Protocolo de atendimento e seguimento fisioterapêutico na fibrose cí­stica / Protocol for physical therapy follow-up and monitoring in cystic fibrosis patients

A Fibrose Cí­stica (FC) requer uma abordagem multidisciplinar culminando em um complexo regime terapêutico. A fisioterapia tem papel fundamental na depuração das vias aéreas, melhora da ventilação pulmonar e da tolerância ao exercí­cio. No entanto, aspectos como acompanhamento da evolução clí­nica do paciente, identificação de perí­odos de exacerbação pulmonar e avaliação da adesão ao tratamento também fazem parte da rotina fisioterapêutica. Com o objetivo de contemplar os principais instrumentos disponí­veis que auxiliam em um melhor controle, acompanhamento e avaliação de pacientes com FC, elaborou-se o PASFIC - Protocolo de Atendimento e Seguimento Fisioterapêutico na Fibrose Cí­stica. Este protocolo inclui 10 critérios: 1) fisioterapia respiratória, 2) escore de gravidade, 3) escores de exacerbação pulmonar, 4) avaliação do peso e da estatura, 5) avaliação respiratória, 6) espirometria, 7) coleta de secreção das vias respiratórias, 8) aderência, 9) habilidades funcionais, 10) anormalidades posturais. A finalidade do PASFIC é caracterizar a população, identificar as alterações clí­nicas e acompanhar a evolução clí­nica e o atendimento fisioterapêutico de pacientes com FC, viabilizando suporte assistencial individualizado, uma melhor adesão ao tratamento e intervenção precoce durante as agudizações pulmonares, facilitando a monitorização pela equipe multiprofissional, otimizando o atendimento de pacientes com FC. (AU)

Cystic Fibrosis (CF) requires multidisciplinary approach culminating in a complex treatment regimen. Physical therapy is an important factor for better management of the disease, playing a key role in airway clearance, lung ventilation and exercise tolerance improvement. However, aspects such as monitoring of patients clinical evolution, identification of periods of acute pulmonary exacerbations and assessment of treatment adherence are also part of the physical therapy routine. In order to cover all instruments that help improve control, monitoring and evaluation of CF patients, a systematic protocol has been developed to qualify and quantify CF patients` interventions data. It includes 10 criteria: 1) Monitoring of physiotherapy techniques, 2) Application of severity score, 3) Application of pulmonary exacerbation scores, 4) Weight and height measurements, 5) Evaluation of respiratory system, 6) Systematic spirometry, 7) Airway secretion collection and register, 8) Monitoring of adherence to treatment, 9) Assessment of functional abilities, and 10) Postural abnormalities. The aim is to characterize the CF population, to identify clinical alterations and to follow up on the disease evolution and physiotherapy assistance for CF patients, as well as to allow individualized care and support, better treatment adherence, and early intervention for pulmonary exacerbations. (AU)

The role of sphingolipid metabolism disruption on lipopolysaccharide-induced lung injury in mice.

AIM: This study assessed pulmonary outcomes generated by inhibiting key enzymes of sphingolipid metabolism pathways related to ceramide synthesis in a murine model of lung injury induced by lipopolysaccharide (LPS). METHODS: C57BL/6 male adult mice received LPS intratracheally and the expressions of acid sphingomyelinase (ASM), neutral sphingomyelinase (NSM), serine palmitoyl transferase (SPT) and dihydroceramide synthase (DS) were assessed at 2, 4, 6, 12 and 24 h after LPS instillation in lung homogenate (n = 30). The pharmacological inhibition of ASM, NSM, SPT and DS were assayed in other mice groups by three different doses of desipramine, GW4869, myriocin and fumonisin, respectively (n = 90). Their most effective doses were administered intraperitoneally 1 or 2 h before LPS to different animal groups (n = 120). Mice underwent determination of pulmonary mechanics, lung histopathological aspects and apoptosis. RESULTS: The expression levels of the enzymes reached their peak at 2-4 h after LPS administration. ASM inhibition attenuated alveolar collapse and GW4869 decreased lung elastance, proinflammatory cytokines' levels and was more effective to improve alveolar collapse than desipramine. On the other hand, SPT blockage aggravated lung lesion and no effects it was observed with fumonisin. Moreover, simultaneous administration of inhibitors (desipramine + GW4869, myriocin + fumonisin and all inhibitors together) resulted in no changes. CONCLUSION: Blockage of sphingomyelinases and the de novo pathways improved and aggravated lung injury, respectively, putatively suggesting specific targets to therapeutic strategies in LPS-induced lung injury.

Intratracheal instillation of coal and coal fly ash particles in mice induces DNA damage and translocation of metals to extrapulmonary tissues.

Continuous exposure to coal mining particles can cause a variety of lung diseases. We aimed to evaluate the outcomes of exposure to detailed characterized coal and coal fly ash (CFA) particles on DNA, lung and extrapulmonary tissues. Coal samples (COAL11 and COAL16) and CFA samples (CFA11 and CFA16) were included in this study. Intending to enhance the combustion process COAL16 was co-fired with a mixture of fuel oil and diesel oil, producing CFA16. Male BALB/c mice were intratracheally instilled with coal and CFA particles. Measurements were done 24h later. Results showed significant rigidity and obstruction of the central airways only for animals acutely exposed to coal particles. The COAL16 group also showed obstruction of the peripheral airways. Mononuclear cells were recruited in all treatment groups and expression of cytokines, particularly TNF-α and IL-1ß, was observed. Only animals exposed to COAL16 showed a significant expression of IL-6 and recruitment of polymorphonuclear cells. DNA damage was demonstrated by Comet assay for all groups. Cr, Fe and Ni were detected in liver, spleen and brain, showing the efficient translocation of metals from the bloodstream to extrapulmonary organs. These effects were associated with particle composition (oxides, hydroxides, phosphates, sulfides, sulphates, silciates, organic-metalic compounds, and polycyclic aromatic hidrocarbons) rather than their size. This work provides state of knowledge on the effects of acute exposure to coal and CFA particles on respiratory mechanics, DNA damage, translocation of metals to other organs and related inflammatory processes.

