Ultrasonography as a way of evaluating the diaphragm muscle in patients with chronic obstructive pulmonary disease.

The respiratory muscles in chronic obstructive pulmonary disease (COPD) patients have reduced strength and resistance, leading to loss of the functional ability of these muscles. Lung hyperinflation is one of the main alterations, and air trapping is the main factor limiting diaphragmatic mobility (DM) in these patients; however, its correlation with functional parameters, exercise capacity, and indicators of disease severity remains underexplored. This study aimed to assess DM in stable COPD patients and relate the findings with parameters such as the 6-minute walk test distance, forced expiratory volume in 1 second (FEV1) %predicted, residual volume (RV) %predicted, and dyspnea. An observational cohort study was conducted to measure DM using ultrasound both at rest (DMrest) and during deep inspiration (DMmax). Forty-nine patients with stable COPD were included in this study. There was a correlation between DMmax and FEV1 %predicted (R = 0.36; P = .012), RV %predicted (r = -0.42; P = .01), RV/total lung capacity (r = -0.61; P < .001), and distance reached in the 6MWT (R = 0.46; P = .001). Patients with a modified Medical Research Council score <2 exhibited greater DM than those with a score ≥2 (mean difference = 13.20 ± 4.6 mm; P = .0059). Similarly, patients with a Body Mass Index, Airflow Obstruction, Dyspnea and Exercise Capacity index ≤4 showed greater DM (61.95 mm) than those with a Body Mass Index, Airflow Obstruction, Dyspnea and Exercise Capacity index >4 (47.89 mm; mean difference = 14.05 ± 5.3 mm; 95% confidence interval = 25.09-3.01 mm). DM is correlated with bronchial obstruction (FEV1), lung hyperinflation (RV and RV/total lung capacity), exercise capacity, and dyspnea in patients with COPD, suggesting its utility as an evaluative tool in this population.

Exploring the impact of the environment on physical activity in patients with chronic obstructive pulmonary disease (EPCOT)-A comparative analysis between suggested and free walking: Protocol study.

BACKGROUND: Individuals with chronic obstructive pulmonary disease (COPD) exhibit reduced levels of physical activity, which are associated with poorer outcomes. The number of clinical trials aiming to promote behavioral changes to increase physical activity in this population has grown; therefore, these trials have yet to produce satisfactory results. An ecological model encompassing individual, social, environmental, and political factors represent a potentially more effective approach to promoting physical activity. While favorable urban environments can positively impact physical activity, specifically tailored environmental interventions for individuals with COPD could enhance their engagement in physical activity. Therefore, the aim of this randomized controlled trial (RCT) study was to analyze the effects of walking in a suggested environment and free walking on physical activity levels in individuals with COPD. METHODS: The environment on physical activity for chronic obstructive disease (EPCOT) is a randomized controlled clinical trial protocol approved by our institution's Ethics Committee and registered with The Brazilian Registry of Clinical Trials (ReBEC) (https://ensaiosclinicos.gov.br, number RBR-4tfwdhp). This protocol will involve 38 volunteers diagnosed with COPD recruited from the pulmonary physiotherapy and rehabilitation service. The volunteers were randomly divided into two walking groups: an experimental group (ERG) with guidance for walking in a suggested environment and an active control group (ACG) instructed to choose their own routes. The intervention consisted of eight consecutive weeks, with progressive walks carried out 3 to 5 times weekly. The primary outcome will be assessing participants' physical activity levels. Secondary outcomes will include exercise capacity, quality of life, dyspnea levels, motivation, anxiety, depression, and perceptions of the environment. All assessments will occur before and after the intervention period, aiming to fill a literature gap by investigating the impact of urban environments on COPD-related physical activity. The results may shed light on the importance of environmental factors in promoting physical activity among individuals with COPD, helping to develop more effective interventions.

Dual-Task Performance in Individuals With Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-Analysis.

Background: Chronic obstructive pulmonary disease (COPD) is characterized by important extrapulmonary alterations that could affect the performance in dual task (DT) (motor and cognitive tasks executed simultaneously), which is defined as DT interference (DTI). Objective: To compare the performance of DT between individuals with COPD and healthy control subjects (HCSs). Methods: The literature search was conducted in seven databases (Medline, Scopus, Web of Science, PEDro, SciELO, LILACS, and Google Scholar) up to December 2023, including studies published in English, Spanish, or Portuguese. Studies with individuals diagnosed with COPD older than 60 years, who were evaluated with any DT assessment, and compared with HCS were included. The quality of the studies was evaluated using the risk of bias in nonrandomized studies of interventions (ROBINS-I). The meta-analysis was performed with JAMOVI software 5.4. The study protocol was registered on PROSPERO (CRD42023435212). Results: From a total of 128 articles, 5 observational studies were selected in this review, involving 252 individuals aged between 60 and 80 years, from France, Italy, Canada, Turkey, and Belgium. Notable DTI was observed in individuals with COPD compared to HCS (standard mean difference [SMD] = 0.91; 95% confidence interval (CI) 0.06-1.75, p = 0.04). Individuals with COPD had impaired gait speed, balance control, muscle strength, and cognitive interference during DT compared to HCS. DT assessment protocols included different combination of motor and cognitive tasks, using functional test, gait analysis, and muscle strength paired with countdown and verbal fluency tasks. Studies presented low (n = 2), moderate (n = 1), and serious (n = 2) overall risk of bias. Conclusion: Older adults diagnosed with COPD exhibited a significant DTI compared to HCSs, which is characterized by poorer physical and cognitive performance during DT execution. These findings highlight the importance of incorporating DT assessments into clinical practice for individuals with COPD.

