Influence of emphysema distribution on pulmonary function parameters in COPD patients

Objective: To evaluate the impact that the distribution of emphysema has on clinical and functional severity in patients with COPD. Methods: The distribution of the emphysema was analyzed in COPD patients, who were classified according to a 5-point visual classification system of lung CT findings. We assessed the influence of emphysema distribution type on the clinical and functional presentation of COPD. We also evaluated hypoxemia after the six-minute walk test (6MWT) and determined the six-minute walk distance (6MWD). Results: Eighty-six patients were included. The mean age was 65.2 ± 12.2 years, 91.9% were male, and all but one were smokers (mean smoking history, 62.7 ± 38.4 pack-years). The emphysema distribution was categorized as obviously upper lung-predominant (type 1), in 36.0% of the patients; slightly upper lung-predominant (type 2), in 25.6%; homogeneous between the upper and lower lung (type 3), in 16.3%; and slightly lower lung-predominant (type 4), in 22.1%. Type 2 emphysema distribution was associated with lower FEV1 , FVC, FEV1 /FVC ratio, and DLCO. In comparison with the type 1 patients, the type 4 patients were more likely to have an FEV1 < 65% of the predicted value (OR = 6.91, 95% CI: 1.43-33.45; p = 0.016), a 6MWD < 350 m (OR = 6.36, 95% CI: 1.26-32.18; p = 0.025), and post-6MWT hypoxemia (OR = 32.66, 95% CI: 3.26-326.84; p = 0.003). The type 3 patients had a higher RV/TLC ratio, although the difference was not significant. Conclusions: The severity of COPD appears to be greater in type 4 patients, and type 3 patients tend to have greater hyperinflation. The distribution of emphysema could have a major impact on functional parameters and should be considered in the evaluation of COPD patients.

Functional Capacity of Patients with Pacemaker Due to Isolated Congenital Atrioventricular Block

Background:Isolated congenital atrioventricular block (CAVB) is a rare condition with multiple clinical outcomes. Ventricular remodeling can occur in approximately 10% of the patients after pacemaker (PM) implantation.Objectives:To assess the functional capacity of children and young adults with isolated CAVB and chronic pacing of the right ventricle (RV) and evaluate its correlation with predictors of ventricular remodeling.Methods:This cross-sectional study used a cohort of patients with isolated CAVB and RV pacing for over a year. The subjects underwent clinical and echocardiographic evaluation. Functional capacity was assessed using the six-minute walk test. Chi-square test, Fisher's exact test, and Pearson correlation coefficient were used, considering a significance level of 5%.Results:A total of 61 individuals were evaluated between March 2010 and December 2013, of which 67.2% were women, aged between 7 and 41 years, who were using PMs for 13.5 ± 6.3 years. The percentage of ventricular pacing was 97.9 ± 4.1%, and the duration of the paced QRS complex was 153.7 ± 19.1 ms. Majority of the subjects (95.1%) were asymptomatic and did not use any medication. The mean distance walked was 546.9 ± 76.2 meters and was strongly correlated with the predicted distance (r = 0.907, p = 0.001) but not with risk factors for ventricular remodeling. (Arq Bras Cardiol. 2014; [online].ahead print, PP.0-0)Conclusions:The functional capacity of isolated CAVB patients with chronic RV pacing was satisfactory but did not correlate with risk factors for ventricular remodeling.

Alternatives to Aerobic Exercise Prescription in Patients with Chronic Heart Failure

