Association of IGF-1 and IGF-2 genotypes with respiratory muscle strength in individuals with COPD: a cross-sectional study / Asociación de los genotipos de IGF-1 e IGF-2 con la fuerza muscular respiratoria en individuos con EPOC: estudio transversal

INTRODUCTION: Chronic obstructive pulmonary disease is a systemic disease characterized not only by respiratory symptoms but also by physical deconditioning and muscle weakness. One prominent manifestation of this disease is the decline in respiratory muscle strength. Previous studies have linked the genotypes of insulin-like growth factor 1 and 2 (IGF-1 and IGF-2) to muscle weakness in other populations without this disease. However, there is a notable knowledge gap regarding the biological mechanisms underlying respiratory muscle weakness, particularly the role of IGF-1 and IGF-2 genotypes in this pulmonary disease. Therefore, this study aimed to investigate, for the first time, the association between IGF-1 and IGF-2 genotypes with respiratory muscle strength in individuals with chronic obstructive pulmonary disease. In addition, we analyzed the relationship between oxidative stress, chronic inflammation, and vitamin D with respiratory muscle strength. METHODS: A cross sectional study with 61 individuals with chronic obstructive pulmonary disease. Polymerase chain reaction of gene polymorphisms IGF-1 (rs35767) and IGF-2 (rs3213221) was analyzed. Other variables, related to oxidative stress, inflammation and Vitamin D were dosed from peripheral blood. Maximal inspiratory and expiratory pressure were measured. RESULTS: The genetic polymorphisms were associated with respiratory muscle strength ( 3.0 and 3.5; = 0.57). Specific genotypes of IGF-1 and IGF-2 presented lower maximal inspiratory and expiratory pressure (<0.05 for all). Oxidative stress, inflammatory biomarkers, and vitamin D were not associated with respiratory muscle strength. CONCLUSION: The polymorphisms of IGF-1 and IGF-2 displayed stronger correlations with respiratory muscle strength compared to blood biomarkers in patients with chronic obstructive pulmonary disease. Specific genotypes of IGF-1 and IGF-2 were associated with reduced respiratory muscle strength in this population.

INTRODUCCIÓN: La enfermedad pulmonar obstructiva crónica es una enfermedad sistémica caracterizada no solo por síntomas respiratorios, sino también por el deterioro físico y la debilidad muscular. Una manifestación destacada de esta enfermedad es el declive en la fuerza de los músculos respiratorios. Estudios previos han vinculado los genotipos de factor de crecimiento insulínico 1 y 2 (IGF-1 e IGF-2) con la debilidad muscular en poblaciones sin esta enfermedad. Sin embargo, existe un vacío de conocimiento con respecto a los mecanismos biológicos subyacentes a la debilidad de los músculos respiratorios, en particular el papel de los genotipos IGF-1 e IGF-2 en esta enfermedad pulmonar. Por lo tanto, este estudio tuvo como objetivo investigar, por primera vez, la asociación de los genotipos IGF-1 e IGF-2 con la fuerza de los músculos respiratorios en individuos con enfermedad pulmonar obstructiva crónica. Además, analizamos la relación entre el estrés oxidativo, la inflamación crónica y la vitamina D con la fuerza de los músculos respiratorios. MÉTODOS: Un estudio transversal con 61 individuos con enfermedad pulmonar obstructiva crónica. Se analizó la reacción en cadena de la polimerasa de los polimorfismos genéticos IGF-1 (rs35767) e IGF-2 (rs3213221). Otras variables relacionadas con el estrés oxidativo, la inflamación y la vitamina D se dosificaron a partir de muestras de sangre periférica. Se midieron las presiones inspiratorias y espiratorias máximas. RESULTADOS: Los polimorfismos genéticos están asociados con la fuerza de los músculos respiratorios (F: 3.0 y 3.5; R2= 0.57). Genotipos específicos de IGF-1 e IGF-2 presentaron bajos valores en las presiones inspiratorias y espiratorias (p<0.05 en todos los casos). El estrés oxidativo, los biomarcadores inflamatorios y la vitamina D no se asociaron con la fuerza de los músculos respiratorios. CONCLUSIÓN: Los polimorfismos de IGF-1 e IGF-2 mostraron correlaciones más sólidas con la fuerza de los músculos respiratorios en pacientes con enfermedad pulmonar obstructiva crónica en comparación con los biomarcadores sanguíneos. Genotipos específicos de IGF-1 e IGF-2 se asociaron con una disminución de la fuerza de los músculos respiratorios en esta población.

