Complicaciones en pacientes usuarios de traqueostomía en unidades de cuidados intensivos. Scoping Review / Complications associated with tracheostomy in adult patients in intensive care units between 2015-2020. A Scoping Review / Complicações associadas à traqueostomia em pacientes adultos em unidades de terapia intensiva no período 2015-2020. Revisão sistemática

Introducción: Los procedimientos de traqueostomía van en aumento en las unidades de cuidados intensivos en el adulto, por lo que las complicaciones asociadas a este procedimiento también incrementan. Se ha identificado que la traqueostomía puede conllevar a complicaciones tanto preoperatorias como postoperatorias, que varían ampliamente entre un 5-40%, entre las más frecuentes están, estenosis traqueal, fístula traqueoesofágica, hemorragia, lesión peristomal, decanulación, infecciones, entre otras, que podrían causar la muerte hasta en 1,4% de las personas. Sin embargo, a nivel mundial muy pocos estudios abordan los conceptos causales o factores de riesgo mecánicos y no mecánicos de este importante tema. Objetivo: Revisar el alcance de la literatura científica disponible sobre las complicaciones de origen mecánico y no mecánico asociadas a la traqueostomía en pacientes adultos en las unidades de cuidados intensivos entre el periodo 2015-2020. Materiales y métodos: se establecieron la pregunta de investigación con metodología "Patient, Intervention, Comparation, Outcome, Time (PICOT)" y los criterios de inclusión para la búsqueda de los referentes bibliográficos de estudios observacionales y experimentales. La información fue consultada en las bases de datos PubMed y EBSCO y los artículos científicos seleccionados fueron los publicados entre los años 2015-2020. Como guía metodológica y de calidad para el presente estudio se utilizó la lista de chequeo PRISMA-ScR. Resultados: las complicaciones con mayor frecuencia son: sangrado 61% presentada (13/21 artículos), estenosis traqueal 28,5% (5/21 artículos), decanulación 23,6% (5/21 artículos), infección de la estoma 19% (4/21 artículos) muerte 19% (4/21) y la dificultad en la inserción de la cánula 19% (4/21 artículos), en cuanto a factores de riesgo mecánicos para éstas sólo se identifica el uso de la técnica Bjork flap (OR=0,4). Entre los no mecánicos se encontraron, obesidad (OR=5,15), diámetro de cánula >6 (OR= 2,6) y ventilación mecánica preoperatoria (OR=3,14). Conclusión:Se logró identificar que las complicaciones relacionadas con la traqueostomía con mayor incidencia son sangrado, estenosis traqueal, decanulación accidental y la muerte. Sin embargo, aún se desconoce si se originan por una causa mecánica o no mecánica durante su manejo en UCI.

Introduction:Tracheostomy procedures in intensive care units are on the rise; however, they can lead to both perioperative and postoperative complications, with a variable incidence from 5 to 40% and even death in up to 1.4% of individuals. Despite this, few studies address causal concepts or mechanical and nonmechanical risk factors about this important topic. Objetive: To review the scope of the available scientific literature on complications of mechanical and non-mechanical origin associated with a tracheostomy. Materials and Methods:The research question and inclusion criteria were established to conduct the search in PubMed and EBSCO databases between 2015 and 2020. The PRISMA-ScR checklist was used in the present study as a methodological and quality guideline. Results:The most frequent complications were bleeding 61%, tracheal stenosis 28.5%, decannulation 23.6% (5/21) , stoma infection 19%, death 19%, and difficult tracheostomy tube insertion 19%. Regarding mechanical risk factors, only the use of the Bjork flap (OR=0.4) was identified as a protective factor. Among the non-mechanical factors, obesity (OR=5.15), tube diameter >6 (OR=2.6), and preoperative mechanical ventilation (OR=3.14) were found. Conclusions: It was possible to identify that the highest incidence of tracheostomy-related complications were bleeding, tracheal stenosis, accidental decannulation, and death; however, it is still unknown whether they originate from a mechanical or non-mechanical cause during intensive care management.

Introdução: Os procedimentos de traqueostomia estão aumentando nas unidades de terapia intensiva, entretanto, podem levar a complicações perioperatórias e pós-operatórias com uma incidência variável entre 5-40% e até a morte em até 1,4% dos indivíduos, apesar disso, poucos estudos abordam os conceitos causais ou fatores de risco mecânicos e não-mecânicos sobre este importante tópico. Objetivo: Rever o escopo da literatura científica disponível sobre complicações mecânicas e não mecânicas associadas à traqueostomia. Materiais e Métodos: a questão da pesquisa e critérios de inclusão foram estabelecidos para a pesquisa nas bases de dados PubMed e EBSCO entre os anos 2015-2020, como guia metodológico e de qualidade para o presente estudo foi utilizada a lista de verificação PRISMAScR. Resultados: As complicações com maior freqüência foram, sangramento 61%, estenose traqueal 28,5%, decanulação 23,6% (5/21, infecção por estoma 19%, morte 19% e dificuldade na inserção da cânula 19%, em relação aos fatores de risco mecânico, apenas o uso da técnica de Bjork Flap (OR=0,4) foi identificado como fator de proteção, entre os fatores não mecânicos foram encontrados: obesidade (OR=5,15), diâmetro da cânula >6 (OR= 2,6) e ventilação mecânica pré-operatória (OR=3,14). Conclusões: Conseguimos identificar que as complicações relacionadas à traqueostomia com maior incidência foram sangramento, estenose traqueal, decanulação acidental e morte, no entanto, ainda não se sabe se elas se originam de uma causa mecânica ou não mecânica durante a gestão dos cuidados intensivos.

