Tratamiento de la inmovilidad cordal bilateral / Bilateral vocal fold immobility treatment

La inmovilidad bilateral de las cuerdas vocales en aducción puede ser provocada por diversas etiologías y pone en riesgo la vida de los pacientes por la disnea grave que puede ocasionar. Existen diversas técnicas quirúrgicas para aumentar el espacio glótico, entre las que prevalecen las cirugías transorales que resecan tejido. El objetivo del presente trabajo es determinar la tasa de resolución de la disnea inspiratoria o decanulación, en pacientes con inmovilidad cordal bilateral en aducción, tratados mediante cordotomía posterior y aritenoidectomía parcial. Fueron tratados en este estudio 17 enfermos por inmovilidad bilateral de las cuerdas vocales en aducción, mediante cordotomía posterior y aritenoidectomía parcial medial por vía transoral con láser de CO2 , cauterio y radiofrecuencia. Ocho pacientes tuvieron traqueostomía. El 75% fueron decanulados. El 100% de los pacientes sin traqueostomía mejoraron la disnea inspiratoria y no tuvieron limitación para las actividades de su vida cotidiana. Como conclusión del trabajo, se determinó que la cordotomía posterior y la aritenoidectomía parcial por vía transoral fueron muy eficaces para mejorar el calibre de la vía aérea superior, con baja morbilidad y sin complicaciones. (AU)

Bilateral medial vocal fold immobility, can be caused by various etiologies and can lead to severe dyspnea that may risk patients life. There are several surgical techniques for increasing the glottic space, prevailing transoral surgeries that remove tissue. The objective of this study is to determine the rate of resolution of inspiratory dyspnea and decanulation in patients with bilateral vocal cord immobility in adduction. In this study 17 patients diagnosed with bilateral vocal fold immobility in adduction were treated with posterior cordotomy and partial medial arytenoidectomy with transoral approach, using CO2 laser, radiofrequency or electrocautery. Eight of our patients were tracheostomized. Six of the tracheostomized patients had their tracheostomies removed (6 out of 8, 75%). Nine without tracheostomy showed improvement of inspiratory dyspnea and had no limitation on their daily lives activities. (9 out of 9, 100%). As a conclussion, we can say that transoral cordotomy and partial arytenoidectomy were very effective in improving the caliber of the upper airway, with low morbidity and no complications. (AU)

Efeitos da acupuntura sobre os pacientes com asma leve e moderada persistentes: um estudo randomizado, controlado e cruzado / Effects of acupuncture on patients with mild to moderate persistent asthma: a randomized, controlled, crossover

Introdução: Este estudo foi realizado com o intuito de avaliar efeitos da acupuntura sobre os pacientes com asma leve e moderada persistentes com o uso de beta-2 agonista ou corticoide inalatório. Métodos e casuística: Trata-se de um estudo prospectivo, duplo-cego, randomizado e cruzado com dois braços. Os 74 pacientes com diagnóstico de asma leve/moderada, de acordo com a classificação de GINA 2002/2003, foram divididos em dois grupos, sendo 31 do Grupo I, e 43 do Grupo II inicialmente. Foram realizadas consultas médicas e exames que incluíram espirometria, citologia de escarro induzido, NO expirado, preenchimento de escala de sintoma, questionários de qualidade de vida de asma e de SF 36, e realização de peak-flow, dependendo da Fase do protocolo. A Fase I constituiu-se dos exames pré-intervenção. Na Fase II, foram realizadas 10 sessões de Acupuntura Real no Grupo I e 10 sessões de Acupuntura Sham no Grupo II, na Fase III, houve 4 semana de washout, na Fase IV, houve a troca de técnicas de acupuntura, sendo uma sessão por semana e, na Fase V, realização dos exames. Resultados: Não há diferença nos critérios de avaliação no pré-tratamento entre dois grupos, com exceção de maior celularidade inflamatória no Grupo II. No entanto, houve uma redução significativa de eosinófilos (p = 0,035) e neutrófilos (p = 0,047), e aumento de macrófagos (p = 0,001), melhora da medida de volume do peak-flow (p = 0,01) na fase IV do Grupo II. No Grupo I, na avaliação de escala de sintomas diária, havia menor uso de medicação de resgate (p = 0,043) na Fase II, e, depois de receber a Acupuntura Sham na Fase IV, havia menos tosse (p = 0,007), menos chiado (p = 0,037), menos dispneia (p < 0,001) e menor uso de medicação de resgate (p < 0,001). No Grupo II, após receber o tratamento com a Acupuntura Sham na Fase II, houve diminuição de tosse (p = 0,037), de chiado (p = 0,013) e de dispneia (p = 0,014), e, na...

