RESUMEN
INTRODUCTION AND OBJECTIVES: Subjects with severe acquired brain injury (sABI) require long-term mechanical ventilation and, as a consequence, the tracheostomy tube stays in place for a long time. In this observational study, we investigated to what extent the identification of late tracheostomy complications by flexible bronchoscopy (FBS) might guide clinicians in the treatment of tracheal lesions throughout the weaning process and lead to successful decannulation. SUBJECTS AND METHODS: One hundred and ninety-four subjects with sABI admitted to our rehabilitation unit were enrolled in the study. All subjects received FBS and tracheal lesions were treated either by choosing a more suitable tracheostomy tube, or by laser therapy, or by steroid therapy, or by a combination of the above treatments. RESULTS: Overall, 122 subjects (63%) were decannulated successfully. Our subjects received 495 FBSs (2.55 per subject) and as many as 270 late tracheostomy complications were identified. At least one complication was found in 160 subjects (82%). In only 11 subjects, late tracheostomy complications did not respond to the treatment and were the cause of decannulation failure. CONCLUSIONS: In conclusion, in sABI patients FBS is able to guide successful tracheostomy weaning in the presence of late tracheostomy complications that could get in the way decannulation.
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Lesiones Encefálicas , Traqueostomía , Humanos , Broncoscopía , Remoción de Dispositivos , Respiración Artificial , Complicaciones Posoperatorias , Lesiones Encefálicas/rehabilitaciónRESUMEN
BACKGROUND: Breathing pattern description and chest wall kinematics during phonation have not been studied in male and female patients with chronic obstructive pulmonary disease. OBJECTIVES: We used optoelectronic plethysmography to provide a quantitative description of breathing pattern and chest wall kinematics. METHODS: Volumes of chest wall compartments (rib cage and abdomen) were assessed in 15 patients while reading aloud (R), singing (SI) and during high-effort whispering (HW). RESULTS: Relative to quiet breathing, tidal volume and expiratory time increased while inspiratory time decreased. The expiratory flow decreased during R and SI, but was unchanged during HW. In males, the end-expiratory volume decreased as a result of a decreased volume of rib cage during R, SI and HW and due to a decreased volume of abdomen during HW. In females, a decrease in end-expiratory volume was accomplished by a decrease in abdominal volume during R and HW. During R, the chest wall end-expiratory volume of the last expiration in females was to the left of the maximal expiratory flow volume curve (MEFV), with still substantial expiratory reserve volume available. In contrast, during SI and HW in females and during all types of phonation in males, chest wall end-expiratory volume of the last expiration was well to the right of the MEFV curve and associated with respiratory discomfort. Gender had a greater importance than physical characteristics in determining more costal breathing in females than in males under all conditions studied. CONCLUSIONS: Phonation imposes more abdominal breathing pattern changes in males and costal changes in females. Expiratory flow encroaches upon the MEFV curve with higher phonatory efforts and respiratory discomfort.
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Fonación/fisiología , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Mecánica Respiratoria/fisiología , Pared Torácica/fisiología , Anciano , Fenómenos Biomecánicos/fisiología , Femenino , Humanos , Mediciones del Volumen Pulmonar , Masculino , Pletismografía/métodos , Factores SexualesRESUMEN
We hypothesized that arm training might affect unsupported arm exercise-related perception by decreasing motor output to arm/torso muscles in patients with chronic obstructive pulmonary disease (COPD). Eleven patients were studied at 80% of peak incremental arm exercise, before and after unsupported arm training. Training increased endurance time, decreased respiratory effort and much more arm effort (by Borg scale) without affecting chest wall dynamic hyperinflation or configuration. Ventilatory response to carbon dioxide output was the same before and after training so that at isotime the reduction in ventilation correlated strongly with a simultaneous reduction in metabolic output. These changes reflect a reduced ventilatory drive. We conclude that: (i) a reduced level of ventilation, relative to a decrease in central motor output, is the contribution of arm training to symptom alleviation during unsupported arm exercise in COPD patients, and (ii) arm training improved patients' exercise-related perception without affecting chest wall operational volumes or configuration.