Clinical Proof of Concept for Stabilization of Tracheostomy Tubes Using Novel DYNAtraq Device.

Introduction: Tracheostomy is one of the most common surgical strategies in intensive care units (ICU) and provides relevant clinical benefit for multiple indications. However, the complications associated with its use range from 5 to 40% according to different series. The risk of these complications could be reduced if fixation strategies and alignment of the tracheostomy tube with respect to the tracheal axis are improved. Aim: To build a functional device of technological innovation in respiratory medicine for the fixation and alignment of tracheostomy cannula (acronym DYNAtraq) and to evaluate its feasibility and safety in a pilot study in mechanically ventilated patients. Methods: Study carried out in four phases: (1) design engineering and functional prototyping of the device; (2) study of cytotoxicity and tolerance to the force of traction and push; (3) pilot study of feasibility and safety of its use in tracheostomized and mechanically ventilated patients; and (4) health workers satisfaction study. Results: The design of the innovative DYNAtraq device included, on the one hand, a connector with very little additional dead space to be inserted between the cannula and the ventilation tubes, and, on the other hand, a shaft with two supports for adhesion to the skin of the thorax with very high tolerance (several kilograms) to pull and push. In patients, the device corrected the malpositioned tracheostomy tubes for the latero-lateral (p < 0.001) and cephalo-caudal angles (p < 0.001). Its effect was maintained throughout the follow-up time (p < 0.001). The use of DYNAtraq did not induce serious adverse events and showed a 70% protective effect for complications (RR = 0.3, p < 0.001) in patients. Conclusion: DYNAtraq is a new device for respiratory medicine that allows the stabilization, alignment and fixation of tracheostomy tubes in mechanically ventilated patients. Its use provides additional benefits to traditional forms of support as it corrects misalignment and increases tolerance to habitual or forced movements. DYNAtraq is a safe element and can reduce the complications of tracheostomy tubes.

Effect of Antioxidants in the Treatment of COPD Patients: Scoping Review.

Chronic obstructive pulmonary disease (COPD) is a common, preventable, treatable lung disease characterized by persistent respiratory symptoms and airflow limitation and multiorgan impact. This affects the nutritional status of patients and requires multidimensional interventions including nutritional interventions according to individual metabolic needs. Our scoping review determined the effects of antioxidants in the treatment of COPD patients and their role in the decrease in the probability of exacerbations, hospital readmissions, and changes in lung function. The sources MEDLINE, LILACS, and Google Scholar were consulted and 19 studies were selected. The most indicated antioxidants are N-Acetylcysteine, vitamins E and D, and Zinc. Other antioxidants from plants or fruits extracts are also being investigated. The beneficial effect of antioxidants in stable or exacerbated patients is not clear, but theoretical and biological arguments of benefit justify lines of research that specify the impact on reducing oxidative stress and negative effects in COPD.

Invention and Pilot Study of the Efficacy and Safety of the SUPRAtube Device in Continuous Supraglottic Aspiration for Intubated and Mechanically Ventilated Patients.

BACKGROUND: Bronchoaspiration of content that accumulates in the supraglottic area (eg, saliva, gastroesophageal reflux) is a risk factor for ventilator-associated pneumonia. A continuous supraglottic suction system may decrease the risk of bronchoaspiration in these patients. OBJECTIVE: (1) Constructing a conceptual model and functional prototype of a continuous supraglottic suction device for use in humans; (2) defining functional characteristics in ex vivo swine head models; and (3) evaluating its efficacy and safety in mechanically ventilated patients. METHODS: Study conducted in three phases. First phase: definition of distances and diameters of the triangle determined by dental arch, posterior oropharynx and vallecula, and diameter of the oropharynx in axial projection; and identification of the declining area of supraglottic suction. Second phase: design engineering and functional prototype evaluated in ex vivo models. Third phase: evaluation of device use in terms of safety and efficacy in ventilated patients. RESULTS: We obtained a final functional model of the SUPRAtube device injected into PVC for medical use. Device effectiveness in in vitro simulation showed a high and fast suction capacity of liquid and thick volumes. Study of swine heads allowed to validate the shape, size and functional fenestration of the device. Study in intubated and mechanically ventilated patients showed a high supraglottic suction capacity and the absence of local adverse events during 72 (7-240) hours of continuous operation. CONCLUSION: Our study describes the process of conceptualization, design and production of a practical, safe, low-cost continuous supraglottic suction device without representing antibiotic pressure, which appears to be a new complementary preventive strategy for the standard management of intubated and mechanically ventilated patients.

