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Nº de abstracts = 44

Modificado em23 Fevereiro 2012

 

Relationship of emphysema and airway disease assessed by CT to exercise capacity in COPD.

Diaz AA, Bartholmai B, San José Estépar R, Ross J, Matsuoka S, Yamashiro T, Hatabu H, Reilly JJ, Silverman EK, Washko GR.: Respiratory medicine, 2010 104(8):1145-51. Pulmonary and Critical Care Medicine Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston MA, USA. Este endereço de e-mail está protegido de spam bots, pelo que necessita do Javascript activado para o visualizar OBJECTIVE: To assess the association of emphysema and airway disease assessed by volumetric computed tomography (CT) with exercise capacity in subjects with chronic obstructive pulmonary disease (COPD). METHODS: We studied 93 subjects with COPD (Forced Expiratory Volume in 1 s [FEV(1)] %predicted mean +/- SD 57.1 +/- 24.3%, female gender = 40) enrolled in the Lung Tissue Research Consortium. Emphysema was defined as percentage of low attenuation areas less than a threshold of -950 Hounsfield units (%LAA-950) on CT scan. The wall area percentage (WA%) of the 3rd to 6th generations of the apical bronchus of right upper lobe (RB1) were analyzed. The 6-min walk distance (6MWD) test was used as a measure of exercise capacity. RESULTS: The 6MWD was inversely associated with %LAA-950 (r = -0.53, p < 0.0001) and with the WA% of 6th generation of RB1 only (r = -0.28, p = 0.009). In a multivariate regression model including CT indices of emphysema and airway disease that were adjusted for demographic and physiologic variables as well as brand of CT scanner, only the %LAA-950 remained significantly associated with exercise performance. Holding other covariates fixed, this model showed that a 10% increase of CT emphysema reduced the distance walked in 6 min 28.6 m (95% Confidence Interval = -51.2, -6.0, p = 0.01). CONCLUSION: These results suggest that the extent of emphysema but not airway disease measured by volumetric CT contributes independently to exercise limitation in subjects with COPD.


Changes in Exhaled Nitric Oxide Related to Estrogen and Progesterone During the Menstrual Cycle.

Piush J. Mandhane, Steven E. Hanna, Mark D. Inman, Joanne M. Duncan, Justina M. Greene, Hong-Yu Wang, Malcolm R. Sears.

Background: Significant changes in asthma and atopy occur through the menstrual cycle. We hypothesized that characteristics of asthma (symptoms, exhaled nitric oxide [eNO] as a marker of airway inflammation, pulmonary function and atopy) vary through the menstrual cycle in relation to changes in estrogen or progesterone, and that this variation is attenuated in women using oral contraception (OC). Methods: Seventeen women with asthma were studied over their menstrual cycle with daily measurements of symptoms, eNO, spirometry, 17β-estradiol and progesterone, and alternate day allergy skin prick tests (SPT). Of 534 potential daily visits, 526 (98.5%) were completed. Results: Individuals not using OC (n = 8) had higher mean eNO levels (48.2ppb, 95%CI: 43.1, 53.3) than women using OC (27.0ppb, 95%CI: 24.2, 29.7; p ≤ 0.005). Among women not using OC, a 10 pmol/L increase in 17β-estradiol levels was associated with a 15.2 ppm decrease in eNO level (95%CI −23.4, −7.0; p < 0.005). In contrast, an increase in progesterone of 0.5 nmol/L was significantly associated with a 10.0ppb increase in eNO (95%CI: 1.2, 18.7; p ≤ 0.05). Consistent and significant results were found for 17β-estradiol and progesterone and SPT. There were no significant associations between sex hormones and markers of asthma among women using OC. Conclusion: During natural menstrual cycles, increases in estrogen levels were associated with decreased eNO levels while increases in progesterone levels were associated with increased eNO levels and SPT wheal size. These effects were not observed among women using oral contraception.

 

Effect of adjunct fluticasone propionate on airway physiology during rest and exercise in COPD. Guenette JA, Raghavan N, Harris-McAllister V, Preston ME, Webb KA, O'Donnell DE.

Respiratory medicine

 

105(12):1836-45, 2012 RATIONALE: Combination therapy with corticosteroid and long-acting ß(2)-agonists (LABA) in a single inhaler is associated with superior effects on airway function and exercise performance in COPD compared with LABA monotherapy. The physiological effects of adding inhaled corticosteroid monotherapy to maintenance bronchodilator therapy (long-acting anticholinergics and LABA singly or in combination) in COPD are unknown.

METHODS: This was a randomized, double-blind, placebo-controlled, crossover study (NCT00387036) to compare the effects of inhaled fluticasone propionate 500 µg (FP500) twice-daily and placebo (PLA) on airway function during rest and exercise, measured during constant work rate cycle exercise at 75% of maximum incremental cycle work rate, in 17 patients with COPD (FEV(1) = 70% predicted).

RESULTS: After treatment with FP500 compared to PLA, there were significant increases in post-dose measurements of FEV(1) (+115 mL, P = 0.006) and the FEV(1)/FVC ratio (+2.5%, P = 0.017), along with decreases in plethysmographic residual volume (-0.32L; P = 0.031), functional residual capacity (-0.30L, P = 0.033), and total lung capacity (-0.30L, P = 0.027) but no changes in vital capacity or inspiratory capacity (IC). Post-treatment comparisons demonstrated a significant improvement in endurance time by 188 ± 362 s with FP500 (P = 0.047) with no concomitant increase in dyspnea intensity. End-inspiratory and end-expiratory lung volumes were reduced at rest and throughout exercise with FP500 compared with PLA (P < 0.05).

CONCLUSION: Inhaled FP500 monotherapy was associated with consistent and clinically important improvements in FEV(1), static lung volumes, dynamic operating lung volumes, and exercise endurance when added to established maintenance long-acting bronchodilator therapy in patients with moderate to severe COPD.

 

 

 

Association of daily physical activity volume and intensity with COPD severity. Jehn M, Schmidt-Trucksäss A, Meyer A, Schindler C, Tamm M, Stolz D

201112

Respiratory medicine, 105(12):1846-52,

PURPOSE: The purpose of this study was to assess whether daily walking activity is indicative of disease severity in patients with COPD.

METHODS: Daily activity was measured by accelerometry in 107 COPD: GOLD II (N=28), GOLD III (N=51), and GOLD IV (N=25). Steps per day and times (min/day) spent passively, actively, walking (WLK, 0-5km/h), and fast walking (FWLK, >5km/h) were analyzed. Total walking time (TWT) was computed.

RESULTS: Times spent WLK (P=0.031), FWLK (P=0.001), TWT (P=0.021), and steps per day (P=0.013) differed significantly between GOLD stages. There was a significant negative correlation between TWK and GOLD stage (R=-0.35; P<0.0001), BODE index (R=-0.58; P<0.0001), and MMRC dyspnea scale (R=-0.65; P<0.0001). Logistic regression analysis showed that both TWT and FWLK were independently and significantly associated with BODE index =6 (P=0.029 and P=0.040, respectively). The corresponding AUC-value with 95% CI for TWT was 0.80 (95% CI: 0.70 to 0.90) and 0.87 (95% CI: 0.81 to 0.94) for FWLK. The corresponding optimal cut-off value for TWT was 33.3min/day (sensitivity: 86%; specificity 70%) and FWLK was 0.10min/day (sensitivity: 93%; specificity 76%).

CONCLUSION: Daily walking activity, in particular walking intensity, is significant predictor of disease severity in patients with COPD. Objective measures of habitual activity might provide additive value in assessing the likelihood of poor prognosis in this patient cohort.

 

 

Pulmonary function, exercise capacity and physical activity participation in adults following burn. Willis CE, Grisbrook TL, Elliott CM, Wood FM, Wallman KE, Reid SL

37(8):1326-33, 2011 DezPURPOSE: To determine the relationship between pulmonary function, aerobic exercise capacity and physical activity participation in adults following burn.

METHODS: Eight burn injured males aged 20-55 years (%TBSA 33.3±18.7, 5.1 years±1.8 post injury), and 30 healthy adult controls participated. Pulmonary function was assessed during rest via spirometry. A graded exercise test measuring peak oxygen consumption (VO(2peak)) and oxygen saturation (S(p)O(2)) was conducted, and physical activity was assessed via the Older Adult Exercise Status Inventory (OA-EI).

RESULTS: No significant correlation was observed between resting pulmonary function, aerobic capacity and physical activity participation for burn injured patients or controls. Two burn injured patients presented with obstructive ventilatory defects, and one displayed a restrictive ventilatory defect. Burn injured patients had a significantly lower VO(2peak) (p9 METs (p=0.01), and significantly greater participation in work-related activity (p=0.038), than healthy controls.

CONCLUSION: Compromised lung function, decreased aerobic capacity and reduced participation in leisure-related physical activity may still exist in some adults, even up to 5 years post injury. Limitations and long term outcomes of cardiopulmonary function and physical fitness need to be considered in the prescription of exercise rehabilitation programmes following burn.

 

 

 

Respir Physiol Neurobiol
Issue: 2-3, 127-8
Agostoni P et, al.