Introduction: This survey has been conducted in order to evaluate the effects of acupuncture in patients with persistent mild and moderate asthma (according to GINA criteria 2003), using beta agonist and/or inhaled glucocorticoid. Methods and patients: This is a prospective, double blinded, randomized and cross-over study with two branches: 74 patients diagnosed with mild and moderate asthma were divided into two groups: Group I with 31, initiating with real acupuncture and Group II, starting with sham acupuncture. Medical interview and laboratory tests including spirometry, induced sputum citology, exhaled NO measurement, quality of life questionnaire (SF-36 and QQL), besides, daily symptom scores and measurement of peak-flow were performed, in the beginning of the study, and in the end of each phase of treatment. Phase I: laboratory tests and other qualitative measurements. There were 10 real acupuncture weekly sessions to Group I and 10 sham acupuncture sessions to Group II in Phase II. On the other hand, in the Phase IV, there was an exchange between Group I and Group II, which was receiving real acupuncture started to receive sham, and vice-versa, the number of sessions remained the same (10 weekly sessions). Phase III, during the interval between Phase II and Phase IV, there was an interval of 4 weeks of washout. Phase V: laboratory tests and other qualitative measurements. Results: There was no difference beween both the groups in all criteria of evaluation pré treatment, with only na exception: in the Group II there was large inflammatory cell counts. However, there was a significant reduction in eosinophils (p = 0.035) and neutrophils (p = 0.047), and increase of macrophages (p = 0.001), improved peak-flow measurement in the morning (p = 0.01) in Group II (started with sham) in Phase IV. In Daily Symptons Score, there was a significant reduction in use of rescue medication (p = 0.043) in Group I (real acupuncture) in Phase II and after received...

Entrenamiento muscular inspiratorio en el paciente con enfermedad pulmonar obstructiva crónica / Inspiratory muscle training in patients with chronic obstructive pulmonary disease

Respiratory muscle weakness is observed in chronic obstructive pulmonary disease (COPD) patients and contributes to hypoxemia, hypercapnia, dyspnoea, nocturnal oxygen desaturation and reduced exercise performance. During exercise it has been shown that diaphragm work is increased in COPD and COPD patients use a larger proportion of the maximal inspiratory pressure (PImax) than healthy subjects. This pattern of breathing is closely related to the dyspnoea sensation during exercise and might potentially induce respiratory muscle fatigue. However, diaphragmatic fatigue was not demonstrated after exhaustive exercise. Studies in patients with COPD have shown natural adaptations of the diaphragm to greater oxidative capacity and resistance to fatigue. The above mentioned considerations gave conflicting arguments to the rationale of inspiratory muscle training (IMT) in COPD. Both IMT alone and IMT as adjunct to general exercise reconditioning significantly increased inspiratory muscle strength and endurance. A significant effect was found for dyspnoea at rest and during exercise. Improvedfunctional exercise capacity tended to be an additional effect of IMT alone and as an adjunct to general exercise reconditioning, but this trend did not reach statistical significance. No significant correlations were found for training effects with patient characteristics. However, subgroup analysis in IMTplus exercise training revealed that patients with inspiratory muscle weakness improved significantly more compared to patients without inspiratory muscle weakness. From this review it is concluded that inspiratory muscle training is an important addition to a pulmonary rehabilitation programme directed at chronic obstructive pulmonary disease patients with inspiratory muscle weakness. The effect on exercise performance is still to be determined. In summary, IMT improves inspiratory muscle strength and endurance, functional exercise capacity, dyspnoea and quality of life. Inspirat...