Background: Exercise is essential for patients with heart failure as it leads to a reduction in morbidity and mortality as well as improved functional capacity and oxygen uptake (v̇O2). However, the need for an experienced physiologist and the cost of the exam may render the cardiopulmonary exercise test (CPET) unfeasible. Thus, the six-minute walk test (6MWT) and step test (ST) may be alternatives for exercise prescription. Objective: The aim was to correlate heart rate (HR) during the 6MWT and ST with HR at the anaerobic threshold (HRAT) and peak HR (HRP) obtained on the CPET. Methods: Eighty-three patients (58 ± 11 years) with heart failure (NYHA class II) were included and all subjects had optimized medication for at least 3 months. Evaluations involved CPET (v̇O2, HRAT, HRP), 6MWT (HR6MWT) and ST (HRST). Results: The participants exhibited severe ventricular dysfunction (ejection fraction: 31 ± 7%) and low peak v̇O2 (15.2 ± 3.1 mL.kg-1.min-1). HRP (113 ± 19 bpm) was higher than HRAT (92 ± 14 bpm; p < 0.05) and HR6MWT (94 ± 13 bpm; p < 0.05). No significant difference was found between HRP and HRST. Moreover, a strong correlation was found between HRAT and HR6MWT (r = 0.81; p < 0.0001), and between HRP and HRST (r = 0.89; p < 0.0001). Conclusion: These findings suggest that, in the absence of CPET, exercise prescription can be performed by use of 6MWT and ST, based on HR6MWT and HRST

Interventions to achieve long-term weight loss in obese older people: A systematic review and meta-analysis

Purpose: the prevalence of obesity is rapidly increasing in older adults. Information is required about what interventions are effective in reducing obesity and influencing health outcomes in this age group. Design: systematic review and meta-analysis. Data sources: thirteen databases were searched, earliest date 1966 to December 2008, including Medline, CINAHL, PsycINFO, the Cochrane database and EMBASE. Study selection: we included studies with participants�۪ mean age 60 years and mean body mass index 30 kg/m2, with outcomes at a minimum of 1 year. Data were independently extracted by two reviewers and differences resolved by consensus. Data extraction: nine eligible trials were included. Study interventions targeted diet, physical activity and mixed approaches. Populations included patients with coronary artery disease, diabetes mellitus and osteoarthritis. Results: meta-analysis (seven studies) demonstrated a modest but significant weight loss of 3.0 kg [95% confidence interval (CI) 5.1���0.9] at 1 year. Total cholesterol (four studies) did not show a significant change: ���0.36 mmol/l (95% CI ���0.75 to 0.04). There was no significant change in high-density lipoprotein, low-density lipoprotein or triglycerides. In one study, recurrence of hypertension or cardiovascular events was significantly reduced (hazard ratio 0.65, 95% CI 0.50���0.85). Six-minute walk test did not significantly change in one study. Health-related quality of life significantly improved in one study but did not improve in a second study. Conclusions: although modest weight reductions were observed, there is a lack of high-quality evidence to support the efficacy of weight loss programmes in older people. ��Keywords: obesity, older, weight loss, meta-analysis, elderly, systematic review

Interventions to achieve long-term weight loss in obese older people

Purpose: the prevalence of obesity is rapidly increasing in older adults. Information is required about what interventions are effective in reducing obesity and influencing health outcomes in this age group. Design: systematic review and meta-analysis. Data sources: thirteen databases were searched, earliest date 1966 to December 2008, including Medline, CINAHL, PsycINFO, the Cochrane database and EMBASE. Study selection: we included studies with participants�۪ mean age 60 years and mean body mass index 30 kg/m2, with outcomes at a minimum of 1 year. Data were independently extracted by two reviewers and differences resolved by consensus. Data extraction: nine eligible trials were included. Study interventions targeted diet, physical activity and mixed approaches. Populations included patients with coronary artery disease, diabetes mellitus and osteoarthritis. Results: meta-analysis (seven studies) demonstrated a modest but significant weight loss of 3.0 kg [95% confidence interval (CI) 5.1���0.9] at 1 year. Total cholesterol (four studies) did not show a significant change: ���0.36 mmol/l (95% CI ���0.75 to 0.04). There was no significant change in high-density lipoprotein, low-density lipoprotein or triglycerides. In one study, recurrence of hypertension or cardiovascular events was significantly reduced (hazard ratio 0.65, 95% CI 0.50���0.85). Six-minute walk test did not significantly change in one study. Health-related quality of life significantly improved in one study but did not improve in a second study. Conclusions: although modest weight reductions were observed, there is a lack of high-quality evidence to support the efficacy of weight loss programmes in older people. ��Keywords: obesity, older, weight loss, meta-analysis, elderly, systematic review��

