Efectos de una sesión de fisioterapia respiratoria en la obstrucción de la vía aérea en niños/as menores de 3 años / Effects of a single chest physical therapy session on bronchial obstruction in children younger than 3 years old

ANTECEDENTES Y OBJETIVO: La fisioterapia respiratoria (FR) es ampliamente utilizada para el manejo de disfunciones respiratorias infantiles, sin embargo, estudios dirigidos a objetivar este efecto son escasos. Por tanto, el objetivo de este estudio fue evaluar el efecto de una sesión de FR sobre la obstrucción bronquial en niños/as menores de 3 años. MATERIALES Y MÉTODOS: Estudio exploratorio. Fueron incluidos un total de 39 menores de 3 años (26 niños y 13 niñas) con diagnóstico de síndrome bronquial obstructivo (SBO). El nivel de obstrucción bronquial fue valorado mediante el score de Tal modificado antes y después de una sesión de FR. Mediante la prueba de Wilcoxon se compararon los niveles de obstrucción bronquial pre y postintervención en todo el grupo, según género y edad. RESULTADOS: Se observó una reducción significativa del grado de obstrucción bronquial en todo el grupo, varones, mujeres, menores y mayores de 9 meses (p < 0,05) posterior a una sesión de FR. CONCLUSIÓN: Una sesión de FR fue efectiva en disminuir el grado de obstrucción bronquial en niños/as con diagnóstico de SBO menores de 3 años

BACKGROUND AND OBJECTIVE: Chest physical therapy (CPT) is widely used for the management of childhood respiratory disorders, however, studies that quantify this effect are scarce. Therefore, the aim of this study was to assess the effect of a single chest physical therapy (CPT) session on the bronchial obstruction of children younger than three years old. MATERIAL AND METHODS: This is an exploratory study. Thirty nine children younger than three years old (26 males and 13 females) with syndrome of bronchial obstruction (SBO) were included. The level of bronchial obstruction was measured with the modified Score of Tal before and after a single CPT session. Through the Wilcoxon test, comparisons of the bronchial obstruction levels were made of the whole group, males, females, and in those younger and older than 9 months as well. RESULTS: Significant reductions in bronchial obstruction levels were seen in all the children, an effect that was also seen in the males, females, and in those younger and older than 9 months (p<.05) after a single CPT session. CONCLUSION: A single CPT session was effective in reducing the bronchial obstruction levels in children with SBO, younger than three years old

Gestão da permeabilidade das vias aéreas à pessoa com patologia respiratória crónica: intervenção do enfermeiro especialista em enfermagem de reabilitação / Management of airway permeability to the person with chronic respiratory disease: intervention of the nurse specialist in rehabilitation nursing

O presente relatório teve como principal objetivo a descrição e análise reflexiva das competências adquiridas ao longo do estágio clínico, realizado em dois campos distintos, num serviço de Medicina de um Hospital central de Lisboa e numa Unidade de Cuidados de Média Duração e Reabilitação (UMDR) na zona confinante de Lisboa, de acordo com a área de especialização em Enfermagem de Reabilitação (ER), para a obtenção do título de grau de mestre na respetiva área. A prática clínica desenvolvida foi sustentada ao abrigo da Teoria do Autocuidado de Orem (2001), constructo teórico que ajudou na estruturação do pensamento e planeamento das intervenções. A patologia respiratória crónica é presentemente identificada como um problema emergente a nível mundial. Em Portugal, constitui uma das principais causas de morbilidade e mortalidade, bem como, a sua forte correspondência em relação aos internamentos e reinternamentos hospitalares. O destaque para a gestão da permeabilidade das vias aéreas foi o foco da minha intervenção, uma vez que a acumulação de secreções é uma forte condicionante à aquisição de prováveis infeções respiratórias, muito evidente na pessoa com patologia respiratória crónica. A reabilitação respiratória, incidindo nos mecanismos de limpeza das vias aéreas, irá possibilitar a libertação de secreções e consequente melhoria da permeabilidade das vias aéreas, reduzindo agudizações da patologia. O Enfermeiro Especialista em Enfermagem de Reabilitação (EEER) deve assegurar a eficácia desses mecanismos, adequando-os o melhor possível a cada pessoa/família, sendo primordial a sua integração e participação no processo de reabilitação. De salientar, o quão me foi possível crescer a nível pessoal e profissional, como futura EEER, pelos conhecimentos e competências adquiridas, destacando outras áreas de intervenção, como a reeducação motora e cognitiva.

