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1.
Can Respir J ; 17(4): 159-68, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-20808973

RESUMO

Pulmonary rehabilitation (PR) participation is the standard of care for patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic despite bronchodilator therapies. However, there are questions about specific aspects of PR programming including optimal site of rehabilitation delivery, components of rehabilitation programming, duration of rehabilitation, target populations and timing of rehabilitation. The present document was compiled to specifically address these important clinical issues, using an evidence-based, systematic review process led by a representative interprofessional panel of experts. The evidence reveals there are no differences in major patient-related outcomes of PR between nonhospital- (community or home sites) or hospital-based sites. There is strong support to recommend that COPD patients initiate PR within one month following an acute exacerbation due to benefits of improved dyspnea, exercise tolerance and health-related quality of life relative to usual care. Moreover, the benefits of PR are evident in both men and women, and in patients with moderate, severe and very severe COPD. The current review also suggests that longer PR programs, beyond six to eight weeks duration, be provided for COPD patients, and that while aerobic training is the foundation of PR, endurance and functional ability may be further improved with both aerobic and resistance training.


Assuntos
Doença Pulmonar Obstrutiva Crônica/reabilitação , Atenção à Saúde , Feminino , Humanos , Masculino , Treinamento Resistido , Fatores Sexuais , Fatores de Tempo
2.
Respirology ; 15(5): 785-95, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-20497386

RESUMO

BACKGROUND AND OBJECTIVE: Creatine improves muscle strength in exercising healthy individuals, and in patients with neuromuscular disease and heart failure. The aim of this study was to assess whether creatine supplementation improves pulmonary rehabilitation (PR) outcomes in patients with COPD. METHODS: A systematic review and meta-analysis was performed of randomized controlled trials published between January 1966 and February 2009 that evaluated the effect of creatine compared with placebo on exercise capacity, muscle strength and health-related quality of life (HR-QoL) in patients undergoing PR for COPD. The pooled estimates were expressed as mean differences (MD) or standardized mean differences (SMD). RESULTS: Four randomized controlled trials that included 151 patients were identified. There was no effect of creatine supplementation on exercise capacity (SMD -0.01, 95% CI: -0.42 to 0.22, n = 151). Creatine supplementation did not improve lower extremity muscle strength (SMD 0.03, 95% CI: -0.55 to 0.61, n = 140) or upper limb muscular strength (SMD 0.02, 95% CI: -0.33 to 0.38, n = 128) compared with placebo. Two studies (n = 48) assessed quality of life using the St. George's Respiratory Disease Questionnaire. There were no differences in HR-QoL according to domain or total scores. Overall, creatine appeared to be safe and was well tolerated. Quality assessment of the studies showed important limitations. CONCLUSIONS: Creatine supplementation does not improve exercise capacity, muscle strength or HR-QoL in patients with COPD receiving PR. However, important limitations were identified in the quality of the available evidence, suggesting that further research is required in this area.


Assuntos
Creatina/administração & dosagem , Suplementos Nutricionais , Doença Pulmonar Obstrutiva Crônica/reabilitação , Creatina/efeitos adversos , Tolerância ao Exercício/efeitos dos fármacos , Humanos , Força Muscular/efeitos dos fármacos , Músculo Esquelético/efeitos dos fármacos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
4.
Chest ; 136(1): 145-154, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19255288

RESUMO

BACKGROUND: Long-acting beta(2)-agonists (LABAs) are recommended as add-on therapy to antiinflammatory treatment in patients with chronic persistent asthma. Results from individual studies evaluating the in vivo antiinflammatory effect of LABAs are conflicting. The purpose of this metaanalysis was to determine whether LABAs have an in vivo antiinflammatory effect compared to placebo and whether the addition of a LABA to therapy with inhaled corticosteroids (ICSs) has a synergistic or additive antiinflammatory effect. METHODS: A systematic search was performed of online databases for randomized controlled trials evaluating the antiinflammatory effects of the following: (1) LABAs compared to placebo; and (2) a LABA plus ICS vs ICS alone in adults and children with asthma. Inflammatory outcome measures included cell counts and markers of cell activation in sputum, BAL fluid, bronchial biopsy specimens, serum, and exhaled nitric oxide (ENO). Data were independently extracted by two study investigators and analyzed to generate standardized mean differences using either a fixed or random-effects metaanalysis depending on the degree of heterogeneity. RESULTS: Thirty-two studies (n = 1,105 participants) met the inclusion criteria. The mean number of participants and mean number of studies for each inflammatory outcome in the metaanalysis was 113.1 (SD, 46.2) and 3.5 (SD, 1.3), respectively. There was no effect of LABA therapy on sputum, BAL fluid, or mucosal inflammatory cells in adults or in children. LABA therapy decreased ENO levels and BAL fluid albumin levels in adults. In children, LABA therapy was associated with a small decrease in serum eosinophils and interleukin-4. CONCLUSION: LABA therapy does not appear to have any clinically important antiinflammatory or proinflammatory effect. LABA therapy decreases BAL fluid albumin levels, suggesting a possible modulating effect on microvascular leakage.