Teste de caminhada de seis minutos em pediatria: discutindo evidências em situações específicas / Six minutes walk test in pediatrics: discussing evidence in specific situations

Teste de caminhada de seis minutos (TC6) tem se mostrado uma ferramenta bem tolerada, confiá- vel e de baixo custo para monitorar a capacidade funcional de crianças e adolescentes saudáveis e em diferentes situações clínicas. Objetivo: Verificar e discutir as evidências científicas do TC6 utilizado em 4 situações específicas da criança com: 1) asma; 2) fibrose cística 3) obesidade e 4) higidez. Método: A busca nas bases de dados foi conduzida utilizando-se as palavras-chaves: teste de caminhada de seis minutos, crianças, adolescentes, obesos, fibrose cística e asma. Consultou-se as bases Pubmed (Medline), Lilacs e PEDro. Foram considerados os ensaios clínicos em português, inglês e espanhol, publicados no período de 2005 a 2016 e incluídos os estudos que abordam o TC6como método de avaliação, monitorização e prognóstico de crianças e adolescentes saudáveis, com diagnósticos de asma, fibrose cística e obesidade. Resultados: Identificou-se 97 artigos, sendo 48 duplicados. Conduziu-se a pré-seleção de 43 estudos dos quais 6foram excluídos, pelo título ou resumo, por não atenderem aos critérios de inclusão. A seleção final totalizou 39 manuscritos para a apreciação na íntegra e discussão na presente revisão. Conclusão: TC6 é reprodutível e validado para a população pediátrica, sendo considerado um instrumento importante para avaliar as implicações das doenças crônicas na capacidade funcional. 1) TC6 tem se mostrado útil pra identificação do prejuízo das atividades de vida diária durante a crise de asma e fora dela, assim como do comprometimento da capacidade funcional diante do hábito de vida sedentário. 2) É adequado para avaliação de programas de reeducação alimentar na obesidade. 3) Na fibrose cística é uma boa ferramenta para avaliação de programas de reabilitação pulmonar e acompanhamento da progressão da doença. 4) Entre os saudáveis observa-se a busca por valores de referência e falta de um consenso sobre a forma de aplicabilidade do teste

The six-minute walk test (6MWT) is regarded as a well-tolerated, reliable and cost-effective tool to monitor the functional capacity of healthy children and adolescents and in different clinical situations. Objective: To verify and discuss the scientific evidence of the 6MWT in four specific situations of children with: 1) asthma; 2) cystic fibrosis 3) obesity and 4) healthy controls. Method: A search was conducted in Pubmed (Medline), Lilacs and PEDro databases with the key words: sixminute walk test, children, adolescents, obesity, cystic fibrosis and asthma. The selected articles were those that reported clinical trials in Portuguese, English or Spanish, published between 2005- 2016 that included studies that assessed the 6MWT as a method of evaluation for monitoring and prognosis of healthy or diseased children and adolescents. Results: We identified 97 articles, 48 of them were duplicate. A pre-selection of 43 remaining studies based on title or summary excluded 6 articles for not meeting the inclusion criteria. Finally, 39 manuscripts were included in this review. Conclusion: 6MWT is reproducible and validated for the pediatric population and is considered an important instrument to assess the implications of chronic diseases on functional status. 1) 6MWT has proven useful to identify function losses to the activities of daily living during or in-between asthma attacks, as well as the functional jeopardy of sedentary habit; 2) It is suitable for assessing nutritional education programs in obesity; 3) In cystic fibrosis, it is a good tool for evaluating pulmonary rehabilitation programs and monitoring of the disease progression; and 4) Among healthy subjects, however, there is still lack of consensus of a reference as well as the most suitable applicability of this test

Alternative Indexes to Estimate the Functional Capacity From the 6-Minute Walk Test in Children and Adolescents With Cystic Fibrosis.

BACKGROUND: Cystic fibrosis is a multi-systemic disease related to reduced functional capacity. The distance covered in the 6-min walk test (6MWT) has been known to assess functional capacity, but little is known about other indexes that can be derived. We sought to compare the performance during the 6MWT and the estimated indexes of functional capacity from the 6MWT between subjects with cystic fibrosis (CF) and healthy individuals as well as to assess the relationship among these indexes and disease severity, pulmonary function, and nutritional status in CF. METHODS: This cross-sectional study was carried out at a university referral center for CF. It included a group of 55 non-oxygen-dependent CF subjects (CF group) with no acute pulmonary exacerbations and a group of 185 healthy controls (control group). All subjects were submitted to 6MWT and anthropometrics measurements. RESULTS: Regarding performance during the 6MWT, the mean values of work, physiological cost index, average velocity, and 6-min walk distance (6MWD) were significantly lower in the CF group than in the control group (work: 21,690.58 ± 10,427.77 vs 26,057.51 ± 11,228.49 m × kg [P = .007]; physiological cost index: 0.31 ± 0.19 vs 0.37 ± 0.17; average velocity: 94.71 ± 12.89 vs 104.55 ± 9.13 m/min [P < .001]; and 6MWD: 568.02 ± 76.31 m versus 627.54 ± 54.81 m [P < .001]). Subjects with less severe CF had higher 6MWD, work, and average velocity during the 6MWT, compared with subjects with more severe CF (P = .008, P = .01, and P = .007, respectively). There was a correlation between 6MWD, work, average velocity, and disease severity and pulmonary function. CONCLUSIONS: Considering the importance of standard measure (6MWD) the in 6MWT, alternative indexes can be useful as complementary outcomes and to provide a better understanding of limiting factors of exercise response in children and adolescents with CF.