The aim of this report is the description and reflexive analysis of the competences acquired during the clinical internship, carried out in two different fields belonging to the area of rehabilitation nursing´s specialization, and with the objective to obtain the title of master's degree in this main area. Both phases of this internship were performed in Lisbon, the first one in the Medicine Service of Lisbon's Central Hospital and the second one in a Medium-Term Care and Rehabilitation Unit. The clinical practice developed was sustained under the Orem's Self-Care Theory (2001), a theoretical construct that helped in structuring the thinking and planning of interventions. The chronic respiratory disease is currently identified as an emerging worldwide problem. In Portugal, it is one of the main causes of morbidity and mortality, as well as, the strong relation with hospitalizations and rehospitalizations. The focus of my intervention was the airway permeability management, since the accumulation of secretions is a strong conditioning for the acquisition of probable respiratory infections, and very evident in the person with chronic respiratory disease. Respiratory rehabilitation focusing on the airway cleaning mechanisms, will release secretions and consequently improve airway permeability, reducing acute pathologies. The rehabilitation nurse specialist must ensure the effectiveness of these mechanisms, adapting them as well as possible to each person/family, being primordial for its integration and participation in the rehabilitation process. It should be also noted that this experience allowed me to grow not only professionally but also personally, as a future rehabilitation nurse specialist, by the knowledge and skills acquired, highlighting other areas of intervention, such as motor and cognitive reeducation.

Outpatient pulmonary rehabilitation for severe asthma with fixed airway obstruction: Comparison with COPD.

Background: The benefit of exercise has been demonstrated in asthma, but the role of pulmonary rehabilitation (PR) in people with severe asthma, especially with airway obstruction, has been less investigated. The activity limitation mechanisms differ in asthma and COPD, so the effect of a PR program not specific to asthma is unclear. Methods: We retrospectively compared the effect of an ambulatory PR program in nonsmoking patients with severe asthma and airway obstruction (FEV1/FVC ratio <70% and FEV1 < 80% measured twice, not under an exacerbation) and sex-, age-, FEV1-, and BMI-matched COPD controls. Results: We included 29 patients, each with asthma and COPD. Airway obstruction was moderate (median FEV1 57% [44-64]). VO2 at peak was higher for asthma than COPD patients (19.0 [15.7-22.2] vs 16.1 [15.3-19.6] ml.min-1.kg-1, p = 0.05). After PR, asthma and COPD groups showed a significant and similar increase in constant work cycling test of 378 [114-831] s and 377 [246-702] s. Changes in Hospital Anxiety and Depression Scale (HAD) total score were similar (-2.5 [-7.0 to 0.0] vs -2.0 [-5.0 to 2.0], p > 0.05). Quality of life on the St. George's Respiratory Questionnaire (SGRQ) was significantly improved in both groups (-14.0 [-17.7 to -2.0], p < 0.005 and -8.3 [-13.0 to -3.6], p < 0.0001). Conclusion: Outpatient PR is feasible and well tolerated in patients with severe asthma with fixed airway obstruction. A nondedicated program strongly improves HAD and SGRQ scores and constant work-rate sub-maximal cycling, with similar amplitude as with COPD.

Discrimination of "hot potato voice" caused by upper airway obstruction utilizing a support vector machine.

