RESUMO
Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient's respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.
RESUMO
Many patients hospitalized with COVID-19 were unable to return to work or their return was delayed due to their health condition. The aim of this observational study was to evaluate the impact of moderate-to-severe and critical COVID-19 infection on persistence of symptoms and return to work after hospital discharge. In this study, two thirds of hospitalized patients with pulmonary involvement reported persistence of symptoms six months after COVID-19 infection, such as memory loss (45.5%), myalgia (43.9%), fatigue (39.4%), and dyspnea (25.8%), and 50% slowly returned to work, with repercussions due to fatigue and/or loss of energy.
Assuntos
COVID-19 , Humanos , Retorno ao Trabalho , Hospitalização , Alta do Paciente , Fadiga/etiologiaRESUMO
This brief communication demonstrates the correlation of persistent respiratory symptoms with functional, tomographic, and transbronchial pulmonary biopsy findings in patients with COVID-19 who had a long follow-up period. We report a series of six COVID-19 patients with pulmonary involvement who presented with persistent dyspnea within 4-15 months of discharge. We performed transbronchial biopsies, and the histopathological pattern consistently demonstrated peribronchial remodeling with interstitial pulmonary fibrosis. Therefore, lung biopsy may be useful in the approach of patients with long COVID-19, although the type of procedure, its precise indication, and the moment to perform it are yet to be clarified. (Brazilian Registry of Clinical Trials-ReBEC; identifier: RBR-8j9kqy [http://www.ensaiosclinicos.gov.br]).
Assuntos
COVID-19 , Doenças Pulmonares Intersticiais , Biópsia/métodos , COVID-19/complicações , Humanos , Pulmão/diagnóstico por imagem , Pulmão/patologia , Doenças Pulmonares Intersticiais/patologia , Síndrome de COVID-19 Pós-AgudaRESUMO
ABSTRACT This brief communication demonstrates the correlation of persistent respiratory symptoms with functional, tomographic, and transbronchial pulmonary biopsy findings in patients with COVID-19 who had a long follow-up period. We report a series of six COVID-19 patients with pulmonary involvement who presented with persistent dyspnea within 4-15 months of discharge. We performed transbronchial biopsies, and the histopathological pattern consistently demonstrated peribronchial remodeling with interstitial pulmonary fibrosis. Therefore, lung biopsy may be useful in the approach of patients with long COVID-19, although the type of procedure, its precise indication, and the moment to perform it are yet to be clarified. (Brazilian Registry of Clinical Trials-ReBEC; identifier: RBR-8j9kqy [http://www.ensaiosclinicos.gov.br])
RESUMO Esta comunicação breve demonstra a correlação de sintomas respiratórios persistentes com achados funcionais, tomográficos e de biópsia pulmonar transbrônquica em pacientes com COVID-19 que tiveram um longo período de acompanhamento. Relatamos uma série de seis pacientes com COVID-19 com acometimento pulmonar que apresentavam dispneia persistente após 4-15 meses da alta. Realizamos biópsias transbrônquicas, e o padrão histopatológico consistentemente demonstrou remodelação peribrônquica com fibrose pulmonar intersticial. Portanto, a biópsia pulmonar pode ser útil na abordagem de pacientes com COVID-19 prolongada, embora o tipo de procedimento, suas indicações precisas e o momento de sua realização ainda não estejam esclarecidos. (Registro Brasileiro de Ensaios Clínicos - ReBEC; número de identificação: RBR-8j9kqy [http://www.ensaiosclinicos.gov.br])
RESUMO
ABSTRACT Many patients hospitalized with COVID-19 were unable to return to work or their return was delayed due to their health condition. The aim of this observational study was to evaluate the impact of moderate-to-severe and critical COVID-19 infection on persistence of symptoms and return to work after hospital discharge. In this study, two thirds of hospitalized patients with pulmonary involvement reported persistence of symptoms six months after COVID-19 infection, such as memory loss (45.5%), myalgia (43.9%), fatigue (39.4%), and dyspnea (25.8%), and 50% slowly returned to work, with repercussions due to fatigue and/or loss of energy.