Bosentan and/or Sildenafil for non-operable chronic thromboembolic pulmonary hypertension

Objectives: To evaluate outcome of patients treated "off-label" by bosentan and/or sildenafil for chronic thromboembolic pulmonary hypertension (CTEPH). Patients and methods: Since 2003, 18 patients (mean age 69 ± 11 years) have been treated with bosentan and/or sildenafil for CTEPH (mean pulmonary arterial resistance 8.1 ± 3.7 U Wood) in Lausanne University Hospital, with a follow-up of at least 12 months. Sixteen of them were inoperable because of distal disease and/or age or significant co-morbidities and 2 had persistent or recurrent pulmonary hypertension despite surgery. Efficacy of treatment was evaluated by comparison of New York Heart Association functional class (NYHA), six-minute walk test (6-MWT) and serum levels of N-terminal-pro brain natriuretic peptide (NT pro-BNP) at baseline (T0) and at 12 months (T12). Wilcoxon rank test was used for statistics. Results: At T0, median NYHA class was III (range II-IV), 6-MWT was 348 meters (5 and 95 centiles:0, 539) and NT pro-BNP was 387 mmol/l (58, 3508). At T12, 11 patients were treated with bosentan, 5 with sildenafil, 1 with inhaled Iloprost (because of failure of the two other treatments) and 1 with a combination of sildenafil and Iloprost. NYHA had improved in 10 patients, remained stable in 7 and worsened in 1 (median decrease 0.5 (-2; 0.2) p = 0.013). Six-MWT improved by a median of 15 meters (-142, +270) (p = 0.047) and NT pro-BNP decreased by a median of 65 mmol/l (-2988, +187) (p = n.s.). Among the 10 patients with a follow-up of 2 years or longer, two thirds remained stable and one third had worsened at 24 month. Treatments were well tolerated and only one patient had significant side effects (cutaneous reaction to bosentan) necessitating a switch to another treatment. Conclusion: In agreement with published data, bosentan and sildenafil improved functional status (NYHA, 6-MWT) and haemodynamics (NT pro BNP) in our patients with inoperable CTEPH. However these medications should not be used as substitute for surgery when the latter is applicable.

Efficacy of a hip flexion assist orthosis in adults with hemiparesis after stroke.

Background During gait, the hip flexors generate 40% of the total power. Nevertheless, no device has been tested extensively for clinical purposes to cope with weakness in the hip flexors in patients with stroke. Objective The purpose of this study was to assess the efficacy and safety of a newly developed hip flexion assist orthosis in adult patients with hemiparesis after stroke. Design The study used a prospective, randomized, before-after trial design. The inclusion criteria were hemiparesis resulting from stroke (onset ≥8 weeks); ability to walk, even if with assistance; and hip flexion weakness (Medical Research Council Scale score ≤4).¦METHODS: /b> The main outcome measures were the 10-Meter Walk Test and the Six-Minute Walk Test. Patients also were evaluated with the Trunk Control Test, the Functional Ambulation Categories, the Motricity Index, and hip flexor strength on the Medical Research Council Scale. Sixty-two survivors of stroke were tested in random order with and without the orthosis. Any adverse event associated with its use was recorded.¦RESULTS: /b> Both the Six-Minute Walk Test and the 10-Meter Walk Test scores improved with the use of the orthosis. A significant negative correlation was found for improvement between scores on the 2 main outcome measures with the orthosis and the Functional Ambulation Categories scores. The improvement in Six-Minute Walk Test scores with the orthosis was related inversely to hip flexor strength.¦CONCLUSIONS: /b> The data showed that the use of a hip flexion assist orthosis can improve gait in patients with poststroke hemiparesis, particularly those with more severe walking impairment.