OBJECTIVES/HYPOTHESIS: "Hot potato voice" (HPV) is a thick, muffled voice caused by pharyngeal or laryngeal diseases characterized by severe upper airway obstruction, including acute epiglottitis and peritonsillitis. To develop a method for determining upper-airway emergency based on this important vocal feature, we investigated the acoustic characteristics of HPV using a physical, articulatory speech synthesis model. The results of the simulation were then applied to design a computerized recognition framework using a mel-frequency cepstral coefficient domain support vector machine (SVM). STUDY DESIGN: Quasi-experimental research design. METHODS: Changes in the voice spectral envelope caused by upper airway obstructions were analyzed using a hybrid time-frequency model of articulatory speech synthesis. We evaluated variations in the formant structure and thresholds of critical vocal tract area functions that triggered HPV. The SVMs were trained using a dataset of 2,200 synthetic voice samples generated by an articulatory synthesizer. Voice classification experiments on test datasets of real patient voices were then performed. RESULTS: On phonation of the Japanese vowel /e/, the frequency of the second formant fell and coalesced with that of the first formant as the area function of the oropharynx decreased. Changes in higher-order formants varied according to constriction location. The highest accuracy afforded by the SVM classifier trained with synthetic data was 88.3%. CONCLUSIONS: HPV caused by upper airway obstruction has a highly characteristic spectral envelope. Based on this distinctive voice feature, our SVM classifier, who was trained using synthetic data, was able to diagnose upper-airway obstructions with a high degree of accuracy. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:1301-1307, 2019.

In Situ and Home Care Nasopharyngeal Intubation Improves Respiratory Condition and Prevents Surgical Procedures in Early Infancy of Severe Cases of Robin Sequence.

AIM: To evaluate the clinical outcome of infants with Robin Sequence (RS) and severe respiratory obstruction managed with nasopharyngeal intubation (NPI). METHODS: This prospective study was conducted with 107 infants with RS admitted to the Hospital for Craniofacial Anomalies of the University of São Paulo (HRAC-USP), from July 2003 to June 2010, diagnosed with severe RS and treated with NPI. The infants were followed up for the first year of life. Clinical findings, morbidity, and mortality were recorded. RESULTS: Of the 223 infants with RS admitted to the hospital in the period studied, 149 were diagnosed with severe respiratory distress and 107 (71.81%) matched all the inclusion criteria. Of those, 78 (73%) presented Isolated Robin Sequence and 29 (27%) presented other syndromes or anomalies associated with RS. NPI treatment lasted an average of 57 days and the mean hospitalization time was 18 days. Although all infants presented feeding difficulties, 85% were fed orally and only 15% underwent gastrostomy. Morbidity was 14% and no deaths occurred. CONCLUSIONS: The children treated with the RS treatment protocol adopted at the HRAC-USP had improved respiratory and feeding difficulties, required a shorter hospitalization time, and presented low morbidity and mortality during the first year of life. The general outcome prevented surgical procedures in early infancy.

Puesta al día en técnicas de fisioterapia respiratoria / Update in respiratory physiotherapy techniques

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Effects of fixed appliances in correcting Angle Class II on the depth of the posterior airway space: FMA vs. Herbst appliance--a retrospective cephalometric study.

OBJECTIVE: The objective of this retrospective study based on the metric evaluation of lateral cephalograms was to investigate the extent to which treatment with two different fixed appliances for the correction of Angle Class II influenced the morphology of the extrathoracic airway space (the posterior airway space, PAS). PATIENTS AND METHODS: A total of 43 patients with Angle Class II malocclusion were classified into two groups according to the appliance used for treatment: the functional mandibular advancer (FMA; n = 18) or the Herbst appliance (n = 25). Lateral cephalograms were taken of each patient at the start of functional jaw orthopedic treatment (time point T1) and at its completion (time point T2). Specific distances and angles were measured and analyzed in a cephalometric analysis. RESULTS: We observed major differences among the 43 patients in the depth of the posterior airway space during treatment with fixed appliances for Angle Class II correction. Regression analysis revealed that changes in sagittal and vertical positions had different effects on the depth of specific PAS sections: increases in anterior facial height are associated proportionately with increases in PAS width, particularly in the upper region. On the other hand, increases in posterior facial height and in the mandible's forward displacement correlated inversely to the decreases in depth, particularly in the central and lower PAS regions. The two treatment appliances (FMA, Herbst appliance) had the same effects on extrathoracic airway depth. CONCLUSIONS: Analyses of lateral cephalograms indicate that Angle Class II treatment with fixed appliances does not prevent sleep apnea in patients at risk. Nevertheless, this study does not permit absolutely reliable conclusions about the dimensions of the pharyngeal airway space. As the lateral cephalogram provides good images of structures in the midsagittal plane but is incapable of imaging the transverse dimension, there is an automatic lack of information concerning the precise width and volume of the extrathoracic airway space.