RESUMO Muitos pacientes hospitalizados com COVID-19 não puderam retornar ao trabalho ou seu retorno foi atrasado devido ao seu estado de saúde. O objetivo deste estudo observacional foi avaliar o impacto da infecção moderada a grave ou crítica por COVID-19 na persistência dos sintomas e no retorno ao trabalho após a alta hospitalar. Neste estudo, dois terços dos pacientes hospitalizados com acometimento pulmonar relataram persistência dos sintomas seis meses após a infecção por COVID-19, como perda de memória (45,5%), mialgia (43,9%), fadiga (39,4%) e dispneia (25,8%), e 50% retornaram lentamente ao trabalho, com repercussões devido à fadiga e/ou perda de energia.
RESUMO
A new concept of multisystem disease has emerged as a long-term condition following mild-severe COVID-19 infection. The main symptoms of this affection are breathlessness, chest pain, and fatigue. We present here the clinical case of four COVID-19 patients during hospitalization and 60 days after hospital discharge. Physiological impairment of all patients was assessed by spirometry, dyspnea score, arterial blood gas, and 6-minute walk test 60 days after hospital discharge, and computed tomographic scan 90 days after discharge. All patients had fatigue, which was not related to hypoxemia or impaired spirometry values, and interstitial lung alterations, which occurred in both mechanically ventilated and non-mechanically ventilated patients. In conclusion, identifying the prevalence and patterns of permanent lung damage is paramount in preventing and treating COVID-19-induced fibrotic lung disease. Additionally, and based on our preliminary results, it will be also relevant to establish long-term outpatient programs for these individuals.
RESUMO
BACKGROUND AND OBJECTIVE: The precise coordination of respiratory muscles during exercise minimizes work of breathing and avoids exercise intolerance. Fibrotic interstitial lung disease (f-ILD) patients are exercise-intolerant. We assessed whether respiratory muscle incoordination and thoracoabdominal asynchrony (TAA) occur in f-ILD during exercise, and their relationship with pulmonary function and exercise performance. METHODS: We compared breathing pattern, respiratory mechanics, TAA and respiratory muscle recruitment in 31 f-ILD patients and 31 healthy subjects at rest and during incremental cycle exercise. TAA was defined as phase angle (PhAng) >20°. RESULTS: During exercise, when compared with controls, f-ILD patients presented increased and early recruitment of inspiratory rib cage muscle (p < 0.05), and an increase in PhAng, indicating TAA. TAA was more frequent in f-ILD patients than in controls, both at 50% of the maximum workload (42.3% vs. 10.7%, p = 0.01) and at the peak (53.8% vs. 23%, p = 0.02). Compared with f-ILD patients without TAA, f-ILD patients with TAA had lower lung volumes (forced vital capacity, p < 0.01), greater dyspnoea (Medical Research Council > 2 in 64.3%, p = 0.02), worse exercise performance (lower maximal work rate % predicted, p = 0.03; lower tidal volume, p = 0.03; greater desaturation and dyspnoea, p < 0.01) and presented higher oesophageal inspiratory pressures with lower gastric inspiratory pressures and higher recruitment of scalene (p < 0.05). CONCLUSION: Exercise induces TAA and higher recruitment of inspiratory accessory muscle in ILD patients. TAA during exercise occurred in more severely restricted ILD patients and was associated with exertional dyspnoea, desaturation and limited exercise performance.
