz were 126.2%±36.2; for resistance at 20 Hz, 128.4%±32.4; reactance at 5 Hz, -0.75±0.68 kPa/L/s; for resonant frequency, 15.6±4.2 Hz. Nine patients (42.8%) had reduced maximum pressures on the manovacuometry: Maximum Expiratory Pressure (MEP) were reduced in eight patients, and inspiratory (MIP) in three. The mean ± SD MIP was 89.4±29.5; MEP, 88±37.7. Conclusion: Mild abnormalities in pulmonary function tests in this series of patients were observed years after treatment for osteosarcoma

Introdução: A quimioterapia usada no osteossarcoma tem potencial para causar danos aos pulmões. Os objetivos deste trabalho foram analisar os volumes e capacidades pulmonares e a força respiratória de pacientes tratados com quimioterapia e cirurgia para osteossarcoma, em uma série prospectiva de casos, em um hospital pediátrico oncológico, por meio da análise de espirometria, oscilometria de impulso e manovacuometria. Relato de caso: Em 21 pacientes, a mediana de idade ao diagnóstico foi de 15 anos e na inclusão de 30 anos. O tempo médio de sobrevida livre de doença foi de dez anos. Houve alterações nos exames em 14 pacientes (66,6%), com distúrbios obstrutivos leves na espirometria em três pacientes (14,3%) e padrões obstrutivos na oscilometria em sete pacientes (33,3%). Na espirometria, os valores de média ± desvio padrão (DP) da capacidade vital forçada (CVF) foram 91,9%±12,2; para o volume expiratório forçado no primeiro segundo (VEF1) foram 87,4%±12,2 e as relações VEF1/CVF, 95,4%±7,9. Na oscilometria, os valores médios ± DP para resistência em 5 Hz foram 126,2%±36,2; para resistência a 20 Hz, 128,4% ± 32,4; reatância a 5 Hz, -0,75 ± 0,68 kPa/L/s; para frequência de ressonância, 15,6±4,2 Hz. Na manovacuometria, nove pacientes (42,8%) apresentaram redução nas pressões: as pressões expiratórias máximas (PEmáx) foram reduzidas em oito pacientes e as inspiratórias (PImáx) em três. A média ± DP da PImáx foi 89,4±29,5; PEmáx, 88±37,7. Conclusão: Observaram-se alterações leves nos testes de função pulmonar anos após o tratamento do osteossarcoma

Introducción: La quimioterapia utilizada en osteosarcoma puede causar daño a los pulmones. Los objetivos de este trabajo fueron analizar los volúmenes y capacidades pulmonares y la fuerza respiratoria en pacientes tratados para osteosarcoma, en una serie prospectiva de casos, en un hospital de oncología pediátrica, mediante el análisis de espirometría, oscilometría de impulsos y manuvacuometría. Relato de caso: En 21 pacientes, la mediana de edad al diagnóstico fue de 15 años y en la inclusión de 30 años. La supervivência media libre de enfermedad fue de diez años. Hubo alteraciones en los exámenes en 14 pacientes (66,6%), con alteraciones obstructivas leves en la espirometría en tres (14,3%), y obstrucción en la oscilometría en siete (33,3%). En espirometría, las medias ± desviación estándar (DE) de la capacidad vital forzada (CVF) fueron 91,9%±12,2; para el volumen espiratorio forzado en el primer segundo (VEF1) fue 87,4%±12,2 y el cociente VEF1/CVF fue 95,4%±7,9. En oscilometría, los valores medios ± DE para la resistencia a 5 Hz fueron 126,2%±36,2; para resistencia a 20 Hz, 128,4%±32,4; reactancia a 5 Hz, -0,75±0,68 kPa/L/s; para la frecuencia de resonancia, 15,6±4,2 Hz. En manuvacuometría, nueve pacientes (42,8%) mostraron una reducción de las presiones: las presiones espiratorias máximas (PEmáx) se redujeron en ocho pacientes y las presiones inspiratorias (PImáx) en tres. La media ± DE del PImáx fue 89,4 ± 29,5; PEmáx, 88±37,7. Conclusión: Se observaron ligeros cambios en las pruebas de función pulmonar años después del tratamiento del osteosarcoma

