Lung Ultrasound and Pulmonary Function Test in Cirrhotic Patients.

Lung ultrasound (LU) is useful in the diagnosis of pulmonary interstitial-alveolar syndrome (IAS) when B-lines are detected. Its prevalence and effect in lung function is not well studied in cirrhotic patients. The objective of this study was to detect the prevalence of interstitial-alveolar involvement with LU and correlate with pulmonary function test to distinguish the effect of ascites and B-lines in pulmonary function. This was an observational single-center study with 49 patients listed for liver transplantation submitted for LU and pulmonary function tests. Patients were divided into 4 groups: no ascites and no B-lines (n = 19), B-lines only (n = 19), ascites only (n = 6), and ascites and B-lines (n = 5). There was a worse forced vital capacity (FVC) in patients with B-lines only (76.1% ± 9.2; P = .0058) and ascites only (66.8% ± 10.2; P = .0010). 1-second forced expiratory volume (FEV1) also was lower in patients with B-lines only (78.5% ± 10.3; P = .0001), ascites only (71.3% ± 13.2; P = .0004), and B-lines and ascites (74.2% ± 7.6; P = .0035). Model for End-Stage Liver Disease score was worse in the group with ascites and B-lines (22.4 ± 10.1; P = .0229). B-Lines reduced FVC and FEV1 in our study and may be an independent factor in worsening pulmonary function in these patients.

Respiratory Profile in Patients After Liver Transplantation.

BACKGROUND: Patients in the immediate post-operative liver transplantation (LxT) period can develop respiratory and functional complications. In the postoperative months, these functions tend to improve. Nevertheless, there are few studies that evaluate precisely and specifically respiratory function in post-LxT long-term after surgery. The objective of the study was to describe the respiratory profile of patients 1 to 6 months after LxT, accompanied by LxT outpatients. METHODS: We included patients between 25 and 60 years old. We excluded patients with chronic renal or cerebrovascular impairment, severe heart disease, and history of lung surgery or liver re-transplantation. Evaluations were carried out on 3 occasions: 1 month, 3 months, and 6 months after LxT. The following evaluations were submitted: respiratory muscle strength (manuvacuometer), value flows and lung volumes (spirometer), and surface electromyography analyzing root mean square in the right (RMS-R) and left (RMS-L) diaphragm. We analyzed MELD (Model for End-Stage Liver Disease). After normality tests, we used the Friedman test (non-parametric values) and ANOVA (parametric values), P ≥ .5 with the use of SPSS 21.0. RESULTS: Patients (n = 15) had a mean age of 53.0 ± 7.5 years and 25.9 ± 4.6 MELD score. The statistically significant value obtained at the 3 occasions of evaluation was RMS-R, with a decline during periods of evaluation. This can be caused by removal of the liver, resulting in a denervation and reduction in compliance of this portion of the muscle. CONCLUSIONS: Patients between 1 and 6 months after transplantation have a specific respiratory profile, close to normal values. However, there are few studies on this subject, and we suggest that more research be done.

Co-infected HIV/hepatitis patients compared with chronic liver patients and healthy individuals: respiratory assessment through surface electromyography and spirometry.

INTRODUCTION: Co-infected HIV and hepatitis subjects are candidates for a liver transplantation because of progressive liver disease. Chronic liver disease, co-infected or not, requires assessment of respiratory function before liver transplantation. The respiratory evaluation of these 2 groups compared with healthy individuals can define deficits, and this can impair a full recovery after transplant surgery. OBJECTIVE: This study sought to compare the respiratory profile in co-infected patients with chronic liver disease who are candidates for liver transplantation with that of healthy subjects. METHODS: Through respiratory evaluation of flows and lung volumes (spirometry), muscle activity (surface electromyography), and maximum pressure (manovacuometer), 250 people were distributed into 3 groups: 14 patients with HIV and liver disease, 65 healthy subjects, and 171 patients with chronic liver disease. The mean age (years) was respectively 47.5 ± 6.2, 48.3 ± 14.1, and 52.9 ± 8.5. The average body mass index (kg/m(2)) of the groups was 24.6 ± 4.5, 26.0 ± 3.2, and 28.5 ± 5.3, respectively. RESULTS: There was a statistical difference among the groups in the root means square (RMS) rectus abdominis (µV) (P = .0016), RMS diaphragm (µV) (P = .0001), maximal inspiratory pressure (cmH2O) (P = .001), forced exhaled volume at the end of first second (%) (P = .002), and maximal mid expiratory flow 25% to 75% (%) (P = .0001) for the Kruskal-Wallis test. The multivariate analysis among the groups showed that the RMS diaphragm had a tendency to discriminate the co-infected subjects. CONCLUSIONS: The co-infected HIV group showed a muscle deficit of diaphragm and rectus abdominis activity, and the liver disease group showed lower indexes in volumes and respiratory flows.

Surface electromyography for respiratory assessment of liver transplant candidates, healthy subjects and after chevron post-operative incision.