Screening tool for restrictive and obstructive ventilatory abnormalities in a population-based survey

Abstract Background: A 6 s spirometry with an inexpensive pocket spirometer efficiently selects individuals for a diagnostic-quality spirometry for airflow limitation, but could also be useful to identify individuals with a restrictive pattern. Objectives: We evaluated an inexpensive simplified spirometer (chronic obstructive pulmonary disease [COPD]-6) as a screening tool to identify spirometric abnormalities. Methods: A population-based survey in Mexico City, with 742 participants performing pre- and post-BD spirometry and a three-maneuver 6 s spirometry (pre-BD) with a COPD-6. We evaluated forced expiratory volume in 1 s (FEV1), FEV6, and FEV1/FEV6 from the COPD-6, crude and expressed as the percentage of predicted (%P), to discriminate post-bronchodilator airflow obstruction (FEV1/forced vital capacity [FVC] <5th percentile) or restriction (FVC or FEV1 <5th percentile with normal FEV1/FVC) through receiver operating characteristics and their area under the curve (AUC). Results: FEV1%P was the best predictor to identify pre- and post-BD ventilatory abnormalities (best cutoff point 87%P, AUC 92% for restrictive pattern, 89% for obstructive pattern, and 91% for any spirometric abnormality). Deriving to clinical spirometry only those with <87%P (26% of the sample) missed only 12% of spirometric abnormalities most of the latter mild. Conclusions: An FEV1 <87%P from a pre-BD 6 s spirometry correctly identified individuals with spirometric ventilatory defects, either obstructive or restrictive.

Correlação entre a diferença da capacidade vital lenta e forçada com a atividade física na vida diária em pacientes com Doença Pulmonar Obstrutiva Crônica / Correlación entre la diferencia en la capacidad vital lenta y forzada con la actividad física en la vida diaria de pacientes con Enfermedad Pulmonar Obstructiva Crónica / Relationship between the difference of slow and forced vital capacity and physical activity in daily life in patients with Chronic Obstructive Pulmonary Disease

RESUMO O objetivo do estudo foi correlacionar a diferença entre capacidade vital lenta (CVL) e capacidade vital forçada (CVF) (CVL-CVF) com a atividade física na vida diária (AFVD) em pacientes com doença pulmonar obstrutiva crônica (DPOC); e verificar as diferenças na AFVD entre indivíduos com CVL maior ou menor do que a CVF. Vinte e oito indivíduos com DPOC (18 homens; 67±8 anos; VEF1: 40±13% previsto) tiveram a função pulmonar avaliada pela espirometria e foram divididos em dois grupos: CVL>CVF (n=17) e CVL≤CVF (n=11). Ademais, tiveram a AFVD avaliada objetivamente pelo monitor de atividade física DynaPort®, que quantifica na vida diária, dentre outros, o tempo gasto por dia andando, em pé, sentado e deitado. Não foram encontradas correlações significativas entre CVL-CVF e as variáveis da AFVD no grupo geral. No grupo CVL>CVF foi encontrada significância estatística na correlação entre a CVL-CVF e o tempo gasto por dia em pé (r=−0,56) e sentado (r=0,75). Já no grupo CVL≤CVF, houve correlação significativa somente com o tempo gasto por dia em pé (r=0,57) e deitado (r=−0,62). Ao comparar ambos os grupos, não houve diferença estatisticamente significante para nenhuma das variáveis da AFVD (p>0,05 para todas). No grupo com CVL maior que a CVF houve correlação alta com o tempo gasto sentado, mas não com o tempo andando. Portanto, indivíduos com maior obstrução ao fluxo aéreo segundo a diferença CVL-CVF tendem a gastar mais tempo em atividades de menor gasto energético, que não envolvam caminhar.

RESUMEN El presente estudio tuvo el objetivo de correlacionar la diferencia entre la capacidad vital lenta (CVL) y la capacidad vital forzada (CVF) (CVL-CVF) con la actividad física en la vida diaria (AFVD) de pacientes con enfermedad pulmonar obstructiva crónica (EPOC); y verificar las diferencias de la AFVD entre individuos con CVL mayor o menor que la CVF. Se evaluaron la función pulmonar de veintiocho personas con EPOC (18 hombres; 67±8 años; VEF1: 40±13% esperado) mediante espirometría, y los dividieron en dos grupos: CVL>CVF (n=17) y CVL≤CVF (n=11). La AFVD también se evaluó objetivamente por el monitor de actividad física DynaPort®, el cual cuantifica el tiempo que se gasta en la vida diaria caminando, de pie, sentado y acostado. No se encontraron correlaciones significativas entre CVL-CVF y las variables de la AFVD en el grupo general. En el grupo CVL>CVF, se encontró una significación estadística en la correlación entre CVL-CVF y el tiempo que se gasta diariamente en pie (r=−0,56) y sentado (r=0,75). El grupo CVL≤CVF presentó una correlación significativa solo con el tiempo que se gasta diariamente en pie (r=0,57) y acostado (r=−0,62). La comparación entre ambos grupos no resultó en diferencias estadísticamente significativas en ninguna de las variables de AFVD (p>0,05 para todas). En el grupo con CVL mayor que la CVF, hubo una alta correlación con el tiempo que se gasta sentado, pero con el tiempo que se gasta caminando no se encontró este resultado. Se concluye que las personas con una mayor obstrucción del flujo de aire de acuerdo con la diferencia CVL-CVF tienden a gastar más tiempo en actividades con menos gasto de energía, las que no implican caminar.