Effects of a short-term rehabilitation program on airway inflammation in children with cystic fibrosis.

BACKGROUND: Respiratory therapy in cystic fibrosis (CF) consists of airway clearance, infection control, and reduction of airway inflammation. It is well recognized that physical activity as well as daily chest physiotherapy, enhance airway clearance. We investigated the effects of pulmonary rehabilitation, including physical activity and chest physiotherapy, on airway inflammation in children with CF. METHODS: Eighteen children with stable CF (six females), aged 8.2-16.2 years, participating in a 3-week multidisciplinary inpatient rehabilitation program were recruited. Assessment at the beginning and the end of the program included clinical score, pulmonary function test, exhaled breath condensate (EBC) and sputum analysis. Sputum supernatant and EBC were analyzed for interleukin (IL)-1b, 6, 8, 10, 12, tumor necrosis factor-alpha (TNF-alpha) and LTB4. RESULTS: Median (IQR) symptom scores decreased from 19 [23] to 16 [21], P = 0.005. Vital capacity and FVC increased significantly (P < 0.05). However no difference was found for the total sputum cells and sputum as well as EBC cytokines between the two visits. Significant correlations were found for sputum IL-1 (+), IL-6 (-), and IL-8 (+) to total sputum cell count and neutrophils and for IL-8 to TNF-alpha. CONCLUSIONS: We have shown that a short-term inpatient rehabilitation for children with stable CF with intensive physical activity mainly improve subjective clinical symptoms and measures of lung function such as VC and FVC but does not influence airflow obstruction and airway inflammation as assessed by sputum and EBC analysis.

Three years of pulmonary rehabilitation: inhibit the decline in airflow obstruction, improves exercise endurance time, and body-mass index, in chronic obstructive pulmonary disease.

BACKGROUND: Pulmonary rehabilitation is known to be a beneficial treatment for COPD patients. To date, however, there is no agreement for how long a rehabilitation program should be implemented. In addition, current views are that pulmonary rehabilitation does not improve FEV1 or even slow its decline in COPD patients. The aim of the study was to examine the efficacy of a 3 year outpatient pulmonary rehabilitation (PR) program for COPD patients on pulmonary function, exercise capability, and body mass index (BMI). METHODS: A matched controlled trial was performed with outcome assessments evaluated at 6, 12, 18, 24, 30, and 36 months. Eighty patients with moderate to severe COPD (age 63 +/- 7 years; FEV1 48% +/- 14) were recruited. The control group received standard care only, while in addition, the case study group received PR for duration of three years. These groups were matched for age, sex, BMI, FEV1% and number of pack-years smoked. RESULTS: The decline in FEV1 after the three years was significantly lower in the PR group compared to control, 74 ml versus 149 ml, respectively (p < 0.001). Maximal sustained work and endurance time improved after a short period of PR and was maintained throughout the study, in contrast to the control group (p < 0.01). A decreased BMI was noted in the control group after three years, while in the PR group a mild improvement was seen (p < 0.05). CONCLUSION: Three years of outpatient pulmonary rehabilitation resulted in modifying the disease progression of COPD, as well as improving physical performance in these patients.

Uneventful recovery from suicidal hanging: a case report.