[Repeatability of spirometrys expiratory flows]. / Repetitividad de los flujos espiratorios de la espirometría.

Background: The quality of the spirometry is estimated with criteria of acceptability and repeatability. The repeatability criteria accepted by consensus is < 0.150 L. Objective: To know the repeatability in quality A spirometry. Material and methods: Analytical cross-sectional design. The demographic variables and the 3 best spirometry curves with normal, suggestive of restriction and bronchial obstruction profiles were obtained from consecutive subjects of both genders from 18 to 80 years of age. The repeatability was analyzed with the mean difference (bias) and the intraclass correlation coefficient. Results: 630 curves from 210 subjects were accepted. Group age 60 ± 15 years. Female predominance 113 (53.8%), occupation: domestic services 61 (29%), and diagnosed with chronic obstructive pulmonary disease: 70 (33.4%). The differences in the curves were < 0.150 L. The mean difference (bias) and the intraclass correlation coefficient (95% confidence interval, 95% CI) of the forced expiratory volume in the first second were 1 vs. 2 maneuver: -0.01 (0.13, -0.14), 0.997 (95% CI 0.996, 0.998); 2 vs. 3 maneuver: 0.00 (0.13, -0.13), 0.997 (95% CI 0.996, 0.998), and maneuver 1 vs. 3: -0.00 (0.16, -0.17), 0.995 (95% CI 0.994, 0.996). Forced vital capacity: 1 vs. 2 maneuver: -0.01 (0.17, -0.18), 0.996 (95% CI 0.995, 0.997); 2 vs. 3 maneuver: 0.01 (0.17, -0.16), 0.997 (95% CI 0.0.996, 0.998), and maneuver 1 vs. 3: -0.00 (0.18, -0.19), 0.996 (95% CI 0.995, 0.997). Conclusion: The repeatability obtained in spirometry with quality A validates the use of the repeatability criterion of 0.150 L.

Introducción: la calidad de la espirometría se estima con criterios de aceptabilidad y repetitividad. La repetitividad aceptada por consenso es < 0.150 L. Objetivo: conocer la repetitividad en espirometrías de calidad A. Material y métodos: diseño transversal analítico. Se obtuvieron las variables demográficas y las 3 mejores curvas de espirometría con perfil normal, que sugiriera restricción y obstrucción bronquial de sujetos consecutivos de ambos géneros de 18 a 80 años. La repetitividad se analizó con la diferencia de medias (sesgo) y el coeficiente de correlación intraclase. Resultados: se aceptaron 630 curvas de 210 sujetos. Edad grupal 60 ± 15 años. Predominio femenino 113 (53.8%), ocupación: servicios domésticos 61 (29%) y con enfermedad pulmonar obstructiva crónica 70 (33.4%). Las diferencias en las curvas fueron < 0.150 L. Las diferencias medias (sesgo) y el coeficiente de correlación intraclase (intervalo de confianza al 95%, IC 95%) del volumen espiratorio forzado en el primer segundo fueron: maniobra 1 frente a 2: −0.01 (0.13, −0.14), 0.997 (IC 95% 0.996, 0.998); maniobra 2 frente a 3: 0.00 (0.13, −0.13), 0.997 (IC 95% 0.996, 0.998), y maniobra 1 frente a 3: −0.00 (0.16, −0.17), 0.995 (IC 95% 0.994, 0.996). La capacidad vital forzada: maniobra 1 frente a 2: −0.01 (0.17, −0.18), 0.996 (IC 95% 0.995, 0.997); maniobra 2 frente a 3: 0.01 (0.17, −0.16), 0.997 (IC 95% 0.0.996, 0.998), y maniobra 1 frente a 3: −0.00 (0.18, −0.19), 0.996 (IC 95% 0.995, 0.997). Conclusión: la repetitividad obtenida en espirometrías con calidad A valida el uso del criterio de repetitividad de 0.150 L.

Evaluating the impact of short-term nitrate-rich dietary supplementation on endothelial function in COPD: A randomized crossover study.

AIM: This study aimed to investigate the acute effects of dietary nitrate ingestion through l-arginine supplementation or dehydrated beet consumption on endothelial function in chronic obstructive pulmonary disease (COPD) patients. The secondary outcome was to analyze arterial stiffness, plasma nitrate, and nitrate/protein concentration. METHODS: In this randomized crossover study, subjects with COPD underwent three series of supplementation: (1) l-arginine, (2) dehydrated beetroot, and (3) a placebo that appeared like the other supplements. Each intervention lasted 14 days, with a 7-day washout period between series. Participants underwent endothelial function assessment using flow-mediated dilatation (FMD), and plasma nitrate levels were measured at the end of each supplementation series. RESULTS: Seventeen subjects (twelve male) completed the study protocol. Only five subjects presented endothelial dysfunction (RHI ≤0.51) at baseline. The mean baseline characteristics included age 66.5 ± 9.4 years, BMI 27.5 ± 4.5 kg/m2, FEV1, 0.79 (0.67-1.06) L. There were no differences (p > 0.05) between the groups or from pre-to post-interventions for RHI and arterial stiffness index (AIx) values, as well as parameters of endothelium-dependent vasodilation, such as blood flow velocity (BFV), shear stress, shear rate, FMD (mm), and FMD%. There was also no differences (p > 0.05) between the groups or from pre-to post-interventions plasma nitrate levels. CONCLUSIONS: Acute dietary supplementation with nitrates, at the doses provided, did not show a significant improvement in endothelial function assessed by FMD, EndoPAT, or plasma nitrate levels in COPD. These findings suggest that a higher dose or prolonged supplementation might be required to achieve a therapeutic effect.