Assuntos
Agonistas de Receptores Adrenérgicos beta 2 , Agonistas Adrenérgicos beta/uso terapêutico , Asma/tratamento farmacológico , Asma/patologia , Administração por Inalação , Agonistas Adrenérgicos beta/administração & dosagem , Adulto , Asma/metabolismo , Criança , Quimioterapia Combinada , Glucocorticoides/administração & dosagem , Humanos , Inflamação/tratamento farmacológico , Inflamação/metabolismo , Inflamação/patologia , Mediadores da Inflamação/metabolismo
5.
Can Fam Physician ; 54(5): 706-11, 2008 May.
Artigo em Inglês | MEDLINE | ID: mdl-18474704

RESUMO

OBJECTIVE: To review the diagnosis, assessment of severity, and management of chronic obstructive pulmonary disease (COPD) and to address the systemic manifestations associated with COPD. SOURCES OF INFORMATION: PubMed was searched from January 2000 to December 2007 using the key words COPD, practice guidelines, randomized controlled trials, therapy, and health outcomes. The Canadian Thoracic Society guideline on management of COPD was carefully reviewed. The authors, who have extensive experience in care of patients with COPD, provided expert opinion. MAIN MESSAGE: Chronic obstructive pulmonary disease is a common systemic disease caused primarily by smoking. Spirometry is essential for diagnosis of COPD and should be integrated into primary care practice. Pharmacologic and nonpharmacologic therapy improves symptoms, capacity for exercise, and quality of life. Smoking cessation is the only intervention shown to slow disease progression. The systemic manifestations and comorbidity associated with COPD need to be identified and addressed to optimize health and quality of life. CONCLUSION: An evidence-based approach to managing COPD along with a primary care chronic disease management model could improve quality of life for patients with COPD.


Assuntos
Doença Pulmonar Obstrutiva Crônica/terapia , Corticosteroides/uso terapêutico , Broncodilatadores/uso terapêutico , Dispneia/etiologia , Feminino , Humanos , Pessoa de Meia-Idade , Oxigenoterapia , Guias de Prática Clínica como Assunto , Atenção Primária à Saúde , Prognóstico , Doença Pulmonar Obstrutiva Crônica/classificação , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/diagnóstico
6.
Can Respir J ; 13(4): 203-10, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-16779465

RESUMO

The major respiratory complications of obesity include a heightened demand for ventilation, elevated work of breathing, respiratory muscle inefficiency and diminished respiratory compliance. The decreased functional residual capacity and expiratory reserve volume, with a high closing volume to functional residual capacity ratio of obesity, are associated with the closure of peripheral lung units, ventilation to perfusion ratio abnormalities and hypoxemia, especially in the supine position. Conventional respiratory function tests are only mildly affected by obesity except in extreme cases. The major circulatory complications are increased total and pulmonary blood volume, high cardiac output and elevated left ventricular end-diastolic pressure. Patients with obesity commonly develop hypoventilation and sleep apnea syndromes with attenuated hypoxic and hypercapnic ventilatory responsiveness. The final result is hypoxemia, pulmonary hypertension and progressively worsening disability. Obese patients have increased dyspnea and decreased exercise capacity, which are vital to quality of life. Decreased muscle, increased joint pain and skin friction are important determinants of decreased exercise capacity, in addition to the cardiopulmonary effects of obesity. The effects of obesity on mortality in heart failure and chronic obstructive pulmonary disease have not been definitively resolved. Whether obesity contributes to asthma and airway hyper-responsiveness is uncertain. Weight reduction and physical activity are effective means of reversing the respiratory complications of obesity.


