Reliability of nasal auscultation and their relation to middle ear condition – a clinical interest to pediatrics respiratory physiotherapy

Background: Acute respiratory infections are usual in children under three years old occurring in upper respiratory tract, having an impact on child and caregiver’s quality of life predisposing to otitis media or bronchiolitis. There are few valid and reliable measures to determine the child’s respiratory condition and to guide the physiotherapy intervention. Aim: To assess the intra and inter rater reliability of nasal auscultation, to analyze the relation between sounds’ classification and middle ear’s pressure and compliance as well as with the Clinical Severity Score. Methods: A cross-sectional observational study was composed by 125 nursery children aged up to three years old. Tympanometry, pulmonary and nasal auscultation and application of Clinical Severity Score were performed to each child. Nasal auscultation sounds’ were recorded and sent to 3 blinded experts, that classified, as “obstructed” and “unobstructed”, with a 48 hours interval, in order to analyze inter and intra rater reliability. Results: Nasal auscultation revealed a substantial inter and intra rater reliability (=0,749 and evaluator A - K= 0,691; evaluator B - K= 0,605 and evaluator C - K= 0,724, respectively). Both ears’ pressure was significantly lower in children with an "unobstructed" nasal sound when compared with an “obstructed” nasal sound (t=-3,599, p<0,001 in left ear; t=-2,258, p=0,026 in right ear). Compliance in both ears was significantly lower in children with an "obstructed" nasal sound when compared with “unobstructed” nasal sound (t=-2,728, p=0,007 in left ear; t=-3,830, p<0,001 in right ear). There was a statistically significant association between sounds’ classification and tympanograms types in both ear’s (=11,437, p=0,003 in left ear; =13,535, p=0,001 in right ear). There was a trend to children with an "unobstructed" nasal sound that had a lower clinical severity score when compared with “obstructed” children. Conclusion: It was observed a good intra and substantial inter reliability for nasal auscultation. Nasal auscultation sounds’ classification was related to middle ears’ pressure and compliance.

Influence of environmental temperature and humidity on the acute ventilatory response to exercise in asthmatic adolescents