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Brazo/fisiología , Disnea/rehabilitación , Terapia por Ejercicio/métodos , Percepción , Enfermedad Pulmonar Obstructiva Crónica/rehabilitación , Anciano , Disnea/etiología , Femenino , Humanos , Masculino , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Pruebas de Función RespiratoriaRESUMEN
No data are available on the effects of the Nuss procedure on volumes of chest wall compartments (the upper rib cage, lower rib cage and abdomen) in adolescents with pectus excavatum. We used optoelectronic plethysmography to provide a quantitative description of chest wall kinematics before and 6 months after the Nuss procedure at rest and during maximal voluntary ventilation in 13 subjects with pectus excavatum. An average 11% increase in chest wall volume was accommodated within the upper rib cage (p=0.0001) and to a lesser extent within the abdomen and lower rib cage. Tidal volumes did not significantly change during the study. The repair effect on chest wall kinematics did not correlate with the Haller index of deformity at baseline. Six months of the Nuss procedure do increase chest wall volume without affecting chest wall displacement and rib cage configuration.
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Tórax en Embudo/cirugía , Pared Torácica/fisiología , Pared Torácica/cirugía , Abdomen/fisiología , Adolescente , Fenómenos Biomecánicos , Humanos , Mediciones del Volumen Pulmonar , Masculino , Pletismografía/métodos , Ventilación Pulmonar/fisiología , Costillas/fisiología , Procedimientos Quirúrgicos Torácicos/métodosRESUMEN
Quantifying chest wall kinematics and rib cage distortion during ventilatory effort in subjects with Pectus excavatum (PE) has yet to be defined. We studied 24 patients: 19 during maximal voluntary ventilation (MVV) and 5 during MVV and cycling exercise (CE). By optoelectronic plethysmography (OEP) we assessed operational volumes in upper rib cage, lower rib cage and abdomen. Ten age-matched healthy subjects served as controls. Patients exhibited mild restrictive lung defect. During MVV end-inspiratory and end-expiratory volumes of chest wall compartments increased progressively in controls, whereas most patients avoided dynamic hyperinflation by setting operational volumes at values lower than controls. Mild rib cage distortion was found in three patients at rest, but neither in patients nor in controls did MVV or CE consistently affect coordinated motion of the rib cage. Rib cage displacement was not correlated with a CT-scan severity index. Conclusions, mild rib cage distortion rarely occurs in PE patients with mild restrictive defect. OEP contributes to clinical evaluation of PE patients.
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Tórax en Embudo/fisiopatología , Pared Torácica/fisiopatología , Abdomen/anatomía & histología , Abdomen/fisiología , Fenómenos Biomecánicos , Niño , Prueba de Esfuerzo , Femenino , Tórax en Embudo/diagnóstico por imagen , Humanos , Capacidad Inspiratoria/fisiología , Mediciones del Volumen Pulmonar , Masculino , Pletismografía , Pruebas de Función Respiratoria , Costillas/fisiología , Pared Torácica/diagnóstico por imagen , Volumen de Ventilación Pulmonar/fisiología , Tomografía Computarizada por Rayos XRESUMEN
AIM: The study of kinematics of the chest wall (CW) could allow us to define the relative deflationary contribution of its compartments during fits of coughing. We hypothesized that if forces applied to the lung apposed rib cage are not commensurate with those applied to the abdomen-apposed rib cage, cough could result in rib cage distortion. METHODS: In 12 (five women) healthy subjects we evaluated the volumes of CW (Vcw) and its compartments: the lung apposed rib cage, the abdomen apposed rib cage and the abdomen, by optoelectronic plethysmography. The loop of volume of the lung apposed rib cage/volume of the abdomen apposed rib cage allowed the calculation of mean rib cage distortion, resulting in a dimensionless number which, when multiplied by 100, gives percentage distortion. Each subject performed voluntary single and prolonged coughing efforts at functional residual capacity (FRC) and after maximal inspiration (max). The normal level of mean distortion was set at <0.5%. RESULTS: The three compartments contributed to reducing end-expiratory Vcw during cough at FRC and prolonged maximum cough, with the latter resulting in the greatest CW deflation. Mean rib cage distortion did not differ between men and women (P > 0.1), but tended to significantly increase from single to prolonged Cough Max (1.3% +/- 1.0 vs. 2.3% +/- 1.6, respectively; P = 0.06). CONCLUSION: Rib cage distortion may ensue during coughing, probably as a result of uneven distribution of forces applied to the rib cage.