Frequência de alterações espirométricas, aprisionamento aéreo e hiperinsuflação pulmonar em crianças e adolescentes com asma grave resistente à terapia: um estudo piloto / Frequency of spirometric changes, air trapping, and lung hyperinflation in children and adolescents with therapy-resistant severe asthma: a pilot study

Objetivos: avaliar a frequência de alterações espirométricas e pletismográficas em crianças e adolescentes com asma grave resistente à terapia (AGRT). Além disso, testaram-se possíveis associações entre esses desfechos. Métodos: trata-se de um estudo retrospectivo, no qual foram incluídas crianças e adolescentes (6-18 anos), com diagnóstico de AGRT, e que se encontravam em acompanhamento ambulatorial regular. Todos deveriam possuir informações antropométricas (peso, altura, índice de massa corporal), demográficas (idade, etnia e sexo), clínicas (teste cutâneo, teste de controle da asma, tabagismo familiar e medicações em uso) e de função pulmonar (espirometria e pletismografia corporal) registradas no banco de dados do serviço. Os testes de função pulmonar seguiram as recomendações das diretrizes nacionais e internacionais. Para fins estatísticos, utilizou-se análise descritiva e o teste de qui-quadrado de Pearson. Resultados: de um total de 15 pacientes com AGRT, 12 deles foram incluídos na amostra. A média de idade foi de 12,2 anos, com predomínio do sexo feminino (66,7%). Destes, 50,0% apresentaram a doença controlada, 83,3% foram considerados atópicos e 50,0% tinham histórico de tabagismo familiar. Em relação aos testes de função pulmonar (% do previsto), as médias dos parâmetros espirométricos e de plestismografia corporal encontraram-se dentro dos limites inferiores da normalidade. Apenas 16,7% da amostra apresentou espirometria alterada (130,0%) e 16,7% hiperinsuflação pulmonar (capacidade pulmonar total>120,0%). Houve frequência estatisticamente maior (p=0,045) de aprisionamento aéreo nos participantes com espirometria alterada, em comparação à espirometria normal. Contudo, não se observou diferença (p=0,341) em relação à hiperinsuflação pulmonar. Conclusões: os achados demonstraram pouco comprometimento espirométrico e dos volumes e das capacidades pulmonares em crianças e adolescentes com AGRT. Além disso, aqueles participantes com espirometria alterada obtiveram frequência maior de aprisionamento aéreo no exame de pletismografia corporal

Aims: to assess the frequency of spirometric and plethysmographic changes in children and adolescents with severe therapy-resistant asthma (SRTA). In addition, possible associations between these outcome were tested. Methods: this is a retrospective study. Children and adolescents (6-18 years old), diagnosed with SRTA and who were in regular outpatient follow-up were included. Everyone should have anthropometric (weight, height, body mass index), demographic (age, ethnicity and gender), clinical (skin test, asthma control test, family smoking and medications in use) and pulmonary function (spirometry and body plethysmography) recorded in the service's database. Pulmonary function tests followed the recommendations of national and international guidelines. For statistical purposes, descriptive analysis and Pearson's chi-square test were used. Results: from a total of 15 patients with SRTA, 12 of them were included in the sample. The average age was 12.2 years, with a predominance of females (66.7%). Of these, 50.0% had the disease under control, 83.3% were considered atopic, and 50.0% had a family history of smoking. Regarding the pulmonary function tests (% of predicted), the means of spirometric parameters and body plestismography were within the lower limits of normality. Only 16.7% of the sample had altered spirometry (<5th percentile), 25.0% air trapping (residual volume>130.0%) and 16.7% pulmonary hyperinflation (total lung capacity>120.0%). There was a statistically higher frequency (p=0.045) of air trapping in participants with altered spirometry, compared to normal spirometry. However, there was no difference (p=0.341) in relation to pulmonary hyperinflation. Conclusions: the findings demonstrated little impairment of spirometry and lung volumes and capacities in children and adolescents with AGRT. In addition, those participants with altered spirometry had a higher frequency of air trapping in the body plethysmography exam.