Assuntos
Obesidade/fisiopatologia , Sistema Respiratório/fisiopatologia , Adiposidade , Resistência das Vias Respiratórias , Sistema Cardiovascular/fisiopatologia , Dispneia/fisiopatologia , Exercício Físico/fisiologia , Humanos , Pneumopatias Obstrutivas/fisiopatologia , Oxigênio/metabolismo , Respiração , Redução de Peso
7.
J Allergy Clin Immunol ; 116(4): 768-72, 2005 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-16210049

RESUMO

BACKGROUND: The early asthmatic response (EAR) to inhaled allergen results from IgE-mediated release of multiple mast-cell mediators, including leukotrienes and histamine, both of which cause bronchoconstriction. Combination therapy directed at blocking the effects of both mediators might protect against the EAR better than either therapy alone. OBJECTIVE: We sought to evaluate the effect of desloratadine and montelukast, administered alone and in combination, on the EAR to inhaled allergen. METHODS: Ten adults with mild-to-moderate atopic asthma participated in a randomized, 4-way crossover study design comparing placebo, 5 mg of desloratadine, 10 mg of montelukast, and the combination administered at 26 hours and 2 hours before each allergen challenge conducted at least 7 days apart. The primary end point was the concentration of allergen that resulted in a 20% decrease in FEV1 (PC20). RESULTS: The geometric mean allergen PC20 (mean log +/- SEM) for combination therapy, montelukast, desloratadine, and placebo was 697 U/mL (2.8433 +/- 0.3253), 338 U/mL (2.5295 +/- 0.2979), 123 U/mL (2.0883 +/- 0.2102), and 104 U/mL (2.0166 +/- 0.2553), respectively (n = 9; P < .00001, ANOVA). Montelukast increased the allergen PC20 4.8-fold, and combination therapy increased the allergen PC20 8.9-fold. The effect of the combination was greater than that with montelukast alone (P < .02). Desloratadine treatment was no different than placebo. CONCLUSIONS: The early response to inhaled allergen was unchanged after desloratadine therapy and partially inhibited with montelukast therapy. The combination of desloratadine and montelukast provided superior efficacy to either blocker administered alone. Investigations into the possible mechanisms of the enhanced inhibition are necessary.


Assuntos
Acetatos/administração & dosagem , Antiasmáticos/administração & dosagem , Asma/tratamento farmacológico , Loratadina/análogos & derivados , Quinolinas/administração & dosagem , Adulto , Alérgenos/administração & dosagem , Asma/imunologia , Asma/fisiopatologia , Testes de Provocação Brônquica , Estudos Cross-Over , Ciclopropanos , Quimioterapia Combinada , Feminino , Volume Expiratório Forçado/efeitos dos fármacos , Humanos , Loratadina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Sulfetos , Fatores de Tempo
8.
Chest ; 127(3): 839-44, 2005 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-15764765

RESUMO

BACKGROUND: Guidelines for the 2-min tidal-breathing and the five-breath dosimeter methods for methacholine challenge have recently been published by the American Thoracic Society (ATS). Although subjects are exposed to twice as much aerosol at any given concentration during the tidal-breathing method compared to the dosimeter method, they were thought to give equivalent results. OBJECTIVE: To compare the 2-min tidal-breathing and the five-breath dosimeter methacholine challenges. SETTING: Tertiary care university-based bronchoprovocation laboratory. PATIENTS: Forty subjects with currently symptomatic asthma. INTERVENTIONS: The two methacholine tests were done in random order on separate days at the same time of day at 1- to 7-day intervals. RESULTS: The dosimeter provocation concentration of methacholine causing a 20% fall in FEV(1) (PC(20)) was almost twice that of the tidal-breathing PC(20): 2.4 mg/mL vs 1.3 mg/mL (paired t test, p < 0.00005). The difference was greater in those with mild airway hyperresponsiveness (AHR) [PC(20) > 1.0 mg/mL; 3.2-fold] compared to those with moderate AHR (PC(20) < 1.0 mg/mL; 1.6-fold) [p = 0.04]. Three subjects with mild asthma and mild AHR (tidal-breathing PC(20), 1.9 to 4.3 mg/mL) had a nonmeasurable PC(20) (> 32 mg/mL) with the dosimeter. CONCLUSIONS: The tidal-breathing method, which exposes the subject to twice as much aerosol at each concentration, produced approximately twice the response. The total lung capacity maneuvers with breathhold during the dosimeter method may inhibit the response in some patients with asthma.