Assuntos
Teste de Esforço , Doenças Pulmonares Intersticiais , Dispneia/etiologia , Humanos , Mecânica Respiratória , Músculos RespiratóriosRESUMO
OBJECTIVES: The scant data about non-cystic fibrosis bronchiectasis, including tuberculosis sequelae and impairment of lung function, can bias the preoperative physiological assessment. Our goal was to evaluate the changes in lung function and exercise capacity following pulmonary resection in these patients; we also looked for outcome predictors. METHODS: We performed a non-randomized prospective study evaluating lung function changes in patients with non-cystic fibrosis bronchiectasis treated with pulmonary resection. Patients performed lung function tests and cardiopulmonary exercise tests preoperatively and 3 and 9 months after the operation. Demographic data, comorbidities, surgical data and complications were collected. RESULTS: Forty-four patients were evaluated for lung function. After resection, the patients had slightly lower values for spirometry: forced expiratory volume in 1 s preoperatively: 2.21 l ± 0.8; at 3 months: 1.9 l ± 0.8 and at 9 months: 2.0 l ± 0.8, but the relationship between the forced expiratory volume in 1 s and the forced vital capacity remained. The gas diffusion measured by diffusing capacity for carbon monoxide did not change: preoperative value: 23.2 ml/min/mmHg ± 7.4; at 3 months: 21.5 ml/min/mmHg ± 5.6; and at 9 months: 21.7 ml/min/mmHg ± 8.2. The performance of general exercise did not change; peak oxygen consumption preoperatively was 20.9 ml/kg/min ± 7.4; at 3 months: 19.3 ml/kg/min ± 6.4; and at 9 months: 20.2 ml/kg/min ± 8.0. Forty-six patients were included for analysis of complications. We had 13 complications with 2 deaths. To test the capacity of the predicted postoperative (PPO) values to forecast complications, we performed several multivariate and univariate analyses; none of them was a significant predictor of complications. When we analysed other variables, only bronchoalveolar lavage with positive culture was significant for postoperative complications (P = 0.0023). Patients who had a pneumonectomy had a longer stay in the intensive care unit (P = 0.0348). CONCLUSIONS: The calculated PPO forced expiratory volume in 1 s had an excellent correlation with the measurements at 3 and 9 months; but the calculated PPO capacity for carbon monoxide and the PPO peak oxygen consumption slightly underestimated the 3- and 9-month values. However, none of them was a predictor for complications. Better tools to predict postoperative complications for patients with bronchiectasis who are candidates for lung resection are needed. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrials.gov: NCT01268475.
Assuntos
Bronquiectasia , Neoplasias Pulmonares , Volume Expiratório Forçado , Humanos , Pulmão , Neoplasias Pulmonares/cirurgia , Pneumonectomia , Complicações Pós-Operatórias , Estudos ProspectivosRESUMO
A new concept of multisystem disease has emerged as a long-term condition following mild-severe COVID-19 infection. The main symptoms of this affection are breathlessness, chest pain, and fatigue. We present here the clinical case of four COVID-19 patients during hospitalization and 60 days after hospital discharge. Physiological impairment of all patients was assessed by spirometry, dyspnea score, arterial blood gas, and 6-minute walk test 60 days after hospital discharge, and computed tomographic scan 90 days after discharge. All patients had fatigue, which was not related to hypoxemia or impaired spirometry values, and interstitial lung alterations, which occurred in both mechanically ventilated and non-mechanically ventilated patients. In conclusion, identifying the prevalence and patterns of permanent lung damage is paramount in preventing and treating COVID-19-induced fibrotic lung disease. Additionally, and based on our preliminary results, it will be also relevant to establish long-term outpatient programs for these individuals.