Effect of tumor and normal lung volumes on the lung volume-dose parameters of IMRT in non-small-cell lung cancer

OBJECTIVES: To explore the effect of tumor and normal lung volumes on lung volume-dose parameters in patients with non-small-cell lung cancer (NSCLC) who had undergone intensity-modulated radiation therapy (IMRT). METHODS: The clinical data of 208 patients with NSCLC who underwent radical IMRT between June 2014 and June 2018 were retrospectively analyzed. A regression model curve was used to evaluate the effect of tumor and normal lung volumes on normal lung relative volumes receiving greater than 5 and 20 Gy (V5, V20), on mean lung dose (MLD), and on absolute volumes spared from greater than 5 and 20 Gy (AVS5, AVS20). RESULTS: The V5, V20, and MLD of the bilateral lung were fitted to a quadratic equation curve with the change in tumor volume, which increased initially and then decreased when the tumor volume increased. The V5, V20, and MLD of the lung reached their apex when the tumor volumes were 288.07, 341.69, and 326.83 cm3, respectively. AVS5 and AVS20 decreased in a logarithmic curve with an increase in tumor volume. The V5, V20, and MLD of the small normal lung volume group were all significantly higher than those of the large normal lung volume group (p<0.001, p=0.004, p=0.002). However, the AVS5 and AVS20 of the small normal lung volume group were all significantly lower than those of the large normal lung volume group (p<0.001). CONCLUSION: The effects of tumor volume and normal lung volume on dose-volume parameters should be considered. AVS5 is an important supplementary dose limitation parameter for patients whose tumor volume exceeds a certain boundary value (approximately 300 cm3).

Efectos fisiológicos de las terapias de soporte respiratorio no invasivo y su potencial rol postextubación / Physiological effects of non-invasive respiratory support therapies and their potential post-extubation role

Posterior a una extubación programada existe un porcentaje de pacientes que fracasa y requiere reintubación (~20%), este evento es conocido como fracaso de extubación, el cual se asocia con mayor morbimortalidad. Para prevenir el fracaso de extubación se han propuesto terapias como la ventilación no invasiva (VNI) y la cánula nasal de alto flujo (CNAF). Estas terapias son capaces de entregar soporte respiratorio postextubación y justifican su uso en los efectos fisiológicos que son capaces de inducir, en dónde el impacto sobre el esfuerzo respiratorio e intercambio de gases sería fundamental. Con esta racionalidad fisiológica se han desarrollado diversos estudios en diferentes contextos clínicos, esto con el fin de dilucidar cuál terapia es la mejor alternativa. En esta revisión narrativa pretendemos describir y analizar los diversos efectos fisiológicos que induce la VNI y la CNAF

The Clinical Efficacy of Pulmonary Hypertension-Specific Agents in Idiopathic Pulmonary Fibrosis: Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials

BACKGROUND: Pulmonary hypertension (PH) is common in patients with idiopathic pulmonary fibrosis (IPF) and is associated with poor outcomes. This study was performed to determine the clinical efficacy of PH-specific therapeutic agents for IPF patients.METHODS: We performed a systematic review and meta-analysis using MEDLINE, EMBASE, and the Cochrane Central Register. We searched randomized controlled trials (RCTs) without language restriction until November 2018. The primary outcome was all-cause mortality to end of study.RESULTS: We analyzed 10 RCTs involving 2,124 patients, 1,274 of whom received PH-specific agents. In pooled estimates, the use of PH-specific agents was not significantly associated with reduced all-cause mortality to end of study compared with controls (hazard ratio, 0.99; 95% confidence interval [CI], 0.92, 1.06; P = 0.71; I² = 30%). When we performed subgroup analyses according to the type of PH-specific agent, sample size, age, forced vital capacity, diffusion lung capacity, and the extent of honeycombing, PH-specific agents also showed no significant association with a reduction in all-cause mortality. A small but significant improvement in quality of life, measured using the St. George Respiratory Questionnaire total score, was found in the PH-specific agent group (mean difference, −3.16 points; 95% CI, −5.34, −0.97; P = 0.005; I² = 0%). We found no significant changes from baseline in lung function, dyspnea, or exercise capacity. Serious adverse events were similar between the two groups.CONCLUSION: Although PH-specific agents provided small health-related quality-of-life benefits, our meta-analysis provides insufficient evidence to support their use in IPF patients.