Assuntos
Asma/diagnóstico , Testes de Provocação Brônquica/métodos , Broncoconstritores , Cloreto de Metacolina , Adulto , Idoso , Asma/fisiopatologia , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Capacidade Pulmonar Total
9.
Ann Allergy Asthma Immunol ; 94(1): 45-7, 2005 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-15702815

RESUMO

BACKGROUND: We have observed that dosimeter-run nebulizers have a much smaller output when manually activated than when breath activated; however, this has not been adequately investigated. OBJECTIVE: To evaluate the effect of different calibration methods on nebulizer output. METHODS: Six healthy subjects performed all calibrations. The nebulizers were operated by 2 different dosimeters and were calibrated to produce 9 microL per actuation by breath activation followed by exhalation to the room. The nebulizers were then operated at these identical settings, and the output determined in 3 ways: (1) breath activation followed by exhalation to the room, (2) breath activation with exhalation into the nebulizer, and (3) manual activation (with no subject using the nebulizer). These 3 methods were termed regular, rebreathe, and manual, respectively. RESULTS: There was a large and statistically significant difference in nebulizer output among the 3 methods. The measured rebreathe outputs (5.6 and 5.7 microL per actuation) were approximately two thirds and the manual outputs (3.2 and 3.9 microL per actuation) were approximately one third of the regular calibration outputs (8.6 and 8.9 microL per actuation); the 2 values are for the 2 dosimeters. The results were highly statistically significant (P < .001). CONCLUSIONS: The method by which a nebulizer-dosimeter system is calibrated results in different nebulizer outputs. This has a high likelihood of influencing the concentration of methacholine causing a 20% decrease in volume in the first second of forced expiration.


Assuntos
Asma/diagnóstico , Cloreto de Metacolina/administração & dosagem , Nebulizadores e Vaporizadores/normas , Testes de Função Respiratória/métodos , Adulto , Calibragem , Humanos , Estudos Prospectivos , Testes de Função Respiratória/normas
11.
J Allergy Clin Immunol ; 114(3): 517-9, 2004 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-15356550

RESUMO

BACKGROUND: Deep inhalation has bronchodilating and bronchoprotective effects, particularly in subjects who are normal or have mild airway hyperresponsiveness (AHR). We have anecdotally observed that the 5 breath to total lung capacity (TLC) dosimeter method reduced the response to methacholine in some subjects with mild AHR. OBJECTIVE: To compare prospectively submaximal inhalations with TLC inhalations during the dosimeter methacholine challenge. METHODS: Sixteen subjects with asthma and a methacholine PC 20 <8 mg/mL performed 2 methacholine challenges in random order; the standard dosimeter method was compared with a modified dosimeter challenge in which methacholine inhalations were performed to approximately 50% to 60% below TLC. RESULTS: The standard methacholine challenge PC 20 was almost twice that obtained with the modified submaximal inhalation method (geometric mean PC 20, 5.2 mg/mL vs 2.8 mg/mL, respectively; P = 0.0216). In the 5 subjects with the mildest AHR, there was a 2.5-fold to 14-fold difference in PC 20 between methods. The standard (full TLC) PC 20 s were falsely negative (>16 mg/mL) in these 5 subjects with current asthma, 4 of whom required inhaled corticosteroids. CONCLUSION: A submaximal inhalation dosimeter methacholine challenge results in a significantly lower PC 20 compared with the standard 5-breath dosimeter method. This effect is limited to the mildly responsive group, probably because of the bronchoprotective effect of the deep inhalation during the standard method, and results in false-negative tests in some subjects.


Assuntos
Asma/diagnóstico , Broncoconstritores/administração & dosagem , Cloreto de Metacolina/administração & dosagem , Nebulizadores e Vaporizadores , Administração por Inalação , Adulto , Testes de Provocação Brônquica , Reações Falso-Negativas , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Espirometria
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