Eucalyptol attenuates cigarette smoke-induced acute lung inflammation and oxidative stress in the mouse.

Short-term cigarette smoke (CS) exposure does not cause emphysema; however, some pathogenesis hallmarks are maintained, such as oxidative stress and inflammation. This study aimed to test the efficacy of eucalyptol against short-term CS exposure in mice. C57BL/6 mice were exposed to 12 cigarettes per day for 5 days (CS group). The control group was exposed to sham smoking. Three groups of mice exposed to CS were treated to different concentrations of eucalyptol (1, 3, 10 mg/mL) via inhalation (15 min/daily) for 5 days (CS + 1 mg, CS+3 mg and CS+10 mg groups). CS group and control one were sham treated by using vehicle. The anti-inflammatory and antioxidant effects of eucalyptol were assessed 24 h after the last CS exposure by determining cell counts, measuring cytokine production and performing western blotting, biochemical and histological analyses. Eucalyptol at 3 mg/mL and 10 mg/mL concentrations reduced total leukocyte numbers compared to the CS group (p < 0.001), while macrophage numbers were reduced at all concentrations (p < 0.001). Myeloperoxidase, used as neutrophil marker, was reduced at 3 mg/mL (p < 0.01) and 10 mg/mL (p < 0.05) concentrations. Eucalyptol reduced cytokine levels (IL-1ß, IL-6 and KC) at 3 mg/mL and 10 mg/mL concentrations (p < 0.01) compared to the CS group. The exception was TNF-α, with a reduction only at 10 mg/mL of eucalyptol compared to the CS group (p < 0.001). Additionally, eucalyptol decreased the NF-kappa B p65 subunit at 3 mg/mL and 10 mg/mL compared to the CS group (p < 0.01). Regarding oxidative stress, eucalyptol reduced reactive oxygen species, superoxide dismutase, catalase and malondialdehyde, mainly at 3 mg/mL and 10 mg/mL concentrations compared to the CS group (at least p < 0.05), parallel to reduced glutathione levels at the same concentrations (p < 0.001). Furthermore, treatment with eucalyptol attenuated CS-induced histopathological alterations. Collectively, these results indicate that eucalyptol acts through a mechanism involving decreased oxidative stress, inflammation and the NF-kappa B p65 subunit against CS-induced acute lung inflammation. Thus, eucalyptol may be a potential agent in the treatment of pulmonary inflammation caused by CS in humans.

Teste de caminhada de seis minutos em crianças com doença respiratória crônica / Six-minute walk test in children with chronic respiratory disease

Introdução: o teste de caminhada de seis minutos (TC6) é amplamente utilizado para avaliar a capacidade funcional em pediatria por ser de fácil administração e baixo custo. Objetivo: avaliar e comparar o desempenho de crianças saudáveis (GC), com fibrose cística (GFC) e síndrome da respiração oral (GRO) no TC6. Método: estudo transversal comparativo controlado. Realizaram-se dois TC6 (TC61 e TC62) segundo recomendação da American Thoracic Society. Aplicou-se o teste de normalidade de Shapiro-Wilk e, para comparação dos dois TC6 em cada grupo, realizou-se o teste-t pareado e posteriormente Anova post-hoc de Bonferroni para as distâncias percorridas (DPTC6). Resultados: participaram 51 crianças (oito a 12 anos), sendo 17 por grupo. Na comparação das DPTC6, apenas o GFC obteve desempenho inferior ao GC nos dois TC6 (p=0,001). Conclusão: o menor desempenho pelo GFC reforça o TC6 como instrumento sensível na avaliação da capacidade de exercício de crianças com doença pulmonar crônica.

Introduction: the six-minute walk test (6MWT) is widely used to assess functional capacity in children because of its easy administration and low cost. Objective: to evaluate and compare the performance of healthy children (CG), cystic fibrosis (CFG) and syndrome of mouth breathing (MBG) the 6MWT. Method: controlled comparative cross-sectional study. There were two 6MWT (6MWT1 and 6MWT2) as recommended by the American Thoracic Society. The Shapiro-Wilk normality test was used and for comparison of the two 6MWT in each group, there was the paired t-test and ANOVA later post-hoc Bonferroni for the distances (D6MWT). Results: 51 children participated (8 to 12 years), 17 per group. In comparing the D6MWT, only the CFG got underperformed the CG in both 6MWT (p = 0.001). Conclusion: the lowest performance by CFG strengthens the 6MWT as a sensitive instrument for assessing exercise capacity of children with chronic lung disease.