Terapia con fibrinólisis local dirigida por catéter en tromboembolismo pulmonar de riesgo intermedio / Therapy with local fibrinolysis directed by catheter in intermediate risk pulmonary thromboembolism

Resumen Introducción: en pacientes con tromboembolia pulmonar (TEP) aguda, la fibrinólisis arterial local puede tener una relación muy favorable entre beneficios y riesgos. Objetivo: caracterizar las condiciones epidemiológicas y clínicas de los pacientes con TEP agudo de riesgo intermedio que han recibido terapia fibrinolítica urgente dirigida por catéter. Métodos: estudio descriptivo de una serie de casos de pacientes atendidos en la Fundación Cardiovascular de Colombia (período 2012-2016) con diagnóstico de TEP de riesgo intermedio llevados a terapia fibrinolítica mediante catéter pulmonar. Resultados: se incluyeron 27 casos (26 pacientes, 57±20 años, 52% mujeres). La confirmación de embolia pulmonar aguda se realizó mediante angiotomografía. El 85% de los casos mostró signos ecocardiográficos de disfunción ventricular derecha, 74% elevación de troponinas, y 82% elevación de BNP o pro-BNP. El tiempo puerta-aguja desde el diagnóstico hasta la fibrinólisis fue de 29±31 horas (máx-min, 2-120). El tratamiento endovascular incluyó alteplasa (dosis total, 47±18 mg) y fragmentación-aspiración mecánica mediante catéter pulmonar. El 78% de los pacientes mostró disminuciones en la PAPm >10% del valor inicial [i.e., pacientes respondedores, ΔPAPm=-27±11% (-9±5 mmHg)]. Cinco pacientes fueron clasificados como no-respondedores (ΔPAPm=-2±7%, -1±4 mmHg). La estancia en UCI fue de 7±5 días (1-19), y la hospitalaria 13 días (1-36). No se presentaron complicaciones de sangrado mayor ni de otra índole. La supervivencia a 90 días fue de 100%. Conclusiones: esta serie observa que la fibrinólisis arterial pulmonar induce una mejoría hemodinámica inmediata en una alta proporción de pacientes con TEPa, con un balance beneficio-riesgo favorable en ausencia de complicaciones atribuibles inmediatas o tardías. (Acta Med Colomb 2019; 44: 17-24).

Abstract Introduction: in patients with acute pulmonary embolism (PE), local arterial fibrinolysis can have a very favorable relationship between benefits and risks. Objective: to characterize the epidemiological and clinical conditions of patients with intermediate-risk of acute PE who have received urgent fibrinolytic therapy directed by catheter. Methods: a descriptive study of a series of cases of patients treated at the Cardiovascular Foundation of Colombia (2012-2016 period) with a diagnosis of intermediate-risk PE who received fibrinolytic therapy using a pulmonary catheter. Results: 27 cases were included (26 patients, 57 ± 20 years, 52% women). Confirmation of acute pulmonary embolism was performed by angiotomography. 85% of the cases showed echocardiographic signs of right ventricular dysfunction, 74% elevation of troponins, and 82% elevation of BNP or pro-BNP. The door-needle time from diagnosis to fibrinolysis was 29 ± 31 hours (max-min, 2-120). The endovascular treatment included alteplase (total dose, 47 ± 18 mg) and mechanical fragmentation-aspiration by pulmonary catheter. 78% of the patients showed decreases in PAPm> 10% of the initial value [i.e., responding patients, ΔPAPm = -27 ± 11% (-9 ± 5 mmHg)]. Five patients were classified as non-responders (ΔPAPm = -2 ± 7%, -1 ± 4 mmHg). The stay in the ICU was 7 ± 5 days (1-19), and the hospital stay was 13 days (1-36). There were no complications of major or other bleeding. The 90-day survival was 100%. Conclusions: this series shows that pulmonary arterial fibrinolysis induces an immediate hemodynamic improvement in a high proportion of patients with intermediate-risk PE with a favorable benefit-risk balance in the absence of immediate or delayed attributable complications. (Acta Med Colomb 2019; 44: 17-24).

Disfunción muscular respiratoria en pacientes llevados a cirugía cardiovascular / Respiratory muscle dysfunction in patients undergoing cardiovascular surgery

Resumen Objetivo: Evaluar la presencia de las alteraciones en la fuerza muscular respiratoria en pacientes programados para la cirugía cardiovascular, el impacto de la cirugía sobre la función muscular respiratoria y su relación con las alteraciones ventilatorias en el postoperatorio mediato. Métodos: Estudio observacional prospectivo. Se realizaron pruebas de funcionalismo respiratorio (espirometría) y pruebas de fuerza muscular respiratoria (inspiratoria: presión inspiratoria máxima y espiratoria: presión espiratoria máxima) en dos momentos: preoperatorio inmediato (2 ± 1 días precirugía) y postoperatorio mediato (2 ± 1 días, antes del alta). Las complicaciones respiratorias incluyeron: la ventilación mecánica prolongada, el tromboembolismo pulmonar, el neumotórax, el hemotórax, la neumonía, el derrame pleural, el edema pulmonar y las atelectasias. Resultados: Se evaluaron 30 pacientes adultos (n = 30) (62 ± 12 años). En el preoperatorio la capacidad espirométrica disminuyó en un 54% (35% alteración obstructiva, 19% no- obstructiva) y la debilidad inspiratoria y espiratoria fue confirmada en un 67 y 100%, respectivamente. Las complicaciones respiratorias estuvieron presentes en un 93% (con mayor frecuencia la atelectasia y el derrame pleural). El deterioro postoperatorio grave de la presión inspiratoria máxima incrementó 10 veces el riesgo de atelectasia (OR = 10, IC 95% 0,85-117,02; p = 0,067). Al alta, la fracción de eyección del ventrículo izquierdo fue 29% menor, la capacidad vital forzada -32%, la presión inspiratoria máxima -32% y la presión espiratoria máxima -32% con respecto al valor inicial. Conclusiones: Los pacientes llevados a la cirugía cardiovascular tienen una insospechada disfunción de los músculos respiratorios que empeora con la cirugía y la hospitalización, que se asocia a un incremento del riesgo de complicaciones respiratorias.