Asthma is a chronic inflammatory disorder of the respiratory airways affecting people of all ages, and constitutes a serious public health problem worldwide (6). Such a chronic inflammation is invariably associated with injury and repair of the bronchial epithelium known as remodelling (11). Inflammation, remodelling, and altered neural control of the airways are responsible for both recurrent exacerbations of asthma and increasingly permanent airflow obstruction (11, 29, 34). Excessive airway narrowing is caused by altered smooth muscle behaviour, in close interaction with swelling of the airway walls, parenchyma retractile forces, and enhanced intraluminal secretions (29, 38). All these functional and structural changes are associated with the characteristic symptoms of asthma – cough, chest tightness, and wheezing –and have a significant impact on patients’ daily lives, on their families and also on society (1, 24, 29). Recent epidemiological studies show an increase in the prevalence of asthma, mainly in industrial countries (12, 25, 37). The reasons for this increase may depend on host factors (e.g., genetic disposition) or on environmental factors like air pollution or contact with allergens (6, 22, 29). Physical exercise is probably the most common trigger for brief episodes of symptoms, and is assumed to induce airflow limitations in most asthmatic children and young adults (16, 24, 29, 33). Exercise-induced asthma (EIA) is defined as an intermittent narrowing of the airways, generally associated with respiratory symptoms (chest tightness, cough, wheezing and dyspnoea), occurring after 3 to 10 minutes of vigorous exercise with a maximal severity during 5 to 15 minutes after the end of the exercise (9, 14, 16, 24, 33). The definitive diagnosis of EIA is confirmed by the measurement of pre- and post-exercise expiratory flows documenting either a 15% fall in the forced expiratory volume in 1 second (FEV1), or a ≥15 to 20% fall in peak expiratory flow (PEF) (9, 24, 29). Some types of physical exercise have been associated with the occurrence of bronchial symptoms and asthma (5, 15, 17). For instance, demanding activities such as basketball or soccer could cause more severe attacks than less vigorous ones such as baseball or jogging (33). The mechanisms of exercise-induced airflow limitations seem to be related to changes in the respiratory mucosa induced by hyperventilation (9, 29). The heat loss from the airways during exercise, and possibly its post-exercise rewarming may contribute to the exercise-induced bronchoconstriction (EIB) (27). Additionally, the concomitant dehydration from the respiratory mucosa during exercise leads to an increased interstitial osmolarity, which may also contribute to bronchoconstriction (4, 36). So, the risk of EIB in asthmatically predisposed subjects seems to be higher with greater ventilation rates and the cooler and drier the inspired air is (23). The incidence of EIA in physically demanding coldweather sports like competitive figure skating and ice hockey has been found to occur in up to 30 to 35% of the participants (32). In contrast, swimming is often recommended to asthmatic individuals, because it improves the functionality of respiratory muscles and, moreover, it seems to have a concomitant beneficial effect on the prevalence of asthma exacerbations (14, 26), supporting the idea that the risk of EIB would be smaller in warm and humid environments. This topic, however, remains controversial since the chlorified water of swimming pools has been suspected as a potential trigger factor for some asthmatic patients (7, 8, 20, 21). In fact, the higher asthma incidence observed in industrialised countries has recently been linked to the exposition to chloride (7, 8, 30). Although clinical and epidemiological data suggest an influence of humidity and temperature of the inspired air on the bronchial response of asthmatic subjects during exercise, some of those studies did not accurately control the intensity of the exercise (2, 13), raising speculation of whether the experienced exercise overload was comparable for all subjects. Additionally, most of the studies did not include a control group (2, 10, 19, 39), which may lead to doubts about whether asthma per se has conditioned the observed results. Moreover, since the main targeted age group of these studies has been adults (10, 19, 39), any extrapolation to childhood/adolescence might be questionable regarding the different lung maturation. Considering the higher incidence of asthma in youngsters (30) and the fact that only the works of Amirav and coworkers (2, 3) have focused on this age group, a scarcity of scientific data can be identified. Additionally, since the main environmental trigger factors, i.e., temperature and humidity, were tested separately (10, 28, 39) it would be useful to analyse these two variables simultaneously because of their synergic effect on water and heat loss by the airways (31, 33). It also appears important to estimate the airway responsiveness to exercise within moderate environmental ranges of temperature and humidity, trying to avoid extreme temperatures and humidity conditions used by others (2, 3). So, the aim of this study was to analyse the influence of moderate changes in air temperature and humidity simultaneously on the acute ventilatory response to exercise in asthmatic children. To overcome the above referred to methodological limitations, we used a 15 minute progressive exercise trial on a cycle ergometer at 3 different workload intensities, and we collected data related to heart rate, respiratory quotient, minute ventilation and oxygen uptake in order to ensure that physiological exercise repercussions were the same in both environments. The tests were done in a “normal” climatic environment (in a gymnasium) and in a hot and humid environment (swimming pool); for the latter, direct chloride exposition was avoided.

Efeito de um programa de exercícios segundo Pilates em indivíduos com asma controlada – controlo motor vs. função ventilatória