Development of a web application to evaluate spirometric curve and clinical variables to support COPD diagnosis in primary care. / Desarrollo de una aplicación web para evaluar los datos de la espirometría y las variables clínicas para apoyar el diagnóstico de EPOC en atención primaria

INTRODUCTION: Choric obstructive pulmonary disease (COPD) is the third mortality cause in the world, and the development of useful diagnostic tools is necessary to improve timely diagnostic rates in primary care settings. OBJECTIVE: To develop a web application displaying spirometric and clinical information - including respiratory symptoms and risk factors- to facilitate a COPD diagnosis. MATERIALS AND METHODS: In this cross-sectional study, an expert consensus was carried out with three specialists using the Delphi method to choose the relevant variables for COPD diagnosis. We developed a Python-based web application to diagnose COPD, displaying the clinical variables deemed relevant by the experts along the spirometric curve. RESULTS: Twenty-six clinical variables were included in the web application for the diagnosis of COPD. A fourth expert used the web application to classify a cohort of 695 patients who had undergone spirometry in a third-level centre and had answered at least one of five questionnaires for COPD screening. Out of the 695 subjects, 34% had COPD, according to the expert that diagnosed them using the web application. Only 42% of the patients in the COPD group had received a previous COPD diagnosis and 19% of the patients in the no COPD group had been misdiagnosed with the disease. CONCLUSION: We developed a web application that displays demographic and clinical information, as well as spirometric data, to facilitate the process of diagnosing COPD in primary care settings.

Introducción. La enfermedad pulmonar obstructiva crónica (EPOC) es la tercera causa de mortalidad en el mundo y es necesario el desarrollo de herramientas diagnósticas útiles para mejorar las tasas de diagnóstico oportuno en los entornos de atención primaria. Objetivo. Desarrollar una aplicación web que muestre la información clínica y de la espirometría ­incluyendo síntomas respiratorios y factores de riesgo­ para facilitar el diagnóstico de la EPOC. Materiales y métodos. En este estudio transversal se realizó un consenso de expertos con tres especialistas usando el método Delphi para elegir las variables relevantes para el diagnóstico de EPOC. Se desarrolló una aplicación web basada en Python que muestra la información clínica relevante según los expertos, junto con la curva y los datos de la espirometría para el diagnóstico de la EPOC. Resultados. Se incluyeron 26 variables clínicas para el diagnóstico de la EPOC. Un cuarto experto utilizó la aplicación web para clasificar una cohorte de 695 pacientes a los que se les había realizado una espirometría en un centro de tercer nivel y que habían contestado al menos uno de los cinco cuestionarios para la detección de la EPOC. De los 695 sujetos, el 34 % tenían EPOC según el experto que les diagnosticó usando la aplicación web. Sólo el 42 % de los pacientes del grupo con EPOC había recibido un diagnóstico previo de la enfermedad y el 19 % de los pacientes del grupo sin EPOC había sido diagnosticado erróneamente con la enfermedad. Conclusión. Se desarrolló una aplicación web que muestra información demográfica y clínica, así como datos espirométricos, para facilitar el proceso de diagnóstico de la EPOC en entornos de atención primaria.

Impact of Real-Time Assessment of Pulse Oximetry on the 6-Min Walk Distance in Patients With Chronic Respiratory Disease.

BACKGROUND: Continuous monitoring of pulse oximetry (SpO2 ) is recommended during the 6-min walk test (6MWT) to ensure that the lowest SpO2 is recorded. In this case, severe exercise-induced desaturation (EID; SpO2 < 80%) triggers walking interruption by the examiner. Our main objective was to assess the impact of this approach on 6MWT distance in patients with chronic respiratory diseases and, second, to evaluate the safety of the test without interruption due to severe EID. METHODS: 6MWTs with continuous monitoring of SpO2 were prospectively performed in subjects with chronic respiratory disease. The participants were randomly allocated to walk with or without SpO2 real-time assessment. SpO2 visualization during the test execution was available only in the first group, and walking interruption was requested by the examiner if SpO2 < 80%. RESULTS: One hundred forty-five participants were included in each group (68.6% females, 62 [52-69] y old) without differences in demographic and resting lung function parameters between them. The main respiratory conditions were COPD (n = 101), asthma (n = 73), pulmonary hypertension (n = 47), and interstitial lung disease (n = 39). The walked distance was similar comparing groups (349.5 ± 117.5 m vs 351.2 ± 105.4 m). Twenty-five subjects presented with severe EID in the group with real-time SpO2 assessment, and 20 subjects had severe EID in the group without real-time assessment respectively (overall prevalence of 15.5%). The 23 participants who had their test interrupted by the examiner due to severe EID in the first group (2 subjects stopped by themselves due to excessive symptoms) walked a shorter distance compared to the 11 subjects with severe EID without test interruption in the second group (9 subjects stopped by themselves due to excessive symptoms): 240.6 ± 100.2 m versus 345.9 ± 73.4 m. No exercise-related serious adverse events were observed. CONCLUSIONS: Interruption driven by severe EID reduced the walked distance during the 6MWT. No serious adverse event, in turn, was observed in subjects with severe desaturation without real-time SpO2 assessment.