Instrumentos objetivos tradicionais de avaliação respiratória em respiradores orais / Traditional instruments objectives of respiratory evaluation in mouth breathers

A obstrução nasal é uma das principais anormalidades que afetam a permeabilidade nasal (PN) e em consequência está associada à respiração oral. Considerando a importância das complicações respiratórias e sua relação com o mecanismo de obstrução nasal, ressalta-se a necessidade e importância desse tipo de avaliação na população pediátrica e adulta. Objetivo: apresentar uma atualização da literatura quanto aos instrumentos objetivos para avaliação da permeabilidade das vias aéreas superiores e sua aplicabilidade na avaliação respiratória de indivíduos RO. Síntese dos dados: a revisão bibliográfica foi realizada utilizando as palavras-chaves: mouth breathing, nasal obstruction, nasal patency evaluation e instrumentos objetivos tradicionais da permeabilidade das vias aéreas: rhinomanometry, sniff nasal inspiratory pressure nasal peak flow, acoustic rhinometry, rhinomanometry e nasal spirometry. Uma síntese dos trabalhos foi organizada apresentando os instrumentos objetivos mais tradicionais encontrados na literatura. Com base nos estudos selecionados, discutiu-se sobre a indicação destes recursos na avaliação da permeabilidade de vias aéreas superiores. Conclusões: a avaliação respiratória objetiva de RO pode ser realizada por diferentes instrumentos tradicionais, utilizados tanto na avaliação, diagnóstico e identificação de efeitos de intervenções de RO.

Teste de caminhada de seis minutos em pediatria: relação entre desempenho e parâmetros antropométricos / Six-minute walk test in pediatrics: the relationship between performance and anthropometric parameters

INTRODUÇÃO: Diferenças antropométricas podem influenciar o desempenho no teste de caminhada de seis minutos (TC6). OBJETIVO: Analisar publicações referentes ao TC6 realizado em crianças e adolescentes e identificar a influência de parâmetros antropométricos no desempenho do teste. MATERAIS E MÉTODOS: Pesquisa nas bases de dados eletrônicas SciELO e MEDLINE, utilizando as palavras-chave: six-minute walk test, children, adolescents, anthropometric measures/variables, growth e exercise tolerance, na busca de estudos envolvendo TC6 em crianças e adolescentes, que apresentem correlação entre dados antropométricos e variáveis do teste. Foram identificados 45 trabalhos relacionados à busca e, após análise dos títulos, resumos e artigos na íntegra, foram incluídos 13 estudos compatíveis com o tema proposto. RESULTADOS: O material elencado aborda o TC6 e sua aplicação em diferentes situações: análise de reprodutibilidade, correlação com teste cardiopulmonar máximo, indicação em diferentes doenças, valores de referência em saudáveis, parâmetro de efeito de programas de prevenção/reabilitação. Muitos trabalhos relacionam a distância percorrida no TC6 com idade e sexo, bem como com variáveis antropométricas, evidenciando frequente correlação com altura, além de idade, peso e índice de massa corporal. Outros dados como comprimento e força de membros inferiores, porcentagem de massas gorda/magra e força muscular respiratória, relacionados às mudanças do período de desenvolvimento infanto-juvenil, também parecem influenciar no desempenho do teste. CONCLUSÃO: Estudos indicam forte influência entre variáveis antropométricas e distância percorrida no TC6 em crianças e adolescentes, e a necessidade de que se esclareça essa associação para que não haja comprometimento do desfecho de estudos e de terapêuticas.

INTRODUCTION: Anthropometric differences may influence the performance in the 6-minute walk test. OBJETIVE: To analyze publications concerning the 6MWT performed in children and adolescents and to identify the influence of anthropometric parameters on test performance. MATERIALS AND METHODS: research in the electronic databases Medline and Scielo using to the keywords: six-minute walk test, children, adolescents, anthropometric measures/ variables, growth and exercise tolerance, in the search of studies involving 6MWT in children and adolescents, that present correlation between anthropometric data and test variables. It was identified 45 studies related to the search and after examination of the titles, abstracts and full articles, it were included 13 compatible studies with the proposed theme. RESULTS: the selected material approach the 6MWT and your application in different situations: analysis of reproducibility, correlation with maximal cardiopulmonary exercise testing, indications in differents diseases, reference values in healthy, effect parameter of prevention/rehabilitation program. Many studies relate the covered distance in 6MWT with age and sex, as well as with anthropometric variables, showing frequent correlation with height, beyond the age, weight and body mass index. Other data such as length and strength of lower limbs, percentage of fat mass/lean and respiratory muscle strength, related to changes in the period of juvenile development, also seem to influence the test performance. CONCLUSION: Studies indicate a b influence between the anthropometric variables and the covered distance in 6MWT in children and adolescents, and the need for better explanation of this association so there is no impairment of outcome studies and therapeutics.

Nível de atividade física de escolares respiradores orais e nasais / Physical activity level of mouth- and nose-breathing scholars

Objetivo: identificar a presença de respiradores orais (RO) e respiradores nasais (RN) na população escolar e caracterizar o nível de atividade física das duas populações. Material e métodos: Caracterizado como descritivo, foi realizado no período de 2 anos, incluindo crianças de 6 e 12 anos de idade de uma escola pública do interior paulista. As mesmas comparecerem ao ambulatório de otorrinolaringologia de um hospital universitário para serem submetidas a exames clínicos (otoscopia, oroscopia e rinoscopia) com a finalidade de identificar e dividir os grupos quanto ao padrão respiratório: respirador oral ou respirador nasal. Em seguida, avaliadores cegos quanto a esse padrão, aplicaram o Questionário Internacional de Atividade Física (IPAQ). Resultados e Conclusão: Participaram do estudo 154 escolares, sendo 84 respiradores orais e, desses, 47 do sexo masculino. A média de idade dos respiradores nasais foi de 9,60±1,33, e 9,17±1,14 dos respiradores orais. Em relação ao nível de atividade física, ambos foram caracterizados como insuficientemente ativos. Verificou-se grande incidência da respiração oral entre os escolares analisados, sendo que, independente do padrão respiratório, respiradores orais ou nasais, as crianças apresentaram baixo nível de atividade física, importante constatação para estratégias preventivas e estimulação da prática de atividade física (NAF) no meio escolar.