ABSTRACT The aim of this study was to correlate the difference of vital capacity (VC) and forced vital capacity (FVC) (VC-FVC) with physical activity in daily life (PADL) in patients with chronic obstructive pulmonary disease (COPD); and investigate the differences in PADL in individuals with VC smaller or greater than FVC. Twenty-eight patients with COPD (18 men, 67±8 years; FEV1: 40±13% predicted) had their lung function assessed by spirometry and were divided into two groups: VC>FVC (n=17) and VC≤CVF (n=11). Furthermore, they had their PADL evaluated by a validated activity monitor which measures, among other variables, time spent/day walking, standing, sitting and lying. There were no correlations between VC-FVC and the variables of PADL in the general group. In the group VC>FVC there was statistically significant correlation between VC-FVC and the time spent/day standing (r=−0.56) and sitting (r=0.75). In the group VC≤CVF , VC-FVC was significantly correlated with time spent/day standing (r=0.57) and lying (r=−0.62). When comparing the groups, there was no statistically significant difference for any variable of PADL (p>0.05 for all). In conclusion, in patients with VC greater than FVC there was high correlation with time spent/day sitting, but not with time spent/day walking. Therefore, individuals with greater airflow obstruction according to the VC-FVC difference tend to spend more time in activities of lower energy expenditure, which do not involve walking.

Effects of high- and moderate-intensity exercise on central hemodynamic and oxygen uptake recovery kinetics in CHF-COPD overlap

The oxygen uptake (V˙O2) kinetics during onset of and recovery from exercise have been shown to provide valuable parameters regarding functional capacity of both chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) patients. To investigate the influence of comorbidity of COPD in patients with CHF with reduced ejection fraction on recovery from submaximal exercise, 9 CHF-COPD male patients and 10 age-, gender-, and left ventricle ejection fraction (LVEF)-matched CHF patients underwent constant-load exercise tests (CLET) at moderate and high loads. The V˙O2, heart rate (HR), and cardiac output (CO) recovery kinetics were determined for the monoexponential relationship between these variables and time. Within-group analysis showed that the recovery time constant of HR (P<0.05, d=1.19 for CHF and 0.85 for CHF-COPD) and CO (P<0.05, d=1.68 for CHF and 0.69 for CHF-COPD) and the mean response time (MRT) of CO (P<0.05, d=1.84 for CHF and 0.73 for CHF-COPD) were slower when moderate and high loads were compared. CHF-COPD patients showed smaller amplitude of CO recovery kinetics (P<0.05) for both moderate (d=2.15) and high (d=1.07) CLET. Although the recovery time constant and MRT means were greater in CHF-COPD, CHF and CHF-COPD groups were not differently affected by load (P>0.05 in group vs load analysis). The ventilatory efficiency was related to MRT of V˙O2 during high CLET (r=0.71). Our results suggested that the combination of CHF and COPD may further impair the recovery kinetics compared to CHF alone.

Evaluating the disease and treatment information provided to patients with chronic obstructive pulmonary disease at the time of discharge according to GOLD discharge guidelines / Avaliação da doença e informações sobre tratamento fornecidas a pacientes com doença pulmonar obstrutiva crônica no momento da alta, de acordo com diretrizes GOLD para alta hospitalar

ABSTRACT Objective To evaluate the disease and treatment information provided to patients with chronic obstructive pulmonary disease at hospital discharge. Methods This was a cross-sectional study including hospitalized patients with chronic obstructive pulmonary disease at three tertiary hospitals. The study was based on seven items of the Global Initiative for Obstructive Lung Disease (GOLD) discharge guidelines. Two hospitals in this study had a Medical Residency Program in Pulmonology, and one did not have the program. Results Fifty-four patients were evaluated. Large amounts of information were provided concerning effective pharmacological maintenance (item 1), blood gas evaluation/measurement of oxygen saturation (item 2), assessment of inhalation technique (item 4), and maintenance therapy (item 5). Less information was provided regarding comorbidity management planning (item 3), the completion of antibiotic/corticosteroid therapy (item 6) and follow-up with the attending physician or specialist (item 7) had less information. We observed significant differences between hospitals for items 1, 4 and 7, and better performance in hospitals with medical residency in pulmonology. Conclusion Hospitalized patients with chronic obstructive pulmonary disease received little to no information about the seven items addressed by GOLD discharge guidelines. This finding suggests that these guidelines should be used more often by clinicians in hospital with or without medical residency in pulmonology. The lack of specialized care resulted in insufficient amount of information for patients with chronic obstructive pulmonary disease at discharge.