Abstract Motivation: To assess the presence of alterations in respiratory muscle strength in patients with a programmed cardiovascular surgery, the impact of the surgery on respiratory muscle function and their relationship with ventilatory alterations during mediate postoperative period. Methods: Prospective observational study. Respiratory function tests (spirometry) and respiratory muscle strength tests (inspiratory: maximum inspiratory pressure, and expiratory: maximum expiratory pressure) were conducted in two moments: immediate preoperative (2 ± 1 days before surgery) and mediate postoperative period (2 ± 1, before being discharged). Respiratory complications included prolonged mechanical ventilation, pulmonary thromboembolism, pneumothorax, hemothorax; pneumonia; pleural effusion; pulmonary edema and atelectases. Results: 30 adult patients were assessed (n = 30) (ages 62 ± 12). Spirometry performance decreased by 54% in the preoperative period (35% obstructive alteration, 19% non-obstructive) and inspiratory and expiratory weakness was confirmed at 67 and 100% respectively. Respiratory complications were present in 93% (more frequently atelectasis and pleural effusion). Severe postoperative deterioration of maximum inspiratory pressure increased by 10-fold the risk of atelectasis (OR = 10, IC 95% 0.85-117.02; p = 0.067). Upon discharge, ejection fraction of the left ventricle was 29% lower, forced vital capacity -32%, maximum inspiratory pressure -32% and maximum expiratory pressure -32% with regards to baseline values. Conclusion: Patients undergoing cardiovascular surgery suffer an unsuspected respiratory muscle dysfunction that worsens with surgery and hospitalisation, associated to a increase of the risk of respiratory complications.

TriBURTER: invención y validación perceptual del dispositivo portátil de vibración de alta frecuencia y entrenamiento muscular para pacientes con enfermedades respiratorias / TriBURTER: invention and perceptual validation of a portable device aimed to induce high- frequency vibration and respiratory muscle training in patients with respiratory diseases

Introducción: los dispositivos respiratorios vibrátiles son útiles como elementos de terapia respiratoria pues facilitan la expectoración de las secreciones bronquiales. Un dispositivo respiratorio de vibración que incorpore válvulas duales representa una innovación relevante respecto a los modelos existentes. El presente estudio describe la invención y evaluación de un nuevo dispositivo médico portátil de vibración de alta frecuencia para uso humano que permite simultáneamente el entrenamiento muscular respiratorio para pacientes con enfermedades respiratorias, al que se ha denominado con el acrónimo TriBURTER. Métodos: se conceptualizaron, diseñaron y construyeron modelos virtuales y prototipos funcionales siguiendo metodología de bioingeniería y evaluación in situ del funcionamiento a través de simuladores electrónicos. Adicionalmente se evaluaron, mediante escalas psicométricas específicas, los aspectos perceptuales de la morfología y funcionamiento del dispositivo tanto en voluntarios sanos como pacientes. Resultados: se creó un dispositivo que logra tres efectos: facilitar la movilización de secreciones bronquiales, inducir efecto de entrenamiento sobre los músculos inspiratorios, e inducir entrenamiento de músculos espiratorios. La evaluación perceptual demostró que el diseño final del dispositivo es seguro, adecuado, suficiente y práctico. Conclusión: TriBURTER es un dispositivo médico innovador de terapia respiratoria vibrátil que facilita el drenaje de secreciones y genera una sobrecarga muscular, tanto inspiratoria como espiratoria, regulable y útil en el tratamiento de las enfermedades respiratorias, y que puede ser aplicado tanto en ámbito ambulatorio como domiciliario u hospitalario. Su evaluación perceptual demostró seguridad clínica y una adecuada aceptación de uso por parte de los voluntarios sanos y pacientes en términos de cualidad y funcionamiento. MÉD.UIS. 2016;29(2):49-57.

Introduction: vibratory devices are used in respiratory therapy in order to facilitate removal of bronchial secretions. A portable hydraulic system incorporating inspiratory and expiratory valves could provide additional advantages over existing ones. The present study describes the invention and evaluation of a new portable medical device able to induce high frequency vibration and allowing respiratory muscle training for patients with respiratory diseases, which has been named with the acronym TriBURTER. Methods: based on conventional methods of bioengineering, a hydraulic device was conceptualized, designed, built, and validated using electronic simulators. In addition, perceptual evaluations of morphology, final prototype design and function were evaluated in both healthy volunteers and patients through specific psychometric scales. Results: a hydraulic device including two unidirectional valves was finally obtained allowing to induce simultaneously a triple effect: mobilization of bronchial secretions, inspiratory muscle training, and expiratory muscle training. Perceptual evaluations showed that the final design is safe, adequate, sufficient and practical. Conclusion: TriBURTER is an innovative hydraulic medical device for respiratory therapy that facilitates drainage of secretions and generates adjustable inspiratory and expiratory muscle loads. The perceptual evaluations of the device showed proper acceptance of use by healthy volunteers and patients in terms of quality and performance. This device is useful for the treatment of respiratory diseases and can be prescribed for both outpatient and domiciliary or hospital settings. MÉD.UIS. 2016;29(2):49-57.