Compromiso pulmonar como manifestación inicial en síndrome de Sjögren primario / Pulmonary involvement as the initial manifestation in primary Sjögren's syndrome

Resumen El síndrome de Sjögren es una enfermedad autoinmune sistémica que afecta principalmente a las glándulas exocrinas, particularmente a las glándulas salivales y lagrimales, pero también puede afectar a otros órganos como la piel, y a regiones extraglandulares como el corazón, los riñones, el cerebro, el sistema hematopoyético y el pulmón. Presentamos el caso de un paciente con síndrome de Sjögren primario cuya primera manifestación de la enfermedad fue hipertensión pulmonar y enfermedad pulmonar intersticial no especificada, con ausencia de síntomas secos. El paciente recibió tratamiento con esteroides y azatioprina, con una respuesta adecuada. Además, se presenta una revisión de la literatura de las principales manifestaciones pulmonares en el síndrome de Sjögren.

Abstract Sjögren's syndrome is a systemic autoimmune disease that mainly affects the exocrine glands, particularly the salivary and the lacrimal glands, but which can also affect other organs such as the skin, and extra-glandular regions such as the heart, kidney, brain, the haematopoietic system and the lung. The case is presented of a patient with primary Sjögren's syndrome, whose first manifestation of the disease was pulmonary hypertension and a non-specific interstitial lung disease, with an absence of sicca symptoms. The patient received treatment with steroids and azathioprine, with an appropriate response. A literature review is also presented on the main pulmonary manifestations in Sjögren's syndrome.

Actualización en espirometría y curva flujo / volumen en escolares y adolescentes / School and adolescent spirometry and flow / volume curve update

Spirometry is the most commonly used test to evaluate lung function in children and adults. To obtain good quality results, several requirements must be fulfilled: professional capacity of the technician, the quality of the equipment, the patient's collaboration, the use of appropriate reference standards. The purpose of spirometry is to define types of ventilatory alterations of the central and peripheral airways, to evaluate the response to bronchodilators and to guide the presence of restrictive diseases. The new consensus of national and international experts are described, which have been perfecting several aspects of this test.

La espirometría es el examen más comúnmente utilizado para evaluar la función pulmonar en niños y adultos. Para obtener resultados de buena calidad deben cumplirse varios requisitos, desde la capacidad profesional del técnico, calidad de los equipos, colaboración del paciente y utilización de patrones de referencia adecuados. La espirometría tiene como utilidad definir alteraciones ventilatorias obstructivas de vía aérea central y periférica, evaluar respuesta a broncodilatador y orientar al diagnóstico de enfermedades restrictivas. Se describen los nuevos consensos de expertos nacionales e internacionales, los cuales han ido perfeccionando varios aspectos de este examen.

Ventilation distribution as a contributor to the functional exercise capacity in patients with systemic sclerosis-associated interstitial lung disease without pulmonary hypertension

Phenotypic differences have been described between patients with systemic sclerosis (SSc)-associated interstitial lung disease (ILD) and SSc-associated pulmonary hypertension, including performance differences in the 6-min walk test (6MWT). Moreover, the correlations between the 6MWT and traditional pulmonary function tests (PFTs) are weak, indicating the need to search for new parameters that explain exercise performance. Thus, our objective was to evaluate the impact of ventilation distribution heterogeneity assessed by the nitrogen single-breath washout (N2SBW) test and peripheral muscle dysfunction on the exercise capacity in patients with SSc-ILD and limited involvement of the pulmonary parenchyma. In this cross-sectional study, 20 women with SSc-ILD and 20 matched controls underwent PFTs (including spirometry, diffusing capacity for carbon monoxide (DLco), and the N2SBW test) and performed the 6MWT and knee isometric dynamometry. The 6-min walking distance (6MWD, % predicted) was strongly correlated with the phase III slope of the single-breath nitrogen washout (phase III slopeN2SBW) (r=−0.753, P<0.0001) and reasonably correlated with the forced vital capacity (FVC) (r=0.466, P=0.008) and DLco (r=0.398, P=0.011). The peripheral oxygen saturation (SpO2) during exercise was not significantly correlated with any of the pulmonary or muscle function parameters. The phase III slopeN2SBW was the only predictive variable for the 6MWD, whereas quadriceps strength and FVC/DLco were predictive variables for SpO2. Ventilation distribution heterogeneity is one factor that contributes to a lower 6MWD in SSc-ILD patients. In addition, muscle dysfunction and abnormal lung diffusion at least partly explain the decreased SpO2 of these patients.