RESUMO Objetivo Avaliar informações sobre a doença e o tratamento fornecidos a pacientes com doença pulmonar obstrutiva crônica no momento da alta hospitalar. Métodos Estudo transversal incluindo pacientes internados com doença pulmonar obstrutiva crônica de três hospitais terciários. O estudo baseou-se em sete itens das diretrizes de alta hospitalar da Global Initiative for Obstructive Lung Disease (GOLD). Dois hospitais participantes deste estudo tinham um Programa de Residência Médica em Pneumologia, e o terceiro não tinha. Resultados Foram avaliados 54 pacientes. Muitas informações foram fornecidas em relação à manutenção farmacológica efetiva (item 1), avaliação de gasometria/medida da saturação de oxigênio (item 2), avaliação da técnica de inalação (item 4) e terapia de manutenção (item 5). Foram fornecidas menos informações em relação ao planejamento do manejo de comorbidade (item 3), a realização de antibioticoterapia/corticoterapia (item 6) e seguimento com o médico assistente ou especialista (item 7). Observaram-se diferenças significativas entre os hospitais para os itens 1, 4 e 7, e melhor desempenho nos hospitais com Programa de Residência Médica em Pneumologia. Conclusão Pacientes hospitalizados com doença pulmonar obstrutiva crônica receberam pouca ou nenhuma informação relacionada aos sete itens abordados pelas diretrizes da GOLD para alta. Esses achados sugerem que essas diretrizes deveriam ser utilizadas com maior frequência por clínicos em hospitais com ou sem Programa Residência Médica em Pneumologia. A falta de atendimento especializado resultou em informação insuficiente para pacientes com doença pulmonar obstrutiva crônica na alta hospitalar.

Qual o melhor protocolo e ponto de corte no teste 4-metre gait speed para discriminar capacidade de exercício na Doença Pulmonar Obstrutiva Crônica? / Which is the best protocol and cut-off point in the 4-metre gait speed test to discriminate exercise capacity in COPD?

RESUMO Objetivo Verificar o poder discriminativo e o ponto de corte de diferentes protocolos do teste 4-metre gait speed (4MGS) para identificar capacidade de exercício preservada ou reduzida no teste de caminhada de 6 minutos (TC6min) em pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC); comparar os protocolos do 4MGS; e comparar as características dos indivíduos de acordo com o melhor ponto de corte encontrado. Métodos Foram avaliados 56 pacientes com DPOC. Todos os pacientes foram submetidos à avaliação das características antropométricas, função pulmonar (espirometria) e capacidade funcional de exercício (TC6min e 4 protocolos do 4MGS). No teste 4MGS, os pacientes foram instruídos a caminhar em velocidade usual e máxima em percursos de 4 metros (4MGS 4m - usual e máximo) e 8 metros (4MGS 8m - usual e máximo). Resultados Somente o protocolo 4MGS 4m-máximo foi capaz de identificar capacidade de exercício preservada no TC6min (AUC=0,70) com correlação moderada entre os testes (r=0,52; P<0,0001). O ponto de corte encontrado no 4MGS 4m-máximo foi de 1,27 m/s. Os pacientes com capacidade de exercício preservada (4MGS 4m-máximo ≥1,27m/s) atingiram maior distância percorrida no TC6min em %predito (91±2 vs 76±3; P<0,0001). Nas outras comparações envolvendo gênero, IMC, VEF1%pred e índice GOLD não ocorreram diferenças significantes entre os grupos. Além disso, a concordância de indivíduos classificados com capacidade de exercício preservada e reduzida no TC6min e no 4MGS 4m-máximo foi significante (P=0,008). Conclusão O teste 4MGS 4m-máximo pode ser utilizado para discriminar capacidade de exercício preservada em pacientes com DPOC, e se correlaciona com o TC6min.