Los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) tienen debilidad de los músculos respiratorios, lo cual contribuye a la disnea, hipoxemia, hipercapnia, desaturación nocturna y limitación de la actividad física. Durante el ejercicio se ha demostrado que aumenta el trabajo del diafragma en pacientes con EPOC y utilizan una mayor proporción de la presión inspiratoria máxima (PImax) comparado con los sujetos sanos. Elpatrón respiratorio anormal de los pacientes con EPOC está relacionado con la sensación de disnea durante el ejercicio y, potencialmente, podría inducir a la fatiga muscular respiratoria. Sin embargo, la fatiga del diafragma no se ha demostrado después de un ejercicio intenso. Los estudios en pacientes con EPOC han demostrado cambios adaptativos en las fibras musculares del diafragma que tienen mayor capacidad oxidativa y resistencia a la fatiga. De este modo, existen argumentos contradictorios en relación al beneficio clínico obtenido con el entrenamiento de los músculos inspiratorios (EMI) en pacientes con EPOC. El EMI aislado o como complemento de ejercicios de reacondicionamiento general aumenta significativamente la fuerza muscular inspiratoria y la resistencia a la fatiga, disminuyendo significativamente la disnea en reposo y durante el ejercicio. Además, los estudios sugieren que el EMI tiende a mejorar la capacidad funcional para realizar ejercicio, efecto favorable que no alcanzó significación estadística. El análisis de subgrupos ha demostrado mayor beneficio clínico del EMI en los pacientes con debilidad muscular inspiratoria. De esta revisión se concluye que el entrenamiento muscular inspiratorio puede ser útil en pacientes seleccionados con enfermedad pulmonar obstructiva crónica, que tienen disfunción muscular inspiratoria comprobada, insertado en un programa de rehabilitación integral. El efecto sobre la capacidad de realizar ejercicio aún no ha sido determinado. En resumen, el EMI aumenta la fuerza muscular inspirator...

Ventilación no invasiva y rehabilitación respiratoria en pacientes con enfermedad pulmonar obstructiva crónica / Noninvasive ventilation and pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

In patients with chronic obstructive pulmonary disease (COPD), pulmonary rehabilitation has been demonstrated to increase exercise capacity and reduce dyspnea. In the most disabled patients, the intensity of exercise during the training sessions is limited by ventilatory pump capacity. Non-invasive ventilation (NIV) support has been used successfully in patients with exacerbation of COPD. However, its benefit in patients with stable COPD or in a pulmonary rehabilitation program is under discussion. This chapter therefore evaluated the scientific evidence regarding the beneficial effect of NIV support in the respiratory rehabilitation on exercise tolerance. Features of the NIV as to when they do it-whether during training or night-and modality were reviewed. Use of noninvasive ventilation in pulmonary rehabilitation was recommended in selected patients with severe COPD or advanced stage, and in those with suboptimal response to exercise training. The use of NIV should be preferably at night, using inspiratory pressure support, which can help achieve a better exercise tolerance, an improvement in gas exchange and a reduction in the overhead of the respiratory muscles and dyspnea (quality evidence B, moderate strength recommendation).

Se ha demostrado que la rehabilitación respiratoria en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) aumenta la capacidad de ejercicio y reduce la disnea. En la mayoría de los pacientes con discapacidad, la intensidad del ejercicio durante las sesiones de entrenamiento se ve limitada por la capacidad de la bomba ventilatoria. La ventilación no invasiva (VNI) ha sido utilizada con mucho éxito en pacientes con EPOC que presentan una exacerbación de su enfermedad. No obstante, su beneficio en pacientes con EPOC estable o en rehabilitación respiratoria está en discusión. En este capitulo se evaluó la evidencia científica que existe en cuanto al beneficio de la ventilación no invasiva (VNI) en la rehabilitación respiratoria. Se revisó la modalidad y las características de la VNI en cuanto a cuando realizarla -si durante el entrenamiento o nocturna-. Se recomendó la utilización de la ventilación no invasiva en rehabilitación respiratoria en pacientes seleccionados, con EPOC en etapa grave o avanzada, y en aquellos con respuestas subóptimas al entrenamiento. La utilización de la ventilación no invasiva debe ser preferentemente nocturna, y utilizando presión de soporte inspiratorio, la cual puede permitir alcanzar una mejor tolerancia al ejercicio, una mejoría del intercambio gaseoso y una disminución de la sobrecarga de los músculos respiratorios y la disnea. (calidad de la evidencia B, fuerza de la recomendación: moderada).