Assuntos
Humanos , Pneumopatias/diagnóstico , COVID-19RESUMO
A new concept of multisystem disease has emerged as a long-term condition following mild-severe COVID-19 infection. The main symptoms of this affection are breathlessness, chest pain, and fatigue. We present here the clinical case of four COVID-19 patients during hospitalization and 60 days after hospital discharge. Physiological impairment of all patients was assessed by spirometry, dyspnea score, arterial blood gas, and 6-minute walk test 60 days after hospital discharge, and computed tomographic scan 90 days after discharge. All patients had fatigue, which was not related to hypoxemia or impaired spirometry values, and interstitial lung alterations, which occurred in both mechanically ventilated and non-mechanically ventilated patients. In conclusion, identifying the prevalence and patterns of permanent lung damage is paramount in preventing and treating COVID-19-induced fibrotic lung disease. Additionally, and based on our preliminary results, it will be also relevant to establish long-term outpatient programs for these individuals.(AU)
Assuntos
Humanos , Pneumopatias/diagnóstico , Pneumopatias/patologia , Pneumopatias/fisiopatologia , COVID-19RESUMO
BACKGROUND: The six-minute pegboard and ring test (6-PBRT) has been used to evaluate functional capacity of the upper limbs in stable chronic obstructive pulmonary disease (COPD) patients. To the best of our knowledge, no studies have evaluated dynamic hyperinflation (DH) during exercise with upper limbs in the hospital setting. The aim of this study was to evaluate physiological responses and DH induced by 6-PBRT in hospitalized patients with acute exacerbation of COPD (AECOPD). METHODS: A cross-sectional study was conducted in a tertiary hospital enrolling patients who were hospitalized due to AECOPD. All included participants underwent an evaluation of lung function and 6-PBRT when they reached minimum clinical criteria. Ventilatory and hemodynamics parameters were monitored during 6-PBRT and until 6 minutes of rest after the test. Symptoms of dyspnea and upper limb fatigue were also measured. RESULTS: Eighteen patients (71.3±5.1 years) with a mean FEV1 of 43.2±18.3% were included in the study (11 females). Prevalence of DH after 6-PBRT was 50% (considering the drop of 150 ml or 10% of inspiratory capacity, immediately after the end of the test). There was a significant increase in respiratory rate, minute volume, dyspnea, and upper limb fatigue after the end of 6-PBRT (p<0.05). Dyspnea recovered more precociously than the perception of fatigue, being reestablished within four minutes of rest. An increase in heart rate, systolic and diastolic blood pressures was also induced by 6-PBRT (p<0.05), requiring 6 minutes of recovery to return to baseline. No adverse events were observed during 6-PBRT. We concluded that 6-PBRT induces physiological changes during its execution, at safe levels, requiring a maximum of 6 minutes for recovery. Finally, the test proved to be safe and applicable for patients hospitalized due to AECOPD.
Assuntos
Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Idoso , Estudos Transversais , Feminino , Volume Expiratório Forçado/fisiologia , Hemodinâmica/fisiologia , Hospitais , Humanos , Capacidade Inspiratória/fisiologia , Masculino , Testes de Função Respiratória , Taxa Respiratória/fisiologiaRESUMO
The diaphragm is the main muscle of respiration, acting continuously and uninterruptedly to sustain the task of breathing. Diaphragmatic dysfunction can occur secondary to numerous pathological conditions and is usually underdiagnosed in clinical practice because of its nonspecific presentation. Although several techniques have been used in evaluating diaphragmatic function, the diagnosis of diaphragmatic dysfunction is still problematic. Diaphragmatic ultrasound has gained importance because of its many advantages, including the fact that it is noninvasive, does not expose patients to radiation, is widely available, provides immediate results, is highly accurate, and is repeatable at the bedside. Various authors have described ultrasound techniques to assess diaphragmatic excursion and diaphragm thickening in the zone of apposition. Recent studies have proposed standardization of the methods. This article reviews the usefulness of ultrasound for the evaluation of diaphragmatic function, addressing the details of the technique, the main findings, and the clinical applications.
Assuntos
Diafragma/diagnóstico por imagem , Ultrassonografia/métodos , Humanos , Doenças Neuromusculares , Músculos Respiratórios , Doenças RespiratóriasRESUMO
BACKGROUND: Fibrotic interstitial lung disease (FILD) patients are typically dyspneic and exercise-intolerant with consequent impairment of health-related quality of life (HRQoL). Respiratory muscle dysfunction is among the underlying mechanisms of dyspnea and exercise intolerance in FILD but may be difficult to diagnose. Using ultrasound, we compared diaphragmatic mobility and thickening in FILD cases and healthy controls and correlated these findings with dyspnea, exercise tolerance, HRQoL and lung function. METHODS: We measured diaphragmatic mobility and thickness during quiet (QB) and deep breathing (DB) and calculated thickening fraction (TF) in 30 FILD cases and 30 healthy controls. We correlated FILD cases' diaphragmatic findings with dyspnea, exercise tolerance (six-minute walk test), lung function and HRQoL (St. George's Respiratory Questionnaire). RESULTS: Diaphragmatic mobility was similar between groups during QB but was lower in FILD cases during DB when compared to healthy controls (3.99 cm vs 7.02 cm; p < 0.01). FILD cases showed higher diaphragm thickness during QB but TF was lower in FILD when compared to healthy controls (70% vs 188%, p < 0.01). During DB, diaphragmatic mobility and thickness correlated with lung function, exercise tolerance and HRQoL, but inversely correlated with dyspnea. Most FILD cases (70%) presented reduced TF, and these patients had higher dyspnea and exercise desaturation, lower HRQoL and lung function. CONCLUSION: Compared to healthy controls, FILD cases present with lower diaphragmatic mobility and thickening during DB that correlate to increased dyspnea, decreased exercise tolerance, worse HRQoL and worse lung function. FILD cases with reduced diaphragmatic thickening are more dyspneic and exercise-intolerant, have lower HRQoL and lung function.