ABSTRACT Objective To determine the discriminative capacity and cut-off point of different 4-metre gait speed test (4MGS) protocols in identifying preserved or reduced exercise capacity using the six-minute walk test (6MWT) in patients with Chronic Obstructive Pulmonary Disease (COPD); also, to compare 4MGS protocols and characteristics of individuals according to the best cut-off point. Methods We evaluated fifty-six patients with COPD, all of which were submitted to the assessment of anthropometric characteristics, pulmonary function (spirometry) and functional exercise capacity (6MWT and four protocols of the 4MGS). In the 4MGS test, patients were instructed to walk at normal pace and at maximum speed in a 4 meters course (4MGS 4m - usual pace and at maximum) and 8 meters course (4MGS 8m - usual pace and at maximum). Results Only the 4MGS 4m-maximum protocol was able to identify preserved exercise capacity in the 6MWT (AUC=0.70) with moderate correlation between them (r=0.52; P=0<0.0001). The cut-off point found in the 4MGS 4m-maximum was 1.27 m/s. Patients with preserved exercise capacity (4MGS 4m-maximum ≥1.27m/s) walker greater distances on the 6MWT in %pred (91±2 vs 76±3; P<0.0001). In the other comparisons involving gender, BMI, FEV1% pred and GOLD index there were no significant differences between the groups. In addition, the agreement of individuals classified as preserved and reduced exercise capacity in the 6MWT and 4MGS 4m-maximum was significant (P = 0.008). Conclusion The 4MGS 4m-maximum test can be used to discriminate preserved exercise capacity in patients with COPD and correlates with the 6MWT.

Avaliação do ventrículo esquerdo em pacientes com DPOC e hipoxemia noturna / Evaluation of the left ventricle in patients with COPD and nocturnal hypoxemia

RESUMO Objetivo Verificar a associação entre massa e espessura do ventrículo esquerdo (VE) e presença de hipoxemia noturna significativa em pacientes portadores de DPOC com hipoxemia diurna leve. Métodos Estudo transversal realizado em pacientes ambulatoriais, clinicamente estáveis, portadores de DPOC e hipoxemia leve (saturação de oxigênio ≥ 90 a ≤ 94%, identificados por oximetria não invasiva) em um centro clínico especializado no atendimento de doenças respiratórias em Goiânia (GO). Todos foram submetidos a avaliação clínica, espirometria, polissonografia, ecocardiografia, gasometria arterial, teste de caminhada de 6 minutos e radiografia de tórax. Resultados Foram avaliados 64 pacientes com DPOC e hipoxemia noturna. Pacientes com hipoxemia noturna significativa apresentaram parâmetros ecocardiográficos associados a mais quantidade de musculatura do VE quando comparados a pacientes com hipoxemia noturna leve. A relação entre volume/massa do VE foi significativamente menor no grupo com hipoxemia noturna significativa (0,64 ± 0,13 versus 0,72 ± 0,12; p = 0,04) e a espessura diastólica do septo interventricular e a espessura diastólica da parede posterior do VE foram significativamente maiores nesse grupo (9,7 ± 0,92 versus 9,1 ± 0,90; p = 0,03) (9,7 ± 1,0 versus 8,9 ± 1,0; p = 0,01). O tempo de sono REM com saturação abaixo de 85% prediz significativamente a espessura do septo (ajuste para índice de massa corporal [IMC], idade e pressão arterial média; r2 = 0,20; p = 0,046). Conclusão Em indivíduos portadores de DPOC e hipoxemia noturna significativa, foi observada associação entre hipoxemia severa no sono REM e parâmetros ecocardiográficos que indicam aumento da massa do VE. Tal fato sugere que esse subgrupo de indivíduos pode se beneficiar de uma avaliação ecocardiográfica do VE.

ABSTRACT Objective To verify association between left ventricular (LV) mass and thickness and the presence of significant nocturnal hypoxemia in patients with COPD with mild diurnal hypoxemia. Methods A cross-sectional study carried out in clinically stable outpatients with COPD and mild hypoxemia (oxygen saturation ≥90 to ≤94%, identified by noninvasive oximetry) in a clinic specialized in the treatment of respiratory diseases in Goiânia-GO. All patients were submitted to clinical evaluation, spirometry, polysomnography, echocardiography, arterial blood gas analysis, 6-minute walk test and chest X-ray. Results Patients with significant nocturnal hypoxemia had echocardiographic parameters associated with increase of LV musculature when compared to patients with mild nocturnal hypoxemia. The LV volume/mass ratio was significantly lower in the group with significant nocturnal hypoxemia (ratio 0.64 ± 0.13 versus 0.72 ± 0.12, p = 0.04), the thickness diastolic diameter of the interventricular septum and the diastolic thickness of the LV posterior wall were significantly higher in this group (9.7 ± 0.92 versus 9.1 ± 0.90 p = 0.03), (9.7 ± 1.0 versus 8.9 ± 1.0, p = 0.01. The time in REM sleep with saturation below 85% significantly predicted septum thickness (adjustment for BMI, age and mean blood pressure, r2 = 0.20; p = 0.046). Conclusion We observed association between severe REM sleep hypoxemia and echocardiographic parameters indicating increased LV mass in individuals with COPD and significant nocturnal hypoxemia. This suggests that this subgroup of individuals may benefit from an echocardiographic evaluation of the left ventricle.