Reference values for pulmonary volumes by plethysmography in a Brazilian sample of white adults / Valores de referência para volumes pulmonares por pletismografia em uma amostra brasileira de adultos da raça branca

ABSTRACT Objective: To derive reference values for healthy white Brazilian adults who have never smoked and to compare the obtained values with reference values derived by Crapo and by Neder. Methods: Reference equations by quantile regressions were derived in 122 men and 122 women, non-obese, living in seven cities in Brazil. Age ranged from 21 to 92 years in women and from 25 to 88 years in men. Lung function tests were performed using SensorMedics automated body plethysmographies according ATS/ERS recommendations. Lower and upper limits were derived by specific equations for 5 and 95 percentiles. The results were compared to those suggested by Crapo in 1982, and Neder in 1999. Results: Median values for total lung capacity (TLC) were influenced only by stature in men, and by stature and age in women. Residual volume was influenced by age and stature in both genders. Weight was directly related to inspiratory capacity and inversely with functional residual capacity and expiratory reserve volume in both genders. A comparison of observed TLC data with values predicted by Neder equations showed significant lower values by the present data. Mean values were similar between data from present study and those derived by Crapo. Conclusion: New predicted values for lung volumes were obtained in a sample of white Brazilians. The values differ from those derived by Neder, but are similar to those derived by Crapo.

RESUMO Objetivo: Derivar valores de referência para brasileiros adultos brancos saudáveis que nunca fumaram e comparar os valores obtidos com os valores de referência derivados por Crapo e por Neder. Métodos: Equações de referência por regressões quantílicas foram derivadas em 122 homens e 122 mulheres, não obesos, em sete cidades do Brasil. A idade variou entre 21 e 92 anos nas mulheres e de 25 a 88 anos nos homens. Os volumes pulmonares foram medidos por pletismógrafo de corpo automatizados SensorMedics, de acordo com as recomendações da SBPT e ATS/ERS. Os limites inferior e superior, expressos pelo percentil 5 e 95, foram derivados por equações específicas. Os resultados foram comparados aos sugeridos por Crapo em 1982 e Neder em 1999. Resultados: Os valores medianos para a capacidade pulmonar total (CPT) foram influenciados apenas pela estatura nos homens, e pela estatura e idade nas mulheres. O volume residual foi influenciado pela idade e estatura em ambos os sexos. O peso se correlacionou diretamente com a capacidade inspiratória e inversamente com a capacidade residual funcional e com o volume de reserva expiratório em ambos os sexos. A CPT observada, comparada com os valores previstos pela equação de Neder, foi significativamente menor. Os valores médios foram semelhantes entre os dados do presente estudo e os de Crapo. Conclusões: Novos valores previstos para os volumes pulmonares foram obtidos em uma amostra de brasileiros de raça branca. Os valores diferem daqueles derivados por Neder, mas são semelhantes aos derivados por Crapo.