Curve-Modelling and Machine Learning for a Better COPD Diagnosis.

Background: Development of new tools in artificial intelligence has an outstanding performance in the recognition of multidimensional patterns, which is why they have proven to be useful in the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Methods: This was an observational analytical single-centre study in patients with spirometry performed in outpatient medical care. The segment that goes from the peak expiratory flow to the forced vital capacity was modelled with quadratic polynomials, the coefficients obtained were used to train and test neural networks in the task of classifying patients with COPD. Results: A total of 695 patient records were included in the analysis. The COPD group was significantly older than the No COPD group. The pre-bronchodilator (Pre BD) and post-bronchodilator (Post BD) spirometric curves were modelled with a quadratic polynomial, and the coefficients obtained were used to feed three neural networks (Pre BD, Post BD and all coefficients). The best neural network was the one that used the post-bronchodilator coefficients, which has an input layer of 3 neurons and three hidden layers with sigmoid activation function and two neurons in the output layer with softmax activation function. This system had an accuracy of 92.9% accuracy, a sensitivity of 88.2% and a specificity of 94.3% when assessed using expert judgment as the reference test. It also showed better performance than the current gold standard, especially in specificity and negative predictive value. Conclusion: Artificial Neural Networks fed with coefficients obtained from quadratic and cubic polynomials have interesting potential of emulating the clinical diagnostic process and can become an important aid in primary care to help diagnose COPD in an early stage.

Functional capacity using sit-to-stand tests in people with chronic obstructive pulmonary disease and its relationship with disease severity-a cross-sectional study with matched controls.

BACKGROUND: Functional capacity impairment is a crucial consequence of chronic obstructive pulmonary disease (COPD). Although it can be identified with simple tests, such as the sit-to-stand tests, its prevalence, relation with disease severity, and the characteristics of people presenting this impairment remain unknown. OBJECTIVE: To explore the functional capacity of people with COPD. METHODS: A cross-sectional study with people with COPD and age-/sex-matched healthy controls was conducted. Functional capacity was assessed with the 5-repetitions (5-STS) and the 1-minute (1-minSTS) sit-to-stand tests. People with COPD were grouped according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classifications. Comparisons between people with COPD and healthy controls, and among GOLD groups were established. Associations between symptoms, muscle strength, quality of life, and measures of functional capacity were explored. RESULTS: 302 people with COPD [79% male; mean (SD) 68 (10) years old] and 304 healthy controls [75% male; 66 (9) years old] were included. 23% of people with COPD presented impairment in the 5-STS and 33% in the 1-minSTS. People with COPD from all GOLD classifications presented significantly lower functional capacity than healthy controls (5-STS: COPD median [1st quartile; 3rd quartile] 8.4 [6.7; 10.6] versus healthy 7.4 [6.2; 9.3] s; 1-minSTS: COPD 27 [21; 35] vs healthy 35 [29; 43] reps). Correlations with symptoms, muscle strength, and quality of life were mostly weak (5-STS: rs [-0.34; 0.33]; 1-minSTS: rs [-0.47; 0.40]). CONCLUSION: People with COPD have decreased functional capacity independently of their GOLD classifications. The prevalence of functional impairment is 23-33%. Because impaired functional capacity is a treatable trait not accurately reflected by other outcomes, comprehensive assessment and management is needed.

Comparable Ventilatory Inefficiency at Maximal and Submaximal Performance in COPD vs. CHF subjects: An Innovative Approach. / Ineficiência Ventilatória Comparável no Desempenho Máximo e Submáximo em Indivíduos com DPOC e ICC: Uma Abordagem Inovadora.

BACKGROUND: Currently, excess ventilation has been grounded under the relationship between minute-ventilation/carbon dioxide output ( V ˙ E - V ˙ CO 2 ). Alternatively, a new approach for ventilatory efficiency ( η E V ˙ ) has been published. OBJECTIVE: Our main hypothesis is that comparatively low levels of η E V ˙ between chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are attainable for a similar level of maximum and submaximal aerobic performance, conversely to long-established methods ( V ˙ E - V ˙ CO 2 slope and intercept). METHODS: Both groups performed lung function tests, echocardiography, and cardiopulmonary exercise testing. The significance level adopted in the statistical analysis was 5%. Thus, nineteen COPD and nineteen CHF-eligible subjects completed the study. With the aim of contrasting full values of V ˙ E - V ˙ CO 2 and η V ˙ E for the exercise period (100%), correlations were made with smaller fractions, such as 90% and 75% of the maximum values. RESULTS: The two groups attained matched characteristics for age (62±6 vs. 59±9 yrs, p>.05), sex (10/9 vs. 14/5, p>0.05), BMI (26±4 vs. 27±3 Kg m2, p>0.05), and peak V ˙ O 2 (72±19 vs. 74±20 %pred, p>0.05), respectively. The V ˙ E - V ˙ CO 2 slope and intercept were significantly different for COPD and CHF (27.2±1.4 vs. 33.1±5.7 and 5.3±1.9 vs. 1.7±3.6, p<0.05 for both), but η V ˙ E average values were similar between-groups (10.2±3.4 vs. 10.9±2.3%, p=0.462). The correlations between 100% of the exercise period with 90% and 75% of it were stronger for η V ˙ E (r>0.850 for both). CONCLUSION: The η V ˙ E is a valuable method for comparison between cardiopulmonary diseases, with so far distinct physiopathological mechanisms, including ventilatory constraints in COPD.