 

 

 


Improvement of heart rate variability after exercise training and its predictors in COPD. Camillo CA, Laburu Vde M, Gonçalves NS, Cavalheri V, Tomasi FP, Hernandes NA, Ramos D, Marquez Vanderlei LC, Cipulo Ramos EM, Probst VS, Pitta F. : 201107 105(7):1054-62.

BACKGROUND: Current literature lacks solid evidence on the improvement of heart rate variability (HRV) after exercise training in patients with COPD. OBJECTIVES: We aimed to investigate changes in HRV after two exercise training programs in patients with COPD and to investigate the determinants of these eventual changes. METHODS: Forty patients with COPD (FEV(1) 39±13%pred) were randomized into high (n=20) or low (n=20) intensity exercise training (3-month duration), and had their HRV assessed by the head-up tilt test before and after either protocols. Baseline spirometry, level of daily physical activity, exercise capacity, body composition, functional status, health-related quality of life and muscle force were also assessed to investigate the determinants of improvement in HRV after the training program. RESULTS: There was a significant improvement in HRV only after the high-intensity protocol (pre versus post; SDNN 29±15ms versus 36±19ms; rMSSD 22±14ms versus 28±22ms; p<0.05 for both). Higher values of biceps brachialis strength, time spent walking in daily life and SDNN at baseline were determinants of improvement in HRV after the training program. CONCLUSIONS: High-intensity exercise training improves HRV at rest and during orthostatic stimulus in patients with COPD. Better baseline total HRV, muscle force and daily physical activity level are predictors of HRV improvements after the training program.

 

The Asthmatic Athlete: Inhaled Beta-2 Agonists, Sport Performance, and Doping. Clinical Journal of Sport Medicine: January 2011 - Volume 21 - Issue 1 - pp 46-50

 

Changes in Exhaled Nitric Oxide Related to Estrogen and Progesterone During the Menstrual Cycle.

Piush J. Mandhane, Steven E. Hanna, Mark D. Inman, Joanne M. Duncan, Justina M. Greene, Hong-Yu Wang, Malcolm R. Sears.

Background: Significant changes in asthma and atopy occur through the menstrual cycle. We hypothesized that characteristics of asthma (symptoms, exhaled nitric oxide [eNO] as a marker of airway inflammation, pulmonary function and atopy) vary through the menstrual cycle in relation to changes in estrogen or progesterone, and that this variation is attenuated in women using oral contraception (OC). Methods: Seventeen women with asthma were studied over their menstrual cycle with daily measurements of symptoms, eNO, spirometry, 17β-estradiol and progesterone, and alternate day allergy skin prick tests (SPT). Of 534 potential daily visits, 526 (98.5%) were completed. Results: Individuals not using OC (n = 8) had higher mean eNO levels (48.2ppb, 95%CI: 43.1, 53.3) than women using OC (27.0ppb, 95%CI: 24.2, 29.7; p ≤ 0.005). Among women not using OC, a 10 pmol/L increase in 17β-estradiol levels was associated with a 15.2 ppm decrease in eNO level (95%CI −23.4, −7.0; p < 0.005). In contrast, an increase in progesterone of 0.5 nmol/L was significantly associated with a 10.0ppb increase in eNO (95%CI: 1.2, 18.7; p ≤ 0.05). Consistent and significant results were found for 17β-estradiol and progesterone and SPT. There were no significant associations between sex hormones and markers of asthma among women using OC. Conclusion: During natural menstrual cycles, increases in estrogen levels were associated with decreased eNO levels while increases in progesterone levels were associated with increased eNO levels and SPT wheal size. These effects were not observed among women using oral contraception.

 

Inspiratory flow resistive loading improves respiratory muscle function and endurance capacity in recreational runners

Mickleborough TD, Nichols T, Lindley MR, Chatham K, Ionescu AA.: Scandinavian journal of medicine & science in sports, 2010, 20(3):458-68. Department of Kinesiology, Indiana University, Bloomington, Indiana 47401, USA.

The purpose of this study was to assess the efficacy of inspiratory flow resistive loading (IFRL) on respiratory muscle function, exercise performance and cardiopulmonary and metabolic responses to exercise. Twenty-four recreational road runners (12 male) were randomly assigned from each gender into an IFRL group (n=8) and sham-IFRL group (n=8), which performed IFRL for 6 weeks, or a control group (n=8). Strength (+43.9%Delta), endurance (+26.6%Delta), maximum power output (+41.9%Delta) and work capacity (+38.5%Delta) of the inspiratory muscles were significantly increased (P<0.05) at rest following the study period in IFRL group only. In addition, ventilation (-25.7%Delta), oxygen consumption (-13.3%Delta), breathing frequency (-11.9%Delta), tidal volume (-16.0%Delta), heart rate (HR) (-13.1%Delta), blood lactate concentration (-38.9%Delta) and the perceptual response (-33.5%Delta) to constant workload exercise were significantly attenuated (P<0.05), concomitant with a significant improvement (P<0.05) in endurance exercise capacity (+16.4%Delta) during a treadmill run set at 80% VO2max in IFRL group only. These data suggest that IFRL can alter breathing mechanics, attenuate the oxygen cost, ventilation, HR, blood lactate and the perceptual response during constant workload exercise and improve endurance exercise performance in recreational runners.

 

 

Swimming-induced pulmonary edema in triathletes

Miller CC, Calder-Becker K, Modave F.: The American journal of emergency medicine, 2010, 28(8):941-6. Department of Biomedical Sciences, Texas Tech University Health Sciences Center at El Paso Paul L. Foster School of Medicine, El Paso, TX 79905, USA.

BACKGROUND: Pulmonary edema related to water immersion has been reported in military trainees and scuba and breath-hold divers, but rarely in the community. To date, no risk factors for this phenomenon have been identified by epidemiological methods. Recently, sporadic reports of swimming-induced pulmonary edema (SIPE) have emerged in the triathlon community. We surveyed the population of a national North American triathlon organization (USA Triathlon) to determine prevalence of and risk factors for symptoms compatible with SIPE. METHODS: We surveyed the population of USA Triathlon through the organization's monthly newsletter distribution channel. We evaluated prevalence of symptoms compatible with pulmonary edema, and then followed up with a case-control study that included additional cases we had identified previously, to identify risk factors for this condition among triathletes. RESULTS: Symptom history compatible with SIPE was identified in 1.4% of the population. Associated factors identified in multivariable analysis included history of hypertension, course length of half-Ironman distance or greater, female gender and use of fish oil supplements. Of the 31 cases reported, only 4 occurred in the absence of any associated factors. CONCLUSIONS: The identification of hypertension and fish oil in particular as risk factors raise questions about the role of cardiac diastolic function in the setting of water-immersion cardiac preload, as well as the hematologic effects of fish oil. Mechanistic studies of these risk factors in a directly observed prospective cohort are indicated.


Sex differences in exercise-induced diaphragmatic fatigue in endurance-trained athletes.

Guenette JA, Romer LM, Querido JS, Chua R, Eves ND, Road JD, McKenzie DC, Sheel AW.: Journal of aAplied Physiology (Bethesda, Md. : 1985).,2010-07 109(1):35-46. School of Human Kinetics, University of British Columbia, Vancouver, British Columbia, Canada.

There is evidence that female athletes may be more susceptible to exercise-induced arterial hypoxemia and expiratory flow limitation and have greater increases in operational lung volumes during exercise relative to men. These pulmonary limitations may ultimately lead to greater levels of diaphragmatic fatigue in women. Accordingly, the purpose of this study was to determine whether there are sex differences in the prevalence and severity of exercise-induced diaphragmatic fatigue in 38 healthy endurance-trained men (n = 19; maximal aerobic capacity = 64.0 +/- 1.9 ml x kg(-1) x min(-1)) and women (n = 19; maximal aerobic capacity = 57.1 +/- 1.5 ml x kg(-1) x min(-1)). Transdiaphragmatic pressure (Pdi) was calculated as the difference between gastric and esophageal pressures. Inspiratory pressure-time products of the diaphragm and esophagus were calculated as the product of breathing frequency and the Pdi and esophageal pressure time integrals, respectively. Cervical magnetic stimulation was used to measure potentiated Pdi twitches (Pdi,tw) before and 10, 30, and 60 min after a constant-load cycling test performed at 90% of peak work rate until exhaustion. Diaphragm fatigue was considered present if there was a >or=15% reduction in Pdi,tw after exercise. Diaphragm fatigue occurred in 11 of 19 men (58%) and 8 of 19 women (42%). The percent drop in Pdi,tw at 10, 30, and 60 min after exercise in men (n = 11) was 30.6 +/- 2.3, 20.7 +/- 3.2, and 13.3 +/- 4.5%, respectively, whereas results in women (n = 8) were 21.0 +/- 2.1, 11.6 +/- 2.9, and 9.7 +/- 4.2%, respectively, with sex differences occurring at 10 and 30 min (P < 0.05). Men continued to have a reduced contribution of the diaphragm to total inspiratory force output (pressure-time product of the diaphragm/pressure-time product of the esophagus) during exercise, whereas diaphragmatic contribution in women changed very little over time. The findings from this study point to a female diaphragm that is more resistant to fatigue relative to their male counterparts.

 

Upper respiratory tract infections and sports

Boffi El Amari E.: Revue Médicale Suisse, 2010, 6(258):1499-503. Service des maladies infectieuses Département de médecine interne, HUG, 1211 Geneve 14.