Comparative Analysis of Lung Perfusion Scan and SPECT/CT for the Evaluation of Functional Lung Capacity / 대한핵의학회잡지

PURPOSE: This study aimed to compare lung perfusion scan with single photon emission computed tomography/computed tomography (SPECT/CT) for the evaluation of lung function and to elucidate the most appropriate modality for the prediction of postoperative lung function in patients with lung cancer.METHODS: A total of 181 patients underwent Tc-99m macroaggregated albumin lung perfusion scan and SPECT/CT to examine the ratio of diseased lung and diseased lobe. Forty-one patients with lung cancer underwent both preoperative and postoperative pulmonary function tests within 1 month to predict postoperative pulmonary function. Predicted postoperative forced expiratory volume in 1 s (ppoFEV₁) was calculated by the % radioactivity of lung perfusion scan and SPECT, and the % volume of the residual lung, assessed on CT.RESULTS: The ratios of diseased lung as seen on lung perfusion scan and SPECT showed significant correlation, but neither modality correlated with CT. The ratios of the diseased lung and diseased lobe based on CT were higher than the ratios based on either perfusion scan or SPECT, because CT overestimated the function of the diseased area. The lobar ratio of both upper lobes was lower based on the perfusion scan than on SPECT but was higher for both lower lobes. Actual postoperative FEV₁ showed significant correlation with ppoFEV₁ based on lung perfusion SPECT and perfusion scan.CONCLUSIONS: We suggest SPECT/CT as the primary modality of choice for the assessment of the ratio of diseased lung area. Both perfusion scan and SPECT/CT can be used for the prediction of postoperative lung function.

Intervenções fisioterapêuticas na função pulmonar em pacientes submetidos a cirurgia bariátrica / Physiotherapeutic interventions in pulmonary function of patients submitted to bariatric surgery

O objetivo desta pesquisa foi buscar na literatura evidências sobre intervenções utilizadas pela fisioterapia em pacientes submetidos a cirurgia bariátrica. Métodos: As buscas foram realizadas nos meses de janeiro e fevereiro de 2018, através do acesso online em bases de dados: Pubmed/Medline, PEDro, Scielo e Lilacs. Utilizou estratégia PICo, onde foram definidos: População (P): Obesidade Mórbida; Interesse (I): Prática baseada em evidências; Contexto (Co): estudos de intervenções. Resultados: Através das estratégias de busca foram encontrados 951 artigos. Após leitura dos resumos, observados critérios de inclusão e exclusão, foram excluí­dos um total de 901, restando 50 artigos que foram lidos na í­ntegra e, em seguida, elegeram-se 10 estudos. As evidências das intervenções do treinamento muscular respiratório podem ser observadas nos ensaios clí­nicos contendo bom rigor metodológico. O treinamento muscular respiratório pode ser considerado como uma intervenção, juntamente com outras terapêuticas (dois ní­veis de pressão ­ Bilevel) que compõem o tratamento de pacientes submetidos í cirurgia bariátrica, auxiliando na obtenção de resultados satisfatórios. Conclusão: O ní­vel de evidência atualmente disponí­veis do impacto das intervenções fisioterapêuticas, como o treinamento muscular respiratório, na função pulmonar de pacientes submetidos í cirurgia bariátrica se mostrou alto. A análise metodológica realizada neste estudo mostrou poucos números de estudos de ensaios clí­nicos, retratando a real necessidade de novos estudos que possam integrar a pratica clí­nica. (AU)

The objective of this study was to search in the literature for evidence on interventions used by physical therapy in patients undergoing bariatric surgery. Methods: The study was performed in January and February 2018, through online access in databases: Pubmed/Medline, PEDro, Scielo and Lilacs. It was used the PICo strategy, and it was defined: Population (P): Morbid Obesity; Interest (I): Evidence-based practice; Context (Co): intervention studies. Results: We found 951 articles. After reading the abstracts and observing inclusion and exclusion criteria, a total of 901 were excluded, remaining 50 articles that were read in full, and then 10 studies were chosen. Evidence from respiratory muscle training interventions can be observed in clinical trials with good methodological rigor. Respiratory muscular training can be considered as an intervention, along with other therapeutics (two levels of pressure - Bilevel) that make up the treatment of patients undergoing bariatric surgery, helping to obtain satisfactory results. Conclusion: The level of evidence currently available on the impact of physiotherapeutic interventions, like respiratory muscular training, on lung function in patients undergoing bariatric surgery was high. The methodological analysis performed in this study showed few clinical trial studies, showing the real need for new studies that could integrate clinical practice. (AU)

Función pulmonar en pacientes con distrofia muscular de Duchenne / Lung function in patients with Duchenne muscular dystrophy

Duchenne Muscular Dystrophy (DMD) is a neuromuscular disease characterized by progressive respiratory impairment, so early assessment of lung function is important to prevent complications, establish the advance of the disease and decide which therapeutic interventions should be made. In this review, the following pulmonary function tests are mentioned: spirometry, lung volumes, maximum mouth pressure, peak cough flow, maximum voluntary ventilation and impulse oscillometry.