FUNDAMENTO: Atualmente, o excesso de ventilação tem sido fundamentado na relação entre ventilação-minuto/produção de dióxido de carbono ( V ˙ E − V ˙ CO 2 ). Alternativamente, uma nova abordagem para eficiência ventilatória ( η E V ˙ ) tem sido publicada. OBJETIVO: Nossa hipótese principal é que níveis comparativamente baixos de η E V ˙ entre insuficiência cardíaca crônica (ICC) e doença pulmonar obstrutiva crônica (DPOC) são atingíveis para um nível semelhante de desempenho aeróbico máximo e submáximo, inversamente aos métodos estabelecidos há muito tempo (inclinação V ˙ E − V ˙ CO 2 e intercepto). MÉTODOS: Ambos os grupos realizaram testes de função pulmonar, ecocardiografia e teste de exercício cardiopulmonar. O nível de significância adotada na análise estatística foi 5%. Assim, dezenove indivíduos elegíveis para DPOC e dezenove indivíduos elegíveis para ICC completaram o estudo. Com o objetivo de contrastar valores completos de V ˙ E − V ˙ CO 2 e η E V ˙ para o período de exercício (100%), correlações foram feitas com frações menores, como 90% e 75% dos valores máximos. RESULTADOS: Os dois grupos tiveram características correspondentes para a idade (62±6 vs 59±9 anos, p>.05), sexo (10/9 vs 14/5, p>0,05), IMC (26±4 vs 27±3 Kg m2, p>0,05), e pico V ˙ O 2 (72±19 vs 74±20 % pred, p>0,05), respectivamente. A inclinação V ˙ E − V ˙ CO 2 e intercepto foram significativamente diferentes para DPOC e ICC (207,2±1,4 vs 33,1±5,7 e 5,3±1,9 vs 1,7±3,6, p<0,05 para ambas), mas os valores médios da η E V ˙ foram semelhantes entre os grupos (10,2±3,4 vs 10,9±2,3%, p=0,462). As correlações entre 100% do período do exercício com 90% e 75% dele foram mais fortes para η E V ˙ (r>0,850 para ambos). CONCLUSÃO: A η E V ˙ é um método valioso para comparação entre doenças cardiopulmonares, com mecanismos fisiopatológicos até agora distintos, incluindo restrições ventilatórias na DPOC.

Respiratory muscle strength can improve the prognostic assessment in COPD.

Impaired lung function, respiratory muscle weakness and exercise intolerance are present in COPD and contribute to poor prognosis. However, the contribution of the combination of these manifestations to define prognosis in COPD is still unknown. This study aimed to define cut-off points for both inspiratory and expiratory muscle strength (MIP and MEP, respectively) for mortality prediction over 42-months in patients with COPD, and to investigate its combination with other noninvasive established prognostic measures (FEV1, V̇O2peak and 6MWD) to improve risk identification. Patients with COPD performed pulmonary function, respiratory muscle strength, six-minute walk and cardiopulmonary exercise tests, and were followed over 42 months to analyze all-cause mortality. A total of 79 patients were included. The sample was mostly (91.1%) comprised of severe (n = 37) and very severe (n = 34) COPD, and 43 (54%) patients died during the follow-up period. Cut-points of ≤ 55 and ≤ 80 cmH2O for MIP and MEP, respectively, were associated with increased risk of death (log-rank p = 0.0001 for both MIP and MEP) in 42 months. Furthermore, MIP and MEP substantially improved the mortality risk assessment when combined with FEV1 (log-ranks p = 0.006 for MIP and p < 0.001 for MEP), V̇O2peak (log-rank: p < 0.001 for both MIP and MEP) and 6MWD (log-ranks: p = 0.005 for MIP; p = 0.015 for MEP). Thus, patients severely affected by COPD presenting MIP ≤ 55 and/or MEP ≤ 80 cmH2O are at increased risk of mortality. Furthermore, MIP and MEP substantially improve the mortality risk assessment when combined with FEV1, V̇O2peak and 6MWD in patients with COPD.

AB2CO risk score for in-hospital mortality of COVID-19 patients admitted to intensive care units.

PURPOSE: To develop a mortality risk score for COVID-19 patients admitted to intensive care units (ICU), and to compare it with other existing scores. MATERIALS AND METHODS: This retrospective observational study included consecutive adult patients with laboratory-confirmed COVID-19 admitted to ICUs of 18 hospitals from nine Brazilian cities, from September 2021 to July 2022. Potential predictors were selected based on the literature review. Generalized Additive Models were used to examine outcomes and predictors. LASSO regression was used to derive the mortality score. RESULTS: From 558 patients, median age was 69 years (IQR 58-78), 56.3 % were men, 19.7 % required mechanical ventilation (MV), and 44.8 % died. The final model comprised six variables: age, pO2/FiO2, respiratory function (respiratory rate or if in MV), chronic obstructive pulmonary disease, and obesity. The AB2CO had an AUROC of 0.781 (95 % CI 0.744 to 0.819), good overall performance (Brier score = 0.191) and an excellent calibration (slope = 1.063, intercept = 0.015, p-value = 0.834). The model was compared with other scores and displayed better discrimination ability than the majority of them. CONCLUSIONS: The AB2CO score is a fast and easy tool to be used upon ICU admission.