Impacto de tres años de experiencia en tromboendarterectomía pulmonar / Three-year impact of experience with pulmonary thromboendarterectomy

Objetivo: Describir la experiencia clínica de una serie de casos de pacientes adultos con hipertensión pulmonar tromboembólica crónica, llevados a tromboendarterectomía pulmonar. Métodos: Estudio descriptivo, retrospectivo, de ocho pacientes adultos llevados a tromboendarterectomía pulmonar en la Fundación Cardiovascular de Colombia, entre febrero de 2010 y abril de 2013. Resultados: se evaluaron 5 mujeres y 3 hombres, con promedio de edad 45 ± 18 años, datos basales promedio de SpO2 92 ± 2%, PaO2/FiO2 244 ± 82, PaCO2 28,8 ± 3,4 mm Hg, presión pulmonar media 53 ± 11 mm Hg y resistencia vascular pulmonar (RVP) 999 ± 414 dyn/s/cm−5. Al tercer día postoperatorio un paciente necesitó oxigenación con membrana extracorpórea (ECMO) venoarterial por 11 días. A los 4 ± 1días de tromboendarterectomía pulmonar, la RVP descendió 71 ± 21% respecto al valor basal (p = 0,002, IC 95%) y la presión pulmonar media disminuyó 32 ± 27 mm Hg (p = 0,001). La SpO2 basal aumentó 96 ± 3%. La sobrevida fue del 100% a los 24 meses de seguimiento, sin reingresos ni recurrencia de tromboembolia pulmonar. Conclusiones: Los resultados institucionales fueron adecuados a corto y mediano plazo. En casos de edema por reperfusión la alternativa de ECMO como soporte vital extracorpóreo es indispensable.

Motivation: To describe clinical experience of a series of cases of adult patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary thromboendarterectomy. Methods: Descriptive retrospective study of eight adults who underwent pulmonary thromboendarterectomy at the Fundación Cardiovascular de Colombia between February 2010 and April 2013. Results:5 women and 3 men were assessed, with an average age of 45 ± 18 years, with avergae baseline data of SpO2 92 ± 2%, PaO2/FiO2 244 ± 82, PaCO2 28.8 ± 3.4 mmHg, average pukmonary pressure of 53 ± 11 mmHg and pulmonary vascular resistance (PVR) of 999 ± 414 dyn/s/cm−5. On the third postoperative day one patient required veno-arterial extracorporeal membrane oxygenation (ECMO) during 11 days. At 4 ± 1 days after pulmonary thromboendarterectomy, PVR decreased 71 ± 21% with regards to baseline value (p = 0.002, IC 95%) and pulmonary pressure was reduced to 32 ± 27 mmHg (p = 0.001). Baseline SpO2 increased 96 ± 3%. Survival rate was 100% after 24 months of follow-up, without readmissions or recurrence of pulmonary thromboembolism. Conclusions: Institutional results were adequate in the short and medium term. Cases with reperfusion edema, the alternative of ECMO as an extracorporeal life support is imperative.

Effects of interval and continuous exercise training on autonomic cardiac function in COPD patients.

BACKGROUND AND AIM: Both interval (IT) and continuous (CT) exercise training results in an improvement of aerobic capacity in patients with chronic obstructive pulmonary disease (COPD); however, their effects on cardiac autonomic function remains unclear. The aim of our study was to evaluate the effect of a supervised CT vs IT on autonomic cardiac function in COPD patients. METHODS: COPD patients were divided into two different groups according to training modality (IT or CT). Autonomic cardiac dysfunction (ACD) was defined as a heart rate recovery lower than 12 bpm heart rate after the first minute of maximal exercise (HRR1 ) and an abnormal chronotropic response (CR) to exercise (<80%). RESULTS: A total of 29 patients {mean [standard deviation (SD)] age: 68 (8) years, %FEV1 : 42 (13) predicted} were trained (15 subjects in the CT group, 14 subjects in the IT group). After training, both groups increased peak oxygen consumption [mean difference ΔVO2 peak: 156 mL/min (P = 0.04) on IT; and 210 mL/min (P = 0.01) on CT], HRR1 [IT, from 10.4 (5) to 13.8 (5) bpm (P = 0.04); and CT, from 14.3 (5) to 17.7 (5) bpm (P = 0.04)] and CR [IT, from 57% (22) to 81% (9) (P = 0.001); and CT, from 48% (28) to 73% (17) (P = 0.001)]. Sixteen patients showed ACD. Among these patients, HRR1 (P = 0.01 for IT and P = 0.04 for CT) and CR (P = 0.001 for IT and P = 0.002 for CT) were enhanced after training. CONCLUSIONS: Both IT and CT exercise training improve heart rate recovery and CR in COPD patients. These benefits could help to individualize exercise training.

High-intensity vs. sham inspiratory muscle training in patients with chronic heart failure: a prospective randomized trial.