Assuntos
Diafragma , Dispneia , Doenças Pulmonares Intersticiais , Qualidade de Vida , Testes de Função Respiratória , Ultrassonografia , Brasil/epidemiologia , Diafragma/diagnóstico por imagem , Diafragma/patologia , Diafragma/fisiopatologia , Dispneia/etiologia , Dispneia/fisiopatologia , Tolerância ao Exercício , Feminino , Humanos , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/epidemiologia , Doenças Pulmonares Intersticiais/fisiopatologia , Doenças Pulmonares Intersticiais/psicologia , Masculino , Pessoa de Meia-Idade , Testes de Função Respiratória/métodos , Testes de Função Respiratória/estatística & dados numéricos , Ultrassonografia/métodos , Ultrassonografia/estatística & dados numéricos , Teste de Caminhada/métodosRESUMO
RESUMO O objetivo desse estudo foi determinar o tempo de oclusão necessário para avaliar a pressão inspiratória máxima (PIMáx) obtida pelo método da válvula expiratória unidirecional em sujeitos sem via aérea artificial. Foram avaliados 31 sujeitos, com idade entre 18 e 60 anos. A PIMáx foi avaliada pelo método convencional (PIMáxconv) e pelo método da válvula expiratória unidirecional (PIMáxuni), sendo a ordem de avaliação definida por meio de sorteio. Para a medida da PIMáxuni, um manovacuômetro digital foi acoplado a uma válvula expiratória unidirecional e máscara orofacial por 20 segundos de oclusão. Nesse período, todos os sujeitos foram encorajados a realizar esforços inspiratórios máximos. Para definir a ótima duração da manobra, o tempo de esforço foi dividido a cada intervalo de 5 segundos (0-5s, 0-10s, 0-15s, 0-20s). Os intervalos de tempo para obtenção da PIMáxuni foram comparados por meio do teste de ANOVA One-way. Para comparação das médias dos valores de PIMáxconv e PIMáxuni, foi utilizado o teste t de Student. O nível de significância foi de 5%. A média dos valores da PIMáxconv foi de -102,5±23,9 cmH2O, enquanto que a PIMáxuni foi de -117,3±24,8 cmH2O (p<0,001). O valor absoluto máximo da PIMáxuni foi alcançado dentro do intervalo de 0-20 segundos, que foi significativamente superior ao valor absoluto máximo obtido nos primeiros 5 segundos (p=0,036). O tempo de oclusão necessário para avaliar a PIMáx pelo método da válvula expiratória unidirecional em sujeitos colaborativos sem via aérea artificial deve ser de pelo menos 20 segundos.