Do Causes Influence Functional Aspects and Quality of Life in Patients with Nonfibrocystic Bronchiectasis?

Background: The denomination of noncystic fibrosis bronchiectasis (NCFB) includes several causes, and differences may be expected between the patient subgroups regarding age, comorbidities, and clinical and functional evolution. This study sought to identify the main causes of NCFB in a cohort of stable adult patients and to investigate whether such conditions would be different in their clinical, functional, and quality of life aspects. Methods: Between 2017 and 2019, all active patients with NCFB were prospectively evaluated searching for clinical data, past medical history, dyspnea severity grading, quality of life data, microbiological profile, and lung function (spirometry and six-minute walk test). Results: There was a female predominance; mean age was 54.7 years. Causes were identified in 82% of the patients, the most frequent being postinfections (n = 39), ciliary dyskinesia (CD) (n = 32), and chronic obstructive pulmonary disease (COPD) (n = 29). COPD patients were older, more often smokers (or former smokers) and with more comorbidities; they also had worse lung function (spirometry and oxygenation) and showed worse performance in the six-minute walk test (6MWT) (walked distance and exercise-induced hypoxemia). Considering the degree of dyspnea, in the more symptomatic group, patients had higher scores in the three domains and total score in SGRQ, besides having more exacerbations and more patients in home oxygen therapy. Conclusions: Causes most identified were postinfections, CD, and COPD. Patients with COPD are older and have worse pulmonary function and more comorbidities. The most symptomatic patients are clinically and functionally more severe, besides having worse quality of life.

Association of IGF-1 and IGF-2 genotypes with respiratory muscle strength in individuals with COPD: A cross-sectional study.

Introduction: Chronic obstructive pulmonary disease is a systemic disease characterized not only by respiratory symptoms but also by physical deconditioning and muscle weakness. One prominent manifestation of this disease is the decline in respiratory muscle strength. Previous studies have linked the genotypes of insulin-like growth factor 1 and 2 (IGF-1 and IGF-2) to muscle weakness in other populations without this disease. However, there is a notable knowledge gap regarding the biological mechanisms underlying respiratory muscle weakness, particularly the role of IGF-1 and IGF-2 genotypes in this pulmonary disease. Therefore, this study aimed to investigate, for the first time, the association between IGF-1 and IGF-2 genotypes with respiratory muscle strength in individuals with chronic obstructive pulmonary disease. In addition, we analyzed the relationship between oxidative stress, chronic inflammation, and vitamin D with respiratory muscle strength. Methods: A cross sectional study with 61 individuals with chronic obstructive pulmonary disease. Polymerase chain reaction of gene polymorphisms IGF-1 (rs35767) and IGF-2 (rs3213221) was analyzed. Other variables, related to oxidative stress, inflammation and Vitamin D were dosed from peripheral blood. Maximal inspiratory and expiratory pressure were measured. Results: The genetic polymorphisms were associated with respiratory muscle strength ( 3.0 and 3.5; = 0.57). Specific genotypes of IGF-1 and IGF-2 presented lower maximal inspiratory and expiratory pressure (<0.05 for all). Oxidative stress, inflammatory biomarkers, and vitamin D were not associated with respiratory muscle strength. Conclusion: The polymorphisms of IGF-1 and IGF-2 displayed stronger correlations with respiratory muscle strength compared to blood biomarkers in patients with chronic obstructive pulmonary disease. Specific genotypes of IGF-1 and IGF-2 were associated with reduced respiratory muscle strength in this population.

Introducción: La enfermedad pulmonar obstructiva crónica es una enfermedad sistémica caracterizada no solo por síntomas respiratorios, sino también por el deterioro físico y la debilidad muscular. Una manifestación destacada de esta enfermedad es el declive en la fuerza de los músculos respiratorios. Estudios previos han vinculado los genotipos de factor de crecimiento insulínico 1 y 2 (IGF-1 e IGF-2) con la debilidad muscular en poblaciones sin esta enfermedad. Sin embargo, existe un vacío de conocimiento con respecto a los mecanismos biológicos subyacentes a la debilidad de los músculos respiratorios, en particular el papel de los genotipos IGF-1 e IGF-2 en esta enfermedad pulmonar. Por lo tanto, este estudio tuvo como objetivo investigar, por primera vez, la asociación de los genotipos IGF-1 e IGF-2 con la fuerza de los músculos respiratorios en individuos con enfermedad pulmonar obstructiva crónica. Además, analizamos la relación entre el estrés oxidativo, la inflamación crónica y la vitamina D con la fuerza de los músculos respiratorios. Métodos: Un estudio transversal con 61 individuos con enfermedad pulmonar obstructiva crónica. Se analizó la reacción en cadena de la polimerasa de los polimorfismos genéticos IGF-1 (rs35767) e IGF-2 (rs3213221). Otras variables relacionadas con el estrés oxidativo, la inflamación y la vitamina D se dosificaron a partir de muestras de sangre periférica. Se midieron las presiones inspiratorias y espiratorias máximas. Resultados: Los polimorfismos genéticos están asociados con la fuerza de los músculos respiratorios (F: 3.0 y 3.5; R2= 0.57). Genotipos específicos de IGF-1 e IGF-2 presentaron bajos valores en las presiones inspiratorias y espiratorias (p<0.05 en todos los casos). El estrés oxidativo, los biomarcadores inflamatorios y la vitamina D no se asociaron con la fuerza de los músculos respiratorios. Conclusión: Los polimorfismos de IGF-1 e IGF-2 mostraron correlaciones más sólidas con la fuerza de los músculos respiratorios en pacientes con enfermedad pulmonar obstructiva crónica en comparación con los biomarcadores sanguíneos. Genotipos específicos de IGF-1 e IGF-2 se asociaron con una disminución de la fuerza de los músculos respiratorios en esta población.