Diastolic function is associated with quality of life and exercise capacity in stable heart failure patients with reduced ejection fraction

Exercise capacity and quality of life (QOL) are important outcome predictors in patients with systolic heart failure (HF), independent of left ventricular (LV) ejection fraction (LVEF). LV diastolic function has been shown to be a better predictor of aerobic exercise capacity in patients with systolic dysfunction and a New York Heart Association (NYHA) classification ≥II. We hypothesized that the currently used index of diastolic function E/e' is associated with exercise capacity and QOL, even in optimally treated HF patients with reduced LVEF. This prospective study included 44 consecutive patients aged 55±11 years (27 men and 17 women), with LVEF<0.50 and NYHA functional class I-III, receiving optimal pharmacological treatment and in a stable clinical condition, as shown by the absence of dyspnea exacerbation for at least 3 months. All patients had conventional transthoracic echocardiography and answered the Minnesota Living with HF Questionnaire, followed by the 6-min walk test (6MWT). In a multivariable model with 6MWT as the dependent variable, age and E/e' explained 27% of the walked distance in 6MWT (P=0.002; multivariate regression analysis). No association was found between walk distance and LVEF or mitral annulus systolic velocity. Only normalized left atrium volume, a sensitive index of diastolic function, was associated with decreased QOL. Despite the small number of patients included, this study offers evidence that diastolic function is associated with physical capacity and QOL and should be considered along with ejection fraction in patients with compensated systolic HF.

Impact of training at ventilatory threshold on cardiopulmonary and functional capacity in overweight patients with chronic kidney disease

INTRODUCTION: Chronic kidney disease (CKD) and obesity are both associated with reduced physical capacity. The potential benefit of aerobic training on physical capacity has been recognized. The exercise intensity can be established using different methods mostly subjective or indirect. Ventilatory threshold (VT) is a direct and objective method that allows prescribing exercise intensity according to individual capacity. OBJECTIVES: To evaluate the impact of aerobic training at VT intensity on cardiopulmonary and functional capacities in CKD patients with excess of body weight. METHODS: Ten CKD patients (eight men, 49.7 ± 10.1 years; BMI 30.4 ± 3.5 kg/m², creatinine clearance 39.4 ± 9.8 mL/min/1.73 m²) underwent training on a treadmill three times per week during 12 weeks. Cardiopulmonary capacity (ergoespirometry), functional capacity and clinical parameters were evaluated. RESULTS: At the end of 12 weeks, VO2PEAK increased by 20%, and the speed at VO2PEAK increased by 16%. The training resulted in improvement in functional capacity tests, such as six-minute walk test (9.2%), two-minute step test (20.3%), arm curl test (16.3%), sit and stand test (35.7%), and time up and go test (15.3%). In addition, a decrease in systolic and diastolic blood pressures was observed despite no change in body weight, sodium intake and antihypertensive medication. CONCLUSION: Aerobic exercise performed at VT intensity improved cardipulmonary and functional capacities of overweight CKD patients. Additional benefit on blood pressure was observed. These results suggest that VT can be effectively applied for prescribing exercise intensity in this particular group of patients.

Protocolo para la evaluación fisioterapéutica inicial y final de pacientes ambulatorios que ingresan a programas de rehabilitación cardiaca fase II

se hace necesario proponer un protocolo con el que se pretende dar las pautas para la valoración fisioterapéutica inicial y final del paciente ambulatorio que ingresa a un programa de rehabilitación cardiaca Fase II, ésta incluye la aplicación de pruebas para evaluar la capacidad funcional, la calidad de vida y los factores de riesgo cardiovascular. Esta evaluación, facilitará el planteamiento de objetivos y la implementación deestrategias de intervención de acuerdo a las necesidades encontradas, así como permitir el seguimiento de los resultados alcanzados. Este análisis puede servir comoherramienta de motivación para el paciente porque es un modo de resumir susprogresos, poniendo de manifiesto tanto aquellas áreas en las que el paciente hahecho un buen trabajo, como aquellas en las que el paciente debe realizar suscambios adicionales para acercarse más al objetivo.