RESUMEN Este estudio busca determinar cuánto tiempo de oclusión es necesario para obtener la presión inspiratoria máxima (PIMáx) por medio del método de la válvula espiratoria unidireccional en individuos sin vía aérea artificial. Se evaluaron 31 sujetos de entre 18 y 60 años de edad. La PIMáx se evaluó mediante el método estándar (PIMáxest) y el método de válvula espiratoria unidireccional (PIMáxuni), siendo que el orden de evaluación se estableció por medio de un sorteo. Para el PIMáxuni, un manovacuómetro digital se ha conectado a una válvula espiratoria unidireccional y una máscara orofacial durante 20 segundos de oclusión. Durante este período, se alentó a los individuos a hacer esfuerzos respiratorios máximos. Para definir la óptima duración de la maniobra, el tiempo de esfuerzo se dividió en intervalos de cinco segundos (0-5s, 0-10s, 0-15s, 0-20s). Los intervalos del tiempo para el PIMáxuni se compararon mediante la prueba ANOVA one-way. Las medias de los valores de PIMáxest y de PIMáxuni se compararon mediante la prueba pareada t de Student. El nivel de significancia se estableció en el 5%. La media de los valores de PIMáxest (-102,5±23,9 cmH2O) presentó una diferencia estadísticamente significativa en comparación con la media de los valores de PIMáxuni (-117,3±24,8 cmH2O, p<0,001). El valor absoluto máximo obtenido de PIMáxuni estaba dentro del intervalo de 0-20 segundos, que fue significativamente superior del valor absoluto máximo durante los primeros 5 segundos (p=0,036). El tiempo de oclusión necesario para registrar la PIMáx por el método de válvula espiratoria unidireccional en individuos colaborativos sin vía aérea artificial debe ser de al menos 20 segundos.
ABSTRACT The aim of this study was to determine how much occlusion time is necessary to obtain maximal inspiratory pressure (MIP) by the unidirectional expiratory valve method in subjects without artificial airway. Thirty-one subjects aged 18-60 years were evaluated. MIP was evaluated by the standard method (MIPstan) and by the unidirectional expiratory valve method MIPuni, with the order of evaluation determined randomly by lot. For MIPuni measurement, a digital vacuum manometer was attached to a unidirectional expiratory valve and an orofacial mask for 20 seconds of occlusion. During this period, all subjects were encouraged to make maximal respiratory efforts. To define the optimum duration of the maneuver, the 20 seconds of effort were partitioned at every five-second interval (0-5s, 0-10s, 0-15s, 0-20s). The time intervals for obtaining MIPuni were compared with the one-way ANOVA test. The mean values of the standard method and the unidirectional expiratory valve method were compared using the paired Student's t-test. The significance level was established at 5%. The mean values for the MIPstan (-102.5±23.9 cmH2O) presented a statistically significant difference as compared to the mean values for MIPuni (-117.3±24.8 cmH2O; p<0.001). Maximal peak values for MIPuni were achieved within the 20-second time window, which differed significantly from the peak values obtained during the first five seconds (p=0.036). The occlusion time necessary to record MIP by the unidirectional expiratory valve method in collaborative subjects without artificial airway should be of at least 20 seconds.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Músculos Respiratórios/fisiologia , Força Muscular/fisiologia , Pressões Respiratórias Máximas/métodos , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Testes de Função Respiratória/métodos , Estudos Transversais , Modalidades de Fisioterapia , Pressões Respiratórias Máximas/instrumentaçãoRESUMO
ABSTRACT Objective: To evaluate the impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer. Methods: Breast cancer patients in whom thoracic radiotherapy was indicated after surgical treatment and chemotherapy were submitted to HRCT, respiratory evaluation, and exercise capacity evaluation before radiotherapy and at three months after treatment completion. Respiratory muscle strength testing, measurement of chest wall mobility, and complete pulmonary function testing were performed for respiratory evaluation; cardiopulmonary exercise testing was performed to evaluate exercise capacity. The total radiotherapy dose was 50.4 Gy (1.8 Gy/fraction) to the breast or chest wall, including supraclavicular lymph nodes (SCLN) or not. Dose-volume histograms were calculated for each patient with special attention to the ipsilateral lung volume receiving 25 Gy (V25), in absolute and relative values, and mean lung dose. Results: The study comprised 37 patients. After radiotherapy, significant decreases were observed in respiratory muscle strength, chest wall mobility, exercise capacity, and pulmonary function test results (p < 0.05). DLCO was unchanged. HRCT showed changes related to radiotherapy in 87% of the patients, which was more evident in the patients submitted to SCLN irradiation. V25% significantly correlated with radiation pneumonitis. Conclusions: In our sample of patients with breast cancer, thoracic radiotherapy seemed to have caused significant losses in respiratory and exercise capacity, probably due to chest wall restriction; SCLN irradiation represented an additional risk factor for the development of radiation pneumonitis.