Left ventricular concentric remodeling in COPD patients: A cross-sectional observational study.

OBJECTIVE: To investigate the association between left ventricular structure and disease severity in COPD patients. METHODS: Twenty-eight COPD patients were stratified according to the disease severity, using the BODE index, into Lower (n=17) and Higher (n=11) groups, composed of patients with lower severity (BODE <5) and higher severity (BODE ≥5), respectively. Left ventricle (LV) was assessed by 2D-echocardiography. BODE index was calculated using body mass index (BMI); forced expiratory volume in the first second (FEV1, %); modified Medical Research Council (mMRC) and distance walked during 6-minute walk test (6MWD). RESULTS: Patients in the Higher group showed lower oxygen arterial saturation (p=0.02), FEV1 (p<0.01) and 6MWD (p=0.02) and higher value of relative posterior wall thickness (RWT) compared to Lower group (p=0.02). There were significant associations between LV end-systolic diameter (LVESD) and BODE index (r=-0.38, p=0.04), LV end-diastolic diameter (LVEDD) and FEV1 (r=0.44, p=0.02), LVEDD and BMI (r=0.45, p=0.02), LVESD and BMI (r=0.54, p=0.003) and interventricular septal thickness and 6MWD (r=-0.39, p=0.04). CONCLUSIONS: More severe COPD patients, BODE score ≥5, may have higher RWT, featuring a possible higher concentric remodeling of LV in this group. Besides that, a greater disease severity may be related to LV chamber size reduction.

Association of IGF-1 and IGF-2 genotypes with respiratory muscle strength in individuals with COPD: a cross-sectional study / Asociación de los genotipos de IGF-1 e IGF-2 con la fuerza muscular respiratoria en individuos con EPOC: estudio transversal

INTRODUCTION: Chronic obstructive pulmonary disease is a systemic disease characterized not only by respiratory symptoms but also by physical deconditioning and muscle weakness. One prominent manifestation of this disease is the decline in respiratory muscle strength. Previous studies have linked the genotypes of insulin-like growth factor 1 and 2 (IGF-1 and IGF-2) to muscle weakness in other populations without this disease. However, there is a notable knowledge gap regarding the biological mechanisms underlying respiratory muscle weakness, particularly the role of IGF-1 and IGF-2 genotypes in this pulmonary disease. Therefore, this study aimed to investigate, for the first time, the association between IGF-1 and IGF-2 genotypes with respiratory muscle strength in individuals with chronic obstructive pulmonary disease. In addition, we analyzed the relationship between oxidative stress, chronic inflammation, and vitamin D with respiratory muscle strength. METHODS: A cross sectional study with 61 individuals with chronic obstructive pulmonary disease. Polymerase chain reaction of gene polymorphisms IGF-1 (rs35767) and IGF-2 (rs3213221) was analyzed. Other variables, related to oxidative stress, inflammation and Vitamin D were dosed from peripheral blood. Maximal inspiratory and expiratory pressure were measured. RESULTS: The genetic polymorphisms were associated with respiratory muscle strength ( 3.0 and 3.5; = 0.57). Specific genotypes of IGF-1 and IGF-2 presented lower maximal inspiratory and expiratory pressure (<0.05 for all). Oxidative stress, inflammatory biomarkers, and vitamin D were not associated with respiratory muscle strength. CONCLUSION: The polymorphisms of IGF-1 and IGF-2 displayed stronger correlations with respiratory muscle strength compared to blood biomarkers in patients with chronic obstructive pulmonary disease. Specific genotypes of IGF-1 and IGF-2 were associated with reduced respiratory muscle strength in this population.

INTRODUCCIÓN: La enfermedad pulmonar obstructiva crónica es una enfermedad sistémica caracterizada no solo por síntomas respiratorios, sino también por el deterioro físico y la debilidad muscular. Una manifestación destacada de esta enfermedad es el declive en la fuerza de los músculos respiratorios. Estudios previos han vinculado los genotipos de factor de crecimiento insulínico 1 y 2 (IGF-1 e IGF-2) con la debilidad muscular en poblaciones sin esta enfermedad. Sin embargo, existe un vacío de conocimiento con respecto a los mecanismos biológicos subyacentes a la debilidad de los músculos respiratorios, en particular el papel de los genotipos IGF-1 e IGF-2 en esta enfermedad pulmonar. Por lo tanto, este estudio tuvo como objetivo investigar, por primera vez, la asociación de los genotipos IGF-1 e IGF-2 con la fuerza de los músculos respiratorios en individuos con enfermedad pulmonar obstructiva crónica. Además, analizamos la relación entre el estrés oxidativo, la inflamación crónica y la vitamina D con la fuerza de los músculos respiratorios. MÉTODOS: Un estudio transversal con 61 individuos con enfermedad pulmonar obstructiva crónica. Se analizó la reacción en cadena de la polimerasa de los polimorfismos genéticos IGF-1 (rs35767) e IGF-2 (rs3213221). Otras variables relacionadas con el estrés oxidativo, la inflamación y la vitamina D se dosificaron a partir de muestras de sangre periférica. Se midieron las presiones inspiratorias y espiratorias máximas. RESULTADOS: Los polimorfismos genéticos están asociados con la fuerza de los músculos respiratorios (F: 3.0 y 3.5; R2= 0.57). Genotipos específicos de IGF-1 e IGF-2 presentaron bajos valores en las presiones inspiratorias y espiratorias (p<0.05 en todos los casos). El estrés oxidativo, los biomarcadores inflamatorios y la vitamina D no se asociaron con la fuerza de los músculos respiratorios. CONCLUSIÓN: Los polimorfismos de IGF-1 e IGF-2 mostraron correlaciones más sólidas con la fuerza de los músculos respiratorios en pacientes con enfermedad pulmonar obstructiva crónica en comparación con los biomarcadores sanguíneos. Genotipos específicos de IGF-1 e IGF-2 se asociaron con una disminución de la fuerza de los músculos respiratorios en esta población.

