Inspiratory muscle training: a way to breathe more easily.
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Breathing Exercises↗
Biomedical subjects
Enrico Clini
Publications and source records attributed to Enrico Clini.
Early physiotherapy in the respiratory intensive care unit.
Physiotherapy is an integral part of the management of patients in respiratory intensive care units (RICUs). The most important aim in this area is to enhance the overall patient's functional capacity and to restore his/her respiratory and physical independence, thus decreasing the risks of bed rest associated complications. This article is a review of evidence-based effectiveness of weaning practices and physiotherapy treatment for patients with respiratory insufficiency in a RICU. Literature searches were performed using general and specialty databases with appropriate keywords. The evidence for applying a weaning process and physiotherapy techniques in these patients has been described according to their individual rationale and efficacy. The growing number of patients treated in RICUs all over the world makes this non pharmacological approach both welcome and interesting. However, to date, there are only strong recommendations concerning the evidence-based strategies to speed weaning. Early physiotherapy may be effective in ICU: however, most techniques (postures, limb exercise and percussion/vibration in particular) need to be further studied in a large population. Evidence supporting physiotherapy intervention is limited as there are no studies examining the specific effects of interventions on long-term outcome.
Breathing Exercises↗
Length and clinical effectiveness of pulmonary rehabilitation in outpatients with chronic airway obstruction.
STUDY OBJECTIVE: To assess the clinical effectiveness of pulmonary rehabilitation (PR) after 10 or 20 consecutive sessions in outpatients with chronic airway obstruction (CAO). DESIGN: Observational prospective cohort trial. SETTING: Outpatient clinic of a rehabilitation center. PATIENTS AND INTERVENTIONS: Twenty-five outpatients (mean age, 65 +/- 9 years [+/- SD]; FEV1, 64 +/- 12% predicted) admitted to a comprehensive PR program, including exercise training. MEASUREMENTS AND RESULTS: The load reached on a cycloergometer (maximal achieved load [W-max]), the maximal and isoload dyspnea and leg fatigue on a Borg scale, 6-min walk distance (6MWD), and the health-related quality of life as assessed using the St. George's Respiratory Questionnaire (SGRQ) [total and components score] have been recorded as outcome measures at baseline, after 10 sessions (T10), and after 20 sessions (T20). The predefined criteria of the clinically significant improvement were as follows: + 15% W-max, + 54 m at 6MWD, - 1 point at isoload dyspnea and leg fatigue, and - 4% at SGRQ scores. There was a mean significant difference between changes at T20 and T10 for 6MWD (- 42.96 m; 95% confidence interval [CI], - 57.79 to - 28.12 m; p = 0.001), total SGRQ (4.80; 95% CI, 2.29 to 7.31; p = 0.001), activity SGRQ (3.60; 95% CI, 0.48 to 6.71; p = 0.025), and symptoms SGRQ (5.96; 95% CI, 2.72 to 9.2; p = 0.001). The percentage of patients who improved was different at T20 as compared with T10 for W-max (68% and 48%, respectively; p = 0.025), 6MWD (76% and 20%, p = 0.001), and total SGRQ (64% and 36%, p = 0.008). CONCLUSIONS: A 10-session course of PR provides only limited clinically significant changes of outcome measures when compared with a 20-session course in outpatients with CAO of mild-to-moderate severity.
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Supported arm training in patients recently weaned from mechanical ventilation.