AIMS: The purpose of this study was to evaluate the effectiveness, feasibility, and safety of a 4-week high-intensity inspiratory muscle training (hi-IMT) in patients with chronic heart failure (CHF). METHODS AND RESULTS: A double-blind randomized clinical trial was carried out in 22 patients with CHF. Participants were assigned to the hi-IMT or sham-IMT group. The trainer device was a prototype of the Orygen-Dual Valve. The training workloads were adjusted weekly at the inspiratory pressure which allowed the performance of 10 consecutive maximal repetitions (10RM). Main outcomes were strength and endurance of the respiratory muscles assessed by maximal respiratory pressures (PImax and PEmax) and a 10RM manoeuvre, respectively. Twenty-one patients presented impairment in respiratory muscle strength and endurance. Patients in the hi-IMT group showed a significant improvement in both strength and endurance: inspiratory muscle strength in the intervention group increased 57.2% compared with 25.9% in the control group (P = 0.001). The percentage change in endurance was 72.7% for the hi-IMT group compared with 18.2% in the sham-IMT group (P < 0.001). No adverse effects occurred during the intervention. CONCLUSION: A 4-week hi-IMT with the use of the Orygen-Dual Valve is shown to be an effective, feasible, and safe tool to improve weakness and fatigue of the inspiratory muscles. The key point of this study is to discuss immediate practical implications in terms of respiratory muscle dysfunction postulated as a potential prognostic factor and as an additional therapeutic target. TRIALS REGISTRATION: NCT01606553.

Injury of peripheral muscles in smokers with chronic obstructive pulmonary disease.

Muscle injury has clinical relevance in diseased individuals because it is associated with muscle dysfunction in terms of decreased strength and/or endurance. This study was aimed at answering three questions: whether the presence of chronic obstructive pulmonary disease (COPD) is associated with peripheral muscle injury; whether muscle injury is associated with some of the relevant functional impairment in the muscles; and whether muscle injury can be solely justified by deconditioning. Twenty-one male COPD patients were eligible for the study. Seven healthy volunteers recruited from the general population were included as controls. Function of the quadriceps muscle was assessed through specific single-leg exercise (strength and endurance). Cellular (light microscopy) and subcellular (electron microscopy) techniques were used to evaluate muscle injury on biopsies from the vastus lateralis muscle. Signs of injury were found in muscles from both control and COPD patients, not only in cases showing severe airflow obstruction but also in the mild or moderate stages of the disease. Current smoking and presence of COPD were significantly associated with increased injury of the muscle as assessed by light and electron microscopy techniques. The authors conclude that peripheral muscle injury is evident in mild, moderate, and severe stages of COPD even in the absence of respiratory failure, hypercapnia, chronic steroid treatment, low body weight, or some coexisting disease. These findings support the theory that systemic factors with deleterious effect are acting on peripheral muscles of smokers with COPD, increasing the susceptibility of the muscle fibers to membrane and sarcomere injury.

Evaluación funcional no-invasiva de la reserva ante la fatiga y la estructura del diafragma mediante ecografía transtorácica en modos B y M / Non-invasive Functional Evaluation of the Reserve in Fatigue and the Diaphragm Structure using Transthoracic Echography in B and M Modes

El diafragma es el principal músculo respiratorio. Sus especiales características han dificultado el diseño de instrumentos capaces de evaluar su estructura y función de forma no invasiva en humanos. El presente estudio fue diseñado para evaluar la potencial utilidad de la ecografía como un método no invasivo para cumplir dichos objetivos.MétodosEl estudio incluyó tres fases: 1) estudio ecográfico en muestras necrópsicas (n=10) de un segmento de pared toraco-abdominal, incluyendo desde piel hasta peritoneo parietal (e.d., estructuras de pared torácica, diafragma, pleura y peritoneo); 2) estudio ecográfico estático de las estructuras anteriores y el diafragma en individuos sanos (n=10) a volúmenes pulmonares normalizados, y 3) estudio ecográfico dinámico de la contracción-relajación del diafragma en los mismos individuos, con cálculo de la velocidad máxima de relajación (VMARdi, mm/seg) en el curso de una prueba específica de resistencia inspiratoria.ResultadosLa ecografía permitió identificar con claridad los límites pleural y peritoneal del diafragma, y cuantificar su grosor (Gdi), en todos los casos, tanto ex-vivo como in-vivo. El estudio dinámico del Gdi mostró un incremento lineal en relación directa con el volumen pulmonar de medición, además de un incremento cíclico durante los movimientos inspiratorios en reposo. En la prueba de resistencia, la VMARdi fue máxima ante cargas bajas y disminuyó progresivamente hasta alcanzar un nadir mínimo (Δ≈−70% del valor inicial) en la claudicación (fatiga). La medición de VMARdi tiene una alta precisión diagnóstica de claudicación.ConclusionesLa ecografía transtorácica del diafragma es un método no invasivo que ofrece resultados prometedores en la evaluación estructural y funcional (e.d., riesgo de fatiga) de dicho músculo. Estos hallazgos son de interés fisiopatológico y podrían ser de utilidad en el contexto asistencial clínico(AU)