Objective: To identify mouth- and nasal-breathing individuals in a school population and to characterize the physical activity level of these groups. Materials and Method: This is a descriptive study performed in two years, including children aged between 6 and 12 years in a public school in the interiorof the Sao Paulo state. They attended an otolaryngology ward of a university hospital to undergo clinical examination (otoscopy, rhinoscopy and oroscopy) with the purpose of identifying and being categorized according to the breathing pattern: mouth or nasal breathing. Then, assessors blind to this standard applied the International Physical Activity Questionnaire (IPAQ). Results and Conclusion: The study included 154 students of which 84 were mouth breathers and, from these, 47 were male. The medium age of the nasal breathers was 9.60 ± 1.33 against 9.17± 1.14 of oral breathers. In relation to physical activity level, both were characterized as insufficiently active. There was a high incidence of mouth breathing among these children and independently from the respiratory pattern, nasal or mouth breathing, they had low level of physical activity, an important finding for preventive strategies and stimulation of physical activity practice in school.

Influence of thoracic spine postural disorders on cardiorespiratory parameters in children and adolescents with cystic fibrosis.

OBJECTIVES: To assess the impact of increased thoracic kyphosis on pulmonary function and functional capacity in children and adolescents with cystic fibrosis (CF) and to verify the influence of disease severity, age and nutritional status on this deformity. METHOD: This was a cross-sectional, analytical study conducted at a university hospital. It included CF patients with confirmed diagnosis and without pulmonary exacerbation. The sample was submitted to postural assessment, spirometry (FEV1, FVC and FEV1/FVC) and 6-minute walk test distance (6-MWT distance). Data were analyzed using the Mann Whitney test, Spearman correlation and logistic regression. RESULTS: Forty-two patients were enrolled, 61.9% presented increase of thoracic kyphosis. There was no difference in values of FEV1, FVC, FEV1/FVC and 6-MWT distance between the groups with or without thoracic kyphosis (p = 0.407; p = 0.756; p = 0.415; p = 0.294). In the group without alteration, patients with more disease severity had a mean FEV1 of 74.1±21.9% and FVC of 79.8±18.7% while in those of lesser severity higher values were found (95.6±12.2% and 97.6±13.2%, respectively) (p = 0.027 and p = 0.027). The presence of kyphosis was correlated with age (p = 0.048) but not with severity (p = 0.151) and body mass index (p = 0.088). CONCLUSIONS: There was a high prevalence of increased thoracic kyphosis in children and adolescents with CF. The deformity did not affect pulmonary function and functional capacity and there was no relationship with disease severity. Regardless of posture, worsening of disease severity determined worsening of pulmonary function.

Influência da alteração postural da coluna torácica em parâmetros cardiorrespiratórios de crianças e adolescentes com fibrose cística / Influence of thoracic spine postural disorders on cardiorespiratory parameters in children and adolescents with cystic fibrosis

OBJETIVOS: Avaliar a repercussão do aumento da cifose torácica na função pulmonar e na capacidade funcional de crianças e adolescentes com fibrose cística e verificar a influência da gravidade da doença, idade e aspectos nutricionais sobre essa deformidade. MÉTODO: Estudo analítico de corte transversal, realizado em um hospital universitário. Incluiu fibrocísticos com diagnóstico confirmado e fora de exacerbação pulmonar. A amostra foi submetida à avaliação postural, registro de parâmetros espirométricos - volume expiratório forçado no primeiro segundo (VEF1), capacidade vital forçada (CVF) e VEF1/CVF - e da distância percorrida pelo teste de caminhada de 6 minutos. Para análise dos dados, utilizou-se teste de Mann-Whitney, correlação de Spearman e regressão logística, considerando-se nível de significância de 5%. RESULTADOS: No total, 42 pacientes foram incluídos, e 61,9% apresentaram aumento da cifose torácica. Não houve diferença nos valores de VEF1, CVF, VEF1/CVF e distância percorrida pelo teste de caminhada de 6 minutos entre os grupos com e sem cifose torácica (p = 0,407; p = 0,756; p = 0,415; p = 0,294). No grupo sem alteração postural, fibrocísticos mais graves apresentaram média de VEF1 de 74,1±21,9% e CVF de 79,8±18,7%, enquanto naqueles de menor gravidade foram verificados valores superiores (95,6±12,2% e 97,6±13,2%, respectivamente) (p = 0,027 e p = 0,027). A presença de cifose correlacionou-se com a idade (p = 0,048), mas não com a gravidade (p = 0,151) e o índice de massa corporal (p = 0,088). CONCLUSÕES: Observou-se uma alta prevalência de aumento da cifose torácica em crianças e adolescentes com fibrose cística. Essa deformidade não alterou a função pulmonar e a capacidade funcional e não teve relação com a gravidade da doença. Independentemente da postura, a piora da gravidade da doença determinou piora da função pulmonar.