STUDY OBJECTIVES: To evaluate the effects of early exercise training in patients recovering from acute respiratory failure needing mechanical ventilation (MV). DESIGN: Prospective, randomized, and controlled study. SETTING: Three respiratory intermediate ICUs (RIICUs). PATIENTS: Of 228 patients admitted to an RIICU, 66 patients weaned from MV from > 48 to < 96 h were considered eligible and enrolled in the study. INTERVENTION: Sixty-six patients were randomized to either supported arm exercise training plus general physiotherapy (gPT) [group 1, 32 patients] or to gPT alone (group 2, 34 patients). MEASUREMENTS AND RESULTS: Twenty-five patients in each group completed the protocol. Group 1 showed a greater improvement in exercise capacity, as assessed by an arm incremental test (IT) [p = 0.003] and an endurance test (ET) [p = 0.021], compared to group 2. Posttraining maximal inspiratory pressure (MIP) significantly improved in both groups (p < 0.001 and p = 0.003 in groups 1 and 2 respectively; not significant). IT isoworkload dyspnea improved significantly in both groups (p = 0.005 and p = 0.009 in groups 1 and 2, respectively; not significant between groups), whereas IT isoworkload peripheral muscle fatigue (p < 0.001), ET isotime dyspnea (p < 0.01), and ET isotime muscular fatigue (p < 0.005) improved significantly in group 1 but not in group 2. IT improvers (chi2 = 0.004) and ET improvers (chi2 = 0.047) were more frequently observed in group 1 than in group 2. Baseline MIP could discriminate for IT (p = 0.013; odds ratio [OR], 1.116) and ET improvers (p = 0.022; OR, 1.067). CONCLUSION: Early upper-limb exercise training is feasible in RIICU patients recently weaned from MV and can enhance the effects of gPT. Baseline inspiratory muscle function is related to exercise capacity improvement.
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Long-term mechanical ventilation and nutrition.
Mechanical ventilation (MV) in chronic situations is commonly used, either delivered invasively or by means of non-invasive interfaces, to control hypoventilation in patients with chest wall, neuromuscular or obstructive lung diseases (either in adulthood or childhood). The global prevalence of ventilator-assisted individuals (VAI) in Europe ranges from 2 to 30 per 100000 population according to different countries. Nutrition is a common problem to face with in patients with chronic respiratory diseases: nonetheless, it is a key component in the long-term management of underweight COPD patients whose muscular disfunction may rapidly turn to peripheral muscle waste. Since long-term mechanical ventilation (LTMV) is usually prescribed in end-stage respiratory diseases with poor nutritional status, nutrition and dietary intake related problems need to be carefully assessed and corrected in these patients. This paper aims to review the most recent innovations in the field of nutritional status and food intake-related problems of VAI (both in adulthood and in childhood).
Adult↗
Assessment of physiologic variables and subjective comfort under different levels of pressure support ventilation.
STUDY OBJECTIVES: To evaluate the effects of 12 ventilator settings (pressure support ventilation [PSV] plus positive end-expiratory pressure [PEEP], 30 + 0 cm H(2)O; 25 + 5 cm H(2)O; 25 + 0 cm H(2)O; 20 + 5 cm H(2)O; 20 + 0 cm H(2)O; 15 + 5 cm H(2)O; 15 + 0 cm H(2)O; 10 + 5 cm H(2)O; 10 + 0 cm H(2)O; 5 + 5 cm H(2)O; 5 + 0 cm H(2)O; and 0 + 5 cm H(2)O) on physiologic variables; the percentage of ineffective efforts; patient comfort; and whether the diagnosis of COPD may influence results. DESIGN: Prospective, randomized, physiologic study. SETTING: Three weaning centers. PATIENTS: Thirty-six consecutive patients (20 patients with COPD). INTERVENTION: Patients were randomly submitted to the 12 settings. MEASUREMENTS AND RESULTS: Breathing pattern, respiratory drive (p0.1), arterial oxygen saturation (Sato(2)), heart rate, percentage of ineffective efforts per minute, patient comfort measured by means of a visual analogue scale (VAS), and BORG scale were recorded under each setting. Under different levels of assistance, breathing pattern, Sato(2), and p0.1 significantly and linearly changed (p < 0.0001) while VAS and BORG scale presented a significant (p = 0.027) U-shaped trend; high or low assistance caused the most discomfort. Under high levels of assistance, a higher (analysis of variance, p = 0.023) frequency of ineffective effort percentage was observed in the subgroup of 26 patients who presented this phenomenon. Breathing pattern significantly (p = 0.013) changed when compared to PSV alone (PSV plus zero end-expiratory pressure [ZEEP]) at the same total inspiratory pressure assistance (PSV plus PEEP). A huge variability among patients in breathing pattern and comfort was found under the setting rated as the most comfortable by patients. The diagnosis of COPD did not influence the overall results. CONCLUSIONS: The following conclusions are made: (1) physiologic variables followed a linear trend, while comfort followed a U-shaped trend under different levels of PSV (irrespective of COPD diagnosis); (2) high assistance caused an increase in ineffective efforts; (3) only the breathing pattern significantly changed when total assistance was given as PSV plus PEEP when compared to PSV alone (PSV plus ZEEP); and (4) the extreme levels of PSV are not associated with the best comfort.