Espirometria de incentivo com pressão positiva expiratória é benéfica após revascularização miocardio / Espirometría incentivada con presión positiva espiratoria es beneficiosa después de revascularización de miocardio / Incentive spirometry with expiratory positive airway pressure brings benefits after myocardial revascularization

FUNDAMENTO: Pacientes que são submetidos à cirurgia de revascularização do miocárdio (CRM) apresentam risco maior para desenvolver complicações pulmonares, como atelectasias, pneumonia e derrame pleural. Estas complicações podem aumentar o tempo de internação hospitalar, a necessidade de recursos financeiros e também se associam com a redução da qualidade de vida e da capacidade funcional a longo prazo. OBJETIVO: Testar se o uso de espirometria de incentivo (EI) associada com pressão positiva expiratória na via aérea (EPAP), após CRM melhora a dispneia, a sensação de esforço percebido e a qualidade de vida 18 meses após a CRM. MÉTODOS: Dezesseis pacientes submetidos a CRM foram randomizados para o grupo controle (n=8) ou para o grupo EI+EPAP (n=8). O protocolo de EI+EPAP foi realizado no período pós-operatório imediato e durante mais 4 semanas no domicílio. Dezoito meses após a CRM foram avaliadas a força da musculatura respiratória, a capacidade funcional, a função pulmonar, a qualidade de vida e o nível de atividade física. RESULTADOS: Após o teste de caminhada de seis minutos (TC6), o escore para dispneia (1,6±0,6 vs 0,6±0,3, P<0,05) e a sensação de esforço (13,4±1,2 vs 9,1±0,7, P<0,05) foram maiores no grupo controle comparado com o grupo EI+EPAP. Na avaliação da qualidade de vida, o domínio relacionado às limitações nos aspectos físicos foi melhor no grupo EI+EPAP (93,7±4,1 vs 50±17, P<0,02). CONCLUSÃO: Pacientes que realizam EI+EPAP apresentam menos dispneia e menor sensação de esforço após o TC6 e também melhor qualidade de vida 18 meses após a CRM.

BACKGROUND: Patients undergoing coronary artery bypass graft (CABG) surgery have higher risk to develop pulmonary complications (PCs) such as atelectasis, pneumonia and pleural effusion. These complications could increase the length of hospital stay, resources utilization and also are associated with reduced quality of life and functional capacity a long term. OBJECTIVE: To test if the use of incentive spirometry (IS) associated with expiratory positive airway pressure (EPAP), after CABG surgery improves dyspnea, effort perceived and quality of life 18 months after CABG. METHODS: Sixteen patients submitted to a CABG, were randomized to a control group (n=8) or IS+EPAP group (n=8). The protocol of IS+EPAP was applied in the immediate postoperative period and following for more 4 weeks in the patient's home. Eighteen months after CABG, the strength of the respiratory muscle, the functional capacity, the lung function, the quality of life and the level of physical activity were evaluated. RESULTS: After six minute walk test (6-MWT), the score of the dyspnea (1.6±0.6 vs 0.6±0.3, P<0.05) and the perceived effort (13.4±1.2 vs 9.1±0.7, P<0.05) were higher in the control group, when compared with the IS+EPAP group. In quality of life evaluation, the domain related to the physical aspects limitations was better in IS+EPAP group (93.7±4.1 vs 50±17, P<0.02). CONCLUSION: Patients that were submitted to IS+EPAP present reduction of dyspnea and lower effort sensation after the 6-MWT, and also a better quality of life 18 months after CABG.