OBJECTIVES: To assess the impact of increased thoracic kyphosis on pulmonary function and functional capacity in children and adolescents with cystic fibrosis (CF) and to verify the influence of disease severity, age and nutritional status on this deformity. METHOD: This was a cross-sectional, analytical study conducted at a university hospital. It included CF patients with confirmed diagnosis and without pulmonary exacerbation. The sample was submitted to postural assessment, spirometry (FEV1, FVC and FEV1/FVC) and 6-minute walk test distance (6-MWT distance). Data were analyzed using the Mann Whitney test, Spearman correlation and logistic regression. RESULTS: Forty-two patients were enrolled, 61.9% presented increase of thoracic kyphosis. There was no difference in values of FEV1, FVC, FEV1/FVC and 6-MWT distance between the groups with or without thoracic kyphosis (p = 0.407; p = 0.756; p = 0.415; p = 0.294). In the group without alteration, patients with more disease severity had a mean FEV1 of 74.1±21.9% and FVC of 79.8±18.7% while in those of lesser severity higher values were found (95.6±12.2% and 97.6±13.2%, respectively) (p = 0.027 and p = 0.027). The presence of kyphosis was correlated with age (p = 0.048) but not with severity (p = 0.151) and body mass index (p = 0.088). CONCLUSIONS: There was a high prevalence of increased thoracic kyphosis in children and adolescents with CF. The deformity did not affect pulmonary function and functional capacity and there was no relationship with disease severity. Regardless of posture, worsening of disease severity determined worsening of pulmonary function.

Exercise capacity, respiratory mechanics and posture in mouth breathers.

UNLABELLED: Chronic and persistent mouth or oral breathing (OB) has been associated with postural changes. Although posture changes in OB causes decreased respiratory muscle strength, reduced chest expansion and impaired pulmonary ventilation with consequences in the exercise capacity, few studies have verified all these assumptions. OBJECTIVE: To evaluate exercise tolerance, respiratory muscle strength and body posture in oral breathing (OB) compared with nasal breathing (NB) children. MATERIAL AND METHOD: A cross-sectional contemporary cohort study that included OB and NB children aged 8-11 years old. Children with obesity, asthma, chronic respiratory diseases, neurological and orthopedic disorders, and cardiac conditions were excluded. All participants underwent a postural assessment, maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), the six-minute walk test (6MWT), and otorhinolaryngologic evaluation. RESULTS: There were 107 children (45 OB and 62 NB). There was an association between abnormal cervical posture and breathing pattern: 36 (80.0%) OB and 30 (48.4%) NB presented abnormal head posture (OR=4.27 [95% CI: 1.63-11,42], p<0.001). The mean MIP and MEP were lower in OB (p=0.003 and p=0.004). CONCLUSION: OB children had cervical spine postural changes and decreased respiratory muscle strength compared with NB.

Exercise capacity, respiratory mechanics and posture in mouth breathers / Capacidade ao exercício, mecânica respiratória e postura em respiradores bucais

Chronic and persistent mouth or oral breathing (OB) has been associated with postural changes. Although posture changes in OB causes decreased respiratory muscle strength, reduced chest expansion and impaired pulmonary ventilation with consequences in the exercise capacity, few studies have verified all these assumptions. OBJECTIVE: To evaluate exercise tolerance, respiratory muscle strength and body posture in oral breathing (OB) compared with nasal breathing (NB) children. MATERIAL AND METHOD: A cross-sectional contemporary cohort study that included OB and NB children aged 8-11 years old. Children with obesity, asthma, chronic respiratory diseases, neurological and orthopedic disorders, and cardiac conditions were excluded. All participants underwent a postural assessment, maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), the six-minute walk test (6MWT), and otorhinolaryngologic evaluation. RESULTS: There were 107 children (45 OB and 62 NB). There was an association between abnormal cervical posture and breathing pattern: 36 (80.0 percent) OB and 30 (48.4 percent) NB presented abnormal head posture (OR=4.27 [95 percent CI: 1.63-11,42], p<0.001). The mean MIP and MEP were lower in OB (p=0.003 and p=0.004). CONCLUSION: OB children had cervical spine postural changes and decreased respiratory muscle strength compared with NB.

A respiração bucal ou oral (RO) crônica e persistente tem sido associada a alterações posturais. Embora alterações de postura, na RO, causem diminuição da força muscular respiratória, menor expansibilidade torácica, prejuízo na ventilação pulmonar com consequências na capacidade de exercício, poucos estudos têm comprovado todas estas situações. OBJETIVO: Avaliar a tolerância ao exercício, a força muscular respiratória e a postura corporal em crianças respiradoras orais (RO), comparadas com respiradoras nasais (RN). MATERIAL E MÉTODO: Estudo de coorte contemporânea com corte transversal, no qual foram incluídas crianças RO e RN de 8 a 11 anos. Foram excluídas crianças obesas, asmáticas, com doenças respiratórias crônicas, distúrbios neurológicos, ortopédicos e cardiopatas. Todos os participantes foram submetidos à avaliação postural, pressão inspiratória máxima (PImáx), pressão expiratória máxima (PEmáx), teste de caminhada de seis minutos (TC6) e avaliação otorrinolaringológica. RESULTADOS: Participaram 107 crianças (45 RO e 62 RN). Houve associação entre alteração da postura cervical e padrão respiratório: 36(80,0 por cento) RO e 30(48,4 por cento) RN apresentaram alteração da postura da cabeça, respectivamente (RCP=4,27[IC95 por cento:1,63 - 11,42], p<0,001). Médias de PImáx e PEmáx foram menores nos RO (p=0,003 e p=0,004). CONCLUSÃO: Crianças RO apresentaram alteração postural da coluna cervical e diminuição da força muscular respiratória quando comparados com RN.

Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children.

OBJECTIVE: To evaluate submaximal exercise tolerance and respiratory muscle strength in relation to forward head posture (FHP) and respiratory mode in children, comparing mouth-breathing (MB) children with nasal-breathing (NB) children. METHODS: This was a controlled, analytical cross-sectional study involving children in the 8-12 year age bracket with a clinical otorhinolaryngology diagnosis of MB, recruited between October of 2010 and January of 2011 from the Mouth Breather Clinic at the State University of Campinas Hospital de Clínicas, located in the city of Campinas, Brazil. The exclusion criteria were obesity, asthma, chronic respiratory diseases, heart disease, and neurological or orthopedic disorders. All of the participants underwent postural assessment and the six-minute walk test (6MWT), together with determination of MIP and MEP. RESULTS: Of the 92 children in the study, 30 presented with MB and 62 presented with NB. In the MB group, the differences between those with moderate or severe FHP and those with normal head posture, in terms of the mean MIP, MEP and six-minute walk distance (6MWD), were not significant (p = 0.079, p = 0.622, and p = 0.957, respectively). In the NB group, the mean values of MIP and MEP were higher in the children with moderate FHP than in those with normal head posture (p = 0.003 and p = 0.004, respectively). The mean MIP, MEP, and 6MWD were lower in the MB group than in the NB group. Values of MIP and MEP were highest in the children with moderate FHP. CONCLUSIONS: Respiratory biomechanics and exercise capacity were negatively affected by MB. The presence of moderate FHP acted as a compensatory mechanism in order to improve respiratory muscle function.

Respiração bucal e anteriorização da cabeça: efeitos na biomecânica respiratória e na capacidade de exercício em crianças / Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children

OBJETIVO: Avaliar a tolerância ao exercício submáximo e a força muscular respiratória em relação à anteriorização da cabeça (AC) e ao tipo respiratório em crianças com respiração bucal (RB) ou nasal (RN). MÉTODOS: Estudo analítico transversal com um grupo controle no qual foram incluídas crianças de 8 a 12 anos com diagnóstico clínico otorrinolaringológico de RB, recrutadas do Ambulatório do Respirador Bucal do Hospital de Clínicas da Universidade Estadual de Campinas, Campinas (SP), entre outubro de 2010 e janeiro de 2011. Os critérios de exclusão foram obesidade, asma, doenças respiratórias crônicas, cardiopatias e distúrbios neurológicos ou ortopédicos. Todos os participantes foram submetidos a avaliação postural, teste de caminhada de seis minutos (TC6) e determinação de PImáx e PEmáx. RESULTADOS: Das 92 crianças do estudo, 30 tinham RB e 62 tinham RN. No grupo RB, não houve diferenças nas médias de PImáx, PEmáx e distância percorrida pelo TC6 (DTC6) entre o grupo com AC classificada como grave ou moderada e aquele com AC normal (p = 0,622; p = 0,957; e p = 0,079, respectivamente). No grupo RN, as médias de PImáx e PEmáx foram maiores no grupo com AC moderada do que naquele com AC normal (p = 0,003 e p = 0,004, respectivamente). Os valores de PImáx, PEmáx e DTC6 foram menores no grupo RB do que no grupo RN. A presença de AC moderada determinou maiores valores de PImáx e PEmáx. CONCLUSÕES: A RB afetou negativamente a biomecânica respiratória e a capacidade de exercício. A presença de AC moderada atuou como um mecanismo de compensação para uma melhor função da musculatura respiratória.

OBJECTIVE: To evaluate submaximal exercise tolerance and respiratory muscle strength in relation to forward head posture (FHP) and respiratory mode in children, comparing mouth-breathing (MB) children with nasal-breathing (NB) children. METHODS: This was a controlled, analytical cross-sectional study involving children in the 8-12 year age bracket with a clinical otorhinolaryngology diagnosis of MB, recruited between October of 2010 and January of 2011 from the Mouth Breather Clinic at the State University of Campinas Hospital de Clínicas, located in the city of Campinas, Brazil. The exclusion criteria were obesity, asthma, chronic respiratory diseases, heart disease, and neurological or orthopedic disorders. All of the participants underwent postural assessment and the six-minute walk test (6MWT), together with determination of MIP and MEP. RESULTS: Of the 92 children in the study, 30 presented with MB and 62 presented with NB. In the MB group, the differences between those with moderate or severe FHP and those with normal head posture, in terms of the mean MIP, MEP and six-minute walk distance (6MWD), were not significant (p = 0.079, p = 0.622, and p = 0.957, respectively). In the NB group, the mean values of MIP and MEP were higher in the children with moderate FHP than in those with normal head posture (p = 0.003 and p = 0.004, respectively). The mean MIP, MEP, and 6MWD were lower in the MB group than in the NB group. Values of MIP and MEP were highest in the children with moderate FHP. CONCLUSIONS: Respiratory biomechanics and exercise capacity were negatively affected by MB. The presence of moderate FHP acted as a compensatory mechanism in order to improve respiratory muscle function.