Upper respiratory tract infections are frequent in athletes. Mainly of viral origin, they are treated symptomatically. Infectious mononucleosis is associated with an estimated 2% per hundred risk of splenic rupture, which occurs between day four and twenty one of the illness. Therefore return to play guidelines recommend avoiding, exercice during the first twenty one days. Physical exercise seems to influence the immune system, depending on the intensity and length of it. But the relationship between physical exercise and risk of infections remains controversial: some articles showing an increase in risk, whereas others suggesting a certain degree of protection, in athletes. The actual generally accepted working theory is the J-curve proposed by Nieman. This model remains to be formally proven.

 


Bronchial challenges and respiratory symptoms in elite swimmers and winter sport athletes: Airway hyperresponsiveness in asthma: its measurement and clinical significance.

Bougault V, Turmel J, Boulet LP.: Chest, 2010, 138(2 Suppl):31S-37S. Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC, Canada.

This study was aimed at the following: (1) the prevalence of airway hyperresponsiveness (AHR) and exercise-induced bronchoconstriction (EIB) in swimmers and winter sport athletes according to the previously recommended regulatory sport agencies criteria, (2) the relationship between respiratory symptoms and AHR/EIB, (3) the impact of the chosen cutoff value for AHR on its prevalence, and (4) the effect on the prevalence of the positive eucapnic voluntary hyperpnea (EVH) test of using the highest vs the lowest spirometric post-EVH values to calculate the magnitude of the airway response. We compared the prevalence of respiratory symptoms with responses to methacholine challenge and EVH in 45 swimmers, 45 winter sport athletes, and 30 controls. Two methacholine challenge cutoffs for AHR were analyzed: < .05). Prevalence of positive EVH tests were 39% in swimmers, 24% in winter sport athletes, and 13% in controls when the highest FEV(1) value measured at each time point post-EVH was used to identify maximal response for calculation of airway response, although these prevalences were higher if we used the lowest value. This study suggests that AHR/EIB is frequent in swimmers, whereas the frequently reported respiratory symptoms in winter sport athletes are often not related to AHR/EIB. Furthermore, the choice of methods for assessing methacholine challenge and EVH responses influences the prevalences of AHR and EIB.


Peak power estimated from 6-minute walk distance in Asian patients with idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease.

Kozu R, Jenkins S, Senjyu H, Mukae H, Sakamoto N, Kohno S.: Respirology (Carlton, Vic.), 2010, 15(4):706-13 Language: eng Country: Australia Department of Rehabilitation Medicine, Nagasaki University Hospital, Nagasaki, Japan.

BACKGROUND AND OBJECTIVE: Pulmonary rehabilitation guidelines recommend cycle ergometry training at an intensity that exceeds 60% of peak power (P(peak)) with the aim of achieving a physiologic response. However, many clinicians do not have access to an incremental cycle ergometry test (ICET) to allow prescription of training intensity. No studies have investigated whether the 6MWT can be used to estimate the P(peak) achieved during an ICET in subjects with IPF or in Asian subjects with COPD. METHODS: A total of 90 Japanese subjects (IPF n = 45, COPD n = 45) undertook a 6MWT and a symptom-limited ICET in random order. Anthropometry, quadriceps strength and lung function were measured. RESULTS: Exercise tests were prematurely terminated in 10 subjects with IPF due to profound oxygen desaturation (SpO(2) < 80%). The ICET elicited higher peak heart rates, dyspnea and leg fatigue in both subject cohorts (all P < 0.01). The magnitude of oxygen desaturation was greater during the 6MWT (P < 0.01). 6MWD was strongly associated with P(peak) (r = 0.80, P < 0.01) in both subject cohorts. In subjects with IPF, the predictive equation that accounted for the greatest proportion of variance in P(peak) included 6MWD and FVC %pred (R(2) = 0.70). In the COPD subjects, 6MWD alone accounted for 64% of the variance in P(peak) and the inclusion of other variables did not increase R(2). CONCLUSIONS: P(peak) can be estimated from the 6MWT in Japanese subjects with IPF and COPD. This may allow individualized prescription of the intensity for cycle-based training based on the 6MWT.

 


Swimming and asthma: factors underlying respiratory symptoms in competitive swimmers.

Päivinen MK, Keskinen KL, Tikkanen HO.: The Clinical Respiratory Journal, 2010, 4(2):97-103. Unit for Sport and Exercise Medicine, Institute of Clinical Medicine, University of Helsinki, Helsinki, Finland.

BACKGROUND: Swimming is recommended for asthmatics. However, many competitive swimmers report asthmatic symptoms. While some studies identify the swimming environment as a trigger for allergy and asthmatic symptoms, even more studies suggest swimming to be suitable for people with allergies and asthma. The factors behind the symptoms were studied first by determining the prevalence of asthma, allergy and self-reported asthmatic symptoms in experienced Finnish swimmers and then by examining the relationships between the reported symptoms and the main triggering factors: medical history, environment and exercise intensity. MATERIALS AND METHODS: Top swimmers (n = 332) of the Finnish Swimming Association registry (N = 4578) were asked to complete a structured questionnaire on their medical history, swimming background, swimming environment and symptoms in different swimming intensities. Two hundred experienced swimmers, 107 females and 93 males, with an average age of 18.5 [standard deviation (SD) = 3.0] years and a swimming training history of 9 (SD = 3.8) years completed the questionnaire. RESULTS: Physician-diagnosed asthma was reported by 32 swimmers (16%), including 24 (12%) with exercise-induced asthma. Physician-diagnosed allergy was reported by 81 (41%) swimmers. Asthmatic symptoms during swimming were described by 84 subjects (42%). Most symptoms occurred when swimming exceeded speeds corresponding to the lactic/anaerobic threshold. Family history of asthma was significant and the most important risk factor for asthmatic symptoms. CONCLUSIONS: The prevalence of asthma in swimmers was higher than in the general population but not different from that in other endurance athletes. Family history of asthma and increased swimming intensity had the strongest associations with the reported asthmatic symptoms.

 

Six-minute walk distance in patients with severe end-stage COPD: association with survival after inpatient pulmonary rehabilitation.

Enfield K, Gammon S, Floyd J, Falt C, Patrie J, Platts-Mills TA, Truwit JD, Shim YM.: Journal of Cardiopulmonary Rehabilitation and Prevention, 2010, 30(3):195-202 . Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA 22908, USA.

Purpose: To evaluate the relationship between the 6-minute walk distance (6MWD) and survival in a cohort of patients with severe end-stage chronic obstructive pulmonary disease (COPD) who received inpatient pulmonary rehabilitation (IPR) from 1995 to 2007. Methods: We retrospectively analyzed 815 patients with severe end-stage COPD who received IPR. 6MWDs before and after IPR (pre-6MWD, post-6MWD) were compared to assess whether 6MWD was significantly changed after IPR. The Kaplan-Meier survival curves were constructed to show the relationship between survival and 6MWD. The age- and or comorbidities-adjusted Cox proportional hazard model was applied to assess association between the survival and the pre-6MWD, post-6MWD, or difference in 6MWD from the pre-6MWD to post-6MWD (Delta6MWD). Results: Baseline demographics demonstrated a median age 74.0 years, mostly women (60.1%), and white (89.9%) patients with significant comorbid diseases who were most recently hospitalized in acute care facilities (95.1%). IPR significantly increased the 6MWD (mean distance change: 86.4 m; 95% confidence interval [CI], 81.5-91.3 m). Pre-6MWD was not significantly associated with survival. However, post-6MWD was significantly associated with age- and comorbidity-adjusted survival (post-6MWD hazard ratio = 1.336; 95% CI, 1.232-1.449 [post-6MWD x m relative to post-6MWD 2x m]), and Delta6MWD was also significantly associated with age-, comorbidities-, and pre-6MWD-adjusted survival (Delta6MWD hazard ratio = 1.337; 95% CI, 1.227-1.457 [Delta6MWD x m relative to Delta6MWD 2x m]). Conclusions: In patients with severe end-stage COPD, IPR significantly improved 6MWD, and the post-6MWD and Delta6MWD were positively associated with the length of survival.


A novel approach to measuring activity in chronic obstructive pulmonary disease: using 2 activity monitors to classify daily activity

Cohen MD, Cutaia M.: Journal of Cardiopulmonary Rehabilitation and Prevention, 2010, (3):186-94. Patient and Pulmonary Services, Veterans Affairs, New York Harbor Health Care Services, 800 Poly Pl., Brooklyn, NY 11209, USA.

Purpose: Patients with chronic obstructive pulmonary disease with a low profile of daily activity have poor health outcomes. Although walking is a common activity, it may not be the most relevant physical activity to measure in this population. It was the purpose of this study to determine the accelerometer-defined thresholds that discriminate a range of daily activities and use these thresholds to assess activity profiles among stages of disease severity. Methods: Subjects with chronic obstructive pulmonary disease (N = 57) completed a standardized sequence of activities that comprised sitting, standing, and walking while wearing an accelerometer on the waist and an actigraph on the wrist. Using a calibration procedure, accelerometer output was translated into speeds. Speeds were estimated for each interval in the testing sequence. Walking and nonacceleration thresholds were derived from the intervals to define 4 activity categories: walking, slow/intermittent walking, active-not-walking, and rest. Subjects wore the 2 devices for 2 days. Accelerometer output was then classified into 1 of the activity categories. Percent time spent in activity categories and speeds generated were compared among Global Initiative for Obstructive Lung Disease (GOLD) stages. Results: The waist-worn accelerometer accurately estimated speeds. Speed thresholds for walking and nonacceleration were 0.70 mph and 0.25 mph, respectively. Among GOLD stages, those with more severe obstruction spent less time in the walking categories and generated slower speeds. Conclusions: The accuracy of these methods to detect a range of physical activities enhances the utility of accelerometers in comparing daily activity in sedentary populations. Measurements of the more subtle activities offer an appealing new area of study.