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.

The Brazilian Portuguese-language version of the Manchester Respiratory Activities of Daily Living questionnaire: construct validity, reliability, and measurement error / Versão em português do Brasil do questionário Manchester Respiratory Activities of Daily Living: validade de construto, confiabilidade e erro de medida

ABSTRACT Objective: To test the construct validity, reliability, and measurement error of the Brazilian Portuguese-language version of the Manchester Respiratory Activities of Daily Living (MRADL) questionnaire in patients with COPD. Methods: We evaluated 50 patients with COPD, among whom 30 were men, the mean age was 64 ± 8 years, and the median FEV1 as a percentage of the predicted value (FEV1%predicted) was 38.4% (interquartile range, 29.1-57.4%). Pulmonary function and limitations in activities of daily living (ADLs) were assessed by spirometry and by face-to-face application of the MRADL, respectively. For the construct validity analysis, we tested the hypothesis that the total MRADL score would show moderate correlations with spirometric parameters. We analyzed inter-rater reliability, test-retest reliability, inter-rater measurement error, and test-retest measurement error. Results: The total MRADL score showed moderate correlations with the FEV1/FVC ratio, FEV1 in liters, FEV1%predicted, and FVC%predicted, all of the correlations being statistically significant (r = 0.34, r = 0.31, r = 0.42, and r = 0.38, respectively; p < 0.05 for all). For the reliability and measurement error of the total MRADL score, we obtained the following inter-rater and test-retest values, respectively: two-way mixed-effects model intraclass correlation coefficient for single measures, 0.92 (95% CI: 0.87-0.96) and 0.89 (95% CI: 0.81-0.93); agreement standard error of measurement, 1.03 and 0.97; smallest detectable change at the individual level, 2.86 and 2.69; smallest detectable change at the group level, 0.40 and 0.38; and limits of agreement, −2.24 to 1.96 and −2.65 to 2.69. Conclusions: In patients with COPD in Brazil, this version of the MRADL shows satisfactory construct validity, satisfactory inter-rater/test-retest reliability, and indeterminate inter-rater/test-retest measurement error.

RESUMO Objetivo: Testar a validade de construto, a confiabilidade e o erro de medida da versão em português do Brasil do questionário Manchester Respiratory Activities of Daily Living (MRADL) em pacientes com DPOC. Métodos: Avaliamos 50 pacientes com DPOC, 30 dos quais eram homens. A média de idade foi de 64 ± 8 anos, e a mediana do VEF1 em porcentagem do previsto (VEF1%previsto) foi de 38,4% (intervalo interquartil: 29,1-57,4%). A função pulmonar e limitações experimentadas durante a realização de atividades cotidianas foram avaliadas por meio de espirometria e da aplicação presencial do MRADL, respectivamente. Para a análise de validade de construto, testamos a hipótese de que haveria correlações moderadas entre a pontuação total no MRADL e parâmetros espirométricos. Analisamos a confiabilidade e o erro de medida entre avaliadores e entre teste e reteste. Resultados: Houve correlações moderadas e estatisticamente significativas entre a pontuação total no MRADL e VEF1/CVF, VEF1 em litros, VEF1%previsto e CVF%previsto (r = 0,34, r = 0,31, r = 0,42 e r = 0,38, respectivamente; p < 0,05 para todas). No tocante à confiabilidade e ao erro de medida para a pontuação total no MRADL entre avaliadores e entre teste e reteste, respectivamente, foram obtidos os seguintes valores: coeficiente de correlação intraclasse de duas vias e efeitos mistos para medidas únicas = 0,92 (IC95%: 0,87-0,96) e 0,89 (IC95%: 0,81-0,93); erro-padrão de medida do tipo concordância = 1,03 e 0,97; mínima mudança detectável no indivíduo = 2,86 e 2,69; mínima mudança detectável no grupo = 0,40 e 0,38; limites de concordância = −2,24 a 1,96 e −2,65 a 2,69. Conclusões: Em pacientes com DPOC, a versão brasileira do MRADL apresenta validade de construto satisfatória, confiabilidade interavaliadores/teste-reteste satisfatória e erro de medida interavaliadores/teste-reteste indeterminado.