The diaphragm is the principal respiratory muscle. Its special characteristics have made it difficult to design instruments capable of performing a non-invasive evaluation of its structure and function in humans. The present study was designed to evaluate the potential use of echography as a non-invasive method to fulfil these objectives.MethodsThe study consisted of three phases: (1) echographic study in autopsy samples (n=10) of a segment of the thoracic-abdominal wall, from the bottom to the parietal peritoneum (i.e., thoracic wall, diaphragm, pleura and peritoneum structures), (2) static echographic study of the previous structures and the diaphragm in healthy subjects (n=10) to standardised lung volumes; and (3) dynamic echographic study of the contraction-relaxation of the diaphragm in the same subjects, calculating its maximum velocity of relaxation (MVrdi, mm/sec) during a specific inspiratory resistance test.ResultsThe echography enabled the pleural and peritoneal limits of the diaphragm to be identified, and quantitate its thickness (Tdi), both ex-vivo and in-vivo, in all cases. The dynamic study of the Tdi showed a linear increase directly associated with the lung volume measurement, as well as a cyclical increase during inspiratory movements at rest. In the resistance test, the MVrdi was maximal with low loads and gradually decrease until reaching a minimum nadir (Δ≈−70% of the initial value) in claudication (fatigue). The MVrdi has a high precision in diagnosing claudication.ConclusionsTransthoracic echography of the diaphragm is a non-invasive method that gives promising results in the structural and functional evaluation (i.e. fatigue risk) of that muscle. These findings are of pathophysiological interest and could be of use in the clinical care context(AU)

[Non-invasive functional evaluation of the reserve in fatigue and the diaphragm structure using transthoracic echography in B and M modes]. / Evaluación funcional no-invasiva de la reserva ante la fatiga y la estructura del diafragma mediante ecografía transtorácica en modos B y M.

UNLABELLED: The diaphragm is the principal respiratory muscle. Its special characteristics have made it difficult to design instruments capable of performing a non-invasive evaluation of its structure and function in humans. The present study was designed to evaluate the potential use of echography as a non-invasive method to fulfil these objectives. METHODS: The study consisted of three phases: (1) echographic study in autopsy samples (n=10) of a segment of the thoracic-abdominal wall, from the bottom to the parietal peritoneum (i.e., thoracic wall, diaphragm, pleura and peritoneum structures), (2) static echographic study of the previous structures and the diaphragm in healthy subjects (n=10) to standardised lung volumes; and (3) dynamic echographic study of the contraction-relaxation of the diaphragm in the same subjects, calculating its maximum velocity of relaxation (MVrdi, mm/sec) during a specific inspiratory resistance test. RESULTS: The echography enabled the pleural and peritoneal limits of the diaphragm to be identified, and quantitate its thickness (Tdi), both ex-vivo and in-vivo, in all cases. The dynamic study of the Tdi showed a linear increase directly associated with the lung volume measurement, as well as a cyclical increase during inspiratory movements at rest. In the resistance test, the MVrdi was maximal with low loads and gradually decrease until reaching a minimum nadir (Δ≈-70% of the initial value) in claudication (fatigue). The MVrdi has a high precision in diagnosing claudication. CONCLUSIONS: Transthoracic echography of the diaphragm is a non-invasive method that gives promising results in the structural and functional evaluation (i.e. fatigue risk) of that muscle. These findings are of pathophysiological interest and could be of use in the clinical care context.

Global muscle dysfunction as a risk factor of readmission to hospital due to COPD exacerbations.

UNLABELLED: Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with several modifiable (sedentary life-style, smoking, malnutrition, hypoxemia) and non-modifiable (age, co-morbidities, severity of pulmonary function, respiratory infections) risk factors. We hypothesise that most of these risk factors may have a converging and deleterious effects on both respiratory and peripheral muscle function in COPD patients. METHODS: A multicentre study was carried out in 121 COPD patients (92% males, 63 ± 11 yr, FEV(1), 49 ± 17%pred). Assessments included anthropometrics, lung function, body composition using bioelectrical impedance analysis (BIA), and global muscle function (peripheral muscle (dominant and non-dominant hand grip strength, HGS), inspiratory (PI(max)), and expiratory (PE(max)) muscle strength). GOLD stage, clinical status (stable vs. non-stable) and both current and past hospital admissions due to COPD exacerbations were included as covariates in the analyses. RESULTS: Respiratory and peripheral muscle weakness were observed in all subsets of patients. Muscle weakness, was significantly associated with both current and past hospitalisations. Patients with history of multiple admissions showed increased global muscle weakness after adjusting by FEV(1) (PE(max), OR = 6.8, p < 0.01; PI(max), OR = 2.9, p < 0.05; HGSd, OR = 2.4, and HGSnd, OR = 2.6, p = 0.05). Moreover, a significant increase in both respiratory and peripheral muscle weakness, after adjusting by FEV(1), was associated with current acute exacerbations. CONCLUSIONS: Muscle dysfunction, adjusted by GOLD stage, is associated with an increased risk of hospital admissions due to acute episodes of exacerbation of the disease. Current exacerbations further deteriorate muscle dysfunction.

Lung function and long-term complications after allogeneic hematopoietic cell transplant.

It is unknown if diminished pulmonary function early after allogeneic hematopoietic transplant is associated with poor long-term outcomes. The objective of this study was to determine if posttransplant lung function is associated with 5-year nonrelapse mortality (NRM) and the development of chronic graft-versus-host disease (cGVHD). Retrospective analysis was done for 2158 patients who had routine pulmonary function testing 60-120 days after transplant between 1992 and 2004. Cox regression was used to assess the hazard ratio for 5-year NRM. A second analysis assessed the hazard ratio for the development of cGVHD. Lung function score was the primary exposure, and was calculated according to forced expiratory volume in 1 second (FEV(1)) and carbon monoxide diffusion capapcity (DLCO). Individual pulmonary function parameters were secondary exposures. The primary outcomes were 5-year NRM and the development of cGVHD. Most patients had normal lung function following transplant. A higher lung function score, signifying greater impairment, was associated with an increased risk of mortality (category 1 hazard ratio [HR] 1.47 [1.17-1.85]; category 2 HR 3.38 [2.53-4.53]; category 3 HR 7.80 [4.15-14.68]). A similar association was observed for all individual pulmonary function parameters. Low FEV(1) was associated with the subsequent development of cGVHD (FEV(1) 70%-79% HR 1.26 [1.01-1.57]; 60%-69% HR 1.48 [1.10-2.01]; <60% HR 2.02 [1.34-3.05]). Models using either lung function score or individual pulmonary function parameters performed about equally well as judged by the C-statistic. Impaired lung function at day 80 posttransplant was associated with a higher risk of NRM. A low FEV(1) following transplant was associated with developing cGVHD within 1 year.