 


Ground walk training improves functional exercise capacity more than cycle training in people with chronic obstructive pulmonary disease (COPD): a randomised trial.

Leung RW, Alison JA, McKeough ZJ, Peters MJ.: Journal of Physiotherapy, 2010, 56(2):105-12. Physiotherapy Department, Concord Repatriation General Hospital, NSW, Australia.

Questions: Does an eight-week program of walk training improve endurance walking capacity in people with COPD compared to cycle training? Does walk training improve peak walking capacity, cycle capacity, and quality of life compared to cycle training? Is the endurance shuttle walk test (ESWT) responsive to change in walking capacity elicited by exercise training? Design: Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Participants: 36 people with stable COPD recruited with four dropouts. Intervention: Participants were randomised into either a walk or cycle training group. Both groups trained indoors for 30 to 45 minutes per session, three times weekly over eight weeks at Concord Hospital. Training intensities were based on baseline peak exercise tests and progressed as able. Outcome measures: The primary outcome was endurance walking capacity measured by the ESWT. Secondary outcomes included peak walking capacity, peak and endurance cycle capacity, and health-related quality of life. Measures were taken at baseline (Week 0) and following training (Week 8). Results: The walk training group increased their endurance walking time by 279 seconds (95% CI 70 to 483) more than the cycle training group. No significant differences between the groups were found for any other outcome. Conclusion: Ground walk training increased endurance walking capacity more than cycle training and was similar to cycle training in improving peak walking capacity, peak and endurance cycle capacity and quality of life. This study provides evidence for ground walking as a mode of exercise training in pulmonary rehabilitation programs.

 

 

Advantages of endurance treadmill walking compared with cycling to assess bronchodilator therapy.

Zhang X, Waterman LA, Ward J, Baird JC, Mahler DA.: Chest, 2010-06 137(6):1354-61. Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756-0001, USA.

BACKGROUND: Walking is a familiar daily activity that is generally limited by breathlessness, whereas cycling is an uncommon physical effort typically limited by leg discomfort. The hypothesis was that patients with COPD would exhibit greater improvements in exercise endurance and relief of breathlessness with bronchodilator therapy during treadmill walking compared with cycling. METHODS: In this randomized, 2 x 2, double-blind, placebo-controlled, crossover trial, 20 patients with COPD (age, 64 +/- 7 years; FEV(1), 56 +/- 14% predicted) performed constant-load endurance exercise on the treadmill and cycle ergometer at 85% of capacity after inhaling normal saline (NS) or arformoterol (ARF) (15 microg). RESULTS: Increases in endurance times and consistency of responses were greater with treadmill walking (Delta: 157 +/- 286 s; P = .024; 80% improved) than with cycle exercise (Delta: 110 +/- 219 s; P = .038; 65% improved) with ARF compared with NS. However, these changes were not significantly different. The slope of breathlessness-time (mean Delta = -29%; P = .007) and the magnitude of oxygen desaturation were significantly lower with ARF compared with NS during treadmill, but not cycle, exercise. Inspiratory capacity values were similar between modes of exercise when comparing the same study medication. CONCLUSIONS: Improved endurance times support both constant-load treadmill and cycle exercise to assess the efficacy of bronchodilator therapy in patients with COPD. Unique differences in physiologic and perceptual responses with bronchodilation demonstrate advantages of treadmill walking as an exercise stimulus.


Characterization of pulmonary arterial hypertension patients walking more than 450 m in 6 min at diagnosis.

Degano B, Sitbon O, Savale L, Garcia G, O'Callaghan DS, Jaïs X, Humbert M, Simonneau G.: Chest, 2010-06 137(6):1297-303. Service de Pneumologie, Hôpital Antoine-Béclère, 157 rue de la Porte de Trivaux, 92141 Clamart, France. D

BACKGROUND: At diagnosis of pulmonary arterial hypertension (PAH), some patients are considered to have a "near-normal" 6-min walk distance (6MWD) (ie, > 450 m). Because they are generally excluded from randomized controlled trials, little is known about these patients. METHODS: We analyzed the baseline characteristics and treatment responses of 49 consecutive patients with a 6MWD > 450 m at the time of newly diagnosed PAH. Data from this cohort were then compared with data from hemodynamically matched patients with a 6MWD 450 m were either in World Health Organization (WHO) functional class (FC) II (n = 23) or III (n = 26) at baseline. Compared with patients in FC II, those in FC III had more severe hemodynamic impairment (ie, a lower cardiac index and higher pulmonary vascular pressures and resistance) but similar 6MWD. At first evaluation after initiation of PAH-specific treatment (3-6 months), FC improved (FC I-II: n = 38; FC III: n = 11, P 450 m, hemodynamic indices and WHO FC were more sensitive than 6MWD in detecting changes secondary to PAH-specific treatments.


Decompression sickness in breath-hold divers: a review.

Lemaitre F, Fahlman A, Gardette B, Kohshi K.: Journal of Sports Sciences, 2009-12-27(14):1519-34. Faculty of Sport Sciences, University of Rouen, Mont-Saint-Aignan, France.

Although it has been generally assumed that the risk of decompression sickness is virtually zero during a single breath-hold dive in humans, repeated dives may result in a cumulative increase in the tissue and blood nitrogen tension. Many species of marine mammals perform extensive foraging bouts with deep and long dives interspersed by a short surface interval, and some human divers regularly perform repeated dives to 30-40 m or a single dive to more than 200 m, all of which may result in nitrogen concentrations that elicit symptoms of decompression sickness. Neurological problems have been reported in humans after single or repeated dives and recent necropsy reports in stranded marine mammals were suggestive of decompression sickness-like symptoms. Modelling attempts have suggested that marine mammals may live permanently with elevated nitrogen concentrations and may be at risk when altering their dive behaviour. In humans, non-pathogenic bubbles have been recorded and symptoms of decompression sickness have been reported after repeated dives to modest depths. The mechanisms implicated in these accidents indicate that repeated breath-hold dives with short surface intervals are factors that predispose to decompression sickness. During deep diving, the effect of pulmonary shunts and/or lung collapse may play a major role in reducing the incidence of decompression sickness in humans and marine mammals.

 

Peak oxygen uptake during the six-minute walk test in diffuse interstitial lung disease and pulmonary hypertension.

Blanco I, Villaquirán C, Valera JL, Molina-Molina M, Xaubet A, Rodríguez-Roisin R, Barberà JA, Roca J.: Archivos de Bronconeumología, 2010, 46(3):122-8. Servei de Pneumologia, Hospital Clínic, Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, España.

INTRODUCTION: The six-minute walk test (6MWT) is widely used in evaluating diffuse interstitial lung disease (ILD) and pulmonary hypertension (PH). However, their physiological determining factors have not been well defined. OBJECTIVE: To evaluate the physiological changes that occur in ILD and PH during the 6MWT, and compare them with the cardiopulmonary exercise test (CPET). MATERIAL AND METHODS: Thirteen patients with ILD and 14 with PH were studied using the 6MWT and CPET on an ergometer cycle. The respiratory variables were recorded by means of telemetry during the 6MWT. RESULTS: Oxygen consumption (VO(2)), respiratory and heart rate reached a plateau from minute 3 of the 6MWT in both diseases. The VO(2) did not differ from the peak value in the CPET (14+/-2 and 15+/-2 ml/kg/min, respectively, in ILD; 16+/-6 and 16+/-6 ml/kg/min, in PH). The arterial oxygen saturation decreased in both diseases, although it was more marked in ILD (-12+/-5%, p<0,01). The ventilatory equivalent for CO(2) (V(E)/VCO(2)) in PH during the 6MWT was strongly associated with functional class (FC) (85+/-14 in FC III-IV, 44+/-6 in FC I-II; p<0,001). CONCLUSIONS: The 6MWT in ILD and PH behaves like a maximal effort test, with similar VO(2) to the CPET, demonstrating a limit in oxygen transport capacity. Monitoring using telemetry during the 6MWT may be useful for the clinical evaluation of patients with ILD or PH.

 

 

Improvement of lasting effects in outpatient pulmonary rehabilitation with special regard to exercise therapy and sports.

Dalichau S, Demedts A, im Sande A, Möller T.: Die Rehabilitation, 2010, 49(1):30-7. Berufsgenossenschaftliche Unfall-Ambulanz und Reha-Zentrum am Airport Bremen, Bremen.