Introdução: Embora existam estratégias para coordenar as funções postural e ventilatória numa situação normal, isto pode não ser verdade quando a necessidade para uma das funções está aumentada, como por exemplo em patologia respiratória (asma) ou no exercício físico, em que subsistem maiores necessidades ventilatórias. O método Pilates, que foca a relação entre o corpo e a disciplina mental, visa prosperar a saúde e o bem-estar pelo enfatizar da boa postura, do alinhamento corporal e da coordenação da ventilação com o movimento. Objectivo: Comparar características de controlo motor e parâmetros ventilatórios em asmáticos controlados e indivíduos sem patologia, e verificar o efeito de um programa de exercícios segundo Pilates nesses outcomes em indivíduos com asma controlada. Métodos: Estudo quasi-experimental, com uma amostra constituída por 21 estudantes voluntários, 7 pertencentes ao “grupo sem patologia”, 7 ao “grupo controlo asmático” e 7 ao “grupo experimental asmático”. Para avaliação do timing de ativação e do padrão de recrutamento muscular no movimento rápido do membro superior foi utilizada eletromiografia de superfície do Diafragma, Eretor da Coluna, Multífidos, Oblíquo Externo, Reto Anterior e Transverso Abdominal/Oblíquo Interno. Foram também avaliados parâmetros de função ventilatória: a percentagem de volume expiratório forçado no primeiro segundo do previsto, o débito expiratório máximo instantâneo, a ventilação máxima voluntária, a pressão inspiratória máxima e a pressão expiratória máxima. As avaliações decorreram antes e após 8 semanas da aplicação de um programa de exercícios segundo Pilates no grupo experimental asmático, com exceção do grupo sem patologia que realizou apenas o primeiro momento de avaliação. Resultados: O grupo controlo asmático apresentou um timing de ativação significativamente maior do Transverso Abdominal/Oblíquo Interno e do Diafragma, em relação ao grupo sem patologia. Nos parâmetros ventilatórios, o grupo controlo asmático apresentou menores valores de percentagem de volume expiratório no primeiro segundo do previsto, de débito expiratório máximo instantâneo e de pressão expiratória máxima. Após a realização do programa de exercícios segundo Pilates verificaram-se alterações significativas no timing de activação do Eretor da Coluna, do Multífidos, do Transverso/Oblíquo Interno e do Diafragma, tendo ambos diminuído no grupo experimental asmático. Ainda, o grupo experimental asmático, em relação aos parâmetros ventilatórios, apresentou diferenças significativas no débito expiratório máximo instantâneo, na ventilação máxima voluntária e na pressão expiratória máxima, tendo ambos aumentado estes valores. Conclusão: Os asmáticos controlados parecem possuir características de controlo motor, especificamente no timing de ativação, e valores de parâmetros ventilatórios diferentes em comparação aos indivíduos sem patologia. O programa de exercícios segundo Pilates, implementado no grupo experimental asmático, parece ter influenciado positivamente esses outcomes.

Analysis of the respiratory dynamics during normal breathing by means of pseudo phase plots and pressure-volume loops

This paper reports on the analysis of tidal breathing patterns measured during noninvasive forced oscillation lung function tests in six individual groups. The three adult groups were healthy, with prediagnosed chronic obstructive pulmonary disease, and with prediagnosed kyphoscoliosis, respectively. The three children groups were healthy, with prediagnosed asthma, and with prediagnosed cystic fibrosis, respectively. The analysis is applied to the pressure–volume curves and the pseudophaseplane loop by means of the box-counting method, which gives a measure of the area within each loop. The objective was to verify if there exists a link between the area of the loops, power-law patterns, and alterations in the respiratory structure with disease. We obtained statistically significant variations between the data sets corresponding to the six groups of patients, showing also the existence of power-law patterns. Our findings support the idea that the respiratory system changes with disease in terms of airway geometry and tissue parameters, leading, in turn, to variations in the fractal dimension of the respiratory tree and its dynamics.

Fractional-order impulse response of the respiratory system

This paper presents the measurement, frequency-response modeling and identification, and the corresponding impulse time response of the human respiratory impedance and admittance. The investigated adult patient groups were healthy, diagnosed with chronic obstructive pulmonary disease and kyphoscoliosis, respectively. The investigated children patient groups were healthy, diagnosed with asthma and cystic fibrosis, respectively. Fractional order (FO) models are identified on the measured impedance to quantify the respiratory mechanical properties. Two methods are presented for obtaining and simulating the time-domain impulse response from FO models of the respiratory admittance: (i) the classical pole-zero interpolation proposed by Oustaloup in the early 90s, and (ii) the inverse discrete Fourier Transform (DFT). The results of the identified FO models for the respiratory admittance are presented by means of their average values for each group of patients. Consequently, the impulse time response calculated from the frequency response of the averaged FO models is given by means of the two methods mentioned above. Our results indicate that both methods provide similar impulse response data. However, we suggest that the inverse DFT is a more suitable alternative to the high order transfer functions obtained using the classical Oustaloup filter. Additionally, a power law model is fitted on the impulse response data, emphasizing the intrinsic fractal dynamics of the respiratory system.