RESUMO Objetivo: Avaliar o impacto da radioterapia torácica na função respiratória e capacidade de exercício em pacientes com câncer de mama. Métodos: Pacientes com câncer de mama com indicação de radioterapia torácica após tratamento cirúrgico e quimioterápico foram submetidas a TCAR, avaliação respiratória e avaliação da capacidade de exercício antes da radioterapia torácica e três meses após o término do tratamento. Foram realizados teste de força muscular respiratória, medição da mobilidade torácica e prova de função pulmonar completa para a avaliação respiratória; realizou-se teste de exercício cardiopulmonar para avaliar a capacidade de exercício. A dose total de radioterapia foi de 50,4 Gy (1,8 Gy/fração) na mama ou na parede torácica, incluindo ou não a fossa supraclavicular (FSC). Histogramas dose-volume foram calculados para cada paciente com especial atenção para o volume pulmonar ipsilateral que recebeu 25 Gy (V25), em números absolutos e relativos, e a dose pulmonar média. Resultados: O estudo incluiu 37 pacientes. Após a radioterapia, observou-se diminuição significativa da força muscular respiratória, mobilidade torácica, capacidade de exercício e resultados da prova de função pulmonar (p < 0,05). A DLCO permaneceu inalterada. A TCAR mostrou alterações relacionadas à radioterapia em 87% das pacientes, o que foi mais evidente nas pacientes submetidas à irradiação da FSC. O V25% correlacionou-se significativamente com a pneumonite por radiação. Conclusões: Em nossa amostra de pacientes com câncer de mama, a radioterapia torácica parece ter causado perdas significativas na capacidade respiratória e de exercício, provavelmente por causa da restrição torácica; a irradiação da FSC representou um fator de risco adicional para o desenvolvimento de pneumonite por radiação.
Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Neoplasias da Mama/radioterapia , Volume Expiratório Forçado/efeitos da radiação , Tolerância ao Exercício/efeitos da radiação , Pneumonite por Radiação/diagnóstico por imagem , Músculos Respiratórios/efeitos da radiação , Músculos Respiratórios/fisiopatologia , Irradiação Linfática/efeitos adversos , Tomografia Computadorizada por Raios X/métodos , Estudos Prospectivos , Relação Dose-Resposta à RadiaçãoRESUMO
BACKGROUND: Most patients with unilateral diaphragm paralysis (UDP) have unexplained dyspnea, exercise limitations, and reduction in inspiratory muscle capacity. We aimed to evaluate the generation of pressure in each hemidiaphragm separately and its contribution to overall inspiratory strength. METHODS: Twenty-seven patients, 9 in right paralysis group (RP) and 18 in left paralysis group (LP), with forced vital capacity (FVC) < 80% pred, and 20 healthy controls (CG), with forced expiratory volume in 1 s (FEV1) > 80% pred and FVC > 80% pred, were evaluated for lung function, maximal inspiratory (MIP) and expiratory (MEP) pressure measurements, diaphragm ultrasound, and transdiaphragmatic pressure during magnetic phrenic nerve stimulation (PdiTw). RESULTS: RP and LP had significant inspiratory muscle weakness compared to controls, detected by MIP (- 57.4 ± 16.9 for RP; - 67.1 ± 28.5 for LP and - 103.1 ± 30.4 cmH2O for CG) and also by PdiTW (5.7 ± 4 for RP; 4.8 ± 2.3 for LP and 15.3 ± 5.7 cmH2O for CG). The PdiTw was reduced even when the non-paralyzed hemidiaphragm was stimulated, mainly due to the low contribution of gastric pressure (around 30%), regardless of whether the paralysis was in the right or left hemidiaphragm. On the other hand, in CG, esophagic and gastric pressures had similar contribution to the overall Pdi (around 50%). Comparing both paralyzed and non-paralyzed hemidiaphragms, the mobility during quiet and deep breathing, and thickness at functional residual capacity (FRC) and total lung capacity (TLC), were significantly reduced in paralyzed hemidiaphragm. In addition, thickness fraction was extremely diminished when contrasted with the non-paralyzed hemidiaphragm. CONCLUSIONS: In symptomatic patients with UDP, global inspiratory strength is reduced not only due to weakness in the paralyzed hemidiaphragm but also to impairment in the pressure generated by the non-paralyzed hemidiaphragm.