BACKGROUND: The aim of this study was to evaluate the effects of outpatient medical rehabilitation (OMR) mainly composed of exercise therapy and sports for patients with asbestosis. Following the Hamburg model, the OMR focuses on keeping up lasting effects. METHOD: In the frame of a pre-experimental study, 113 male asbestosis patients aged 66.1+/-5.8 years participated 6 hrs. a day five times a week over a period of three weeks in phase 1 of the OMR consisting of evidence-based contents of the pulmonary rehabilitation. Directly after that further therapeutic applications with the main focus on exercise therapy and sports were Applied for 3 hrs. once a week over a period of twelve weeks (phase 2). After phase 2 the rehabilitation centre led the patients into sports groups near their places of residence (phase 3). The effects of the OMR were evaluated at the beginning (T1), at the end of phase 1 (T2) and phase 2 (T3) as well as 6 (T4) and 18 months (T5) after T3 by means of a suitable assessment. RESULTS: Compared to T1 physical fitness (6-minute Walk Test, Hand-Force Test) as well as health-related quality of life (SF-36), dyspnea (BDI/TDI) and oxygen partial pressure (pO2) were significantly improved in T2. These positive effects could be confirmed in T3. 89 patients (79%) were doing health-related sports regularly 6 and 18 months after T3 and could preserve their health outcome in T4 and T5, while the effects of rehabilitation of the 24 patients breaking off any sporting activities wore off again down to and even below the starting condition at T1. CONCLUSIONS: In spite of a restrictive pulmonary disease, specific exercise therapy and sports are able to mobilize physical reserves of performance and induce an increasing quality of life as well as a higher resilience in activities of daily living. These positive effects could be stabilized persistently by a regular training once a week. Thus, the results emphasize the necessity to include strategies of aftercare in the concept of rehabilitation.


 

Bronchial epithelial damage after a half-marathon in nonasthmatic amateur runners.

Chimenti L, Morici G, Paternò A, Santagata R, Bonanno A, Profita M, Riccobono L, Bellia V, Bonsignore MR.: American Journal of Physiology. Lung cellular and molecular Physiology

201006 298(6):L857-62. Dept. Biomedico Di Medicina Interna & Specialistica, Section of Pneumology, Univ. of Palermo, Via Trabucco 180, 90146 Palermo, Italy.

High neutrophil counts in induced sputum have been found in nonasthmatic amateur runners at rest and after a marathon, but the pathogenesis of airway neutrophilia in athletes is still poorly understood. Bronchial epithelial damage may occur during intense exercise, as suggested by investigations conducted in endurance-trained mice and competitive human athletes studied under resting conditions. To gain further information on airway changes acutely induced by exercise, airway cell composition, apoptosis, IL-8 concentration in induced sputum, and serum CC-16 level were measured in 15 male amateur runners at rest (baseline) and shortly after a half-marathon. Different from results obtained after a marathon, neutrophil absolute counts were unchanged, whereas bronchial epithelial cell absolute counts and their apoptosis increased significantly (P < 0.01). IL-8 in induced sputum supernatants almost doubled postrace compared with baseline (P < 0.01) and correlated positively with bronchial epithelial cell absolute counts (R(2) = 0.373, P < 0.01). Serum CC-16 significantly increased after all races (P < 0.01). These data show mild bronchial epithelial cell injury acutely induced by intense endurance exercise in humans, extending to large airways the data obtained in peripheral airways of endurance-trained mice. Therefore, neutrophil influx into the airways of athletes may be secondary to bronchial epithelial damage associated with intense exercise.


Peak oxygen uptake during the six-minute walk test in diffuse interstitial lung disease and pulmonary hypertension

Blanco I, Villaquirán C, Valera JL, Molina-Molina M, Xaubet A, Rodríguez-Roisin R, Barberà JA, Roca J.: Archivos de Bronconeumología, 201003 46(3):122-8. Servei de Pneumologia, Hospital Clínic, Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, España.

Introduction: The six-minute walk test (6MWT) is widely used in evaluating diffuse interstitial lung disease (ILD) and pulmonary hypertension (PH). However, their physiological determining factors have not been well defined. Objective: To evaluate the physiological changes that occur in ILD and PH during the 6MWT, and compare them with the cardiopulmonary exercise test (CPET). Material and methods: Thirteen patients with ILD and 14 with PH were studied using the 6MWT and CPET on an ergometer cycle. The respiratory variables were recorded by means of telemetry during the 6MWT. Results: Oxygen consumption (VO(2)), respiratory and heart rate reached a plateau from minute 3 of the 6MWT in both diseases. The VO(2) did not differ from the peak value in the CPET (14+/-2 and 15+/-2 ml/kg/min, respectively, in ILD; 16+/-6 and 16+/-6 ml/kg/min, in PH). The arterial oxygen saturation decreased in both diseases, although it was more marked in ILD (-12+/-5%, p<0,01). The ventilatory equivalent for CO(2) (V(E)/VCO(2)) in PH during the 6MWT was strongly associated with functional class (FC) (85+/-14 in FC III-IV, 44+/-6 in FC I-II; p<0,001). Conclusions : The 6MWT in ILD and PH behaves like a maximal effort test, with similar VO(2) to the CPET, demonstrating a limit in oxygen transport capacity. Monitoring using telemetry during the 6MWT may be useful for the clinical evaluation of patients with ILD or PH.

 

Improvement of lasting effects in outpatient pulmonary rehabilitation with special regard to exercise therapy and sports

Dalichau S, Demedts A, im Sande A, Möller T.: Die Rehabilitation, 201002 49(1):30-7. Berufsgenossenschaftliche Unfall-Ambulanz und Reha-Zentrum am Airport Bremen, Bremen.

Background: The aim of this study was to evaluate the effects of outpatient medical rehabilitation (OMR) mainly composed of exercise therapy and sports for patients with asbestosis. Following the Hamburg model, the OMR focuses on keeping up lasting effects. Method: In the frame of a pre-experimental study, 113 male asbestosis patients aged 66.1+/-5.8 years participated 6 hrs. a day five times a week over a period of three weeks in phase 1 of the OMR consisting of evidence-based contents of the pulmonary rehabilitation. Directly after that further therapeutic applications with the main focus on exercise therapy and sports were Applied for 3 hrs. once a week over a period of twelve weeks (phase 2). After phase 2 the rehabilitation centre led the patients into sports groups near their places of residence (phase 3). The effects of the OMR were evaluated at the beginning (T1), at the end of phase 1 (T2) and phase 2 (T3) as well as 6 (T4) and 18 months (T5) after T3 by means of a suitable assessment. Results: Compared to T1 physical fitness (6-minute Walk Test, Hand-Force Test) as well as health-related quality of life (SF-36), dyspnea (BDI/TDI) and oxygen partial pressure (pO2) were significantly improved in T2. These positive effects could be confirmed in T3. 89 patients (79%) were doing health-related sports regularly 6 and 18 months after T3 and could preserve their health outcome in T4 and T5, while the effects of rehabilitation of the 24 patients breaking off any sporting activities wore off again down to and even below the starting condition at T1. Conclusions : In spite of a restrictive pulmonary disease, specific exercise therapy and sports are able to mobilize physical reserves of performance and induce an increasing quality of life as well as a higher resilience in activities of daily living. These positive effects could be stabilized persistently by a regular training once a week. Thus, the results emphasize the necessity to include strategies of aftercare in the concept of rehabilitation.


New insights in the pathogenesis of high-altitude pulmonary edema.

Scherrer U, Rexhaj E, Jayet PY, Allemann Y, Sartori C:: Progress in Cardiovascular Diseases, 2010 May-Jun 52(6):485-92. Department of Internal Medicine and the Botnar Center for Extreme Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.

High-altitude pulmonary edema is a life-threatening condition occurring in predisposed but otherwise healthy individuals. It therefore permits the study of underlying mechanisms of pulmonary edema in the absence of confounding factors such as coexisting cardiovascular or pulmonary disease, and/or drug therapy. There is evidence that some degree of asymptomatic alveolar fluid accumulation may represent a normal phenomenon in healthy humans shortly after arrival at high altitude. Two fundamental mechanisms then determine whether this fluid accumulation is cleared or whether it progresses to HAPE: the quantity of liquid escaping from the pulmonary vasculature and the rate of its clearance by the alveolar respiratory epithelium. The former is directly related to the degree of hypoxia-induced pulmonary hypertension, whereas the latter is determined by the alveolar epithelial sodium transport. Here, we will review evidence that, in HAPE-prone subjects, impaired pulmonary endothelial and epithelial NO synthesis and/or bioavailability may represent a central underlying defect predisposing to exaggerated hypoxic pulmonary vasoconstriction and, in turn, capillary stress failure and alveolar fluid flooding. We will then demonstrate that exaggerated pulmonary hypertension, although possibly a conditio sine qua non, may not always be sufficient to induce HAPE and how defective alveolar fluid clearance may represent a second important pathogenic mechanism.


Prevention and treatment of high-altitude pulmonary edema.

Maggiorini M.: Progress in Cardiovascular Diseases, 2010 May-Jun 52(6):500-6. Intensive Care Unit, Department of Internal Medicine, University Hospital, Rämistrasse 100, CH-8091 Zurich, Switzerland.