Mass of intercostal muscles associates with risk of multiple exacerbations in COPD.

BACKGROUND: The potential role of decreased respiratory muscle mass, if any, in mediating the susceptibility to exacerbation in COPD patients has not been determined. We hypothesized that a decrease in respiratory muscle mass is associated with increased risk of multiple hospital admissions due to acute exacerbations of the disease. METHODS: Eligible cases and controls (n=20) were identified from records of our department's pulmonary clinic. Ten subjects diagnosed with COPD (males, 66+/-7yr, Body Mass Index (BMI)=26+/-4kg/m(2)) were identified as fragile patients. Fragility was defined as four or more admissions in the previous year due to severe exacerbations of the disease. Fragile patients were matched with 10 non-fragile controls, defined as COPD patients who had required only one admission due to exacerbation of the disease. Criteria for 1:1 matching included ethnicity, gender, age, BMI, degree of airflow obstruction (i.e., FEV(1)), comorbidity and chronic treatment. Multiple computed tomography (CT) scan slices were obtained to assess area and attenuation coefficients of multiple upper limb, thorax, abdomen and lower limb muscles. RESULTS: CSA of intercostal and abdominal muscles was significantly decreased in fragile COPD patients (right side intercostals, mean relative difference (MRD)=-14%, p=0.010; OR (95% CI)=2.2 (1.1-4.8), p=0.021; left side, MRD=-13%, p=0.007; OR=2.2 (1.1-4.5), p=0.027). CSA and attenuation coefficients of all other muscle compartments showed no statistical differences between the two study groups but showed the same trend. Strength of the inspiratory and expiratory muscles did not differ between the two study groups. CONCLUSIONS: This study shows that the risk for multiple admissions due to a COPD exacerbation associates with a marked decrease in the CSA of the intercostal muscle compartment.

Influence of pretransplantation restrictive lung disease on allogeneic hematopoietic cell transplantation outcomes.

We conducted a 15-year retrospective cohort study to determine the prevalence of restrictive lung disease before allogeneic hematopoietic cell transplantation (HCT), and to assess whether this was a risk factor for poor outcomes. A total of 2545 patients were eligible for the analysis. Restrictive lung disease was defined as a total lung capacity (TLC) < 80% of predicted normal. Chest x-rays and /or computed tomography (CT) scans were reviewed for all restricted patients to determine whether lung parenchymal abnormalities were unlikely or highly likely to cause restriction. Multivariate Cox proportional hazard and sensitivity analyses were performed to assess the relationship between restriction and early respiratory failure and nonrelapse mortality. Restrictive lung disease was present in 194 subjects (7.6%) before HCT. Among these cases, radiographically apparent abnormalities were unlikely to be the cause of the restriction in 149 subjects (77%). In unadjusted and adjusted analyses, the presence of pulmonary restriction was significantly associated with a 2-fold increase in risk for early respiratory failure and nonrelapse mortality, suggesting that these outcomes occurring in the absence of radiographically apparent abnormalities may be related to respiratory muscle weakness. These findings suggest that pulmonary restriction should be considered a risk factor for poor outcomes after transplantation.

Sustained CTL activation by murine pulmonary epithelial cells promotes the development of COPD-like disease.

Chronic obstructive pulmonary disease (COPD) is a lethal progressive lung disease culminating in permanent airway obstruction and alveolar enlargement. Previous studies suggest CTL involvement in COPD progression; however, their precise role remains unknown. Here, we investigated whether the CTL activation receptor NK cell group 2D (NKG2D) contributes to the development of COPD. Using primary murine lung epithelium isolated from mice chronically exposed to cigarette smoke and cultured epithelial cells exposed to cigarette smoke extract in vitro, we demonstrated induced expression of the NKG2D ligand retinoic acid early transcript 1 (RAET1) as well as NKG2D-mediated cytotoxicity. Furthermore, a genetic model of inducible RAET1 expression on mouse pulmonary epithelial cells yielded a severe emphysematous phenotype characterized by epithelial apoptosis and increased CTL activation, which was reversed by blocking NKG2D activation. We also assessed whether NKG2D ligand expression corresponded with pulmonary disease in human patients by staining airway and peripheral lung tissues from never smokers, smokers with normal lung function, and current and former smokers with COPD. NKG2D ligand expression was independent of NKG2D receptor expression in COPD patients, demonstrating that ligand expression is the limiting factor in CTL activation. These results demonstrate that aberrant, persistent NKG2D ligand expression in the pulmonary epithelium contributes to the development of COPD pathologies.

El entrenamiento muscular debe administrarse como un fármaco / Pulmonary rehabilitation should be prescribed in the same way medications are prescribed

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