Chronic Obstructive Pulmonary Disease in Heart Failure: Challenges in Diagnosis and Treatment for HFpEF and HFrEF.

PURPOSE OF REVIEW: Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF), and it has a significant impact on the prognosis and quality of life of patients. Additionally, COPD is independently associated with lower adherence to first-line HF therapies. In this review, we outline the challenges of identifying and managing HF with preserved (HFpEF) and reduced (HFrEF) ejection fraction with coexisting COPD. RECENT FINDINGS: Spirometry is necessary for COPD diagnosis and prognosis but is underused in HF. Therefore, misdiagnosis is a concern. Also, disease-modifying drugs for HF and COPD are usually safe but underprescribed when HF and COPD coexist. Patients with HF-COPD are poorly enrolled in clinical trials. Guidelines recommend that HF treatment should be offered regardless of COPD presence, but modern registries show that undertreatment persists. Treatment gaps could be attenuated by ensuring an accurate and earlier COPD diagnosis in patients with HF, clarifying the concerns related to pharmacotherapy safety, and increasing the use of non-pharmacologic treatments. Acknowledging the uncertainties, this review aims to provide key clinical resources to support better physician-patient co-decision-making and improve collaboration between health professionals.

Pressure Support Ventilation Versus T-piece as Spontaneous Breathing Trials for Extubation of Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Weaning patients with COPD from mechanical ventilation (MV) presents a challenge, as literature on this topic is limited. This study compares PSV and T-piece during spontaneous breathing trials (SBT) in this specific population. METHODS: A search of PubMed, EMBASE, and Cochrane in September 2023 yielded four randomized controlled trials (RCTs) encompassing 560 patients. Among these, 287 (51%) used T-piece during SBTs. RESULTS: The PSV group demonstrated a significant improvement in the successful extubation rate compared to the T-piece (risk ratio [RR] 1.14; 95% confidence interval [CI] 1.03-1.26; p = 0.02). Otherwise, there was no statistically significant difference in the reintubation (RR 1.07; 95% CI 0.79-1.45; p = 0.67) or the ICU mortality rates (RR 0.99; 95% CI 0.63-1.55; p = 0.95). CONCLUSION: Although PSV in SBTs exhibits superior extubation success, consistent weaning protocols warrant further exploration through additional studies.

Heart failure worsens leg muscle strength and endurance in coexistence patients with COPD and heart failure reduced ejection fraction.

PURPOSE: Exercise intolerance and dyspnoea are clinical symptoms in both heart failure (HF) reduced ejection fraction (HFrEF) and chronic obstructive pulmonary disease (COPD), which are suggested to be associated with musculoskeletal dysfunction. We tested the hypothesis that HFrEF + COPD patients would present lower muscle strength and greater fatigue compared to compared to the COPD group. METHODS: We included 25 patients with HFrEF + COPD (100% male, age 67.8 ± 6.9) and 25 patients with COPD alone (100% male, age 66.1 ± 9.1). In both groups, COPD severity was determined as moderate-to-severe according to the GOLD classification (FEV1/FVC < 0.7 and predicted post-bronchodilator FEV1 between 30%-80%). Knee flexor-extensor muscle performance (torque, work, power and fatigue) were measured by isokinetic dynamometry in age and sex-matched patients with HFrEF + COPD and COPD alone; Functional capacity was assessed by the cardiopulmonary exercise test, the 6-min walk test (6MWT) and the four-minute step test. RESULTS: The COPD group exhibited reduced lung function compared to the HFrEF + COPD group, as evidenced by lower FEV1/FVC (58.0 ± 4.0 vs. 65.5 ± 13.9; p < 0.0001, respectively) and FEV1 (51.3 ± 17.0 vs. 62.5 ± 17.4; p = 0.026, respectively) values. Regarding musculoskeletal function, the HFrEF + COPD group showed a knee flexor muscles impairment, however this fact was not observed in the knee extensors muscles. Power peak of the knee flexor corrected by muscle mass was significantly correlated with the 6MWT (r = 0.40; p < 0.05), number of steps (r = 0.30; p < 0.05) and work ratepeak (r = 0.40; p < 0.05) in the HFrEF + COPD and COPD groups. CONCLUSION: The presence of HFrEF in patients with COPD worsens muscular weakness when compared to isolated COPD.