We distinguish two forms of high altitude illness, a cerebral form called acute mountain sickness and a pulmonary form called high-altitude pulmonary edema (HAPE). Individual susceptibility is the most important determinant for the occurrence of HAPE. The hallmark of HAPE is an excessively elevated pulmonary artery pressure (mean pressure 36-51 mm Hg), caused by an inhomogeneous hypoxic pulmonary vasoconstriction which leads to an elevated pulmonary capillary pressure and protein content as well as red blood cell-rich edema fluid. Furthermore, decreased fluid clearance from the alveoli may contribute to this noncardiogenic pulmonary edema. Immediate descent or supplemental oxygen and nifedipine or sildenafil are recommended until descent is possible. Susceptible individuals can prevent HAPE by slow ascent, average gain of altitude not exceeding 300 m/d above an altitude of 2500 m. If progressive high altitude acclimatization would not be possible, prophylaxis with nifedipine or tadalafil for long sojourns at high altitude or dexamethasone for a short stay of less then 5 days should be recommended.

 

 

Measurement of COPD severity using a survey-based score: validation in a clinically and physiologically characterized cohort.

Eisner MD, Omachi TA, Katz PP, Yelin EH, Iribarren C, Blanc PD.: Chest, 2010, 137(4):846-51. University of California San Francisco, 505 Parnassus Ave, M-1097, San Francisco, CA 94143-0111, USA.

Background: A comprehensive survey-based COPD severity score has usefulness for epidemiologic and health outcomes research. We previously developed and validated the survey-based COPD Severity Score without using lung function or other physiologic measurements. In this study, we aimed to further validate the severity score in a different COPD cohort and using a combination of patient-reported and objective physiologic measurements. Methods: Using data from the Function, Living, Outcomes, and Work cohort study of COPD, we evaluated the concurrent and predictive validity of the COPD Severity Score among 1,202 subjects. The survey instrument is a 35-point score based on symptoms, medication and oxygen use, and prior hospitalization or intubation for COPD. Subjects were systemically assessed using structured telephone survey, spirometry, and 6-min walk testing. Results: We found evidence to support concurrent validity of the score. Higher COPD Severity Score values were associated with poorer FEV(1) (r = -0.38), FEV(1)% predicted (r = -0.40), Body mass, Obstruction, Dyspnea, Exercise Index (r = 0.57), and distance walked in 6 min (r = -0.43) (P < .0001 in all cases). Greater COPD severity was also related to poorer generic physical health status (r = -0.49) and disease-specific health-related quality of life (r = 0.57) (P < .0001). The score also demonstrated predictive validity. It was also associated with a greater prospective risk of acute exacerbation of COPD defined as ED visits (hazard ratio [HR], 1.31; 95% CI, 1.24-1.39), hospitalizations (HR, 1.59; 95% CI, 1.44-1.75), and either measure of hospital-based care for COPD (HR, 1.34; 95% CI, 1.26-1.41) (P < .0001 in all cases). Conclusion: The COPD Severity Score is a valid survey-based measure of disease-specific severity, both in terms of concurrent and predictive validity. The score is a psychometrically sound instrument for use in epidemiologic and outcomes research in COPD.


Airway responses to methacholine and exercise at high altitude in healthy lowlanders.

Pellegrino R, Pompilio P, Quaranta M, Aliverti A, Kayser B, Miserocchi G, Fasano V, Cogo A, Milanese M, Cornara G, Brusasco V, Dellacà R.: Journal of Applied Physiology, 2010, 108(2):256-65. Allergologia e Fisiopatologia Respiratoria, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy.

Peribronchial edema has been proposed as a mechanism enhancing airway responses to constrictor stimuli. Acute exposure to altitude in nonacclimatized lowlanders leads to subclinical interstitial pulmonary edema that lasts for several days after ascent, as suggested by changes in lung mechanics. We, therefore, investigated whether changes in lung mechanics consistent with fluid accumulation at high altitude within the lungs are associated with changes in airway responses to methacholine or exercise. Fourteen healthy subjects were studied at 4,559 and at 120 m above sea level. At high altitude, both static and dynamic lung compliances and respiratory reactance at 5 Hz significantly decreased, suggestive of interstitial pulmonary edema. Resting minute ventilation significantly increased by approximately 30%. Compared with sea level, inhalation of methacholine at high altitude caused a similar reduction of partial forced expiratory flow but less reduction of maximal forced expiratory flow, less increments of pulmonary resistance and respiratory resistance at 5 Hz, and similar effects of deep breath on pulmonary and respiratory resistance. During maximal incremental exercise at high altitude, partial forced expiratory flow gradually increased with the increase in minute ventilation similarly to sea level but both achieved higher values at peak exercise. In conclusion, airway responsiveness to methacholine at high altitude is well preserved despite the occurrence of interstitial pulmonary edema. We suggest that this may be the result of the increase in resting minute ventilation opposing the effects and/or the development of airway smooth muscle force, reduced gas density, and well preserved airway-to-parenchyma interdependence.


Neurophysiological comparison between the Sit-to-Stand test with the 6-Minute Walk test in individuals with COPD.

Canuto FF, Rocco CC, de Andrade DV, Sampaio LM, Oliveira CS, Corrêa FI, Stirbulov R, Corrêa JC.:

Electromyography and Clinical Neurophysiology, 2010,50(1):47-53. July Nine University Center - UNINOVE, São Paulo, SP, Brazil.

Objectives: The Sit-to-Stand test (SST) is accepted and utilized during functional assessments of COPD patients, along with the 6-Minute Walk test (6MWT). Since there is a lack of evidence in literature regarding the neurophysiological effectiveness of SST compared to 6MWT, the present study is justified with the Purpose of assessing the neurophysiological effectiveness of SST in comparison to the 6MWT during the functional assessment of such patients, once it is known that both tests are good predictors of functional state. Methods: Fourteen patients with moderate to severe COPD randomly performed the 6MWT and the SST with a 30-minute interval in between tests. Blood lactate was collected along with the median frequency (MDF), obtained with the electromyography of the muscles rectusfemoris (RF), vastus lateralis (VL), tibialis anterior (TA), and soleus (SO) for the comparison of the neurophysiological effectiveness. Results: The results of the blood lactate concentration during rest and at the end of the functional tasks along with the results from the angular coefficient (AC) obtained from the median frequency were analyzed with the Student t test. The initial and final values obtained from SST and 6MWT were compared within each activity, along with the comparison between the initial and final values for each functional test. A significant difference (p = 0.0005) was only verified between the initial and final values of SST. Conclusion: We found neurophysiological correlation between both tests which enabled us to suggest that SST may determine functional status as easily as the 6MWT in regard to neurophysiological effectiveness.

 

Inspiratory muscle training improves 100 and 200 m swimming performance.

Kilding AE, Brown S, McConnell AK.: European Journal of Applied Physiology, 2010, 108(3):505-11. School of Sport and Recreation, Faculty of Health and Environmental Sciences, AUT University, Auckland, New Zealand.

Inspiratory muscle training (IMT) has been shown to improve time trial performance in competitive athletes across a range of sports. Surprisingly, however, the effect of specific IMT on surface swimming performance remains un-investigated. Similarly, it is not known whether any ergogenic influence of IMT upon swimming performance is confined to specific race distances. To determine the influence of IMT upon swimming performance over 3 competitive distances, 16 competitive club-level swimmers were assigned at random to either an experimental (pressure threshold IMT) or sham IMT placebo control group. Participants performed a series of physiological and performance tests, before and following 6 weeks of IMT, including (1) an incremental swim test to the limit of tolerance to determine lactate, heart rate and perceived exertion responses; (2) standard measures of lung function (forced vital capacity, forced expiratory volume in 1 s, peak expiratory flow) and maximal inspiratory pressure (MIP); and (3) 100, 200 and 400 m swim time trials. Training utilised a hand-held pressure threshold device and consisted of 30 repetitions, twice per day. Relative to control, the IMT group showed the following percentage changes in swim times: 100 m, -1.70% (90% confidence limits, +/-1.4%), 200 m, -1.5% (+/-1.0), and 400 m, 0.6% (+/-1.2). Large effects were observed for MIP and rates of perceived exertion. In conclusion, 6 weeks of IMT has a small positive effect on swimming performance in club-level trained swimmers in events shorter than 400 m.


Respiratory health effects of ultrafine and fine particle exposure in cyclists.

Strak M, Boogaard H, Meliefste K, Oldenwening M, Zuurbier M, Brunekreef B, Hoek G.: Occupational and Environmental Medicine, 2010, 67(2):118-24.

Institute for Risk Assessment Sciences, Division of Environmental Epidemiology, Utrecht University, PO Box 80178, 3508 TD Utrecht, The Netherlands.

Objectives: Monitoring studies have shown that commuters are exposed to high air pollution concentrations, but there is limited evidence of associated health effects. We carried out a study to investigate the acute respiratory health effects of air pollution related to commuting by bicycle. Methods: Twelve healthy adults cycled a low- and a high-traffic intensity route during morning rush hour in Utrecht, The Netherlands. Exposure to traffic-related air pollution was characterized by measurements of PM(10), soot and particle number. Before, directly after and 6 h after cycling we measured lung function (FEV(1), FVC, PEF), exhaled NO (FE(NO)) and respiratory symptoms. The association between post- minus pre-exposure difference in health effects and exposure during cycling was evaluated with linear regression models. Results: The average particle number concentration was 59% higher, while the average soot concentration was 39% higher on the high-traffic route than on the low-traffic route. There was no difference for PM(10). Contrary to our hypothesis, associations between air pollution during cycling and lung function changes immediately after cycling were mostly positive. Six hours after cycling, associations between air pollution exposure and health were mostly negative for lung function changes and positive for changes in exhaled NO, although non-significant. Conclusions: We found substantial differences in ultrafine particle number and soot exposure between two urban cycling routes. Exposure to ultrafine particles and soot during cycling was weakly associated with increased exhaled NO, indicative of airway inflammation, and decrements in lung function 6 h after exposure. A limitation of the study was the relatively small sample size.