Is multidimensional scaling suitable for mapping the input respiratory impedance in subjects and patients?

This paper presents the application of multidimensional scaling (MDS) analysis to data emerging from noninvasive lung function tests, namely the input respiratory impedance. The aim is to obtain a geometrical mapping of the diseases in a 3D space representation, allowing analysis of (dis)similarities between subjects within the same pathology groups, as well as between the various groups. The adult patient groups investigated were healthy, diagnosed chronic obstructive pulmonary disease (COPD) and diagnosed kyphoscoliosis, respectively. The children patient groups were healthy, asthma and cystic fibrosis. The results suggest that MDS can be successfully employed for mapping purposes of restrictive (kyphoscoliosis) and obstructive (COPD) pathologies. Hence, MDS tools can be further examined to define clear limits between pools of patients for clinical classification, and used as a training aid for medical traineeship.

Intrinsic fractal dynamics in the respiratory system by means of pressure-volume loops

This contribution presents novel concepts for analysis of pressure–volume curves, which offer information about the time domain dynamics of the respiratory system. The aim is to verify whether a mapping of the respiratory diseases can be obtained, allowing analysis of (dis)similarities between the dynamical pattern in the breathing in children. The groups investigated here are children, diagnosed as healthy, asthmatic, and cystic fibrosis. The pressure–volume curves have been measured by means of the noninvasive forced oscillation technique during breathing at rest. The geometrical fractal dimension is extracted from the pressure–volume curves and a power-law behavior is observed in the data. The power-law model coefficients are identified from the three sets and the results show that significant differences are present between the groups. This conclusion supports the idea that the respiratory system changes with disease in terms of airway geometry, tissue parameters, leading in turn to variations in the fractal dimension of the respiratory tree and its dynamics.

A theoretical study on modelling the respiratory tract with ladder networks by means of intrinsic fractal geometry

Fractional order modeling of biological systems has received significant interest in the research community. Since the fractal geometry is characterized by a recurrent structure, the self-similar branching arrangement of the airways makes the respiratory system an ideal candidate for the application of fractional calculus theory. To demonstrate the link between the recurrence of the respiratory tree and the appearance of a fractional-order model, we develop an anatomically consistent representation of the respiratory system. This model is capable of simulating the mechanical properties of the lungs and we compare the model output with in vivo measurements of the respiratory input impedance collected in 20 healthy subjects. This paper provides further proof of the underlying fractal geometry of the human lungs, and the consequent appearance of constant-phase behavior in the total respiratory impedance.

In-shoe plantar pressures and ground reaction forces during overweight adults' overground walking

Purpose: Because walking is highly recommended for prevention and treatment of obesity and some of its biomechanical aspects are not clearly understood for overweight people, we compared the absolute and normalized ground reaction forces (GRF), plantar pressures, and temporal parameters of normal-weight and overweight participants during overground walking. Method: A force plate and an in-shoe pressure system were used to record GRF, plantar pressures (foot divided in 10 regions), and temporal parameters of 17 overweight adults and 17 gender-matched normal-weight adults while walking. Results: With high effect sizes, the overweight participants showed higher absolute medial-lateral and vertical GRF and pressure peaks in the central rearfoot, lateral midfoot, and lateral and central forefoot. However, analyzing normalized (scaled to body weight) data, the overweight participants showed lower vertical and anterior-posterior GRF and lower pressure peaks in the medial rearfoot and hallux, but the lateral forefoot peaks continued to be greater compared with normal-weight participants. Time of occurrence of medial-lateral GRF and pressure peaks in the midfoot occurred later in overweight individuals. Conclusions: The overweight participants adapted their gait pattern to minimize the consequences of the higher vertical and propulsive GRF in their musculoskeletal system. However, they were not able to improve their balance as indicated by medial-lateral GRF. The overweight participants showed higher absolute pressure peaks in 4 out of 10 foot regions. Furthermore, the normalized data suggest that the lateral forefoot in overweight adults was loaded more than the proportion of their extra weight, while the hallux and medial rearfoot were seemingly protected.