BACKGROUND: Surface electromyography is a noninvasive technique for detecting the activity of skeletal muscles and especially the muscles for respiratory compliance; namely, the diaphragm and rectus abdominis. This study compares these muscles in healthy individuals, liver disease patients, and after abdominal surgery. OBJECTIVE: To study muscle activity by surface electromyography of the right diaphragm muscles and right rectus abdominis (root means square, RMS), and the manovacuometry muscle strength (maximal inspiratory pressure, MIP; and maximal expiratory pressure, MEP). RESULTS: We evaluated 246 subjects who were divided into 3 groups: healthy (65), liver disease (171), and post-surgery (10). In liver disease group the BMI was higher significantly for ascites (P = .001), and was increase in RMS rectum (P = .0001), RMS diaphragm (P = .030), and a decreased inspiratory and expiratory indices (P = .0001) pressure in the post-surgery group. A multivariate analysis showed tendency to an increased BMI in liver disease and in the post-surgery groups correlated with an increased RMS rectum and the lower MIP/MEP (P = .11). The receiver operating characteristic curve showed that RMS rectus was capable of discriminating liver disease and post-surgery patients from healthy subjects (area = 0.63; 95% CI 0.549-0.725). CONCLUSION: The muscle activity of normal individuals is lower than in subjects with deficit muscles because less effort is necessary to overcome the same resistance, observed by surface electromyography and muscle strength.

Evaluation of functional status, pulmonary capacity, body composition, and quality of life of end-stage liver disease patients who are candidates for liver surgery.

INTRODUCTION: Muscular weakness in combination with malnutrition can induce a global motor impairment and physical inactivity, adversely impairing the daily living activities and quality of life of end-stage liver disease patients who are candidates for liver transplantation. OBJECTIVES: To evaluate functional status, pulmonary capacity, body composition and quality of life in end-stage liver disease patients who are candidates for liver transplantation; to verify if there is a correlation between the functional variables of the individuals tested through the 6-minute walk test (6MWT) and covariables: pulmonary function test (PFP), quality of life and body composition. METHODS: This study was carried out at the Liver Transplantation Unit of the State University of Campinas (UNICAMP). We included 46 patients with end-stage liver disease who underwent the following evaluations: medical history, quality of life questionnaire "Short Form 36" (SF-36), surface electromyography (sEMG) of the diaphragm and rectus abdominis muscles, body composition assessment by electrical vioimpedance (BIA), 6MWT and PFP. RESULTS: Univariate analysis and Pearson's correlation found correlations between distance walked on 6MWT and QOL (P = .006 and P = .02) and TBW (P = .5 and P = .02). Pearson's correlation were found between respiratory variables of 6MWT, QOL, and PFP. CONCLUSION: The functional status may be correlated to body composition, quality of life and pulmonary capacity of patients with liver disease, candidates for transplantation.

Validation of 20-meter corridor for the 6-minute walk test in men on liver transplantation waiting list.

BACKGROUND: Guidelines established by the American Thoracic Society recommend the use of corridors 30 m in length for the 6-minute walk test (6MWT). However, not all institutions have such long corridors, which hinders or prevents 6MWT performance and use of its benefits. OBJECTIVE: To compare the distances walked by male patients with cirrhosis on the liver transplantation waiting list, we performed 6MWT on corridors 20 and 30 m long. METHODS: This prospective study included 10 patients on the waiting list for liver transplantation. They underwent 2 walk tests: the first test in a 20 m corridor and the second in a 30 m corridor. We assessed physiologic variables (heart rate, oxygen saturation, arterial blood pressure) and the subjective sensation of dyspnea at rest at 6 and 9 minutes after each walk. Statistical analysis was performed using the Wilcoxon test. RESULTS: Data are expressed as mean ± sd. Patient age was 59 ± 10 years. The distances walked by the patients were shorter than those predicted for their age and gender (586 ± 45 m) in both tests, no significant difference was observed between the first and the second 6MWT (437 ± 101 m vs 465 ± 80 m; P=.131) or among the physiologic variables. CONCLUSION: We concluded that a 20 m corridor can be used safely and effectively as an alternative to 30 m for the 6MWT for male patients with cirrhosis on the liver transplantation waiting list.

Comparison of surface electromyography in respiratory muscles of healthy and liver disease patients: preliminary studies.

INTRODUCTION: Surface electromyography (SEMG) is described as a technique to detect voluntary muscle activity. In the respiratory muscles, diaphragm and the rectus abdominis-are especially important for respiratory compliance. OBJECTIVE: We sought to study the activity of muscles using SEMG of the right diaphragm and the right rectus abdominis in healthy subjects versus liver disease patients (LDS). METHOD: Each group of 30 male patients underwent SEMG with electrodes attached to the dermis surface at the xiphoid and below the right costal margin (channel 1). For the rectus abdominis, we placed the electrodes on the right 5 cm below the umbilicus. The variables studied were: root mean square (RMS), maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP). We also evaluated age, weight, body mass index, smoking history lifestyle sedentary preexistent chronic lung disease. Nonparametric tests were used for statistical analysis. RESULTS: There were significant differences (P>0001) between the groups regarding MEP and MIP values showing low pressures in the LDS group. RMS of the rectus abdominis showed a trend (P=.059) toward compliance in the LDS group. Compared with the healthy subjects, there were 18% versus 5% sedentary individuals; only 10% versus 27.3% were smokers or former smokers and chronic lung disease was present in 2% versus 4%. CONCLUSION: The respiratory muscle evaluation using SEMG detected decreased respiratory muscle strength and a trend to rectus abdominis compliance among LDS.