 

 

Modificado em 31 de Maio de 2010

 

Bilateral pulmonary emboli in a collegiate gymnast: a case report.

Kahanov L, Daly T.: Journal of Athletic Training, 2009 44(6):666-71. Indiana State University, Athletic Training Department, C-06, Terre Haute, IN 47809, USA..

Objective: To characterize the diagnosis of pulmonary embolism in collegiate student-athletes and to raise awareness among sports medicine providers of the possibility of this potentially fatal disease in the student-athlete population. Background: An 18-year-old, previously healthy National Collegiate Athletic Association Division I female gymnast complained of intense pain, bilaterally, deep in her chest. The athlete was referred to her team physician, who identified normal vital signs but referred her to the emergency room because of significant pain. The student-athlete was diagnosed with bilateral pulmonary emboli in the emergency room. Diferencial diagnosis: Pneumonia, renal calculi, upper urinary tract infection, intercostal muscle strain or rib fracture, pancreatitis, gall bladder disease, gastritis, ulceration, esophagitis, infection, tumor, pulmonary embolism. Treatment: The student-athlete was immediately placed on anticoagulants for 6 months. During that time, she was unable to participate in gymnastics and was limited to light conditioning. Uniqueness: Documented cases of female student-athletes developing a pulmonary embolism are lacking in the literature. Two cases of pulmonary embolism in male high school student-athletes have been documented, in addition to many cases in elderly and sedentary populations. Conclusions: All health care providers, including sports medicine professionals, should be aware that this condition may be present among student-athletes. During the initial evaluation, prescreening should include questions about any previous or family history of pulmonary embolism or other blood clots. Athletes who answer positively to these questions may have a higher likelihood of pulmonary embolism and should be referred for testing.


Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease.

Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF.: Archives of Physical Medicine and Rehabilitation, 2010, 91(2):221-5. School of Physiotherapy, La Trobe University, Melbourne, Australia.

Objective: To establish the minimal important difference (MID) for the six-minute walk distance (6MWD) in persons with chronic obstructive pulmonary disease (COPD). Design: Analysis of data from an observational study using distribution- and anchor-based methods to determine the MID in 6MWD. Setting: Outpatient pulmonary rehabilitation program at 2 teaching hospitals. Participants: Seventy-five patients with COPD (44 men) in a stable clinical state with mean age 70 years (SD 9 y), forced expiratory volume in one second 52% (SD 21%) predicted and baseline walking distance 359 meters (SD 104 m). Interbvention s: Not applicable. Main outcome measures: Participants completed the six-minute walk test before and after a 7-week pulmonary rehabilitation program. Participants and clinicians completed a global rating of change score while blinded to the change in 6MWD. Results: The mean change in 6MWD in participants who reported themselves to be unchanged was 17.7 meters, compared with 60.2 meters in those who reported small change and 78.4 meters in those who reported substantial change (P=.004). Anchor-based methods identified an MID of 25 meters (95% confidence interval 20-61 m). There was excellent agreement with distribution-based methods (25.5-26.5m, kappa=.95). A change in 6MWD of 14% compared with baseline also represented a clinically important effect; this threshold was less sensitive than for absolute change (sensitivity .70 vs .85). Conclusions: The MID for 6MWD in COPD is 25 meters. Absolute change in 6MWD is a more sensitive indicator than percentage change from baseline. These data support the use of 6MWD as a patient-important outcome in research and clinical practice.

 


Modificado em 22 de Maio de 2010, Sábado

 

Clinical determinants of the 6-Minute Walk Test in bronchiectasis.

Lee AL, Button BM, Ellis S, Stirling R, Wilson JW, Holland AE, Denehy L.: Respiratory Medicine, 2009 103(5):780-5. School of Physiotherapy, The University of Melbourne, Melbourne, 3004 Victoria, Australia.

Background: The 6-Minute Walk Test (6MWT) is a widely used measurement of functional exercise capacity in chronic lung disease. While exercise intolerance has been identified in patients with bronchiectasis, the clinical determinants of the 6MWT in this population have not been examined. The aim of this study was to 1) establish the relationship between the 6-Minute Walk Distance (6MWD), disease severity and Health-Related Quality of Life (HRQOL) and 2) identify predictors of exercise tolerance in adults with bronchiectasis. Methods: The 6MWT was performed in 27 patients with bronchiectasis (mean [SD] FEV(1) 73.9% predicted [23.4]). Disease severity was assessed using spirometry and HRCT scoring while HRQOL was evaluated using the St George's Respiratory Questionnaire (SGRQ) and the Short-Form 36 (SF-36). The relationships were evaluated using correlation and multiple regression. Results: The 6MWD correlated positively with FVC (r=0.52, p<0.01), generations of bronchopulmonary divisions (r(s)=0.38, p<0.05) and SF-36 physical summary (r=0.71, p0.5, p<0.001). Multiple regression analysis indicated that the SGRQ activity, symptom scores and generations of bronchial divisions involved were identified as independent predictors of the 6MWD, explaining 76% of the variance. Conclusions: Measures of HRQOL demonstrated a stronger association with the 6MWD compared to physiological measures of disease severity in patients with predominantly mild to moderate bronchiectasis.

 

 

Spontaneous pneumomediastinum and epidural pneumatosis in an adolescent precipitated by weight lifting: a case report and review.

Sadarangani S, Patel DR, Pejka S.: The Physician and Sportsmedicine, 2009, 37(4):147-53. Michigan State University/Kalamazoo Center for Medical Studies, Kalamazoo, MI 49008, USA.

Spontaneous pneumomediastinum is an uncommon condition in athletes. The most common cause of spontaneous pneumomediastinum is alveolar rupture into the bronchovascular sheath as a result of increased intrathoracic pressure. Epidural pneumatosis (pneumorrhachis) has been rarely associated with spontaneous pneumomediastinum. In this article, we describe a case of a 17-year-old male who presented with neck and chest pain that started 14 hours after a weight lifting session. He developed both a pneumomediastinum and epidural pneumatosis--an association that is rarely reported in a setting without trauma. To our knowledge, there have been only 5 case reports of pneumomediastinum precipitated by weight lifting. Improper breathing technique during weight lifting can increase the intrathoracic pressure and the risk of pneumomediastinum; hence, it is important that physicians and trainers who work with athletes provide instructions regarding proper breathing techniques during weight lifting. In addition to the case discussion, this article reviews spontaneous pneumomediastinum and epidural pneumatosis.

 


Exhaled nitric oxide and airway hyperresponsiveness in workers: a preliminary study in lifeguards.

Demange V, Bohadana A, Massin N, Wild P.: BMC Pulmonary mMdicine, 2009, 9:53. INRS, Département Epidémiologie en Entreprise, Rue du Morvan, CS 60027, 54519 Vandoeuvre-lès-Nancy Cedex, France.

Backbround: Airway inflammation and airway hyperresponsiveness (AHR) are two characteristic features of asthma. Fractional exhaled nitric oxide (FENO) has shown good correlation with AHR in asthmatics. Less information is available about FENO as a marker of inflammation from work exposures. We thus examined the relation between FENO and AHR in lifeguards undergoing exposure to chloramines in indoor pools. Methods: 39 lifeguards at six indoor pools were given a respiratory health questionnaire, FENO measurements, spirometry, and a methacholine bronchial challenge (MBC) test. Subjects were labeled MBC+ if the forced expiratory volume (FEV1) fell by 20% or more. The normalized linear dose-response slope (NDRS) was calculated as the percentage fall in FEV1 at the last dose divided by the total dose given. The relation between MBC and FENO was assessed using logistic regression adjusting on confounding factors. The association between NDRS and log-transformed values of FENO was tested in a multiple linear regression model. Results: The prevalence of lifeguards MBC+ was 37.5%. In reactors, the median FENO was 18.9 ppb (90% of the predicted value) vs. 12.5 ppb (73% predicted) in non-reactors. FENO values >or= 60% of predicted values were 80% sensitive and 42% specific to identify subjects MBC+. In the logistic regression model no other factor had an effect on MBC after adjusting for FENO. In the linear regression model, NDRS was significantly predicted by log FENO. Conclusions: In lifeguards working in indoor swimming pools, elevated FENO levels are associated with increased airway responsiveness.

 

Are asthma-like symptoms in elite athletes associated with classical features of asthma?

T K Lund, L Pedersen, S D Anderson, A Sverrild, V Backer: Br J Sports Med 2009;43:1131-1135.