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Non-pharmacological treatment for chronic obstructive pulmonary disease.
Evidence-based guidelines on treatment of patients with Chronic Obstructive Pulmonary Disease (COPD) have recently been developed. Non-pharmacological therapy of COPD has been receiving more interest and has been evolving rapidly in the last decade as an essential part of COPD treatment. In fact, non-pharmacological treatment is a complementary approach mainly in the advanced stages of COPD. Most of these care options appear to benefit patients in terms of quality of life and cost-effectiveness. The aim of the present review is to survey the most important non-pharmacological treatments for COPD (smoking cessation, rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation, and surgery) and their usefulness based on the currently available evidence. This review is based on an evaluation of the literature using a multimethod approach. A computerized MEDLINE search from 1966 through June 2003 was undertaken using the search terms pulmonary rehabilitation, surgery, smoking cessation, respiratory insufficiency/failure, and lung disease/obstructive. Non pharmacological treatment of COPD is a real option to successfully treat these patients and prevent further deterioration. All the included therapies are based on actual scientific evidence for patient benefits. To date, smoking cessation, comprehensive rehabilitation and long-term oxygen therapy are widely accepted as therapies which may positively impact the long-term management of COPD patients.
Humans↗
Nitric oxide and pulmonary circulation.
The aim of this review is to outline the characteristics of pulmonary circulation in health and disease and to define the value of exhaled NO (eNO) as a means to assess the involvement of pulmonary circulation in pathology. The discovery of the endocrine role of the endothelium has generated great interest in its potential role in regulating the vascular tone of the pulmonary vascular bed. Nitric oxide (NO)-mediated, endothelium-dependent relaxation has been demonstrated in the pulmonary arteries of animals and humans. Changes in the NO pathway in pulmonary hypertension are not completely understood. It is clear that NO has an important role in modulating the response to acute hypoxia, increased flow, and shear stress. The amount of exhaled NO (eNO) in different species may be easily measured, reflecting the overall NO metabolism from the lung (thus including epithelial, endothelial and other cell activity). The development of pulmonary hypertension secondary to systemic (systemic sclerosis, chronic heart failure) or pulmonary (COPD) diseases appears to be associated with a decrease in eNO production both at rest and during exercise. Chronic inhalation of NO appears to protect against pulmonary hypertension in animal models. Exhaled NO is attracting interest for its in vivo ability to represent the features of pulmonary circulation in pathology.
Animals↗
Predictors of change in exercise capacity after comprehensive COPD inpatient rehabilitation.
BACKGROUND: In order to evaluate the factors associated with change in exercise capacity after comprehensive inpatient Pulmonary Rehabilitation (IPR) we studied 132 consecutive adults with Chronic Obstructive Pulmonary Disease (COPD) recovering from an acute exacerbation. MATERIAL/METHODS: Lung function, arterial blood gases, and respiratory muscle strength were measured at baseline. Perceived breathlessness (B), 6-minute walk distance (6MWD), dyspnea at rest and post-exertion (D), hospital anxiety and depression (HAD), and health-related quality of life were assessed before (T0) and after (T1) IPR. The patients were divided into two groups depending on the change in 6MWD: Improvers (IM at least +54 meters after IPR, n=81) or Non-Improvers (NIM, less than 54 meters or no change, n=51). RESULTS: At T1 61% of the patients showed improvement as here defined. The IM group showed lower 6MWD and higher B and resting-D at T0 than NIM (p<0.05). A stepwise multiple regression analysis was performed using 6MWD change as the dependent variable. and anthropometric and physiological measures at T0 as the independent variables. This regression model explained 26% of the 6MWD-change; 6MWD and PaO2 significantly contributed to this model. CONCLUSIONS: In COPD patients recovering from an acute exacerbation, the predicted change in exercise capacity using anthropometric, demographic, clinical, and physiological variables after 2 weeks of comprehensive IPR is likely to be low. The baseline level of exercise performance and arterial oxygenation show the most consistent correlation with change in walking ability in these patients.