Influência do choro e de padrões respiratórios na deposição de medicação inalatória em crianças / The influence of crying and breathing pattern on inhalatory drug deposition in children

OBJETIVO: Verificar a influência do choro e de padrões respiratórios na eficácia da terapia inalatória em crianças. FONTES DE DADOS: busca sistemática por artigos científicos referentes ao tema nas bases de dados Cochrane Controlled Trials Data Base, MedLine e Science Direct, publicadas no período de 1994 a 2009. Utilizaram-se os descritores: "choro", "inalação", "aerossol", "trabalho respiratório" e "criança", nos idiomas português e inglês. SÍNTESE DE DADOS: Foram selecionados 13 artigos, 12 em inglês e um em português. A maioria dos trabalhos apresenta os efeitos da terapia inalatória em crianças, sem discutir a influência do choro e de diferentes padrões respiratórios sobre a deposição da medicação. Estudos que fizeram essa relação verificaram que a respiração e, principalmente, o choro reduzem a quantidade de fármaco que chega às vias aéreas periféricas. Autores discutem as diferenças anatômicas e fisiológicas do sistema respiratório da criança que podem interferir na eficácia da terapia inalatória. Porém, a maioria deles não analisa a influência qualitativa e quantitativa dos padrões respiratórios e do choro sobre a mecânica pulmonar. CONCLUSÕES: O choro e os padrões respiratórios influenciam na terapia inalatória, sendo atribuída ao choro a redução significativa da deposição medicamentosa nas vias aéreas. Pouco se sabe sobre o princípio determinante para a alteração do potencial de deposição, pois são escassas as evidências sobre o tema, apesar de sua relevância no manejo de afecções pulmonares da população pediátrica.

OBJECTIVE: To verify the influence of crying and breathing patterns in the effectiveness of inhalatory therapy in children. DATA SOURCES: Systematic search of scientific studies on the subject in the Cochrane Controlled Trials Database, MedLine and Science Direct, published from 1994 to 2009. The descriptors "crying", "inhalation", "aerosol", "work of breathing" and "child", in Portuguese and in English, were applied. DATA SYNTHESIS: 13 studies were selected, 12 in English and one in Portuguese. Most studies reported the effects of inhalation therapy in children, without discussing the influence of crying and breathing patterns on the deposition of the medication. Studies related to this subject found that the respiratory pattern, especially the cry, reduces the amount of drug that reaches the peripheral airways. Authors discuss the anatomical and physiological differences between adults' and children's respiratory system that may interfere with the effectiveness of inhalation. However, most of them do not examine the qualitative and quantitative influence of the breathing patterns and crying on pulmonary mechanics. CONCLUSIONS: Crying and breathing patterns influence the inhalation therapy. The presence of cry significantly reduces the amount of drug deposition in the airways. There is insufficient evidence about the possible mechanisms that explain potential changes of inhalatory drugs deposition in children, despite its relevance to the management of pediatric pulmonary disorders.

Abordagem global de uma intervenção fisioterapêutica na onfalocele gigante / Global approach to a physiotherapy intervention in giant omphalocele

Descrever os efeitos da utilização de recursos instrumentais e cinesioterapêuticos em parâmetros cardiorrespiratórios, espirométricos e na qualidade de vida de uma adolescente com diagnóstico de Onfalocele Gigante (OG), doença pouco abordada na literatura em relação à intervenção da fisioterapia respiratória e motora. Paciente de 16 anos, com diagnóstico de OG, realizou acompanhamento fisioterapêutico, cuja conduta envolveu o uso do Threshold®, Respiron®, fortalecimento e alongamento da musculatura global e de grupos musculares específicos, para a melhora do padrão postural. Os dados de função pulmonar referente à saturação de oxigênio, freqüências respiratória e cardíaca, pressão inspiratória e expiratória máximas, teste de caminhada de seis minutos e parâmetros espirométricos foram as variáveis quantitativas de efeito consideradas antes e após o período de cinco meses de tratamento. Houve melhora de todas as variáveis quantitativas de função pulmonar em relação aos valores basais, bem como melhora da qualidade de vida e da sensação de dispnéia referidas pela adolescente. O uso de recursos fisioterapêuticos instrumentais para fortalecer a musculatura inspiratória, melhorar a ventilação, diminuir a dispnéia e aumentar a tolerância ao exercício, além de uma abordagem postural para desenvolver equilíbrio da biomecânica músculo-esquelética, podem ser uma alternativa a ser utilizada como conduta no tratamento de pacientes com OG.

To describe the effects of using specific physiotherapeutic resources and kinesiotherapy on cardiorespiratory and spirometric parameters, and on the quality of life of an adolescent diagnosed with Giant Omphalocele (GO), a disease little-known in the literature as regards respiratory and motor intervention. In a 16-year-old patient diagnosed with GO, the physiotherapy was monitored involving the use of Threshold® and Respiron®, strengthening and stretching the musculature overall as well as in specific groups to improve the postural alignment. Data for pulmonary function regarding blood oxygenation, breath and heart rate, maximum inhalation and exhalation pressures, six-minute walk tests, and spirometric parameters were the effective quantitative variables considered before and after the five-month treatment period. There was a general improvement in all the quantitative variables for pulmonary function compared to baseline values, as well as an improvement in the quality of life and of the feelings of dyspnea mentioned by the adolescent. The use of specific physiotherapeutic resources to fortify the natural inhalational musculature, to improve ventilation, to reduce dyspnea, and to increase the tolerance to exercise, aside from a postural approach to developing bio-mechanical musculoskeletal equilibrium, can be an alternative to be used as a path of treatment for patients with GO.