Background: Asthma is frequent in elite athletes and clinical studies in athletes have found increased airway inflammation. Objective: To investigate asthma-like symptoms, airway inflammation, airway reactivity (AR) to mannitol and use of asthma medication in Danish elite athletes. Methods: The study group consisted of 54 elite athletes (19 with doctor-diagnosed asthma), 22 non-athletes with doctor-diagnosed asthma (steroid naive for 4 weeks before the examination) and 35 non-athletes without asthma; all aged 18–35 years. Examinations (1 day): questionnaires, exhaled nitric oxide (eNO) in parts per billion, spirometry, skin prick test, AR to mannitol and blood samples. Induced sputum was done in subjects with asthma. Results: No significant difference was found in values for eNO, AR and atopy between 42 elite athletes with and 12 without asthma-like symptoms. Elite athletes with doctor-diagnosed asthma had less AR (response dose ratio 0.02 (0.004) vs 0.08 (0.018) p<0.01) and fewer sputum eosinophils (0.8% (0–4.8) vs 6.0% (0–18.5), p<0.01) than non-athletes with doctor-diagnosed asthma. Use of inhaled corticosteroids was similar in the two groups (not significant). In all, 42 elite athletes had asthma-like symptoms but only 12 had evidence of current asthma. Elite athletes without asthma had asthma-like symptoms more frequently than non-athletes without asthma (68.6% vs 25.7%, p<0.001). Conclusion: Asthma-like symptoms in elite athletes are not necessarily associated with classic features of asthma and alone should not give a diagnosis of asthma. More studies are needed to further investigate if and how the asthma phenotype of elite athletes differs from that of classical asthma.

 

 

Effects of chlorine and exercise on the unified airway in adolescent elite Scottish swimmers.

Clearie KL, Vaidyanathan S, Williamson PA, Goudie A, Short P, Schembri S, Lipworth BJ.: Allergy

2010, 65(2):269-73. Department of Medicine and Therapeutics, Ninewells Hospital, University of Dundee, UK.

Background: Chlorine metabolites and high training load may produce exercise-induced bronchospasm (EIB) in elite swimmers. The aim of this study was to assess the combined effects of chlorine and exercise on the unified airway of adolescent elite swimmers. Methods: The Scottish Midlands District squad were assessed during an indoor pool session at the National Swimming Academy. Athletes trained at least 8 h per week. Subjects underwent tidal (T(NO)) and nasal (N(NO)) exhaled NO and peak nasal inspiratory flow (PNIF) pre and post a 2 h session. A physiological exercise challenge assessed EIB in n = 36 swimmers (>10% fall in forced expiratory volume in 1 s (FEV(1))). Results: Combined and free chlorine levels (mg/l) were 1.66 and 0.3 respectively. n = 36 swimmers (mean age 13.3 years) were assessed: n = 8 (22%) had known asthma; n = 13 (36%) had a positive physiological challenge; 18 (50%) complained of symptoms suggestive of EIB. n = 10/28 (36%) who did not have asthma were found to have a positive exercise challenge. There was no significant association between reported exercise symptoms and positive exercise test. There was no significant change in T(NO) or N(NO) for pre vs postexposure, irrespective of asthma diagnosis or AHR. n = 15 (42%) swimmers complained of worsening nasal symptoms postexposure, but only n = 7 (14%) had a demonstrable fall in PNIF (mean 33 l/min). No significant association was found between PNIF and symptoms. Conclusions: Combined exposure to chlorine and exercise did not affect surrogate markers of inflammation in the unified airway. There was a high prevalence of undiagnosed EIB.

 

The 6 minute walk in idiopathic pulmonary fibrosis: longitudinal changes and minimum important difference.

Swigris JJ, Wamboldt FS, Behr J, du Bois RM, King TE, Raghu G, Brown KK.: Thorax, 2010, 65(2):173-7. Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.

Rationale: The response characteristics of the 6 minute walk test (6MWT) in studies of idiopathic pulmonary fibrosis (IPF) are only poorly understood, and the change in walk distance that constitutes the minimum important difference (MID) over time is unknown. Objectives: To examine changes over time in distance walked (ie, 6MWD) during the 6MWT and to estimate the change in distance that constitutes the MID in patients with IPF. Methods: Data from a recently completed trial that included subjects with IPF who completed the 6MWT, Saint George's Respiratory Questionnaire (SGRQ) and forced vital capacity (FVC) at 6 and 12 months were used to examine longitudinal changes in 6MWD. Both anchor- and distribution-based approaches as well as linear regression analyses were used to determine the MID for 6MWD. The SGRQ Total score and FVC were used as clinical anchors. Main results: Among 123 subjects alive and able to complete the 6MWT at both follow-up time points, 6MWD did not change significantly over time (378.1 m at baseline vs 376.8 m at 6 months vs 361.3 m at 12 months, p=0.5). The point estimate for the 6MWD MID was 28 m with a range of 10.8-58.5 m. Conclusion: In a group of patients with IPF with moderate physiological impairment, for those alive and able to complete a 6MWT, 6MWD does not change over 12 months. At the population level, the MID for 6MWD appears to be approximately 28 m. Further investigation using other anchors and derivation methods is required to refine estimates of the MID for 6MWD in this patient population.


A simple and portable breathing circuit designed for ventilatory muscle endurance training (VMET).

Balaban DY, Regan R, Mardimae A, Slessarev M, Han JS, Wells GD, Duffin J, Iscoe S, Fisher JA, Preiss D.: Respiratory Medicine, 2009 103(12):1822-7, Department of Anesthesiology University Health Network, Toronto, Canada.

Background: Ventilatory muscle endurance training (VMET) involves increasing minute ventilation (V (E)) against a low flow resistance at rest to simulate the hyperpnea of exercise. Ideally, VMET must maintain normocapnia over a wide range of V (E). This can be achieved by providing a constant fresh gas flow to a sequential rebreathing circuit. The challenge to make VMET suitable for home use is to provide a source of constant fresh gas flow to the circuit without resorting to compressed gas. Methods: Our VMET circuit was based on a commercial sequential gas delivery breathing circuit (Pulmanex Hi-Ox, Viasys Healthcare, Yorba Linda, CA USA). Airflow was provided either by a small battery-driven aquarium air pump or by the entrainment of air down a pressure gradient created by the recoil of a hanging bellows that was charged during each inhalation. In each case, fresh gas flow was adjusted to be just less than resting V (E). Eight subjects then breathed from the circuit for three 10min periods consisting of relaxed breathing, breathing at 20 and then at 40L/min. We monitored V (E), end-tidal PCO2 (PetCO2) and hemoglobin O2 saturation (SpO2). Results: During hyperpnea at 20 and 40L/min, PetCO2 did not differ significantly from resting levels with either method of supplying fresh gas. SpO2 remained greater than 96% during all tests. Conclusion: Isocapnic VMET can be reliably accomplished with a simple self-regulating, sequential rebreathing circuit without the use of compressed gas.


Exercise capacity of children with pediatric lung disease.

Zavorsky GS, Kryder JR, Jacob SV, Coates AL, Davis GM, Lands LC.: Clinical and Investigative Medicine. Médecine clinique et experimentale, 2009 32(6):E302. Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University, Saint Louis, MO 63117, USA.

Background: Pulmonary function of children with cystic fibrosis (CF) and bronchopulmonary dysplasia (BPD) is similar at rest even though the mechanisms of injury differ. We sought to compare the peak exercise responses in children with BPD versus CF while controlling for pulmonary impairment, nutritional status, gender, age, height, and predicted forced expired volume in 1 second (approximately 73% of predicted). Methods: Nine BPD children and 9 CF children underwent spirometry and a progressive exercise test to maximum on a cycle ergometer. Results: There was no difference between groups in body mass percentile (CF:97 +/- 13%, BPD: 98 +/- 11%), peak power output (Wpeak) (CF:67 +/- 19 W, BPD:73 +/- 28 W), % predicted Wpeak (CF:83 +/- 28%, BPD:88 +/- 15%), peak oxygen uptake (VO2peak, CF: 38 +/- 7 ml/kg/min, BPD: 39 +/-6 ml/kg/min), or % predicted VO2peak (CF:99 +/- 16 %, BPD:96 +/- 27%). Conclusions: Children with mild pulmonary impairments are able to achieve a near normal peak power output and a normal VO2peak. Neither the aetiology nor the developmental onset of the process appears to be important influences on VO2peak or Wpeak.

Prognostic value of the 6min walk test in bronchiolitis obliterans syndrome.

Nathan SD, Shlobin OA, Reese E, Ahmad S, Fregoso M, Athale C, Barnett SD.: Respiratory Medicine,

2009, 103(12):1816-21. Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, VA 22042, United States.

Bronchiolitis Obliterans Syndrome (BOS) complicates the course of many lung transplant recipients. It carries significant risk of morbidity and mortality, but its course is difficult to characterize. We evaluated the prognostic utility of the 6min walk test (6MWT) obtained after the onset of BOS in 42 patients. This was compared to the prognostic significance of changes in the FEV(1). The median time between the onset of BOS and the 6MWT was 109 days. The median decline in the FEV(1) from baseline to BOS onset was 25.7%, while the median change over the ensuing 3 months was 12.5%. Neither of these was predictive of subsequent mortality. The 6MWT yielded averages in the resting saturation, lowest saturation, distance walked and maximal Borg scores of 97%, 90.2%, 323m and 2.35, respectively. The best of these parameters in discriminating survival was the distance. Patients who walked further than 330m had a median survival of 1178 days versus 263 days for those who walked less (p<0.0001). We conclude that the 6MWT provides important prognostic information in patients with BOS and might perform better than spirometry. Use of this test might allow different clinical phenotypes to be discerned.

 

 
 

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