Assuntos
Diafragma/diagnóstico por imagem , Diafragma/fisiopatologia , Pressão , Paralisia Respiratória/fisiopatologia , Adulto , Idoso , Estudos de Casos e Controles , Estudos Transversais , Feminino , Volume Expiratório Forçado , Capacidade Residual Funcional , Humanos , Masculino , Pessoa de Meia-Idade , Nervo Frênico/fisiopatologia , Paralisia Respiratória/patologia , Ultrassonografia , Capacidade VitalRESUMO
Background: The 6-minute pegboard and ring test (6-PBRT) is a useful test for assessing the functional capacity of upper limbs in patients with stable COPD. Although 6-PBRT has been validated in stable patients, the possibility of a high floor effect could compromise the validity of the test in the hospital setting. The aim of this study was to verify the convergent validity of 6-PBRT in hospitalized patients with acute exacerbation of COPD (AECOPD). Methods: A cross-sectional study was conducted in a tertiary hospital. Patients who were hospitalized due to AECOPD and healthy elderly participants, voluntarily recruited from the community, were considered for inclusion. All participants underwent a 6-PBRT. Isokinetic evaluation to measure the strength and endurance of elbow flexors and extensors, handgrip strength (HGS), spirometry testing, the modified Pulmonary Functional Status Dyspnea Questionnaire (PFSDQ-M), the COPD assessment test (CAT), and symptoms of dyspnea and fatigue were all measured as comparisons for convergent validity. Good convergent validity was considered if >75% of these hypotheses could be confirmed (correlation coefficient>0.50). Results: A total of 17 patients with AECOPD (70.9±5.1 years and forced expiratory volume in 1 second [FEV1] of 41.8%±17.9% of predicted) and 11 healthy elderly subjects were included. The HGS showed a significant strong correlation with 6-PBRT performance (r=0.70; p=0.002). The performance in 6-PBRT presented a significant moderate correlation with elbow flexor torque peak (r=0.52; p=0.03) and elbow extensor torque peak (r=0.61; p=0.01). The total muscular work of the 15 isokinetic contractions of the elbow flexor and extensor muscles showed a significant moderate correlation with the performance in 6-PBRT (r=0.59; p=0.01 and r=0.57; p=0.02, respectively). Concerning the endurance of elbow flexors and extensors, there was a significant moderate correlation with 6-PBRT performance (r=-0.50; p=0.04 and r=-0.51; p=0.03, respectively). In relation to the upper-extremity physical activities of daily living (ADLs) assessed by means of PFSDQ-M, there was a significant moderate correlation of 6-PBRT with three domains: influence of dyspnea on ADLs (r=-0.66; p<0.001), influence of fatigue on ADLs (r=-0.60; p=0.01), and change in ADLs in relation to the period before the disease onset (r=-0.51; p=0.03). The CAT was also correlated with 6-PBRT (r=-0.51; p=0.03). Finally, the performance in 6-PBRT showed a significant moderate correlation with the increase in dyspnea (r=-0.63; p=0.01) and a strong correlation with the increase in fatigue of upper limbs (r=-0.76; p<0.001) in patients with AECOPD. Convergent validity was considered adequate, since 81% from 16 predefined hypotheses were confirmed. There was no correlation between 6-PBRT and patients' height. The performance in 6-PBRT was worse in patients with AECOPD compared to healthy elderly individuals (248.7±63.0 vs 361.6±49.9 number of moved rings; p<0.001). Conclusion: The 6-PBRT is valid for the evaluation of functional capacity of upper limbs in hospitalized patients with AECOPD.