Although hanging accounts for a considerable number of suicidal deaths in Sri Lanka, on rare occasions the victims survive. A few cases have been reported in the literature where victims survived after varying periods of unconsciousness. It has been observed that death does not necessarily result from hanging, provided the victim is brought down promptly and resuscitated actively and vigorously. This paper focuses on an unusual case of a 39-year-old male who survived after resuscitation, without any adverse neurological outcome, after a suicide attempt by hanging.

Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance.

STUDY OBJECTIVES: To analyze the physiologic effects and tolerance of mechanical insufflation-exsufflation (MI-E) for patients with chronic ventilatory failure of various etiologies. DESIGN: Prospective clinical trial. SETTING: Rehabilitation unit of a university hospital. PATIENTS OR PARTICIPANTS: Thirteen patients with amyotrophic lateral sclerosis (ALS), 9 patients with severe COPD, and 7 patients with other neuromuscular disorders (oNMDs) with chronic airway secretion encumbrance and decreases in oxyhemoglobin saturation (Spo(2)). INTERVENTIONS: Pressures of MI-E of 15 cm H(2)O, 30 cm H(2)O, and 40 cm H(2)O were cycled to each patient, with 3 s for insufflation and 4 s for exsufflation. One application was six cycles at each pressure for a total of three applications. MEASUREMENTS AND RESULTS: We continuously evaluated respiratory inductance plethysmography (RIP) and Spo(2) during every application. Peak cough flow (PCF) and dyspnea (Borg Scale) were also measured before the first and after the last application. The technique was well tolerated in all patient groups. Median Spo(2) improved significantly (p < 0.005) in all patient groups. Median PCF improved significantly (p < 0.005) in the ALS and oNMD groups from 170 to 200 L/min and from 180 to 220 L/min, respectively, and dyspnea improved significantly in the patients with oNMDs and patients with COPD from 3 to 1 and from 2 to 0.75, respectively. Breathing pattern characteristics (RIP) did not deteriorate after MI-E in any patient groups. Inspiratory flow limitation significantly decreased at the highest MI-E pressures for the ALS group. CONCLUSIONS: Our results confirm good tolerance and physiologic improvement in patients with restrictive disease and in patients with obstructive disease, suggesting that MI-E may be a potential complement to noninvasive ventilation for a wide variety of patient groups.

[Botulinum toxin type A-induced "rebalancing" in bilateral vocal cord paralysis?]. / Botulinum-Toxin-A-induzierte "Rebalanzierung" bei beidseitiger Stimmlippenparese?

BACKGROUND: Upper airway obstruction due to bilateral vocal cord paralysis in an 80-year-old female patient was successfully relieved by injection of botulinum toxin A (BTA) into the laryngeal adductor muscles. The patient achieved satisfactory airway ventilation. Spirograms obtained preoperatively and postoperatively documented improved peak flow rates and 1-s forced expiratory volume values. Voice quality was breathy after the injection; however, neither aspiration nor dysphagia developed. Surprisingly, the maximum phonation time increased. PATIENTS AND METHODS: During a follow-up check 4 months later, the patient still reported less dyspnea although the vocal cords were closer together than initially after the injection. The decrease in dyspnea as reported by the patient lasted approximately 2 years. RESULTS: The improvement in breathing following injection of BTA can be interpreted as a paralysis or weakening of the laryngeal adductors. However, it remains unclear why the maximum phonation time increased. Comparable findings, i.e., improvement in overall laryngeal function, are described in the literature as BTA-mediated laryngeal rebalancing.

The use of manual hyperinflation in airway clearance.

Manual lung hyperinflation (MH) is one of a number of techniques which are employed by the physiotherapist in the critical care setting. The technique was first described with physiotherapy 30 yrs ago and commonly involves a slow, deep inspiration, inspiratory pause and fast unobstructed expiration. The use of MH varies between and within countries. It is commonly employed by physiotherapists to assist in the removal of secretions and re-expand areas of atelectasis. Despite the popularity of the technique, research examining its efficacy is conflicting, especially the effect of MH on cardiovascular parameters. Recent studies examining mucociliary transport in intubated and ventilated patients have shown impaired clearance of secretions, but research evaluating the role of MH specifically in airway clearance is scant. The use of the additional physiotherapy techniques, gravity assisted drainage and chest wall vibrations, may enhance the efficacy of MH in promoting airway clearance, but further research is necessary. Controversy exists regarding the safety and effectiveness of application of manual lung hyperinflation in intubated patients. Clearly, more randomized controlled studies are necessary in order to provide a sound scientific rationale for the application of manual lung hyperinflation in the treatment of critically ill patients.