La Distrofia Muscular de Duchenne (DMD) es una enfermedad neuromuscular (ENM) con compromiso respiratorio progresivo, por lo que la evaluación precoz de la función pulmonar es importante tanto para prevenir complicaciones, definir la progresión de la enfermedad y decidir la implementación de intervenciones terapéuticas. En esta revisión se mencionan las siguientes pruebas de función de pulmonar: espirometría, volúmenes pulmonares, presiones máximas en boca, peak flow de tos, ventilación voluntaria máxima y oscilometría de impulso.

Effect of Scapular Brace on the Pulmonary Function and Foot Pressure of Elderly Women with Forward Head Posture

PURPOSE: Changes in the curvature of the vertebral columns of elderly women with increasing age causes various side effects and disorders. Therefore, this study was conducted to evaluate the effectiveness of the 8-figure scapular brace to improve pulmonary function and balance ability based on lung capacity and foot pressure by increasing the vertebral curvature. METHODS: Seventeen elderly women with a forward head posture were selected. Women were asked to wear the 8-figure scapular brace and the forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were measured, as were changes in foot pressure. Measurements were conducted three times each and the mean values were used for subsequent analyses. For static evaluation, we used the paired t-test to identify differences between pre and post values. RESULTS: There was no significant difference in FEV1 and FVC before and after use of the brace (p>0.05); however, there was a significant decrease in forefoot pressure and an increase in rearfoot pressure following application of the brace (p < 0.05). CONCLUSION: Application of the 8-figure scapular brace to correct vertebral curvature in elderly women influenced pressure distribution change from immediate effect body arrange of cervical and thoracic. However, wearing the 8-figure scapular brace may interfere with expansion of the chest and therefore respiratory muscle activity. Accordingly, it is necessary to apply appropriate treatment when wearing a scapular brace and to allow a sufficient intervention period while also providing therapeutic interventions such as posture correction or respiration training.

Nitrogen single-breath washout test for evaluating exercise tolerance and quality of life in patients with chronic obstructive pulmonary disease

Pulmonary function tests (PFTs) traditionally used in clinical practice do not accurately predict exercise intolerance in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to assess whether the nitrogen single-breath washout (N2SBW) test explains exercise intolerance and poor quality of life in stable COPD patients. This cross-sectional study included 31 patients with COPD subjected to PFTs (including the N2SBW test) and a cardiopulmonary exercise test (CPET). Patients were also evaluated using the following questionnaires: the COPD assessment test (CAT), the 36-Item Short Form Health Survey (SF36) and St. George's Respiratory Questionnaire (SGRQ). Peak oxygen uptake (peak VO2) was negatively correlated with the phase III slope of the N2SBW (SIIIN2) (r=-0.681, P<0.0001) and positively correlated with forced expiratory volume in one second (FEV1; r=0.441, P=0.013). Breathing reserve was negatively correlated with SIIIN2, closing volume/vital capacity, and residual volume (RV) (r=-0.799, P<0.0001; r=-0.471, P=0.007; r=-0.401, P=0.025, respectively) and positively correlated with FEV1, forced vital capacity (FVC) and FEV1/FVC (r=0.721; P<0.0001; r=0.592, P=0.0004; r=0.670, P<0.0001, respectively). SIIIN2 and CAT were independently predictive of VO2 and breathing reserve at peak exercise. RV, FVC, and FEV1 were independently predictive of the SF36-physical component summary, SF36-mental component summary, and breathing reserve, respectively. The SGRQ did not present any independent variables that could explain the model. In stable COPD patients, inhomogeneity of ventilation explains a large degree of exercise intolerance assessed by CPETs and, to a lesser extent, poor quality of life.