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Effects of respiratory therapist-directed protocol on prescription and outcomes of pulmonary rehabilitation in COPD inpatients.
BACKGROUND: The use of respiratory therapist-directed (RD) protocols in non-ICU hospitalized patients decreases respiratory care charges as compared with physician-directed (PD) protocols. OBJECTIVES: To determine whether RD or PD protocol assessments in COPD patients may impact: (1) prescription of respiratory treatments, and (2) outcomes of pulmonary rehabilitation program (PRP). METHODS: In a retrospective observational case-control study, 73 cases (RD) were compared with controls (PD) matched for age, sex, FEV1 and diagnosis of either chronic airflow obstruction (CAO), pulmonary emphysema (PE) or chronic respiratory insufficiency (CRI). PRP programs were specifically tailored and assessed for inpatients with moderate to severe COPD. Type of PRP protocol (P), number of respiratory treatments (RT), number of exercise training prescription (EXP) and failure (EXF), time to start PRP (T) and length of hospital stay (LOS) were recorded. Perceived breathlessness (B) as assessed by MRC scale, 6-min walk meters (6MWD), and BORG-dyspnea at rest (D-rest) and end of effort (D-effort) were also assessed as outcome measures before (T0) and after (T1) the PRP. RESULTS: Frequency distribution of P, EXP and EXF was similar in the two groups. However, prescription of additional RT (1.9 +/- 0.8 and 2.5 +/- 1.1 days, p<0.01), T (1.2 +/- 0.4 and 1.8 +/- 1.2 days, p<0.001) and LOS (17.2 +/- 2.0 and 18.2 +/- 1.8 days, p<0.05) were lower in cases than in controls. Both cases and controls similarly improved (p<0.0001) B, 6MWD, D-rest and D-effort at T1. CONCLUSIONS: RT-directed assessment results in less respiratory treatments prescription than PD-directed protocol and it does not affect the outcomes of in-hospital pulmonary rehabilitation of COPD patients.
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Occupational therapy and pulmonary rehabilitation of disabled COPD patients.
BACKGROUND: Occupational therapy (OT) has been defined as a task of rehabilitation for disabled patients, giving them maximal function and independence to sustain specific activities of daily living. OBJECTIVES: To evaluate the effectiveness of OT as an adjunctive measuring during pulmonary rehabilitation (PR) of hospitalized COPD patients. METHODS: A prospective clinical trial with parallel groups was undertaken in severely disabled COPD patients (n = 71, age 73 +/- 5 years). They were assigned to either OT+PR (n = 47, FEV1 46 +/- 21%pred.) or PR (n = 24, FEV1 44 +/- 12%pred.). PR consisted of eighteen 3-hour daily sessions, whilst OT (domestic activities) was added 3 times a week up to nine 1-hour sessions. Six-min walk (6MWD) with evaluation of BORG dyspnea (D) and leg fatigue (F) scores at end of effort, breathlessness sensation (B) by means of the MRC scale as well as the number of functions lost in the Basic Activity of Daily Living (BADL) categories were assessed as outcomes before (T0) and after (T1) rehabilitation. RESULTS: 6MWD (from 165 +/- 63 to 233 +/- 66 and from 187 +/- 52 to 234 +/- 65 m in the OT+PR and PR groups, respectively), D (from 4.9 +/- 2.1 to 3.2 +/- 1.6 and from 5.3 +/- 2.1 to 3.4 +/- 2.1), F (from 6.1 +/- 0.5 to 4.5 +/- 1.7 and from 5.9 +/- 0.8 to 4.3 +/- 0.8) and B (from 4.3 +/- 0.9 to 3.0 +/- 0.9 and from 4.2 +/- 1.0 to 3.2 +/- 0.8) had similarly improved (p < 0.01) in both groups at T1. The percentage distribution of patients across the BADL categories significantly changed (p = 0.004) in OT+PR (from 17 to 61%, from 70 to 34% and from 23 to 5% in categories A, B and C, respectively) but not in the PR group. CONCLUSIONS: The addition of OT to comprehensive PR is able to specifically improve the outcome of severely disabled COPD inpatients.
Activities of Daily Living↗