Laser bronchoscopy with transglottic/supraglottic ventilation to relieve dysphonia and subglottic obstruction.

Dysphonia after endotracheal intubation usually indicates a glottic lesion but it can also herald an obstructing subglottic airway mass. Outpatient strobovideolaryngoscopy may be anatomically extended by transglottic videotracheobronchoscopy to achieve a thorough examination of the proximal bronchi, trachea, subglottis, glottis, and supraglottis in selected cases. Combining these techniques with lateral soft tissue x-ray studies of the neck in two patients with dysphonia and stridor, nearly identical postendotracheal intubation subglottic severely obstructing granulation "tumors" were diagnosed. Operative subglottic resection with a rigid ventilating laser bronchoscope combined with transglottic/supraglottic anesthetic ventilation techniques and contact-tip Nd-YAG laser phototherapy relieved the dysphonia and airway obstruction simultaneously. Normal vocal quality and full anatomical airway patency were achieved in both cases. Follow-up postoperative vocal rehabilitation and medical therapy sustained the surgical results.

Improving perception of air flow obstruction in asthma patients.

OBJECTIVE: The objective of the study was to train asthma patients to improve their ability to discriminate added resistive loads. METHODS: Training consisted of a task in which patients judged the relative difficulty of breathing through two circuits. Difficulty of breathing through the circuits was varied by addition of resistive loads. We assigned 45 patients randomly to one of three conditions: a feedback plus fading condition, a feedback condition, and a control condition. RESULTS: Feedback of accuracy of judgments coupled with fading resulted in reduction of difference threshold. Neither feedback alone nor a control condition in which patients were given experience in making judgments without feedback resulted in threshold change. CONCLUSIONS: Perception training with added resistive loads may help patients to detect an increase in air flow obstruction due to asthma before it becomes severe.

Obstructive and restrictive pulmonary dysfunction increases disability in Parkinson disease.

OBJECTIVE: The purpose of this study was to determine in Parkinson disease the impact of pulmonary dysfunction on daily living activities (DLA). PATIENTS: Extrapyramidal motor impairment, pulmonary dysfunction, and DLA disabilities were studied in 58 Parkinson patients consecutively enrolled in a rehabilitation service at a university hospital. MAIN OUTCOME MEASURES: Extrapyramidal motor impairments were assessed by the Unified Parkinson's Disease Rating Scale (UPDRS) and the DLA disabilities by the UPDRS, Hoehn-Yahr, and Schwab-England scales. The pulmonary dysfunctions were assessed by spirometry with flow-volume loops, body plethysmography with lung volumes computation, and maximal inspiratory and expiratory static mouth pressures. RESULTS: Parkinson patients showed important modifications of pulmonary function with a decrease in forced vital capacity, forced expiratory volume in the first minute, and arterial PO2, and an increase in residual volume and total airway resistance (RAW). In addition, they showed a high incidence of airway ventilatory obstructions and restrictive dysfunction. The impact of lung disease on daily living activities in Parkinson disease patients was higher in subjects with restrictive pulmonary dysfunctions (Schwab-England test and turning in bed and adjusting bedclothes, walking, falling, and freezing when walking items of UPDRS) and airway obstructions (handling utensils, dressing and hygiene items of UPDRS). CONCLUSIONS: Airway obstructions or restrictive pulmonary dysfunctions present a high prevalence in Parkinson disease, contributing as a main factor for DLA dysfunctions. The evaluation and rehabilitation of respiratory disturbances should be systematically included in the management of these patients.