FUNDAMENTO: Pacientes que son sometidos a cirugía de revascularización del miocardio (CRM) presenta mayor riesgo de desarrollar complicaciones pulmonares, como atelectasias, neumonía y derrame pleural. Estas complicaciones pueden aumentar el tiempo de internación hospitalaria, la necesidad de recursos financieros y también se asocian con la reducción de la calidad de vida y de la capacidad funcional a largo plazo. OBJETIVO: Probar si el uso de espirometría incentivada (EI) asociada con presión positiva espiratoria en la vía aérea (EPAP), después de la CRM mejora la disnea, la sensación de esfuerzo percibido y la calidad de vida 18 meses después de la CRM. MÉTODOS: Dieciocho pacientes sometidos a CRM fueron aleatorizados para el grupo control (n=8) o para el grupo EI+EPAP (n=8). El protocolo de EI+EPAP se realizó en el período postoperatorio inmediato y durante 4 semanas más en domicilio. Dieciocho meses después de la CRM se evaluaron la fuerza de la musculatura respiratoria, la capacidad funcional, la función pulmonar, la calidad de vida y el nivel de actividad física. RESULTADOS: Después del test de caminata de seis minutos (TC6), el score para disnea (1,6 ± 0,6 vs 0,6 ± 0,3, P < 0,05) y la sensación de esfuerzo (13,4 ± 1,2 vs 9,1 ± 0,7, P < 0,05) fueron mayores en el grupo control comparado con el grupo EI+EPAP. En la evaluación de la calidad de vida, el dominio relacionado con las limitaciones en los aspectos físicos fue mejor en el grupo EI+EPAP (93,7 ± 4,1 vs 50 ± 17, P < 0,02). CONCLUSIÓN: Pacientes que realizan EI+EPAP presentan menos disnea y menor sensación de esfuerzo después del TC6 y también mejor calidad de vida 18 meses después de la CRM.

[Evaluating the applicability of post thyroidectomy drainage in the prevention of respiratory distress sencondary to hematoma formation of the surgical site]

Hematoma is a rare but potentially dangerous complication of thyroidectomy that can lead to airway obstruction and respiratory distress.The use of drain age tube for prevention of hematoma has met with reservations. In a randomaized controlled trial, thyroidectomized patients treated as groups with and without drains were assessed and compared with regard to hematoma formation, respiratory distress and duration of admission. 48 pts without drains [51.1% male, mean age 37 yrs] and 52 pts with drains [52% male, mean age 41.5 yrs] were studied. Two patients who had drainage tubes developed hematoma and respiratory distress [p<0.005]. There was no hematoma formation and respiratory distress in the group] without drains. Duration of hospitalization in the group without drain age tube was 2.9 days [SD 1.3 days], and in the group with drain age tube 4.1 days [SD 1.5 days] with a p>0.05

Dispnéia em DPOC: relação entre a limitação ao exercício e as atividades de vida diária / COPD and dyspnea: correlation between exercise limitation and activities of daily life

As principais metas do Programa de Reabilitação Pulmonar são a redução dos sintomas, melhora na qualidade de vida e maior independência nas atividades de vida diária e prática. O objetivo deste trabalho foi avaliar se a melhora da capacidade física(endurance) contribui para uma menor sensação de dispnéia para as Atividades de Vida Diárias(AVDs). A amostra foi composta por 45 pacientes estáveis, com doença Pulmonar Obstrutiva Crônica (DPOC) num estudo retrospectivo com amostra não probabilística intencional. Os pacientes foram submetidos a um programa de Reabilitação Pulmonar de 36 sessões e, avaliados antes e após os três meses pelo mesmo avaliador. Foi aplicado o teste de endurance e realizada a avaliação da dispnéia, utilizando Escala de Borg (0-10) para duas atividades de vida diária: Subir rampa (com inclinação de 5 por cento) durante cinco minutos com velocidade de 2,5 Km/h e carregar peso (5Kg) caminhando 50 metros. Em termos de 5 por cento existe evidência de que ocorreu redução na média dos valores de dispnéia (segundo Escala de Borg) para as duas atividades de vida diária analisadas (p<0.0001 em 5 por cento) e, também, na média do tempo de endurance (p<0.001 em 5 por cento).