Mecanismos fisiopatológicos de la sarcopenia en la EPOC / Pathophysiological mechanism of sarcopenia in COPD

La sarcopenia es una enfermedad caracterizada por la pérdida de masa muscular, fuerza muscular y rendimiento físico, siendo la principal causa de fragilidad en los adultos mayores. La sarcopenia es altamente prevalente en individuos con enfermedad pulmonar obstructiva crónica (EPOC) que conduce a un mal pronóstico y una mayor mortalidad en esta población. La presencia de sarcopenia en la EPOC es probablemente el resultado de la interacción entre factores externos e internos como la inflamación sistémica, el estrés oxidativo y los polimorfismos genéticos, frecuentemente observados en individuos con esta enfermedad respiratoria. Esta revisión resume el conocimiento sobre los mecanismos patogénicos asociados con la sarcopenia en la EPOC.

Sarcopenia is a disease characterized by loss of skeletal muscle, muscle strength and physical performance, being the major cause of frailty in the elderly. The sarcopenia is highly prevalent in individuals with Chronic obstructive pulmonary disease (COPD) leading to a poor prognosis and higher mortality in this population. The presence of sarcopenia in COPD is likely the result by the interaction between external and internal factors as systemic inflammation, oxidative stress and genetic polymorphisms, frequently observed in individuals with this respiratory disease. This review summarizes the current knowledge about the pathogenic mechanisms linking COPD with sarcopenia.

Association of bone mineral density with chronic obstructive pulmonary disease in postmenopausal women

Abstract Background Osteoporosis (OP) is common in patients with chronic obstructive pulmonary disease (COPD). The relationship between OP and COPD has been primarily studied in male patients, and few reports are available in postmenopausal women. Objective The purpose of this study was to investigate the association between bone mineral density (BMD) and COPD in postmenopausal women. Methods This cross-sectional study included 133 clinically stable female ex-smokers with confirmed COPD, and 31 age-matched “ex-smoker” female controls. We analyzed groups according to their airway obstruction category. BMD was measured on dual-energy X-ray absorptiometry images of the left femoral neck. Results Patients with COPD had lower T-scores and higher prevalence of osteopenia/OP than the control group. In the COPD group, the airway obstruction category was significantly associated with the T-score after adjustment for confounders. Multivariate logistic regression analysis showed COPD was an independent marker for increased risk of osteopenia/OP in postmenopausal women. Conclusions COPD and airway obstruction category were strongly related to BMD. Postmenopausal women with COPD, especially those with severe airway obstruction, had a higher prevalence rate and a higher risk of osteopenia and OP than female controls without COPD.

Controversies and limitations in the diagnosis of chronic obstructive pulmonary disease

Abstract Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality worldwide. While the cut-off point to define airflow obstruction has been controversial, it is widely accepted that the spirometry test is vital, as well as performing it after using a bronchodilator. The 6-second spirometry and the forced expiratory volume in 1 second/forced expiratory volume in 6 seconds (FEV1/FEV6) have demonstrated validity for defining obstruction, and it would be advisable to incorporate them in the definitions of obstruction. Another relevant issue is that spirometry with borderline obstruction can vary over time, changing to above or below the cut-off point. Thus, surveillance should be considered over time, repeating the spirometry to have a greater certainty in the diagnosis. The objective of this article was to conduct an in-depth review of the controversies in the diagnosis of COPD. During the past years, COPD definition has been updated in different times; however, it is now considered more as a complex syndrome with systemic participation, requiring a multidimensional assessment, and not only a spirometry.

Small airway disease in COPD associated to biomass exposure

Abstract Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous entity that may result from different causative agents and risk factors and may follow diverse clinical courses, including COPD secondary to biomass smoke exposure. At present, this phenotype is becoming more important for two reasons: first, because at least almost half of the world’s population is exposed to biomass smoke, and second, because the possibility of it being diagnosed is increasing. Biomass smoke exposure COPD affects primarily women and is related with insults to the airways occurred during early life. Although constituents of biomass smoke and tobacco smoke are similar, the physiopathological changes they induce differ depending not only on the chemical composition (related with the type of fuel used) but also on the particle size and the inhalation pattern. Evidence has shown that biomass smoke exposure affects the airway, predominantly the small airways causing anthracofibrosis and peribronchiolar fibrosis changes that will clinically translate into chronic bronchitis symptoms, with a high impact on the quality of life. In this review, we focus especially on the main epidemiological and clinical differences between COPD secondary to biomass exposure and COPD caused by tobacco exposure.