Cardiovascular fitness and cardiovascular risk factors among obese men and women aged 58 years and older, in Portugal

Background: A better physical fitness may have survival advantages in adults. Aim: To analyze the relationship between cardiorespiratory fitness and cardiovascular risk factors among obese subjects aged 58 years and older. Material and Methods: Cardiorespiratory fitness using the six-minute walk test, body composition by dual-energy x-ray absorptiometry and blood pressure were measured in a non-representative sample of 76 obese Portuguese subjects aged 58 to 87 years (55 women). Participants were stratified in tertiles of walking capacity according to the six-minute walk test. Results: Six minutes walk test results were negatively correlated with percentage body fat (r = -0.28; p = 0.012) and systolic blood pressure (r = -0.23; p = 0.045). Participants located in the lowest tertile for the six minutes walk test had an odds ratio of 4.34 (95% confidence intervals: 1.02-18.43) for elevated blood pressure. Conclusions: A lower six minutes walk test result is associated with a higher risk for high blood pressure. (Rev Med Chile 2012; 140: 1164-1169).

Step Counting and Energy Expenditure Estimation in Patients With Chronic Obstructive Pulmonary Disease and Healthy Elderly: Accuracy of 2 Motion Sensors

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Ánálise da capacidade funcional e da distribuição regional da ventilação pulmonar em pacientes com doença de chagas

INTRODUCTION: Cardiac and pulmonary manifestations of the Chagas disease (CD) affect between 20-30% of the infected subjects. The chronic Chagas cardiomyopathy (CCC) has some peculiarities such as arrhythmias and, especially heart failure (HF) and is potentially lethal due to left ventricular dysfunction. How respiratory disorders, patients get progressive loss of functional capacity, which contributes to a poor quality of life related to disease. Measurements of lung volume by the movement of the chest wall surface are an alternative evaluation of lung function and kinematics of complex thoracoabdominal for these patients. OBJECTIVE: evaluate the kinematics of the thoracoabdominal complex through the regional pulmonary volumes and to correlate with functional evaluation of the cardiorrespiratory system in patients with Chagas disease at rest. MATERIALS AND METHODS: a cross-section study with 42 subjects had been divided in 3 groups, 15 composed for patients with CCC, 12 patients with HF of different etiologies and 15 healthful presented control group. An optoelectronic plethysmography (POE), Minnesota questionnaire, six minute walk test, spirometer and manovacuometer was used. RESULTS: It was observed in the 6MWT where group CRL presented greater distance 464,93±44,63m versus Group HF with 399,58± 32,1m (p=0,005) and group CCC 404±68,24m (p=0,015), both the groups presented difference statistics with regard to Group CRL. In the manovacuometer 54,59±19,98; of the group CCC and 42,11±13,52 of group IC found group CRL presented 81,31±15,25 of the predicted versus, presenting in relation to group CRL. In the POE it observed a major contribution in abdominal compartment in patients with IC if compared like CCC and control groups. On the basis of the questionnaire of quality of life of Minessota, verified a low one groups CCC and IC 43,2±15,2 and 44,4±13,1, respectively (p<0,05) when compared with the control group (19,6±17,31). CONCLUSION: it seems that the patients with CCC possess same functional and respiratory characteristics, observed for the POE, 6MWT, manovacuometer and spirometer to the patients of group HF, being able to consider similar interventions for this complementary group as therapeutical of this neglected disease

Efeitos do treinamento muscular inspiratório domiciliar sobre a atividade eletromiográfica dos músculos respiratórios em asmáticos: estudo piloto