Análise da capacidade vital e da máxima capacidade de insuflação: relação com a função bulbar nos doentes com Esclerose Lateral Amiotrófica

Introdução: A Esclerose Lateral Amiotrófica (ELA) é considerada uma das doenças neuromusculares (DNM) com características mais limitantes e fatais, sendo caracterizada por fraqueza muscular progressiva. Objectivo: Analisar a evolução da Capacidade Vital e da Máxima Capacidade Inspiratória em doentes com ELA e a sua relação causal com a função bulbar. Procedimentos: A partir de uma população alvo de 203 pacientes com ELA, foram incluídos no estudo aqueles que tinham entre 2 a 4 testes de função respiratória considerados válidos (CV <2000ml) perfazendo um total de 22 indivíduos. As medidas CV e MCI foram analisadas. Resultados: A CV diminuiu ao longo do tempo (media±desvio padrão no 1ºmomento de avaliação =1779,5±692,3; media±desvio padrão no 4ºmomento de avaliação =1108,6±475,7). O comportamento da MCI foi mais estável ao longo dos 4 momentos de avaliação. Avaliou-se a correlação entre as duas variáveis, destacando-se a relação existente entre as duas nos doentes bulbares (coeficiente = 1). Quando avaliada a diferença entre a CV e a MCI, verificamos que o nível de significância no grupo (n=22) aumentou ao longo do tempo. Ao comparamos esta diferença por subgrupos, registou-se uma diferença significativa apenas nos doentes bulbares (1ºmomento – p=0,008 e último momento de avaliação – p 0). Conclusão: Nos doentes com disfunção bulbar a CV diminui ao longo do tempo. A relação entre MCI e CV é um bom factor preditivo da evolução e prognóstico da doença e de diagnóstico do envolvimento da musculatura bulbar.

Analysis of the Respiratory Dynamics During Normal Breathing by Means of Pseudophase Plots and Pressure–Volume Loops

This paper reports on the analysis of tidal breathing patterns measured during noninvasive forced oscillation lung function tests in six individual groups. The three adult groups were healthy, with prediagnosed chronic obstructive pulmonary disease, and with prediagnosed kyphoscoliosis, respectively. The three children groups were healthy, with prediagnosed asthma, and with prediagnosed cystic fibrosis, respectively. The analysis is applied to the pressure-volume curves and the pseudophase-plane loop by means of the box-counting method, which gives a measure of the area within each loop. The objective was to verify if there exists a link between the area of the loops, power-law patterns, and alterations in the respiratory structure with disease. We obtained statistically significant variations between the data sets corresponding to the six groups of patients, showing also the existence of power-law patterns. Our findings support the idea that the respiratory system changes with disease in terms of airway geometry and tissue parameters, leading, in turn, to variations in the fractal dimension of the respiratory tree and its dynamics.

The influence of gait cadence on the ground reaction forces and plantar pressures during load carriage of young adults

Biomechanical gait parameters—ground reaction forces (GRFs) and plantar pressures—during load carriage of young adults were compared at a low gait cadence and a high gait cadence. Differences between load carriage and normal walking during both gait cadences were also assessed. A force plate and an in-shoe plantar pressure system were used to assess 60 adults while they were walking either normally (unloaded condition) or wearing a backpack (loaded condition) at low (70 steps per minute) and high gait cadences (120 steps per minute). GRF and plantar pressure peaks were scaled to body weight (or body weight plus backpack weight). With medium to high effect sizes we found greater anterior-posterior and vertical GRFs and greater plantar pressure peaks in the rearfoot, forefoot and hallux when the participants walked carrying a backpack at high gait cadences compared to walking at low gait cadences. Differences between loaded and unloaded conditions in both gait cadences were also observed.