Supervivencia en una cohorte de pacientes con enfermedad pulmonar obstructiva crónica acorde a la clasificación GOLD 2017 / Survival in a cohort of patients with chronic obstructive pulmonary disease according to GOLD 2017 classification

Hasta el momento, no existe información sobre la evolución de los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) de acuerdo con la nueva clasificación GOLD 2017. El objetivo de este estudio fue determinar, en una cohorte de pacientes con EPOC seguidos por veinte años, la influencia del cambio a la nueva clasificación en resultados de supervivencia por grupos y su asociación con otras variables como comorbilidades. Se evaluaron enfermos con EPOC (definición GOLD 2017) con seguimiento desde enero de 1996 a diciembre de 2016. Se usaron estadísticas convencionales y análisis de supervivencia de Log- Rank (Mantel-Cox). Se analizaron 354 pacientes: edad 66.5 ± 8.4, 66.7% hombres; ex-tabaquistas: 74.2% (56 paquetes-año); índice de Charlson 4.1 ± 1.7. A los 20 años, estaban vivos 219 (62%) y fallecidos 135 (38%), con un seguimiento de 28 meses (12-54.7). En el análisis uni y multivariado, el sexo masculino y la edad se asociaron a mayor mortalidad. Teniendo en cuenta solo la espirometría, a peor grado de obstrucción al flujo aéreo, la supervivencia es menor. Con la clasificación ABCD 2017, la peor supervivencia se encuentra en el grupo D y solo en este grupo es independiente del nivel de deterioro del VEF1 (p = 0.005). La nueva clasificación ABCD es predictora de mortalidad solo si está asociada a la función pulmonar.

Until now, there is no information on the evolution of patients with chronic obstructive pulmonary disease (COPD) according to the new GOLD classification. The objective of this study was to determine, in a cohort of patients with COPD followed by twenty years, the impact of the change to the new classification: survival by groups and their association with other variables such as comorbidities. COPD patients (GOLD 2017 definition) were evaluated with follow-up since January 1996 to December 2016. Conventional statistics and Log-Rank survival analysis (Mantel-Cox) were used. We analyzed 354 patients: age 66.5 ± 8.4, 66.7% men. Former smokers 74.2% (56 pack-year). Charlson index 4.1 ± 1.7. At the end of study 219 (62%) were alive and 135 (38%) died. The follow-up was 28 months (12-54.7). In the univariate and multivariate analysis, male sex and age were associated with higher mortality. Considering only the spirometry, to a worse degree of airflow obstruction, corresponded a lower survival. With the ABCD 2017 classification, the worst survival was observed in group D. Only in this group, survival is independent of the level of deterioration of FEV1 (p = 0.005). The new ABCD classification is a mortality predictor, only if it is associated to pulmonary function.

Estrategias de problematización e intervención de Kinesiología / Fisioterapia para un paciente con una afección ventilatoria crónica reagudizada / Problematizing strategies and intervention of Kinesiology / Physiotherapy for a patient with aggravated chronic ventilatory condition

La Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud (CIF), permite organizar la información mediante un lenguaje trans-disciplinario. Al respecto, es fundamental complementarlo con una epistemología propia para generar prácticas clínicas eficientes. La enfermedad pulmonar obstructiva crónica (EPOC), se ha convertido en una condicionante negativa de función, movimiento y salud en la población. Proponemos un modelo de razonamiento en kinesiología/fisioterapia para disfunciones del movimiento humano aplicado a una fase crónica ventilatoria irreversible. Paciente de 74 años con EPOC. Plantea como necesidad, la "mínima asistencia para realizar su aseo personal", lo que se estableció como contexto funcional crítico (CFC). Se entrenó progresivamente, según velocidad, por 36 sesiones, de 30 minutos. La espirometría no presentó cambios. Mejoró la capacidad de trabajo físico, calidad de vida y el CFC se hizo independiente. La intervención derivada del diagnóstico mediante estrategias de problematización permitió una mejora clínica eficiente de los indicadores evaluados.

The International Classification of Functioning, Disability and Health (CIF), make it possible to organize information through a trans-disciplinary language. In this regard, it is essential to complement it with an own epistemology to generate efficient clinical practices. Chronic obstructive pulmonary disease (COPD) has become a negative condition of function, movement and health in the population. We propose a model of reasoning in kinesiology/ physiotherapy for dysfunctions of human movement applied to an irreversible chronic ventilatory phase. Patient of 74 years old patient with COPD. As a necessity, it poses the "minimum assistance to perform personal hygiene", which was established as a critical functional context (CFC). He trained progressively, according to speed, for 36 sessions of 30 min. The spirometry did not change. The capacity for physical work, quality of life improved, and the CFC became independent. The intervention derived from the diagnosis by problematizing strategies allowed an efficient clinical improvement of the evaluated indicators.