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Tos/fisiopatología , Costillas/fisiopatología , Pared Torácica/fisiología , Adulto , Fenómenos Biomecánicos , Tos/patología , Femenino , Humanos , Masculino , Pletismografía , Mecánica Respiratoria/fisiología , Costillas/patología , Pared Torácica/patologíaRESUMEN
This study hypothesises that regardless of the global score of dyspnoea intensity, different descriptors may be selected by asthmatic patients during short cardiopulmonary exercise test (sCPET) and methacholine (Mch) inhalation. It also examines whether different qualitative dyspnoea sensations can help explain the underlying mechanisms of the symptom. Minute ventilation (V'E), tidal volume (VT) and inspiratory capacity (IC) were measured in 22 stable asthmatic patients, and the sensation of dyspnoea during Mch inhalation and sCPET was quantitatively (Borg scale) and qualitatively (descriptors) assessed. The work rate and oxygen uptake (V'O2) were also measured during sCPET. Airway obstruction and hyperinflation, as measured by IC reduction, were the best correlates for dyspnoea with Mch. During sCPET, changes in WR, V'O2, V'E and VT significantly correlated with Borg score, with V'E being the best predictor of dyspnoea; IC decreased in eight patients. Furthermore, chest tightness (68%) was the highest reported descriptor during Mch inhalation, whereas work/effort (72%) was the highest during sCPET. In conclusion, obstruction/hyperinflation and work rate are highly reliable predictors of Borg rating of dyspnoea during methacholine inhalation and short cardiopulmonary exercise testing, respectively. Regardless of the global score of intensity dyspnoea, different descriptors may be selected by patients during short cardiopulmonary exercise testing and methacholine inhalation. Various qualities of dyspnoea result from different pathophysiological abnormalities.
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Asma/psicología , Pruebas de Provocación Bronquial/psicología , Disnea/psicología , Prueba de Esfuerzo/psicología , Cloruro de Metacolina , Rol del Enfermo , Administración por Inhalación , Adulto , Anciano , Obstrucción de las Vías Aéreas/diagnóstico , Obstrucción de las Vías Aéreas/fisiopatología , Obstrucción de las Vías Aéreas/psicología , Asma/diagnóstico , Asma/fisiopatología , Disnea/diagnóstico , Disnea/fisiopatología , Femenino , Humanos , Mediciones del Volumen Pulmonar , Masculino , Persona de Mediana Edad , Esfuerzo Físico/fisiología , Psicofísica , EspirometríaRESUMEN
AIMS: We used for the first time a non-invasive optoelectronic plethysmography to assess breathing movements and to provide a quantitative description of chest wall kinematics during phonation. METHODS: Volumes of different chest wall compartments (abdomen and lung apposed to rib cage and abdomen) were assessed using optoelectronic plethysmography in 16 normal Italians (eight men) during reading, singing and high-effort whispering (HW). RESULTS: During phonation the breathing pattern was different from quiet breathing and exercise. (1) During phonation, tidal volume and expiratory time increased while inspiratory time decreased. The expiratory volume changes and flows during HW were considerably greater than during vocalization. During HW, the overall end-expiratory thoracic volume significantly decreased as a result of decreased volume of all compartments and essentially impinged on the maximal expiratory flow-volume curve. (2) While, as previously shown, during exercise the expired volume is due entirely to the abdomen, during phonation all three chest wall compartments contribute to it. Under all conditions studied breathing was, on average, more costal in females than in males but this was mainly related to different size rather than gender per se. CONCLUSIONS: Physical characteristics have a greater importance than gender in determining breathing pattern and chest wall kinematics during phonation. The activity of the control of expiration during phonation is more complex than during exercise.
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Fonación/fisiología , Mecánica Respiratoria/fisiología , Adulto , Antropometría , Fenómenos Biomecánicos , Ejercicio Físico/fisiología , Femenino , Volumen Espiratorio Forzado/fisiología , Humanos , Masculino , Persona de Mediana Edad , Pletismografía/métodos , Pruebas de Función Respiratoria , Caracteres Sexuales , Pared Torácica/fisiología , Capacidad Vital/fisiologíaRESUMEN
Feedback from sensory elements as well as projection from higher Central Nervous System structures modify the level and pattern of motor outflow to the respiratory muscles and hence ventilation. In this review we describe the different methods to evaluate the degree to which higher centers determine the level and pattern of ventilation and coordinate use of the respiratory muscles in healthy humans and in patients with a number of respiratory disorders.