Asthma treatment aims to achieve and maintain the control of the disease for prolonged periods. Inspiratory muscle training (IMT) may be an alternative in the care of patients with asthma, and it is used as a complementary therapy to the pharmacological treatment. Thus, the aim of this study was to investigate the effects of a domiciliary program of IMT on the electromyographic activity of the respiratory muscles in adults with asthma. This is a clinical trial in which ten adults with asthma and ten healthy adults were randomized into two groups (control and training). The electrical activity of inspiratory muscles (sternocleidomastoid (ECM) and diaphragm) was obtained by a surface electromyography. Furthermore, we assessed lung function (spirometry), maximal inspiratory pressure - MIP - (manometer). The functional capacity was evaluated by six minute walk test. Participants were assessed before and after the IMT protocol of 6 weeks with POWERbreathe® device. The training and the control groups underwent IMT with 50% and 15 % of MIP, respectively. The sample data were analyzed using SPSS 20.0, attributing significance of 5 %. Were used t test, ANOVA one way and Pearson correlation. It was observed an increase in MIP, after IMT, in both training groups and in healthy sham group (P < 0.05), which was accompanied by a significant increase in ECM activity during MIP in healthy training group (1488 %) and in asthma training group (ATG) (1186.4%). The ATG also showed a significant increase in diaphragm activity in basal respiration (48.5%). Functional capacity increased significantly in the asthma sham group (26.5 m) and in the asthma training group (45.2 m). These findings suggest that IMT promoted clinical improvements in all groups, especially the ATG, which makes it an important complementary treatment for patients with asthma

Comparação das respostas fisiológicas entre diferentes testes funcionais em obesos

obesity affects rightly functional capacity diminishing the cardiovascular system efficiency and oxygen uptake (VO2). Field tests, such as, Incremental Shuttle Walking Test (ISWT) and Six Minute Walk Test (6MWT) has been employed as alternative of Cardiopulmonary Exercise Test (CPX), to functional assessing for conditions which transport of oxygen to peripheral is diminished. Nevertheless, the knowing about metabolic variables response in real time and it comparing among different maximal and submaximal tests in obese is absent. Aim: to compare cardiopulmonary, metabolic response during CPX, ISWT and 6MWT and to analyse it influence of adiposity markers in obese. Material e Method: crosssectional, prospective study. Obese included if: (BMI>30Kg/m2; FVC>80%), were assessed as clinical, anthropometric (BMI, body adiposity index-BAI, waist-WC, hip- HC and neck-NC circumferences) and spirometry (forced vital capacity-FVC, Forced expiratory volume-1°second-FEV1, maximal voluntary ventilation-MVV) variables. Obese performed the sequence of tests: CPX, ISWT and 6MWT. Throughout tests was assessed breath-by-breath by telemetry system (Cortex-Biophysik-Metamax3B) variables; oxygen uptake on peak of activity (VO2peak); carbon dioxide production (VCO2); Volume Expiratory (VE); ventilatory equivalents for VO2 (VE/VO2) and CO2 (VE/VCO2); respiratory exchange rate (RER) and perceived effort-Borg6-20). Results: 15 obese (10women) 39.4+10.1years, normal spirometry (%CVF=93.7+9.7) finished all test. They have BMI (43.5+6.6kg/m2) and different as %adiposity (BAI=50.0+10.5% and 48.8+16.9% respectively women and men). Difference of VO2ml/kg/min and %VO2 were finding between CPX (18.6+4.0) and 6MWT (13.2+2.5) but not between ISWT (15.4+2.9). Agreement was found for ISWT and CPX on VO2Peak (3.2ml/kg/min; 95%; IC-3.0 9.4) and %VO2 (16.4%). VCO2(l/min) confirms similarity in production for CPX (2.3+1.0) and ISWT (1.7+0.7) and difference for 6MWT (1.4+0.6). WC explains more the response of CPX and ISWT than other adiposity markers. Adiposity diminishes 3.2% duration of CPX. Conclusion: ISWT promotes similar metabolic and cardiovascular response than CPX in obese. It suggesting that ISWT could be useful and reliable to assess oxygen uptake and functional capacity in obese